Download 15_252 Linear Accelerator

Board Paper 13.10.15
Item 15/252
To improve health and provide excellent care
Title:
Business Case for the replacement of the 4th Liner Accelerator
in the North Wales Cancer Centre
Author:
Mr Damian Heron, Director of the North Wales Cancer Network
Responsible
Director:
Mr Geoff Lang, Director of Strategy
Summary of Key
Issues:
The 4th Linear Accelerator in the North Wales cancer centre is now
nearing the end of its operational life and is presenting problems in
terms of reliability and resilience.
The attached Business Case sets out a series of options for the
replacement of this capacity and recommends that the 4th Linear
Accelerator be replaced.
The business case has been reviewed by the Finance and
Performance sub-Committee and other appropriate committees as
outlined in the organisation’s Procedure Manual for Managing
Capital Projects. Access to Charitable Funds has been agreed by
the Charitable Funds Committee.
Action Required By To: (Please tick all that apply. This section should match the
recommendations made in the paper)
Board:
Note
Endorse
Ratify
Approve
√ That the Board approve the replacement of
the 4th linear accelerator with capital funding
from Charitable Funds.
Key Impacts:
(Please provide a short summary against all that apply)
Corporate
Adequate capacity for radiotherapy treatment is
Objective
critical for the Board to achieve its targets in
terms of timeliness of treatment for cancer
patients.
Finance
The capital and revenue consequences are
summarised in the paper. Capital for this
investment is proposed to be sought from
charitable funds.
Quality Impact
Assessment
The proposed investment will support the
delivery of a high quality service.
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Health and Care
Standards
The proposed development is relevant to the
following standards:
Equalities,
Diversity &
Human Rights
Risk &
Assurance
Safe care
Effective care
Timely care
The preferred option maintains the existing
delivery model.
The business case has been completed in
accordance with the organisation’s Procedure
for Managing Capital Projects. It incorporates
a risk assessment.
Disclosure:
Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
Board Coversheet v6.0 May 2015
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Replacement linear accelerator – Overview
1) Purpose
The purpose of this paper is to describe the preferred option of procurement of a
replacement linac that would maintain the current establishment of 4 machines using
them all in delivery of radiotherapy.
2) Current provision
The North Wales Cancer Treatment Centre (NWCTC) at Glan Clwyd Hospital was
established in 2000 with the purpose of providing external beam radiotherapy to the
North Wales population. Previously radiotherapy was delivered by Clatterbridge
Cancer Centre (CCC), Wirral and The Christie, Manchester.
Currently NWCTC houses 4 linacs in 5 bunkers – this resource delivers
approximately 90% of the external beam radiotherapy required by the North Wales
population.
Linear accelerators
The operational life of a linac is widely considered to be 10 years and Table 1
describes where the machines are in terms of their life cycle.
Table 1. Current linear accelerators -NWCTC
Machine
Machine 1
Machine 2
Machine 3
Machine 4
Age
11 years
6 years
6 years
2 years
Replacement Year
2014
2020
2020
2023
It is noteworthy that Machine 1 is the last of the initial three machines purchased
post 2000 and as such it does not have the same technical abilities that machines 3
to 4. This significantly restricts the type of treatment and patients that can utilise this
machine.
Funding
Revenue funding of the radiotherapy/physics service is based on a 3 machine
service however the centre was in receipt of a new additional 4th machine in 2013
which increased the establishment to 4 viable machines. Attempts have been made
to use all 4 machines in a manner that increases flexibility and business continuity
but this had gradually degraded due to the viability of the now obsolete machine and
the revenue being limited to a 3 machine service.
3) Capacity drivers
There are a range of drivers that support the need for development in radiotherapy
services
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3.1 Cancer burden
Whilst the rise in the number of new cancer cases is relatively subtle year on year in
North Wales the increase in oncology treatment including radiotherapy is more
consistent with on average a 6% increase in workload being seen year on year.
3.2 Waiting times
Increasingly the 62 day cancer waiting time (USC) has been an issue in radiotherapy
and though access to radiotherapy has been the cause of relatively few breaches a
considerable effort is now required to move patients within the system to ensure
radiotherapy is delivered by breach dates.
The key issue regarding waiting times is that of time to radiotherapy for all
indications and Table 2 below identifies performance within Wales.
Table 2. Radiotherapy treatment times in Wales – April 2015.
Referrals (Radical)
Referrals (Palliative)
Total
Waiting times – Target 100%
within 28 days with radical
intent
Waiting times – Target 100%
within 14 days with radical
intent
Velindre
208
86
294
Swansea
115
60
175
North Wales
95
60
155
94.2%
93%
69.5%
96.5%
100%
60%
This performance has been noted during Peer Review with waiting times for
radiotherapy being recorded formally as a serious concern
3.3 Demand predictions
The updated “Radiotherapy Equipment Needs and Workforce implications 20062016. Welsh Scientific Advisory Committee” recommends that, even if capacity is
increased from 2011 levels by 20%, NWCTC will require a minimum of 5 linacs by
2016 and a minimum of 6 linacs by 2020 to deliver the service.
Activity for capacity and demand discussions is now quoted in “attendances” rather
than “fractions”, where a “fraction” is equivalent to 0.87 “attendances”. The Malthus
Cymru model takes into account incidence and demographics.
For NWCTC, the Malthus tool projects a demand of 43,200 attendances by 2016
(equivalent to 49,655 fractions or 49.6 linac hours per day) and 47,800 attendances
(equivalent to 54,942 fractions or 54.9 linac hours) by 2020 assuming an access
rate of 41%. This analysis would suggest 5 lin accs functioning approximately 10 hrs
per day on average.
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In addition, NRAG recommends that radiotherapy services consider the introduction
of a service efficiency machine and that radiotherapy services plan so that they
operate at 87% capacity to allow for breakdowns and variations in demand.
3.4) Strategic actions
As part of the cost improvement programme within the Cancer Clinical Programme
Group (CPG) a programme of oncology consolidation has taken place over the past
5 years resulting in repatriation of radiotherapy work from Clatterbridge Cancer
Centre (CCC). As such radiotherapy is now offered to patients with colorectal, upper
GI and breast cancer who would have previously attended CCC via Chester. In
addition radiotherapy for primary brain tumours has been repatriated from CCC for
all cases within North Wales.
Although this action required some local investment and has added to the overall
workload it is acknowledged that the reduction in the CCC contract has been
approximately £1.6m.
3.5) Technology
Changes in radiotherapy technology have been identified such as Intensity
Modulated Radiation Treatment (IMRT) and there has been an expectation that all
relevant patients are now subject to this technique. North Wales has responded to
this demand with IMRT being delivered to most patients who would benefit from the
technique.
However this technique can only be delivered by 2 of the current 4 linacs and as a
result flexibility within the overall radiotherapy resource has become more limited.
4) Options
4.1) Short term/immediate options
A number of options have been considered as part of the business case and these
are considered below in Table 3.
Table 3. Option appraisal
Option1
Description
Advantages
Do nothing
Do not replace the obsolete linac and no other actions
No funding implications
No additional work required maintaining a 4th machine
Disadvantages Reduction in capacity leading to increased waiting times and
breaches
No contingency for breakdowns and servicing leading to regular
periods when only 2 linacs might be available
Option 2
Do nothing and extend the working day on the three remaining
linacs
Description
Do not replace the obsolete linac and extend the working day on
the remaining linacs to make up the available hours lost – could
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include weekends
Advantages
No capital purchase required
Increased in treatment option times for patients
Disadvantages Possible increase in revenue funding to ensure all linacs are
staffed for longer periods with full support staff, physics and clinical
back up.
Formal staff negotiation required as may describe changes to
contract
Increased likelihood of breakdowns as linacs are utilised more fully
No contingency for breakdowns and servicing leading to regular
periods when only 2 linacs might be available
Option 3
Outsource activity
Description
Do not replace the obsolete linac but outsource activity to local
oncology centres out of area.
Advantages
No capital purchase required
Disadvantages Increased travel for patients
Unclear as to whether capacity exists in other organisations
Revenue implications of new contract with selected provider
Fragmentation of cancer pathway leading to potential for errors
and delays
Governance concerns regarding oncology decision making
Complexity regarding patient selection i.e. outsource by type of
cancer or by address. Former is clinically easiest but has greatest
problems in terms of travel, latter clinically very complex
Significant patient related issues in terms of information, Welsh
language etc.
Reversal of strategic direction leading to reputational damage
Option 4
Outsource activity and extend the working day on the remaining
three linacs
Description
As above
Advantages
No capital purchase required
Disadvantages Increase in revenue funding to ensure all linacs are staffed for
longer periods with full support staff, physics and clinical back up
and payment for outsourced activity.
Formal staff negotiation required as describes possible changes to
contract
Increased likelihood of breakdowns as linacs are utilised more fully
No contingency for breakdowns and servicing leading to regular
periods when only 2 linacs might be available
Increased travel for patients
Fragmentation of cancer pathway leading to potential for errors
and delays
Governance concerns regarding oncology decision making
Complexity regarding patient selection i.e. outsource by type of
cancer or by address. Former is clinically easiest but has greatest
problems in terms of travel, latter clinically very complex
Significant patient related issues in terms of information, Welsh
language etc.
Reversal of strategic direction leading to reputational damage
Option 5
Replace the obsolete linac
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Description
Replace the obsolete linac and formally expand the department to
a 4 linac centre.
Advantages
Will expand capacity to better meet cancer and radiotherapy
waiting times.
New linac will also increase flexibility through being able to move
patients between all available machines as they will compatible.
Essential business continuity around 3 linacs will be maintained as
a 4th linac will provide greater flexibility for maintenance and
breakdowns.
Breakdowns are likely to decrease as a replacement linac will
improve reliability and be under initial warranty.
Up-scaling of capacity through extended days will be easier
through provision of 4 compatible linacs.
Disadvantages Capital costs will need to be secured
Revenue costs will need to be secured over and above the current
revenue spent on the current 4th obsolete linac
Failure to find the additional revenue will mean an expensive new
linac is not fully utilised although the innate flexibility in having a
new 4th linac would remain advantageous.
The preferred option at this time is Option 5
4.2) Long term/strategic options
As mentioned earlier the “Radiotherapy Equipment Needs and Workforce
implications 2006-2016, Welsh Scientific Committee” recommends that NWCTC will
require a minimum of 6 linacs by 2020. There are a number of significant details that
need to be understood as a result of this statement;
• there are currently only 5 bunkers at NWCTC and as a result a 6 linac service
would also require a build of a 6th bunker on the NWCTC site. This would be a
significant capital project.
•
An additional build of this nature may coincide with other capital schemes that
may arise e.g. PET-CT, brachytherapy. Not only would these issues have
implications for the capital available but also they are likely to compete for the
same physical space on the Glan Clwyd site
•
Taking into account the useful life left on the current linacs, to have 6
functional linacs by 2020 would suggest the purchase of 5 new linacs
including the one being considered within this document.
It is evident that a 6 linac service at NWCTC by 2020 would have significant financial
implications with the capital requirements alone potentially being between £9 and
£15m.
4.2.1) Clatterbridge Cancer Centre (CCC)
2020 also represents the year that CCC has declared its intention to relocate the
Merseyside regional oncology service to the Royal Liverpool Hospital site. The driver
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for this has in the main been the fact that the vast majority of the 1.8 -2m population
it serves live north of the Mersey some considerable distance from the current Wirral
site.
CCC have three significant challenges as part of this strategic move;
1)They will need to serve the population of Wirral (320,000) with oncology care and
as such will need to consider retention of some of their current services on the Wirral
site beyond 2020.
2) The current CCC site on Wirral is based on providing capacity for all of
Merseyside so the organisation will own a site with significant redundant capacity in
2020. This redundancy however will only become evident once capacity has been
secured in Liverpool itself so CCC will more than likely have to right off viable
capacity on Wirral in 2020.
3) Decommissioning of the excess capacity and facilities will have an associated
cost and risk.
This development may provide opportunities for North Wales in that the redundant
capacity at CCC available in 2020 could be taken up by North Wales in line with the
capacity already identified in “Radiotherapy Equipment Needs and Workforce
implications 2006-2016”. This approach has resonance for North Wales as certainly
patients in the east of North Wales face travel times to NWCTC equal to those
experienced if travelling to CCC at Wirral.
It is perceived that utilisation of redundant capacity at CCC on Wirral has a range of
advantages for both North Wales and CCC and as such preliminary discussions are
taking place between the two organisations.
It must be noted that none of the above can progress before 2020 and as such
this strategic approach does not impinge upon this business case.
5) Capital Implications of the preferred option
It is estimated that the capital purchase of a replacement linac is £1.7m.
This figure is referred to as a ‘turnkey’ option in that it includes all the work
necessary to deliver and utilise the new machine.
5.1) Sourcing the capital
In light of the current availability of capital in Wales the Cancer CPG approached
charitable sources and funds for the required capital. This approach has the added
advantage of being VAT/Capital charges exempt.
Table 4. Charitable capital donations – August 2015.
Fund
Ron and Margaret
Smith Cancer charity
Legacy
Notes
Written donation agreed by the committee on
basis of use for a linear accelerator
Agreed with legal representative for allocation
to support a linear accelerator. Due to be
released Sept 2015.
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Sum
£950k
£500k
Awyr Las
Considered by the Charity Committee –June
2015
Total
£250k
£1.7m
6) Revenue Implications of the preferred option
In order to fully utilise a 4th linac there are revenue implications regarding staffing
and maintenance.
A fully functioning linac will require approximately 6 additional therapy radiographers
of mixed seniority. It is estimated that this will cost an estimated £250k per annum.
A maintenance contract will also be required although initially this will be provided
under warranty.
6.1) Sourcing the revenue
The revenue for the staffing has already been highlighted and addressed by the
CPG.
Additional staff have been recruited to cover a range of maternity leaves and when
staff return from maternity leave the new recruits will be retained expanding the
establishment to cater for a 4th linac. As part of this approach the wider staffing within
the department will be reviewed to ensure the required skill mix.
Funding for the approach above was approved as an additional pressure supported
by the savings made through repatriation of oncology activity from CCC (see earlier
3.4).
A maintenance contract will be required but this will initially be off set by the fact that
the linac is under warranty. A further off set will be the increased maintenance costs
required by the current obsolete 4th machine.
Whilst Physics staff may require investment it is noted that they already have a
commitment to the current 4th linac, a commitment that maybe greater than expected
due to breakdowns and obsolescence.
7) Risks
There are a number of risks associated with this case and these are considered in
Table below
Table 5. Linac purchase risk assessment
Risk
Assessment
Rating
Failure to replace the linac Failure to replace the obsolete linac red
will inevitably reduce the service to 3
linacs and increasingly 2 linacs as
servicing/breakdowns increase.
This will decrease capacity that is
already proven to be inadequate
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Local purchase in light of
strategic option that might
use other providers
Waste of charitable funds
due to lack of revenue
Recruitment of staff that
might not be used if no
purchase made
Purchase now does not contradict a Green
strategic option around outsourcing
or utilisation of neighbouring
facilities.
Regarding the latter they will not be
available until 2020 when in fact 2
more linacs reach obsolescence in
North Wales
Funds have been earmarked for this Green
purpose by the fundholders.
In 5 years time two more linacs will
require replacement and this
machine will fulfil its full potential
then even if it is not fully utilised
now.
Currently staff have been recruited
Green
to cover maternity leave. It remains
unknown what hours the staff will
want to return on and it is likely that
they will seek to negotiate a
reduction in hours.
Turnover will provide internal
vacancies.
Developments in the North West in
the next 2 years will see a significant
recruitment of therapy radiographers
and as such internal turnover is
likely
8) Conclusion and preferred option
The preferred option is that a new linac is purchased to replace the current obsolete
machine. This would maintain an establishment of four linacs but assumes that the
fourth linac is used as a fully functioning asset.
Replacement would also expand capacity through provision of greater flexibility
between linacs and less breakdown/maintenance time.
Much has already been done to make this option viable with considerable charitable
funding being secured. Approval of this case would secure the final element of
charitable funding ensuring purchase of the linac VAT exempt. The revenue impact
of the linac in terms of staffing in particular has already been addressed through the
need to cover a significant number of maternity leaves – the recruits through
employment on permanent contracts in essence become the workforce for the fourth
machine when the maternity leaves return.
Strategically the radiotherapy service will need to take radical steps either in terms of
significant local investment or forming a partnership with other providers but this only
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really becomes into focus in 2020. This timeline, married to the out of service date of
the other linacs in NWCTC, nullifies any risk around strategic fit.
The significant risk is the ability to deliver radiotherapy now in line with UK targets.
NWCTC fails to do this now and its only realistic option for improving its performance
in the immediate future is to replace its obsolete linac and maximise the
replacement.
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