To provide the Committee in Common with: An overview of the process taken by the EOC Evaluation Group in evaluating proposals to host EOCs in the SEL

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2 To provide the Committee in Common with: An overview of the process taken by the EOC Evaluation Group in evaluating proposals to host EOCs in the SEL model The recommendations made by the EOC evaluation group in relation to the application of hurdle criteria, the scoring of nonfinancial criteria, and the assessment of the financial analysis Based on this assessment, the recommendation made by the EOC evaluation group on the configuration options that could proceed to consultation and if any option could be considered as a preferred option. 2

3 1. Overview Evaluation Process 2. Provider submissions received 3. Hurdle criteria commentary 4. Non-financial commentary Including updated travel analysis using SEL patient activity Including updated quality analysis/review of GiRFT reports from independent clinical expert 5. Financial Analysis 6. Recommendation to CiC 3

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5 There are many possible options for configuring the two elective orthopaedic centres in SEL. During 2016 providers have developed submissions to host one of the two centres. By applying agreed evaluation criteria, the evaluation panel will recommend the most appropriate to the committee in common. The process is mapped out below: March st submission: initial long list identified July nd submission: Long list options for evaluation November 2016 CiC agree consultation on shortlisted options (inc. preferred option) Several potential sites and options 4 potential sites and 6 potential options Providers develop expressions of interest to host EOC and identify sites not suitable to host Providers develop full submissions for sites on the long list 1. Application of hurdle criteria by evaluation panel shortlist of options identified 2. Application of non financial and financial criteria by evaluation panel. Recommend a preferred option to CiC & business case created 5

6 Voting/scoring members Name Dr. Jonty Heaversedge Dr. Hany Wahba Moira McGrath/Sarah Cottingham Dr. Faruk Majid Dr. Jhumur Moir (on behalf of Dr. Ombarish Banerjee) Mark Cheung Organisation Southwark CCG Greenwich CCG Lambeth CCG Lewisham CCG Bexley CCG Bromley CCG Non-voting/scoring members Name Patrick Figgis John King Gaby Charing (in place of Ian Fair) Rikki Garcia Mr. Julian Owen Tom Brown Aileen Buckton Sarah Blow Malcolm Hines Mark Easton Organisation/Role PwC (Independent chair) PPV and chair of PPAG PPV Healthwatch Greenwich Independent Orthopaedic Clinician Director MSK Clinical Business Unit & Consultant T&O Surgeon Cambridge University Hospitals NHS Trust London Borough Bexley London Borough Lewisham OHSEL Planned Care SRO Chief Officer, Bexley CCG OHSEL Planned Care CFO Chief Financial Officer, Southwark CCG OHSEL Programme Director 6

7 Name Organisation Declared interests Dr. Jonty Heaversedge Southwark CCG Director of Vitality Ltd User of health service in Southwark Dr. Hany Wahba Greenwich CCG Joint Medical Director of Grabadoc Board member of Grabadoc Moira McGrath Lambeth CCG None Dr. Faruk Majid Lewisham CCG None Dr. Jhumur Moir Bexley CCG (None received) Mark Cheung Bromley CCG User of health service in Lambeth Sarah Cottingham Lambeth CCG (deputised for Moira McGrath at 31/08 meeting) None 7

8 Name Organisation Declared interests John King PPV and chair of PPAG Health user at Kings college Hospital and GSTT Member Southwark CCG EPEC Patient rep from EPEC to the Dulwich Programme Board Member of NHSE Adult screening board (London) Member of 111 procurement board Gaby Charing PPV Health user at Kings college Hospital and Guy s Hospital Rikki Garcia Healthwatch Greenwich (None received) Mr. Julian Owen Independent Orthopaedic Clinician, Director MSK Clinical Business Unit & Consultant T&O Surgeon Cambridge University Hospitals NHS Trust (None received) Tom Brown London Borough Bexley None Aileen Buckton London Borough Lewisham (None received) Sarah Blow Malcolm Hines OHSEL Planned Care SRO Chief Officer, Bexley CCG OHSEL Planned Care CFO Chief Financial Officer, Southwark CCG None None Mark Easton OHSEL Programme Director Director of octopus Ltd 8

9 Hurdle Criteria Description Pass/ Fail Safety & Emergency departments can continue to be delivered from the current 1 sustainability locations in SEL Trauma continuing to be provided in Trusts that currently do so Located in SE London 2 Clinical Requirements This option has the potential to meet the clinical requirements (provider characteristics) set out in the model 3 Patient Experience (Accessibility) Where there is a multi-site option sites are distributed between inner and outer SEL to be accessible to SEL patients (e.g. an option does not have two sites both inner) 4 Finance The option has a positive contribution to addressing the whole system financial challenge when compared to the do nothing scenario The proposed option demonstrates commitment to the commercial principles set out in the specification 5 Deliverability The option is able to deliver the demand and capacity requirements for a consolidated elective centre (50% of SEL activity, based on central case assumptions) 9

10 Non-Financial Evaluation Criteria Weighting Description Supporting analysis 6 Travel & Access 17% Impact on total transport times Travel time analysis (for patients by car and public transport including average travel times by mode of transport) 7 Deliverability 25% 7a. The option is sufficiently flexible, adaptable and resilient to meet the requirements of growth or changes in future demand or change in national policy. i.e. the option demonstrates appropriate flexibility 7b. Ease of implementation: the option can be delivered within a reasonable timescale with minimal risk around transition including impacts and disruption to existing services. Capacity and capability: The option demonstrates the appropriate capacity and capability to deliver the change/transition Points scored resilience to alternative demand scenarios (other than the central one) Estimate of number of years for implementation Estimate of transition risk 7c. Where investment is required, the ease of obtaining required funding or financing is considered. Assessment of financing/funding options (shortlist only) 8 Quality 17% The operating model provides evidence on how it will optimise both functional and clinical outcomes for all patients receiving elective orthopaedic care in SEL. Quality impact assessment (e.g. governance and quality systems) Comparison of current clinical quality of sites which are expected to deliver future inpatient activity under each option 9 Patient Experience 17% The option promotes equality and minimises disadvantage of protected groups as required by the Equality Act The model demonstrates how it will optimise patient experience Equality impact assessment Friends and family and CQC inpatient survey performance against national benchmark 10 Research & Education 7% The model provides support the further development of research and education activity Assessment of impact on research and education 11 Workforce 17% The option is staffable and is attractive to health care professionals working in SEL Estimate of future vs actual workforce Estimate of impact on current job roles 10

11 Description Supporting analysis 12 Financial Affordability The cost (e.g. capital, revenue and transition) is affordable for the organisations impacted Capex investment Productivity projections Revenue and cost projections 13 Organisational Sustainability The option maintains or improves all organisational positions. Any option which could destabilise the ongoing financial and organisational viability of individual providers or commissioners without a compensating strategy will be ruled out. Impact analysis on trust current vs future revenue and cost Approach to Assessment of Options 1. Firstly, the evaluation group will apply the Hurdle Criteria and pass or fail each configuration option. 2. Configuration options that pass the hurdle criteria will be scored by the evaluation group on the Non-Financial Criteria. Scores will be based on the scoring methodology set out on the following page and weighted as per the agreed criteria. 3. In addition the financial evaluation subgroup have assessed the financial viability of each option so that as well as an assessment of non-financial rankings, the panel can assess the financial criteria. An informed commentary on the financial aspects will be provided. The evaluation group will recommend to the Committee in Common: Which options should be taken forward to business case development, and, potentially, consultation What the ranking is of options that are viable, and provide a supporting commentary. What options are not viable and should not form options in the consultation. The design of the evaluation criteria is such that if an option is financially viable it is ranked on non-financial scores. The committee will need to check that the separation of financial and non-financial criteria has not led to a perverse outcome in terms of an option with marginal non-financial benefit scoring higher that an option which is significantly better value for money. It is important to note the evaluation committee is undertaking an assessment not a final decision. There will be further layers of scrutiny by the Committee in Common, the NHSE assurance process and the public consultation. The Committee in Common will take the final decision following consultation, if it is required. 11

12 Detailed analysis has been provided to members of the Evaluation Group in advance of today s workshop, providing information and analysis on each option against the criteria. The scoring members of the Evaluation Group will be tasked with scoring the options based on this analysis. The aim will be to arrive at a single agreed set of scores for each option. A scale of -5 to +5 for each criteria will be used with 0 representing the do minimum base case. Firstly the hurdle criteria will be applied. Options that the evaluation panel agree do not pass will be discounted and may therefore not be scored by the group on the non-financial and financial evaluation criteria The majority of measures will subjectively appraised based on an evaluators perspective. This perspective will be informed by the analysis provided and group discussion. Score Non-Financial Financial +1 to to - 5 better service provision Do minimum / base case worse service provision A net present value (NPV) The Total value of each option incorporating future capital and revenue implications and compared on like-forlike basis will be produced. An option will need to have a positive NPV to progress. The evaluation group and decision-making bodies will take financial criteria into consideration when making recommendations or decisions. Consideration will be given to any significant outliers. The group will use a moderated scoring approach. This means that each evaluator scores each option following a discussion by the group. Where there is variation there is a moderation process which will result in an agreed score. In the unlikely event that there is disagreement with the group a vote can take place at the discretion of the chair. In this case the majority (4 votes) will determine the score. If the vote is tied the two scores are averaged. The weighting would then be applied to the moderated score. 12

13 As described in the scoring methodology, each potential configuration option will be evaluated by comparing to the current configuration of services. A scale of -5 to +5 for each criteria will be used with 0 representing the do minimum base case. To enable this comparison to be made, all providers have been asked in their submissions how they would plan to meet the expected rises in patient demand across SEL at all the sites that currently provide elective orthopaedic inpatient care. In this scenario all providers would individually develop services, improve productivity and fund extra capacity to meet patient demand over the next five years, whilst also aiming to deliver the recommendations of the GiRFT report. It should be noted that by increasing capacity at each provider in this way it is unlikely that the full benefits to patients and the wider healthcare system, as described in the GiRFT report and the EOC model of care, could be delivered as effectively as they would be by two consolidated EOCs within SEL. In particular it would be harder to deliver the minimum required volumes per surgeon at each site, there would not be the benefit in terms of quality and safety of operating in a single orthopaedic clinical network across providers and there efficiency benefits may be lower due to not operating at sufficient scale. 13

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15 Four provider proposals have been submitted to host an EOC in the south east London model: Provider 1 Guy s and St Thomas NHS Foundation Trust 2 Lewisham and Greenwich NHS Trust 3 Dartford & Gravesham NHS Trust and Oxleas NHS Foundation Trust 4 Kings College Hospital NHS Foundation Trust Proposed Site Guy s Hospital Lewisham Hospital Queen Mary s Hospital, Sidcup Orpington Hospital Each submission will be analysed against the hurdle criteria and evaluation criteria as paired configuration options 15

16 As the agreed model is for two EOCs within SEL, this therefore means there are the following potential configuration options at this stage: Configuration Proposed Site A Proposed Site B 1. Guy s Hospital Lewisham Hospital 2. Guy s Hospital Orpington Hospital 3. Lewisham Hospital Orpington Hospital 4. Guy s Hospital Queen Mary s Hospital, Sidcup 5. Lewisham Hospital Queen Mary s Hospital, Sidcup 6. Orpington Hospital Queen Mary s Hospital, Sidcup Potential configuration options will be compared with the do minimum option, where elective orthopaedic inpatient care is provided at all existing sites - but with additional capacity to meet rising demand. This configuration will be labelled option 0. Some criteria can be analysed at site level, direct from the submissions that providers have given, and others will need to be considered in configuration options (particularly those relating to travel and finance) Sites and options will first have to pass the hurdle criteria before being scored by the panel on the non financial and financial evaluation criteria. 16

17 As part of the submission of expressions of interest in March 2016, providers identified their sites that they deemed not suitable to host one of the two EOCs in the SEL model. Below is the rationale submitted for each site: Provider GSTT LGT Suggested site to be discounted St Thomas Hospital Queen Elizabeth Hospital Provider Rationale We have made a decision to expand facilities on the current Guy s, which is an elective, and cancer hospital, rather than the St Thomas which is largely an emergency hospital. Our elective orthopaedic activity is currently delivered at Guy s and is well set up with adjacent wards, surgical admission lounge, and recovery areas and full access to all services required to treat complex and routine patients. Situating an Elective Orthopaedics Centre at Guy s fits with the principles of the GIRFT report by allowing elective orthopaedics beds and theatres to remain ring-fenced and this prevents outliers and cancellations. Any expansion of the St Thomas site will be required to meet the increasing demand on emergency and associated services. Consideration was given to the location of an EOC on the Queen Elizabeth Hospital (QEH) site. This option was rejected because of the emergency nature of the activity on this site and the existing shortfall in bed capacity. In addition, the QEH estate is also limited by a fragile service infrastructure and the QEH PFI contract arrangement lacks the flexibility of the Lewisham site for redevelopment or reconfiguration. Given these circumstances, the development of an EOC on the QEH site would be challenging to achieve successfully both in terms of cost and timeline. 17

18 As part of the submission of expressions of interest in March 2016, providers identified their sites that they deemed not suitable to host one of the two EOCs in the SEL model. Below is the rationale submitted for each site: Provider Suggested site to be discounted Provider Rationale KCH Denmark Hill Cost m est capital to extend current campus or relocate services to accommodate in existing estate, new build est 50-80m. Deliverability - Limited potential we have ring-fenced clean beds on Coptcoat Ward (15 beds) but the site is currently 54 short based on bed capacity modelling. Would need to relocate beds worth of activity elsewhere or undertake new build to accommodate. Would require 2 additional laminar flow theatres. KCH Princess Royal University Hospital Cost - Estimated as prohibitive due to PFI contract. Deliverability - Limited potential site currently 40 beds short based on bed capacity modelling. Would need to relocate beds worth of activity to accommodate. Would require additional 2-3 laminar flow theatres. The evaluation panel recommend to the Committee in Common that the sites proposed by providers as not suitable to host an EOC are discounted from the evaluation process and therefore will not be considered for hosting an EOC in SEL. 18

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20 Hurdle Criteria Description Pass/ Fail Safety & Emergency departments can continue to be delivered from the current 1 sustainability locations in SEL Trauma continuing to be provided in Trusts that currently do so Located in SE London 2 Clinical Requirements This option has the potential to meet the clinical requirements (provider characteristics) set out in the model 3 Patient Experience (Accessibility) Where there is a multi-site option sites are distributed between inner and outer SEL to be accessible to SEL patients (e.g. an option does not have two sites both inner) 4 Finance The option has a positive contribution to addressing the whole system financial challenge when compared to the do nothing scenario The proposed option demonstrates commitment to the commercial principles set out in the specification 5 Deliverability The option is able to deliver the demand and capacity requirements for a consolidated elective centre (50% of SEL activity, based on central case assumptions) 20

21 A joint submission has been made by Dartford & Gravesham NHS Trust and Oxleas NHS Foundation Trust to host elective inpatient orthopaedic services from the Queen Mary s Hospital site in Sidcup. The joint submission and accompanying letter acknowledges that: OHSEL have requested that both centres be able to accommodate medically complex patients, which we would categorise as ASA 3 and 4. It is viable for QMH to provide services for those patients with an ASA grade of 1 or 2 as these patients would not require critical care. The provision of a high dependency unit is not considered feasible in terms of clinical safety, workforce and affordability. Medically complex (ASA grades 3 or 4) patients would therefore not be suitable to undergo surgery at QMH. For this reason, a stage two submission has been submitted on the basis of only routine and non-complex activity being undertaken at QMH. We recognise that this does not meet the requirements however, we have continued with a high level submission to allow OHSEL to assess a clinically viable option for the site. Page 3 of the QMH proposal states: For these reasons we have assumed 45% of routine activity could take place at QMH. There will be no critical care facilities at QMH. 21

22 Therefore it is recommended to the evaluation panel that the proposal is evaluated against the hurdle criteria in the following way: The QMH submission does not meet hurdle criteria 2 clinical requirements. This criteria states that the option has the potential to meet the clinical requirements (provider characteristics) set out in the model. As acknowledged in the submission, the QMH site would not meet the specification and therefore would not meet this criteria. The QMH submission does not meet hurdle criteria 5 deliverability. This criteria states that the option is able to deliver the demand and capacity requirements for a consolidated EOC. In our previous discussions with all providers this has equated to 50% of the total projected SEL routine and complex activity at each site in the two centre model. Given that it has been assumed that only 45% of the routine case mix can take place at the QMH site, this criteria is therefore not met. These recommendations have been shared with Dartford & Gravesham NHS Trust and Oxleas NHS Foundation Trust prior to the evaluation workshop. The evaluation panel recommend to the Committee in Common that the proposal to host an elective orthopaedic centre at QMH does not pass the hurdle criteria and therefore should not be taken forward in the evaluation of proposals and possible configurations. 22

23 Hurdle Criteria 3 Patient Experience (Accessibility) Description Where there is a multi-site option sites are distributed between inner and outer SEL to be accessible to SEL patients (e.g. an option does not have two sites both inner) The evaluation group discussed two approaches to applying this criteria: 1. Applying the Greater London Authority (GLA) definition of inner and outer London boroughs. In this case as the borough of Lewisham is an inner London borough and Option 2 (Guy s and Lewisham) would be discounted on this basis. 2. Consider the accessibility of all proposed sites to all patient populations across SEL, both inner and outer London, as part of the panels analysis of travel impact in the non-financial evaluation criteria therefore not discount option 2 at this stage. The evaluation panel agreed that as this hurdle criteria relates to understanding the accessibility impact on patients, it did not make sense to discount the Guy s and Lewisham option on the basis of the Lewisham site being within an inner London borough. The panel agreed that the accessibility of all configuration options would be considered in the analysis of travel information as part of the scoring of the non-financial criteria 23

24 Hurdle Criteria 4 Finance Description The option has a positive contribution to addressing the whole system financial challenge when compared to the do nothing scenario The proposed option demonstrates commitment to the commercial principles set out in the specification 5 Deliverability The option is able to deliver the demand and capacity requirements for a consolidated elective centre (50% of SEL activity, based on central case assumptions) 24

25 total recurrent expenditure Millions Comparison of FY21 total recurrent expenditure ( m) 70 All options are forecast to deliver reductions in recurrent expenditure by FY21 compared to the baseline. 60 0% (4%) (9%) 50 (16%) Elective Orthopaedic Baseline Costs EOC located at UHL and Guy's Hospital EOC located at Guy's Hospital and Orpington Hospital EOC located at Orpington Hospital and UHL 25

26 The activity in each of the options has been scaled to ensure that each site delivers 50% of the baseline activity in FY21. When undertaking the Implementation Business Case, further work will be required to test different activity projection scenarios. 26

27 Hurdle Criteria 1 Safety & sustainability Description Emergency departments can continue to be delivered from the current locations in SEL Trauma continuing to be provided in Trusts that currently do so Located in SE London Option 1 Guys + Lewisham Pass/ Fail Option 2 Guys + Orpington Option 3 Orpington + Lewisham Pass Pass Pass 2 Clinical Requirements This option has the potential to meet the clinical requirements (provider characteristics) set out in the model Pass Pass Pass 3 Patient Experience (Accessibility) Where there is a multi-site option sites are distributed between inner and outer SEL to be accessible to SEL patients (e.g. an option does not have two sites both inner) Pass Pass Pass 4 Finance The option has a positive contribution to addressing the whole system financial challenge when compared to the do nothing scenario Pass Pass Pass The proposed option demonstrates commitment to the commercial principles set out in the specification 5 Deliverability The option is able to deliver the demand and capacity requirements for a consolidated elective centre (50% of SEL activity, based on central case assumptions) Pass Pass Pass The evaluation panel recommend to the Committee in Common that configuration options 1, 2 and 3 pass all hurdle criteria and can proceed to non-financial and financial evaluation. 27

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29 Initial travel analysis was undertaken at a population level across SEL. This analysis mapped journey times from lower super output areas (LSOAs) across SEL to hospital sites and was weighted by population. On review of the analysis, the evaluation panel felt it did not accurately reflect journey times for patients who would actually be using the service, nor did it describe the expected impact that changes would have on patients. Following consideration by the evaluation panel, the following updates have been made to ensure that the analysis presented back to the panel shows a more accurate reflection of the impact on actual patient journeys: Points raised at the evaluation group There was uncertainty about whether modelled car journey times reflect actual journey times. Particular reference was made to trips to Orpington Hospital. Analysis is undertaken for the whole population rather than patients who use the service. Time taken / ability to park at provider sites is not included in analysis. Familiarity or complexity of journeys is a challenge for particular sections of the population this has not been accounted for. Delays to journeys and service cancellations are not taken into account. Updated analysis Further independent checks of journey time data and reliability of travel models Undertake comparison between AM peak travel time and PM peak time Develop presentation of metrics and analysis to clearly show the impact in terms of the increase in peoples journey times in more detail Travel analysis is updated to understand the impact for actual service users over the 2015/16 period to ensure the hospital choices that patients currently make is considered This is recognised to be an issue at many sites in SEL, further feedback from the public on issues will be sought during consultation Familiarity and complexity of journeys will be considered in detail as part of the development of the equalities analysis during consultation The model takes into account some delays and congestion as the data used is informed by real journey times. 29

30 Analysis has been updated to reflect the actual sites that elective orthopaedic patients choose to travel to when accessing inpatient services during 2015/16. The model has been adapted so that the journeys that patients made to their chosen site in this period are maintained when those sites are in the configuration option. When a patient s chosen site is not in the configuration option, the model then finds the next nearest hospital in SEL using the travel model described below. This allows us to see the number of patients who need to travel to a different site under each option, and if that site is closer or further away than the site they would have previously chosen. Car travel model Generated using RouteFinder software based on GPS times from TomTom satnavs. Data is from March 2015 and times calculated based on the average journey speed across the time period in weekdays The RouteFinder software can then find the shortest journey time between two points. Public transport travel model Generated using TRACC software, includes timetable information for bus, coach, tram, underground and rail from Q Includes walking time to allow connection to and from the public transport network. Walks are limited to 800m at a speed of 3.5 kmph Where a change of service is required an additional 5 minutes is applied before making the next connection. The TRACC software combines all the routing and timetabled information to return the minimum time between two points that can be completed within the time period. For both car and public transport the AM peak (7-10am) time period has been use to show the impact of longest journeys at the morning rush hour. The car model provide the journey time based on road s average speeds during the time period selected and therefore do not attempt to model every possible journey experience or routes which could be impacted by temporary road works or similar issues. Public transport models are based on published timetables and therefore are based on the assumption that the timetables run to time. Both methods are therefore not designed to model the longest possible journeys but serve to provide a consistent basis for comparing different option configurations. 30

31 Checks of the car and public transport models have been undertaken against Google Maps online route planner. Modelled travel times were compared with the times estimated by Google. If a time is within + or - 20% of the time suggested by the model then the journey is deemed accurate. 20% has been used as a majority of the car journey times in the study area are within 30 mins so equates to around 6 minutes difference at the most. Car travel AM peak. 40 journeys were checked across all scenarios. 92% were within 20% of the time estimated by Google. 3 journeys were outside of the 20% range, 2 of these were journeys of 3 minutes where Google showed a 4 minute journey time. Public transport AM peak. The model used is TRACC industry standard and approved by DfT. 40 modelled journeys were checked across all scenarios. 70% were within 20% of the time estimated by Google. Some were slower and some were faster. Variations are likely to be due to different assumptions used by different models around issues such as: Walking distances: models allow users to walk different distances to public transport stops, which can lead to different overall journey times. Interchanges: TRACC uses a 5 minute interchange time (between two different modes of public transport modes); other models may incorporate longer or shorter waiting times. Walking distances: Different models are based on different walking speeds to and between public transport stops. TRACC uses a walking speed of (3.5km/h) which is slower that the 4.8km/h used by Google. Comparisons were also made between the AM peak (7-10am) and PM peak (4-6pm) travel times for car journeys. Average journey time across the whole study area was comparable in the AM peak and PM peak periods: AM peak average: 9.99 minutes PM peak average: 9.93 minutes 31

32 Travel analysis has been undertaken to reflect the actual choices elective orthopaedic patients made when accessing inpatient services during 2015/16. By analysing postcode information for the 6,870 SEL CCG patients who live in SEL, an assessment was made of the hospitals that patients currently travel to. Where do patients currently choose to travel to for their care? 15% (1,027) of patients who live in SEL currently choose to have their care or are referred to a hospital sites outside of SEL. 85% (5,843) patients choose SEL hospitals. Of these patients, two-thirds choose to travel or are referred to a hospital that isn t their nearest. This implies that whilst travel is an important factor to consider when understanding the impact of potential changes in services, patients already make choices in where they access inpatient elective orthopaedic care and most of the time they do not choose their nearest site. This also means that under each option there are some patients that will have the option of travelling to a site that is closer than the current site they choose to access. 32

33 % of Elective orthopaedic inpatients who live in SEL (6,870 patients) Option 1 (Guy's and Lewisham) 15% 36% 49% Option 2 (Guy's and Orpington) 15% 53% 32% Option 3 (Lewisham and Orpington) 15% 38% 47% 0% 20% 40% 60% 80% 100% Currently choose to travel outside of SEL Can choose to travel to the same hospital as they currently do Would need to travel to a different hospital than the one they currently choose If those who choose to travel to hospitals outside of SEL continue to, this implies that: Almost a third (32%) of SEL patients would need to travel to a different SEL hospital in Option 2 Less than half of SEL patients would need to travel to a different SEL hospital in Options 1 and 3, (49% and 47% respectively) 33

34 Car Travel (AM peak, 7-10am) % of Elective orthopaedic inpatients who live in SEL and would need to travel to a different hospital than their current choice Option 1 (Guy's and Lewisham) 23% 26% Option 2 (Guy's and Orpington) 7% 25% Option 3 (Lewisham and Orpington) 21% 26% 0% 10% 20% 30% 40% 50% 60% Can choose a hospital nearer than the one they currently choose Would need to travel to a hospital further away than the one they currently choose As some patients currently choose to travel to a SEL hospital that isn t their nearest: Under options 1 and 3 between 21-23% could choose a shorter journey than they currently do if travelling by car. In all options around a quarter of SEL patients would need to travel to a hospital that is further away than their current choice if travelling by car. 34

35 Car Travel (AM peak, 7-10am) % of elective orthopaedic inpatients who live in SEL (6,870 patients) with an increase in journey time <10 minute increase minute increase minute increase Option 1 (Guys and Lewisham) 14% 10% 2% Option 2 (Guys and Orpington) 10% 14% 2% Option 3 (Lewisham and Orpington) 12% 14% 0% For the 25-26% of SEL patients that would need to travel further, the additional journey time experienced in all options is rarely longer than 20 minutes. Increases in journey times across all options are consistently distributed. Options 2 and 3 have slightly more people with journeys that are mins longer than option 1. 35

36 Public Transport Travel (AM peak, 7-10am) % of Elective orthopaedic inpatients who live in SEL and would need to travel to a different hospital than their current choice Option 1 (Guy's and Lewisham) 27% 22% Option 2 (Guy's and Orpington) 10% 22% Option 3 (Lewisham and Orpington) 17% 30% 0% 10% 20% 30% 40% 50% 60% Can choose a hospital nearer than the one they currently choose Would need to choose a hospital further than the one they currently choose As some patients currently choose to travel to a SEL hospital that isn t their nearest: Between 10% and 27% of SEL patients could choose a shorter journey than they currently do if travelling by public transport. Under options 1 and 2, 22% of SEL patients would need to travel to a hospital that is further away than their current choice if travelling by public transport. This rises to 30% under option 3. 36

37 Public Transport Travel (AM peak, 7-10am) % of elective orthopaedic inpatients who live in SEL (6,870 patients) with an increase in journey time <10 minute increase minute increase minute increase >30 minute increase Option 1 (Guys and Lewisham) 9% 6% 4% 3% Option 2 (Guys and Orpington) 11% 7% 4% 1% Option 3 (Lewisham and Orpington) 7% 10% 11% 1% For the 22-30% of SEL patients that would need to travel further, the additional journey time experienced in all options is rarely longer than 30 minutes. More patients see an increase in journey time of between 10 and 30 minutes in option 3 (21%) than in options 1 and 2 (10 or 11%). 37

38 Current travel choices: 15% of patients who live in SEL currently choose to have their care at hospital sites outside of SEL. 85% of patients choose SEL hospitals. Of these patients, two-thirds choose to travel to a hospital that isn t their nearest. This suggests that whilst travel impact is important, a majority of patients already make choices to travel to access elective orthopaedic care, or are referred to sites that aren t their nearest. Impact of the options patients travel choices: Option 2 minimises the number of patients that would need to choose a different hospital than they presently do (32%) compared with around half of patients in options 1 and 3. However, options 1 and 3 would allow more patients to travel to a closer hospital site than the site they currently choose, particularly for car travel. For those that would have to travel further than the site they currently choose, the additional travel time is largely consistent when travelling by car. However option 3 shows more people with a longer additional public transport journey time than options 1 and 2. 38

39 Criteria Weighting Description Supporting analysis 6 Travel & Access 17% Impact on total transport times Travel time analysis (for patients by car and public transport including average travel times by mode of transport) Evaluation Commentary Option 1 Guys + Lewisham Option 2 Guys + Orpington Option 3 Orpington + Lewisham Suggested commentary: The evaluation panel have considered the choices SEL patients currently make when accessing elective orthopaedic care with the choices that patients can make under each option. This shows that less patients would need to make a different choice of site in option 2, but more patients would be able to choose a site closer to them than they currently choose in options 1 and 3. Whilst each option does allow some patients to choose a closer site than they currently do, all options should still be given a common negative score, as all proposals would require a similar number of patients to travel further. 39

40 Criteria Weighting Description Supporting analysis 7 Deliverability 25% Evaluation 7a. The option is sufficiently flexible, adaptable and resilient to meet the requirements of growth or changes in future demand or change in national policy. i.e. the option demonstrates appropriate flexibility 7b. Ease of implementation: the option can be delivered within a reasonable timescale with minimal risk around transition including impacts and disruption to existing services. Capacity and capability: The option demonstrates the appropriate capacity and capability to deliver the change/transition 7c. Where investment is required, the ease of obtaining required funding or financing is considered. Points scored resilience to alternative demand scenarios (other than the central one) Estimate of number of years for implementation Estimate of transition risk Assessment of financing/funding options (shortlist only) Commentary Option 1 Guys + Lewisham Option 2 Guys + Orpington Option 3 Orpington + Lewisham The evaluation panel recommend the scoring based on: The relative ease and quicker timescales by when Guy s and Orpington can deliver 50% of SEL activity Funding proposals at Guys were unclear, King s would borrow at market rate, Lewisham propose two different timescales based on different funding models Lewisham was felt to score lower based on the level of capital required, longer timescales to deliver, the larger step up in activity that would need to be delivered and the higher risk of being able to maintain a ring fenced elective service on an acute site 40

41 Following provider presentations to the evaluation panel, each trust provided the evaluation group s independent clinical expert with their 2014 and 2015 GiRFT reports for review. The GiRFT team also provided a comparison for each trust. On review of this information the independent clinical expert recommends that: There's no outstanding unit, though GSTT leads with Friends and Family LGT has improved over the GiRFT period (between the 2014 and 2015 reports) now equalling, but not bettering, the other providers in certain areas. All 3 providers are all relatively low volume units, have overused un-cemented THR s and have poor length of stay with average outcomes for both THR and TKR The reports emphasise the scope for the providers to improve efficiency and quality thereby delivering better value for money As there is significant room for improvement in all 3 units it s down to which providers/ lead clinicians are best placed to lead the changes required There would be value in encouraging out of region visits to see best practice in operation The independent clinical expert rated the Clinical Leads at the presentations GSTT > KCH > LGT in this respect Therefore it is suggested that the scoring of the quality criteria remain as agreed by the panel. 41

42 Criteria Weighting Description Supporting analysis 8 Quality 17% Evaluation -5 The operating model provides evidence on how it will optimise both functional and clinical outcomes for all patients receiving elective orthopaedic care in SEL Commentary Quality impact assessment (e.g. governance and quality systems) Comparison of current clinical quality of sites which are expected to deliver future inpatient activity under each option Option 1 Guys + Lewisham Option 2 Guys + Orpington Option 3 Orpington + Lewisham The evaluation panel recommend the scoring based on: Guy s having developed the most detail regarding the clinical network and governance required. The centralisation of elective orthopaedic services on the Orpington site having already lead to better quality care. The Lewisham presentation did not describe the development of the wider clinical network in detail The review of each trust s GiRFT report by the independent clinical expert confirmed this scoring 42

43 Criteria Weighting Description Supporting analysis 9 Patient Experience 17% The option promotes equality and minimises disadvantage of protected groups as required by the Equality Act The model demonstrates how it will optimise patient experience Equality impact assessment Friends and family and CQC inpatient survey performance against national benchmark Evaluation Commentary Option 1 Guys + Lewisham Option 2 Guys + Orpington Option 3 Orpington + Lewisham The evaluation panel recommend that all proposals should receive +1 for the equalities component, however it was acknowledged that the continued development of the equalities analysis during consultation would support a better understanding of any differences by site and impact on travel for these populations. The panel agreed that the Option 2 should receive +2 overall due to the positive patient feedback of the service delivered at both sites 43

44 Criteria Weighting Description Supporting analysis 10 Research & Education 7% The model provides support the further development of research and education activity Assessment of impact on research and education Evaluation Commentary Option 1 Guys + Lewisham Option 2 Guys + Orpington Option 3 Orpington + Lewisham The evaluation panel recommend the scoring based on: Guy s was the only proposal that presented about research opportunities Orpington gave detail on the training and development of anaesthetists and the potential research and education opportunities this could lead to. Lewisham s presentation and Q&A did not provide sufficient additional detail of research and education planning 44

45 Criteria Weighting Description Supporting analysis 11 Workforce 17% The option is staffable and is attractive to health care professionals working in SEL Estimate of future vs actual workforce Estimate of impact on current job roles Evaluation Commentary Option 1 Guys + Lewisham Option 2 Guys + Orpington Option 3 Orpington + Lewisham The evaluation panel recommend the scoring based on: All options should be attractive places to work compared to the current configuration, and hence evaluate positively Lewisham was felt to be a higher risk due to the number of appointments that would need to be made GSTT is noted as an attractive employer in SEL already Orpington can better mitigate transition risks for the workforce, having already had experience of consolidated services 45

46 Option 1 Option 2 Option 3 Non-Financial Evaluation Criteria Weighting Guys + Lewisham Guys + Orpington Orpington + Lewisham 6 7 Travel & Access Deliverability 17% 25% Option 1 Guys + Lewisham Quality 17% Option 2 Guys + Orpington Patient Experience 17% Research & Education 7% Workforce 17% Option 3 Orpington + Lewisham

47 47

48 Providers were invited to submit a series of financial pro-forma indicating their estimated costs from 2015/16 to 2020/21 in three potential scenarios: 1. The base case, with elective orthopaedic services continuing to be provided according to the current configuration, whilst meeting expected growth in patient demand and deliver GiRFT recommendations; 2. Costs associated with hosting the elective orthopaedic centre; and 3. Costs associated with not being chosen to host the elective orthopaedic centre. Submissions from all three trusts were compared to the baseline to assess the cost increase of the hosting Trust and the cost decrease of the not hosting Trust. In order to assess the consistency of submissions, the percentage cost increase in the hosting option and percentage cost decrease in the not hosting options were compared across submissions. Any unexpected variations were flagged to provider finance teams, who were requested to clarify or amend their submissions on this basis. 48

49 Metric Option 0 Option 1 Option 2 Option 3 Configuration option Elective EOC located EOC located at EOC located Orthopaedic at UHL and Guy's Hospital at Orpington Baseline Guy's Hospital and Orpington Hospital and Costs Hospital UHL Five year total cost 323.5m 330.5m 335.8m 333.7m FY21 recurrent cost 57.3m 48.0m 54.9m 52.1m Payback period N/A 6 years 10 years 7 years 20 year NPV (NPV) 823.0m 722.5m 809.3m 766.3m 20 year Internal Rate of Return (IRR) N/A 29% 12% 24% 5 year Return on Investment (ROI) NA year Return on Investment (ROI) NA FY21 reduction in cost per spell vs base case 0.0% -16.0% -4.1% -8.8% Five year total capital expenditure 2.1m 14.3m 4.1m 13.3m Five year total non-recurrent expenditure - 0.3m - 0.3m 49

50 While all three options reduce costs compared with the 2020/21 do nothing scenario, this table indicates: Option 1 (locating the EOCs at University Hospital Lewisham and Guy s Hospital) seems to offer the greatest benefit both in terms of reduction in cost by 2020/21 and in terms of Net Present Value. However, this option also has the greatest capital requirement and the highest double running costs. Therefore affordability for the local health and care economy will need to be considered in depth. Option 2 (locating the EOCs at Guy s Hospital and Orpington Hospital) seems to offer the lowest benefit of the three do something options. However it does so with the lowest capital expenditure requirement (approximately 2.0m million more than would be spent if no change were required). Option 3 (locating the EOCs at University Hospital Lewisham and Orpington Hospital) offers a lower benefit than Option 1 but with a smaller capital requirement. However the NPV improvement is still more than 56m over twenty years and the IRR is over 20%. 50

51 It is important to note that taking a shorter or longer term view could significantly impact the option selected: In taking a short term view (for example five years), Option 2 appears less attractive from a financial point of view than Options 1 and 3. This is because, while the capital cost is significantly lower, the savings do not offset the double running costs associated with the option. This leads to the negative 5 year return on investment. In taking a longer term view (for example 20 years), Options 1 and 2 offer similar returns on investment as, while the recurrent saving is lowest in Option 2, the upfront capital expenditure requirement is also considerably lower. Over this longer time period, Option 3 offers a considerably lower return on investment than the other two options. Further work to better understand the double running costs (and consider how these could be minimised through an efficient transition) will need to be undertaken on any options taken forward to further appraisal stages following consultation. This will have a significant impact on these short and long term views of return on investment. 51

52 The assessment of the financial hurdle criteria have been conducted on a pass/fail basis i.e. as long as an option presents a saving compared to the base case, it would be progressed. All three options have an FY21 recurrent cost and a 20 year net present value (NPV) that is less than the base case and therefore pass the financial hurdle criteria. Key findings include: Option 2 (Guy s and Orpington) represents the lowest capital investment, roughly a quarter of the other two options. Option 1 (Lewisham and Guy s) has the fasted payback period of 6 years (i.e. by the end of FY21). Option 2 (Guy and Orpington) will break even in FY26. All options 20 year NPV are within c. 10% of each other with Option 1 (Lewisham and Guy s) offering the largest savings. 52

53 The Evaluation Group therefore makes the following recommends to the Committee in Common: 1. The following sites should not be considered for hosting an EOC in the SEL model: St Thomas Hospital (GSTT) Queen Elizabeth Hosptial (LGT) Denmark Hill (KCH) Princess Royal University Hospital (KCH) Queen Mary s Hospital (Oxleas/DGT) 2. The assessment of the non-financial criteria showed that: All of the paired configuration options were considered better for patients in SEL than the scenario where providers plan to continue to meet growth in demand and deliver GiRFT recommendations without consolidating. Option 2 (Guy s and Orpington) scored the highest on non-financial criteria out of 5. The scoring of Option 1 (Guy s and Lewisham) and Option 3 (Lewisham and Orpington) was more comparable, and respectively. 53

54 The Evaluation Group therefore makes the following recommends to the Committee in Common: 3. The assessment of the financial implications of each configuration shows that: All configurations are cheaper over a 20 year NPV and have cheaper running costs in FY21 than the scenario where providers continue with plans to meet growth in demand and deliver GiRFT recommendations without consolidating. 4. Compared to the scenario where providers continue with plans to meet growth in demand and deliver GiRFT recommendations without consolidating: Option 2 (Guy s and Orpington) represents the lowest capital investment, roughly a quarter of the other two options. Option 1 (Lewisham and Guy s) has the fasted payback period of 6 years (i.e. by the end of FY21). Option 2 (Guy and Orpington) will break even in FY26. All options 20 year NPV are within c. 10% of each other with Option 1 (Lewisham and Guy s) offering the largest savings. Therefore the evaluation panel recommend to the Committee in Common that all of the three configuration options put forward under the two site consolidated model should be taken forward for public consultation. These three configurations should all be considered as preferred options when compared against the existing provider plans to develop services individually to meet demand and deliver GiRFT. This is due to all three having evaluated better than providers existing plans on both the non financial and financial criteria. 54