NHS England. 1m - 3m Business Case Proforma. NHS England Trafford Clinical Commissioning Group. NHS England Trafford Clinical Commissioning Group

Transcription

1 NHS England 1m - 3m Business Case Proforma Sponsoring NHS Organisation NHS England Trafford Clinical Commissioning Group Source of Capital / Revenue NHS England Trafford Clinical Commissioning Group Title of Scheme Shrewsbury Street Village (subject to rebranding exercise due to complete October 2015) Capital Value ( 000 inclusive VAT) Revenue Value ( 000 inclusive VAT) ,585,250 ex VAT 10,000 ex VAT (for legal fees) ,000 ex VAT (for legal fees) ,000 ex VAT (for fixtures and fitting) ,903 pa ex VAT Total 2,695,250 ex VAT Total 5,207,090 ex VAT 100,000 ex VAT (for fixtures and fittings) Contact Details Ian Currell Director Finance of Lancashire and Greater Manchester ian.currell@n hs.net Julie Powell Primary Care Transformation Manager - Finance TCCG 1

2 Shrewsbury Street Village Executive Summary The Shrewsbury Street Village is a 19.6m development funded by Trafford Housing Trust (THT) and supported by Trafford Metropolitan Borough Council (TMBC). The project is underpinned by the Old Trafford Master Plan (OTMP) (1) which was developed in response to a number of issues being identified within the local communities of Old Trafford including poor access to health care, higher than average levels of health and social care deprivation, poor education, poor training and employment opportunities, compounded by an increasingly high crime rate. The Shrewsbury Street Village Project is described as an intergenerational hub comprising of 81 extra care apartments complimented with a range of community services including a new Primary Health Care Medical facility, a pharmacy, a library and contact centre, flexible use community space and enterprise units, along with a community café. All services and design have been co-produced with the local community as part of extensive collaborative consultation. Strategically, the geographical location of the Shrewsbury Street Village is of significance. Located in the electoral ward of Clifford, which is one of the three electoral wards comprising the locality of Old Trafford, Clifford is the most deprived area in the Borough of Trafford and is in the bottom 10% of most deprived areas in the whole of England. The central location of the Shrewsbury Street Village in Clifford will enable accessible services and resources for all members of the Old Trafford community and will have a genuine impact on improving the lives of the residents within the local community. The Shrewsbury Street Village is also located centrally between the existing locations of Brook s Bar Medical Centre (Chorlton Road) and Ayres Road Surgery (Ayres Road) and can be easily reached on foot within five minutes from the existing Practice locations. This will therefore not disadvantage individuals registered with the Practices and will indeed enhance the experience for individuals; provide better access through the availability of additional car parking; enhanced public transport routes; and, compliance with the Disability Discrimination Act (DDA) and Care Quality Commission (CQC) standards for Primary Care premises. This Business Case progresses the Project Initiation Document (PID) submitted to NHSE and TCCG in October 2014 which proposes the re-location of Brook s Bar Medical Centre and Ayres Road Surgery to the Shrewsbury Street Village. In addition to the re-location of the two Practices, TCCG have requested that additional space is included within the design to accommodate above Practice Primary and Community Care Services. The footprint for the proposed new Primary Health Care Centre comprises of a Net Internal Area (NIA) of 1,025.5m 2 split between the three partner organisations as follows: Brook s Bar Medical Centre 430.8m 2 Ayres Road Surgery 263.7m 2 2

3 TCCG 331.1m 2 which is inclusive of space and resources shared between the General Practices and TCCG. Within the NIA an allowance has been made for storage space on the ground floor of 9.6m 2 which will be charged at per annum and not at the cost per m 2 as agreed with the District Valuer. Ten car parking spaces for exclusive use will also be provided at 3,000. The Business Case presents two funding options for consideration by the NHS a revenue option and a capital option. Revenue Option The District Valuer has determined a rental cost of per m 2 (rounded to per m 2 ) exclusive of VAT as being value for money to the NHS. This would represent a combined annual rent of 166,452 per annum exclusive of VAT plus 3,000 for car parking spaces and 450 for ground floor storage space. This creates a revenue requirement of 169,903. This is split between the General Practices and TCCG as follows: Brook s Bar Medical Centre Ayres Road Surgery TCCG 430.8m 2-71,317 per annum ex VAT 263.7m 2-43,812 per annum ex VAT 331.1m 2-54,773 per annum ex VAT The Practices are currently in receipt of a combined notional rent of circa 48, The net additional requirement in notional rent for the General Practices is estimated at 67,129 exclusive of VAT per annum. The rent costs have been fixed for the Term of the Lease and will therefore not be subject to rent review and are based upon a straightforward cost recovery model. The estimated costs for TCCG are 54,773 per annum exclusive of VAT and as with the Practices is based upon a straightforward cost recovery model. The Term of the Lease for the revenue option is based on a thirty year Full Insuring and Repairing (FIR) Lease commencing in September 2017 with a break clause at year twenty. Should the break clause be invoked at year 20 this will attract a financial penalty. The penalty will be the financial liability for the rental income from the point at which the break is initiated i.e. year twenty to the end of the agreed Lease Term and has been set by the Office of the District Valuer at 1,290,941 ex VAT. The Head Lease will be between THT and NHS Property Services (NHSPS) with the latter entering into Under Lease agreements with the General Practices and TCCG. The revenue cost for the term of the Lease is estimated at 5,097,090 excluding VAT. Capital Option The capital value of the Project is estimated at 2,585,250 exclusive of VAT based upon a single capital contribution. The capital contribution payment would be required on or before start on site (expected to be January 2016) and is therefore payable in Financial Year

4 As in the revenue option, NHSPS would be required to enter into a Head Lease with THT on an FIR basis over a Lease term of thirty years without a break clause. In this option, there will be no recourse to rent review. This is on the basis that the capital payment negates the need for a revenue stream to fund the Project and that the Lease costs per annum would be at a peppercorn rate ( 1.00 per annum). The revenue option generates a requirement of an additional 121,903 per annum excluding VAT which takes into account the current reimbursement of 48,000 received by the Practices. Over the Lease Term this equates to a new revenue requirement of 3,657,090 exclusive of VAT. Should the capital option be preferred and to draw a comparison, this would represent an annual rent of 86,175 per annum exclusive of VAT. It could be further argued in favour of the capital option that this could represent a revenue cost improvement of 1,440,000 over the Term of Lease as there would be no requirement to continue to fund the rent reimbursements currently provided to the General Practices. The District Valuer has recommended to the NHS that whilst the revenue option does represent value for money, the capital option is even better value for money and has recommended that the capital option be the preferred option. The Practices and TCCG will be responsible for funding their facilities management and service charge costs. The Practices will be making a funding application to NHSE / TCCG for a contribution to legal fees, Stamp Duty Land Tax (SDLT) and the costs for fixtures and fittings as they are entitled to under the National Health Service (General Medical Services Premises Costs) Directions 2013 (2). 4

5 Contents 1. Introduction and Background 2. The Proposal 3. The Practices 3.1 Brook s Bar Medical Centre 3.2 Ayres Road 4. Context 4.1 Health Inequalities and Deprivation 4.2 Old Trafford Master Plan / Trafford Housing Trust 4.2 Primary Care 5. Support for the Development 6. Procurement Process / Contract Arrangements 7. The Development 7.1 The Development Site 7.2 Traffic / Transport Impact Plan (Green Traffic Plan) 7.3 Approach to BREEAM 7.4 Planning Application / Planning Consent 7.5 Compliance with DH Guidance (including Infection Control) 7.6 Construction Programme 7.7 Schedule of Accommodation 7.8 Floor Plans 8. Local Approval Process 9. Case for the Re-Location of Brook s Bar Medical Centre and Ayres Road Surgery 10. Strategic Case 11. Financial Case 11.1 Revenue Option 11.2 Capital Option 11.3 Value for Money Appraisal / Recommendation 12. Service Charges 13. Facilities Management 14. Non-recurrent Funding 15. GPIT 16. Legal Framework 16.1 Revenue Option 16.2 Capital Option 16.3 Renewal of Head Lease 17. Option Appraisal 18. Summary 19. Recommendation References Appendices 5

6 1. Introduction and Background The Shrewsbury Street Village is a 19.6m development funded by Trafford Housing Trust (THT) and supported by Trafford Metropolitan Borough Council (THBC). The project is underpinned by the Old Trafford Master Plan (OTMP) which was developed in response to a number of issues being identified including poor access to health care, higher than average levels of health and social care deprivation, poor education, poor training and employment opportunities accompanied with increasingly high crime rates. The vision for Old Trafford Masterplan is to create a vibrant, sustainable community, with quality housing, an excellent environment, and good connections to employment opportunities together with improved retail and community facilities and access to Primary Health Care and Community Health Services. The vision for Shrewsbury Street is much greater than simply the provision of a new building. The aim is to deliver a project which is the most amazing, innovative, multi-use development which puts people first; is delivered for and with the community to meet their future needs and aspirations; and acts as a catalyst for change in the way such developments are viewed, designed, managed, accessed and used. The project involves combining Trafford Housing Trust, Council and Church land to create a fantastic new intergenerational hub. This will include an 81 apartment extra care scheme, based upon the House our Aging Population Panel for Innovation (HAPPI) principles alongside a new Primary Care Medical Facility, a pharmacy and a number of clinical services; together with a future proof community centre with a focus on wellbeing, enterprise, technology and advice which will not only re-provide for existing services such the library and community facilities but will go much further and create a real centre for Old Trafford. Throughout the development process, extensive consultation has been facilitated within the local communities and with key stakeholder organisations where wide support has been demonstrated for the Project. The consultation further demonstrated overwhelming support from the local communities and key stakeholders to develop and integrate a new Primary Health Care medical facility within the Project to re-provide for Brook s Bar Medical Centre and Ayres Road Surgery accompanied with additional space for commissioned services. THT subsequently entered into discussions with NHS England (NHSE) Local Area Team and Trafford Clinical Commissioning Group (TCCG) with the purpose of determining whether a new Primary Health Care medical facility would be feasible (and affordable) as part of the Shrewsbury Street Village development. Both NHSE and TCCG agreed that a new Primary Health Care medical facility is potentially viable and approaches were made to two local General Practices Brook s Bar Medical Centre and Ayres Road Surgery with the intention of co-locating the in the proposed new medical facility at Shrewsbury Street Village. Both Practices have welcomed the opportunity to re-locate from their existing Practices and both Practices have recognised that to achieve the strategies outlined for Primary Health 6

7 Care and Community Services in Old Trafford they will need to re-locate to new Practice premises. Both Practices have served their local communities well over a number of years but neither are able to develop further on account of the physical constraints imposed by their current Practice locations. Both Practices are landlocked which prohibits any opportunity for further expansion and both have poor access; have non compliant consulting and treatment rooms; and, have serious shortfalls in meeting DDA requirements. The ages of the Practices does give rise to serious concern in respect of their continued ability to meet the statutory requirements for Primary Care Premises and to meet the exacting standards set by the Care Quality Commission. Any new investment into the existing Practices would have no obvious benefit and at best would only provide short term fix as opposed to a long term and sustainable solution and which would not make any significant impact or contribution to the strategies for improving Primary and Community Care Services in Old Trafford. The re-location of the Practices to the Shrewsbury Street Village would enable the Practices to meet the DDA requirements and standards. Perhaps more importantly it would also provide the Practices with a genuine opportunity to work differently and innovatively and to provide a much wider range of services and thus improve the overall experience for every individual when they visit their Practice. The TCCG five year Strategic Plan Our Vision for your Health (3) highlights three high level strategic health aims for the people of Trafford as follows: Every child has the best start in life A reduced gap in life expectancy Improved mental health and wellbeing All three aims are essential to improving the lives of people in Old Trafford due to the high percentage of young people; the lower life expectancy rate; the high levels of people claiming incapacity benefit and the high number of individuals experiencing mental health problems. Shrewsbury Street Village has a key role in supporting this strategy. This is a view that is shared by all partners and stakeholders and the recognition that increased co-ordination and collaboration between commissioners and providers is critical to achieve these strategic aims. In working together and focusing on the more social and economic issues identified within the Old Trafford Master Plan, the Shrewsbury Street Village will enable people in Old Trafford to make changes in their lifestyles. It will also have a positive impact on the general health of the local communities through the provision of a wider range of quality health and wellbeing services in a Primary Health and Community Care environment and will genuinely provide younger people with the opportunity to develop and influence their future and future lifestyles. 7

8 The Shrewsbury Street Village will provide a real opportunity to offer improved access to General Practice and related services; and will enable a wider range of services to be delivered closer to where people live. It will also help to reduce the pressures on secondary care services. TCCG are looking to further develop and expand integrated pathways of care and Shrewsbury Street Village has been recognised as a key strategic hub from which to deliver these integrated pathways of care. The above strategic aims are supported by the following strategic objectives: Consistently achieve local and national quality standards Deliver an increasing proportion of integrated services from primary care and community settings Reduce the gap in health outcomes between the most and least deprive communities in Trafford Ensure a financially stable health economy The key initiative is for TCCG to become a level four Primary Care Co-Commissioner. The advantages of co-commissioning for the local population are principally that TCCG will have greater decision making ability in how Primary Care and Community Services will be delivered; how contracts are managed locally; the development of Primary Care premises; the configuration of Primary Care providers; and, to improve the co-ordination of local authority and enhanced services provided locally by the NHS. The Strategic Plan is further supported by TCCG s strategy for primary care Integrated Primary Care Development and improvement Strategy (4) which builds upon the patient centred integrated pathways and with a wider range of services being delivered within Primary Care and Community environments, accompanied with improved access and a wider range of appointment times. The benefits that will be derived from the development of a new Primary Care Medical facility located at Shrewsbury Street Village can be summarised as follows: A new and purpose built Primary Care Medical Facility that will be sustainable for the next 30 years and beyond. A Primary Care Medical facility that will be compliant with CQC and DDA standards in an environment that will improve the individual experience. A Primary Care Medical facility that will bring together both General Practice services and Primary Care and Community Services into one location. Further enhancement of the ability to deliver integrated pathways of care close to where people live. Transfer of services provided in Secondary Care to Primary Care. Improved access times accompanied with a wider range of appointment choices. Opportunity for Primary Health Care services to integrate with local authority and other services e.g. public health and education to improve the overall health and well being of the Trafford communities. 8

9 The new Primary Care Facility would achieve the aspirations of the local community in the development of new Practice Premises and services for the wider benefit of the Trafford community. 2. The Proposal This Business Case progresses the Project Initiation Document (PID) submitted to NHSE and TCCG in October 2014 and proposes the re-location of Brook s Bar Medical Centre and Ayres Road Surgery to the Shrewsbury Street Village. In addition to the re-location of the two Practices, TCCG has requested that additional space is included within the design to accommodate above Practice commissioned Primary and Community Care Services. The footprint for the proposed new Primary Health Care Centre comprises of a Net Internal Area (NIA) of 1,025.5m 2 and split between the three partner organisations as follows: Brook s Bar Medical Centre 431.8m 2 Ayres Road Surgery 263.7m 2 TCCG 331.1m 2 which is inclusive of space and resources which are shared between the parties. The Guidance received from NHSE in relation to the development and submission of a Full Business Case requests that the context for the proposal be included within the body of the text and is required to make reference to: The condition of the existing Practice Premises The Health and Social Care issues which the project is intended to address The strategic context in respect of local Health Policy for Primary Care The local Health Strategies and Policies for Trafford are well documented and should be familiar to the local Health Organisations for which this Business Case is intended and for the purposes of the Business Case we have summarised the main themes and how they relate to the Project Proposal. The other key area, and for our colleagues who are well versed in Local Health Strategy and Policy, is Section 11 that sets out the funding options and terms for the Proposal. 2. The Practices 2.1 Brook s Bar Medical Centre Brook s Bar Medical Centre is a General Medical Service (GMS) Practice comprising of four General Practitioners and a Practice List of circa 6,000. The Practice is accommodated within a three storey former residential property of traditional construction built in the late 19 th century. The Practice has a footprint of 606m 2 which includes the addition of an extension and provides 41m 2 for a local pharmacy. 9

10 The Practice is planning to increase the number of General Practitioners in the future. This is partly to accommodate the expected increase within the local population over the course of the next two to three years, including the Shrewsbury Street Village development and the recent addition of 100 new dwellings in the area accompanied with a further 250 new dwellings being planned by THT as part of the Old Trafford Master Plan. The Practice is also anticipating that a wider range of Primary Care Services will be required to be delivered within Primary Care environments and they are currently planning how they will provide a wider range of enhanced services. The current Practice is located on Chorlton Road which is only a few minutes from Shrewsbury Street. The result is that the relocation to Shrewsbury Street would have limited impact on the current Practice List and their ability to access services, and indeed access is likely to be improved, particularly for those residing in Old Trafford. The Practice is currently staffed as follows: X 4 General Practitioners X 1 Practice Manager X 1 Deputy Practice Manager X 2 District Nurses Visiting X 2 Health Visitors Visiting X 2 Practice Nurses X 1 Midwife Visiting X 1 Community Drug Worker Visiting X 1 Health Care Assistant X 1 Office Manager X 1 Administrator X 8 Receptionists and is open at following times: Opening Hours Consultations AM Consultations PM Monday 8.30am 7.45pm 9.00am - noon 3.00pm 7.30pm Tuesday 8.30am 7.45pm 8.00am - noon 3.45pm 7.30pm Wednesday 8.30am - noon 9.00am - noon Closed Thursday 8.30am 7.45pm 8.00am - noon 3.45pm 7.30pm Friday 8.30am 6.30pm 9.00am - noon 3.00pm 5.30pm In addition the Practice provides appointments for individuals at Jubilee Court who are able to book appointments through the routine Practice booking system. Jubilee Court was the previous Branch Practice of the Brook s Bar Medical Centre. The Practice also provides a walk in service as follows with the majority of consultations not requiring a pre booked appointment. Day Walk In AM Walk In PM By Appointment 10

11 Monday 11.00am - noon 5.00pm 6.15pm Tuesday 11.00am - noon 5.00pm 6.15pm Wednesday 11.00am noon Thursday 11.00am - noon Friday 11.00am - noon 5.15pm 6.15pm The following table illustrates the average number of appointments per month by clinic type. Clinic Type Number of Attendances 24 Hour BP Monitoring 4 Baby Clinic 52 Blood Clinic 32 Default/routine clinic appointments Extra Patients 14 Follow Up 17 GP Use Extra Patients 98 Jubilee Court Appointment Only 10 Jubilee Court Walk In 273 Minor Surgery 18 Same Day Appointments 44 Triage 2 Urgent Appointments 613 (set as default) Total (includes urgents seen same day) The Practice provides the full range of services as expected under the GMS contract arrangements accompanied with special interest services including, for example, from minor surgery, child health surveillance, gynaecology and diabetes. The Practice also provides the following service by appointment: Ante Natal and Baby Clinics Asthma Clinic Diabetic Clinic Community Drug / Counselling Clinic CHD clinic Smoking Cessation Clinic Minor Surgery Clinics Wound Clinics To support the case for Brook s Bar Medical Centre to re-locate to new Practice Premises at the Shrewsbury Street Village a condition appraisal / 6 facet survey of the existing practice was undertaken by the Howarth Litchfield Partnership on the 3 rd February These surveys are recommended in NHS Estatecode as the preferred methodology applied to determine the condition, functionality and suitability of NHS premises across a range of 11

12 criteria. The minimum standard to be achieved across the criteria is Condition B. The outcomes of the assessment of Brook s Bar Medical Centre are presented in the table below: Assessment Criteria Rating Commentary Physical Condition C operational but major repair or replacement will be required soon within three years for building elements and one year for engineering elements Functional Suitability C not satisfactory and major change needed Space Utilisation F a satisfactory level of utilisation Quality D a very poor facility requiring significant capital investment or replacement Fire, Safety and Statutory Requirements C building with known contravention of one or more of the standards which falls short of B Environmental Management D GJ per 100 cubic metres The assessment criteria for the 6 facet survey are attached at Appendix 1 and the full assessment for Brook s Bar Medical Practice is attached at Appendix 2. The outcomes of the 6 facet survey for Brook s Bar Medical Centre demonstrates that the Practice falls below the minimum requirement of condition B across all of the criteria which strengthens the case for the Practice to re-locate to a modern and purpose built facility. The physical condition of the Practice would indicate that major investment or replacement of the existing premises within the next three years is required. This fits comfortably within the timescales for the completion of Shrewsbury Street Village. When accompanied with the poor scores in functional suitability, quality, fire, safety, statutory requirements and environmental management the future sustainability beyond the next three years would not be achievable. 2.2 Ayres Road Surgery Ayres Road Surgery is the Branch Practice of Gorse Hill Medical Centre. The Practice is a Personal Medical Service (PMS) Practice with three General Practitioners and a Practice List of circa The Practice is a converted late Victorian dwelling occupying an end of terrace plot with an extension to the rear. The area of the Practice is circa 210m 2. The Practice is currently reviewing the number of General Practitioners required by the Branch Practice in keeping with the anticipated growth of population and housing in the area over the course of the next few years and including the Shrewsbury Street development. In addition, the Practice is forward planning for the delivery of additional services resulting from the continued development of services deliverable within Primary Care settings. If the Practice cannot re-locate to new Practice Premises the delivery of these enhanced services within Primary Care will not be achievable. 12

13 The current Practice is located at 109 Ayres Road which is only a few minutes from Shrewsbury Street. The result is that the relocation to Shrewsbury Street would have limited impact on the current Practice List and their ability to access services, and indeed access is likely to be improved, particularly for those residing in Old Trafford. The Practice is currently staffed as follows: X 3 General Practitioners X 1 Practice Director X 1 Practice Nurses X 2 Administrators X 3 Receptionists In addition the practice has a number of community service clinicians that visit on a regular basis e.g. Child Health Visitors, District Nurses. Practice opening times are as follows: Opening Hours Consultations AM Consultations PM Monday 8.30am 7.45pm 10.00am 1.00pm 4.00pm 7.30pm Tuesday / Thursday / 8.30am 6.30pm 10.00am 1.00pm 4.00pm 6.30pm Friday Wednesday 8.30am 1.00pm 10.00am 1.00pm Closed The following table illustrates the average number of appointments per month by clinic type. Clinic Type Number of Attendances Routine GP appointments 550 Emergency GP appointments 350 Telephone appointments 160 Home Visits 30 Practice Nurse Appointments (annual 210 reviews, chronic disease monitoring, BPs) Blood clinic 30 Minor Surgery 5 Total 1335 The Practice provides the full range of services as expected under the PMS contract arrangements accompanied with special interest services including, for example, minor surgery, child health surveillance, gynaecology and diabetes. The Practice also provides the following service by appointment: Ante Natal and Baby Clinics 13

14 Asthma and COPD Clinics Diabetic Clinic CHD clinic Smoking Cessation Clinic Minor Surgery Clinics Immunisations e.g. flu, pneumococcal, child health The Ayres Road Surgery was assessed against the NHS Estatecode methodology on the 3 rd February 2015 by the Howarth Litchfield Partnership. The full assessment is attached at Appendix 3 and the table below summarises the outcome of the 6 facet survey. Assessment Criteria Rating Commentary Physical Condition C operational but major repair or replacement will be required soon within three years for building elements and one year for engineering elements Functional Suitability C not satisfactory and major change needed Space Utilisation U generally under used and utilisation could be significantly increased Quality D a very poor facility requiring significant capital investment or replacement Fire, Safety and Statutory Requirements C building with known contravention of one or more of the standards which falls short of B Environmental Management D GJ per 100 cubic metres The outcomes of the 6 facet survey for Ayres Road Surgery are almost identical to Brook s Bar Medical Practice demonstrating that the Practice falls below the minimum requirement of condition B across all of the criteria which strengthens the case for the Practice to relocate to a modern and purpose built facility. The physical condition of the Practice would indicate that major investment or replacement of the existing premises within the next three years is required. This fits comfortably within the timescales for the completion of Shrewsbury Street Village. When accompanied with the poor scores in functional suitability, quality, fire, safety, statutory requirements and environmental management the future sustainability beyond the next three years would be extremely questionable. As highlighted above both Practices are very similar in nature and condition. Each has served the local population of Old Trafford well over a number of years. However, both are now at the point where they are outgrowing the premises and are lacking the physical resources required to allow the Practices to utilise the specialist skills that are available and to deliver the additional services they aspire to. The age profile of both Practices does give rise to serious concerns in respect of its continued ability to meet the statutory requirements for Primary Care Premises and to meet the exacting standards expected by the Care Quality Commission. Both Practices are landlocked on all sides which prohibits any opportunity for further expansion. Any new investment into the existing Practice would have limited benefit and at 14

15 best would only provide a short term fix as opposed to a long term and sustainable solution. The re-location of the Practices to the Shrewsbury Street Village would enable both Practices to meet these requirements and standards but more importantly would provide both Practices with the genuine opportunity to work differently and more innovatively; to provide a much wider range of services which reflect the needs of the local population; to provide a wider range of appointments in keeping with the local lifestyle changes and to ensure the future sustainability of Primary Care services in Old Trafford. The Premises Condition Appraisals referenced above do provide compelling evidence that new Practice Premises are a pre-requisite for the future of both Practices and the Shrewsbury Street Village provides a unique opportunity within which to develop new and purpose built Practice Premises which may not be available in the future. 3. Context The following sections establish the context for the Shrewsbury Street Village development and the proposal to re-locate Brook s Bar Medical Centre and Ayres Road Surgery along with the development of new clinical space for above Practice commissioned services. 3.1 Health and Social Care Context Trafford Wider Context The Borough of Trafford covers an area of 40 square miles and comprises of 21 Electoral Wards as illustrated in the map below. TMBC is coterminous with TCCG and covers the geographical area of Greater Manchester from Partington in the West, Sale Moor in the East, Old Trafford in the North and Hale in the South. 15

16 The current population of Trafford is estimated at 230,000 and is expected to increase by 13.9% by 2030 with an increase of 14.2% in the 0 to 17 years age range; an increase of 8.1% in the 18 to 64 years age range and an increase of 38% in those over 65 years. However the greatest rate of increase is predicted to be in those over 85 years where it is estimated that the population will increase by circa 44%, thus increasing this demographic from 5,000 to 8,900. In Trafford, 80.4% of the population report their ethnicity as being White British. Of the remaining 19.6%, White Other (which includes origins from other European countries), Asian and Asian British, Indian and Pakistani groups make up the highest proportion. Most of the electoral wards in Trafford are fairly similar in terms of life expectancy however there are inequalities between and amongst genders. Women in Urmston and Bucklow St Martin in the West Locality live significantly shorter lives than women in Hale Central or Hale Barns in the South Locality with the difference in life expectancy being 7.9 years. Men in Bucklow St Martins and Gorse Hill in the North Locality live significantly shorter lives when compared with Hale Central of Brooklands in the South Locality with the difference in life expectancy being 7.6 years. Collecting reliable ward level data on mental health and mental illness is not always 100% reliable but at a Borough level it is acknowledged that there are high levels of mental health issues and mental illness in Trafford. Levels of mixed anxiety and depression are higher than the England average with 11.14% of year olds experiencing mental health problems. The average for England is 8.92%. Rates of depression and anxiety among social care users is significantly higher with 51.2% of individuals engaged with social services reporting that they feel moderately or extremely anxious or depressed. The average for England is 53.4%. 16

17 These high rates of reported anxiety and depression within social care users correlate directly to the areas in the Borough of highest deprivation where the incidence of mental ill health is significantly higher. Trafford provides a full range of Primary Care Services delivered by 35 GP practices, 33 dental practices, 62 pharmacies and 30 opticians. Many of the General Practices provide extra opening hours to enhance the range of appointments available to their Practice populations accompanied with enhanced services such as minor surgery, support for substance misuse and regular health checks for individuals in residential and nursing home care. Some General Practices offer in house services to support local access to services such as phlebotomy, ECG and psychological therapies. Whilst appearing impressive at a superficial level, Primary Care does have significant issues that will need to be addressed in the short, medium and long term as follows: In General Practice referral rates to Secondary Care services for first appointment attendance were 243 per 1,000 of the population. The national average is 192 per 1,000 of the population which is significantly lower than the referral rates within Trafford. A number of potential reasons have been cited for this such as higher levels of morbidity in the local population, ineffective management of presenting conditions in Primary Care accompanied with what has been determined as a high number of inappropriate referrals. Prescribing rates measured in the same period indicated that the spend in Trafford per 1,000 of the population was 92,633. The national average per 1,000 population is 79,662. The cause for this would appear to be the higher numbers of elderly people within the Trafford population although this has yet to be demonstrated statistically. Recent measures have compared the non elective admissions in with non elective admissions In Trafford there has been a 29% increase in non elective admissions. The average for England in the same period was 7%. In the General Practices in Trafford had 72,999 admissions into Secondary Care services. Out of these admissions, less than half were elected admissions 34,975 or 38% which presents a significant issue for Primary Care in respect of reducing the number and volume of non elected admissions into Secondary Care. In both health and economic terms, the profile of Trafford is close to the average for England as a whole and the local population is among the healthiest in the North West. However, it must be recognised that the North West is the least healthy region in England. Life expectancy for both men and women is lower than the national average, 79.5 years for men and 83.5 years for women. Old Trafford Context The Trafford borough experiences significant disparate socio-economic factors with some of the most affluent areas in the country situated alongside areas that are in the worst 10% nationally for deprivation. The most economically and socially deprived neighbourhoods in 17

18 Trafford also have the greatest levels of health deprivation with the worst being in the north of the Borough in the Electoral Wards of Clifford and Longford. The geographical area of Old Trafford spans the electoral wards of Clifford, Longford and Stretford, is located to the south west of Manchester City Centre and occupies a strategic location within Greater Manchester area. Whilst being famous for its sporting venues, Old Trafford is also adjacent to important strategic locations such as the Exchange Quay financial quarter, Trafford Park and Media City. The area is well connected to the core conurbation areas through Metrolink and nationally via the A56 corridor and internationally through Manchester Airport which is within a twenty minute commuting distance. Despite the strategic location, Old Trafford it is still ranked as one of the most deprived areas nationally with the Electoral Wards of Clifford and Longford falling within the bottom 10% of most deprived areas in England. The current estimated population of Old Trafford is estimated at 47,358 residing in 19,894 households. Old Trafford, despite being the second smallest locality within the Borough of Trafford covering an area of 19.6km 2 is the most densely populated area within the Borough. It is estimated that 46% of the population fall within the Black and Minority Ethnic (BME) groups. The average for the Borough of Trafford is 20%. It has been identified that there is both a higher risk and incidence for developing long term health conditions such as diabetes and heart disease in this group. Reports from Primary Care services in Old Trafford would indicate that they have the highest numbers of people with diabetes across the whole of Trafford. Life expectancy is 7.9 years lower for men and 7.6 years lower for women when comparing the most deprived areas with the least deprived areas in the Borough. As stated above, Old Trafford has higher levels of deprivation when compared to the Trafford average and precipitates higher levels of disease, illness (including mental health) and mortality. The area has high levels of child poverty where it is estimated that in the Clifford Ward alone, 43% of children are living in poverty. Childhood obesity in Old Trafford is significant and it estimated that the Old Trafford electoral wards have the highest levels of childhood obesity measured at Year 6 (Age 10/11) with 23% of the total children being classed as obese. Stretford and Longford electoral wards have the highest rates of emergency hospital admissions for heart attack. Clifford, Longford and Stretford have high rates of hospital admissions for coronary heart disease. Furthermore, Clifford and Longford have high rates of planned / elective hospital admissions for coronary heart disease. Stretford has the highest rate of emergency hospital admissions for injurious falls in people aged 65 years and over in the whole of Trafford. 18

19 Old Trafford also has the highest incidence of lung cancer associated with high rates of alcohol and smoking. In terms of disease prevention and early diagnosis, Primary Care services have reported that Old Trafford has the lowest uptake for cervical screening and bowel cancer screening accompanied with low levels of uptake in vaccinations. The highest incidence of alcohol related hospital admissions in Trafford are reported to be from the electoral wards that comprise Old Trafford. 3.2 Strategic Context OTMP / THT The strategic case for the development of a new Primary Health Care facility as part of the Shrewsbury Street Village development needs to be considered in the wider context of a number of interrelated strategies and the commitment of the partner organisations to work together for the benefit of the Old Trafford community. To establish the context of the strategic case for the new Primary Care Medical Facility reference will be made to the Old Trafford Master Plan, the THT development proposal for Shrewsbury Street Village, the NHSE Greater Manchester Primary Care Commissioning Strategy Our Five Year Strategy for improving Primary Care in Greater Manchester (5), the TCCG strategy Our Vision and your Health and the accompanying Integrated Primary Care Development and Improvement Strategy Before considering the intent of the Old Trafford Master Plan, the Plan must be placed in the wider context of the Borough and the strategic geographical location of the Shrewsbury Street Village in the regeneration of the Old Trafford community. The OTMP is a long term plan to regenerate the northern sector of Old Trafford. The Masterplan was developed in recognition that Old Trafford has a number of inherent problems in terms of the quality of housing, unemployment, access to facilities, education and being one of the most deprived areas in England. THT, TMBC and the HCA is in the process of delivering the Masterplan for Old Trafford with the aim to "create a vibrant, sustainable community, with quality housing, an excellent environment, and good connections to employment opportunities together with improved retail and community facilities" by improving existing homes, building new homes to meet local need, improving the environment and working with partners and residents to ensure that training, education, health and wellbeing are a key part of any development and ensuring that there is a real focus on adding value and improving lives. This work has now started and early projects include the refurbishment of 5 tower blocks where the aim was to improve the energy efficiency and reduce bills for tenants; demolition of tower blocks to make way for new family accommodation and the development of nearly 100 new homes to meet local needs with a further 60 homes to be delivered within the next 12 months. 19

20 As part of the Masterplan THT has committed to making a difference in Old Trafford by providing new homes and improving the social and economic environment. This includes developing an extra care scheme in order to support Old Trafford s aging population to be able to live independently, and to improve health and wellbeing for the whole community. Whilst a number of different options were considered, the rational for selecting the Shrewsbury Street site is described below in the context of Why Shrewsbury Street?, Why Now?, and Why is it the Right Thing To Do? Why Shrewsbury Street? The site is located in the centre of Old Trafford and is identified as the prime location for the development of the Shrewsbury Street Village. THT has worked closely with TMBC and St Bride s church to agree a land assembly model that will allow the site to be maximised to deliver all the services highlighted above. Following consultation, there was a strong view and support for the development of a Primary Care Medical facility as part of the wider development. The Shrewsbury Street site was identified by the local NHS organisations as being an ideal location to re-locate two General Practices in the neighbourhood Brook s Bar Medical Centre and Ayres Road Surgery who both have ambitions to develop new Practice Premises. The proximity of the playing fields provides further opportunities to create a hub for the local schools and the wider community and will incorporate new sports changing facilities. Sites located on Stretford Road and Tamworth were considered for the project but were discounted on account of not being acceptable locations for the proposed Primary Care Medical facility and because they would not support the objectives of the development. Both sites were also not considered central enough to support the needs of the local communities. Other sites were explored but were discounted on account of the problems associated with securing the land and the subsequent problems associated with land assembly. Why Now? Evidence dictates that there is a growing elderly population in Old Trafford resulting in the need to introduce community solutions that will support the growth in this sector of the population. The Old Trafford Masterplan is quite specific in the strategic need to develop an extra care scheme in the North of the Borough and supports the wider strategic objectives within the Masterplan to house the population in homes that meet with individual needs. There is also increasing acceptance that the current practice of whole families living together may not be either feasible or desirable in the long term future. The Shrewsbury Street Village is supported by THT s Independent Living Offer and has been further supported by a grant of 3.04m by the Department of Health. Why is it the Right Thing To Do? The proposed site for the development is within the ownership of THT and TMBC and whilst the existing site is well used it is now outdated and of poor design. Old Trafford, as 20

21 evidenced above, experiences significant health issues and health inequalities which need to be addressed as a priority. The integration and co-location of the two General Practices into a purpose built Primary Care facility will contribute significantly to addressing these issues and to ensure that Primary Care services will be sustainable into the long term future. Locally, there is the intention to close Stretford Memorial Hospital and to re-locate services provided by the Community Hospital elsewhere. The Shrewsbury Street Village provides this opportunity and indeed to locate services closer to the resident population of Old Trafford. There are also potential additional savings to be made on the ancillary services that are required to support the project.3.3 Strategic Context Primary Care The strategic focus for Primary Care in Trafford is twofold. First is for TCCG to become a Level 4 Co-commissioner of Services and second is for TCCG to further develop and expand the fully integrated pathways of care within Primary Care and community settings. The settings for these integrated pathways of care are described as hubs that will reach into the local communities and where individuals will have access to a wide range of different and complimentary services and within modern Primary Care premises. The Healthier Together Programme (6), accompanied with the Greater Manchester Primary Care Commissioning Strategy Our Five Year Strategy for Improving Primary Care in Greater Manchester underpin the strategies that TCCG have developed for Trafford and to deliver the improvements in Primary Care. The two essential reference documents are the TCCG Strategic Plan Our Vision for your Health and the Integrated Primary Care Development and Improvement Strategy For the purposes of the Full Business Case, an assumption has been made that colleagues within the local NHSE Area Team and TCCG are familiar with the strategic documents underpinning the Primary Care Strategy for Trafford and have therefore summarised the salient points that relate to the development at Shrewsbury Street. As stated above the local TCCG Primary Care Strategy is underpinned by the Greater Manchester Primary Care Strategy which emphasises the need for clinicians, practitioners and partner organisations to work together to improve standards and to provide high quality care close to where individuals live and to improve access to a wider range of primary and community care services. The main focus being on: Muliti-disciplinary primary and community care with General Practice being the coordinators of care The involvement of individuals and their families in this care Services being more widely accessible and responsive to individual needs The increase in services provided outside of hospital environments Accompanied with the improvement in both quality and safety for those individuals accessing services. 21

22 The Greater Manchester strategy requires that local commissioning organisations across Greater Manchester fully embrace the following key messages when planning their local strategies for Primary Care. To integrate the strategic planning and provision of Primary Care services to align with local in and out of hospital services across Greater Manchester To respond to the need to deliver enhanced and extended Primary Care services outside of existing working arrangements to support urgent care and to facilitate the continuity of care outside of hospital for individuals who have complex needs or are at end of life To respond to the needs and wishes of individuals who wish to have quality care delivered conveniently and closer to home To respond to the needs and wishes of the Greater Manchester Business Community to have more accessible Primary Care for wider economic benefit To increase the range and scope of services provided in Primary Care by Primary Care contractors and to utilise and develop the skill mix and competencies that are required to meet the changing needs for care outside of hospital To promote wellness and prevent ill health by integrated working across the public sector to address the key determinants of poor health and to influence lifestyle choices and access to wellness, screening and preventative services To offer early intervention when individuals become ill or develop a long term health conditions, to provide optimum management of the condition with the individual and their families as the empowered partners in their care and to enable individuals to die in the place of their choosing when at the end of life To provide a broad and co-ordinated approach to ensure the wellbeing. Independent living and best care for the most vulnerable groups. 22

23 TCCG have stated that their strategic aim is to: Ensure that the health services that we manage for the people of Trafford are provided at the right place and at the right time, and that services are safe, of a high quality and are of high quality. Shrewsbury Street Village will deliver this by providing GP services, along with local priority wrap around services in a easily accessible, central location, in a building which is fully DDA and CQC compliant. It will also provide a number of other services and be a one stop shop in order that local people can deal with a number of issues in one place, all of which will have a positive impact on health & wellbeing. The TCCG strategy is underpinned by the following four strategic objectives: Consistently achieve local and national quality standards Deliver an increasing proportion of services from Primary Care and community services in an integrated way Reduce the gap in health outcomes between the most and least deprived communities in Trafford Ensure a financially sustainable health economy The Trafford strategy for Primary Health Care is built upon co-commissioning and individually centred integrated pathways of care accompanied with a wider range of services being delivered within Primary Care and community environments and improved access. In order to translate and deliver the Greater Manchester Primary Care Strategy locally TCCG has, as a Level 4 Co-Commissioner, committed to develop and improve integrated pathways of care based upon a hub model and which the Shrewsbury Street Village Project will form the north hub. The Shrewsbury Street Village Project is being viewed as the key element to the delivery of TCCG strategies within the north of the Borough and Old Trafford. As a Co-commissioner, the intention of TCCG over the next five years is to deliver: A 15% reduction in unplanned admissions to hospital and attendances at Accident and Emergency departments A reduction in the number of unplanned admission excess days A substantive improvement in the integration of General Practice with Primary care and Community Services to enable high quality care to be delivered close to where people live and to improve the overall experience for individuals A single integrated patient information system which will mean that information will only need to provided once and not at every episode of care A single care plan which all practitioners and clinicians will have access to A much improved access to services delivered in the evenings and weekends A substantial increase in both the number of services that can be delivered locally. 23

24 And within primary care to: Improve enhanced out of hours services and access and to ensure continuity of care Implement the Primary Care Quality Commission Compliance Programme Implement the community based standards for Primary Care Implement the Primary Care Performance Standards Implement the Primary Care Practice Support Programme Maximise the use of the Primary Care Disease Prevalence and Quality Data Integration is being viewed by TCCG as the key mechanism to improve both the health and social wellbeing for the population of Old Trafford characterised by: Improving health and social wellbeing through the course of life as opposed to providing a reactive service Investing in healthy lifestyles to maintain wellbeing and to enable independent living Maintaining a positive focus on the prevention and reduction of illnesses with a high prevalence in the Borough cardiovascular disease / cancer / chronic obstructive pulmonary disease Reducing the inequalities in health and wellbeing between the most deprived and least deprived areas in the Borough Focusing the strategy for health and social wellbeing towards early intervention and prevention Improving the end of life treatment and experience Developing the integrated pathways of care for elderly people and the social services that will enhance the quality of life. And within Primary Care to: Develop new services Inter-practice patient flows, specialist locality services Improve access Improve quality of care and reduce variation through sharing best practice and care quality commission compliance process Develop robust clinical and non-clinical support networks Maximise the use of the skills and competencies of the work force Be more productive and efficient in General Practice through the achievement of economies of scale accompanied with the sharing of resources Increase access to and continuity of care for patients, through locality enhancements Achieve greater integration of care between general practice and community, social and mental health care services Increase the range of locally commissioned services delivered at scale from a locality provision. And with Public Health to: Promote individual lifestyle changes by offering a choice of wellbeing services NHS Health Checks, sexual health services, drugs and alcohol advice 24

25 Engage with and encourage communities which are less likely to access services Ensure individuals and their families are engaged and make informed decisions about participation in national screening programmes and to ensure inequalities are addressed Promote wellbeing by treating individuals holistically in both mental and physical ill health Promote effective self management for people who experience long term illness Improve the management of co-morbidities by addressing the causes of early mortality 4. Support for the Development Trafford Housing Trust Board Minute supporting the Project is attached at Appendix 4 Book s Bar Medical Centre Letter to NHSE supporting the Project is attached at Appendix 5 Greater Manchester West, Mental Health Foundation Trust Letter to TCCG from CEO Greater Manchester West, Mental Health Foundation Trust supporting the Project is attached at Appendix 6 5. Procurement Process and Contract Arrangements Identity Consult Ltd was appointed by THT on 28 th January 2014 to act as Employers Agents / Cost Consultants for the Shrewsbury Street Village Project. Included with the remit of Identity Consult Ltd was to manage a competitive tender process to appoint the main contractor for the Project. The process involved a two stage process with Stage 1 being the appointment of the main contractor and Stage 2 being the completion of the detailed design work, the agreement of the contract sum and the execution of the construction contract. Willmott Dixon Housing Ltd was appointed on 5 th August 2014 from the HCA s Developers Partner Panel following a competitive tender process which considered both quality and price. The contract comprises of a JCT Design and Build 2011 with the standard amendments and all contract documents were signed on 20 th March The Development 6.1 The Development Site The existing Shrewsbury Street Community Centre is located in the centre of a largely residential area adjacent to a number of small retail units which are sufficient in number to 25

26 qualify the area as a local centre and is designated as local centre within TMBC s core strategy. The site covers an area of approximately 12,924m 2 (1.29 hectares / 3.19 acres) and is currently home to the existing library and community facilities as well as St Brides Church and its Parsonage. Included within the site, and on the south eastern border, is the former site of the Isobel Balie Lodge an outdated sheltered housing development which has been demolished. The site is generally flat and contains either built form or hard standing and is largely devoid of any significant trees. The development site and the parcels of land that comprise the development are in the ownership of: TMBC (indicated in yellow on the map below) St Brides Church in the Diocese of Manchester (indicated in green on the map below) THT (indicated in blue on the map below) The red line on the above map illustrates the development boundary which has been assembled by the current landowners working in partnership to deliver a holistic neighbourhood hub for the local population of Old Trafford. There are no previous planning applications which are relevant to planning application for the site and historically this area of Old Trafford was under developed until the mid 19 th century when residential properties and St Brides Church were developed in