Paper G1 BUSINESS CASE. Community Chronic Pain Service

Paper G1 BUSINESS CASE Community Chronic Pain Service 21st October 2015

INSERT TITLE OF BUSINESS CASE BUSINESS CASE 29 October 2015 Paper Page 2 of 33

1.0 Background information 1.1 Project Team Project Sponsor (SRO) Mark Eaton Project Lead (PM) Russell Foster Contract Lead Stephen Dixon Provider Lead Clinical Lead (CRO) Dr Mitch Garsin Finance Lead Christopher Perera Quality & Patient Engagement Lead Diana Garanito 1.2 Version Control Date Author Summary of Changes 21 st July 2015 Russell Foster First draft 20 th August Russell Foster Addition of case studies and appendices 28 th August Mark Eaton Edit by Mark Eaton, addition of financial modelling 8 th September Russell Foster Addition of further financial modelling data 23 rd Sept Russell Foster Further review of modelling data 28 th Sept Mark Eaton Additional editing and modelling data 14 th October Russell Foster/Chris Perera Updated modelling data 21 st October Russell Foster Additional project costs included 1.1 For PMO Use Approved By Date of Approval Location of File Finance Lead Budget Allocated Budget Code Budget Holder Delivery Plan Due Page 3 of 33

2.0 Executive Summary In June 2014, a Business Case was presented to HCCG Governing Body which requested agreement to the implementation of a Chronic Pain service model as recommended by the Hillingdon Pain Management Clinical Working Group (CWG). The CCG Governing body recommended developing a Community Chronic Pain service through a contract variation with THH. This has not been implemented, and activity remains high, along with costs, and the pathways remain fragmented. The three year MSK QIPP plan was based on implementing a fully integrated MSK CATS service. However, only Trauma and Orthopedic patients are being triaged and assessed by this service. The consequences are confused MSK services with inefficient cross service care and in many cases the creation of a revolving door for patients. Appendix 2 illustrates this pathway fragmentation in Hillingdon. HCCG has identified THH as being a significant outlier in terms of V48 and V54 Spinal procedures compared to all other secondary care pain centres in NW London. Following continuous informal negotiations since December 2014, a Contract Query Notice has been issued to resolve the problem. A joint Task and Finish Group is putting in place appropriate referral protocols, pathways and discharge criteria to bring the number of V48 and V54 Spinal procedures in line with the other seven NWL CCGs. HCCG has proposed a capped cost for annual V48 and V54 Spinal procedures to the North West London average which equates to a QIPP saving of over 300,000. THH have rejected this proposal. HCCG has also been negotiating an episodic cost for chronic pain services with THHFT since December 2014. A HCCG proposal which would produce a QIPP saving of 100,000 has also been rejected by THH. The case studies of other Community Chronic Pain services in Appendix 1 demonstrate that there are successful alternative solutions available. Soft market testing has shown that there is a market for innovative chronic pain service providers. Options Available 1. Do Nothing 2. Procure a new Community Chronic Pain Service 3. Implement a new Community Chronic Pain Service via a Contract Variation with THH Service Cost Comparisons Service Cost Comparison Cost 2016/17 Cost 2017/18 Cost 2018/19 OPTION 1 2,107,721 2,206,783 2,310,502 OPTION 2 1,781,854 1,464,404 1,392,200 OPTION 3 1,919,096 1,787,233 1,754,983 Page 4 of 33

QIPP Savings Comparisons QIPP Savings - Comparison Savings 2016/17 Savings 2017/18 Savings 2018/19 Three Year Savings OPTION 1 v OPTION 2 325,867 246,513 175,922 788,302 OPTION 1 v OPTION 3 188,625 161,925 135,970 465,520 Decision Required The Finance and QIPP Committee and Governing Body are invited to Support the proposed Option 2 below to enable a Community Chronic Pain service to be procured and implemented in 2016/17. Page 5 of 33

3.0 Purpose To compare the costs/benefits associated with either implementing a Community Chronic Pain service via a procurement, or by developing the secondary care Chronic Pain service that is already in place with THHFT. 4.0 Objectives 1. To ensure that GPs are supported to encourage patient prevention activities and self-care, and when appropriate, provide clear chronic pain pathways for onward referral. 2. To implement a community assessment and treatment service to ensure that patients are treated in the most appropriate place and given the treatment most appropriate to their needs. 3. To minimise the number of patients that are referred to secondary care for assessments and treatments that are not necessary. 4. To commission the service with a contract term of up to 5 years. 5. To implement this service by end of Quarter 2 in FY 2016/17. 5.0 Background Hillingdon MSK Services - The Current Position Spend on MSK services in 2014/15 was 23,451,948. This is reported by Trauma and Orthopedics; Chronic Pain; Rheumatology and Community Services Physiotherapy delivered by CNWL. The forecast spend reported under Chronic Pain is expected to be 2,013,105 in 2015/16. Appendix 2 shows how patients with chronic pain follow many different pathways of care, and potentially find themselves receiving treatment that clinically adds little or no benefit to their condition that is not cost effective. The Hillingdon MSK services activity can be broken down as follows: CNWL Physiotherapy This service operates under a block contract agreement with an annual cap on total activity of HCCG. Annual activity for 2015/16 is of 33,796. Average cost per activity of 52.16. The service is based at seven sites across Hillingdon Borough, the majority of their patients are under 60 and mobile. The service refers some patients directly to the Pain Management CBT service but not to the CATS T &O service. THHFT Physiotherapy This service has a pain management specialist and takes referrals from GPs, and consultant referrals from other areas of THHFT secondary care, mainly T & O. There were 2552 GP referrals in 2014/15 and 9311 follow ups, with an average cost per activity of 44. There were a small number of referrals for management of either continence, balance or neurological problems. THHFT Pain Management CBT and Pain Centre The THHFT Pain Education and Management service offers both group and individual interventions. It received 498 referrals in 2014/15. The majority of referrals were received from other THHFT departments in particular the pain clinic and physiotherapy. GP referrals are low despite marketing to Hillingdon practices. Service users are offered an 8 week group Pain management Programme run weekly for 3 hours. The cost of this service is not separated from the Pain clinic costs see Table 1. Page 6 of 33

The Pain Clinic administers acupuncture and tens therapy and medicines review. GP first appointments to this service increased 19% year on year between 2013/14 and 2014/15, but total follow up appointments have only increased by 9% during the same period, indicating that some of these referrals may not have been necessary compared to the previous year. It is likely that a Community triage and assessment service including pain consultants, could have helped GPs both reduce total referrals and improve the quality of appropriate referrals to ensure that a higher proportion actually require follow up treatment. Rheumatology Services This is a relatively small service with 531 attendances in 2014/15 and new to follow up ratio of 4.19. Growth has been relatively flat over the last three years. The service provides Injection clinics, Telephone services, general appointments and a small number of day case treatments. There is a GP advice email service which provides advice directly to GPs on treatment options. The service previously had a clinical working group with clinicians from primary and secondary care which met over a period of time in 2013/14 The group was stopped when a decision was reached that Rheumatology required investment as opposed to delivering any cost savings. Anecdotal evidence suggests that there are some problems with the pathways to this service, for long waiting times for arranging biopsies via Rheumatology referrals. THHFT are currently recruiting an additional consultant. Pain Management CBT and Pain Centre This is a consultant led service that triages patients referred primarily by GPs and then books assessments with either Extended Service Practitioners (ESP) or with a consultant. Some patients are then referred on to THHFT Pain and Rheumatology services. There does not appear to be an agreed activity plan for this service for 2014/15, and the spend on this service appears under T&O in SUS and SLAM because there is no individual code for CATS T & O. The Case for Change The Community Chronic Pain business case in 2014 stated that the financial benefits would be driven by: A reduction in consultant outpatient first appointments, follow ups and procedures Implementation of a community tariffs model Reducing the number of revolving door patients Reduction in the use of medication, and more effective use of medication Since then the following issues have arisen: a) MSK first appointment outpatient activity has not only increased significantly since June 2014,) it has increased more per 1000 patient population than any other NW London CCG (Appendix 3). b) In the same period, follow up activity has decreased, suggesting that many patients may have benefitted from being treated in primary/community care rather than secondary care. c) THHFT has been identified as a clear outlier in terms of V48 (Thermal denervation of the spinal facet joint) and V54 (Injection around spinal facet of spine) procedures compared to other secondary care pain centres in NW London - see Appendix 6a and 6b. Page 7 of 33

Table 1 below shows the historic total spend (and spend at THHFT) on all V48 and V54 Joint injections normally administered to treat patients with chronic pain. Table 1 Spend Breakdown 2013/14 2014/15 Year on Year Change Spend 2015/16 @ 4.7% growth Total HCCG Spend on V48 107,424 150,471 +29% 157,543 Total HCCG Spend on V54 426,385 436,362 +2% 456,871 TOTAL 533,809 586,833 +9% 614,414 Spend with THHFT on V48 94,616 133,872 +29% 140,164 Spend with THHFT on V54 367,610 350,438-5% 366,908 TOTAL 462,226 484,310 +5% 507,072 d) Between April 2014 and July 2014, 20 Hillingdon practices referred patients for 4 or more V48 or V54 pain procedures these patients therefore received on average one procedure every 4 months. e) Following a Contract Query Notice over the V48 and V54 outlier activity, THH has identified 622 patients that have remained in their Chronic pain service for at least 3 years without being discharged. f) THH and HCCG have not agreed an episodic cost for Chronic pain. The latest proposal submitted by THH will not contribute anything to the 2015/16 QIPP target. g) THHFT did not accept the previous service specification. They have challenged whether it is fit for purpose in the following areas: o o o o o o The discharge process is unclear The 4 week referral to assessment response time is unrealistic The KPIs are unclear and not standardised with other specialties The specification does not outline treatment thresholds or pathways The evidence base is out of date, as the 2009 NICE guidelines are being re-written The 7 day working specification requires further discussion to factor in an increase in activity Conclusions The increasing trend of MSK and Chronic Pain first appointments is financially unsustainable. The service specification must be updated a new draft has now been developed. Patients relying on spinal procedures may benefit from alternative treatment in the community. A solution must be found that is brought under contract with appropriate KPI reporting, and that integrates smoothly with the other MSK pathways. The case studies in Appendix 1 provide evidence that innovative, cost saving solutions are available from alternative providers. Page 8 of 33

6.0 OPTIONS 6.1 OPTION 1: Do Nothing ` BENEFITS There will be no additional clinical benefits to patients as the current service would not change. RISKS (No mitigations) Incumbent provider not incentivised to work with the health sector (particularly GPs) on more effective pathways and innovative approaches. Referral activity into secondary care for patients with pain related conditions continues to rise. Compound growth of this activity is 4.7% per year over the next 3 years (see Table 3). Service costs will increase in line with this activity increase. The number of patients referred into secondary care for spinal procedures who may otherwise have benefitted from alternative non-invasive treatment will continue to increase, adding to the revolving door patient numbers, which will adversely affect waiting times for other patients. Table 2: How Chronic Pain activity and costs remain in Secondary Care with OPTION 1. MSK SPECIALITY - Activity Baseline 2015/16 Activity 2016/17 Activity 2017/18 Activity 2018/19 Activity Acute FA 1,185 1,241 1,299 1,360 Acute FU 2,510 2,628 2,752 2,881 SECONDARY CARE CHRONIC PAIN: Procedures (smaller IP) 1,387 1,452 1,520 1,592 All other CHRONIC PAIN: Inpatients (Not including Spinal Injections) 1,114 1,166 1,221 1,279 CHRONIC PAIN V48/V54 Day Case Joint Injections 834 873 914 957 Total Acute Activity 7,030 7,361 7,707 8,069 FA Community Service 0 0 0 FU Community Service 0 0 0 Total Community Activity 0 0 0 MSK SPECIALITY - Cost Baseline 2015/16 Cost Cost 2016/17 Cost 2017/18 Cost 2018/19 Acute FA 245,370 256,902 268,976 281,618 Acute FU 242,761 254,170 266,116 278,624 SECONDARY CARE CHRONIC PAIN: Procedures (smaller IP) 52,350 54,810 57,387 60,084 All other CHRONIC PAIN: Inpatients 858,210 898,546 940,778 984,994 CHRONIC PAIN V48/V54 Day Case Spinal Injections 614,414 643,292 673,526 705,182 Total Acute Spend 2,013,105 2,107,721 2,206,783 2,310,502 FA Community Service 0 0 0 0 FU Community Service 0 0 0 0 Total Community Spend 0 0 0 MSK SPECIALITY - Cost Baseline 2015/16 Page 9 of 33 2016/17 2017/18 2018/19 Annual Cost 2,013,105 2,107,721 2,206,783 2,310,502 Transition Costs 0 Total Annual Costs 2,107,721 2,206,783 2,310,502

6.2 OPTION 2: Procure a new Community Chronic Pain service. This option was the alternative part of the recommended option in the original Community Chronic Pain service submitted to HCCG Governing Body in June 2014. The service would be put out to tender under a 3 year contract (+2 year Extension option), and subsequently mobilised after Quarter 1 in July 2016. How the new Community Chronic Pain Service will work The procurement will be based on the provision of a single point of access Community Chronic Pain service that consists of a consultant led multi-disciplinary team of pain, physiotherapy and psychotherapy specialists that triage, assess and treat patients in a community setting. Recent soft market testing, and dialogue with local clinicians has produced feedback on the following service elements: Use of mobile digital technology solutions to encourage more self-management. Use of online pain management programme tools. Use of Primary care tools such as STarT to aid GP decision-making. Including the provision of community based injection therapies. Criteria which clearly identify what procedures can be done in the Community and not in acutes. Support for GPs to improve prescribing standards. KPIs designed to track improvements in patients clinical outcomes. A pricing structure that is designed y to cap predicted activity and penalise activity under-performance. There would be a need to de-commission the THHFT Pain Clinic, the Pain Management CBT service, and all chronic pain related THHFT physiotherapy. HCCG would also need to consider moving the flow of chronic pain related activity to the CNWL community service contract, or merging the two physiotherapy services. The proposed Community Chronic Pain service pathway is illustrated in Appendix 5. BENEFITS It provides an opportunity to refine the specification which was developed in 2014 which does not reflect current best in class Community Chronic Pain services See Appendix 1 Case Studies. It provides an opportunity for the commissioner to formally engage with the market to explore best in class community based chronic pain services and associated commercial models. It will reduce the current avoidable steps and delays in the patient pathway. It will permanently reduce the number of new revolving door patients. It will reduce the number of patient referrals to secondary care. It will reduce the overall cost of the service by reducing overall activity and bringing the majority of the remaining activity into the community at a tariff below PbR. RISKS Decommissioning of some of the incumbent provider s chronic pain services leads to a deterioration of the relationship should it fail to win the bid, which affects the quality of other MSK services delivered by the provider. MITIGATION: HCCG continue to work collaboratively with THH and support them informally up to the point of formal procurement, and follow formal due process to prove that HCCG has acted in a fair and transparent manner. Page 10 of 33

The procurement process is delayed or stopped due to unforeseen circumstances (e.g. Government Policy; or local factors) which delays the new service implementation, and associated QIPP benefits are not realised against plan. MITIGATION: The Procurement Mobilisation Plan is revalidated and approved by the Finance and QIPP committee. Revolving Door patients must be appropriately discharged to the new community chronic pain service. There are 622 such patients who have been receiving spinal injections for at least 3 years by THH. Managing this transition without the appropriate resource will block the flow of patients into the new service. MITIGATION: A Transition cost of 90,000 has been estimated for moving revolving door patients out of hospital into the community. See Transition Cost Assumptions (page 11). Table 3: How Chronic Pain activity and costs move from Acute Care to the Community with OPTION 2. MSK SPECIALITY - Activity Baseline 2015/16 Activity 2016/17 Activity 2017/18 Activity 2018/19 Activity Acute FA 1,185 948 569 441 Acute FU 2,510 2,003 1,323 755 SECONDARY CARE CHRONIC PAIN: Procedures (smaller IP) 1,387 1,109 998 998 All other CHRONIC PAIN: Inpatients (Not including Spinal Injections) 1,114 891 891 891 CHRONIC PAIN V48/V54 Day Case Joint Injections 834 417 208 156 Total Acute Activity 7,030 5,368 3,989 3,241 FA Community Service 614 932 922 FU Community Service 827 1,925 2,494 Total Community Activity 1,441 2,857 3,416 MSK SPECIALITY - Cost Baseline 2015/16 Cost Cost 2016/17 Cost 2017/18 Cost 2018/19 Acute FA 245,370 196,295 117,819 91,315 Acute FU 242,761 193,700 127,941 72,964 SECONDARY CARE CHRONIC PAIN: Procedures (smaller IP) 52,350 41,880 37,690 37,690 All other CHRONIC PAIN: Inpatients 858,210 686,408 686,408 686,408 CHRONIC PAIN V48/V54 Day Case Spinal Injections 614,414 307,207 153,275 114,976 Total Acute Cost 2,013,105 1,425,491 1,123,132 1,003,353 FA Community Service 0 114,365 173,741 171,795 FU Community Service 0 71,998 167,530 217,053 Total Community Cost 186,363 341,271 388,848 TOTAL COST 2,013,105 1,611,854 1,464,404 1,392,200 MSK SPECIALITY - Savings Page 11 of 33 Baseline 2015/16 2016/17 2017/18 2018/19 Annual Cost 2,013,105 1,611,854 1,464,404 1,392,200 Procurement, Mobilisation and Transition Costs 170,000 Annual Savings against baseline 231,251 147,450 72,203

High Level MSK Activity Assumptions Although THH covers 83% of secondary care chronic pain, tthe new service will manage demand of all secondary care activity in the same way. THHFT Pain Clinic is de-commissioned and resource moved into the new Community Chronic Pain service at end of Qtr 1 2016/17. Pain Clinic FAs are referred to the new service in Qtr 2, 3 and 4 2016/17. Pain related THHFT Physiotherapy is de-commissioned and resource moved into the new Community Chronic Pain service from Qtr 2 2016/17. THH Physiotherapy FAs are referred to the new service from Qtr 2 2016/17. Pain Management Clinic (CBT) is de-commissioned and resource moved into the new Community Chronic Pain service from Qtr 2 2016/17. Rheumatology and T & O activity is not affected. A reduction in analgesic and co-analgesic drug costs has not been calculated at this stage. Detailed Chronic Pain Activity Assumptions in Table 3 Baseline activity is assumed to be annual activity during 2014/15 plus 4.7% growth. FA and FU activity (into community) increases by 20% in year 1, reduces by 10% in years 2 and 3. Secondary Care Chronic Pain procedures decreases by 20% in year 1 and 10% in Years 2 and 3. All other Chronic Pain IP activity decreases by 20% in year 1 and then remains at zero growth. V48/V54 spinal injection activity decreases by 50% in year 1 and 25% in years 2 and 3. All spinal patient activity moving into the community is reduced by 50% i.e. for every two new patients treated in acute, only one new patient requires treatment in the community. All activity that is moved into the community is done so at 90% of PbR which is taken into account by annually rebasing the block contract. Transition Cost Assumptions in Table 3 The main transition cost will be as a result of moving revolving door patients out of hospital into the community service. Currently 622 patients have been identified by THH as being under secondary care chronic pain treatment for more than 3 years. By July 2016 (start of new Community Chronic Pain service mobilisation) there would still be 200+ revolving door patients, of which 50% could feasibly be moved into community care with an appropriate intensive treatment management plan during the three month mobilisation period. Provision of resource to provide this intensive treatment would be 600/patient: (100 x 600) = 60,000. The remaining 50% of patients could be moved into community care with a less intensive treatment management plan during the three month mobilisation period. Provision of resource to provide this intensive treatment would be 300/patient: (100 x 300) = 30,000. TOTAL TRANSITION COSTS: 90,000 Page 12 of 33

Procurement & Mobilisation Cost Assumptions in Table 3 Cost Rate Total Procurement support from SBS 30 35 days 18,000 Internal Procurement Project Management interim day 60 days @ 36,000 rate plus Agency margin 600/day External clinical specialist support 4 x 0.5 days @ 2,000 500 per session Internal Service Mobilisation Project mamnagement 40 days @ 24,000 interim day rate plus Agency margin 600/day TOTAL 80,000 Therefore OPTION 2 Total additional costs in Year 1 = 170,000 Page 13 of 33

6.3 OPTION 3: Implement Community Chronic Pain service via contract variation. The new Community Chronic Pain service is implemented via a contract variation with incumbent provider, but the provider fails to deliver the required transformation in service delivery and achieves only half the QIPP savings delivered in OPTION 2. BENEFITS It will reduce the current avoidable steps and delays in the patient pathway. It will reduce the number of new revolving door patients, but by only half as well as OPTION 2. It will reduce the number of patient referrals to secondary care, but only half as much as OPTION 2. It will reduce the overall cost of the service by reducing overall activity and bringing the majority of the remaining activity into the community at a tariff below PbR, but only half as much as OPTION 2. Patients will benefit from the clinical improvements associated with implementing the new service: reduction in the cohort of revolving door patients; waiting times to community and secondary care would be reduced. QIPP savings would be sub optimal to OPTION 2 due to lack of incentive by the provider to reduce total chronic pain activity. The CCG maintains and improves the working relationship with THHFT around the joint long term development of a more integrated MSK service. RISKS Little incentive on the incumbent provider to change its invasive treatment culture. New service lapses towards the status quo, QIPP savings target not realised. MITIGATION: HCCG plan Continue to action and report weekly Task & Finish Group sessions and escalate any issues which block progress to senior management on both sides. THHFT refuse to agree the QIPP savings plan and do not sign the contract variation, status quo maintained. MITIGATION: HCCG uses soft market testing output to benchmark the service specification content, and share content with THHFT to achieve joint agreement to implement. Contract variation not agreed by THHFT unless it is based on payment by activity not outcomes. There is no incentive for the provider to manage demand. MITIGATION: There is no overall mitigation to the perverse incentives that this scenario will create other than strong contract performance management by both commissioner and provider. Page 14 of 33

Table 4: How Chronic Pain activity and costs move from Acute Care to the Community with OPTION 3 MSK SPECIALITY - Activity Baseline 2015/16 Activity 2016/17 Activity 2017/18 Activity 2018/19 Activity Acute FA 1,185 1,066 896 832 Acute FU 2,510 2,256 2,021 1,894 SECONDARY CARE CHRONIC PAIN: Procedures (smaller IP) 1,387 1,248 1,198 1,198 All other CHRONIC PAIN: Inpatients (Not including Spinal Injections) 1,114 1,002 1,002 1,002 CHRONIC PAIN V48/V54 Day Case Joint Injections 834 625 520 494 Total Acute Activity 7,030 6,197 5,637 5,420 FA Community Service 439 532 540 FU Community Service 574 1,227 1,354 Total Community Activity 1,012 1,759 1,893 MSK SPECIALITY - Cost Baseline 2015/16 Cost Cost 2016/17 Cost 2017/18 Cost 2018/19 Acute FA 245,370 220,729 185,529 172,277 Acute FU 242,761 218,197 195,472 183,190 SECONDARY CARE CHRONIC PAIN: Procedures (smaller IP) 52,350 47,103 45,215 45,215 All other CHRONIC PAIN: Inpatients 858,210 771,924 771,924 771,924 CHRONIC PAIN V48/V54 Day Case Spinal Injections 614,414 460,482 383,148 363,998 Total Acute Cost 2,013,105 1,718,435 1,581,287 1,536,604 FA Community Service 0 81,727 99,180 100,559 FU Community Service 0 49,933 106,766 117,820 Total Community Cost 131,660 205,946 218,379 TOTAL COST 2,013,105 1,850,096 1,787,233 1,754,983 MSK SPECIALITY - Savings Baseline 2015/16 2016/17 2017/18 2018/19 Annual Cost 2,013,105 1,850,096 1,787,233 1,754,983 Mobilisation and Transition Costs 69,000 Annual Savings against baseline 94,009 62,862 32,251 Chronic Pain Activity Assumptions in Table 4 As the service would be operated by the incumbent provider, it is assumed, based on historic performance that all activity efficiencies will be achieved at 50% of the rate of OPTION 2. Page 15 of 33

Transition Cost Assumptions in Table 4 Transition costs do not include procurement, but only 50% of the 200 revolving door patients are moved back into the community, incurring 50% of the cost of OPTION 2. TOTAL TRANSITION COSTS: 90,000/2 = 45,000 Procurement & Mobilisation Cost Assumptions in Table 4 Cost Rate Total Procurement support from SBS Nil Nil Internal Procurement Project Management Nil Nil interim day rate plus Agency margin External clinical specialist support Nil Nil Internal Service Mobilisation Project 40 days @ 24,000 management interim day rate plus Agency margin 600/day TOTAL 24,000 Therefore OPTION 3 Total additional costs in Year 1 = 69,000 6.5 Preferred Option The recommendation to the Governing Body is to approve Option 2 which will not only provide the biggest improvements in patient benefits, but will provide the best value for money solution. See Section 9.0. 6.6 Implementing the Preferred Option Approach The high level approach to implementing the preferred option is summarised in Table 5 below: Table 5 Deliverable Activities Who Involved By When Review Existing services Complete Incumbent provider engagement Draft Specification Review existing QIPP targets, activity and spend, benchmark with local and UK CCGs. Research evidence base for future services. Review previous service strategy and what was delivered against targets. Collate all relevant data. Discuss performance of current services. Identify and rectify current issues. Share early commissioning intentions Review and update in light of benchmark intelligence Current providers, clinical lead, finance, informatics Incumbent providers, clinical lead, contract lead CCG Clinicians Complete Complete Page 16 of 33

Patient & public engagement Soft market Testing Complete detailed financial modelling Drive a full 12 week consultation: Draft & distribute patient questionnaire. Facilitate focus Groups. Illicit feedback from GPs. Present evidence based examples from other recent CCG Chronic Pain consultations Brief SBS. Create MOI, Provider Questionnaire, publish with Draft Spec on Contracts Finder, and assess level of market interest to inform market engagement strategy. Collate feedback, input to draft Spec Financial expectations/ efficiency targets/ investment funds identified. Activity levels identified. Financial implications on other services modelled. CCG Comms Team, Current providers, public, GPs SBS Informatics, Finance October 2015 Complete October 2015 Contracting Model proposed Obtain approval to proceed to procurement Develop Procurement Plan Formally engage market Plan and facilitate Bidder event Evaluate bids Approve contract award Notify Bidders Sign contract Mobilise contract Commence Service Clarify how intended service integrates with the MSK and other health economies. Define contract model and payment mechanisms. Submit and present Business Case to Governing Body for decision Governance arrangements, check conflicts of interest, identify panel members. Agree evaluation approach, bidder questions etc. Create internal comms plan. Finance, Clinical Lead, GPs Governing Body. SBS SBS, HCCG Team October 2015 November 2015 November 2015 Advertise tender on Contracts Finder + direct email. SBS November 2015 Ensure comprehensive understanding by bidders SBS CCG Comms November about the service and procurement process. Team 2015 Brief panel members. Respond to clarification questions. Evaluate, moderate, record scores & rationale. Recommend preferred bidder to GB Engage with preferred bidder, send notification letters out, confirm end of standstill period Further engagement with preferred bidder, agree conditions precedent. Develop mobilization Plan. Ensure transparency of contract award Make ready for service commencement. Manage service transition. Complete Lessons Learned report SBS, Bid team CCG Governing Body Preferred bidder, SBS, CCG Comms team CCG Contracts Team, Preferred bidder, CCG Comms Team Preferred Bidder, CCG Team January 2015 February 2015 March 2015 April 2016 End of June 2016 1 st July 2016 Page 17 of 33

7.0 Benefits Area Description of Measure/s Baseline Target Deadline Total QIPP Finance savings over 3 Reduction in Chronic Pain spend and years End of Qtr 4 activity in line with Business Case QIPP 2015/16 compared to 2020/21 targets. OPTION 1 of 788,302 Evidence of patients taking effective self-control of their condition (Via Pain Self-Efficacy Questionnaire) Quality Quantifiable improvements in patients perception of their pain (Via EQ5D/Start Back Tool) Patients having a positive outcome in their physical, psychological and/or social needs (Via Pain Self-Efficacy Questionnaire). No baseline available at present 92.5% Average for all measures By end of Qtr 2 of Year 1 Contract Increase in patient s self-reported levels of functional gain (Via Pain Self-Efficacy Questionnaire). Safety Delivery against all agreed adult safe guarding protocols and procedures set out in service specification. NA 100% compliance Report to CCG monthly from month 1 of Contract Referrals to be seen and assessed by Triage team within specified lead time. 4 8 weeks 100% <4 weeks Performance All patients have an agreed PMP during first assessment OP to surgical procedure conversion rate 100% NA 100% 95% By end of Qtr 1 Year 1 Contract Other Patient Satisfaction SUI s, Complaints and Never Events Number of DNA s by New Appointment and Follow Up NA NA NA 90% satisfied minimum response rate of 30% 100% compliance <5% Report to CCG as necessary Monthly Page 18 of 33

8.0 Timescales See Section 5.5. Benefits will be delivered initially over the three year contract period, but with an option to extend by a further two years. 9.0 Finance Table 6 and 7 illustrate how the QIPP savings would compare with the other options by implementing Option 2 - Procure the new Community Chronic Pain Service. Table 6 Service Cost Comparison Cost 2016/17 Cost 2017/18 Cost 2018/19 OPTION 1 2,107,721 2,206,783 2,310,502 OPTION 2 1,781,854 1,464,404 1,392,200 OPTION 3 1,919,096 1,787,233 1,754,983 Table 7 Net QIPP Savings Comparison Savings 2016/17 Savings 2017/18 Savings 2018/19 Three Year Savings OPTION 1 v OPTION 2 325,867 246,513 175,922 788,302 OPTION 1 v OPTION 3 188,625 161,925 135,970 486,520 Conclusion Implementing Option 2 will deliver 788,302 more savings than Option 1, and 301,782 more savings than OPTION 3. Table 8 Funding Amounts ( 000s) Option 2 Funding Source Period Non-Recurrent Recurrent Cost Centre Initial Procurement & Mobilisation 80,000 tbc Year 1 Transition - Year 1 QIPP savings 90,000 tbc Year 2 Nil Year 3+ Nil Page 19 of 33

10.0 Risks, Issues and Dependencies 10.1 Risks (things that may happen) Risks Likelihood Impact Total Financial modelling assumptions for Option 2 cannot be reasonably validated, new service implementation delayed. MITIGATION: Continue to re-validate data assumptions with CCG Finance Team as new intelligence is gathered up to procurement 2 5 10 Not enough potential bidders confirm that they can achieve financial balance against the service specification, procurement is delayed, new service implementation delayed. MITIGATION: Plan in an extended question & answer period with potential bidders during procurement to ensure bids are credible. HCCG decide choose Option 3, negotiate with incumbent to vary their contract, financial and clinical benefits do not materialise. MITIGATION: Continue to develop closer tactical and strategic working relationship with THH re MSK strategy to ensure minimum impact of pain activity and revenue being diverted elsewhere. 3 4 12 3 5 15 10.2 Issues (things that are already happening that need to be considered) Issues Mitigation Owner Contract Query Notice issued for THH being outlier for V48 & V54 spinal procedures. Informal negotiations with THH over Chronic Pain episodic costs have reached an impasse. Recent track record of MSK demand management by incumbent provider (e.g. T&O FA OP activity), and performance management of the MSK contract by the commissioner is poor. Identification of the real potential Chronic Pain activity and cost is difficult because some is referred to, and coded as T & O, Physio and Rheumatology. RAP Task & Finish Group progressing actions to address Continue to maintain dialogue and place on formal meeting agenda in order to progress to resolution (MSK CWG?) Operational relationship (regarding MSK services) with THH and HCCG is improving via more regular formal and informal dialogue. Working collaboratively with CNWL and THHFT to agree a best estimate of chronic pain activity flowing through physio, T & O and Rheumatology pathways. Russell Foster/ Derval Russell Russell Foster/Derval Russell Russell Foster/Derval Russell Russell Foster 10.3 Dependencies (things that this project is dependent upon) Dependency Impact on Project Owner Credible working assumptions of post contract Chronic Pain activity to inform the financial model. High if financial modeling leads to inaccurate estimate v post contract actual Russell Foster/Finance Strategic direction of travel re THH moving to ACO for all community services Timeline and details unknown at present Ceri Jacob Completion of patient/public engagement Procurement open to challenge if EIA is not completed Page 20 of 33 Russell Foster

11.0 Governance & Evaluation The CCG Executive has overall responsibility for the programme; its functions are to approve and sign off recommendations made by the Finance and QIPP Committee. This Committee will monitor the project s progress against plan and ensure that the risks and issues are appropriately managed. The Project Team will be put in place following the Governing Body decision, and is likely to consist, of the following members: Mark Eaton HCCG QIPP and Transformation Lead Russell Foster MSK Programme Lead Dr. Mitch Garsin MSK Clinical Lead Alex Long SBS Procurement support Chris Perera HCCG Finance Lead Emma-Jane Leslie HCCG Communications Lead Procurement Panel Lay members tbc Page 21 of 33

APPENDIX 1 CASE STUDIES IN CHRONIC PAIN SERVICES In considering the options available to HCCG, the following case studies illustrate how a community based model of care could deliver this solution. Case Study 1 Telford & Wrekin and Shropshire CCG This CCG ran a 12 month Pilot with a private sector provider - Pain Management Solutions, who then won a bid to provide a full triage assessment and treatment pain management service for NHS Telford & Wrekin and Shropshire in a primary care setting for patients with chronic non - cancer pain. They treat patients in a multi-disciplinary model and have access to a range of disciplines and interventions that can deal with the physical, psychological and social needs of patients with chronic pain. This includes spinal injections delivered in the community. During the Pilot the level of referrals to secondary care pain services dropped significantly. Waiting times were reduced and a large number of patients in secondary care who had been receiving long standing injection therapy were discharged back to their GPs. Pain Management Solutions contract with 18 UK CCG s and their current injection rate is averaging around 7% compared to a nationwide rate of 70%. The new service commenced in June 2015 and he provider is paid at 90% of National Tariff under a Local Variation approved by Monitor. Estimated annual spend on the services if the provider was paid for with the nationally determined price and currency would be 683,122. The CCG s estimated annual spend in 2015/16 with the local variation in place will be 522,201. This is an estimated annual saving of 23% which factors in the lower community tariff and the cost efficiencies of reduced activity to secondary care. The provider states that initially, referral numbers to the new service tend to be much higher in the first year due to the new service giving GP's access to evidence based Pain Management Programmes* (PMP) within the community, but injection rates are lower, with higher levels of 1:1 appointments and group pain management programmes. There is a low re referral rate of around 5% into their service (normally for patients whom repeated injections or top up acupuncture is appropriate). Current average spend per patient across their contracts is 667. Case Study 2 Somerset CCG Somerset CCG have worked collaboratively with Wiltshire CCG and the British Pain Society to implement a new pain pathway. The aim of the service is to enable adults who live with persistent pain, to understand and come to terms with their pain, and to adopt strategies for living, which allow them to lead as fulfilling and independent lives as possible. These aims of the service are achieved by service users gaining good health literacy, becoming activated and being supported to better self-manage. The service has four main components: The clinical service: Offers triage, assessment, personalised care planning and access to other services such as community physiotherapy and structured exercise programmes, plus: Specialist injection therapy is arranged with an appropriate provider where required Medication reviews User-led Pain Management Programmes Intensive psychologist-led Pain Management Programmes On-line self - management programmes with telephone coaching support One to one support through motivational interviewing Page 22 of 33

One to one intensive support from a psychologist practicing CBT As an exception, the consideration of the need to be referred to an inpatient pain management services and arranging this with an appropriate provider where required Referring service users on promptly where other pathologies suspected Facilitating discharge through a shared decision making format The collection and collation of service utilisation, effectiveness, safety and patient experience data Training and support: The service provides an ongoing and rolling training programme for GPs and other front line staff which aims to increase the knowledge and skills of these staff in supporting service users to confidently manage their persistent pain. The training programme covers the following: Develop service user perspectives Definitions, myths and misconceptions about persistent pain The cost of pain to individuals and the health economy The importance of service user empowerment, activation and self-management An overview of the Somerset model of care, the new service and how to access it Optimal analgesics Specialist injections and the Somerset Clinical Consensus on the use of injections for long term pain Case Studies Access to peer group support programmes: The service supports service users to attend a pain management group work program which uses licenced online tools to offer the benefits of tracking patient activity and pain scores, and even suggesting the best exercise to pursue based on the patients individual pain scores. For face to face therapy patients are given access to the Expert Patient Persistent Pain Programme (PPP) which is a self-management course for people living with day-to-day persistent pain. The course, through a process of discussion, peer support and supported goal setting and action planning helps participants learn how to deal effectively with the challenges of living with daily pain. It is delivered by trained and accredited tutors living with persistent pain themselves who have become confident self-managers of pain. The programme is run over six weekly sessions that deal with areas covered in the course such as: Overcoming common misconceptions, fears and beliefs about pain Acceptance and taking responsibility Pacing daily activities Stretching and exercising techniques where to begin Keeping a pain diary and tracking your progress Dealing with set backs Patient activation (knowledge, skills and confidence to self-manage) is a primary outcome measure which is collated before and after the programme. Online support and signposting: Patients learn how to manage pain from other people who are already managing (so-called social modelling ). There are also disadvantages: Not all service users want to join a group The waiting time for a local programme can be many weeks Costs averages 300 per person who attends the programme Page 23 of 33

Skills attrition; the knowledge, skills and confidence to manage pain tend to erode over time unless support is ongoing To mitigate against these disadvantages, the service also offers: An on-line self-management programme ( Pathway through Pain ) An on-line personal organiser ( Know Your Own Health ) which is given to people to use whilst working with the service and after they have chosen to be discharged. Know Your Own Health contains a number of elements: A curated web-browser that helps people find personalised information about managing pain A local service directory- updated by service users Personal trackers to support people to track and maintain progress towards goals A social networking site- for people with pain in Somerset A structured support group, closely allied to Know Your Own Health1, but also offering the opportunity for ongoing face to face contact and structured lay-led support The care pathway can be found here http://www.somersetpain.co.uk/about-the-painservice/?category=323 The clinical lead worked with colleagues, service users and commissioners to develop a map of interventions across the care pathway and to describe an ideal pathway from the perspective of the service user. Disinvestment in low value interventions and investment into high value interventions were clearly described as a set of key performance indicators, subject to annual review. The commissioner agreed a capitated budget for the first 2 years of the new service, subject to performance review. 18 months into the transformation, all KPIs are on track, disinvestment in low value interventions has progressed satisfactorily and on a base budget of 1,000,000, over 250,000 has been saved. 20% of this is real saving and the rest has been re-invested in high value interventions; namely on-line services and group and peer-peer support. The system of financial incentives within the overall programme budget is an essential part of this innovation. Here is a Somerset s patient s account of her Pain Journey When I first attended the Somerset Community Pain Management Service, I was looking for a magic quick fix solution, a pain killer that would magically take the pain away. I have been suffering from chronic leg pain for a few years and was feeling at the end of my tether, with the pain dominating my life. The nurse explained to me the gateway of pain and that stress and negative thoughts increase the amount of pain you experience, and that the way forward would be through closing this gateway, using relaxation methods and pacing myself. I was put forward for the online Mindfulness programme, which I found enormously useful. It teaches you to live with it rather than fight it, through meditation exercises, relaxation, mind retraining exercises, awareness of sensation and pacing activity. It s not a quick fix and it s an ongoing learning curve and I still have pain when I over do things but I feel more confident about being in control of it and the affect it has on my life. I feel more positive Page 24 of 33

about the future now, being able to work with the pain rather than fight against it. Accepting it and pacing myself more, I do feel more back in control. When I have a flare up, I have learnt to accept, meditate, relax and pace myself and sure enough I feel much better and in control again. I think the secret is getting in control again rather than feeling it s controlling you. You feel back in the driver s seat. Case Study 3 Notingham CCG Nottingham CCG commission a similar model of chronic pain care to Somerset. The Nottingham Back and Pain Team use a bio psychosocial approach to treat patients with longstanding pain. The team comprises physiotherapists, nurses, occupational therapists, cognitive behavioral therapists and psychologists. The service forms part of the local pain management pathway, providing an additional management tier for those patients who no longer benefit from primary care intervention, but do not require secondary care for therapeutic treatments. Fig 1 Pain Management Pathway for Nottingham CCG patients. Page 25 of 33

Case Study 4 Pennine MSK Partnership Pennine MSK Partnership is a service that has been commissioned by Oldham CCG for several years to provide care for the patients of Oldham in orthopedics, rheumatology and chronic pain in a community setting across several sites in and around Oldham. This organisation was the first in the UK to deliver an integrated MSK service under a prime contractor model (for Oldham CCG). This model has an innovative approach of the provider taking on financial and clinical accountability for the whole MSK pathway, including secondary care, by agreeing a programme budget for the entire contract period. Pennine MSK Partnership is part of a collaborative partnership with the Pennine Acute Hospitals NHS Trust, and the Psychological Medicine Service at Pennine Care NHS Foundation Trust, which in June this year implemented a new joined up patient centred Community Pain service. This service puts the emphasis on supporting people to make informed decisions, manage their care and have an improved quality of life. The new three tier service is run by a highly experienced multi-disciplinary team of health professionals who are all specialists in pain, including Pain Specialist Nurses, Pain Specialist Physiotherapists, Cognitive Behaviour Therapists, and Clinical Psychologists supported by Pain Consultants and Liaison Psychiatrists where necessary. Tier one will be coordinated by the patient's GP practice and patients will see Community Physiotherapists and Psychological Therapists. Tier two is being delivered by Pennine MSK Partnership where all patients are assessed by a Pain Specialist clinician and a self-help care plan will be developed in partnership with each patient. The team in tier two comprises Pain Specialist Physiotherapists, Pain Specialist Nurses, Psychological Therapists and a GP with a special interest in pain. This team is integrated with the community rheumatology service and the community orthopedic service within Pennine MSK Partnership. Similarly to the Nottingham model, patients with persistent pain receive their care in either tier one or tier two in the community, but those with the most complex needs receive additional care from tier three, where they will be assessed by a Clinical Psychologist, Liaison Psychiatrist, Pain Consultant and Pain Specialist Nurse. The new three tier service will help patients develop strategies for coping with their pain. Interventions on offer include one to one appointments and group work which addresses the physical, social and psychological effects of pain to give patients the best outcomes. Page 26 of 33

Case Study 5 - Kent Community Health NHS Trust Community Chronic Pain Service In 2006 an MSK Integrated Clinical Assessment and Treatment Service (ICATS) was developed by Kent Community NHS Trust which includes an ICATS for people suffering from chronic pain. The service operates a Single Point of Access model for all chronic pain referrals in the area. All new referrals into the service are paper triaged by either senior community clinicians or hospital anesthetists on a rota basis. The service supports patients to achieve long term selfmanagement and reduce dependence on healthcare systems; and supports referrers with help and advice through email / telephone support. The Service provides a moderate, long term, self-management approach and receives 400-500 new referrals each month (commissioned for 500). Of those referrals approximately 60% will remain within the community service and the remaining 40% will be directed to the acute service. The service discharges similar number of patients per month as it receives in referrals. Discharge does not mean that a patient is cured of chronic pain, but that they are able to self-manage their condition effectively. It operates a 12 month open door policy for patients who have been discharged 82% patients sustain discharge, 9% directly refer back into service and 9% referred via GP after 12 month period. The community service has helped to reduce duplicate referrals and provide GPs with clear pathway for referring patients. Work with pharmacy services has reduced the analgesic prescribing budget The common themes from these case studies are: Support for GPs to Primary Care to treat patients in the community and to help them manage their own care. Community access points that involve multi-disciplinary teams that assess patients and adopt a cohesive approach to discharge or handover to other parts of the health sector. Outcomes that are focused on a sustained reduction of activity into secondary care. Other potential future models (but no case studies available): I. CCG works in collaboration with one or more GP Networks. Groups of GPs combine with nurses, other community health services, hospital specialists and perhaps mental health and social care to create integrated out-of-hospital care through a Multispecialty Community Provider, to develop their own Chronic Pain CATS. II. CCG works in collaboration with a secondary care provider which becomes an Accountable Care Organisation/Partnership to which the CCG budget would be delegated to, along with the primary care budget for the area. Chronic pain management, and indeed MSK services as a whole would become part of this budget. Page 27 of 33

APPENDIX 2 Illustration of Fragmented MSK Pathways in Hillingdon Page 28 of 33

APPENDIX 3 MSK OP FA activity per 1000 list size Between April 2013 and May 2015 compared to the seven other NWL CCGs. The graph shows that HCCG appears to have been an outlier since April 2013, and that this gap has increased significantly from June 2014 to May 2015. Page 29 of 33

APPENDIX 4 Telford & Wrekin and Shropshire CCG Pain Management Referral Activity following implementation of Pain management solutions Pilot Page 30 of 33

APPENDIX 5 An illustration of the new Community Chronic Pain service pathway The pathway above ensures that patients with chronic pain have a single point of access to the new Pain service, and a single point of access to the patient s chosen secondary care provider. Patients may be referred for physiotherapy as part of their initial pain treatment and self-management, before being referred by to the Chronic Pain triage service. This service will manage the majority of patients in the community by facilitating individual and group therapies, which include exercise and cognitive behavioural therapy, and discharging patients to their GP with individual management plans. Note that the secondary care Physiotherapy and CBT Pain Management services would be de-commissioned. All chronic pain related Physio and CBT would be delivered in the community. Page 31 of 33