IMProVE Outline Business Case, Community Transformation across South Tees

Transcription

1 IMProVE Outline Business Case, Community Transformation across South Tees

2 1 Acknowledgements The assistance with and contributions to this business case from departments throughout NHS South Tees Clinical Commissioning Group is gratefully acknowledged. Special thanks to the strategic partners working collaboratively on the IMProVE programme and in support of this business case. 2

3 Table of Contents IMProVE Outline Business Case,... 1 Community Transformation across South Tees Acknowledgements Glossary of Terms... 5 Foreword Executive Summary Introduction IMProVE Transformation Vision Ability to Deliver the Vision and New Model of Care Developing Option/s for Delivering the Model of Care Efficiency & Effectiveness Conclusion Strategic Case South Tees Area Health and Wellbeing Summary IMProVE Transformation Programme Stroke Rehabilitation Step-Up and Step-Down In-patient Care Engagement Engagement Public and Patient Engagement Strategic Partners Estates NHS Property Services Report Estate Options Travel Analysis Development of Options Quality Criteria Option Appraisal Bed Modelling Preferred Option Finance

4 7 Programme Management Programme Structure Programme and Milestones Service Review and Pathway Development Workforce Estates Equality Impact Assessment Appendices Appendix A - Bed Modelling Appendix B - NHS Property Services Limited Estate Report for South Tees CCG 60 Appendix C Equality Impact Assessment Appendix D The IMProVE Accessibility Travel Analysis Appendix E Medworxx Report Bed Utilisation

5 2 Glossary of Terms Ambulatory care Health services provided on an outpatient or treatment basis to those who visit a health care facility and depart after treatment on the same day. Ambulatory care sensitive conditions Better Care Fund (BCF) Clinical Commissioning Group (CCG) COPD CHD EIA Integrated Care Intermediate Care A category of physiological disorders of which severe conditions or episodes are considered preventable through medication, home care, and a healthy lifestyle. In this way, occurrences and recurrences of emergency hospitalisations and admissions can be prevented. There are over 20 disorders that can be classified under ambulatory care sensitive conditions, some of which are cardiovascular diseases, diabetes, and hypertension. Other conditions are asthma, chronic urinary tract infections, and gastroenteritis. The 3.8 billion Better Care Fund (formerly Integration Transformation Fund) was announced by the Government in the June 2013 Spending Round, to ensure a transformation in integrated health and social care. The BCF is a single pooled budget to support health and social care services to work more closely together in local areas. Clinical Commissioning Groups are groups of GPs responsible for designing local health services in England. CCG s do this by commissioning or buying health and care services including: Elective hospital care Enhanced Rehabilitation care Urgent and emergency care Most community health services Mental health and learning disability services Clinical Commissioning Groups work with patients and healthcare professionals and in partnership with local communities and local authorities. All GP practices have to belong to a Clinical Commissioning Group. Chronic Obstructive Pulmonary Disease Coronary Heart Disease Equality Impact Assessment A tool for identifying the potential impact of policies, services and functions on patients and staff Care provided by different health and wellbeing agencies working together. Intermediate care aims to provide a genuine alternative to hospital admission for some carefully selected patients and, 5

6 secondly, to provide early supported discharges for others. Both aims require the provision of opportunities for further assessment and enhanced rehabilitation of older people. JSNA Long Term Condition (LTC) NHS Property Services NHS England ONS Primary Care PTS QIPP QOF Reablement Enhanced Rehabilitation Service model Service pathway SUS Joint Strategic Needs Assessment Conditions which require long term management outside hospital such as diabetes or chronic obstructive pulmonary disease. NHS Property Services manages, maintains and improves NHS properties and facilities, working in partnership with NHS organisations to create safe, efficient, sustainable and modern healthcare and working environments. NHS England Performance manages CCGs, Hosts Commissioning Support Units and directly commissions 20bn of Primary Care and Specialist services Office of National Statistics Primary care is many people's first point of contact with the NHS. Around 90 per cent of patient interaction is with primary care services. In addition to GP practices, primary care covers dental practices, community pharmacies and high street optometrists. Patient Transport Services Quality Innovation Productivity and Prevention Quality Outcomes Framework Services for people with poor physical or mental health to help them accommodate their illness or condition by learning or relearning the skills necessary for daily independent living. Enhanced rehabilitation is a treatment or treatments designed to facilitate the process of recovery from injury, illness, or disease to as normal a condition as possible. The proposed design and grouping of service elements and how they work together. The journey through a service from the patient s perspective in accessing care and/or treatment and the steps in that journey. Secondary Uses Service (Patient Data) 6

7 Foreword South Tees Clinical Commissioning Group was established in April As a clinically led organisation we quickly identified that one of our key priorities was to improve the health and wellbeing of our vulnerable and elderly population. We know that the numbers of older people in our area are growing and as general practitioners working in South Tees we know this represents one of our biggest challenges. Over the past year we have been working with other clinical colleagues across health organisations and our colleagues in the local councils to develop proposals for how care can be more effectively provided. When we spoke to our patients and carers in the autumn of 2013 they told us that they wanted services that are more joined up, accessible and provided closer to home where possible. Above all our patients wanted services that keep them safe and independent in their own homes for as long as possible. We want to invest more in services that can be provided in and around people s homes allowing them to manage their condition in a supported way and prevent further deterioration into ill health. In order to do this we are proposing a range of changes to how existing services are delivered. We recognise that to make these changes will require investment, along with making the best use of our existing resources; people, finance and estate. Our business case demonstrates that we are not currently using these resources to their best effect. Through redesign we can deliver an improved model of care that is less reliant on hospital based services, benefiting not only the elderly and vulnerable but the whole of the South Tees population. Dr Henry Waters Chairman, NHS South Tees Clinical Commissioning Group 7

8 1 Executive Summary 1.1 Introduction This section provides a high level summary of the major points contained within this Outline Business Case. You may see some aspects of this section repeated within the main body of the document or expanded in more depth. NHS South Tees Clinical Commissioning Group (CCG) is made up of members from 49 GP Practices working together to commission (buy) services for around 280,000 local people. Our members tell us that they became GPs to make a difference to people s lives. They now have the opportunity to do this on a much larger scale as part of NHS South Tees CCG. Our members see patients every week and it s important they continue to talk with, and listen to, patients and carers about their health and their experiences of local services. GP practices are supported by a wider NHS team who work with the CCG to help take forward our plans and make real and lasting improvements for local people whilst making the best use of the NHS resources entrusted to us. Our mission is improving health together. We know that we need the support of local partners, patients, carers and the general public in order to design and develop new and innovative healthcare services. We are working hard to develop meaningful relationships with a range of local organisations including mental health and hospital trusts, local authorities, voluntary and independent sectors. NHS South Tees CCG has a budget of around 384 million which equates to approximately 1,313 per person. There are currently 49 GP practices in the CCG area and the population is served by James Cook University Hospital located in Middlesbrough, providing district hospital and a number of specialist services. Community health services in the CCG area include four community hospitals, three of which are located in Redcar and Cleveland (Guisborough, Redcar, and Brotton) and one in Middlesbrough. This community hospital service provision is managed by South Tees NHS Foundation Trust and provides a range services including stroke, in-patient, out-patient, diagnostics, minor injuries and therapies. Mental health services are delivered by Tees Esk and Wear Valley (TEWV) NHS Foundation Trust. In the South Tees area we face some big health challenges. These include: Heart disease and stroke Cancer Illnesses caused by smoking Illnesses caused by alcohol Managing hospital admissions and demand within primary care services Financial pressures 8

9 Overall health inequalities with significant differences in the health of some groups within our population Our Aims are to: Reduce health inequalities Reduce variable access to healthcare Continuously improve wellbeing Drive up the quality of health services Our Values: Patient centered services the well-being of patients always comes first Continuous improvement recognising innovation and supporting education Respect listening to and valuing everyone s views Honesty telling the truth and being realistic about what we can and cannot do Integrity acting in a selfless, impartial and trustworthy manner In support of the delivery of our aims in April 2013 NHS South Tees CCG established an advisory group, a strategic partnership to help the system deal with some of the health and social care challenges that will be faced in the coming years. We agreed that we needed to focus on addressing the needs of our vulnerable and elderly population by integrating care and doing so in a more proactive way. Hence the programme was designated as Integrated Management and Proactive Care for the Vulnerable and Elderly (IMProVE). NHS South Tees Clinical Commissioning Group (CCG) covers a geographical area of almost 300 square kilometres with a total population of approximately 273,742 (Middlesbrough with a population of 138,744 in an area of square kilometres and Redcar and Cleveland with a population of 134,998 in a geographical area covering square kilometres). The health of people living in the South Tees area is generally improving; however it is still significantly worse than the England average. Historically, South Tees has been highly dependent on heavy industry for employment, which has left a legacy of industrial illness, disability and multiple long term conditions. Demographic analysis indicates that the population as a whole will increase by 2.19% by 2021; however, within that there is a significant increase in the numbers of people over the age of 65 where a 23% increase is projected by 2021 compared with The demand for care and support, particularly for residential care for older people, continues to increase as people are generally living longer due to medical advances, and the transition into old age of the baby boom generation. There will be a significant increase in the number of people aged over 85, and an increase in the 9

10 number of people living with dementia. These continued rises will not be matched by resources available to local authorities. Therefore, new and more cost effective approaches to supporting individuals are needed. 1.2 IMProVE Transformation Vision The IMProVE Advisory Group is an economy wide strategic partnership including clinicians and professionals, the membership comprises representatives from the following organisations: NHS South Tees Clinical Commissioning Group South Tees Hospital NHS Foundation Trust Tees Esk and Wear Valleys NHS Foundation Trust Middlesbrough Borough Council Redcar and Cleveland Borough Council Durham, Darlington and Tees Area Team (NHS England) Healthwatch (Middlesbrough & Redcar) The model of care that the IMProVE Programme is working to implement is based on the principles of right care, right place, at the right time, with the overall aim being to provide care as close to home as possible, wherever this can be done safely and cost effectively, with an increased emphasis on patient choice, and empowering the patient to manage their own care where this is appropriate. The objectives of the IMProVE Programme are: Figure 1.1 IMProVE Programme Objectives To offer targeted and proactive individualised case management in a community setting with a range of additional support services for patients aimed at maintaining and improving their current health To improve routine care for all patients with long term conditions to prevent deterioration of their overall condition To reduce avoidable unplanned hospital admissions and readmissions for all patients following an exacerbation of their long term condition or deterioration of general health To identify the need for and improve access to a range of integrated support services on a 24/7 basis to allow them to better manage their own condition and remain as independent as possible To improve outcomes for elderly and frail patients and those with long term conditions To identify early, via the use of a predictive risk tool, those patients at risk of a future admission To effectively deliver care and support for patients through making the best use of our available resource 10

11 The work of the IMProVE Advisory Group to date has culminated in the development of a proposed new model of care for South Tees based on the following principles which are person centred: Figure 1.2 IMProVE Vision and Principles The model encompasses the service elements set out in the table below: Figure 1.3 Service Elements Step-down inpatient care Step-up care High quality packages of planned care supporting vulnerable adults in effective recovery and reablement, in particular those patients recovering from stroke and fractured neck of femur. Beds for elderly patients requiring stabilisation or treatment in order to avoid secondary care admission such as, remobilisation following falls, exacerbation of long-term conditions, end of life support and for minor illnesses, e.g. urinary tract infections and chest infections 11

12 Multi-disciplinary team (MDT) assessments A greater range of out-patient services Medical day units Assessment units, or hubs to provide MDT local rapid assessment and comprehensive diagnostics for elderly patients With supporting diagnostics to help clinicians make quicker diagnoses Providing simple care locally, IV antibiotics, blood transfusions and potentially some cancer therapies 1.3 Ability to Deliver the Vision and New Model of Care In order gain a wider view on the future vision and to assess the ability to implement the proposed new model of care over the next two to five years, the IMProVE Advisory Group commissioned a number of reviews and studies. These included: A bed modelling study An estates review A workforce review An accessibility travel plan A clinical review of community hospital provision A series of clinical and public engagement initiatives The outcome of each review is detailed throughout the business case and summarised below: Figure 1.4 Summary Review Findings IMProVE Review/Study Summary Findings Location in this Business Case Bed Modelling Study Study based on community step up/down beds. There are currently 132 beds and the study demonstrated that based on current utilisation the optimum number of beds would be 102. However, with a range of IMProVE initiatives aimed at supporting people in their own homes, a conservative estimate on the optimum number is around 68 by 2016/17. Estate Review Review focusing on the condition and functionality of the community hospitals. Identifies issues with the long term viability of Carter Bequest Hospital and Guisborough Primary Care Hospital due to condition and the 12 Appendix A Appendix B

13 Workforce Review assessment of current functionality. There is a potential shortfall in funded therapy staffing to meet patient needs. There are no major causes for concern over the supply of suitably competent staff to meet any increased demand. The main challenge is the culture change that will be required to deliver care closer to home. Section 7.3 Workforce An Accessibility Travel Plan In terms of private car travel to any of our main health care sites, given the data available at this stage, analysis indicates that all sites are accessible within a 30 minute timescale. 3.3 Travel Analysis and Appendix D Recognises the importance of Public Transport and access to Patient Transport Services (PTS) for those that are eligible. Clinical Review of Community Hospital Provision Clinical review considering quality, sustainability and efficiency of the community hospitals to deliver our model now and into the future found that Carter Bequest Hospital and Guisborough Primary Care Hospital were ranked worst when measured against the agreed criteria. Section 4.2 Option Appraisal Clinical and Public Engagement The principles of IMProVE were strongly supported during all engagement phases. Around half of the public surveyed supported the idea of reducing the bed base and providing greater care in homes and in the community. Amongst other things, respondents felt that this would aid recuperation and promote independence. Many qualified their support for the potential closure of beds with the need to improve community health and social care services first. Section Engagement 13

14 1.4 Developing Option/s for Delivering the Model of Care CCG clinicians, supported by a range of partners, carefully considered the outcomes of all the above reviews and studies in order to develop a proposed plan for delivering the future model of care. The clinical debate has focused around the model of care that is required for the future, namely: A mixed model of community based service response, Stroke rehabilitation delivered to best practice, Step-up and step-down in-patient care, An assessment hub where elderly patients can be quickly assessed and diagnosed and where day treatments, such as intravenous (IV) therapies and cancer therapies can be delivered, Palliative/End of life care where the individual s preferred place of death would be in a community hospital, Improved pathways of care and discharge, Community stroke teams to deliver early supported discharge, Increased reablement, rapid response and therapy capacity, The model was then used as the basis for evaluating the current community estate and its capacity to support its delivery, alongside clinically developed key criteria as set out in section 4.1. There is recognition that service transformation takes time and therefore the CCG s preferred approach encompasses three key elements, delivered in a phased approach as follows: PHASE 1 DESCRIPTION Development of a mixed model of community based service responses which focus on improving pathways of care and discharge processes, implementing a community stroke team, increasing reablement, rapid response and therapy capacity together with the development and implementation of a Single Point of Access and Assessment Hub DATE/S April March Centralisation of stroke services and enhanced rehabilitation to one facility and the reduction of the stroke bed base. 14 April 2015

15 Alongside this will run the reduction of the community bed base across the community hospital estate and lead to the closure of Carter Bequest Hospital in Middlesbrough 3 Redevelopment of void space within both Guisborough and East Cleveland Hospitals and the further reduction of the community bed base to a minimum of 62 including the closure of the community beds within Guisborough Hospital April 2015 March Efficiency & Effectiveness Within a three year period, the preferred option will release a minimum of 1M per annum on a recurrent basis. This resource will be reinvested into direct patient care, including increasing the numbers of clinical staff and allied health professionals available within the community. Further details are provided in section Conclusion NHS South Tees CCG and its strategic partners on the IMProVE Advisory Group recognise the significant challenge associated with looking after people well when they are older, particularly given the demographics of our population. Without significant change it is widely acknowledged that the NHS as a whole cannot continue to improve standards of care, in line with best practice, while rising to the challenge of population growth, increasing need and complexity. The engagement that has taken place has demonstrated clear support for the principles of IMProVE and supporting people more in their own homes. There are mixed views about the future of community beds and yet the bed modelling study demonstrated poor utilisation across a number of sites. The NHS Property Services estate report identifies significant issues with both the condition and functionality of two of the four community hospitals in South Tees. The challenge presented is clear, if we continue to utilise our resources maintaining outdated estate, we cannot channel this resource into new more effective services, delivering direct patient care in a range of settings including patients own homes. In light of this a single preferred option has been developed based upon the ability to provide quality, sustainable and efficient community services. NHS South Tees CCG recognises the need to engage further about this option and undertake detailed feasibility work within a robust programme management structure. Consequently a phased approach to development is proposed commencing with stroke rehabilitation, which the IMProVE work has indicated is an immediate concern and needs to be 15

16 improved now to meet best practice and; a gradual reduction in community beds as further IMProVE initiatives are rolled out. Programme milestones are as follows: Figure 1.5 High Level Programme Milestones PHASE DESCRIPTION DATE/S 1 Undertake further work to develop the community hub/assessment model Undertake transition planning for stroke rehabilitation and community bed reduction. Undertake engagement. 2 Implement revised stroke rehabilitation model of care. Reduce community bed base. 3 Redevelopment of estate/ eradication of void space implement community hub/ assessment model. 2 Strategic Case April 2014 March 2016 April 2015 March 2016 April 2015 March South Tees Area Health and Wellbeing Summary NHS South Tees Clinical Commissioning Group (CCG) covers a geographical area of almost 300 square kilometres with a total population of approximately 273,742 (Middlesbrough with a population of 138,744 in an area of square kilometres and Redcar and Cleveland with a population of 134,998 in a geographical area covering square kilometres). Urban densities are focused around the principal towns of Middlesbrough and Redcar, with the predominance of rural areas being located on the east coast of Redcar and Cleveland. Figure Map of NHS South Tees CCG Area Carter Bequest Hospital Redcar Primary Care Hospital Guisborough Primary Care Hospital East Cleveland Hospital 16

17 The above map indicates the position of the four community hospitals within South Tees. The health of people living in the South Tees area is generally improving; however it is still worse than the England average. Historically, South Tees has been highly dependent on heavy industry for employment, which has left a legacy of industrial illness, disability and multiple long term conditions. The Index of Multiple Deprivation from the Office of National Statistics (ONS) indicates that a significant proportion of the population live within the most deprived areas. Figure 2.2 Map: Index of Multiple Deprivation (ONS) Of the population, approximately 48,689 (18%) are over the age of 65, and demographic data indicates that there will be a significant increase in the number of people over 85 including those living with dementia. Figure 2.3 Projected Demographic Change (Office of National Statistics) Authority Mid-2012 population estimate 2021 population projection Number No. (%) aged 65 + No.(%) aged 85 + Number % aged 65 + % aged 85 + Middlesbrough 138,744 21,293 (15.35%) 2,591 (1.87%) 144,275 24,997 (17.33%) 3,911 (2.71%) Redcar & Cleveland 134,998 27,396 (20.29%) 3,259 (2.41%) 135,466 31,782 (23.46%) 4,540 (3.35%) Total 273,742 48,689 (17.7%) 5,850 (2.1%) 279,741 56,779 (20.2%) 8,451 (3.2%) 17

18 Source: ONS mid-2012 population estimates and interim mid-2011 based population projection This 23% increase in the number of people over the age of 65 living in the area will have a major impact on health and care services. Increasing life expectancy, whilst a positive position, does create challenges with increased morbidities and long term conditions leading to higher GP consultation rates and higher hospital attendance and admission rates. The graph below, demonstrates that long term health and disability problems are greater in South Tees than the rest of the North East and nationally. Figure 2.4 Long- term health problem or disability aged 65 and above Although only a quarter of patients with emergency admissions at James Cook University Hospital are aged 75 or over, these patients account for the majority of emergency bed days: Figure 2.5 Analysis of Admissions Data JCUH Sept 2012 Oct 2013 Age Number of Patients 18,093 6,044 Number of Spells/Days 25,480 9,867 NEL Admission Rate (NEL Admissions per 1000 head of population) Total Length of Stay (days) 69,966 86,713 Average Length of Stay per Spell (days) 2.75 days 8.79 days 18

19 Around 65% of service users aged 75+ with an emergency admission have a diagnosis of chronic obstructive pulmonary disorder, coronary heart disease, stroke or diabetes, which may or may not be the primary reason for their hospital admission. Over a quarter of these have two or more of the above conditions. This analysis was undertaken using James Cook University Hospital (JCUH) data from September 2012 to October In addition the South Tees population has an increasing number of unplanned hospital admissions which are well above the national average. The chart below taken from Emergency admissions to hospital: managing the demand (National Audit Office, 2013) shows South Tees to be an outlier with unplanned hospital admissions per 1,000 registered patients, which is significantly higher than NHS Hartlepool and Stockton on Tees which stands at Both are significantly higher than the England average of Figure 2.6 Emergency Admissions per 1,000 Registered Patients Should rates of emergency admissions in South Tees be reduced to a similar level to NHS Hartlepool and Stockton on Tees this would equate to a reduction in emergency admissions of 29%. The average cost of an emergency admission across the South of Tees is circa In order to bring South of Tees levels in line with the national average, acknowledging however the higher levels of deprivation across our region, a reduction of 47.9% would be required. The JSNA s for Middlesbrough and for Redcar and Cleveland demonstrate that over the last ten years, the death rate from all causes has fallen steadily for men, but has fluctuated for women. The early death rate from heart disease and stroke has fallen 19

20 and the early death rate from cancer has also fallen, but has stabilised recently. South Tees ranks higher than the England average for almost all disease prevalence. For the number and percentage of diseases recorded for the Quality Outcomes Framework (QOF) for the practices in NHS South Tees CCG in 2012/13 for all but one indicator, prevalence in South Tees is above average. In both Middlesbrough and Redcar and Cleveland we have continuing challenges in relation to the rate of hip fractures, sexually transmitted diseases, smoking related deaths and hospital stays for alcohol related harm, all of which are worse than the England average. Obesity levels too are worse than the England average. The demand for care and support, particularly for residential care for older people, continues to increase as people are generally living longer due to medical advances, and the transition into old age of the baby boom generation. There will be a significant increase in the number of people aged over 85, and an increase in the number of people living with dementia. These continued rises will not be matched by resources available to local authorities. Therefore, new and more cost effective approaches to supporting individuals are needed. 2.2 IMProVE Transformation Programme In April 2013 NHS South Tees CCG established the Integrated Management and Proactive Care for the Vulnerable and Elderly (IMProVE) Advisory Group, a strategic partnership comprising: NHS South Tees Clinical Commissioning Group South Tees Hospital NHS Foundation Trust Tees Esk and Wear Valleys NHS Foundation Trust Middlesbrough Borough Council Redcar and Cleveland Borough Council Durham, Darlington and Tees Area Team (NHS England) Healthwatch (Middlesbrough and Redcar) The model of care the IMProVE Programme is working to implement is based on the principles of right care, right place, at the right time, with the overall aim being to provide care as close to home as possible, wherever this can be done safely and cost effectively, with an increased emphasis on patient choice, and empowering the patient to manage their own care where this is appropriate. The objectives of the IMProVE Programme are: 20

21 Fig 2.7 IMProVE Programme Objectives To offer targeted and proactive individualised case management in a community setting with a range of additional support services for patients aimed at maintaining and improving their current health To improve routine care for all patients with long term conditions to prevent deterioration of their overall condition To reduce avoidable unplanned hospital admissions and readmissions for all patients following an exacerbation of their long term condition or deterioration of general health To identify the need for and improve access to a range of integrated support services on a 24/7 basis to allow them to better manage their own condition and remain as independent as possible (For e.g. through the use of Digital Care) To improve outcomes for elderly and frail patients and those with long term conditions To identify early, via the use of a predictive risk tool, those patients at risk of a future admission To effectively deliver care and support for patients through making the best use of our available resource Importantly, the vision is to move away from the reactive care models that have developed over time to models of care that are proactive in enabling a range of interventions to prevent deterioration in a person s condition and an avoidable hospital admission. This includes early identification of those patients who may be at risk of their long term condition deteriorating; working with them and their carers or family to maintain their independence and if they do fall ill, return them to the best state of health as is possible. The IMProVE transformation programme seeks to develop a truly integrated model of care, which spans both health and social care, delivered 24 hours per day, 7 days a week and closer to an individual s home. Service responses will be integrated and make best use of the estate to make care accessible, with a strong emphasis on prevention of disease and deterioration of long term conditions as well as and the promotion of healthy living. A clinical review identified that work should be prioritised to further develop proposed service models which require delivery from a community facility, be that patients own homes and/or community hospitals. The IMProVE Programme is continuing to look at what needs to be done over the medium and long term but in the short term the following services prioritised for development are: Stroke rehabilitation delivered to best practice; Step-up and step-down rehabilitation in-patient care; 21

22 The creation of an assessment hub where elderly patients can be quickly assessed and diagnosed and where day treatments, such as IV therapies and cancer therapies can be delivered; and; Palliative/End of Life care to ensure a suitable range of options are provided to ensure individuals have choice, were possible, in relation to their place of death This approach of ensuring that issues that need to be addressed immediately are prioritised whilst planning for longer term transformation is critical to business continuity and sustainability. 2.3 Stroke Rehabilitation There are around 110,000 strokes and 20,000 transient ischemic attacks (TIAs) per year in England. Whilst stroke mortality rates have been falling steadily since the late 1960 s, stroke has become the leading cause of adult disability and costs the NHS over 3 billion a year. Around one in four people who have a stroke die as a consequence of it and around half of stroke survivors are left dependent on others for everyday activities. In the South Tees area, people suffering from stroke are admitted to a dedicated stroke unit at the James Cook University Hospital. In 2013, 426 people from the South Tees area were treated for stroke at the James Cook University Hospital. Of these 426 people 39 were hospitalised more than once for their stroke(s). On this basis 1.5 people per 1000 head of population had a stroke within the South Tees area in When this is applied to the projected demographic increase in population there is an increase of 11.7% in cases between 2011 and This equates to 476 cases per annum by Following acute treatment at James Cook University Hospital, most patients are transferred for rehabilitation to Carter s Bequest Community Hospital in Middlesbrough or Guisborough Hospital. Delivering stroke rehabilitation services on a number of sites has proved difficult to maintain, with staff spread more thinly, diluting the level of input from the specialist stroke team. In particular, there are difficulties sustaining the required levels of therapy to patients and these are not delivered across a seven day period. The current configuration of the service locally clearly does not meet the national best practice clinical guidance as detailed by The National Institute of Health Care and Excellence (NICE) in June 2013: 22

23 Figure National Institute of Health and Care Excellence (NICE) Clinical Guidelines for Stroke Rehabilitation (June 2013) People with disability after stroke should receive rehabilitation in a dedicated stroke inpatient unit comprising a dedicated stroke rehabilitation environment and subsequently from a specialist stroke team within the community A core multidisciplinary stroke rehabilitation team should comprise of professionals with expertise in stroke rehabilitation from both health and social care Health and social care professionals should work collaboratively to ensure a social care assessment is carried out promptly, where needed, before the person with stroke is transferred from hospital to the community Offer early supported discharge to people with Stroke as long as a safe and secure environment is provided. This should be part of a skilled stroke rehabilitation service and should consist of the same intensity of therapy and range of multidisciplinary skills available in hospital. It should not result in a delay in delivery of care. Offer initially at least 45 minutes of each relevant stroke rehabilitation therapy for a minimum of 5 days per week to people who have the ability to participate, and where functional goals can be achieved. If more rehabilitation is needed at a later stage, tailor the intensity to the person's needs at that time Review the health and social care needs of people after stroke and the needs of their carers at 6 months and annually thereafter. These reviews should cover participation and community roles to ensure that people's goals are addressed. NHS South Tees CCG has recognised that driving improvements for stroke rehabilitation is a priority to bring it in line with other areas both nationally and regionally. Organised stroke units with a specialist multidisciplinary stroke team result in less dependency and death. Early supported discharge gives better outcomes in physical health and results in less strain on the caregiver. Currently NHS South Tees CCG has no community stroke service which could support patients early discharge from hospital with rehabilitation at home. The most successful rehabilitation services include personalised rehabilitation plans, physiotherapy and occupational therapy with proactive follow-up. Rehabilitation should begin as soon as possible and be home based where possible. Rehabilitation should be provided at different levels of intensity in order to support and maximise independence. The National Clinical Guidelines for Stroke (Royal College of Physicians, fourth edition, 2012) advocates that commissioning organisations such as NHS South Tees CCG should commission: An in-patient stroke unit capable of delivering stroke rehabilitation for all people with stroke admitted to hospital. Supported discharge to deliver stroke specialist rehabilitation at home or in a care home, in liaison with inpatient services. Rehabilitation services capable of meeting the specific health, social and vocational needs of people of all ages The significance of the national drivers to improve the quality of service delivery are recognised locally within: 23

24 NHS South Tees CCG Clear and Credible Plan 2012 where Stroke and Heart Disease are identified as the biggest health challenges across South Tees. NHS South Tees CCG Commissioning Intentions for NHS South Tees CCG 2 Year Operational Plan and 5 Year Strategic Plan. Better Care Fund Plan. In order to develop a quality Stroke Rehabilitation Service in line with national guidance and best practice, NHS South Tees CCG is proposing to centralise Stroke Rehabilitation Services onto one community hospital site and develop a Community Stroke Team (or Early Supported Discharge Team) from April The implementation of Early Supported Discharge Teams elsewhere has led to a reduction in the number of stroke beds required within the community base by as much as 40% allowing more services to be delivered in people s own home. The CCG proposes that within the centralised Stroke base a conservative reduction to 12 beds will be required in order to meet the best practice service model for the South Tees area. Figure 2.9 Comparison of Current and Proposed Stroke Rehabilitation Model SERVICE ELEMENT CURRENT SERVICE PROPOSED SERVICE COMMUNITY REHABILITATION TEAM EARLY DISCHARGE SUPPORT TEAM COMMUNITY HOSPITAL BEDS Multi-disciplinary therapy support provided in the community hospitals with some home assessments. None Development of community rehabilitation team to provide intensive multi-disciplinary therapy support provided in the community hospitals. Majority of support provided in people s own home. Commenced April 2014 as an enabler for service change and to remain in situ to support new model. The proposed service model seeks to shift the emphasis of care so that people are supported in their own homes as soon as it is clinically safe to do so. The transition to a new service model requires careful planning where reducing clinical risk throughout is the guiding principle. Consequently NHS South Tees CCG and its strategic partners recognise that there needs to be a significant element and period of community development to complement the proposal for a centralised stroke model. This also needs to be aligned with providing quality care and support to the 24

25 frail and elderly. A twenty four month programme of development through to April 2016 includes the following activities, some which have already taken place: Working with local authority partners to increase capacity of reablement services Agree and implement pathways for patient transfer of care with key stakeholders Work with all partners to progress the continual improvement of discharge processes from James Cook University Hospital Continue development of pathways of care, including defining and agreeing therapies and treatments that could be safely and effectively delivered in a community setting Further expansion of rapid response services with the potential for a night sitting service Implementation of a South of Tees Single Point of Access and Community Assessment Hub for health and social care Review current out-patient resource and develop plan to support improved provision across the South Tees community estate Market test redevelopment of void space within Community Hospitals Review diagnostic provision and develop a plan to support improved provision across the South Tees community estate The continued development of the Stroke reconfiguration is part of the ongoing Programme Management of change covered in section 7 of this document. 2.4 Step-Up and Step-Down In-patient Care NHS South Tees CCG are in an unusual position compared with neighbouring CCGs in that the community based estate includes four community hospitals which between them have 132 beds: Figure 2.10 Community Hospital Beds at March 2014 Hospital Bed Designation Total no of beds Stroke Rehab Other Carter Bequest Hospital East Cleveland Hospital Guisborough General Hospital Redcar Primary Care Hospital Grand Total

26 The table excludes the number of beds (20) at the Middlesbrough Intermediate Care Centre. The number of beds at Guisborough does not include ten beds that have been closed for over twelve months. Bed occupancy varies across the four hospital sites with a number of the community hospital beds being under-utilised. Stroke bed utilisation is good at an average of 80.5% but bed occupancy for patients with other conditions is as low as 32% in Guisborough Hospital and 65% in East Cleveland Hospital (reviewed over an eighteen month period from April 2012 to September 2013). The table below indicates the number of lost bed days at each of the community hospitals between the periods from September 2012 to March The key reasons identified for the lost days can be summarised as essential repairs, routine repairs and maintenance and staff availability. It is estimated that unused/unoccupied space in the community hospitals is costing around 1.9 million a year. This is indicated in Appendix B - Estates Report. Furthermore bed analysis detailed at Appendix A, and summarised below, indicates that there is an over capacity of beds across the four community hospitals. The community hospitals in South Tees are being used mainly as step down facilities (i.e. patients are transferred there following an unplanned admission at the James Cook University hospital) rather than step up (i.e. patients are admitted directly to the community hospital when their condition deteriorates in order to prevent a crisis happening). The average length of stay for step down patients is 28 days, with over seven out of ten staying 14 days or more. An assessment of bed usage in the community hospitals showed that almost half of the patients didn t need to be in a hospital bed but were there mainly due to insufficient home based health and social care services. Further analysis of the length of stay within community hospitals has shown that approximately 7% of patients return to an acute setting on average after 5 days or less from being stepped down to a community hospital. A quarter of all patients are transferred back to an acute hospital at some point during their community stay. Figure 2.12 Community Hospital Transfers from James Cook University Hospital in 2013 Community Hospital Transfer s from JCUH 26 Transfers from Transfers from Community Hospital to Acute Community Hospital to Acute in 5 Days or Less Number % Number % Carter Bequest Hospital % % East Cleveland Hospital % % Guisborough Primary Care Hospital % % Redcar Primary Care Hospital % % Grand Total % %

27 The table above highlights the impact of too many Acute (James Cook) hospital beds being occupied by people who do not medically need to be there (up to 33% of occupied beds), as highlighted within the Medworxx Bed Utilisation report at Appendix E and the implications of increased pressure to transfer patients out to a community hospital. In addition, with the right community services, fewer people would also need to go into residential care. According to the National Adult Social Care Intelligence Service in Redcar and Cleveland there are 24% more admissions of people over the age of 65 in residential care than authorities with similar populations and 59% more than the England average. Clinicians state that the level and frequency of rehabilitation that some patients receive in a community hospital needs to be improved. Working with both partners and the public NHS South Tees CCG want to bring about some changes which will provide better and more responsive care for older and vulnerable patients. The model of care NHS South Tees would want to see implemented is based on the principles of right care, right place, at the right time, with the overall aim being to provide care as close to home as possible, wherever this can be done safely and cost effectively, with an increased emphasis on patient choice, and empowering the patient to manage their own care where this is appropriate. Most importantly, the vision is to move away from the reactive care model currently provided to one which is more proactive and responsive in delivering a range of interventions aimed at preventing deterioration in a person s condition and an avoidable hospital admission. This includes early identification of those patients who may be at risk of their long term condition deteriorating; working with them and their carers or family to maintain their independence and if they do fall ill, return them to the best state of health as is possible. 2.5 Engagement In acknowledging that changes need to be made to the current health model, in order to ensure a stable and effective health economy for the future, the IMProVE Advisory Group recognised the need to take a proactive approach to engage all stakeholders in the development of services for the future. NHS South Tees CCG has sought to learn and build on areas of good practice from other areas in the UK, where fully integrated services for elderly patients, and those with long term conditions, have been successfully rolled out, creating economic and quality improvements across the whole system. There is extensive evidence from across the UK to support development of enhanced community based services for the frail elderly, those patients with one or more long term conditions, and those who are at risk of escalation of a chronic health condition. NHS South Tees CCG has strongly encouraged clinical ownership and leadership to drive community transformation and service improvement. This approach clearly aligns to the coalition Government s White Paper entitled Equity and Excellence 27

28 Liberating the NHS, released in July 2012 which described a series of sweeping reforms designed to put clinicians at the forefront of decision making in the NHS, and promised that the system will focus on personalised care that reflects individuals health and care needs, supporting carers and encouraging integration and local partnerships. Since September 2013 there has been a programme of engagement with clinicians as follows: GPs: Within the Locality Councils (Middlesbrough, Langbaurgh and Eston) Clinical Professional Forum Through the Clinical Council of Members, including CCG Clinical Leads from South Tees GP Practices GP Clinicians Event Practice Updates and Visits Many of my patients were transferred from James Cook University Hospital to a community hospital, not because they had further medical need but because there was not the appropriate care and support available within the community to support them in their own home. Patients want to be in hospital when this is clinically appropriate, but want to be home when they are well. We must make the changes which are already in place in many other parts of the country and support our patients in their own home as much as possible rather than move them from hospital bed to hospital bed Dr Ali Tahmassebi, GP, Redcar & Cleveland. Provider Partner Clinicians: Through an engagement event with South Tees Hospitals Foundation Trust (STHFT) (including STHFT clinicians, managers and South Tees GPs) With STHFT Chiefs of Service (STHFT Clinicians) I applaud and fully support the endeavour of the CCG to transform community services within the IMProVE programme service model. Central to this work is the provision of an improved coordinated Rehabilitation service in the community where the patient s needs for that stage in their recovery of function and independence are best met, and the unit has the appropriate skills and facilities to manage them. I firmly believe that a stronger Rehabilitation Service can only be a force for good in supporting the patient and their family and carers to achieve their maximum potential for recovery of function, and quality of life. Colonel Michael Stewart CBE, Clinical Director in Orthopaedics, South Tees NHS Trust.The focus of clinical engagement has not only been to raise awareness of the IMProVE programme but to actively seek involvement in shaping the future model of care, determining the quality criteria and proposal for the transformation of community services. 28

29 2.5.1 Engagement Public and Patient In July 2013 NHS England published The NHS belongs to the people: a call to action which called on the public, NHS staff and politicians to have an open and honest debate about the future shape of the NHS in order to meet rising demand, introduce new technology and meet the expectations of its patients. This was set against a backdrop of a static funding allocation over future years which, if services continue to be delivered in the same way, as now, taking account of inflation and increased demand will result in a funding gap which could grow to 30bn between 2013/14 to 2020/2021. For South Tees this equates to a funding gap of 179 million. This five year planning guidance advocates a number of key ambitions which include: Improving the health related quality of life of the 15 million+ people with one or more long-term condition, including mental health conditions Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital Increasing the proportion of older people living independently at home following discharge from hospital In response to this call for action during autumn 2013 and as part of the IMProVE work to gain a better understanding of what is important to patients and carers in terms of the services they receive, the CCG carried out an extensive process of engagement with key stakeholder organisations, the public, patients, carers and MPs. This work focused on seeking views on services for the vulnerable and elderly and those living with long-term health conditions such as diabetes, heart disease or chronic obstructive pulmonary disease (COPD). Initially views were sought from local people through a questionnaire together with a series of five public drop-in events, the purpose of which was to inform the shaping of a future model of care. To assist further with this development, the CCG commissioned a local voluntary organisation, Carers Together, to conduct an indepth survey seeking views and opinions from over 300 elderly patients and their carers. Over 400 carers, patients, service providers and members of the general public responded to the engagement activity. The majority were over 65 years of age and included people who were elderly, vulnerable, and housebound, had limited mobility or were living with a significant long-term condition. The CCG also spoke to a number of carers. Respondents were drawn widely from the South Tees area including Redcar, Eston, Brotton, Middlesbrough and Guisborough. A number of key themes emerged from the work which is outlined in the table below. These can be categorised under quality and sustainability and have directly informed the development of service proposals. 29

30 Fig 2.13 Summary of Patient and Public Feedback Quality of care provided Care closer to home Quality of community provision Where should care be provided Co-ordination of services GP access Access to information Most respondents felt they had received sufficient support to manage their condition, although a range of potential improvements were identified. These are reflected in the comments provided throughout this paper. There was considerable support for the suggestion that more care should be provided in the home or in a community setting. Respondents felt that this could aid recovery, prolong independence and keep hospital beds free for the seriously ill. However, many commented that for this vision to become a reality, community-based care would need to improve significantly. The quality and extent of community-based services was a recurring theme. Respondents identified a number of areas for improvement including more frequent and longer home visits from both health professionals and home care providers, more rapid assessment of need and access to services and equipment, more practical support in the home, and on-call support available on weekends and in the evenings. There were a number of comments about hospital discharges being delayed because of lack of provision. Some respondents suggested drop-in or day facilities should be available locally. Overall, the majority felt that the location of care should be determined by the needs of the patient. Most felt that a mixture of home, community and hospital-based care should be available. Overall, respondents felt that local services were organised well. However, there were a significant number of comments about the need for better collaboration and coordination across health and social care organisations and between different services. Many felt that information was not always passed from one service to another effectively; that there was poor communication between providers and silo working was common. While many were happy with the support provided by their GP surgery, poor access to appointments was a recurring theme. Respondents were unhappy with the length of time they had to wait for a GP appointment and felt that GPs should spend more time visiting patients in their own home. There were also comments about continuity of care and the importance of being able to see the same GP on a regular basis. While most people said that they knew who to contact for advice, guidance or support in relation to their long-term condition, we 30

31 don t know whether this was the right person. Over half felt that more information or guidance would be helpful. This included the need better information about social care provision and more information about specific conditions such as dementia and arthritis. Some respondents were concerned about the consistency of information and whether it was up to date. The importance of ensuring that not only patients but also their carers/families understood the information being given was also raised. Physiotherapy and occupational therapy services Dementia services Care homes Hospital beds There were a number of comments about the length of time taken for assessments/access to services. Some commented that this was impacting upon recovery and hospital discharge. The need for improvement in services was mentioned by a number of people. This ranged from better information for patients and their carers through to the extent of the services available locally. A few respondents identified the need for good, local care homes. There were a few comments about the lack of staff training and the impact this had on the delivery of care closer to home. When asked to consider a reduction in the number of community beds, respondents were divided. There was some confusion about the difference between community and acute beds with a number commenting that beds were needed in case of a flu epidemic or major incident. Around half supported the idea of closing beds and providing greater care in the community. Amongst other things, respondents felt that this would aid recuperation and promote independence. Many qualified their support for the closure of beds with the need to improve community health and social care services first. Some questioned whether there was sufficient budget/staff to develop and improve community services in line with the CCG s vision. Those who were largely against any reduction in bed numbers felt that there was already a shortage of bed, evidenced by the length of time people had to wait for admission. The view that having too many beds was preferable to having too few was given by a number of respondents. Some disputed the case for a reduction in beds, citing the growing elderly population and suggesting that further analysis was needed. Opinions differed on the impact of closing community beds with 31

32 some reflecting that it would take pressure off the hospital system and others claiming it would increase demand for acute beds. Community Hospitals Cost of travel More staff, more money Reliance on elderly relative for support/care Keeping carers/family informed Listening to patients There was some support for local community hospitals. Respondents valued their proximity to home/relatives/friends, particularly where there was a reliance on public transport, while others felt that they took the strain off acute beds. A few felt there needed to be more local beds for recuperation/respite. Some respondents mentioned the difficulty/cost of travelling to GP appointments and other services using public transport/taxis. The lack of public transport was raised. There were a number of comments about the need for greater investment in health and social care services. Many of the respondents were being cared for by elderly relatives or were elderly carers and felt that this needed to be recognised. There were several comments about the need to keep family members/carers informed in general about health conditions and how to deal with them. Some also mentioned wanting to be kept up to date with the specific requirements of those they were caring for. A few people made comments about the need to listen to patients. Some made the point that carers needed to be included in discussions in cases where patients found it difficult to get their point across without assistance Engagement Strategic Partners In delivering any future model of care and transformation of provision, the CCG recognises that this can only be achieved in by working closely with its partners. Since May 2013 the CCG has committed to a programme of engagement with the Health and Wellbeing Boards, Overview and Scrutiny Committees and Healthwatch. Health and Wellbeing Boards: The Health and Wellbeing Boards play a vital role in ensuring the alignment of strategic plans across the broader health and social care community. To this end the governance arrangements relating to the IMProVE programme have ensured a significant connectivity between the two local Health and Well Being Boards via the IMProVE Advisory Group, maintaining continued buy-in to the strategic plans for all member organisations and in support of the Health and Wellbeing Strategies of both Boards. 32

33 The diagram below illustrates the governance structure of the CCG and the IMProVE programme. Fig 2.14 NHS South Tees CCG Governance Structure The CCG has also actively engaged with both the Redcar and Cleveland Health and Wellbeing and Middlesbrough Health and Wellbeing Board. This has reached an audience including Council Members, the public and press. As a member of the Middlesbrough Health and Social Care Delivery Partnership and the Redcar and 33

34 Cleveland Health and Wellbeing Executive the CCG has ensured regular dialogue around IMProVE. This has further ensured that the IMProVE transformational programme remains aligned to both Health and Wellbeing Strategies. Further opportunities to engage on the proposals are planned for April 2014 including: Middlesborough Health and Wellbeing Partnership 28 th April 2014 Redcar Health and Wellbeing Executive 29 th April 2014 Overview and Scrutiny The CCG has maintained an active engagement with the South Tees (Joint) Overview and Scrutiny Committee through regular structured timetabled meetings. This has been invaluable and hugely constructive; back in 2009 scrutiny raised issues with regard to the current stroke provision and pathway. In August 2013 the committee made recommendations for improvement to the questionnaire for public engagement as well as advising on improvements for targeting hard to reach groups which have shaped the proposed model of care. More recently the CCG has updated the North Yorkshire Overview and Scrutiny on IMProVE s transformational programme. The CCG had further opportunity to engage with the South Tees (Joint) Overview and Scrutiny Committee on the 7 th April At this committee, whilst not scrutinising the proposal at this stage, it was commented that the CCG had presented a compelling case for change. Healthwatch Through the development of the model of care and the transformation proposals the CCG has engaged with Healthwatch in both Middlesbrough and Redcar and Cleveland. The importance of the work being undertaken has been recognised by Healthwatch, who now have a delegated officer sitting on the IMProVE Advisory Group. South Tees Hospitals NHS Foundation Trust The Trust has been fully engaged both in the Advisory Group and via the Health and Well Being Boards and Clinically led IMProVE workstream in the development of the model of care. The Trusts Board has received a number of updates on the progress being made in relation to the programme including the pre-engagement work and case for change. The knowledge and learning gained from engaging with all stakeholders has shaped and ensured buy in to the future model of care and underpins the proposal being put forward. 34

35 3 Estates 3.1 NHS Property Services Report Following work over a period of months and the receipt of a provisional report in December 2013 South Tees CCG received a final report in February 2014 that had been commissioned from NHS Property Services relating to the utilisation and condition of NHS owned and leased community estate. The report refers to all community estate but concentrates specifically on the four community hospitals in the South Tees area: Redcar Primary Care Hospital Carter Bequest Hospital Guisborough Primary Care Hospital East Cleveland Primary Care Hospital The report is included at Appendix B and summarises the findings of a 6 facet survey assessing; functional suitability, physical condition, space utilisation, quality, fire and health and safety, environmental management and backlog maintenance. The findings illustrated that there were some significant issues that need to be addressed primarily: There is void space within these hospitals equating to 1.95 million per annum in value. The condition and functionality of the Carter Bequest Hospital is assessed as poor with high backlog maintenance. Guisborough Primary Care Hospital requires an investment of 1.2 million in its engineering infrastructure. NHS Property Services Limited also report that, at present, income from tenants does not cover running costs in relation to the South Tees community estate and there is a national imperative to address this, reduce void space and manage the estate more effectively. The NHS Property Services report does not recommend a course of action but does outline a series of options and opportunities relating to the potential disposal or partial disposal of community hospitals and facilities. 35

36 3.2 Estate Options The estates report completed by NHS Property Services outlines some potential options for relocating services and indicative costs for redeveloping empty and unused (void) space. The options assume the retention of Redcar Primary Care Hospital and then either retain, dispose or partially dispose of some or all of the other sites. Redcar Primary Care Hospital is retained in the NHS Property Services assessment on the basis that: the NHSPS reports gives a clear indication that void space at Redcar could accommodate new service models for stroke, assessment hub, outpatients and rehabilitation. Redcar Primary Care Hospital was built in 2010 and is subject to a further 30 year Private Finance Initiative lease agreement. The table below summarises the high level data in the report for ease of reference. Figure 3.1 Summary Estate Information Community Carter Bequest Hospital Hospital Guisborough Primary Care Hospital East Cleveland Primary Care Hospital Gross Internal Area (square metres) Backlog Maintenance* Annual NHSPS Operating Cost 2490 sq.m 4126 sq.m sq.m 885,867 1,318, , ,951 1,026,076 1,389,000 Void Costs 76, , ,000 Can the facility support future models of care in terms of functionality? (NHSPS Assessment) No Yes with some refurbishment. ** Yes with some refurbishment.** Comments Partial disposal involves retention of the GP Surgery (Cambridge Medical Group) and demolition and make good the remainder of the site. Partial disposal possible as this site is comprised of 3 buildings. Partial disposal not felt to be an option. NHSPS recommend either retention or disposal. Wards are currently not in use leading to high void space/cost. 36

37 *Includes reported backlog maintenance plus expected replacement/upgrade of mechanical and electrical engineering infrastructure over the next 5 years. **indicative refurbishment cost circa 1.2million. The refurbishment options in the NHS Property Services report centre on accommodating a new service model for stroke, an assessment hub incorporating diagnostics, some out-patient accommodation and facilities for enhanced rehabilitation. This is consistent with the objectives of the IMProVE programme. At face value the sites most at risk due to condition and the assessment of current functionality are Carter Bequest Hospital and Guisborough Primary Care Hospital. Carter Bequest Hospital The Carter Bequest Hospital was built in 1924, it s 90 years old and has a gross internal area of 2490 square metres. The property is owned by NHS Property Services Limited. Currently the hospital accommodates: Figure 3.2 Carter Bequest Service Profile at March 2014 SERVICE PROVIDER OR STATUS FACILITY COMMENTS Cambridge Medical Group Tenant sq.m general practice Service has tenancy rights/ tenancy agreement and any relocation requires negotiation and agreement. Cambridge Ward Oxford Ward South Tees NHS FT South Tees NHS FT sq.m sq.m 10 stroke beds and 34 intermediate care step up/down beds Community Services Occupational Therapy South Tees NHS FT sq.m office accommodation Community Services - SaLT South Tees NHS FT sq.m office and consulting accommodation Community Services Tissue South Tees NHS FT 22 sq.m office accommodation 37

38 Viability Community Services Administration South Tees NHS FT sq,m office accommodation Stroke Association Tenant sq.m office accommodation Vacant Vacant 55.99sq.m office accommodation Service has tenancy rights/tenancy agreement. Relocation requires negotiation and agreement. Guisborough Primary Care Hospital Guisborough Primary Care Hospital was built in 1839 and has had further development over the last 175 years with significant expansion from the original build. The hospital has a gross internal area of 4126 sq.m and currently accommodates: Figure 3.3 Guisborough Primary Care Hospital Service Profile at March 2014 SERVICE PROVIDER OR STATUS FACILITY COMMENTS Community Dental Rehabilitation Ashwood Chaloner Ward Priory Ward North Tees and Hartlepool NHS FT Stroke Association Tees, Esk and Wear NHS FT South Tees NHS FT South Tees NHS FT sq.m dental surgeries plus reception and administration sq.m A NHSE Commissioned service needs negotiation to relocate. The Stroke Association is a charity - NHS PS has no formal agreement in place sq.m Community mental health resource centre sq.m sq.m 10 stroke beds and 18 intermediate step up/down beds (Chaloner Ward closed during 2012/13) 38

39 Day Hospital Minor Injuries X-ray Administration Community Services Adult Dietetics Community Services District Nurses Community Services Health Visitors Community Services Occupational Therapy Community Services Physiotherapy Community Services School Health Community Services School Nurses South Tees NHS FT South Tees NHS FT South Tees NHS FT South Tees NHS FT South Tees NHS FT South Tees NHS FT South Tees NHS FT South Tees NHS FT South Tees NHS FT South Tees NHS FT South Tees NHS FT sq.m Frail elderly sq.m Average attendance very low circa 6/7 attendances per day sq.m standard x-ray suite sq.m office accommodation STFT confirm that x-ray equipment would need replacing in the next 3 years at an estimated cost of 120k. Chaloner Building sq.m Chaloner Building sq.m Chaloner Building sq.m Chaloner Building sq.m Chaloner Building sq.m Chaloner Building sq.m Chaloner Building sq.m Chaloner Building 39

40 3.3 Travel Analysis The CCG geographical area includes a number of urban centres and a significant rural area in East Cleveland. In recognition of the feedback received via the public engagement exercises and by listening to patients views regarding accessibility to services as being an important factor in the patient experience, the CCG commissioned Tees Valley Unlimited to undertake an accessibility study for the hospitals within the CCG area. Please see Appendix D - The IMProVE Accessibility Travel Analysis. This study demonstrated that: In terms of private car travel to any of the site, given the data available at this stage, analysis indicates that all sites are accessible within a 30 minute timescale. Both James Cook Hospital and Guisborough Hospital provide access during regular hours to 75% of the population of Middlesbrough and Redcar & Cleveland within one hours travel by public transport. Both sites benefit from a wide variety of public transport services relatively close to the hospital, James Cook Hospital will see an increase in options with the opening of the rail station at the hospital. However accessibility to Guisborough Hospital reduces significantly later in the evening with only two buses serving the hospital hourly. Carter Bequest Hospital can be accessed by around 45 % of the population within the hour; this would be increased with the opportunity to change buses at the undercover Middlesbrough Bus Station. However, accessibility to the site via public transport is lower than that of all the other locations in this report. East Cleveland Hospital provides access to a wide area of East Cleveland which would have significant travel times to access care in Middlesbrough, Redcar or Whitby. Even with the lower population density in this rural area, greater than 50% of the population can access the hospital within the one hour target. Redcar Hospital location has relatively good accessibility; the bus service serving the hospital is high frequency and serves a significant proportion of the population, with 74% being able to access within the hour, and 61% able to access the facility later in the evening. The interchange possibility in Redcar would further increase accessibility. Improvement works to the existing waiting facilities would be favourable; providing a better option for bus users, and is something to consider in the longer term. To gain a greater understanding of how our patients access the Community Hospitals a Primary Care Hospital transport survey has been undertaken. An example of the output from this survey can be seen below, this shows that out of the 40

41 seventy one people surveyed that visited the East Cleveland Primary Care Hospital fifty one of whom travelled by car, this equates to 72%. Figure 3.4 Community Hospital Transport Survey Results Hospital Ambulance Bus Car Taxi Walk/Cycle Total East Cleveland Primary Care Hospital (1%) (18%) (72%) (1%) (7%) 71 Carter Bequest Hospital (6%) (10%) (69%) (8%) (6%) 48 Guisborough Hospital (3%) (15%) (69%) (8%) (8%) 13 Redcar Primary Care Hospital (11%) (4%) (64%) (7%) (14%) 28 Total of Surveys Received (4%) (13%) (69%) (5%) (8%) 160 Note: percentages are rounded to nearest 1% 41

42 4 Development of Options 4.1 Quality Criteria The CCG Executive have agreed a set of quality criteria, based on a clinical view of what would need to be in place to deliver the best model of care. This has been informed through broad clinical engagement including GPs, Consultants and Clinicians within STHT and Community Clinicians. These criteria were based around key aspects of our proposed model which require delivery within community estate: Stroke rehabilitation delivered to best practice; Step-up and step-down in-patient care; An assessment hub where elderly patients can be quickly assessed and diagnosed and where day treatments, such as intravenous (IV) therapies and cancer therapies can be delivered; and; Palliative/End of Life care where the individual s preferred place of death would be in a community hospital. The initial set of quality criteria were established as: Adequate numbers of ward staff who can deal with elderly patients with comorbidities including dementia Adequate therapy in-put physiotherapy and occupational therapy Meets NHS Standards for quality and safety Meets NHS essential standards for environment Meets environment standards for dementia Fit for purpose rehabilitation Facilities Access to x-ray facility 85% Utilisation of beds as a minimum bed occupancy Access to community staff with necessary palliative care training Patients are able to have a choice of their preferred place of death, based on provision of appropriate level of privacy and dignity Access to near patient testing Ultrasound Facility Adequate Parking Impact upon other services delivered from that Estate Appropriate patient and public access which was further defined as: o % of population living within 30 minutes drive o % of population able to access location by public transport within 1 hour o % of population able to access location by public transport in-hours o % of population able to access by public transport out-of hours 42

43 In addition to these criteria the following reports were commissioned to further inform and support plans for implementing the proposed model of care as outlined within this outline business case: Estates review Workforce review Transport plan Bed modelling Financial plan 4.2 Option Appraisal Following development of the quality criteria, three events were planned to discuss and agree the criteria with wider stakeholders and also offer the option to add or change the criteria assessing what was most important. The three events were; CCG Clinical Council of Members attended by a representative GP from each practice Engagement Event James Cook University Hospital attended by Consultants, GPs and community clinical staff Stakeholder Event, Riverside Stadium, Middlesbrough 52 representatives from 20 organisations including local healthcare providers and community and voluntary sector organisations All GPs were also given the opportunity to comment electronically on the proposed criteria At the first of the three meetings held with the Clinical Council of members, the group were asked to rate all criteria as high, medium or low. It became apparent at this session that the majority of attendees felt that the criteria ought to be rated as essential or desirable and this was subsequently introduced. All opinions and ratings were then collated which gave the CCG further insight as to the level of agreement towards the proposed criteria and model. The majority of the criteria were rated as essential with desirable tending to relate to the percentage of the population able to access the services via public transport. If no comments were made then it was assumed that there was agreement with the CCG s original suggested rating. The tables below demonstrate an aggregated consensus on the criteria specific to delivering: Improvements in Stroke Rehabilitation Improvements in step up/step down in-patient care Improvements in Palliative/End of Life Care in community beds Increased out-patient provision in the community 43

44 Development of an assessment hub/medical day unit to provide rapid assessment, diagnostics and simple treatments, e.g. IV antibiotics, cancer therapies 4.1 Aggregated Consensus Criteria Generic to all services Essential Desirable Meets NHS essential standards for environment Meets environment standards for dementia. Adequate numbers of staff who can deal with elderly patients, co-morbidities, and dementia. Impact upon other services delivered from that Estate Accessibility % of population living within 30 minutes drive. % population able to access via public transport within 1 hr. % population able to access via public transport in hours. % population able to access via public transport out of hours. Affordability of required development Yes Yes Yes Yes Yes Yes Stroke Rehab Essential Desirable Specialist stroke rehabilitation delivered on one site according to NICE guidance Access to X-ray facility Yes Yes Step Up/Step Down Essential Desirable Fit for purpose rehabilitation facilities X-ray facility Yes Yes 44

45 Ultrasound facility Near Patient Testing or urgent access to labs Yes Yes Assessment Hub/Day Treatments Essential Desirable Estate capacity to accommodate patients for up to 4hrs for assessment and 24hrs for treatment. Access to Pharmacy *Critical mass of patients requiring assessments and medical day case therapies Yes Yes Yes OPD Essential Desirable *Critical mass of OPD activity Access to x-ray Access to ultrasound Yes Yes Yes Palliative Care In-Patient Care Essential Desirable Room for relatives to stay Private room to maintain privacy and dignity *critical mass refers to the fact that a certain number of patients, staff or resources must be available before the activity, effort or project would be functional or viable On considering further development of the criteria it was necessary to make a number of assumptions that would support delivery of the proposed model of care and to ensure efficient, quality services. The following assumptions were made and again agreed through the process of continued engagement: The only sites being considered in this process are: Redcar, Guisborough, East Cleveland and Carter Bequest. The services that need to be delivered are: Step up/step down Rehab, Stroke, Outpatients, Assessment Hub / Medical day unit and Palliative/End of Life Care. The assessment Hub is partially dependant on being in close proximity to a bed base 45 Yes Yes

46 Out Patients can be provided at any site and other current community locations Bed utilisation is to be maintained at 85% with an occupancy tolerance of 75 95% In line with best practice, Stroke rehabilitation should be provided on 1 site X-ray facility and near patient testing/access to urgent laboratory reporting is essential for Assessment Hub Redcar Primary Care Hospital is to be retained as it is a Privately Funded Initiative (PFI) with a 35 year lease contract (30 years still to run) Feedback from the IMProVE public engagement activity undertaken between September and November, 2013, had clearly demonstrated agreement with the CCG s proposed model of care to deliver more care in patients homes; although there was some nervousness from the public around the prospect of potentially closing beds prior to the development of additional community services. 4.3 Bed Modelling South Tees health community has undertaken and commissioned a number of activities to understand the current and future bed base for non-acute care. NHS South Tees CCG and South Tees Foundation Trust commissioned Medworxx to undertake a review of bed occupancy across the Acute and Community Hospitals. This report concluded that 49% of patients in community beds and 33% of patients in acute hospital beds did not have an acute medical need and could have been appropriately supported by other services. For further evidence see Appendix E Medworxx Report Bed Utilisation. Another independent report, (South Tees Intermediate Care Services Systems Modelling Project, June 2013) was also commissioned. The work undertaken between October 2013 and April 2013 carried out a review of intermediate care services in South Tees to ensure optimised services for local people. The objectives of the work were identified as: To develop a common understanding of the system(s) and services that currently provide an intermediate tier function including the community hospitals; Analyse needs, current service activity and patient flows; To use the available information to develop a quantified systems model of the intermediate tier locally; To use the model to test out the impact across the whole system (health and social care) of alternative scenarios for the provision of intermediate tier services Through this work a number of issues were highlighted by clinicians and social care staff working within the acute trust and community services. This primarily focused on the appropriateness and timing of transfer and discharge from James Cook University Hospital, the level of rehabilitation available in community hospitals and 46

47 that some of the patients could have been appropriately managed within their own homes. The model to test out the impact used existing activity/occupancy data as well as projected demographic changes. The scenario modelling consisted of a number of components: Fig 4.1 Components of Scenario Modelling Component 1 Component 2 Component 3 Component 4 Component 5 Component 6 Implement Nursing Rapid Response. Patients are admitted to nursing Rapid Response as an alternative to an admission to JCUH. Shift in long stay referrals to intermediate care. A proportion of long stay patients discharged from JCUH who are currently referred to bed-based intermediate care (in community hospitals or social care beds) are provided with alternative domiciliary intermediate care. Reduce delays in discharging long stay patients from JCUH. The average length of stay for long stay unscheduled admissions in JCUH is reduced: the reduction is made in the average system delay i.e. in the length of stay after the end of active treatment. Change average length of stay in community hospitals. Average length of stay is reduced in community hospitals for admissions from the community and for admissions from JCUH. Reduce bed capacity in community hospitals. Bed capacity is reduced in community hospitals. Priority for admission to community hospitals is given to referrals from the community (step-up) Diversion of potential long stay admissions to the intermediate tier (community hospitals and/or domiciliary intermediate care). A proportion of patients currently admitted to JCUH who go on to become long stay admissions are instead referred to the intermediate tier (i.e. community hospitals and/or domiciliary intermediate care). Three scenarios were modelled using variations of the components listed above which were then discussed with the CCG and other health and social care partners. Scenario 1: being Do nothing. Scenario 2: based on the following bullets recognises the interdependencies and was evaluated as a very achievable model: An increased target of 35 referrals per week into Rapid Response nursing rather than referral to JCUH o Represents less than one referral a week per practice or from all care providers 47

48 A reduction in the average length of stay for long stay patients in community hospitals by 2 days. o Consensus amongst clinical colleagues was that this was both realistic and achievable given the average length of stay in a community hospital for a transferred patient from James Cook is around 28 days An increase of 50% of long stay patients discharged from JCUH into domiciliary and Intermediate Care beds rather than Community Hospital beds over a 1 year period. o Consensus amongst clinical colleagues was that this was both realistic and achievable with improvements in discharge processes, better use of intermediate care bed provision and current and planned increases in reablement services Scenario 3: Increasing the scale and pace of the above (doubling referrals to rapid response and diverting more patients to domiciliary care) was also discussed and whilst it was felt that this too was achievable, modelling assumptions were made on scenario 2, a more conservative option. Earlier this year, the CCG also undertook a review of current and historic demand for beds within the system, over an 18 month period in order to triangulate the existing bed modelling assumptions. Currently there are 132 non acute beds (18 of which are dedicated to stroke patients) available in the South Tees areas, plus an additional 20 at the Middlesbrough Intermediate Care Centre. Considering all of the above, the evidence indicates that currently there is a bed surplus across South Tees Community Hospitals. In fact, the system could operate now with 102 beds supported by the imminent introduction of a Community Stroke Team. This is the equivalent of one community hospital bed base. It is anticipated that with the successful implementation of scenario 2 the optimum bed number will be approximately 68 over a two year period. Community Hospital Review The next stage of developing the option involved applying the agreed criteria individually to each of our four community hospitals to assess their quality and ability to deliver the proposed model of care now and into the future. Criteria were divided into: Quality ability to deliver services now and provide a quality service Sustainability ability to deliver future developments and accommodate expansion of community services Efficiency cost effectiveness and ability to deliver model currently and into the future 48

49 Fig 4.2 Synopsis of Options for Delivery of Future Model (Quality, Sustainability and Efficiency) Quality Redcar Guisborough East Cleveland Carter Ability to deliver improved stroke rehabilitation model Fully met Modern rehabilitation facilities, benefits from hydrotherapy pool and transition flat Partially met short term only would need significant remedial work to incorporate all associated stroke services/therapies Partially met would require reconfiguration of ward areas at cost Not met does not have x-ray facility Ability to deliver improved step/up and step down inpatient rehabilitation Fully met Modern rehabilitation facilities Partially met would need some remedial work to improve environment and colocation of associated services Partially met would require reconfiguration of ward areas at cost Not met does not have x-ray facility Ability to deliver improved inpatient palliative/end of life care Fully met All single rooms Partially met Only 4 single rooms. Would require significant remedial work to expand and reconfigure Partially met 6 single rooms would require remedial work to expand and reconfigure Partially met 8 single rooms. Would need remedial work to expand at significant cost. Meets NHS essential standards for environment Fully met A standard for quality Partially met B standard, would require significant investment to achieve A grading Partially met B standard but with no significant issues Partially met C standard and will never be able to achieve A standard due to the age and nature of the building Measure from Facet Survey contained within Estates Report: Key to Facet Survey A = a facility of excellent quality; B = a facility requiring general maintenance investment only; C = a less than acceptable facility requiring capital investment; 49

50 Accessibility Good accessibility for whole population Good accessibility for whole population Least accessible for Middlesbrough patients but offers good accessibility for rural East Cleveland Fairly good accessibility for Middlesbrough but limited access for East Cleveland s rural population Sustainability Redcar Guisborough East Cleveland Carter Ability to deliver future Out Patients developments Ability to deliver future assessment hub/day treatments development Maintenance of building over next five years Fully met Fully met has capacity now and benefits from attached pharmacy New building no significant issues (PFI) Partially met would need some remedial work and investment Partly met would need remedial work and investment Older building high maintenance costs 1.6 million Fully met Partially met would need remedial work with minimal investment Partially met fairly modern building 25 years old will require maintenance programme over next 5 years 900K Workforce Met Met Met Met Not met no room for OPD expansion Not met no room for expansion, no x-ray facility Older building high maintenance cost for a small bedded unit 420K 50

51 Efficiency Redcar Guisborough East Cleveland Carter Flexibility to utilise void space Currently 942K Cost for any required development to deliver model Impact upon other services delivered from that Estate Modern property, layout of building is really designed for specialist health care use Currently 364K Opportunities for clinical, office and other services 592K Building could be split easily and offers a variety of potential uses None Yes - Yes Yes None Minor Injuries Unit Out-patient services Limited Community Estate in Guisborough to transfer OPD services Minor Injuries Unit GP Surgery 82K Limited. Would offer some office space GP Surgery Limited number of other services 51

52 5 Preferred Option NHS South Tees CCG is clear that services need to develop to deliver more care in patient s own homes and in the community, moving away from a bed based model of care. The modelling work demonstrates that the need for beds will diminish over time as a result of improving and investing in alternative community provision despite the predicted increasing elderly population. Indeed bed modelling demonstrates that there is already a significant bed surplus. However, there is recognition from all parties that before reducing the bed base to the levels predicted, there is a need to ensure the new model of care is working. The clinically agreed criteria have been used to assess whether South Tees community hospitals are capable of delivering the proposed new model of care. It is clear from this exercise that: Currently only Redcar Primary Care Hospital is capable of delivering the proposed full model of care Guisborough Primary Care Hospital and East Cleveland Primary Care Hospital currently deliver elements of the proposed model but would require investment to realise fully delivery Carter Bequest Hospital is currently not capable of delivering the model of care to the standards required and would not be capable of doing so in the future without significant investment. Carter Bequest Hospital could never reach an A standard for quality environment due to the age and nature of the building, and therefore it is unsustainable and not fit for the future. It is important that the rurality of East Cleveland is taken into account and as such there is a need to provide accessible services within this locality. East Cleveland Primary Care Hospital is a fairly new building but currently has a large amount of empty space which lends itself to redevelopment. Guisborough Primary Care Hospital is split into two buildings, the building which houses beds is an old building (main building) and not sustainable in the long term, a second, newer building (the Chaloner Building - primarily used for administration, see table Fig. 3.3) houses a number of out-patient and community services. Guisborough lacks alternative community health estate. Retaining and developing out-patient services are central to the planned model and therefore it is proposed to retain and develop the newer building to support the delivery of the model for increased outpatient services. It is important to ensure any new service model is working before any reduction in the bed base. Redcar Primary Care Hospital is the estate of choice for stroke rehabilitation and the assessment hub, offering excellent modern rehabilitation facilities without the need for additional investment. In 52

53 centralising stroke beds at the Redcar Primary Care Hospital site, the need for beds at Carter Bequest Hospital and Guisborough Primary Care Hospital are significantly reduced. Carter Bequest Hospital, as previously stated, scores low for quality, sustainability and efficiency, does not support the delivery the proposed model of care and is therefore not sustainable for the future.. There are currently very few community services delivered from this site and these could easily be accommodated elsewhere. Middlesbrough already has alternative community estate where out-patient and community services are delivered, e.g. One Life and North Ormesby Health Village which have available capacity. In view of this, the age and unsustainability of the building, it is proposed that Carter Bequest Hospital should be the first facility to reduce bed numbers with re-provision of all other services/office accommodation. There is recognition, however, that GP services for this population will need to be retained and the Area Team will work closely with the practice to ensure future premises and honour their existing lease arrangement. As the model develops and becomes embedded, the need for community beds will further reduce. As previously stated, Guisborough Primary Care Hospital is unable to deliver the best practice model of care for stroke and therefore its bed base will reduce when stroke is centralised. The quality and age of the building are such that this building is unsustainable without significant financial investment. Thus the proposal is that Guisborough Primary Care Hospital should be the second bed base to close, whilst retaining and expanding out-patient and community services. East Cleveland Primary Care Hospital, a newer more sustainable building capable of increasing capacity and suitable for re-development is therefore the best choice for retention. This site provides accessible services to the more rural population and will be retained together with Redcar Primary Care Hospital. The proposed option is therefore as follows: Community development - April 2014 March 2016 Further development of community services to include: Implement a community stroke (early supported discharge) team Carry out resource review of therapy/capacity & demand recruit as necessary Working with local authority partners to increase capacity of reablement services Agree and implement pathways for patient transfer of care with key stakeholders 53

54 Work with all partners to progress the continual improvement of discharge processes from James Cook University Hospital Continue development of pathways of care, including defining and agreeing therapies and treatments that could be safely and effectively delivered in a community setting Further expansion of rapid response services including night sitting service as appropriate Implementation of a South of Tees Single Point of Access and Community Assessment Hub for health and social care Review current out-patient resource and develop plan to support improved provision/re-provision across South Tees community estate Market test re-development of void space within Community Hospitals Review diagnostic provision and develop plan to support improved provision across South Tees community estate By 1 st April 2015 Centralisation of stroke to meet best practice and commissioning of a community stroke team to be based within Redcar Primary Care Hospital Re-providing CCG commissioned services from Carter Bequest Hospital elsewhere, including services provided at home and reducing the bed base across the estate to 80 closing Carter Bequest Hospital. By 1 st April 2016 Redevelopment of estate in Guisborough, including increase in outpatient services Redevelopment of void space in East Cleveland Primary Care Hospital As a result of increased community and home based provision, closure of bed base at Guisborough Primary Care Hospital resulting in a further reduction to 62 community beds The preferred option therefore includes the development of a mixed model of community service responses, the centralisation of stroke services and rehabilitation in line with national best practice, a phased reduction of the community bed base to meet optimum capacity requirements and the development of the void community estate. The CCG has further engaged with stakeholders with regard to this preferred option before seeking final agreement. This engagement included a further stakeholder event, individual practice meetings with member practices, discussion at the CCG Clinical Council of members and meetings with local authority partners, including Chairs of both Health and Wellbeing Boards. Sign-off of the agreed option was subject to discussion at the CCG Governing Body meeting on the 23 rd April

55 6 Finance In line with the above, the focus of the financial model is to optimise the use of the estate. The current financial regime requires the CCG to cover the costs of NHS Property Services Ltd where facilities are empty or effectively subsidised. The CCG s current financial strategy is to minimise these costs. A summary of the estate costs is set out in the table below. This illustrates that the cost of the estate can, within a three year period, be reduced by 1M per annum on a recurring basis. The four community hospitals currently pay annual rents of 5.74M to NHS Property Services Ltd. In addition the CCG pays 1.95M to NHS Property Services Ltd to cover the costs of poorly utilised and subsidised space within the four hospitals. This means that the current estate is costing the health economy a minimum of 7.7M each year excluding the cost of any future refurbishment to bring it up to modern NHS standards. We know that future refurbishment will be a more significant issue for ageing estate such as Guisborough Primary Care Hospital and Carter Bequest Hospital. It is proposed that by 2017/18 Redcar should be fully utilised, empty space in East Cleveland rented to other organisations, facilities in Guisborough remodelled and Carter Bequest Hospital will have closed as new services are in place, freeing up 1M recurrently as previously stated. It is likely that the CCG will need to reinvest 100,000 to support the costs of re-providing some estate within this reorganisation. In addition, it is expected that our new model of care, as well as improving patient outcomes, will also deliver financial benefits. For example, by applying the predictive risk tool and better supporting people with long term conditions to self-manage, we are likely to see a fall in the number of emergency admissions. Likewise, expanding rapid response services delivered in patients own homes will also reduce admissions to hospital, freeing up resources for greater investment in improved patient care. 55

56 Carters Bequest Hospital (CBH) East Cleveland Hospital (ECH) Guisborough General Hospital (GGH) Redcar Primary Care Hospital (RPCH) Community Primary Care TOTAL Fig 6.1 Financial Plan Financial Year Comments 2013/14 Comments 000s 000s 000s 000s 000s 000s Total Cost 000s Rent 525 1, , ,736 CCG Void costs ,948 Total 601 1,893 1,065 4, , /15 Comments 000s 000s 000s 000s 000s 000s Total Cost 000s Rent Increased occupancy of RPCH 525 1, , ,207 CCG Void costs Reduced Void costs at RPCH ,477 Total 601 1,893 1,065 4, , /16 000s 000s 000s 000s 000s 000s Total Cost 000s Rent No rent for CBH following decommission. Additional rent cost for services being delivered in Community / Primary Care settings - 1, , ,782 CCG Void costs 3 months double running of CBH following decommissioning ,555 Total 154 1,893 1,065 4, , /17 Comments 000s 000s 000s 000s 000s 000s Total Cost 000s Anticipated increase in rent at GGH and RPCH due to Rent refurbishment/additional services provided from setting - 1, , ,603 CCG Void costs All premises fully occupied Total - 1, , , /18 Comments 000s 000s 000s 000s 000s 000s Total Cost 000s Rent - 1, , ,691 CCG Void costs Total - 1, , ,691

57 7 Programme Management 7.1 Programme Structure The CCG recognises that Programme Management methodology allows for the coordination, direction and overseeing of the implementation of a set of related projects and activities in order to deliver outcomes and benefits related to the organisations strategic objectives. Programmes deal with outcomes, projects deal with outputs. Programme management and project management are complementary approaches therefore programme management provides an umbrella under which a number of interrelated and interdependent projects can be coordinated, managed and delivered. Programme management integrates the projects so that it can deliver outcomes greater than the sum of its parts and is underpinned by the following principles of: Leading change Envisioning and communicating a better future Implementing structure, processes and plans Focusing on benefits and threats Adding value Designing and delivering a coherent capability Learning from experience Remaining aligned to strategy Currently the CCG is undertaking a number of work streams encompassing a number of current interrelated and interdependent projects being delivered in isolation, which together form a synergy for the IMProVE transformation. The CCG recognises a robust PMO approach requires development and establishment to maximise successful delivery. The model below in Fig 7.1 sets out the approach to Programme Management and associated Governance arrangements. Fig 7.1 Programme Management Model 57

58 7.2 Programme and Milestones The table below sets out a number of high level milestones, these will be expanded on and further defined once the outcome of the consultation process is known. Figure 7.2 High Level Programme Milestones PHASE DESCRIPTION DATE/S 1 Undertake further work to develop the community hub/assessment model Undertake transition planning for stroke rehabilitation and community bed reduction. Undertake engagement 2 Implement revised stroke rehabilitation model of care Reduce community bed base 3 Redevelopment of estate/ eradication of void space implement community hub/ assessment model. April 2014 March 2016 April 2015 March 2016 April 2015 March Service Review and Pathway Development As part of the ongoing programme of work a number of clinical services require further development to define their future configuration, these have been identified as: Stroke Rehabilitation Enhanced Rehabilitation Urgent Care Including Minor Injuries Palliative Care Assessment Hub Out Patients Heart Failure Dementia COPD Digital Care All of the above will be defined within work streams as part of the ongoing programme management. 58

59 7.4 Workforce In response to developing a new model of care for the future, the CCG has recognised that the workforce required to deliver quality of care is key for successful delivery. Recognising the significance of this, the CCG has commissioned an external workforce analysis and plan to assess the capacity and skills of the current workforce and the capacity and skills required for the future. The preliminary findings of this work identify: There is a potential shortfall in funded therapy staffing to meet patient need There are no major causes for concern over the supply of suitably competent staff to meet any increased demand The main challenge is the culture change that will be required to deliver care closer to home The CCG will establish a specific work stream to carry this forward within the transformational programme. 7.5 Estates In order to meet a new model of care for the future within the current community estate, the CCG has recognised that a detailed feasibility appraisal around the potential relocation of services from Carter Bequest Hospital and Guisborough Primary Care Hospital requires development. This together with the development of a transition plan will be taken forward through a newly established Estates specific work stream within the IMProVE transformation programme. 7.6 Equality Impact Assessment An equality impact assessment has been completed for the preferred option and is included at Appendix C. This is an iterative process and therefor the EIA will remain as a live document along this journey and will be updated as necessary. 59

60 8 Appendices Appendix A - Bed Modelling Appendix B - NHS Property Services Limited Estate Report for South Tees CCG Appendix C Equality Impact Assessment Appendix D The IMProVE Accessibility Travel Analysis Appendix E Medworxx Report Bed Utilisation 60

61