Scottish Ambulance Service Communications and IT Services Department

Ambulance Telehealth Outline Business Case Version 2.3 January 2014

Page | 1 of 82

Owner: Version No: Doc & page: Review arrangements: Roslyn Scott 2.3 83 pages Project End Stage Reports Date of Release: Date Intranet Implementation: Executive Approval by: 15 Oct 2013 Posting: TBC On release Pamela McLauchlan PFPI Requirements: Assessed as meeting the National Standards for Community Engagement checklist & all necessary consultation requirements by project manager/ lead officers. Equality & Diversity Impact Assessment: No issues relating to equality and diversity have been identified within the document. Risk Impact Assessment: No significant areas of risk have been identified within the document. Data Protection: No issues relating to data protection have been identified within the document. Freedom of Information & Corporate Communications: No areas within the document impact on FOI or Corporate Communications. Distribution Arrangements: TBC Important Information: Prints of this document are uncontrolled and may not be extant or approved versions – check with the Service intranet and or document author/ owner. The Scottish Ambulance Service title, crest, uniform & vehicle design are variously protected in European, UK & Scottish law. In addition, all copyright is retained by the Service © Scottish Ambulance Service 2006 who will always act to redress any identified breach or non-authorised use. The Service adheres to Data Protection, Freedom of Information and Public Sector Information Regulations – further information on these; our licensing requirements and copying approvals are available on the Scottish Ambulance Service web site or on request. Note that this document may be liable to release to other parties under Freedom of Information legislation and the SAS use of email Policy. Please support the Service’s Environmental Programme by not printing this document unnecessarily

Page | 2 of 82

Document Change Control Document Reference:

Ambulance Telehealth - Outline Business Case

Version:

Version 2.3

Status:

For Executive Approval

Date:

06 January 2014

Related Documentation:

Ambulance Telehealth - Operational Requirements Document 1.0 Ambulance Telehealth - Initial Agreement 1.0 SAS eHealth ICT Strategy 2012_2017 Working Together for Better Patient Care 2010-2015

Change Record Change Record Date Filename 29.04.2013- Ambulance Telehealth - Outline Business Case 0.1 05.06.2013 05.06.2013 - Ambulance Telehealth - Outline Business Case 0.2 17.06.2013 17.06.2013 Ambulance Telehealth - Outline Business Case 0.3 20.06.2013 Ambulance Telehealth - Outline Business Case 0.4 06.08.2013- Ambulance Telehealth - Outline Business Case 0.5 23.08.2013 23.08.2013 Ambulance Telehealth - Outline Business Case 1.0 29.08.2013

Ambulance Telehealth - Outline Business Case 1.1

02.09.2013

Ambulance Telehealth – Outline Business Case 1.2 Ambulance Telehealth – Outline Business Case 1.3 Ambulance Telehealth – Outline Business Case 1.4 Ambulance Telehealth – Outline Business Case 1.5 Ambulance Telehealth – Outline Business Case 1.6

25.09.2013 27.09.2013 30.09.2013 14.10.2013

15.10.2013

Ambulance Telehealth – Outline Business Case 1.7

22.10.20.13

Ambulance Telehealth – Outline Business Case 1.8

Changes First Draft Development

Changed by R Scott

Draft Development

R Scott

Draft Development Draft Development Draft Development

R Scott R Scott R Scott

Versioned document for exec approval Document content changes based on initial feedback Document structure changes based on SG guidelines Added sections based on SG guidelines Changes to economic case

R Scott

Formatting changes

J Baker

Changes incorporating comments from Director of Finance Changes incorporating comments from Director of Service Delivery as well as formatting changes Changes incorporating comments from Chief Executive

M Barnes

Page | 3 of 82

R Scott M Barnes J Baker M Barnes

M Barnes

M Barnes

02.12.13 06.01.14 14.01.14

Ambulance Telehealth – Outline Business Case 1.9 Ambulance Telehealth – Outline Business Case 2.0 Ambulance Telehealth – Outline Business Case 2.1

Changes to correct Option 2 costs Amendments to reflect phased release of capital funding Amendments to estimated revenue costs

M Barnes M Barnes M Barnes

Distribution Record Date 23.08.2013 01.10.2013 15.10.2013 02.12.2013

Distribution John Baker & David Kinnaird for CITSD approval Pamela McLauchlan Executive Team Capital Investment Group, Scottish Government

Sent by R Scott J Baker M Barnes M Barnes

Page | 4 of 82

Table of Contents Section 1: Executive Summary ................................................................................................................. 9 1.1 Introduction .................................................................................................................................... 9 1.2

Strategic Case ............................................................................................................................. 9

1.2.1 Strategic Context .....................................................................................................................................9 1.2.2

Investment Objectives ................................................................................................................... 10

1.2.3

Existing Arrangements ................................................................................................................... 12

1.3 Economic Case .............................................................................................................................. 13 1.3.1 Main Business Options ......................................................................................................................... 13 1.3.2 Preferred Way Forward ........................................................................................................................ 14 1.3.3 Short Listed Options ............................................................................................................................. 14 1.3.4 Economic Appraisal .............................................................................................................................. 14 1.3.5 Sensitivity Analysis................................................................................................................................ 15

1.4 Commercial Case ........................................................................................................................... 16 1.4.1 Procurement Strategy .......................................................................................................................... 16 1.4.2 Possible Procurement Methodologies ................................................................................................. 16 1.4.3 Potential Scope and Services ................................................................................................................ 16 1.4.4 Potential Charging Mechanisms ........................................................................................................... 16 1.4.5 Potential Key Contractual Implications ................................................................................................ 16 1.4.6 Potential Personnel Implications .......................................................................................................... 16 1.4.7 Potential Implementation Timescales .................................................................................................. 17

1.5 Financial Case ................................................................................................................................ 17 1.5.1 Financial Appraisal ................................................................................................................................ 17

1.6 Management Case ........................................................................................................................ 21 1.6.1 Programme Structure and Governance Arrangements for OBC Development ................................... 21 1.6.2 Programme Structure and Governance Arrangements post OBC ........................................................ 21 1.6.3 Risk Management Strategy................................................................................................................... 21 1.6.4 Migration Strategy and Implementation Planning ............................................................................... 21 1.6.5 Benefits Realisation .............................................................................................................................. 21 1.6.6 Post Project Evaluation ......................................................................................................................... 22

1.7 Conclusion and Recommendation ................................................................................................ 22 1.7.1 Preferred Option Statement................................................................................................................. 22 1.7.2 Recommendation ................................................................................................................................. 23

Page | 5 of 82

Section 2: Introduction and Purpose ..................................................................................................... 24 2.1 Introduction .................................................................................................................................. 24 2.1.1 Programme Description........................................................................................................................ 24

Section 3: Strategic Case ........................................................................................................................ 26 3.1 Strategic Context ........................................................................................................................... 26 3.1.1 External Strategy .................................................................................................................................. 26 3.1.2 Internal Strategies and Plans ................................................................................................................ 27

3.2 Organisational Overview ............................................................................................................... 29 3.3 Investment Objectives .................................................................................................................. 30 3.4 Existing Arrangements .................................................................................................................. 32 3.4.1 Summary of History .............................................................................................................................. 32 3.4.2 Business Needs – Drivers for Change ................................................................................................... 33 3.4.3 Current Situation .................................................................................................................................. 35

3.5 Business Scope and Key Service Requirements ............................................................................ 35 3.5.1 Business Scope...................................................................................................................................... 35 3.5.2 Resultant Service Requirements........................................................................................................... 36

3.6 Benefits Criteria ............................................................................................................................ 36 3.7 Strategic Risks ............................................................................................................................... 37 3.8 Constraints and Dependencies ..................................................................................................... 37 3.8.1 Constraints............................................................................................................................................ 37 3.8.2 Dependencies ....................................................................................................................................... 37

3.9 Stakeholder Analysis ..................................................................................................................... 38 Section 4: Economic Case....................................................................................................................... 39 4.1 Critical Success Factors ................................................................................................................. 39 4.2 Main Business Options .................................................................................................................. 39 4.2.1 Early Appraisal Process ......................................................................................................................... 39

4.3 Preferred Way Forward ................................................................................................................ 41 4.4 Short Listed Options ...................................................................................................................... 41 4.4.1 Option 2: Update the system software but not the hardware ............................................................ 41 4.4.2 Option 4: Update the rear terminal hardware and software to improve electronic patient reporting platform only ................................................................................................................................................. 43 4.4.3 Option 5: Update the full mobile data solution within the vehicle to provide end-to-end Ambulance Telehealth solution. ....................................................................................................................................... 47

4.5 Benefits Appraisal ......................................................................................................................... 51 Page | 6 of 82

4.5.1 Benefits Analysis and Scoring ............................................................................................................... 51 4.5.2 Benefits Appraisal Summary................................................................................................................. 57

4.6 Risk Assessment ............................................................................................................................ 58 4.6.1 Risk Assessment of the Options ........................................................................................................... 58 4.6.2 Risk Analysis.......................................................................................................................................... 62 4.6.3 Risk Appetite......................................................................................................................................... 62

4.7 Optimism Bias ............................................................................................................................... 62 4.8 Economic Appraisal ....................................................................................................................... 63 4.9 Sensitivity Analysis ........................................................................................................................ 63 Section 5 Commercial Case ..................................................................................................................... 65 5.1 Procurement Strategy ................................................................................................................... 65 5.2 Possible Procurement Methodologies .......................................................................................... 65 5.3 Potential Scope and Services ........................................................................................................ 65 5.4 Potential charging mechanisms .................................................................................................... 66 5.5 Potential key contractual implications ......................................................................................... 66 5.6 Potential Personnel Implications .................................................................................................. 66 5.7 Potential Implementation Timescales .......................................................................................... 66 Section 6 Financial Case .......................................................................................................................... 67 6.1 Financial Appraisal ........................................................................................................................ 67 6.1.1 Capital Costs ......................................................................................................................................... 67 6.1.2 Revenue Costs ...................................................................................................................................... 68

Section 7 Management Case .................................................................................................................. 71 7.1 Programme Structure and Governance Arrangements for OBC Development ........................... 71 7.2 Programme Structure and Governance Arrangements post OBC ................................................ 71 7.3 Risk Management Strategy ........................................................................................................... 73 7.4 Migration Strategy and Implementation Planning ....................................................................... 73 7.5 Benefits Realisation....................................................................................................................... 74 7.6 Post Project Evaluation ................................................................................................................. 74 Section 8 Conclusion and Recommendation .......................................................................................... 76 8.1 Preferred Option Statement ......................................................................................................... 76 8.2 Recommendation .......................................................................................................................... 77 Appendices .............................................................................................................................................. 78 Appendix A - Screen Prints from current system................................................................................ 78 Appendix B Financial and Economic Appraisals .................................................................................. 79 Page | 7 of 82

Option 2 ......................................................................................................................................................... 79 Option 4 ......................................................................................................................................................... 79 Option 5 ......................................................................................................................................................... 79

Appendix C Calculation of Optimism Bias ........................................................................................... 80 Appendix D - Links to relevant Programme and Project Management Information and Guidance .. 81 Appendix E Glossary of Terms ............................................................................................................ 82

Page | 8 of 82

Section 1: Executive Summary 1.1 Introduction The Scottish Ambulance Service is proposing a new programme named 'Ambulance Telehealth' to refresh the mobile data technology used on the frontline A&E ambulance fleet to provide electronic allocation and mobilisation to emergency, urgent and routine patient incidents; and an electronic patient reporting tool to record all clinical information in relation to the care of those patients. The programme is fully aligned with the Scottish Government 2020 vision for healthcare as it will facilitate the use of new technologies to enable more people to live longer healthier lives at home through taking more diagnostic and treatment skills and equipment into patient’s homes. It will improve patient care, simplify the patient reporting process and, critically, support Telehealth connections from within the ambulance environment to allow patients to connect with health care professionals (HCP) without the need to travel long distances to hospital when physical contact between a HCP and a patient may not be necessary. Where possible, video communications may also be established from the mobile data terminal within the patient's home, using the in-vehicle network as a communications hub. The new systems will provide a central point for collection and distribution of all electronic patient monitoring data from a variety of patient monitoring tools within the vehicle e.g. blood testing devices etc. This Business Case will document the justification for the undertaking of the Ambulance Telehealth programme, based on the estimated costs (of development, implementation and incremental ongoing operations and maintenance costs) against the anticipated benefits to be gained and offset by any associated risks. The business case covers the procurement of a replacement hardware and software solution for allocation & mobilisation, automatic satellite navigation and electronic patient reporting in the unscheduled care environment, consisting of the installation of appropriate, vehicle based mobile data terminals (MDT), robust and secure mobile data communications, customised application software and support for appropriate clinical devices. This programme will deliver a number of benefits including an improved, simplified interface for ambulance staff, via a solution that will be easier and less expensive to manage, support and maintain. The new system will improve the patient experience by creating access to alternative healthcare support from within the community, reducing the need to transport and admit patients to hospital unnecessarily, which will in turn provide additional benefits in terms of improved patient safety and efficiency savings.

1.2

Strategic Case

1.2.1 Strategic Context As outlined in Section 3 of this document, cognisance has been taken of relevant local and national policy and strategy including the following: Page | 9 of 82





External Strategy: o Scottish Government and NHS Scotland eHealth Strategy o NHS Scotland 2020 Vision o National Delivery Plan for Telehealth and Telecare o Spending Review / Austerity Internal Strategies and Plans o The Scottish Ambulance Five Year Strategic Framework o HEAT Targets (Health, Efficiency, Access and Treatment) o eHealth ICT Strategy 2012 – 2017

1.2.2 Investment Objectives The investment objectives for this programme have been developed from the premise that it is essential that the Service have access to enhanced mobile data services in order to meet the demands placed on it by the Scottish public in an efficient and effective manner and thereby protect patient safety and care. The current systems for providing these services have been in place since 2007 and are now in need of replacement due to the age of the system hardware and the need to advance towards use of newly available technology to improve communications and enhance patient care. Therefore the following investment objectives have been developed to ensure that the Service has access to improved mobile data services through 2016 and beyond: Table 1/1

Strategic Objective

1

2

3

Summary of Strategic Project Objectives

Strategic Link to eHealth Delivery Plan To deliver an improved patient-driven user Healthcare services are more interface which will result in more efficient. accurate and improved completion of electronic patient report forms. To ensure front terminal compliance with Vehicle Type Approval guidelines issued by the Vehicle Certification Agency under the CEN standard (BS EN 1789:2000) for Medical Vehicles and their Equipment from 2015.

Not applicable to eHealth delivery plan but delivers on the SAS HEAT target to provide a safe environment for the delivery of healthcare services.

To deliver a robust and reliable hardware solution which supports wireless data communications outside of the dock and can therefore be used effectively at the point of care. This will result in improved turnaround times at incidents where a patient is not conveyed to hospital.

Healthcare services are more efficient Healthcare workers have better access to the information they need

Page | 10 of 82

4

5

6

To provide a solution which supports access to external clinical information to aid clinical decision making and access to Back Office systems for incident reporting, eForm completion and accessing business information which will reduce the amount of time ambulance crews need to spend completing administrative tasks on station.

Healthcare services are more efficient Healthcare workers have better access to the information they need Improve the safety of people taking medicines and their effective use

To enable data links to patient monitoring equipment within the vehicle to allow automatic population of clinical data. This will increase the accuracy of clinical recording and speed up the record completion process.

Healthcare Services are more efficient

To enable electronic data sharing between responding vehicles to avoid duplication of effort and to ensure that all responding clinicians can review the full treatment record for the patient.

Healthcare services are more efficient

Performance data is readily available to proactively improve service delivery

Healthcare workers have better access to the information they need. People with long term conditions are better supported

7

To deliver a mobile Telehealth interface to support video connections to health care professionals from within the ambulance environment (dependant on bandwidth availability) to allow patients to connect with clinicians without the need to travel to a hospital or clinic where a physical consultation may not be necessary. This will improve ambulance journey efficiency, reduce unnecessary hospital attendance and will allow patients to access enhanced healthcare services from within their community.

Healthcare services are more efficient Healthcare workers have better access to the information they need People with long term conditions are better supported People will be treated at home or in their own community

Page | 11 of 82

1.2.3 Existing Arrangements 1.2.3.1 Summary of History The Scottish Ambulance Service (SAS) introduced Cab Based Terminals in all frontline A&E vehicles between April and October 2007. The Cab Based solution includes a front and rear computer terminal, providing allocation, mobilisation and satellite navigation facilities in the front of the vehicle and an electronic patient reporting system (ePacer) in the rear of the vehicle. Since the introduction of the electronic patient reporting (ePRF) system, more than 3.5 million patient records have been uploaded to the ePRF database and SAS data warehouse. Since its introduction in 2007, the allocation & mobilisation and ePacer applications have been subject to continual software updates to improve health & safety, clinical recording and to introduce aids to clinical decision making. Updates to the system include:           

improved data message alerting facility; front to rear terminal end of shift checks to ensure all clinical records are complete; SEWS (Scottish Early Warning System) calculations; a sepsis scoring tool; a pandemic flu diagnostic tool; a communications tool to aid communication with disabled people or non-English speakers; real-time lookup to the Emergency Care Summary to access information about a patients' medical history; successful pilot projects to transfer the ePRF directly to the receiving hospital in real-time; Access to JRCALC and SAS specific clinical guidelines; Inclusion of the PVC Care Bundle; Improvements to layout, input options and recording tools

In addition to the software updates, improvements have been made to the hardware installed in the vehicles by introducing a cable-free docking solution with an improved rubber-casing to protect the unit in the rear of the vehicle. A revised hardware solution was also identified and purchased to cater for the smaller Paramedic Response and Urgent Tier vehicles. These were provided with a smaller 8" front terminal and an updated central communications unit, known as the TVC 3000. Commercial in Confidence information removed 1.2.3.2 Business Needs - Drivers for change The key drivers for change are described in Section 3 of the document and include   

Improved patient care through the use of technology Scottish Government 2020 vision – treating patients out with the hospital environment Cost savings to wider NHS in terms of reduced hospital admissions, A&E attendances and outpatient attendances Page | 12 of 82

     

Significant improvements in terms of reduction in travel for patients in the more remote and rural parts of Scotland Existing contracts expiry dates Ageing technology and equipment Cost savings e.g. through consolidated contract structure Greater data volume services Type approval legislation for ambulance vehicles

1.2.3.3 Current Situation Further software enhancements to the existing platform have now been ceased, with the exception of urgent clinical developments, in anticipation of this redevelopment programme. We are currently looking at ways to ensure that any vehicles purchased from January 2013 onwards are compliant with the type approval legislation will come into force in 2015 although there is no expectation that we will need to back-fit older vehicles to comply with this. We are dealing with an increasing number of faults related to poor battery performance on the existing units and whilst these are continually refurbished as part of the maintenance contract, there is reluctance from staff to carry the units outside of the vehicle as they have no confidence in the battery life. Recent developments, such as the early warning alert for sepsis which is being trialled with NHS Fife, have produced disappointing results due to the lack of data communications when the unit is undocked. Feedback from staff has highlighted that without a wireless data connection they are unable to trigger the sepsis alert as they often cannot re-dock the unit whilst the vehicle is in motion, on route to the hospital, for health and safety reasons. Future developments of real-time data transfer will also be dependent on this type of wireless communication.

1.3 Economic Case 1.3.1 Main Business Options 1.3.1.1 Early Appraisal Process A high level technology review identified that there were five potential technology solutions that could be considered to meet the operational requirements, and these were compared against the ‘Status Quo’ or ‘Do Nothing/Do Minimum’ option The following options were assessed and recommended for rejection as potential solutions in the Initial Agreement which was approved by the SAS Board and the Scottish Government Capital Investment Group (CIG).  

Option 1 Do Nothing Option 3 Update the system hardware but not the software

Page | 13 of 82

Full details of all five options are contained within Section 4.1 of this document

1.3.2 Preferred Way Forward Based on the feedback received from the CIG, Options 2, 4 and 5 as described in the Initial Agreement have been taken forward and fully appraised as feasible options to be considered in this Outline Business Case. Option 2 has been put forward as the 'do the minimum' approach whilst options 4 and 5 represent the options to 'do something'.

1.3.3 Short Listed Options The following options were subject to a full economic and financial analysis, details of which are included in Sections 4 and 5 of this document: 





Option 2 Update the system software but not the hardware o This option provides an updated software interface which gives an improved look and feel to the allocation & mobilisation, satellite navigation and patient reporting software. However, this option would not meet the Service and Scottish Government aspirations of delivering locally based care without the need for transportation to hospital. This option would deliver limited functional benefits to users due to the technology limitations of the existing hardware i.e. while clinical diagnostic equipment can be interfaced into this option, it would be limited by the capability of the existing hardware and would require significant additional investment. Option 4 Update the rear terminal hardware and software to improve electronic patient reporting platform only o This option will deliver a revised hardware and software solution to replace the existing TMC1350 tablet used in the rear of ambulance vehicles for recording a clinical patient record using the ePacer software platform. However this is a complex solution which requires different suppliers for the front and back terminals and potentially front terminal hardware in new vehicles being different to older vehicles due to the Type Approval legislation. This option would not allow for a full Telehealth video solution to be implemented and will therefore not provide remote clinical support to patients and paramedics to reduce the need for transport to hospital and to support the 2020 vision of healthcare provision at home or in a homely setting. Commercial in confidence information removed Option 5 Update the full mobile data solution within the vehicle to provide end to end Ambulance Telehealth solution o This option updates the front a rear terminal hardware and software and implements a true broadband and wireless communication infrastructure. It will enable clinical diagnostic equipment to be interfaced into the software and hardware to meet the strategic objectives of the 2020 vision and means the Service will be able to further develop the solution as technology advances.

1.3.4 Economic Appraisal The economic appraisal considers the benefits, costs and risks of the shortlisted options to inform a value for money assessment and arrive at a rank order of the options in terms of value for money. Page | 14 of 82

The economic appraisal is shown in the table below: Table 1/2

Option

BENEFITS

COSTS

Costs per Benefit

Weighted Benefit Score

Equivalent Annual Charge

£000 / Points

Points

£

£

Option 2 Update System software 107 3,476,827 but NOT hardware Option 4 Update rear terminal HW 359 6,731,444 and SW for ePRF only Option 5 Update the full mobile data solution for 784 6,308,605 full Telehealth system Commercial in confidence information removed

Costs per Benefit Rank Order (lowest cost per benefit first)

RISK

Median risk quotien t

Costs per Benefit % of Total

RISK

% of Total

%

%

32,493.7

3

50.00

55

43

18,750.5

2

32.00

32

28

8,046.7

1

34.00

13

29

The table shows that Option 5 is the highest ranking option based on benefits gained versus expenditure. Option 5 also carries a low risk profile.

1.3.5 Sensitivity Analysis 





As shown in the Economic Appraisal Table above, Option 5 has been given the highest rank order in terms of costs per benefit. In order to test the sensitivity of this outcome, analysis has been performed to determine the increase in costs or decrease in benefits which would be required to amend the rank order of the options. The cost per benefit of Option 5 would have to increase by a minimum of 421% before the rank order would change with option 4 becoming the highest ranking option. This represents a significant increase and shows that, in terms of cost, the option is not very sensitive to fluctuation. The benefits gained from Option 5 would have to decrease by a minimum of 58% before the rank order is changed to favour option 2. This represents a significant increase and shows that, in terms of benefits, the option is not very sensitive to fluctuation.

Page | 15 of 82

1.4 Commercial Case 1.4.1 Procurement Strategy The Service has a highly skilled and experienced Procurement Team who will work with the Project Team during the FBC development phase to produce the sourcing strategy. This will include determining the most appropriate route to market to be used.

1.4.2 Possible Procurement Methodologies At this stage of the programme, the most appropriate procurement methodology has yet to be determined. It will be identified during the collation of the sourcing strategy. The Scottish Government Procurement Journey Route 3 will be followed given the expected value of the programme. The Procurement Journey has been developed by the Scottish Government to support procurement activity and standardise the process as far as possible. It uses a decision matrix based on several factors including value, risk and the need for advertising to determine the ‘Route’ to be followed.

1.4.3 Potential Scope and Services It is likely that the ultimate solution will consist of several complementary contracts for multiple services including hardware with installation and maintenance, software applications and licences, interfaces, communications bearers, tracking and navigation, Wi-Fi and potentially some medical devices with maintenance.

1.4.4 Potential Charging Mechanisms The Programme will incur significant capital and revenue costs over its lifecycle. It is difficult to estimate the relative capital / revenue costs at this stage particularly as the solution is likely to be a composite offering from a number of suppliers implemented over a period spanning three financial years. However, detailed cost models will be obtained through the procurement process and included in the FBC.

1.4.5 Potential Key Contractual Implications Given that the solution delivered by the Ambulance Telehealth Programme will be a replacement for a current solution that is integral to the efficient and effective delivery of operational ambulance services across Scotland, careful consideration will need to be given to how a seamless contract transition can be achieved, especially if multiple vendors are involved. Key considerations will include potential contract durations and technology refresh requirements.

1.4.6 Potential Personnel Implications

Page | 16 of 82

At this stage in the business case development, it is not expected that there will be any permanent change to the Service establishment as a result of the Ambulance Telehealth Programme, however the technology will enable the Service staff to diagnose and treat more patients in their home. As a result there may be skills implications and these are currently under consideration as part of the Service’s Strategic Workforce Planning which will be completed by March 2014.

1.4.7 Potential Implementation Timescales Based on current projected timescales it is expected that the procurement phase of the Programme will take place during financial year 2014/15 and that all relevant contracts will be in place by the end of financial year 2015/16. Given the nature of the programme of work, the implementation is likely to be phased over a period spanning financial years 2014/15, 2015/16 and 2016/17. This is necessitated by the complex logistical dynamics that will be encountered with commissioning up to 700 vehicles spread throughout the country. The exact nature and timescales for implementation will continue to be developed in the Final Business Case and throughout the tendering and contracting phases.

1.5 Financial Case 1.5.1 Financial Appraisal A full financial appraisal of all options has been undertaken to determine the anticipated costs associated with the implementation of the Ambulance Telehealth programme. In this section we are concerned not with the theoretical cost indicators used in the economic appraisal, but with actual forecast costs, including VAT, and their affordability in relation to the funding streams likely to be available. Optimism bias is excluded from the financial appraisal. 1.5.1.1 Capital Costs The capital costs associated with each option are shown in the table below: Table 1/3

Option 2

Option 4

Option 5

£1,622,020

£5,676,933 £5,982,641

Financial Appraisal (includes all irrecoverable VAT) Total Capital Costs Programme Life (years)

3

3

3

Average Annual Capital over Programme Life (Actual expenditure is likely to be incurred in only 2 of the 3 years of the duration of the project)

£811,010

£2,838,467 £2,991,321

New Depreciation Charges (to be written off over 7 years)

£1,622,020

£5,676,933 £5,982,641

COMMERCIAL IN CONFIDENCE INFORMATON REMOVED

Page | 17 of 82

1.5.1.2 Revenue Costs The anticipated revenue costs (excluding new depreciation charges) associated with each option are shown in the table below: Table 1/4

Financial Appraisal (includes all irrecoverable VAT) Option 2 Option 4 Option 5

Year 1

£ 1,017,958 1,020,958 1,027,958

Year 2 £ 1,203,000 1,413,458 1,017,958

Year 3 £ 1,003,000 1,533,000 1,287,500

Year 4 £ 1,003,000 1,003,000 757,500

Year 5 £ 1,003,000 1,003,000 757,500

Year 6 £ 1,003,000 1,003,000 757,500

Year 7 £ 1,003,000 1,003,000 757,500

Currently around £1m of expenditure is incurred each year by the Service for mobile data support, hardware warranty and software support. Anticipated savings associated with Option 5, the preferred option is shown in the table below: COMMERCIAL IN CONFIDENCE INFORMATON REMOVED Table 1/5

Financial Appraisal (includes all irrecoverable VAT) Option 5 Revenue Costs Current Revenue Expenditure Estimated Additional Funding Required / (Savings Generated) 1

Year 1 1,027,958 1,017,958

Year 2 £ 1,017,958 1,017,958

Year 3 £ 1,287,500 1,017,958

Year 4 £ 757,500 1,017,958

Year 5 £ 757,500 1,017,958

Year 6 £ 757,500 1,017,958

Year 7 £ 757,500 1,017,958

10,000

0

269,542 1

(260,458)

(260,458)

(260,458)

(260,458)

£

- Cost shown is projected ‘worst case’. The actual Year 3 revenue increase will be refined during FBC development

It is anticipated that the estimated additional costs of £10,000 in Year 1 will be met from the Service’s existing recurring revenue allocation. The revenue costs for Year 3 shown in table 1/5 are based on information currently available along with estimated implementation timescales and may well be subject to change. It is worth noting that Option 5 revenue costs are based on an estimated 700 vehicles being fitted with the new hardware and software, however the current contract is for 595 vehicles and so this is reflected in the figures provided for current revenue expenditure. If the Option 5 figures are reworked using 595 vehicles as opposed to 700 (to give a ‘like for like’ comparison), the seven year revenue savings are estimated at £1.35m and the total net programme costs, including capital Page | 18 of 82

expenditure, are an estimated £3.7m. The revenue costs associated with Option 5 and the implementation timescales will be refined during the development of the Full Business Case COMMERCIAL IN CONFIDENCE INFORMATON REMOVED

1.5.1.3 Capital Charges The capital charges for Option 5 are based on an average 7 year asset life and it has been assumed that depreciation will be applied using the straight line method. It is assumed that the Service will fund the impact of the new depreciation charges and the following table outlines the charges over the 7 years: Table 1/6

Year 1 Capital Charges New Depreciation Charges

£ 428,571

Year 2 £ 428,571

Year 3 £ 854,663

Year 4 £ 854,663

Year 5 £ 854,663

Year 6 £ 854,663

Year 7 £ 854,663

The demonstration of the affordability of this programme will continue to be tested fully throughout the different approval stages of this project which will include the development of a fully detailed revenue model within the next FBC stage. COMMERCIAL IN CONFIDENCE INFORMATON REMOVED

1.5.2 Funding Arrangements The main funding source for the capital requirements is anticipated to be via Scottish Government capital allocation. The Service has considered entering into a leasing arrangement with suppliers for the capital purchase, however as it is anticipated to result in higher costs along with more complex contract management implications this option has not been pursued. It is anticipated that the allocation of capital funding will be released by Scottish Government in two phases. The first phase will consist of £3m being released in financial year 2014/15. There will then be a one year gap with the remaining £3m being released in 2016/17. Estimated costs used in the Economic and Financial Appraisals contained within this Outline Business Case have taken account of this phased approach for release of capital funding.

Page | 19 of 82

Revenue costs will be offset against current revenue expenditure which will cease when the existing system is de-commissioned. As shown in Table 1/5, the new recurring costs are anticipated to be significantly lower than those currently incurred and will therefore result in annual revenue savings for the Service from Year 4 onwards. This is mainly due to the reduction in the costs of mobile data support.

Page | 20 of 82

1.6 Management Case 1.6.1 Programme Structure and Governance Arrangements for OBC Development As outlined in the Initial Agreement document approved by the CIG earlier in the year, the development of this Outline Business Case (OBC) has been carried out by Service staff members and the process has been overseen and governed by the Service eHealth Board.

1.6.2 Programme Structure and Governance Arrangements post OBC As with all large complex programmes undertaken by the Scottish Ambulance Service, the Ambulance Telehealth Programme will be managed and governed in line with the principles of Managing Successful Programmes (MSP) good practice as well as Prince 2 project management guidance. The next phase of the programme will be the development of a Final Business Case (FBC). It is during this phase that more robust and formal programme governance arrangements will be put in place. A dedicated programme board is currently being established to oversee the Programme for the remainder of its lifecycle for the development of the FBC through procurement and implementation to benefits realisation and programme closure. The Ambulance Telehealth Programme Board will sit within current Service programme governance structures.

1.6.3 Risk Management Strategy The risk management strategy that will be applied to the Ambulance Telehealth Programme will follow the corporate risk management strategy and arrangements that are managed by the National Risk and Resilience Department (NRRD) and are already embedded within the Service.

1.6.4 Migration Strategy and Implementation Planning Detailed migration and implementation planning has still to be carried out. This will be completed during the period between OBC approval and FBC completion but it is likely to span a period of three financial years.

1.6.5 Benefits Realisation The compilation of a detailed benefits realisation plan will be carried out as part of the FBC process. The Service has a tried and tested benefits management process whereby a realisation plan is Page | 21 of 82

produced for each benefit. The Programme Director will oversee the creation and management of the benefits realisation plan. Due to the nature of the implementation plan, spanning three financial years along with a period of parallel running of existing systems, it is likely that the operational and financial benefits will only begin to be realised from year 3 onwards. Every effort will be made by the Programme Board to improve on this if at all possible.

1.6.6 Post Project Evaluation The aim of post project evaluation is to learn lessons from completed programmes and projects with a view to improving future project design, management and implementation. The compilation of a detailed post programme evaluation plan will also be carried out as part of the FBC process. Again, using information and lessons learned from recent programmes, it is expected that the evaluation team will comprise of in-house resources and that their role will be to use a programme framework matrix to assess the extent to which the programme has been implemented as planned and to identify and propose any lessons that might be incorporated into future programmes.

1.7 Conclusion and Recommendation 1.7.1 Preferred Option Statement This paper sets out the proposal, together with the associated benefits, costs and risks, for the Service to implement an appropriate, affordable, Ambulance Telehealth solution for the unscheduled care service, in support of the Service’s Strategic Development Framework and the continued investment in ICT Systems, to improve operational performance, and quality of service. With the decision to invest and the content of the investment having already been resolved in principle, this paper sets out the options for how the project could be delivered. The preferred option for investment is Option 5 as this option fully meets the operational, clinical and technical requirements of the Service, maximising benefits to staff, patients and healthcare partners alike whilst carrying the minimum business risk. Option 5 meets the 2020 aspirations of the Service and the Scottish Government by enabling more people to be cared for at home or in a homely setting and provides a full Telehealth solution to enhance clinical decision support and to facilitate patient referral to community based care providers rather than an a default admission to hospital. The technology will be future proof as far as possible to allow further development of the system as technology advances and matures to ensure that the Service provides the best possible service to patients through technology innovation. The Service has consulted internally and externally (through appropriate Stakeholder events) about these proposals and the Service’s stakeholders are fully supportive of the proposals. The aim is to implement an Ambulance Telehealth solution over a period of three financial years, following the formal award of contract, with a phased go‐live across the existing three ACC Operational areas (North, East and West). Page | 22 of 82

The project would deliver the objectives of:       

Delivering an improved patient-driven user interface Ensuring compliance with Vehicle Type Approval guidelines Delivering a robust and reliable hardware solution which supports wireless data communications Supporting access to internal and external systems to aid clinical decision making and improve administrative processes. Enabling data links to peripheral patient monitoring equipment to allow automatic population of clinical data. Enabling electronic data sharing between responding vehicles Delivering a mobile Telehealth interface to support video connections to health care professionals from within the ambulance environment.

1.7.2 Recommendation An option appraisal has been undertaken in accordance with guidance issued by the Scottish Government Capital Investment Group, and appropriate to the scale of the project. The preferred option is Option 5, as this offers the best value for money, and is affordable. It is recommended that the Scottish Ambulance Service Board and Scottish Government Capital Investment Group approve this option for expansion into a Final Business Case.

Page | 23 of 82

Section 2: Introduction and Purpose 2.1 Introduction 2.1.1 Programme Description The Scottish Ambulance Service is proposing a new programme named 'Ambulance Telehealth' to refresh the mobile data technology used on the frontline A&E ambulance fleet to provide electronic allocation and mobilisation to emergency, urgent and routine patient incidents; and an electronic patient reporting tool to record relevant clinical information in relation to the care of those patients. The programme is fully aligned with the Scottish Government 2020 vision for healthcare as it will facilitate the use of new technologies to improve patient care, and will simplify the patient reporting process. It will also support Telehealth connections from within the ambulance environment to allow patients to connect with health care professionals (HCP) without the need to travel long distances to hospital when physical contact between an HCP and a patient may not be necessary. Where possible, video communications may also be established from the mobile data terminal out with the vehicle. The new systems will provide a central point for collection and distribution of all electronic patient monitoring data from any patient monitoring tools that are available within the vehicle e.g. blood testing devices, ultrasound etc. This Business Case will document the justification for the undertaking of the Ambulance Telehealth programme, based on the estimated costs (of development, implementation and incremental ongoing operations and maintenance costs) against the anticipated benefits to be gained and offset by any associated risks. The business case covers the procurement of a replacement hardware and software solution for allocation & mobilisation, automatic satellite navigation and electronic patient reporting in the unscheduled care environment, [A&E, Urgent Tier, Paramedic Response Units (PRU) and Specialist Operations Response Teams (SORT)], consisting of the installation of appropriate, vehicle based mobile data terminals (MDT), robust and secure mobile data communications, customised application software and support for appropriate clinical devices. The potential hardware and application software, system interfacing, user training and maintenance services are summarised below: 

Implementation scope: Fixed MDT installed as 'front terminals' (or equivalent audio-based or combined front and rear terminal solution) in all unscheduled care vehicles in accordance with Vehicle Type Approval legislation running Allocation & Mobilisation software; Robust, Dockable/Un-Dockable MDT installed as 'rear-terminals' in all unscheduled care vehicles (approximately 700 vehicles) running electronic patient reporting software and provision of a modified 'lite' ePRF solution for First Responders, BASICS, Ambulance Officers and other responding personnel; In-vehicle clinical monitoring equipment provision and / or support; Page | 24 of 82



Timeframe: It is proposed to implement the Ambulance Telehealth solution as part of a rolling upgrade programme within the 2014/15, 2015/16 and 2016/17 financial years calendars, subject to Business Case approval, appropriate funding availability and the supplier ability to run the old and new systems concurrently while migration to the new systems takes place;



Technology scope: covers all aspects of implementation and system interfacing to existing systems including the C3 Command and Control system, Data Warehouse, back-end communications and ePRF servers, Emergency Care Summary, SCI Store and Ensemble interfaces; as well as interfacing to new systems to support telemedicine, telemetry for near patient testing and wireless connectivity when in range of the home network. Clinical monitoring equipment where appropriate and affordable;



Staff affected: Unscheduled Care frontline operational staff, who will be the primary users of the Ambulance Telehealth system alongside other responder groups, who will access the software on different hardware platforms;



Mobile Data Applications Provided: Allocation & Mobilisation, Electronic Patient Report Form, Telehealth data and video links, intranet, e-mail, e-Forms, Internet access to appropriate websites, clinical applications and back office systems;



System Installation, Configuration and Acceptance Testing: Installation to agreed quality and Health & Safety Standards, customised configuration of application software and complete end to end acceptance testing;



End User Training: Delivery of end user training course for all staff, to ensure complete familiarity of the Ambulance Telehealth equipment and software and maximised use of investment;



Maintenance Services: Establishment of an appropriate hardware/software maintenance contract that fully underpins the operational and contractual requirements of the unscheduled care service and, at a minimum, meets the threshold requirements identified in the Operational Requirements.

This programme will deliver a number of benefits including an improved, simplified interface for ambulance staff, via a solution that will be easier and less expensive to manage, support and maintain. The new system will improve the patient experience by creating access to alternative healthcare support from within the community, reducing the need to transport and admit patients to hospital unnecessarily, which will in turn provide additional benefits in terms of efficiency savings and improved patient safety. Although not in scope at this time, due to the recent investment made in mobile data technology for the Patient Transport Service (PTS), it is envisaged that the proposed modular approach being taken within this Programme will facilitate and support any potential future alignment of Unscheduled Care and Scheduled Care mobile technologies. Page | 25 of 82

Section 3: Strategic Case 3.1 Strategic Context 3.1.1 External Strategy 3.1.1.1 Scottish Government and NHS Scotland eHealth Strategy In 2012, the Scottish Government published a revised eHealth Strategy 2012-2017, and to ensure that the Service was fully aligned with this strategy, it was decided to review the existing eHealth ICT Strategy and produce a new five year strategy covering the period, April 2012 to March 2017. The main components / deliverables of the ICT eHealth Strategy contribute towards achieving NHS Scotland’s strategic aims with improvements to the following main areas:      

Healthcare services are more efficient People are supported to communicate with the NHSS Care is better integrated and people with long term conditions are better supported Clinicians have better access to the information they need Improve the safety of people taking medicines and their effective use Performance data are readily available to proactively improve service delivery

3.1.1.2 NHS Scotland 2020 Vision The NHS Scotland 2020 Vision is: '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.' The Ambulance Telehealth programme fully supports the 2020 vision by enabling access to healthcare services within the community by utilising the ambulance vehicle as a technology hub for real-time data sharing and live patient consultation with remote healthcare professionals. 3.1.1.3 National Delivery Plan for Telehealth and Telecare A National Delivery Plan for Telehealth and Telecare for Scotland to 2015 was published in December 2012 to drive improvement, integration and innovation through partnerships with NHS Boards, Local Authorities and other key stakeholders supported by the SCTT and Joint Improvement Team. The National Delivery Plan sets out four strategic ambitions for the next three years: Page | 26 of 82

  



Telehealth and Telecare will enable choice and control in health, care and wellbeing services for an additional 300,000 people; People who use our health and care services, and staff working with them, will increasingly demand the use of Telehealth and Telecare as positive options; There is an established Centre of Excellence, where an interacting community of academics, practitioners and industry innovate to meet future challenges and provide benefits for Scotland's health, wellbeing and wealth; and Scotland is recognised worldwide as a chosen location for trialling innovative Telehealth and Telecare services products.

This programme is fully focused on utilising advanced Telehealth technologies to deliver care to patients within their home setting, whenever possible. It will also deliver enhanced integration with our partner organisations and is therefore aligned with the strategic ambitions set out in the National Delivery Plan. 3.1.1.4 Spending Review / Austerity The Ambulance Telehealth Programme will take the current financial landscape into account and in particular the current Spending Review which requires difficult decisions to be taken if public services are to be maintained as available funds decrease. As a result, there will be considerable emphasis placed on cost-effectiveness and value for money throughout the programme lifecycle.

3.1.2 Internal Strategies and Plans 3.1.2.1 The Scottish Ambulance Service Five Year Strategic Framework The Service is just past the mid-way point of a five year strategic framework “Working Together for Better Patient Care” which was published in January 2010. “Working Together for Better Patient Care” established the vision to deliver the best patient care for people in Scotland, when they need it, where they need it putting our patients at the heart of everything the Service do. This strategy was, and continues to be, focused on three main goals: 1. To improve patient access and referral to the most appropriate care 2. To deliver the best service for patients 3. To engage with all of our partners and communities to delivery improved healthcare. Points 1 & 2 above are underpinned by the effective and efficient use of mobile data services, whether it be the allocation and mobilisation of emergency crews to an incident via the mobile data terminal, or passing of clinical patient data to the receiving Emergency Department prior to arrival with the patient. 3.1.2.2 HEAT Targets (Health, Efficiency, Access and Treatment) Each NHS Board must set out in a Local Delivery Plan (LDP), an annual delivery agreement with the Scottish Government Health Department, based on key Ministerial targets. LDPs reflect the HEAT Core Set – the key objectives, targets and measures that reflect Minister’s priorities for the Health portfolio. The key objectives are as follows, with the HEAT acronym derived from the initials: Page | 27 of 82



Health Improvement for the People of Scotland – improving life expectancy and healthy life expectancy



Efficiency and Governance Improvements – continually improve the efficiency and effectiveness of the NHS



Access to Health Services – recognising patient’s need for quicker and easier use of NHS services; and



Treatment Appropriate to Individuals – ensure patients receive high quality services that meet their needs.

Building upon the recommendations contained within the Scottish Government Healthcare Quality Strategy for NHS Scotland, May 2010, and more recently, the Scottish Government paper on Achieving Sustainable Quality in Scotland’s Healthcare – A ‘2020’ Vision, the Service revisited, and revised its mission statements, long term corporate objectives, and key result areas. This resulted in the development of the Service’s HEAT Delivery Plan and Corporate Plan in order to fully support the Healthcare Quality Strategy ambitions for NHS Scotland which are to be: 

Person-Centered – mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individuals needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making. Clinically Excellent – the most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. Leading Edge – Processes and New Technology will be aligned and developed wherever possible, to fully underpin the Operational Service Delivery requirements of both the Unscheduled and Scheduled Care Services. Safe – there will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times.







3.1.2.3 eHealth ICT Strategy 2012 - 2017 The Service firmly believes that eHealth has a vital role to play in shifting the balance of care as timely information on a patient’s condition will allow them to be appropriately cared for in their own environment. The Service also believes that eHealth can assist with diagnosis and treatment performed through Telehealth and decision support from distant clinicians, especially in the remote and rural parts of Scotland. In support of this belief, the Service has developed a 5-year eHealth Strategy and will: 

Continue to develop ‘See and Treat’ technology to enable people to be treated in their own community supported by access to an appropriate and secure communications infrastructure without the need for an A&E attendance or admission. In particular the service wishes to expand near patient diagnostic testing where it is safe and effective to do so. Page | 28 of 82













Aim to improve the availability of appropriate securely held information for its clinicians and to provide the tools to use and communicate that information effectively to improve the quality of care it provides to patients. Continue to develop access to ECS and KIS for frontline clinicians, and will continue to develop interfaces which pass information to A&E departments electronically prior to the patient’s arrival, thus improving the outcome for patients and developing a system that is streamlined and reduces waste and harmful impacts on patients. Continue to work with Scottish Government and Healthcare Partners to develop its mobile voice and data strategy for both the Unscheduled and Scheduled Care Services and to facilitate the secure exchange of patient centred care information through better use of integration technology. Ensure all systems are as efficient as possible, and that waste and inefficiency is minimised, producing cash savings. Benefits will be measured to enable value for money to be demonstrated as part of the aim. Progress the development of mobile broadband solutions, in order that it can contribute to enhancing overall patient care in the local communities, through the transmission of Clinical Telemetry, Telehealth and Telemedicine applications and exploit ation of mobile communication device technology and on-line services. Support people to manage their own health and wellbeing, and to become more active participants in the care and services they receive through better use of information systems. The Service recognises however that eHealth is only one aspect of the support individuals require to enable them to manage their own health and well being and will continue to provide links to other support mechanisms as not all patients have access to e -systems.

Through the Ambulance Telehealth Project, the Service aims to develop a secure communications capability that will underpin the various integrated eHealth applications delivered through the eHealth Strategy. This will be an innovative programme, utilising new technologies and fit-for-purpose system interfaces to provide a system which not only meets the needs of the ambulance service in the short term, but future-proofs the development capabilities of the ambulance service to continually enhance the in-vehicle technology throughout the lifecycle of the hardware to meet demand for new services.

3.2 Organisational Overview The Scottish Ambulance Service is one of eight Special Health Boards within NHS Scotland. It is also one of the three emergency services. With over 4,300 staff and an overall budget of over £220million, the Service is at the frontline of the NHS in Scotland providing an emergency ambulance service to a population of over 5 million people serving all of the nation’s mainland and island communities. In addition, the Patient Transport Service (PTS) undertakes over 1.3 million journeys every year. The PTS service provides care for patients who need support to reach their healthcare appointments due to their medical or mobility needs. Page | 29 of 82

The Service is just past the midway point of a five year strategic framework “Working Together for Better Patient Care” which was published in January 2010. “Working Together for Better Patient Care” established the vision to deliver the best patient care for people in Scotland, when they need it, where they need it, putting our patients at the heart of everything we do. The strategy was, and continues to be, focused on three main goals: 1. To improve patient access and referral to the most appropriate care 2. To deliver the best service for patients 3. To engage with all of our partners and communities to deliver improved healthcare

3.3 Investment Objectives The investment objectives for this programme have been developed from the premise that it is essential that the Service have access to enhanced mobile data services in order to meet the demands placed on it by the Scottish public in an efficient and effective manner and thereby protect patient safety and care. The current systems for providing these services have been in place since 2007 and are now in need of replacement due to the age of the system hardware and the need to advance towards use of newly available technology to improve communications and enhance patient care. Therefore the following investment objectives have been developed to ensure that the Service has access to improved mobile data services through 2016 and beyond: Table 3/1, Objectives

Strategic Objective

1

2

3

Summary of Strategic Project Objectives

Strategic Link to eHealth Delivery Plan To deliver an improved patient-driven user Healthcare services are more interface which will result in more efficient. accurate and improved completion of electronic patient report forms. To ensure front terminal compliance with Vehicle Type Approval guidelines issued by the Vehicle Certification Agency under the CEN standard (BS EN 1789:2000) for Medical Vehicles and their Equipment from 2015.

Not applicable to eHealth delivery plan but delivers on the SAS HEAT target to provide a safe environment for the delivery of healthcare services.

To deliver a robust and reliable hardware solution this supports wireless data communications outside of the dock and can therefore be used effectively at the point of care. This will result in improved turnaround times at incidents where a patient is not conveyed to hospital.

Healthcare services are more efficient Healthcare workers have better access to the information they need

Page | 30 of 82

4

5

6

7

To provide a solution which supports access to external clinical information to aid clinical decision making and access to Back Office systems for incident reporting, eForm completion and accessing business information which will reduce the amount of time ambulance crews need to spend completion administrative tasks on station.

Healthcare services are more efficient Healthcare workers have better access to the information they need Improve the safety of people taking medicines and their effective use

To enable data links to patient monitoring equipment within the vehicle to allow automatic population of clinical data. This will increase the accuracy of clinical recording and speed up the record completion process.

Healthcare Services are more efficient

To enable electronic data sharing between responding vehicles to avoid duplication of effort and to ensure that all responding clinicians can review the full treatment record for the patient.

Healthcare services are more efficient

Performance data is readily available to proactively improve service delivery

Healthcare workers have better access to the information they need.

People with long term conditions are better supported To deliver a mobile Telehealth interface to Healthcare services are more support video connections to health care efficient professionals from within the ambulance environment (dependant on bandwidth Healthcare workers have better availability) to allow patients to connect access to the information they with clinicians without the need to travel need to a hospital or clinic where a physical consultation may not be necessary. This People with long term conditions will improve ambulance journey efficiency, are better supported reduce unnecessary hospital attendance and will allow patients to access enhanced People will be treated at home or healthcare services from within their their own community community.

Page | 31 of 82

3.4 Existing Arrangements 3.4.1 Summary of History The Scottish Ambulance Service (SAS) introduced Cab Based Terminals in all frontline A&E vehicles between April and October 2007. The Cab Based solution includes a front and rear computer terminal, providing allocation, mobilisation and satellite navigation facilities in the front of the vehicle and an electronic patient reporting system (ePacer) in the rear of the vehicle. Since the introduction of the electronic patient reporting (ePRF) system, more than 3.5 million patient records have been uploaded to the ePRF database and SAS data warehouse. The ePacer system in the rear of the vehicle records relevant clinical observations and treatments undertaken during the period of care undertaken by ambulance service staff. The ePacer system was designed in partnership with the software supplier and was built as a patient-centred application which should be quick and easy to complete without the need to access drop-down lists or excessive typing. The ePacer application uses a series of selection tools to record patient observations. There is no requirement to record negative observations as only the positive selections made will be printed to the final ePRF. A selection of screen prints from the current system is provided in Appendix A The information collected in the ePRF is stored in a centralised clinical database for clinical reporting and audit. Since its introduction in 2007, the allocation & mobilisation and ePacer applications have been subject to continual software updates to improve health & safety, clinical recording and to introduce aids to clinical decision making. Updates to the system include:           

Improved data message alerting facility; Front to rear terminal end of shift checks to ensure all clinical records are complete; SEWS (Scottish Early Warning System) calculations; A sepsis scoring tool; A pandemic flu diagnostic tool; A communications tool to aid communication with disabled people or non-English speakers; Real-time lookup to the Emergency Care Summary to access information about a patients' medical history; Successful pilot projects to transfer the ePRF directly to the receiving hospital in real-time; Access to JRCALC and SAS specific clinical guidelines; Inclusion of the PVC Care Bundle; Improvements to layout, input options and recording tools

In addition to the software updates, improvements have been made to the hardware installed in the vehicles by introducing a cable-free docking solution with an improved rubber-casing to protect the unit in the rear of the vehicle. Page | 32 of 82

A revised hardware solution was also identified and purchased to cater for the smaller Paramedic Response and Urgent Tier vehicles. These were provided with a smaller 8" front terminal and an updated central communications unit, known as the TVC 3000. The introduction of the SAS Data Warehouse in 2010 has provided direct access to ePRF reports for all front-line managers. The Data Warehouse comprises in excess of 200 standard reports which allow users to report at all levels from national through to individual performance and across all clinical datasets. The data warehouse also generates all reports required by the SAS Board, Scottish Government and other key stakeholders. In 2012, SAS were appointed as an Official Publisher for Statistics. This means there is a requirement for the Service to publish accurate statistics in a planned and open manner. The Service won the EHI 2010 award for 'Best Use of Technology in Healthcare' and took the 'Overall Winner' award at the EHI 2010 awards ceremony based on the mobile data technology and the advancements made in linking our electronic clinical reports with other systems. Commercial in confidence information removed

3.4.2 Business Needs – Drivers for Change 3.4.2.1 Improved Patient Care Through the Use of Technology One of the primary drivers for change is the desire to improve patient safety and care through the use of enhanced in-vehicle technology including, but not limited to, improved navigation aids to get to patients faster, improved decision support tools to ensure patients get the most suitable treatment or intervention and improved clinical tools to assist diagnosis and monitoring. 3.4.2.2 Scottish Government 20:20 Vision Another primary driver for change is the Scottish Government 2020 Vision, the Ambulance Telehealth programme aims to enable access to healthcare services within the community by utilising the ambulance vehicle as a technology hub for real-time data sharing and live patient consultation with remote healthcare professionals. 3.4.2.3 Cost Savings for NHS Scotland Partners A further driver for change is the requirement to provide healthcare more efficiently. The Ambulance Telehealth Programme will form an integral part of the Scottish Ambulance Service strategy to significantly reduce unnecessary conveyance to hospital. This will be achieved by providing our staff with access to viable and reliable alternative care pathways. This in turn will reduce the demand for hospital services and provide our Partners with cost saving opportunities.

Page | 33 of 82

3.4.2.4 Existing Contracts Expiry Dates A significant driver for change is the fact that the existing contract to supply the Service with mobile data services expires in 2016. Although this date may at first appear to be some way off, the reality is that although the Service could realistically go to market and procure off-the-shelf mobile data services over a relatively short timescale, development and implementation of the preferred solution is likely to take 2-3 years to complete. As a result, the timescales for renewing, extending or replacing the current supplier contract is estimated to be at least 2 years. 3.4.2.5 Ageing Technology & Equipment Another significant driver for change is the need to replace the ageing equipment currently in use in the ambulances which has been in continuous use for the past 6 years. The hardware is becoming increasingly unreliable, particularly in regard to poor battery performance. There are also limitations in further developing the software as a result of the major technology advancements seen across the ICT industry since 2007 which cannot run on the existing hardware and software platforms. 3.4.2.6 Cost Savings e.g. Through Consolidated Contract Structure The Service currently spends circa £1.6m per annum on mobile data services, through the existing supplier contract. Given the current economic climate, the Service are keen to explore all potential options for reducing, or at least containing, these costs. COMMERCIAL IN CONFIDENCE INFORMATON REMOVED 3.4.2.7 Greater Data volume Services Mobile data transmission services are currently provided through a single supplier contract to provide mobile data connections via the Vodafone mobile telephone network. One of the main drivers for the Ambulance Telehealth Project is to support frontline ambulance services and improve the scope and quality of patient care through the provision of mobile broadband speed data services.

3.4.2.8 Type Approval Legislation for Ambulance Vehicles The Vehicle Certification Agency has issued a new CEN standard (BS EN 1789:2000) for Medical Vehicles and their equipment which includes a new Vehicle Type Approval guideline to ensure the safety of both patients and paramedics. This is a voluntary standard but given its importance, it is adopted across the health industry as a purchasing requirement when buying new vehicles. This new guideline is widely expected to impact on the choice and fitting of mobile data equipment in the driver cabin of the ambulance. It is anticipated that our current standard hardware selection will not comply with this new standard due to the size of the terminal and the fixed docking station. Page | 34 of 82

3.4.3 Current Situation Further software enhancements to the existing platform have now been ceased, with the exception of urgent clinical developments, in anticipation of this redevelopment programme. We are currently looking at ways to ensure that any vehicles purchased from January 2013 onwards are compliant with the type approval legislation which will come into force in 2015 although there is no expectation that we will need to back-fit older vehicles to comply with this. We are dealing with an increasing number of faults related to poor battery performance on the existing units and whilst these are continually refurbished as part of the maintenance contract, there is reluctance from staff to carry the units outside of the vehicle as they have no confidence in the battery life. Recent developments, such as the early warning alert for sepsis which is being trialled with NHS Fife, have produced disappointing results due to the lack of data communications when the unit is undocked. Feedback from staff has highlighted that without a wireless data connection they are unable to trigger the sepsis alert as they often cannot re-dock the unit whilst the vehicle is in motion, on route to the hospital, for health and safety reasons. Future developments of real-time data transfer will also be dependent on this type of wireless communication. A full operational requirements determination and analysis has been completed and documented in support of this programme. This document will be used to compile the functional specification document to be issued to all interested suppliers at the tender stage. The Initial Agreement in support of the Ambulance Telehealth programme was approved by the SAS Board in April 2013 and was tabled at the Scottish Government Capital Investment Group (CIG) meeting in May. The CIG requested some additional information in regard to some of the points contained in the IA and a re-submission of the document was made. The IA has since been approved and this Outline Business Case is the next step in securing approval and funding to proceed with the programme. The OBC is expected to be submitted to the CIG in November 2013. The full Business Case will be developed and submitted during 2014

3.5 Business Scope and Key Service Requirements 3.5.1 Business Scope The scope of the programme covers the replacement of the existing mobile data systems and enabling emergency vehicles as wireless communications hubs for the secure transmission of patient data between systems and healthcare partners. The scope also covers provision of mobile data services to other Responder types utilised by the Ambulance Control Centres (ACC) such as Community First Responders and BASICS-trained clinicians

Page | 35 of 82

3.5.2 Resultant Service Requirements In terms of mobile data, current services are considered to be inadequate due to network coverage and bandwidth (data-rate) limitations, ageing hardware and out-dated software platforms. Therefore the high-level service requirements can be summarised as: 





Mobile data services o Improve current data collection functionality o Improve hardware platform o Increase coverage compared to current arrangements o Increase bandwidth compared to current arrangements o Enhance the services and capabilities available in the Ambulance environment o Enhance satellite navigation that can be updated regularly and simply Mobile Telehealth services o Provide real-time transfer of diagnostic data from near-patient testing equipment o Enable video conferencing to 3rd party health care professionals from within the ambulance environment to allow patients access to care from within their community to reduce hospital admissions Clinical monitoring o Provide and / or support clinical devices in order to facilitate enhanced clinical monitoring and recording

3.6 Benefits Criteria The main benefit that will be delivered by this programme is that the Service will be able to offer all of Scotland’s residents and visitors efficient and effective A&E Ambulance services with more care provided locally. By treating and referring patients to healthcare services within the community, patient journeys will be reduced, providing efficiencies in terms of fuel costs, reduced mileage and maintenance on Service fleet vehicles. Over time, the Service should see greater resource availability and will be in a position to streamline resource allocation to incidents where a conveying response may not be required. Patient safety will be improved due to the availability of real-time data for use by HCPs and ambulance crews will be better supported in patient-centred clinical decision making. Benefit and efficiency gains will be seen in the wider NHS economy in terms of enhanced information sharing of patient data, reduced hospital admissions and reduced attendance at A&E. There is also evidence to support the claim that by treating patients in the most appropriate care setting, clinical outcomes will improve, and patients will be treated in the environment they prefer. A full benefits analysis is included in section 4 of this document

Page | 36 of 82

3.7 Strategic Risks Risks to the programme will be identified, mitigated and controlled in accordance with standard programme governance methodology using both a “Likelihood” and “Impact” assessment. The main high level risks identified at this early stage are:   

That the programme does not deliver within the required timescales That the programme is not provided with the level of resources it requires That the programme does not deliver a solution that meets the minimum / essential user requirements

A full risk assessment is included in Section 4 of this document.

3.8 Constraints and Dependencies 3.8.1 Constraints The main constraints related to this programme that have been identified so far are:     

Timescales – e.g. the current contract expires in 2016 Procurement legislation – e.g. OJEU thresholds Technical – e.g. the ability of telecoms providers to deliver high speed mobile broadband Commercial / Legal / Contractual – e.g. the legality of extending the current Terrafix (Commercial in Confidence information removed) contract if required or desired Resources – e.g. financial envelope

3.8.2 Dependencies The key dependency related to this programme is the National Delivery Plan for Telehealth and Telecare as set out by the Scottish Centre for Telehealth and Telecare (SCTT). This sets out the contribution that Telehealth and Telecare can make to wider strategic policies for health, care, housing and wellbeing in Scotland. The programme will also take cognisance of the SAS Future Mobile Communications (SAS FMC) Programme and the Scottish Future Communications Programme (SFCP) which is focussed on providing the future voice and data communication needs of Scotland’s Emergency Services as well as other non blue-light agencies.

Page | 37 of 82

3.9 Stakeholder Analysis The following key stakeholder groups have been identified for this programme: Table 3/5, Stakeholders

Internal Stakeholders SAS Board Operations Medical Directorate Management Information Procurement Finance ICT Ambulance Control Centres Health & Safety Training & Development Equality & Diversity Partnership Forum Risk & Resilience Communications & Engagement

External Stakeholders Scottish Government NHS Scotland eHealth Directorate NHS Scotland Health Boards Patient Groups/Representatives Community Current A&E mobile data supplier Fleet supplier Current PTS mobile data supplier Current defibrillator supplier Other current clinical equipment suppliers Media Trade Unions

Stakeholder needs will be identified and assessed throughout the project and a formal communications plan will detail the communication activities which will take place to ensure that all key stakeholders remain informed and engaged with this programme.

Page | 38 of 82

Section 4: Economic Case 4.1 Critical Success Factors The following critical success factors have been identified for this programme:         

Availability of sufficient funding to support development, training and implementation Organisational support for the programme NHSS Health Board support for the programme Availability of dedicated programme resources throughout programme lifecycle Ability of suppliers to provide a solution that meets the identified Operational Requirements Availability of proven and trusted technology to meet the Operational Requirements Availability of public communications network in Scotland to support the solution nationally Provision of a solution which meets all 'Threshold' needs identified in the Operational Requirements Provision of a solution which meets some or all of the 'Objective' needs identified in the Operational Requirements

4.2 Main Business Options 4.2.1 Early Appraisal Process A high level technology review identified that there were five potential technology solutions that could be considered to meet the Operational Requirements, and these were compared against the 'Status Quo' or 'Do Nothing /Do Minimum Option'. The following options were assessed and recommended for rejection as potential solutions in the Initial Agreement which was submitted to the CIG for consideration. 4.2.1.1 Option 1: Do nothing Outline Description: Allow the existing contract to expire in 2016 and cease using mobile data services. Evaluation: Undesirable. This would fail to meet the Service requirements and would have a detrimental impact on patient safety and care. It would also compromise the Service position as a Category 1 emergency responder. Recommendation: Reject option.

Page | 39 of 82

Table 4/1, Option 1 Appraisal

Technology Do Nothing / Do Minimum Option.

Rationale for Rejection  Electronic processes for Allocation & Mobilisation, satellite navigation/routing to incidents and recording of patient report forms would cease with crews reverting to paper-based processes. 

Additional cost to the Service to dispose of legacy equipment, provide a paper based solution and for storage of patient records.



Inability to contribute towards external and internal strategic objectives.



Writing off equipment, development costs incurred.



No service development potential.



No telemedicine support.



Harmful to reputation of the organisation.



Likely to lower staff morale.

infrastructure,

services

and

The Capital Investment Group agreed that this was an unrealistic approach and should not be taken forward to the Outline Business Case for further appraisal. 4.2.1.2 Option 3: Update the system hardware but not the software Outline Description: Update the front and rear-terminal hardware but continue to run with legacy software. Evaluation: Feasible but Undesirable. Whilst there is little doubt that this option would deliver an acceptable mobile data solution, it would not allow the Service to meet the strategic objective of supporting people to manage their own health and wellbeing, and to become more active participants in the care and services they receive through better use of information systems. Hardware selection would be limited to a Windows-based system to support the existing software. Recommendation: Reject option.

Page | 40 of 82

Table 4/2, Option 3 Appraisal

Technology Maintain the existing software but upgrade the system hardware

Rationale for Rejection  Limited benefit from introduction of new hardware as the software does not support finger-gesturing operation and other display technologies available on the hardware to improve user experience. 

Hardware options will be limited to Windows-based devices to support the current software.



Additional future investment would be required to update the software to meet Operational Requirements including links to patient monitoring equipment and Back Office systems.



Additional cost to the Service in the short term to ensure software will comply with the introduction of the Common Triage System (in collaboration with NHS 24).



Service development potential will be limited by the capability of the software.



Staff support for the programme likely to be limited.

The Capital Investment Group agreed with the recommendation to reject this as a potential option. It has therefore not been appraised within this document.

4.3 Preferred Way Forward Based on the feedback received from the CIG, Options 2, 4 and 5 as described in the Initial Agreement have been taken forward and fully appraised as feasible options to be considered in this outline business case. Option 2 has been put forward as the 'do the minimum' approach whilst options 4 and 5 represent the options to 'do something'.

4.4 Short Listed Options 4.4.1 Option 2: Update the system software but not the hardware Detailed Description: Option 2 will deliver an updated user interface on both the front and rear terminals whilst maintaining the existing hardware within the vehicle.

Page | 41 of 82

While an updated software interface would provide an improved look and feel to the allocation & mobilisation, satellite navigation and patient reporting software, this option would not meet the Service and Scottish Governments aspirations of delivering locally based care without the need for transportation to hospital. This option would deliver limited functional benefits to users due to the technology limitations of the existing hardware i.e. while clinical diagnostic equipment can be interfaced into this option, it would be limited by the capability of the existing hardware and would require significant additional investment. The ePRF software will be updated to make the user interface more user friendly in line with feedback regarding the current navigation through the system. This would assist in increasing the level of completion and accuracy within the patient report forms to aid clinical reporting.

Evaluation: Undesirable. Whilst this option could deliver an acceptable mobile voice and data solution, it is likely to produce limited return on investment due to the technical limitations of the existing hardware and the increasing fault maintenance costs associated with supporting ageing equipment. This option also carries the risk that the supplier may cease maintenance on the existing hardware forcing us into a technology refresh at a later date. This option would curtail the strategic objective of working with other public bodies whilst levering best value through economies of scale. Additional costs would also be incurred in providing new vehicles with alternative hardware to comply with Type Approval legislation. This option would not meet the Scottish Governments 2020 vision of enabling people to live longer healthier lives at home or in homely setting. It also does not provide the functionality of interfacing clinical diagnostic equipment to the system. Table 4/3, Option 2 Appraisal

Technology Rationale for Evaluation Maintain the existing  Maintains the use of the existing hardware for allocation & hardware but upgrade the mobilisation, satellite navigation/routing to incidents and the system software completion of electronic patient report forms. 

Lower investment cost for software replacement only.



Maintains existing back-end infrastructure and databases.



Improved user interface.



Increase in ePRF completion and accuracy.



Seamless implementation process



Additional cost to the Service in the short term to provide additional spares capacity to support expected increase in maintenance faults.

Page | 42 of 82



Additional cost to the Service to provide an alternative front terminal solution in all newly purchased vehicles to comply with Type Approval legislation from 2015. Redundant front terminals could be used as spares to negate the previous issue.



Limited benefit from introduction of new software as the hardware does not support finger gesturing technology, wireless communications or video technology required to meet the needs identified in Operational Requirement and to support Telemedicine facilities.



New software may not be compatible with PTS Mobile Data solution



Interfaces to patient monitoring equipment and Back Office Systems will require additional investment and will be difficult/impossible to achieve with existing hardware technology.



Will require bespoke user training to ensure best use of the ePRF software.



Service development potential will be limited by the capability of the hardware.

4.4.2 Option 4: Update the rear terminal hardware and software to improve electronic patient reporting platform only Detailed Description of the Proposed System: Option 4 will deliver a revised hardware and software solution to replace the existing tablet used in the rear of the ambulance vehicles for recording a clinical patient record. In order to achieve this, the interface unit within the vehicle will also be replaced to provide the technology requirements to support the updated tablet. The software will be provided in three different formats for use by different levels of responder using a variety of devices. The majority of users will access the system from within an A&E response vehicle and therefore the hardware and software solution for this vehicle type is considered to be the main development stream of this programme and is described in this section. The software and hardware solutions for other responder types will be fully scoped and developed in a later phase of the programme. The hardware solution for frontline A&E vehicles will be in the form of a touch screen tablet using a touch screen keypad. The hardware will be secured in the vehicle by means of a docking station and designed for use in the mobile environment i.e. it will be a ruggedised product which is drop-proof and hard wearing or; supplied with a sleeve or protective casing to provide the same levels of Page | 43 of 82

protection whilst conforming to HEI legislation and user-needs, such as operational when wearing protective gloves. The hardware provided for the interface unit will support GPRS, wireless broadband and Bluetooth connectivity to ensure it is compatible with other patient monitoring systems within the vehicle and can communicate effectively with SAS systems in real-time. In cases where wireless connections cannot be achieved, data will be stored for automatic transfer when communications are restored. The diagram below represents multiple wireless data interfaces between patient monitoring equipment and the tablet PC:Diagram 4/4, In-Vehicle Wireless Communications

Wireless connections between patient monitoring devices and MDT

Auto-completion of Vital Signs in ePRF

Warnings for out-of-parameter readings

The ePRF will be driven by the patient information already collected by the Ambulance Control Centre (ACC), ensuring that relevant clinical fields are presented for completion. The software will also provide an element of clinical guidance by way of alerts for out of parameter patient observations. The Data Warehouse connections to the database will also remain in place thereby reducing development costs and ensuring that the programme can be rolled out in a phased approach with minimum disruption to Management Information output. The Data Warehouse and C3 interfaces will be enhanced to provide historical information regarding patients who have previously presented to the Ambulance Service to improve understanding of a patient's condition and aid patient care. The diagram below represents the workflow to pass this information to paramedics responding to an incident:Diagram 4/5, Pre-arrival data gathering Page | 44 of 82

Automatic database search for previous calls from telephone number with matching patient details

Data Warehouse Link to populate patient name, date of call & diagnostic code recorded

Automatic KIS lookup based on patient demographics

ECS/KIS Record transmitted to vehicle with incident details

Transfer of upto 5 records back to C3 for sending to vehicle

Incident Logged at ACC

ePRF created using patient demographics to provide data fields and images relevant to patient age/sex/chief complaint

Automatic CHI lookup & collection as demographics are populated on MDT

The solution will allow for improved referral of patients by providing local and National contact details for relevant specialties. The revised system will act as an information portal to access a wide range of resources such as clinical guidelines, poisons information, medical dictionaries, incident reporting to inform clinical decision making and to maximise the availability of internal and external resources for users. Option 4 will integrate new and existing communication systems to provide automated patient information and support to responding resources, receiving clinicians and direct to the patient's GP (where possible). The system will also support the first class delivery of health care for all patients. Option 4 will provide the following capabilities:           

Electronic data recording of all patient observations Data links to automatically record output from patient monitoring and diagnostic equipment Data sharing between responding resources to provide a single patient ePRF with input from multiple clinicians. Access to clinical support tools documentation Access to patient history information both internal and external Access to internal resources including Datix and SAS policies Intuitive interface based on patient age, sex and chief complaint Clinical Decision support with automatic warning flags for out-of-parameter observations A robust, secure and reliable hardware platform to enable mobile working Support real-time data links to receiving hospitals for electronic patient handover Support data transfer to patients' GP Page | 45 of 82

 

Accurate clinical data for reporting and auditing Automatic CHI lookup

The solution will meet all Threshold performance parameters identified in the original ePRFII Operational Requirements and will strive to meet as many of the Objective parameters as possible within the funding and technology constraints. Evaluation: Feasible but Undesirable. Whilst there is little doubt that this option could deliver a fit for purpose mobile data solution, it could potentially create a more complex solution with different suppliers for the front terminal and back terminals with the requirement for an interface between them. Additional costs would also be incurred in providing new vehicles with alternative front terminal hardware to comply with Type Approval legislation. By failing to update the legacy front terminal hardware or software, we will leave ourselves open to an increase in fault maintenance costs associated with supporting ageing equipment in the front of the vehicle. This option also carries the risk that the supplier may cease maintenance on the existing front-terminal hardware forcing us into a technology refresh at a later date. This option would not allow for a full Telehealth video solution to be implemented providing remote clinical support to patients and paramedics to reduce the need for transport to hospital and to support the 2020 vision to support healthcare provision at home or in a homely setting. Table 4/6, Option 4 Appraisal

Technology Update the rear terminal hardware and software to improve electronic patient reporting platform only

Rationale for Evaluation  Will implement a high performance and robust ePRF solution to meet all threshold objective parameters identified in relation to ePRF improvement in the Operational Requirements. 

Will achieve some of the Objective performance parameters identified in the Operational Requirements subject to funding and availability of technology.



Does not ensure front terminal compliance with Type Approval legislation.



Does not achieve all Threshold and Objective parameters identified in relation to allocation & mobilisation identified in Operational Requirements.



Will be based on ‘Open’ Systems Architecture that will provide a solid development platform to support future service delivery developments.



Will maximise the Service’s long term development and investment requirements.

Page | 46 of 82



Will support wireless data connections to patient monitoring equipment to enable telemedicine facilities to be introduced.



Does not support video Telehealth links to external clinicians.



Will require bespoke User Training



May not be compatible with PTS Mobile Data System but will be capable of running in tandem to support a phased rollout and use of legacy software on PTS vehicles (if required).

4.4.3 Option 5: Update the full mobile data solution within the vehicle to provide end-to-end Ambulance Telehealth solution. Detailed Description: Update the front and rear-terminal hardware and software and implement true broadband and wireless communication infrastructure. This option will enable the ambulance vehicle as a wireless communications hub to support allocation & mobilisation tools in the front of the vehicle, electronic patient reporting and data sharing in the rear of the vehicle and to enable wireless communications both inside and outside the vehicle to support Telehealth and external data sharing connections to healthcare partners. Mobile broadband communications will be supplied for a selection of vehicles to reduce geographical inequity in the provision of ambulance services. In order to maximise the potential for data coverage, in pre-identified remote areas where mobile broadband coverage is most likely to be limited, a limited number of vehicles will be fitted with satellite capability. Diagram 4/7 overleaf represents a possible technology setup within the ambulance vehicle:

Page | 47 of 82

Diagram 4/7, Potential vehicle configuration

Allocation & Mobilisation: The allocation & mobilisation solution will integrate new and existing communication systems to provide automated dispatch information to ambulance crews to support rapid response and attendance to emergency and urgent incidents. The new allocation & mobilisation system will provide the following capabilities:        

An interface with the command and control system to provide allocation messages presented via an audio or visual interface Automatic updates to incident and location information Crew warning facility to advise of potential dangers on scene A communication interface between the ambulance and control room to support inbound crew contact via a voice or text solution Automatic Satellite Navigation to incident address via an audio or visual interface Automatic passing of patient demographics and incident details to ePRF Pre-arrival patient information from ECS/KIS records via an audio or visual interface Provision of a mapping update system to ensure satellite navigation data and maps can be continuously maintained.

Electronic Patient Reporting: The new ePRF will integrate new and existing communication systems to provide automated patient information and support to responding resources, receiving clinicians Page | 48 of 82

and direct to the patient's GP (where possible). The system will also support the effective and efficient delivery of health care for all patients. The new ePRF will provide the following capabilities:             

Electronic data recording of all patient observations Data links to automatically record output from patient monitoring and diagnostic equipment Data sharing between responding resources to provide a single patient ePRF with input from multiple clinicians. Access to clinical support tools Access to patient history information both internal and external Access to internal resources including Datix and SAS policies Intuitive interface based on patient age, sex and chief complaint Clinical Decision support with automatic warning flags for out-of-parameter observations A robust, secure and reliable hardware platform to enable mobile working Support real-time data links to receiving hospitals for electronic patient handover Support data transfer to patients' GP Accurate clinical data for reporting and auditing Automatic CHI lookup

Telehealth: The Telehealth solution will provide a new communication system to link ambulance staff and patients with external healthcare providers to enhance clinical decision support and to facilitate patient referral to community based care providers rather than automatic defualt to hospital. It is currently envisage that the Telehealth solution will provide the following capabilities: 

         

Enable the ambulance vehicle as a secure communications hub supporting mobile wireless broadband for data and video streaming, backed up by the existing communication technologies. Access to Telehealth services via a centralised database or hub holding accurate information about local facilities, contacts and operating times. Video conferencing facility provided via a portable video camera, preferably tablet based Full audit trail of Telehealth connections and clinical decision taken Camera mounting facility for use in patients home Camera mounting facility for use in vehicle Still image capture and transfer facility Secure storage facility for images ePRF data transfer facility in support of still or live video images, possibly via an email facility Visible communications display to allow users to determine whether video connections can be achieved Automatic switch to voice/radio communications facility

Evaluation: Desirable. This option would allow the Service to meet the strategic objectives of supporting people to manage their own health and wellbeing, and to become more active participants in the care and services they receive through better use of information systems and working with other Page | 49 of 82

public bodies whilst levering best value through economies of scale. By establishing the Ambulance as a wireless hub for telecommunications and introducing hardware and software built on the latest technologies, the Service will be in the best possible position to further develop technology links with medical equipment, health boards and other partners throughout the lifecycle of the product, as the technology matures, ensuring that the Service continues to provide the best possible service to patients through technology innovation. The contract structure is likely to be complex with the potential for multiple suppliers to be involved in providing different elements of the overall solution. Despite this, SAS believes that this programme is achievable with the correct programme governance and resource arrangements in place to take it forward. The implementation of this programme will be very challenging, but not impossible, to achieve, particularly whilst maintaining ‘business as usual’ operations. However, the implementation risks can be managed through diligent planning which will involve a phased rollout and may involve running dual-systems in tandem throughout the implementation phases.

Table 4/8, Option 5 Appraisal

Technology Rationale for Evaluation Update both the hardware  Will implement a high performance and robust Mobile Data and software platform Solution to meet all threshold parameters identified in the Operational Requirements. 

Ensures front terminal compliance with Type Approval legislation.



Will achieve some, if not all, of the Objective performance parameters identified in the Operational Requirements subject to funding and availability of technology.



Will be based on ‘Open’ Systems Architecture that will provide a solid development platform to support future service delivery developments.



Will maximise the Service’s long term development and investment requirements.



Will support video technology and wireless data connections to patient monitoring equipment to enable telemedicine facilities to be introduced.



Will require bespoke User Training



May not be compatible with PTS Mobile Data System but will be capable of running in tandem to support a phased rollout and use of legacy software on PTS vehicles (if required).

Page | 50 of 82

4.5 Benefits Appraisal 4.5.1 Benefits Analysis and Scoring The benefits assessment was carried out by the Appraisal Team which consisted of stakeholder representatives from across the Service. The benefit criteria were weighted and each option was scored (out of 10) against the weighted benefit criteria. The benefit criteria were discussed and agreed by the Appraisal Team. The weighting of the criteria, the scoring of the options against those criteria and the rationale to support the scoring are shown in the tables below:Table 4/9, Benefit Criteria

Organisational benefits

Staff

Direct benefits for Patients

Benefit Category

Benefit Criteria

Score Weight /100

1 HEALTH GAIN To what extent does the option demonstrably promote better health outcomes for patients? 2 EQUITY To what extent does the option demonstrably promote equitable access by patients to healthcare. This criterion is about the extent to which the service provided takes account of the needs of the patient.

100

13

86

11

3 BUSINESS CONTINUITY/RELIABILITY OF SERVICE PROVISION To what extent does the option promote business continuity? How resilient are the business processes and the information technology underlying the option? How reliable is the option in delivering patient benefit? 4 BENEFITS FOR STAFF To what extent does the option relieve stress on staff and provide job satisfaction? To what extent is health and safety maximised under the option? 5 PARTNERSHIP/INTER-AGENCY COLLABORATION To what extent does the option facilitate collaboration with Scottish Ambulance Service partners such as NHS Boards and Trusts (incl. NHS24), GPs, the voluntary sector, local authorities, other emergency services? 6 EFFICIENCY IN USE OF NHS RESOURCES To what extent does the option provide efficiency in the use of NHS resources (Scottish Ambulance Service and other NHS resources)?

70

9

80

11

95

13

95

13

7 SERVICE DEVELOPMENT POTENTIAL To what extent does the option provide a platform for further developments in ambulance services? To what extent does the option complement other developments in the Service?

84

11

Page | 51 of 82

Implementation Factors

8 PRACTICALITY To what extent is the option straightforward to implement/project manage e.g. In terms of Human Resource implications? To what extent does the option minimise disruption to existing ambulance services? 9 POLITICAL ACCEPTABILITY To what extent is the option likely to be politically deliverable? Total

50

7

90

12

750

100

Table 4/10, Benefits Scoring of Options Options are scored by inserting a value between 0 and 10 in the boxes against each criterion. 1 and 2 = Doesn't meet criterion; 3 and 4 = Slightly meets criterion; 5 and 6 = Almost fully meets criterion; 7 and 8 = Fully meets criterion; 9 and 10 = Meets criterion exceptionally

Organisatio nal benefits

Staff

Direct benefits for Patients

Benefit Category

Benefit Criteria

1 HEALTH GAIN To what extent does the option demonstrably promote better health outcomes for patients? 2 EQUITY To what extent does the option demonstrably promote equitable access by patients to healthcare? This criterion is about the extent to which the service provided takes account of the needs of the patient. 3 BUSINESS CONTINUITY/RELIABILITY OF SERVICE PROVISION To what extent does the option promote business continuity? How resilient are the business processes and the information technology underlying the option? How reliable is the option in delivering patient benefit? 4 BENEFITS FOR STAFF To what extent does the option relieve stress on staff and provide job satisfaction? To what extent is health and safety maximised under the option? 5 PARTNERSHIP/INTER-AGENCY COLLABORATION To what extent does the option facilitate collaboration with Scottish Ambulance Service partners such as NHS Boards and Trusts (incl. NHS24), GPs, the voluntary sector, local

Option 2:

Option 4:

Option 5:

Update the system SOFTWARE but NOT the HARDWARE

Update the Rear Terminal HARDWARE & SOFTWARE to improve ePRF only

1

3

Update the FULL MOBILE DATA SOLUTION to provide end - end Ambulance Telehealth Solution 7

1

2

8

1

6

8

1

4

8

1

3

9

Page | 52 of 82

Implementation Factors

authorities, other emergency services?

6 EFFICIENCY IN USE OF NHS RESOURCES To what extent does the option provide efficiency in the use of NHS resources (Scottish Ambulance Service and other NHS resources)? 7 SERVICE DEVELOPMENT POTENTIAL To what extent does the option provide a platform for further developments in ambulance services? To what extent does the option complement other developments in the Service? 8 PRACTICALITY To what extent is the option straightforward to implement/project manage e.g. In terms of Human Resource implications? To what extent does the option minimise disruption to existing ambulance services? 9 POLITICAL ACCEPTABILITY To what extent is the option likely to be politically deliverable?

1

3

8

1

5

9

2

8

4

1

1

8

Page | 53 of 82

Table 4/11, Benefits: Rationale for Scoring of the Options

Benefit Category

Benefit Criteria

Scoring Rationale

Direct benefits for Patients

HEALTH GAIN To what extent does the option demonstrably promote better health outcomes for patients?

OPTION 2 scores low across all of the criterion as it does not fulfil any of the key objectives of the programme. Nor does it take SAS any further down the journey towards the Scottish Government 2020 vision for NHS or indeed the e-Health strategic goals. Although more practical to implement, it simply affords an improved software platform but does not provide for future development, improve on system reliability or business continuity. OPTION 4 will deliver an improved system for recording patient data but will not provide the platform required for full Telehealth capability. OPTION 5 will provide a fully upgraded system which enables patient access to professional, clinical NHS personnel via real time video links. This will be particularly beneficial in treating patients in their home setting or community, reducing the need for hospitalisation and reducing the risks inherent with transportation and proximity to infection. EQUITY OPTION 2 scores low across all of the criterion as it does not fulfil any To what extent does the of the key objectives of the programme. Nor does it take SAS any option demonstrably further down the journey towards the Scottish Government 2020 vision promote equitable access for NHS or indeed the e-Health strategic goals. Although more practical by patients to to implement, it simply affords an improved software platform but healthcare? This criterion does not provide for future development, improve on system reliability is about the extent to or business continuity. which the service OPTION 4 will not offer any increase in equity in terms of patient care provided takes account as patients in rural areas will continue to be disadvantaged by the poor of the needs of the communications cover in many of these areas. patient. OPTION 5 will improve the care of patients including those in many rural areas who will benefit from video links to health care professionals using mobile broadband communications. Shared decision making will be supported by means of the link to professionals at an NHS hub and admissions will be reduced as a result, in accordance with the Scottish Government 2020 vision. BUSINESS OPTION 2 scores low across all of the criterion as it does not fulfil any CONTINUITY/RELIABILITY of the key objectives of the programme. Nor does it take SAS any OF SERVICE PROVISION further down the journey towards the Scottish Government 2020 vision To what extent does the for NHS or indeed the e-Health strategic goals. Although more practical option promote business to implement, it simply affords an improved software platform but continuity? How resilient does not provide for future development, improve on system reliability are the business or business continuity. processes and the OPTION 4 will improve the reliability of equipment in the rear cab information technology hence business continuity will be improved. This improvement will be underlying the option? limited though as front cab equipment will still be old and unreliable How reliable is the option leading to increasing levels of down time. in delivering patient OPTION 5 provides a totally new range of hardware which will give benefit? maximum reliability, less down time and improved business continuity.

Page | 54 of 82

Organisational benefits

Staff

BENEFITS FOR STAFF To what extent does the option relieve stress on staff and provide job satisfaction? To what extent is health and safety maximised under the option?

PARTNERSHIP/INTERAGENCY COLLABORATION To what extent does the option facilitate collaboration with Scottish Ambulance Service partners such as NHS Boards and Trusts (incl. NHS24), GPs, the voluntary sector, local authorities, and other emergency services? EFFICIENCY IN USE OF NHS RESOURCES To what extent does the option provide efficiency in the use of NHS resources (Scottish Ambulance Service and other NHS resources)?

OPTION 2 scores low across all of the criterion as it does not fulfil any of the key objectives of the programme. Nor does it take SAS any further down the journey towards the Scottish Government 2020 vision for NHS or indeed the e-Health strategic goals. Although more practical to implement, it simply affords an improved software platform but does not provide for future development, improve on system reliability or business continuity. OPTION 4 will provide an improved ePRF system with a more user friendly interface and improved access to patient data as required. Stress levels of busy ambulance staff will be reduced by auto fill of important ePRF fields with essential information needed for correct decision making at the point of treatment. Opportunities will be provided for improved H&S of ambulance staff through retrofit of hardware that complies with the Vehicle Type Approval guidelines. OPTION 5 offers all of the benefits of option 4 but has the advantage that full Telehealth will reduce stress on ambulance staff by enabling decisions relevant to the patients treatment to be shared with an NHS professional at the other end of a live video link. Furthermore, interfaces with peripheral equipment such as defibrillator machines will result in a more comprehensive set of patient data to enable decision making. All hardware will be replaced in line with Vehicle Type Approval, enhancing health and safety of ambulance staff and patients in transit. OPTION 2 scores low across all of the criterion as it does not fulfil any of the key objectives of the programme. Nor does it take SAS any further down the journey towards the Scottish Government 2020 vision for NHS or indeed the e-Health strategic goals. Although more practical to implement, it simply affords an improved software platform but does not provide for future development, improve on system reliability or business continuity. OPTION 4 given that this option only covers the rear terminal equipment, it only partially enables full collaboration and partnership working with other agencies. OPTION 5 provides an enabler for maximum collaboration through the myriad of interfaces that are enabled using open systems architecture and industry standard communications channels. OPTION 2 scores low across all of the criterion as it does not fulfil any of the key objectives of the programme. Nor does it take SAS any further down the journey towards the Scottish Government 2020 vision for NHS or indeed the e-Health strategic goals. Although more practical to implement, it simply affords an improved software platform but does not provide for future development, improve on system reliability or business continuity. OPTION 4 affords some efficiency savings in that the new equipment deployed will have a lower fault rate than current equipment. This will result in reduced support costs in terms of hours spent on repairs and travel time in attending to the incident. OPTION 5 through achievement of all of the key objectives of this programme, option 5 offers efficiencies through reduction of hospital admissions, reduced maintenance costs, reduced ambulance mileage Page | 55 of 82

and fuel costs and introduces a potential scope for reduction in vehicles and supporting resources. SERVICE DEVELOPMENT POTENTIAL To what extent does the option provide a platform for further developments in ambulance services? To what extent does the option complement other developments in the Service?

OPTION 2 scores low across all of the criterion as it does not fulfil any of the key objectives of the programme. Nor does it take SAS any further down the journey towards the Governments 2020 vision for NHS or indeed the e-Health strategic goals. Although more practical to implement it simply affords an improved software platform but does not provide for further developments or improve on system reliability or business continuity. OPTION 4 ties us into our current supplier and therefore imposes limitations on future developments which rely on open systems architecture and industry standard interfaces. That is not to say that some interfaces could not be developed but they would be limited by the technology used and the capabilities of a single supplier. OPTION 5 has been designed specifically to enable open systems architecture and therefore an almost limitless potential to build on the platform that will be provided. There will be a built in equipment refresh programme using commercially available equipment to enable SAS to keep abreast of advancements in technology without the recurring need for total system replacements. Interfaces to patient care equipment will be supported and automatic communications of results enabled.

Page | 56 of 82

Implementation Factors

PRACTICALITY To what extent is the option straightforward to implement/project manage e.g. In terms of Human Resource implications? To what extent does the option minimise disruption to existing ambulance services? POLITICAL ACCEPTABILITY To what extent is the option likely to be politically deliverable?

OPTION 2 scores low across all of the criterion as it does not fulfil any of the key objectives of the programme. Nor does it take SAS any further down the journey towards the Governments 2020 vision for NHS or indeed the e-Health strategic goals. Although more practical to implement it simply affords an improved software platform but does not provide for further developments or improve on system reliability or business continuity. OPTION 4 is a practical solution with limited disruption to the service. Not a full blown programme, manageable as Business as Usual (BAU). OPTION 5 is a major project or perhaps a programme of smaller projects. Complex in nature with many links to other agencies and partners. Difficult to implement but will achieve all key objectives of the project and make good progress towards the 2020 vision and e-Health strategies. OPTION 2 scores low across all of the criterion as it does not fulfil any of the key objectives of the programme. Nor does it take SAS any further down the journey towards the Scottish Government 2020 vision for NHS or indeed the eHealth strategic goals. Although more practical to implement, it simply affords an improved software platform but does not provide for future development, improve on system reliability or business continuity. OPTION 4 will not curry favour politically as it does little to answer the requirements of the Governments vision for 2020; it is limited in what it achieves for e-Health and does not meet the key objectives of this programme. This would be a costly exercise for little return on investment. OPTION 5 scores highly in this category as it is, by design, the best option in regard to meeting the requirements of the 2020 vision, e-Health strategies and the key objectives of the programme.

4.5.2 Benefits Appraisal Summary The outcome of the benefits assessment is, detailed below: Table 4/12, Benefits: Rank Order of the Options

Option

Weighted Score /1000

Option 2: Update the system SOFTWARE but NOT the HARDWARE Option 4: Update the Rear Terminal HARDWARE & SOFTWARE to improve ePRF only Option 5: Update the FULL MOBILE DATA SOLUTION to provide end - end Ambulance Telehealth Solution

107 359

Rank Order of Options in terms of Benefits 3 2

784

1

Page | 57 of 82

4.6 Risk Assessment 4.6.1 Risk Assessment of the Options The risk assessment was carried out by the Appraisal Team which consisted of stakeholder representatives from across the Service. The risks associated with each option were discussed and agreed by the appraisal team and the likelihood and potential impact of the risks were assessed in line with standard risk assessment criteria. The risk appraisal for each option is shown in the following tables:-

Page | 58 of 82

Table 4/14, Option 2 Risk Assessment Option 2 Update the system software but not the hardware Project / Risk Risk Description Business Category Risk

Business

Business

Business

Business

Business

Project

Business

STRAT

OPS

TECH

POL

TECH

STRAT

Likelihood of Occurrence (Scale 1-5)

Magnitude of Impact (Scale 1,4,9,16,25)

Risk Quotient (Likelihood x Impact)

There is a risk that this investment will be regarded as a holding position only and will provide no real benefit to the organisation. This option will NOT improve the rate of failure of current hardware in the vehicles. There is a risk that fault rates will increase and vehicles will be subjected to increasing down time as a result This option will not answer the requirements of the new Vehicle Type Approval guidelines leaving the organisation at risk of litigation. This option will not provide any progress towards the governments 2020 vision leaving the organisation open to criticism.

5

16

80

There is a risk that future system development cannot be achieved due to the technology and comms limitations with the existing hardware and software This option does not fulfil any of the key objectives of the project.

5

SUPP

There is a risk that the supplier of this option ceases to do business and leaves SAS with no support, maintenance or development opportunities. Business continuity would clearly be compromised. Median Risk Quotient for the Job/Task/Project Mean Risk Quotient for the Job/Task/Project

Risk Rating

High 5

16

80 High

5

9

45 Moderate

5

9

45 Moderate

9

45 Moderate

5

16

80 High

2

25

50 High 50.00 61.00

Rational

Given that this option does not provide any real progress towards the project key benefits or the Governments 2020 vision, it might be regarded as being not the most appropriate use of budget in a climate of austerity. Ambulance hardware will not be replaced in this option. Currently the hardware is six years old and failure is becoming a real issue. This will only increase with time leading to a situation whereby ambulances will be "out of service" whilst emergency repairs are carried out to ageing hardware. The VTA is a voluntary standard however, due to the importance of the requirements for ensuring the safety of both patients and paramedics it has been widely viewed as a requirement for ambulances and therefore adopted within the health industry. Given that the 2020 vision states that "Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions", this option does not improve patient care within the ambulance or in the home. By retaining the existing equipment, development opportunities will be significantly reduced due to the lack of wireless data communications and constraints around using the Windows XP platform for software development. The key objectives of the project are all enablers to improved patient care. This option will simply provide a more up to date software application and will not provide the necessary improvements required to move forward towards 2020 and e-Health visions. Given the single supplier nature of this option it is possible, although not likely, that they may cease to trade leaving SAS in an untenable position of having no support for a business critical application.

High High

Page | 59 of 82

Table 4/15 Option 4 Risk Assessment Option 4 Update the rear terminal hardware and software to improve the ePRF platform only Project / Business Risk

Risk Category

Risk Description

B

POL

B

B

FIN

Tech

Likelihood of Occurrence (Scale 1-5)

Magnitude of Impact (Scale 1,4,9,16,25)

Risk Quotient (Likelihood x Impact)

This option will provide limited progress towards the governments 2020 vision leaving the organisation open to criticism.

5

9

45

There is a risk, that, as this option ties us into a single supplier that there will be not real possibility for competition reducing the power of the buyer to attain best value.

5

There is a risk that Vehicle Type Approval will not be met in full by this option.

5

Risk Rating

Moderate

4

20 Low

9

45 Moderate

B

FIN

P

STRAT

P

OPS

B

B

B

LEG

SUPP

Given the likely costs of this option there is a risk that SAS will see a low return on the investment made.

3

There is a risk that failure to meet key project objectives will impact on the overall benefits aimed for. As with all change, there is a risk that end users may be reluctant to embrace the new technology and processes that will accompany the changes.

5

9

45

3

4

12

There is a risk with this option that, given the single supplier circumstances, we may face a challenge from other suppliers in the market place who may feel that the process has not been fair and equitable.

2

There is a risk that the supplier of this option ceases to do business and leaves SAS with no support, maintenance or development opportunities. Business continuity would clearly be compromised.

2

OPS

There is a risk that business continuity will be compromised due to the age of the front cab hardware which will cease to be supported under a new contract Median Risk Quotient for the Job/Task/Project Mean Risk Quotient for the Job/Task/Project

5

9

16

25

4

27

Rational

Given that the 2020 vision states that "Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions", this option only goes some way to improving patient care within the ambulance or in the home but is limited on how far this can be extended. As this option is an upgrade to current systems, we are tied into single supplier procurement. Thus increasing the risk that best value will not be attained through the normal channels of competitive tendering. This could result in an inferior product at an inflated cost. The VTA is a voluntary standard however, due to the importance of the requirements for ensuring the safety of both patients and paramedics it has been widely viewed as a requirement for ambulances and therefore adopted within the health industry. There is scope to apply approved standards to rear terminal equipment , but front cab equipment will remain the same.

Moderate

The cost for this option will be considerable, and given that this option will NOT deliver on Telehealth, there is very little evidence of the potential return on investment.

Moderate

Key objectives 2 and 7 will not be met with this option. Thus both vehicle type approval and the whole Telehealth vision would not be possible.

Low

There will inevitably be changes to process as the ePRF system is changed. This will meet with some resistance from ambulance staff as they come to terms with the extent of the changes.

Moderate

Given the single supplier nature of this option and the significant costs involved, it is a risk that under European procurement rules that we may face a challenge in our process leading to lengthy delays in the project.

High

Given the single supplier nature of this option it is possible, although not likely, that they may cease to trade leaving SAS in an untenable position of having no support for a business critical application.

32

50

20 Low 32.00

Moderate

33.00

Moderate

Front cab hardware is old and unreliable. This will lead to increased ambulance "down time" waiting for equipment to be replaced.

Page | 60 of 82

Table 4/16, Option 5 Risk Assessment Option 5 Update the full mobile data solution within the vehicle to provide end-to-end Ambulance Telehealth solution Project / Risk Risk Description Likelihood Magnitude Risk Risk Business Category of of Impact Quotient Rating Risk Occurrence (Scale (Likelihood (Scale 1-5) 1,4,9,16,25) x Impact) B

B

B

P

B

P

P

P

Pol

Strat

Leg

Tech

Strat

Ops

Ops

Tech

There is a risk that this, the preferred option, might, once costed, prove to be unaffordable in terms of budget awarded from The Scottish Government.

2

There is a risk that the investment might not deliver the expected outcomes.

3

Given the complexities involved with this option there is an increased risk of legislative challenge on procurement process.

1

There is a risk that the need to manage several suppliers will lead to disputes in the project

4

There is a risk that not all partners will be bought into the project thus affecting negatively on the expected outcomes of the change process As with all change, there is a risk that end users may be reluctant to embrace the new technology and processes that will accompany the changes. There is a risk that the complexity of the procurement process and multi supplier management might adversely affect the tolerances of the project

3

There is a risk that the complexity of the technical requirements of the proposed solution might adversely affect the tolerances of the project

4

16

32 Moderate

16

48 Moderate

16

16 Low

9

36 Moderate

9

27 Moderate

3

4

12 Low

4

9

36 Moderate

9

36 Moderate

Median Risk Quotient for the Job/Task/Project

34.00

Mean Risk Quotient for the Job/Task/Project

30.00

Rational

This option is the only real way forward to meet the requirements of 2020, e-Health and the key objectives of the project. However it will attract some considerable set up costs which may prove too costly for government capital grants. Given that this is a "first" in terms of Telehealth implementation, there is always a risk that the investment may not deliver the expected outcomes. This, of course, will be carefully managed to minimise this risk. This option involves input from many separate contractors (perhaps under a single prime contractor), and will attract increased possibility of legislative challenge around European procurement rules. Multi supplier management is a complex process with some suppliers entering into a "blame" culture. This could lead to disputes with the customer bearing the brunt of the consequences. Like all business change programmes, this project will depend heavily on total buy in of all stakeholders for a successful outcome. Anything less will result in not all key objectives being met. There will inevitably be changes to process as the ePRF system is changed and new Telehealth processes introduced. This will meet with some resistance from ambulance staff as they come to terms with the extent of the changes. The complexity of procurement and multi supplier management could increase the risks of the project straying outside pre agreed tolerances in terms of timescales and costs. The technical complexities of the project are sufficiently high as to present the possibility of the project straying outside of the pre-agreed tolerances in terms of timescales and cost which could affect the end product.

Moderate Moderate

Page | 61 of 82

4.6.2 Risk Analysis The outcome of the risk analysis is detailed below:  



Option 2 presents a Median Risk Quotient of 50 which is regarded as HIGH. Based on risk assessment alone this would not be a recommended option. Option 4 presents a Median Risk Quotient of 32 which is regarded as MODERATE. Based on risk assessment alone this would be a recommended option and will be further assessed in terms of benefits and costs Option 5 presents a Median Risk Quotient of 34 which is regarded as MODERATE. Based on risk assessment alone this would be a recommended option and will be further assessed in terms of benefits and costs.

4.6.3 Risk Appetite It is recognised that complete elimination of risk is a worthy but an unachievable goal. In certain circumstances, calculated risk taking may be required to achieve creative or innovative solutions to improve services to patients and to promote a learning culture within the Service. In terms of managing risk, the Service promotes and fosters a culture which is open and honest about mistakes in order that lessons can be learned and shared to reduce the likelihood of them recurring in the future. The Scottish Ambulance Service aims to control, eliminate or reduce significant risk to an acceptable level by creating a culture founded upon assessment and prevention rather than reaction and remedy. An acceptable level of risk is defined as a level in keeping with national strategy and relevant guidelines, compliance with national standards, guidelines and legislation. Processes are in place to reduce very high risks to an acceptable level.

4.7 Optimism Bias There is a tendency for project managers to underestimate the anticipated costs and duration of a project whilst overestimating the projected benefits. An optimism bias appraisal has been completed to calculate the effects of increasing cost estimates, decreasing the projected benefits and extending the timescales over which the costs and benefits are assumed to accrue, compared to the initial unadjusted estimates for each option. The purpose of the optimism bias is to identify contributory factors which may impact upon the project costs and timescales and to continually manage and mitigate these. A net present value (NPV) is calculated based on the percentage of mitigation applied to each contributory factor which is expected to reduce over time as the project progresses. Optimism bias has been taken into consideration when producing the equivalent annual charge figures shown in the economic appraisal table.

Page | 62 of 82

The optimism bias summary can be found in Appendix B of this document.

4.8 Economic Appraisal The economic appraisal considers the benefits, costs and risks of the shortlisted options to inform a value for money assessment and arrive at a rank order of the options in terms of value for money. The economic appraisal is shown in the table below: Table 4/18 Economic Appraisal

Option

Option 2 Update System software but NOT hardware Option 4 Update rear terminal HW and SW for ePRF only Option 5 Update the full mobile data solution for full Telehealth system

BENEFITS

COSTS

Costs per Benefit £000 / Points

Costs per Benefit Rank Order (lowest cost per benefit first)

Weighted Benefit Score

Equivalent Annual Charge

Points

£

£

107

3,476,827

32,493.7

3

359

6,731,444

18,750.5

784

6,308,605

8,046.7

RISK

Costs per Benefit % of Total

% of Total

%

%

50.00

55.00

43.00

2

32.00

32.00

28.00

1

34.00

13.00

29.00

Median risk quotient

RISK

Commercial in confidence information removed The table shows that Option 5 is the highest ranking option based on benefits gained versus expenditure. Option 5 also carries a low risk profile.

4.9 Sensitivity Analysis 





As shown in the Economic Appraisal Table 4/18 above, Option 5 has been given the highest rank order in terms of cost per benefit. In order to test the sensitivity of this outcome, analysis has been performed to determine the increase in costs or decrease in benefits which would be required to amend the rank order of the options. The cost per benefit of Option 5 would have to increase by a minimum of 421% before the rank order would change with Option 4 becoming the highest ranking option. The represents a significant increase and shows that, in terms of cost, the option is not very sensitive to fluctuation. The benefits gained from Option 5 would have to decrease by a minimum of 58% before the rank order is changed to favour Option 2. The represents a significant decrease and shows that, in terms of benefits, the option is not very sensitive to fluctuation. Page | 63 of 82

Page | 64 of 82

Section 5 Commercial Case 5.1 Procurement Strategy The Service has a highly skilled and experienced Procurement Team who will work with the Project Team to develop the sourcing strategy. This will include determining the most appropriate route to market to be used. Further details will be included in the Final Business Case (FBC) preparation. A Prior Information Notice will be issued to enable interested suppliers to be identified. This will be followed by an ‘Open Day’ to undertake market engagement with potential suppliers. The output of the open day will be used to influence the development of the procurement strategy for the Programme and specification for the solution.

5.2 Possible Procurement Methodologies As with many large technology programmes, there are a number of potential procurement methodologies including a traditional ITT or a competitive dialogue exercise. At this stage of the programme, the most appropriate procurement methodology has yet to be identified. As with the procurement strategy mentioned in Section 5.1, the most appropriate procurement methodology will be identified during the collation of the sourcing strategy. The Scottish Government Procurement Journey Route 3 will be followed given the expected value of the programme, although some elements of the requirement maybe available via frameworks or not meet the requirements of Route 3 if taken individually. The Procurement Journey has been developed by the Scottish Government to support procurement activity and standardise the process as far as possible to try and simplify it for buyers and suppliers. There is a decision matrix based on several factors including value, risk and the need for advertising to determine the ‘Route’ to be followed.

5.3 Potential Scope and Services It is likely that the ultimate solution will consist of several complementary contracts for multiple services including hardware with installation and maintenance, software applications and licences, interfaces, communication bearers, tracking and navigation, Wi-Fi and potentially some medical devices with maintenance. It is currently envisaged that this procurement may involve multiple lots or the use of frameworks, however further work will be carried out during the development of the sourcing strategy and the specification to determine exactly how all the elements of the programme should be grouped together to form the various contracts required to deliver the optimum overall solution. The greatest risk with multiple contracts is a lack of accountability or responsibility between multiple suppliers for providing a seamless and well integrated solution. However, clear specifications for the different elements and unambiguous requirements placed on suppliers will mitigate this risk and is likely to provide better value for the programme overall. Therefore an important aspect of this process will be the clear scoping of requirements to ensure that they dovetail together without unnecessary overlap and the resultant inefficiencies this would introduce. Page | 65 of 82

5.4 Potential charging mechanisms The programme will incur significant capital and revenue costs over its lifecycle. Current plans are being formulated on the basis that the Scottish Government Capital Investment Group will underwrite the capital costs and that the revenue costs will be met from current Service funding. In addition, there is scope to utilise the Service eHealth Strategic Fund allocation to provide additional resources during the planning, delivery and transition phases if required. It is difficult to estimate the relative capital / revenue costs at this stage particularly as the solution is likely to be a composite offering from a number of suppliers implemented over a period spanning three financial years. However, detailed cost models will be obtained through the procurement process and included in the FBC.

5.5 Potential key contractual implications Given that the solution delivered by the Ambulance Telehealth Programme will be a replacement for a current solution that is integral to the efficient and effective delivery of operational ambulance services across Scotland, careful consideration will need to be given to how a seamless contract transition can be achieved, especially if multiple vendors are involved. The expected contract durations will be refined during the procurement phase, however there is a recognition that a ‘one size fits all’ approach may not be appropriate and alternative approaches will have to be considered e.g. shorter contract term may be more appropriate for the communications bearer to enable transition to new services as they become available or affordable. It is also recognised that, given the pace of technology change, it may be prudent to structure some contracts to accommodate technology refresh during the contract life to ensure the solution remains fit for purpose over the full contract term.

5.6 Potential Personnel Implications At this stage in the business case development, it is not expected that there will be any permanent change to the Service establishment as a result of the Ambulance Telehealth Programme. It is, however, expected that a number of fixed term or day rate contract staff will be required during the planning and implementation stages of the Programme. In addition, the Service will explore whether TUPE may apply to any of the existing service provider’s staff.

5.7 Potential Implementation Timescales Based on current programme timescales, and to fit in with the expiry of current contracts, it is expected that the procurement phase of the Programme will take place during financial year 2014/15 and that all relevant contracts will be in place by the end of financial year 2015-16. Given the nature of the programme of work, the implementation is likely to be phased over a period spanning financial years 2014/15, 2015/16 and 2016/17. This is necessitated by the complex logistical dynamics that will be encountered with commissioning up to 700 vehicles spread throughout the country. The exact nature and timescales for implementation will continue to be developed in the Final Business Case and throughout the tendering and contracting phases. Page | 66 of 82

Section 6 Financial Case 6.1 Financial Appraisal A full financial appraisal of all options has been undertaken to determine the anticipated costs associated with the implementation of the Ambulance Telehealth programme. In this section we are concerned not with the theoretical cost indicators used in the economic appraisal, but with actual forecast costs, including VAT, and their affordability in relation to the funding streams likely to be available. Optimism Bias is excluded from the financial appraisal.

6.1.1 Capital Costs The capital costs associated with each option are shown in the table below: Table 6/1

Option 2

Option 4

Option 5

Financial Appraisal (includes all irrecoverable VAT) Total Capital Costs

£1,622,020

Project Life (years)

3

£5,676,933 £5,982,641 3

3

Average Annual Capital (Actual expenditure is likely to be incurred in only 2 of the 3 years of the duration of the programme)

£811,010

£2,838,467 £2,991,321

New Depreciation Charges (to be written off over 7 years)

£1,622,020

£5,676,933 £5,982,641

COMMERCIAL IN CONFIDENCE INFORMATON REMOVED A detailed breakdown of these costs can be seen in Appendix B. These costs have been produced using a variety of sources including:  Scottish Government Framework Agreements for tablets  Internet research for satellite communication costs  Dialogue with the current providers of the Service’s mobile data  Costs currently being incurred by the Service for wireless communications installations Clearly at this stage certain assumptions have had to be made to make the costing exercise possible and these include:  Commissioning of up to 700 vehicles (current CBT contract is for 595 vehicles)  Acceptance of user informed operational requirements  The Service’s technical infrastructure topography will not change Accepting these assumptions involves an element of risk in that the assumptions may not hold true for the duration of the project. However, the risk element will be mitigated through rigorous due diligence at each successive stage of the project to minimise any risk of under or over financing the requirements.

Page | 67 of 82

6.1.2 Revenue Costs The anticipated revenue costs (excluding new depreciation charges) associated with each option are shown in the table below and are based on indicative costs obtained in dialogue with suppliers of the Service’s current mobile data solution along with published rates from commercial airtime and satellite service providers. It is understood that these rates may be subject to change as progress is made towards the Final Business Case and contract negotiations. Assumptions have been made in deriving the revenue costs which include commissioning of 700 vehicles and no change to the Service’s current network topology. As the Final Business Case and eventual competitive tender are advanced these revenue costs will be continually revisited and revised as the requirements for the final solution becomes clear. Table 6/2

Financial Appraisal (includes all irrecoverable VAT) Option 2 Option 4 Option 5

Year 1 1,017,958 1,020,958 1,027,958

Year 2 1,203,000 1,413,458 1,017,958

Year 3 1,003,000 1,533,000 1,287,500

Year 4 1,003,000 1,003,000 757,500

Year 5

Year 6

1,003,000 1,003,000 757,500

1,003,000 1,003,000 757,500

Year 7 1,003,000 1,003,000 757,500

A detailed breakdown of the costs shown in Table 6/2 can be found in Appendix B. Currently around £1m of expenditure is incurred each year by the Service for mobile data support, hardware warranty and software support. Anticipated savings associated with Option 5, the preferred option is shown in the table below: Table 6/3

Financial Appraisal (includes all irrecoverable VAT) Option 5 Revenue Costs Current Revenue Expenditure Estimated Additional Funding Required / (Savings Generated) 1

Year 1

Year 2

Year 3

Year 4

Year 5

Year 6

Year 7

1,027,958 1,017,958

1,017,958 1,017,958

1,287,500 1,017,958

757,500 1,017,958

757,500 1,017,958

757,500 1,017,958

757,500 1,017,958

10,000

0

269,542 1

(260,458)

(260,458)

(260,458)

(260,458)

- Cost shown is projected ‘worst case’. The actual Year 2 revenue increase will be refined during FBC development Page | 68 of 82

It is anticipated that the estimated additional costs of £10,000 in Year 1 will be met from the Service’s existing recurring revenue allocation. The revenue costs for Year 3 shown in table 6/3 are based on information currently available along with estimated implementation timescales and may well be subject to change. It is worth noting that Option 5 revenue costs are based on an estimated 700 vehicles being fitted with the new hardware and software, however the current contract is for 595 vehicles and so this is reflected in the figures provided for current revenue expenditure. If the Option 5 figures are reworked using 595 vehicles as opposed to 700 (to give a ‘like for like’ comparison), the seven year revenue savings are estimated at £1.35m and the total net programme costs, including capital expenditure, are an estimated £3.7m. The revenue costs associated with Option 5 and the implementation timescales will be refined during the development of the Full Business Case COMMERCIAL IN CONFIDENCE INFORMATON REMOVED 6.1.2.1 Capital Charges The capital charges for Option 5 are based on an average 7 year asset life and it has been assumed that depreciation will be applied using the straight line method. It is assumed that the Service will fund the impact of the new depreciation charges and the following table outlines the charges over the 7 years: Table 6/4

Year 1 Capital Charges New Depreciation Charges

£ 428,571

Year 2 £ 428,571

Year 3 £ 854,663

Year 4 £ 854,663

Year 5 £ 854,663

Year 6 £ 854,663

Year 7 £ 854,663

COMMERCIAL IN CONFIDENCE INFORMATON REMOVED The demonstration of the affordability of this programme will continue to be tested fully throughout the different approval stages of this project which will include the development of a fully detailed revenue model within the next FBC stage. 6.2 Funding Arrangements The main funding source for the capital requirements is anticipated to be via Scottish Government allocation. The Service has considered entering into a leasing arrangements with suppliers for the capital purchase, however as it is anticipated to result in higher costs along with more complex contract management implications this option has not been pursued.

Page | 69 of 82

It is anticipated that the allocation of capital funding will be released by the Scottish Government in two phases. The first phase will consist of £3m being released in financial year 2014/15. There will be a one year gap with the remaining £3m being released in 2016/17. Estimated costs used in the economic and financial appraisals contained within the Outline Business Case have taken account of this phased approach for release of capital funding. Revenue costs will be offset against current revenue expenditure which will cease at the expiry of the supplier contract in 2016. It is anticipated that the new recurring costs will be significantly lower than those currently incurred and will therefore result in a net annual revenue saving for the Service over the projected life of the solution.

Page | 70 of 82

Section 7 Management Case 7.1 Programme Structure and Governance Arrangements for OBC Development As outlined in the Initial Agreement document approved by the CIG earlier in the year, the development of this Outline Business Case (OBC) has been carried out by Service staff members and the process has been overseen and governed by the Service eHealth Board. A working group identified the need to provide ambulance crews with accurate, up to date information about the location of an incident, how to get there and as much detail as possible about the expected condition of the patient they are attending. The collection and passing of incident timestamps back into the command and control system is also considered an essential element for operational performance recording. The group identified the need to collect accurate patient date for operational management, receiving clinicians, GP’s and SAS management information to be able to make informed and timely decisions regarding patient, patient saftety and best clinical practice. The working group identified the need to support patient care within the community to reduce unnecessary transport and admission to hospital by providing access to remote clinical support from health care partners to make informed and timely decisions regarding the appropriate care pathway for the patient. The mission need of the programme further supports the goal to provide a seamless, interoperable system that supports operations across all areas of care and promotes data sharing and data quality. Once the OBC document has undergone internal review it will be presented to the full Scottish Ambulance Board for approval. It will also be presented to the Scottish Government Capital Investment Group and the eHealth Strategy Board.

7.2 Programme Structure and Governance Arrangements post OBC As with all large complex programmes undertaken by the Scottish Ambulance Service, the Ambulance Telehealth Programme will be managed and governed in line with the principles of Managing Successful Programmes (MSP) good practice as well as Prince 2 project management guidance. As opposed to replicating the detail in the body of this OBC document, further information on the various roles, structures and governance arrangements recommended by MSP and PRINCE2 can be accessed if required by following the links provided in Appendix C. The next phase of the Programme will be the development of a Final Business Case (FBC). It is during this phase that more robust and formal programme governance arrangements will be put in place. These arrangements will reflect the scale and complexity of the Ambulance Telehealth Programme.

Page | 71 of 82

A dedicated programme board is currently being established to oversee the Programme for the remainder of its lifecycle from the development of the FBC through procurement and implementation to benefits realisation and programme closure. The full membership of the Programme Board will be finalised by the end of November 2013, however, it is likely that it will follow the template used by recent programmes of similar scale with membership including but not limited to the following:            

Executive Director representative (Programme Sponsor) Non-Executive Director representative Patient and Staff representative Programme Director Programme Manager Senior Operational representative Senior Clinical representative Senior Finance representative Senior Strategy representative Senior Fleet representative Head of Procurement General Manager ICT

The Ambulance Telehealth Programme Board will sit within current Service programme governance structure as outlined in the diagram below:

Page | 72 of 82

Plans are currently being finalised for the recruitment of a number of key roles to drive the Programme Forward, these include a dedicated Programme Director, a dedicated Programme Manager and a Technical Lead. Once the Programme Board is established and key Programme roles have been filled, the Programme Director and Programme Manager will be charged with building a Programme Team to assist in driving the programme forward on a day to day basis. Again, it is highly likely that they will follow the template used by recent programmes of a similar scale with representation coming from the following areas of the Service:          

Operations Clinical Finance Strategy Fleet Procurement H&S Information Governance Corporate Communications ICT

7.3 Risk Management Strategy The risk management strategy that will be applied to the Ambulance Telehealth Programme will follow the Corporate Risk Management Strategy and arrangements that are managed by the National Risk and Resilience Department (NRRD) and are already well embedded within the Service. The Programme Director will be responsible for maintaining a comprehensive risk and issues register using the corporate risk register template, copies of which are available on request.

7.4 Migration Strategy and Implementation Planning Detailed migration and implementation planning has still to be carried out. This will be completed during the period between OBC approval and FBC completion but it is likely to span a period of three financial years. However, the following key principles will underpin any future migration strategy. Safety: need to keep operating safely and in line with existing (or improved) Operational Performance whilst implementing any changes (e.g. it may be necessary to consider vehicle installation to be performed out of normal working hours to minimise potential operational disruption; Flexibility: The roll out plan should be capable of being adjusted in the light of lessons learned; Process Continuity: a period of ‘dual-running’ will be supported as required to provide the opportunity for full testing before Ambulance Telehealth goes fully ‘live’ in the operational environment; Page | 73 of 82

Human Resources: need to take account of existing human resources and their requirement to learn new skills; Information Governance and Security: must ensure that all patient identifiable information that is transmitted to and from the mobile data terminals is held secure, and can be removed from the terminals when it is no longer required; Phasing: the mobile data solution will be introduced in a phased approach within each ACC Operational Area, with review and evaluation at the end of each phase, before progressing to the next;

7.5 Benefits Realisation The compilation of a detailed benefits realisation plan will be carried out as part of the FBC process. The Service has a tried and tested benefits management process whereby a realisation plan is produced for each benefit detailing the following:       

The description of the benefit The intended outcome in financial and non-financial terms The tasks to be undertaken, and by whom, in order to enable the benefit to be realised How the realisation of the benefit will be monitored The current baseline performance Who has overall responsibility for ensuring that the benefit will be realised The target date when the benefit will be reviewed

The Programme Director will oversee the creation and management of the benefits realisation plan. Due to the nature of the implementation plan, spanning three financial years along with a period of parallel running of existing systems, it is likely that the operational and financial benefits will only begin to be realised from year 3 onwards. Every effort will be made by the Programme Board to improve on this if at all possible.

7.6 Post Project Evaluation The aim of post-project evaluation is to learn lessons from completed programmes and projects with a view to improving future project design, management and implementation. The compilation of a detailed post programme evaluation plan will also be carried out as part of the FBC process. Again, using information and lessons learned from recent programmes, it is expected that the evaluation team will compromise of in-house resources and that their role will be to use a programme framework matrix to assess the extent to which the programme has been implemented as planned, and to identify and propose any lessons that might be incorporated into future programmes. It is also expected that the post-project evaluation exercise will take around one month to complete, and that it will be carried out approximated 3-6 months post project implementation. Since the evaluation will be carried out in-house, and as it will largely be a ‘desktop’ exercise, no significant costs are anticipated at this stage. The post project evaluation Page | 74 of 82

exercise will be built into the Service Internal Audit Plan, with the output being reported to appropriate governance boards.

Page | 75 of 82

Section 8 Conclusion and Recommendation 8.1 Preferred Option Statement This paper has set out the proposal, together with the associated benefits, costs and risks, for the Service to implement an appropriate, affordable, Ambulance Telehealth solution for the unscheduled care service, in support of the Service’s Strategic Development Framework and the continued investment in ICT Systems, to improve operational performance, and quality of service. With the decision to invest and the content of the investment having already been resolved in principle, this paper sets out the options for how the programme could be delivered. The preferred option for investment is Option 5 as this option fully meets the operational, clinical and technical requirements of the Service, maximising benefit to staff, patients and healthcare partners alike whilst carrying the minimum business risk. The Service has consulted internally and externally (through appropriate Stakeholder events) about these proposals and the Service’s stakeholders are fully supportive of the proposals. Research undertaken as part of the OBC preparation has revealed that no other UK Ambulance Service currently has Ambulance Telehealth capability similar to that proposed as the preferred option. In addition, although some UK Services are considering the potential benefits of an enhanced ambulance Telehealth capability, no other UK Service has advanced plans to implements a similar solution at this time. This suggests that, in UK terms, the Scottish Ambulance Service are likely to be the first ambulance service to embrace the potential opportunities and benefits identified for Option 5 within this OBC. There are, however, examples of vehicle based Telehealth service provision in Europe and the rest of the world. These will be further investigated during the FBC stage with a view to ensuring that any good practice and lessons learned are incorporated into the Scottish Ambulance Service Ambulance Telehealth solution. The aim is to implement an Ambulance Telehealth solution over a period of three financial years, following the formal award of contract, with a phased go‐live across the existing three ACC Operational areas (North, East and West). The programme would deliver the objectives of:       

Delivering an improved patient-driven user interface Ensuring compliance with Vehicle Type Approval guidelines Delivering a robust and reliable hardware solution which supports wireless data communications Supporting access to internal and external systems to aid clinical decision making and improve administrative processes. Enabling data links to peripheral patient monitoring equipment to allow automatic population of clinical data. Enabling electronic data sharing between responding vehicles Delivering a mobile Telehealth interface to support video connections to health care professionals from within the ambulance environment.

Page | 76 of 82

8.2 Recommendation An option appraisal has been undertaken in accordance with guidance issued by the Scottish Government Capital Investment Group, and appropriate to the scale of the programme. The preferred option is Option 5, and this offers the best value for money, and is affordable. It is recommended that the Scottish Ambulance Service Board and Scottish Government Capital Investment Group approve this option for expansion into a Final Business Case.

Page | 77 of 82

Appendices Appendix A - Screen Prints from current system COMMERCIAL IN CONFIDENCE INFORMATION REMOVED

:

Page | 78 of 82

Appendix B Financial and Economic Appraisals Option 2

COMMERCIAL IN CONFIDENCE INFORMATION REMOVED

Option 4

COMMERCIAL IN CONFIDENCE INFORMATION REMOVED

Option 5

COMMERCIAL IN CONFIDENCE INFORMATION REMOVED

Page | 79 of 82

Appendix C Calculation of Optimism Bias

COMMERCIAL IN CONFIDENCE INFORMATION REMOVED

Page | 80 of 82

Appendix D - Links to relevant Programme and Project Management Information and Guidance The following links give information on the various roles, structures and governance arrangements recommended by MSP and PRINCE2:

The Department for Business Innovation & Skills – ‘Guidelines for Managing Projects: How to organise, plan & control projects’ https://www.gov.uk/government/publications/guidance-on-organising-planning-and-managing-projects

The Department for Business Innovation & Skills – ‘Guidelines for Managing Programmes: Understanding Programmes and Programme Management’ https://www.gov.uk/government/publications/guidelines-for-managing-programmes-understanding-programmes-and-programme-management

The Department of Health Informatics Directorate – ‘Programme & Project Sponsorship -Building the Right Team’ http://www.connectingforhealth.nhs.uk/systemsandservices/icd/informspec/p3m/resource/capability/sro/building2.pdf

Page | 81 of 82

Appendix E Glossary of Terms Acronym/Term

Descriptor

Acronym/Term

Descriptor

A&E ACC BNF CEN CHI CIG Datix ECS eForm eHealth EHI EMDC ePacer ePRF ePRFII GP HCP HEAT HEI IA

Accident & Emergency Ambulance Control Centre British National Formulary European Committee for Standardisation Community Health Identifier Capital Investment Group Incident Management Software Emergency Care Summary Electronic Form Electronic Health Systems E-Health Insider Emergency Medical Dispatch Centre Name of ePRF software system current in use Electronic Patient Report Form Original project name for Ambulance Telehealth General Practitioner Health Care Professional Health, Efficiency, Access & Treatment targets Healthcare Environment Inspectorate Initial Agreement

ICT JRCALC KIS LDP MDT NPV OBC PC PTS PVC Care Bundle SAS SCTT See & Treat SEWS TMC1350 TVC3000 VAT VTA Windows XP

Information & Communications Technology Joint Royal Colleges Ambulance Liaison Committee Key Information Summary Local Delivery Plan Mobile Data Terminal Net Present Value Outline Business Case Personal Computer Patient Transport Service Peripheral Vascular Catheter Care Bundle Scottish Ambulance Service Scottish Centre for Telehealth & Telecare Care pathways for non-transferred patients Scottish Early Warning System Equipment installed in A&E vehicles Equipment installed in smaller A&E vehicles Value Added Tax Vehicle Type Approval Windows operating system

Commercial in confidence information removed

Page | 82 of 82