Our Hospital Programme Outline business case

R.124-2021 (re-issue)

Our Hospital Project

Outline Business Case

CONTENTS

CONTENTS .................................................................................................................................................. 2

1. INTRODUCTION .................................................................................................................................. 9  The Our Hospital Project ............................................................................................................... 9  The Our Hospital SOC (November 2020) ..................................................................................... 9  Pre-OBC Approvals....................................................................................................................... 9  The Our Hospital OBC .................................................................................................................. 9  The Scope of the Our Hospital Project OBC............................................................................... 10  Green Book (2020)...................................................................................................................... 11  OBC independent review ............................................................................................................ 11  Purpose of the OBC .................................................................................................................... 11  Full Business Case ..................................................................................................................... 11
2. EXECUTIVE SUMMARY.................................................................................................................... 12  The Strategic Case ..................................................................................................................... 12  Introduction ....................................................................................................................... 12  Work re-confirmed at the OBC Stage ................................................................................. 12

1. Our Hospital Project investment objectives ........................................................................ 12
2. Benefits ............................................................................................................................... 13

 Constraints .......................................................................................................................... 14  Dependencies ..................................................................................................................... 15  The Economic Case .................................................................................................................... 15  Purpose of the Economic Case .......................................................................................... 15  Work undertaken at the SOC stage and updates to the Case in this OBC ........................ 15  Critical Success Factor and Shortlisted Options ................................................................. 16  Site Evaluation .................................................................................................................... 16  Functional Brief ................................................................................................................... 17  Baseline Comparator Capital Costs .................................................................................... 17  New Build Capital Costs...................................................................................................... 18  Benefits Appraisal ............................................................................................................... 19

1. Approach taken for qualitative benefits ............................................................................... 19
2. Qualitative Benefit Scoring .................................................................................................. 20
3. Future quantification of benefits .......................................................................................... 20
4. Benefits appraisal conclusion.............................................................................................. 20
5. Risk appraisal ...................................................................................................................... 21  NPC Analysis ...................................................................................................................... 21  Conclusion .......................................................................................................................... 21

 The Financial Case ..................................................................................................................... 22  Introduction ......................................................................................................................... 22

 Our Hospital Project financial impact .................................................................................. 22  Affordability ......................................................................................................................... 24  The Commercial Case ................................................................................................................ 24  Introduction ......................................................................................................................... 24  Form of contract .................................................................................................................. 25  Current Status of DDP Contract .......................................................................................... 25  DDP Supply Chain Procurement Strategy (Stage 2 Procurement) .................................... 25  Land transactions associated with the project .................................................................... 25  Build Scheme information ................................................................................................... 25  The Management Case............................................................................................................... 25  Introduction ......................................................................................................................... 26

3. THE STRATEGIC CASE .................................................................................................................... 27  Introduction ................................................................................................................................. 27  Purpose of the Strategic Case ............................................................................................ 27  Work undertaken at the SOC Stage and updates to the Case in this OBC ........................ 27  System and Organisational Overview ......................................................................................... 27  Overview of the Island's Healthcare System ...................................................................... 27  Population and Demand...................................................................................................... 30  Structure of HCS ................................................................................................................. 31  Complex care – off island services ..................................................................................... 33  Digital transformation .......................................................................................................... 34  Learning and Development ................................................................................................. 36  Ambulance Services ........................................................................................................... 36  Policy review ....................................................................................................................... 37  Health and care system transformation .............................................................................. 39  Proposed future model of care ............................................................................................ 40  Existing Hospital Estate Overview .............................................................................................. 41  History of the site ................................................................................................................ 41  The Case for Change .................................................................................................................. 43  The current condition of the hospital estate ........................................................................ 44  Mental health services ........................................................................................................ 46  Other healthcare facilities in Jersey .................................................................................... 47  Poor functional suitability and configuration of the site ....................................................... 47  Poor resiliency ..................................................................................................................... 49  The Case for Change: Conclusion .............................................................................................. 49  Our Hospital Project investment objectives ................................................................................ 50  SOC Stage .......................................................................................................................... 50  OBC Stage .......................................................................................................................... 50

 SMART Objectives .............................................................................................................. 52  Benefits ....................................................................................................................................... 55  Long-list of benefits produced at SOC Stage...................................................................... 55  OBC Stage ......................................................................................................................... 56  Constraints .................................................................................................................................. 58  Dependencies ............................................................................................................................. 58

4. THE ECONOMIC CASE..................................................................................................................... 59  Introduction ................................................................................................................................. 59  Purpose of the Economic Case .......................................................................................... 59  Work undertaken at the SOC Stage and updates to the Case in this OBC ........................ 59  Critical Success Factors.............................................................................................................. 60  The long list ................................................................................................................................. 60  Overview of the longlist ....................................................................................................... 61  Longlist appraisal ................................................................................................................ 62

 The shortlist ................................................................................................................................. 64  Re-testing of Critical Success Factors and long-list at OBC stage ..................................... 65  Site Evaluation ............................................................................................................................ 66  Functional Brief ........................................................................................................................... 68  SOC Stage .......................................................................................................................... 68  OBC Stage .......................................................................................................................... 69

1. Demand and Capacity Modelling ........................................................................................ 69
2. In-patient bedrooms ............................................................................................................ 70
3. Aim of the functional brief.................................................................................................... 70

 Capital costing of the shortlisted options .................................................................................... 73  Baseline Comparator Option ............................................................................................... 73

1. Further development of the Baseline Comparator Option at OBC Stage ........................... 73
2. Baseline Comparator description and assumptions at OBC Stage .................................... 74  New Build Option ................................................................................................................ 78  Cost assumptions on the New Build Option........................................................................ 79

 Lifecycle expenditure .......................................................................................................... 83  Revenue costs ............................................................................................................................ 83  Baseline Comparator Option ............................................................................................... 84  New Build Option ................................................................................................................ 84  Potential Savings under consideration........................................................................................ 84  Benefits appraisal........................................................................................................................ 87  Introduction ......................................................................................................................... 87  The Process for identifying Benefits ................................................................................... 87  Allocation of benefits to categories ..................................................................................... 88

 Qualitative Benefits ............................................................................................................. 93  Future quantification of benefits ........................................................................................ 105  Benefits appraisal conclusion............................................................................................ 108  Risk appraisal ............................................................................................................................ 108  Risk Register ..................................................................................................................... 108  Quantitative OBC Project Risk Register ........................................................................... 109  Baseline Comparator Project Risk Register...................................................................... 114  Risk conclusion ................................................................................................................. 117  NPC Analysis ............................................................................................................................ 117  NPC Assumptions ............................................................................................................. 117  NPC Calculations .............................................................................................................. 118  NPC per Benefit Point ....................................................................................................... 118  NPC Conclusion ................................................................................................................ 118  Sensitivities ............................................................................................................................... 118  Sensitivity 1 - 10% increase in capital costs of the New Build option ............................... 119  Sensitivity 2 - 50% increase in Baseline Comparator Option Weighted Benefit Score .... 119  Sensitivity 3 – Combination Sensitivity ............................................................................. 120  Conclusion ................................................................................................................................ 120

5. THE FINANCIAL CASE.................................................................................................................... 122  Introduction ............................................................................................................................... 122  Purpose of the Financial Case .......................................................................................... 122  Work undertaken at the SOC Stage and updates to the Case in this OBC ...................... 122  Proposed Funding Solution ....................................................................................................... 122  Interim funding solution ..................................................................................................... 122  Our Hospital Capital funding solution ................................................................................ 123  Our Hospital Revenue funding solution ............................................................................ 124  Proposed funding assumptions ......................................................................................... 124  Our Hospital Project financial impact ........................................................................................ 125  Initial capital costs ............................................................................................................. 125  Indicative Funding example .............................................................................................. 126  Operational Revenue costs ............................................................................................... 127  Annual Revenue Impact ............................................................................................................ 127  Capitalisation of Costs & Balance Sheet Treatment ................................................................. 128  Projected Cash Flow ................................................................................................................. 129  Efficiency savings...................................................................................................................... 129  Affordability ............................................................................................................................... 129  Accounting & tax treatment ....................................................................................................... 130  Accounting Treatment ....................................................................................................... 130

 Tax Treatment ................................................................................................................... 130

6. THE COMMERCIAL CASE .............................................................................................................. 131  Introduction ............................................................................................................................... 131  Purpose of the Commercial Case ..................................................................................... 131  Work undertaken at the SOC Stage and updates to the Case in this OBC ...................... 131  Procurement Summary ............................................................................................................. 131  Summary of Our Hospital procurement options ........................................................................ 132  Contract strategy options .................................................................................................. 132  Tendering strategy options................................................................................................ 133  Determining the preferred procurement strategy .............................................................. 134  Routes to market for the procurement of a Design & Delivery Partner ............................ 135  Conclusion of the Our Hospital procurement strategy .............................................................. 136  Design & Delivery Partner Procurement Process ..................................................................... 137  Service requirements ........................................................................................................ 137  Procurement Law .............................................................................................................. 137  Early Market Engagement................................................................................................. 138  Summary of Design & Delivery Partner Procurement Process ................................................ 138  Key contractual information....................................................................................................... 139  Form of contract ................................................................................................................ 139  DDP Contract .................................................................................................................... 140  DDP Supply Chain Procurement Strategy (Stage 2 Procurement) .......................................... 140  Overarching strategy ......................................................................................................... 141  Objectives.......................................................................................................................... 141  Construction Workstreams ................................................................................................ 142  Governance for the 2 stage procurements ....................................................................... 142  Tendering Strategy Options .............................................................................................. 142  DDP Contract Strategy Options ........................................................................................ 143  Tender Process ................................................................................................................. 143  Contract Form ................................................................................................................... 144  Risk Management ............................................................................................................. 144  Best Value ......................................................................................................................... 144  Conclusion of the DDP Supply Chain Procurement Strategy ........................................... 144  Personnel .................................................................................................................................. 144  Opportunities in relation to the Our Hospital Programme ......................................................... 145  Potential Vacant Sites ....................................................................................................... 145  Units 9 & 10 St Peter's Technical Park ............................................................................. 147  Land transactions associated with the project .......................................................................... 147  Private Patients ......................................................................................................................... 147

 Current Private Patients services ...................................................................................... 147  Our Hospital Private Patients strategy .............................................................................. 148  Private Patient Financial analysis ..................................................................................... 149  Our Hospital Technical Design and Build Information .............................................................. 150  RIBA Plan of Work ............................................................................................................ 150  Construction Risk Register................................................................................................ 150  Decant of Departmental Services ..................................................................................... 150  Planning Application.......................................................................................................... 151  Social Value ...................................................................................................................... 151  Equipment Strategy........................................................................................................... 151  Facilities Management Strategy ........................................................................................ 152  Healthcare Planner input into design ................................................................................ 152  Build Scheme information ................................................................................................. 152

7. THE MANAGEMENT CASE............................................................................................................. 153  Introduction ............................................................................................................................... 153  Purpose of the Management Case ................................................................................... 153  Work undertaken at the SOC Stage and updates to the Case in this OBC ...................... 153  Stage of project and Project Plan ............................................................................................ 153  Contract Management plan ............................................................................................... 155  Post-Project Evaluation ..................................................................................................... 156  Programme ....................................................................................................................... 156  Project Management arrangements .......................................................................................... 156  Project Approvals .............................................................................................................. 157  Project Reporting and monitoring ............................................................................................. 157  Outline roles and responsibilities .............................................................................................. 158  Programme governance structure .................................................................................... 158  Individual roles and responsibilities .................................................................................. 159  Use of specialist advisers.......................................................................................................... 160  Government Team Project Budget ........................................................................................... 161  Project Delivery – Planning Application .................................................................................... 161  Benefits Management ............................................................................................................... 162  Change Management................................................................................................................ 162

 Following assessment of the change the outcome will be recorded and reported back to the PMO and Contract Supplier Manager for implementation. Risk Management .................................... 163

 Advisor Team ............................................................................................................................ 165  Engagement and Communications Approach .......................................................................... 165  Learning and continuous improvement ..................................................................................... 168  Conclusion ................................................................................................................................ 168 Appendix A – Appendix list ....................................................................................................................... 170

Appendix B – Abbreviations ...................................................................................................................... 171 Appendix C – Policy/Publications reviewed - links ................................................................................... 174 Appendix D – OHP New Risk Template ................................................................................................... 175 Appendix E – Benefits Register Template ................................................................................................ 176 Appendix F – OHP Project Manual ........................................................................................................... 177

1. INTRODUCTION

 The Our Hospital Project

On 13 May 2019, the Chief Minister announced proposals to establish an entirely new project Our Hospital' to deliver a new hospital by 2026.

The purpose of this Outline Business Case ("OBC") is to set out the case for a new hospital to be built to replace the existing Jersey General Hospital and builds on the Strategic Outline Case ("SOC") which was approved in November 2020. The subsequent chapters set out this case in considerable detail but before going into the detail of the Outline Business Case, it is first important to provide a recap of how this stage has been reached and the project approvals which have already been obtained.

 The Our Hospital SOC (November 2020)

The SOC was developed during 2020 and was approved by the Our Hospital Project (OHP) Governance in November 2020. The SOC primarily set out the Case for Change and performed a long-listing exercise which resulted in the short-listing of the New Build Option and a baseline comparator Do Minimum option (also referred toas the Baseline Comparator Option) for further development at OBC Stage.

The SOC was more advanced than a traditional SOC would be in a UK for a number of reasons which are set out below:

• Commercial Case - The procurement strategy had concluded that an early appointment of a Design & Delivery Partner ("DDP") would deliver the best outcome for the Project. The process to tender and appoint a Design & Delivery Partner (ROK/FCC JV) had successfully concluded before the completion of the SOC and therefore the Commercial Case was largely complete at the SOC stage with fairly limited updates needed in the OBC.

• Management Case – the early appointment of the DDP also resulted in the management processes and governance being more advanced than would typically be seen at the SOC stage.

• Economic Case – the early appointment of the DDP led to more detailed cost information being available than would usually be available at SOC Stage. However, all cost information is being refreshed in this OBC to reflect the significant development of the design to RIBA Stage 2.

 Pre-OBC Approvals

The following OH Project approvals had already been made before work commenced on this OBC in January 2021:

• Chief Minister formally established the Our Hospital Project – May 2019

• Appointment of ROK/FCC JV as the Design and Delivery Partner with a specific contract to deliver the Pre-Construction Services Agreement ("PCSA") works – July 2020 (OHP Governance approval)

• Selection of Overdale as the site to deliver the new hospital – November 2020 (States Assembly approval). Following the decision on site evaluation in November work has progressed on the preferred option as identified and agreed at SOC stage including land assembly / site acquisitions and design

 The Our Hospital OBC

This OBC has been developed following the principles set out in the UK HM Treasury Green Book 5 Case Business Case Model. The Green Book is internationally recognised as being a gold standard process for developing a business case and is therefore being followed by the Government of Jersey for major

Projects and in the development of this project. The OBC is the second stage of the Green Book process with its primary purpose typically being to assess the shortlisted options in more detail and select a preferred option whilst gaining clarity around the affordability of the scheme and its proposed procurement.

This OBC sets out each of the Green Book 5 cases and builds on the work undertaken at SOC Stage:

• Strategic Case - sets out the overall context for the project and makes the Case for Change alongside setting out the Project Objectives and the Critical Success Factors. The Strategic Case was largely complete at SOC stage and therefore the case has only been updated to reflect these changes.

• Economic Case – sets out the long-listing process and assesses the shortlisted options considering cost, benefit and risk. This OBC describes the work that took place at SOC stage to consider the long- list of options and to produce the shortlist, before developing the analysis of the shortlisted options. More detailed cost, benefits and risk analysis is also presented

• Financial Case – considers the funding options available to deliver the project and sets out the indicative financial position of the shortlisted options

• Commercial Case – sets out the options for delivering the proposed options and how those will be procured. This OBC builds on the detailed procurement process that was undertaken at the SOC Stage and presents more detail on the proposed design and commercial solution

• Management Case – details the management structure and processes put in place for the project and sets out the required project management costs

In addition to this, the OBC has also been informed by the principles of the PRINCE2 Business Case Development process which has significant cross over with the Green Book process particularly in the areas of options appraisal, benefits and investment appraisal techniques.

 The Scope of the Our Hospital Project OBC

The purpose of this Our Hospital OBC is to present the case for a new hospital to be constructed in Jersey. There are a number of other strategies being developed which are linked to the Our Hospital Project, but these sit out-with the scope of this Our Hospital OBC. These include:

• The Jersey Care Model ("JCM") – the JCM was developed in 2019 / 2020 and the outputs of the JCM, alongside General Hospital design requirements, were used to help inform the Functional Brief and in turn the site evaluation process. The Functional Brief has been designed with the aim of providing sufficient flexibility in order to be fit for any likely model of care designed to meet the needs of the Jersey population in the future, including the currently proposed JCM. The delivery of the Our Hospital Project is based on the assumptions set in the Functional Brief, with the JCM siting outside the scope of this OBC.

• Digital – the Capital costing for the new hospital as set out with this Our Hospital OBC assumes that the backbone infrastructure for the GoJ of Jersey digital solution needs to be provided as part of the design. HCS has developed a wider digital strategy, to deliver the new equipment and software which will be used in the new hospital. The delivery of the Our Hospital project is based on the digital requirements set out in the Functional Brief, which is in turn informed by this Digital Strategy, however the Digital Strategy is outside the scope of this OBC.

• Facilities Management – a separate Facilities Management Business Case is being prepared and will be presented for approval separately. This will consider the future operating model for Facilities Management. This Our Hospital OBC has therefore not included any costs or benefits associated with future Facilities Management Services.

 Green Book (2020)

During the course of the production of this OBC the UK Government have published The Green Book (2020), the latest update to the Green Book Guidance. A review of the updated guidance has informed the development of this OBC.

 OBC independent review

Global Construction advisor, Mott McDonald has been appointed to undertake an independent review on the OBC as the drafts progress. The outputs from this review have been incorporated into this OBC. Mott McDonald are currently working with the UK Department of Health to review business cases being developed in the UK for the UK Government Hospital Building programme and are therefore uniquely placed to carry out this review.

 Purpose of the OBC

The Purpose of this OBC is:

• To meet the Jersey Public Finance Manual ("PFM") requirement for a major project to develop an OBC prior to implementation; and

• To help inform a detailed Proposition which is being developed which will be presented to the States Assembly for debate in September 2021 and will include a request for approval to fund the Our Hospital Capital Costs set out within this OBC

 Full Business Case

Following successful approval of this OBC, the next stage of the Business Case process is a Full Business Case (FBC) which is typically completed on the point of execution of the main construction contract. It is anticipated that the Our Hospital Project will reach FBC Stage in 2022 and it is understood that oversight of the FBC would be through the OHP Governance Structure (i.e. the Senior Officer Steering Group and the Our Hospital Project POG).

2. EXECUTIVE SUMMARY

This section has been provided to give a summary of the information that is set out in the subsequent chapters, providing an overview of each of the 5 cases.

 The Strategic Case

 Introduction

The Our Hospital SOC sets out, in considerable detail, the overview of the Island's healthcare system and the case for change. Whilst this detail is still presented in the main body of this OBC, it has been summarised as follows at a high level for the Executive Summary as there have been very limited changes since the SOC Stage:

• Overview of the Island's Healthcare System

• Healthcare Delivery

• Heath and Community Services

• The current health estate

• The case for change

• The current condition of the hospital building and the HCS estate

• High risk of failure of some elements of the hospital detailed in the Six Facet Survey unless there is significant intervention

• Reconfiguration of the current building would incur significant costs to address the infrastructure issues and high ongoing lifecycle expenditure

• A significant refurbishment would not facilitate changes to space, clinical flow and adjacency issues

• Issues caused by the lack of co-location of key functions, including Mental Health Services

The case for change has concluded that in around five years the existing hospital risks becoming life expired and without significant investment the physical structure of the building could start to pose a risk to patient and staff safety if no action is taken. The running costs will quickly become unaffordable due to the amount of investment required to bring the hospital up to the statutory and regulatory standards required.

 Work re-confirmed at the OBC Stage

1. Our Hospital Project investment objectives

The Project investment objectives for any potential investment were developed using a workshop approach to ensure that the outcomes required by key stakeholders have been considered and included.

During the development of the OBC, a workshop was held with the Our Hospital Project team on Monday 8th February 2021 to review the Our Hospital Project Investment Objectives.

The key objectives of the Our Hospital Project were agreed to be:

1. To provide high quality, efficient and effective care for all patients and service users that is timely, accessible and delivers the best possible experience for patients, service users, visitors and staff
2. To deliver integration of physical and mental health care and services including co-location of an Acute and General Hospital and Mental Health Services
3. To deliver an Acute and General Hospital with co-located mental health and other services currently delivered offsite that is safe, compliant, flexible, delivers an optimised planned preventative maintenance regime and is right sized for the future delivery of clinical and other services, and enables service transformation

4. To deliver a new hospital that ensures the financial sustainability of the health economy
5. To deliver a new hospital that contributes to building a thriving community and well-being of staff and patients with positive socio-economic and environmental impacts

The updated objectives were reviewed and confirmed at the Clinical & Operational Client Group (COCG) meeting held on Thursday 4th March 2021.

2. Benefits

During the OBC workshop the long-list of benefits at the SOC was reviewed. The following revised set of benefits was produced which takes into account the development of the Project over the past 12 months and including the impact of the Covid-19 pandemic.

Figure 1: OBC Benefits

The updated benefits were reviewed and confirmed at the Clinical and Operational Client Group (COCG) meeting held on Thursday 4th March 2021.

 Constraints

The constraints of the project are:

• Physical safety of the hospital's patients and staff must be maintained throughout the life of the project by ensuring sustainable provision of healthcare services

• Meeting the Planning requirements

• Achieve completion of Clinical Commission by the end of 2026

• Leading to a fast-tracked compressed timetable

• Affordability of the project

• Lack of construction supply chain choice due to industry demands

• Political uncertainty.

 Dependencies

The dependencies of the project are:

• An adequate financing option is available and affordable

• Ensuring there are sufficient public transport options to the site for patients and staff

• Planning consent for the construction of the hospital is vital to the project

• The business case is approved by the Government of Jersey and any other relevant bodies

• Acquisition of the land required to deliver the project, through use of CPO Powers if required

 The Economic Case

 Purpose of the Economic Case

This Economic Case sets out the longlist of potential options for intervention and summarises the shortlisting exercise which was undertaken at the SOC stage using the project's Critical Success Factors. The site evaluation appraisal process was taking place in parallel with the development of the SOC, and therefore the new build option set out in the Longlist below was site agnostic at the SOC Stage.

In the OBC, the two shortlisted options from the SOC stage are assessed in more detail considering costs (both capital and revenue), benefits and risk. The case concludes with the recommendation to proceed with the preferred option.

 Work undertaken at the SOC stage and updates to the Case in this OBC

SOC Stage

During the development of the SOC, the following process was undertaken:

• A longlist of options was developed and assessed using Critical Success Factors. This identified that a New Build option was the only option that met the project's strategic objectives and was shortlisted along with a Do Minimum comparator (as required by the Green Book). This

shortlisting was approved through the HCS Executive and subsequent SOC approval process through the project governance.

• The New Build option was site agnostic at the time of shortlisting, as the process was being run in parallel to the site evaluation process.

• The site evaluation process assessed a broad range of locations, with a final recommendation of

a new build at the Overdale site. The selection of Overdale was recommended by the Political Oversight Group (POG) to the Council of Ministers (COM), who endorsed that decision and took the proposition to the States Assembly for Approval. Approval was given by the States Assembly in November 2020.

• High level analysis on cost, benefits and risk was undertaken on Overdale versus the Do Minimum Comparator and the new build at Overdale was selected as the preferred way forward.

OBC Stage

The OBC builds on the analysis undertaken at SOC stage, and in particular provides new analysis on costs, benefits and risks with a new Economic Appraisal (including NPC analysis), the key updates for which are:

• Development of the Do Minimum comparator: further work was undertaken to define and cost the Do Minimum comparator which highlighted that to continue the existing health services in Jersey, significant construction work around the HCS estate would be required, leading to increased costs. This option is referred to as the Baseline Comparator Option. A specific costed risk register for this has also been prepared by the GoJ Cost Consultant.

• Development of the New Build option (preferred way forward): A RIBA2 design has been developed with the Design & Development Partner, and RIBA3 design is now commencing, picking up feedback received on RIBA2. This has been costed by the Design & Delivery Partner and benchmarked by the GoJ Cost Consultant to assess risk and opportunities. As with the Baseline Comparator, a risk register has also been prepared and costed.

• Benefits: Additional work to identify and refine benefits has been undertaken, and particularly to start the process to quantify benefits where possible. Workshops were undertaken to qualitatively score benefits and approved through a number of sessions with the HCS Executive, the Our Hospital Citizens' Panel and the Our Hospital Health Worker's Panel.

This Executive Summary only deals with the key updates to the Economic Case which have taken place in the OBC phase and focuses on Costs, Benefits, Risks and Net Present Cost (NPC) analysis. Sections of the Economic Case which were completed at the SOC stage have not been re-presented in the Executive Summary.

 Critical Success Factor and Shortlisted Options

During the development of the OBC, a workshop was held with the Our Hospital Project team on Monday 8th February 2021 in order to review the Our Hospital Project Critical Success Factors and consider if any changes to the long-list and shortlisting process were required.

It was agreed at this meeting to remove Critical Success Factor 6 (affordability) as a Project CSF with affordability now being assessed as part of the cost analysis set out later in this Economic case.

The agreed shortlisted options from the SOC were re-confirmed and taken forward for more detailed assessment in this OBC and from this point onwards in the Economic and Financial Case the options shall be referred to as the:

• New Build Option (which had been shown at SOC stage to achieve the CSF). The New Build Option aims to provides a new general hospital for Jersey by Dec 2026 that meets both the requirements of the Functional Brief and Employer's Requirements.

• Baseline Comparator Option (which did not achieve the CSF but was selected as a comparator to comply with Green Book guidance).

This Baseline Comparator Option (which was originally named the "Do Minimum" Option in the SOC in line with Green Book terminology) seeks to provide a refurbishment of certain elements of the existing HCS estate and recognises that the condition challenges set out in the Case for Change represent significant challenges

The capital costs associated with each option is set out in more detail below.

 Site Evaluation

The SOC has already detailed the Site Evaluation Process that led to the States decision to confirm Overdale as the preferred site to deliver the Our Hospital Project.

 Functional Brief

The Our Hospital Functional Brief (version 6.1) was completed by MJ Medical in November 2020 and adopted as the core of the projects Employer's Requirements.

A discrete event simulation model was developed which estimated the flows of demand through the new hospital, taking account of peaks/troughs in demand during the course of the year.

The model utilised data from the calendar year 2019 as its baseline position, including information on demand for the Emergency Department, inpatient beds, day case trolleys, theatres and outpatient clinics. There were also a number of areas that were additionally built into the modelling such as demand for critical care, chemotherapy chairs, etc. All of the modelling was split by elective and emergency pathways and was further subdivided into medical and surgical specialties to take account of the very different pathways for each of these types of care.

The model was initially run through to 2036 on a 'do nothing' basis. In doing this, it made use of Statistics Jersey's +1,000 net migration population projections to estimate an age-adjusted growth for services over this period.

Following this, a series of interventions as identified through the Jersey Care Model programme were applied to create the 'do something' case.

The outputs of the demand and capacity modelling were used to inform the discussions on the Functional Brief for the new hospital, where additional operational adjustments were made (e.g. to take account of the fact that operationally three Resus bays will be required in the Emergency Department even though the daily demand for these bays would not directly support this).

The Functional Brief was developed with the Design and Delivery Partner as part of the Employers Requirement's to inform the design for the new hospital and included the detailed functions which needed to be included in the Our Hospital design.

 Baseline Comparator Capital Costs

The Baseline Comparator Capital costs set out in the table below have been produced by the GoJ Cost Consultant T&T based on the work undertaken to date on the Baseline Comparator Option.

The costs for the new hospital included herein benchmark in line with comparable current major UK hospital schemes, taking into consideration the applicable regulations, Jersey location factor, and abnormal aspects of the Our Hospital programme of works.

A summary of the assumptions used are set out below:

Table 1: Baseline Comparator Capital Costs

 New Build Capital Costs

As the DDP has been appointed they have supported the development of the OBC, and have provided guidance on the costs for the New Build Option including informing costs for the main works, design and professional fees, inflation, the DDP contingency, the Pre-Construction Stage Agreement (PCSA) phase, overhead and profit percentages, demolition and the decant and re-provision of services from Overdale.

Advice was sought from the DDP on preliminaries (the element of the costs related to providing general plant, site staff, facilities, site based services and other items not included in the main works costs) and the DDP provided an initial position. However the level indicated was not within the typical values expected for a project such as this, and so the current cost plan uses a preliminary allowance based on the advice of the GoJ's professional team, and benchmarked against other similar projects, with allowance made for the unique challenges of delivery in Jersey. Further work to continue to market test and review the preliminaries is scheduled to take place during the next stage.

Table 2: Total Capital Costs

 Benefits Appraisal

The benefits expected from the Our Hospital Project are set out by beneficiary in section 3.7 of the Strategic Case. In the Economic Case this is further developed by looking to quantify and evaluate the benefits by allocating them to categories and identifying the financial, economic or non-quantifiable impacts that the Our Hospital will deliver.

This assessment then forms part of the overall evaluation of the options to determine the preferred option. The Green Book splits UK benefits into the following four categories:

• Cash releasing benefits

• Monetisable non-cash releasing benefits

• Quantifiable but not monetisable benefits

• Qualitative unquantifiable benefits

For the purposes of the Our Hospital OBC, benefits to the staff, patients, the GoJ public sector as a whole and the wider benefits to Jersey society are considered.

1. Approach taken for qualitative benefits

The benefits identified for qualitative scoring were initially assessed and scored at an Our Hospital Project Team workshop on 8th February 2021. During the workshop, the following was considered and agreed:

• A confirmed long-list of benefits

• Identification of benefits which could be quantified

• A qualitative scoring methodology

• Weighting for each qualitative benefit

• Indicative scores for each qualitative benefit for both the New Build Option and the Baseline Comparator

Following the conclusion of the benefits workshop, the outcomes were subsequently tested and ultimately confirmed at:

• HCS Executive – February 2021

• Clinical and Operational Client Group (COCG) – 4th March 2021.  

• The Health Workers Panel – 13th April 2021

• The Citizens Panel – 15th April 2021  

Further details on the outcomes of this process are set out below.

2. Qualitative Benefit Scoring

As described above, each of the benefits has been scored as part of a workshop and further feedback sought from a wide range of stakeholders. The final approved scores, and corresponding rationale, for both the Baseline Comparator and Our Hospital options are:

• Baseline Comparator Option – 1.9

• New Build Option – 4.2

3. Future quantification of benefits

Currently identified benefits for quantification

All benefits have remained qualitative for the purposes of this OBC. However, extensive discussion has been undertaken and work is underway to quantify and/ or monetise a number of benefits for the New Build option and progress is described in the Economic Case. Benefits where quantification has commenced include:

Monetised benefits (cash and non-cash releasing)

• 17: Hospital facilities which attract highly skilled staff, assists in closing vacancy factor and improves existing staff retention

• 25: More efficient maintenance provision due to co-location and modern facilities

• 34: Increase private patient provision to deliver a surplus which can be reinvested into HCS services

Quantified benefits

• 3: Facilities which address the healthcare needs of all patients

• 11: Better sign-posting, easier way-finding leading to a more efficient patient experience

• 29: First class Healthcare facilities

• 20: Increased integration enabling greater efficiency across services

• 18: Improved staff wellbeing

• 31: Job creation opportunities for Islanders

• 32: Development of apprenticeships and increased training opportunities

• 34: Creation of low carbon generating facilities.

4. Benefits appraisal conclusion

The Baseline Comparator option continues to be constrained by the existing location and layout of the Jersey General Hospital and the wider HCS estate. This means that there is limited scope for the functional improvement of the hospital to meet the strategic objectives and result in low qualitative scores against the expected benefits. The limited improvements to the functional space means that the wider benefits to patients, staff and the community can also not be achieved.

In contrast, the New Build Option will deliver significant benefits to all types of beneficiaries from the GoJ public sector through to patients using the facilities. Further work will continue to quantify and/ or monetise these benefits as far as possible to demonstrate the positive impact the New Build Option will have and enable the benefits to be managed and realised.

5. Risk appraisal

To assess, and where possible, quantify the risks an OBC Project Risk Register has been produced to summarise the key project risks for the OBC stage for the New Build Option.

The OBC Project Risk Register was developed by MACE, T&T and EY to combine the GoJ allocated risks that had been identified through the project risk appraisal processes. These risks have been scored on a likelihood / impact basis and, where possible, have been quantified.

In addition, as part of the development of the Baseline Comparator Option, a GoJ Baseline Comparator Risk Register has been produced. This has been developed by MACE, T&T and EY and has been scored on a likelihood / impact basis and where possible the risks have been quantified.

Both Risk Registers were tested with OBC Project Team on 19th May 2021.

 NPC Analysis

The Net Present Cost of the capital and revenue costs for each option is set out below and indicates that New Build Option offers the lower Net Present Cost (£745.4m) compared to other the Baseline Comparator Option (£764.5m) and a significantly lower Net Present Cost per Weighted Benefit Point.

Table 3: NPC per Weighted Benefit Point

The Economic Case also sets out Sensitivity Analysis that has been carried out to provide further analysis on the findings set out in the Economic Case.

Conclusion

The Our Hospital Project New Build Option at Overdale represents an exciting and ambitious scheme which can help deliver a meaningful change to the delivery of health services in Jersey and deliver a hospital which is fit for purpose today and for the future.

The Economic Case reconfirms the New Build Option at Overdale as the Preferred Option for re- developing the healthcare estate in Jersey, for the following key reasons:

• The New Build Option is the only option that achieves the CSF

• The New Build Option is cheaper is absolute terms and NPC terms than the Baseline Comparator Option

• The New Build Option delivers greater benefits to patients, staff, HCS and the wider community

The New Build Option will deliver significantly more benefits to all stakeholders, scoring 4.2 out of 5 against the Baseline Comparator 1.9 for the weighted benefit score. Work is currently underway to quantify and/or monetise these benefits where possible, particularly around the clinical and social benefits that the hospital will bring which is expected to reinforce the case for the New Build option.

The Our Hospital Project offers an opportunity to modernise not just the healthcare facilities in Jersey, but to be a key enabler of change for the wider Jersey healthcare system. The new hospital will provide a facility which conforms to the highest standard of clinical care, both now and into the future and will be a centrepiece of which the Island can be proud.

In contrast the Baseline Comparator Option will not be able to achieve these benefits. The facilities in their current state, and even following significant refurbishment, will remain restricted by the functional layout and quality of the building structures. This prevents the current hospital ever being able to deliver any improvements to adjacencies or co-location of mental health services, thereby not meeting the expectations of patients, staff or the wider community.

The Baseline Comparator option also does not deliver a sustainable solution for the delivery of healthcare services at the existing Jersey General Hospital site – and represents a more expensive option in both absolute terms and in NPC terms due to the significant refurbishment that would be required. On top of this, the Baseline Comparator option carries substantial risk both in terms of the condition of the existing facilities and the ability to attract and retain the best possible clinical staff for the Island.

In addition, any deferral of a decision to invest in the hospital at this stage could potentially have a significant impact in the future. This is because of the expected pressure on the construction industry due to the pipeline of hospital developments in the UK and the high construction inflation rates in Jersey.

 The Financial Case

 Introduction

As detailed in the Economic Case, a Preferred Option (i.e. the New Build Option) has now been selected and this Financial Case sets out the financial implications of delivering that Preferred Option. This involves setting out the up-front Capital Cost, the whole life financing implications of those capital costs and the whole lifecycle associated with the Preferred Option.

A detailed Proposition is being developed which will be presented separately to the States Assembly for debate in September 2021 and will include approval to fund the Our Hospital Capital Costs set out within this OBC. The Proposition will outline the options that have been considered in relation to funding the Our Hospital Project. For the purposes of the Our Hospital OBC, a series of funding assumptions have been made by the GoJ Treasury, but the ultimate decision will be made by the States Assembly when the proposition is debated in September 2021.

 Our Hospital Project financial impact

Table 4: Capital costs for New Build Option

Funding has already been provided for the Design & Delivery Partner Pre-construction and Government Team Costs / land assembly for 2019 (£0.5m), 2020 (£10.6m) and up to 30 June 2021 (£20m).

For illustrative purposes only, an indicative funding example has been set out below based on an estimated bond charges and funding requirement. The final funding requirement will be agreed via the Proposition that will be debated in the States Assembly in September 2021.

Table 5 below sets out the annual revenue impact in 2027 (unindexed and indexed) of the New Build Option. The example below shows the impact of setting aside a flat bond principle repayment annually in order to ensure funds are available to meet the liabilities when they fall due.

The average annual cost of the bond interest is £19.3m p.a. over a 30-year (Bond A) and 40-year (Bond B) tenor, at which point the bond would need to be either repaid or refinanced. The payment of the annual bond coupon is a new cost to Government and a funding source will need to be identified

The additional spend for Year 1 of the new hospital is detailed in the table below. Indexation is applied at the Jersey standard inflation rate of 3% in the Indexed column:

Table 5: Year 1 Annual Revenue Cost (2027) for New Build Option

 Affordability

The financial analysis currently performed on the New Build Option shows the revenue impact of the financing charges, lifecycle and shuttle bus costs. The impact of Facilities Management and Utilities along with potential clinical, operational and financial benefits is excluded for the analysis set out above. Work on benefits will continue during FBC stage.

Based on the information set out above, the GoJ will need to fund on-going financing, lifecycle and shuttle bus costs.

The decision to fund the on-going revenue costs associated with the scheme will be made by the GoJ and therefore the scheme will be affordable if the GoJ agrees to fund it.

 The Commercial Case

 Introduction

The Commercial Case presented in the SOC provided detail on the procurement strategy and process which led to the appointment for the pre-construction stage of the ROK FCC Joint Venture "ROK / FCC JV" as the Design and Delivery Partner "DDP". These sections are not summarised in this Executive Summary but are updated for the OBC.

In addition to this, a number of commercial opportunities and land transactions associated with the proposed new hospital are described in the OBC.

This commercial case also sets out the key design work undertaken to date by the DDP.

 Form of contract

As was set out at SOC Stage the form of contract utilised is the NEC3 Option suite of Standard Forms of Contract, an industry and market accepted suite of contracts and agreed to be best suited to the project.

 Current Status of DDP Contract

The ROK/FCC Pre Construction Services Agreement ("PCSA") Contract was signed on the 23rd July 2020. The PCSA contract is now expected to run until c. mid-2022. Following satisfactory completion of the PCSA stage the arrangement enables the project to proceed through entering into NEC3 Option C Target Cost Contract with the DDP. The target cost within that contract would be subject to a pain/gain share between the DDP and the GoJ.

 DDP Supply Chain Procurement Strategy (Stage 2 Procurement)

The SOC sets out the principle of adopting a two stage procurement approach to drive greater value for money in the tendering of construction packages. Whilst this strategy leads to the DDP being responsible for tendering the works packages, in line with the strategy below, the GoJ will need to pre-approve the letting of each package and also approve the appointment of the successful bidder following a robust tender evaluation.

The OBC has been updated to summarise the DDP strategy for this procurement which has now been developed to set out plans for the procurement of their supply chain.  This DDP Supply Chain Procurement Strategy sets out the plan to deliver the GoJ objectives with the intended outcome of delivering best value for the OH Project and the GoJ. The overarching strategy is to achieve maximum value by promoting a high-performance, collaborative culture throughout the supply chain, which underpins resilient delivery, mitigates risk and maximises the impact of the supply chain in legacy activities

This strategy will evolve as the project develops and progresses and further revisions of the strategy will be issued to reflect this.

 Land transactions associated with the project

Various land and buildings close to, or adjacent to the Overdale site were identified as necessary to enable the Our Hospital Scheme.

At the time of this OBC, a number of sites/properties have already been successfully purchased by the GoJ, with a number of others still being negotiated. The current total estimated costs of the sites / properties is £34.3m (this includes sites that have already been purchased and those still in negotiation, and includes costs associated with CPO should this be required).

 Build Scheme information

The RIBA Stage 2 Concept Design Report ("RIBA 2 Report") for the Our Hospital Project was completed and shared by the DDP in May 2021. The purpose of the Stage 2 report was to "prepare outline proposals which reflect a series of relevant project and design strategies and establish the clear direction and content of the project". Work has now commenced on the RIBA Stage 3 Developed Design, incorporating feedback on the RIBA 2 report to develop a design which will enable the scheme to be submitted as a Full Planning Application in late 2021.

 The Management Case

 Introduction

This section of the OBC addresses the achievability' of the preferred way forward. The Management Case sets out the reporting structure, management arrangements and details of the delivery teams in place to deliver the programme.

The Management Case section of this OBC has been produced in line with UK HM Treasury Green Book Guidance and also the principles of PRINCE2.

The Management Case at SOC stage already covered the key areas outlined below due to the stage of development of the programme:

• An overarching project management approach, including stakeholder and change management

• The outline programme timeline and milestones

• Summarised approach to risk and benefit management, including contingency plans and post- project evaluation

To reflect the progress made in the programme to OBC, the following additional information or updates have been made to the Management Case:

• The project plan has been updated to reflect the information on the construction programme prepared as part of the RIBA 2 design process

• Project management approach has been updated to reflect the latest Project Manual

• Costs have been updated to reflect the latest cost information

Other sections of the Management Case have been reviewed and updated where required but remain substantively the same as those in the SOC and are included for reference.

3. THE STRATEGIC CASE  Introduction

 Purpose of the Strategic Case

The Strategic Case sets out the background to the delivery of healthcare services in Jersey and then details the reasons that an intervention is required in the Case for Change.

 Work undertaken at the SOC Stage and updates to the Case in this OBC

SOC Stage

During the development of the SOC, the following was detailed in the Strategic Case:

• An overview of the Jersey Healthcare System including the current model of care, acute services, children's services, complex off-island care, ambulance and mental health

• The structure of Health and Community Services (HCS)

• Healthcare policy, system transformation and proposed future model of care

• Overview of the existing estate and the issues associated with it (e.g. physical condition of buildings, lack of co-location)

• The Case for Change (e.g. poor condition of estate, limited options to redevelop)

• Project Investment Objectives and Critical Success Factors

• Long-list of Benefits

• Constraints and Dependencies.

OBC Stage

As outlined above, the Strategic Case was substantively complete at the SOC Stage and therefore the only changes made related to either new information becoming available or re-testing of previous assumptions. The key updates that were made are outlined below:

• A workshop was held with the Our Hospital Project team on Monday 8th February 2021 in order to review the Our Hospital Project Investment Objectives and long-list of Benefits. This resulted in some updates to both which are presented in the relevant section of this OBC.

• The benefits agreed above were then assessed using SMART (Specific, Measurable, Actionable, Relevant, Time-based)

Other sections of the Strategic Case have been reviewed and updated where required but remain substantively the same as with the SOC and are included for reference.

 System and Organisational Overview

 Overview of the Island's Healthcare System

Healthcare delivery

The Health and Community Services Department (HCS) is the principal provider of health care in Jersey. It operates in the context of a wider primary care system. Primary care is provided by independent GPs, dentists, pharmacists and optometrists, a comprehensive network of voluntary and community organisations and independent provision to support health and social care. Acute secondary care is delivered through the islands General Hospital, located in St Helier and mental health inpatient services in Orchard House.

Jersey has 14 general practices, which are used for first stage diagnosis and treatment, as well as a referral function to secondary care. General practice operates under a co-pay system, with the Government of Jersey paying a top-up to supplement the private cost of visiting a GP. The cost is on a payment for service basis, with each face to face appointment attracting a fee. Analysis suggests that private primary care is a contributory factor linked to disproportionately high attendance levels at the hospital for both emergency treatment and follow up appointments.

HCS delivers a broad range of key functions covering the operational delivery and governance expected within any modern, comprehensive healthcare system. HCS is a significant employer on the island, with a workforce establishment of circa 2,400 whole time equivalent (WTE) staff and a budget of £239m (revenue) and £9m (capital) in 2020.

Specialist tertiary level services are provided at off-island locations, typically across the UK. Arrangements for the care of these patients is managed by the General Hospital.

The Island has an active private healthcare sector which operates both within the hospital and at other independent locations on the island. There is significant scope to expand on the current private practice offer, given the level of underutilised private insurance many islanders hold.

The current model of care is summarised in the diagram below, which shows the hospital in the centre of care.

Figure 2: Current model of care

Health and wellbeing

In 2019, almost three-quarters of adults in Jersey (73%) described their health as good or very good. This proportion is down from 81% in 2018. The percentage describing their health as good, bad and very bad was fairly constant over all age groups. Those describing their health as very good decreased with age, with a corresponding increase in those who described their health as fair.

In 2019 25% of Jersey adults reported having a longstanding physical or mental health condition. In 2018 the median age of death for Jersey residents was 81 (female 83, male 78).

Statistics Jersey's Life Expectancy report says that between 2016 and 2018 the average life expectancy for new-born Jersey females was 84.6 years, while for males it was 80.8 years.

By comparison English women can expect to live for 83.2 years, while for men the life expectancy is 79.6 years. Figures for 65-year-old Islanders indicate that men who have reached that age can expect to live for a further 19.4 years, on average, and women will on average have an extra 21.8 years of life.

Morbidity and disability  

Neoplasms (cancers) remain the most frequent cause of death, accounting for almost one in three (30%) of all deaths (2018 data). On average, there are 977 malignant cancers diagnosed each year in Jersey (2010-2014). Non- melanoma skin cancer (NMSC) accounts for around 39% of the annual mean count, with the three most commonly registered cancers after NMSC being prostate, breast and lung cancer. The age-standardised rate for head and neck cancer, hepatobiliary cancer, lung cancer, malignant melanoma, prostate cancer and paediatric cancers in Jersey was higher than in the South West of England and England as a whole. However, death rates are largely similar to those in England.

It is estimated approximately 13% of the population suffer from hypertension compared to 20% in the UK. Obesity levels in Jersey at 17% are lower than the estimated 29% of UK population.

In 2019 a quarter (25%) of all adults reported having a longstanding physical or mental health condition: similar to 2018 (27%), while 47% said that their life was limited a little by their health and 19% said their life was limited a lot. The proportion of adults that reported a longstanding health condition increased with age.

Around 8% of the island population have two or more conditions. This increases to more than half of the population over 60.

In 2015, the States of Jersey Social Policy Unit commissioned a survey of households to establish the prevalence of disability in Jersey. The survey found 14 per cent of all residents living in private households (around 13,900 residents) had a disability as defined by the UK Equality Act 2010 (this is that they have a physical or mental condition or illness lasting or expected to last 12 months or more which impacts on their ability to carry out day to day activities a little or a lot).

Mental health

Islanders report an average mental wellbeing score on the short Warwick-Edinburgh scale as 26 – in line with the rest of the UK. However, 27% of Islanders have high levels of anxiety; 21% are lonely often or some of the time; and 49% of working Islanders say they spend too much time at work – a figure which has steadily risen from 37% in 2013. 71% of working adults say they spend too little time on hobbies and interests, and more than half say they spend too little time with their families.

The number of attendances presenting to the Emergency Department (ED) with a mental health problem has been rising, with a rate of 873 attendances per 100,000 population in 2019, the highest rate since 2013. 22% of these attendances involved deliberate self-harm and over the last three years, the ED has dealt with an average of 204 self-harm cases a year.

Existing ED activity analysis conducted for the Jersey Care Model (JCM) review shows that 2.4% of ED activity (960 attendances in 2018) may be due to mental health. These include activities associated with attempted suicide, deliberate self-harm, or referred to psychiatric liaison team.

Of these:

• 41.6% of mental health related attendances were discharged home

• 22.1% were referred to Psychiatric Liaison Team

• 7.3% were transferred to Orchard House

Infant and child health

In 2019 the crude birth rate was 8.89 live births per 1,000 population, which is a decline from previous years. Over the three-year period 2015-2017, the infant mortality rate for Jersey was 1.0 per 1,000 live births. This is lower than the 3.9 per 1,000 seen in England during the same timeframe. In 2018 there were 2,771 children under the age of 13 seen at the Emergency Department following an accidental injury.

The Jersey School Survey (2018) reveals that 51% of respondents aged 12-13, 24% of respondents aged 14-15 and 8% of respondents aged 16-17 had never drunk alcohol. Over the three-year period 2016- 2018, there were 55 admissions to hospital of under 18-year olds with a primary or secondary diagnosis for an alcohol-specific condition. During the same three-year period the alcohol-specific hospital admissions for children under 18 years per 10,000 children was 9.10.

The Jersey School Survey (2018) also shows that 81% of respondents aged 12-13, 67% of respondents aged 14-15 and 48% of respondents aged 16-17 had never smoked. The survey also found one in ten (11%) of children reported someone smoking in their home, and one in twenty (5%) reported someone smoking in their car, at least occasionally. The Jersey School Survey (2018) also revealed 2% of respondents aged 12-13, 15% of respondents aged 14-15 and 28% of respondents aged 16-17 had ever taken a drug.

During the 2018/2019 academic year one in five (21%) 4-5 years olds were overweight or obese, compared to around one in three children aged 10 to 11 (30%). The 2018 Jersey School Survey found that 18% of surveyed children and young people (Years 6, 8, 10 and 12) reported meeting the recommended level of physical activity. Older respondents were found to be less physically active. This was also higher in males (20%) than females (16%).

Lifestyle

In 2015, 12% of adults smoked daily, compared with 19% in 2005. The latest Jersey Annual Social Survey to look at alcohol use in Jersey (2018) showed that 10% of respondents reported never drinking alcohol but of those who drank around a quarter (23%) were found to be drinking at hazardous or harmful levels. The last time children and young people were asked about alcohol (2018 school survey) showed the proportion of pupils who had drunk alcohol in the 7 days prior has reduced for all year groups since 2006, from 40% of Year 10s and 21% of Year 8s in 2006 to 24% of Year 10s and 5% of Year 8s in 2018

Alcohol played a role in 14% of all crimes recorded in Jersey in 2018. Of specific types of crime:

• One-in-four assaults and more than  one-in-three serious assaults were recorded by police as involving alcohol.

• Two-fifths of domestic assaults involved alcohol.

• Two-fifths of assaults and half of the serious assaults in the St Helier night-time economy involved alcohol.

The population has relatively low levels of ethnic diversity. 46.4% of individuals identify as White Jersey' and 32.7% identify as White British'. 8.2% of residents were born in Portugal/Madeira. 3.3% of residents are Polish whilst 7.1% of residents are Irish, French and Other White compared with 19% in 2005 (2013 – UK 19%).

 Population and Demand

Population and demand assumptions have been used to help inform the functional brief for the proposed Our Hospital. This is set out in more detail in section 4.6 (Functional Brief) of the Economic Case.

 Structure of HCS

HCS has a mandate to provide safe, sustainable, affordable and integrated services which enable Islanders to live longer, healthier and productive lives.  

The Government structure for the overall Jersey Health and Care system is built around five groups with four cross cutting services as outlined in Figure 3 below.

Figure 3: Jersey Health and Community Services Care Model Structure

The HCS groups and services include:

• Prevention, Primary and Intermediate Care: Within this care group HCS supports the care co- ordination, primary care governance and operational oversight and partnership working with Primary and Community Care providers.

• Women, Children and Family Care: This care group provides services throughout the Hospital and Community that relate to Women, Children and Families. These include functions such as maternity, gynaecology,  assistive  reproduction  and  the  special  care  baby  unit.  This  Care  Group  provides leadership in partnership work with the Department of Children, Young People, Education and Skills around Child and Adolescent Mental Health services.

• Secondary Scheduled & Tertiary Care: Relates to many of the specialist hospital functions covering inpatient wards, acute medicine and surgical services. This Care Group leads on partnership with wider Government colleagues in Justice and Home Affairs who lead the Ambulance Service, a critical part of the unscheduled care pathway.

• Tertiary Care: This is the function that facilitates and enables off island care in emergency and planned circumstances. The majority of tertiary care services are provided by NHS hospitals within the UK.

• Secondary  Unscheduled  Care:  Supports  emergency  care  services  covering  the  Accident  and Emergency  Department  and  Emergency  Assessment  Unit  at  the  hospital.  As  noted  above,  the Secondary Scheduled & Tertiary Care Group also forms a critical part of the unscheduled care pathway.

• Social Care: Is the function that commissions personal care and co-ordination which is led by the Social Worker profession. This service has oversight of Learning Disability services and works in close conjunction with the Mental Health Care Group.

• Mental Health: Covers HCS's inpatient units and community facing services including functions like Jersey Talking Therapies and Drug and Alcohol services.

• Quality and Safety: Overarching over all of the Care Group functions is the Quality and Safety Care Group which incorporates the offices of the Chief Nurse and Group Medical Director. This care group ensures services are delivered to the required professional and quality standards with the appropriate level of oversight and assurance. Infection prevention and control is also part of this Care Group.

• Clinical Support Services and Cancer: Brings together all of the diagnostic functions such as pathology and radiology as well as important support functions like pharmacy. This care group is responsible for servicing all of HCS's Care Group functions and objectives and also develops the Cancer Strategy for the Island.

• Non-Clinical Support Services: Includes all of the estate, facilities and non-patient facing services such as administrative services.

These are further illustrated in the in the figure below.

Figure 4: Jersey Health and Community Services Care Group Structures

Within the HCS Care Groups, the organisation aligns its people and resources to the service requirements. Each of these groups:

• has direct accountability for delivering a group of related services.

• is clinically and professionally led.

• is required to work collaboratively with other groups for the benefit of the whole system.

In addition to the Care Group structures, HCS also has an Improvement portfolio which drives the strategic change programme. The oversight and delivery of digital change projects sits within the central Modernisation & Digital Directorate which is part of the Chief Operating Office of the Government of Jersey.

The key objective as a department is to drive the integration of Health and Community services, enabling continuity of care for patients and clients to the required care standard.

This structure is further illustrated in the in the figure below.

Figure 5: Jersey Health and Community Services Governance Structure

 Complex care – off island services

For reasons of scale, where volumes are too low to provide a safe and sustainable service, tertiary care is delivered off Island, in the UK. Currently the majority of services provided off Island are low volume, high cost specialities or sub-specialities.

In 2019, 2,478 patients received 5,938 treatments from UK healthcare providers at a cost of £13m. In addition, there were 301 Jersey Emergency Transport Service Charter Flights. The size of this, virtual capacity' i.e. in-patient beds, operating theatre sessions, workforce and some out-patient and ambulatory capacity not physically provided on Island in the current and future General Hospital reflects a clinical choice, where patient safety and clinical outcomes determine the number and types of patients who receive treatment off-island.  

It should be noted that the above relates strictly to acute and general hospital activity. Mental health is commissioned on the basis of individual patient need as required.

In the future, the number and relative proportion of Islanders needing care off Island may potentially increase, with a consequent growth in the cost and clinical risk in providing tertiary and emergency treatment in this way. Alternative strategies may help to mitigate this growth, but the impact is anticipated to be limited. For example, current General Hospital patients benefit from specialist skills provided by visiting Consultants. This approach is only effective if the conditions of such patients allow them to be batched' e.g. types of surgery. It does not provide a solution for Islanders requiring emergency or complex acute medical care.

Referrals for complex care are based on the patient need basis. 80% of all off island activity is sent to 10 UK hospitals (listed below); the other 20% is made up by a further 80 hospitals.

Table 6: Acute Care Providers

 Digital transformation

Digital Background

Digital Delivery of the health digital programme and strategy sits with the central Modernisation and Digital Directorate which is part of the Chief Operating Officer (COO). The clinical lead is the Clinical Chief Information Officer (CCIO) who sits within HCS.

The wider underpinning programme for digital infrastructure is also led across Government by the Chief Operating Officer (COO). The programme and funding included in the government plan for 2021-2024 includes Cyber security, Microsoft upgrades and infrastructure. As such, the Our Hospital Project will provide the backbone for the delivery of the Digital Strategy with the new hospital and not the programme itself.

Digital strategy for health and care in Jersey

The Digital Strategy for Health and Care in Jersey set out the broad ambitions and approach to digitising' the whole health and care system so that the benefits of digital technologies can in turn deliver benefits to patients, service-users and care professionals alike.

The vision is: "Jersey is a digitally integrated' health and care system that uses technology to deliver accessible, joined-up, person-centred care that is safe, effective and efficient, where data is used intelligently to improve every aspect of care, and where innovation flourishes".

In order to achieve this vision, Jersey will put in place a number of key technical and operational components over the next five-ten years:

• Ensuring that each part of the health and care has a core patient / service user records-keeping and administration system in place, which meets basic maturity' levels and supports open standards.

• Implementing a universal identifier for all persons, based around the "People Directory", and integrating that into electronic systems, interfaces and interchanges between all parts of the health and care landscape.

• Implementing a Jersey Care Record; a universal online record of individuals' interactions with health and care organisations, and a hub' for implementing cross-sector business logic' such as safety alerting', all accessible through a single public-facing portal.

• Creating electronic care plans, closely coupled with Jersey Care Record, so that all care professionals, and patients/service-users have access to that information, wherever they are

• Supporting pathways of care, in combination with online digital care records, electronic care plans, and intelligent use of data to monitor compliance.

• Facilitating much more effective care professional to care professional communication with technology

• Creating a repository of health and care data and using a combination of human and machine driven analysis, improve how care is planned, delivered and managed.

• Developing the digital competence of care professionals and islanders, so that they can exploit digital technologies effectively.

• Create an infrastructure and environment that promotes health and care research, development and innovation.

The digitalisation of health and care services in Jersey is intended to address a broad range of issues relating to the provision of a digitally enabled and fully integrated health and care system in Jersey. These can be categorised as:

1. Unplanned care – for the ambulance service or the hospital emergency department there is no way of accessing a patient's primary care clinical record other than asking the patient (assuming this is within their capacity). Lack of such information may result in defensive care, less appropriate treatment and possible medication issues.
2. Care planning – as people live longer, potentially with multiple co-morbidities the need for sharing care plans with the patient and those health and care professionals looking after them is becoming more and more important, such plans might include:
   1. Patient preferences e.g. do not resuscitate, preferred place of care, patient aware of diagnosis, next of kin
   2. Individual care plans e.g. target ranges for clinical indicators such HbA1c
   3. Multi-Disciplinary Team (MDT) joint decisions regarding patient care pathways
3. Shared care – for patients receiving treatment from multiple healthcare providers there is a need to ensure that the overall treatment given is effectively joined up, an example might be a diabetes patient being treated and reviewed by their GP, receiving specialist care from the Diabetes Centre, annual retinal screening from an optician and contributing themselves through a personal health record.
4. Safeguarding – where safeguarding concerns are raised either through a health & care provider or in the community there is a need to ensure that this information can be coordinated, accessed and reviewed where needed.
5. Health data analysis –a need to use data available from all health & care providers to support:

1. Health resource planning
2. Risk stratification
3. Decision making
4. Improvement of healthcare programmes (population management)
5. Improve quality, performance & workflow

6. Integrated Care Records – the need to integrate, access and share patient clinical data such as allergies, medication and co-morbidities is vital in the provision of a high quality health service, for a prescriber this means having access to all relevant patient data that might impact the choice of drug, e.g. a severe allergic reaction to penicillin informing choice of antibiotic, or a drug being given to treat a current condition taken into consideration when treating a newly diagnosed co-morbidity.

 Learning and Development

The current estate has limited ability to provide best practice learning and development facilities in a location that enables staff to access them easily during the working day. The estate does provide some space for training, but the location and type of spaces do not support modern healthcare learning and development needs.

The ability for Jersey to provide a strong learning and development offer to staff during their training, and through the development of their careers, is critical for staff attraction, retention and development, and to develop links with training hospitals and universities outside the UK.

The Clinical Development & Training team organise and deliver mandatory clinical training, annual major incident and specialist training for all staff. The team also provide training courses to outside organisations and work closely with the Nurse Education Centre and Resuscitation Officer, ensuring clinical training remains a key priority for clinical staff.

 Ambulance Services

The Ambulance Service provides high-level pre-hospital care to the Island of Jersey 24 hours per day. These services can be split into the following six categories:

• Frontline Operations

• Communications

• Patient Transportation

• Partnerships and Voluntary Services

• Clinical Development and Training

• Fleet and Technical Services

The frontline operations are responsible for the day-to-day running of the Ambulance Service and respond to 999 emergency and urgent care calls from General Practitioners/Health clinicians.

Communication for the Ambulance service is provided by the Combined Control Centre (CCC). The CCC answers 999 calls for both the Emergency Ambulance and Fire and Rescue Services, process and coordinate non-emergency calls and monitor the Occupational Therapy department's Community Alarm Service (CAS).

Patient Transport Services (PTS) operate Monday to Friday for patients to and from hospital outpatient appointments, inter-hospital transfers and day centres. Patient Transportation also includes an intermediary crew who provide a link between the Frontline Operations and PTS, acting as first responders for emergencies when frontline crews are all dispatched to calls.

Several volunteer groups support the Ambulance Service. The Partnership and Voluntary Services include Co-Responders, Community First Responders, an Ambulance Support Unit and Voluntary Care Service.

The Fleet and Technical Services (FTS) team provide services and support to the Frontline/ Patient Transport Services (PTS) Departments, Health Supply/Maintenance teams as well as the greater health community.

The Ambulance Service's Vision is to provide the right care at the right time to ensure those with the most life-threatening problems receive the most urgent and clinically appropriate response.

Through their 70 full-time and part-time staff, the services stated aims are:

• Provide the highest standard of care and compassion to those in need of our Services in the community we serve

• Provide more collaboration and improve the emergency response to the public

• Maintain strong links within Health and Community Services due to the nature of the work undertaken by the Ambulance Service

• Keep patients at the heart of our thinking and service delivery.

 Policy review

Policy overview

The Government of Jersey has set out its vision for Health and Community Services; to create a healthy island with safe, high quality, outcome focussed, affordable care that is accessible when and where our service users need it.

Implicit in this vision is the need to move towards a new care model if we are to provide sustainable and high-quality services for Islanders. Traditionally, health and care in Jersey has relied on a secondary care focused model, which has contributed to centralised, institutional based care, with cumbersome discharge routes back into the community and limited access to reablement. In order to deliver patient focussed, outcome-based care, there is a need to implement a model which allows for a more holistic view of health and care, and to develop a stronger model for out of hospital care services; which will compliment essential in-hospital services.

Through the Common Strategy Policy 2018 to 2022, the Government of Jersey has committed to providing affordable, efficient and cost-effective public services which meet the standards that Islanders expect, and the proposals for Health and Care in Jersey aligns with the five strategic priorities:

• We will put children first

• We will improve Islanders' wellbeing and mental and physical health

• We will create a sustainable, vibrant economy and skilled local workforce for the future

• We will reduce income inequality and improve the standard of living

• We will protect and value our environment

As is explained further in other sections of this Business Case, the new Jersey Care Model (JCM) has an ambition to improve Islanders' wellbeing and mental and physical health, and to enable islanders to enjoy long, healthy and active lives. Our Hospital is a key part in supporting citizens with a need for acute and emergency care that cannot be provided within other care settings of the health economy.

Policy Journey

In 2011, the Jersey Health and Social Services published the Green Paper Caring for each other, Caring for Ourselves'. This set out a thirty-year vision and a ten-year plan for health and care services in the Island, including a vision for how health and care services would be modernised and expanded in the community to deliver more round-the-clock care with a view to reducing admissions. It set out a desire to move towards a less medicalised, paternalistic approach to care and mirrored aspirations elsewhere in the world to better integrate services to provide a more joined up approach. The Green Paper also acknowledged the need for a new hospital, and within this context, for the new care model to facilitate a shift to a more community focused model of care at the point at which a new hospital was built.

In 2012, this was developed into a White Paper which set out a ten-year vision in more detail. Consultation on the White Paper highlighted concerns around access to primary care, and in particular the barriers that the current co-payment presented for children and those on low incomes to accessing care.

Following the publication of the White Paper, the States of Jersey published Health and Social Services: A New Way Forward (P.82/2012). This set out a stark imperative for change in the way services are delivered in order to be sustainable and avoid service closures and rationing going forward.

The White Paper set the foundation for the strategic direction of health and social care on the Island. It then signposted business area-specific strategies being created under the main P.82 umbrella: Acute Service Strategy 2015-2024 (2016), A Mental Health Strategy for Jersey 2016-2020 (2015), A Sustainable Primary Care Strategy for Jersey 2015-16 (2016), HSSD Informatics Strategy 2013-2018 (2013), and the Digital Health and Care Strategy (2017).

In 2020, the Government of Jersey published Departmental Operational Business Plans, including HCS. The vision to enable Islanders to live longer, healthier and more productive lives by ensuring the provision of safe, sustainable, affordable and integrated services that are delivered in partnership with others was restated, along with five key objectives:

• Redesign of the health and social care system to deliver safe, sustainable and affordable health and community services

• Improved health outcomes by reducing the incidence of mortality, disease and injury in the population

• Improved consumer experience of Health and Community Services

• Promotion of an open culture based on good clinical and corporate governance with a clear emphasis on safety

• Manage the Health and Community Services budget to deliver services in accordance with the Medium-Term Financial Plan, Government Plan and our aligned efficiency programme.

In March 2020, the Government of Jersey published A Health and Wellbeing Framework for Jersey, which provides further detail on how critical prevention and early intervention actions will be driven forward.

.

Policy/Publications reviewed:

• Imagine Jersey 2035 (2008)

• Island Plan 2011

• St Helier Development and Regeneration Strategy (2008)

• Strategic Plan 2015-2018 (2015)

• P.82/2012 Health and Social Services: A New Way Forward and its amendment

• The States of Jersey Hospital Pre-Feasibility Spatial Assessment Brief (2013)

• Acute Service Strategy 2015-2024 (2016)

• Health and Social Services Department Business Plan (2017)

• A Mental Health Strategy for Jersey 2016-2020 (2015)

• Out of Hospital and Long-Term Conditions OBC 2016

• A Sustainable Primary Care Strategy for Jersey 2015-16 (2016)

• Jersey Carers' Strategy (2017)

• HSSD Informatics Strategy 2013-2018 (2013)

• Disability Strategy for Jersey (2017)

• Future Jersey 2017-2037 (2017)

• Digital Health and Care Strategy (2017)

• One Health and Community Services (2018)

• Common Strategic Policy 2018 to 2022

• Health and Wellbeing Framework for Jersey (2020)

 Health and care system transformation

As with any healthcare system, there is a need for continuous review and improvement of how services are being delivered in a streamlined and effective way and the existing structures that support service delivery, ensuring they are both future proofed and able to respond to changing population needs and medical and technological advances.

Current state

Assessment has been undertaken on the current provision of health and social care services within Jersey and the following challenges have been identified:

Secondary Care Focused Model

• The Hospital is the centre of care for the island, with the system heavily reliant on bedded capacity, particularly for older demographic care

• There is a relatively high rate of low acuity ED attendances which could be more appropriately treated elsewhere

• The theatre suites are underutilised, both in terms of scheduling and volume of day case activity

• Long length of stay in rehabilitation beds and a high flow rate into Long Term Care (residential)

• Outpatient new to follow up ratio is high in comparison with benchmarks.

Intermediate and Ambulatory Care

• Rapid response services are not optimised and reablement services are limited

• There is a lack of positive risk taking in the current service configuration

• The current teams are not configured to manage higher risk patients due to lack of 24/7 cover and skills mix

• Jersey runs a hospital led model where patients are brought into hospital as the default option

• Lack of 24/7 Community Nursing means that there is no nursing cover to support people at home overnight, resulting in admission to hospital being the default option

• Mental Health Crisis prevention service requires development to support increased demand. Prevention, Primary, Community

• There are limitations in the services offered due to the funding and payment framework

• The payment model does not incentivise self-care, collaboration or innovation

• Deskilled workforce in primary care due to secondary care focused model

• Long term condition management is typically run in secondary care, e.g. Diabetes

• Lack of standardised approach to how conditions are managed across care settings

Mental Health

• Mental health services are not integrated with physical health services and people are often kept in hospital longer than they should, because ongoing care at home is not provided

• Unscheduled Mental Health care within the Emergency Department is interdependent on the mental health service availability

• There is a lack of community specialist resource to facilitate timely discharge from acute settings

• There is a recruitment challenge for key skilled roles such as Registered Mental Health Nurses, Medical Staff and Allied Health Professionals

• The current Mental Health Estate doesn't provide a therapeutic environment of care

• There is a lack specialist resource to provide mental health care co-ordination. However there are good relations with external partners which supports the local provision

Community Care

• 24/7 community nursing not in place

• Services are not optimally commissioned and managed

• Social Care model is over-reliant on high cost / dependency residential care

• Limited options for Long Term Care other than residential care

• Community mental health offering over-subscribed and needs development.

Direct access services

• Primary care services such as Pharmacy, Dental and Ophthalmology are not optimised

• Funding mechanisms not in place to encourage extended service provision

• Most services are accessed / paid for directly by the public, e.g. Dental and Ophthalmology

• Technology and information sharing are sometimes a barrier to joined up service provision.

Social Care and External Partners

• Jersey has a very strong voluntary sector and social care market, but it could be better coordinated and is difficult to navigate, especially in times of crisis

• Over £80m is raised annually, one-in-eight adults on the island are volunteering.

• £18m  commissioned  services  and  approved  providers,  although  not  through  coordinated commissioning

• Duplication of services and back office functions

• Lack of understanding and signposting of all services

• Carers are not adequately supported by the current system as many are supported by the voluntary sector and Parishes.

Proposed future model of care

Taking into consideration the outcome of the review of the current state, and building on HCS's ambition (aligned to the Government of Jersey's strategic priority (Common Strategic Policy 2019)) to improve islanders' wellbeing and mental and physical health, HCS have developed their vision for the future of health and community services across Jersey in the Jersey Care Model (JCM).  

The aim of for the JCM is to create a healthy Island with safe, high-quality, outcome-focused, affordable care that is accessible when and where service users need it. It will put Islanders at the heart of care. This will start with better self and preventative care, supported by a range of community health services. The hospital will continue to provide both critical services and specialist care.

The JCM was reviewed and stress tested by PwC ( Price Waterhouse Coopers) (completed May 2020). The outcome of the review was considered by the HCS team and further refined to take into account the impact of the COVID-19 pandemic. Outputs have been presented to the Council of Ministers and it has subsequently been approved following debate in States Assembly in Q4 2020. The revised model has also been independently reviewed and tested by the Health Scrutiny Committee, supported by their advisors.

Demographic modelling, undertaken by PWC, has determined the physical capacity required for a new hospital based on demographic changes up to 2036. Alongside this, PWC have calculated the impact that the operational improvements (detailed in the JCM) to bring Jersey in line with first class healthcare systems will have on the capacity required. The model utilised data from the calendar year 2019 as its baseline position, including information on demand for the Emergency Department, inpatient beds, day case trolleys, theatres and outpatient clinics. There were also a number of areas that were additionally built into the modelling such as demand for critical care, chemotherapy chairs, etc. All of the modelling was split by elective and emergency pathways and was further subdivided into medical and surgical specialties to take account of the very different pathways for each of these types of care.

The model was initially run through to 2036 on a 'do nothing' basis. In doing this, it made use of Statistics Jersey's +1,000 net migration population projections to estimate an age-adjusted growth for services over this period. Following this, a series of interventions as identified through the Jersey Care Model programme were applied to create the 'do something' case. A summary of the Do Nothing / Do Something Cases is:

1. Do Nothing: healthcare services continue in line with the existing operating model.
2. Do Something: based upon the adoption and implementation of a healthcare transformation programme such as the Jersey Care Model and involving Jersey specific pathway and process improvements to bring healthcare in line with best practice standards e.g.:

• length of stay reductions

• introduction of admission avoidance schemes

• enhanced intermediate care offer

• increased day surgery rates

• adoption of emerging healthcare improvement opportunities (e.g. digital advances)  

The Do Something model was approved on the basis that transformation and modernisation is custom practice globally across health care systems. The programme in Jersey will be supported through the delivery of the Jersey Care Model and other schemes that develop in line with wider health economy and Government of Jersey quality and service improvement programmes.

The outputs of the demand and capacity modelling were used to inform the discussions on the Draft Functional Brief for the new hospital, where additional operational adjustments were made (i.e. to take account of the fact that operationally three Resus bays will be required in the Emergency Department even though the daily demand for these bays would not directly support this).

 Existing Hospital Estate Overview

 History of the site

Jersey General Hospital is a significant 40,032m² facility located in the heart of St Helier and operates as the only acute and general hospital facility on the island. It is located on a heavily developed town centre site of some 1.85 hectares with blocks extending up to eight storeys high.

Most of the current clinical facilities date from the 1960s, but with the granite block dating back to 1765, and as a result exhibits serious levels of dilapidation. Significant elements of building structure and engineering services are now beyond their useful economic life and will need to be replaced in the near future .

In response to concerns over the extent of dilapidation and functional obsolescence, and to ensure that it adopted a responsible approach to premises management, HCS commissioned a specialist report in 2015 that considered the extent of deficiency against current UK NHS premises standards. It considered the use, condition and compliance of the facilities against the following six key aspects.

Table 7: Six Facet Survey

An update to this review was undertaken for a second time in 2019 and the findings of this updated six- facet survey are set out below. The survey confirmed the following:

• With the exception of some refurbished areas, the majority of the hospital's external fabric and engineering services have exceeded design life and are considered to meet classification category C, which is below satisfactory standard and needing major replacements within 1 year for engineering elements.

• Although major refurbishment of some areas, such as operating theatres has been undertaken in the last three years, the building footprint is still significantly below the size and configuration that meet the functional requirements of modern operating theatre standards.

• Some aspects of statutory deficiency are difficult to address due the physical construction of the buildings or where only reconstruction would address the issues.

• Many areas of the hospital exhibit poor functional suitability and are classified as below that which would be considered as unacceptable against UK NHS standards (D).

• Due to their age, many of the operational spaces do not meet current Health Building Notes (HBN) standards, restricting both the effectiveness and safety and have poor positional relationships with other functions within the hospital.

• Some building areas are of poor quality in terms of their effectiveness as working environments and as spaces for modern healthcare;

• Spaces are cramped and wouldn't achieve common healthcare standards such as the HBN standards used in the UK

• There is a general absence of rooms dedicated to confidential conversations with staff, patients and carers and between staff members.

• Cramped and inflexible office areas exist on most floors.

Additional detail of the results of the updated six facet survey is provided within section 3.4 The Case for Change.  

Figure 6: Extract from the 2019 Six Facet Survey

A summary of the key is set out below. Key:

A: building complies with all statutory requirements and relevant guidance.

B/F building where action will be required in the current plan period to comply with relevant guidance and statutory requirements. C: building with known contravention of one or more standards which falls short of B.

D: building areas which are below C standard.

X: Supplementary rating added to C or D to indicate that nothing, but a total rebuild, or relocation will suffice (that is improvements are either impractical or too expensive to be tenable).

The poor condition of the existing hospital highlighted in both iterations of the six-facet survey is also of broader concern as:

• Its condition and configuration is not in keeping with modern healthcare and is unlikely to be consistent with the contemporary expectations of the island's population.

• As a strategic asset, the hospital's poor condition and potentially more limited capability due to spatial constraints is likely to form a disincentive or barrier to the islands efforts to recruit key individuals to work and live on the island.

• Adopting a watch and wait' estates strategy can only be a very time limited approach as the likelihood of a building failure or statutory breech will only increase.

 The Case for Change

The Case for Change detailed below was originally produced by the HCS team as part of the SOC development in 2020. The Case for Change was reviewed and updated where appropriate by the HCS team in early 2021 as part of the OBC Development.

The Case for change was reviewed and confirmed at the Clinical & Operational Client Group (COCG) meeting held on Thursday 4th March 2021. The attendees at the meeting were:

• Director General, HCS (CHAIR)  

• Head of Communication - HCS  

• Chief Pharmacist  

• Associate Managing Director, Modernisation

• Group Director, Commercial Services  

• Consultant Gastroenterologist  

• Chief Clinical Information Officer  

• Operational Programme Manager  

• Policy Principal Employment and Social Security  

• Head of Estates  

• Associate Managing Director, Care Groups

• Therapies Lead

 The current condition of the hospital estate

As has been set out the General Hospital site comprises of a number of buildings across a large site, with clinical accommodation dating generally from the 1960's but with the Granite Block dating back to 1765. There is a disparate collection of buildings developed over a long time to different health policies, operational practices and construction standards. As a result, facilities are in poor condition with the worst areas of building and engineering infrastructure presenting daily operational difficulty.

As a result of the Six Facet Survey, it is now known that some aspects of the hospital are in a sufficiently poor condition that the risk of building failure is high and is increasing each year. In these cases, the scale of such a failure would severely limit the hospital's ability to manage its way through any emerging crisis resulting in a significant risk of building closure and health service interruption.

A detailed six-facet' survey undertaken by specialist consultants in 2015, confirmed that, despite significant capital investment, the decline had continued now to a point where full refurbishment or complete infrastructure replacement would now be required.

Faced with this, the hospital's estates team identified the major areas of concern and implemented a tactical backlog investment plan to address the most serious and technically correctable issues. However, this recognised and relied upon the intention to develop a new hospital and therefore targeted investment to key areas of the poorest condition or of imminent failure only whilst implementing increased monitoring of the hospital's overall condition. Consequently, significant dilapidation remains.

An updated review was carried out in 2019 which highlights further rapid deterioration of the overall condition of the Hospital. Reconfiguration of the current building will, in nearly all aspects, require investment to address infrastructure issues whilst at the same time not addressing the inherent space, clinical flow and adjacency issues.

Complete redesign of the hospital is required to meet the current and future acute clinical needs of the population and detailed clinical reconfiguration will form an integral part of the future development of a new hospital.

The table below summarises some aspects emerging from the 2019 six-facet report and confirms the extent of corrective work needed and which could not be delivered in an active General Hospital with little redundancy.

Table 8: 2019 six-facet survey summary

 Mental health services

Orchard House, St Saviours currently delivers Mental Health Services, including inpatients. The geographical isolation of Orchard House and the current condition of the environment, both internal and external, require the service to be co-located into the new hospital campus.

Orchard house is currently undergoing essential maintenance works at a cost of £670k in order to comply with a Health and Safety Inspectorate (HSI) notice. There may also be a requirement for fire stopping (circa £200k) and failing heating pipes (£TBC) with the expectation that these can be managed within existing contingencies. However, despite this immediate spend, Orchard House is expected to close within the next 18 months with Mental Health Services transferring into Clinique Pinel and Rosewood House. In order to accommodate the transfer of these services in 2021, Clinique Pinel is currently undergoing a £7.9m refurbishment / extension. The project is currently due to complete April 2022.

The challenges facing Mental Health Services are well known and some elements are consistent with most health and care jurisdictions. Key issues include the following:

• Physical and mental health services are not currently integrated.

• There is a recruitment challenge for key skilled roles such as Registered Mental Health Nurses, Medical Staff and Allied Health Professionals.

• The current Mental Health Estate doesn't provide a therapeutic environment of care.

• There is a lack of care co-ordination.

• The wider system of Government such as Housing and Economic prosperity need to be linked to our strategic plans for mental health.

The need for the relocation of the service provided is primarily driven due to the clinical, operational and environmental risks. The upgrade of the current environment was considered but ruled out due to a number of the identified risks not being mitigated through this approach. The key risks are:

Operational

• Isolated location, there is no direct support from other health facilities or colleagues during times of challenge.

• Lack of support or resource for physical conditions

Environmental (These have been mitigated over the past year as best as possible)

• Poor external lighting

• Potholed roads leading to Orchard House

• Tiles from Queens House falling into outside garden areas

• Poor sight lines

• Inadequate windows (not ligature free)

• Problems with the internal nurse alarm system (possibly due to the amount of granite)

• Legionella risk

Clinical

• No enhanced care facilities to Psychiatric Intensive Care Unit (PICU) standards

• Limited availability to provide a Place of Safety

• Risk to patient and staff safety due to young people breaking into Queens House

As a result, facilities are in poor condition with the worst areas of building and engineering infrastructure presenting daily operational difficulty. Complete redesign of the mental health facilities is required to meet the current and future mental health needs of the population.

 Other healthcare facilities in Jersey

In addition to the Jersey General Hospital and St Saviours sites, there are two additional sites which deliver healthcare services which would be impacted by a new build hospital if a decision was taken to proceed with a new build hospital. These sites are:

• Overdale Hospital site

• Five Oaks

Overdale provides a range of healthcare services including rehabilitation, a children's development and therapy centre, older people mental health and memory services and specialist outpatient facilities and clinical and non-clinical support services.  

Five Oaks currently provides the Theatre Sterile Supply Unit which is also being considered for inclusion in a potential new build hospital in order to achieve greater adjacencies and efficiencies. Jersey General Hospital's catering facilities are currently delivered off-site at the St Peters Industrial Park. This is rented at a cost of circa £313k per annum over a 20 year lease (circa £6.2m).

More detail is included in section 4.6 (Functional Brief) which details the range of services proposed to be included in the new hospital and section 6.10 (Opportunities in relation to the Our Hospital Programme) which considers the potential options for sites which could become vacant following the building of the new hospital.

 Poor functional suitability and configuration of the site

In addition to its poor condition, the estate of Jersey General Hospital is inappropriately configured to deliver safe and effective care. The condition of the buildings and poor layout of the site make it a challenging environment to deliver 21st century care. This poses many challenges in terms of delivering healthcare services at the hospital safely, to a high clinical standard and efficiently.

Consequently, it is not considered appropriate to plan to continue to provide clinical services in the existing hospital given that it fails to meet current building and operational standards, nor can it safely and effectively cater for the projected clinical demand.

In particular, there are increasing levels of operational risk, actual in-service failure and elevated operational cost due to following:

• The existing provision of functional types, sizes and relationships of rooms do not meet current UK healthcare design guidance, space standards and current best working practices

• The existing provision of the numbers of beds available and the provision of single bedroom accommodation does not meet current emergency demand, nor projected future daily demands whilst operating at recognised best practice occupancy rates

• The constraints imposed by an estate comprising a disparate collection of buildings and associated building services' infrastructure of varying vintages from the 1800s to the present day, lead to inefficiencies in linking the various clinical services throughout the hospital and restrict the opportunities for adapting the existing facilities to meet current and future demands

• The alteration and refurbishment of the existing buildings will never, as a consequence of the inherent condition and compromises in space and clinical adjacencies, allow the same level of benefits to be secured as would be possible in the development of a replacement hospital.

Ad-hoc development of the hospital historically has resulted in a number of poor adjacencies between departments. The layout of the hospital is not conducive to efficient or high quality healthcare, with significantly large distances between departments that would benefit clinically from being adjacent. This is both inefficient, involves the public transfer of patients, presenting real privacy and dignity issues and also represents clinical safety and risk issues given the distance with which patients need to be transferred. For example, the current JGH delivers poor adjacencies between diagnostics (such as imaging) and the departments such as Inpatients and Emergency. This increases travel times for both patients and staff, which can be crucial in emergency situations, but which also reduces efficiency day-to-day.

The age and the piecemeal construction of the site has resulted in a lack of flexibility. There is very little generic space that could be used to support changes in services and models of care over time. This means that changes to services require expensive and suboptimal capital developments that have to fit around existing buildings. This limits the potential for future service development as well as the potential for new technology and innovation. It is therefore acknowledged that clinical adjacencies cannot be addressed on the site without major reconfiguration or redevelopment.

The impact of poor adjacency therefore includes:

• Patients' journeys around the site being below expected standards

• An increased cost for portering services and ambulance services needed to transport patients safely

• Increased clinical risk, in particular due to the lack of adjacency between critical departments such as A&E, maternity, theatres and Intensive Care Units.

Despite significant elements of urgent capital investment, the condition of the hospital has continued to deteriorate in recent years. Alongside this, the hospital has had to contend with increasing activity driven by population change and a general increase in the expectations of islanders. As a result, the pressure on the hospital has never been higher with aspects of poor condition and spatial organisation hampering performance.

The impact of this on the hospital and patients includes:

• Poor privacy, dignity and patient experience

• Only a minority of patients having the choice of a single room - this may have a particular impact on some groups of patients and limits choice to all patients admitted

• Infection control is severely hampered by the lack of isolation facilities

• A poor ability to use space flexibly, in part due to issues with access to toilet facilities

• Large bays in typical wards are difficult to clear without having a major impact on bed availability.

The following headline issues that have been identified remain of significant concern for the provision of health and care services and the urgency for these issues to be addressed is increasing over time:

• The inefficient and aging design of the estate has led to poor clinical adjacencies

• There are poor space standards which are compromising effective care delivery

• There is a lack of flexibility to accommodate service delivery

• There is poor separation of clinical and non-clinical flows

• There is poor gender separation and lack of privacy

• There is poor supporting mechanical and engineering infrastructure

• There is poor fire compartmentalisation to allow progressive horizontal evacuation

• Maintenance costs are continuing to escalate, as mechanical and electrical plant reaches the end of its useful life.

The current configuration of the site means it is not set up to meet these requirements and would need significant redevelopment and change to be in a position to deliver this ambition properly.

These spatial dilapidation difficulties cannot be addressed through piecemeal replacement of building elements and a complete redesign of the hospital will be required to meet the current future acute clinical needs of the population.

In the absence of this, pressure will continue to grow and the hospitals overall contribution to transformation strategies such as the new care models, like the Jersey Care model or the Digital Strategy, will be impaired.

 Poor resiliency

As detailed above, there is an increasing risk of infrastructure failure to a considerable proportion of the existing campus. Without careful management this would potentially therefore impact on the safe, effective and consistent delivery of operational services and ultimately therefore care for patients. Whilst there is ongoing management to mitigate the risk of failure to the physical environment, this cannot eliminate the risk of a serious failure i.e.: hot water services.

 The Case for Change: Conclusion

The Our Hospital Project needs to deliver a meaningful change to the delivery of health services in Jersey and deliver a hospital which is fit for purpose today and in the future. Based on the analysis, there is a clear case for change:

• The condition of the estate is poor and presents significant challenges that will increase in around five years' time. Facilities are in poor conditions with the worst affected areas of the building presenting daily operational difficulty. Some aspects of the hospital are in such poor condition that the risk of failure is increasing.

• In order to achieve the expected benefits of more effective ways of working and/or new models of care, a significant change will be required in the way hospital services are delivered

• Reconfiguration of the current building will, in nearly all aspects, require significant refurbishment costs to address infrastructure issues and high ongoing lifecycle expenditure whilst at the same time not addressing the inherent space, clinical flow and adjacency issues.

There is an exciting vision for the Our Hospital project which can support and enable change across the way health services are delivered in Jersey as well as providing a hospital facility which is fit for purpose and delivers Value for Money to the people of Jersey.

 Our Hospital Project investment objectives

 SOC Stage

As part of the development of the SOC, a workshop was held on Thursday 27th February 2020 with the HCS Executive Group in order to discuss and agree the following:

1. The Our Hospital Project investment objectives
2. The Critical Success Factors
3. A short-list of options to progress to Outline Business Case (OBC).

The following attended the workshop:

• Director General, Health and Community Services (HCS)

• Group Managing Director, Health and Community Services

• Group Medical Director, Health and Community Services

• Chief Nurse, Health and Community Services

• Human Resources Director, Health and Community Services

• Health Modernisation Director, Health and Community Services

• Head of Finance Business Partnering, Treasury and Exchequer

• PwC Healthcare Lead.

The Project investment objectives for any potential investment were developed using a workshop approach to ensure that the outcomes required by key stakeholders have been considered and included.

The key objectives of the Our Hospital Project described at SOC were:

1. To provide high quality, efficient and effective care for all patients and service users that is timely, accessible and delivers the best possible experience for patients, service users, visitors and staff
2. To deliver integration of physical and mental health care and services including co-location of an Acute and General Hospital and Mental Health Services
3. To deliver a healthcare estate including an Acute and General Hospital that is safe, compliant, flexible and right sized for the future delivery of clinical and other services, and enables service transformation
4. To deliver a new hospital that ensures the financial sustainability of the health economy
5. To deliver a new hospital that contributes to building a thriving community and well-being of staff and patients with positive socio-economic and environmental impacts.

The outcomes of the HCS Executive Group workshop were tested and re-affirmed at the Associate Medical Directors meeting on Wednesday 18th March 2020.

 OBC Stage

During the development of the OBC, a workshop was held with the Our Hospital Project team on Monday 8th February 2021 in order to review the Our Hospital Project Investment Objectives.

The following attending the workshop:

• Clinical Director Our Hospital Project

• Health Modernisation Director, Health and Community Services

• Client Project Manager

• Our Hospital Project Cost Consultants

This workshop proposed an update to Objective 3 in order to recognise that the Our Hospital Project is to deliver a new acute and general hospital, not a full healthcare estate and also to emphasise the importance of delivering facilities which can be more easily maintained in the future. It is intended that this objective captures the requirement to provide a facility that is able to support services transformations, such as the new models of care, and the digital strategy. All other objectives were confirmed as still being appropriate.

The updated objectives are listed below:

1. To provide high quality, efficient and effective care for all patients and service users that is timely, accessible and delivers the best possible experience for patients, service users, visitors and staff
2. To deliver integration of physical and mental health care and services including co-location of an Acute and General Hospital and Mental Health Services
3. To deliver an Acute and General Hospital with co-located mental health and other services currently delivered offsite that is safe, compliant, flexible, delivers an optimised planned preventative maintenance regime and is right sized for the future delivery of clinical and other services, and enables service transformation
4. To deliver a new hospital that ensures the financial sustainability of the health economy
5. To deliver a new hospital that contributes to building a thriving community and well-being of staff and patients with positive socio-economic and environmental impacts.

The updated objectives were reviewed and confirmed at the Clinical & Operational Client Group (COCG) meeting held on Thursday 4th March 2021. The attendees at the meeting were:

• Director General, HCS (CHAIR)

• Head of Communication - HCS

• Chief Pharmacist

• Associate Managing Director, Modernisation

• Group Director, Commercial Services

• Consultant Gastroenterologist

• Chief Clinical Information Officer

• Operational Programme Manager

• Policy Principal Employment and Social Security

• Head of Estates

• Associate Managing Director, Care Groups

• Therapies Lead

• Associate Medical Director Surgical Services (TEAMS)

• Consultant in Anaesthesia & Intensive Care

• Associate Medical Director Medicine

• Head of Clinical Support services and Cancer AMD

 SMART Objectives

Green Book guidance requires that all objective identified as part of the OBC must be SMART. I.e.

• Specific

• Measurable

• Actionable

• Relevant

• Time-based

The table below sets out how each Objective will be SMART. Work will continue to refine the mechanisms for measuring the objectives, and for setting timescales to achieve them, based on the benefits developed for FBC.

Table 9: SMART Objectives

 Benefits

 Long-list of benefits produced at SOC Stage

The table below outlines the key benefits of the Our Hospital Project by stakeholder group as developed as part of the SOC development in February 2020.

Table 10: SOC Benefits

 OBC Stage

During the OBC workshop the long-list of benefits at the SOC was reviewed. The following revised set of benefits was produced which takes into account the development of the Project over the past 12 months and in particular the impact of the Covid-19 pandemic.

Table 11: OBC Benefits

The updated benefits were reviewed and confirmed at the Clinical & Operational Client Group (COCG) meeting held on Thursday 4th March 2021. The attendees at the meeting were:

• Director General, HCS (CHAIR)

• Head of Communication - HCS

• Chief Pharmacist

• Associate Managing Director, Modernisation

• Group Director, Commercial Services

• Consultant Gastroenterologist

• Chief Clinical Information Officer

• Operational Programme Manager

• Policy Principal Employment and Social Security

• Head of Estates

• Associate Managing Director, Care Groups

• Therapies Lead

• Associate Medical Director Surgical Services (TEAMS)

• Consultant in Anaesthesia & Intensive Care

• Associate Medical Director Medicine

• Head of Clinical Support services and Cancer AMD

 Constraints

The constraints of the project are:

• Physical safety of the hospital's patients and staff must be maintained throughout the life of the project by ensuring sustainable provision of healthcare services.

• Meeting Planning requirements.

• Achieve completion of Clinical Commission by the end of 2026.

• Leading to a fast-tracked compressed timetable

• Accessibility – language, disability access.

• Affordability of the project.

• Lack of construction supply chain choice due to industry demands

• Political uncertainty

 Dependencies

The dependencies of the project are:

• An adequate financing option is available and affordable.

• Ensuring there are sufficient public transport options to the site for patients and staff.

• Planning consent for the construction of the hospital is vital to the project.

• The business case is approved by the Government of Jersey and any other relevant bodies.

• Acquiring land, including use e of CPO Powers where required.

4. THE ECONOMIC CASE  Introduction

 Purpose of the Economic Case

The case for change has concluded that in around five years' time the existing hospital will reach a point where significant intervention is required to avoid the estate become unusable. The running costs will quickly become unaffordable due to the amount of investment required to bring the hospital up to the statutory and regulatory standards expected.

The Economic Case considers the potential options for interventions to address these issues and assesses the shortlisted options using costs, benefits, risk and Net Present Cost economic analysis in order to confirm a Preferred Option.

 Work undertaken at the SOC Stage and updates to the Case in this OBC

SOC Stage

During the development of the SOC, the following process was undertaken:

• A longlist of options was developed and assessed using Critical Success Factors. This identified that a New Build option was the only option that met the project's strategic objectives and was shortlisted along with a Do Minimum comparator (as required by the Green Book). This

shortlisting was approved through the SOC approval process.

• The New Build option was site agnostic at the time of shortlisting, as the process was being run in parallel to the site evaluation process.

• The site evaluation process assessed a broad range of locations and led to the selection of Overdale being recommended by the Political Oversight Group (POG) to the Council of Ministers (COM), who endorsed that decision and took the proposition to the States Assembly for Approval. Approval was given by the States Assembly in November 2020.

• High level analysis on cost, benefits and risk was undertaken on the New Build versus the Do Minimum Comparator and the New Build at Overdale was selected as the preferred way forward.

OBC Stage

The OBC builds on the analysis undertaken at SOC stage, and in particular provides new analysis on costs, benefits and risks with a new Economic Appraisal, the key updates for which are listed below:

• Development of the Do Minimum/Baseline Comparator: further work was undertaken to define and cost the Do Minimum comparator which highlighted that to continue the existing health services in Jersey, significant construction work around the HCS estate would be required, leading to increased costs A specific costed risk register for this has also been prepared by the GoJ Cost Consultant.

• Development of the New Build option (preferred way forward): A RIBA2 design has been developed with the Design & Delivery Partner (DDP), and work on RIBA3 has commenced. The design has been costed by the DDP and benchmarked by the GoJ OHP Cost Consultant to assess risk and opportunities. As with the Baseline Comparator, a risk register has also been prepared and costed.

• Benefits: Additional work to identify and refine benefits has been undertaken, and particularly to start the process to quantify benefits where possible. Workshops were undertaken to qualitatively score benefits and approved through a number of sessions with the HCS Executive, the Our Hospital Citizens' Panel and the Our Hospital Health Workers' Panel.

Other sections of the Economic Case have been reviewed and updated where required but remain substantively the same as with the SOC (e.g. longlisting process, site evaluation) and are included for reference.

 Critical Success Factors

At the SOC stage, the Economic Case assessed the options for intervention to establish the preferred way forward. To facilitate this process, a workshop was held on Thursday 27th February 2020 with the HCS Executive Group in order to discuss and agree the following:

1. The Our Hospital Project investment objectives
2. The Critical Success Factors
3. A short-list of options to progress to Outline Business Case (OBC)

The following attending the workshop:

• Director General, Health and Community Services (HCS)

• Group Managing Director, Health and Community Services

• Group Medical Director, Health and Community Services

• Chief Nurse, Health and Community Services

• Human Resources Director, Health and Community Services

• Health Modernisation Director, Health and Community Services

• Head of Finance Business Partnering, Treasury & Exchequer

• Consultant Trauma and Orthopaedic Surgeon

• PwC Healthcare Lead

The Critical Success Factors were developed to support in the shortlisting exercise, giving consideration to the strategic objectives outlined in the Strategic Case. They provide the key outcomes that must be achieved by the project. These were agreed through the workshop set out above with key stakeholders and are provided below:

1. Does the option support the safe delivery of high-quality, efficient and effective care in the future?
2. Can the option be delivered by the required operational date of 2026?
3. Does the option accommodate a mix of co-located clinical and supporting facilities, including mental health facilities?
4. Is the option flexible enough to support the delivery of healthcare in the future?
5. Does the option offer the prospect of continuing to provide safe and effective care during the delivery of the new hospital?
6. Is the option likely to be affordable from both a revenue and capital perspective?
7. Does the option allow sufficient space for future expansion if required?

The outcomes of the HCS Executive Group workshop were tested and re-affirmed at the following additional groups:

• Our Hospital Project Team – Wednesday 4th March 2020.

• Associate Medical Directors Meeting – Wednesday 18th March 2020 (virtual meeting).

 The long list

 Overview of the longlist

The longlist of options was identified at a workshop approach with key stakeholders. As outlined above, the site evaluation process was undertaken in parallel to this process and therefore the new build option was site agnostic during the SOC shortlisting process.

The table below outlines the longlist of options.

Table 12: The SOC stage longlist of options

 Longlist appraisal

Approach

The longlist of options included all potential interventions, including those that may not be viable to implement.

A shortlisting workshop was undertaken to identify the viable and non-viable longlist options. The non- viable options were not be taken through for further analysis at the SOC Stage.

To identify the non-viable options, each option was assessed against the Critical Success Factors set out in section 4.2 using the following criteria:

Table 13: Critical Success Factor criteria

If an option scored red in any of the Critical Success Factors, it was deemed unviable and therefore not short-listed. The outcome of the appraisal is shown in the table below.

Table 14: SOC stage longlist appraisal

It was agreed that CSF6 – Affordability would not be assessed at the SOC stage as the GoJ Treasury was still exploring options around the financing of the proposed scheme. Affordability would therefore be assessed in the OBC Financial Case once the options have been shortlisted and costed in more detail.

The assessment against the CSFs showed that the Do Nothing' and Do Minimum' options are not viable because they:

• Do not address the existing functional and spatial deficiencies or deliver any operational improvement.

• Will not provide the necessary capacity to deal with future care models or other service transformation

• Do not support delivery of the digital transformation required

• Do not address future patient expectations by offering limited scope for single bedroom provision or co- location of mental health services.

The decision-making process established that all proposed refurbishment options would also not achieve the CSFs because:

• The existing site would not be able to accommodate the co-location of mental health services without a full redevelopment of the site. This therefore meant that the refurbishment options would not support a core requirement of the Our Hospital Project.

• Without a reconfiguration of services to improve functional suitability, the existing hospital is restricted in its ability to support the delivery of future models of care due to condition of the site and building structures.

• The condition of the building does not lend itself to a major refurbishment without causing significant disruption to patients and staff.

• A refurbishment would not rectify the long-term building condition issues at the current hospital with the situation further complicated by the presence of significant asbestos which makes building maintenance and refurbishment extremely difficult with its specialist removal having to be managed during any building change.

• Continuing to use the existing site would have a negative impact on the recruitment and retention of staff at least through the lengthy maintenance works.

• The current layout and clinical adjacencies at the existing site would never allow the same level of benefits to be derived from a refurbishment option as would be possible in a new build option.

As the New Build option enabled full design and scoping flexibility at the SOC stage, it is able to meet all of the CSFs as the hospital can be designed to meet requirements. It is therefore taken forward for further assessment.

 The shortlist

Based on the appraisal set out above, the shortlisted options to be taken forward for further assessment in the SOC are detailed below.

Table 15: SOC stage shortlist of options

The Do Nothing Option was not shortlisted as a comparator option for the following reasons:

• Without substantial investment in the infrastructure of the existing Jersey General, the condition of the physical infrastructure of the buildings would make it unsafe to continue to provide healthcare services from the facility and it will not be possible to continue to deliver services beyond 2026. This would result in healthcare services needing to be predominantly delivered off-Island. The level of investment required to keep the hospital open is set out in the Do Minimum Case.

• If the existing JGH was to continue to be used beyond 2026, there would be significant strain placed on the delivery of safe clinical services. For example, a programme of significant remedial works which involved shutting down areas of the hospital for periods of times (i.e. wards, theatres, clinics etc.) would put significant pressure on the ability of HCS to meet patient needs. At a minimum, this would lead to increased waiting times or more patients going of island in the short term, but in a worst-case scenario without any mitigation could ultimately lead to direct clinical risks, especially in instances where remedial work was reactive.

• The recent Covid-19 pandemic has highlighted that the existing estate is not designed to provide suitable patient / public flows through the hospital or to allow for operational hot / cold sites. This issue was managed in 2020 with the building of the Nightingale Hospital but the existing site could not be safely reconfigured without significant disruption and cancellation of services to deliver operational hot / cold sites in the future. The proposed Our Hospital would however have the flexibility built in.

Therefore, the only comparator option which could be deliverable is the Do Minimum option, which has been shortlisted as the comparator option. More detail on the Do Minimum option is set out in section of this Economic Case.

 Re-testing of Critical Success Factors and long-list at OBC stage

During the development of the OBC, a workshop was held with the Our Hospital Project team on Monday 8th February 2021 in order to review the Our Hospital Project Critical Success Factors and consider if any changes to the long-list and shortlisting process were required.

The following attending the workshop:

• Clinical Director Our Hospital Project

• Health Modernisation Director, Health and Community Services

• Client Project Manager

• Our Hospital Project Cost Consultants

• Our Hospital Project Management Office.

This workshop concluded that whilst affordability (CSF 6) is critical to the overall delivery of the project, it was however not possible to assess affordability during the workshop as the detailed costs information on each option was not available. On this basis it was agreed to remove Critical Success 6 (affordability) as a Project CSF with affordability now being assessed as part of the cost analysis set out later in the Financial Case. As this CSF had not been used as part of the assessment of long-list options at the SOC stage, no update is required to that assessment. The revised confirmed list of Critical Success Factors is set out below:

1. Does the option support the safe delivery of high-quality, efficient and effective care in the future?
2. Can the option deliver by the required operational date of 2026?
3. Does the option accommodate a mix of co-located clinical and supporting facilities, including mental health facilities?

4. Is the option flexible enough to support the delivery of healthcare in the future?
5. Does the option offer the prospect of continuing to provide safe and effective care during the delivery of the new hospital?
6. Does the option allow sufficient space for future expansion if required?

The long-list was re-tested and confirmed as still being appropriate at the 8th February 2021 meeting outlined above. No changes were proposed to the Critical Success Factor scoring and therefore the New Build Option remained the only shortlisted option with the Do Minimum option also still shortlisted as the comparator option.

The updated Critical Success Factors were reviewed and confirmed at the Clinical & Operational Client Group (COCG) meeting held on Thursday 4th March 2021. The attendees at the meeting were:

• Director General, HCS (CHAIR)

• Head of Communication - HCS

• Chief Pharmacist

• Associate Managing Director, Modernisation

• Group Director, Commercial Services

• Consultant Gastroenterologist

• Chief Clinical Information Officer

• Operational Programme Manager

• Policy Principal Employment and Social Security

• Head of Estates

• Associate Managing Director, Care Groups

• Therapies Lead

• Associate Medical Director Surgical Services (TEAMS)

• Consultant in Anaesthesia & Intensive Care

• Associate Medical Director Medicine

• Head of Clinical Support services and Cancer AMD

 Site Evaluation

In a parallel process to the development of the SOC, the Our Hospital Project team undertook a detailed site evaluation process to identify the best site for the development of a new hospital. The first phase was a five stage process engaging with multiple stakeholders to identify a shortlist.

• Stage 1 – Call for sites

• Stage 2 – Clinical criteria for site assessment – site area

• Stage 3 – Clinical criteria for site assessment - timetable

• Stage 4 – Criteria by the Citizens' Panel

• Stage 5 – Application of the criteria by Site Evaluation Panel: Shortlisting

A longlist of 82 sites was identified in stage 1 comprising suggestions made by members of the public through a "call for sites", along with the suggested sites from the previous Future Hospital project.

The longlist of sites was reduced from 82 to 39 in stage 2 through the application of the minimum site requirement. Health Planning experts and colleagues from Health and Community Services determined the minimum ground floor size/footprint of the hospital through an assessment of the clinical services

required on the ground floor. Additional areas to the ground floor brief included areas for internal circulation and service space, external areas (i.e. ambulance drop off and patient drop-off/pick-up), a hospital service yard, essential services which could be located on adjacent or nearby sites and car parking.

Three sizing and configuration options were established which could enable the required hospital to be constructed:

• Option 1- main site and directly adjacent ancillary site that could accommodate all support services

o Essential ground floor hospital area requirement = 23,243m2

o Adjacent site = 8,504m2

o Car parking – 800 spaces over 2 x floors = 9,219m2

• Option 2 – main site with basement to accommodate essential support services and a separate facility within 15 minutes' walking distance for non-essential support services.

o Essential ground floor hospital area requirement = 22,890m2

o Adjacent site = 3,590m2

o Car parking – 800 spaces over 2 x floors = 9,219m2

• Option 3 – a variant of Option 2 but displacing mental health facilities, theatre sterile supply unit, engineering and estates functions to a separate site no more than 15 minutes' drive from the main site. This option was recommended by HCS clinical and health professionals to not be pursued. HCS considered that this option was not clinically palatable and was an excessive dilution of the ambitions of the JCM, particularly with respect to co-locating within or adjacent to the main hospital. As a result, Option 3 was not explored further.

Option 1 and option 2 were taken forward with the total area then assessed against the long list of potential sites.

In stage 3, each of the 39 sites were then assessed to determine if any factors restricted the deliverability of an operational hospital by the end of 2026. The following factors were considered as part of the deliverability criterion:

• Ownership of the proposed site

• Availability of developed land

The application of the criteria reduced the list of sites from 39 to 17.

A Citizens' Panel was formed following an anonymised selection process from Island applications who met the selection criteria. This process was aimed at ensuring that the Panel was reflective of the Island's population and supported by colleagues from the Health and Community Services.

The Panel developed the criteria that they believed were important in determining the site for the Hospital. This formed the sequential test which consisted of 22 questions in order to narrow down the remaining 17 sites.

Stage 5 applied the criteria determined by the Panel in stage 4. A Site Evaluation Panel ratified the initial assessment of sites in stages 1-4 and tested those sites remaining against the sequential test criteria.

The sequential test involved ruling out any site that did not meet the criteria for a test and was therefore not considered for the remaining tests. The application of the test criteria reduced the list of sites from 17 to 5.

This process resulted in the following five sites being shortlisted:

• Fields to the North of Five Oaks

• Millbrook Playing Fields and fields to the north

• People's Park

• Overdale

• St Andrew's Park, First Tower

The next steps to identify a single preferred site involved detailed feasibility studies (both desk-based and on-site technical assessments) and impact assessments. These were undertaken by the Design & Delivery Partner and included the following stages:

1. Site acquisition and community involvement of the shortlist of sites
2. On-site technical assessments considering the infrastructure characteristics
3. Impact assessment on the site and its surroundings
4. Consult and engage with the Jersey Architecture Commission and the Citizens' Panel
5. Report of the outcomes of the assessments to the Political Oversight Group and then Council of Ministers

Following the completion of the acquisition and community involvement study (July 2020) and the access to the site and preliminary assessments (mid-August 2020), sufficient information emerged that only Overdale and People's Park have the potential to deliver the Our Hospital Project as currently defined. The decision was summarised in a GoJ Paper dated 18th August 2020.

Further work was performed on both remaining options during September 2020 with further detail emerging on the site specific costs of each option. Both options were presented in detail to a Council of Ministers meeting on Thursday 1st October 2020. The decision was made to propose proceeding with Overdale as the preferred site for the new hospital. In support of this, Council of Ministers also decided to propose the use of Compulsory Purchase legislation to make the site available in time. This was then debated during the November sitting of the States Assembly.

 Functional Brief

 SOC Stage

In order to support the site evaluation process, a draft functional brief exercise was undertaken at SOC stage to determine the minimum ground floor sizing requirements of the new build option. This process was primarily to support the site evaluation but also enabled a detailed review and challenge of potential functional areas which could be included in the proposed new build hospital.

A functional brief report was prepared which set out the strategic rationale for additional functional areas, capital cost and revenue impact for each area, and any potential savings from a consolidation onto a single site.

MJ Medical, with support from PwC, developed the indicative sizing for the new hospital, using the current Jersey General Hospital as the starting point, and adjusted the sizing to be in line with current UK regulations and the estimated impact of the HCS efficiency work which was being undertaken at the time:

• Current Jersey General Hospital size (40,032m2)
• Jersey General Hospital uplifted to current standards (55,482m2)
• New hospital without the HCS efficiency work being achieved (uplifting for future demand) (79,618m2)
• New hospital with the HCS efficiency work being achieved (66,947m2)

The Jersey Care Model helped inform the development of the SOC functional brief to support the site evaluation process, but it does not define the clinical and non-clinical design requirements. The Our Hospital Project will be delivered independent of the Jersey Care Model.

 OBC Stage

The Our Hospital Functional Brief (version 6.1) was completed by MJ Medical in November 2020. This Functional Brief reflects the clinical requirements of the population of the Island, the Our Hospital clinical leadership team, current best health practice, operational aspirations and design principles, as developed through the initial consultation workshops. The starting point for the Functional Content' has been created based on the results of a HCS review and stress test of the JCM undertaken from October 2019 to June 2020. The output of the review has been augmented through a series of interactive clinical workshop sessions with the Health and Community Services leadership and the Our Hospital clinical leadership teams. This content has been further developed and refined in consultation with the clinical and non-clinical teams who operate the current hospital. In addition to setting out the functional requirements and key flows and adjacencies of the hospital, it also provided the wider brief for the design for the new hospital, including:

• Site context and character

• Design and operational principles

• Approach to standardisation and repeatable rooms

• Expansion, adaptability and flexibility

• Diversity and equality

• Digital (Information Management and Technology) requirements

• Infection control

The Employer's Requirements, which includes the Functional Brief, was developed with the DDP as the basis for the design of the new hospital, highlighting key areas that needed to be considered in the design to achieve the Critical Success Factors and Strategic Investment Objectives. The DDP have developed their design in response to these requirements, and as set out in more detail in the Commercial Case, their Concept Design report summarises the progress that has been made at RIBA Stage 2 in achieving this.

1. Demand and Capacity Modelling

As has been described in the Strategic Case a discrete event simulation model was developed that estimated the flows of demand through the new hospital, taking account of peaks/troughs in demand during the course of the year.