Meeting of Governing Body Date: Tuesday Time: 1.30pm Location: The Vassall Centre, Gill Avenue, Downend, BS16 2QQ Agenda number: 6.1 Report title: Healthy Weston Report Author: Katie Norton Report Sponsor: Julia Ross 1. Purpose Healthy Weston is a priority transformation programme which is being led by the Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group (BNSSG CCG) as part of the wider BNSSG Healthier Together Partnership. The purpose of this paper is to seek the CCG Governing Body s approval of the evaluation criteria that will be used to assess the clinical service options being developed through the Healthy Weston Programme, and ultimately to decide upon the future shape of services provided at Weston General Hospital to meet local people s needs. 2. Recommendations The Governing Body is asked to approve the evaluation criteria as set out in Appendix 1 of this paper. 3. Executive Summary The Commissioning Context for North Somerset published in October 2017 set out the intent of BNSSG CCG to work in close collaboration with local providers, key stakeholders, service users and the public to co-design a model of care focusing on primary care (General Practice) working at scale and providing strong system
leadership, stronger, more integrated community services and a stronger, more focused hospital in Weston. Over the last year patients, carers, members of the public, staff, providers of health and care services, and other stakeholders took part in a widespread conversation about the future of health and care services. Through this process, three clear programmes of work were identified: 1. Improvements to services that can be implemented immediately or imminently for example practices working together to deliver more efficient back office support. 2. Improvements that can be implemented but require further work up, including a supporting business case for example establishing a crisis café for people with mental health needs. 3. Changes that impact directly on delivery of a clinically and financially sustainable model of services at Weston General Hospital. Items 1 and 2 are moving forward but more work was required to build on the ideas developed for Weston General Hospital to ensure it has a vibrant and dynamic future at the heart of a system of care to meet local population needs for the long term. Through this work we have recognised that there will be a need for formal public consultation to agree changes to the way services are delivered at the hospital. Over the summer we have undertaken a programme of clinical design work involving doctors, nurses and other health and social care workers from across BNSSG. The Healthy Weston Clinical Design and Delivery Group reviewed national and international best practice pathways and different ways of offering services to meet changing health needs, and considered the way services should be provided to ensure a strong and focused hospital in Weston. As a result a range of clinical service models have emerged and some clear options for further detailed analysis and evaluation have been developed. This work will form part of a pre-consultation business case, which must be approved by NHS England with additional assurance through the South West Clinical Senate. Subject to this assurance process, a full public consultation will be undertaken to gather further insight and feedback and, combined with all the other data and evidence gathered (activity, travel times, workforce, finances etc.), to enable the CCG Governing Body to make a final decision on the future shape of services at Weston General Hospital. Page 2 of 11
In support of this process, the Governing Body is asked to approve the evaluation criteria that will be used to appraise the clinical service options developed by the Clinical Design and Delivery Group. The evaluation criteria have been developed through an inclusive process, including with members of the public and clinical and executive leaders, and tested by the Healthy Weston Public and Patient Reference Group. They have been endorsed by the Healthy Weston Steering Group for recommendation to the Governing Body. 4. Financial resource implications There are no financial implications arising from the approval of the evaluation criteria. The criteria have been informed and endorsed by the STP Directors of Finance to ensure appropriate financial consideration of any clinical service options. 5. Legal implications The Health and Social Care Act 2012 places specific duties on CCGs to involve people in planning and decisions about service provision, while maintaining the autonomy of local areas. There is also extensive guidance from the Department of Health and NHS England about service change and public consultation. Legal and professional advice is being sought to ensure the process stays in line with regulations and legal requirements, including full participation in the NHSE PCBC process. There has been significant involvement of the public and clinicians in the development of the evaluation criteria and formal approval by the Governing Body is an important governance milestone. 6. Risk implications The Healthy Weston Programme has a comprehensive approach to risk management. Formal Governing Body approval of the evaluation criteria is an important mitigation to ensure an objective and transparent process to assess clinical service options. 7. Implications for health inequalities Reducing health inequality is an underpinning theme throughout the Healthy Weston Programme and is included in the evaluation criteria. A full equality and quality impact assessment will be undertaken as the options for service change are determined. This will form a key piece of evidence and assurance in the Pre-Consultation Business Case. Page 3 of 11
8. Implications for equalities (Black and Other Minority Ethnic/Disability/Age Issues) A full equalities impact assessment will be undertaken to be included within the PCBC. 9. Implications for Public Involvement The evaluation criteria have been informed by extensive discussion and feedback as part of the early phases of the Healthy Weston engagement, with further discussion and testing through both the Clinical Design and Delivery Group and the Healthy Weston Public and Patient Reference Group more recently. The evaluation criteria have been shared with the North Somerset Health Overview and Scrutiny Panel. There is a comprehensive communication and engagement strategy to support the Healthy Weston Programme and a detailed pre-consultation engagement plan is in place and being progressed. Page 4 of 11
Agenda number: 6.1 Report title: Healthy Weston 1. Introduction Healthy Weston is a priority transformation programme which is being led by the Bristol, North Somerset and South Gloucestershire CCG as part of the wider BNSSG Healthier Together partnership. The purpose of this paper is to seek the CCG Governing Body s approval of the evaluation criteria that will be used to assess the clinical service options being developed through the Healthy Weston Programme, and ultimately to decide upon the future shape of services provided at Weston General Hospital to meet local people s needs. 2. Background The Commissioning Context approved and published by the NHS Bristol, North Somerset and South Gloucestershire CCGs in October 2017 set out a clear vision for local services and, specifically for a new model of care on the Weston General Hospital site 1. The document is explicit that doing nothing is not an option. It confirms that the CCG is determined to work with health and social care partners, and the wider community, to design a new model of care that is best able to meet the needs of the local population in a way that is clinically and financially sustainable. 1 Healthy Weston: Joining up services for better care in the Weston Area. A Commissioning Context for North Somerset 2017/18 2020/21. NHS Bristol, North Somerset and South Gloucestershire CCGs, October 2017 Page 5 of 11
Summary Vision for local services & a new model of care (from the Healthy Weston Commissioning Context) 1. Primary Care (General Practice) working at scale & providing strong system leadership:. A key objective is to support primary care to be more robust, working together more effectively with each other, with other health and care services and the wider community system to help people to stay well, independent and at home wherever possible. A significant dimension of this work will also be improving our messaging and support for patients to enable them to choose self-care options wherever appropriate. 2. Stronger, more integrated community services supported by a Health & Care Campus model at the WGH site: A key objective of the new model of care is to bring together services and resources that are already in place, centred around closer collaboration between primary care and the wider community system as a whole. This will mean patients receive a more coherent, high quality and effective service which is proactive and responsive to their needs, and will maximise the role of the Hospital and the specialist diagnostics and expertise. 3. A stronger, more focused acute model at Weston General Hospital: A key objective is to address the long standing financial and clinical sustainability challenges experienced by Weston Area Health Trust, and specifically Weston General Hospital. Some hospital services will continue to be provided locally, other services may need to move off-site to another acute hospital(where it makes sense to do so and some new services may be provided. Under Regulation 23, NHS England, CCGs, public and independent sector providers of NHS services must consult with the local authority about any proposals for a substantial development or variation of the health service in the Authority s area. Substantial is not, however, defined and therefore as the proposals for change develop we are working closely with North Somerset Health Overview & Scrutiny Panel (HOSP) who will have a key role in determining whether proposed changes meet the threshold for full public consultation. Where formal consultation is needed, the CCG is required to develop a Pre- Consultation Business Case (PCBC), which must be approved by NHS England. The PCBC provides the evidence that NHS England s five tests for service change have been addressed, clearly setting out the process for developing proposals for change and their individual and inter-relational implications in terms of clinical and financial sustainability. The PCBC will be expected to set out clearly how preferred Page 6 of 11
options have been developed and appraised and give assurance on the system s ability to implement changes if agreed. 3. Healthy Weston Co-Design Late last year and earlier this year patients, carers, members of the public, staff, providers of health and care services, and other stakeholders took part in a widespread conversation about the future of health and care services in Weston. Through this process, three clear programmes of work were identified: Summary of NHS England s 5 Key Tests for Service Change - Evidence of strong public and patient engagement - Consistency with current and prospective need for patient choice - Evidence of clear clinical evidence base - Evidence of support for proposals from clinical commissioners Where reductions in hospital bed numbers are anticipated, proposals will have to meet one of the following three conditions: - There is sufficient alternative provision in place alongside or ahead of bed closures - Evidence that specific new treatments or therapies will reduce specific categories of admissions - Evidence credible plans to improve efficiency 1. Improvements to services that can be implemented immediately or imminently. For example, a new unified approach to GPs providing services to local care homes; standardising telephony and shared back office IT systems for GPs to increase resilience; and training primary and community staff in more advanced and standardised frailty assessments. 2. Improvements that can be implemented but require further work up, including a supporting business case to ensure they are viable and have appropriate funding and support. For example, establishing a mental health crisis café, better integration of children s services, and social prescribing (a means of enabling GPs, nurses and other primary care professionals to refer people to a Page 7 of 11
range of local, non-clinical services for example, volunteering, gardening befriending, or a range of sports). 3. Changes that impact directly on delivery of a clinically and financially sustainable model of services at Weston General Hospital. Over the past year by working together we have made some immediate improvements and identified potential new ways of delivering services. However, the conversation highlighted that there are still significant challenges that need to be addressed to be confident that all services can be delivered in a sustainable way to met the needs of the population, particularly at Weston General Hospital where some of the current challenges are felt most. For services to be clinically and financially sustainable for the long term they must: Have enough qualified and specialist staff Be organised and delivered in such a way that they meet national quality and safety standards Have recurrent funding that is spent in the most efficient way, so we get best value for every taxpayer s pound. We are now building on the ideas developed for Weston General Hospital to ensure it has a vibrant and dynamic future at the heart of a system of care to meet local population needs for the long term. Through this work we have recognised that we need to be bolder and more creative if we are to deliver best possible sustainable health and care services in and outside of hospital in the future. Through the summer clinicians and health and care professionals from across the area have been meeting to explore how our existing health and care services might be designed and run differently in the future. This group includes clinical commissioners, GPs from local practices, hospital doctors, nurses, allied health professionals such as physios and other therapists, paramedics and social care professionals from Weston Area NHS Health Trust, University Hospitals Bristol NHS Foundation Trust, Avon and Wiltshire Mental Health Partnership NHS Trust, North Bristol NHS Trust, South West Ambulance Service NHS Foundation Trust and North Somerset Council. As well as our focus on the Weston area we are working with colleagues in Bristol and North Somerset to identify the services that Weston General Hospital is best placed to provide so it becomes a stronger, more focused hospital, and which services may be more effectively provided for local people by one of the other hospitals. We are also maintaining links with Somerset CCG and Taunton and Somerset NHS Foundation Trust to ensure the needs of the population in the north of Somerset are considered in the work. Page 8 of 11
The clinical design work has looked at national and international best practice pathways and different ways of offering services to meet changing health needs and operational challenges. From this thinking and work over the summer a process is in place, using co-designed evaluation criteria, to develop some clear options for further detailed analysis and evaluation. This process will enable the development of a pre-consultation business case, which must be approved by NHS England with additional assurance through the South West Clinical Senate. The PCBC will provide the evidence that NHS England s five tests for service change have been addressed, including quality, clinical and financial sustainability, assurance on how the preferred options have been developed and appraised, and on the system s ability to implement changes if agreed. Subject to this assurance process, a full public consultation will be undertaken, to gather further insight and feedback and, combined with all the other data and evidence gathered (activity, travel times, workforce, finances etc.), to enable the CCG Governing Body to make a final decision on the future shape of services. 4. Development of Options and Evaluation Criteria Through the Healthy Weston Clinical Services Design and Delivery Group, clinical colleagues have been working to describe best practice pathways. These are being used to set out the range of clinical service models for core services and to understand their clinical interdependencies. The full list of options will go through a process of assessment and evaluation as summarised below to identify the most suitable options for service provision on the Weston General Hospital site. This process will ensure input from clinicians, service users, carers and other key partners. An equality impact assessment will also be an integral part of the process. Page 9 of 11
To support this process, a set of evaluation criteria have been developed, building on the extensive feedback from our co-design work. Summary of the key issues for participants at the Healthy Weston engagement event on 19 th April 2018 (130 participants) It is proposed that there should be no weighting applied to the criteria. This reflects the views and feedback from colleagues involved in the development of the criteria and learning from other areas who have been engaged in similar work. The evaluation criteria have been further developed through an inclusive process with clinical and executive leaders, tested and informed by the Healthy Weston Public and Patient Reference Group, and shared with the North Somerset Health Overview and Scrutiny Panel. The Healthy Weston Steering Group, comprising of the most senior leaders of organisations across BNSSG, has endorsed the evaluation criteria for recommendation to the Governing Body. Page 10 of 11
5. Next Steps The evaluation criteria provide an important framework to support refining of the options in preparation for full public consultation to ensure it is robust, open and transparent. The intention is to work through October to apply the agreed criteria to the clinical service options identified by the Healthy Weston Clinical Services Design and Delivery Group. This will be progressed through extensive local engagement with service users, carers, general public and clinical colleagues and staff and enable development of the PCBC. The Governing Body is asked to approve the evaluation criteria as set out in Appendix 1. Page 11 of 11
Evaluation criteria FOR APPROVAL BY CCG GOVERNING BODY 21 ST September 2018
Proposed evaluation criteria Evaluation criteria Defined as 1 Quality of Care 1.1 Clinical effectiveness 1.2 Patient and carer experience 1.3 Safety 2 Access to care 2.1 Impact on patient choice 2.2 Distance, cost and time to access services 2.3 Service operating hours 3 Workforce 3.1 Scale of impact 3.2 Impact on recruitment, retention, skills 4 Value for money 4.1 Forecast income and expenditure at system and organisation level 4.2 Capital cost to the system 4.3 Transition costs required 4.4 Net present value (10, 20 and 60 year) 5 Deliverability 5.1 Expected time to deliver 5.2 Co-dependencies with other strategies/strategic fit 1 2
1 Proposed sub-criteria: Quality of care Evaluation criteria Clinical effectiveness Questions to test Will this option lead to people receiving equal or better quality care/outcomes of care in line with national standards and local or best practice? Will this option result in more effective prevention in order to improve life expectancy in the system and reduce health inequalities? Will this option account for future changes in the population size and demographics? Will this option lead to more people being treated by teams with the right skills and experience in the right place? Patient and carer experience Will this option improve continuity of care for patients? (e.g. reduce number of hand offs across teams / organisations, increase frequency of single clinician / team being responsibility for a patient)? Will this option enable greater opportunity to link with voluntary / community sector health and wellbeing services? Will this option improve quality of environment in which care is provided? Patient safety Will this option allow for patient transfers/emergency intervention within a clinically safe time-frame? Will travel time impact on patient outcome? Will this option offer reduced levels of risk (e.g., staffed 24/7 rotas, provide networked care, implement standardisation)? Source: CSDDG, Patient and Public Liaison Groups, Steering Group 3
2 Proposed sub-criteria: Access to care Evaluation criteria Impact on patient choice Questions to test Does this option increase or decrease choice for patients? Will this option make it easier for people to understand which services they can access when and where? Distance, cost and time to access services Will this option increase/reduce travel time and/or cost for patients to access specific services? Will this option involve patients travelling more/less frequently, change the number of journeys to access urgent medical intervention? Will this option reduce/increase patients' waiting time to access services? Will this option increase/reduce travel time and/or cost for carers and family? Will this option support the use of new technology to improve access? Service operating hours Will this option improve operating hours in line with the needs of the population? Does the option reduce the risk of unplanned changes and improve service resilience? Source: CSDDG, Patient and Public Liaison Groups, Steering Group 4
3 Proposed sub-criteria: Workforce Evaluation criteria Questions to test Scale of impact What proportion of current staff will be impacted by the changes across the system? Impact on recruitment, retention, skills Will this option improve the recruitment and retention of permanent staff with the right skills, values and competencies? Will it enable staff to maintain or enhance competencies? (e.g., impact on volumes of activity / specialism; increased training / opportunity for accreditation and career progression) Is the staff travel, relocation or retraining required for this option acceptable? Is it possible to develop the skills base required in an acceptable time frame? Will this option optimize the use of clinical staff and enable them to work at the top of their license? Will this option enable accountability and governance structures to support staff? Will this option increase multi-disciplinary / cross-organisational working? Source: CSDDG, Patient and Public Liaison Groups, Steering Group 5
4 Proposed sub-criteria: Finance/value for money Evaluation criteria Questions to test Costs & income What are the implications on income and expenditure for each acute Trust within the system? Does this option reduce the requirement for additional provider subsidy? What are the implications for total acute spend across the health and care system? What are the opportunities for investing in more appropriate / alternative settings of care? Capital cost to the system What would the capital costs be to the system of each option, including refurbishing or rebuilding capacity in other locations? Can the required capital be accessed and will the system be able to afford the necessary financing costs? Transition costs What are the transition costs (e.g., relocating staff, training and education costs)? Net present value What is the 10, 20 and 60 year NPV (net present value) of each option, taking into account capital costs, transition costs and operating costs? Source: CSDDG, Patient and Public Liaison Groups, Steering Group 6
5 Proposed sub-criteria: Deliverability Evaluation criteria Expected time to deliver Questions to test Is this option deliverable within 5 years? How quickly could this option deliver benefits? Codependencies Is this option compatible with the Healthier Together STP vision? Does this option support the Healthy Weston vision? Does this option enable the system to maximise the role of and adapt to new technologies? Will this option rely on other models of care / provision being put in place and if so, are these deliverable within the necessary timeframe? Will the wider system be able to deliver on this change including the community and voluntary sector? Can the additional capacity requirements be delivered? Will it destabilize any other providers in a way that can not be managed (e.g. cost, safety)? Does the system have access to the infrastructure, capacity and capabilities to successfully implement this option? Source: CSDDG, Patient and Public Liaison Groups, Steering Group 7