A Review of The Our Hospital Project

November 2022

Minister of Infrastructure Housing and Environment Government of Jersey

November 2022

Disclaimer: This document was prepared for the sole use of the Government of Jersey

Contents

Foreword from the Minister for Infrastructure ............................................... 4 Executive Summary ........................................................................................ 7 Section 1: Introduction and Scope of Report ................................................ 21

Section 2: Background to OHP Proposals and Emerging Delivery and Affordability Risks ............................................................................................................ 27

Section 3: Stakeholder Interviews and Submissions - What We Heard ............ 29

Section 4: The State of The Existing Hospital Including an Assessment of the Measures Required to Ensure That They Remain Fit for Purpose ...................... 34

Section 5: Measures Currently Being Undertaken to Improve and Transform Jersey's Health Service ................................................................................................... 35

Section 6: Identification and Examination of Options to Permit Both Future Affordability and Delivery of Appropriately Provisioned Hospital Solution..... 36

Section 7: Conclusions .................................................................................. 58 Appendices ................................................................................................... 62

Foreword from the Minister for Infrastructure

As the saying goes, a week is a long time in politics. And over the past nine months every week seems to have produced another layer of instability. War in Eastern Europe, a fuel and energy crisis, the potential for recession and higher inflation now set the scene.

In terms of infrastructure, this means that large-scale capital projects across the globe face greater uncertainty. The cost of materials has risen sharply as markets compete for the same supplies, with long lead times as a result of severely disrupted supply chains.

The cost of energy is rising, and there are shortages of labour as a result of Covid- 19 and Brexit. Against this backdrop, contractors internationally are naturally more wary about under-pricing contracts and taking on greater risk. And in order to safeguard themselves against fluctuations in their direct costs, fixed prices may be a thing of the past as project prices rise.

Jersey's situation is no different.

When the funding model for the Our Hospital (OH) project was first revealed, Jersey was hoping for an average return on its £1bn strategic reserve fund of 4.6% (2% above the Fiscal Policy Panel's long-term RPI assumption) over a 40 year period, and borrowing costs to be fixed at 2.5% for the duration.

The financial markets environment has changed considerably, and a return to stability may not be achieved any time soon. The strategic reserve will not reach its target this year and the cost of borrowing is considerably higher. The change in circumstances provides part of the backdrop to this review and, perhaps unavoidably, frames some of the fundamental thinking, particularly the need for a more robust approach to risk management in the volatile economic climate we now face. However, the situation is not without opportunity.

Recognising the amount of information and knowledge accumulated during the OH process, it was decided that the review work could be undertaken by our existing experienced local team, with the assistance and oversight of a Principal Expert Advisor; in this case, Mr Alan Moore OBE TD DL BSc (Hons) FRICS.

Until retirement in September 2021, Mr Moore was the Director of Strategic Capital Development within the Western Health & Social Care Trust and in this capacity was the Senior Responsible Owner responsible for the successful delivery of a £1Bn capital investment programme within health in the West of Northern Ireland.

His responsibilities included the delivery of the South West Hospital at Enniskillen, the new Omagh Hospital and Primary Care Complex at Omagh, The North West Cancer Centre and the phased re-development of the Altnagelvin Area Hospital at Londonderry

Having assembled a small team and drafted an appropriate Terms of Reference which ruled out a return to site selection, a number of options were considered and a comprehensive consultation process began with 20 stakeholder meetings involving over 60 individuals in total.

Accepting that the current hospital may be required to stay in service for slightly longer than anticipated, the hospital's maintenance team were consulted and assurances were given that all required resources would be made available to keep the existing hospital buildings safe, without unnecessary bureaucratic process.

With regard to the review, the focus has, first and foremost, been to ensure that the conclusion would lead to the best possible facilities for both patients and health-care staff, in all areas.

In the process, every effort has also been made to combine this focus with an emphasis on some form of project phasing (possibly dual site or hybrid' model) to spread the financial risk over a longer period and deliver better value for money to the taxpayer, whilst recognising the urgent need to progress as quickly as possible.

In addition, devising a scheme where buildings could be designed to a scale more compatible with their surroundings, requiring less impact on the existing environment, and offering better project access to local construction firms and associated building trades. Finally, to allow for future, cost effective expansion, using modern methods of construction.

The resulting recommendations are unlikely to please everyone, but have been reached after careful consideration of the evidence presented and have set out the roadmap for our best chance of achieving the high quality future hospital facilities which the Island needs, but in a way that is both affordable and achievable in the shortest possible timescales.

It is time to put aside the public discord of the past and progress at pace, alongside a constructive dialogue with Health-care workers, Clinicians, Scrutiny, Assembly members and all Islanders, including neighbours and interest groups.

Finally, I should like to offer my sincere thanks to the Principal Expert Advisor, those Government of Jersey officers directly involved in the production of this Review (and those supporting its delivery in the background), the stakeholders who have provided evidence that led to its conclusions, and the individuals providing quality assurance for their constructive feedback.

Executive Summary

In accordance with its terms of reference, and the Chief Minister's 100-day plan, this Review has been established to consider whether any changes can be made to the hospital project to deliver a more affordable and appropriate alternative. In short, within the constraints of 100-day review period and the need for further detailed design and cost assessments, the conclusion of the Review is yes':

• A prudent risk management approach can be taken to deliver a more affordable project through a different financing model, and by spreading commitment to spend over a longer period, rather than progressing a single large-scale and high-cost scheme with cost estimates for construction outside the forecasts within the Outline Business Case.

• Services can be broken over two or more sites to deliver a more appropriate service provision – to ensure that given our island context, the broad range of services delivered by Jersey's Health and Community Services continue to be delivered safely on-island but do not have the same degree of environmental or infrastructure impacts as a single-site scheme.

Existing Facilities and Their Maintenance

The Review recognised the absolute necessity to ensure that the existing Jersey General Hospital site infrastructure at Gloucester Street remains safe whilst the various developments are constructed. To this end, additional funding should be made readily available to utilise in the event that it is required since it is recognised that there is a significant and increasing backlog to address. If necessary, further surveys (such as the six-facet survey) should be funded to ensure that those areas that pose most risk are prioritised and have not changed since the previous survey. Currently, £5m per annum of funding for capital maintenance of the existing health and care estate is available as part of the Government Plan. It was further agreed that a working group should be formed to identify interim solutions that could improve current working conditions and patient outcomes.

It should be noted that the ambitious target for delivery of the whole of the services provided in the Functional Brief by 2026 was under pressure: preliminary construction programmes for delivery of the whole of the current Overdale proposals indicated completion beyond that date. This would only have been confirmed at Main Contract Award. Additional provision for the maintenance of services of the Jersey General Hospital is therefore also likely to have been required for this scenario.

Measures being undertaken to improve and transform Jersey's health service (provided by Minister for Health and Social Services, Karen Wilson )

Changes in the delivery of modern healthcare over the last forty years have meant that the current hospital is no longer able to respond to the increasing demands placed upon it nor does it meet patients' expectations for privacy and dignity or meet the requirements of clinical staff to enhance the quality of the care they provide. Despite efforts to maintain the hospital environment through a programme of upgrade and maintenance, we have reached a point where we can no longer sustain this at the current hospital.

As part of the above, we mirror health economies across the world who are redefining and redesigning their hospitals in response to developments in clinical practice and moving towards increasing some aspects of care in the community.

New hospital facilities therefore must be capable of meeting changes to care over time and delivering services, support developments in new health technologies, and provide an environment in which to attract staff. They need to offer flexibility, support integrated care delivery, be fit for purpose, and meet the expectations of patients and clinicians engaged in delivering person centred care. Critical to their success is the expertise to deliver such specialist facilities.

Affordability of the Current Scheme

In the first instance, the Review considered the affordability of the current project in light of recent global events that have considerably altered the financial climate and fractured international supply chains.

The Government of Jersey's Chief Economic Adviser has provided the following information on the global economic context:

The latest forecast from the International Monetary Fund (IMF) is for global growth of 3.2% this year and 2.9% next, much lower than the 6.1% seen in 2021. By any comparison, this is a significant drop off from the global growth position. Whilst circa 3% growth might appear strong in a normal national context, in a global context anything below 3% is very low, and as such these figures need to be interpreted as a particularly problematic global economic outlook.

The key risks to the global outlook relate to supply-chain disruption due to the ongoing war in Ukraine and bounce back from the pandemic. The war has disrupted the global economy due to international tensions with Russia and led to higher global commodity prices for key Russian and Ukrainian exports such as oil, gas and grain. Imposed sanctions have also had an impact on the economies imposing them, mainly in places of needing to source alternative supply-chains.

Commodity price increases and lingering supply-demand imbalances have led to increased 2022 inflation projections. The IMF in their most recent 6 monthly report (June 2022) forecast 6.6% in advanced economies and 9.5% in emerging market and developing economies. The most recently published figure for RPI inflation rate in Jerseys is 10.4% at September 2022[1].

Much of this has led to increased interest rates in most developed countries, with anticipation of higher interest rates to come. Borrowing for investment will therefore be significantly more expensive now that it was just a few months ago and it is likely that these interest rate rises will be the new norm. Market projections for 2023 are above 4% and long term borrowing in the UK (Gilt Yields) are still above 3.6% despite recently falling (following the new government in the UK).

The most recent Fiscal Policy Panel report suggests that evidence from the labour market and businesses shows that the economy has been recovering well from the Covid-19 pandemic. The construction sector faces a shortfall of workers and materials. Currently, it appears that Jersey's labour market has been resilient to the global shocks and the economy overall remains in a good position to weather them, however these shocks represent a short-term risk to the economic recovery as does the lack of spare capacity for large projects and programmes.

In this context, it has concluded that the scheme in its current form and delivery model is unachievable within the original £620 million envelope established to fund the contracted elements of the project. Current estimates are now between £70 million and £115 million in excess of that figure.

Affordability should also be considered in the context of changes to markets and the global economic environment, and the associated pressures this will no doubt place upon government finances. It would no longer seem prudent to expend such a large sum on one project in such uncertain times.

Further, in the current arrangement, there is little flexibility in the timing of the commitment to commence main works and so this could be required when costs are at their most volatile and least affordable. The project could be delayed until more stable times, but the risk could return mid-project with the same consequence. It could be argued that current effects are transitory; however, it may also be the case that the previous environment of sustained, low interest rates was also transitory. In any circumstance, it is unlikely that the mechanism described in the Funding Proposition would remain the preferred choice and alternatives would be explored.

Finally, as could be interpreted from the economic analysis above, there is an increasing suggestion that there may be a global recession in the short to medium term. Infrastructure projects, including investment in healthcare facilities are a proven means of stimulating areas of the local economy but to do so, they need to be accessible to those businesses. The current model places the procurement control within one off-island and one on-island contractor rather than maximising the supply base. The current proposal does not target expenditure to those areas of the island economy that could be most in need, delivering best value for money and therefore contributes to it being unaffordable.

In line with the conclusion that the current scheme at Overdale is unaffordable, it was similarly concluded that a relocation of the proposal, a lift and shift' of design and functional delivery elements of the scheme, to the existing hospital site at Gloucester Street was also unaffordable, and completely unachievable from a space planning perspective.

Review Methodology and Options Appraisal

In reaching these conclusions, the Review team undertook a review of documentation, took into consideration evidence from key stakeholders through interviews and in writing (over sixty stakeholders were consulted), and undertook visits to various healthcare facilities elsewhere in Northern Ireland, some for similar population sizes.

The facilities in Northern Ireland were selected since they had been delivered by the Lead Advisor and consequently, the Review team was able to understand how these had been affected, the standards to which they had been designed and the consequent outcomes that they had achieved. Further, one of the hospitals was in a remote location and so had some similarities with Jersey's healthcare requirements. Despite Jersey's higher GDP, the island has not been able to deliver healthcare facilities to similar standards and so the Review team hoped to understand how Government of Jersey might be able to learn from the example of Northern Ireland Healthcare Trusts.

It is important to note that this Review has been substantially completed within 100 days, during which time it is very challenging to collect any new evidence to support the Review outcome. In contrast, this Review has sought to review existing sources of evidence and discussed these with stakeholders – often those that had produced the evidence in the first instance. It is imperative to note that this Review cannot replace a detailed business case approach and quantitative analysis of options, which will need to be undertaken in due course.

Subsequent to its conclusions about the current scheme and the option to relocate the existing functional brief to the Gloucester Street site, the Review team undertook an options appraisal on additional options, to establish whether any of these could deliver a more affordable and appropriate alternative.

In line with the terms of reference, the Review has not sought to reopen the site assessment process to an extensive list of locations across the Island. This is because this approach would create a significant delay in progress and almost certainly would not enable the delivery of a new hospital within the required timescale. The Review options were therefore limited to permutations around the existing Jersey General Hospital site and nearby sites in Government of Jersey ownership and the Overdale site, as designated as a site for a new hospital for Jersey in the Bridging Island Plan 2022-2025[2]. As a result, the options assessed were:

1. Develop Overdale as a single hospital site with a significant reduction in designed space allocation.

2. Redevelop the existing hospital site at Gloucester Street in a phased manner, with a similar reduction in designed space allocation to Option 1, whilst maintaining existing hospital services as work proceeds.
3. Redevelop the existing hospital site at Gloucester Street and the adjacent Kensington Place site in a phased manner, with a similar reduction in designed space allocation to Option 1, whilst maintaining existing hospital services as work proceeds
4. A hybrid phased option, developing hospital facilities over both Overdale and Gloucester St/Kensington Place, ensuring the most advantageous division of services whilst continuing to deliver safe clinical services and minimising any potential impacts (emergency, ambulatory, intermediate care, rehabilitation, etc).

All of the options above are able to deliver safe clinical and operational services.

It should be noted that option 4 is not the same as the previous dual site solution since that only explored the refurbishment and redevelopment of the existing Jersey General Hospital site over many phases rather than new build developments of adjacent sites that avoid complex works on an existing, operational site and associated enabling works.

Criteria For Assessment

The criteria for options appraisal were based upon critical success factors outlined in HM Treasury Green Book guidance on appraisal and evaluation of policies, projects and programmes[3]. The criteria can be grouped as:

• Deliverability/Achievability

• Affordability

• Suitability

• Social Value

• Operations

• Capacity and Capability

• Innovation

• Strategic fit and meets business needs

• Potential value for money

• Supplier capacity and capability

• Potential affordability

• Potential achievability

Conclusions

When weighing up the available evidence, the Review considered the adoption of a phased option delivered over two or more sites, Overdale and Gloucester Street/Kensington Place, would provide the best opportunity to make the scheme more affordable and appropriate. Whilst it must be recognised that this approach will not use all the material that has been developed to date, a substantial portion can be modified and adapted as well as the work that was developed as part of the Future Hospital proposals.

Part of the consideration of taking this approach is because there is currently significant cost uncertainty – the larger the scheme, the more uncertainty there is – not for the known elements of the work, but for inflation and risk contingencies. This Review does not therefore give precise figures in relation to the extent of saving that can be achieved but does provide some indicative estimations, at today's prices.

It is considered that  a multi-site phased approach, broken up into smaller packages of work, presents a prudent risk management approach to deliver a more affordable project through a different financing model. In addition, it is considered that by spreading then commitment to spend over a longer period, and executing some elements of construction in the shortest time possible, this would create an environment where some health facilities could be replaced and momentum gathered to deliver the project. This view is in contrast to the single large-scale and high-cost scheme with cost estimates for construction outside the forecasts within the Outline Business Case, making it unaffordable within current approvals.

In addition to being affordable, to be appropriate, the right services must be delivered in the right place. Consequently, the Review recommends that further, comprehensive consultation should take place with all stakeholders, but especially healthcare staff and clinicians, before determining the locations of the different services. Some adjacency of service are absolutely essential and these will provide a critical mass' of departments that should stay together. Whilst the majority of clinicians consulted as part of the Review work to date have articulated a strong preference for a single-site solution, it is recognised that changes to project affordability as a result the global economic environment and the overall community perspective mean that the project context has changed and an appropriate risk management approach is prudent. Furthermore, that there is an overriding need to deliver modern healthcare facilities for Jersey and that a hybrid or multi-site option is workable and a considerably more favourable solution than a potential further prolonged delay to identify an alternative affordable single site option.

Additional work will be required to further refine the functional brief agreed as part of the Our Hospital project; an outline of a possible division of delivery location for services that is liable to change following consultation could be:

• Phase A

o Elective in-patient and day surgery (public and private)

o Ambulatory care and outpatients

o The possibility of including some kind of primary care services should not be discounted (could be either phase).

o Intermediate care services, including rehabilitation

• Phase B

• Urgent Treatment Centre, Emergency and in-patient services and associated diagnostics
• Intensive Treatment Unit
• Women's and Children's services
• Knowledge and Education Centre (could be either phase)

The Review also found that mental health services could be established at a separate standalone location, which could be on the Overdale site, although further work would need to be undertaken to validate this possibility.

The Review reached this conclusion for the following reasons:

1. It was recognised that all previous scheme iterations relied on a single highly concentrated site solution, which brought all services onto a single relatively confined location. The need for appropriately sized sites capable of supporting the scale of services provided was reinforced during the fact-finding trip to visit various hospital facilities in Northern Ireland. Any variation of the currently planned scheme would therefore benefit from the larger initial footprint for services provided by two larger sites rather than just one, whilst still enabling room for future expansion, disposals of sites or use for other strategic priorities.

2. Dividing the services over distinct and separate sites provides an appropriate response to public feedback to reduce the environmental impact of the current scheme on the lands adjacent to Overdale whilst still providing world class health facilities. The associated cost saving is estimated to be circa £50 million at today's prices taken from acquisitions to date and estimates for the access works. All cost savings described in this report are estimates informed by evidence provided by project cost consultants and the experience of the Principal Expert Adviser. Further work will need to be undertaken to fully validate these estimates as part of the business case process. It is also recognised that for some, the environmental impacts are outweighed by the benefits of healthcare facilities all in one location.
3. Separating the scheme into smaller constituent elements will interest a larger number of contractors rather than only the very largest of contractors. Through distributing and phasing the scheme into smaller elements, it allows for a procurement approach that will enable a greater local contractor interest and for them to have a larger stake, in any partnership with larger, off-island firms that are more experienced in the delivery of health care facilities. It should be recognised that a programme of works does bring added complexity and possibly risk, but it could be argued that this is offset by increased diversity of supply chain (i.e., no single point of failure). This approach has also been adopted for other capital projects and has proved successful, i.e., the Sewage Treatment Works.
4. There will also be increased benefits for the local economy and increased social value through training initiatives, upskilling islanders to maintain the infrastructure that is being delivered. Indeed, evidence presented from the local construction industry expressed frustration that the scale of the current project precluded many of the local contracting industry from fully participating and that phased smaller contracts permitted better value for money and lower tenders to be achieved. In addition, stakeholders also noted that although smaller, those phased contracts were likely to remain of sufficient size and scale to attract international construction interest. The new government also intends to play a greater and more inclusive role in island wide construction planning, and it is anticipated that, in future, there may be significant opportunity to programme other projects more accurately in order to provide a more consistent overall development profile.

5. In turn, this could drive more competitive bids and leave a higher percentage of the overall project spend circulating within the Jersey economy. This could have the potential for a 5-10% capital cost reduction with savings estimated to be circa £30-60 million at today's prices and engender greater buy-in and commitment. These figures are estimates but were tested with project advisors during stakeholder meetings from their experience of competitive bids. However, reliance on a greater number of contractors could increase the risk of slippage along the project's critical path; conversely it also spreads the risk across a larger number of organisations, potentially increasing resilience.
6. Revisiting the scheme requirement allows consideration of future digital healthcare services delivery (such as remote monitoring and online consultations) to be incorporated into any revised proposal and thus future space requirements. This would have a beneficial effect on the future efficiency of Jersey's health service and provide the potential for a 2.5-5% cost capital cost reduction savings estimated to be circa £15-30 million at today's prices. These space reductions were tested with Digital Specialists within OHP Advisor organisations and are commensurate with savings seen on schemes in Northern Ireland. In line with the discussion on page 23, any investment in digital schemes should be balanced with a number of considerations, such as potential space reduction, clinical benefit, and geographic context. Smaller facilities within the hybrid model described above also allows for the increased potential for lower cost off-island modular construction for some buildings. Whilst historically, these solutions were not robust, they are now designed to the same standards and with the same life expectancy as in-situ construction. This type of approach could still optimise involvement for local contractors and mitigate against inflationary pressures if the local construction industry remains strong and demand continues to outstrip supply, as currently. This could have the potential for a 2.5-5% cost capital cost reduction savings estimated to be circa £15-30 million at today's prices. These are estimated from savings in overall programme time for preliminaries.
7. Evidence presented by clinicians arising from experience of the delivery of mental health services suggested that the Functional Brief in relation to Mental Health should be reviewed. It may be more appropriate that acute mental health services are co-located with other services. This is a significant amendment from the current Functional Brief and needs careful exploration. Delivery of this separate project should be at pace.

8. In addition to the above and in line with HM Treasury best practice, any revised proposal and associated business case should also reflect and offset the market values of health care facilities no longer required against the proposed scheme. Whilst this could reduce the capital cost of the proposals going forward, the realisation of any capital receipts would be dependent on political decisions regarding the future alternative uses of sites currently part of the health estate, for example the Gloucester Street General Hospital. Estimated value circa £15-20 million at today's prices on the basis of recent land transactions for affordable housing.
9. Crucially, the phased or hybrid model allows the delivery of future health care facilities to be risk managed. In other words, phasing the various elements provides an opportunity to take the development forward within the realm of current affordability and to carefully balance investment in the current estate with investment in the construction of new facilities when the market conditions are more favourable. This also allows for the scheme to progress within and beyond the mandate of the current Government as and when funding is secured. A phased solution can also better harness improvements in digital healthcare and every evolving healthcare equipment.

Being mindful of past delays and the age and deteriorating condition of the existing hospital facility, the Review recognised that the hybrid phased option, if accepted, should be progressed at pace and within clearly defined timescales in order to retain public confidence. It is acknowledged that the project will have to work hard to ensure clinicians also understand and can accept the reasons that previous proposals are no longer affordable and that this phased approach is the solution that is most achievable. The project team needs to ensure that all work undertaken to date is exploited to minimise any rework by clinicians. Ministers have provided clear direction to the Review that construction of new facilities must commence within the current electoral term.

Phasing Opportunities

Although subject to availability and profiling of capital funding, relevant approvals and favourable tendering conditions, the Review would suggest the

following phased development programme as a target to be followed:

• Phase 1 – Development of services at Overdale to be commenced on site within 24 months with a 36month construction programme to completion.

• Phase 2A – Development of phase 2 services at Kensington Place to be commenced on site within 36 months with a 36-month construction programme to completion

• Phase 2B - Development of remaining services in part of the current Hospital Site at Gloucester Street adjacent to Kensington Place, following completion of Phase 1 and 2A. This final phase to be commenced on-site within 72 months, with a 24 month construction programme to completion

• A review of the requirements for Mental Health facilities to be commenced immediately and proposals on site within 36 months with a 24-month construction programme to completion

Within these timelines, it may be possible to commence enabling works, subject to planning permission, on each of the phases twelve months in advance of the main schemes.

Other Considerations

It is recognised that within a phased hybrid option, there may be a degree of duplication in some clinical infrastructure which will have revenue implications, for example diagnostics facilities. There may also be increased staffing requirements, depending on the division of any services. However, the duplication of same may be appropriate in comparison to the potential costs savings that could be achieved and, in many cases, there may already be duplication of equipment. Any such comparison would need to be considered as part of a detailed options appraisal as part of the business case process. However, it should be noted that there may be a compelling argument and benefits for providing such duplication to ensure additional flexibility and resilience that would also be assessed against cost in any business case. This the direction of travel for some Health Authorities in the UK and indeed in Northern Ireland. It is possible to also provide resilience on a single site although there would be less mitigation if the whole site suffered an issue, i.e., fire or emergency event.

Appropriate resourcing of current healthcare facilities is recognised to be a global issue, also noted in Northern Ireland. Additional staffing would therefore seem to add to an existing issue. However, there is a reasonable timeframe to fully understand the reasons for current recruitment and retention issues and put in place strategies to attract staff. This is beyond the scope of this review and the hospital project itself, however it is anticipated that new, fit-for-purpose healthcare, knowledge and education facilities, will assist with this existing issue and help to mitigate the risk arising from any additional staffing requirement.

Following a recent visit to the redevelopment works at the former Les Quennevais School, the Minister for Infrastructure and Minister for Health and Social Services consider that there may be an opportunity to retain these facilities as a point of delivery for health and care in the longer term. This could be considered as part of Strategic Proposal 4 of the Bridging Island Plan regarding a west of Island planning framework and masterplan for Les Quennevais and adjacent areas and will be discussed with the Minister for Environment and the Connétable of St Brelade.

In addition, the Review team considers that it could be prudent to undertake a separate review in relation to the Island's mental health facilities requirements, to fully understand where they might best be located, whilst ensuring the right range of services are available to Islanders and fit as part of a holistic programme of healthcare facilities redevelopment.

As will be appreciated, the Review has been undertaken in a very constrained timeline: it is hoped these recommendations offer a roadmap to progressing the critically needed and long overdue healthcare facilities for the Island.

Should the Review recommendations be accepted, it is essential that a further, more detailed analysis is undertaken with respect to clinical risk, cost and planning assumptions before any final decisions are ratified.

Next Steps

The next steps that would take approximately three to six months would be:

1. Further consultation with stakeholders, especially healthcare staff on the services that should be provided in any hybrid or phased solution
2. Ensure sufficient funding to minimise clinical and operational risk at JGH

3. Commission review of requirements for mental health facilities to be commenced immediately
4. Ensure an appropriately sized political oversight group is in place that meets regularly and can make effective, timely decisions, in line with the Comptroller and Auditor General's 2017 report on Decision Making: Selecting a Site for the Future Hospital[4]
5. A mandate is prepared, providing an initial project plan, including potential resourcing and timelines.
6. Feasibility studies to convert current designs and proposals into initial proof of concept designs and costings
7. Report and Proposition in the States Assembly for phased or hybrid solution at Overdale and Gloucester Street
8. Development of business case
9. Identify and secure funding of project through States Assembly and Government Plan processes.

Section 1: Introduction and Scope of Report

Introduction

The construction of new health care facilities is one of the most important tasks faced by the incoming government owing to the condition of the existing facilities and the clinical need and has been a subject of public and political interest for some time. The complexity of the approach, requirements, timescale for delivery, cost and financing has meant that the project has seen a number of iterations, none of which has achieved the construction milestone of a modern, affordable, value for money, fit for purpose, and efficient hospital for Jersey providing appropriate and modern healthcare services.

The case for new hospital facilities that are appropriate to the island of Jersey has been established and accepted by the public. As such, the Chief Minister has outlined the requirement for a review that will allow the Government of Jersey to make properly informed decisions about the future of the project. The aim is to provide evidence-based recommendations for the future of the project and to consider whether there may be options to deliver a more affordable and appropriate alternative – it will not seek to re-run or critique decision-making of the project to date. The Review scope seeks to expand on and explore the concepts of affordability and appropriateness.

Review Scope

The Review has:

• Assessed the affordability of the current project in light of recent global events that have considerably altered the financial climate and fractured international supply chains.

• Considered the state of the existing hospital and associated health and care facilities, including an assessment of the measures required to ensure that they remain fit for purpose pending the delivery of new health and care facilities.

• Considered measures currently being undertaken to improve and transform Jersey's health service during this period.

• Examined various options from a scope, operational efficiency, cost, programme and local economic impacts perspective, including, but not limited to:

• a scheme at Overdale;
• a scheme on the existing Gloucester Street site, utilising adjacent sites, such as Kensington Place;

• opportunities for a longer-term phased development at Overdale or Gloucester Street, and;
• the opportunity to use secondary sites to complement the delivery of health and care from a primary hospital location.

A new site assessment process is not part of the Review, as this would not enable the delivery of a new hospital within the required timescale.

Care has been taken to ensure that the development incorporates provision of delivery space for an appropriate range of health and care service for Jersey, contributes to a whole system' of healthcare, addresses future care needs, is aligned to evidence-based models of care and includes opportunities to exploit innovation and digital methods of care delivery.

The Review has sought to identify where opportunities to reduce cost or increase and add value might arise. Areas of focus include, but are not limited to:

• Reducing construction costs – for example by reviewing scope, size of development or alternative delivery techniques such as Modern Methods of Construction/modular build (without compromising on quality of build or clinical risk factors).

• Reducing associated infrastructure costs – for example, by reducing the requirement for transport measures and road improvements

• Reducing overall cost – for example by disposing of land not required for health facilities or delivering value by enabling other strategic objectives of the Government of Jersey

• Phasing of activity – breaking the construction into phases over a longer period of delivery may be an appropriate risk management response. In other words, whilst a phased build might appear to cost more on paper, due to inflationary changes as time passes, real terms adjusted costs may be comparable. The key mitigation opportunity arising from phasing is therefore the distribution of costs over a longer time. This could make delivery more affordable for Government finances at any given point, particularly in an uncertain global economic environment, when compared to a single-phased approach that may require commitment of significant resources at a stroke. Phasing may also enable more flexibility in the timing of large expenditure, permitting optimal funding arrangements.

• Procurement approach – for example providing greater opportunity to tender smaller work packages to the local construction industry, getting the best agreements in place with contractors regarding their overheads and profit, and identifying a partner or partners that will leave a lasting legacy in Jersey in terms of social value – leaving professionally-trained and knowledgeable local residents with transferable skills that can benefit the island in future projects once the health care facilities have been delivered.

• Digital health – for example, optimising the use of remote consultations to reduce the need for clinical floor space or exploiting telehealth internet of things devices connected to central analytics and software could achieve efficiencies and opportunities to reduce scale, whilst potentially improving clinical outcomes and achieving efficiencies. However, Jersey's small geography means that accessibility to its health and care services is excellent, and remote consultations for those without mobility challenges may not prove to be as successfully adopted on a Jersey-only basis as they might be on a greater geographic scale. Remote consultations may be more successful if they can be offered to island residents appropriately from off-island, but necessary controls would need to be put in place from a clinical governance perspective and a significant culture shift with respect to health and care services consumption within Islanders will be required. Telehealth is also of benefit for peer-to-peer communication.

At the same time, the digital environment continues to evolve and, and investment in digital health technologies must carefully balance benefit, cost, and other interdependencies, such as implications for the hardware/software framework to enable delivery, as well as clinical governance, regulation, licensing costs and data protection/permissions access. Notwithstanding, these are barriers to delivery which are challenging but can be overcome. In addition, opportunities for progress in this should be exploited as the world moves towards a more digital delivery environment. Indeed, Jersey should be aspiring to achieve high-standards of digitally embedded healthcare, as expressed in the Digital Health Strategy that was developed in partnership with Digital Jersey in 2016[5], and ambitions to achieve the highest level of digital health care maturity – HIMSS7[6]. However, the ability to deliver such ambitions has been slower than anticipated, and greater focus will be required in setting out a roadmap for an achievable delivery plan with appropriate levels of investment and culture change management. It might be that a dedicated digital health team needs to be established, most likely with an external partner with a proven track record in order to achieve digital ambitions.

Process

The Review has been informed by:

• A review of key project documents and sources of challenge and/or scrutiny, pertaining to various iterations of the project

• Evidence from a range of stakeholders

• Visits to completed hospital projects elsewhere in the British Isles.

An appraisal of the options outlined above has been undertaken, using criteria based upon critical success factors outlined in HM Treasury Green Book guidance on appraisal and evaluation of policies, projects and programmes. The criteria were:

• Potential deliverability/achievability, to consider

o Time

o Scale and phasing, local involvement and engagement

• Potential affordability, to consider

o Capital cost

o Global economic circumstances and risks

o Financing options

• Suitability – strategic fit and meets business needs, to consider

o Scope and functional brief

o Clinical and operational need

o Clinical and operational risk

• Social value and potential value for money, to consider

o Local economic impacts

o Social, economic and environmental costs, including proportionality of ancillary infrastructure

o Benefits and risks

• Operations

o Operational costs, including revenue and staffing costs

• Supplier capacity and capability, to consider

o Procurement and team assembly

o Local involvement

• Innovation

o Opportunities for taking advantage of digital health care

o Modern Methods of Construction

Whilst a reasonable assessment of each option has been undertaken for each criterion, based upon the evidence considered, including expert evidence from officers and advisers with extensive professional experience such as commercial and cost consultants, designers, engineers and quantity surveyors, the options appraisal will not be based on fully weighted quantitative measures. Such analysis would normally be undertaken to formulate a detailed business case.

However, this Review does provide an evidence-based appraisal of options, relative to one another, to identify opportunities to reduce cost and add value, and present a new direction of travel and associated phased action plan for decision makers to consider.

Stakeholders were selected on the basis of their knowledge and experience. They have not been asked to declare any conflicts of interest since they are not able to make decisions and their evidence will be shared widely and subject to public scrutiny.

It is important to note that following this Review, if decision makers change the mandate of the Our Hospital project, this report does not replace the processes required as part of Government of Jersey governance frameworks.

The Review has been led by the Minister for Infrastructure and supported by a Principal Expert Adviser, Mr Alan Moore OBE TD DL BSc (Hons) FRICS, who has extensive experience of large-scale capital projects in health and care.

The Review and advice provided by expert adviser(s) will be presented to the States Assembly by the Minister.

The Review Team

The Review Lead is the Minister for Infrastructure, Deputy Tom Binet .

Deputy Binet is supported by:

• The Minister for Health and Social Services, Deputy Karen Wilson

• The Assistant Minister for Health and Social Services, Deputy Rose Binet

The Principal Expert Adviser to the Review is Alan Moore OBE TD DL BSc (Hons) FRICS.

The Review team has been supported by Government of Jersey officers:

• Information relating to current and previous iterations of the hospital project has been provided by the Acting Our Hospital Project Director.

• Operational advice has been provided by to the Review by the Associate Managing Director of Health and Community Services.

Additional quality assurance has been provided by subject matter experts:

• Clinical assurance has been provided by the Medical Director of Health and Community Services, Patrick Armstrong.

• Insight into local industry has been provided by former Director General for Growth, Housing and Environment, John Rogers.

• Insight into digital health has been provided by the Chief Executive Officer of Digital Jersey, Tony Moretta.

• Further independent challenge has been provided by Dr Graham Root.

These individuals have not contributed directly to the content of the Review or influenced its outcomes but have provided critical friend challenge ahead of publication. They have reviewed the content for factual accuracy within their field of knowledge and identified areas where more or less focus should be required to produce a rounder, more coherent publication.

The Minister for Infrastructure would like to express his thanks to all of the Review team and expert quality assurance support for their input into this Review.

Section 2: Background to OHP Proposals and Emerging Delivery and Affordability Risks

Introduction

The current Jersey General Hospital in St Helier is tired and deteriorating. Previous projects have looked at delivering a new hospital for Jersey, most recently the Future Hospital Project, which preceded the current Our Hospital Project.

The Our Hospital Project (OHP) was initiated in 2019, which is the latest in a series of iterations to progress new hospital facilities spanning over 10 years.

To meet the clinical needs of the Island through OHP, the new hospital was anticipated to be deliverable by 2026, when costs to maintain the deteriorating hospital estate escalate sharply, could start to impact the delivery of care and mean greater expenditure on facilities that are due to be replaced.

Subsequent to the States Assembly receiving the OHP mandate, a number of specialist external States of Jersey employees were appointed, and professional services engagements put in place to support a public procurement exercise to identify and select a Design Delivery Partner (DDP), progress site selection, assist with OBC completion and submission of the Planning Application.

The DDP was appointed in July 2020 to support in these activities as part of a Pre-Construction Services Agreement (PCSA). This means that no build contracts were entered into, but the DDP would support the Government of Jersey to deliver a Technical Design and would be the preferred partner at the point of entering into construction contracts.

Overdale was endorsed as the preferred site for a new hospital by the States Assembly in November 2020 and the Assembly approved a funding model for the project in October 2021 on the basis of an Outline Business Case (OBC) produced in the Spring and Summer of that year.

In parallel, other key actions were progressed in relation to planning, land acquisition and other pre-contract award requirements. Following a Public Inquiry, conditional planning permission for the Overdale site was approved by the former Minister for the Environment in May 2022 following recommendation from Planning Inspector. The Government of Jersey is continuing to pursue the Planning Obligation Agreement for the Overdale site, which will provide a constructive baseline from which to work. This means that whatever the agreed direction of travel, the project will have an approved planning permission, and the reduction in scale of any future proposed development at Overdale can be balanced against it, as well as allowing the demolition and clearing of the site for any enabling works once any relevant conditions are discharged.

Discussions between the Government of Jersey and the DDP about ongoing affordability within the current uncertain economic climate have been on-going over several months. Regrettably, the DDP and expert cost consultants have recently advised that the current scheme is not likely to be deliverable within the budgets approved by the States Assembly. The current cost plan is estimating that costs will be £70 million to £115 million in excess of the figures provided in the OBC. As a result, Government of Jersey has recently taken steps to bring to a conclusion the PCSA contract by mutual agreement. This was on completion of Royal Institute of British Architects (RIBA) Stage 3 Spatial Coordination in September 2022. Completion at the end of a RIBA Stage means that there is a package of work that can be used to specify and brief any future project. It also could be continued from this stage in the future, if desirable.

As a result of the changes to the global economic context and its likely impacts on the  affordability of the current scheme, the Government of Jersey has initiated a review led by the Minister of Infrastructure Housing and Environment and supported by an expert adviser, with support from OHP team members to consider options and provide advice to the Assembly as to whether changes can be made to the hospital project to deliver a more affordable and appropriate alternative.

Section 3: Stakeholder Interviews and Submissions – What We Heard

Over twenty interviews have been held with the Review team with over sixty stakeholders who have been instrumental in developing previous or current proposals or healthcare schemes elsewhere. Summaries of information that was discussed at these interviews are provided in Appendix C. Some of the key messages are provided in this section:

• Cost estimates for the schemes have significantly increased since the OBC and this can be linked to global economic circumstances and the disruption of supply chains

• Cost estimates provided in the OBC are likely to be exceeded without alterations to the Functional Brief although one interviewee considered that it was still possible to deliver the currently constituted scheme within this envelope although they are not involved in the scheme and it was subject to certain conditions.

• There are various mechanisms that could be used to fund the current scheme; if the funding were required imminently, it is unlikely to be the funding mechanism presented in the OBC since financial markets are currently volatile and the short- term outlook for interest rates and investment returns is challenging. Longer term it is anticipated that this mechanism might become possible again.

• It could be beneficial to have flexibility in timing for raising funds that would be possible in a phased approach rather than for one large project. This is true for a one site or multi-site proposal.

• A risk-based approach has been adopted to manage existing hospital buildings since a new hospital has been expected for the last ten years. "Doing nothing is not an option".

• A number of works are essential to deliver services safely and so have been undertaken or planned to be undertaken. Further, the Review supports forming a working group to deliver small, short-term projects that would improve current working conditions and patient outcomes, i.e., quick wins'.

• Increased budgets are likely to be required to manage operational risks in those departments where new hospital facilities will not be delivered by 2026 although this may have been necessary even with the existing scheme.

• Phased solutions may permit whole buildings to be delivered earlier and healthcare service benefits to flow sooner. On a more constrained site, this will be less possible.

• Senior clinicians and managers in HCS were extensively consulted on the current brief for the hospital and the departmental and room layouts.

• They confirmed that they were challenged during the consultation process and not all requests were necessarily incorporated

• The majority would like to see the current proposals move forward but reluctantly acknowledge that global events necessitate a review of the current scheme and requirement to consider alternative, more affordable solutions

• There are different options that could deliver a scheme that achieves new, fit for purpose healthcare facilities that could meet clinicians' and users' requirements

• Further detailed work on the impact of each option is required to fully understand any potential clinical and operational risks and likely impacts and mitigate these although some can be inferred

• Jersey has specific recruitment challenges with some staff attracted to the Island because of the Our Hospital Project'

• Education and learning is central to developing and maintaining high quality and safe health care in addition to maintaining recruitment and retention. It is vitally important that Education is given significant prominence in any project.

• Many health workers and clinicians expressed concern that they would need to further input into proposals for healthcare facilities. There was frustration that they had made significant contributions to previous proposals and there was little appetite to start again.

• The importance of communication with all healthcare staff and islanders over different channels and locations was emphasised.

• Opportunities to modernise and upgrade electronic systems and technological platforms are available and should be explored further. Digital Health Specialists confirm that for example in outpatients, these could lead up to a one third reduction in patient presentations and up to a twenty percent space savings.

• Non-delivery of these digital aspirations is a considerable risk. A dedicated digital health team needs to be established most likely with an external partner with a proven track record in order to achieve digital ambitions.

• From the ambulance and patient transport services perspective, all potential sites are viable options however the factors that need careful consideration are access and egress to the site, traffic flows and safety of the crews. Evidence was provided to the Public Inquiry of the importance of these aspects and the challenges in mitigating these risks with one-way systems or hurry- signals/traffic lights.

• If a dual or multi-site solution were being explored, then distance to and from sites, as well as additional journeys an out of town option would generate, needs to be considered.

• Consideration also needs to be given to the amount of space that is available on any site for the segregation and manoeuvring of emergency vehicles adjacent the healthcare buildings. Out of town options have provided more opportunities for this than urban settings, owing to additional availability of space.

• A development of this scale presents clear constraints, challenges, and infrastructure needs as well as opportunities (and opportunity cost) in relation to sites released

• Any development also has to follow due regulatory process. As experience in this project shows, there is no straightforward site from an infrastructure or planning point of view. Each site has its unique challenges which will need to be overcome before development proceeds.

• Ancillary infrastructure is normally proportionate to the scale of any development proposal; consequently, there may be potential to reduce planned mitigations if the impacts are lower, such as for transport infrastructure.

• The Minister for Environment may decide that Planning Inquiries are not necessary where development is on an existing hospital site (and the proposed development is of a similar or smaller scale) or where a Planning Permission is already in place.

• There are milestones and overall timelines that are typically required for any large construction project, and will be applicable to proposals for new hospital facilities whether at Overdale or Gloucester Street or a hybrid scheme.

• Time needs to be allowed for political decision making, such as Decisions in the States Assembly. If required, also for any revised project mandate and funding.

• The fastest solution to deliver would be the developed solution for Overdale.

• The slowest solution to deliver would be a redevelopment at Gloucester Street, using only land currently within public ownership.

• The current commercial model with a DDP was agreed at a different time with a different market outlook.

• The project has been a clinically led one, with the design team responding to the clinical user requirements and the contractor looking at the logistical approach and supply chain.

• The shape of the team will depend on the type of scheme and the chosen approach. However, there should be a Senior Responsible Owner assigned and the Project Director role should be filled by an employee of the Government of Jersey.

• Given the nature of the project, it is always likely that a blend of local and off- island skills and knowledge will be required; the larger the scheme, the more likely that there will be a larger requirement from off-island resources.

• Conversely, a smaller or phased solution will enable larger involvement and buy- in from local contractors and construction professionals where there is capacity.

• Members of the Jersey Construction Council were in favour of increased opportunities to become involved in the design and construction of new healthcare facilities that would also support increased training and educational opportunities for those seeking careers in the construction industry.

• Any project of this size needs a Government client team function, to oversee and control the work of the contractors or consultants. GoJ does not carry this level of capacity in house and therefore there is a need for client functions to also be understood and funded, to ensure GoJ interests are protected.

• The new government also intends to play a greater and more inclusive role in island wide construction planning, and it is anticipated that, in future, there may be significant opportunity to programme other projects more accurately in order to provide a more consistent overall development profile, helping to balance supply and demand in the construction market and consequent pricing.

• The Public Finance Manual does require all procurement to deliver Value for Money; this is normally demonstrated through a tender process.

• GoJ can and sometimes does request to use UK Government contractual frameworks and this is appropriate and possible in certain circumstances. However, this does not normally obviate a tender process.

In the following sections of the report, further information is provided regarding the current condition of healthcare facilities and the steps that have been agreed to manage extant and emerging risks as well as measures that are currently being taken to improve and transform Jersey's health service.

Section 4: The State of The Existing Hospital Including an Assessment of the Measures Required to Ensure That They Remain Fit for Purpose

The Review heard that a large proportion of the existing hospital infrastructure is ageing and reaching operational failure. This has long been recognised and the reason that there have been several iterations of hospital project seeking to replace it. Not only has the ageing infrastructure not been replaced, maintenance spend has been minimised to avoid abortive cost.

In 2019,  a master condition survey (six facet survey)  was undertaken that identified £83 million to upgrade as far as is possible existing infrastructure. The department is assigned an annual budget of £5 million which is managed on a risk prioritisation basis, balancing against clinical requirements and accessibility to operational areas.

There are a number of areas where there is a single point of failure, and it remains challenging to manage these risks. These are in mechanical /electrical services, the building fabric, including water and fire compliance which presents a daily challenge to infection prevention and control. Managing these risks also contributes to current operational costs.

The Review heard directly about the additional health and safety measures and constraints associated with construction works on live healthcare sites and that this can lead to increased pricing or a reluctance to undertake works when other opportunities might be available. They are also factors in any redevelopment of the existing Jersey General Hospital site.

It is absolutely imperative that existing Jersey General Hospital site infrastructure at Gloucester Street remains safe whilst the various developments are constructed. To this end, additional funding should be (and is currently being) made readily available to utilise in the event that it is required.  

It was further agreed that a working group should be formed to identify interim solutions that could improve current working conditions and patient outcomes.  

Section 5: Measures Currently Being Undertaken to Improve and Transform Jersey's Health Service

Provided by Minister for Health and Social Services, Karen Wilson :

The general direction of travel in health economies internationally is ensuring hospital-based care is of high quality and focused on delivering specialist care and treatment. Alongside this, developments in primary care and in the community are supporting the delivery of person-centred care, focusing on early intervention, prevention and self-care.

The original intention behind the JCM was to make progress towards a more community based/primary care focused model of service but is currently paused following concerns raised by the public about the delivery of such an approach for Jersey.

In this context the new hospital facilities need to be flexible enough to deliver health and care services in the context of any future healthcare model. The healthcare model will inform the brief for new healthcare facilities and will be constantly evolving.

Section 6: Identification and Examination of Options to Permit Both Future Affordability and Delivery of Appropriately Provisioned Hospital Solution

The Review, in considering the current proposal to build the new hospital as currently configured at Overdale, has concluded that this is unachievable within the original £620 million envelope established to fund the contracted elements of the project. The current cost plan is estimating that costs will be £70 million to £115 million in excess of the figures provided in the OBC. This scenario is as a result of global economic circumstances.

It would be possible to return to the States Assembly for a larger capital bid, however given current global economic circumstances, there would remain a risk that an even larger sum would be required and there would have to be significant contingencies. Seeking any approval of a new funding envelope is likely to take in the order of three months. Since the current contractual relationship with the DDP is predicated on one large construction contract, with rapid site delivery, the current PCSA with the DDP has been brought to a conclusion at the end of RIBA3.

It was similarly concluded that a relocation of the Overdale proposal as currently configured to the existing hospital site at Gloucester Street was similarly unaffordable since any benefits achieved from reduced ancillary works will be equivalent to the costs of working within a constrained town centre setting. There would also be increased clinical and operational risks from development of an existing hospital site. These can be significantly mitigated but will continue to impact services users and providers as well as increase cost. There will also be additional design costs and larger abortive costs from the current expenditure to date. From a practical perspective, it is also going to be more challenging to mitigate environmental challenges of any designs since even with a reduced scope, volumetric requirements would still be larger than the Future Hospital proposals that twice were not able to secure a successful Planning determination. It is therefore concluded that relocation of the currently configured proposals to Gloucester Street would not be affordable and are unachievable from a space planning perspective.

Both of these options have therefore been discounted from further consideration.

Further Options for Consideration:

The Review has identified the following further options for consideration with a view to increasing affordability and still achieving the new modern healthcare facilities for Jersey. In line with the terms of reference, the Review has not sought to reopen the site assessment process to an extensive list of sites across the Island. This is because this approach would create a significant delay in progress and almost certainly would not enable the delivery of a new hospital within the required timescale. The review options were therefore limited to permutations around the existing Jersey General Hospital site including nearby sites in Government of Jersey ownership and the Overdale site, as designated as a site for a new hospital for Jersey in the Bridging Island Plan 2022-2025[7].

In considering the options it was determined that two variants of a reduced scheme at Overdale should be explored. All of the options below are able to deliver safe clinical and operational services.

Option 1A: A reduced scope hospital at Overdale – Develop Overdale as the sole Hospital site with a significant reduction in designed space allocation.

Option 1B: A reduced scope hospital at Overdale – Develop Overdale as the sole Hospital site with a significant reduction in designed space allocation and in a phased manner.

Option 2: Gloucester Street with a scope reduced from the current scheme – Redevelop the existing hospital site at Gloucester Street with a similar reduction in designed space  allocation  as  Option 1,  and in a phased manner,  whilst maintaining existing hospital services as work proceeds.

Option 3: Gloucester Street and Kensington Place with a scope reduced from the current scheme – To redevelop the existing hospital site at Gloucester Street and the adjacent Kensington place site with a similar reduction in designed space allocation as Option 1, and in a phased manner, whilst maintaining existing hospital services as work proceeds.

Option 4: A multi-site scheme, delivered across Overdale and Gloucester Street/Kensington Place sites – A hybrid, phased option developing hospital services over more than one site with a similar reduction in designed space allocation as Option 1. This would most likely be Overdale and Gloucester St/Kensington Place. Grouping of services (that could be combined) could be:

• Emergency and In-patient services with associated diagnostics, Intensive Treatment Unit,

• Intermediate Care Beds and Rehabilitation

• Urgent Treatment Centre, Ambulatory care and Outpatients (and possibly GP services)

• Elective In-patient and Day Surgery

• Mental Health services would also be established at Overdale or at a separate standalone location in line with best clinical practice

The Review has identified and appraised options in line with the criteria derived from HM Treasury Green Book critical success factors outlined on page 12. Within the constraints of these criteria, the Review considered a number of other important factors that should be taken into account:

1. In terms of Strategic Fit, it is important to design a facility that:

1. Delivers an advantageous solution in terms of hospital design and functionality both now and into the future, embracing opportunities for modernisation of clinical practice where appropriate.
2. Does not compromise on clinical safety.

2. In terms of potential value for money and supplier capacity and capability, ensure the best value team assembly and opportunities for Islanders, permitting where possible any benefits of greater market competition and past project design expenditure are retained. It must be noted that previous false starts on the project will have damaged the Island's reputation in the supplier market, and care should be taken to appropriately engage local and international markets to identify the widest pool of potential suppliers and achieve the best value for money, within the procurement parameters set out in the Public Finances Manual.
3. In terms of potential achievability, timely hospital delivery and commissioning within affordability constraints. Ministers have provided clear direction to the Review that construction of new facilities should commence within the current electoral term. This means that some options are likely to perform less well against the achievability criterion, given that the overall programme is likely to be elongated as design completion will take a greater amount of time, and that, dependent on the procurement approach, further tender activity may be required that would mean that construction would be less likely to commence within the current electoral term.

4. There is no contemplation of not working to healthcare planning standards or designs that have not been demonstrated to be clinically or operationally safe, generally codified through Health Building Notes (HBN) and Health Technical Memoranda (HTM). All options require a reduction to the currently drawn proposals to achieve affordability and a hybrid solution necessitates a division of services between sites. Whilst the Review has heard from health workers and senior operational managers and clinicians, there is noover- riding consensus on those areas or departments that should be reduced or removed from current proposals or the optimal division between sites. Further consultations with healthcare workers and senior clinicians is therefore essential and will take at least one month.
5. Work could be undertaken to identify opportunities and maximise advancements in digital health care services that have taken place since the writing of the Functional Brief and as a consequence of Covid. Investment in these technologies needs to be appraised with a cost/benefit approach, and further consultation is required with clinical and operational teams in HCS to establish the extent to which these could be incorporated into any revised Functional Brief and associated design proposals. Notwithstanding, review participants agreed that these could contribute to a 2.5 to 5% capital cost reduction, estimated to be circa £15 to £30 million at today's prices. However, in order to realise these kinds of savings, these figures will need to be validated alongside an achievable plan to realise Jersey' digital strategy ambitions, with a dedicated team where appropriate.
6. Evidence presented by clinicians arising from experience of the delivery of mental health services suggested that the Functional Brief in relation to Mental Health should be reviewed. It may be more appropriate that acute mental health services are co-located with other similar services. This is a significant amendment from the current Functional Brief and should be addressed by a separate project team and come forward as a separate programme of works.

A high-level narrative bringing out the key differences between the performance of options against each criterion follows. A RAG-rated summary of how options performed relative to each other can be found in the table on page 51.

Application of Critical Success Factors to Options Option 1A: A Reduced Scope Hospital At Overdale

Develop  Overdale  as  the  sole  hospital  site  with  a  significant  reduction  in designed space allocation and no phasing.

Option 1B: A Reduced Scope Hospital At Overdale Delivered In A Phased Manner

Develop  Overdale  as  the  sole  Hospital  site  with  a  significant  reduction  in designed space allocation and in a phased manner.

Option 2: Gloucester Street With A Scope Reduced From The Current Scheme

Redevelop the existing hospital site at Gloucester Street with a similar reduction in designed space allocation as  Option 1,  and in a phased manner, whilst maintaining existing hospital services as work proceeds.

Option 3: Gloucester Street And Kensington Place With A Scope Reduced From The Current Scheme

To redevelop the existing hospital site at Gloucester Street and the adjacent Kensington Place site with a similar reduction in designed space allocation as Option 1, and in a phased manner, whilst maintaining existing hospital services as work proceeds.

Option 4: A Multi-Site Scheme, Delivered Across Overdale And Gloucester Street/Kensington Place Sites

A hybrid, phased option developing hospital services over more than one site with a similar reduction in designed space allocation as Option 1. This would most  likely  be  Overdale  and  Gloucester  St/Kensington  Place.  Grouping  of services (that could be combined) could be:

• Emergency and In-patient services with associated diagnostics, Intensive Treatment Unit,

• Intermediate Care Beds and Rehabilitation

• Urgent Treatment Centre, Ambulatory care and Outpatients (and possibly

GP services)

• Elective In-patient and Day Surgery

• Mental Health services would also be established at Overdale or at a separate standalone location in line with best clinical practice.

Summary of Options Appraisal – Relative comparison of options – all options can deliver clinically and operationally safe healthcare facilities

It should be noted that the current Overdale Scheme and that scheme transposed to Gloucester Street are unaffordable and the latter, also unachievable. Therefore a detailed analysis has not been prepared for these schemes.

Section 7: Conclusions

When weighing up the available evidence, the Review considered the adoption of a phased option delivered over two or more sites, Overdale and Gloucester Street/Kensington Place, would provide the best opportunity to make the scheme more affordable and appropriate. However, it is challenging in the current uncertain financial climate to give precise figures in relation to the extent of saving that can be achieved.

In addition to being more affordable, to be appropriate, the right services must be delivered in the right place. Consequently, the  Review recommends that further, comprehensive consultation should take place with all stakeholders, but especially healthcare staff and clinicians before determining the locations of the different services. Some adjacency of service are absolutely essential and these will provide a critical mass' of departments that should stay together.

Additional work will be required to further refine the functional brief agreed as part of the Our Hospital project; an outline of a possible division of delivery location for services that is liable to change following consultation could be:

• Phase A

o Elective in-patient and day surgery (public and private)

o Ambulatory care and outpatients

o The possibility of including some kind of primary care services should not be discounted (could be either phase).

o Intermediate care services, including rehabilitation

• Phase B

• Urgent Treatment Centre, Emergency and in-patient services and associated diagnostics
• Intensive Treatment Unit
• Women's and Children's services
• Knowledge and Education Centre (could be either phase)

The Review also found that mental health services could be established at a separate standalone location, which could be on the Overdale site, although further work would need to be undertaken to validate this possibility.

Being mindful of past delays and the age and deteriorating condition of the existing hospital facility, the Review recognised that the hybrid phased option, if accepted, should be progressed at pace and within clearly defined timescales in order to retain public confidence. Ministers have provided clear direction to the Review that construction of new facilities should commence within the current electoral term.

Phasing Opportunities

Although subject to availability and profiling of capital funding, relevant approvals and favourable tendering conditions, the Review would suggest the following phased development programme as a target to be followed:

• Phase 1 – Development of services at Overdale to be commenced on site within 24 months with a 36month construction programme to completion.

• Phase 2A – Development of phase 2 services at Kensington Place to be commenced on site within 36 months with a 36-month construction programme to completion

• Phase 2B – Development of remaining services in part of the current Hospital Site at Gloucester Street adjacent to Kensington Place, following completion of Phase 1 and 2A. This final phase to be commenced on-site within 72 months, with a 24 month construction programme to completion

• A review of the requirements for Mental Health facilities to be commenced immediately and proposals on site within 36 months with a 24-month construction programme to completion

Within these timelines, it may be possible to commence enabling works, subject to planning permission, on each of the phases twelve months in advance of the main schemes.

Other Considerations

It is recognised that within a phased hybrid option, there may be a degree of duplication in some clinical infrastructure which will have revenue implications, for example diagnostics facilities. There will also be increased staffing requirements, depending on the division of any services. However, the duplication of same may be appropriate in comparison to the potential costs savings that could be achieved and in many circumstances, equipment may already be duplicated. Any such comparison would need to be considered as part of a detailed options appraisal as part of the business case process. However, it should be noted that there may be a compelling argument for providing such duplication to ensure additional flexibility and resilience. This the direction of travel for some Health Authorities in the UK and indeed in Northern Ireland.

Appropriate resourcing of current healthcare facilities is recognised to be a global issue, also noted in Northern Ireland. Additional staffing would therefore seem to add to an existing issue. However, there is a reasonable timeframe to fully understand the reasons for current recruitment and retention issues and put in place strategies to attract staff. This is beyond the scope of this review and the hospital project itself, however it is anticipated that new, fit- for-purpose healthcare, knowledge and education facilities, will assist with this existing issue and help to mitigate the risk arising from any additional staffing requirement.

As will be appreciated, the Review has been undertaken in a very constrained timeline. There was a restricted timescale to carry out the Review, but it is hoped these recommendations offer a roadmap to progressing the critically needed and long overdue healthcare facilities for the Island.

Should the Review recommendations be accepted, it is essential that a further, more detailed analysis is undertaken with respect to clinical risk, cost and planning assumptions before any final decisions are ratified.

Next Steps

The next steps that would take approximately three to six months would be:

1. Further consultation with stakeholders, especially healthcare staff on the services that should be provided in any hybrid or phased solution
2. Ensure sufficient funding to minimise clinical and operational risk at JGH
3. Commission review of requirements for mental health facilities to be commenced immediately
4. Ensure an appropriately sized political oversight group is in place that meets regularly and can make effective, timely decisions, in line with the Comptroller and Auditor General's 2017 report on Decision Making: Selecting a Site for the Future Hospital[1]
5. A mandate is prepared, providing an initial project plan, including potential resourcing and timelines.
6. Feasibility studies to convert current designs and proposals into initial proof of concept designs and costings
7. Report and Proposition in the States Assembly for phased or hybrid solution at Overdale and Gloucester Street
8. Development of business case

Identify and secure funding of project through States Assembly and Government Plan processes.

9

Acknowledgements  

The Ministers and Review group would wish to acknowledge with thanks those who provided assistance in the production of this report

Appendices

• Appendix 1: Stakeholders Interviewed and Evidence Taken as Part of The Review

• Appendix 2: List of Hospitals Visited as Part of The Review and Summary Report Regarding Same

• Appendix 3: The Current Condition Of The Jersey General Hospital And Working On An Operational Healthcare Site

• Appendix 4: Further Information From Our Hospital Project Team And Advisors

• Appendix 5: Applying £804million Overall Capital Costs

Appendix 1: Stakeholders Interviewed and Evidence Taken as Part of The Review

Appendix 2: List of Hospitals Visited as Part of The Review and Summary Report

Regarding Same

1. Overview Of Northern Ireland Hospital Visit

As part of the Government 100-day review of the Our Hospital Project a small group of officers and HCS staff (HCS Medical Director, Associate Managing Director and OHP Acting Project Director) travelled to Northern Ireland to support the Minister for Infrastructure, Tom Binet , who is leading the 100-day review. The group visited a number of best-in-class hospitals that had been delivered as capital projects by teams working to the Principal Expert Adviser. In addition, those hospitals were set up to serve similar population sizes to Jersey's facilities.

2. Healthcare Facilities

All the hospitals visited formed part of the Western Health and Social Care Trust in Northern Ireland:

1. Altnagelvin Hospital Londonderry
2. Northwest Cross-Border Cancer Centre, Londonderry
3. Grangewood Acute Psychiatric Hospital, Londonderry
4. Omagh Hospital and Primary Care Complex, Co Tyrone
5. South West Acute Hospital, Enniskillen

Altnagelvin Hospital

Altnagelvin is an acute hospital which offers a range of services, including a 24-hour Accident and Emergency Department and is one of Northern Ireland's five designated cancer units. It has472 inpatient beds and36 day case beds.

The hospitalis currently undergoing a major redevelopment programme, consisting of a phased development with a number of new build extensions already delivered on the site with several phases still planned. The Cancer Centre and north wing ward block being two of the more recent developments. Refurbishment of existing buildings, including the central tower block, has also been undertaken although to deliver less clinically intense activities.

The main hospital building consists of a 12 storey tower block with a number of adjoining new extensions accommodating the outpatient's department, day case unit, medical imaging, theatres, surgical wards, maternity ward, oncology unit, physiotherapy department.There are also separate buildings such as the Renal Unit, Breast Screening Unit, laboratories, and the pharmacy building. All of the main buildings are linked by two main corridors, with segregation achieved on different levels; underground supports the delivery of goods, ground floor level is for visitor traffic and the first floor is utilised for patient transfer across site. Demonstrating that although a mix of buildings, old and new are in existence, it is still possible to segregate flows and maintain dignity of patients.

The phased redevelopment of the site was possible owing to its out of town location, being originally surrounded by green open areas.

Altnagelvin has been a well-established site for delivering systemic anti-cancer treatment (SACT) for over a decade. However, with the recent establishment of a brand new state-of- the-art Cancer Centre on-site, the Trust is now in a privileged position to enable a catchment area consisting of approximately 500,000 residents to avail of both Chemotherapy and Radiotherapy Services closer to home. This is to residents both within Northern Ireland and the Republic of Ireland. Radiotherapy treatments have been provided since 2016 and are delivered five days a week, Monday to Friday.

Grangewood

Grangewood is an acute mental health inpatient unit situated in the central aspect of Gransha Park, an estate on the outskirts of Derry, where each building located on this site is surrounded by significant green open areas.

The new crisis unit provides inpatient acute mental health care, alongside a 24 hour, seven days a week crisis response and home treatment service. Flexibility of care is provided within patients own homes or at the new unit as an inpatient.

Grangewood is a modern, patient-centred facility with 30 beds and single ensuite facilities for service users. There is also a fully operational day care facility providing therapeutic activities, assessment, and many single and group activities such as physical health classes, pottery, art, social, education and employment. There is flexibility within the unit to flex up to 39 beds as required. The unit is 3,500 sqm and was built at a cost of £10.8m and opened in 2012

The Omagh Hospital And Primary Care Complex:

This facility offers Primary Care alongside Ambulatory Care in a unit that opened in June 2017. This development replaced an acute hospital following a reconfiguration of services across the area and at the outset was  not  a welcomed development  due to  the loss of the community's local hospital.

Most of the local GP practices moved into the centre and now work alongside each other providing routine and out of hours GP access. They are co-located to the nurse led Minor injuries walk in centre, providing 24 hour access. Major traumas and emergencies are not treated on this site and would be taken to Altnagelvin or South-West Acute Hospital (SWAH). Also adjacent is a Nurse Led cardiac care service, a protocol followed service that assesses and triages patients with suspected cardiac problems, referring only those patients with a true cardiac concern to the main hospital centre.

A large number of varied Outpatients Clinics are delivered onsite, with a dedicated Women's Health centre and sexual health clinic. In addition, there is also a Mental Health outpatient service and a 16 station renal dialysis satellite unit.

Three theatres provide a range of day case surgery, adjacent to an endoscopy unit, with 22 recovery beds for patients' recuperation. Transfer rates (into the main hospital site) as a result of failed day cases or intraoperative complications are monitored and are low.

There are two inpatient wards providing 40 single ensuite bedrooms, delivering Palliative Care and Rehabilitation. The rehabilitation beds have strict admission criteria with the routine length of stay being 14 days.

This was a £110m development built in 2017 at a design size of 20,285 sqm.

The South West Acute Hospital (SWAH):

This relatively new hospital is situated in Enniskillen and was opened in June 2012, with patients transferring from the old Erne Hospital. There are up to 210 inpatient beds with 22 day case beds, serving a population of a similar size to Jersey.

This was a Private Finance Initiative (PFI) build which was constructed over 3 years, delivering 67,376 sqm of space at a construction cost of £230m. The team future proofed the size by adding additional capacity at the outset which was to remain mothballed until required. This was done to save significant future costs that would arise because of the PFI funding method.

Contained within are all the services that you would expect to find in a general acute hospital and is a similar size with a similar feel to the current proposals for the new hospital at Overdale. Complementary to the healthcare services are an education centre, lecture theatre, some key worker accommodation, an energy centre and a creche. The Trust is experiencing similar challenges recruiting staff at all levels, but especially Medical and Nursing staff and have advised that on reflection they should have increased the number of key worker residential units that formed part of the scheme.

3. Modern Methods Of Construction (MMC)

The McAvoy Group visit was to their factory in Lisburn, on the outskirts of Belfast. The team met their Chief Executive Officer, the Head of Design & Technical Services, the Modular Hire & Sales Director, along with other members of the team who provided an overview of the company, the projects that they had delivered and supported by a factory walkabout.

The group delivers modern methods of construction, building prefabricated units within a factory setting and then transporting and assembling on site. They have provided many healthcare facilities, both permanent and temporary, purchased and leased, to a number of UK health providers.

Within the factory, at the time of our visit, we saw a ward being constructed that was destined for the Good Hope Hospital in Birmingham as temporary bed facilities to assist with their elective post-Covid backlog completed to HBN/HTM standards. They were able to provide a number of case studies that had been delivered within short time frames to meet demand, some of which can be found on their website, including the Northumbria Specialist Emergency Care Hospital and Kingston Hospital, Mental Health Assessment Unit.

Their primary areas of focus are education, commercial and healthcare.

4. Objectives Of The Visit And Observations

The aims and objectives of the visit was to inspect a number of recently built hospitals and healthcare extensions and gain insight into a modern method of construction. Against the following objectives, the team made these observations from the visit, particularly relevant to future healthcare in Jersey: