Relación con otras organizaciones privadas

Size and Probability o f R isk and Risk M anagem ent to D ate

T he in n o v a tiv e care co n cep ts to b e introduced b y th e Trust during the d ev elo p m en t o f the n ew h osp ita l includ e:

• T h e acu te a ssessm e n t unit (5 6 bed s) • T h e critical care unit (4 0 b ed s) • T h e a d o le scen t unit (35 b ed s)

• T h e am bulatory intervenention al unit (in terven tion eq u ip m en t o n ly ).

A total o f 131 o f the n e w h ospital's 6 2 9 bed s h a v e b e e n a llo ca ted to th e s e m u lti-sp ecia lty areas. E ach co n cep t h as a s lig h tly different risk p rofile. T h e acu te a ssessm e n t unit requires a redu ction in the num ber o f b ed s currently supporting A & E from 72 to 5 6 and relies on the im p lem en ta tio n o f n e w w o rk in g practices b y m e d ica l and n u rsin g s ta ff for it to b e achieved. T he 4 0 b ed critical care unit b rings together the Trust's current 2 2 b ed s d esig n a ted for in ten siv e care, togeth er w ith the cardiac H D U b ed s, a lo n g sid e a central resource for h igh d ep en d e n c y p atien ts w h o currently find th em se lv es cared for on gen eral w ards. T he risk o f ov er -p ro v isio n h ere arises i f d ep en d en cy le v e ls redu ce or the n um ber o f h ig h ly dependent p atien ts falls.

T he 35 b ed a d o le scen t unit b rings together patien ts from the a g e o f 12 to 19 and w h o have sp ecia list n eed s togeth er onto on e floor o f the h osp ital. G iv en that ea ch floor can

acco m m o d a te a th eoretical m a xim u m b ed co m p lem en t o f 63 b ed s, th ere is a risk that either lo w er or v er y v o la tile le v e ls o f activity cou ld m ak e sp a ce u sa g e in th is u nit in efficien t. F in a lly , the am bulatory interventional unit acco m m o d a tes th e h osp ital's im ag e-gu id ed

th erapies and p rocedu res on on e floor. T his represents a sig n ifica n t ch a n g e from the d isp ersed and w id e ly fragm ented service currently b e in g d elivered .

R is k M a n a g e m e n t P o s t F B C A p p r o v a l

E ach c o n ce p t h a s arisen from internal d iscu ssio n s, facilitated m u lti-d iscip lin ary groups or from p rogram m es w h ic h h a v e b een planned for so m e tim e and w h ich w ill b e im p lem en ted w e ll b efore the c o m p le tio n o f the n e w h ospital. E ach w ill b e introduced in to the h o sp ita l u sin g sim u lation and, w h ere p o s s ib le , p re-com p letion p ilo tin g (for ex a m p le the acute a ssessm e n t w ard w ill be p ilo ted a lm o st im m ed ia tely , starting in A u gu st 1999).

Perhaps, the greatest risk in term s o f operational w o rk in g p ractice is p resen ted b y the large g en eric w ards m a in ly b eca u se th ey are largely u ntested in the U K . G en erally, th ese 5 0 -6 0 bed w ards are rep la cin g m u ch sm a ller wards (1 4 b ed w ards are c o m m o n in T h e M id d le sex H ospital). T h e Trust is se e k in g to m an age and m itigate risk around the im p lem en ta tion o f n e w w orkin g p ractices for th e n e w h o sp ita l b y fo cu sin g o n the d ev elo p m en t o f integrated care path w ays and a sso cia ted p ro to c o ls to b e d ev elo p ed and d elivered b y m u lti-d iscip lin a ry team s w e ll b efo re the n e w h osp ita l is co m p lete. O n ce th ese p rotocols are d ev elo p ed , w o rk in g p ractices in the existin g h o sp ita ls w ill b e am end ed as far as is practicable g iv e n th e p h y sica l constraints. In addition, sim u la tio n o f h o w the units w ill w ork in practice o n c e the n e w h o sp ital o p en s w ill b e com p leted as part o f gen eral clin ica l and n o n -clin ica l training.

C o n tin g e n c y P la n n in g

C learly, the fact that the Trust is seek in g to d ev elo p and introduce in n o v a tiv e care con cep ts b rin g s risks that w o u ld n ot b e present i f the traditional infrastructure o f acute care w ere s im p ly b e in g recy cled . H a v in g said this, the Trust is aw are that it is b reak ing n e w ground and n e e d s to en su re b o th that im p lem en tation risk is m in im ised and that c o n tin g en cy plan s are av a ila b le sh o u ld critical assu m ptions prove to be incorrect.

S o m e co n cern h as b een exp ressed that the acute a ssessm e n t unit w ill p ro v e to b e too sm all to a cco m m o d a te the required activity, esp ec ia lly i f the en v isa g ed ch a n g es in m ed ical and nurse p ra ctice are n o t forth com in g. T h e num ber o f b ed s on th e acute a ssessm e n t unit is n o t e a sily in crea sed a lth ou gh the p rojected throughput o f the unit is d eterm in ed b y a series o f

a ssu m p tio n s, s o m e o f w h ich co u ld b e am ended to create additional ca p a city in the umt. C h a n g es to k e y assu m p tion s co u ld include:

• R e d u ce av era ge len gth o f sta y on the unit prior to d isch arge into oth er h o sp ital b ed s (u sin g earlier d isch a rge from the projected three day stay) thereby in crea sin g the caselo a d on the larger h o sp ita l b ed p o o l

• Increase p re-a sse ssm en t triage direct to sp ecia lty b ed s for so m e grou p s o f patients su ch as re -a d m issio n s, thereby increasin g the caselo ad on the larger h o sp ita l b ed p o o l.

I f th ere is a su stain ab le redu ction in the le v e l o f in te n siv e and h ig h d ep en d en cy activ ity there m a y b e lim ited s c o p e to d ev elo p increased a ssessm en t b ed s b y transferring the Trust's 15 renal w atered inpatient b ed s adjacent to a sm aller critical care unit, th ereb y freein g up general inp atien t ca p acity for u se as additional assessm en t b ed s.

University College London Hospitals NHS Trust Full Business Case for Redevelopment

I f th e a d o le scen t unit p ro ves to b e o v erly large it w o u ld b e p o s s ib le to integrate it w ith

inp atient paed iatrics freein g up a ward floo r for u se b y other c lin ic a l se r v ic e s or w h ich can be c lo s e d and left unstaffed , thereby saving the m ajority o f the running co sts.

I f th e am bulatory interventional unit proves to b e to o large in term s o f s p e c ific procedures, the Trust w o u ld see k to re v ie w the sp ace d ed icated to intervention w ith a v ie w to creating space for th o se outpatient c lin ic s w h ich w ill rem ain o ff-s ite (for ex a m p le o p h th a lm o lo g y ).

14.3 Research

1 4 .3 .1 S iz e a n d P r o b a b ility o f R isk a n d R is k M a n a g e m e n t to D a te

R esea rch risk for U C L H co m e s largely from the lo s s o f research & d ev elo p m en t in co m e in th e future as N H S priorities encourage research & d ev elo p m en t to b e undertaken o u ts id e L o n d o n and in n on -h osp ital subjects. T he im p act o f a lo s s o f research in c o m e is m a gn ified by th e la rg ely fix e d nature o f m an y research & d ev elo p m en t c o sts em b ed d ed w ith in h ospitals w h ic h support the research w ork o f m ajor aca d em ic partners.

It is im portant to rea lise that the probability o f lo s s o f research & d ev elo p m en t in c o m e for U C L H is n o t increased b y the d evelop m en t o f th e n e w h o sp ita l. T h e risk ex ists already and th e ju d g e m e n ts to b e m ad e around risk e sse n tia lly r e v o lv e around w h eth er or n ot the

d ev elo p m en t o f the n e w h ospital im proves or im p ed es the Trust's a b ility to acco m m od ate any risk s that d o crystallise.

T a b le 1 4 .3 sh o w s that research & d ev elo p m en t fu n d in g earned b y T rusts located in L ondon d om in a tes the national picture. L ondon, n o w o n ly o n e o f eig h t r e g io n s, accoun t for 70% o f th e n ation al research & d evelop m en t spend. It w o u ld b e d ifficu lt to co n clu d e that, as a region, L o n d o n ’s share o f the national research & d ev elo p m en t le v y w o u ld n o t c o m e under inten se pressu re from the other sev e n region s at the n ex t b id d in g round. A b e s t ca se assu m ption for N H S T rusts in L ondon currently en joyin g sig n ific a n t research & d e v e lo p m e n t in c o m e m ight b e that th e reg ion retains its current le v e l o f funding.

T h e p rob ab ility o f risk crystallisin g at particular N H S Trusts h o w e v e r , can b e m itigated b y en su ring that the Trust's research program m e c lo s e ly fits the criteria b y w h ich b id s w ill, in the future, b e appraised. S u ch criteria w ill include:

• H ig h q uality o f the research product as extern ally a ssessed (m a in ly through the H E FC E R esea rch A ssessm en t E x ercise (R A E ))

• A lig n in g the research & d evelop m en t p rogram m e b e in g su pp orted b y the Trust c lo s e ly w ith national N H S priorities

• In crea sin g the proportion o f research co sts w h ic h support th e c o sts o f research undertaken b y th e N H S 's approved partners.

A n a n a ly sis o f U C L H 's research & d evelop m en t ser v ic e support c o s ts su g g ests that there are a num ber o f reasons to co n clu d e that the risk o f research & d e v e lo p m e n t in c o m e lo ss faced by U C L H is con siderab ly lo w er than that b ein g fa ced b y h osp ita l N H S T rusts in L on d on m ore gen era lly .

R e s e a r c h Q u a lity

A sig n ific a n t factor in m aintaining or lo sin g research & d ev elo p m en t in c o m e w ill b e the qu ality o f research w ork b ein g undertaken. T he results o f the m o st recen t R A E s h o w s U C L M e d ica l S c h o o l are p rod ucin g p re-em in en t m e d ica l research. A n um ber o f su b jects receiv ed 5 and 5* aw ards w h ic h d en otes research o f international standing. T h e o verall average institution al R A E scores for all subject d isc ip lin e s and for b io m ed ica l su b jects is sh o w n at T a b le 1 4 .4 . T he ratings o f U C L M ed ical S ch o o l are u n iform ly e x c e lle n t in a n ational con text.

A lig n in g th e R e s e a r c h P o r tfo lio w ith N a tio n a l P r io r itie s

From U C L H 's p oin t o f v ie w it is co m fortin g to s e e that cancer, coronary heart d ise a se , m ental h ealth and a g ein g h a v e b een reco g n ised b y the Clark Group as research & d ev elo p m en t p riorities. D e p e n d in g on the p recise d efin itio n o f research & d e v e lo p m e n t b e in g undertaken