Property and Asset Management Strategy (PAMS) 2015

NHS Shetland - Property and Asset Management Strategy (PAMS) 2015

In September 2010 the Scottish Government issued CEL 35 (2010) ‘Policy for Property and Asset Management in NHS Scotland’. This Chief Executives letter sets out the requirement for each NHS Scotland Board to produce a Property and Asset Management Strategy (PAMS) which will be reviewed, updated and submitted annually to the Scottish Government. The purpose of the PAMS is to ensure that the utilisation of all land, buildings, Information Management and Telecommunications (IM&T), Medical Equipment and Vehicles assets are managed effectively and optimised in terms of financial and service benefit. CEL 35 (2010) is clear in its scope that in addition to the assets held by the Board it will also cover assets held by NHS 3rd parties including: GPs, Pharmacies, Opticians and Dentists.

NHS Shetland has produced a PAMS in 2011, 2012, 2013 and 2014 and is endeavouring to develop this Strategy as a document for the future that is a focussed and coherent strategic tool for the whole of NHS Shetland, the Shetland Islands and its people.

This document will follow the structure shown in the broad headings of:

Where are we now? The current condition of the assets.

Where do we want to be? How the Clinical strategy is driving the future shape of the assets and how the current assets are being managed.

How do we get there? The projects and process’ that are being and have been developed to achieve the position NHS Shetland has decided it wants to be in.

Roles and Responsibilities: How the PAMS will be implemented and how it will achieve the answers to the above questions.

Performance Monitoring: How NHS Shetlands assets performance is improving against its own targets and against the National landscape.

Through these sections the PAMS aims to show how:

 NHS Shetlands assets are currently performing,  the assets are being managed ,  the equipment maintenance and replacement is planned,  the service developments guided by the Scottish Governments 2020 vision are and will be facilitated by the boards assets,  the healthcare needs of the population of the Shetland Isles are and how these are being delivered,  the healthcare needs of Shetland are changing,  NHS Shetland are performing against the quality ambitions,  the structure of the organisation involves all stakeholders,  it is envisaged that NHS Shetlands assets are able to be flexible against different future scenarios.

Planned Benefits of the PAMS:

 It is expected that the implementation of this PAMS will address the high risk and significant backlog through targeted maintenance works and will be able to show a marked improvement in the Estates condition in years to come and clearly indicate the service and cost benefits that will be provided.  The targeted works will allow a cash flow analysis to be constructed for the period of the PAMS and inform the future beyond.  The Board wide adoption of the PAMS will provide a greater understanding of the aligned strategy of all the asset sets and allow a focussed direction of all staff involved in asset management.  This greater understanding will encourage discussion about the assets and how they are being provided to enable services to be delivered, these discussions will be a catalyst to allow the PAMS Development group, and beyond, to consider innovative ideas and techniques, which will lead to improvements and added value to NHS Shetland Services.  The information provided in the various sections of the PAMS can inform strategic option appraisal to give focus on future investment options available.  These investment options will be clearly identified and informed at an early stage and will streamline the early stages of the procurement process.  The PAMS gives a holistic approach to the Boards Strategy and informs all stakeholders to how they fit into the overall picture of service delivery and how their contribution to the Asset base is making a real difference to the patient and service outcomes: keeping the services person-centred, making the environment safer and all work-streams as effective as possible.  The information in the PAMS will give a clear indication of whether or not the strategy is being effective and achieving the expected improvements.  The PAMS aims to build flexibility to ensure assets meet changing service needs and continue to do so as service strategies evolve.  The PAMS is where a potential redistribution of expenditure on assets, as is expected to be the case, from the built Estate to more mobile assets that enable services to be delivered in the community and in people’s homes, as the Scottish Governments 2020 vision comes to fruition, can be illustrated.

The above Benefits of the PAMS are outcomes that can be taken from commitment to the PAMS and to the information that informs it and this will grow year on year as performance can be measured and the success’ can be clearly identified along with the issues that are a cause for concern. This PAMS will identify the current state of the assets, discuss the drivers for change and identify what is being done as a result of the direction these drivers are steering the board and how all of this is implemented and measured.

Property and Asset Management Strategy 2015-2025

Author LB Reviewed RR Sponsor RR

Status FINAL VA 08/9/2015

NHS Shetland: Property and Asset Management Strategy 2015 Contents

Contents

Executive Summary

1.0 Introduction

2.0 Where are we now? 2.1 The Shetland Islands 2.2 Population 2.3 NHS Shetland Services 2.4 NHS Shetland Estate 2.4.1 Property Type 2.4.2 Property Age 2.4.3 Property Tenure 2.4.4 Physical Condition 2.4.5 Statutory Compliance 2.4.6 Backlog Maintenance 2.4.7 Energy and Carbon Reduction 2.4.8 Sustainability 2.4.9 Space, Quality and Function 2.4.9.1 Smarter Offices 2.4.10 Progress in the last year 2.5 NHS Shetland Transport 2.5.1 Vehicle Fleet 2.5.2 Travel 2.5.3 Inter-Island Expenses 2.6 NHS Shetlands Medical Equipment 2.7 NHS Shetlands Information Management and Telecommunications (IM&T) 2.8 Summary – Where are we now?

3.0 Where do we want to be? 3.1 National Policy Drivers for Change 3.1.1 Scottish Governments Quality Strategy and 2020 vision 3.1.2 NHS Shetlands ‘2020Vision of Shetlands Healthcare’ 3.2 Local Service Strategies and Initiatives 3.2.1 NHS Shetland Board Objectives 3.2.2Public Consultation towards a Clinical Strategy 3.2.3 NHS Shetland Clinical Strategy 2011-2014 3.2.4 Primary Care Strategy 3.2.5 Palliative Care Strategy 3.2.6 Health and Social Care Integration 3.3 Other Drivers for Change 3.3.1 Patient attendances at GBH 3.3.2 Projected Population 3.3.3 Finance 3.4 Scenario Planning 3.5 Impact of Change Proposals on Property Assets 3.5.1 Acute - Hospital 3.5.2 Primary Care - Health Centres 3.5.3 Dentistry 3.5.4 Underutilised Property 3.5.5 Leased Property 3.5.6 Surplus Properties 3.5.7 Backlog 3.6 Vehicles 3.7 Medical Equipment 3.8 IM&T 3.9 Targets for Change – Ongoing Performance Management 2

NHS Shetland: Property and Asset Management Strategy 2015 Contents

3.10 Summary – Where do we want to be?

4.0 How do we get there? 4.1 Short Term Strategy (2015 - 2016) 4.1.1 Capital Projects 2015 - 16 4.1.2 Disposals of Surplus Properties 4.1.3 Terminating Lease of Breiwick House 4.1.4 Compliance and Risk 4.1.5Estate and Asset Management System (EAMS) 4.1.6 Cost Book Data 4.1.7 Vehicles 4.1.8 Medical Equipment 4.1.9 IM&T Assets 4.1.10 Soft Facilities 4.2 Medium Term Strategy (2015 - 2020) 4.2.1 Gilbert Bain Hospital Redesign Options 4.2.2 Dentist Capacity Assessment 4.2.3 Releasing additional/spare Space Utilisation Capacity 4.2.4 Energy and Emissions 4.2.5 IM&T Assets 4.2.6 10 Year Capital Programme 4.3 Longer Term Strategy (2020 - 2025 and beyond) 4.3.1 Replacement of Gilbert Bain Hospital 4.3.2 Longer Term Drivers for IM&T Assets

5.0 Roles and Responsibilities 5.1 Management Structure 5.2 Workforce Planning 5.3 Next Step Action Plan

6.0 Performance Monitoring: 6.1 Property 6.1.1 Key Performance Indicators 6.1.2 Quality Ambition 6.1.3 Energy 6.2 Vehicles 6.3 Medical Equipment 6.4 IM&T 6.5 Clinical Performance Monitoring 6.6 Responsibilities 6.7 Stakeholders Comment

NHS Shetland: Property and Asset Management Strategy 2015 Executive Summary

Executive Summary

Context

The Shetland Isles are one of the most remote locations in Scotland and the local community and NHS Shetland are therefore subject to a number of challenges:

 the islands can be cut off from the Mainland in bad weather and as a result NHS Shetlands contingency planning is essential to the smooth running of services  staff recruitment and retention remain a major issue for NHS Shetland as a result of:  competition for staff from the oil and gas industry across a range of disciplines  remoteness acting as a major barrier to attracting and retention of new staff to the islands.  challenges in accessing good quality and affordable residential accommodation  the need to locate and retain good quality residential accommodation for short term & visiting staff  limited resources available on Shetland to provide technical support where authorised personnel are required for safe compliance.  requirement for a range of assets across the islands that are underutilised (e.g. low mileage of vehicles, low usage of medical equipment and throughput for building assets  sustainability of service provision and skills retention due to low patient throughput  delivery of the required range of services in a safe and effective manner  financial and logistical impact of travel for both patients and staff with a significant proportion of services provided on the Shetland mainland  limitations of local infrastructure – in particular electricity distribution grid.

The Oil and Gas industry is currently undergoing a major resurgence in terms of investment, with a continued associated influx of personnel (between 5& 10% of the total population of Shetland). While much of this workforce is temporary and has not had a major impact on the NHS there has been a steady growth in activity from these workers.

It has also been one factor, in the steadily, but slowly, growing population of Shetland.

While Shetland has a population that is currently younger than the national average the population is now increasingly elderly with all the implications this has for the provision of health services.

Estate

The estate ( 32 properties), is very varied from single room Health Centres on isolated ,non doctor, islands to the Gilbert Bain Hospital; This is the only Acute site on the Islands and dominates the property portfolio at almost a third of the total NHS Shetland floor area. The Gilbert Bain Hospital is over 50 years old which impacts on its physical condition and currently accounts for half of the Boards backlog maintenance.

All property is owned by the Board except for one leased property (Breiwick House) that provides office and staff residential accommodation in Lerwick. This lease is to be extended following an Option Appraisal

NHS Shetland: Property and Asset Management Strategy 2015 Executive Summary

Brevik House was deemed to provide functionally unsatisfactory and poor quality accommodation and after a recent refurbishment of the Montfield Site the Board Headquarters was relocated into the Montfield Site with Brevik House sold in August 2015.

The Burra Staff Residential Accommodation was declared surplus and is in the process of being sold.

With the introduction of 1new private dental practice and the imminent opening of an Independent (NHS committed) Dental practices being opened in Lerwick in 2015, long term decisions will need to be made on the future of the property at 92 St Olaf St.

NHS Shetland performs well in relation to energy consumption and environmental management but the scope for further improvement is more limited with only minor zoning alterations to improve control of heating and a final phase of efficient light fitting replacements identified as the only viable improvements by an external energy audit.

Scalloway Health Centre has relocated to new accommodation with an Option Appraisal on-going for the use/disposal of the existing Scalloway premises.

Assets

Vehicles

The vehicle fleet (58) is all leased. The leased vehicles, on 3 year terms, provides a fleet of high quality and new vehicles that are functionally suitable, safe and reliable. There is a desire to expand the Boards electric vehicle fleet (1) but this remains dependent on the economic viability and the availability of grant assistance.

NHS are actively engaging with the North of Scotland boards to progress a North Fleet Management and Logistics Structure which may be led by Fleet Management – NHS Highland and Logistics Management – NHS Grampian

In partnership with Shetland Island Council suitable sites have been identified and installed for electric vehicle charging points

Medical Equipment

Pressure on the Capital allocation and revenue funding with competing priorities continues to challenge a future replacement programme and will require careful reprioritisation year on year.

IM &T

NHS Shetland: Property and Asset Management Strategy 2015 Executive Summary

 Improve the availability of appropriate information for healthcare workers and the tools to use and communicate that information effectively to improve quality  Improve the safety of people taking medicines and their effective use  Provide clinical and other local managers across health and social care spectrum with the timely management information they need to inform their decisions on service quality, performance and delivery Clinical & Service Context

NHS Shetlands Clinical Strategy (2011) was developed from our 2020 Vision for Shetlands’ Healthcares. This strategy identified a number of key objectives:

1. Reduce unnecessary patient travel, particularly to Aberdeen; 2. Integrate community and hospital services, especially nursing; 3. Develop a one stop shop approach to making appointments, starting with the hospital; 4. Retain GP services in their current locations; 5. Develop a more responsive mental health team; 6. Proceed with a formal process to close NHS inpatient services on the Montfield site; 7. Strengthen resilience of healthcare on non-doctor islands; 8. Remodel clinical staffing to respond to the national shortage of junior doctors and challenges to the recruitment & retention of staff.

To support these objectives a number of service redesign and efficiency programmes and options have been developed or are being developed. Some of these programmes will have an impact upon our asset base namely:

 Increased and improved use of technology for remote consultation  Use of Telehealth to reduce unnecessary travel for follow up appointments  Improved utilisation of our estate through on island clinics – delivered through outreach services or supported via telehealth equipment  Matching bed capacity to demand  Expansion of Gynecology services provided locally in Shetland through repatriation  Day Surgery unit increased capacity  More efficient use of current estate – improved throughput, effective and efficient space utilisation  Investment and improved medical equipment to support repatriation of services. (e.g. Sleep studies – investment in kit to facilitate unnecessary patient travel to Aberdeen, Edinburgh or Glasgow)

In order to progress these objectives a Redesign Project manager has been appointed

These will also be influenced by the ongoing Integration of Health and Social Care services.

NHS Shetland: Property and Asset Management Strategy 2015 Executive Summary

NHS Shetland and Shetland Island Council Integration Scheme has been approved by the Cabinet Secretary for Health and Wellbeing and the Integrated Joint Board (IJB) became legally established in June 2015

The emphasis of work on the IJB will now shift from establishing the partnership to continuing to progress the operational integration of services and joint strategic planning.

To support and develop ongoing capacity planning the Board commissioned a study by Healthcare Planners in 2013 which highlighted

 A bottleneck in Day patient pathways and  Potential for reduced bed numbers.

The study produced a ‘long list’ of options which were taken through more detailed ‘option appraisal’ to allow long term decisions around the hospital estate.

The options were

 Option A – New Hospital  Option B – Refurbish Reception /OPD Areas  Option C – Create increased Ambulatory Care Unit  Option D – Compliant 2 Unit Hospital  Option E - Do Nothing  Option F – Strategic Decision (to reduce bed base)

In considering these options, the Board recognised that these are not all mutually exclusive and that there are competing drivers influencing the choice, including:

 there are no quick wins  suggested options have limited revenue potential (as standalone options) – “we cannot build our way out our financial challenges”  Bed occupancy is not optimal, but refurbishment led schemes to address this would be expensive  we have inconsistency in our approach to the management of older peoples care and slow stream rehabilitation  we need to think differently about mode/location of service delivery, LoS, discharge planning - cultural shift  acknowledge the impact of external factors (other NHS partners and social care)

Taking these factors into consideration, alongside the overall projected financial background of the Board, it was agreed that the smaller scale projects provide a more realistic opportunities for redesign.

Therefore Option C (Increased Ambulatory Care Unit) was prioritised and is being progressed through an Initial agreement and Business Case with funding options under discussion with Scottish Government.

The plans around the remaining options are;

NHS Shetland: Property and Asset Management Strategy 2015 Executive Summary

Option A – 2014 Condition Survey data (FCA) to be analysed, during 2015, using the Capital Management Tool for scenario planning and support the agreement of projected replacement timescales

Option B – No progress planned

Option D – Target programme 2018/19 commencement (est. three year project)

Option E – Option C prioritised

Option F – On going opportunities

NHS Shetland: Property and Asset Management Strategy 2015 Executive Summary

Key Priorities

Short Term

In 2015/17 there will be a focus on:

 review the Risk Assessments on the 2014/15 Gilbert Bain Hospital Backlog Survey  review the Risk Assessments on the remaining Estate Backlog  Improving the Physical Condition of the estate by continuing to target high risk and significant backlog maintenance  a review of Medical Equipment to develop a 10 year Capital and Revenue replacement programme  improving wireless, mobile, remote and virtual working through IM&T  continue to implement the outcomes of the Soft FM review  continue the updating of EAMS data and risk assessments;  utilise the Capital Planning tool to inform decision about the timing of decisions on the planning for a replacement for the Gilbert Bain Hospital  complete SCART 2 when issued and set a realistic target score for improvement  consider the impact on the Estate of the – Primary Care Strategy ,Mental Health Review and Dental Strategy , and Integrated Services which are due to be revisited during 2015/16  completion ,relocation and opening of new Scalloway Health Centre  develop and agree a realistic target for Energy reduction  develop and agree a realistic target for CO2 emission s reduction  progress the Ambulatory Care Initial agreement & Business Case and progress funding options with the Scottish Government  space utilisation – Carry out level2 survey  estate quality – Carry out a level 2 survey  estate functional suitability – Carry out a level 2 survey  progress options for improving accommodation for Mental Health Staff and Service Delivery, including “places of safety” for patients experiencing a Mental Health crisis

Medium Term

In the Medium Term, (i.e. over the next five years);

 prioritise the backlog maintenance programme to reflect an assumed 10 year budget profile  progress Ambulatory care unit to completion  progress planning and decisions on refurbishment of GBH wards (Option D above)  prioritised replacement of the highest risk items of Medical Equipment  continued improvement in the stability of IM&T and a focus on providing services more efficiently in terms of staff workflow and financially through partnership with other NHS Boards and at a national level.

Long Term

NHS Shetland’s Longer Term Strategy, up to the year 2024 includes;

NHS Shetland: Property and Asset Management Strategy 2015 Executive Summary

 towards the end of the 10 year planning cycle revisit timescale for long term replacement of GBH and if necessary commence Business planning cycle  replacement of telephone system with internet protocol based system,  progress Electronic Patient record system including historical records,  reduction in physical IM&T assets by increased use of secure cloud computing

NHS Shetland: Property and Asset Management Strategy 2014 Introduction

1.0 Introduction

Fundamental to the development of NHS Shetlands PAMS are the service led policies and strategy documents:

1. The Scottish Governments 2020 vision 2. The Healthcare Quality Strategy for NHSScotland 3. Better Health Better Care initiative 4. NHS Shetlands Clinical Strategy (published in 2011)- ( Will be superseded by a Joint Strategic Commissioning Plan for 2016/7 to 2019/20) 5. NHS Shetlands own ‘2020 Vision of Shetlands Healthcare – Fitting together a vision of future health and care services in Shetland’ document (produced in 2005) 6. Delivering for Remote and Rural Healthcare (produced in 2007) 7. Oral Health (Dental) Strategy (under review - target completion 2015) 8. Mental Health Strategy (Implementation Plan in development – target completion 2015) 9. Joint Strategic Commissioning Plan 2015/16 10. Primary Care Strategy (under development – target completion 2015) 11. Localities Planning

This document will follow the structure shown in the broad headings of:

Where are we now? The current condition of the assets.

Where do we want to be? How the Clinical strategy is driving the future shape of the assets and how the current assets are being managed.

How do we get there? The projects and process’ that are being and have been developed to achieve the position NHS Shetland has decided it wants to be in.

Roles and Responsibilities: How the PAMS will be implemented and how it will achieve the answers to the above questions.

Performance Monitoring: How NHS Shetlands assets performance is improving against its own targets and against the National landscape.

NHS Shetland: Property and Asset Management Strategy 2014 Introduction

Through these sections the PAMS aims to show how:

NHS Shetlands PAMS development group consists of:

 Head of Estates and Facilities  Chief Medical Physics Officer  Director of Nursing & Acute Services  Head of IM&T and eHealth  Transport & Purchasing Manager  Director of Finance

This group has been identified as the technical stakeholders with the appropriate skills and knowledge to inform the development of the PAMS.

This group will aim to meet at regular intervals to ensure that the PAMS is being developed in accordance with the clinical strategy and is being effectively and timeously implemented. This group and its members will continuously consider the scope of consultation and governance to ensure that it is covering the pertinent issues and that it is consulting the right stakeholders across Shetland.

The PAMS document is a compilation of the work that the various Asset management teams undertake individually and is pulled together by the Capital Management Group (CMG) alongside the Asset Management Group (AMG) and Clinical Services Management. The regular discussions in these forums informs the prioritisation of the capital expenditure over the next 5 years and informs the strategy over the period of the PAMS and beyond.

This PAMS will cover a 10 year period from 2015 – 2025 and will address potential longer term issues and how these may affect NHS Shetlands assets.

Planned Benefits of the PAMS:

NHS Shetland: Property and Asset Management Strategy 2014 Introduction

 the targeted works will allow a cash flow analysis to be constructed for the period of the PAMS and inform the future beyond.  the Board wide adoption of the PAMS will provide a greater understanding of the aligned strategy of all the asset sets and allow a focussed direction of all staff involved in asset management.  this greater understanding will encourage discussion about the assets and how they are being provided to enable services to be delivered, these discussions will be a catalyst to allow the PAMS Development group, and beyond, to consider innovative ideas and techniques, which will lead to improvements and added value to NHS Shetland Services.  the information provided in the various sections of the PAMS can inform strategic option appraisal to give focus on future investment options available.  these investment options will be clearly identified and informed at an early stage and will streamline the early stages of the procurement process.  the PAMS gives a holistic approach to the Boards Strategy and informs all stakeholders to how they fit into the overall picture of service delivery and how their contribution to the Asset base is making a real difference to the patient and service outcomes: keeping the services person-centred, making the environment safer and all work-streams as effective as possible.  the information in the PAMS will give a clear indication of whether or not the strategy is being effective and achieving the expected improvements.  the PAMS aims to build flexibility to ensure assets meet changing service needs and continue to do so as service strategies evolve.  the PAMS is where a potential redistribution of expenditure on assets, as is expected to be the case, from the built Estate to more mobile assets that enable services to be delivered in the community and in people’s homes, as the Scottish Governments 2020 vision comes to fruition, can be illustrated.

These benefits are expected to be delivered through a commitment to the PAMS and to the information that informs it. This will grow year on year as performance can be measured and success can be identified along with the issues that are a cause for concern.

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? 2.0 Where are we now?

2.1 The Shetland Isles

The Shetland Isles, are the northernmost remote group of islands in the UK, 100miles form the northernmost tip of mainland Scotland and 220miles from Aberdeen (the closest major population centre). Access to and from the Islands is always weather dependent and the Islands can be cut off with disruption to either the Ferry or Air Services or, on occasion, both for prolonged periods. For example in January2014 ship services into Lerwick were severely disrupted for over a week causing supply problems for all services on the islands – not least the NHS. This is mitigated through robust contingency planning and the experience of departments.

The most significant economic development on the Islands remains the ongoing construction of an extension and refurbishment to the Sullom Voe Oil and Gas Terminal which has resulted in an influx of several thousand workers whose presence will remain at least until 2018 and probably beyond. This is a significant swelling of the temporary population of Shetland and there continues to be some impact on NHS Shetland even though the oil Terminal provides access to its own Health staff and most workers are health screened and registered with their hometown GP. Once these oil & gas terminal works are complete there is unlikely to be a large residual increase in population, as running a facility of this nature doesn’t use the same staffing numbers as have been required to build it. It is also likely that long term staffing may well still be based on shift workers who will not settle on the islands.

Unemployment is significantly low at 0.5% with staff recruitment & retention particularly challenging and impacted by problems with the provision of short term and permanent residential accommodation.

2.2 Population

Shetland has a current population (not taking into account the influx of oil workers noted above) of circa 23,200 (refer to the chart below) this is a continuation of a long standing (30 years and more) gentle upward trend

Population by age and sex (2011 census)

7000 6000 5000 Male 4000 Female 3000 Total 2000 1000 0 0-15 16-29 30-49 50-64 65-74 75+

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? In 2012 there were 9,976 households in Shetland which was exactly the same as the year before (below the Scottish average increase of 0.4%) although up 4.6% from 2007 (significantly greater than the Scottish average increase of 2.9%).

The projected population figures will be discussed further in the ‘Where do we want to be?’ Section.

2.3 NHS Shetland Services

NHS Shetland provides the population of the Shetland Isles with access to all the services available to the population of Scotland in as equitable a manner as possible given its remote, rural, island location. Below is a graphical representation of the service model provided by NHS Shetland:

MAINLAND SHETLAND COMMUNITY HOSPITAL

A && E E Critical Care Care General Medicine Community Services Complex/SpecialistComplex/Specialist General Surgery Surgery ContinuingContinuing Care Care MedicineMedicine & Surgery & Surgery Maternity Mental HealthMental Health TraumaTrauma Maternity Child HealthChild Health IntensiveIntensive Care Care GynecologyGynaecology RehabilitationRehabilitation Acute Geriatric Medicine DiagnosticsDiagnostics Rehabilitation Diagnostics

Mainland Shetland Consultants Primary Care Consultants / and Teams Teams Mainland Consultants

The following map & diagram highlights the location of NHS Shetland’s single hospital site, the Gilbert Bain Hospital (GBH). It also outlines the main clinical services delivered from this location. A challenge for such a ‘Remote and Rural (island) hospital’ is its ability to provide a full spectrum of acute services in a safe, effective and financially viable manner.

Therefore, NHS Shetland is reliant on significant support from NHS Grampian and other NHS Boards to ensure that patients have access to all the clinical services they need and expect from either visiting consultants or services on the Scottish mainland. This remains challenging for this support to be provided as provider Boards face their own service delivery pressures.

These off island services require a significant amount of administration, disruption and travel for patients and visiting consultants between the Shetland Isles and Scottish mainland. There is also a reliance on NHS Grampian’s Clinicians coming to the Islands to provide various specialist services which are not viable to host permanently. NHS Shetland currently spends, over £5m on its SLA with Grampian to ensure that Shetland islanders have access to all the treatments which are available to the rest of the population of Scotland and more than £2.75 m on patient travel.

Acute Services provided in the Gilbert Bain Hospital, Lerwick:

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?

Gilbert Bain Hospital

 Accident and Emergency  Occupational Therapy  Anaesthetics  Occupational Health  Audiology  Outpatients Dept  Children and Young Peoples Health  Orthotics Services  Patient Travel  Continence Advisory Services  Paediatrics  Chiropody  Physiological Measurements  Day Surgery  Physiotherapy  Dental  Podiatry  Dietetics  Rehabilitation  Health Improvement  Renal  Hearing Tests/Hearing Aids  Ronas Ward – Rehabilition/Older  High Dependency Unit People care  Macmillan Nursing  Speech and Language Therapy  Maternity  Theatres  Medical Imaging  Ward 1 - Surgical  Ward 3 - Medical Ferry: In addition there are various departments necessary to provide the correct Lerwick - Clinical Support to deliver Clinical Services across Shetland: Kirkwall - Aberdeen . Medical Physics . Laboratory Sumburgh . Admin Airport

In addition to the acute care provided in the GBH (and by NHS Grampian), community healthcare services are delivered from a range of primary care facilities located around the Isles (as illustrated below).

Primary Care Services provided throughout Shetland Mainland and to Shetlands Islands:

NHS Shetland: Property and Asset Management Strategy 2014 Appendix A - Maps

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? SHETLAND PRIMARY CARE HEALTH CENTRES (Figures correct at 1 Apr 2014)

Unst Health Centre

Hillswick Health Centre GPs: 1 + 1 associate Register total: 578 GPs: 1 GP + 1 associate Register total: 754

Fetlar Non doctor island, resident nurse Population 80 Covered by Yell Health Centre Brae Health Centre GPs 2 Register total: 2486 Yell Health Centre Covers Fetlar (non doctor island with resident nurse) Bixter Health Centre GPs: 1 + 1 associate GPs: 1 GP / linked to Scalloway Register total: 1073 practice Register total: 1143

Papa Stour Out Skerries Non doctor island, no resident nurse Non doctor island, resident nurse Population 34 Population 80 Covered by Walls Health Centre Covered by Whalsay Health Centre

Whalsay Health Centre Covers Skerries (non doctor island with resident nurse)

Foula GPs: 3 PT GPs RegisterTotal: 1144 Non doctor island population, resident

nurse Population 23 Covered by Walls Health Centre *Relative position indicative Bressay Non doctor island – population 402 Covered by Lerwick Health Centre Walls Health Centre Covers Foula & Papa Stour (non doctor islands with resident nurse) Lerwick Health Centre Covers Bressay (non doctor island with resident nurse) GPs: 1 + 1 associate (Shared with GPs: 7 + locums Bixter) Register total: 9005 Register total: 722

Levenwick Health Centre Scalloway Health Centre Covers Fair Isle (non doctor island with resident nurse)

GPs: 2 + 1 Associate GPs: 2 + 1 associate Register total: 3296 Register total: 2685

Fair Isle Non doctor island population, resident nurse Population 69 Covered by Levenwick Health Centre *Relative position indicative

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? A significant, ongoing challenge for NHS Shetland is its ability to deliver healthcare services in a constantly sustainable manner.

The patient throughput for some services are, at times, lower than you would expect to sustain that services however, this is preferable to the comparably high cost of transporting patients to Mainland Scotland and more importantly to the Clinical risk and poor access to services that would result if services were not provided in Shetland

Its small scale specialist services are also particularly vulnerable to staff absence, retention and recruitment. Services can be reliant on individual, qualified Healthcare professionals whose absence can severely affect service delivery; sometimes at short notice which requires the additional expense of temporary locums.

These challenges are a common factor for all remote and rural hospital services; and are an important consideration in the overall financial viability of the Board’s services and the effective delivery of services for the local community.

2.4 NHS Shetland Estate

2.4.1 Property Types

NHS Shetland has the following distribution of Healthcare Facilities

Hospital  Gilbert Bain Hospital, Lerwick - inpatient acute/surgical care, rehabilitation, outpatients, medical and maternity services

Staff Accommodation  Goodlad Crescent – Lerwick  Breiwick House – Lerwick  Nederdale – Lerwick  Montfield, Lerwick  Scalloway Road, Lerwick  Nurse’s House, Skerries  Nurse’s House, Foula  Nurses’ House, Fair Isle  Nurse’s House, Fetlar  Burra House (surplus)

Office Accommodation  Breiwick House – Lerwick  Brevik House – Lerwick (surplus / sold)  Gilbert Bain Hospital  Montfield, Lerwick

Health Centres  Bixter Health Centre  Brae Health Centre  Hillswick Health Centre

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?  Lerwick Health Centre  Levenwick Health Centre  Scalloway Health Centre  Unst Health Centre  Walls Health Centre  Whalsay Health Centre  Yell Health Centre  Foula Health Centre  Fair Isle Health Centre  Skerries Health Centre (part of house)  Fetlar Health Centre (part of house)

Dental Facility – NHS premises  Montfield, Lerwick  Brae  Yell  St Olaf St, Lerwick  Whalsay

Anticipated that during 2015 1 additional independent practice will open with the potential to deliver NHS services.

3rd Party/Independent Contractors Properties Pharmacies  Boots Pharmacy – Brae  Brae Pharmacy – Brae  Freefield Pharmacy – Lerwick  A.L. Laing Pharmacy – Lerwick  Scalloway Pharmacy – Scalloway

Opticians  Miller Opticians – Lerwick  Kelly opticians – Lerwick  Specsavers - Lerwick

General Practitioners Practices – None (delivered from NHS Shetland owned Health Centres)

Dental Practices – Independent practices in private ownership that do not provide NHS services

 Dental Shetland  Dental Family

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?

99 Other, 87 2 42 Dental Practice, 1,078 Property Type by area (m ) 25 Staff Residential Accommodation, 1,292 01 Acute Hospital

01 Acute Hospital, 7,344 08 Multi Service Site 24 Support Facilities, 991 21 Health Centre 23 Offices, 1,833 08 Multi Service Site, 2,791 22 Clinics (including Day Hospitals and Resource Centres) 23 Offices

24 Support Facilities 22 Clinics (including Day Hospitals and 25 Staff Residential Accommodation 21 Health Centre, 5,000 Resource Centres), 530 42 Dental Practice

99 Other

The relative sizes of the types of property can be seen in the above chart – this illustrates that the NHS Shetland Estate is dominated by the Gilbert Bain Hospital (the only Acute facility on the Islands).

The second largest property type is Health Centres which is reinforced by their dominance in numbers in the list of Healthcare Facilities listed above.

The 3rd largest segment is taken up by a single ‘Multi Purpose Site’; ‘Montfield’ – The largest property on this site was until a couple of years ago an Acute facility with bedded wards but this has been altered in various phases to contain:

 Care Home leased by Shetland Islands Council  Board Headquarters (including Shetland Island Council integrated staff)

The remainder of the site contains

 The Main Dental Facility for the Islands  Staff Development training facility  Staff residential accommodation (nursing)  Accommodation leased by Scottish Ambulance Service (SAS are seeking to relocate)

The Montfield Site contains Staff residences and it is noted that there are several other staff residences owned by NHS Shetland.

These are an extremely important asset to the Board and although a significant burden on management resources are integral to the attraction and retention of short and long term staff to the Islands and therefore integral to the Boards ability to provide a Health service.

There is an ongoing scarcity of affordable property both to rent or buy on the islands – exacerbated by the current influx of construction workers (indeed there are several accommodation barges in Lerwick and Scalloway harbours to make up the remaining shortfall of accommodation that the islands cannot provide) and the premium prices that remote and in demand island properties command which many staff simply could not afford to pay.

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? Another unique aspect of NHS Shetland is the Variety of the scale and type of buildings that this includes.

There is the Gilbert Bain Hospital (photo 1) which is a conventional purpose built medium sized 1960s concrete framed building;

Photo 1: The Gilbert Bain Hospital

There are more recently built large Health Centres such as Lerwick Health Centre (photo 2);

Photo 2: Lerwick Health Centre

Down to the smallest of properties on isolated non doctor islands such as Foula (pop 25), the Nurses House (Photos 3 & 4) with an ancillary modular building Clinic (until recently the house was the clinic).

Photo 3: Foula Nurses House before clinic annex. Photo 4: Foula clinic annex building.

NHS Shetlands Property assets amount to a total Net Book value of £26.91M the breakdown of these by type of building asset is indicated below:

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? Land £614k

Gilbert Bain Hospital £12,936k

Other buildings £12,547k

Residential properties £1,436k

25 Staff Residential Property Type by Net Book Value Accommodation, £354,034 01 Acute Hospital, £12,064,363 23 Offices, £670,220 01 Acute Hospital

22 Clinics 08 Multi Service Site (including Day Hospitals and 21 Health Centre Resource Centres), £127,035 22 Clinics (including Day Hospitals and 08 Multi Service Site, Resource Centres) 23 Offices 21 Health Centre, £5,209,926 £7,820,730 24 Support Facilities

25 Staff Residential Accommodation

42 Dental Practice

99 Other

Again this reinforces the dominance of the Gilbert Bain Hospital as the major asset almost comparable with the value of the Montfield site and all the Health Centres combined.

2.4.2 Property Age

As can be seen (in the chart below) there is very little of the Estate that is new and again the bulk of the area (43%) falls into the 1900-1960 category – due to the Gilbert Bain Hospital being built in 1960 – this does skew the look of the age profile as if it had been completed one year later 35% of the Estate would have been included in the category of less than 55 years old but as the categories stand 43% of the estate is in the category of 56 to 114 years old.

The other older age category (pre 1900 – now over 114 years old) is also due to change as one of the two sites that fall into this category; Brevik House (the former Board Headquarters) was sold in August 2015 (marketed: March 2014), this would eliminate over 90% of this category. Leaving only the 75m2 ‘90 St Olaf St’ from 1890 in this category - (potential for disposal following the Dental review during 2016/17).

However the disposal of St Olaf St property may prove difficult as the likely purchase would be as a dwelling and the change of use conversion cost from a Dental Practice to a dwelling, further compounded by the building improvement works may not lend itself to an attractive purchase.

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? Area (m2) Backlog Cost

Pre 1900 879.00 £316,400.00 1900 - 1960 1,706.00 £439,992.25 1961 - 1980 12,182.00 £1,135,758.50 1981 - 2000 6,594.00 £353,661.50 2001 or more recent 1,320.00 £20,340.00 Unreported 0.00 £45,940.00 TOTALS 22,681.00 £2,312,092.25

2.4.3 Property Tenure

NHS Shetland owns all except one of the properties it operates from, the exception being Breiwick House which is leased from the Lerwick Hotel and contains both Offices on the ground floor and Staff Accommodation (Junior Doctors) on the first floor.

Following an Option Appraisal this lease is to be extended due to the lack of viable and cost effective alternatives within the existing NHS Estate, Shetland Island Council or the market place for either office or staff residential accommodation.

NHS Shetland Analysis of Property Ownership Area (GIA) sq m % of Total Count of Area Blocks

Leased 1,033.00 4.55 1 Owned 21648.00 95.45 34 Third Party Ownership 0.00 0.00 0 Unreported 0.00 0.00 0 TOTALS 22681.00 100.00 35 NB: Block 00 has been excluded from this table (Source EAMS Board Report)

2.4.4 Physical Condition

The following description is the Ranking Protocol as set out in the NHS Scotland Property Appraisal

Manual:Ranking Protocol 9.4 Each of the building Elements and Sub-Elements will be appraised and assigned a rank dependent on its overall condition in accordance with the following definitions: A - Excellent/as new condition (generally less than 2 years old); - Expected to perform as intended over its expected useful service life. B - Satisfactory condition with evidence of only minor deterioration; - Element/Sub-Element is operational and performing as intended. C - Poor condition with evidence of major defects; - Element/Sub-Element remains operational but is currently in need of major repair or replacement. D - Unacceptable condition; - Non-operational or about to fail; The Physical Condition- Has reached of the the Estate end of is its illustrated useful life. in the following chart: 39% of the overall Physical ConditionX -is Supplementary reported as ratingCondition added Cto – D Not only Satisfactoryto indicate that it is impossible to improve without replacement.

This is attributable to the Gilbert Bain Hospital Block classed as a Condition C

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? There are several properties which make up the 25% proportion of Very Unsatisfactory Estate.

 Fetlar Nurses house – works progressed (EAMS due to be updated)  Gilbert Bain Hospital Laundry – works prioritised for 2016/ 17  Brevik House – declared surplus and sold in 2015/16  Scalloway Health Centre – relocated in 2015/16  Foula Nurses House - works progressed (EAMS due to be updated)  Burra Nurses House - declared surplus and due for disposal settlement 2015/16  St Olaf Street Dental – potential for disposal (2016/17)  Fair Isle Nurses House - works progressed (EAMS due to be updated)

Estate Physical Condition

A – Very Satisfactory B – Satisfactory C – Not Satisfactory D – Very Unsatisfactory

2.4.5 Statutory Compliance

Audit & Risk Tool (SCART)

NHS Shetland currently achieves an overall compliance in the Statutory Compliance Audit & Risk Tool (SCART) of 74% SCART compliance.

As can be seen in the table below the major Site the GBH is the best performer in terms of compliance. NHS Shetlands at 74% is almost exactly in line with the overall 2014 Scottish average compliance (73%).

Until recently the Head of Estates and Facilities was the only resource to maintain and improve the SCART score to the 2020 Performance Target of 95%.

With the recent appointment of an Estates Maintenance Manager the available resources have increased and as such in conjunction with HFS a risk based Action plan based on the new question set is being developed which is due to be finalised by August 2015

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? The Action plan will highlight the significant costs for the required compliance training (AP etc) and the burden placed on our small staff number over a wide breadth of subjects.

The Action plan will highlight the practical issues of ensuring compliance at the non doctor island properties where access and resources are challenging

This Action Plan will be presented to the Board with proposals

 For managing and controlling the risks  For resource allocations in respect of both revenue and capital  Reporting

Discussions are ongoing with the other island boards and NHS Grampian to investigate potential shared identified resources and expertise for SCART.

NHS Shetland through Strategic Facilities Group is actively engaging in a repository for NHS Scotland Boards policies and procedures

% Compliance for Each Site in NHS Shetland

Site Name % Compliance Gilbert Bain Hospital 79.8 Montfield Hospital 77.89 Scallow ay Health Center 76.58 Whalsay Health Center 76.06 Yell Health Center 75.27 Brae Health Center 73.53 Bixter Health Center 73.5 Walls Health Center 71.65 Unst Health Centre 71.62 Hillsw ick Health Center 71.23 Lerw ick Health Center 70.35 Levenw ick Health Center 68.67 Average Compliance for Inspections 73.85 above (%) Average Compliance For ALL Sites, ALL 73.89 Site Types and ALL Health Boards (%)

Fire Safety and Compliance

Fire Safety Risk assessment have been carried out on all premises and are reviewed annually/3 yearly as property type requires. The Risk assessments are within the EAMS Fire Manager System These Risk assessments in conjunction with the Scottish Fire and Rescue service annual Gilbert Bain Hospital audit form the basis for a prioritised Fire Action Plan which forms a Rolling Programme of works to reduce the fire risk and enable full compliance with the current legislation.

A Fire Committee meets quarterly to manage progress of the Action Plan

Water Safety and Compliance

Risk assessments of all properties have been completed and an Action Plan developed in conjunction with the Authorising Engineer and the Infection Control Committee

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? The Risk assessments and Action Plan form the basis for a Rolling Programme of works to reduce the risk and compliance.

NHS Shetland Water Group has been established and liaises directly with NHS Grampian Water group

Asbestos Compliance

Risk Assessments have been carried out which are reviewed annually

Training is provided to relevant staff and the current Asbestos Policy and Asbestos Management Plan are for review during 2015

Display Energy Certificates

Display Energy Certificates (DECs) show the actual energy usage of a building, the Operational Rating, and help the public see the energy efficiency of a building. This is based on the energy consumption of the building as recorded by gas, electricity and other meters. The DEC should be clearly displayed at all times and clearly visible to the public. A DEC is always accompanied by an Advisory Report that lists cost effective measures to improve the energy rating of the building.

Display Energy Certificates are required for buildings with a total useful floor area over 500m2 that are occupied by a public authority and institution providing a public service to a large number of persons and therefore visited by those persons. The useful floor area limit will be reduced to 250m2 in July 2015.

With the reduction of the useful floor area limits to 250m2 the following properties require a DEC;  Montfield Staff Accommodation  Montfield Dental  Scalloway Health Centre (New)

The following properties will require an annual update;  Gilbert Bain Hospital  Brae Health Centre  Montfield Board Headquarters  Lerwick Health Centre

Challenges

Shetland Islands Council is in partnership with NHS Shetland to provide the DEC’s, during 2015, as there is a limited capacity within the local market place.

Health Care Associated Infection

Head of Estates and Facilities is a member of the Infection Control Team

This team annually prioritises the areas for improvement which forms the basis for the Rolling Programme of HAI improvement works

Procedures will require to be reviewed during 2015 to reflect the latest Guidance (SHFN 30) and the workshop provided Health Facilities Scotland

Environmental Compliance

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? An environmental audit has been carried out (2014) on the main site (Gilbert Bain Hospital) and an Action Plan developed in conjunction with the audit team.

This Action Plan has been used to form a basis for a Rolling Programme of compliance works

Further audits will be carried out following the programmed 2015 review of Corporate Greencode by Health Facilities Scotland.

NHS Shetland has an established relationship with NHS Grampian and NHS Orkney to provide risk awareness, policies, procedures and collaboration in recognition of the limited scope for specialist knowledge and experience.

This is further supported by the inter island Group meetings hosted by HFS

Challenges

Risk management and achieving compliance within reducing Capital and Revenue resources

2.4.6 Backlog Maintenance

NHS Shetland has a Total Backlog Maintenance figure of £2,312,092.20

This comprises of

Physical Backlog - £2,043,819.75

Statutory Backlog - £268,272.50

High Risk - £39,550

Significant - £1,440,356.70

The overall distribution of risk rated costed backlog and changes are illustrated in the table below.

Backlog Cost – Clinical Backlog costs – Non Clinical Total Backlog costs – All

Areas Areas Areas

Year Moderate risk Moderate risk Moderate risk

Lowrisk Significant Risk Risk High Total Backlog Lowrisk Significant Risk Risk High Total Backlog Lowrisk Significant Risk Risk High Total Backlog

2015 £0.20 £0.13 £1.18 £0.03 £1.54 £0.24 £0.25 £0.25 £0.00 £0.74 £0.44 £0.38 £1.43 £0.03 £2.28 2014 £0.30 £0.10 £1.50 £0.30 £2.20 £0.10 £0.20 £0.80 £0.20 £1.30 £0.30 £0.30 £2.30 £0.50 £3.49

The significant improvement and variances from 2014 to 2051 are

 Total Backlog – reduction by £1.21m  Clinical High Risk - £0.27m  Clinical Significant Risk – £0.32m

These are the result of the

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?  Updated Phase 6 Condition surveys (December 2014) which addressed the previous Estates surveys.  Risk assessments more accurately completed to reflect High and Significant Risk impacts  Historical data updated into EAMS

The overall distribution of risk rated backlog is illustrated in the table below.

Risk Profiled Backlog

100% 50% 0%

The two tables below illustrate the backlog amount against the property type and then the significant and high risk backlog against property type, which confirms that there is a larger proportion of significant and high risk backlog against the GBH than other property types.

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?

21 Health Centre, Backlog per Property Type £120,520

01 Acute Hospital

08 Multi 08 Multi Service Site Service Site, £193,196 21 Health Centre 01 Acute Hospital, £977,000 22 Clinics (including Day Hospitals 22 Clinics and Resource Centres) (including Day Hospitals and23 Offices Resource Centres), 24 Support Facilities £172,455

99 Other, £79,541 23 Offices, 25 Staff Residential Accommodation £163,850 43 Pharmacy, £0 24 Support 41 GP Practice Facilities, £40,611 42 Dental Practice, £225,916 25 Staff Residential 42 Dental Practice Accommodation, £70,730

Significant and High Backlog per Property Type

01 Acute Hospital

08 Multi Service Site 01 Acute Hospital, 21 Health Centre £1,599,250 22 Clinics (including Day Hospitals 08 Multi Service and Resource Centres) Site, £415,250 23 Offices

24 Support Facilities

21 Health 25 Staff Residential Centre, Accommodation 99 Other, £73,265 £7,000 41 GP Practice 24 Support 22 Clinics 42 Dental Practice, 42 Dental Practice Facilities, £329,735 (including Day £100,730 Hospitals and 43 Pharmacy 25 Staff Residential 23 Offices, £200,000 Resource Accommodation, Centres), 99 Other £3,450 £71,000

2.4.7 Energy and Carbon Reduction

The town of Lerwick is the beneficiary of a District Heating system that was constructed in 1998 providing heating to both domestic and non domestic properties. 29

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? ‘Hot water is pumped around Lerwick through underground, insulated pipes and enters properties through a heat exchanger, supplying their heating and hot water needs. The heat used in the scheme is generated at a Waste to Energy Incinerator located on the outskirts of Lerwick. The incinerator at the Energy Recovery Plant burns domestic and commercial waste from Shetland, Orkney and from the offshore oil industry, reducing the amount of waste going to landfill.’

Source: Shetland Heat, Energy and Power; website; homepage.

The GBH (and all the NHS properties in Lerwick) are connected to the District Heating System. NHS Shetland are a key users of this integrated system and as such at present there may be limited scope for seeking alternative sources of supply without materially affecting the overall scheme.

Discussions are ongoing with SHEAP to update their emissions data and to address the charging rates.

A feasibility study has been carried out for a potential Biomass scheme at the Gilbert Bain Hospital however this was discounted as not representing value for money.

NHS Shetlands Acute Estate (the GBH) has been subject to a (5year) scrutiny of its energy performance as has all of Scotland’s Acute Estate and is the subject of the Energy and CO2 reduction HEAT Targets set by the Scottish Government.

The NHS Scotland 5 year Overall HEAT Performance Target -Energy Efficiency Target has been met

The NHS Scotland 5 year Overall HEAT Performance Target - CO2 Fossil Fuel Target has not been met as the District Heating supply emissions are beyond the control of the user.

The HEAT targets are due to be replaced commencing in 2015/16

It will be each NHS Board’s responsibility to set their own energy and GHG targets in accordance with the NHSScotland Energy and Greenhouse Gas Reporting and Targeting regime : 2014 – 2020/21 There are two sets of Targets: basic and stretch

The basic target should be based on what the NHS Board thinks could be achieved on their estate assuming that the level of investment for energy efficiency projects remains at current levels. This target should include the impact of all energy projects already agreed and funded.

The stretch target should be based on what the NHS Board thinks could be achieved on their estate assuming that all identified projects receive 100% funding. This target should include the impact of all energy projects already agreed and funded, plus those identified as ‘potential’ for which approval and funding have yet to be agreed.

An agreed list of sites is anticipated to be reached and issued by HFS during 2015

Targets can then be formulated however they are anticipated below

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? Table 1: Energy and GHG Reduction Target NHS Shetland : Energy & GHG Reduction Targets for 2020/21 Criteria (against 3-year average baseline 2011/12, 2012/13 and 2013/14) Basic Stretch Electricity Fossil Fuel Electricity Fossil Fuel 0.5% 0.5% 1.0% 1.0% Energy Consumption (kWh/m2) Combined Combined 0.5% 1.0% Greenhouse Gas Emissions 2 0.5% 1.0% (kgCO2e/m ) NHS Shetland Percentage of Total Energy Consumption from Criteria Renewable Energy Sources Basic Stretch Percentage of heat consumption from renewable 0% 0% energy sources Percentage of electricity consumption from renewable 0% 0% energy sources Percentage of total consumption from renewable 0% 0% energy sources

The Basic reductions are based on a reduction in consumption within the sites following staff awareness and zoning within the Gilbert Bain hospital

A feasibility study has determined that wind turbines are not viable until a grid connection is established with mainland

An energy audit identified minor works to health centre storage heating which are programmed and a proposed external insulation of the Gilbert Bain Hospital (Stretch)

Challenges

Meeting the Basic target will be difficult with a lack of viable alternatives and limited capital and revenue resources.

2.4.8 Sustainability

Sustainability Development

Scottish Government (CEL 15) Sustainability Development Strategy for NHSScotland creates a framework within which NHS Shetland can prioritise, develop and manage their actions and performance.

In particular we were required to develop and implement a Sustainability Development Action Plan (SDAP)

SDAP has been developed and is being revised to reflect the annual review carried out by HFS

The main strands to the Action Plan are

 Corporate Greencode 31

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?  Good Corporate Citizenship  Waste Management and Minimisation  Climate Change Adaptation  Biodiversity and Greenspace  Sustainable Procurement

Following a recent visit, presentation and workshop by Health Facilities Scotland (Head of Sustainability) a Sustainability and Environmental Management Group has been convened to take ownership of the SDAP and the associated strands

The Sustainability and Environmental Management Group will report to the Board on an annual basis on progress on the SDAP and the associated strands

Challenges

Managing the Sustainability Development Action Plan

Climate Change Public Bodies Duties Reporting

Scottish Government require NHS Shetland to complete and submit a mandatory template on an annual basis on or before 31st October

The 2015 submission is on a voluntary basis but boards are recommended to submit during the “pilot” year in order to commence their data gathering and establish an understanding of the template

The template is still under review and NHS Guidance has yet to be issued.

Challenges

However the draft version indicate that the annual completion of this template will present resource challenges within the existing staffing.

Training is scheduled for – Sustainable Procurement, Climate Change Reporting, Greencode and Carbon Footprint however attendance at these can be prohibitive due to travel costs and a lack of video conference as a viable alternative.

2.4.9 Space, Quality and Function

The Space Utilisation, Quality of Environment and Functional Suitability are documented in the Estate and Asset Management System and currently indicate that the Estate is performing as shown below:

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?

Estate Functional Suitability 72% of NHS Shetlands Estate is Functionally Suitable this leaves 20% as 8% Not Satisfactory and 8% Very 1% 20% Very Satisfactory A unsatisfactory. A significant proportion Satisfactory B of the Very Unsatisfactory 8% is Brevik House. 71% Not Satisfactory C Very Unsatisfactory D

Estate Quality The Quality of NHS Shetlands Estate follows a similar pattern to the Functional Suitability with 67% 1% 19% 13% Very Satisfactory A satisfactory this leaves 19% as Not Satisfactory B Satisfactory and 13% Very unsatisfactory. A significant proportion 67% Not Satisfactory C of the Very Unsatisfactory 13% is again Very Unsatisfactory D Brevik House.

Estate Space Utilisation NHS Shetland has an almost fully utilised Estate and zero overcrowded facilities. The geography of the Shetland 2% Not Used E Isles location means that a degree of Under Used U contingency is built into how the 98% services are delivered. There is only one Fully Used F set of Acute Healthcare facilities in the Overcrowded O Shetland Isles and where a decision has been made to provide a clinical service the facilities to provide this must be made available – there is spare capacity in the Space Utilisation of many of the these facilities however they are fully utilised in terms of their designed service delivery.

The EAMS data for the Facets 4, 5 and 6 (Space Utilisation, Quality and Space Utilisation respectively) is currently based on a Level 1 Survey (Desktop analysis).

No survey updates were carried out in 14/15

The NHS Scotland Property Appraisal Manual recommends an appraisal Level at Level 2 (a combination of on-site visual inspection of each department together with discussions with Users and consideration of acceptable space standards by an Estates and/or Service Manager). 33

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?

 Level 2 surveys are to be undertaken in 2015 in conjunction with expertise and onsite training from Health Facilities Scotland colleagues to enable future surveys to be carried out competently by in house staff

This is anticipated to provide a more accurate picture of the estate and enable the development of repatriation of services in particular to the Gilbert Bain Hospital within appropriate spatial, quality and identified underused accommodation.

This updated data set will assist with the Primary Care Strategy and Localities Planning

2.4.9 .1 Smarter Offices

Following the relocation of the Board headquarters (Brevik House) to Montfield (first floor) which included the relocation and integration of NHS Shetland and Shetland Island Council staff any further opportunities for rationalisation and space reduction are considered minimal. The Board relocation included shared meeting rooms, training space and hot desks. Any further opportunities are likely to follow as integrated services and Localities Planning develop. The Multi Agency Group (quarterly) is a forum for discussion with Shetland Island Council and other local public bodies for opportunities within individual property portfolios.

Shetland Island Council and the Board are currently working jointly to develop office and clinical accommodation options for the delivery of Adult Mental Health, Child Mental Health and Drugs and Alcohol service across both estates.

2.4.10 Progress in the last year

Capital Projects undertaken to upgrade the Estate and reduce the High and Significant Risk Backlog in the last year are listed below:

 Scalloway Health Centre relocation  Pharmacy Ventilation  Legionella Improvements Rolling Programme  Gilbert Bain Hospital - Ventilation Rolling Programme  Gilbert Bain Hospital – Fire Improvements  Gilbert Bain Hospital – Window Replacements  Gilbert Bain Hospital – Chimney upgrade

The significant percentage (55%) of the 2014/15 Capital allocation (£1.05) was prioritised by the Capital Management Group to address identified High risk Medical equipment replacement Programme.

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? An updated Gilbert Bain Hospital Condition Survey (2010) has been recently completed (December 2014) by CAPITA in conjunction with NHS Estates and robust Risk Assessments commenced on the high and significant criteria.

The reduction in the 2015 Backlog of £1.21m is a combination of factors

 Updated CAPITA survey of Gilbert Bain Hospital (Previously carried in house 2010)  EAMS data updated to reflect survey and historical backlog completion  Risk assessments carried out in line with Property Appraisal Manual guidance

The survey update and updated risk assessments will be used during 2015/16 to develop a 5 year Backlog Rolling programme.

Challenges

 Continuing to reduce the Backlog within the constraints of capital and revenue resources  Managing the Backlog risks within constraints of staffing ,capital and revenue resources

2.5 NHS Shetland Transport

2.5.1 Vehicle Fleet

The NHS Shetland fleet consists of 58 leased Crown Vehicles

The Crown vehicles are distributed as follows:

 20 x Community Nursing  2 x Podiatry  8 x Dental  7 x Maternity  7 x Estates  1 x Health Promotion  1 x Laundry  1 x Occupational Therapy  4 x Out of Hours  2 x Physiotherapy  4 x Primary Care  1 x Supplies Department

The Community Nursing vehicles are located at various NHS Health Centre’s across Shetland to enable the Nurses to make Home visits.

The Shetland Isles is made up of smaller Isles who do not have a Doctor situated on the Island. Shetland has 4 Islands that do not have a Doctor but do have a Community Nurse and have been allocated larger vehicles because the vehicle must be large enough to accommodate a stretcher. These four Islands have a KIA Ceed. With no Garages on the Islands, the fuel is sent over in Jerry Cans. The average mileage is 100 miles per month. The KIA Ceed costs the Board £2615.00 per year which is on a 3 year Contract Lease from Arnold Clark, who is the NHS Scottish National Contract Supplier. 35

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? The Transport Manager is responsible for arranging a yearly servicing of the vehicles situated on the Small Islands; this tends to take place in the summer months. The vehicle arrives on the local ferry in the morning, serviced locally in the afternoon and returned back to the Island early evening. The nurse arranges to hire a vehicle from a local resident for one day as cover in case of any emergencies.

The rest of the fleet comprises of KIA Rio’s and Ford Transits with one further vehicle which is Electric driven.

Except for Estates, Supplies and the Laundry vehicles, the rest are used for Home visits and Health Centre visits which reduces the number of patients travelling long distances to the main Hospital situated in Lerwick.

NHS Shetland staff travel to the larger Islands that include Unst, Yell and Whalsay to visit patients at their Local Health Centre’s. To travel to the Unst Health Centre, this comprises 4 ferry journeys and is a four hour round trip. In the case of Podiatry and Physiotherapy, it is cheaper for them to visit Unst and treat a number of patients in one day than for the patients to travel to Lerwick and claim their travel expenses etc (the journey is a 110 mile round trip with ferry costs of £8.20).

The Dental fleet includes 2 vehicles that are solely used for Child Smile; this is for staff that visit all schools to treat school children. The other 6 vehicles are used for the Dental staff that travel to Dental Surgeries across Shetland.

The Estates fleet is used for Staff who maintain all of the Boards buildings across Shetland. There are 9 Health Centres in Shetland and the Estates Team is required to maintain the buildings and carry out waste collections (the Estates Department is located in Lerwick).

Laundry has a vehicle which is required to collect and deliver linen in Shetland. NHS Shetland has the linen contract for the Sullom Voe Oil Terminal which is situated 40 miles North of Lerwick. The Terminal employs 2,000 people, and the contract is mainly for Boiler Suits.

There is one ‘doctor on call vehicle’ in/on each of: Lerwick, Yell, and Whalsay. These 3 vehicles are also used during normal working hours for the doctors who are required to attend any emergencies etc these vehicles are fully equipped with medical Equipment which enables an immediate response in any emergencies.

The 11 Lease Vehicles are used by either Mental Health Staff or Community Nursing Staff. These Staff travel more than 3500 Business miles per year on Home visits and is considered financially cheaper for the Board for these Staff members to have a Lease Vehicle.

All the vehicles are leased on a 3 year contract through the NHS Scottish National Contracts. For cars, Shetland uses Arnold Clark and for Vans, LEX Autolease. As can be seen in the graphs below due to the 3 year lease contracts the age and physical condition of the vehicles is very good and it should be noted that there are no 4 or 5 year old vehicles, as a new vehicle is provided at the end of each lease, except for the one owned car, on which currently, the annual maintenance is minimal.

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?

Age profile of Vehicles 50 45 40 35 30 > 5 years 25 2 to 5 years 20 Less than 2 years 15 10 5 0 Pool/Opps cars Small van Large vans

Quality Profile of Vehicles 50 45 40 35 Poor - signs of significant wear and 30 damage 25 Acceptable - some signs of wear and 20 minor damage 15 Good - no significant wear or damage 10 5 0 Pool/Opps cars Small van Large vans

The One electric car is used by a Community Nurse who is located in Lerwick and is used around the Central mainland of Shetland. The Shetland Island Council contributed with a Government grant to allow NHS Shetland to accept a 3 year lease for £2492.88 per year. This costs £1000.00 more per year than it is to lease a standard KIA Rio. However, with zero fuel, a lesser servicing requirement and zero tax, the 3 year saving to the Board is £2757.00.

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? Distribution of fuel type

50 45 40 35 Electric 30 Bio fuels 25 LPG 20 15 Diesel 10 Petrol 5 0 Pool/Opps cars Small van Large vans

The Mainland vehicles in Shetland do an average of 6,000 miles per year and the small Island vehicles do an average of around 1,200 miles per year. This results in an average mileage per vehicle of around 5500miles per year (more information can be found in Appendix C). This figure rose significantly from 2012 to 2013 reflecting more intensive use of these assets and has had a minimal drop this year.

Ave Mileage per vehicle 6000

4000

2000

0 2012 2013 2014

There is one owned vehicle assets; a mobile dental unit (being used statically as an ancillary dental surgery at the Montfield Dental Department). Assets have a net book value of, £8.6K respectively -

Annual lease cost/vehicle (£s)

£4,000

£3,000

£2,000

£1,000

£0 2012 2013 2014

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?

The leases amount to an annual cost of £152K which is a fairly large increase since the previous year from an average of £2,674 last year to £3,056 this year.

2.5.2 Travel

In 2014/15 NHS Shetland spent a total of £2.923m on patient travel.

There is a budget of £2.7m in 2015/16.

This figure is extremely high compared to other Boards. However when you take into account the remoteness of Shetland and the limitations of the Boards ability to provide some of the more specialist services close to the population it becomes clear that this high cost is as a result of having to ferry or fly patients to the Scottish Mainland, for consultations and procedures.

There is a requirement to fly over 10,500 patient journeys estimated per year to provide the necessary level of healthcare, which cannot currently be provided in Shetland.

This is of course a major focus within the Board to minimise the need for these flights not least from a financial and environmental impact but also to reduce the extent of risk, stress and inconvenience caused to patients.

Repatriation of services is under constant review and evaluated and challenged as to their necessity and/or viability as an integral part of the Clinical Strategy and service redesign.

Currently opportunities identified and being developed are

 General Outpatient Follow ups  ENT  Orthopaedics - Outpatients and minor operations  Gynaecology

The repatriation of Gynaecology services is planned for autumn 2015 with the appointment of a Consultant Obstetrician based at the Gilbert Bain Hospital (September 2015).

IM&T solutions are also being used and further considered as a way of reducing travel requirements and are discussed further in the ‘Where do we want to be?’ section.

Air Ambulance transfers from and within Shetland are not included in the travel data

Challenges

Identifying and implementing the opportunities for reducing the extent of Patient Travel without affecting service delivery

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? 2.5.3 Inter-Islands Travel expenses

Island life presents communication challenges and the necessity for travel to the Scottish Mainland is the extreme end of the scale. However patients on the outlying Shetland Islands have a similar issue in their access to Acute Healthcare – the more remote patients are supported in their travel costs to make the often arduous journey to the Gilbert Bain Hospital in Lerwick a little less stressful (refer to the Map and travel distances of the Shetland Isles in Appendix A). Patients who have to travel 30 miles or more to hospital, or have a sea journey of more than 5 miles, can claim for fares paid in excess of £10.00 under the Highlands and Islands Travelling Expenses Scheme.

The review of the Primary Care Strategy, the Joint Strategic Commissioning Plan and Localities Planning will further consider this issue.

2.6 NHS Shetland Medical Equipment

The quantity of biomedical equipment in Shetland is in the order 3000 items. This has a value in the region of £5 million with an average asset life of 10 years. Approximately 2400 items of equipment are in use in the Gilbert Bain Hospital with the remainder in use in Primary Care and Community Nursing.

It should be noted that the Boards major item of Equipment is its CT scanner which is located in the GBH – this was procured as a result of a local fundraising initiative very generously achieved by the local community with some spare funds to allow the running of the facility for a period. The CT scanner had previously been considered by the Board but it could not justify the installation in a business case as the capital cost was deemed too high. Since its installation, however, it has been a huge success and has eliminated many journeys to Aberdeen and it has increased the islands ability to diagnose patients locally. Many patients who may not have been able to travel to Aberdeen or whose journey may not have previously been justified can now be scanned in Lerwick for a fraction of the cost. As with many of the facilities and services described in this section NHS Shetland has some spare capacity in terms of the intensity of usage of this equipment however it has been invaluable in providing equity of care to Shetland Islanders with the rest of Scotland. While having this CT scanner is a fantastic facility it does have to be maintained and there has been some significant expenditure recently. This will mean that careful consideration needs to be made when it comes to the end of its lifecycle.

Appropriate arrangements are in place for the effective management of medical equipment. Each item of equipment is uniquely bar-coded for tracking purposes and is individually identified. Individual equipment records are kept on a computerised database along with a comprehensive history. The electronic inventory of medical equipment includes a range of data, a subset of which is the recommended dataset for individual items of equipment as laid out in CEL (35) 2010. These are as follows:  Unique individual equipment identification number and barcode  Serial number  Location  Model  Make  Supplier 40

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?  Manufacturer  Date of acquisition  Purchase price  Asset life  Maintenance type  Planned maintenance schedule  Electrical safety testing schedule  Service history  Anticipated replacement date and cost

From this extensive database the following graph illustrates the age profile in terms of value of the significant types of Medical Equipment.

Age Value Volume Profile - Capital Equipment Total Value £3.9m CT Scanner (Refurbished Mar 13) Fluoroscopy 120 (Refurbished X-Ray 100 Apr 2011) OPG 80 60 Anaesthetic 40 Ultrasound Machines Scanners 20 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

At 10 year lifecycle annual spend = £390k

Compiled by: Graham Southern No of Iitems Value £10,000s

It can be seen from this graph that there is a large expenditure due within the next year to replace the existing anaesthetic machines. Six machines need to be replaced with an initial indicative cost of £180k.

The following chart illustrates that 79% of NHS Shetlands Medical Equipment is classed as either as new or serviceable with 11% due for replacement. It shows a further 10% where replacement is indicated, which would be expected when average lifecycle is 10 years.

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?

Up to 2010/11 there was an annual allocation of approximately £300k to purchase replacement medical equipment. This enabled NHS Shetland to maintain a reasonable level of up-to-date technologies which, with good servicing and maintenance, provided safe accurate and effective equipment.

In 2011/12 the total allocation for Estates, IT and medical equipment was in the region of £200k. This meant that a substantial amount of the rolling replacement program for medical equipment had to be deferred to reflect this downturn in funding. The process of selecting equipment replacement has become more challenging as the capital allocation has reduced.

In 2012/13 there was limited scope for equipment replacement as most of the allocation was required for much-needed improvements in the estate and to refurbish the CT scanner. The remainder had to be very carefully targeted to ensure the most vital equipment carrying the greatest risk was replaced in priority order.

In 2013/14 the allocation for medical equipment replacement was in the region of £157k which was sufficient to replace three items of equipment.

In 2014/15 There was an allocation in the region of £500k. This has allowed us to carry out the much needed replacement of an X-Ray room £278k, an ultrasound scanner £91k, light source £19k, a mobile X-Ray machine at £72k, a cardiac output monitor £9k and a range of audiology equipment at £16k.

The Board also purchased an additional dialysis machine and reverse osmosis machine with a value of £17k. A further two machines and associated water treatment plants at £34k, are to be purchased in 2015/16 in order to meet an increase in demand on the service.

Challenges faced in the management of Medical Equipment

There have been increases in capital equipment over recent years resulting in increased costs associated with maintenance and repairs however the annual departmental non-pay budget has been reduced by approximately 13%. This has lead to a reduction in the replacement of non-capital

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? equipment and will result in an increasingly ageing portfolio of equipment. It has also been necessary to reduce the frequency of some planned maintenance schedules in order to reduce costs. This has the effect of increased failure rates and longer repair times.

The options would be to either reduce the equipment portfolio or increase the non-pay budget.

2.7 NHS Shetlands Information Management & Telecommunications (IM&T)

Current status and investment needs associated with IM&T Assets

NHS Shetland's eHealth Plan & IM&T assets offer the opportunity to improve the quality of healthcare delivery through the introduction and use of modern technology to both healthcare professionals and patients.

NHS Shetland's main IM&T assets consist of:

 Servers,  Cabling networks,  wireless networks,  Video conferencing facilities and audio visual systems,  Fixed and mobile telephony ,  Specialist and standard software packages  Specialist self-contained system (previously categorised as medical equipment)  Desktop computers and mobile devices

The following table provides details of the replacement value of each of these asset types:

IM&T Asset Replacement Value Percentage Value Servers and Storage £400,000 22% Cabling networks, £250,000 14% wireless networks, £60,000 3% Video conferencing facilities and audio £50,000 3% visual systems, Fixed and mobile telephony , £400,000 22% Specialist self-contained systems £250,000 14% (Medical Imaging, Physiological Measurements and other Healthcare Sciences) Desktop computers and mobile £400,000 22% devices TOTAL £1,810,000 100%

The IM&T infrastructure for NHS Shetland is in a robust and stable condition, as a result of several programmes of major upgrade of the core network and server estate. To build resilience into the architecture, a full Disaster Recovery site was established in the Shetland Islands Council (SIC) data centre. The data backup systems have been continually improved to ensure robust backup and recovery provision is in place including offsite storage of backup devices. This data programme of

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? data integrity assurance is being extended to primary care on 15/16 so that GP Practice data is backed up to the central data centre. We have made significant progress on integrating IM&T infrastructure with Shetland Islands Council. Following the co-location of several NHS and SIC staff cohorts, it has been agreed to implement a ‘trust’ relationship between the two organisations at the user authentication layer. This will enable the appropriate control and sharing of data and resources without the need for user separate user credentials for each organisation. The server estate in our data centre is almost fully virtualised and has been migrated from Blade technology to traditional server through capital investment during 14/15 at a cost of £50,000. Whilst blade technology can provide savings in space and power when the chassis are fully populated, due to our size, this was not the case and the balance savings were not realised. Blade technology is complex to maintain and manage and did not provide advantages over traditional servers. As well as migrating our server estate, we have refreshed all network switch devices in the our three main Lerwick campus sites, namely the Gilbert Bain Hospital, Lerwick Health Centre and Breiwick House at a cost of £25,000. This has increased performance, reliability and has standardised the network infrastructure. Our remote site N3 connections have been migrated from N3 to SWAN. While we are still seeing some performance issues with the new service, reliability has increased and we expect performance issues to be resolved in due course. Our primary data centre link has yet to be migrated, but the work on this is underway. We use the SIC fibre network to provide wide area network links between several sites, and this has saved NHS Shetland considerable potential capital costs in network provision. This is being extended further in 15/16 with the council, via its Shetland Telecom trading arm providing SWAN connectivity for Capita. This means we will benefit from the SWAN central model of service, but with local expertise we can leverage to ensure robust connectivity and best of available breed services. In terms of sharing across the north of Scotland NHS boards, we have now implemented a replacement Patient Management System that is hosted by NHS Grampian, significantly reducing the costs of implementation from circa £1m to circa £200,000. The next phase of this programme will see real-time bed management implemented, which will increase patient safety and form part of the solutions to reduce delayed discharge. We have implemented Digital Dictation and Electronic Document Transfer solutions in 14/15 and this has resulted in significant time and cost savings across the organisation. We are continuing to extend use of these solutions to integrate with other NHS Boards, further improving service and generating savings. We are engaging with our Acute Services via a standing programme board in order to find ways to leverage our strategic partnership with NHS Grampian for access to other eHealth services and integration of systems. This will both facilitate better patient care and repatriation of services, where possible, back to Shetland. This could result in significant reduction in patient travel costs, as well as improved patient experience. Considerable work has been undertaken within the IM&T department to formalise working practices, embed quality, and deliver a consistent, resilient, sustainable service. However within a small team environment, operational necessity makes effective change challenging to achieve. It is therefore planned to invest considerable effort in the further implementation of ITIL-based practice 44

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? (the international standard for IT service management). This will be achieved by a programme of formal training, and internal working groups, with business and clinical engagement. With a robust framework in place, strategic planning becomes embedded in operational activity and not a separate exercise. The core components planned for ITIL-based service delivery are finalisation of a System Catalogue, a Service Catalogue, and an agreed Service Level Agreement across all parts of the organisation, including primary care. NHS Shetland and SIC are about to go live with a shared Service Desk solution and as part of this are aligning all SLA’s and Service Offerings to drive efficiency through IM&T service delivery through both organisations. Performance of IM&T assets is managed and monitored via a number of tools included local and national real-time network monitoring tools and virtual environment management. It is planned to introduce key performance indicators to report on performance including trending so that more effective capacity planning can be achieved.

Capital Investment in IM&T has remained stable in the previous 3 years at circa £100,000 per year, and this is planned to continue, with an increase in 2017/18 to £400,000 to facilitate a replacement of the fixed telephony system.

Challenges faced in the management of IM&T assets

We are generally in a strong position regarding our core IM&T infrastructure. However we now face financial challenges regarding the continued requirement to refresh hardware and software at the user level. For example in 14/15 significant investment was required in a desktop refresh programme to enable migration from Windows XP to Windows 7. This programme is 75% complete with further investment required in 15/16.

Desktop refresh was funded via IM&T revenue budgets by finding savings in existing support contracts, and reinvesting the savings in the desktop estate.

In 15/16 we face another challenge to fund a required update of our licences for Microsoft standard product suites. This is due to three factors: products reaching end of life; Microsoft licensing cost increases; and a need to change our licensing strategy from perpetual (purchase once) licences to a subscription (annual cost). Funding for any licence investment in 15/16 is expected to be around £40,000 and this has yet to be identified.

Opportunities for improvement in the support role offered by IM&T assets

All strategic and operational IM&T activities are underpinned by a local IM&T 3 year strategy and an eHealth plan (refer to Appendix E). The eHealth plan describes the activities that we will undertake to deliver the Scottish Government eHealth Strategy. The NHS Shetland eHealth Strategic aims are:  Maximise efficient working practices, minimise wasteful variation, bring about measurable savings and ensure value for money  Support people to communicate with NHS Scotland, manage their own health and wellbeing, and to become more active participants in the care and services they receive  Contribute to care integration and to support people with long term conditions

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?  Improve the availability of appropriate information for healthcare workers and the tools to use and communicate that information effectively to improve quality  Improve the safety of people taking medicines and their effective use  Provide clinical and other local managers across health and social care spectrum with the timely management information they need to inform their decisions on service quality, performance and delivery eHealth Strategic investment in IM&T in 15/16

Specifically, via eHealth Strategic funding we will aim to: In 2015/16 we will increase shared service provision via the Shetland data sharing partnership and NHS North of Scotland eHealth group. A programme manager for the north of Scotland eHealth group has recently been appointed. One of the first projects they will undertake is the delivery of shared authentication of users across all six north of Scotland boards. This will significantly improve access to essential resources for clinicians as they provide care across boards as well as efficient sharing of networks for other staff. We will continue to mobilise our staff through opportunistic increased provision of tablets, expansion of Wi-Fi provision, and deployment of mobile access to clinical and business resources and secure deployment of content to mobile devices via our Mobile Device Management (MDM) platform. NHS Shetland eHealth and SIC ICT departments are actively engaged to integrate IT services and tools where possible. For example we will go live with a new shared Service Desk solution in July 2015. We are seeking to increase sharing of applications, share expertise to create a sustainable IT workforce for public services in Shetland and to align strategies, plans and procedures to support H&SCI and increase efficiency. We will further increase the use of Video Conferencing for staff and use for interaction with patients. In 2015/16 additional staff resource will be put in place temporarily and part of this posts remit will be to pilot the use of VC to engage with patients in their homes, or at healthcare facilities closer to their homes than the Gilbert Bain Hospital. In 2017/18 we plan to replace the current fixed telephony system with an IP telephony solution. If possible we will fully integrate this with the SIC system so that we can leverage free calls between the two organisations. In the intervening period we will extend our telephony contract with BT Global Services as National Procurement have negotiated further savings on this contract with BT. We will seek to reduce printing costs where possible through increased multi-function device deployment and corresponding reduction in the desktop printer estate. We will support the Boards efficiency and redesign programme by facilitating access to remote clinical systems, providing access to our system to remote clinicians, and increasing patient information flow. This will support reduced travel costs by repatriation of services. In 2015/16 we will commence the digitisation of our paper-based patient records by investing in high-volume scanners and a document storage solution. This forms part of our overall electronic patient record programme and will both provide access to patient information in more timely manner, increase patient safety, and reduce reliance on paper.

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? The implementation of electronic diagnostic test order communications (Order Comms) is a key element of the eHealth Strategy. As part of this we will implement Order Comms for laboratory ordering from Primary Care, and Radiology ordering from Acute in the next two years. This will improve efficiency for both requestors and diagnostic service providers. In order to comply with legislation regarding the delivery of Endoscopy services in Acute, we will implement an endoscopy management system. This is essential to ensure the service (a major part of NHS Shetland theatre activity) can continue to be delivered locally. NHS Shetland does not yet have a clinical portal as per the eHealth aim for all boards. However it is planned that this will be delivered with an increase scope to include our public sector partners to develop an integration health and social care Portal. This portal will deliver in the following three key areas:  A single presentation layer for access to patient information across multiple applications across multiple agencies  A mechanism to match patient and client records across multiple systems with differing indexes to identify patients and clients

 A data sharing solution to deliver both child information sharing (GIRFEC) and adult protection. To support the 6th strategic eHealth aim of providing timely management information to clinicians and other manager, we will develop a joint Healthcare Intelligence resource within existing skill sets across NHS Shetland and the SIC. We will seek to maximise use of existing and emerging national data intelligence resources, and develop our own local skills and solutions. The aim is to empower managers to effectively plan service provision and react to changing trends in service requirements. We will engage in national programmes to increased access to services online e.g. patient access to their own health record, and GP systems such as online appointment booking and prescription ordering, and resources for self-management of conditions. This will support national strategies designed to keep patients at home for longer and improve access to NHS service in ways that suit the patient.

Capital investment in IM&T in 15/16

For IM&T assets, a budget allocation of £100,000 will be used to:

Procure high volume scanners and document storage in support of our transition to electronic patient records.

Implement a Secure Card solution for authentication to network and printing resources that will integrate with any future secure entry requirements and streamline the staff ID card processes. This will improve system security, provide simpler access to resources for time-pressured clinicians and will be part of enabling a north of Scotland shared authentication model for NHS systems.

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now? Undertake a refresh programme for rural Health Centre network switch devices to improve performance and standardise the network infrastructure in line with the work already completed in our Lerwick sites.

Deliver a virtualisation programme for Health Centre servers utilising identical hardware and software environments in each site. This will allow us to both reduce the physical servers in each site from three down to one, while at the same time separating functions out onto separate virtual instances. This will reduce downtime required for upgrade and maintenance and enable simpler support of systems. We will purchase a core network switch for our disaster recovery infrastructure located at the SIC data centre. This will both improve access to service at the DR site in the event of a failover, and also enable easier delivery of NHS services to SIC buildings as required when staff co-locate. As part of our work towards delivery the Scottish Government Information Governance and Security Framework, we will implement a solution to provide both vulnerability testing and intrusion detection. This will provide suitable assurance that the IM&T infrastructure is appropriately secure information assets and help minimise risk of unauthorised internal or external access.

2.8 Summary – Where we are now?

The main messages from the ‘Where are we now?’ Section are summarised below:

 challenges with transport and service implications of significant travel disruption  variations in population due to the oil industry.  generally static population but increasingly aged profile – major challenge for future.  delivery of a spectrum of services on a safe effective and financially viable manner: o Transport links to and from NHS Grampian are a significant financial and logistical challenge.  sustainability of service provision due to small patient throughput.  important need to provide good quality staff residential accommodation for staff retention.  NHS Shetlands dominant asset the Gilbert Bain Hospital (GBH) is over 50 years old  limited resource numbers affect the doubling up of authorised people in terms of statutory compliance but safe compliance is still required.  total of Backlog Maintenance has reduced  high and significant risk Backlog Maintenance has reduced  NHS Shetland performs well in terms of energy consumption and but there is little scope for further significant improvements and the basic and stretch targets should reflect this  need for vehicle assets across the isles outweighs the consistency of annual usage. The predominance for lease arrangements means that the vehicles are in good condition, reliable and well maintained.  travel costs are a significant but necessary financial burden between the Isles and over to the Scottish Mainland.  despite significant investment in 2014/15 pressure will remain on the Medial Equipment replacement budget which will challenge a future replacement programme (10 Year Plan).

NHS Shetland: Property and Asset Management Strategy 2015 Where are we now?  recent investment in IM&T infrastructure now provides a robust and stable system and there is an ongoing focus towards using technology to improve patient experience and travel costs.

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be? 3.0 Where do we want to be?

Having briefly introduced the Shetland Isles and looked at what NHS Shetlands Estate and Assets are, where they are and their condition this section looks at the projects and process’ that are being and have been developed to achieve the position NHS Shetland has decided it wants to be in.

3.1 National Policy Drivers for Change

3.1.1 Scottish Governments Quality Strategy and 2020 vision

The Scottish Governments Quality Strategy has over recent years embedded, throughout every single element of the NHS, its core values of being:

 Safe  Person Centred  Effective

These values are the underlying values of everything the NHS does and with these as the foundations the Scottish Government (in their 2020 Vision) have concisely described the way it envisages healthcare should be delivered. This has synergy with the current drive for efficiencies that are required. Reducing the need for hospital treatment of patients and moving this care into the community setting will also support the required efficiencies. Below is NHS Scotland’s ‘2020 Vision’ statement:

Our ‘2020 Vision’

Our vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting.

We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self management. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions. There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.

3.1.2 NHS Shetlands ‘2020Vision of Shetlands Healthcare’

In April 2005 NHS Shetland produced their very own ‘2020 Vision of Shetlands Healthcare’, which was an all encompassing look at the Shetland Isles, its geography, demography, economy and history all in the context of the Health of, and provision of Health services to the Shetland Islands population and how all stakeholders envisaged how their Healthcare would look in the year 2020.

There was extremely extensive consultation of stakeholders undertaken within the local Community and the NHS itself which is described in the document which is included in Appendix K.

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be? This 2020 vision, at an early stage, identified some key objectives and a number of core principles on which the future healthcare provision should be based:

OBJECTIVES FOR FUTURE HEALTHCARE DELIVERY IN SHETLAND

 To sustain core services and maintain viability  To ensure the future retention and recruitment of staff  To enhance training and development opportunities  To develop partnership working with other agencies  To strengthen and develop health promotion and education.  To enhance primary care services  To provide care in the most appropriate setting  To maximise the potential benefits of new technology  To improve the environment of health care facilities

PRINCIPLES FOR FUTURE HEALTHCARE DELIVERY IN SHETLAND

 Emergency care services must be maintained locally, including medicine, surgery and maternity;  Care should only be provided in a hospital setting if it cannot be provided safely and effectively in the community;  Patients should only be sent out with Shetland for healthcare if it cannot be provided safely and effectively in Shetland;  Attendance at hospital for diagnostic tests and investigations, outpatient consultations and minor procedures should be kept to a minimum;  Healthcare should be provided in multi-professional teams, with reliance on individuals kept to a minimum.

All of these principles and objectives are still entirely relevant to the population of Shetland and are still embedded as the basis of the current Clinical Strategy.

It can be seen that, the objectives and principles identified are clearly aligned with the Scottish Government’s Quality ambitions and 2020vision.

3.2 Local Service Strategies and Initiatives

3.2.1 NHS Shetland Board Objectives

NHS Shetlands Board has identified a short but far reaching set of Objectives (as stated on the NHS Shetland website) that encompass and are consistent with the, Quality Strategy’s key values, 2020 Vision and Health and Social Care Integration:

 to continue to improve and protect the health of the people of Shetland  to provide quality, effective and safe services, delivered in the most appropriate setting for the patient

We need to make sure people are admitted to hospital only when it is not possible or appropriate to treat them in the community - and where someone does have to go to hospital, it should be as a day case where possible. Action identified by SG 2020 vision.

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be?  to redesign services where appropriate, in partnership, to ensure a modern sustainable local health service  to provide best value for resources and deliver financial balance.  to strengthen organisational capacity, capability and resilience

3.2.2 Public Consultation towards a Clinical Strategy

As with the 2020vision, there was a robust and extensive consultation of stakeholders to ensure their engagement with the process of updating its Clinical Strategy

We need a shared understanding with everyone involved in delivering healthcare services which sets out what they should expect in terms of support, involvement and reward alongside their commitment to strong visible and effective engagement and leadership which ensures a real shared ownership of the challenges and solutions. Action identified by SG 2020 vision.

The Consultation process identified that ‘people essentially could not live in Shetland in the 21st century without’:

 A hospital that provided an Accident and Emergency service, with the associated functions to support that, including medical teams and an operating theatre;  A maternity service that could also respond to emergencies;  Dental services including the emergency dental service;  On island specialism’s including medicine and surgery;  Access to primary and community services;  A commitment from Scottish mainland health boards to provide visiting clinical expertise to Shetland

And that services in Shetland had to be:

 Safe in the delivery of the functions and to have clear governance arrangements, particularly where patients were being treated by our own clinicians and clinicians from other health boards;  Effective, in that services in Shetland had to be as good as the rest of Scotland with the appropriate infrastructure to support that delivery to the required standard;  Resilient enough to take account of events such as adverse weather;  Able to respond to fluctuations in demand, including an adequate inpatient bed base to meet known demand patterns;  Responsive to the changing demographics and needs of the population

All of the above findings underpin the Objectives and Principles of future healthcare identified in NHS Shetlands: 2020Vision, which in turn are all clearly aligned with the Scottish Governments/Our ‘2020 vision’.

3.2.3 NHS Shetland Clinical Strategy 2011-2014:

This clinical strategy will be replaced in due course in conjunction with the development of the Joint Strategic Commissioning Plan, Planning for Localities and the Primary Care Strategy during 2015/16.

This review and emerging outcomes from the Integrated Joint Board will provide direction of travel for both NHS Shetland and Shetland Island Council asset base. 52

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be?

NHS Shetlands current Clinical Strategy (published in 2011 and covering the period to the end of December 2014 is the evolution of NHS Shetlands ‘2020Vision of Shetlands Healthcare’. This strategy document pulled together all the messages identified in 2020vision of Shetlands Healthcare along with other key policy documents and initiatives:

 Better Health Better Care  09/10 Plan for Sustainable services for NHS Shetland  Equally Well  Delivering Remote and Rural Healthcare  Patient Focus Public Involvement and  Healthcare Quality Strategy for NHS Scotland

Through the course of the Public consultation, and in consideration of these policy documents and initiatives eight key themes were identified - these and their current status are described in the following table:

Key Theme: Current Status: 1. Reduce unnecessary patient Careful consideration of service provision in Shetland as opposed to journeys, particularly to Aberdeen; travel to Aberdeen and indeed in people’s homes as opposed to Lerwick are constantly under review and are being mitigated by IT initiatives as detailed in the Redesign Objectives.

2. Integrate community and Integration of Community and Hospital services will be the major thrust hospital services especially of the Primary Care Strategy. nursing;

3. Develop a one stop shop Review of patient pathways as part of the Redesign Objectives make approach to making appointments, appointments more efficient. starting with the hospital;

4. Retain GP services in their The retention of GP Services is paralleled in retention of the existing current locations; Health Centres.

5. Develop a more responsive Mental Health response is an important part of the Redesign Objectives mental health team; and was identified in the Annual Review

6. Proceed with a formal process Montfield Site has now closed all Inpatient Services. to close NHS inpatient services on the Montfield site;

7. Strengthen resilience of Non-doctor islands have had recent and ongoing investment in the healthcare on non-doctor islands; suitability of Nurses Houses and introduction of the Foula telehealth pilot as a part of the Redesign Objectives.

8. Remodel clinical staffing to The Clinical Staffing Review has set out various proposals to address the respond to the national shortage fragility of service provision associated with the recruitment and of junior doctors and challenges to retention of Staff. the recruitment & retention of staff.

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be? These themes have informed the current Clinical Strategy Direction of Travel and have since evolved into numerous Efficiency and Redesign projects which are being regularly assessed in terms of their target performance, progress and traffic lighting the risks and trajectory.

Efficiency and Redesign

The Efficiency and Redesign projects which are directly affecting or are affected by the Estate and Assets are summarised below:

- More use of technology for remote consultations & Use of technology for patient consultations as an alternative to travelling.  Reviewing current care pathways to implement teleheathcare solutions, where appropriate (e.g. remote access to clinical teams, telecare equipment in people’s homes etc) as per e-Health strategy.  Isle of Foula telehealth pilot  Expand video conferencing facilities and links with Clinicians in Aberdeen

We need to develop a shared understanding with the people of Scotland which sets out what they should expect in terms of high quality healthcare services alongside their shared responsibility for prevention, anticipation, self management and appropriate use of both planned and unscheduled/ emergency healthcare services, ensuring that they are able to stay healthy, at home, or in a community setting as long as possible and appropriate. Action identified by SG 2020 vision.

- Matching bed capacity to demand  Reviewing access to Primary Care services e.g. hub and spoke models for services to maximise efficiency and access – OPD clinic at GBH  Healthcare planner consultation of OPD and bed usage.  Feasibility options developed to add capacity to GBH. – Ambulatory Care

- Extension of Gynaecology services provided in Shetland  The numbers of patients that attend the GBH for Gynaecology and Obstetrics as inpatients, Outpatients and a good proportion of Day Cases are some of the highest throughput services and the better service that can be provided locally the less requirement to use the SLA with NHS Grampian, in turn less travelling and reduction in costs.  Additional vehicles have been provided in the last year.  Additional Ultrasound equipment purchased.  Obstetrician appointed

We need to prioritise anticipatory care and preventative spend e.g. support for parenting and early years. Action identified by SG 2020 vision.

3.2.4 Primary Care Strategy

While there is not currently a standalone Primary Care Strategy the current Clinical Strategy is very clear in its key themes that GP services will be retained in their Current locations. It can also be seen that there is a joined up thinking between Primary and Secondary care as the Clinical Strategy

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be? document illustrates that the Primary Care principles are inherently embedded (as noted above) in all strategic clinical thinking and in line with the Scottish Governments 2020vision.

A new Primary Care Strategy is now under development and will define the future of primary care delivery in the context of the Scottish Governments ‘20:20 vision’. This is likely to include issues such as:

1. Increase accessibility; 2. Locality presence; 3. Focus resources on frontline delivery; 4. More use of technology for remote consultations; 5. Right clinician, right place, right time; 6. More joined up working between localities; 7. Increase joint working between staff in hospital and community setting

The work on the Primary Care Strategy is currently underway and is due for completion in 2015/16. This will support the development of the Joint Strategic Commissioning Plan and Localities Plans during 2015/16

3.2.5 Palliative Care Strategy

NHS Shetland has a Palliative Care Strategy that was originally developed in 2009 and has recently been revised. It sets out the following targets for redesign which are ongoing and underpin messages within the Clinical Strategy.

Priorities set in 2009  Formalise how the co-ordinator role is determined and what the role entails which will include elements of planning and co-ordination of care and ensuring timely and relevant information is communicated to all other professionals involved, particularly when a patient is transferred between care settings and between health boards.

Current position (2013)  Revised models of the singled shared assessment and GIRFEC for children have been implemented.  The Liverpool Care Pathway (LCP) and other models of structured, individualised care planning have been implemented.

Going Forward (2013 - 2016)  Develop a model of intermediate care, which supports the availability of ‘hospital at home’ services and time limited, intensive input to people with long term conditions  Develop a model which identifies named practitioners to take the lead role in the overall co- ordination of care for people who have palliative and end of life care requirements. The practitioners will be GPs, District Nurses and Specialist Nurses who will have a specific remit for working with community nurses, social care teams, therapists and specialist services.  Develop a ‘case management’ approach which clearly identifies practitioners who will act as care co-ordinators for people who have palliative care and subsequent end of life care needs. The approach will emphasise the role of the community nurse in providing practical,

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be? day to day advice and care as well as the supervision of input from social care and healthcare support workers.

We need to prioritise support for people to stay at home/in a homely setting as long as this is appropriate, and avoid the need for unplanned or emergency admission to hospital wherever possible. Action identified by SG 2020 vision.

3.2.6 Health and Social Care Integration

NHS Shetland and Shetland Island Council Integration Scheme has approval from the Cabinet Secretary for health and Wellbeing and Sport The Integrated Joint Board (IJB) became legally established on 27th June 2015.

The IJB will then begin to meet to shift the focus from establishment to the things they can do to improve service delivery. Strategic planning for integrated health and social care services will be directed through the development and adoption of a Joint Strategic (Commissioning) Plan and Locality Planning.

Shetland will continue to have a number of 7 localities for the purposes of Locality Planning

 North Isles – Yell, Unst and Fetlar  Whalsay and Skerries  North Mainland - Brae/Hillswick  West Mainland - Bixter/Walls (including Foula)  Central – Scalloway/Burra  Lerwick and Bressay  South Mainland - Levenwick (including Fair Isle)

At this stage it is uncertain as to the impact the Joint Strategic (Commissioning) Plan, Locality Planning and Primary Care review will have on the NHS Shetland asset base. However current indications do not suggest a significant change from the “status quo”.

We need to secure integrated working between health and social care, and more effective working with other agencies and with the Third and Independent Sectors. 3.Action3 Other identified Drivers by SG for2020 Change vision.

3.3 Other Drivers for Change

3.3.1 Patient attendances at GBH

The patient attendances at the GBH have changed over recent years. The ongoing trend towards increased Outpatient activity has resulted in a number of previous alterations and expansion to be made to the existing hospital accommodation.

There is also a correlation between the increasing outpatient activity, plus a proportional increase in Day Cases and the gradual reduction in Inpatient Episodes.

Whilst the Day Cases activity appears to have remained fairly constant in recent years it is recognised that there is an issue around accommodation capacity for day surgery spaces in the GBH.

This was supported by work carried out by the commissioned Health Care Planners 56

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be? A Standard Business Case is currently being developed to increase the capacity from 6 to 12 in the Ambulatory Care Unit

Caring for more people in the community and doing more procedures as day cases where appropriate will result in a shift from Challengesacute to community -based care. This shift will be recognised as a positive improvement in the quality of our healthcare services, progress towards our vision and therefore the kind of service change we expect to see. ThisAction is currently identified byis fundedSG 2020 vision.within the 5 year capital however discussions are ongoing with Scottish

Discussions are underway with the Scottish Government for centralised funding as this level of capital expenditure from our base allocation would impact on the available capital funding for Backlog

3.3.2 Projected Population

There is a trend, as is expected and is common to Scotland and the UK, of an increase in elderly population which has been identified and is expected to continue – evidence of how this ongoing shift in age of population is influencing provision of Healthcare services in Shetland is illustrated in the Clinical Strategy by the number of redesign projects that are aimed at caring for Elderly patients in their communities and the Palliative Care Strategy.

3.3.3 Finance

NHS Shetland’s annual overall core budget is approximately £40.8m of which the Capital budget is circa £1.05m per annum

Due to cost pressures exceeding funding increases in recent years NHS Shetland must now look to find in the region of £8m in efficiency savings over the next 5 years to maintain financial balance.

It is not currently assumed that the Scottish Government will increase the allocation beyond inflation.

Challenges

The challenge will remain to fund from with the annual Capital Allocation and revenue the competing risk priorities

 Backlog Maintenance  Medical Equipment replacement  Ambulatory Care

3.4 Scenario Planning

All the above identifies NHS Shetlands known objectives for change and outlines the impact this may have on the Boards properties and other assets. The future, however, is uncertain which can affect the way in which assets are planned. This following section considers some of these as yet unknown objectives to envisage the impact they may have if they occurred.

A Scenario Planning exercise was undertaken which involved the Chief Medical Physics Officer, Head of Estates, Transport & Purchasing Manager and Director of Nursing, Midwifery & AHPs.

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be? This exercise discussed several potential Scenarios that could conceivably develop in the Shetland Isles in foreseeable future (circa 10 years as a basis for discussion) and the likely consequence noted in bold against each scenario:

 Current Natural Gas find increases and produces a further Influx of oil/gas workers beyond the projected population, although there is a large current influx of workers this is a temporary situation and the end result of large oil/gas investment is a very small increase in population and of healthy young people, and their families, resulting in an almost unnoticeable impact on NHS Shetland and hopefully a proportion of these jobs would be taken up by local people in any case – this is based on past experience: Modest Increase in demand.  North Sea Oil and Gas reserves dry up: this is extremely unlikely to happen in the next ten years. This would result in there being significantly less jobs in Shetland and eventual depopulation: Progressive decrease in Demand for services.  Health and Social Care Integration: o All assets are handed over to NHS Shetland – Medical Equipment is already maintained by NHS. Vehicles, IM&T and Property would require some additional resources and appropriate funding to manage and maintain this influx: Significant increase in investment required (shifted from SIC to NHS). o Assets Managed in an arms-length structure – no operational impact: Neutral Impact on asset base.  NHS Scotland restructuring – no immediate effect to NHS Shetland: Neutral Impact on Assets.  Reduced funding from Central government: Pressure on maintaining Asset Base, potential rationalisation.  Continuation and exacerbation of current overspend: Pressure to reduce spend impacting on maintaining Asset Base, potential rationalisation of estate required.  Increased funding from Central government: Additional resources available to enable service redesign and improve asset base.  Realisation of reduction in current expenditure: Additional resources available to enable service redesign and improve asset base.  Depopulation of outer islands towards Lerwick – increased demand in Lerwick, reduced and removed demand on islands: Reduction in demand.  Rise in private healthcare provision as competition to NHS Services: Potential reduction in Demand.  A sharp increase in numbers of patients eligible for new surgery/treatment, for instance an increase in obese patients eligible for weight loss surgery – these types of treatment may have to be provided by NHS Grampian however there are likely to be some cases that will be best treated in Shetland: Increase in demand.  Shetland Gets a National Grid Connection – this would allow windfarms to become very profitable on Shetland and create a huge surplus of energy, reducing directly island energy costs and releasing funds. This would also provide a more robust infrastructure to the Islands: Additional resources available to enable service redesign and improve asset base.  Increased funding/grants for innovative IT and low emissions vehicles made available – potential to deliver IT solutions to staff working in the community and to shift the vehicle asset base towards more sustainable travel all providing a more efficient service delivery and reduced costs: Increase in demand for IT assets and support. 58

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be?  Recently reported Dementia treatments reduce/eliminate dementia incidence: Gradual decrease in demand.  Better/earlier diagnosis of Mental Health issues – potential increased demand due to more confirmed treatable cases but less acute cases from undiagnosed cases: Increased demand for Community based care and a potential reduction in property assets.  Continued confidence in the sustainable direction of governance in the Shetland Islands, including less reliability on public funding creating a better quality of life and continuing the values inherent in Shetland Culture of voluntary work and ‘help thy neighbour’, confirmation of Shetland to be the Best Rural place to live, may result in a gradual increase in population although less demand on the health services due to better health and voluntary care: overall a neutral impact on demand.  Further Global Economic slump – only increases the attractiveness of the Shetland Isles for Islanders to return and others to immigrate for work in the oil industry which has sheltered the Islands from the worst of a recession: Increased demand whilst reduced funds.

These Scenarios generally fall into the categories of drivers as below:

 Increased demand,  Reduced demand,  Increased resources  Reduced resources

Each of a broad brush selection of actions to address the Scenarios can be placed in the appropriate section of the category spectrum as follows:

Increased

 Continue with service redesign  Investment in innovative IT and low emissions vehicles. initiatives based on increasing  efficiency focussing on more efficient Investment in manpower to manage increased asset base. patient pathways.  Further services Repatriated requiring asset support.  Invest in new Tech. and Vehicles to  Develop plans for replacement to GBH as demand realise potential savings. outstrips supply of in and out-patient provision.  Repatriate appropriate services where asset investment is minimal.

Demand

Decreased Resources Resources Increased

 Continue with service redesign  Manage incremental downsizing of estate appropriate to initiatives based on increasing demand: manage disposals appropriately or increase efficiency. sharing of resources with SIC.  Revaluate size of asset base.  Repatriate services where appropriate, facilitated by  Invest in new Tech. and Vehicles to investment in new technology and assets. realise potential savings.  Outsource unsustainable services.  Invest in preventative care in community provision of staff, technology and equipment.

Demand Decreased

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be? Through the discussions, it is clear that NHS Shetland are in fact already undertaking or at least addressing all the action points which occur in the ‘Decreased Resources’ side of the spectrum and through the Clinical Services Management Team, the gathering of ‘metrics’ and progress risk matrix that inform the Service Redesign Pathways (which all feedback into the update of the Clinical Strategy), are fully aware of the changes in direction that could be required should certain scenarios change the Shetland Isles in the future.

Furthermore, it is current opinion that the property based assets that would be affected by scenario driven service redesign have sufficient inherent capacity to handle the pace of any change in demand that may occur.

3.5 Impact of Change Proposals on Property Assets

3.5.1 Acute Hospital

The GBH is underutilised in terms of the Patient throughput and this is a major thrust of the current Clinical Strategy. As the main asset of NHS Shetland a greater understanding is required of how it can offer opportunities to:

 Reduce costs  Maximise investment (in the Hospital)  Improve operational efficiency

The key drivers identified from the current Clinical Strategy and current Service Redesign Pathways are:

 All specialties are high variety and low volume  Day Surgical Unit – does not support good patient flow  Average bed occupancy fluctuates – difficult to match capacity and demand with the departments in the current configuration  We provide specialist services e.g. from generic clinical departments opportunity to redesign? (mental health place of safety etc)  We want to offer more services in Shetland

All these factors point to significant potential within the GBH for effective and extensive redesign of services and the Building itself to support these changes.

Challenges

Identification, prioritisation and implementation of redesign options within the constraints of limited resources for investment

3.5.2 Primary Care - Health Centres

The current Clinical Strategy has identified that all the current Health Centre locations will be maintained for the provision of clinical services.

This is further emphasised on the Island communities, and has been reinforced by the recent refurbishment of Foula and Fair Isle Health Centres which enhanced the properties by providing a 60

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be? separate accommodation for the Clinic service provision which had hitherto been shared within the Nurses domestic accommodation.

There are no plans for any immediate developments or disposals in the Health Centre provision but this will be tested in the Primary Care Review in conjunction with the Joint Strategic Commissioning Plan and Localities Planning due for completion in 2015/16.

3.5.3 Dentistry

The Clinical Strategy has identified that the Dental Services should be maintained and enhanced where possible within the islands.

Dental Services is the subject of a detailed review by the new Dental Director which is due for completion in 2015

It is anticipated that the potential impact of independent dental practices serving NHS patients may result in a rationalisation of the NHS dental provision with the potential for the disposal of surplus property

3.5.4 Underutilised Property

There are areas of the Estate which are known to be underutilised and there are also known areas of potential opportunities through service redesign that could release capacity in areas which hitherto would have been regarded as Fully Utilised.

Challenges

Identification, prioritisation and implementation of redesign options within the constraints of limited resources for investment

Culture change in space utilisation.

3.5.5 Leased Property

Currently the only leased property is Breiwick house.

This lease is due for renewal in Sept 2015.

A Feasibility Study concluded the “status quo” as the preferred option and is being progressed with the owner to renew and extend the lease

3.5.6 Surplus Properties

A Property Review concluded that the Burra Nurse’s House, Brevik House and Staff house at Scalloway were surplus

 Scalloway has been sold and  Burra is due for disposal during 2015  The sale of Brevik concluded in August 2015

The disposal of Brevik will improve the overall condition of the Estate

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be? Potential exists for the disposal of further property following the Dental review and the additional Independent Practices to Shetland

3.5.7 Backlog

The high level of ‘High Risk Backlog’ was of particular concern in 2014/15 and especially since the significant proportion of it occurred in the Gilbert Bain Hospital, and reported as Physical Condition C.

The 2014 update of the EAMS data, which followed the accelerated Phase 6 tranche of condition surveys in 2015 by the commissioned consultants (CAPITA), provides a more accurate assessment of the extent and level of backlog which has allowed better informed Risk assessments to be carried out.

This accurate and updated data will inform the prioritisation of backlog works over the future

The Capital Planning Tool will output the most accurate lifecycle models possible and enable scenario planning and timescales to be carried out in respect of the long term future of the Gilbert Bain Hospital

The GBH is not currently earmarked for immediate replacement within the ten year plan however it is anticipated that during 2015 a timeline based on the Capital Planning Tool scenario planning will be presented to the Board for consideration and future planning.

The current assumptions are based on a preliminary run of the Capital Planning Tool.

This demonstrated that the requirement for a focussed backlog programme to reduce backlog and extend the lifetime of the GBH, for potentially another 20 years, is required to prevent it from reducing to Physical Condition D.

The challenge will be to secure the necessary funding and staffing resources (estimated £500k pa) from within the Board’s competing capital priorities

 To enable this position and maintain the Gilbert Bain Hospital at a minimum Condition C while through the Ten Year Plan targeting a Condition B  To manage the risks

The Board through the Capital Management Group recognise the requirement for continued investment in the maintenance and risk management of the assets.

The Director of Human Resources and Support Services is the designated responsible officer for risk for the Board and reports through the Corporate Risk Register and Risk Management Committee.

The risk mitigation actions are progress reported to Capital Management Group on a quarterly basis supplemented with monthly meetings of the Asset Management Group.

The Head of Estates and Facilities presents an update report to the Board meetings

Service departments and staff report asset and infrastructure risks and actions using DATIX

Estates and Facilities staff have regular staff and Supervisor meetings

Challenges 62

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be? The challenges will be to secure the necessary funding and staffing resources (estimated £500k pa) from within the Board competing capital and revenue priorities

 To maintain the at the current condition  To manage the risks  To achieve compliance

3.6 Vehicles

NHS Shetland is in a positive situation of having a very young and appropriate fleet of vehicles as a result of the policy of leasing almost all of the vehicles. Ultimately the one owned car will be disposed of once it shows that it is no longer economical to retain it against the costs of a new leased car. It has been identified that the electric car that is currently being used is a real success and it would be a real desire to be able to acquire more electric vehicles.

There has been a commitment, as previously identified by NHS Shetland through the clinical Strategy, to maintaining the current level of service on the remote and island communities. There is very little scope for rationalising the vehicle usage in these locations as they are committed to being there and in the island locations they double as the emergency response vehicle. Recognition of this provision by the Scottish Ambulance Service is sought.

The current electric car was procured in partnership with Shetland Islands Council (SIC) who contributed with a Government grant to allow NHS Shetland to accept a 3 year lease for £2492.88 per year. This costs £1000.00 more per year than it is to lease a standard KIA Rio. However, with zero fuel, a lesser servicing requirement and zero tax, the 3 year saving to the Board is £2757.00. It would be a real desire to continue and broaden this partnership and involvement with SIC in terms of vehicle usage and procurement and combining the weight of both organisations may open some channels to additional funding or simply to drive lifecycle costs to a level where the cost gap is reversed to make electric vehicles more cost effective than petrol/diesel, notwithstanding the environmental benefits.

Given the geography of the Shetland Isles there are numerous synergies in the requirements of NHS Shetland and SIC, in terms of the functional suitability and utilisation of vehicles to and from locations all over the islands. NHS Shetland is keen to open discussions with SIC however there has not yet been any willingness shown from the Council side to look at the opportunities for partnership.

This may change with the Integration and the need for both bodies to identify efficiency savings

Where we want to be - Realising the significant benefits to the population of the Shetland Isles if a joint NHS-Council; Vehicle-transport Strategy could be developed.

Once the Clinical redesign, Dental Strategy, Primary Care Strategy and Localities Planning are completed and/or moved on to the next stage of development it will become clear as to the vehicle requirements to provide the redesigned services.

Given the policy of leasing the vehicle fleet means that any given service’s requirements can be met at very short notice.

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be? The opportunity to extend the number of electric vehicles may become more viable as a local garage is considering investing in the provision of local servicing .At present all electric vehicles have to be serviced on the Scottish mainland .

Potential exists for 10 cars due their small mileage trips.

Membership of the North of Fleet Scotland Management Group which is currently being explored by the North of Scotland Boards has the potential to provide management and operational savings although these may be limited.

3.7 Medical Equipment

Medical equipment is no different to any other type of equipment in that as it ages, it is more prone to breakdown. There inevitably comes a point that spare parts become scarce or impossible to source and manufacturer support is withdrawn. This can lead to a situation where equipment fails in service and cannot be brought back into operation. This results in rapid, unplanned, unbudgeted spending on essential equipment in order to try and maintain services.

There are generally only very modest developments in the requirements for new Medical Equipment within NHS Shetland which are driven by the Service redesign that is ongoing, these need to be incorporated into the prioritised expenditure as they are required/requested.

There is a planned replacement programme for medical equipment. In addition to this, additional factors are also considered during the lifespan of equipment such as:

 general condition  wear  damage  reliability  clinical or technical obsolescence  availability of spares  cost effectiveness of ownership  decontamination / reprocessing.

To maintain a rolling replacement program of the Medical Equipment assets, an annual budget of approximately £300,000 is required. Until recently there was an allocation of approximately £300,000 to purchase replacement equipment. This enabled NHS Shetland to maintain an acceptable level of up-to-date technologies which, with good servicing and maintenance, provide safe accurate and effective equipment.

In 2011/12 the total allocation for Estates, IT and medical equipment was in the region of £200,000. This meant that a substantial amount of the rolling replacement program for medical equipment had to be deferred to reflect this downturn in funding with a consequential effect. The process of selecting equipment replacement has become more challenging as the capital allocation has been deferred and reduced.

Medical Physics have an identified 10 year rolling Programme of equipment replacement. The Equipment Backlog totalled £651k (estimate) excluding revenue for minor equipment, and should this not be addressed within 2015-16 this is likely to impact on service delivery.

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be? Major medical equipment replacement “one off” such as the scanner will have to be considered in future years

Delivery of the Ten Year Plan and rolling replacement programme, including “one off”, is where we want to be for Medical Equipment

3.8 IM&T

All strategic and operational IM&T activities are underpinned by a local IM&T 3 year strategy and an eHealth plan. The eHealth plan describes the activities that we will undertake to deliver the Scottish Government eHealth Strategy. The NHS Shetland eHealth Strategic aims are (where we want to be):

 Maximise efficient working practices, minimise wasteful variation, bring about measurable savings and ensure value for money  Support people to communicate with NHS Scotland, manage their own health and wellbeing, and to become more active participants in the care and services they receive  Contribute to care integration and to support people with long term conditions  Improve the availability of appropriate information for healthcare workers and the tools to use and communicate that information effectively to improve quality  Improve the safety of people taking medicines and their effective use  Provide clinical and other local managers across health and social care spectrum with the timely management information they need to inform their decisions on service quality, performance and delivery Specifically, to achieve these aims we want to:

 Reduce energy consumption – complete virtualisation of datacentre, remote hosting, cloud computing, power management

 Reduce desktop estate costs – virtualisation, mobilisation, BYOD, flexible working  Mobilise our staff – increased provision of tablets, Wi-Fi, mobile clinical apps, application and content deployment via Mobile Device Management (MDM)

 Integrate – increased sharing of buildings, shared networks, shared expertise (sustainable IT workforce for public services in Shetland)

 Increase use of Video Conferencing - 100% Cisco jabber coverage  Virtualise Health Centre IT with identical hardware and software environments (do 1 thing 10 times, instead of 10 different things)

 Reduce fixed landline costs – implementation of IP Telephony in 17/18  Reduced mobile telephony costs – national contract

 Reduced printing costs  Reduced travel costs by repatriation of services, telehealth projects, flexible working

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be?  Reduced paper – digital dictation, electronic document management, mobile content management

 Electronic patient record – access to patient information in timely manner, increased patient safety, reduced paper.  Reduced software licence costs – more national pricing negotiation

 Ensure best use of existing software assets  Increased Wi-Fi coverage across all sites.

 All public sector organisations in Shetland sharing a single wide area, and local area networks

 Fully integrated clinical systems across health and social care

 Increased access to services online e.g. own health record, online appointment booking, online prescription ordering, remote clinics– reduce appointments, empower patients to manage own health

 Implement ITIL framework across all IM&T activity.

3.9 Targets for Change – Ongoing Performance Management

The Key Performance indicators (KPIs), used in the SAFR Report are used to indicate how NHS Shetland are performing now, and over the last couple of years, as illustrated in the Performance Monitoring Section (6.0) of this document.

Those targets are set out on the basis of the information in this PAMS and will be used in future to monitor the Performance of the PAMS and inform the evolution of the PAMS.

3.10 Summary – Where do we want to be?

This section has shown how the Clinical strategy is driving the future shape of the assets and how the current assets are being managed and can be summarised as follows:

 A clear set of themes identified in the Clinical Strategy driven by the Scottish Governments 2020 Vision and NHS Shetlands 2020Vision of Shetlands Healthcares objectives and principles:

1. Reduce unnecessary patient journeys, particularly to Aberdeen; 2. Integrate community and hospital services especially nursing; 3. Develop a one stop shop approach to making appointments, starting with the hospital; 4. Retain GP services in their current locations; 5. Develop a more responsive mental health team; 6. Proceed with a formal process to close NHS inpatient services on the Montfield site; 7. Strengthen resilience of healthcare on non-doctor islands; 8. Remodel clinical staffing to respond to the national shortage of junior doctors and challenges to the recruitment & retention of staff. 66

NHS Shetland: Property and Asset Management Strategy 2014 Where do we want to be?

 Service Redesign options being developed, several of which currently and are projected to impact on the asset base:

 More use of technology for remote consultation & Use of technology for patient consultations as an alternative to travelling  Matching bed capacity to demand – Ward redesign  Extension of gynecology service delivery provided in Shetland  Ambulatory Care

 Health and Social Care Integration and the outcomes of the Joint Strategic Commissioning Plan ,Localities Planning and Primary Care Strategy review will have to considered as to their impact on the future for the asset base  Population level slightly increasing but ageing – which will have little immediate effect on NHS Shetlands capacity although all the principles in the 2020vision and Palliative Care Strategy become increasingly relevant to address the ageing population sustainably.  Patient traffic in GBH slightly trending away from in-patients but is significantly increased in terms of Outpatients and has plateaued in Day case numbers – highlighting a need to understand these trends.  Focus on Underutilised areas of property and identifying opportunities to increase capacity to allow rationalisation of Estate.  Vehicles leasing strategy allows quick reaction to change if required and maintains a young and fit for purpose fleet.  Medical Equipment requires the rolling replacement plan to be implemented but funding the plan will be a major challenge.  Drivers for investment in IM&T identified from the eHealth Strategy:  Maximise efficient working practices, minimise wasteful variation, bring about measurable savings and ensure value for money  Support people to communicate with NHS Scotland, manage their own health and wellbeing, and to become more active participants in the care and services they receive  Contribute to care integration and to support people with long term conditions  Improve the availability of appropriate information for healthcare workers and the tools to use and communicate that information effectively to improve quality  Improve the safety of people taking medicines and their effective use  Provide clinical and other local managers across health and social care spectrum with the timely management information they need to inform their decisions on service quality, performance and delivery  Significantly reduce wastage.

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there? 4.0 How do we get there?

NHS Shetland’s approach to improving the way in which all of its assets support the effective delivery of healthcare services and financial efficiency for the Board is divided into three distinct phases – its short, medium and longer term strategies.

4.1 Short Term Strategy (2015-16)

4.1.1. Capital Plan

NHS Shetland’s short term strategy is to deliver its annual Capital Plan and programme of works.

For property assets, this will be focussed towards improving the physical condition of the estate, and reducing the risks associated with outstanding backlog maintenance and statutory compliance works. The budget for these works in 2015/16 is limited to £100,000 for capital works and £350,000 for backlog maintenance works.

The prioritised Capital programme for the coming year 2015/16 has been agreed and is set out below Capital Programme 2015-16

Approved Project Title Job Budget £000's Projects 15-16 Code Capital Project KC/ Ambulatory Care Z1516A £126 GBH LB Capital Project LB/ Mental Health Crisis Z1516B £25 GBH DM Accommodation Capital Project TB Critical Care (HDU) Z1516C £15 GBH A Capital Project RW Pharmacy Z1516D £55 GBH Capital Project LB Renal Improvements Z1516E £95 GBH Capital Project LB Endoscope Washers Z1516F £112 GBH (phase 2) Capital Project LB Contingency Z1516G £16

IT CC Medrex Scanners Z1516H £40 IT CC Intrusion Detection Z1516I £20 IT CC Health Centre Network Z1516J £15 Switches IT CC Core Network Switch Z1516K £20 IT CC ID Cards Z1516L £10 Backlog LB HAI Compliance -Rolling Z1516M £15 Programme Backlog RW Fire Compliance - Z1516N £20 Rolling Programme

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there? Backlog MG Water Compliance – Z1516O £10 Rolling Programme Backlog MG Reactive Backlog- Z1516P /LB £100,000 Backlog MG Emergency Lights Z1516P1 £10 Backlog MG GBH – Unit offices roof Z1516P2 £10 Backlog MG GBH - Heating Z1516P3 £20 Backlog MG GBH - Nitrogen Store Z1516P4 £5 Backlog MG St Olaf St- Water Main Z1516P5 £3.5 Backlog LB Greencode - Rolling Z1516P6 £5 Programme Backlog LB Fire - Bullyseye Z1516P7 £6.5 Backlog MG NDI Houses – Rolling Z1516P8 £10 Programme Backlog LB Contingency Z1516P9 £30 Backlog GBH MG Ventilation - Rolling Z1516Q £55 Programme Backlog All Sites MG Electrical - Rolling Z1516R £20 Programme Backlog GBH RW Render (Elevation) Z1516S £50 Backlog various RW Windows - Rolling Z1516T £25 Programme Backlog various LB DDA – Rolling Z1516U £5 Programme Med Physics GBH GS Medical Imaging dual Z1516V £30 head pump injector Med Physics GBH GS Theatre video Z1516W £70 gastroscopes x 2 (£35k each) Med Physics GBH GS Theatre Z1516X £15 laryngofibrescope Med Physics GBH GS Theatre insufflator Z1516Y £10 Med Physics GBH GS Theatre colonoscope x 2 Z1516Z £76 (£38k each)

Unapproved and Unfunded Projects - 2015-16

Capital Project Mental Health Place of Safety £95

GBH M LB/D

Capital Project Mental Health Staff £40

GBH AccommodationM LB/D Capital Project LB Ultrasound Room £125 GBH

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there? Other features of NHS Shetland’s Short Term Strategy include:

4.1.2 Disposals of Surplus Properties

As detailed previously, Brevik House and Burra Staff Accommodation have been declared Surplus and will be disposed of as per the requirements of the Property Transaction Handbook as soon as practically possible.

The disposal of Brevik House will reduce the backlog by £220K, will reduce the area of Very Unsatisfactory Physical Condition by 3% and reduce the area of Functionally Very Unsatisfactory buildings by 3%.

Consideration of the Dental Review, the impact of additional Independent Practices and the potential for disposal of existing property. The potential disposal would reduce the backlog by £96k all of which is High and Significant risk.

The disposal of the Burra Nurses House will reduce backlog by £52k of which £32k is significant risk

4.1.3 Terminating Lease of Breiwick House A feasibility study/impact assessment of the rationalisation of the Staff Accommodation properties was undertaken to ensure that the correct Staff Accommodation room capacity is available to support staffing requirements within the owned but underutilised Goodlad Crescent or Port Arthur residential accommodation in order to identify options to relocate the staff accommodation from Breiwick House. Feasibility studies on creating additional capacity in the Gilbert Bain Hospital or Montfield sites to incorporate the Office accommodation currently within Breiwick House was carried out.

These concluded the status quo as the preferred option and negotiations are ongoing to finalise an extended lease with the owner

4.1.4 Compliance and Risk

The current 74% SCART compliance is someway short of NHS Scotland’s preferred compliance position of 95% by 2020.

There has, over the last years, been a difficulty in terms of staff resources and training in the specific criteria within Estates to undertake the required assessments and there will be a renewed effort to ensure that a regular update of SCART is undertaken throughout 2015/16 in conjunction with the release of the SCART revised and new question sets.

With the recent appointment of an Estates Maintenance Manager the available resources have increased

HFS Training and awareness of the revised and new question sets is due to be completed in July 2015

A preliminary risk based Action Plan based on the unissued new and revised question set is being developed which is due to be finalised by August 2015 (this will need updated when SCART is formally re issued – no date has been set)

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there? The preliminary Action Plan is anticipated to highlight the significant costs that will be required for the necessary Estates compliance training SCART (AP etc),Greencode etc and the burden placed on our small staff number to carry out the training over a wide breadth of subjects and act in the designated roles and responsibilities.

The Plan will highlight the requirement for additional Authorising Engineers with the associated costs of the appointment, audits, travel and accommodation

The Plan will highlight the practical issues of ensuring compliance at the non doctor island properties where access and resources are challenging

This Action Plan will be presented to the Board with proposals

 For managing and controlling the identified risks  For resource allocations in respect of revenue to ensure compliance  For resource allocations in respect and capital to ensure compliance  For improved reporting (to highlight the risks and assurances in risk management).

Discussions are ongoing with the other island boards and NHS Grampian to investigate potential shared resources and expertise for specifically SCART and Corporate Greencode.

NHS Shetland through Strategic Facilities Group are actively encouraging a repository for NHS Scotland Boards policies and procedures

4.1.5 Estate and Asset Management System (EAMS)

There has been recent progress in updating the backlog entries following the 2014 Gilbert Bain Hospital Condition Survey. This updated data and a regular review of backlog progress will now enable EAMS to have sufficiently accurate data to be used as a strategic tool to produce the risk assessed backlog list and allow the board to pinpoint the annual prioritisation of works to be managed as efficiently as possible.

Further assessment of the High and Significant Risks is required in conjunction with Clinical staff

EAMS imported to the Capital Planning Tool will enable scenario planning exercises to be carried out on the Gilbert Bain Hospital to determine the long term options for its sustainability and future replacement.

Challenges

Scenario planning for the long term future of health care service delivery and budget provision

4.1.6 Cost Book Data It is recognised that there are some issues with the cost book data submitted by NHS Shetland.

These figures are out of alignment with the Scottish average and the other island (Orkney and Western Isles), remote (Highland) and next closest in size (Borders) Boards.

Efforts are continuing with NHS Orkney to determine the variances in data input.

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there? These comparisons will also be possible with the use of the Benchmarking Dashboard tool to understand if these are inconsistencies in data reporting or other reasons why they are occurring.

Challenges

Identifying the variances

4.1.7 Vehicles

Approaches to Shetland Island Council (SIC) to discuss partnership opportunities have, resulted in mixed progress and ongoing opportunities to engage with SIC are being investigated. As the cost of fuel increases and the cost of Electric cars decreases, the financial and environmental benefits of leasing electric vehicles will allow renewal of lease vehicles with Electric vehicles to become the norm. Charging points for a fleet of Electric Vehicles will of course be a necessity – funding opportunities will further enable NHS Shetland in partnership with Shetland Island Council to assist with the installation of charging points. Challenges Identifying funding opportunities for additional electric vehicles

4.1.8 Medical Equipment

There is a list of capital equipment that requires replacement and does not take account of those items below the capital threshold. When procurement is deferred over time, it inevitably leads to an increase in the replacement backlog. A 10 year plan of funding allocation is to be developed and presented to the Board so that it reflects the spending profile requirements for the short to medium term. This will help bring the replacement program closer to target and minimise the risks associated with long term under investment in equipment replacement.

If it is not possible to match the allocation with the spend profile then replacement will need to continue to be focussed on replacing the equipment which poses the greatest risks. For this reason, the list of equipment for each year has been put into priority order. It must be borne in mind that if equipment is not replaced in the year it is due, the priority order for the following year would need to be adjusted to reflect this.

Challenges The Capital allocation is anticipated to be insufficient to fund the peak demands of major equipment replacement and additional funding is likely to be requested from Scottish Government

4.1.9 IM&T Assets For IM&T assets, a budget allocation of £100,000 will be used for:

 Continued Wi-Fi infrastructure installation until 100% coverage across the estate.  Remote Access Solution via capital investment - Simpler, more robust remote desktop solution to enable productivity and reduce support requirements for remote staff.  Increase availability of multi-function devices, reduce number of desktop printers, implement print management software, centralise printing budgets.

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there?  Increase availability of IP VC’s and Cisco Jabber  Electronic document flow from acute to primary care – complete EDT and Digital Dictation projects (to reduce paper, increased data security, and efficient delivery of information to support care.  Implement Software Asset management system (Certero AssetStudio – full picture of current licence compliance position, ability to detect unused licences and re-utilise elsewhere, remotely deploy software quickly  Mobile Application and Content Deployment – make use of existing Airwatch MDM to achieve this.  National mobile telephony contract call-off (when suitable framework for island boards is agreed by NPS).  Virtualise Primary Care server estate and standardise network infrastructure.  Establish System Catalogue, Service Catalogue and Service Level Agreements.

4.1.10 Soft Facilities The Annual State of NHS Scotland Assets and Facilities Report for 2014 highlighted a number of concerns for the Soft FM Service delivery within NHS Shetland. This was qualified by the following cautions within the SAFR because

 The size and scope of each Board's estate has historically developed over time.

 Increased spending can be a result of an improvement initiative.

 Boards may use different service delivery models to suit local circumstances i.e. number and type of duties carried out by domestic services staff may vary from site to site.

 Smaller Boards will be unable to achieve the economies of scale evident in the larger Boards.

 There are different specifications between Boards in the scope of each service.

 Allocation of costs between services and sites may not be uniform.

 Annual variances in non-recurring expenditure may distort operational KPIs i.e. expenditure on backlog incorporated within annual property maintenance costs.

 The introductions of new initiatives which improve performance take time to implement across NHSScotland.

 Clinical complexity / specialist services vary between hospitals and may drive cost differentials i.e. specialist clinical activity may result in higher clinical waste quantities and costs.

 Differences in pay and supplies costs across geographic areas i.e. some Boards may incur higher cost arising from remote and rural locations Notwithstanding the above caution the table below still highlights a number of concerns which were brought to the attention of the Board.

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there?

Board Building Cleaning Property PFI - Energy Rates Catering Portering Laundry & Waste Area sq.m Costs £ maintena Facilities Costs £ Costs £ Cost £ per Costs £ Linen Cost Cost £ per per per sq.m nce Managem per sq.m per sq.m consumer per £ per consumer Consumer (from costs £ ent (from (from week consumer consumer week Week Cost per Costs £ Cost Cost (from week week (from Cost (from Book) sq.m per Book) Book) Cost (from Cost (from Cost Book) Cost (from sq.m Book) Book) Book) Book) Cost (from Book) Cost Book)

NHS Greater 3.1 37.3 28.7 35.2 33.0 14.3 73.4 53.8 26.6 11.9 Glasgow NHS Lothian 3.3 39.8 32.8 61.3 32.9 15.0 89.3 47.1 25.5 8.2

NHS Tayside 4.6 32.4 33.2 0.0 23.4 13.0 77.4 58.3 39.1 10.7

NHS Grampian 3.4 57.1 34.6 0.0 42.5 16.0 82.0 58.3 30.6 13.2

NHS Fife 4.4 32.9 20.8 82.1 17.2 12.5 81.6 46.4 27.9 11.4

NHS Ayrshire 3.0 40.0 49.2 17.4 24.9 11.6 84.4 56.3 40.1 10.4 & Arran NHS 2.0 43.7 88.4 117.4 25.0 18.4 88.3 30.4 41.1 15.3 Lanarkshire NHS Highland 3.3 41.0 37.2 15.3 49.0 18.1 100.6 39.0 27.8 10.6

NHS Forth 3.0 44.0 41.8 21.5 29.5 22.7 87.0 29.1 36.8 10.3 Valley NHS Dumfries 3.2 58.5 48.2 17.6 30.1 14.7 104.1 26.5 41.5 15.8 & Galloway NHS Borders 3.1 44.4 39.9 0.0 28.0 15.8 75.6 28.0 25.8 10.3

Golden Jubilee 6.3 23.2 53.0 0.0 50.0 27.1 97.7 55.3 56.6 39.0

State Hospital 3.3 61.2 34.5 0.0 38.2 23.6 104.6 16.5 7.5 5.0

NHS Western 3.5 41.1 40.4 0.0 50.5 23.9 121.1 32.3 43.2 19.1 Isles NHS Shetland 3.6 75.1 144.1 0.0 52.9 19.8 302.2 123.1 82.5 7.7

NHS Orkney 2.9 61.3 63.8 0.0 50.9 25.2 107.3 54.7 101.1 13.2

NHS Scotland 3.28 40.26 37.00 35.28 31.37 15.26 83.50 47.84 31.60 11.64 2013 Cost Book Average*

The Board meeting in April 2014 confirmed that an extensive review of Facilities Services is required to be carried out.

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there? This review was carried progressed during 2014/15 with the assistance of experienced staff from Health Facilities Scotland with the data collection, data assessment and the development of options considered at a workshop with relevant staff and a subsequent presentation to the Senior Management Team (SMT).

Options for progressing were approved by SMT and the Strategy and Redesign Committee with an update Report due to be presented to the Board in late 2015

The following have been introduced

 Porters weekend staffing structure revised  Standard working hours reduced to 37.5  Zonal cleaning system  Office cleaning schedule reduced  Micro fibre mopping system  Dedicated Staff training and learning support  Replacement machine floor scrubbers  National suppliers – dry goods  Joint tendering – Shetland Island Council  Bank staff – recruitment drive  Employee of the Month  External funding – Training SVQ - £15,000.00  Gilbert Bain – IT Staff computer  Monthly Supervisors meetings  Fortnightly Porters meetings  Facilities Staff Meetings  Radios  Supervisors – phones

The following options will be considered during 2015/16

 Relocate Sewing room to Laundry  Cease alterations to Staff uniforms  Cease laundering staff uniforms (exceptions will apply)  Porters to Estates  Sleepknit bedding  Reduce canteen opening hours  National suppliers – Frozen foods  Porters night duties  Porters tracking system  Domestic Management System  No night Porters  Staff rest rooms – rationalise  Mail runs – reduce frequency  Staffing levels – Banding  Caretaker – Lerwick Health Centre  Caretaker – Brae Health Centre

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there? The Business Cases to progress any of these options will be carried out in parallel with our Cost book data inputs and the ongoing challenges of identifying revenue savings for the Board.

Challenges

Significant challenges will be developing the Business Cases for change within staffing resources.

4.2 Medium Term Strategy (2015-2020)

NHS Shetland’s medium term strategy will be to implement its 5 year Capital Plan.

5 Year Capital Programme

2015/16 PROJECT YEAR 2 YEAR 3 YEAR 4 YEAR 5 YEAR 1 (£000)

I.T. PROJECTS 105 50 100 400* 100

MEDICAL EQUIPMENT 201 74 150 200 200 PROJECTS

CAPITAL PROJECTS 300 0 100 100 100

AMBULATORY CARE 126 836 412 0 0 PROJECTS

BACKLOG MAINTENANCE 318 100 228 350 600 PROJECTS

TOTAL 1050 1050 1050 1050 1050

This 5 Year Capital Programme allocation has been provisionally approved and will be revisited on an annual basis by Capital Management Group and then signed off within the Local Delivery plan (LDP). This will allocate specific identified project funding and rolling programmes based on the Initial Proposal bids and risk assessed prioritisation for each financial year.

The Initial Proposal bids in future years are anticipated to reflect the Strategies and outcomes of in particular the Integration Joint Board, Dental Review, and Primary Care review

The 5 year Capital Programme will be presented to the Board for consideration and approval annually and for any significant changes.

The 5 Year Capital Programme will require to be revisited during 2015/16 should additional funding be secured for the Ambulatory Care project from Scottish Government

The bid for additional funding reflects the benefits of the Ambulatory Care project and the impact and risks to the existing 5 year capital programme in terms of available funding for backlog and replacement equipment

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there? 4.2.1 Gilbert Bain Hospital Redesign Options

A key part of our medium term plan, has been the ongoing process of investigating the strategic options available within the plan development for ensuring that it continues to have a sustainable hospital based service.

Whilst there is not an imminent intention to replace the Gilbert Bain Hospital, it has been highlighted elsewhere in this PAMS that the building is over 50 years old and is beginning to suffer from physical condition related issues. However as a result of the recent condition survey and preliminary Capital Planning Tool exercise it is anticipated that with an estimated annual investment of £500,000 to address ongoing Backlog, Compliance and Maintenance risks the premises can be maintained at the current condition and life expectancy for a minimum of 20 years. This is to be presented to the Board for consideration in September 2015.

A recent analysis of patient throughput, including detailed analysis of bed usage, has been used to fully understand the future challenges that the Board faces.

As a result of these assumptions, hospital redesign options were developed and an initial, brief option appraisal exercise carried out in consultation with Health Care Planners (Buchan Associates). The options considered are outlined below:

Option A – New Hospital

 Number of beds 48 (single rooms) approaching best in class  Diagnostics, Facilities, OPD, Pharmacy etc on site  Cost of the new build - approx £50-60m (12,000 square metres)

 Cost of site – approx £3m (14 acres)  Cost of equipment/fit out – approx £8m  Revenue costs per year (pay back on capital project) = 2.5% of the general allocation approx £1.35M  Revenue savings per year – approx £200,000 (staffing)  Benefits – optimal layout of services and facilities to maximise opportunity for efficiency and patient flow  Challenges – cost of the scheme, timing (existing building rating OK for 20 years+)

The predicted minimum remaining lifespan of the existing Hospital has been evaluated as 20 years, given that there is a 10max year project lifecycle it has been identified that in ten years time the decision would be expected to be made on implementing the procurement of a replacement Hospital for the GBH. This is effectively discounting Option A at this time.

Option B – Refurbish Reception /OPD Areas

 Number of beds 63  Diagnostics, Facilities, DSU, Pharmacy etc on site  Refurbish main OPD and consolidate similar areas & reception  Cost of the refurbishment £330,000  Revenue costs per year (pay back on capital project) - £8,250  Revenue savings per year – approx £25,000 (staffing)

 Benefits – increased capacity for visiting services, repatriation, potential increase in patient/staff satisfaction  Challenges – poor return on investment (revenue costs will remain the same/increase), “build-ability”, utilisation levels will remain the same, inefficiencies in some pathways will not be addressed NHS Shetland: Property and Asset Management Strategy 2015 How do we get there? Option C – Create Ambulatory Care Unit  Number of in patient beds TBA  Diagnostics, Facilities, OPD, Pharmacy etc on site  12 trolleys to accommodate day surgery and ambulatory patients (requiring interventions)  Cost of the refurbishment £1.04M  Revenue costs per year (pay back on capital project) - £25,000  Revenue savings per year – approx £200,000 (SLA)

 Benefits – improved utilisation, improved efficiency, ability to repatriate services, potential to use/reduce inpatient beds, possible revenue savings  Challenges – savings would be marginal unless they are aligned to other service redesign ideas, “build- ability” and retaining/delivering core services

Option D – Compliant 2 Unit Hospital

 Number of in patient beds 46 (Plus 5 Maternity)  Diagnostics, Facilities, OPD, Pharmacy etc on site  12 trolleys to accommodate day surgery and ambulatory  Cost of the reconfiguration - £5.1M + £1.04M  Revenue costs per year (pay back on capital project) - £150,000  Revenue savings per year – approx £500,000 (staffing)

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there? Option E - Do Nothing

 Benefits – no capital outlay, services continue to be delivered  Challenges – revenue costs will remain the same, reduced ability to progress repatriation of services, utilisation levels will remain the same, inefficiencies in pathway design will not be addressed, patient/staff dissatisfaction

Option F – Strategic Decision (to reduce bed base)

 We take a strategic decision to reduce the bed base by closing a unit (evidence suggests we can do this – but there are risks)

 Capital cost – nil  Revenue savings per year – approx £600,000  Testing proof of concept – keep unit ‘moth balled’ for approx 12 months and monitor the impact  Challenge is managing the acute/slow stream patients in the remaining units which cannot be reconfigured for compliance due to the restricted footprint of the building

In considering of all these options, the Board has been clear that there are competing drivers influencing this chioce:

 We have to make a decision – no quick wins  Suggested options have limited revenue potential (as stand alone options) – “we cannot build our way out and find the savings”  Bed occupancy is not optimal, but refurbishment led schemes to address this would be expensive  We have inconsistency in our approach to the management of older peoples care and slow stream rehabilitation  We need to think differently about mode/location of service delivery, LoS, discharge planning - cultural shift  Acknowledge the impact of external factors (other NHS partners and Social care)

Taking all these factors into consideration, along with the current financial background of the Board, it was concluded by the Board that the better, relatively minor impact opportunities will support the current Service Redesign objectives in creating a more efficient patient pathway across Outpatient, In-patients and Day Cases.

Investment in a replacement hospital currently assumed not to be required for another 20 years (subject to Capital Planning Tool exercise)

The outcome of this Initial review of options was developed further and prioritised

This has been used to form elements the Ten Year Plan including the Ambulatory Care unit and future consideration of further Ward Redesign

With the completion of the Capital Planning Tool through NHS National Services Scotland, Procurement, Capital and Facilities (previously known as Health Facilities Scotland), a further life cycle costing analysis can be undertaken to add weight to these option appraisals.

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there? The Capital Planning Tool when implemented will enable further evidence to determine an optimum replacement timescale for the GBH.

At the conclusion of the redesign process it is envisaged that several additional outcomes will have been achieved of:

 Improving clinical outcomes  Improving compliance  Improving patient/staff experience

Challenges

Ambulatory Care (Option C)

Is currently funded over three financial years, commencing 2015/16 from within the Boards Capital Allocation. However it is recognised that this will reduce the available funding for Backlog.

Therefore Scottish Government have been approached for an additional allocation (subject to SIG project approval). Initial responses have been positive.

Ward Redesign

This is not affordable within the anticipated Board Capital allocation in 2019/20, 2020/21 and 2021/22

This project would be subject of a bid to Scottish Government (LDP) but it is recognised that with the projected restraints on capital that no early decision may be forthcoming and/or no award will be granted.

4.2.2 Dentist Capacity Assessment

A Shetland wide Dental Capacity Assessment will be undertaken, by the Dental Director, following the opening of new Independent dental practices. When complete and in conjunction with the Dental Strategy review this will inform the future plans for St Olaf Street Dental Surgery.

St Olaf St premises would require major Backlog investment in the short/medium term

4.2.3 Releasing additional/spare Space Utilisation capacity

Ways in which the spare capacity in Healthcare facilities (Fully utilised in terms of the design of the clinical service – although this may be only a three days a week service) can be realised through minimal adaption of existing facilities to allow additional services and functions to be provided in these spaces (for the additional two days a week) are currently being investigated through the Primary Care Strategy

There is also the situation that there is some spare capacity in the assets that may be able to be released by the minimal adaptations described above but there is the issue of current limitations of the flexibility in the delivery of Services, for example the Out-patients Dept recently had alterations of £750,000 to make it fit for purpose however the Out-Patients Services close at 5pm, if extra hours

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there? could be introduced into the length of opening hours it would be possible to significantly increase this and many other services capacity with limited or no impact on the assets of property – these opportunities are also being investigated through the service redesign.

Challenges

Culture change in space utilisation and service delivery

Investment in spend to change

4.2.4 Energy and Emissions

Proposals about how to achieve the basic energy and emissions targets are required.

Feasibility Studies have discounted wind turbines and Biomass installation as not viable and Energy Audits have identified limited opportunities

CEEF funding is no longer available and limited Capital funding is available from within the Capital allocation.

Areas of improvement will be

 Further LED installation  Zoning to Gilbert Bain Hospital  Staff awareness  Emissions data from SHEAP (risk of increase)

The last of the ‘quick win’ projects that is deemed commercially viable, which are targeted to be implemented is to install LED lighting in Lerwick Health Centre.

Enhanced zoning of the heating system in the Office areas of the GBH is targeted to be implemented to allow the BMS system to isolate 9am-5pm areas from 24hour operated areas.

4.2.5 IM&T Assets Implement Order Communications (Trakcare in Secondary Care, tender for solution for primary care).

 Virtual Desktop Infrastructure (VDI) solution – ‘sweat the assets’, stabilise the desktop environment, centralise management. This will require capital investment as the core computing power is returned to the centre from the desktop, but will reduce revenue costs of desktop rolling upgrade programme.

 Virtual Application Solution – remove legacy compatibility issues, maximise application licence utilisation, simplify administration.

 Work with other boards, and nationally to leverage potential costs savings in negotiations with software vendors when procuring low volume software by aggregating volumes.

 Work with other boards, and nationally to commission mobile versions of clinical applications (or commission third parties to do this if cheaper)

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there?  More access to NHS Grampian systems to support repatriation of services – Grampian clinicians able to access grampian systems when in Shetland.

 Implementation of business intelligence software to provide decision-makers access to real-time information that will allow fast and agile planning of services (6th eHealth Strategic aim).

4.2.6 10-Year Capital Programme

The following table is the outline 10 Year Capital Programme.

CURRENT YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 YEAR 6 YEAR 7 YEAR 8 YEAR 9 YEAR 10 CAPITAL - 15/16 PROGRAMME (assumes ambulatory funded from capital allocation) IT 105 50 100 400 100 100 100 100 100 100 MEDICAL 201 74 150 200 200 200 200 200 200 200 EQUIPMENT BACKLOG 318 100 228 350 600 600 600 600 600 600 MAINTENANCE AMBULATORY 126 836 412 0 0 0 0 0 0 0 CARE CAPITAL 300 0 100 100 100 100 100 100 100 100 PROJECTS

FUTURE YEAR 1 YEAR 2 YEAR3 YEAR 4 YEAR 5 YEAR 6 YEAR 7 YEAR 8 YEAR 9 YEAR 10 ANTICIPATED - 15/16 MAJOR CAPITAL PROJECTS - UNFUNDED REPLACEMENT 0 0 0 0 0 0 0 1200 0 0 SCANNER REPLACEMENT 0 0 0 0 0 0 800 0 0 0 FLUOROSCOPY X RAY UNIT REPLACEMENT 0 0 0 0 0 200 0 0 0 0 WASHER DISINFECTOR X RAY 0 0 0 0 0 0 0 0 0 250 MACHINE WARD 0 0 0 300 2850 2850 0 0 0 0 REDESIGN TOTAL 0 0 0 300 2850 2850 800 1200 0 0 UNFUNDED

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there? FUTURE YEAR 1 YEAR 2 YEAR3 YEAR 4 YEAR 5 YEAR 6 YEAR 7 YEAR 8 YEAR 9 YEAR 10 ANTICIPATED - 15/16 MINOR REVENUE EQUIPMENT REPLACEMENT PROGRAMME MINOR 90 90 90 90 90 90 90 90 90 90 EQUIPMENT REPLACEMENT - < £5,000

The 10 Year Capital Programme is based on the long term projections for;

 Backlog Maintenance, IT, Medical Equipment and Capital Projects.

CMG has approved this spend profile in principle but will require to be reviewed annually to reflect the Capital Allocation and any emerging priorities and/or slippage.

This has enabled the setting of a Capital Programme for 2015-16.

Should the Ambulatory Care project be funded by Scottish Government with an additional allocation the Ten Year Plan will require to be reprioritised with the under spend allocation to Backlog Maintenance.

The Ten Year plan will need to be further reviewed when following the outcomes from the Capital Planning Tool exercise in respect of the long term future for the GBH ,however it is not anticipated that the Gilbert Bain replacement timeline this will materially affect the current Plan

4.3 Longer Term Strategy (2020 - 2025 and beyond)

4.3.1 Replacement of Gilbert Bain Hospital

The process of procurement of a new hospital has currently been outlined for commencement in 9- 10 years time to be able to deliver a new hospital in 20 years time. The initial option appraisal process included in the Medium Term Strategy Section outlines how a new hospital might look. However the Clinical Strategy is evolving and the service delivery models may be quite different by the ‘decisions point’ around the year 2023.

NHS Shetland: Property and Asset Management Strategy 2015 How do we get there?

At this stage the table above illustrates a prediction of the remaining lifespan of the GBH and will be further reviewed with the implementation of Capital Planning tool in respect of the long term future for the GBH. This will be refined during 2015.

The recent Condition Survey will provide updated data for input into the Capital Planning Tool which should enable the establishment of a potential replacement timeline based on scenario planning

It is anticipated that the required replacement timescale is likely to extend beyond the current estimated 20 years

4.3.2 Longer Term Drivers for IM&T Assets

 Full electronic patient record by fully integrating clinical systems and digitising of historical records.  IP Telephony to replace existing managed service. Reduced total cost of ownership, integrated voice and data network, directory services integration  Fully integrated IT systems sitting on the network layer, by virtue of SWAN code of connection  Increased use of secure cloud computing to significantly reduce IT systems physically hosted by NHS Shetland.

NHS Shetland: Property and Asset Management Strategy 2014 Roles and Responsibilities

5.0 Roles and Responsibilities

5.1 Management Structure

NHS Shetlands PAMS is ultimately the responsibility of the Chief Executive. The Asset Management Champion has been agreed as the Finance Director with the Head of Estates and Facilities as the Lead in producing the PAMS. The Heads of the Medical Physics Department, IM&T and eHealth Department and Transport & Purchasing Manager are all major contributors in respect of Medical Equipment, IM&T and Vehicles respectively. All these contributors, including the Estates manager are responsible for their own area of the Asset base. They are also collectively responsible, along with the Finance Director in ensuring that the Strategy is delivered as planned and ensuring that the resultant performance of is as expected.

There are a number of important Groups/Teams/Committees and Policies/Strategies that influence the PAMS whose relationships to each other are illustrated in the diagram below:

NHS Shetland Board

Strategy Redesign Committee

Local Delivery Plan

Primary Care Strategy

PAMS Localities Planning

Joint Strategic Capital Clinical Commissioning Plan Managment Services Group Management Clinical Strategy Asset Management Clinical Services Group 2020 Public Vision Patient Forum

NHS Shetland: Property and Asset Management Strategy 2014 Roles and Responsibilities

Each of the Groups/Teams have regular meetings the remit and the members of each of these groups is detailed below:

Board Meetings: Held Bi-monthly, members:

 Chair  Non-Executive Board Members  Director of Nursing, Midwifery and Allied Health Professionals  Medical Director  Director of Human Resources and Support Services  Chair, Area Clinical Forum  Director of Finance  Chief Executive  Chair, Area Partnership Forum  Director of Public Health

The corporate risks associated with property and assets have been under reported to the Board over previous years and it is intended to address this during 2015/16 and to highlight risks and provide assurance.

Strategy Redesign Committee: Held prior to each Board Meeting, members are as per the Board Meeting. This committee meets to discuss the major issues on the agenda of the Board Meetings.

Clinical Services Management: This meeting discuss’ the Primary Care ,Dental and Clinical Services, how they are managed and future planning including development of brief for equipment needs to pass to the CMG. The Members include CMG members who can offer immediate feedback on the equipment requirements and vice versa the Clinical Services Management can offer comment on the CMGs asset management proposals. Members are:

 Director of Nursing & Acute Services  Director of Community Health & Social Care  Clinical Heads of Departments  Members of Consultants Group  Associated Healthcare Professionals Representative  Director of Public Health  Chief Nurse  Child & Family Health Manager  Director of Finance  Director of Pharmacy  Medical Director  Hospital Manager  Assistant Medical Director

Asset Management Group (AMG): This group convenes for a 30min informal meeting weekly and formal monthly meetings. The purpose of these meeting is to make sure that all projects are hitting their programmes and spend targets – this meeting informs the CMG meeting. Members are:

 Head of Estates and Facilities

NHS Shetland: Property and Asset Management Strategy 2014 Roles and Responsibilities

 Head of Medical Physics  Head of IM&T and eHealth Dept  Capital Projects Manager  Head of Finance and Procurement

Capital Management Group (CMG): This Group meets at 3 monthly intervals. This is the formal forum for the allocation and recording the progress of current projects .Annually CMG gathers all the Initial Proposals submitted for capital expenditure and risk assess’ and prioritises all requests based on the initial submissions and presentations by the appropriate bidders to ensure that the investment would be the best value for money.

These assessed and prioritised proposals form the prioritised projects, within the framework of the PAMS and the 5 Year Capital Plan, which CMG would propose to the Strategy Redesign Committee for consideration and approval at the Board Meeting. This Group consists of:

 Chief Executive  Head of Estates and Facilities  Head of Medical Physics  Head of IM&T and eHealth Dept  Director of Nursing and Acute Services  Medical Director  Director of Finance  Director of Community Care  Staff Representative

If there were to be any deviations from the PAMS the CMG meeting would be the one that such a proposal would be proposed and the prioritisation process would be undertaken again and proposed to the Strategy Redesign Committee if deemed necessary. Any deviation must still be aligned with the various current Clinical and Property and Asset Management Strategies.

The nature of the size of NHS Shetland, as can be seen in the lists of members of the various Groups/Teams above, means that there are individuals who are represented on multiple forums, this cross group involvement enables a full understanding of the Capital Plan and all the constraints and opportunities that are occurring. This multiple involvement also means that a quick turn-around on feedback from one group to another (from Clinical Services Management to CMG and back to CMG for instance), and the fact that the Finance Director (the asset Management Champion) is on the CMG and the Board allows a greater degree of knowledge of the circumstances underlying the Capital Plan, having been involved in its development.

Patient Public Forum (PPF) & Area Partnership Forum (APF): There are annual PPF and APF meetings at which the Head of Estates and Facilities makes a presentation of the progress of the Previous Years Capital Plan and the coming years proposals on the Capital Plan (this is also available on the NHS Shetland website). These meetings are designed to inform the Public and Local Partners but also to gain feedback and constructive criticism, where appropriate, on how the PAMS is performing in parallel with the various Clinical Strategy’s performance. Members of the Public have been embedded into appropriate project teams and this will continue in 2015/16.

NHS Shetland: Property and Asset Management Strategy 2014 Roles and Responsibilities

The level of involvement of the Public is clear to see in their engagement in the ‘2020 Vision of Shetlands Healthcare’ and the Clinical Strategy’s development and this interest has been consistent since these documents were developed.

Public engagement is established in Community Planning and Localities Planning proposals and is anticipated in the Dental review and Primary Care Strategy

Multi Agency Property Group: This group has been established for a number of years with purpose of providing a discussion forum of the major property and land owners within the public sector to identify any joint working opportunities and strategies. The members on the group are - Shetland Island Council, NHS Shetland, Scottish Ambulance Service, Police Scotland, Scottish Fire Service, and Hjaltland Housing Association.

During 2014 this membership was widened to Lerwick Port Authority and the utility companies.

5.2 Workforce Planning

The Board Workforce Plan in line with CEL 32 (2011) Guidance is currently under review and due for completion July 2015.

At this stage of the 2015 review early indications in respect of Estates and Facilities staff are that the following issues remain from 2014 and will require to be considered over a number of years.

 Age profile of existing staff  Skills and Knowledge retention  Low unemployment (0.5%)  Market forces  Local skills shortage  Recruitment  Affordable staff accommodation

In order to address these issues

 A major recruitment drive has been carried out  Extensive external funded (NES) training opportunities have been developed ( and are oversubscribed)  Working with Shetland Island Council to establish opportunities for Modern Apprenticeships  Property review confirms the continuation of the NHS Shetland staff accommodation portfolio

5.3 Next Step Action Plan

The Short Term Action plan:

Is the annual Capital Plan and delivery of the programme of works which will be implemented and managed by the appropriate Heads of departments? 88

NHS Shetland: Property and Asset Management Strategy 2014 Roles and Responsibilities

The ongoing Service reviews, Integrated Joint Board and redesigns developments will inform the Board and in turn the CMG and the PAMS for 2016.

Strong and decisive implementation of all the action points noted in the ‘How do we get there?’ Section of this PAMS document.

There is a Corporate Risk Register however the implementation of the PAMS does not currently appear on it. This will be a consideration during 2015/16 to be taken forward to the Strategy and Redesign Committee as a proposal to add it to the Corporate Risk Register.

Continue to improve quality of data to ensure that the KPIs are as accurate and therefore useful as possible and use the KPIs to report and inform the CMG, Clinical Services Management and Board of progress and of course next years PAMS document.

Engage with the newly introduced Capital Planning Tool to ensure that the best value for money and the correct timing of medium and longer term elements of the PAMS are achieved.

The Medium Term Action Plan: is the development and implementation of the 5 year Capital Plan. It is likely that this will evolve as there will be some constraints on whether all of the Plan can be achieved and thereafter a reprioritisation will be required. Health and Social Care Integration is a great opportunity for a better Patient Pathway and the PAMS must be agile enough to allow the implications of this to assimilate into the day to day running and at a strategic level.

The Long Term Action Plan: is arrival at the 2020 vision. It has been demonstrated that NHS Shetland are very well placed in terms of the 2020 visions required actions are and have been embedded in the Clinical Strategy and Service Redesign and as a result inherently into the PAMS. The reviews, impact of integration and redesign feed back into the development of the Clinical Services and as time passes and the shape of the suite of services that NHS Shetland delivers in the longer term must be understood and included in the PAMS in years to come.

NHS Shetland: Property and Asset Management Strategy 2014 Performance Monitoring

6.0 Performance Monitoring

6.1 Property

6.1.1 Key Performance Indicators

To date NHS Shetland has not used KPIs to monitor the performance of the building Estate. For this PAMS the same list of KPIs as is used in the SAFR report has been used.

 The size and scope of each Board's estate has historically developed over time.

 Increased spending can be a result of an improvement initiative.

 Boards may use different service delivery models to suit local circumstances i.e. number and type of duties carried out by domestic services staff may vary from site to site.

 Smaller Boards will be unable to achieve the economies of scale evident in the larger Boards.

 There are different specifications between Boards in the scope of each service.

 Allocation of costs between services and sites may not be uniform.

 Annual variances in non-recurring expenditure may distort operational KPIs i.e. expenditure on backlog incorporated within annual property maintenance costs.

 The introduction of new initiatives which improve performance take time to implement across NHSScotland.

 Clinical complexity / specialist services vary between hospitals and may drive cost differentials i.e. specialist clinical activity may result in higher clinical waste quantities and costs.

 Differences in pay and supplies costs across geographic areas i.e. some Boards may incur higher cost arising from remote and rural locations

The table below shows the KPIs from the SAFR document broken down into NHS Scotland overall performances, NHS Shetland performances (as far as possible and utilising the most up to date information to provide data for the current situation) and to add a comparison the other two island boards; NHS Orkney and NHS Western Isles along with the next smallest board; NHS Borders and NHS Highland as a comparison against a (in some regards) similarly rural and remote catchment area

NHS Shetland: Property and Asset Management Strategy 2014 Performance Monitoring

NHS Scotland (from SAFRs) Orkney NHS Shetland

KPINo. 2012performance 2013performance 2014performance 2014(SAFR) 2012 shetland (PAMSPro-formas) 2013(SAFR) 2014 (3iShetland report/SAFR) Board Target Scottish Target Shetland NHS Patient Percentage of properties categorised as either A or B Centered 1 for Physical Condition facet of estate appraisals 71 66 58 28 29 30 50 90 60 Percentage of properties categorised as either A or B 2 for Quality facet of estate appraisals 61 65 65 81 88 68 68 90 71 Positive response to Patient Questionnaire on patient 3 rating of hospital environment 83 85 90 90 93 91 95 95 4 Percentage of properties less than 50 years old 73 71 74 52 44 49 53 70 60

5 PAMS Quality Checklist Overall Score (max score 100) 60 65 72 77 40 49 - 95 70 6 Overall percentage compliance score from SCART 68 72 73 72 71 65 74 95 85 Safe 7 Cost per square metre for backlog maintenance 215 193 181 607 318 177 161 100 161

Signif icant and high risk backlog maintenance as 8 percentage of total backlog expenditure requirement 45 43 47 14 85 79 70 10 50 Percentage of properties categorised as either A or B 9 for Functional Suitability facet of estate appraisal 65 67 64 45 65 72 72 90 74 Percentage of properties categorised as ‘Fully Utilised’ f or space utilisation facet of estate Effective 10 appraisals 75 77 77 44 68 73 97 90 90 Building Area sq.m per Consumer Week (from Cost 11 Book) 0.11 3.3 3.28 2.9 7.1 3.6 3 - 12 Cleaning Costs £ per sq.m (from Cost Book) 992 40.6 40.26 61.3 54.9 75.1 36.5 Property maintenance costs £ per sq.m (from Cost 13 Book) 965 34.8 37 63.8 42.6 144.4 31.3 - PFI - Facilities Management Costs £ per sq.m (from 14 Cost Book) 861 31.6 35.28 0 0 0 28.4 - 15 Energy Costs £ per sq.m (from Cost Book) 612 26.5 31.37 50.9 26.9 52.9 23.9 - 16 Rates Costs £ per sq.m (from Cost Book) 511 13.5 15.26 25.2 9.7 19.8 12.2 -

17 Catering Cost £ per consumer week (from Cost Book) 77 79.1 83.5 107.3 327.4 302.2 71.2 - Portering Costs £ per consumer week (from Cost 18 Book) 45 46.4 47.84 54.7 0 123.1 41.8 - Laundry & Linen Cost £ per consumer week (from Cost 19 Book) 22 32.8 31.6 101.1 111.9 82.5 29.5 - 20 Waste Cost £ per consumer week (from Cost Book) 10 10.5 11.64 13.2 15.6 7.7 9.5 -

In addition the table above indicates all the aspiration Scottish 2020 targets and against KPIs that NHS Shetland has been able to set a target these are noted (right hand column) – the background to these targets is in the following brief analysis of the KPIs:

KPI 1 - The percentage of properties that are categorised as either A or B for Physical Condition facet of estate appraisals has increased again this year to 50% an increase of 20% from last year – this is largely due to the refurbishment of the 1st floor of Montfield site into the new Board Headquarters being reflected in the updated EAMS.

This figure will further increase once Brevik House (the old Board Headquarters) is sold – in the next few months.

A 10% improvement in this KPI could be expected in the next 5 years, within the level of funding available and the disposals currently anticipated

KPI 2 - Percentage of properties categorised as either A or B for Quality facet of estate appraisals has remained static at 68%, there was a step down in this percentage three years ago as the quality of data did not reflect the 88% reported in the Estate and Asset Management System (EAMS). 91

NHS Shetland: Property and Asset Management Strategy 2014 Performance Monitoring

This remains above the Scottish average - the NHS Scotland target is 90%, once Brevik House has been sold NHS Shetlands figure should rise to 71%.

The level two surveys programmed for 2015 may impact on the current scoring

KPI 4 - Percentage of properties less than 50 years old – this has slowly risen over the last two years and although well below the Scottish average is not of particular concern and will again improve with the disposal of Brevik House (54%) and potential disposal of St Olaf St It is unlikely that until the Gilbert Bain and/or Montfield Sites are replaced and disposed of the target cannot be set any higher.

KPI 6 - Overall percentage compliance score from SCART is currently at 74% which is close to but slightly above the Scottish average. All SCART topics are risk assessed and prioritised against the Capital Budget review criteria. It should be noted that it is extremely difficult to achieve full compliance with several of the SCART topics as the breadth of expertise and contingency is sometimes and periodically just not possible in the island environment – for example: the specialist skills available to provide the numbers of authorised persons in this case providing two Medical Gas Authorised persons.

The recent appointment of an experienced Estates Maintenance Manager, with associated targeted training, Authorising appointments and collaboration with other north boards is anticipated to increase compliance

KPI 7 - Cost per square metre for backlog maintenance has steadily and significantly reduced over the last two years and is standing at £161/m2.

This is mainly due to continued work on improving the accuracy of data, as can be seen by the large drop three years ago.

NHS Shetland is still some way off the target of £100/m2 however does stand well ahead of the Scottish average of £181/m2.

With a notional additional markup of 20% on all works in the Shetland Isles due to the local economy and the recent 13% inflation increase it may be difficult to get to the Scottish target.

With the current level of backlog maintenance expenditure NHS Shetlands target is currently to remain at the same cost per square metre.

KPI 8 - Significant and high risk backlog maintenance as percentage of total backlog expenditure requirement is currently 70%, and has hovered close to this level for the last couple of years - the Scottish target is to bring this down to 10% and the Scottish average has been steadily reducing to the current 47%.

Again this figure will reduce once Brevik House, Burra Nurses House, are removed from the EAMS system upon final disposal

The extent of High Risk and associated expenditure has reduced which reflects a more accurate understanding of the meaning of what is classed as High Risk and the resulting updated risk assessment and the Condition surveys carried by an external consultant. 92

NHS Shetland: Property and Asset Management Strategy 2014 Performance Monitoring

The level of Significant Risk is due to be revisited during 2015 in conjunction with Clinical staff and it is considered that this to will reduce as a consequence of understanding the meaning of what is classed as Significant Risk

It is recognised that previous Risk assessment did not fully engage with relevant clinical staff and did not reflect the understanding of the criteria for each Risk level and as such were Risk.

Backlog maintenance will also be more targeted and resourced to address High and Significant Risks over the 5 year plan.

KPI 9 - Percentage of properties categorised as either A or B for Functional Suitability facet of estate appraisal is currently 72% the same as previous years figure however again with the disposal of Brevik House and Burra House this will again increase this percentage by a modest 2% this increase to 74% the target for next year.

The level two surveys by HFS programmed for 2015 may impact on the current scoring

The short term target is to improve by the 1% identified once Brevik House is disposed and a reassessment once the GBH review identifies the preferred option to be taken forward.

KPI 10 - Percentage of properties categorised as ‘Fully Utilised’ for space utilisation facet of estate appraisals is recorded as 97%. NHS Shetland is in the situation of being one of the most remote Boards and as such have facilities, estate, assets and services which have additional capacity but they are fully utilised in terms of the full scope of any given service is delivered in its location. For instance; where it is part of the Clinical Strategy to maintain a presence on an Island Community but the population (Fair Isle or Foula) would not normally sustain a Clinic these Assets are ‘fully utilised’ for the purpose they have been provided whereas if this were a mainland Clinic it would be massively under-utilised.

There are a few locations that have been identified as under-used and these are spaces that could potentially be used to provide multiple services – the Primary Care Strategy development that is ongoing and Localities Planning will identify any opportunities for providing multiple uses in these locations.

The level two surveys by HFS programmed for 2015 may impact on the current scoring

KPIs 11 – 20 – The remaining KPIs are all dependant on Cost book information and it has been noted that NHS Shetland have some apparent anomalies in terms of the figures relative to other boards.

It is recognised that Cost book data input is not consistent within all Boards

These figures are being investigated to understand if and what these anomalies are and discussions have commenced with NHS Orkney as the most appropriate comparator.

KPIs 12, 17, 18 & 19 - These KPIs are the subject of a major review in conjunction with the NSS HFS Progamme Director for Soft Facilities this review has been completed.

A number of options have been identified and implemented which should be reflected in future cost book and SAFR for 2015.

NHS Shetland: Property and Asset Management Strategy 2014 Performance Monitoring

Further options are being developed as Option Appraisals, Feasibility studies and Business Cases for consideration and approval by Strategy and Redesign Committee during 2015

This review is also being carried out in parallel with review of the inputs to the Cost Book as noted above.

6.1.2 Quality Ambition

Each of the KPIs in the above table relates directly to one of the Quality Ambitions set out in the NHS Scotland Quality Strategy as can be seen by the groupings in the table. Below is a brief description of NHS Shetlands progress against each of these Key Drivers from the Quality Strategy:

Patient Centred - NHS Shetland are improving their performance in terms of KPIs nos 1-5 slowly and steadily and the data for these KPIs will continue to be collated in years to come to allow monitoring and proof of the continued improvements being made. It should be noted that over and above the physical assets data that has been able to be collated for this PAMS document KPI no. 3 ‘Positive response to the Patient Questionnaire on patient rating of ‘hospital environment’ has reduced by 2 % to 91% but remains above the national average.

Safe – No improvement in SCART performance but this is anticipated to improve in 2015 although uncertainty remains as the new version is rolled out.

Cost per m2 remains static which reflects the budget constraints faced by the Board and the Capital Allocation .However continued investment will provide an ongoing a safer built environment than in terms of these KPIs although still well short of the target.

Significant action will be taken to improve the data regarding the percentage of all risk categories of backlog based on a better understanding to give a clearer picture of how NHS Shetland is performing.

Effective – NHS Shetland are performing generally below the Scottish average the KPIs

These KPIs are mainly informed from Cost Book data and work is currently ongoing to understand if and why there is a discrepancy in the data being entered and thereafter allow some work to be done on addressing the abnormally high figures on the facilities related KPIs. Where there is a good level of performance is against the Functional Suitability of the Estate which is a major influence on how the patient survey figures KPI no. 3 are influenced and how the clinical services are delivered despite the shortcomings in other areas.

6.1.3 Energy

KPI no. 15 address’ energy costs and is performing similar of its remote and Island contemporary Board.

Various Feasibility Studies and an Energy Audit have identified limited value for money opportunities for reducing energy cost.

Cost is however only one strand of the Energy Story and as discussed in the ‘Where are we now?’ Section energy in the Acute Estate is the subject of a HEAT target which is due to change.

NHS Shetland: Property and Asset Management Strategy 2014 Performance Monitoring

6.2 Vehicles

There are several datasets available against various strands of performance of the vehicle assets of NHS Shetland

In terms of the Quality ambitions, the Quality Profile of the Vehicles is an indicator of how Safe the asset base is – this profile illustrates that NHS Shetlands policy of leasing all (except for one historically owned car) vehicles provides as Safe as possible a driving environment for its staff.

Quality Profile of Vehicles 40 35 30 Poor - signs of significant wear and 25 damage 20 Acceptable - some signs of wear and 15 minor damage 10 Good - no significant wear or damage 5 0 Pool/Opps cars Small van Large vans

The Effective strand of the Quality ambitions can be linked to the age profile of the vehicle asset base, again due to the policy of leasing across the board NHS Shetland achieve an exceptionally effective fleet of vehicles which are effectively renewed every three years and no vehicle is over 3 years old.

NHS Shetland: Property and Asset Management Strategy 2014 Performance Monitoring

Cars annual age comparison Small Vans annual age comparison

40 40 35 35 30 30 Small Vans 5+ 25 Cars 5+ 25 20 20 cars 3-5 Small Van 3-5 15 15 10 cars <2 10 5 5 small vans <2 0 0 2012 2013 2014 2012 2013 2014

Large Vans annual Age comparison

40 35 30 Large vans 5+ 25 20 Large vans 3-5 15 10 5 large vans <2 0 2012 2013 2014

These datasets are routinely gathered annually and will be able to be used as an indicator in years to come along with the lease costs, average mileage, fuel types etc.

6.3 Medical Equipment

Items of Medical Equipment are such complex technical assets that there could be a variety complicated performance indicators developed, as NHS Shetland hold an extremely detailed database of all Medical Equipment assets they own and service

The reality of the management of the Medical Equipment is that the number of items is sufficiently small that the Medical Physics Dept has a very good handle on the age, condition, effectiveness and therefore safety of each category of equipment and through the regular Capital Management Group meetings the annual priority and a long term plan (10 Year) for investment to manage the ever aging asset base.

6.4 IM&T

There is not yet currently a full inventory of IM&T equipment assets available to NHS Shetland however this is a work in progress and it is one of the national initiatives that the result will be an extremely powerful tool to allow detailed analysis of the asset base and make even better strategic decisions informed by some real evidence.

6.5 Clinical Performance Monitoring

NHS Shetland: Property and Asset Management Strategy 2014 Performance Monitoring

The Clinical Strategy’s Redesign Objectives are being closely monitored and in terms of progress and effectiveness and are reported on in up to the Board Meetings in the Board Report submissions which are available on the NHS Shetland Website. Over and above the redesign monitoring the precursor to even the Clinical Strategy is the raw ‘metrics’ that are produced by NHS Shetland along with the ISD standard datasets.

These all inform the discussions held at the Clinical Services Management Team Meetings and subsequently the decisions that are made to form the Clinical Strategy. The Clinical Strategy is also available on the NHS Shetland website

6.6 Responsibilities

As described in the ‘Roles and Responsibilities’ Section the Finance Director is directly responsible for the implementation of the PAMS and is therefore inherently compelled to ensure that the PAMS performance is achieving results. The KPIs noted in this section are all extremely good tools for monitoring the performance of the PAMS year on year. The array of meetings described in the ‘Roles and Responsibilities’ Section and the transparency of all decisions and progress means that the responsible person for each of the asset types is constantly in touch with and answerable to the Finance Director and will be reporting the performance of each applicable strand of the PAMS. The current financial pressures that the Board find themselves under means that the achievement of all the workstreams as efficiently and effectively as possible to give the greatest impact on NHS Shetlands assets in as efficient a way as possible to provide the Safest, most Effective and Persons Centred NHS Shetland is of utmost importance.

6.7 Stakeholders Comment

As has been described in previous sections and is illustrated by the breadth of consultation there are very good channels of communication between the Public and the Board and within the organisation with the Staff Side Representative present within on the Capital Management Group. In particular the Public Patient Forum (PPF) and Area Partnership Forum (APF) are forums of which the main aim is in fact to receive feedback and constructive criticism, if appropriate, on the delivery of the Clinical Services (Clinical Strategy implementation) and where, how safe, how effective and how Person Centred they are – in effect commenting on the delivery of the Property and Asset Management Strategy.