Transformation of A&E, Acute Medicine and General Surgery Services across Greater Manchester

Transcription

1 Transformation of A&E, Acute Medicine and General Surgery Services across Greater Manchester Healthier Together Full Business Case Edition /09/17 Version 3.6 1

2 Document cover sheet Document information Draft 3.6 Document title: Date: 15/09/17 Owner: Author: Healthier Together Full Business Case Ed Dyson (GM SRO) NHS Transformation Unit Version Editor Changes made Date Mellanie Patterson Drafting 23/02/2017 Mellanie Patterson Addition of amendments suggested by sectors 15-31/03/ Jessica Boothroyd Updates to financial figures throughout report and appendices 09/05/ Lee Hay Addition of amendments 24/05/ Jessica Boothroyd & Lee Hay Amendments and updates 12/09/ Lee Hay Formatting 13/09/ Lee Hay Programme plan update 14/09/2017 Version Reviewer Comments 1.9 Alex Heritage Review 23/02/ Clare Powell Review 12/09/ Clare Powell Review 15/09/2017 Version 3.6 2

3 Author s Note This business case has been produced to support the Greater Manchester application for national capital funding to enable implementation of the Healthier Together model of care. The Heathier Together Joint Committee will receive this business case at its 19 September meeting in order to: - Receive assurance that the implementation plans remain consistent with the original Healthier Together model of care as described in the Decision Making Business Case; and - Provide GM level endorsement of the business case prior to onward submission in the national capital allocation process. This document contains commercially sensitive information relating to anticipated capital spend in each sector. In the public facing version of this document, these capital figures will be redacted. The grounds for this are to ensure appropriately competitive contractor procurement, and thereby safeguard value for money. Beyond September 2017, some business case content will require further development at sector level. Specifically this includes: Commercial case content. Due to the significant costs involved, Trusts did not commence detailed design work at risk prior to the identification of a capital funding source. Consequently, detailed design work did not begin in earnest until the 2017/18 financial year. At the date of this business case, and following the identification of a capital source for the programme, all sectors are working to develop detailed designs to support a full commercial business case. It is expected that supporting commercial case content will be available for the South East and Manchester and Trafford sectors by December 2017, with the North West and North East sector commercial case content available early in The commercial case within this September 2017 business case is therefore limited to a high level summary of the physical capital requirements of the programme, the estimated costs of that requirement, and how this will be financed. Funding agreement finalisation. At the time of this business case, appropriate capital and transitional funding sources have been identified to support the affordability of the capital and transitional costs of implementation. Funding of the recurrent revenue implications has been agreed in two sectors, whilst work continues to urgently complete and finalise these agreements in the remaining two sectors. These agreements will then require ratification through local Trust Boards and CCG Governing Bodies. Organisation level financial statement impacts. Once funding agreements have been finalised for all sectors, the impact on the prime financial statements will be calculated at organisation level, and included in the sector appendices of the final business case. Version 3.6 3

4 Contents 1 Executive Summary Introduction Why are these service changes a priority for Greater Manchester? General surgery Emergency medicine Acute medicine Proposed model of care GM Sector Overview Proposed Benefits Value for money Financial Overview Interdependencies A phased implementation Readiness Assessment GM Strategic case - why the proposed changes are required Background Case for change Clinical priorities for GM Emergency Medicine Acute Medicine General Surgery Supporting services - Radiology Summary Proposed model of care developments Overview of the new Model of Care - how will GM services operate differently The high risk General Surgery model of care Paediatric General Surgery Emergency medicine and acute medicine model of care Key support services Critical Care Radiology North West Ambulance Service Compliance of the model of care with the outline model of care Proposed estate developments Proposed workforce developments Local sensitivities Implementation plan Benefits Interdependencies and enablers Version 3.6 4

5 Major Trauma Diagnostic image sharing Record sharing Risks Approval and assurance of the Decision Making Business Case Approvals and assurance Economic Case what is the preferred option and its implication Introduction Longlisting and Shortlisting of options Appraisal of shortlisted options Refinement of the costs and benefits of option 4.4a Benefits Sensitivity Analysis Commercial case Financing the preferred option and procurement Introduction Physical capital requirement and cost of that requirement How this will be financed Financial Case cost implications of the preferred option Capital Costs Summary of capital requirements Capital funding Comparison to the DMBC Transitional Costs Non recurrent revenue costs IT costs of implementation (DataWell) Residual stranded costs at non-hub sites Non contracted pay costs Phasing of transitional costs Comparison to the DMBC Revenue Costs Management case Programme Governance Clinical Oversight of Healthier Together Programme resourcing Project plan Change management Management of benefits realisation Benefits realisation planning Clinical standards and baseline Progress monitoring Version 3.6 5

6 6.7 Risk management Appendices Appendix 1: Manchester and Trafford Sector Manchester and Trafford model of care Manchester and Trafford estate requirements Manchester and Trafford sector workforce requirements Manchester and Trafford Capital Costs breakdown Manchester and Trafford reconciliation to DMBC Capital figure Manchester and Trafford Revenue Costs Manchester and Trafford Transitional Costs Manchester and Trafford Funding sources Appendix 2: North East Sector North East sector model of care North East sector estate requirements North East sector consultant workforce requirements North East sector Capital Costs breakdown North East sector reconciliation to DMBC Capital figure North East Sector Revenue Costs North East Sector Transitional Costs North East Sector Funding sources Appendix 3: North West Sector North West sector model of care North West sector estate requirements North West sector workforce requirements North West sector Capital Costs breakdown North West sector interdependencies North West sector reconciliation to DMBC Capital figure North West sector Revenue Costs North West Sector Transitional Costs North West Sector Funding sources Appendix 4: South East sector South East sector model of care South East sector estate requirements South East sector workforce requirements South East sector Capital Costs breakdown South East sector reconciliation to DMBC Capital figure South East Sector Revenue Costs South East Sector Transitional Costs Funding Sources Appendix 5: North West Ambulance Service (NWAS) Version 3.6 6

7 7.5.1 The role of NWAS in the Healthier Together Model of Care The Healthier Together transfer model The impact on NWAS Appendix 6: Review of updated economic case against DMBC Capital Revenue costs Conclusion on DMBC decision Appendix 7: Anticipated efficiencies and valued benefits Purpose of this appendix Overview of anticipated efficiencies Methodology used to quantify efficiencies Impact of each efficiency by sector Consolidated revenue benefits Risks to the quantification of the efficiencies anticipated Version 3.6 7

8 1 Executive Summary 1.1 Introduction In 2012, Health and Care Leaders across Greater Manchester (GM) identified the need to address the variation in care and outcomes for patients across Greater Manchester. A formal programme of change resulted in the 12 Greater Manchester CCGs supported by the GM Combined Authority (GMCA) proposing changes to primary care, community care and some hospital services (A&E, Acute Medicine and General Surgery). Senior clinicians from across the conurbation designed new standards of care and, based on these, a new model of care (or way of delivering services). A formal public consultation was completed during 2014 resulting in the proposals being refined and communicated widely to all partners and stakeholders. Following a unanimous decision by GM CCGs to support the implementation of the programme on the 15th of July 2015 a judicial review was then successfully defended. Healthier Together initiated implementation in January Healthier Together forms an integral part of the five year vision for GM, as articulated in the STP document Taking Charge Together. This establishes a strategic narrative following engagement with NHS commissioners, providers and local authorities, alongside best practice from national and international experts, to identify five key areas for transformational change in GM (figure 1.1). Figure 1.1 Healthier Together is now considered a key building block by the GM Health and Social Care Partnership. It forms a core and integrated component of Devolutions Theme 3 work programme, entitled Standardising Acute and Specialised Care. As the first programme of scale to implement since Devolution, it demonstrates GMs ability to make real regional change. Healthier Together now underpins newer developments including the emerging Hospital Based Services Strategy and are Version 3.6 8

9 complementary to the development of Central Manchester University Hospitals NHS Foundation Trust and University Hospital of South Manchester NHS Foundation Trust into a Single Hospital Service. 1.2 Why are these service changes a priority for Greater Manchester? Healthier Together was initiated due to the unacceptable variations of care, and lack of compliance with national standards that exist in Greater Manchester for General Surgery, Emergency Medicine and Acute Medicine. The case for change (December 2013) highlighted the need to improve quality and safety in these services and the development of the clinical standards supports this improvement in order to improve outcomes. Since the establishment of the CCG s, the Association Governing Group (AGG) has taken on the GM wide governance arrangements for strategic change programmes. In March 2017, the AGG endorsed and supported: A refreshed clinical case for change, which in light of more recent guidance is even more compelling; and A report on the developing sector models of care, and compliance against the original model of care consulted upon. This report identified any variations to the original model of care, and the rationale for any changes. None of the variations were determined to be either significant or material General surgery The case for change in general surgery is based on well evidenced variation in the standard of care provided and resulting outcomes for patients. The standard of care provided in Greater Manchester does not meet national clinical standards and varies significantly; the number of emergency general surgery admissions, average length of stay, compliance with key standards in National Emergency Laparotomy audit, access to diagnostics and use of ambulatory care is different across each of our sites. Since Healthier Together was introduced, our Trusts have now committed to participate in the National Emergency Laparotomy Audit (NELA) in order to track performance and this indicates the main challenges evident 3 years ago persist. The case has recently been further strengthened by the continued reduction in access to radiology workforce. Radiology is pivotal to delivery of high quality and timely general surgery, and is particularly relevant in the high risk emergency and elective surgical populations. Tackling variation in General Surgical outcomes to bring Greater Manchester in line with the best hospitals in the UK will mean that we have the opportunity to save the lives of up to 300 residents of Greater Manchester every year Emergency medicine The NHS is experiencing unprecedented demand for urgent and emergency care; here in Greater Manchester demand for emergency departments is increasing year on year and subsequently departments are struggling to meet waiting time targets (see the chart below). Furthermore, there is Version 3.6 9

10 significant variation in the attainment of quality and safety standards across our emergency departments, due in main to shortages in medical and nursing staff and over-reliance on locum and temporary staff. Table 1.1: GM Quarterly Performance against the 95% National Standard (FY 16/17)) Organisation Q1 Q2 Q3 Q4 Bolton NHS Foundation Trust 82.3% 85.0% 80.1% 82.9% Central Manchester University Hospitals NHS Foundation Trust 93.6% 93.0% 91.1% 90.2% Pennine Acute Hospitals NHS Trust 85.7% 84.4% 79.7% 78.8% Salford Royal NHS Foundation Trust 92.2% 87.8% 83.9% 79.8% Stockport NHS Foundation Trust 82.1% 76.7% 75.3% 75.4% Tameside And Glossop Integrated Care NHS Foundation Trust 90.4% 86.0% 82.3% 83.9% University Hospital Of South Manchester NHS Foundation Trust 76.9% 90.8% 86.8% 87.7% Wrightington, Wigan And Leigh NHS Foundation Trust 92.3% 91.2% 83.6% 83.0% GM Average 87.8% 87.5% 83.7% 83.3% National Average 90.3% 90.6% 87.9% 87.6% Acute medicine As seen Nationally, Greater Manchester has an increasingly frail elderly population and there is a growing need for care for patients with acute medical presentations. However, across Greater Manchester, there are different models of care and corresponding staffing models causing high variation in outcomes for patients, shown through variation in length of stay and readmission rates to Acute Medical Units (AMUs) between hospitals. Not all sites can attain the quality and safety standards, including standards from the Society for Acute Medicine which recommends 12 hours of consultant cover, 7 days per week. This may contribute to further variation in care and outcomes in the evenings and weekends in individual hospitals. 1.3 Proposed model of care The aim of the HT programme is to deliver a clinically led transformation of acute services which improves outcomes for patients; and which is operationally and financially sustainable. The programme forms part of a wider GM strategy: Taking Charge, which through the devolution of health and social care in GM, aims to standardise acute care across the region to improve services for the benefit of patients. All hospitals in Greater Manchester will make a series of improvements to the way that they deliver Acute Medicine, A&E and General Surgery in order to deliver a step change in performance. This means, for example, that all hospitals will introduce or expand: Senior decision making at the front door Consultant Cover will be increased to a minimum of 12 hours (16 at a hub site where the higher acuity patients are received). Senior decision making at the front door can significantly reduce admissions and length of stay. Signposting to primary care and management of chronic attenders All hospitals will introduce a more consistent mechanism to manage these attendances. Version

11 Use of alternatives to admission Ambulatory care will be expanded, with A&E patients seen on the day by the appropriate specialism for issues such as extremity fractures, chest pain, shortness of breath and headaches rather than being admitted for lengthier ward stays. Management of frail elderly All hospitals will introduce, if it does not already exist, a multidisciplinary frail elderly assessment team that reaches into the Emergency Department and Acute Medical Unit. Timely diagnostics All hospitals will set key performance indicators to track and manage timely availability of diagnostics, with processes to ensure a 60 minutes turnaround for standard emergency blood tests and the availability of a radiologist to review images 24/7. The model of care will also concentrate high risk elective and all emergency general surgery from 9 sites onto 4 hub sites. High acuity (very sick) patients requiring specialist care will be transferred and receive that care at a hub that specialises in that type of care. This allows the re-organisation of the workforce, which is currently overstretched over multiple sites, in a more effective way. Each hub site will collaborate with at least one other hospital in a single service, with staff working as one team. This means that if a patient is transferred to a hub site for specialist care, there are pathways and processes in place to do this seamlessly. Staff will also work across sites in the single service, ensuring they continue to build both low acuity and high acuity experience. To concentrate high acuity patients onto our four hub sites, a number of capital investments are proposed. Since the Healthier Together decision significant work has been undertaken to assess whether NWAS paramedics can identify emergency general surgical patients for immediate conveyance to the general surgical hub sites. An extensive audit showed that these patients do not present with symptoms that can be identified in an ambulance and as such these patients will continue to be conveyed to the nearest A&E as they are now. Version

12 Figure 1.2: Hospitals collaborating in Single Services (sector) Further clarification on the Future Model of Care was provided to the four sectors in April 2016 by the Chief Medical Officer and Clinical Champions; the sectors have since been developing local models of care over the past 18 months. An assurance process was established to ensure that the local implementation of HT complies with the HT model and standards of care and that the implementation conditions and equalities implementation conditions set out by the Committees in Common in July 2015 are met. The stage 2 (Design of model of care and pathways) reviews were designed to achieve clinical assurance, focusing on the design of the sector s models of care, to ensure they will deliver the standards and principles of the HT model of care. The stage 2 review was split into three parts: Stage 2a: Presenting the model of care (clinical teams); Stage 2b: Actions and follow up on the model of care and presentation of the medical model of care (clinical teams); Stage 2c: Sector Senior Responsible Officer and Programme Director sign off. Each sector has worked to develop detailed models of care that fit with the model outlined in the DMBC, and meets the Healthier Together standards whilst addressing any emergent factors potentially impacting the original model of care identified during the detailed design phase and assured through the review process. A key example is that in the DMBC it was envisaged that the North West Ambulance Service (NWAS) would develop a pathfinder tool to determine the most appropriate place for patients to receive their care. This assumption has been rigorously tested through audits as part of the assurance process, with experts concluding there were not sufficient medical differentiators to identify emergency general surgical patients (operative and conservatively managed) at pre-hospital stage. Version

13 Therefore the current pattern of attendance for emergency general surgery patients is expected to continue. Through the development of local care models, clinical pathways and A&E consultant staffing levels have been iterated accordingly. For example, multiple non-hub sites have extended the hours of A&E consultant presence to reflect anticipated demand, in addition to an increase in General Surgical consultant presence at non-hub sites beyond a 3-4 hour hot clinic provision as initially deemed suitable for such a site. The end result is more robust consultant level cover across GM to ensure senior decision making and timely patient review. Other examples include: Better defining the activity codes that are considered to be high risk and producing local pathways (such as ambulatory care) in order to refine the level of activity that will transfer to the HT hub site in that sector; Refining the outline estimates of implications for beds and capital at each site and, based on that; Refining the outline workforce modelling, to describe the numbers of staff and coverage that will be provided within that sector; Establishing a more detailed understanding of the volume of activity transferring to the hub sites, in turn informing the on-site presence requirements to meet demand; and The National Major Trauma Service specification requires consultant general surgeon response within 30 minutes. This enables the resident hubs to now become non-resident depending on their assessment of demand during the stage 2 review. 1.4 GM Sector Overview The table below summarises the hub site investment in each sector: Table 1.2: Summary of Capital Investment Required Within Each Sector Sector Requirement Manchester and Trafford 2 wards, 3 critical care beds, 1 theatre At Central Manchester Foundation Trust, the hub site, the Trust will develop 2 wards to house both the elective and non-elective activity that will transfer. The areas are currently in use by other services, which will be decanted and rehoused to accommodate the new wards. The Trust will also develop an additional emergency theatre in a shelled area in the existing main theatre footprint to accommodate the additional non-elective/emergency activity and the semi-planned theatre lists associated with the Ambulatory care service. Critical care will be expanded by 3 beds in a shelled area of the newly created surgical high level dependency/step down unit. Existing Ambulatory Care space on both sites be reconfigured to facilitate the new Ambulatory Care model (with extended patient assessment and opening into evenings and weekends). A small amount of additional equipment will allow for a more comprehensive assessment and treatment to prevent unnecessary admission. Version

14 Sector Requirement There is a risk that an additional 200k of capital costs will be incurred. This is currently being assessed within the sector. North East Sector 2 wards, 4 critical care beds, 1 theatre Pennine Acute Hospitals Trust, which operates 4 hospitals In the North East sector, will construct a new 2 storey building at first and second floor levels on the Royal Oldham hospital site to provide 2 surgical wards and one theatre. It will also include a critical care ward (given that the additional critical care capacity required cannot be incorporated within the current landlocked footprint). North West Sector 2 wards, 6 critical care beds, 2 theatres (one elective and one non-elective) Salford Royal Foundation Trust, which manages one hospital in Salford, has been selected as both a hub site for Healthier Together and the single Major Trauma Centre for Greater Manchester. SRFT have already cleared space for the erection of a new four storey building to allow for both the additional Healthier Together and Major Trauma activity. This includes inpatient beds, critical care beds and two new theatres South East Sector Equipping 1 ward, Equipping critical care beds Equipping theatre, Expanding A&E Expanded CT, Expanded Endoscopy Stockport Foundation trust will create a larger, 6 bedded, Resus suite to accommodate the additional high acuity demand, with the old space used to introduce 4 dedicated consultant-led Rapid Access Treatment trolleys The Trust will develop a two storey design which will minimise the potential for patients to have to wait in corridor space, and increase clinical capacity, including an additional theatre It will also rehouse some of the activity currently undertaken in the Cardiac Catheter and Pacing Lab, which currently sits in the A&E footprint into the new theatre complex, allowing the development of a Frailty Assessment Unit 1.5 Proposed Benefits Once implemented, Greater Manchester will be at the forefront in providing high quality and safe care through collaborative, networked working as described in the Five Year Forward View and the Keogh Review 1. l For general surgery, the consolidation of high risk elective and emergency general surgery services onto 4 hub sites will increase consultant presence at hub sites, improve access to theatres and critical care and enable quality and safety standards to be met. For the vast majority of patients, 1 Transforming urgent and emergency care services in England Version

15 they will continue to present or be taken by ambulance to their local A&E, which could be a nonsurgical hub site; upon which clear protocols will be followed by the A&E medical staff. Enacting these protocols in liaison with the consultant at the hub site, will ensure appropriate transfer of patients, appropriate access to ambulatory care and the appropriate management of risk. This will ensure demand across the sector is effectively managed. GPs will also have access to an opinion from the consultant at the hub site, upon the need to refer a patient. The demand for transfer of emergency patients has been estimated by sector, and used by the North West Ambulance Service to determine the investment in additional vehicles required, which have been incorporated into the business case. The demand for surgical ambulatory care services has been estimated at between 20%- 30% of current admissions. For emergency and acute medicine a recent review by ECIP (the Emergency Care Improvement Programme) anticipates, if the model is completely, effectively and consistently implemented a significantly positive effect on flow and therefore performance within GM A&Es 2. We anticipate significant improvements in: Ambulance teams waiting with patients in corridors; ED four hour waiting times and 12 hour trolley waits ; Diagnostics turnaround; Admissions through ED (14% reduction in admissions, equivalent to 37,000 admissions cross GM) General Surgery length of stay 3 ; Outcomes and mortality, with the opportunity to save up to 300 lives each year through General Surgery interventions alone; Readmissions following ED, Acute Care or General Surgery care; and Patient and staff satisfaction. 1.6 Value for money Following the unanimous decision to implement the preferred service configuration option, sector teams have worked to operationalise the clinical model and to refine costs. The economic case in this business case has been updated to incorporate these revised costs and demonstrates that: Doing nothing remains clinically unacceptable. When compared to the do minimum option, the preferred option has a higher Net Present Value and therefore demonstrates value for money. 2 February 2017 desktop review of Healthier Together standards. Performance uplift is heavily dependent on the complete and consistent application of the model. ECIP have also suggested additional improvements that can enhance flow and waiting time performance, which will be built into the implementation. 3 Based on a comparison by each sector of each Trusts length of stay, by HES HRG code, to the upper quartile nationally. Version

16 Therefore the economic case demonstrates that the preferred option, as decided by the Joint Committee in 2015, still demonstrates value for money at a GM level. 1.7 Financial Overview The capital required to support the implementation of the programme is detailed above. The transitional costs of implementation are set out below and in more detail in the financial case, along with the funding sources identified. Table 1.3: Transitional Costs 000 Manchester and Trafford sector North East sector North West sector South East sector NWAS GM PMO Total Implementation Costs , ,913 Project Management , ,864 Workforce 2,088 1, ,130 Revenue consequences of capital 728 1,063 1,791 TOTAL 3,186 1,854 5,256 1, ,518 In addition to the transitional costs above, there is a risk that stranded costs and non-contracted pay costs will arise. These are further explained and quantified in the financial case, along with a summary of potential funding sources identified should these costs eventuate. The recurrent revenue impact of Healthier Together consists of: Activity moves impact at hub: This is the income relating to the general surgery activity which is transferring from non-hub sites to hub sites, offset against the related operating expenditure required to deliver that activity to current clinical standards. Healthier Together Standards: This is the cost required to meet the Healthier Together clinical standards, and includes consultant cost, other staff cost and some non-staff costs. Revenue consequences of capital: This is the annual PDC and depreciation charges associated with the capital investment required for the programme. Ambulance costs: These are the costs of the additional ambulance conveyances from nonhub to hub sites. The recurrent revenue impacts by sector are set out in the table below. Table 1.4: Recurrent Revenue Impact Recurrent Annual Revenue Impact ( 000) Version

17 Activity moves impact at hub Healthier Together standards Revenue consequences of capital Ambulance Costs Manchester and Trafford (1,561) 2, North East sector - 6,747 1, North West sector 1,569 3,197 2, South East sector 172 1,916 1, TOTAL ,060 5, The funding agreements reached in relation to the capital, transitional and revenue impacts of the programme are detailed in the Financial Case. 1.8 Interdependencies The implementation of Healthier Together at Salford Royal Foundation Trust requires the development of a new building to house additional inpatient beds, critical care beds and theatres. The building will be partially funded through Healthier Together funding and partially funded through a Major Trauma project, allowing Salford Royal to become the lead Major Trauma Centre for Greater Manchester. Should the Major Trauma project not be funded, there is potential for the cost of the Healthier Together capital build to rise. Whilst there are some IT enablers that will support Healthier Together, including improved record and image sharing, these do not affect our ability to go live and are considered to be enablers. However, it is important that these enablers are developed during 2017/18 in support of activity transfers. 1.9 A phased implementation Whilst all of the hub sites require some capital investment to absorb 8,102 high acuity episodes transferred from non-hub sites, the size of the investment and complexity of the work varies: North East Sector: The sector will commence the delivery of ambulatory care and transfer of high risk elective patients towards the end on 2017/18 over a 12 month. However, consolidating high acuity care equivalent to 2,201 episodes at the hub site is dependent on a capital build, at a proposed cost of 24.8m, which will be completed by c. April North West Sector: Similarly, whilst the North West Sector can transfer a small cohort of elective patients to the hub site and start the hub and non-hub site working together in a collaborative single service in 2018, the sector will not be able to consolidate high acuity activity equivalent to 1,260 episodes until a new build is complete in c. January 2020 at a proposed cost of 18.5m. Given that the hub Trust requires a new building to accommodate Version

18 both Healthier Together and Major Trauma, both schemes are co-dependent on the funding of the similarly timed Major Trauma project (captured in a separate business case) 4. South East Sector: More immediately and at a lower cost, Stockport Foundation Trust can expand its ED and theatre space, as described above, to absorb the additional demand, equivalent to 2,388 episodes at the hub site by c. October 2018 at a much lower cost of 9.9m Manchester and Trafford Sector: Central Manchester Foundation Trust hub site can reconfigure their existing space to accommodate 1,890 episodes at a cost of 10.2m by c. December This drives a phased implementation as outlined in the following roadmap 5 : Figure 1.3: Implementation Roadmap 4 It is possible to build a new building to accommodate only Healthier Together. However there is a financial benefit in consolidating the capital requirements of Healthier Together and Major Trauma. 5 Assuming approval of the business case in September 2017 Version

19 1.10 Readiness Assessment The following table provides an assessment of whether the proposed changes are ready to implement Table 1.5: Programme Readiness Readiness Counterfactual evidenced (scheme avoids operational/quality harm) Support to national and GM strategic objectives Complete? Yes see case for change in outline business case ( Healthier Together Decision Making Business Case ) and this full business case. The clinical case was developed through 80 GM clinical congresses/workshops assured by the National Clinical Advisory Team (NCAT). The standards were recently re-tested for impact on 12 hour waits with NHSIs Emergency Care Improvement Programme Team (ECIP). Healthier Together supports the GM strategy Taking Charge, as a formal part of the Theme 3 workstream. It forms the cornerstone of the emerging Hospital Based Services Strategy and a number of other programmes including the Single Hospital Service for Manchester. It also national strategic objectives: It stretches across primary care, integrated care and acute care, with the primary care element already increasing primary care access in order to reduce inappropriate acute attendances The acute workstream, for which capital funding is sought, ensures care is more cost effective and appropriate by: centralising high acuity care onto four specialist hub sites; and making improvements to the way that care is delivered, such as expansion of ambulatory care (with patients seen the same day in a clinic rather than being admitted for lengthy stays on a ward). The proposals are in line with the networked models of care described in the Five Year Forward View and Keogh review. Locally, Healthier Together underpins a number GM hospital based services strategies for example the Single Hospital Service between University Hospital South Manchester and Central Manchester Foundation Trust Affordability evidenced The Outline Business Case, describes affordability and value for money and was assessed by the ten Greater Manchester CCGs on the 15th of July The CCGs took a unanimous decision to implement the changes. Over 2015, Trusts have worked together to develop the detailed design and refresh their financial estimates. These have not materially changed from the estimates described in the Outline Business Case and are presented in this Full Business Case. Greater Manchester will support transitional and recurrent revenue costs NHS England Assurance (inc. four Completed in 2015 Evidenced in the Outline Business Case Version

20 tests) Financial return Outline Business Case ( Decision Making Business Case ) signed off by GM Can Demonstrate Best Possible Value Full Business Case signed off by GM Single Oversight Framework Evidenced in the Economic Case Agreed unanimously by all 12 CCGs as a Committees in Common in 2015 The decision to implement Healthier Together was taken in July 2015 and therefore preceded the Best Possible Value Framework. However, a coherent decision making process was undertaken. The programme was assessed on the factors that are included in the framework, for example, clinical effectiveness and safety, patient experience, revenue costs and capital costs. The decision making process was thoroughly tested when a full judicial review was successfully defended in January 2015 September 2017 Trusts have modelled the impact on income and expenditure locally to support the 4 May central STP submission. In three sectors the programme will not impact on the SOF metrics for any trusts in the sector. In the South East Sector, the hub site (Stockport FT) anticipate that the increased use of agency staff during the transitional period will adversely affect the SOF metrics of the Trust for one year only. Ready to implement Trusts are ready to start phased implementation from quarter Version

21 2 GM Strategic case - why the proposed changes are required 2.1 Background Greater Manchester is a vibrant and dynamic conurbation with great potential for economic growth and prosperity. However, the population of Greater Manchester has traditionally suffered some of the poorest health in England. Good progress has been made in addressing the health challenges posed by the burden of disease associated with social deprivation, poor mental health, cancers, cardiovascular disease and poor lifestyle choices leading to problems of obesity, alcohol related morbidity and smoking related disease. However, significant health inequalities remain. In Greater Manchester we therefore face a significant challenge - and yet the current organisation of hospital services in Greater Manchester is already unsustainable. A number of Trusts in Greater Manchester are facing significant financial challenges. In addition, in many services a lack of availability of suitably trained staff means that workforce is overstretched and failing to meet national clinical standards. These issues will only deepen as demand and costs continue to rise and budgets remain constrained. In 2012, Health and Care Leaders across Greater Manchester (GM) identified the need to address the variation in care and outcomes for patients across Greater Manchester. A formal programme of change resulted in the 12 Greater Manchester CCGs supported by the GM Combined Authority proposing changes to primary care, community care and some hospital services (A&E, Acute Medicine and General Surgery). A case for change was developed through 84 clinical congress/workshop sessions attended by over 370 clinicians. Clinicians also described a consistent cohort of standards that, if adopted across the conurbation, would significantly reduce variation and improve performance and quality. Each of our hospitals would need to change to meet these standards, and a new operating model was developed. The design work involved patients, carers and members of the public throughout, culminating in a full public consultation of 2.8m people in the summer Over 29,000 residents formally responded and many more attended events and heard about the proposals. Table 2.11: 2014 Formal Public Consultation Summary Leaflets delivered to all 1,250,000 households across Greater Manchester and Glossop Over 450 engagement events and activities held in every district, attracting over 23,000 people Almost 700 media articles generated across all platforms including TV, print, radio and internet E-bulletins sent to over 90,000 people Over 90 advertisements placed in newspapers Over 150 outdoor adverts, posters and billboards, viewed over 21 million times 7 social media platforms accessed, engaging with over 8,500 people and organisations Version

22 Over 1,000 bus adverts Over 1000 radio adverts Over 50,000 unique visitors to the Healthier Together website Over 200,000 consultation documents distributed Post-consultation, public feedback was collated into themes and considered by a number of technical governance groups (for example, Finance and Estates and Clinical Advisory ). Every significant feedback theme was responded to in a comprehensive and publically available Decision Making Business Case. For example, feedback suggested that travel data was out of date and could be improved. This was captured in a Consultation Feedback Table and reviewed by the Transport Advisory Group. A decision was then taken to update the data prior to decision making. A full patient impact assessment was undertaken, and the reach of the consultation to protected groups and the wider public was also assessed. The Healthier Together Joint Committee (previously convened as a Committees in Common ) assessed the proposals and public response and unanimously agreed the implementation of Healthier Together and the preferred hub sites in late A subsequent judicial review, which was publically reported, was successfully defended. Healthier Together initiated implementation in January 2017 and is now considered a flagship GM programme, forming the cornerstone of the Health and Social care Partnerships strategy for hospital based services (Theme 3). It seeks to ensure that decisions about services result in the delivery of improved and equitable services for patients across GM and the wider area that GM hospitals serve; and that these services are clinically and financially viable and sustainable across GM. Healthier Together is an integral part of Theme 3, and there is a strong commitment to delivering the Healthier Together outcomes. The clinical case for change for Healthier Together is strong, and the programme has not only provided the basis for devolved working across GM, but the single service model of care has laid the foundations for the development of new models of care within Theme 3, and will provide a building block for the configuration of services. It is also recognised however that the changed environment requires that this be done in a pragmatic manner which allows for a continued interaction with broader service reconfiguration plans so as to make Healthier Together more affordable. Theme 3 is placing a high priority on this through the work to develop the hospital based services strategy. To strengthen the governance arrangements, Healthier Together and Theme 3 activities are set to be unified through one common governance structure. Version

23 2.2 Case for change Clinical priorities for GM The Healthier Together programme was initiated in 2012 due to the unacceptable variations of care and lack of compliance with national standards that existed in Greater Manchester (GM) for General Surgery, Emergency Medicine and Acute Medicine Emergency Medicine The NHS is experiencing unprecedented demand for urgent and emergency care. Here in Greater Manchester demand for emergency departments is increasing year on year, and subsequently departments are struggling to meet waiting time targets. Table2.2: GM A&E Performance Against the 95% National Standards (FY 16/17) 6 Organisation Q1 Q2 Q3 Q4 Bolton NHS Foundation Trust 82.3% 85.0% 80.1% 82.9% Central Manchester University Hospitals NHS Foundation Trust 93.6% 93.0% 91.1% 90.2% Pennine Acute Hospitals NHS Trust 85.7% 84.4% 79.7% 78.8% Salford Royal NHS Foundation Trust 92.2% 87.8% 83.9% 79.8% Stockport NHS Foundation Trust 82.1% 76.7% 75.3% 75.4% Tameside And Glossop Integrated Care NHS Foundation Trust 90.4% 86.0% 82.3% 83.9% University Hospital Of South Manchester NHS Foundation Trust 76.9% 90.8% 86.8% 87.7% Wrightington, Wigan And Leigh NHS Foundation Trust 92.3% 91.2% 83.6% 83.0% GM Average 87.8% 87.5% 83.7% 83.3% National Average 90.3% 90.6% 87.9% 87.6% Table2.3: GM A&E Performance - Number of patients waiting >12 hours from decision to admit Organisation Q1 Q2 Q3 Q4 Bolton NHS Foundation Trust Central Manchester University Hospitals NHS Foundation Trust Pennine Acute Hospitals NHS Trust Salford Royal NHS Foundation Trust Stockport NHS Foundation Trust Tameside And Glossop Integrated Care NHS Foundation Trust University Hospital Of South Manchester NHS Foundation Trust Wrightington, Wigan And Leigh NHS Foundation Trust GM Total National Total GM as a % of National 23.3% 41.7% 24.7% 21.6% There is also significant variation in the attainment of quality and safety standards. The summary table below shows the overall level of compliance across a selection of national standards for urgent, acute and emergency medicine, based on a review by the National Clinical Advisory Team in Based on national NHS England statistics Version

24 Table 2.4: National Clinical Advisory Team independent assessment of compliance of GM Trusts with national and GM A&E and Acute Medicine quality and safety standards, 2013 U&EM CMFT UHSM SRFT Bolton WWL Tameside Stockport Pennine % Fully compliant 76% 76% 82% 70% 41% 43% 49% 59% % Partially compliant 14% 14% 5% 3% 13% 19% 32% 16% % Not evidenced 5% 8% 8% 5% 22% 22% 0% 3% % Non-compliant 5% 2% 5% 22% 24% 16% 19% 22% % Not applicable 0% 0% 0% 0% 0% 0% 0% 0% A further review has now been undertaken to test whether clinical compliance remains an issue in GM. The table below shows the results of a self-assessment, undertaken in 2016 by GM Trusts using a different methodology (including a wider set of Healthier Together standards and a more detailed approach). The table below, which should not be directly compared to the NCAT review, indicates that GM Trusts report that they continue to face challenges consistently delivering national and GM standards. Table 2.5: Local self-assessment of compliance of GM Trusts with national and GM A&E and Acute Medicine quality and safety standards, 2016 U&EM CMFT UHSM SRFT Bolton WWL Tameside Stockport Pennine % Fully compliant 28% 50% 48% 37% 52% 11% 15% 35% % Partially compliant 46% 33% 46% 26% 22% 6% 28% 46% % Not evidenced 26% 15% 4% 30% 15% 74% 42% 2% % Non-compliant 0% 2% 2% 7% 11% 9% 15% 17% % Not applicable 0% 0% 0% 0% 0% 0% 0% 0% Where areas of non-compliance or partial compliance have been identified, these have fallen into the following general themes: Lack of defined pathways including ambulatory care systems; Not meeting Radiology standards (24/7 access to Consultant led in house reports within 1 hour); Insufficient multi-disciplinary care for the frail elderly; In adequate access to support services essential for discharge; and Insufficient intervention to reduce chronic attenders. Version

25 Staffing standards are of particular concern: The number of substantive, accredited A&E consultants within GM Trusts varies greatly, with rotas often supplemented with inconsistent and expensive locum support. Variation is not explained by differences in the demand dealt with by each A&E. Four Trusts have an establishment below the College of Emergency Medicine guideline of 10 WTE. For example the A&E at North Manchester A&E, part of The Pennine Acute Hospitals Trust, is a large A&E which receives over 100,000 attendances a year. In 2016 the A&E service at the site was operating with less than 3 WTE consultants. The fragility of the A&E service was recognised in the Trust s 2016 Inadequate rating 7. There are also gaps in consultant presence at times when demand is high. In most Trusts consultant presence matches weekday demand in the daytime until but then significantly reduces, despite demand continuing at a high level until at least Similarly during weekends, consultant staffing does not closely match demand. Similarly there is a significant range in the number of substantive A&E middle grades with a number of trusts are using consultants to fill middle grades rotas, putting further pressure on consultants who are required to act down. The chart below shows the GM consultant gap at the Outline Business Case ( Decision Making Business Case ) stage. Table 2.6: Consultant gap to meet minimum national standards at each site at DMBC stage (Autumn 2015) Consultants 2015 Baseline (WTE) Requirement to meet national standards (WTE) Gap Autumn 2015 (WTE) Emergency Medicine Some headway has been made in recruiting posts in preparation for the implementation of Healthier Together, but it is still not possible to deliver national and GM standards at every site without reconfiguring the service Acute Medicine As seen nationally, Greater Manchester has an increasingly frail elderly population and there is a growing need to care for patients with acute medical presentations. However, across Greater Manchester: there are different models of care; there are different staffing models; and, 7 The Trust is now making significant improvements under the guidance of an Improvement Board and steer from Salford Royal Foundation Trust and Central Manchester Foundation Trust Version

26 there is variation in attainment of clinical standards, including standards from the Society for Acute Medicine which recommends 12 hours of consultant cover, 7 days per week. This variation contributes to high variation in: length of stay; readmission rates to Acute Medical Units (AMUs) between hospitals; and patient outcomes General Surgery General surgery is a surgical specialty that focuses on abdominal organs including oesophagus, stomach, small bowel, colon, liver, pancreas, gallbladder and bile ducts, and sometimes includes endocrine procedures such as operations involving the thyroid gland (depending on local referral patterns). They also deal with diseases involving the skin, breast and soft tissue. Nationally, surgical morbidity and mortality rates for high-risk elective and emergency general surgical patients compare unfavourably with international results, with evidence of higher mortality and morbidity in these cohorts of patients. Evidence of variation in surgical practice can be seen in published National Surgical Audit Programmes: National Emergency Laparotomy Audit (NELA) (2014 and 2015) National Bowel Cancer Audit (2014, 2015 and 2016) A number of national publications that incorporate GM data also demonstrate ongoing clinical challenges: Nuffield Trust, Challenges and Opportunities in Emergency General Surgery, 2016 NCEPOD, "Treat the cause", 2016 NCEPOD, " Time to Get Control", 2016 Variation in practice remains a priority for professional surgical bodies and this is recognised as pivotal to improving surgical outcomes, including mortality. Evidence includes: The National Bowel Cancer Audit Programme The Association of Coloproctology of Great Britain and Ireland, Resources for Coloproctology Standards Summary, 2015 The Association of Coloproctology of Great Britain and Ireland 2012: Ileal Pouch Registry Report. National Emergency Laparotomy Audit Programme 2014 onwards NICE October 2016: Molecular testing strategies for Lynch syndrome in people with colorectal cancer Version

27 Consistent quality improvement themes drawn from research include: Identification of risk for patients, undergoing both elective and emergency 8 procedures; Understanding by clinical teams of true risk; Standardising of clinical pathways, including the value of post-operative planned critical care ( Swart M, Carlisle JB, Goddard J Br J Anaesthesia 2017;118: , Chana P, Joy M, Casey N et al BMJ Open 2017;e014484); and Making appropriate use of associated specialities such as radiology 9 o The clinical workforce census (2016) describes a 51% increase in NHS outsourcing spend and 9% vacancy. o Standards for Provision of a seven day acute care diagnostic radiology service (2015) states that robust IT infrastructures should be in place to support image and report sharing. A recent study 5 of 69,490 high risk emergency general patients (including 19,082 who underwent emergency abdominal surgery) admitted to 23 centres across Australia, England and the USA from 2007 to 2012 showed: 7 and 30 day mortality, readmission rates and length of stay were worse in English units. Key features for the cohorts were: Low intensive care unit bed ratios were associated with worse outcomes, including higher post-operative mortality. Representing the increasing view that all major intra-abdominal surgery patients would benefit from direct admission post operatively to critical care. Having dedicated EGS teams cleared of elective commitments with formalised handovers was associated with a significant improvement in 7 day mortality in the procedure subgroup and a 22% improvement in long length of stay for EGS patients 10. In addition: Across the UK emergency general surgery is delivered on many sites, each of which undertakes a relatively small number of high risk cases. This model overstretches resources, making the delivery of standards, such as the availability of senior decision makers, challenging. 8 A number of papers have recently assisted in clarifying which emergency patient pathways would be described as high risk (Nuffield Trust, 2016, commissioned by the Royal College of Surgeons, CEPOD 2016 Treat the Cause, NCEPOD 2016 Time to get Control, National Emergency Laparotomy Audit Programme). 9 The Royal College of Radiologists London, Standards for Provision of a seven day acute care diagnostic radiology service 2015; Provision of interventional radiology services 2014; Investing in interventional radiology workforce: the quality and efficiency case 2014; Clinical Radiology workforce census Chana P, Joy M, Casey N, et al. Cohort analysis of outcomes in emergency general surgical admissions across an international benchmarking collaborative. BMJ Open 2017;7:e doi: /bmjopen ) Version

28 Greater emphasis has recently been placed on the need to provide equity through the provision of 7 day services in the NHS (Seven day services in hospitals: clarification of priority clinical standards, NHS Improvement December 2016). In Greater Manchester, performance for high-risk emergency and elective general surgery reflects this national picture. Emergency general surgery is carried out in nine acute hospitals in Greater Manchester with significant challenges, caused by variation in the number of consultant general surgeons, anaesthetists and supporting diagnostic services available. The services are characterised by the following features: There is variation in the number of emergency general surgical admissions. The numbers vary across GM from approximately 8 to 28 patients a day, of which only 2 to 7 patients require an operation. The average length of stay for non-elective general surgery patients varies significantly across the GM footprint; Variation persists in compliance with key standards in NELA: early input from senior clinicians, timely antibiotic therapy, estimation of risk, timely access to theatre and postoperative access to critical care. The use of ambulatory care for surgical patients is not yet optimised. There is a negative correlation between the number of admissions and the crude mortality rate for patients aged 75 years old and above. There are significant challenges in radiology within GM with variable access to 24/7 in house diagnostic radiology reporting and delivery of interventional radiology. All radiology departments in GM have reliance on outsourcing companies and this is increasing particularly at night for emergency patients. Trainee recruitment in General Surgery is falling with an inability to fill national training posts in The summary tables below shows high variation and low compliance with national clinical standards across GM in 2013 and today. Table 2: National Clinical Advisory Team independent assessment of GM Trust compliance against national and GM General Surgery quality and safety standards, 2013 GENERAL SURGERY CMFT UHSM SRFT Bolton WWL Tameside Stockport Pennine % Fully compliant 68% 75% 68% 54% 32% 21% 54% 46% % Partially compliant 21% 11% 32% 10% 14% 25% 32% 25% % not evidenced 11% 7% 0% 29% 50% 50% 4% 29% % Non-compliant 0% 7% 0% 7% 4% 4% 10% 0% % Not completed 0% 0% 0% 0% 0% 0% 0% 0% Version

29 As described above, a further review has now been undertaken to test whether clinical compliance remains an issue in GM. The table below shows the results of a self-assessment, undertaken in 2016 by GM Trusts using a different methodology (including a wider set of Healthier Together standards and a more detailed approach). The table below, which should not be directly compared to the NCAT review, indicates that GM Trusts report that they continue to face challenges consistently delivering national and GM standards. Table 2.83: 2016 Local self-assessment of compliance against national and GM General Surgery quality and safety standards, GENERAL SURGERY CMFT UHSM SRFT Bolton WWL Tameside Stockport Pennine % Fully compliant 39% 44% 23% 37% 50% 6% 23% 40% % Partially compliant 50% 39% 37% 53% 39% 23% 52% 50% % Not evidenced 8% 14% 34% 8% 2% 69% 21% 2% % Non-compliant 3% 3% 6% 2% 9% 2% 4% 8% % Not completed 0% 0% 0% 0% 0% 0% 0% 0% Where areas of non-compliance have been identified, these have fallen into the following general themes: Timeliness of consultant surgeon review; Formal pathways for unscheduled adult general surgical care; Radiology standards (24/7 access to Consultant led in house reports within 1 hour); Access to non-vascular and vascular interventional radiology ; Sepsis and haemorrhage pathways; Medicine for Care of the Older Person (MCOP) for patients over 70; Profiling of surgical workload; Reviews of surgical patient outcomes; and Bed occupancy and flow of surgical patients within the system. In addition to the issues identified there is also an opportunity to enhance perioperative pathways by the introduction of ERAS+ (enhanced recovery from surgery), which reduced surgical length of 11 This is based on a self-assessment, overseen by the Healthier Together programme team and shared across Trusts via the Healthier Together Delivery Board Version

30 stay by 3 days at Central Manchester Foundation Trust in This pathway has now been adopted by the National Accelerator Programme as an initiative for widespread adoption. As with A&E and Acute Medicine, general surgery staffing is overstretched and staffing standards are of particular concern. Table 2.9: Consultant gap to meet minimum national and GM quality and safety standards at each site under the current as-is model of care at Outline Business Case stage (Autumn 2015) Consultants 2015 Baseline(WTE) Requirement to meet national standards (WTE) Gap Autumn 2015 (WTE) Surgery Some headway has been made in recruiting posts in preparation for the implementation of Healthier Together, but it is still not possible to deliver national and GM standards at every site without reconfiguring the service. The impact of this variation in standards and an overstretched workforce can be seen in National Emergency Laparotomy Audit (NELA). NELA data, which, since Healthier Together has been introduced, GM Trusts have now committed to report. The key areas of performance which uniformly create challenges across GM are: Review by a consultant surgeon within 14 hours of emergency admission to hospital; Timely access to theatre; Estimation of risk for all patients pre-operatively; Direct supervision of all high risk patients surgery by a consultant surgeon and a consultant anaesthetist; and Immediate admission to critical care post-surgery for all high risk patients (p-possum mortality risks of >5%). The challenges for GM are reflected in high variation in 30 day mortality for patients undergoing an emergency laparotomy, with some sites exceeding the national average of 11%. GM outcomes have not improved since NELA began, which is at variance to the national picture which has seen a reduction in mortality in some sites. 12 "Anaesthesia, 2017, Impact of a peri-operative quality improvement programme on post- operative pulmonary complications" Version

31 Table 2.10: 30 day risk-adjusted mortality for patients between December 2013 and November 2015 Provider 30 day mortality % Wythenshawe Hospital 6.8 Stepping Hill Hospital 6.9 Manchester Royal Infirmary 8.4 North Manchester General Hospital 9.3 Royal Bolton Hospital 10.3 Royal Oldham Hospital 10.4 Salford Royal Hospital 11.0 Royal Albert Edward Infirmary 13.3 Tameside General Hospital Patients with Colorectal cancer For patients with colorectal cancer in GM, a subset of general surgery, the number of cases in each site is relatively small and varies from 72 to 140 patients per year (NBCOA 2016), of which up to 21% have their major surgery carried out as an urgent/emergency case. As with wider general surgery, GM standards and outcomes vary and are sometimes below the national average: The use of laparoscopic surgery is below the national average in GM (range 19% to 75%), (National average 61%); The proportion of patients staying in hospital > national average (5 days) is high in GM at 78% (range 69%-90%); The average adjusted 90-day mortality rate in the GM network is 4.7% (range 1.5% - 7.8%), which is higher than national average of 3.8%; The average adjusted 2-year mortality rate in the GM network is 22.5% (range 13.8% 42.9%), which is higher than National average 20.9%; An average of 10.3% of patients are readmitted within 30 days (range 4.3% to 15.2%); and The need for rescue following surgery, for example due to an anastomotic leak, is ~8% for elective patients and 11% for emergency patients. Version

32 2.2.4 Supporting services - Radiology Radiology, a vital supporting service, similarly faces significant workforce challenges which will need to be resolved to enable the improvement of A&E, Acute Medicine and General Surgery. The current workforce challenge results in a heavy reliance for the majority of sites in GM on outsourcing all or a significant element of their emergency workload for reporting. Outsourcing of this type of work has been recently described by the Royal College of Radiology as being associated with a risk of discrepancy greater than that recorded for in house reporting. Whilst in-house consultants achieve a major discrepancy rate of 3.1%, outsourced reporting of CT scans for patients proceeding to emergency laparotomy is associated with a major discrepancy rate of 12.7% (BrJRad 2016 Howlett et al.) The discrepancy rate would appear greatest in those patients having an urgent or emergency CT Abdomen. There is recognition that radiology has a manpower crisis and that different ways of working are required to maximise productivity and improve quality. This has been described in a number of publications including Who Shares Wins-efficient collaborative radiology solutions. RCR Oct These publications support the development of network teleradiology IT platform across a clinical network and this work is already being undertaken in other geographies such as East Midlands and Liverpool. There is ongoing GM PACS reprocurement which supports this model. In addition there are significant challenges in delivering resilient 7 day basic and intermediate non vascular interventional radiology services across GM. The reasons for this reside in the level of skillsets on some sites, numbers of radiologists and absence of on call radiologists out of hours on many sites. Currently only 3 of the 9 sites can deliver a 7 day service. As a consequence delivery of timely non-vascular intervention is variable, and delay may adversely impact patient outcomes. With respect to vascular interventional radiology, GM is served by 2 teams of radiologists. One (CMFT/UHSM) provide an extensive service to GM and further afield, but current numbers of radiologists prevent this team from separating elective and emergency work. This team also provide VIR services for elective activity on 4 sites. This means that currently only 3 of the 9 sites (2 of the proposed 4 sectors) are compliant with the standards in NCEPOD 2016 Time to get Control standards for gastrointestinal haemorrhage. This pathway integrates endoscopy, vascular interventional radiology and general surgery. The expected incidence of upper GI haemorrhage in GM is cases per year in each hospital. 25% will be high risk and 50-60% will present out of hours. Stratification of risk for individual patients is possible using endoscopic scoring system and clinical features such as evidence of a re-bleed, systolic blood pressure at time of bleed and evidence of other co-existing pathology Summary The above evidence provides a continued compelling case to reconfigure A&E, Acute Medicine and General Surgical hospital services that is fully supported by GM clinicians, providers and commissioners. The other associated and related clinical services which should also be considered as single services in the model are Critical Care and Radiology. The above sections provide evidence of a continued strong clinical case for reconfiguring A&E, Acute Medicine and General Surgical hospital services to address variation and improve outcomes for GM Version

33 patients. This affirms the case for change developed through 84 clinical congress/workshop sessions attended by over 370 clinicians in and endorsed by the Healthier Together Committee in Common in July Proposed model of care developments The above evidence provides a compelling case to reconfigure A&E, Acute Medicine and General Surgical hospital services that is fully supported by GM clinicians, providers and commissioners. To reduce variation and achieve a step change in performance, commissioners worked with 380 senior clinicians and other stakeholders over a series of 84 clinical congresses and workshops to set a series of 400 minimum standards, largely based on national standards from Royal Colleges, which will be adopted uniformly. For example, every hospital will establish or expand ambulatory care. They also designed, with input from patients, a new model of care or way of operating across GM hospital sites to deliver those standards Overview of the new Model of Care - how will GM services operate differently To meet a consistent set of minimum standards all hospitals in Greater Manchester will make a series of improvements to the way that they deliver Acute Medicine, A&E and General Surgery in order to deliver a step change in performance. This means, for example, that all hospitals will introduce or expand: - Senior decision making at the front door Consultant Cover will be increased to a minimum of 12 hours (16 at a hub site where the higher acuity patients are received). Senior decision making at the front door can significantly reduce admissions and length of stay. - Signposting to primary care and management of chronic attenders all hospitals will introduce a more consistent mechanism to manage these attendances. - Use of alternatives to admission for example ambulatory care will be expanded, with A&E patients seen on the day by the appropriate specialism for issues such as extremity fractures, chest pain, shortness of breath and headaches rather than being admitted for lengthier ward stays. - Management of frail elderly all hospitals will introduce, if it does not exist, a multidisciplinary frail elderly assessment team that reaches into the Emergency Department and AMU. - Timely diagnostics all hospitals will set KPIs relating to timely availability of diagnostics, with processes to ensure a 60 minute turnaround for standard emergency blood tests and the availability of a radiologist to review images 24/7. The scheme will also concentrate high risk elective and all emergency general surgery from 9 sites onto 4 hub sites. The design of the new model of care, which describes how our hospitals will operate to deliver new standards of care, based on the following design principles: Version

34 1. Hospital services will be provided locally whenever possible. 2. Hospital services will be provided at a site specialising in certain types of care (e.g. general surgery) when needed. 3. Hospital services will be provided to a defined standard. 4. Care will be consultant delivered. 5. Services will be provided over seven days with no deterioration in service provision at the weekends. 6. Sites will collaborate in delivery of the in scope services through the single services model in their sector. 7. Within each sector one site will deliver the in-patient services for high risk elective and high risk emergency general surgical adult patients. 8. Within GM, high risk patients with a medical or surgical pathology will where possible be diverted directly to the most appropriate hospital site and will bypass their local A&E. For some conditions these receiving A&Es will serve the GM population, for others there will be a sector receiving A&E. 9. Sites undertaking high risk general surgery must have a co-located A&E. 10. Every site will have an Acute Medical Unit (AMU) and a Critical Care Unit (CCU). Clinicians also agreed that hospitals should collaborate to deliver A&E, Acute Medicine and General Surgery in networks, called single services. Within each network, one site would become a hub that specialises in emergency and high risk general surgery. These hub sites will see a larger number of patients each year from across a larger geography of Greater Manchester, enabling them to become centres of excellence in caring for seriously ill patients. Patients will have their diagnostics, low risk procedures and outpatients appointments at their local sites (close to home where possible), with those patients assessed as requiring specialist care transferred to the hub site. Version

35 Figure 2.1: Hospitals collaborating in single service networks Emergency Department - Self presenting surgical emergencies - Access to surgical opinion from linked hospital treating high risk general surgical patients Emergency Department - Self presenting surgical emergencies - Surgical presence in the Emergency Department To support this, ED, General Surgical, Anaesthetics and Critical Care staff will work in a single team ensuring that effective working relationships are established. General Surgeons will rotate across the single service network, ensuring that they continue to experience a range of higher and lower acuity patients. The picture below shows the single service network arrangement, formed over four sectors, that was agreed by Greater Manchester CCGs on the 15th of July Figure 2.22: Single service networks - "sectors" Version

36 2.3.2 The high risk General Surgery model of care The design of the Emergency general surgery model of care is summarised below: GPs and Emergency Medicine will refer to local hot clinics/ambulatory care, where appropriate; and when advice is needed from a senior surgeon outside of the times hot clinic/ambulatory care is staffed locally, this is obtained from the general surgeon on duty at the linked surgical hub site. To facilitate this, diagnostic tests may be undertaken locally, with results shared with the general surgeon on duty in the linked hub site via the PACs IT system. Hot Clinics/Ambulatory care will be available locally to facilitate prompt semi-elective admissions, with the patient initially being seen in A&E before being referred for a procedure within the next hours. This service should be provided for 3-4 hours per day, 7 days per week. For patients initially admitted on non-hub sites (for example onto the acute medical wards) who then required a general surgical opinion; diagnostics should be undertaken on the nonhub sites to facilitate clinical opinions being given by the general surgeon on duty in the linked hub site via PACs. All emergency general surgical patients will be admitted to sites specialising in emergency and high risk complex elective general surgery (surgical-hub sites); whether for conservative management or a procedure. The surgical hub site will deliver an increase in consultant presence for surgical assessment, with the addition of a separate consultant available for undertaking Emergency General Surgery 7 days per week, with the level of presence of both roles based on local demand. There are four groups of emergency patients for which local pathways have been devised: 1. Patients requiring an inpatient emergency procedure these should be transferred to the surgical hub site 2. Patients requiring conservative inpatient watch and wait management with a mortality of >5% - these patients require significant surgical, diagnostic and associated service input and as such should be transferred to the surgical hub site 3. Patients who are suitable for referral to a prompt semi-elective or elective pathway including ambulatory care, hot clinic, outpatients, early elective lists 4. Patients requiring conservative inpatient watch and wait with a mortality <5% who are not suitable for referral to a semi-elective or elective pathway The design of the elective general surgery model of care is summarised below: High risk complex inpatient elective general surgery should be co-located with emergency general surgery. Examples of High risk complex patients to be managed at the surgical hub site include: patients scheduled for colorectal resections/interventions; patients undergoing high risk upper GI procedures and patients scheduled for a lower risk surgical procedure but with significant comorbidity. Version

37 Co-location of emergency and high risk-elective surgery will allow for increased delivery of subspecialised rotas. The diagram below describes what this would Implementation of the model of care and standards will improve patient care for patients like Lynda. This is illustrated below. Figure 2.3: Example patient story Patient with a bowel obstruction, Lynda 69 Lynda is 69 and one evening she develops vomiting, severe and worsening stomach pain and so her husband takes her to North Manchester General A&E. At 8pm at the A&E, Lynda is assessed by the A&E consultant who is on shift. She examines Lynda and arranges blood tests and scans The results come back and the A&E consultant suspects a general surgical condition and contacts the single service General Surgical Consultant who is working in the Royal Oldham The A&E and General Surgical consultants review the scans online and discuss Lynda s condition. A bowel strangulation is suspected. At 9pm Lynda is transferred to the Royal Oldham where she is met by the General Surgical Consultant and taken to the ward before surgery. Lynda is prepared for theatre. At 11pm Lynda is taken to theatre for surgery where she is operated on by a consultant General Surgeon and Anaesthetist After surgery Lynda recovers in an intensive care bed at the Royal Oldham and is checked on by the General Surgical consultant Lynda is now seen by the A&E consultant, not a junior member of staff Lynda s test results are reviewed straight away by the specialist General Surgical Consultant There is a another General Surgery consultant ready to operate on Lynda, this means no delay to Lynda s operation and that other emergency patients can still be assessed while she is in theatre Lynda is taken to theatre only 4 hours after leaving home Because Lynda s operation was done quickly none of her bowel had died and the surgeon was able to repair the strangulation. Because she was in Intensive Care, signs of an infection were spotted early and she was given medication to stop her becoming really sick. Lynda had her follow up outpatients close to home at North Manchester General Paediatric General Surgery The pathway for children is sometimes different to adults because, when children are particularly sick, it is often better if they are cared for by a surgeon/team that specialise in paediatric care. Salford Royal Foundation Trust, the hub site in the North West Sector, does not provide paediatric services. Therefore the pathway for children, can be summarised as follows: All children who are seriously ill with general surgical conditions, e.g. Generalised peritonitis, Bowel obstruction, will be transferred to the Royal Manchester Children s Hospital. Children under 5 years old with serious illness, including suspected appendicitis will be transferred to the Royal Manchester Children s Hospital. Children over 5 years old who require an admission for an acute general surgical condition will be transferred to one of the four Healthier Together hub sites Emergency medicine and acute medicine model of care The design of the elective general surgery model of care is summarised below: All A&Es and Acute Medical Units will make changes to meet national and GM quality and safety standards. For example: Version

38 Senior decision making at the front door consultant cover will be increased to a minimum of 12 hours (16 at a hub site where the higher acuity patients are received). Senior decision making at the front door can significantly reduce admissions and length of stay Signposting to primary care and management of chronic attenders all hospitals will introduce a more consistent mechanism to manage these attendances. Use of alternatives to admission for example ambulatory care will be expanded, with A&E patients seen on the day by the appropriate specialism for issues such as extremity fractures, chest pain, shortness of breath and headaches rather than being admitted for lengthier ward stays. Management of frail elderly all hospitals will introduce, if it does not exist, a multidisciplinary frail elderly assessment team that reaches into the Emergency Department and AMU. Timely diagnostics all hospitals will set KPIs relating to timely availability of diagnostics, with processes to ensure a 60 minutes turnaround for standard emergency blood tests and the availability of a radiologist to review images 24/7. No A&E will close as a result of Healthier Together. Every A&E will continue to open 24/7 (excluding the Urgent Care Centres in Trafford and Rochdale). Every A&E will have a minimum of 12 hours of consultant presence 7 days per week. These A&Es will be co-located with low risk general surgical sites. A&Es co-located with the four general surgical units that care for patients with life threatening illnesses will have a minimum of 16 hours of consultant presence 7 days per week. A&Es will work in single service partnerships of A&Es with longer and shorter hours of consultation presence. As well as evidence suggesting better outcomes for treatment of some high risk patients through conveyance to high risk sites, the other driver for A&E change is limited availability of emergency medical workforce. As such sectors have been requested to work collaboratively to ensure that A&E standards are met at all sites within the sector and to explore single service arrangements to provide greater resilience. Through the assurance of sector models of care, reviews have been undertaken to assess proposals to achieve the A&E and Acute Medical standards. Version

39 Figure 2.4: A&E and Acute Medicine single service General Surgery - Self presenting surgical emergencies - Access to surgical opinion from linked hospital treating high risk general surgical patients General Surgery - Self presenting surgical emergencies - Surgical presence in the Emergency Department Every hospital will have an Acute Medical Unit with 12 hours consultant cover, 7 days per week Acute Medical Units will be supported by a Critical Care Unit in each hospital. In order to meet growing demand, an Acute Medical Unit (AMU) providing short term care up to ~72 hours will be provided in every hospital in Greater Manchester which will provide care to GM quality and safety standards, for the patients from the local community. This will facilitate close linkages with local social care, primary care, family and carer support. The service in each hospital will be consultant led, seven days per week. The units will work in partnership with the Emergency Department to deliver rapid assessment, diagnosis and treatment for patients with acute medical presentations; supported by seven day working from social care, therapies and pharmacy. To improve quality and safety standards, an investment in additional A&E and acute medical consultants are required. 2.4 Key support services Critical Care Every hospital will have a Critical Care Unit. Surgical hub sites will be centres of excellence for critical care patients arising from the services provided at those sites. Delivering a breadth of critical care services across a sector. Non-hub sites will be centres of excellence providing critical care services to patients in local area. Highly complex patients may require transfer to services at the specialist site. Critical care units will continue to treat a variety of patients including acute medical, general surgical and other patients who do not fall within the scope of Healthier Together. Version

40 It is assumed that critical care capacity for general surgical patients will be reduced on nonsurgical-hub sites and increased on surgical-hub sites in line with changes in demand. Critical care capacity will be maintained on every site for acute medical patients. Critical care units on non- surgical hub sites will work with surgical hub site in single service partnerships. Critical care doctors and some nurses will work across the critical care units within the single service partnership to maintain skills Radiology 24/7 diagnostic reporting service at each site with 24/7 compliance to access of modalities. Non-vascular interventional service to be provided 7 days per week at a sector level (at a Greater Manchester level out of hours). Vascular interventional radiology to be provided 24/7 days per week at a Greater Manchester level through a network solution North West Ambulance Service A number of pathways for emergency high risk patients are now fully embedded in Greater Manchester through a partnership with NWAS: Patients with Major Trauma Acute myocardial infarction Patients with a Stroke Since the Healthier Together decision significant work has been undertaken to assess whether NWAS paramedics can identify emergency general surgical patients for immediate conveyance to the general surgical hub sites. An extensive audit showed that these patients do not present with symptoms that can be identified in an ambulance and as such these patients will continue to be conveyed to the nearest A&E as they are now. Through the development of local care models, clinical pathways and A&E consultant staffing levels have been iterated accordingly. For example, multiple non-hub sites have extended the hours of A&E consultant presence to reflect anticipated demand, in addition to an increase in General Surgical consultant presence at non-hub sites beyond a 3-4 hour hot clinic provision as initially deemed suitable for such a site. The end result is more robust consultant level cover across GM to ensure senior decision making and timely patient review. Aligned to this: Work has been undertaken to assess feasibility of a pathway for shocked patients with upper gastrointestinal haemorrage (GI bleed). National evidence suggests these patients require endoscopy within 2 hours of their bleed. As such immediate conveyance and treatment to a site capable of delivering this is essential. This additional pathway will be implemented as part of Healthier Together. There are other medical conditions for which timely expert interventions will have significant patient benefits, such as shock due to infection. In these cases there will be benefit for Version

41 patients being conveyed directly from out of hospital to the high acuity sites. Assessing the feasibility of such a pathway is now necessary Compliance of the model of care with the outline model of care On the 7 th of March 2017 the CCG Association Governing Group confirmed that they had received assurance that the detailed model of care, developed during 2016, is not materially different to the model of care described in the outline Business Case. 2.5 Proposed estate developments To accommodate the centralisation of high acuity demand at four hub sites, capital investment will be required. The table below summarises the requirement. Table 2.11: Capital requirements by sector Sector Requirement Manchester and Trafford 2 wards, 3 critical care beds, 1 theatre At Central Manchester Foundation Trust, the hub site, the Trust will develop 2 wards to house both the elective and non-elective activity that will transfer. The areas are currently in use by other services, which will be decanted and rehoused to accommodate the new wards. The Trust will also develop an additional emergency theatre in a shelled area in the existing main theatre footprint to accommodate the additional non-elective/emergency activity and the semi-planned theatre lists associated with the Ambulatory care service. Critical care will be expanded by 3 beds in a shelled area of the newly created surgical high level dependency/step down unit. Existing Ambulatory Care space on both sites be reconfigured to facilitate the new Ambulatory Care model (with extended patient assessment and opening into evenings and weekends). A small amount of additional equipment will allow for a more comprehensive assessment and treatment to prevent unnecessary admission. There is a risk that an additional 200k of capital costs will be incurred. This is currently being assessed within the sector. North East Sector 2 wards, 4 critical care beds, 1 theatre Pennine Acute Hospitals Trust, which operates 4 hospitals In the North East sector, will construct a new 2 storey building at first and second floor levels on the Royal Oldham hospital site to provide 2 surgical wards and one theatre. It will also include a critical care ward (given that the additional critical care capacity required cannot be incorporated within the current landlocked footprint). North West Sector 2 wards, 6 critical care beds 2 theatres (one elective and one non-elective) Salford Royal Foundation Trust, which manages one hospital in Salford, has been selected as both a hub site for Healthier Together and the single Major Trauma Centre for Greater Manchester. SRFT have already cleared space for the erection of a new four storey building to allow for both the additional Healthier Together and Version

42 Sector Requirement Major Trauma activity. This includes inpatient beds, critical care beds and two new theatres South East Sector Equipping 1 ward, Equipping critical care beds Equipping theatre, Expanding A&E Expanded CT, Expanded Endoscopy Stockport Foundation trust will create a larger, 6 bedded, Resus suite to accommodate the additional high acuity demand, with the old space used to introduce 4 dedicated consultant-led Rapid Access Treatment trolleys The Trust will develop a two storey design which will minimise the potential for patients to have to wait in corridor space, and increase clinical capacity, including an additional theatre It will also rehouse some of the activity currently undertaken in the Cardiac Catheter and Pacing Lab, which currently sits in the A&E footprint into the new theatre complex, allowing the development of a Frailty Assessment Unit These final requirements have changed since the DMBC as further work has been undertaken to refine the estates needs at each Trust. The detailed of the changes are set out in Figure 51: Capital Funding Reconciliation to DMBC in section 5.1. The total capital requirement of 63.3m is within 1% of the DMBC figure. 2.6 Proposed workforce developments The table below summarises the workforce requirements by sector. Table 2.12 Workforce requirements by sector Consultant speciality Additional Consultants Required (WTEs) Acute and Emergency Medicine General Surgery Local sensitivities The following section outlines how local sensitivities to the Healthier Together plans have been highlighted and shows how they are being managed and mitigated. The Healthier Together public consultation attracted a wide range of views from the local population and local organisations. A total of 22,541, consultation questionnaires were received in addition to 658 responses to the residents survey from randomly selected residents; 95 written submissions from individuals; 130 organised questionnaires; 894 pledges of support; 2,792 attendees of centrally organised public meetings; and 4 petitions with a total of 5,751 signatures. An independent report on the formal consultation programme was commissioned and conducted by Opinion Research Services (ORS) from Swansea University. The feedback from the consultation was summarised into the following themes: Version

43 Case for Change and Vision Model of care Transition and Implementation Decision Making Processes Data Queries (including travel and access issues) Consultation Process The feedback to the questions raised are summarised in Appendix to the Decision Making Business Case. In addition to pubic consultation feedback, an independent organisation, Mott MacDonald, assessed and fed back both the positive and negative impacts of the proposals on protected groups. This analysis was developed through desktop review, analysis and a programme of local engagement events where equality and community group representatives were invited to share their views on potential impacts and mitigating actions. The Integrated Impact Assessment identified a number of mitigating actions that could be put in place during implementation to mitigate the negative impacts of the proposals. An Equalities Advisory Group has been established and one of the roles of this group is to review and advise on the implementation of these mitigations. The group has reviewed the mitigating actions and identified priority actions. These are outlined below: Theme Equalities Implementation Conditions Transition 1 Clear and regular communication is provided to staff and patients 2 Training and development of Single Service staff to better support patients with specific needs Travel and Access Service change 3 Coordinated transport planning and information on transport options is incorporated into Single Service implementation plans 4 An appraisal of priority access to car parking facilities at each Single Service hospital site is completed and reviewed by commissioners 5 An evaluation to appraise the extension of the volunteer driver scheme is completed 6 A common policy for travel reimbursement/set tariffs for taxis is established within each Single Service 7 Improved publicity of community transport schemes and travel voucher schemes to be provided 8 Patients are offered a choice of appointment times for elective care 9 An appraisal of flexible visiting times within a Single Service is completed in advance of any changes taking place Monitoring 10 Commissioners will establish a monitoring/evaluation process to assess the progress of all IIA Implementation conditions In addition, when the decision on the geography of the 4 single services in GM within the Healthier Together model was taken on the 15 th July 2015, a number of Implementation Conditions were set, these included. Implementation Conditions Version

44 Programme Requirements Condition 1 Regular data collection, review and monitoring is implemented Condition 2 Structured process of peer review across GM Condition 3 Establishment of a Greater Manchester Clinical Alliance Condition 4 Joint appointments to Single Services Condition 5 Appointment of GM clinical leadership for implementation Condition 6 Formation of Single Service Research Hubs Condition 7 Development of a GM governance framework Condition 8 Formation of a CCG and Regulatory Body Alliance to support implementation To ensure the implementation of Healthier Together aligns and meets these conditions, Greater Manchester CCGs have commissioned the Transformation Unit to oversee the overall programme plan and assure that local models of care comply with the Healthier Together model and standards. 2.8 Implementation plan Whilst all of the hub sites require some capital investment to absorb 8,102 high acuity episodes transferred from non-hub sites, the size of the investment and complexity of the work varies: North East Sector: The sector will commence the delivery of ambulatory care and transfer of high risk elective patients towards the end on 2017/18 over a 12 month. However, consolidating high acuity care equivalent to 2,201 episodes at the hub site is dependent on a capital build, at a proposed cost of 24.8m, which will be completed by c. April North West Sector: Similarly, whilst the North West Sector can transfer a small cohort of elective patients to the hub site and start the hub and non-hub site working together in a collaborative single service in 2018, the sector will not be able to consolidate high acuity activity equivalent to 1,260 episodes until a new build is complete in c. January 2020 at a proposed cost of 18.5m. Given that the hub Trust requires a new building to accommodate both Healthier Together and Major Trauma, both schemes are co-dependent on the funding of the similarly timed Major Trauma project (captured in a separate business case) It is possible to build a new building to accommodate only Healthier Together. However there is a financial benefit in consolidating the capital requirements of Healthier Together and Major Trauma. Version

45 South East Sector: More immediately and at a lower cost, Stockport Foundation Trust can expand its ED and theatre space, as described above, to absorb the additional demand, equivalent to 2,388 episodes at the hub site by c. October 2018 at a much lower cost of 9.9m Manchester and Trafford Sector: Central Manchester Foundation Trust hub site can reconfigure their existing space to accommodate 1,890 episodes at a cost of 10.2m by c. December The diagram below shows the overall roadmap. Figure 2.5: Programme implementation roadmap 2.9 Benefits The key objectives of Healthier Together is to deliver a clinically led transformation of acute services that delivers better outcomes which is operationally and financially sustainable. The benefits from achieving these objectives are set out below. Version

46 Once implemented, Greater Manchester will be at the forefront in providing high quality and safe care through collaborative, networked working as described in the Five Year Forward View and the Keogh Review 14. Recent review by ECIP anticipates, if the model is completely, effectively and consistently implemented a significantly positive effect on flow and therefore performance within GM A&Es 15. We anticipate significant improvements in: Ambulance teams waiting with patients in corridors ED four hour waiting times and 12 hour trolley waits Diagnostics turnaround Admissions through ED (14% reduction in admissions equivalent to 37,000 admissions cross GM) Length of stay (c. 1 day reduction in general surgery LOS16) Outcomes and mortality up to 300 lives saved each year through General Surgery interventions alone Readmissions following ED, Acute Care or General Surgery care Patient and staff satisfaction The expected benefits of the model of care are summarised below: 14 Transforming urgent and emergency care services in England 15 February 2017 desktop review of Healthier Together standards. Performance uplift is heavily dependent on the complete and consistent application of the model. ECIP have also suggested additional improvements that can enhance flow and waiting time performance, which will be built into the implementation. 16 Based on a comparison of each Trusts length of stay, by HES HRG code, to the upper quartile nationally. This is likely to be a reasonable estimate; introduction of ERAS+, a pathway development that will be rolled out through Healthier Together, at CMFT in 2016 for all surgery patients reduced length of stay of by 3 days. Version

47 Figure 2.6: Summary of Healthier Together improvements and how these drive benefits Version

48 The diagram below provides additional detail on the benefits expected in relation to the emergency care model of care and how these can be measured. Figure 2.7: Emergency care model of care benefits Version

49 A similar diagram below provides additional detail on the benefits expected in relation to the Acute Medicine model of care and how these can be measured. Figure 2.8: Acute Medicine Model of Care Benefits Version

50 Finally, the diagram below provides additional detail on the benefits expected in relation to the General Surgery model of care and how these can be measured. Figure 2.9: General Surgery Model of Care Benefits Version

51 2.10 Interdependencies and enablers Major Trauma The implementation of the Healthier Together programme is interdependent with the development of a lead Major Trauma Centre for Greater Manchester at Salford Royal Foundation Trust (SRFT). This is because SRFT are planning to build a new building to house both developments. If the Major Trauma programme is not funded, the capital costs of the implementing in the North West Sector may be significantly higher Diagnostic image sharing Shared digital imaging and radiology provisions, with seamless access to radiological imaging between the hub and non-hub sites is a critical component of fluid, cross organisational decision making. Currently the technology enabling the sharing of diagnostic imaging across GM, which is at the end of its contract and is being re-procured, fails to realise this, with a proliferation of providers offering fragmented and often manually intensive remote reporting services. The Greater Manchester Clinical Advisory Group for Radiology is currently working towards the reprocurement of an enhanced digital platform, PACS, seeking to maximise the effectiveness and efficiency of digital imaging across GM. Whilst implementation of Healthier Together is not a direct interdependency of the re-procurement, the opportunities and benefits the project offers are significant and integral to the achievement of HT standards for Radiology. The following table outlines key aspects of the standards and the level of interdependency between PACS and HT: Version

52 Table 2.11: Interdependency between Healthier Together and PACS re-procurement and upgrade explained HT reference Extract from HT standard Current position GM CIP contribution R1a Hospital inpatients must have scheduled seven-day access to diagnostic services and consultant directed completed reporting X-ray o Imaging available 24/7 within 1 hour for critical patients 12 hours for urgent patients 24 hours for non-urgent patients o A Radiology Consultant will be available 24/7 for advice if requested by a senior clinician. This standard is being achieved variably across GM particularly for non-urgent patients. Extensive use made of outsourcing arrangements. Radiology consultant out of hours often very remote lacking knowledge of GM services and processes. Almost certain increases in demand combined with probable workforce shortages will increase pressure on consultant directed completed reporting. Seamless out of hours image sharing across GM is a pre requisite for more developed local cover arrangements. Allowing a wider pool of radiologists to work together will facilitate improved cover for specialist work. Greater efficiency in reading of images, MDT preparation etc is essential to increase workforce flexibility to cope with rising demand and workforce shortages. R1b Hospital inpatients must have scheduled seven-day access to diagnostic services and consultant directed completed reporting: Computerised tomography (CT) o Imaging available 24/7 within 1 hour for critical patients, 12 hours for urgent patients 24 hours for non-urgent patients o Reporting provided within 1 hour for critical patients, 12 hours for urgent patients 24 hours for non-urgent patients As above As above Version

53 R1c R1d Hospital inpatients must have scheduled seven-day access to diagnostic services and consultant directed completed reporting: Ultrasound (adults) o In routine working hours imaging and reporting by a suitable qualified practitioner available within 1 hour for critical patients 12 hours for urgent patients 24 hours for non-urgent patients o Outside of routine working hours Most emergency cases will require CT rather than US. If US is required then it should be discussed by the senior clinical team with the Radiologist on-call. Hospital inpatients must have scheduled seven-day access to diagnostic services and consultant directed completed reporting: Magnetic resonance imaging (MRI) o Reporting provided within 1 hour for critical patients 12 hours for urgent patients 24 hours for non-urgent patients As above As above As above As above R3 UEAM38 Digital PACS systems adhere to recognised standards allowing rapid transfer of images across GM of sufficient diagnostic quality to allow remote reporting. This will facilitate rapid management decisions. When immediate outcome is dependent on imaging studies for all non elective radiographs a provisional report is available within 30 minutes and a definitive report within 1 hour. Image transfer is possible although highly inefficient for planned care. It is not possible out of hours thus hindering rapid management decisions. There is currently limited capacity for high quality remote monitoring. GMCIP will achieve this standard for elective and non elective patients. Improved diagnostic quality will be achieved. By facilitating collaborative working across a wider pool of radiologists, it will more likely that the most urgent reporting timescales can be achieved. Version

54 UEAM37 Images must be available via digital PACS systems for review in ED, AMU and other clinical areas, such as ICU. Within hospitals this might be achieved currently. GM wide image sharing will facilitate this across multiple location including new clinical areas such as primary care. UEAM43 VIR6 24/7 Consultant radiologist available for advice The radiologist does not need to be on site but needs to be available 24/7 to view images on PACs and provide advice Sites must ensure that PACS access to their individual service is immediately available to all radiologists in their network who provide an on-call interventional radiology service to their site. Remote reporting not widely used, and where it exists, is restricted to that locality. Seamless image sharing across GM will facilitate remote viewing particularly in an environment where the workforce is increasingly limited compared to the demand. Not currently compliant GM wide image sharing will facilitate this. Version

55 The current outline business case for GM collaborative image sharing establishes a management plan forecast to complete implementation by Q4 2018/19, with several finance options being explored Record sharing A second core enabler of Healthier Together is the ability to access patient records across an array of providers and care settings, to optimise accurate and timely decision making. At present GM primary and secondary care providers operate across a plethora of IT systems with variable compatibility, and distinct lack of functionality with regards to the effective transfer of patient records. The Greater Manchester Academic Health Science Network (GM AHSN) has established a programme, which is an innovative digital infrastructure that enables doctors and care professionals in Greater Manchester, East Cheshire and East Lancashire to share and view the patient and client information they need, when they need it, to improve care. It will provide Greater Manchester with a platform that supports better use of existing data and enable GM to be at the forefront of modern healthcare, changing the health data landscape: Figure 2.10: Datawell For NHS Organisations, this will create a framework to simplify and enable easier sharing of data. To do this a node will be created in every participating organisation to which data will be added. These nodes are designed to only allow sharing of data with other nodes and will validate all data requests against computable information sharing agreements. This allows all members to participate but ensures that each member retains local control of how their data is used, and whom it is shared with. Funding for this or other similar solutions, is seen as a key enabler for Healthier Together, and other transformation programmes, and will be sought through the GM Digital Fund where required. 55

56 2.11 Risks Key risks are detailed below: Table 2.12: Risks Workforce: Key Risks Ability to recruit required number of consultants to deliver the HT standards Changes to working patterns with new model may ability to retain and recruit staff Impact of training requirements of junior medical staff due to HT impacting service provision at non-hub sites. Mitigating Factors GM Workforce Reference Group to develop strategies focussing on key aspects of programme deliverables including recruitment, assessment of pipeline consultants within the GM system, terms and conditions and consistent application of policy and principles. Collaboration with Health Education England to ensure attractive training propositions for junior medical trainees across GM balanced with service stability for all sites. Established sector workforce and HR groups reviewing recruitment strategies linking to the wider GM picture, with robust staff communication and engagement strategies. Phased implementation plan across GM facilitates a sequential approach to recruitment where appropriate. GM review of clinical pathways to maximise efficient use of the workforce. Clinical Champions input to lead early engagement with staff groups, Unions, colleges etc. Radiology: Workforce challenges to delivery core requirements of HT Sub-specialty delivery of interventional radiology Existing reporting pressures Readiness assessment focusing on cultural aspects of change, supplementary to systems and structural change requirements. Radiology Clinical Advisory Group and Vascular Interventional Radiology sub groups established. with strong links to HT and pathway development, in additional to sectors developing local models to ensure 7 day delivery of level 1 competencies. Radiology standards agreed. Collaborative Image Sharing business case in development to enhance efficiencies and reporting capability. GM Workforce Group focussing on Radiology workforce requirements linked to wider Theme 3 requirements. 56

57 Transfer of Patients: Potential clinical dis-benefit of double ambulance transfers of patients from a non-hub to a hub. The potential dis-benefit of double ambulance journeys continues to be reviewed by the NWAS task and finish group with senior clinicians addressing any potential risks and issues. The evidence from NHS Lothian will continue to be explored in more detail as well as GM initiatives that transfer patients from a receiving A&E site to a specialist centre, such as Neurosurgery, Stroke, PCI, Major Trauma and existing Fairfield & Trafford models. NWAS business case provides sufficient capacity for the transfer of all patients from a non-hub to a hub site, using Optima modelling system to account for additional resources required. Similar models to Healthier Together exist such as NHS Lothian, where patients are transferred from an A&E receiving site to a specialist colorectal site for emergency laparotomy intervention, with excellent patient outcomes such as mortality rates for emergency laparotomy. Examples of existing pathways that transfer patients from one A&E to another, such as Fairfield model for emergency general surgery, Neurosurgery, Stroke, Major Trauma and PCI. Delivery of standards & benefits Healthier Together standards and benefits of the programme not being achieved. Critical Care Compliance: Critical Care services in 2/4 sector hubs not being compliant with National Critical Care Guidance. This is due to workforce shortage of ICM consultants. Equalities: Risk that HT model creates inequity and fails to ensure patient voice heard through the planning and implementation stages. GI Bleed Patients: The risk that patients with life threatening gastrointestinal haemorrhage arriving in ED at non hub sites. Sectors not compliant with NICE/CEPOD standards. Benefits baseline completed in April Shared with sectors. Review and audit process to be developed and agreed with board linking to external independent support to facilitate process with use of audit data, hard copy evidence and peer review. Clinical Benefits dashboard developed and agreed via delivery board and reporting to commence from November 2017 Compliance being managed by Critical Care Network across GM. Risk highlighted to AGG on 21st March Programme Team to liaise with CC Network. Equalities advisory group established alongside the development of Integrated Impact Assessment (IAA) implementation condition with reporting function through the HT delivery board. Delivery of sector level equality impact assessments and patient voice groups and inclusion of patient in various working groups in addition to strengthening links with wider Theme 3 changes. NWAS medical pathfinder has GI haemorrhage included as indication for divert. GI Bleeds pathways under development and shared with sectors via Clinical Alliance. To be assessed as part of go-live plan and readiness asst. Clinical Lead to assure sectors approach. GI Bleeds workshop to be held following sector specific meetings on 26th October

58 Funding: Risk of failure to secure capital via national route Risk of lack of transitional funding to support implementation Stranded costs Risk of failure to agree recurrent revenue impact of delivering Healthier Together System Assurance: The system needs assurance, through the FBC that HT is affordable and deliverable (e.g. that workforce can be put in place) before funding and implementation is agreed The treasury allocated full capital request of 63m on 19 July Following GM approval the FBC will be submitted to national authorities for final approval and release of capital. The commercial case component will be completed now sectors are moving at risk ahead of the release of national funds through the procurement stages to complete the detailed design phase. Transformation Oversight Funding Group decision delivered on 28 June 2017 to support 17.2m and GM CCG monies to the value of 5.5m made available to support the transitional process. A large percentage of the TFOG funding supports any unmitigated stranded costs, with the expectation that organisations and sectors will work to mitigate their available assets. For example linking Theme 3 changes, looking to agreements around reciprocal activity flows, explore independent sector opportunities to deliver work referred to private sector back to the NHS, links with integrated programmes and wider estates strategies. Recurrent revenue agreements in place in two sectors, North West Sector expected to conclude imminently and the GM HSCP to support conclusion of negotiations in South East Sector. Funding oversight provided by the Finance Executive Group. Production of a full FBC agreed with sectors. Governance process approved and Executive function process established. Production of accompanying paper to provide assurance on risks, funding, case for change and value for money to be presented at the Theme 3 executive and finance executive group prior to final approval at the Joint Committee Approval and assurance of the Decision Making Business Case The Decision Making Business Case was ultimately agreed by, and documented the unanimous decision of, the 12 Greater Manchester CCGs (15 th of July 2015). Prior to this approval, a number of other approvals and assurance processes were successfully navigated: The NHS England Investment Committee met on 7 th of July 2015, giving the programme full assurance to proceed with decision making The Service Reconfiguration Oversight Group met on the 9 th of June 2015 and recommended the programme for assurance to the Investment Committee: The OGSCR s recommends to the Investment Committee that the Greater Manchester CCGs are in a position to make a considered decision. The Committee is recommended to approve the CCGs moving to make a decision on the final service and site configuration through their Committee-in-Common. It is also recommended that the ongoing requirement for assurance of the implementation phase is considered alongside broader discussions about the devolution of powers to Greater Manchester. 58

59 The Regional Management Team met on the 1 st of June 2015, recommending the programme to the Service Reconfiguration Oversight Group with the following statement: The North region confirms that the programme is fully aligned with the direction of travel outlined in the 5 Year Forward View, and the development of single service models will support the development of 7 day services in line with national policy. The Greater Manchester Joint Scrutiny Committee: The GM Health and Wellbeing Board have expressed strong support for the Healthier Together programme, and its aims and objectives as part of the wider Health and Social Care reform programme. The Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 set out the responsibilities upon local authorities with regard to consultations by the NHS. In summary, where a responsible person has under consideration any proposal for a substantial development of the health service in the area of a local authority, or for a substantial variation in the provision of such service the person must consult the authority. Where a responsible person consults more than one local authority those local authorities must appoint a joint overview and scrutiny committee for the purposes of the consultation. Only that joint committee may make comments on the proposal under the regulations, request provision of information, and request members or employees of the responsible person to attend it to answer questions. These arrangements were made and regular updates and sign offs undertaken throughout the Healthier Together pre-consultation phase. In addition, Healthier Together attended Greater Manchester Health and Wellbeing Boards between September 2012 and decision making in July Greater Manchester, Lancashire & South Cumbria Clinical Senate: In April 2014, the newly formed Greater Manchester, Lancashire and South Cumbria Clinical Senate received a commission by the Senior Responsible Officer for Healthier Together to provide clinical advice to commissioners that would assure the recommendations made by the NCAT. The group subsequently provided an Independent Clinical Review of Recommendations in June 2014, demonstrating significant progress; either partial or full completion of all outstanding NCAT actions. Those that are partially completed relate to actions required in implementation. Healthier Together then produced a subsequent report describing completion of those actions. National Clinical Advisory Team: NCAT assured the clinical programme work through an informal and formal review of the Future Model of Care. On the 17th December 2013, a panel of NCAT members undertook a formal review of the model of care. The panel met with the Senior Responsible Officers for all three elements of the programme, members of the Clinical Reference Group, Clinical Champions and members of the Programme team. Presentations were given about primary care, integrated care and the hospital elements of the programme. Following the panel the NCAT team endorsed the model of care and provided a report to the Programme: The unanimous opinion of the NCAT panel is to strongly support the programme and to give clinical assurance that the programme can proceed to public consultation. The panel offered strong approval of the programme s ambition, vision and scope together with an impressive public and clinician 59

60 engagement. The commitment to the process of all the Local Authorities, Health and Well Being Boards and all NHS Organisations is hugely impressive. It is the panel s opinion that the programme offers an approach and modelling that is an exemplar for the NHS and its partners as they grapple with improving safety, value and sustainability in financially more austere times. On the 11th September 2013, a panel of National Clinical Advisory Team (NCAT) members had previously conducted an informal review. Panel members included: Professor David Colin-Thomé chair and NCAT input into Primary Care, Long Term conditions and unscheduled care; Professor Kate Costeloe (Paediatrician); Suzanne Truttero (Consultant midwife), and; Mr Tony Giddings (General Surgeon). The NCAT informal review report, sent to Greater Manchester on 27th September 2013 recommended that: The panel expressed support for the ambition, scale and development of the strategy and programme although there are specific issues to be addressed before the formal NCAT review takes place prior to formal public consultation. The NCAT panel for the formal review will include an expert in acute and emergency medicine. NCAT also independently assessed each Trust against national and GM standards, generating a RAG rating and assessment that no GM Trusts is currently meeting all of the standards. Department of Health, Health Gateway Review: The Health Gateway Review Process provides all NHS and other health public sector organisations with confidential independent peer review support for their projects and programmes. Supported by the Cabinet Office and managed by the Department of Health, Health Gateway Reviews provide assurance to programme and project owners that their project is on course to deliver the desired outcomes, on time and within budget. Gateway Reviews are mandatory for all programmes and projects being undertaken by NHS organisations that are assessed as high risk. A Gateway Review is also required prior to public consultation when any service transformation is proposed. The programme completed a Stage 0 review in November The report recognised that a good start had been made but identified the significant challenge and resource constraints facing the programme at that time (now resolved). In relation to the clinical work forming the foundation of the case for change and model of care the confidence assessment comments: A good start to the development of this Programme has been made with very good work undertaken to provide clinically led and compelling cases for change across a number of work streams, together with clear future service visions. There is clear clinical and managerial consensus for the need to change and emerging clarity on the future service visions. A third and final gateway review was undertaken in November The previous review focused on the Programme s readiness for public consultation. This Review followed the public consultation in the period from July to October 2014, and was focused on the Programme s readiness for making a decision on options in July

61 The Review Team was impressed with the progress made by the Programme Team since the last review. A robust Pre-Consultation Business Case was prepared and public consultation was achieved despite a number of challenges. Numerous key stakeholders said that this progress had been achieved because of the clear leadership of the Programme Team and the commitment of team members. Although there were clear challenges within the public consultation process, not least the pejorative interpretations of the nomenclature, there were a number of aspects which we consider best practice. A confidence assessment of amber was given indicating that programme delivery is feasible. All six recommendations were addressed before decision making commenced. A further review was completed in March 2014, the purpose of which was to assess the programme s readiness for public consultation. The review recognised the progress made in relation to developing the clinical standards, and also highlighted the work required to be undertaken in advance of consultation. Seven key recommendations were made and a confidence assessment of amber was given. The programme addressed all recommendations before launching its public consultation. NHS England: NHS England has distinct roles with regard to service change and specifically the Healthier Together programme, they are: offering advice and ongoing assurance (on the integrity and viability) of proposals as overseer of the local health system; and ensuring alignment between change programmes and future strategy as a direct commissioner of services. The Pre-Consultation Business Case (PCBC) was approved by NHS England prior to consultation. Monthly meetings were held between February and June 2014 to review the Pre-Consultation Business Case and supporting documents. This involved information being submitted to the Assurance Panel and questioning of the programme team where necessary. A regular report was prepared by the Area Team Director to the National Service Reconfiguration Oversight Group (SROG) detailing progress and adherence to the aforementioned assurance criteria. NHS England s assurance process identifies that following consultation, proportionate on-going NHS England oversight arrangements will be agreed with commissioners (Effective service change: a support and guidance toolkit, NHS England, 2014). Post consultation, NHS England sought assurance of the following elements: 1. That the consultation and subsequent analysis has been undertaken to best practice standards and all views expressed have been properly taken account of; 2. That the resulting range of options developed by the CiC are strategically coherent from a system point of view, and they align with NHS England s views as a co-commissioner of services for people in GM; 3. Of those options, those which are then progressed to the next stage (for a CiC decision) remain within acceptable financial and quality parameters (as identified in pre-consultation assurance), and the impact of each option (on organisations, sites and population groups) has been fully assessed and is considered acceptable; 4. Any requirement for further consultation or engagement has been properly considered in line with best practice; 5. Stakeholder handling plans are robust; and 6. The implementation framework is robust with risks properly mitigated. 61

62 The Department of Health s four tests for service change were applied at each stage (throughout the programme lifecycle), the tests are: GP commissioner support; a solid clinical evidence base; good engagement; and being mindful of patient choice. Assurance of these elements was undertaken in a phased manner during the post consultation decision making phase of the programme. NHS England and the CCGs Committees in Common agreed a timetable for the assurance of these factors, and worked collegiately to deliver the evidence required. The six elements of assurance were considered in a small number of phases as per the agreement between NHS England and the Committees in Common. This approach was endorsed by the OGSCR chair on 1 May The diagram below summarises some of the evidence provided to NHS England. Table 2.13: Summary of Evidence Provided to NHS England 1 Review of communications and engagement strategy The Reach and Engagement Report outlines the approach taken during consultation to ensure that as many people were engaged and made aware of HT proposals as possible. The report outlines how the consultation was planned, in terms of branding and the key products which were used to share information relating to the changes. It also details the approach to communications and marketing activity (i.e. radio and local media), what materials were distributed and where for maximum impact, and the different types of engagement events which were delivered across the Greater Manchester and relevant boundary area footprint 2 Independent analysis of consultation feedback, including effectiveness of engagement with groups with protected characteristics The Consultation Feedback has been analysed by Opinion Research Services (ORS). ORS were appointed by HT to facilitate aspects of the consultation process and to provide an independent report of the formal consultation programme. As a research practice with wide-ranging experience of controversial statutory consultations across the UK, ORS is able to certify that the formal consultation processes undertaken by Healthier Together has been both intensive and extensive. Overall, ORS has no doubt that the exercise has been conscientious, competent and comprehensive in eliciting the opinions of stakeholders and many members of the public. 3 Audit trail demonstrating how feedback has been drawn into coherent themes of evidence to help shape decision making The Integrated Impact Assessment and accompanying appendices ensured that those involved in the decision making on proposed changes to service configuration understood the impact these had on the population it serves. In particular, attention was given to those groups and communities who may be most vulnerable to changes. The IIA report also outlined mitigating actions which minimise the risk and impact to them. The aim of the IIA was to explore the positive and negative consequences of different options and produce a set of evidence-based, practical recommendations, which could then be used by decision-makers to maximise the positive impacts and minimise any negative impacts of proposed policies or projects. 4 Audit trail demonstrating feedback themes have been fully considered as evidence in developing the range of options The Consultation Feedback Themes explains how consultation feedback has been reviewed, grouped into themes and responded to. The Lessons Learned Report collates both the stakeholder feedback and internal team feedback post consultation process. The report outlines the range of lessons learned and the subsequent actions taken in response to feedback - notably, a revision of the governance structure to maximise stakeholder involvement during the decision making phase of the programme. 5 Options are described in terms that allow strategic coherence to be tested at patient pathway and organisational levels 62

63 The Co-dependency Review Paper outlines service co-dependencies and those in scope of the Healthier Together programme, bearing in mind that co-dependent services do not always need to be offered on the same site. The report details work done both before and after consultation, outlining in particular the work undertaken to respond to consultation feedback. An Independent Clinical Review Team has been established for the purpose of assuring strategic clinical coherence. This process is set out in the agreed Terms of Reference. This group collated detailing work on co-dependencies, organisational information and site maps to understand the issues surrounding the services under review. An independent clinical panel, made up of a bespoke group of clinical experts with professional credibility and independence, reviewed the report and drew attention to any risks for further consideration before progressing their proposals. 6 Proof that consideration has been given to prior commitments made by the NHS and commitments in HT process hold true Healthier Together has a very clear goal and set of commitments: We are committed to shifting resources from hospitals, allowing us to provide the right services for people at home or closer to home. We are committed to people being seen more quickly by their GP, and to helping people to help themselves, where they are able to. The Consultation Feedback Themes provides details of Healthier Together commitments which were reinforced during and after consultation. For example, the promises that no A&Es would be closed as a result of the Healthier Together programme. 7 Demonstrable sign-up from all commissioners (inc. NHS England) to options Satisfied by the Department of Health s 4 Tests: GP Commissioner Support (see element 15 of this table) 8 Evidence of aligned strategic intentions: 1. Alignment with specialised commissioning intentions The scope of specialised commissioning within the context of Healthier Together is adult major trauma. 2. Alignment with Caring Together (East Cheshire) and any other neighbouring programmes Healthier Together can only align its strategic intentions with proposals which are in the public domain. Therefore, at this point in time, it is not appropriate or possible to provide this evidence. 9 Detailed supporting information for each option, allowing analysis of quality and financial implications (to include modelling of activity, financial and workforce implications for each option) A number of groups with representation from hospitals and Clinical Commissioning Groups (CCGs) across Greater Manchester have been set up to provide challenge and assurance on the modelling methodology: Finance and Investment Group (FIG) Data modelling and advisory Group (DMAG) Estates & Infrastructure Group. In addition, BDO LLP was commissioned to provide external oversight and assurance into the Healthier together programme, specifically on the activity, financial, capital and workforce model. BDO have worked with their partners EC Harris and Centre for Workforce Intelligence to provide this assurance. The role of EC Harris was to assure the Estates and Capital infrastructure modelling, whilst the Centre for Workforce Intelligence have reviewed and assured the workforce modelling. 10 Explanation of the interaction between the HT work and the Manchester Devolution work on overall financial sustainability Healthier Together is one of a number of key areas of Devolution work and Theme 3 which is currently collaboratively directed and will be recognised as shared content in the GM Strategic Plan. A Devolution Finance Group has been established to lead on the financial work required to support the development of the Comprehensive Spending Review and the GM Strategic Plan for August The plans will include: 63

64 2015/16 will be the baseline year High level modelling will to identify the likely position and gap over a five year period. The work will be informed by clear principles that organisations can sign up to. It will show a GM rather than locality level position. The principles and first cut of the model will be reviewed at the Directors of Finance Meeting on 19 June A review of the various plans and pieces of work in place A view on what can be achieved through efficiencies and productivity improvements (informed by benchmarking and national studies). The strong platform for collective decision making within Healthier Together has been rolled out to ensure clinically and financially sustainable acute and hospital based services will be delivered through Devolution. The planning assumptions used for Healthier Together are consistency in terms of demand and capacity planning with current service planning. 11 Demonstration that HT does not prejudice the ability to deliver an overall solution to Manchester s financial challenge Financial Modelling - The PCBC referenced 22m of health economy savings, this has been re-tested within this management report and adjusted to 20m. As the 22m was calculated on 2012/13 data, this has been updated as per consultation feedback and consequently health economy savings have been adjusted. As part of this work, the transition and capital investment costs required have also been identified. Links have been made with Chief Financial Officers and Local Authority Treasurers to develop a GM Comprehensive Spending Review, which will calculate the full extent of the GM financial challenge. Healthier Together is one programme of work which will contribute towards the narrowing of the income/spending gap. 12 Impact assessment for each proposal, examining impact by organisation, specific sites, geographical populations, groups of service users, groups with protected characteristics This Integrated Impact Assessment report was produced by Mott MacDonald, with quality assurance provided through an IIA Steering Group. The IIA evidence suggests that there are five protected characteristic groups which have been identified as having a disproportionate need for the services under review. They are: age (older people); disabled people; BAME groups; gender (both men and women) and deprived communities. In addition to the qualitative travel and access challenges which have been identified by stakeholders, analysis has identified that older people (those over 65 years of age), and disabled people to a lesser extent (3-4% and 1-2% respectively), are disproportionately impacted across all options compared to the overall population impacted. Across both the Greater Manchester CCG catchment and the wider study area, the proportion of the population from BAME groups impacted under each of the options is less than the proportion of the overall population. A similar pattern can be seen for deprivation in the Greater Manchester CCG analysis, however, when considering the wider catchment area, for those living in deprived communities, the proportions impacted within three of the options (Options 4.4, 5.1 and 5.2) are higher than the proportions of the overall population potentially impacted. When considering travel impacts in relation to specific equality groups, there is little variation in the proportions impacted compared with the overall population. For those that are impacted there is a higher proportion, Options 4.2, 4.3, 4.4, 5.1 and 5.2 identify that there is a higher proportion of those living in deprived communities who would experience an additional journey time of over 15 minutes compared to the overall population. 13 Impact assessment for specialised services and future intentions Within section 7.8 of the IIA a range of service impacts have been considered, some potentially positive and some negative. Many of these have already been recognised by Healthier Together and its partners and as a result work is already planned or underway to ensure that these impacts have been appropriately considered prior to implementation. This will seek to minimise the likelihood of these 64

65 impacts being realised. Whilst these do not significantly vary within each option, the potential impacts relating to capacity of hospital sites providing high risk general surgical care and ambulance services, and the resilience of services are likely to be greater under the four sites options (Options 4.1, 4.2, 4.3 and 4.4). Achieving workforce standards would have created more challenges under the five site options (Options 5.1, 5.2, 5.3 and 5.4). 14 Any requirement for further consultation or engagement has been properly considered in line with best practice Assured locally: To date, no responses or issues have been identified that would warrant further consultation. Regular updates will continue with GM JOSC. 15 Stakeholder handling plans are robust Assured locally: Healthier Together is working with local Healthwatch organisations to co-design an engagement mechanism which enables patients, carers and members of the community across Greater Manchester to provide assurance and inform implementation planning using patient experience and knowledge of local services. 16 Implementation framework credibly demonstrates how proposals will be implemented, including relationship between key organisation s business plans and alignment with commissioner s intentions. Chapter 20 of the DMBC outlines the potential considerations for implementing Healthier Together, and, incorporating relevant learning from other programmes. This chapter also puts forward a suggested approach for implementation. 17 Ongoing compliance with DH s four tests for service change: 1. Public and patient engagement test Outlined in Chapter 3 of the DMBC 2. Patient Choice The Patient Choice Report details how patient choice has been considered following feedback from public consultation and also on the three in-hospital services- Emergency Medicine, General Surgery and Acute Medicine. This has been considered by our Clinical and Patient Safety Group. 3. GP commissioner support Terms of Reference for Healthier Together Committees in Common outlines how the Healthier Together CiC are to be established and constituted, and voting and decision making arrangements. 4. Clinical evidence base The Co-dependency Approach Paper outlines the relevant clinical considerations for the decision making phase of the programme, alongside the Co-dependency Final Independent Financial Assurance: An independent advisor, BDO LLP, assured the financial analysis (and any updates made in response to public consultation feedback). Independent Clinical Review of Co-dependencies: To support and assure the Healthier Together Co-dependencies work an independent literature review was carried out by the NHS Midlands and Lancashire Commissioning Support Unit. An independent clinical panel was also convened to assure the review of co-dependencies undertaken by the programme post consultation. Assurance and approvals milestones are summarised below. 65

66 Table 2.14: Assurance and approvals milestones NHS England strategic sense check 13 Feb 2014 NHS England Regional Director letter to Area Team Director detailing assurances required 1 May 2014 NHS England Assurance process (inputs included a Clinical Senate review and a Gateway Team review) and formal assurance panel, chaired by Area Team Director May - June 2014 Service Reconfiguration Oversight Meeting 3 June 2014 Extraordinary Service Reconfiguration Oversight Meeting 26 June 2014 Dame Barbara Hakin (National Director, Commissioning Operations) letter to CCGs detailing assurance position 7 July 2014 Healthier Together Consultation Launch 8 July 2014 Regional Management Team Meeting 1 June 2015 Service Reconfiguration Oversight Group 9 June 2015 Investment Committee 7 July 2015 CCG Committees in Common 14 July Approvals and assurance Healthier Together is one of the largest clinical and quality improvement programmes in England, including primary care, joined up care and hospital care. As such, it has been subject to extensive assurance, scrutiny and oversight throughout its programme lifecycle. A myriad of GM groups have convened to input to the FBC inclusive of: Cost and efficiency principles developed by GM Programme Directors, 17 th February Cost and efficiency principles agreed by GM CFOs, 21 st February AGG endorsement of continued strength of the clinical case for change and model of care compliance, 7 th March Finance Executive Group focus on core financial components of FBC, multiple dates. Healthier Together oversight, Q1 2017/18. In addition the following governance approval route has been established to confirm the various elements of the FBC: Theme 3 Executive 12th September - to receive the FBC accompanying paper and a briefing on any outstanding issues in relation to the local and national processes. Recommendation: Theme 3 Executive, on behalf of the Theme 3 Board to sponsor the GM FBC. 66

67 Extraordinary FEG 14th September to receive the GM FBC and accompanying paper. Recommendation: to confirm and assure the financial aspects of the GM FBC and agree any further actions and / or amendments. Joint Committee (as a sub meeting to the existing JCB meeting) - 19th September - to receive the GM FBC and accompanying paper. Recommendation: endorse the GM FBC and reconfirm commissioner support for HT implementation. 67

68 3 Economic Case what is the preferred option and its implication 3.1 Introduction The purpose of this chapter is to describe the process that has already been followed to select a preferred option for the configuration of services in single service networks. This includes: the process undertaken to identify the long list of options and then reduce this to the short list; the options appraisal and governance processes undertaken in 2015 to select a preferred option from the short list; how costs and benefits have since been refined; the net present value of the programme; and how financial benefits will be monitored. 3.2 Longlisting and Shortlisting of options At the Pre-Consultation Business Case stage a long list of seven key options in relation to the configuration of single services was considered. These were: Do nothing Do Minimum - All 10 hospitals increase their workforce to deliver the national and GM clinical standards Designate six hospitals as specialist hub sites Designate five hospitals as specialist hub sites Designate four hospitals as specialist hub sites Designate three hospitals as hub specialist sites Designate two hospitals as hub specialist sites Within each of these five specialist site options there were a number of sub-options depending on which hospital would be the specialist site and which local hospitals would form the single service along with the specialist hub. It was agreed during the Pre-Consultation Business Case that due to the geography of the region and the stated Healthier Together Principles: Central Manchester University Hospitals, Salford Royal Hospital and Royal Oldham Hospital would constitute three of the specialist sites. Three specialist hospitals were too few for the hub and spoke single service model to work. Six specialist sites were too many for the hub and spoke single service model to work. 68

69 The Pre-Consultation Business Case was signed off by the Healthier Together Committees in Common (CiC), NHS England and the Greater Manchester Joint Overview and Scrutiny Committee. The Decision Making Business Case (Outline Business Case) therefore considered four short listed options: Option 1 - Do nothing Option 2 - Do Minimum - All 10 hospitals increase their workforce to deliver the Healthier Together clinical standards Option 3 - Designate five hospitals as specialist sites Option 4 - Designate four hospitals as specialist sites Table 3.1: Summary of shortlisted options Option Overview of options Reason for including Option 1 Do nothing There are no changes to the clinical model and the minimum clinical standards are not delivered at any provider hospital As the control against which to evaluate the other options. Clinically this option is not acceptable. Option 2 All hospitals deliver the standards This option would see all provider trusts increasing the clinical workforce to deliver the standards but would not encourage cross Trust collaboration Delivers the clinical benefits without the need for reconfiguration. Option 3 5 hub sites deliver the standards This option designates 5 hospitals as specialist sites, where workforce would increase to deliver the standards. The hub site would then work collaboratively with other neighbouring trusts to ensure all high risk patients across Greater Manchester could access appropriate clinical care Delivers the clinical benefits and requires Trusts to collaborate in the single service model. Recognises the fact that recruiting staff at all sites is not feasible, both from a recruitment and recurrent cost perspective. Option 4 4 hub sites deliver the standards This option designates 4 hospitals as specialist sites, where workforce would increase to deliver the standards. The hub site would then work collaboratively with other neighbouring trusts to ensure all high risk patients across Greater Manchester could access appropriate clinical care Delivers the clinical benefits and requires Trusts to collaborate in the single service model. Recognises the fact that recruiting staff at all sites is not feasible, both from a recruitment and recurrent cost perspective. 69

70 3.3 Appraisal of shortlisted options A significant amount of analysis and detailed modelling of the four shortlisted options (including four sub-options for options 3 and 4) was undertaken, with sensitivity analysis. This considered: Impact on the volume of activity transferred to the hub site; Implications for the number of beds at all sites; Implications for workforce requirements, based on ability to achieve key quality and safety standards with projected activity; Implications for estates when additional activity is transferred to the hub site; Financial implications, including capital costs and revenue cost impacts; An assessment of the transport and access impact for patients; An assessment of public opinion, developed following feedback from a large scale Public Consultation; and, A risk assessment of each option. The diagram below summarises the analysis. Table 3.2 Capacity, estates, transport and financial impacts of options considered in Decision Making Business Case (OBC) Option Option 1 Activity and beds required Estates requirement Workforce Transport Financial Impact No change No change No change No change No change Do nothing Option 2 All provider trusts deliver the standards No change No change 99 additional consultants 234 other staff No change Capital cost nil Recurrent revenue cost 35.1m Option 3 5 hub sites deliver the standards Activity moves to hub sites, requiring additional beds and theatre capacity at hub sites Capital investment required for inpatient beds, operating theatres and diagnostic services at hub site 54 to 56 additional consultants and 130 other staff No patient would have travel time in excess of 45 minutes Capital cost 30m to 64.6m Recurrent revenue cost 10.3m to 15.0m before revenue cost of capital Option 4 Activity moves Capital 42 to 44 No patient Capital cost 70

71 4 hub sites deliver the standards to hub sites, requiring additional beds and theatre capacity at hub sites investment required for inpatient beds, operating theatres and diagnostic services at hub site additional consultants and 104 other staff would have travel time in excess of 45 minutes 35.8m to 74.8m Recurrent revenue cost 5.1m to 9.1m before revenue cost of capital Options 3 and 4 had a number of sub-options for the different configurations of the single service collaboration model, which is the reason for a range of capital and recurrent revenue impacts. The diagram below describes some of the risks that were also taken into account. Table3.2: Risks considered as part of the shortlisted options appraisal Option Risk Mitigation Conclusion Option 1 Do nothing No improvement in clinical standards. Avoidable deaths would not be reduced Not applicable Not acceptable from a clinical perspective Option 2 All provider trusts deliver the standards Trusts will not be able to recruit all the required staff The recurrent revenue cost of 35.1m would make this option unsustainable Financially unsustainable Option 3 5 hub sites deliver the standards High risk patients would have to travel further to specialist site Trusts will not be able to recruit all the required staff For all options considered, patient travel times were limited to 45 minutes New GM HR processes to be set up to attract and recruit more e.g. national campaigns and joint campaigns between hospitals that struggle to recruit and those that do not NPV (calculated on a cost avoidance basis) ranged from 89m to 98m over 20 years. Option 4 4 hub sites deliver the High risk patients would have to travel further to specialist site Trusts will not be able to For all options considered, patient travel times were limited to 45 minutes HR processes to be set up to NPV (calculated on a cost avoidance basis) ranged from 113m to 128m over 20 years. 71

72 standards recruit all the required staff recruit (as above) Option 4 is the preferred option based on all factors taken together. The net present value (NPV) of the options was calculated, including a separate NPV for each of the sub-options considered within Option 3 and Option 4. The net present value for four sites was higher than the net present value for five sites for all sub-options. On 17th June 2015 the Healthier Together Committees in Common (CiC) voted unanimously for Option 4: four single services. This decision was reached based on a variety of factors including workforce considerations, affordability and value for money, public feedback, and travel and access. Within Option 4 there were twelve sub-options dependent on which site was designated as the fourth specialist site and then the configuration of the single services across Greater Manchester. The table below sets out all twelve options. Table 3.4: Sub-options within option 4 Option reference Suboption Sub option reference Specialist sites a Salford North Manchester Non-hub sites for A&E, Acute Medicine and General Surgery (but might be a specialist site for other services not in scope of Healthier Together) Central Oldham Bolton South Manchester and Trafford Tameside and Stockport Bury and Wigan 2 4.1b Salford North Manchester and Bury Central Oldham Bolton South Manchester and Trafford Tameside and Stockport Wigan 3 4.1c Salford North Manchester and Wigan Central Oldham Bolton South Manchester and Trafford Tameside and Stockport Bury 4 4.1d Salford Wigan Central Oldham South Manchester and Trafford Tameside and Stockport 72

73 Bolton Bury and North Manchester a Salford Bury and North Manchester Central Oldham Wigan South Manchester and Trafford Tameside and Stockport Bolton 6 4.2b Salford North Manchester Central Oldham Wigan South Manchester and Trafford Tameside and Stockport Bolton and Bury a Salford Bolton and Wigan Central Oldham South Manchester North Manchester and Trafford Bury and Tameside Stockport 8 4.3b Salford Bolton and Wigan Central Oldham South Manchester North Manchester and Trafford Bury Stockport and Tameside a Salford Bolton and Wigan Central Oldham Stockport South Manchester and Trafford Bury and North Manchester Tameside b Salford Bolton and Wigan Central Oldham Stockport Tameside and Trafford Bury and North Manchester South Manchester c Salford Bolton and Wigan 73

74 Central Oldham Stockport North Manchester and Trafford Bury South Manchester and Tameside d Salford Bolton and Wigan Central Oldham Stockport North Manchester and Trafford Bury and Tameside South Manchester On 15th July 2015 all 12 CCGs came together as a Committees in Common to select a preferred option for implementation. CiC members received information and presentations for all the criteria (Quality and Safety; Travel and Access; Transition; and Affordability and Value for Money). The committee concluded that most of the criteria did not distinguish between the sub options; the key differentiator between options was travel and access. In light of the evidence, CiC members voted unanimously in favour of option 4.4a as the preferred option for implementation. Table 3.5: Preferred sub-option Option reference Suboption Sub option reference Specialist hub sites a Salford Bolton and Wigan Non-hub sites for A&E, Acute Medicine and General Surgery (but might be a specialist site for other services out of scope of HT) Central Oldham Stockport South Manchester and Trafford Bury and North Manchester Tameside As the decision was taken in July 2015, a review of the options appraisal has been undertaken to ensure the decision is still valid taking into account the updated figures and changes that have happened in the intervening period. The conclusion of this review is that the figures which informed the decision made at the time of the DMBC have not changed materially, meaning that the decision made by the Committee in Common in July 2015 remains valid. On this basis it had been concluded that option 4.4a is still the preferred option for the Healthier Together programme. The details of this review are set out in Appendix Refinement of the costs and benefits of option 4.4a Following the unanimous decision to implement option 4.4a, during 2016 sector teams have conducted a detailed design phase to operationalise the clinical model and to refine cost estimates. The updated figures, presented in the Executive Summary, are reconciled here to the Decision Making/Outline Business Case. 74

75 Table 3.6: Reconciliation of updated cost estimates and Decision Making/Outline Business Case estimates Cost Category DMBC 000 FBC 000 Comment Capital 63,330 63,347 Capital plans have been developed and refined since the DMBC. Current capital costs are within 5% of the DMBC figure. Transitional nonrecurrent revenue 11,550 12,519 These costs relate to implementation costs ( 6,598k) workforce costs ( 4,130k) and revenue consequences of capital ( 1,791k). The revenue consequences of capital have been included in the transitional figures but were not envisaged or quantified at the DMBC stage. In addition there is a risk of Non contracted pay costs of 5,025k and stranded costs of a maximum of 18,490k which have not been included on the basis that these costs are expected to be partially or fully mitigated. Revenue: Income transferring to hub sites Operating costs at hub sites Net operating impact on hub site Consultant workforce cost (40,630) (21,751) Refinements to the clinical model have impacted on the activity transferring to the hub sites, with consequent impacts on income and operating expenses. 34,980 22,204 (5,650) 453 8,926 4,880 A high estimate of consultant cost was used at DMBC which has subsequently been refined to a more realistic figure. Other staff cost Not quantified 8,202 The non-consultant workforce requirement was not quantified in the DMBC, as the non-consultant cost avoided is in proportion to the number of sites designated as hub sites and therefore on a costavoidance basis the non-consultant workforce cost would not have impacted on the decision made. Recurrent revenue consequences of capital 4,999 5,752 The DMBC estimate has been refined and reflects some shorter asset lives driving a higher initial annual revenue consequence of capital. Ambulance costs Not quantified 829 Recurrent revenue costs of ambulance transfers were not quantified in the Decision Making Business Case, but have since been developed following the subsequent audit which proved that the anticipated pathfinder was not viable. 75

76 The table below provides a breakdown of the refined and updated estimate of capital costs, with funding sought centrally. Table3.7: Capital Costs Quantum by Development TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS Further details are provided in the sector Appendices 1 to 4. Revenue costs have also been further refined, including taking account an improved estimate of the workforce requirements beyond Consultants. The current estimate of the Healthier Together revenue impacts on the hub sites are summarised below, and set out in greater detail in the Financial Case and in the sector appendices. Table 3.8: Recurrent revenue costs (does not include any efficiency benefits) Annual Revenue impact of HT 000 MaT NES NWS SES GM TOTAL Income transferring to hub sites (5,647) - (9,734) (6,370) (21,751) Income adjustments with (861) (273) Commissioners Total income transfers (6,508) - (9,734) (5,782) (22,024) Operating costs 4,947-11,303 5,954 22,204 Consultant workforce cost 690 1,759 1, ,880 Other staff cost 1,196 4,988 1, ,202 Other stepped cost of implementation Revenue consequences of capital 693 1,728 2,073 1,258 5,752 Ambulance costs Total gross annual revenue impact 1,557 8,703 6,987 3,575 20,822 At all sites, during the transitional period, there will be non-recurrent costs of implementation. Refined and updated transitional costs are summarised below: Table 3.9: Transition cost breakdown MaT NES NWS SES NWAS GM PMO Total Implementation Costs , ,913 Project Management , ,685 Workforce 2,088 1, ,130 Revenue consequences of capital 728 1,063 1,791 TOTAL 3,188 1,854 5,256 1, ,519 76

77 This table does not include the stranded costs or non-contracted pay costs, on the basis that these costs are expected to be fully or partially mitigated. There is a risk that stranded costs would arise if the loss of general surgery income at a non- hub site could not be matched by the immediate removal of equivalent cost (for example, overhead costs). Stranded costs over 3 years have been calculated (using a consistent methodology across Greater Manchester) as being a maximum of 18.5m. Organisations will continue to work together at both local and STP level to mitigate these costs as far as possible. Funding sources have been identified to underwrite the majority of stranded costs should these eventuate. Greater Manchester is currently reconfiguring more than half of its acute services under Devolution and there is genuine opportunity to address this, although a residual risk remains that stranded costs could remain after the first three years following the service transfers. Work will continue in the relevant sectors to ensure all stranded costs are addressed within the first three years. There is also a risk that non-contracted pay costs of up to 5.0m could be required non-recurrently pending the substantive recruitment of new staff. This figure represents the maximum estimate of the premium element of payments which may be required to secure appropriate staffing if providers are unable to recruit substantively. It is expected that this risk will be partially mitigated through both local and STP level action, and that any non-mitigated element will be funded locally in sectors. 3.5 Benefits Following the refinement of the capital, revenue and transitional costs described above, the programme Net Present Value has been recalculated. As set out above, do nothing is not a viable option as this would be clinically unsafe and does not deliver the required clinical standards. The Do Minimum option, (option 2 - All 10 hospitals increase their workforce to deliver the national and GM clinical standards) is therefore the option against which the economic benefit has been assessed. Once the initial investment phase is completed and full implementation is completed, the annual impact of Healthier Together compared to the Do Minimum option is as follows: Table 3.9: Annual Revenue Impact Annual Revenue impact of HT 000 MaT NES NWS SES GM TOTAL Total gross annual revenue impact 1,557 8,703 6,987 3,575 20,822 Cost avoided (5,480) (12,615) (8,496) (6,414) (33,004) Net annual revenue impact (3,923) (3,911) (1,509) (2,839) (12,182) The costs avoided relate to the costs of additional consultants, their close team and other staff at the non-hub sites who would have been required to delivered the clinical standards at all 10 trusts across Greater Manchester. The 33,004k of avoided cost is comprised of: 24,802k of avoided cost relating to consultants and their close team 8,202k of avoided cost relating to other staff costs 77

78 Consultants and their close team The consultants close team required to deliver the standards at all 10 trusts recognises the fact that consultants do not work in isolation and is based on the following ratios: 0.30 WTE nurses per consultant 0.20 WTE admin staff per consultant 0.15 WTE junior medics (middle grades) per consultant 0.15 WTE junior medics (junior grades) per consultant This methodology was used at the time of the Decision Making Business Case and has been adopted for the benefit analysis, net present value calculation in this full business case. Applying this methodology gives a recurrent revenue cost of 24,802k as the cost of the consultants and their close team required to deliver Healthier Together standards at all sites. Other staff costs Implementing Healthier Together standards involves additional other staff (HCAs, nurses, pharmacists) as well as consultants. These other staff costs were not quantified in the Healthier Together Decision Making Business Case. As sectors have commenced detailed implementation planning, they have now identified and quantified the need for these additional staff. The recurrent revenue cost of these other staff totals 8,202k per year, which is included in the recurrent revenue costs of the programme. To update the counterfactual comparator for the benefit analysis and net present value calculation in this full business case, this same value has been used as an approximation of the cost to deliver at all 10 sites. This is considered to be the most prudent approach, rather than trying to calculate a fictional counterfactual figure. Adopting this approach understates the do minimum position, and consequently understates the Net Present Value and Return on Investment of the scheme. Scheme benefits The base NPV and ROI calculations include the following: Capital costs of 63,347k; The gross annual revenue impact as described above covering (consultant, staff costs and other revenue costs) compared to the Do Minimum case; Non-recurrent revenue transitional costs of 12,519k; the stranded costs of 18,490k; and the non-contract pay costs of 5,025k. 78

79 The NPV of Healthier Together is therefore as follows: Table 3.10: NPV Net present value Gross m Over 20 Years Over 25 Years Over 60 Years This generates a discounted return on investment (ROI) as follows: Table 3.11: ROI Return on investment Return Over 20 Years 2.2 Over 25 Years 2.5 Over 60 Years 4.2 Both the NPV and return on investment figures demonstrate that the Healthier Together clinical model even including the risk of stranded costs and non-contract pay costs provides better value than each Trust delivering the standards on their own. The NPV calculations have not taken into account a number of non-valued benefits associated with the new model of care to minimise the risk of double counting benefits with other on-going clinical efficiency schemes across Greater Manchester. These are: General surgery: reduction in length of stay. General surgery: reduction in readmissions. A&E: reducing admissions. Less time for ambulance teams waiting with patients in corridors. Decreased ED four hour waiting times and 12 hour trolley waits. Improved diagnostics turnaround. Improved outcomes and mortality up to 300 lives saved each year through General Surgery interventions alone. Increased patient and staff satisfaction. The potential benefits from these clinical efficiencies are set out and quantified where possible in Appendix 7. 79

80 3.6 Sensitivity Analysis In order to understand the sensitivity of the NPV and ROI on the key assumptions a best case and worst case have been assessed. Best case scenario The assumptions in the best case scenario are: Only 50% of stranded costs are realised as other mitigating actions reduce these costs; Staff costs of HT model are 25% lower than currently forecast. In this case the NPV and ROI are as follows: Table 3.12: NPV & ROI Best Case Best case scenario Over 20 Years Over 25 Years Over 60 Years NPV 'm ROI Worst case scenario The assumptions in the worst case scenario are: capital costs are understated by 25%; transitional costs 25% understated; stranded costs exist at Tameside until 2026/27; and staff costs to deliver Healthier Together are understated by 25%. Table 3.13 NPV & ROI Worst Case Worst case scenario Over 20 Years Over 25 Years Over 60 Years The sensitivities run in this worst case scenario are considered to address all the major cost streams and risks identified. The above calculation demonstrates that even under this scenario Healthier Together still delivers a positive NPV, even over 20 years and delivers a positive return on investment. NPV 'm ROI 80

81 4 Commercial case Financing the preferred option and procurement 4.1 Introduction Due to the significant costs involved, Trusts did not commence detailed design work at risk prior to the identification of a capital funding source. Consequently, detailed design work did not begin in earnest until the 2017/18 financial year. At the date of this business case, and following the identification of a capital source for the programme, all sectors are working to develop detailed designs to support a full commercial business case. It is expected that supporting commercial case content will be available for the South East and Manchester and Trafford sectors by December 2017, with the North West and North East sector commercial case content available early in The commercial case within this September 2017 business case is therefore limited to a high level summary of the physical capital requirements of the programme, the estimated costs of that requirement, and how this will be financed. 4.2 Physical capital requirement and cost of that requirement The physical capital requirement of the proposals in each sector is largely driven by the level of general surgery activity transferring from non-hub sites to hub sites and constraints of the existing estate and capacity in the sector. Each hub site will require additional ward and theatre capacity to serve the additional general surgery activity which will be met at the hub site. In the M&T and SES sectors, reconfiguration and extension works are required to meet this requirement. In the NES and NWS, existing capacity constraints require new buildings to house the additional wards and theatres required. Table 4.1: Physical capital requirement in each sector Sector Requirement Manchester and Trafford 2 wards, 3 critical care beds 1 theatre At Central Manchester Foundation Trust, the hub site, the Trust will develop 2 wards to house both the elective and non-elective activity that will transfer. The areas are currently in use by other services, which will be decanted and rehoused to accommodate the new wards. The Trust will also develop an additional emergency theatre in a shelled area in the existing main theatre footprint to accommodate the additional non-elective/emergency activity and the semi-planned theatre lists associated with the Ambulatory care service. Critical care will be expanded by 3 beds in a shelled area of the newly created surgical high level dependency/step down unit. Existing Ambulatory Care space on both sites be reconfigured to facilitate the new Ambulatory Care model (with extended patient assessment and opening into evenings and weekends). A small amount of additional 81

82 Sector Requirement equipment will allow for a more comprehensive assessment and treatment to prevent unnecessary admission. There is a risk that an additional 200k of capital costs will be incurred. This is currently being assessed within the sector. North East Sector 2 wards 4 critical care beds 1 theatre Pennine Acute Hospitals Trust, which operates 4 hospitals In the North East sector, will construct a new 2 storey building at first and second floor levels on the Royal Oldham hospital site to provide 2 surgical wards and one theatre. It will also include a critical care ward (given that the additional critical care capacity required cannot be incorporated within the current landlocked footprint). North West Sector 2 wards 6 critical care beds 2 theatres (one elective and one non-elective) Salford Royal Foundation Trust, which manages one hospital in Salford, has been selected as both a hub site for Healthier Together and the single Major Trauma Centre for Greater Manchester. SRFT have already cleared space for the erection of a new four storey building to allow for both the additional Healthier Together and Major Trauma activity. This includes inpatient beds, critical care beds and two new theatres South East Sector Equipping 1 ward Equipping critical care beds Equipping theatre Expanding A&E Expanded CT Expanded Endoscopy Stockport Foundation trust will create a larger, 6 bedded, Resus suite to accommodate the additional high acuity demand, with the old space used to introduce 4 dedicated consultant-led Rapid Access Treatment trolleys The Trust will develop a two storey design which will minimise the potential for patients to have to wait in corridor space, and increase clinical capacity, including an additional theatre It will also rehouse some of the activity currently undertaken in the Cardiac Catheter and Pacing Lab, which currently sits in the A&E footprint into the new theatre complex, allowing the development of a Frailty Assessment Unit The timing of the capital cost is anticipated to span 5 years. For MaT sector and SES the majority of costs will be incurred in 2017/18. However, for NES and NWS, where significant new buildings will be 82

83 required, the capital cost will span a longer timeframe. This is set out in the table below and in the sector appendices. Table 4.2: Phasing of Capital Costs TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS 4.3 How this will be financed The following options have been considered for funding the developments described within this business case. Private Funding Public Funding: PDC Public Funding: Capital Investment Loan Internal Cash Resources A quantitative and qualitative assessment of each option is set out below. Table 4.3: Assessment of funding options Funding option Private Funding 3.5% interest Total annual cost 2.2m Description Other considerations Viable option This would involve the hub site trusts borrowing money from a private sector partner such as a commercial bank or through a commercial partner Based on 2016/17 audited accounts for the four hub site trusts: Central Manchester Hospitals NHS Foundation Trust reported a deficit for the year of 94.7m. Pennine Acute Hospitals NHS Trust reported a deficit for the year of 2.4m following receipt of 43.9m of nonrecurrent support. No Salford Royal NHS Foundation Trust reported a surplus for the year of 9.9m. Stockport NHS Foundation Trust reported a deficit for the year of 6.3m. The financial position of the trusts in question and the length of the programme payback period mean that this option is likely to be difficult and prohibitively time-consuming to access. Given this, a private funding option is not considered viable at this time due to the imminent capital requirement to support the planned go live dates 83

84 Public Funding: PDC 3.5% interest Total annual cost 2.2m Public Dividend Capital is only available in exceptional circumstances to support capital investment in NHS trusts. Such circumstances include where a trust has a zero or low prudential borrowing limit and/or where a major capital scheme forms part of the financial recovery of the trust. The DH reviews the policy on providing exceptional PDC annually. Assets that have been financed using PDC are subject to a capital charge of 3.5% on average net book value Hub site trusts would need to demonstrate the capability to service the loan and/or capital charges Yes Public Funding: Capital Investment Loan 4.0% interest Total annual cost 2.4m Capital Investment Loans another funding option available to the trusts is through interest bearing Capital Investment Loans accessed through NHS Improvement, with final approval for funds required coming from DH itself. Unlike PDC, Capital Investment Loans have a fixed repayment term and the value of the asset is offset by the outstanding principal value of the loan, hence effectively removing the 3.5% capital charge, to be replaced with the principal and interest repayment profile of the Capital Investment Loan. Market testing indicates interest rates of around 4% are anticipated Hub site trusts would need to demonstrate the capability to service the loan and/or capital charges Yes Internal Cash Resources There are a number of potential options available to the hub site trusts to fund the investment from internal cash resources. These include utilising revenue surpluses, sales proceeds from owned assets and working capital Given the challenging financial position of the hub site trusts and other estate development plans, an internal cash resource funding option is not considered viable at this time No For the reasons described above, public funding is considered to be the only viable option for funding the Healthier Together developments. 84

85 5 Financial Case cost implications of the preferred option This following section describes the affordability and sources of budget funding for the preferred option, 4.4a. 5.1 Capital Costs Summary of capital requirements The capital requirement for Healthier Together (HT) amounts to 63.3 million across Greater Manchester. By sector, the breakdown of this cost is as follows: Table 5.1: Breakdown of capital investment by sector Sector Requirement Manchester and Trafford 2 wards 3 critical care beds 1 theatre At Central Manchester Foundation Trust, the hub site, the Trust will develop 2 wards to house both the elective and non-elective activity that will transfer. The areas are currently in use by other services, which will be decanted and rehoused to accommodate the new wards. The Trust will also develop an additional emergency theatre in a shelled area in the existing main theatre footprint to accommodate the additional non-elective/emergency activity and the semi-planned theatre lists associated with the Ambulatory care service. Critical care will be expanded by 3 beds in a shelled area of the newly created surgical high level dependency/step down unit. Existing Ambulatory Care space on both sites be reconfigured to facilitate the new Ambulatory Care model (with extended patient assessment and opening into evenings and weekends). A small amount of additional equipment will allow for a more comprehensive assessment and treatment to prevent unnecessary admission. There is a risk that an additional 200k of capital costs will be incurred. This is currently being assessed within the sector. North East Sector 2 wards 4 critical care beds 1 theatre Pennine Acute Hospitals Trust, which operates 4 hospitals In the North East sector, will construct a new 2 storey building at first and second floor levels on the Royal Oldham hospital site to provide 2 surgical wards and one theatre. It will also include a critical care ward (given that the additional critical care capacity required cannot be incorporated within the current landlocked footprint). North West Sector 2 wards 6 critical care beds 2 theatres (one elective and one non-elective) 85

86 Sector Requirement Salford Royal Foundation Trust, which manages one hospital in Salford, has been selected as both a hub site for Healthier Together and the single Major Trauma Centre for Greater Manchester. SRFT have already cleared space for the erection of a new four storey building to allow for both the additional Healthier Together and Major Trauma activity. This includes inpatient beds, critical care beds and two new theatres South East Sector Equipping 1 ward Equipping critical care beds Equipping theatre Expanding A&E Expanded CT Expanded Endoscopy Stockport Foundation trust will create a larger, 6 bedded, Resus suite to accommodate the additional high acuity demand, with the old space used to introduce 4 dedicated consultant-led Rapid Access Treatment trolleys The Trust will develop a two storey design which will minimise the potential for patients to have to wait in corridor space, and increase clinical capacity, including an additional theatre It will also rehouse some of the activity currently undertaken in the Cardiac Catheter and Pacing Lab, which currently sits in the A&E footprint into the new theatre complex, allowing the development of a Frailty Assessment Unit Capital funding The Greater Manchester Health and Social Care Partnership (GMHSCP) submitted a bid for the full 63.3 million (alongside a capital bid of 30m for Major Trauma) to NHS England in May In mid-july, the GMHSCP were informed that Greater Manchester has been awarded the full capital requested for both the Healthier Together and Major Trauma programmes. This is made up partly of STP funding and partly from DH Capital. The receipt of capital funding is contingent on completion of an appropriate Full Business Case Comparison to the DMBC The table below shows that the overall revised capital cost of HT is consistent with the estimate set out in the Decision Making Business Case (DMBC), however there has been movement between the sector requirements and this is described: Table 5.2: Capital Funding Reconciliation to DMBC TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS 86

87 Transitional Costs Non recurrent revenue costs Transitional (non recurrent revenue) costs relating to implementation have been categorised in the following manner: Implementation Costs: This relates predominantly to preparatory works e.g. building design and site clearance. Project Management: These costs have been calculated at both sector and GM level on a post by post basis. Workforce: This relates to additional staffing required over and above 'business as usual' as the new clinical model embeds. Revenue Consequences of Capital during transition: This is the PDC cost of the new builds in two sectors where the asset construction spans two financial years Transitional costs of implementation totalling 11.7m will be funded by the Greater Manchester Transformation Fund. These are set out in the table below. Table 5.3: Transitional Funding 000 Manchester and Trafford sector North East sector North West sector South East sector NWAS Total Implementation Costs , ,913 Project Management , ,875 Workforce 2,088 1, ,130 Revenue consequences of capital 728 1,063 1,791 TOTAL 3,186 1,854 5,256 1, ,709 In addition, Greater Manchester Project Management costs of 809k will be met through Greater Manchester CCGs, bringing the total of non-recurrent revenue costs to 12,519k IT costs of implementation (DataWell) IT costs relating to the implementation of DataWell have already been funded or are expected to be met through the GM Digital Fund. As the DataWell IT solution is already being progressed across Greater Manchester to support the provision of a number of different clinical services, the costs of DataWell implementation have not been attributed to the Healthier Together business case. 87

88 5.1.6 Residual stranded costs at non-hub sites During the transitional period, there is a risk that stranded costs will arise at non-hub sites. Stranded costs would arise if the loss of general surgery income at a non-hub site could not be matched by the immediate removal of equivalent cost (for example, overhead costs). As the North East sector is one trust, no stranded costs are expected in this sector. This is on the basis that there will be no change in income and therefore no impact on corporate overheads, and that operating costs will be managed between hospital sites within the trust. Stranded costs over 3 years have been calculated at the non-hub sites (using a consistent methodology across Greater Manchester) as being a maximum of 18.5m. This is set out in the table below. Table 5.4: Stranded Costs / / / / / / 23 Total Manchester and Trafford UHSM NHS FT 398 1,673 1, ,062 North West Sector Bolton NHS FT Wrightington Wigan and Leigh NHS FT ,408 1,566 1,256 5,230 South East Sector Tameside and Glossop Integrated Care NHS FT - 2,953 3,452 1, ,432 TOTAL 398 4,626 5,444 4,638 2,128 1,256 18,490 These costs have been calculated by applying a consistent methodology, which ignores the existing loss attributable to general surgery provision at non hub sites. In the Manchester and Trafford sector, the stranded cost figures presented above assume full abatement of stranded costs two years after the merger of Central Manchester University Hospitals NHS FT and University Hospital South Manchester NHS FT. Full mitigation within the timeframes envisaged is expected to present a significant challenge in the South East sector, due to the imminent timing of implementation and the quantum of fixed and overhead costs involved at Tameside and Glossop Integrated Care NHS FT. Organisations will continue to work together at both local and STP level to mitigate these costs as far as possible, and over time these stranded costs are expected to work out of the system. Greater Manchester is currently reconfiguring more than half of its acute services under Devolution, providing genuine opportunity to mitigate stranded costs at acute provider sites. Funding sources have been identified to underwrite the majority of stranded costs (up to 10.92m) should these materialise. This funding would be met by the Greater Manchester Transformation Fund (up to 5.46m) and Greater Manchester CCGs (up to 5.46m), with the remainder to be funded locally by the affected providers. 88

89 5.1.7 Non contracted pay costs In addition to the transitional costs described above, there is a risk that non-contracted pay costs of up to 5.0m could be required non-recurrently pending the substantive recruitment of new staff. The maximum costs anticipated are set out below: Table 5.5: Non Contracted Pay Costs / / / / 21 Total North East Sector 666 1,997 1,548-4,211 North West Sector South East Sector TOTAL 666 2,480 1, ,025 The 5,025k represents the maximum estimate of the premium element of payments which may be required to secure appropriate staffing if providers are unable to recruit substantively. It is expected that this risk will be partially mitigated through both local and STP level action, and that any nonmitigated element will be funded locally in sectors. This risk is most material in the North East sector where non contracted pay costs are estimated at up to 4.2m. Therefore, North East providers and commissioners are reviewing their implementation plans and are bringing forward the timing of their consultant recruitment. Given existing workforce in the sector, the Manchester and Trafford sector do not anticipate difficulty in recruiting substantively. Consequently, no non contracted pay costs are expected in this sector Phasing of transitional costs The phasing of the non-recurrent transitional costs (as set out in para above) relating to implementation is summarised below. This table does not include the stranded costs or non contracted pay costs set out above, on the basis that these costs are expected to be fully or partially mitigated. Table 5.6: Transition Costs Phasing / / / / 21 Total Manchester and Trafford 1, ,186 North East Sector ,854 North West Sector 1,865 2,306 1,086-5,256 South East Sector ,163 NWAS Greater Manchester PMO TOTAL 5,751 4,080 2, ,519 89

90 5.1.9 Comparison to the DMBC The table below compares the programme transitional costs of 12.52m above with the 11.55m of transitional costs that were estimated in the Decision Making Business Case. Table 5.7: Reconciliation of Transition Costs between Full Business Case and Decision Making Business Case (DMBC) Revenue Transitional 000 DMBC FBC Commentary IT Cost 1,000 - IT costs relating to the implementation of DataWell have already been funded or are expected to be met through the GM Digital Fund. As the DataWell IT solution is already being progressed across Greater Manchester to support the provision of a number of different clinical services, the costs of DataWell implementation have not been attributed to the Healthier Together business case. Implementation Cost 6,000 6,598 In line with the DMBC. Relates to 1.91m of Implementation Cost and 4.68m of PMO costs across sectors and centrally. Ambulance Cost Lower than the OBC - anticipated ambulance costs related to the development of the general surgery pathfinder. As this is no longer considered clinically viable, this development cost will not be incurred. Workforce 4,100 4,130 In line with the DMBC. Revenue Cost of capital 1,791 At DMBC stage revenue consequences of capital were valued but were not classified alongside other Implementation Costs. TOTAL TRANSITIONAL COSTS AS ENVISAGED AT DMBC 11,550 12,519 There has been 8% increase from DMBC, due in the main to the inclusion of the revenue cost of capital figure, which has now been quantified. 5.2 Revenue Costs The recurrent revenue impact of Healthier Together, when compared to current Do Nothing provision, consists of: Activity moves impact at hub: This is the income relating to the general surgery activity which is transferring from non-hub sites to hub sites, offset against the related operating expenditure required to deliver that activity to current clinical standards. Healthier Together Standards: This is the cost required to meet the Healthier Together clinical standards, and includes consultant cost, other staff cost and some non-staff costs. Revenue consequences of capital: This is the annual PDC and depreciation charges associated with the capital investment required for the programme. 90

91 Ambulance costs: These are the costs of the additional ambulance conveyances from nonhub to hub sites. These costs were not anticipated in the DMBC but have subsequently been deemed to be necessary due to the non-viability of the anticipated clinical pathfinder The recurrent revenue impacts by sector are set out in the table below, and are further disaggregated and described in the sector appendices. Table 5.8: Recurrent Revenue Impacts Summary Recurrent Annual Revenue Impact ( 000) Activity moves impact at hub Healthier Together standards Revenue consequences of capital Ambulance Costs Manchester and Trafford (1,561) 2, North East sector - 6,747 1, North West sector 1,569 3,197 2, South East sector 172 1,916 1, TOTAL ,060 5, Ambulance costs of 829k will be funded by commissioners as part of the GM ambulance commissioning round. In Manchester and Trafford and the North East sector, providers and commissioners have reached agreement on the funding of the other recurrent revenue impacts. These agreements will require ratification through local Trust Boards and CCG Governing Bodies following Greater Manchester approval of the Healthier Together Business Case. In the North West sector and in the South East sector, providers and commissioners have reached partial agreement on the funding of the recurrent revenue impacts. Work continues to urgently complete and finalise these agreements. Healthier Together standards costs include consultant costs, other staff costs and some non-staff costs, and are further disaggregated below. 91

92 Table 5.9: Recurrent Revenue Impact Recurrent Annual Revenue Impact ( 000) Consultant costs Other staff costs Non staff costs TOTAL Manchester and Trafford 690 1, ,200 North East sector 1,759 4,988-6,747 North West sector 1,487 1,710-3,197 South East sector ,916 TOTAL 4,880 8, ,060 Comparison to the DMBC The table below compares the recurrent revenue impacts to those envisaged in the Decision Making Business Case. Table 5.10: DMBC costs Cost Category DMBC 000 FBC 000 Comment Consultant workforce cost 8,926 4,880 A high estimate of consultant cost was used at DMBC which has subsequently been refined to a more realistic figure. In addition, baseline consultant numbers have changed since the time of the DMBC. Other staff cost Not quantified 8,202 The non-consultant workforce requirement was not quantified in the DMBC, as the nonconsultant cost avoided is in proportion to the number of sites designated as hub sites and therefore on a cost-avoidance basis the nonconsultant workforce cost would not have impacted on the decision made. Revenue consequences of capital 4,999 5,752 The OBC estimate has been refined and reflects some shorter asset lives driving a higher initial annual revenue consequence of capital. Ambulance costs Not quantified 829 Recurrent revenue costs of ambulance transfers were not quantified in the Decision Making Business Case, but have since been developed following the subsequent audit which proved that the anticipated pathfinder was not viable. 92

93 6 Management case The following section describes the management of the programme, including programme governance; team management structure; resourcing and roles and responsibilities; programme planning; risk management and benefits management. 6.1 Programme Governance The programme governance was revised for implementation in October 2016 in response to the GM H&SC Partnership changes and from February June 2017 with the addition of the Healthier Together Executive chaired by the Programme Sponsor (Chief Officer of the Greater Manchester Health and Social Care Partnership, Jon Rouse). The delivery of Healthier Together is overseen by the Healthier Together Delivery Board which is independently chaired, and reports into the Theme 3 Board, as part of the formal governance of the Greater Manchester Health and Social Care Partnership. The revision of the governance in October 2016 agreed the standing down of the Healthier Together Joint Committee, with the Joint Commissioning Board (see wider Health & Social Care Partnership Governance) taking over the role of future Greater Manchester commissioning decisions. Until such time as the Joint Commissioning Board is legally constituted to take on this role, the Healthier Together Joint Committee can be convened as required. The current governance structure for the programme is summarised below: Figure 6.1: Healthier Together Programme Governance 93

94 The Summary roles of the Healthier Together Governance Groups are described below: Table 6.1: Healthier Together Governance Groups Group Membership Frequency Summary purpose Theme 3 Board Theme 3 Executive Lead Provider Executives, Commissioner Executives, Local Authority Representative(s), Finance and Estates Representatives, GP Provider(s), Patient representative(s), Clinical representative(s), Other Theme leads and enabling work stream leads Monthly Oversee and assure the development of a long term strategy for acute and specialised services (A&SS) across GM. Oversee and assure the development of the clinical model and associated strategies (workforce, estates, digital) to deliver the AS&S strategy. Oversee and assure the development of an options appraisal for the delivery of the A&SS strategy. Receive assurance that changes affecting hospital services are in line with the emerging strategy e.g. Healthier Together implementation. Receive assurance that interdependencies between Theme 3 and the other Taking Charge Thematic Groups are managed. HT Delivery Board CCGs & Providers (including NWAS), PMO reps (TU and sectors) Monthly Forum for commissioners, providers and sector leads to oversee delivery of the agreed model of care. Reporting and assurance of single service (sector) progress. Highlight and agree management of strategic risks. Highlight and agree issues that would benefit from a GM approach. Provide oversight for implementation readiness. GM Clinical Alliance HT Chief Medical Advisor, Clinical Champions, Single Service Clinicians, NWAS Monthly Guardians of the Healthier Together model of care and standards. Oversee the development of consistent patient pathways. Assure clinical go-live readiness of each single service. Support the management of clinical risk 94

95 during implementation. Reduce variation between single services by sharing best practice. Sector Governance Each of the four sectors has been responsible for determining their own local governance and reporting arrangements between the relevant provider and commissioner partners. As part of the overall programme governance, each sector is required to report monthly, in writing, to the Healthier Together Delivery Board via a standard status reporting template created for this purpose. This status report covers the clinical, estate / capital, workforce, financial and communication / engagement activities required to implement Healthier Together. This status report has been in place since January Clinical Oversight of Healthier Together As part of the reconfiguration decision taken in July 2015, GM commissioners specified a number of implementation conditions attached to the implementation of the programme. Two of the conditions specified by commissioners related to clinical oversight of the programme: Condition 3 - Establishment of a Greater Manchester Clinical Alliance Condition 5 Appointment of GM clinical leadership for implementation These conditions have been addressed in the way the programme has been structured for implementation. This is described below. Appointment of GM clinical leadership for implementation The following clinical leadership roles were appointed to in spring 2016 to support implementation planning: Healthier Together Chief Medical Advisor Clinical Champion A&E Clinical Champion Acute Medicine Clinical Champion General Surgery Clinical Champion Anaesthetics & Critical Care Clinical Champion Senior Nurse Clinical Champion - Radiology Clinical leadership has recently been reviewed for 2017 with the following agreed until 31 March

96 Table 6.2: Clinical Champion Resourcing Clinical leadership for implementation Sessions / PAs per week Chief Clinical Advisor 2 Emergency medicine Clinical Champion 0.5 Anaesthestics/Critical Care Clinical Champion 0.5 General Surgery Clinical Champion 1 Radiology Clinical Champion 1 Establishment of a Greater Manchester Clinical Alliance The GM Clinical Alliance was established in February 2016, and clarification of its role was provided to and endorsed by the HT Delivery Board in April The role of the Alliance is to ensure the clinical effectiveness of the programme. Membership brought together the core Healthier Together clinical team (Chief Medical Advisor and six Clinical Champions) with clinical leadership from the four sectors. It has also brought together much wider clinical representation through sharing events and clinical workshops. The initial clinical approach included development of GM pathways for paediatric general surgery, radiology and NWAS. GI haemorrhage was later identified as an interdependent service that also required a unified approach. Clinical groups for each of these specialties were later established Key outputs from the Clinical Alliance The clarification of the model of care for general surgery was ratified by the 12 CCG leads and representatives in April The paper was developed in order to provide clinically focussed clarification of the definition of high risk general surgery, to support sectors in development of their local model of care. To ensure the model was aligned with the latest clinical guidance it was produced following review of the latest data and evidence from the National Bowel Cancer Audit, National Emergency Laparotomy Audit and other sources to identify patients at highest risk using, for example, trends in unscheduled returns to theatre. In addition, the clarification paper drew on The Nuffield Trust s definition of high risk case mix (Emergency General Surgery: Challenges and Opportunities, 2013). The National Emergency Laparotomy Audit (NELA) aligns well to the pathway and clinical standards for general surgery and is be a key source of data to monitor progress against the standards and, ultimately, realisation of the benefits. As is shown in the case for change there is a significant way to go to meet the standards. Following the audit, GM results for years 1 and 2 were shared through the Clinical Alliance. In audit year 3 a HT NELA dashboard was produced to encourage sharing of data and best practice across GM in real time. The dashboard shows real-time performance against some of the standards, supporting sector teams to monitor improvements in between annual audit publication. The Clinical Alliance has proven to be an impactful way to share the latest clinical guidance and best practice. Through the Clinical Alliance other audit results have been shared for discussion and 96

97 identification of areas for improvement, including National Cardiac Arrest Audit (NCAA) and National Bowel Cancer Audit (NBOCA). A variety of other best practice has been shared through themes at the Clinical Alliance, for example guidance on Ambulatory Care and presentations from sector leads whose ambulatory care provision was already showing demonstrable benefits. Dedicated workshops were held around Colorectal MDTs and ERAS+ in December Colorectal MDTs are to be established in all sectors by Quarter /18. A common set of principles for MDTs were agreed. Outputs and quantifiable benefits were also identified to facilitate progress monitoring and shared best practice. ERAS+ optimises pre-operative care for high risk elective surgery and colorectal cancer patients and offers enhanced post-operative recovery in order to reduce complications and adverse outcomes including mortality, longer length of stay or reduced long term survival rates. It has been projected that reduced length of stay can result in 500k annual savings for large hospitals. Due to the link with high risk general surgery Medical Directors agreed that Healthier Together would be an appropriate vehicle to support delivery of ERAS+ in GM. Progress so far includes the establishment of a GM Steering Group, development of the project plan and the first draft of the business case. UHSM are expected to go live in April 2017, with six trusts to follow by January Wider GM Clinical Sharing Events The Clinical Alliance has hosted three wider sharing events, bringing together many more clinical and programme representatives from all sectors with two purposes: For sector HT teams share their local models of care and plans with each other, For GM clinical leads to share guidance and GM models and pathways. Three sharing events have been held so far. All three events were very well attended by sector representatives including clinical staff, programme teams and other senior managers from all trusts participating in Healthier Together. On 18th August 2016 the first event was held focussed on sector general surgery models of care. On 8th December 2016 the second event focussed on sector medical models of care. On 9th February 2017 sectors shared their progress and lessons learned. GM presentations included proposed models for radiology, paediatric general surgery and GI haemorrhage plus a presentation on developing a blended workforce for A&E. On 5 th May sectors participated in a sharing event for workforce models of care in general surgery and clinical pathway design. 97

98 Clinical work-streams and sub-groups Radiology To ensure a coordinated approach to radiology services a single Clinical Champion was appointed to provide guidance to both Healthier Together and the Collaborative Imaging Procurement Project (CIPP). A single Radiology Clinical Advisory Group (CAG) was also established with the remit of providing clinical guidance for both projects. Both projects and all GM trusts are represented on the CAG, and they are supported by a single project manager from the TU. The five work streams identified in the Scope of GM Radiology paper (approved by the Delivery Board in July 2016) were: Support the re-procurement of a PACS/VNA system for Greater Manchester; Review the Healthier Together clinical standards for radiology; Delivery of resilient radiology models in each sector to meet the Healthier Together standards; Deliver sector based non-vascular interventional radiology; Deliver a pan Greater Manchester solution for vascular interventional radiology. The first meeting took place in July 2016; the CAG are now a well-established group with good engagement from all GM trusts and two sub-groups of the CAG were established to represent interventional radiology. The quality and safety standards pertaining to radiology were reviewed and re-written to align with the NHS 7-day service standards. New clinical standards have been agreed for Vascular Interventional Radiology (VIR) and Non-Vascular Interventional Radiology (NVIR) via the sub-groups. These services were not included in the original Healthier Together standards but are now recognised as pivotal to the pathway as they deliver life-saving interventions for sepsis and GI haemorrhage. Trusts have completed self-assessment against the new clinical standards. Consensus on core, intermediate and advanced/complex competencies for NVIR has been reached and a review of the skills mix and competencies in GM has been completed. It has been established that sector NVIR rotas will be necessary to ensure 7-day cover with an appropriate skills mix. A pan- GM solution for VIR will now be delivered through the theme 3 vascular services reconfiguration. Compliance with the clinical standards is likely to remain challenging, even in light of joint working. Radiology services are under immense strain with workforce numbers failing to keep pace with the increasing demand for scans and x-rays. The Royal College of Radiologists (RCR) workforce census (2015) highlights what they call an ongoing crisis and notes that the North West has the highest number of vacant posts in the UK. Workforce gaps are causing increasing reliance on outsourcing (the cost in GM is estimated at 10m per year). In addition to cost there are some clinical risks associated with outsourcing, including higher discrepancy rates, which have not been understood until recently. In February 2016 the Radiology CAG were asked to participate in a Provider Federation Board sponsored workshop to develop a GM vision for Radiology Services that would maximise current capacity and create a more sustainable service. It is likely the role of the CAG will 98

99 be expanded creating to cover wider GM improvement initiatives ensuring a coordinated long term strategy to meet increasing and conflicting demand. Paediatric General Surgery Post public consultation a co-dependency framework was developed, and paediatric general surgery was identified as a co-dependent service with implications for the safe implementation of Healthier Together. The co-dependency is related to paediatric general surgery services, calling upon Healthier Together in-scope services, namely adult general surgery. It was concluded that paediatric general surgery was moderately dependent on the Healthier Together in-scope services and as such would require support from Emergency and High Risk Elective General Surgery (24/7) via a robust pathway or on-call arrangement. It was agreed that robust pathways for paediatric general surgery would have to be in place within a sector before any patient movement under the Healthier Together programme. A task and finish group was established in June 2016 with leads and key clinicians from the Strategic Clinical Networks (SCN) and Senate Greater Manchester, Lancashire and South Cumbria (NHS England), the Children s Surgery Operational Delivery Network and Healthier Together. Leads for general surgery and anaesthesia joined the group, and input was obtained from the paediatric radiology lead. The group have developed and agreed clinical standards for paediatric general surgery, anaesthesia and radiology. The group have now agreed the clinical pathways which specify when a child should be treated at the tertiary site (RMCH), surgical hub site or other sites with a paediatric inpatient unit. The Partnership Board have agreed that North West sector require an exception to the GM model as the surgical hub (SRFT) does not have an inpatient paediatric unit. It is expected that the sector will make a decision on which site will provide emergency paediatric general surgery by October The group suggested that it would be valuable to have a Clinical Governance Board for paediatric emergency general surgery, hosted by Royal Manchester Children s Hospital (RMCH) to support the effective delivery of these pathways and ensure care provided to children requiring emergency general surgery meets the prescribed standards. As part of this, it has also been identified that an educational group should be convened to look at what is required to build confidence and competence outside of RMCH for emergency paediatric general surgery. These groups will be composed of clinical representatives from specialities across each of the Healthier Together sectors and will report into the Health and Social Care Partnership governance structure. Gastrointestinal haemorrhage A task and finish group for GI haemorrhage was established in November 2016 and brings together consultant gastroenterologists and vascular interventional radiologists. The group is also supported by the Clinical Champions for general surgery and critical care/anaesthesia. The group was established to ensure that existing GI bleed units would not be destabilised by the Healthier Together reconfiguration. In addition the group agreed it would be beneficial to develop pathways and clinical standards to standardise the quality of services across GM. 99

100 The group were also tasked with investigating the potential for an NWAS pathfinder to divert major GI haemorrhage to the Healthier Together hub sites. In the A&E and NWAS model paper submitted to the Delivery Board in October 2016 it was proposed that the streaming of patients directly to hub site A&Es would commence with significant gastrointestinal haemorrhage. The work of this group is ongoing, but draft clinical pathways and clinical standards have been developed and are expected to be signed off imminently. 6.3 Programme resourcing The Healthier Together Implementation team comprises a central programme team, a clinical team, and sector teams. Within each sector, and NWAS, local programme teams have been established to lead the implementation of the clinical models in their sector under the leadership of a sector Programme Director. An oversight and assurance role is provided by the central programme team using PRINCE2 methodology. The central team works closely with sector teams to ensure delivery against plan and supports the Healthier Together Delivery Board. The following Programme Management, clinical redesign and clinical lead resourcing has been proposed to support the transition of services in 2017/18, and formed part of the bid to the Transformation Fund: Table 6.3: Greater Manchester Programme Resourcing Role Total Days (17/18) TU Director Oversight 52 Programme Director 156 Deputy Director 156 Senior programme management 208 Senior finance support 52 Project management 208 Analytical support 39 Administration and project support

101 Additional clinical resourcing is summarised below: Table 6.4: Clinical resourcing 2017/18 resourcing Sessions (PAs) per week PAs per month PAs per quarter Total 2017/18 GM Clinical Leadership GM Clinical Lead Emergency Medicine Clinical Champion Anaesthestics/Critical Care Clinical Champion General Surgery Clinical Champion Radiology Clinical Champion Each sector team has also put in place a suitable project team. 101

102 6.4 Project plan An outline of the high-level project plan, including its phases and sub-phases, is provided below. Figure 6.2: Summary Programme Plan Work area What (and who will lead this) Oct 17 Nov 17 Dec Q1 Funding Finalise revenue agreements Complete commercial cases as required for central approval. Operational and Clinical Continue to service and support the Clinical Alliance to exercise its clinical oversight duties, problemsolving and dissemination of agree pathways and protocols. Support the development of ambulance Inter facility transfer framework, pathways and protocols for patient transfers with sectors and NWAS. Support the Theme 3 GM Workforce Reference Group to identify and support workforce strategies for the delivery of HT. Q2 Support sectors to develop robust clinical pathways that meet the requirements of the model of care and are operationally deliverable. Benefits Monitoring Implement sector reporting dashboard for collecting and presenting benefits. Facilitate the development of an ongoing annual audit process for HT standards. Readiness and Phasing Assess compliance with implementation conditions and equality commitments. Complete readiness assessments for all sectors prior to implementation. Complete readiness assessment for NWAS. Support sectors as required during go live From 2018 Communications Establish Communication and Engagement network with GM Partnership support Contribute to the development of a communications plan for the implementation phase of HT Agree the respective roles and responsibilities for the TU and the Partnership in the delivery of communications and engagement activities as defined in the plan 102

103 6.5 Change management The phased implementation plan will be directly supported both internally within the sectors and externally by the core HT programme team, HT delivery board and Clinical Alliance. Key learning will be identified following each milestone change and fed back through agreed assurance processes. To supplement the change process, each sector will utilise the Mckinsey 7s model to ensure thorough understanding of the interdependencies between the Hard and Soft elements of change. It provides a holistic mechanism to review the interconnected dimensions as a way of assessing the overall impact of change within an organisation. In terms of applying the framework the following steps have been identified: Step 1. Identify the areas that are not effectively aligned Step 2. Determine the optimal organisation design Step 3. Decide where and what changes should be made Step 4. Make the necessary changes Step 5. Continuously review the 7s Figure 6.3: 7S Change Management Methodology 103

104 6.6 Management of benefits realisation Benefits realisation planning Clinical benefits will be measured using the quality and safety standards plus the clinical outcomes identified below. Figure 6.4: Benefits Summary The approach to managing the clinical benefits is illustrated as below, and a benefits realisation template has been approved to be used to capture the pre-implementation baseline (step 4 in the illustration). Figure 6.5 Clinical Benefits 104

105 6.6.2 Clinical standards and baseline The evaluation approach was agreed in January 2016 and a decision was taken to carry out a full audit at all participating sites to establish a baseline against which progress could be measured. The baseline audit covered three areas: 1. Clinical standards, outcomes and activity 2. HR & Workforce 3. Equalities conditions The baseline of performance against the Healthier Together Quality and Safety standards for general surgery and urgent, acute and emergency medicine (UAEM) was the most complex of these activities. Each provider trust was asked to submit a self-assessment against the standards and evidence in support of this assessment. The Healthier Together team used a combination of evidence submitted by trusts and national data sources to establish current compliance. The team s initial assessment of this evidence identified that further work was required to provide a reliable 2016 baseline result that can be used to measure progress as sectors move through the implementation phase. We also identified an opportunity to streamline the assessment process going forward. The following actions were recommended and endorsed by the Delivery Board: Review of the Healthier Together clinical standards and evidence requirements by the Clinical Champions. Prioritise deal breaker or go/no go standards that are key to safe, successful implementation of Healthier Together. Carry out independent clinical review of the baseline. Utilise objective validated national data or local audits where possible to validate performance against the clinical standards. Review the evidence requirements to reduce the variation in approach. Provide sectors with an opportunity to supplement their submission with additional evidence to substantiate their 2016 self-assessment in order to make the baseline as accurate as possible. Subsequently the clinical standards to be monitored during implementation have undergone a thorough review. Priority standards have been agreed for general surgery, acute and emergency medicine. The evidence requirements and thresholds for compliance with these standards have been reviewed, and external validated data and audit sources will be used to monitor progress wherever possible Progress monitoring To move towards more regular progress monitoring, an in-depth review of available national and local audit data has been undertaken and trusts have been actively encouraged to participate in and share data from relevant national audits including: 105

106 National Emergency Laparotomy Audit (NELA) Greater Manchester Critical Care and Trauma Network s peer review report Society for Acute Medicine Benchmarking Audit (SAMBA) National Bowel Cancer Audit (NBOCA) National Cardiac Arrest Audit (NCAA) National Oesophago-Gastric Cancer Audit (NOGCA) These audits (in particular the first three) are being actively used to assess progress against the Healthier Together quality and safety standards. All relevant national audit results have been shared and discussed through the GM Clinical Alliance and sector sharing events. In order to assess progress against the general surgery standards on a real-time basis all GM sites agreed to share access to the NELA database allowing us to produce more up-to-date data in the form of a dashboard. In NELA audit year 3 we began producing a HT NELA dashboard to encourage sharing of data and best practice across GM. The dashboard shows real-time performance against the standards, supporting sector teams to monitor improvements in between annual audit publication. The dashboard also summarises the previous year s results in the table. Where applicable these have been RAG rated to show the current level of performance against the agreed thresholds for compliance. An example sector dashboard is shown below. Figure 6.6: NELA dashboard examples 106

107 6.7 Risk management Risks are identified through the HT governance structure. Chairs and Project Leads for each project stream are responsible for highlighting and escalating through the governance structure any risks and issues that they become aware of. Additionally, existing risks will be monitored and all reasonable attempts will be made to be mitigated. Risks will be documented on an internal risk register document that will be used as directed by the Programme Director by all members of the project team. The Programme Director will be responsible for ensuring that the risk register is regularly completed and mitigating actions are updated. All risks will be given a rating of low, medium, high or very high, with the latter only being used where a risk is deemed to be a potential risk to the continuation of the programme. All risks, regardless of rating will be allocated a responsible governance group, dependent on the project steam the risk is most related towards. All risks will be communicated to all stakeholders of the programme as is relevant. Identified risks will cover all aspects of the programme, such as: Clinical Finance HR & Workforce Sector issues Discussion of open risks will be a standing agenda item for all groups as above. Risks would be communicated to groups through pre-meeting papers, sent a week in advance. Aside from Project Sub-groups, the discussion of risks at each meeting will be documented through meeting minutes. Meeting minutes will detail any action points in relation to open risks, including changing of scoring or mitigating action. Additionally, meeting minutes will detail any newly identified risks. The Programme Director will ensure that newly identified risks are recorded on the register weekly. Each month, in the week prior to the HT Delivery Board, the Programme Team will undertake a review of all risks. Risks may also be identified through groups within the Implementation Programme governance structure. It is expected that members of governance groups would be expected to raise any risks relevant to their area of expertise. Risks will also need to be managed within sector project teams. The expectation is where a sector is aware of a risk within their sector, that may be relevant to other sectors or the Healthier Together programme as a whole, the risk should be escalated to the Healthier Together Delivery Board using the standard status report template and raised under the risk standing agenda item. 107

108 Key current risks are detailed below: Table 6.5: Summary of risks Workforce: Key Risks Ability to recruit required number of consultants to deliver the HT standards Changes to working patterns with new model may ability to retain and recruit staff Impact of training requirements of junior medical staff due to HT impacting service provision at non-hub sites. Mitigating Factors GM Workforce Reference Group to develop strategies focussing on key aspects of programme deliverables including recruitment, assessment of pipeline consultants within the GM system, terms and conditions and consistent application of policy and principles. Collaboration with Health Education England to ensure attractive training propositions for junior medical trainees across GM balanced with service stability for all sites. Established sector workforce and HR groups reviewing recruitment strategies linking to the wider GM picture, with robust staff communication and engagement strategies. Phased implementation plan across GM facilitates a sequential approach to recruitment where appropriate. GM review of clinical pathways to maximise efficient use of the workforce. Clinical Champions input to lead early engagement with staff groups, Unions, colleges etc. Radiology: Workforce challenges to delivery core requirements of HT Sub-specialty delivery of interventional radiology Existing reporting pressures Readiness assessment focusing on cultural aspects of change, supplementary to systems and structural change requirements. Radiology Clinical Advisory Group and Vascular Interventional Radiology sub groups established. with strong links to HT and pathway development, in additional to sectors developing local models to ensure 7 day delivery of level 1 competencies. Radiology standards agreed. Collaborative Image Sharing business case in development to enhance efficiencies and reporting capability. GM Workforce Group focussing on Radiology workforce requirements linked to wider Theme 3 requirements. 108

109 Transfer of Patients: Potential clinical dis-benefit of double ambulance transfers of patients from a non-hub to a hub. The potential dis-benefit of double ambulance journeys continues to be reviewed by the NWAS task and finish group with senior clinicians addressing any potential risks and issues. The evidence from NHS Lothian will continue to be explored in more detail as well as GM initiatives that transfer patients from a receiving A&E site to a specialist centre, such as Neurosurgery, Stroke, PCI, Major Trauma and existing Fairfield & Trafford models. NWAS business case provides sufficient capacity for the transfer of all patients from a non-hub to a hub site, using Optima modelling system to account for additional resources required. Similar models to Healthier Together exist such as NHS Lothian, where patients are transferred from an A&E receiving site to a specialist colorectal site for emergency laparotomy intervention, with excellent patient outcomes such as mortality rates for emergency laparotomy. Examples of existing pathways that transfer patients from one A&E to another, such as Fairfield model for emergency general surgery, Neurosurgery, Stroke, Major Trauma and PCI. Delivery of standards & benefits Healthier Together standards and benefits of the programme not being achieved. Critical Care Compliance: Critical Care services in 2/4 sector hubs not being compliant with National Critical Care Guidance. This is due to workforce shortage of ICM consultants. Equalities: Risk that HT model creates inequity and fails to ensure patient voice heard through the planning and implementation stages. GI Bleed Patients: The risk that patients with life threatening gastrointestinal haemorrhage arriving in ED at non hub sites. Sectors not compliant with NICE/CEPOD standards. Benefits baseline completed in April Shared with sectors. Review and audit process to be developed and agreed with board linking to external independent support to facilitate process with use of audit data, hard copy evidence and peer review. Clinical Benefits dashboard developed and agreed via delivery board and reporting to commence from November 2017 Compliance being managed by Critical Care Network across GM. Risk highlighted to AGG on 21st March Programme Team to liaise with CC Network. Equalities advisory group established alongside the development of Integrated Impact Assessment (IAA) implementation condition with reporting function through the HT delivery board. Delivery of sector level equality impact assessments and patient voice groups and inclusion of patient in various working groups in addition to strengthening links with wider Theme 3 changes. NWAS medical pathfinder has GI haemorrhage included as indication for divert. GI Bleeds pathways under development and shared with sectors via Clinical Alliance. To be assessed as part of go-live plan and readiness asst. Clinical Lead to assure sectors approach. GI Bleeds workshop to be held following sector specific meetings on 26th October

110 Funding: Risk of failure to secure capital via national route Risk of lack of transitional funding to support implementation Stranded costs Risk of failure to agree recurrent revenue impact of delivering Healthier Together System Assurance: The system needs assurance, through the FBC that HT is affordable and deliverable (e.g. that workforce can be put in place) before funding and implementation is agreed The treasury allocated full capital request of 63m on 19 July Following GM approval the FBC will be submitted to national authorities for final approval and release of capital. The commercial case component will be completed now sectors are moving at risk ahead of the release of national funds through the procurement stages to complete the detailed design phase. Transformation Oversight Funding Group decision delivered on 28 June 2017 to support 17.2m and GM CCG monies to the value of 5.5m made available to support the transitional process. A large percentage of the TFOG funding supports any unmitigated stranded costs, with the expectation that organisations and sectors will work to mitigate their available assets. For example linking Theme 3 changes, looking to agreements around reciprocal activity flows, explore independent sector opportunities to deliver work referred to private sector back to the NHS, links with integrated programmes and wider estates strategies. Recurrent revenue agreements in place in two sectors, North West Sector expected to conclude imminently and the GM HSCP to support conclusion of negotiations in South East Sector. Funding oversight provided by the Finance Executive Group. Production of a full FBC agreed with sectors. Governance process approved and Executive function process established. Production of accompanying paper to provide assurance on risks, funding, case for change and value for money to be presented at the Theme 3 executive and finance executive group prior to final approval at the Joint Committee. 110

111 7 Appendices 7.1 Appendix 1: Manchester and Trafford Sector The following appendix provides sector level detail in support of the GM Business Case Manchester and Trafford model of care Key highlights from the model of care are outlined below, followed by a summary table which provides an assessment of different aspects of the local model of care against the Healthier Together model. Key highlights Ambulatory care Ambulatory care surgical pathways have been developed across the sector, with consensus about the case mix suitable. These include: non-specific abdominal pain, biliary colic, mild cholecystitis, abscesses, proctology, hernias, and simple diverticulitis. Plans are in place to provide a 4 hour clinic, 7 days per week on both the non-surgical hub site (UHSM) and the surgical-hub site (MRI). ERAS+ ERAS+ optimises pre-operative care for high risk elective surgery and colorectal cancer patients and offers enhanced post-operative recovery in order to reduce complications and adverse outcomes including mortality, longer length of stay or reduced long term survival rates. The ERAS+ programme is already in place at CMFT and due to the link with high risk general surgery GM Medical Directors have agreed that Healthier Together would be an appropriate vehicle to support delivery of ERAS+ in GM. A GM Steering Group has been developed, with plans for the programme to be introduced in UHSM first, resulting in one sector being complete. 111

112 The following tables compare the plans which the sectors have developed for the implementation of the Healthier Together against the Healthier Together model of care. It includes an assessment of variation against the different elements of the model. It should not be taken as a reflection of their current compliance with the Healthier Together model. Table 7.1.1: Summary of the model of care within the MAT sector Healthier Together model Assessment Notes: Manchester and Trafford Sector 1. Emergency General Surgery All emergency high risk general surgical patients are admitted to sites specializing in emergency and high risk elective general surgery (surgical-hub sites). Each sector should have a pathway in place for: See below High Risk Patients requiring an inpatient emergency general surgical procedure should be transferred to the hub site: - Emergency Laparotomy - Patients identified in the Nuffield 2016 paper on Emergency General Surgery - NCEPOD 2016 Treat the Cause (Acute Pancreatitis, calculus cholecystitis necessitating admission) - NCEPOD 2016 Time to Get Control ( following stratification at therapeutic endoscopy and according to GM pathways) All emergency general surgery patients requiring admission are to be transferred to the surgical hub site (MRI). Patients receiving certain categories of specialised care at UHSM to be treated at UHSM. 112

113 Healthier Together model Assessment Notes: Manchester and Trafford Sector 2. Elective general surgery High risk patients requiring conservative inpatient watch and wait management - these patients require significant surgical, diagnostic and associated service input and as such should be transferred to the hub site or another GM hub site in a networked model if determined by GM clinical pathway: - As identified in Nuffield 2016 paper - NCEPOD 2016 Treat the Cause (Acute Pancreatitis, calculus cholecystitis necessitating admission) - NCEPOD 2016 Time to Get Control (following stratification at therapeutic endoscopy and according to GM pathways) Patients who are suitable for referral to a prompt semielective or elective pathway including ambulatory care, hot clinic, outpatients, early elective lists. Low risk patients requiring conservative inpatient watch and wait who are not suitable for referral to a semi-elective or elective pathway. A) All high risk elective general surgery is undertaken a surgical-hub sites. This includes: a) All Patients with colorectal cancer b) All Patients with colorectal surgery for other indications as identified in clarification paper (2016) c) Other high risk procedures as identified in the clarification paper (April 2016) d) Patients undergoing a low risk procedure but anticipated to require critical care post-operatively All emergency general surgery patients to be transferred to the surgical hub site (MRI), is inclusive of Acute Pancreatitis and calculus cholecystitis requiring an in-patient admission. Patients receiving certain categories of specialised care at UHSM to be treated at UHSM. MRI is GM hub for Severe Acute Pancreatitis and VIR hub for variceal bleeding. MRI currently 1 of 2 VIR sites for non-variceal bleeding. Plan to meet standards at both sites within the sector. Any emergency patient requiring overnight admission, regardless of risk will be transferred to the surgical hub (MRI). Patients receiving certain categories of specialised care at UHSM to be treated at UHSM. All high risk (complex) elective general surgery patients to be transferred to the surgical hub site (MRI). 113

114 Healthier Together model Assessment Notes: Manchester and Trafford Sector due to their co-morbidities Colorectal MDT process in place at a sector level, ready for the transfer of high risk elective patients from April 2017 ERAS+ programme in place to support high risk elective patients CPET in place to provide estimation of risk pre-operatively All low risk elective surgery to be offered by all sites based on local population requirements. Plans are complete for the establishment of a Colorectal MDT in preparation for the transfer of high risk elective patients to be completed by November A successful test run of the Colorectal MDT took place in March 2017, with the first formal Colorectal MDT commencing April ERAS + programme and CPET service already established in MRI. Low risk elective general surgery will be offered at both sites (MRI, UHSM). Low risk elective activity at MRI for local population only. 3. General surgical workforce 4. Emergency Medicine a) Surgical hub site 24/7 assessment 14/7 operating (CEPOD) Assumed revised model on the non-hub sites 10 hours consultant presence including daily ambulatory care provision Unpredictable on- call cover A&E consultant cover: MRI: 16 hour consultant presence on surgical hub site (until 00.00) with on-call following this. This is to accommodate Major Trauma Torso role. 12 hours consultant presence for operating on the surgical hub site. The intention is for on-call provision for surgical hub and non-surgical hub, for three sub-specialty consultant rotas, which includes Colorectal. Please note that advice on the provision of 24/7 presence for the purposes of Major Trauma has changed. Please see section 2. UHSM 10 hours presence Unpredictable on call 24/7 emergency medicine consultant presence at the surgical hub site (MRI). 114

115 Healthier Together model Assessment Notes: Manchester and Trafford Sector workforce a) Surgical hub sites: minimum 16 hours/7 days, Major Trauma Centre 24 hours b) Non-surgical hub sites: minimum of 12 hours/ 7 days. 16 hours emergency medicine consultant presence at the non-surgical hub site (UHSM). 5. Acute Medicine workforce Acute medical consultant cover: Each site 12 hours consultant cover, 7 days per week Plan in place to deliver workforce standards at both sites. 6. Critical Care a) Critical Care services meet national requirement to be a closed service CMFT and UHSM are compliant. b) Provision of ERAS+ and CPET programme within the sector ERAS+ programme already in place at CMFT and plan in place for development at UHSM. 7. Radiology a) 24/7 diagnostic reporting service at each site with 24/7 compliance to access of modalities Current provision of on-call consultant radiologist on both sites 24/7 b) Non-vascular interventional service to be provided 7 days per week at a sector level or GM Current provision of non-vascular interventional rota available 7 days a week. c) At least 1 site in GM to have a 24/7 NVIR rota d) Vascular interventional radiology to be provided 24/7 days per week at a GM level (network solution). Current provision of 24/7 vascular interventional rota and a network solution for Salford, Bolton, Wigan, Stockport and Tameside. 115

116 The following section outlines the requirements for the delivery of this model of care: Manchester and Trafford estate requirements The table below summarises estates developments required to support the new model of care. Table 7.1.2: Manchester and Trafford Estates Requirements General Surgery improvements A&E improvements Acute improvements Activity 225 elective patients move to hub No estate development No estate development site required in this sector required in this sector Inpatient beds Critical Care beds Operating Theatres 1,665 non elective patients move to hub site 38 additional inpatient beds required at hub site 2 wards 3 additional critical care beds required at hub site 1 additional emergency theatre Manchester and Trafford sector workforce requirements Additional consultant workforce is required in the sector to deliver the General Surgery clinical standards. The additional requirement is summarised in the table below. Table : Manchester and Trafford Workforce Numbers WTE Baseline HT Requirement Recruitment required Acute and Emergency Medicine * General Surgery *2 WTE of additional consultants for medical Ambulatory Care are required due to the current pressure on both A&E units within the sector. Current demand means that existing A&E consultants do not have the capacity within their current job plans, to also cover the expansion in Ambulatory Care required, as expected within the Healthier Together workforce model Manchester and Trafford Capital Costs breakdown The commercial case above identified a capital cost budget for Healthier Together of 63m. Within the Manchester and Trafford sector, the capital cost is 10,160k. A breakdown of this figure is provided below. Table 7.1.4: Manchester and Trafford Capital Investment TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS Table 7.1.5: Manchester and Trafford Capital Cost Timings TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS A risk of 200k has been identified by the sector in relation to capital costs and is being reviewed with a view to mitigating the risk or finding an alternative funding source. 116

117 7.1.5 Manchester and Trafford reconciliation to DMBC Capital figure This table shows that the revised capital cost of HT in the Manchester and Trafford sector is higher than the DMBC. Table 7.1.6: Manchester and Trafford Capital Funding Reconciliation TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS Manchester and Trafford Revenue Costs Revenue cost to commissioners In the Manchester and Trafford sector, there will be an annual decrease in revenue cost to commissioners relating to Healthier Together of 861k. This is due to more patients being paid for under a lower ambulatory care tariff in the new model. Revenue cost at hub sites The following table outlines the recurrent revenue costs of Healthier Together at the sector hub site, the Manchester Royal Infirmary. Table 7.1.7: Manchester and Trafford: Hub site Recurrent Revenue Cost to implement HT Costs Total 000 Total 000 Income transferring to hub site (5,647) Operating costs increase at hub site: Surgical beds 2,050 Critical care beds 920 Support services 1,326 Joint working 314 Other costs 651 5,261 Consultant workforce additional cost 690 Other staff additional cost 1,196 Revenue consequence of capital (see below) 693 Ambulance costs 225 Total costs 2,418 In the Manchester and Trafford sector, it is anticipated that these revenue consequences will be fully offset by the annual efficiencies anticipated by the programme, which are summarised below. The methodology used to calculate these efficiencies is fully described in Appendix

118 Table 7.1.8: Potential efficiencies 000 General Surgery Length of stay General surgery Readmissions A&E Admissions Total revenue benefits MAT 1, ,842 9,723 There are risks to the recognition of these benefits in isolation for Healthier Together in the Manchester and Trafford sector, notably: Efficiencies relating to reducing A&E admissions have been assumed in isolation. Locality schemes, which are at an emergent stage across Greater Manchester, also project A&E efficiencies and consequently there is a risk that benefits may be double counted across the system. The business case for the Shared Hospital Service in the Manchester and Trafford Sector (MAT) will be the means by which many of the efficiencies are delivered and there is a risk that length of stay benefits may be double counted if both schemes go ahead. Further work is required to establish the appropriate allocation of benefits. Revenue consequences of capital The total capital investment required in the Manchester and Trafford sector is 10,160k. This investment will have revenue consequences in terms of annual depreciation and either PDC dividend or interest on loans, depending on the source of finance. The forecast impact is as follows: Table 7.1.9: Manchester and Trafford: Revenue costs of capital TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS Revenue costs at non-hub sites Revenue costs at non-hub sites relate to the general surgery activity which has transferred to the hub site, where an element of the associated cost cannot be immediately removed at the non-hub (for example, overhead costs). These are stranded costs. Over time these stranded costs are expected to work out of the system. For example, reciprocal activity transfers driven by other system reconfiguration work currently in progress (including under Theme 3) are expected to make use of non-hub site capacity. The following table outlines the annual stranded costs of Healthier Together at the sector non-hub site. 118

119 Figure : Manchester and Trafford revenue costs at non-hub site Costs Total 000 Income loss 6,508 Costs of surgical beds saved (1,650) Cost of critical care beds saved (802) Support services costs saved (563) Excess of income loss over costs saved (stranded costs) 3,493 Over the first 3 years of implementing Healthier Together the total stranded costs have been calculated at 4,062k Manchester and Trafford Transitional Costs Transitional costs relating to implementation have been categorised in the following manner: Implementation Costs. This relates predominantly to preparatory works e.g. building design and site clearance Project Management. These costs have been calculated at both sector and GM level on a post by post basis Workforce. This relates to additional staffing required over and above 'business as usual' as the new clinical model embeds. Agency Costs. There is a risk that the additional workforce required to deliver the Healthier Together clinical standards cannot be recruited to substantively. This figure represents the maximum estimate of the premium element of payments which may be required to secure appropriate staffing if providers are unable to recruit substantively. Transitional funding has been requested from the Greater Manchester Transformation Fund in February The outcome of this request is expected in March IT costs are not anticipated in the Manchester and Trafford sector due to existing working arrangements providing appropriate functionality to support Healthier Together data sharing, pending the outcome of the Single Hospital Services consultation. Table : Manchester and Trafford Transitional Costs Cost 2016/ / / /20 Total 000 Implementation Costs Project Management Workforce ,088 TOTAL 280 1, ,

120 An application to the Greater Manchester Development Fund has been made for 544.9k to cover the transitional costs already incurred in 2016/17 and forecast for quarter /18. The balance of the transitional cost is covered by the Healthier Together application to the Greater Manchester Transformation Fund Manchester and Trafford Funding sources Capital funding is being sought from public funding sources, as described in the Commercial Case. Transitional funding has been requested from the Greater Manchester Transformation Fund. The recurrent revenue impact of the programme at the hub site is expected to be fully mitigated by the efficiencies anticipated by the programme. 120

121 7.2 Appendix 2: North East Sector The following appendix provides sector level detail in support of the GM Business Case North East sector model of care Key highlights from the model of care are outline below, followed by a summary table which provides an assessment of different aspects of the local model of care against the Healthier Together model. Key highlights Colorectal MDT A Colorectal MDT is already in place with the sector (started in August 2015); this happens each Friday where approx. 40 cases are discussed, supported by an MDT coordinator and standardised proformas and processes. MDT clinical lead assists the process who manages the meeting closely. 121

122 The following tables compare the plans which the sectors have developed for the implementation of the Healthier Together against the Healthier Together model of care. It includes an assessment of variation against the different elements of the model. It should not be taken as a reflection of their current compliance with the Healthier Together model. Table 7.2.1: Summary of the model of care within the NE sector Healthier Together model Assessment Notes: North East Sector 1. Emergency General Surgery All emergency high risk general surgical patients are admitted to sites specializing in emergency and high risk elective general surgery (surgical-hub sites). Each sector should have a pathway in place for: See below High Risk Patients requiring an inpatient emergency general surgical procedure should be transferred to the hub site: - Emergency Laparotomy - Patients identified in the Nuffield 2016 paper on Emergency General Surgery - NCEPOD 2016 Treat the Cause (Acute Pancreatitis, calculus cholecystitis necessitating admission) - NCEPOD 2016 Time to Get Control (following stratification at therapeutic endoscopy and according to GM pathways) High risk patients requiring conservative inpatient watch and wait management - these patients require significant surgical, diagnostic and associated service input and as such should be transferred to the hub site or another GM hub site in a networked model if determined by GM clinical pathway: All emergency general surgery to be transferred to the surgical hub site (ROH). All emergency general surgery to be transferred to the surgical hub site (ROH). GM pathways agreed, inclusive of Acute Pancreatitis and calculus cholecystitis requiring an in-patient admission. 122

123 Healthier Together model Assessment Notes: North East Sector - As identified in Nuffield 2016 paper - NCEPOD 2016 Treat the Cause (Acute Pancreatitis, calculus cholecystitis necessitating admission) - NCEPOD 2016 Time to Get Control (following stratification at therapeutic endoscopy and according to GM pathways) Patients who are suitable for referral to a prompt semi-elective or elective pathway including ambulatory care, hot clinic, outpatients, early elective lists. Low risk patients requiring conservative inpatient watch and wait who are not suitable for referral to a semi-elective or elective pathway. Models yet to be developed, however plans in place for development of ambulatory care service in line with requirements. Any emergency patient requiring overnight admission, regardless of risk will be transferred to the surgical hub (ROH). 2. Elective general surgery A) All high risk elective general surgery is undertaken a surgical-hub sites. This includes: a) All Patients with colorectal cancer b) All Patients with colorectal surgery for other indications as identified in clarification paper (2016) c) Other high risk procedures as identified in the clarification paper (April 2016) d) Patients undergoing a low risk procedure but anticipated to require critical care post-operatively due to their co-morbidities b) Colorectal MDT process in place at a sector level, ready for the transfer of high risk elective patients from April 2017 c) ERAS+ programme in place to support high risk elective patients d) CPET in place to provide estimation of risk pre-operatively All high risk elective general surgery patients to be transferred to the surgical hub site (ROH). Colorectal MDT already in place within the sector. CPET and ERAS+ agreed by the sector and included in model, not currently in place. 123

124 Healthier Together model Assessment Notes: North East Sector All low risk elective surgery to be offered by all sites based on local population requirements. Low risk elective including day case will be provided across the sector 3. General surgical workforce a) Surgical hub site 16/7 assessment 14/7 operating (CEPOD) Unpredictable on-call cover ROH 16/7 Consultant ward/assessment presence 12.5/7 Consultant surgeon presence for emergency operating b) Assumed revised model on the non-hub sites NMGH: 10 hours consultant presence including daily ambulatory care provision Unpredictable on- call cover 12.5/7 consultant ward/assessment presence at nonsurgical hub sites. c) Fairfield General Hospital - Fairfield General Hospital is in the scope of HT for Emergency Medicine and Acute Medicine service only i.e. not for General Surgery. However, one of the standards under Urgent and Acute Medicine UEAM18 states that: There must be on-site senior support at ST3+ level 24 hours per day within the core specialties in Acute Medicine, Critical care, Anaesthetics, General Surgery, Orthopaedics, Paediatrics & Emergency Medicine It has been confirmed through discussions with the chief medical advisor and the general surgery clinical lead in the North East sector that this standard is not required to be met on the Fairfield site. Instead, existing arrangements will continue, which include 124

125 Healthier Together model Assessment Notes: North East Sector 4. Emergency Medicine workforce A&E consultant cover: a) Surgical hub sites: minimum 16 hours/7 days, Major Trauma Centre 24 hours patients who present at Fairfield who need a general surgical input being transferred to ROH. These pathways need development. This negates the need for any further general surgical workforce at Fairfield, as always intended in the HT model of care. Plans in place to provide: 16 hours presence of emergency medicine consultant at ROH b) Non-surgical hub sites: minimum of 12 hours/ 7 days. 12 hours cover at NMGH and FGH*. *Note that the consultant workforce at NMGH is currently assisted by a GM solution with support from SRFT and CMFT. 5. Acute Medicine workforce Acute medical consultant cover: Each site 12 hours consultant cover, 7 days per week Plan in place to deliver workforce standards but challenges exist in gaining in-reach services support to acute medicine, e.g. cardiology, respiratory, geriatric medicine. 6. Critical Care a) Critical Care services meet national requirement to be a closed service Bury, North Manchester and Royal Oldham ICU currently meet standards. Royal Oldham HDU is currently not compliant. Action plan in place to make the service compliant. b) Provision of ERAS+ and CPET programme within the sector GM Medical Directors and GM CCGs have agreed to the roll out of ERAS+ across Greater Manchester. Sector has included these in their model, not currently in place. 125

126 Healthier Together model Assessment Notes: North East Sector 7. Radiology a) 24/7 diagnostic reporting service at each site with 24/7 compliance to access of modalities A radiology single service within the sector is proposed. There will be challenges in meeting the Healthier Together standards, as currently there is no provision of consultant on-call overnight at the hub and non-hub sites, for no-interventional input. (required for paediatric standards) The diagnostic capability at ROH is not adequate to meet projected demand with the need for another CT scanner. b) Non-vascular interventional service to be provided 7 days per week at a sector level or GM c) At least 1 site in GM to have a 24/7 NVIR rota d) Vascular interventional radiology to be provided 24/7 days per week at a GM level (network solution). A radiology single service within the sector is proposed. Sector currently provides both a non-vascular and vascular interventional service which is compliant with the standards. There are challenges to the resilience of the workforce as currently does not meet 1:6 rota national standards. 126

127 7.2.2 North East sector estate requirements The table below summarises estates developments required in the sector to support the new model of care. Table 7.2.2: North East sector Estates Requirements General Surgery improvements A&E improvements Acute improvements Activity 254 elective patients move to hub No estate development No estate development site required in this sector required in this sector Inpatient beds Critical care beds Operating theatres. 1,947 non elective patients move to hub site 47 additional inpatient beds required at hub site 2 wards 4 additional critical care beds required at hub site a ward build is required to accommodate this because the current critical care space is landlocked 1 Operating theatre North East sector consultant workforce requirements Additional consultant workforce is required in the sector to deliver the Acute and Emergency Medicine and General Surgery clinical standards. The additional requirement is summarised in the table below. Table 7.2.3: North East sector Workforce Numbers WTE Baseline HT Requirement Recruitment required Acute and Emergency Medicine General Surgery North East sector Capital Costs breakdown The Commercial case above identified a capital cost budget for Healthier Together of 63m. Within the North East sector, the capital cost is 24,837k. A breakdown of this figure is provided below. Table 7.2.4: North East sector Capital Investment TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS Table 7.2.5: North East sector Capital Cost Timings TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS North East sector reconciliation to DMBC Capital figure This table shows that the revised capital cost of HT in the North East sector is similar to that the DMBC. 127

128 Table 7.2.6: North East sector Capital Funding Reconciliation TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS North East Sector Revenue Costs Revenue cost at hub sites The following table outlines the recurrent revenue costs of Healthier Together at the sector hub site, the Royal Oldham Hospital. Within the sector, minimum changes to net operating costs are anticipated due to the sites all forming part of the same trust. Table 7.2.7: North East sector: Hub site Recurrent Revenue Cost to implement HT Costs Total 000 Income transferring to hub site - Operating costs increase at hub site: - Consultant workforce additional cost 1,759 Other staff additional cost 4,987 Revenue consequence of capital (see below) 1,729 Ambulance costs 228 Total 8,703 In the North East sector, it is anticipated that these revenue consequences will be partly offset by the annual efficiencies anticipated by the programme, which are summarised below. The methodology used to calculate these efficiencies is fully described in Appendix 7. Table 7.2.8: Annual Efficiencies 000 General Surgery Length of stay General surgery Readmissions A&E Admissions Total revenue benefits NES ,168 Revenue consequences of capital The total capital investment required in the North East sector is 24,837k. This investment will have revenue consequences in terms of annual depreciation and either PDC dividend or interest on loans, depending on the source of finance. The forecast impact is as follows: Table 7.2.9: North East Sector: Revenue costs of capital TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS Revenue costs at non-hub sites 128

129 As the North East sector is one trust, no stranded costs have been recognised at the non-hub sites in this sector. This is on the basis that there will be no change in income and therefore no impact on corporate overheads, and that operating costs should be able to be managed between trust hospital sites North East Sector Transitional Costs Transitional costs relating to implementation have been categorised in the following manner: Implementation Costs. This relates predominantly to preparatory works e.g. building design and site clearance Project Management. These costs have been calculated at both sector and GM level on a post by post basis Revenue Consequences of Capital during transition. This is the PDC cost of the new build as the asset construction spans two financial years. Figure : North East sector Transitional Costs Cost 2017/ / / / Total 000 Implementation Costs Project Management Revenue Consequences of Capital during transition TOTAL ,854 There is a risk that non-contracted pay costs of up to 4.2m could be required non-recurrently pending the substantive recruitment of new staff. This figure represents the maximum estimate of the premium element of payments which may be required to secure appropriate staffing if providers are unable to recruit substantively. It is expected that this risk will be partially mitigated through both local and STP level action, and that any non-mitigated element will be funded locally in sectors North East Sector Funding sources Capital funding is being sought from public funding sources, as described in the Commercial Case. Transitional funding has been requested from the Greater Manchester Transformation Fund. The recurrent revenue impact of the programme at the hub site is not expected to be fully mitigated by the efficiencies anticipated by the programme. Consequently sector commissioners and the sector provider are in the process of agreeing how recurrent revenue pressures will be funded. 129

130 7.3 Appendix 3: North West Sector The following appendix provides sector level detail in support of the GM Business Case North West sector model of care Key highlights from the model of care are outline below, followed by a summary table which provides an assessment of different aspects of the local model of care against the Healthier Together model. Key highlights Ambulatory care Plans are in place for standardising the offer of ambulatory care at each site. Standard pathways and criteria for common conditions to be developed, phased go live starting with weekend service across all sites from April Capital build Through the Healthier Together programme and the Major Trauma programme for Greater Manchester a four-storey new building with be erected at SRFT to accommodate the additional activity from both programmes. This will include 3 wards, 7 critical care beds and 2 theatres. 130

131 The following tables compare the plans which the sectors have developed for the implementation of the Healthier Together against the Healthier Together model of care. It includes an assessment of variation against the different elements of the model. It should not be taken as a reflection of their current compliance with the Healthier Together model. Table 7.3.1: Summary of the model of care within the NW sector Healthier Together model Assessment Notes: North West Sector 1. Emergency General Surgery All emergency high risk general surgical patients are admitted to sites specializing in emergency and high risk elective general surgery (surgical-hub sites). Each sector should have a pathway in place for: See below High Risk Patients requiring an inpatient emergency general surgical procedure should be transferred to the hub site: - Emergency Laparotomy - Patients identified in the Nuffield 2016 paper on Emergency General Surgery - NCEPOD 2016 Treat the Cause (Acute Pancreatitis, calculus cholecystitis necessitating admission) - NCEPOD 2016 Time to Get Control (following stratification at therapeutic endoscopy and according to GM pathways) High risk patients requiring conservative inpatient watch and wait management - these patients require significant surgical, diagnostic and associated service input and as such should be transferred to the hub site or another GM hub site in a networked model if determined by GM clinical pathway: High-risk only emergency surgery patients will be transferred to the surgical hub site (SRFT) with low risk in-patients remaining at both non-hub sites. The model includes moving patients who require conservative management in this category, to the surgical hub site or another GM hub site according to GM pathways, inclusive of Acute Pancreatitis and calculus cholecystitis requiring an in-patient admission. 131

132 Healthier Together model Assessment Notes: North West Sector - As identified in Nuffield 2016 paper - NCEPOD 2016 Treat the Cause (Acute Pancreatitis, calculus cholecystitis necessitating admission) - NCEPOD 2016 Time to Get Control (following stratification at therapeutic endoscopy and according to GM pathways) Patients who are suitable for referral to a prompt semi-elective or elective pathway including ambulatory care, hot clinic, outpatients, early elective lists. Low risk patients requiring conservative inpatient watch and wait who are not suitable for referral to a semi-elective or elective pathway. Plan for ambulatory care to be offered across the sector (3-4 hours per day, 7 days per week). Low risk emergency activity to be retained at the non-hub sites as long as contained within workforce modelling: Royal Bolton Hospital (RBH) and Wrightington, Wigan and Leigh (WWL). 2. Elective general surgery A) All high risk elective general surgery is undertaken a surgical-hub sites. This includes: a) All Patients with colorectal cancer b) All Patients with colorectal surgery for other indications as identified in clarification paper (2016) c) Other high risk procedures as identified in the clarification paper (April 2016) d) Patients undergoing a low risk procedure but anticipated to require critical care post-operatively due to their co-morbidities b) Colorectal MDT process in place at a sector level, ready for the transfer of high risk elective patients from April 2017 c) ERAS+ programme in place to support high risk elective patients d) CPET in place to provide estimation of risk pre-operatively High-risk (complex) elective patients will be transferred to the surgical hub site (SRFT). Discussions are taking place about the establishment of Colorectal MDTs in the sector and introduction of ERAS+ programme/cpet. 132

133 Healthier Together model Assessment Notes: North West Sector 3. General surgical workforce All low risk elective surgery to be offered by all sites based on local population requirements. a) Surgical hub site 24/7 assessment 14/7 operating (CEPOD) b) Assumed revised model on the non-hub sites Low risk elective activity will be retained at the non-hub sites. Low risk elective activity at SRFT for local population only. SRFT: 24 hours consultant presence for surgical assessment 14 hour consultant presence for undertaking Emergency General Surgery *An additional 6 hour in-patient assessment role has been included by the sector above the recommendations of the Chief Medical Officer. Local provider to commissioner dialogue will be necessary to support/challenge this role. WWL & RBH: 10 hours consultant presence including daily ambulatory care provision Unpredictable on- call cover 12 hours consultant presence due to the volume of patients expected on the non-hub sites Unpredictable on-call cover 4. Emergency Medicine workforce A&E consultant cover: a) Surgical hub sites: minimum 16 hours/7 days, Major Trauma Centre 24 hours SRFT to provide 24 hours of emergency medicine consultant presence. b) Non-surgical hub sites: minimum of 12 hours/ 7 days. RBH and WWL to provide 16 hours of emergency medicine consultant presence due to the volume of attendances on the nonhub sites. This is on a background of the sector and GM having major workforce issues in this area. 5. Acute Medicine workforce Acute medical consultant cover: Each site 12 hours consultant cover, 7 days per week Plan in place to deliver workforce standards at all three sites but challenges exist in meeting these currently. 133

134 Healthier Together model Assessment Notes: North West Sector 6. Critical Care a) Critical Care services meet national requirement to be a closed service WWL and Royal Bolton are both compliant; Salford Royal has a plan in place for compliance from 1 st April b) Provision of ERAS+ and CPET programme within the sector GM Medical Directors and GM CCGs have agreed to the roll out of ERAS+ across Greater Manchester. 7. Radiology a) 24/7 diagnostic reporting service at each site with 24/7 compliance to access of modalities b) Non-vascular interventional service to be provided 7 days per week at a sector level or GM c) At least 1 site in GM to have a 24/7 NVIR rota d) Vascular interventional radiology to be provided 24/7 days per week at a GM level (network solution). A radiology single service within the sector is proposed. There will be challenges in meeting the Healthier Together standards, as currently there is no provision of consultant on-call overnight at the hub and non-hub sites, required for paediatric standards. A radiology single service within the sector is proposed. There will be challenges in meeting the Healthier Together standards, as currently there is no provision of non-vascular interventional radiology at the weekend. It has been suggested that a sector solution for providing weekend cover is explored Vascular interventional radiology currently provided as part of network solution with CMFT. 134

135 7.3.2 North West sector estate requirements The table below summarises estates developments required in the sector to support the new model of care. Table 7.3.2: North West sector Estates Requirements General Surgery improvements A&E improvements Acute improvements Activity 363 elective patients move to hub site 1,260 non elective patients move to hub site No estate development required in this sector No estate development required in this sector In-patient beds Critical Care beds Operating Theatres. 54 additional inpatient beds required at hub site 2 wards 6 additional critical care beds required at hub site 1 ward 2 theatres (including 1 emergency theatre) North West sector workforce requirements Additional consultant workforce is required in the sector to deliver the General Surgery clinical standards. The additional requirement is summarised in the table below. Table 7.3.3: North West sector Workforce Numbers WTE Baseline HT Requirement Recruitment required Acute and Emergency Already meeting the Medicine standards General Surgery North West sector Capital Costs breakdown The Commercial case above identified a capital cost budget for Healthier Together of 63m. Within the North West sector, the capital cost is 18,450k. A breakdown of this figure is provided below. Table North West sector Capital Investment TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS Table 7.3.5: North West sector Capital Cost Timings TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS North West sector interdependencies The implementation of Healthier Together programme is interdependent with the development of a lead Major Trauma Centre for Greater Manchester at Salford Royal Foundation Trust. This is because SRFT are planning to build a new building to house both developments. If the Major Trauma programme is not funded, the costs of the implementing in the North West Sector will be significantly higher. 135

136 7.3.6 North West sector reconciliation to DMBC Capital figure This table shows that the revised capital cost of HT in the North West sector is lower than the DMBC figure, due to the co-location with the Major Trauma Centre described above. Table North West sector Capital Funding Reconciliation TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS North West sector Revenue Costs Revenue cost at hub sites The following table outlines the recurrent revenue costs of Healthier Together at the sector hub site, Salford Royal. Table 7.3.7: North West sector: Hub site Recurrent Revenue Cost to implement HT Costs Total 000 Income transferring to hub site (9,734) Operating costs increase at hub site: 11,303 Consultant workforce additional cost 1,487 Other staff additional cost 1,710 Revenue consequence of capital (see below) 2,073 Ambulance costs 148 Total 6,987 In the North West sector, it is anticipated that these revenue consequences will be partly offset by the annual efficiencies anticipated by the programme, which are summarised below. The methodology used to calculate these efficiencies is fully described in Appendix 7. Table 7.3.8: North West sector annual efficiencies 000 General Surgery Length of stay General surgery Readmissions A&E Admissions Total revenue benefits NWS ,965 7,897 Revenue consequences of capital The total capital investment required in the North West sector is 18,450k. This investment will have revenue consequences in terms of annual depreciation and either PDC dividend or interest on loans, depending on the source of finance. The forecast impact is as follows: 136

137 Table North West Sector: Revenue costs of capital Costs Total 000 Capital Investment 18,450 Revenue costs of capital Depreciation 1,470 PDC Dividend 603 Total 2,073 Revenue costs at non-hub sites Revenue costs at non-hub sites relate to the general surgery activity which has transferred to the hub site, where an element of the associated cost cannot be immediately removed at the non-hub (for example, overhead costs). These are stranded costs. Over time these stranded costs are expected to work out of the system. For example, reciprocal activity transfers driven by other system reconfiguration work currently in progress (including Devolution Theme 3) are expected to make use of non-hub site capacity. The following table outlines the annual stranded costs of Healthier Together at the sector non-hub sites. Table : North West sector revenue costs at non-hub sites Costs 2019/ / / Income loss 9,734 9,734 9,734 Operating costs saved (6,574) (8,154) (8,478) Excess of income loss over costs saved (stranded costs) 3,160 1,580 1,256 Stranded costs of 5,996k are expected over the first three years of implementation, with 766k at the Royal Bolton Foundation Trust and 5,230k at Wrightington, Wigan and Leigh Foundation Trust North West Sector Transitional Costs Transitional costs relating to implementation have been categorised in the following manner: Implementation Costs. This relates predominantly to preparatory works e.g. building design and site clearance Project Management. These costs have been calculated on a post by post basis Workforce. This relates to additional staffing required over and above 'business as usual' as the new clinical model embeds. Revenue Consequences of Capital during transition. This is the PDC cost of the newbuild as the asset construction spans two financial years Transitional funding has been requested from the Greater Manchester Transformation Fund in February The outcome of this request is expected in March

138 Table : North West sector Transitional Costs Cost 2017/ / /20 Total Implementation Costs 1,250 1,250 Project Management ,153 Workforce 1, ,792 Revenue consequences of capital ,063 Total costs 1,865 2,306 1,086 5,256 There is a risk that non-contracted pay costs of up to 418k could be required non-recurrently pending the substantive recruitment of new staff. This figure represents the maximum estimate of the premium element of payments which may be required to secure appropriate staffing if providers are unable to recruit substantively. It is expected that this risk will be partially mitigated through both local and STP level action, and that any non-mitigated element will be funded locally in sectors North West Sector Funding sources Capital funding is being sought from public funding sources, as described in the Commercial Case. Transitional funding has been requested from the Greater Manchester Transformation Fund. The recurrent revenue impact of the programme at the hub site is expected over time to be fully mitigated by the efficiencies anticipated by the programme. Sector commissioners and the providers are in the process of agreeing how recurrent revenue pressures will be funded in the medium term. 138

139 7.4 Appendix 4: South East sector The following appendix provides sector level detail in support of the GM Business Case South East sector model of care Key highlights from the model of care are outline below, followed by a summary table which provides an assessment of different aspects of the local model of care against the Healthier Together model. A&E capacity Through the Healthier Together programme a two-storey expansion of Stepping Hill Hospital A&E department is planned, with a 5.2 million capital investment proposed. o This will see the creation of a 6 bedded Resus suite to provide the required additional clinical capacity to safely treat the anticipated increase in high acuity emergency surgery patients, but also provide the opportunity to reuse the existing Resus for 4 dedicated consultant-led Rapid Access Treatment trolleys. In addition to increasing the clinical capacity of the department, the expansion area will be a two storey design, providing additional operating space for the theatre complex situated above the Emergency Department. o Expanding the complex by one theatre will not only provide much needed expansion capacity to future proof the complex in preparation for the subsequent phases of Healthier Together, but also provide the opportunity to rehouse some of the activity currently undertaken in the Cardiac Catheter Lab to the theatre complex. o The Cardiac Catheter Lab is currently co-located in the footprint of the Emergency Department, alongside the Ambulatory Care Unit and with the relocation of services to the theatre complex, will provide the opportunity to develop a fully integrated Frailty Assessment Unit within the footprint of the Emergency Department. o The development of a Frailty Assessment Unit would allow the Trust to adopt best practice for the management and treatment of frail, elderly patients. Ambulatory care Sector level pathway and protocols in place for ambulatory care; which will be delivered via a 4 hour clinic, 7 days per week, on both the non-surgical hub site (TGH) and the surgical-hub site (SFT). Pathways are in place for patients with: LIF pain (mild diverticulitis), RUQ pain (mild cholecystitis / biliary colic), non-specific abdominal pain, RIF pain (clinically not appendicitis). It is expected that 30% of emergency general surgical patients can be managed in this manner. North East Cheshire Please note that arrangements for North East Cheshire patients aren t included in the table below, however, the latest commissioning intentions for East Cheshire CCG propose a transfer of high risk General Surgery from East Cheshire Trust to Stockport, with the expectation being that this will take place at some point in 2017/18. Options for the future of East Cheshire Trust are to be considered between local partners and regulators over the next six months and formal consultation will be scheduled as necessary. 139

140 The following tables compare the plans which the sectors have developed for the implementation of the Healthier Together against the Healthier Together model of care. It includes an assessment of variation against the different elements of the model. It should not be taken as a reflection of their current compliance with the Healthier Together model. Table 7.4.1: Summary of the model of care within the SE sector Healthier Together model Assessment Notes: South East Sector 1. Emergency General Surgery All emergency general surgical patients are admitted to sites specializing in emergency and high risk (complex) elective general surgery (surgical-hub sites). Each sector should have a pathway in place for: See below High Risk Patients requiring an inpatient emergency general surgical procedure should be transferred to the hub site: All emergency general surgery to be transferred to the surgical hub (SFT). - Emergency Laparotomy - Patients identified in the Nuffield 2016 paper on Emergency General Surgery - NCEPOD 2016 Treat the Cause (Acute Pancreatitis, calculus cholecystitis necessitating admission) - NCEPOD 2016 Time to Get Control ( following stratification at therapeutic endoscopy and according to GM pathways) High risk patients requiring conservative inpatient watch and wait management - these patients require significant surgical, diagnostic and associated service input and as such should be transferred to the hub site or another GM hub site in a networked model if determined by GM clinical pathway: All emergency general surgery to be transferred to the surgical hub (SFT), inclusive of Acute Pancreatitis and calculus cholecystitis, requiring an in-patient admission. Therapeutic endoscopy not 24/7 currently in sector but action plan to 140

141 Healthier Together model Assessment Notes: South East Sector - As identified in Nuffield 2016 paper - NCEPOD 2016 Treat the Cause (Acute Pancreatitis, calculus cholecystitis necessitating admission) - NCEPOD 2016 Time to Get Control (following stratification at therapeutic endoscopy and according to GM pathways) Patients who are suitable for referral to a prompt semielective or elective pathway including ambulatory care, hot clinic, outpatients, early elective lists. deliver in place. Sector to be supported in meantime by MRI. Plan for 7 day access to ambulatory care across the sector. Low risk patients requiring conservative inpatient watch and wait who are not suitable for referral to a semi-elective or elective pathway. All emergency general surgery to be transferred to the surgical hub (SFT). 2. Elective general surgery All high risk elective general surgery is undertaken a surgical-hub sites. This includes: a) All Patients with colorectal cancer b) All Patients with colorectal surgery for other indications as identified in clarification paper (2016) c) Other high risk procedures as identified in the clarification paper (April 2016) d) Patients undergoing a low risk procedure but anticipated to require critical care post-operatively due to co-morbidities. Colorectal MDT process in place at a sector level, ready for the transfer of high risk elective patients from April 2017 ERAS+ programme in place to support high risk elective patients All High-risk (complex) elective patients plus any other elective activity where the patient has a high risk condition (even if their procedure is non-high risk) as a basis for modelling, the Sector has estimated based on the number of non-high risk procedure patients staying longer than three days in the base year. Operationally, the direction of such patients will be based on a standard risk assessment.). Discussions are taking place about the establishment of Colorectal MDTs in the sector in preparation for the transfer of high risk elective. The first combined meeting is to take place in May ERAS + and CPET services being developed and included in their model. 141

142 Healthier Together model Assessment Notes: South East Sector CPET in place to provide estimation of risk pre-operatively All low risk elective surgery to be offered by all sites based on local population requirements. Low risk short stay elective general surgery with expected stay of <3 days will remain at the non-surgical hub (TGH). All other elective activity to be delivered at the surgical hub (SFT). 3. General surgical workforce a) Surgical hub site 16/7 assessment 14/7 operating (CEPOD) Unpredictable on-call cover Low risk short stay elective general surgery to also be delivered at (SFT) for the local population. SFT: 13 hr./7 presence for surgical assessment 12 hr./7 consultant surgeon presence for operating Chief medical officer and clinical champions have confirmed that this level of cover is appropriate given the volume of patients within the sector; subject to on-going activity analysis. 4. Emergency Medicine workforce b) Assumed revised model on the non-hub sites 10 hours consultant presence including daily ambulatory care provision Unpredictable on- call cover A&E consultant cover: a) Surgical hub sites: minimum 16 hours/7 days, Major Trauma Centre 24 hours TGH 10 hours consultant presence Unpredictable on call 16 hours emergency medicine consultant presence at the surgical hub site (SFT). Workforce issues continue. b) Non-surgical hub sites: minimum of 12 hours/ 7 days. 12 hours emergency medicine consultant presence at the non-surgical hub site (TGH) 5. Acute Medicine workforce Acute medical consultant cover: Each site 12 hours consultant cover, 7 days per week 12 hours acute medical consultant presence at the non-surgical hub site (TGH) and the surgical hub site (SFT). 142

143 Healthier Together model Assessment Notes: South East Sector 6. Critical Care a) Critical Care services meet national requirement to be a closed service Stepping Hill and Tameside are compliant. b) Provision of ERAS+ and CPET programme within the sector 7. Radiology a) 24/7 diagnostic reporting service at each site with 24/7 compliance to access of modalities b) Non-vascular interventional service to be provided 7 days per week at a sector level or GM GM Medical Directors and GM CCGs have agreed to the roll out of ERAS+ across Greater Manchester. Mode includes service on SFT site, not in place yet. Stepping Hill is compliant. There will be challenges in meeting the Healthier Together standards in Tameside with the number of radiologists from February There is currently a network arrangement in place for MR scanning. A plan is in place for 7 day provision of non-vascular interventional radiology. c) At least 1 site in GM to have a 24/7 NVIR rota d) Vascular interventional radiology to be provided 24/7 days per week at a GM level (network solution). Vascular interventional radiology currently provided as part of network solution with CMFT. 143

144 Healthier Together Full Business Case South East sector estate requirements The table below summarises estates developments required in the sector to support the new model of care. Table 7.4.2: South East sector Estates Requirements General Surgery improvements A&E improvements Acute improvements Activity 205 elective patients move to hub site 2,183 non elective patients move to hub site Inpatient beds Critical Care beds Operating Theatres A&E capacity 34 additional inpatient beds required at hub site 1 large ward 4 additional critical care beds required at hub site Up to 9 sessions per week 1 theatre Additional emergency bays in A&E department Provision of an additional acute ward within M Block at Stepping Hill Hospital, reoccupying a former clinical area currently used as office space, allowing location of additional general surgical beds, close to Theatres in D Block. The related general surgery activity which will be transferring from Tameside to Stockport is broken down below. Table 7.4.3: General Surgery activity transferring from Tameside to Stockport Category CholecystectomyCR CR Endo GS HPB No Proc Other UGI Total Complex Simple Complex Elective/Overnight/ High Risk Elective/Overnight/ No Procedure (LOS >3 days) Elective/Overnight/ Non High risk (LOS > 3 days) Non Elective/ Overnight/Endoscopy Non Elective/Overnight/High Risk Non Elective/Overnight/No Procedure Non Elective/Overnight/Non high risk ,292 1, TOTAL , ,

145 Healthier Together Full Business Case South East sector workforce requirements Additional consultant workforce is required in the sector to deliver the Acute and Emergency Medicine and General Surgery clinical standards. The additional requirement is summarised in the table below. Table 7.4.4: South East sector Workforce Numbers WTE Baseline HT Requirement Recruitment required Acute and Emergency Medicine General Surgery South East sector Capital Costs breakdown The Commercial case above identified a capital cost budget for Healthier Together of 63m. Within the South East sector, the capital cost is 9,900k. A breakdown of this figure is provided below. Table 7.4.5: South East sector Capital Investment TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS Table 7.4.6: South East sector Capital Cost Timings TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS South East sector reconciliation to DMBC Capital figure This table shows that the revised capital cost of HT in the South sector is above the DMBC figure, for the reasons described in the table below. Table 7.4.6: South East sector Capital Funding Reconciliation TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS South East Sector Revenue Costs Revenue Cost to Commissioners In the South East sector, there will be an annual increased revenue cost to commissioners relating to Healthier Together of 588k. This is due to an increase in post-operative critical care bed days in line with clinical standards. 90% of this additional cost relates to Tameside CCG patients and so will be borne by Tameside CCG. The 588k is a cost to the sector as a whole, but represents additional income to the hub site. Revenue cost at hub sites The following table outlines the recurrent revenue costs of Healthier Together at the sector hub site, Stepping Hill. 145

146 Healthier Together Full Business Case Table 7.4,7: South East sector: Hub site Recurrent Revenue Cost to implement HT Costs Total 000 Income transferring to hub site (6,370) Operating costs increase at hub site 5,954 Consultant workforce additional cost 943 Other staff additional cost 160 Cost of joint sector working at hub site 271 Revenue consequence of capital (see below) 1,124 Ambulance costs 228 Total 2,309 In the South East sector, it is anticipated that these revenue consequences will be partly offset by the annual efficiencies anticipated by the programme, which are summarised below. The methodology used to calculate these efficiencies is fully described in Appendix 7. Table 7.4.8: South East SectorAnnual Efficiencies 000 General Surgery Length of stay General surgery Readmissions A&E Admissions Total revenue benefits SES ,124 4,489 There are risks to the recognition of these benefits in the South East sector, notably: Efficiencies relating to reducing A&E admissions have been assumed in isolation. Locality schemes, which are at an emergent stage across Greater Manchester, also project A&E efficiencies and consequently there is a risk that benefits may be double counted across the system. Revenue consequences of capital The total capital investment required in the South East sector is 9,900k. This investment will have revenue consequences in terms of annual depreciation and either PDC dividend or interest on loans, depending on the source of finance. The forecast impact is as follows: Table 7.4.9: South East Sector: Revenue costs of capital TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS Of the 1,258k total revenue consequences of capital in the sector, 1,124k relates to the hub site, with 134k incurred annually at the non-hub site. Revenue costs at non-hub sites 146

147 Healthier Together Full Business Case Revenue costs at non-hub sites relate predominantly to the general surgery activity which has transferred to the hub site, where an element of the associated cost cannot be immediately removed at the non-hub (for example, overhead costs). These are stranded costs. Over time these stranded costs are expected to work out of the system. For example, reciprocal activity transfers driven by other system reconfiguration work currently in progress (including Devolution Theme 3) are expected to make use of non-hub site capacity. The following table outlines the annual costs of Healthier Together at the sector non-hub site, Tameside General Hospital. Table : South East sector revenue costs at non-hub site Costs Total 000 Income loss 5,782 Operating costs saved (1,822) Excess of income loss over costs saved (stranded costs) 3,960 Cost of joint sector working at non-hub site 542 Revenue costs of capital at non-hub site 134 Total 4,636 Resolution of stranded costs in the South East sector is a significant challenge given the hub site, Tameside General Hospital, which is a small district hospital with a new PFI build that attracts significant overhead costs. Applying the agreed stranded costs methodology over 3 years the value of stranded costs are 8,437k, however there is a risk that the assumed mitigation of costs in the later years will not materialise. Work is on-going to identify opportunities to mitigate the stranded costs South East Sector Transitional Costs Transitional costs relating to implementation have been categorised in the following manner: Implementation Costs. This relates predominantly to preparatory works e.g. building design and site clearance Project Management. These costs have been calculated on a post by post basis Workforce. This relates to additional staffing required over and above 'business as usual' as the new clinical model embeds. Transitional funding has been requested from the Greater Manchester Transformation Fund in February The outcome of this request is expected in March Table : South East sector Transitional Costs Cost 2017/ / Total 000 Implementation Costs Project Management Workforce TOTAL ,

148 Healthier Together Full Business Case There is a risk that non-contracted pay costs of up to 400k could be required non-recurrently pending the substantive recruitment of new staff. This figure represents the maximum estimate of the premium element of payments which may be required to secure appropriate staffing if providers are unable to recruit substantively. It is expected that this risk will be partially mitigated through both local and STP level action, and that any non-mitigated element will be funded locally in sectors Funding Sources Capital funding is being sought from public funding sources, as described in the Commercial Case. Transitional funding has been requested from the Greater Manchester Transformation Fund. The recurrent revenue impact of the programme at the hub site is not expected to be fully mitigated by the efficiencies anticipated by the programme. Consequently sector commissioners and the sector provider are in the process of agreeing how recurrent revenue pressures will be funded. The diagram below sets out the recurrent revenue funding sources identified in the South East sector to date. 148

149 Healthier Together Full Business Case 7.5 Appendix 5: North West Ambulance Service (NWAS) As outlined in the main body of this business case, the principles of the Healthier Together Model of Care are outlined below: 1. Hospital services will be provided locally whenever possible. 2. Hospital services will be provided at a site specialising in certain types of care (e.g. general surgery) when needed. 3. Hospital services will be provided to a defined standard. 4. Care will be consultant delivered. 5. Services will be provided over seven days with no deterioration in service provision at the weekends. 6. Sites will collaborate in delivery of the in scope services through the single services model in their sector. 7. Within each sector one site will deliver the in-patient services for high risk elective and high risk emergency general surgical adult patients. 8. Within GM high risk patients with a medical or surgical pathology will where possible be diverted directly to the most appropriate hospital site and will bypass their local A&E. For some conditions these receiving A&Es will serve the GM population, for others there will be a sector receiving A&E. 9. Sites undertaking high risk general surgery must have a co-located A&E. 10. Every site will have an Acute Medical Unit (AMU) and a Critical Care Unit (CCU) The role of NWAS in the Healthier Together Model of Care A number of pathways for emergency high risk patients are now fully embedded in Greater Manchester through a partnership with the North West Ambulance Service (NWAS): Patients with Major Trauma; Acute myocardial infarction; and Patients with a Stroke. Since the HT decision to implement four single services across Greater Manchester for general surgical services, significant work has been undertaken to assess whether NWAS paramedics can identify emergency general surgical patients for immediate conveyance to the general surgical hub sites. An extensive audit showed that these patients do not present with symptoms that can be identified in an ambulance and as such these patients will continue to be conveyed to the nearest A&E as they are now. Aligned to this: Work has been undertaken to assess feasibility of a pathway for shocked patients with upper gastrointestinal haemorrhage (GI bleed). National evidence suggests these patients require endoscopy within 2 hours of their bleed. As such immediate conveyance and treatment to a site capable of delivering this is essential. This additional pathway will be implemented as part of Healthier Together. 149

150 Healthier Together Full Business Case There are other medical conditions for which timely expert interventions will have significant patient benefits, such as shock due to infection. In these cases, there will be benefit for patients being conveyed directly from out of hospital to the high acuity sites. Assessing the feasibility of such a pathway is now necessary. Consequently, plans for the transfer of high risk emergency general surgical patients from non-hub sites to surgical hub sites have been made. Each sector has identified the expected volume of high risk patients who will require transfer. Please see the diagram below which shows the four sectors and the expected activity flows of emergency general surgical patients which for the region is estimated as approximately 6,800 patients. These transfers will be in addition to the current NWAS activity of conveyances to, from and between these hospital sites. Figure 7.5.1: HT four single services for general surgery patients 1,942 NEL 1,260 NEL 1,980 NEL 1,665NEL 150

151 Healthier Together Full Business Case The Healthier Together transfer model In order to determine the impact of these additional transfers, the level of acuity of these general surgical patients (identified as needing to transfer to the surgical hub site), have been categorised into: 1. Patient needs urgent surgery: immediate destination is the operating theatre at the surgical hub site; 2. Patient may need surgery within the next hours: immediate destination is an ICU bed at the Hub; 3. Patient may need surgery within the next hours: immediate destination is an HDU bed at the Hub; and 4. Patient may need surgery within the next hours: immediate destination is a surgical ward bed at the Hub. It is proposed that clinicians use these simple categories to determine the level of response from NWAS. Clinical discretion is expected to be used with escalation through this framework under certain circumstances. It should be noted that there may be a very small number of patients who are too sick for transfer i.e. needs an immediate life-or-death laparotomy, with features that make this very time critical. Therefore, there will be some circumstances where clinical expertise, theatre space and critical care capacity are immediately available at a non-hub site and the balance of risk precludes inter-hospital transfer (at any level of priority). This would be an exception and require clinical justification. It is expected that further detail on the logistics of these transfers will be developed as guidance for the sectors in preparation for implementation, this will cover for example: which communication channels will be used, which clinician phones which clinician within the single service, where in the hospital the ambulance should arrives at, how patients are booked in, what happens if the patient deteriorates on the journey etc. 151

152 Healthier Together Full Business Case The impact on NWAS Work was then undertaken to determine whether these categories of acuity could be mapped to the current NWAS framework for inter-facility transfers or whether a new framework specific to Healthier Together patients was required. The current framework used by the North West Ambulance Service to categorise patients who require transfer between facilities is outlined in the tables below. Table 7.5.1: NWAS inter-facility transfer framework Transportation choices for patients 152

153 Healthier Together Full Business Case 153

154 Healthier Together Full Business Case The Healthier Together clinical champions were able to map the categories of emergency general surgery patients requiring transfer (based on acuity), to this current NWAS framework. The table below maps these categories to the NWAS priority of transfer/ required response time. 154