Evaluation of Business Case for modular cath lab at UHW Celeste O'Callaghan to: secgen 22/06/201811259 Cc: Tracey Conroy. Sinead Quill . Sec Gen Please ?nd attached an evaluation done by this unit, which hard copy. Kind regards Celeste b22_6_18.docx Final Business Case 'Modular 2018 2019.docx C_eleste O'Callaghan Principal Of?cer Acute Hospitals Policy Unit 4 A?n Roinn Sl?inte Department of Health Teach Hawkins, Sr?id Hawkins, Baile Atha Cliath 2, 002 VW90 Hawkins House. Hawkins Street. Dublin 2. 002 VW90 1. Tracey Conroy Secretary General 3. RunaiAire Re: Preliminary evaluation of a Business Case for the deployment of a Modular Cath Lab at University Hospital Waterford Background 1. On 14 February 2018, the Minister met with South East Oireachtas members to discuss cardiac services in the south east. At this meeting, he indicated that he would give some consideration to the various issues raised by the group, including the potential for the deployment of a modular cath lab at University Hospital Waterford The justification for a modular cath lab, as outlined by South East Oireachtas members, was that it offered an interim solution ahead of the completion of the National Review, and that interventional cardiology service requirements were not being met at UHW. They also proposed that this would be a cost- effective solution. On 29 March, in a note to the Minister, which outlined the potential for the deployment of a modular cath lab at having regard to feasibility issues set out in the note, the Department advised that: - The timeframe for completion of a modular cath lab as outlined above is not compatible with consideration of this option as an interim solution ahead of the completion of the National Review. - The waiting lists for both diagnostic and interventional cath lab procedures are demonstrating good performance at UHW with the majority of patients waiting less than 6 months for either. - The Modular Buildings Framework only includes contractors that supply accommodation only builds and accordingly staffing would need to be recruited for a modular lab. A modular cath lab would therefore entail both revenue and capital costs, which are not justified in terms of service need as set out in the Herity report and accepted by the Minister. 0n 4 April, the Minister?s adviser, responded on the Minister?s behalf noting that he had expressed disappointment at the lack of progress on recruitment for the existing cath lab and had asked for proposals on the continued deployment of the mobile cath lab in light of this. He also asked for further work to be done on a spaci?c proposal for in this regard, she clari?ed that a Business Case had been submitted to the and also referred to a representation received from Senator Paudie Coffey. To Note: This Business Case relates to the deployment of a modular cath lab at UHW and was drafted in January 2018. On 13 April, the Department asked the HSE to submit the business case for the modular cath lab for University Hospital Waterford along with its evaluation of it, in relation to feasibility, cost and timelines as well as value for money and quality and patient safety. On 14 June, at the request of the Minister, the Department again asked that the HSE submit the business case for the modular cath lab for UHW by 21 June and that this submission should include the key steps necessary to commission such a lab and the associated timelines and costs. Page 1 of 10 6. On 21 June, the HSE submitted the Business Case, which it noted had been developed by Waterford University Hospital. The HSE noted that it is assumed that any consideration of proposals for additional cardio-cath lab services in Waterford will take place in the context of the recommendations of the Herity report; that progress has been made in relation to recruitment to expand the number of sessions in the existing cath lab (as recommended by Herity). It further stated that it would request that the activity information in the Business Case be updated to reflect the latest position (April 2018} and that its Estates and Finance functions would validate the timescales and costings. it also noted that the Business Case is predicated on the need for additional funding in 2018 and 2019. The Business Case 7. The Business Case proposes three options for the management of the cardiology waiting lists in UHW. Option 1 - the implementation of additional sessions in the existing cath lab as per the Herity Report. It estimates that this option will cost (based on 1-2 patients per session) ?705,291. Option 2 - the implementation of a modular lab following the end of the mobile cath lab contract in February 2018. It estimates that this option would have casted ?3,443,826 Option 3 - an incremental/phased approach to the implementation of the modular cath lab, which would have required maintaining the mobile cath lab in place for diagnostic services until and March 2018, installation of a modular cath lab from April to September, 3 days per week for diagnostic services only and commencement of a full modular cath lab service, 5 days per week from October to December 2018. It estimates that this option would have cost ?1,857,000. 8. .The Business Case proposes that Option 3 would provide the additional capacity required both for the management of elective waiting lists and the standards for the management of CODE STEMI and Non STEMI patients. Evaluation of the Business Case 9. In the absence of an evaluation from the HSE, the Department's evaluation is provided below; Quality and patient safety Cost Value for money Timelines Feasibility General Comments 10. The Business Case was developed in January 2018 and doesn?t factor more recent developments in UHW into its proposals i.e. continued deployment of the mobile cath lab and recruitment to'support the extension of the operating hours of the existing cath lab. There are factual inaccuracies in the Business Case as outlined at Appendix 1. 5 and 6 of the Business Case outline the rationale for a modular cath lab in UHW, which is not sufficiently supported by evidence set out in the Business Case, and which raises some issues of concern in relation to the current provision of cardiology services (Appendix 2). Quality and patient safety 11. in noting that ?The National Acute Coronary Programme 2012 states that to provide a safe equitable and reliable service, all Primary centres should employr at least two Cardiac Page 2 of 10 12. Cost 13. Cotheterisotion Lobs?, the Business Case states that the provision of a modular cath lab would provide immediate access to the main cath lab for emergency patients presenting with from 9am to 5pm, presumably because of increased capacity overall. The Business Case states that the referral rate for PPCI is (95 approx. per annum). It is of note that this does not meet the BCIS standard of a minimum of 150 PPCIs per annum to allow for a concentration of volume and critical mass of trained operators to provide a safe service. in his 2016 report, Dr Herity also noted that the annual referral rate for PPCI at UHW fell short of the BCIS standard and therefore recommended the cessation of 9-5 PPCI in UHW. The role of a modular cath lab in supporting provision of PPCI at is therefore not consistent with the recommendations of the Herity report. The cost estimates for each of the 3 options in the Business Case are based on calculations contained in tables 2, 3 and 4 of the Business Case. Having reviewed these tables, there appear to be numerous miscalculations in each (Appendix Therefore, it is not possible to evaluate the cost of the preferred option proposed [or either of the other two options) on the basis of the information currently submitted, and further information and evaluation of the costs will be required from the HSE. Value for money 14. Given the miscalculations referred to above, it is also not possible to make a de?nitive determination on the value for money of the preferred option outlined in the Business Case. Timelines 15. 16. 17. The associated timeframe for completion of modular builds will vary depending on the size and intended use. The indicative timeframe for the development of modular builds as outlined by the HSE is 62 weeks {which includes procuremEnt, planning application, construction and commissioning {Appendix 4) The Business Case proposes that, in the case of the preferred option, Option 3, an incrementalfphased approach to the implementation of the modular cath lab, installation of 3 Modular Cath Lab could take place almost immediately, to September 2018, for diagnostic services only with commencement of full modular cath lab service 5 days per week from October to December 2018. It is unclear how the installation of a modular cath lab could be as immediate as proposed in the Business Case, given public procurement regulations and the time to comply with same. Furthermore, on the basis of the estimated timeframes outlined in Appendix 4 and halving the contractor?s construction period, it is estimated that it would take 49 weeks to construct the modular cath lab, bringing the opening date into late Spring 2019 if commenced immediately. Page 3 of 10 Feasibility 18. 19. The HSE has advised that it has a Modular Build Framework in place. This Framework only includes contractors that supply ?accommodation only? builds and accordingly staffing would need to be recruited for the modular cath lab. A modular cath lab would therefore entail both revenue and capital costs, which are not justified in terms of service need as set out in the Herity report. Furthermore, any efforts in relation to the recruitment of staff should be, in the ?rst instance, focused on staffing for the existing cath lab, as recommended in Herity. This would negate the need for the modular lab because, as concluded by Herity, the needs of the effective catchment of UH?v?vl could be met by increasing the hours per week that the existing lab is operational. Conclusions and recommendation 21. 22. 23. 24. 25. 26. Given the time that has elapsed since the development of the Business Case and developments at UHW in the meantime, the Business Case will require updating to reflect the current position with regard to the mobile cath lab and expected developments with regard to staffing for the existing cath lab at UHW. This should include activity data, as well as costs and timelines. Given the factual inaccuracies and the miscalculations on the Tables, on which the need for the modular lab is based, the Business Case will require revisions and corrections before a ?rm conclusion in relation to cost and value for moneyr can be reached. The Business Case proposes that the availability of the modular cath lab would allow better access to the main cath lab for - this is not consistent with the Herity Report recommendations, which proposed that should cease in UHW, given that the annual number of cases does not meet with BCIS Standards. Furthermore, the Herity Report concluded that the needs of the effective catchment population of UHW could be met if the operating hours of the existing cath lab were extended. The recommendation for a modular cath lab is therefore not consistent with the Herity Report. The HSE has advised of recent progress with recruitment efforts for the existing cath lab and in that context, the deployment of a modular lab may now be unwarranted. Any staf?ng challenges in regard to additional sessions in the existing cath lab will also apply in regard to a modular cath lab. The National Review of Specialist Cardiac Services, now underway, will inform future investment in cardiac services nationally. Accordingly, it is not possible to recommend proceeding with a modular cath lab on the basis of the Business Case outlined. Acute Hospitals Policy Unit 4 strongly recommends that the project not proceed at this time, in advance of more detailed information on costs and timelines. Page 4 of 10 Next steps The Department will seek detailed information on costs and timelines for provision of a modular cath lab from the HSE as a matter of urgency. The HSE will also be asked to complete its evaluation of the Business Case as already requested. Celeste O?Colloghon Acute Hospitals Pollcy Unlt 4 22 June 2018 Page 5 of 10 Appendix 1: lnaccuracies in the Business Case - The Business Case states that the cath lab in UH?v?vr to a population of 497,578 {Census 2011}. The Heritv report concluded that based on the 2016 Census, the effective catchment population of cath lab Is 286,147. - The Business Case states that the Heritv Report published in July 2016 recommended the provision of 3 additional Cath lab sessions per week by extension of the working dav three evenings per week. This is inaccurate -the Heritvr Report recommended 2 additional cath lab sessions to bring the weekly total up to 12. - The Business Case states that, of the patients who received diagnostic angiograms in Cork and the UHW Mobile Cath Lab, 30% required follow on PCI procedures, which it states has hugelv increased the pressure on capacity in the main cath lab. Waiting lists data for May 2018 {Appendix 5} does not bear out this contention - 261 diagnostics 245 interventional procedures - The Business Case states that it has identified a phased approach to the operation of a modular cath lab in UHW in 2018 'in the context of available resources?. ?1m euro is available in 2018 to address waiting lists for exisiting cath lab and for deployment of mobile cath lab. The mobile cath lab has been in situ for 25 weeks in 2018 3: 40k per week [as advised by HSE) ?1m. Costing provided for preferred option in the Business Case, the incremental approach to implementation of modular cath lab Feb-Dec 2018 ?1,852,000. Resources in 2018 are, therefore, unavailable for this option. - The Business Case calculations in relation to activity, capacity and capacity de?cits on which the Business Case for the modular lab is based are inaccurate (please see Appendix 3 for more detail in that regard}. Page 6 of 10 Appendix 2 Rationale for the Modular Build The Business Case states that the provision of a modular lab would; expedite the delivery of Code STEMI services between Sam-5pm to patients who are within the ACS life-critical 90mins from ambulance direct to catheterisation laboratory, and thus deliver the most effective therapy for cardiac patients with resulting reduction in morbidity and mortality. It would be of concern if such cases are not currently being expedited in the PPCI service currently available in UHW. provide the additional capacity required to reduce the numbers of patients waiting and the wait times for elective interventional procedures. However, it is clear that wait times for elective procedures would also be reduced if existing cath lab provided two additional sessions per week as recommended in the Herity Report. lead to compliance with the basic criteria of the National AC5 Programme for STEMI and NSTEMI patients. It would be concerning if these criteria were not being complied with currently. immediately reduce the number of in-patient bed days and re?admissions required in the SE Hospitals for patients requiring cardiology intervention [current L05 5-10 days awaiting coronary intervention, immediate decrease to <2 days) across all 4 hospitals in the area. There is no evidence provided to support this assertion. cut out rollovers of in-patientsfout patients from the work list due to complex cases and emergencie, and that day to day work lists would not be compromised. Suf?cient detail or evidence is not provided in this regard. facilitate the development of cardiac service innovations, such as the rapid access chest pain clinics and subspecialist cardiology services in the SE Area. These are matters which will be informed by the National Review of Specialist Cardiac Services. Page 7 of 10 Agpendix 3 - Miscalculations on Tables 2.3 and 4 Table 2 above identifies the number of referrals to the UHW cath lab in 2017. The table also identi?es the number of procedures performed and procedures categories. The procedure numbers include all cardiac procedures including PCI and devices. The average conversion rate to PCI was 30%. - The sum of individual procedures is less than the total number of procedures performed - 2839 versus 3530 Table 3 identifies the capacitv for diagnostics and PG procedures in a second or modular cath lab working from 9 am to 5pm Monday to Friday. - There is a 30% PCI conversion rate from diagnostics to interventions number of therefore should be 345.6 - 1152 384 1536 rather than 1920 as stated in this table Table 4 identi?es the demand and capacity for cath lab procedures. The de?cit is calculated on the average waiting list for procedures plus an additional 30% for PCI conversion. An additional 10% has also been included to meet the ACS standards for the management of patients within 48 hours of presentation. The table indicates requirements for interventional procedures are on the basis of 2017 activity data. lf so, it should reflect the ?gure for diagnostic procedures (in Table 1} and applying the 30% P61 conversion rate but it appears to be using number of procedures requested - 2292 - Table 2. - Table 4 applies the 30% PCI conversion rate to the total number of procedures performed rather than to number of diagnostics performed. The figure appears to be inaccurate in relation to average waiting list for procedures 3530x0.3 1059 column states 1560 - Number of diagnostics performed in 2017 as outlined in Table 2 (1580} and apply the 30% conversion rate 474. . - 10% non Stemi access 47.4 and add average waiting list for procedures 521.4 procedues capacity deficit rather than 1216 as stated Page 8 of 10 Appendix 4 - Indicative timeframe for the development of modular builds as outlined bv the HSE - Preparation of tender documentation by HSE, having regard to site spec: 4 weeks - Period for development of tender submission by tenderers: 6 weeks - Evaluation of tenders: 3 weeks - Award of contract: 1 week - Project design work and development of planning application by contractor: 4 weeks - Planning application to grant of planning: 10-12 weeks 0 Fire safety Cert (within Planning period 7 days): 0 Disability access certi?cate (also within Planning Period) 0 No works on site or off-site manufacture of modular unit during planning probation period) - Contractor?s construction period: 26 weeks. - Commissioning equipment including electrics, linkages to services: 5 weeks Total: 62 weeks Page 9 of 10 Agpendix 5 - Cardiology Waiting List data 28 May 2018 As at 28 May 2013: . - 24S peopie were waiting for a diagnostic procedure. Of these, 93% were waiting for less than 6 months. 261 people were waiting for an interventional procedure. Of these, 98% were waiting for less than 6 months Cardiology Diagnostic Procedures Waiting 28Tot May 2013 months months months months months al Total 175 52 12 3 245 Cardiology interventional Procedures Waiting 28Tot May 2013 months months months months months al Total 210 46 4 1 251 Page 10 of 10 Ospid?nl Ollsca?e Phan? Lcif'l?'e UniversityHUSPimI Wateq?ard - Ul i in! - BUSINESS CASE AMNA GEMENTOF SOUTHEAST CARDIAC CA THLAB WAITING LIST UNIVERSITY HOSPITAL WATERFORD (PROVISION OF MODULAR CA LAB) January 2018 if {fairer-sin! Hospital Warsrford Background: This business case provides the rationale for the provision of a Modular Cath Lab on the grounds of University Hospital Waterford to manage the Cardiac Catheterisation Laboratory (Cath Lab) waiting list and to provide timely access for Primary PCI and other Cardiac Cath lab procedures using the capacity provided by 2 Cath Labs at the hospital. In the context of available resources the Business Case identifies a phased approach to implementation in 2018. In October 2012 University Hospital Waterford was identi?ed as the designated Primary PCI Centre under the ACS Programme to cover the areas of Waterford, Kilkenny, South Tipperary and Wexford General, Monday to Friday 9 am -5 pm. (National AC8 programme Model of Care Programme March 2012). The Cath Lab at UHW provides an equal access service for all Cardiac Cath Lab procedures to the four acute hospitals in the South East Area. i.e. University Hospital Waterford, Wexford General Hospital, St. Luke's General Hospital, Kilkenny, and South Tipperary General Hospital. The service is provided to a population of 497,528 (Census 201 The service at UHW is provided from a single Cath Lab providing an emergency Primary service and an elective diagnostic and interventional procedures service for urgent and routine patients. The referral rate for Primary patients is 8 and an average of 130 patients per month are referred for elective procedures in the Cath lab The National Acute Coronary Programme 2012 states that to provide a safe equitable and reliable service, all Primary PCI centres should employ at least two Cardiac Catheterisation Labs. The Cath Lab elective waiting list numbers and waiting times have been reduced considerably over the course of 2017. The total number of patients waiting in January 201? was 691 and the longest wait time was 13 months. The waiting list was addressed through ongoing activity in the existing Cath lab, the outsourcing of 394 patients to CUH and the Bons in Cork and the provision of a Mobile Cath_Lab on site at UHW for a period of 20 weeks from 02 October 201 T. The mobile Cath Lab was provided to address the remaining long waiter waiting list of 430 patients, 370 of whom have been seen to date. The contract for the Mobile Cath lab is due to ?nish on 14th February 2013. Following the above interventions the total Waiting List as of the January 2018 is 375 and the longest wait time is 8-12 months [6 patients). The majority of patients are now waiting 0?3 months and 3?6 months as per Table 1 below: Page I 2 Jan 2018 FE Uni varsity Respite! Warcd?crd Tablel 0-3 3-6 5-8 8-12 Total 305 ST 6 6 375 Cath Lab Waiting List Management Strategies The Herity Report published in July 2016 recommended the provision of 3 additional Cath lab sessions per week by extension of the working day three evenings per week. This proved to be problematic in relation to the recruitment of staff for overtime and additional basic hours. A total number of 2 additional sessions were held and due to the complexity of procedures only 1 2 additional patients were treated per session. This proved to be poor value for money and due to the fact that the Cath lab frequently runs over time it was not possible to treat the numbers of patients required to manage the waiting list. For the purpose of discussion this option has been costed in this business case as Option 1. The Mobile Cath lab which successfully assisted in the management of the diagnostic waiting list is limited to use for diagnostic angiograms only and does not provide facilities for any more complex procedures. Of the 420 patients who received diagnostic angiograms in Cork and the UHW Mobile Cath Lab 30% required follow on PCI procedures which has hugely increased the pressure on capacity in the main Cath lab. The provision of a Mobile Modular Cath Lab would provide the capacity to manage patients who convert from diagnostics to interventional procedures. It would also provide capacity to provide immediate access to the main Cath lab for emergency patients presenting with STEMI from 9am to 5pm. Table 2 below identi?es the Capacity and Demand for Cath Lab Services in 2017 and Average demand for a modular Cath lab in 2018. Page 3 Jan 2018 Ff Univemiiy Hospital! Warezford Activity and Capacity Activity in UI-IW Cath Lab. The following activity was managed in 201? in the UHW Cath Lab Table 2 UHW Cath Lab Activity UHW Cath Lab 2017 Procedures Requested 2992 Procedures Performed 3530 Total No Patients 2493 Diagnostics 1580 PCI 772 Primary PCI 83 Devices 404 Note Procedures number performed higher than requested due to clinical ?ndings on diagnostics. Table 3 Proposed Additional Activity UHW Modular Cath Lab Procedures Annual Diagnostics 1152 334 Total 1920 The above proposed activity is based on 3 procedures 5 days per week it 48 weeks. The following capacity deficit has been identi?ed based on 2017 activity, waiting lists and complexity. Table 4 UHW Cath Lab Capacitv I Demand 201? Total Procs *Avg Waiting Procs Performed Avg Conversion List for "Target Non- Capacity Patients Referred Avg Diag Procs [Complexity] Rate to PCI Procedures STEMI Access De?cit 2498 2992 3530 30% 1550 156 1716 includes 3096 Conversion 10% increase for Non Timefrome Fach Jan2018 If Universio' Hospital Waterford Table 2 above identi?es the number of referrals to the UHW Cath Lab in 2017. The table also identi?es the number of procedures performed and procedures categories. The procedure numbers include all cardiac procedures including PCI and devices. The average conversion rate to PCI was 30%. Table 3 above identi?es the capacity for diagnostics and PCI procedures in a second or modular cath lab working from 9 am to 5pm Monday to Friday. Table 4 above identi?es the demand and capacity for oath lab procedures. The de?cit is calculated on the average waiting list for procedures plus an additional 30% for PCI conversion. An additional 10% has also been included to meet the ACS standards for the management of patients within 48 hours of presentation. Overall Rationale for a Modular Cardiac Catheterisation Laboratory The South East area urgently needs an appropriate Cath lab service to adequately address the tangible cardiac needs of the area. This should be constituted through the provision of a second Cath lab in UHW to allow a reliable and realistic Cath lab service provision for this area. in the context of the current Cardiac Cath lab demands, a dual Cath lab facility should operate on a 9:00am to 5:00pm basis, with provision for the clinical service outside that period to be provided from another national site until clinical demand justi?es otherwise. The commissioning ofa modular Cath lab at UHW will: - Expedite the delivery of Code STEMI services between 9am-5pm to patients who are within the ACS life-critical 90mins from ambulance direct to catheterisation laboratory, and thus deliver the most effective therapy for cardiac patients with resulting reduction in morbidity and mortality. I Expedite the Treatment of patients ACS guidelines now require treatment within 48 hours. 0 Provide the additional capacity required to reduce the numbers of patients waiting and the wait times for elective interventional procedures. - 0 Lead to compliance with the basic criteria of the National ACS Programme for STEMI and NSTEMI patients. Page 5 Jan 2018 If Uni varsity ospifal Waterford Immediately reduce the number of in-patient bed days and re-admissions required in the SE Hospitals for patients requiring cardiology intervention (current LOS 5-10 days awaiting coronary intervention, immediate decrease to <2 days) across all 4 hospitals in the area. Cut out rollovers of in-patientsfout patients from the work list due to complex cases and emergencies. Day to day work lists will not be compromised. Allow effective cardiac catheterisation lab downtime. Rapid invasive treatment of patients with myocardial infarction minimises myocardial damage and reduces the incidence of chronic heart failure and heart disorders. Reduction in waiting lists and alleviation of pressure on ambulance services and existing centres (CorldDublin) with signi?cant cost saving. Ensure optimum patient safety, satisfaction, continuity of care and cost effectiveness in the treatment of cardiac patients. Facilitate the development of cardiac service innovations, such as the rapid access chest pain clinics, which will have a dramatic impact on the burden of referrals to the ED. This will lead to reduced trolley waits in the department. Facilitate the development of subspecialist cardiology services in the SE Area. The presence of a second lab would facilitate the development of non-invasive services, and electrophysiology services locally. Options for Management of Waiting List Option 1 Implementation of 3 additional Cath Lab Sessions Out of Hours as per the Herity Report. Previous Efforts to implement these sessions have not been successful due to recruitment issues and ability to provide required capacity due to complexity of procedures required. Average Annual Capacity 288 Patients Procedures, Calculated Capacity De?cit 2018 1716, Calculated De?cit Balance 4,428. Total Annual Cost based on 1?2 patients per session ?705,791 Costing Details Appendix I. This is not a preferred option as it does not provide suf?cient capacity and is not value for money. Pagel 6 Jan 2013 If? Unirem'n' Hospital Warsd'ord Option 2 Implementation of Modular Cath Lab following end of Mobile Cath Lab contract in February 2018. Average Annual Capacity 2018 1,600, Calculated Capacity Deficit 2018 1716, Calculated De?cit Balance -116 Average 12 Month Capacity 1,920 The above capacity includes all levels of procedures. Total Annual Cost ?4,132,592 Total Cost March December 2018 Costing Details A ppendur 2 This option meets all of the criteria and would provide the additional capacity required both for the management of the elective waiting lists and the standards for the management of CODE STEMI and Non STEMI patients. 0 tion 3 Ingremental .1 Phased approach to the implementation of the Modular Cath Lab. This approach requires maintaining the Mobile Cath Lab in place for Diagnostic Services until the end of March 2018, Installation of a Modular Cath Lab from April to September 2018, 3 days per week for diagnostic services only and commencement of full modular Cath lab service 5 days per week from October to December 2018. Average Annual Capacity 1488, Calculated Capacity De?cit 2018 1716 plus 446 conversions 2162 Calculated De?cit Balance 4578 The above capacity provides for diagnostic patients only from Feb 15th to 30?? September 2018. Average 30% Conversion Patients added to Waiting List following diagnostic angiograms 446 Total Cost 15th February to 31st December 2018 61,857,000 Page 1 Jan 2018 if University aspire! Wareij'ord This incremental option is the recommended option for 2018 with a 1riew to moving to Option 2 in 2019. It meets 70% of capacity requirements and also reduces additional resource requirements for 2013. Costing Details Appendix 3. Page I 8 Jan 2013 f; 2231:] i9 I Has. . 1. TraceyConroyt/ . 542,93 8?.ch OQ 1T, 2. Secretary General Yquic 2de ?redial-3.0.. 60? 3. RunaiAire g3)? ?ag! 0i} attest-lg ,72 Re: Preliminary evaluation of a Business Case for the deployment of a Modular Cath Lab a 6 University Hospital Waterford Background - 1. On 14 February 2018, the Minister met with South East Direachtas members to discuss cardiac services in the south east. At this meeting, he indicated that he would give some consideration to the various issues raised by the group, including the potential for the deployment of a modular cath lab at University Hospital wateriord The justification for a modular cath lab, as outlined by South East Direachtas members, was that it offered an interim solution ahead of the completion of the National Review, and that intenrentional cardiology service requirements were not being met at UHW. They also proposed that this would be a cost- effective solution. 2. On 29 March, in a note to the Minister, which outlined the potential for the deployment of a modular cath lab at UHW having regard to feasibility issues set out in the note, the Department advised that: The timeframe for completion of a modular cath lab as outlined above is not compatible with consideration of this option as an interim solution ahead of the completion of the National Review. - The waiting lists for both diagnostic and interventional cath lab procedures are demonstrating good performance at UHW with the majority of patients waiting less than 6 months ioreither. - The Modular Buildings Framework only includes contractors that supply accommodation only builds and accordingly staffing would need to be recruited for a modular lab. A modular cath lab would therefore entail both revenue and capital costs, which are not justi?ed in terms of service need as set out in the Herity report and accepted by the Minister. 3. 0n 4 April, the Minister?s adviser, responded on the Minister?s behalf noting that he had expressed disappointment at the lack of progress on recruitment for the existing cath lab and had asked for proposals on the continued deployment of the mobile cath lab in light of this. He representation received from Senator Paudie Coffey. To Note: This Business Case re'lates to the deployment ofa modular oath lab at UHW and was drafted in January 2013. 4. On :18 April, the Department asked the HSE to submit the business case forthe modularcath lab for University Hospital Waterford along with its evaluation of it, in reiation to feasibility, cost and timelines as well as value for money and quality and patient safety. 5. On 14 June, at the request of the Minister, the Department again asked that the HSE submit the business case for the modular cath lab for uew by 21 June and that this submission should include the key steps necessary to commission such a lab and the associated timelines and costs. Page 1 of 10 T. 6. On 21 June, the HSE submitted'the Business Case, which it noted had been developed by Waterford University Hospital. The HSE noted that It is assumed that any consideration of proposals for additional cardlo-cath lab services in Waterford will take place in the context of the recommendations of the Herity report: that progress has been made in relation to recruitment to expand the number of sessions in the existing cath lab {as recommended by Herity). It further stated that it would request that the activity information in the Business Case be updated to re?ect the latest position (April 2018) and that its Estates and Finance functions would validate the timescales and costings. It also noted that the Business Case is predicated on the need for additional funding in 2013 and 2019. The Business Case 7. The Business Case proposes three options for the management of the cardiology waiting lists 'in UHW. - Option 1 . the implementation of additional sessions in the existing cath lab as per the Herity Report. It estimates that this option will cost-{based on 1-2 patients per session} ?705,291. - Option 2 the implementation of a modular lab following the end of the mobile cath lab contract in February 2018.?lt estimates that this option would have casted ?3,443,326 - Option 3 - an incremental/phased approach to the implementation of the modular cath lab, which would have required maintaining the mobile cath lab in place for diagnostic services until end March 2018, installation of a modular cath lab from April to September, 3 days per week for diagnostic services only and commencement of a full modular cath lab service, 5 days per week from October to December 2018. It estimates that this option would have cost ?1,352,000. B. The Business Case proposes that Option 3 would provide the additional capacity required both for the management of elective waiting lists and the standards for the management of CODE and Non STEMI patients. Evaluation of the Business Case 9. In the absence of an evaluation from the HSE, the Department's evaluation is provided below; - Quality and patient safety - Cost - Value for money - Timelines - Feasibility General Comments 10. The Business Case was developed in January 2018 and doesn't factor more recent developments in UHW into its proposals i.e. continued deployment of the mobile cath lab and - recruitment to support the extension of the operating hours of the existing cath lab. There are factual inaccuracies in the Business Case as outlined at Appendix 1. P35 5 and 6 of the Business Case outline the rationale for a modular cath lab in UHW, which is not suf?ciently supported by evidence set out in the Business Case, and which raises some issues of concern in relation to the current provision of cardiology services {Appendix Quality and patient safety 11. in noting that The National Acute Programme 2012 states that to provide a safe equitable and reliable service, all.Primary centres should employ at least two Cardiac Page 2 of 10 12. Cost 13. Cotheterlsotion Loos", the Business Case states that the provision of a modular oath lab would provide immediate access to the main cath lab for emergency patients presenting with from 9am to 5pm, presumably because of increased capacity overall. 'The Business Case states that the referral rate for PPCI is 8 [95 approx. per annum}. It is of note that this does not meet standard of a minimum of 150 PPCIs per annum to allow for a concentration of volume and critical mass of trained operators to provide a safe service. In his 2016 report, Dr Herity also noted that the annual referral rate for PPCI at UHW fell short of the 305 standard and therefore recommended the cessation of.9-5 PPCI in Ui-lw. The role of a modular oath lab in supporting provision of at UHW is therefore not consistent with the recommendations of the Herlty report. The cost estimates for each of the 3 options in the Business Case are based on calculations contained in tables 2, 3 and 4 of the Business Case. Having reviewed these tables, there appear to he numerous mlscaiculations in each [Appendix 3). Therefore, it is not-possible to evaluate the cost of the preferred option proposed (or either of the other two options) on the basis of the information currently submitted, and further information and evaluation of the costs will be required from the. HSE. Value for money 14. Given the mlscaiculations referred to above, it is also not possible to make a de?nitive determination on the value for money of the preferred option outlined In the Business Case. Timelines 15. 16. 17. The associated timeframe for completion of modular builds will vary depending on the size and intended use. The indicative timeframe for the development of modular builds as outlined by the HSE is 62 weeks [which includes procurement, planning application, construction and commissioning (Appendix 4) The Business Case proposes than, in the case of the preferred option, Option 3, an incrementalfphased approach to the implementation of the modular oath lab, installation of a Modular Cath Lab could take place almost immediately, to September 2013, for diagnostic - services only with commencement of full modular cath lab service 5 days per week from October to December 2018. it is unclear how the installation of a modular cath lab could be as immediate as proposed in the Business Case, given public procurement regulations and the time to comply with same. Furthermore, on the basis of the estimated timeframes outlined in Appendix 4 and halving the contractor's construction period, It is estimated that it would take 49 weeks to construct the modular oath lab, bringing the opening date into late Spring 2019 if commenced immediately. Page 3 of 10 Feasibility 13. 19. The HSE has advised that it has a Modular Build Framework in place. This Framework only includes contractors that supply ?accommodation onlyf builds and accordingly staffing would need to be recruited for the modular cath lab. A modular cath lab would therefore .entail both revenue and capital costs, which are not justified in terms of service need as set out in the Herity report. Furthermore, any efforts in relation to the recruitment of staff'should be, in the first instance, focused on staf?ng for the existing cath lab, as recommended In Herity. This would negate the - need for the modular lab because, as concluded by Herity, the needs of the effective catchment of UHW could be met by increasing the hours per week that the existing lab ls operational. Conclusions and recommendation 20. - 21. 22. 23. 24I 25. 25. Given the time that has elapsed since the development of the Business Case and developments at UHW in the meantime, the Business Case will require updating to reflectthe current position with regard to the mobile cath lab and expected developments with regard to staffing for the existing cath lab at UHW. This should include activity data, as well as costs and timelines. Given the factual inaccuracies and the miscalcuiations on the Tables,- on which the need for the modular lab is based,-the Business Case will require revisions and corrections before a firm conclusion in relation'to cost and value for money can be reached. The Business Case proposes that the availability of the modular cath lab would allow better access to the main cath lab for - this is not cdnsistent with the Herity Report recommendations, which proposed that PPCI should cease in UHW, given that the annual number of cases does not meet with BCIS Standards. - Furthermore, the Herity Report concluded that the needs of the effective catchment population of UHW could be met if the operating hours of the existing cath lab were extended. The recommendation fora modular cath lab is therefore not consistent with the Herity Report. The HSE has advised of recent progress with recruitment efforts for the existing cath lab and in that context, the deploymeht of a modular lab may now be unwarranted. Any staffing challenges in regard to additional sessions in the existing cath lab will also apply in regard to a modular cath lab. The National Review of Specialist Cardiac Services, now underway, will inform future investment in cardiac services nationally. Accordingly, it is not possible to recommend proceeding with a modular cath lab on the basis of the Business Case outlined. Acute Hospitals Policy Unit 4 strongly recommends that the project not proceed at this time, in advance of more detailed information do costs and timelines. Page 4 of 10 Next steps 27. The Department will seek detailed information on costs and timeiines for provision of a modular cath lab from the HSE as a matter of r.gency The HSE will also be asked to complete its evaluation of the Business Case as already requested. este O?Cailaghan Acute Hospitals Policy Unit 4 22 June 2018 SECRETARY vars?mca . Roma? 3? ?7 mummy: at} Page 5 of 10 Appendix 1: Inaccuracles in the Business Case The Business Case states that the oath lab in UHW to a population of 497,5?8 {Census 2011). The Heritv report concluded that, based on the 2015 Census, the effective catchment- population of UHW cath lab is 235,141 The Business Case states that the Heritv Report published in July 2016 recommended the provision of 3 additional Cath lab sessions per week by extension of the working day.r three evenings per week. This is inaccurate - the Heritv Report recommended 2 additional cath lab sessions to bring the weekly total up to 12. The Business Case states that, of the patients who received diagnostic angiograms in Cork and the UHW Mobile Cath Lab, 30% required follow on PCI procedures, which it states has hugely increased the pressure on capacity in the main oath lab. Waiting lists data for May 2018 {Appendixsi does not bear out this contention 251 diagnostics 245 interventional procedures . The Business Case states that it has identified a phased approach to the operation of a modular oath lab in in 2013 ?in the context of available resources?. elm euro is available in 2018 to address waiting lists for exisiting cath lab and for deployment of mobile cath lab. The mobile cath lab has been in situ for 25 weeks'in 2013 at 40k per. week {as advised by HSE) Elm. Costing provided for preferred option in the Business Case, the incremental approach to implementation of modular cath lab Feb-Dec 2013 ?1,857,000. Resources in 2013 are, therefore, unavailable for this option. The Business Case calculations in relation to activity, capacity and capacity deficits on which the Business Case for the modular lab is based are inaccurate {please see Appendix 3 for more detail in that regard}. Page 6 olen appendix 2 - Ratlonale forthe Modular Build. The Business Case states that the provision of a modular lab would; expedite the delivery of Code STEMI services between 9am-5pm to patients who are within the ACS life-critical 90mins from ambulance direct to catheten'sation laboratory, and thus deliver the most effective therapy for cardiac patients with resulting reduction in morbidityr and mortality. it would be of concern if such cases are not currently being expedited in the PPCI service currently available in UHW. provide the additional capacity required to reduce the numbers of patients waiting and the wait times for elective interventional procedures. However, it is clear that wait times for elective procedures would also be reduced if existing cath lab provided two additional sessions per week as recommended in the Heritvr Report. - lead to compliance with the basic criteria of the National AC5 Programme for STElv'll and NSTEMI patients. it would be concerning if these criteria were not being complied with currently. immediately reduce the number of in-patient bed davs and required in the SE Hospitals for patients requiring cardiology intervention {current L05 5-10 days awaiting coronary intervention, Immediate decrease to <2 days) across all 4 hospitals in the area'. There is no evidence provided to support this assertion. cut out rollovers of in-patientsfout patients from the work list due to complex cases and emergencie, and that day to dav work lists would not be compromised. Sufficient detail or evidence is not provided in this regard. facilitate the development of cardiac service'innovations, such as the rapid access chest pain clinics and subspecialist cardiologv services in the SE Area. These are matters which will be informed by the National Review of Specialist Cardiac Services. Page a of 10 Appendix 3- Miscaiculations on Tables 2.3 and 4 Table 2 above identi?es the number of referrals to the UHW cath tab in 2017. The table also identi?es the number of procedures performed and procedures categories. The procedure numbers include all cardiac procedures including PCI and devices. The average conversion rate to was 30%. - The sum of individual procedures is less than the total number of procedures performed - 2339 versus 3530 - Table 3 identi?es the capacity for diagnostics and PCI procedures in a second or modular cath-iab working from 9 am to 5pm Monday to Friday. - There is a 30% conversion rate from diagnostics to interventions number of PCis therefore should be 345.5 .- 1152 334 1536 rather than 1920 as stated in this table Table 4 Identi?es the demand and capacity for cath lab procedures. The de?cit is calculated on the average waiting list for procedures plus an additional 30% for PCI conversion. An additional 10% has also been included to meet the AC5 standards intr the management of patients within 43 hours of presentation. - The table indicates requirements for interventional procedures are on the basis of 291? activity data. if so, it should re?ect the figure for diagnostic procedures (in Table 1i and appiving the 3095 conversion rate but it appears to be using number of procedures requested - 2292 -?Tabie 2. - Table 4 applies the 30% PCI conversion rate to the total number of procedures performed rather than to number of diagnostics performed. The ?gure appears to be inaccurate in relation to average waiting list for procedures 3530x03 1059 column states 1550 - Number of diagnostics performed in 201? as outlined in Table 2 [1530) and apply the 30% conversion rate 424. - 10% non Stemi access 47.4 and add average waiting list for procedures 521.4 procedues ca pacitv de?cit rather than 1716 as stated Page 8 of 10 Aggendln '4 - Indicative timeframe for the deuelogment of modular builds as outlined by the HSE 4 weeks - Preparation of tender documentation by HSE, having regard to site spec: - Period for development of tender submission by tenderers: 6 weeks of tenders: 3 weeks -_Award of contract: 1 week .. Project design work and development of planning application by contractor: 4 weeks - Planning application to grant of planning: 10-12 weeks Fire safety Cert {within Planning period i' day's): . Disability access certificate [also within Planning Period] 0 No works on site or off-site manufacture of modular unit'clurlng . planning probation period] - Contractor?s construction period: 25 weeks. - Commissioning equipment Including electrics, linkages to services: 5 weeics Total: 52 Weeks Page 9 oil!) Appendix 5 Cardiology Waiting List data - 23 Mag 2018 As at 28 May 2018: - 245 people were waiting for a diagnostic procedure. Of these, 93% were waiting for less than 5 months. - 261 people were waiting for an interventional procedure. Of these, 98% were waiting for less than 5 months Cardiology Diagnostic Procedures Waiting 23?? 0'3 3'5 5'9 9'12 12 24 TD: May 2018 months months months months. months . a Total 176 52 12 3 2 245 Cardiology intewentional Procedures Waiting 0'3 3'5 5'9 9'12 1-2-24 Tot May 2018 months months months months months al Page 10 of 10 Gear Oihrioctitai [fr-R Feldhmeennacht na Seubhlse Slainle .Oh'gAonad 4a Ares Dargan An CeaniarTneas Baile Atha Cliath ti Acute Operations Health Service Executive . Unit 4a The Dargan Building 5 Houston South Dunner Dublin 5 . . Tracey Conroy Assistant Secretary Acute Division Department of Health Hawkins House Dublin 1 21 June 2013 Dear Tracey Attached please find a business case prepared by Waterford Regional Hospital and submitted to the HSE by the SSW Hospital Group relating to the provision of a modular cardio-catheterisation laboratory at Waterford. The business case refers to the provision of a modular cath lab. We have received and reviewed this document and have a number of observations are as follows; 1. Any consideration of proposals for additional cardio-cath lab services in Waterford will we assume take place in the context of the recommendations of the Herity report as adopted by Government and the cardiology review to be undertaken by the Department of Health. 2. The specifics of the proposal attached identify three options which in effect in 2019 become two options with the preference being expressed for a modular Cath lab on site as against the current approved development which is for additional sessions within the current facility. The currently approved development related to recruiting staff to provide these extra sessions, pending this recruitment a mobile cath lab has been provided at Waterford. While recruitment is ongoinglfor these additional staff it has proved slow and difficult._The posts required to facilitate the extended day working were originally submitted to the in June 201? as reduced WTE posts (as recommended in the Herity Report). All efforts to fill the posts proved unsuccessful. in March 2013 the posts were resubmitted through the recruitment process as 1 WTE per post as was recommended and support by the and Acute Operations. MRS have provided the most recent update on the posts required to expand the existing cath lab: Grade iv' 1 WTE: Campaign underway: Awaiting formation of National Panel. Porter 1 WTE: The post is listed to be expressed to panel and this will be completed this week 3" Senior Cardiac Physiologist 1 WTE: The post is listed to be expressed to panel and this will be completed this week. Senior Radiographer 1 WTE: Post accepted in early stages of clearance. )5 Staff Nurse 1 WTE: will be progressed through the existing local panel UHW. 3. Subject to further dialogue with the Department of Health we can ask that the activity information in this report is updated to reflect the latest position which would be April 2013 Ettliilli-ti?l?lrilr: H11): Ftutrr .h i Sun-inn .A ?53.33? tgizg?? . a) G?ar omrlocmal na slam Aonad Ila Ares Damn An Caantar Thea: BaileAlha casino Acute Oparallons Health Service Exeunlve Unit 4a The Dargan Building Houston South Quarter Dublin 8 and also that the timescales and costings are validated with our Estates and Finance functions should this prove helpful. Clearly the business case is predicated on the need for additional funding in 2018 and 2019. I assume this matter would be addressed with the HSE if it arose. We are available to discuss the attached'business case as required. Yours sincerely Liam Woods nlilrlim :1 Mon lrmu Iliullm? . l-mlill mlmill Service 05PMUliscailePharM?r'lgt .. .. ?w RegwmICmr CmfreSnuMEust BUSINESS CASE MNAGEMNT OFSOUTH EAST CARDIAC CATH MB WHITEVG LIST UNIVERSITY HOSPITAL WATERFORD (PROVISION OF MOD ULAR LAB) January 2018 m? Unfair-nin- Hospital Waterford Background: This business case provides the rationale for the provision of a Modular Cath Lab on the grounds of University Hospital Waterford to manage the Cardiac Catheterisation Laboratory (Cath Lab) waiting list and to provide timely access for Primary PCI and other Cardiac Cath lab procedures using the capacity provided by 2 Cath Labs at the hospital. In the context ofavaillble resources the Business Case identi?es a phased approach to implementation in 20 8. In October 20l2 University Hospital Waterford was identifiEdJ-?as the designated Primary PCI Centre under the ACS Programme to cover the areas o?i??i?eyl?ord, Kilkenny, South Tipperary and Wexford General, Monday to Friday 9 am -5 Mode! ofCar-e More}: 2012). I I . ?12. The Cath Lab at provides an equal for all Cardi'act?b'agt?h Lab procedures to the four acute hospitals in the South East University i-iospitali'liyaterford, Wexford General Hospital, St. Luke's General-?gspital, Killte?ti'iiy?gai?di?outh Tipperaryl'tii'rneral Hospital. The service is provided to a populationf4971?78 (Cens?sggi The service at UHW is proyidcd From {single an emergency Primary service and an electiveftl?iaignd?i?and service for- urgent and routine patients.,The and an average of 30 patients per month are mthe Cath lab The National: 2 states that to provide a safe equitable and relmblesemca?a?pnmawCl ce?tfasi-jih?hldihmpl?b? at least two Cardiac Catheterisation Labs. 23:? . The Cath La?jelective numbers and waiting times have been reduced considerably over the eoursh?i?Z?l?i. The total numberi'oi' patients waiting in January was 65? and the longest wait waiting list was addressed through ongoing activity in the existing Cath lab, patients to CUH and the Eons in Cork and the provision of a Mobile Cath Lab onsrteat'UH for a period of 20 weeks from 02 October 20 7. The mobile Cath Lab was provided to address the remaining long waiter waiting list of 430 patients. 370 of whom have been seen to date. The contract for the Mobile Cath lab is due to ?nish on 14?? February ZDIS. Following the above interventions the total Waiting List as of the 4'11 January 2018 is 375 and the longest wait time is 3-12 months (6 patients). The majority of patients are now waiting 0-3 months and 3-6 months as per Table below: Page I2 Jan rE Uni Hospital ll?a regret-d Table! 0-3 3-6 5-8 8-12 Total 305 57 6 are Cath Lab Waiting List Management Strategies - The Herity Report published in July 2016 recommended the provision of 3 additional (3th lab sessions per week by extension of the working day three even ipgs per week. This proved to be problematic in relation to the recruitment ofstaf?i? for overtime-Zaiid additional basic hours. A total number of 2 additional sessions were held and due to t1ltelie&niplexity of procedures only 1 2 additional patients were treated per session. This?proveiliif? bezij?i'olgr value for money and due to the fact that the Cath lab frequently runs over timett was not possuble to treat the numbers of patients required to manage the waiting list. Forthe purpose of? this option has been coated in this business case as Option The Mobile Catb lab which in thepgatjaiglcment of the dia?iipstie waiting list is limited to use for diagnostic and'iidesgnot provide facilities For any more complex procedures. I . or the 420 patients who and the one: Mobile Cath Lab 30% required pr?o'egdlures the pressure on capacity in the main Cath lab. .k ?l The provisjioniotj-aMobilc ModularCathLabwould :provide the capacity to manage patients who di'ag?no'stic'sitp int?Erientional procedures It would also provide capacity to provide immediate access to the niamCathl?bfor emer?chey patients presenting with from Dam to 5pm 1.. Table 2 belowid?iiti?es the Capacity and Demand For (3th Lab Services in 2017 and Average demand for a manages labjijiigw I 3. Page? Jan 2018 HIItI-cuig' Hmpimt It?med?m! Activity and Capacity Activity in UHW Cath Lab. The following activity-was managcd in 2017 in the UHW Cath Lab Table-2 [inW (29 ?1.119.131- ,1 _ActiigityUHw Cath Lat-2201? .. i . .2999 ETQEMQEWWU 2999 :Pi??an?ii?w_ .i 33.0.. .- ?99. . fit- . AddItIcnai Activity rural. ModularICath [319; iPr__?_c_edurcs_ . .. 3999109995-. . EPCI .91; - [2319 -- Total i ?Aquaiting' I Pcrformedi ?Tarinthn-E Capacity} Patients?efcrred' LAUgQiag _Prcc_s_?_ ecu" "$519349ch Deficit; 2493. .. 2992'; 9939} 3995; 1959, 153: 1219; i Page? Jnnl?l? If: Unit-ruin Hospital Table 2 above identi?es the number of referrals to the UHW Cath Lab in 2017. The table also identi?es the number of procedures performed and procedures categories. The procedure numbers include all cardiac procedures including PCI and devices. .The average conversion rate to was 30%. Table 3 above identi?es the capacity for and PCI procedures in a second or modular oath lab working from 9 am toSpmMonday to Friday. 'Table 4 above identi?es the demand andcapactty foreath labiprocedures. The de?cit is calculated on the average waiting list for procedures plus an additional 30% for PCI conversion; An additional?Elmira has also been in?ected to meet the ACS standards for the managgment of hours of presentation. .. r. Overall Rationale Laboratory .1 - ag- I.-. The South East areaugently needs an labs-'siirvice to adequately' address the tangible cardiac needs?citfithp area-??ns shouldi??ponstituted through the provision of a second Cath lab lab service provision for this area. In the context ofthecurrentCardiacCath Cath lab facility should operate on a prdii hrsjon for service outside that period to be provided from anotheripational site iinti l__cliniciilEdemandjusti?es otherwise. -.I The a lab at UHW will: - Expedite the deliint?glof services between 9am-5pm to patients who are within the ACS life-critical <90mms from ambulance direct to catheterisation laboratory, and thus deliver the most effective-therapy for cardiac patients with resulting reduction in morbidity and mortality. - Expedite the Treatment of patients ACS guidelines now require treatment within 48 hours. - Provide the additional capacity required to reduce the numbers of patients waiting and the wait times for elective interventional procedures. . Lead to compliance with the basic criteria of the National AC8 Programme for STEM I and NSTEMI patients. Page] .5 - Jun ZDIB r-n. If Unlmalnr "Medal-d I Immediately reduce the'number oi? in-patient bed days and re-admissions required in the SE Hospitals for patients requiring cardiology intervention (current L08 days awaiting coronaryinterventien, immediate decrease to <2 days) across all 4 heapitals in the area. I Cut out relievers of in-patientslout patients from the work list due to complex cases and emergencies. Day to day work lists will net be compromised. I Allow effective cardiac catheterisation lab downtime. - Rapid invasive treatment of patients with myocardial infarction minimises myocardial damage and reduces the incidence of chronic heart failure and heart disorders. 0 Reduction in waiting lists and alleviation of pressure onifai?tbulance services and existing centres (CorldDublin) with signi?cant cost saving. - Ensure optimum patient safety, satisfaction, and cost effectiveness in the treatment of cardiac patients. - Facilitate the development of cardiac servieefi?iitdvations, rapid access chest pain clinics, which will have a dramatic burden of ED. This will lead toreduced trolley waits in the department. - Facilitate the development of suhspecialist in the SE'Area The presence of a second lab would faciliia'tenhthe devel'd??niidiit" of non-invasive": services, and electrophysiology services locallfl'; Option 1 I of Hours as per the Herity Report. sessionsli'itave h'dt' been successful due to recruitment issues and ability?te provide rad?ired captidity due to 'eei'?plexity of procedures required. Average Andi-idligapaeity Calculated Capacity De?cit 201 8 6, Calculated De?cit-?niance - 428 Total Annual Cost basalt-mad patients per session ?705,791 Costing Details Appendix This is not a preferred option as it does not provide suf?cient capacity and is not value for money. Page 6 Jun ZDIE Uni I wet 9' Hospital ll?nter? rd Option 2 Implementation of? Modular Cath Lab following end of Mobile (3th Lab contract in February 20l8. Average Annual Capacity 20 I 8 4- Calculated Capacityr De?cit 2018 Calculated De?cit Balance -116 Average 12 Month Capacity 1,920 The above capacity includes all levels of procedures. Total Annual Cost ?4,132,592 Total Cost March - December 2013 63,443,826 eating Details Appendix 2 This option meets all of the . rould capacity-rebuked both for the management of the elective the standards for the management of CODE .STEMI and Non patients. Optioli 3 4.1.- if; Incremental Call: Lab. This approach requiresiinlaintaining?gihe Lab in place for Diagnostic Services until the end of Lab from April to September 20l8, 3 days per weckfordragnosttc of full modular. Cath lab service 5 days pej?ve'r?k from Gatling to bailey-thee 20bit- Average ?it-Ht" Capacity De?cit 2013 1716 Plus 446 r3216: Calculated Deficit Balance The above capacity provides for diagnostic patients on!)r from Feb 15?" to 30'? September 2018. Average 30% Conversion Patients added to Waiting List following diagnostic angiograms 446 Total Cost 15?? February to 31" December 2018 ?1,857,000 Page 7 Jan 21518 .--L If Universal "aspire! ??nfer?rd This incremental eption is the fec' 'ihh?e?'d??io' 'tionifol-ZQOI with a view to moving to Option 2 in 20l9. It meets 70% of capacity requirements and also reduces additional resource requirements for 20i8. - Costing Details Appendir 3. Page]! - Note from Secretary General to Tracey Conroy on June 2013. Tracey, Please record and arrange a letter'for mete DG, reflecting the Minister?s directions as set out here. JB zaxoexzms Note from Minister Simon Harris, TD. to Secretaryr General, Jim Breslin ZEIOBHS Jim As discussed, Having considered the submission, the letter from the HSE National Director of Acute Hospitals and the attached business case, I believe there is merit in the proposal for a modular cardio-cath lab in UHW in order to address waiting times and provide a better service for the people of Waterford and the South East. I accept there is some further work required on the detail and I request that the Dept proceed without delay to engage with the HSE on the next steps in providing a modular lab. I understand the timeline as set out in the submission but I wish to see this included in the 2019 estimates and work should begin immediately on the process to deliver it as quickly as possible. Simon Harris . . ?Why/092 Kmamhmw?nw Wang I. "Rm, . . AL. V/?mu Ed @303 maul.? EU .97 (giant/b1} . . avgr?inv; 0M v. (Wyf?l??i relay AWL. .mu? 9, nl?uIHJVz?Ja Wavy} gray/(L. ?ail ./oHuwmn.lu\ .muL: pig/Wu a gab? /V1f wag) n{ n. /n/.11 manta! Mrvl/IQ Umn?adg? mm??nm Egan. mm??um mama? US. 2.3 IUJ HE +mumL$mm?am avian d- 0 fan. {3113. y. F: Ey/Vx?m a} [ff-VI.) . (Lyn/f ./Cr hill-U. F. Fw: Update from Minister Simon Harris Joanne Lonergan to: Sinead Quill, Celeste O'Callaghan 03/07/201819251 History: This message has been replied to and fowvarded. Sinead, Further to earlier exchange re PQ. Thanks. Jo Forwarded by Joanne on 03/07/2018 19:50 From: Fiona To: "Simon.Harris" Date: 02/07/2018 13: Subject: Update from Minister Simon Harris Dear Oireachtas member, Please note the attached update from Minister Simon Harris Kind regards Fiona DEB Letter to South East Oir Membersdocx Fiona Nugent Parliamenta A on Harris TD Minister for Health Monday, 2 July 2018 Dear Direachtas Member, 1 am writing to let you know that I believe there is merit in the proposal for a modular cardio- catheterisation laboratory at UHW in order to address waiting times at the hospital and provide a better service for the people of Waterford and the South East. I have received advice from the HSE and there is some further work required on the detail however I have asked my Department to proceed without delay to engage with the HSE on the next steps in providing a modular lab. I understand the timeframe for the development of modular builds as outlined bv the HSE must include tendering, project design work, planning, construction and commissioning, so it will take until next vear to deliver but I am committing that this will be funded in the 2019 Estimate and that work should begin immediately on the process to deliver it. In the meantime the mobile lab will remain on site and the National Review of Specialist Cardiac Services continues to progress. Yours sincerely, Simon Harris TD Minister for Health