Agenda Item 5.5
7 OCTOBER 2009
Report of Mr Brian Steven
Director of Business Development and Performance
Paper prepared by Mr Brian Godfrey Divisional General Manager, Diagnostic
and Therapeutic Services.
Mr Ronnie Hood Commissioning Manager, Radiology.
Business case to support the procurement of a second fixed
Subject/Title site Positron Emission Tomography - Computed
Tomography (PET-CT) scanner at St James‟s University
Cancer Research United Kingdom(CRUK ) Our Strategy Background papers 2009-2014
Following informal approval by the Trust Board at the Board Purpose of Paper Discussion Group on the 27th August 2009, this paper
seeks approval of the proposal to proceed with the
procurement of a second PET CT scanner. The paper
highlights the significant opportunity presented for a
competitive world class research facility using PET-CT and
demonstrates the revenue streams required to support this
procurement. The Business Case also highlights
opportunities for both National Health Service (NHS) and
Private Patients (PP) to use this scanner, and highlights the
potential benefits for patient care and income generation.
To seek formal Trust Board approval for this project and Action/Decision required proceed with the procurement process following a
successful bid through the National Institute for Health
Research (NIHR) for the capital funding of a PET-CT
Cancer Research United Kingdom(CRUK ) Our Strategy ? NHS strategies and policy 2009-2014
NHS Operating Framework
Achieving excellent clinical outcomes ? Trust’s Strategic Direction Improving the way we manage our business ? Corporate objectives Becoming the hospital of choice for patients and staff.
LTHT Research & Development Strategy (R & D)
Resource impact Capital and Revenue implications are explained in the
Consideration of legal issues Directorate will procure and comply with all relevant Trust
legal and procurement policies.
Acronyms and abbreviations Explained at first use.
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Agenda Item 5.5
THE LEEDS TEACHING HOSPITALS NHS TRUST
TRUST BOARD - 7th OCTOBER 2009 - SUMMARY PAPER
BUSINESS CASE FOR THE PROCUREMENT OF A SECOND FIXED SITE
PET-CT SCANNER IN BEXLEY WING, ST JAMES’S UNIVERSITY HOSPITAL
1. PURPOSE OF THE PAPER
This paper seeks formal Trust Board approval to progress with the procurement process
of a Positron Emission Tomography – Computed Tomography (PET-CT) scanner
following a successful bid for capital monies through the National Institute for Health
Research (NIHR). The purpose of the bid was to fund, through the National Health
Service (NHS), high-quality patient-focussed research with the purchase and installation
of a second PET-CT scanner, in Bexley Wing, adjacent to the Independent Sector (IS)
In January 2008 St. James‟s Institute of Oncology (SJIO) opened on the St James's
University Hospital (SJUH) campus bringing together expertise in cancer research and
physical sciences with imaging capabilities. The SJIO incorporates the Leeds
Experimental Cancer Medicine Centre (ECMC) with a dedicated Oncology Clinical
Research Facility (OCRF) which opens in October 2009, comprising protected research
beds and day-case unit, and the Cancer Research UK Clinical Centre that has an
extensive programme of laboratory and clinical research, and is part of the Leeds
Institute of Molecular Medicine (LIMM) on the same campus. Fitted out (i.e. radiation
shielded) space for two PET-CT scanners within a dedicated PET-CT centre in this
building is under contract to be completed by March 2010. An Independent Sector
Provider (ISP) owned PET-CT scanner will be installed in early 2010, as part of the DH-
procured national contract for PET-CT. However, routine clinical service demand is
already near contractual expectation and only a small proportion of capacity on this
scanner will be available to support R&D.
3. BENEFITS TO LTHT
? Uniquely position LTHT to place itself as a world class research centre and market
leader in the north of England.
? Improve the competitive advantage of LTHT
? Enhanced recruitment/retention of high calibre individuals
? Increased opportunities for income generation
? Infrastructure for 2nd scanner already exists in Bexley Wing
? Facilitates repatriation of Paediatric patients who current travel to London for this
? The ability to flex staff according to need, based on income guaranteed from sign
up to research trials and associated funding streams.
? Improved diagnostic accuracy, better staging of oncology patients and the
potential to reduce futile surgery.
? There will be an option for us to compete for the current National Contract in 2013
(worth approximately ?2M per year).
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Agenda Item 5.5
The Leeds service is already the largest provider centre in the Northern PET-CT contract
and there has been a steady increase in referrals since its inception. The Trust will be in
a very good position to take on this already „established‟ service with all its associated
income in 2013.
The research scanner gives us the opportunity to ensure that we will be able to train our
workforce accordingly, placing the Trust in pole position to take on this contract.
4. KEY ISSUES
Key issues for consideration by the Board are as follows:
? The NIHR has approved the LTHT bid for ?2.132m to facilitate the establishment
of this key research facility
? The Department of Health has recognised the under resourcing of PET-CT
imaging within the NHS
? The ISTC contract expires in 2013 presenting LTHT with further opportunities for
? LTHT currently employs the leading Consultant Radiologists in this field within the
north of England.
? Surrounding Trusts are aware of the business opportunities presented by a PET-
CT service and are keen to invest in such areas to grow their market share, and
reduce our monopoly.
This represents a unique opportunity for LTHT to position itself as one of the leading
imaging research centres in the country. This facility will enhance our reputation in
oncological research and contribute greatly to the achievement of the Trust‟s objectives.
Research leaders and clinicians within Radiology and across the Trust view this as a real
positive step and an endorsement of their current research portfolio which enhances the
Since the announcement from the NIHR we have already been approached to provide
PET-CT to two areas in support of their research initiatives which total 125 scans per
year this already represents the anticipated first year research scans illustrated later in
We have been conservative in our predictions of anticipated use but we are confident
that the research income and the use of PET-CT across a wider range of specialties
represents a relatively low risk to the Trust which is further reduced if we were to be
successful in winning the contract in 2013 for the work currently undertaken within the
6 RECOMMENDATION nd PET-CT scanner The Trust Board is asked to approve this Business Case for a 2
funded from the NIHR 09/10 capital monies and authorise the procurement and
installation of the scanner.
Divisional General Manager
Division of Diagnostic and Therapeutic Services
29th September 2009
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Agenda Item 5.5
LEEDS TEACHING HOSPITALS NHS TRUST
BUSINESS CASE FOR THE PROCUREMENT OF A SECOND FIXED SITE
PET-CT SCANNER IN BEXLEY WING, ST JAMES’S UNIVERSITY HOSPITAL
This paper seeks formal Trust Board approval to progress the procurement and installation
of a Positron Emission Tomography – Computed Tomography (PET-CT) scanner following a
successful bid for capital monies through the National Institute for Health Research (NIHR).
This business case was discussed at a Board Discussion Group on the 27th August 2009
when informal approval was given to proceed with the procurement process and
confirmation sent to the NIHR of the Trust‟s support for this initiative.
This is an opportunity for LTHT to confirm the intention to create a leading UK and European
cancer and molecular imaging research centre at St James‟s University Hospital. This
development will open up unique opportunities for research and attract potentially lucrative
new income streams. A second PET-CT scanner will help LTHT achieve the excellent
clinical outcomes which characterise a hospital of choice in addition to improving the way we
manage our business. Although it is acknowledged that there is a degree of risk, we believe
that this risk is manageable. Our financial assessments at this stage are robust, and, this is an opportunity to demonstrate that LTHT is an organisation that not only delivers its
business objectives but also values research, innovation and development.
2. Background and Strategic Fit
PET is a powerful imaging tool which can demonstrate changes in the function of cells
before there is any detectable change in the size and shape of organs and tissues. By
combining PET with CT, it is possible to overlay this functional information on a detailed
anatomical map of internal structure. This has revolutionised the imaging of cancer and
promises to do the same for heart disease and brain disorders.
Realising that the United Kingdom(UK) was falling behind other developed countries in
implementing the new technology, the Department of Health (DH) initiated an IS PET-CT
procurement and awarded the northern contract to Alliance Medical (AML). The timeframe
for implementation of an IS fixed site PET-CT scanner within Bexley Wing has been delayed
and LTHT currently have interim mobile provision from AML. It is evident from projected
demand analysis that the IS will have difficulty meeting the required increase in oncology
activity. Despite the mobile scanner increasing operational frequency, there remains a lack
of capacity to undertake research and non-oncology activity. There is also insufficient
capacity to meet private sector and paediatric demand. It is primarily towards the areas
stated that this business case is targeted.
2.2 Strategic Fit and Opportunities
There are major opportunities for the use of PET-CT within research projects as recognised
by the NIHR in funding the Trust‟s bid for ?2.1m to provide a PET-CT scanner to support
Research and Development in Leeds. Because this research is subject to external bids, it is
anticipated that there will be an incremental growth of research activity and, initially, this will be supplemented by the previously identified unmet demand in oncology. There is also
robust evidence for the use of PET-CT in improving patient management by improved
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Agenda Item 5.5
diagnostic accuracy, better staging (thus avoiding futile surgery), monitoring the response to
treatment and radiotherapy treatment planning. All of these are outside the scope of the IS
contract. In addition, no other major private facility in the North of England caters for private
PET-CT referrals and this unmet demand represents significant opportunity for the Trust.
The Trust has attracted a team of researchers with a proven track record in molecular
medicine and clinical oncology research. Provision of additional PET-CT capacity would
enable research support and further develop a facility unique in the UK and, probably
The Directorate has engaged with research leaders and clinicians in both oncology and non-
oncology areas and letters of support are appended to this business case. In addition, there
is interest from charitable sources to contribute to the revenue costs of this second scanner.
A further example of the potential to increase our PET-CT scanning ability is the partnership
between the Trust and Nova Healthcare which has recently launched a neurosurgical
service using a gamma knife. When fully operational, this service will require approximately
50 PET - CT scans per year.
The Radiology Directorate believe that the research use of the scanner and the ability to
undertake both NHS and private scans makes this a viable proposition, with the use of PET -
CT increasing in non-oncology areas such as cardiac and neurosciences the viability and
potential profit increases. National evidence and guidance quotes the advantages of using
PET-CT. Should this become the approved recommended imaging technique, the
Directorate will enlist appropriate commissioner support. Trust Board approval to submit this
bid and be successful with the capital allocation will enable us to exploit current and future
research projects and open negotiation with commissioners.
2.3 Letters of Intent and Support
A number of letters have been received by the Directorate expressing strong clinical support
for this proposal with some including estimates of activity. The letters also outline how this
facility will not only cement the Trust‟s position as an internationally competitive centre for
research in oncology, but will also place the Trust in a position to exploit the emerging
potential for research using PET-CT within other clinical specialties.
Appendix 1, Dr. A. Crellin, Director of Clinical Oncology, LTHT.
Appendix 2, Dr. D. Jackson, Clinical Lead, Yorkshire Cancer Research Network and Co- director, West Yorkshire Comprehensive Local Research Network.
Appendix 3. Professor P. Rabbitts, Professor of Experimental Respiratory Research, Leeds Institute of Molecular Medicine.
Appendix 4, Professor S.G. Ball, British Heart Foundation, Professor of Cardiology.
Appendix 5, Mr. N. Phillips, Consultant Neurosurgeon, LTHT
Appendix 6, Professor C. Twelves, Professor of Clinical Phamacology and Deputy Director Leeds Cancer Research UK Clinical Centre
Appendix 7, Dr. A. Glaser, Consultant, Yorkshire Regional Centre for Paediatric Oncology and Haematology.
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2.4 Summary of benefits
? Facilitate the establishment of the St. James‟s Institute of Oncology as an internationally
competitive centre for oncology research – an aim which has wide support. LTHT will
be in a strong position to compete for research funding along with the „golden triangle‟ of
London, Oxford and Cambridge, and with competing local providers from whom there is
interest. ? Guarantee capacity for work that has not been prioritised within the national contract and
also allow LTHT to sub-contract sessions to the IS when, as evidence predicts, their fixed
scanner is unable to meet increasing demand (see 3.2). ? Allow LTHT to establish a staff base trained in PET-CT which will place us in an
advantageous position when the current IS contract ends in 2013 as it will facilitate
competitive tendering for the national contract.
? Place LTHT in the best possible position to take advantage of further income potential,
via the growing range of evolving applications in other specialties. ? Improved diagnostic accuracy, better staging of oncology patients, thereby reducing futile
3. Impact on Activity and Case for Demand
3.1 Research and Development
There are already strong collaborative links between the University of Leeds, Cancer Research UK, the Medical Physics Department at LTHT and internationally renowned
clinicians with proven track records in academic research. The St James‟s Institute of Oncology brings this team together under one roof in the largest oncology centre in Europe, incorporating the Leeds Experimental Cancer Medicine Centre (ECMC) with dedicated clinical research facilities and beds reserved for research, and the CR-UK Clinical Centre which is part of the Leeds Institute of Molecular Medicine. They will perform important work in (inter alia) phase I, II and III cancer clinical trials using PET-CT as a new tool in evaluating tumour response to novel drugs and demonstrating proof-of-principle, and will also develop the role of PET-CT in radiotherapy planning. A number of oncology research trials involving PET-CT have already begun recruiting in the Yorkshire Cancer Research Network and these include funding streams for imaging costs through the Comprehensive Local Research Network (CLRN). Other cancer trials already within the NIHR portfolio require additional PET-CT, either as the subject of the study or used to evaluate other interventions, in clinically relevant areas such as lung cancer (Lung ART), mesothelioma (MARS), lymphoma (IELSG 26, RATHL), gastrointestinal cancers (SCOPE-1, PACER, FOXTROT), melanoma,
paediatric oncology, myeloma and head & neck cancers (PET-NECK). The incorporation and evaluation of PET in drug development is an explicit priority for the ECMC network and our recruitment to early phase oncology trials will increase due to the additional capacity created by the new Oncology Clinical Research Facility (OCRF)
There are a number of developmental areas in Neurology which includes differentiating between recurrence and radio necrosis in brain tumours in children. This would not only attract referrals from across the Yorkshire and Humberside region, but nationally. The National Institute of Health Research is investing heavily in clinical trials and LTHT will be in a position to attract this investment; in part through the National Cancer Research Network.
LTHT has also established an international reputation in cardiac imaging research and there is interest in extending this work to include the cardiac applications of PET-CT. The British Heart Foundation (BHF) has a MRI scanner on the LGI site and funds the Leeds based CE-MARC trial with associated income of ?1.3 million. The trial compares techniques for the investigation of ischemic heart disease (IHD). Given the political priority accorded to the
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diagnosis and treatment of IHD and the proven commitment of the BHF to Leeds, there is likely to be a significant funding stream for research programmes involving cardiac PET-CT.
3.1.1 Research activity for NIHR portfolio trial patients (PET CT)
2010/11 2011/12 2012/13 2013/2014
Research patients 150 200 250 300
These numbers are based on current NIHR portfolio trials which are already recruiting. There is every likelihood that there will be significantly more demand for research PET-CT scans as a surrogate end point measure of therapeutic response in Oncology. A range of trials are in development which will be supported by commercial funding by external pharma sponsors and the LTHT allocation from comprehensive local cancer networks (See 4.3.1). There is also increasing recognition that PET-CT is the optimal non-invasive modality for early assessment of regional and global metabolic changes in many tumours following therapeutic interventions. This is particularly important in early clinical trials and in the assessment of novel, expensive or potentially toxic therapies, and targeted therapies that may be cytostatic rather than cytotoxic. These trials form potentially an important element of our ECMC activities and recruitment into such trials mandates additional PET-CT capacity via a 2nd fixed-site scanner. As one of only four UK centres awarded additional Cancer Research UK/NIHR ECMC funding paediatric oncology/haematology we will collaborate with other UK centres performing phase I/II studies through the Therapeutic Steering Group of the Children‟s Cancer and Leukaemia Group (former UKCCSG) and European centres via the Innovative Therapies for Children with Cancer to develop functional imaging in this patient group. Agents studied in adults and children will include those evaluated through the Cancer Research UK New Agents Committee by the Drug Development Office. For example, the Chief Investigator (CI) for the first phase I study as part of the Cancer Research UK Clinical Development Programme is based in Leeds; the study will run from 2010 and incorporates PET-CT scanning. Likewise, the forthcoming international Ewing sarcoma clinical trial is about to be submitted to the relevant national authorities for approval. The primary objective is to improve survival, with a secondary objective being to determine the value of FDG-PET-CT in the diagnosis and response evaluation of these patients; the UK CI is based in LTHT and we propose to lead this part of the study including radiological review, data collection and analysis. In lymphoma, NCRI studies for early Hodgkins (already running), all other Hodgkins (RATHL - in setup) and the next main B cell study (in draft) will all require several PET-CT scans per patient; together they are expected to accrue from all haematological units in the Yorkshire & Humber region as there will be no other static PET-CT resource.
3.2 Independent sector capacity issues
The mobile IS PET-CT is operating at almost full capacity; currently only ambulatory patients can use this service. Once the static service is operational and includes service delivery to inpatients also, the facility will be operating to full capacity. There is provision in the northern contract for transfer of demand and associated funding between centres. There is increased demand from a growing and ageing population as is the pressure to develop the role of PET-CT in monitoring response to treatment in radiotherapy planning, and for non-oncology indications (cardiology and neurology).
The installation of a second PET-CT scanner managed by LTHT will enable the Trust to deliver additional capacity and also provide resilience should the private sector service fail or be withdrawn. Advice from the Strategic Health Authority (SHA) is that, subject to their agreement, any activity over and above that required under the terms of the national procurement can be undertaken out-with that contract and that there is no requirement to operate a second scanner in partnership with AML.
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3.3 Non NHS Patients (Private and Overseas)
Public awareness of the role of PET-CT in improving cancer outcomes is resulting in
increased demand for the service from self-funding patients, commercial institutions and
medical insurers. Private patients from the Leeds area are currently travelling to PET
centres in London for their scans. These patients could be repatriated to LTHT with a net
profit of ?700-800 per patient. In the past year or so, the interim mobile PET-CT service at
Seacroft Hospital has scanned a small but increasing number of private patients (95 scans)
without marketing the service and because of limited availability. Growth in private activity
will accelerate as the benefits of PET-CT in cardiology and neurology (particularly dementia
screening) is brought to public attention. The IS provider does not have the capacity to
capture this activity and, with appropriate marketing, it represents a significant commercial
opportunity for LTHT. There will also be demand from private hospitals which lack the
infrastructure and skilled staff to provide their own service.
3.3.1 Projected private patient activity (PET CT)
2010/11 2011/12 2012/13 2013/14
Private patients 100 140 140 140
3.4 PET–CT for Radiotherapy Planning
PET –CT has provided a new approach to the management of cancer patients by allowing
the incorporation of biological information about tumour behaviour into the radiotherapy
treatment planning process. The combination of information from PET and CT in a single
imaging system used to obtain fused anatomical and functional image data is rapidly
becoming an accepted method of tumour volume delineation for radiation planning. Should
additional scanning capacity become available via a second fixed site scanner, the potential
for using PET-CT for radiotherapy planning would be of considerable benefit for the patients
of Leeds and beyond, both for clinical service and future research projects.
This facility will also be used with MRI to plan treatment of brain tumours using the recently
installed Gamma Knife. This will create a unique combined facility and would, therefore,
attract supra-regional referrals.
3.4.1 Projected annual radiotherapy planning activity (PET-CT)
Tumour Type PET-CT scans per year
Lung 50 Rectal/Anal 45 Lymphoma 50 Head and Neck 250 (inc 50 cases from Neurosciences related to the Gamma Knife.
CNS 90 Breast Clinical trial – number to be determined
Gynaecology 40 Sarcoma Clinical trial – number to be determined
Oesophagus 30 Total (minimum) 555
3.5 PET-CT for Cardiovascular Disease
There has been a considerable increase in the use of PET-CT in modern management of
cardiovascular disease and there is substantial support from the British Heart Foundation
(BHF) via the Cardiac Imaging Group for further extensive research. In particular, newer
developments which will enable plaque composition in the vessel wall to be assessed using
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PET-CT rather than the simple degree of anatomical obstruction available by using CT. Most myocardial infarcts take place on non obstructing coronary lesions and the composition of the offending underlying plaque is thought to determine the likelihood to rupture and is highly relevant to the outcome of carotid artery disease. This would equate to 20 clinical patients in year 1 with many more than this in the longer term via appropriately funded research programmes. Access to PET-CT for research will become a prerequisite if the Trust is to stay at the forefront as a leading regional cardiac clinical service and research centre. The development of PET-CT to support this cardiac work is essential and likely to be so for other areas of cardiovascular surgery; for example surgery of carotid artery disease.
3.6 Additional activity - NHS patients
As highlighted earlier in this paper, it is anticipated that demand for PET-CT scans within the LTHT catchment area for oncology related diagnosis will quickly exceed the capacity of the AML scanner. There is potential for LTHT to undertake this excess as a subcontractor to AML or, as a potential independent provider directly funded by commissioners. It is difficult to estimate the level of demand as this will be determined by a number of drivers; commissioning guidelines, commissioning arrangements under the national IS contract (including spare capacity at other sites) and commissioner intentions. An assessment has been made based on the fact that the AML service will commence fully in 2010.
3.6.1 Projected additional NHS activity (PET CT)
2010/11 2011/12 2012/13
Additional NHS patients 100 300 1000
In addition, paediatric NHS patients under the age of 12 and any children requiring sedation or general anaesthetic currently have to travel to London for provision of PET-CT. The supporting infrastructure exists within the Bexley Wing to provide this service locally.
The cost of a new PET-CT scanner has been based on estimates from the NHS Supply Chain at approximately ?2 million which includes the equipment, installation and modification required to the existing Radiopharmacy department. The financial table refers to a scanner purchased from the NIHR research bid and the revenue costs met by LTHT.
The Directorate recognise and are committed to ensuring the Trust receives a return on the investment, however, the capital funding has already been agreed via NIHR and as such this project is not competing with other Trust projects for the use of its scarce capital allocation.
The overall revenue position is summarised below. The table assumes a phased increase of activity to utilise 4 sessions largely in respect of research and private activity. The balance of sessions will be utilised to support the expansion in PCT demand for scans identified earlier in this paper. The viability of this service is dependant upon attracting research and
increasing private patient use of PET-CT. Additional NHS activity and associated income will reduce the financial risk to the Trust. The basis of the increase within each category of activity is detailed below. The table identifies the capital cost based on the outright purchase of the scanner. This may change and probably reduce dependant on the procurement process followed or the potential contributions from charitable sources or the private sector.
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1.ACTIVITYPrivate Patients2010/112011/122012/13ResearchRT Planning via clinical trial funding100140140NHS Patients150200250TOTAL2502502502.STAFFINGWTECostWTECostWTECost1003001,000Consultant?104,0000.3?31,2000.45?46,8000.6?62,4006008901,640RadiographersB7?40,8510.4?16,3400.6?24,5111?40,851RadiographersB6?34,1510.4?13,6600.6?20,4911?34,151(all at mid-point)Admin supportB4?22,8920.4?9,1570.6?13,7351?22,892Admin supportB2?17,1000.4?6,8400.6?10,2601?17,100Medical PhysicsB8A?49,6760.3?14,9030.45?22,3540.7?34,773PharmacistB8A?49,6760.05?2,4840.075?3,7260.1?4,968Pharmacy tech.B3?19,5740.2?3,9150.3?5,8720.4?7,830Total staffing?98,499?147,749?224,964
12 mth warranty Yr1?185,000?185,000Radiopharmaceuticals?105,000?155,750?287,000Facilities costs?10,000?10,000?10,000Total other costs?115,000?350,750?482,000
Income Per Private Patient?150,000?210,000?210,000Income Per Research Patient?150,000?200,000?250,000Income Per RT Planning funded via clinical trial?250,000?250,000?250,000Income per NHS Patient?100,000?300,000?1,000,000Total Income ?650,000?960,000?1,710,000
6.POSITIVE CONTRIBUTION ?196,501?227,502?776,036
The above table demonstrates the viability of this investment, as the income in the first year
is expected to cover all costs including capital charges and make a positive contribution to
the Radiology Directorate income. As mentioned earlier there may also be opportunities for
some of the staff costs to be funded from charitable sources.
4.3.1 Research funding
The revenue costs associated with research will be covered by the price quoted for scanning
in the many initiatives, examples of which are contained in the letters of support in the
appendices. These include the following examples:-
? Cancer Research UK (and other non-commercial funding) for particular research
programmes. The facility would form part of the CRUK centre which would
significantly increase the likelihood of securing additional research funding. It may
be possible to also secure funding from Yorkshire Cancer Research as there is no
other comparable facility in Yorkshire.
? Commercial funding to support clinical trials participation and agent development
including a partnering agreement with an equipment manufacturer and a large
? Appeal Fund and Charitable donations.
Negotiations are ongoing with the West Yorkshire Comprehensive Local Research Network
and NHS Specialist Commissioning Group regarding support costs for Research and
Development being met by the NHS.
A demand for 150 research scans per annum has been identified by the clinical lead for
research from YCRN based upon demand from current or pending studies. It is anticipated
that this level of demand would continue on an ongoing basis as cancer is the Trust‟s largest
and strongest area of clinical research. However, this is a conservative estimate of the total
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