BUSINESS CASE FOR LEVEL 2 SPECIALIST NEURO-REHABILITATION BEDS : SLIDE PACK & FINANCIAL MODEL

BUSINESS CASE FOR LEVEL 2 SPECIALIST NEURO-REHABILITATION BEDS : SLIDE PACK & FINANCIAL MODEL V8 June 2015 1

Index Executive summary Slides 3-5 Business Case on a Page Slide 6 Model methodology Index/ Summary Slide 7 A. Methodology for calculating DTOC, beds and costs: Slide 8 1. Nos. of Neuro Rehab patients experiencing DTOC Slide 9 2. Nos. of required Neuro Rehab beds Slide 10 3. Cost of Level 2 Neuro Rehab beds Slide 11 Summary methodology for investment Slide 12 B. Benefits Methodology Steps: Slide 13 1. Calculate # of Neuro Rehab patients experiencing DTOC per provider Slide 14 2. Calculate average bed days lost per DTOC Slide 15 3. Summary of benefits - Neuro-rehab DTOC Slide 16 4. Summary of Benefits ongoing care Slide 17 Funding Arrangements Options Appraisal Slide 18 to 31 2

Executive Summary: introduction Specialist rehabilitation is the total active care (assessment, treatment and management) of patients with a disabling condition, and their families, by a multi-professional team who have undergone recognised specialist training in rehabilitation, led /supported by a consultant trained and accredited in rehabilitation medicine (RM). (Professor Stokes- Turner 2010). This summary slide sets out the business case and financial modelling for the commissioning of additional capacity for Level 2 Specialist Neuro-Rehabilitation Service (SNRS). The identified capacity resource needed to meet current recognised need is equivalent to a total of 19 SNRS Level 2 beds. The proposed service model will provide a more flexible model of bed based and non-bed based/specialist outreach service to meet the varying needs for specialist neuro-rehabilitation for either bedded or community based interventions linking both acute and community pathways. The business case has identified that meeting this recognised need will result in immediate clinical and economic outcomes for patients across West London, Central London and Hammersmith and Fulham CCGs, namely: Provide positive patient experience by substantially reducing unwarranted delay to their next phase of care Reduce additional cost in the acute hospital costs associated with increased length of stay in hospital Measurable improvement in patent outcomes due to improved functional gain as a result of timely interventions and reductions avoidable complications; Quantifiable reduction in long-term (continuing care) costs due to a measurable reduction in the person s weekly on-going care costs. Supporting transitions in care back to localities following rehabilitation. 3

Executive summary: demand & capacity Currently state: 10 commissioned SNRS block beds across the Triborough. This is currently being provided at the Albany Unit, Queens Square, London and provided by the University College of London Hospitals Foundation Trust (UCLH). Significant and increasing Delayed Transfers Of Care (DTOC) in hospitals 6 to 10 weeks DTOC not only impacts on patient experiences of care, but also reduces the benefits to be gained from early intervention on reducing dependency levels Ad hoc out of area spot purchasing, and lost of opportunity in enhancing clinical outcomes and reducing longer term cost for on-going care. Future state: Financial Model quantifies the capacity and investment required to provide a clinical and cost efficient model of care which will significantly reduce: DTOC pressures and acute bed days lost for this patient cohort by 85% Reduce dependency levels leading to reductions in on-going care costs by atleast 481 per week per patient. This is a first step in understanding and monitoring demand and capacity required for this cohort of patients. This is due to lack of complete data. However there is sufficient data set on neuro-rehab demand and delays to analyse, extrapolate and to make an informed estimation on current demand. This is explained in slides 7 and 8 onwards. 4

Executive summary: engagement & recommendation 5 The Business Case for additional capacity has been determined through extensive sector work - coordinated through Imperial College Health Partners (ICHP) the designated regional clinical and academic science network involving: Patients and their families/carers, and representative groups e.g. Health Watch Clinical input from a range of clinicians, practitioners and managers across Acute Hospital Trusts, Clinical Commissioning Groups, Community Health Care providers, Adult Social Care, and Third Sector (Headway) The following four options were examined in the business case are: Do nothing and maintain the status quo; Commission 19 additional SNRS beds resource to provide both a bedded and non-bedded/ Community Outreach model of care within the Triborough CCGs areas; Commission 19 additional SNRS beds within the Triborough area plus the 10 beds currently at the Albany Rehabilitation Unit; Undertake a whole service redesign of the full care pathway. This business case recommends option 2 to commission additional capacity equivalent to 19 SNRS Level 2 beds resource to meet the current and future demand requirements. This will ensure the provision of flexible model of care to meet the varying needs for specialist neuro-rehabilitation.

Business Case on a Page patient flows Black arrows show current flows for most patients requiring bedded Neuro-rehab Longer waits in Hospital for limited Out of Area Level 2 provision Increased dependency & avoidable complications Reduced wait & Timely transfer Longer LOS Reduced outcomes Long-term care in Independent Hospitals Long Acute Hospital stays Local level 2 Specialist Neuro-Rehab Service (SNRS) Beds Transfer to local community based Specialist Neuro-Rehab Outreach Service (SNROS) Level 2 Reduced dependency & improved outcomes Home Nursing Home Key: Community Independence Services (CIS) and Community Rehab Teams (CRTs) Community CIS/CRTs Hospital Nurs/Res Care Local Neuro Rehab Existing flows to reduced benefits = costs New flows to increase benefits = reduce costs 6

Model Methodology Index / Summary Costs Benefits 1 Neuro Rehab DTOC patients Neuro Rehab DTOC patients (ICHT) Neuro Rehab DTOC patients (Chelwest) Neuro Rehab DTOC patients 2 Required Level 2 Beds Average Bed days lost per DTOC 3 4 Cost of Neuro Rehab Level 2 Bed Savings from avoiding a DTOC (DTOC cost reduction) Savings in Long-term care costs (weekly) Financial Summary 7

Methodology for calculating DTOC, beds & costs 1 Calculate the number of neuro rehabilitation DTOC patients Data sources : ICHT DTOC data (13-14 and 14-15) National DTOC data 2 Calculate required number of neuro rehabilitation beds Commissioner Assumptions: Bed occupancy rates LOS 3 Calculate the cost of a Level 2 neuro rehabilitation bed Benchmarking analysis National Tariff Level 2 Guide base rates OBD shadow tariff (Putney) ARU Contractual value (10 beds) 8

1) Calculating the number of Neuro rehabilitation DTOC patient numbers ICHT Neuro Rehab DTOC Data (13/14) Imperial Chelwest 81 28 *34.6% *34.6% calculated from comparing total number of Neuro Rehab DTOCs from ChelWest to those from ICHT based on 2013/2014 data and methodology. Imperial Neuro-Rehab DTOC patients 13/14 81 Chelwest Neuro-Rehab DTOC patients 13/14-28 Calculation : 81/28= 0.346 (34,6%) ICHT Neuro Rehab DTOC Patients Data (14/15) (prorated for full year) Imperial 77 ICHT Neuro Rehab DTOC Patients Data (8 months in 14/15) Imperial 51 Extrapolated using monthly averages Estimated ChelWest 14/15 Neuro Rehab DTOC patients Chelwest 26 Total Triborough Estimated Neuro Rehab DTOC Patients 14/15 Imperial Chelwest 77 26 Total: 103 Key: Assumption Known Data 9

2) Calculating the number of neuro rehabilitation beds required to reduce DTOC s *LOS and occupancy rate : Standard Occupancy rate assumptions for Level 2 bed unit, based on Albany Unit information provided by Ray Boateng Neuro Rehabilitation DTOC (2014/15) Length of Stay Target bed occupancy rate Neuro Beds required 103 56 85% 19 (18.6) Calculation: ((Total neuro rehab DTOC s* LOS)/ Target Occupancy)/365 ((103*56) / 85%)/ 365 Key: Assumption Known Data 10

3) Calculate the cost of a Level 2 Neuro-rehab bed Average benchmark analysis - 3,605 per week: Calculating the average cost of current provision and 14-15 national tariff plus MFF: National tariff ( 3,715 per week) Hospital based Level 2 beds guide base rate (Hillingdon Hospitals Alderbourne and Mount Vernon units, Albany unit 2,741 per week) Occupied Bed Day for Independent hospital (Putney) - 4,359 per week The average cost provides basis for market testing. Commissioning envelope - 3715 per week Recommended that the commissioning investment based on conservative scenario to be based National Tariff Plus MFF. Therefore commissioning financial envelope: 19 beds x 3,715 weekly bed cost x 52 weeks = 3,591,340 Weekly rate per bed = 531 11

Summary methodology for investment Investment Patients experiencing DTOC for neuro rehabilitation (Imperial and Chelwest) Average LOS Level 2 Rehab bed 56 Assumed target bed occupancy 2 85% Total shortage of beds 19 3 14-15 National Tariff + MFF for Level 2 cost (weekly cost per bed) 3,715 itional required 19 Neuro Beds cost 3,591,340 1 103 Benchmark Analysis 1 2 3 Calculate the number of neuro rehabilitation DTOC patients Calculate required number of neuro rehabilitation beds Calculate the cost of a Level 2 neuro rehabilitation bed 12

Benefits Methodology 1 2 Calculate the number of neuro rehabilitation DTOC patients per provider Calculate average bed days lost per DTOC Data sources : ICHT DTOC data (13-14 and 14-15) National DTOC data Data sources and assumptions: ICHT and National DTOC data (13-14 and 14-15) 85% reduction target on DTOCs 3 Calculate the cost of a DTOC (neuro rehabilitation) Rehabilitation cost analysis Triborough Data Cost of 282 per bed day 4 Calculate Longterm Care savings due to neuro rehab Source: 2005 research studies evidencing reduction in on-going care: 481 per week. This is used as conservative estimate. National benchmarking average from 2012 2014/15 suggest saving to be 534 13

3) Calculate cost of a DTOC - Benefits Breakdown Imperial DTOC Savings ( 274,574) ChelWest DTOC Savings ( 95,095) Total Benefits ( 369,669) 77 Patients at 282/day for 15 DTOC days at 85% reduction rate 77 x 282 x 15 x 85% = 274,574 26 Patients at 282/day for 15 DTOC days at 85% reduction rate 26 x 282 x 15 x 85% = 95,095 282/day for DTOC derived from cost data set provided by H&F CCG (Sharon Robson) 15 days is average DTOC, calculated from a two year average calculation of Imperial patients experiencing DTOC (see slide 7) divided by the total number of DTOC days they experienced. 14

2) Calculate average bed days lost due to DTOC Average Bed days lost per DTOC Final Two year average Bed days lost per DTOC (*) 2013-2014 (*) 2014-2015 13-14 and 14-15 data (*) Methodology: 19.6 10.4 15.0 Total Bed days lost / Number of DTOC patients 85% reduction rate of total DTOC bed days 12 (12.7) 15

Financial Summary of Benefits - DTOC Benefits (*) Patients experiencing DTOC for neuro rehabilitation (Imperial) 1 77 Average bed days 15.0 2 % Reduction of total DTOC (assumption) 85% Average DTOC cost per bed (daily) 3 282 Savings from reduced DTOC (Imperial) - 274,574 Patients experiencing DTOC for neuro rehabilitation (Chelwest) 1 26 Average bed days 15.0 2 % Reduction of total DTOC (assumption) 85% Average DTOC cost per bed (daily) 3 282 Savings from reduced DTOC (ChelWest) (*) - 95,095 1 2 3 Calculate the number of neuro rehabilitation DTOC patients per provider Calculate average bed days lost per DTOC Calculate the cost of a DTOC (neuro rehabilitation) * Note on Chelwest DTOC savings: Reflected to show financial impact, but savings have already been identified in other WL CCG QIPP schemes, quantifying DTOC savings (WL003) 16

4) Financial Summary savings on on-going care Evidence from research Study 1 (See Business Case: Turner Stokes et. al, 2005) show that in 2005 the mean average for long-term care cost saving impact following a specialist neuro-rehabilitation intervention was 481 per week per patient due to the reduction in dependency levels. This is what has been used for the business case. Current UK Rehabilitation Outcomes Collaborative (UKROC) benchmarking data (see appendix slide 28) show that the 3 year mean average from 2012/13 2014/15 is 534 per week. Therefore the calculations for long-term care savings are very prudent and conservative. (see appendix) The table below provides a 3 years projection on the minimum cumulative financial impact on long-term savings for the SRNS supporting a projected average of 103 patients each year assuming each patient survives during the 3 year period. The projected long-term cost savings for the 3 year contract life is estimated at 15.5m Long-term care (LTC) savings per year Patients 2016/2017 2017/2018 2018/2019 Total impact LTC savings Year 1 103 2,576,102 2,576,102 2,576,102 7,728,307 LTC savings Year 2 103 2,576,102 2,576,102 5,152,204 LTC saving Year 3 103 2,576,102 2,576,102 Total LTC savings DTOC savings per year Total financial benefit CCGs investments per Year Net costs(+)/benefits (-) 309 2,576,102 5,152,205 7,728,307 15,456,613 369,669 369,669 369,669 1,109,007 309 2,945,771 5,521,874 8,097,976 16,565,621 3,591,340 3,591,340 3,591,340 10,774,020 + 645,568-1,930,534-4,506,636-5,791,601 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2117444/ 17

FUNDING ARRANGEMENTS Options appraisal for funding split per CCG 18

Options for funding split OPTION 1 OPTION 2 OPTION 3 OPTION 4 OPTION 5 CCG Equal Split Activity Activity - 2 yr Avg DTOC Ratio (Option 3&4) CL 33.33% 37.00% 41.50% 38.00% 39.75% WL 33.33% 36.00% 36.00% 22.00% 29.00% H&F 33.33% 27.00% 22.50% 40.00% 31.25% 1) Equal 3 way split 2) % split based on Albany usage for 14/15 - CL (37%), WL (36%), H&F (27%) 3) % split based on Albany usage 2yr average (2013-14 /15) : CL (41.5%), WL (36%), H&F ( 22.5%). Please note 2013/14 usage - CL (46%), WL (36%), H&F (18%) 4) % split based on Imperial DTOC for 14-15 DTOC % till Feb 2015 are 40% HF, 38% CL, and WL 22% (this is heavily weighted against HF) 5) Combined averages for options 3 and 4 19

Caveats Limitations OPTION 1 As was recommended in the latest edition of the Business Case, a three way CCG split is the most sensible and pragmatic approach for initial investment. This simplicity of this can be re-balanced based on actual usage activity. CCG Finance Leads may accrue up to an additional 20% (as worst case scenario) and re-evaluate financial positions once activity data became available. OPTIONS 2 (Albany usage % for 2013/14 ) & OPTION 3 (Albany usage % for 2013/14 2015/16) Albany does not provide for the full spectrum of Level 2 beds therefore data on usage is only useful for understanding demand for certain patient cohorts only e.g Stroke patients. Whereas this may provide Central and West London CCGs with some indication of their usage, access is limited for H&F CCG - therefore provides only a partial indication of demand for H&F in addition to the limitations above. This is especially the case for 2013-2014 period. OPTION 4 National DTOC reporting categorises Neuro-delays under Category C Further Non-acute NHS care. Category C includes NHS Cont Care and End of Life Care etc. Therefore ICHT data accurately captures the totality of neuro-delays. ICHT is also the biggest referrer for Neuro-rehab. However, the ICHT DTOC data for neuro-rehab is heavily weighted towards H&F CCG in particular as patients are unlikely to end up in Chelwest. Monthly neuro - DTOC from Chelwest is unavailable. 20

Option 1) Equal Three way split: Financial Summary (2016-2017) The full year financial investments for 2016/17 are set below. This is a three way split part year effect, and will be rebased at the end of year based on usage. Activity - 2 yr CCG Equal Split Activity Avg DTOC Ratio CL 33.33% 37.00% 41.50% 38.00% 39.75% WL 33.33% 36.00% 36.00% 22.00% 29.00% H&F 33.33% 27.00% 22.50% 40.00% 31.25% 2016/2017 FYE H&F WL CL Total Drivers Current Investment (15/16) New Investment (16/17) Total Investment (16/17) 418,845 1,278,238 1,011,490 2,708,573 778,264-81,125 185,623 882,767 1,197,113 1,197,113 1,197,113 3,591,340 2015/2016 full year investment identified for SNRS resource 2016/2017 additional FYE investment for SNRS resource 2016/2017 full year investment for SNRS resource Gross Benefits (DTOC) - 123,223-123,223-123,223-369,669 Reduction in DTOCs Total Net Investment 1,073,890 1,073,890 1,073,890 3,221,670 21 Time Frame : April 2016 - Mar 2017

Option 2) Albany Activity usage Split (2013/14): Financial Summary (2016-2017) The full year financial investments for 2016/17 are set below. This is an option that represents funding arrangements based on Albany Rehabilitation Unit Activity Activity - 2 yr CCG Equal Split Activity Avg DTOC Ratio CL 33.33% 37.00% 41.50% 38.00% 39.75% WL 33.33% 36.00% 36.00% 22.00% 29.00% 2016/2017 FYE H&F WL H&F 33.33% 27.00% 22.50% 40.00% 31.25% CL Total Drivers Current Investment (15/16) New Investment (16/17) Total Investment (16/17) 418,845 1,278,238 1,011,490 2,708,573 550,813 14,644 317,306 882,767 969,662 1,292,882 1,328,796 3,591,340 2015/2016 full year investment identified for SNRS resource 2016/2017 additional FYE investment for SNRS resource 2016/2017 full year investment for SNRS resource Gross Benefits (DTOC) - 99,811-133,081-136,778-369,669 Reduction in DTOCs Total Net Investment 869,851 1,159,801 1,192,018 3,221,670 Time Frame : April 2016 - Mar 2017 22

Option 3-2 year Average Albany Activity usage: Financial Summary (2016-2017) The full year financial investments for 2016/17 are set below. This is an option that represents funding arrangements based on Albany Rehabilitation Unit Activity (2 year period) Activity - 2 yr CCG Equal Split Activity Avg DTOC Ratio CL 33.33% 37.00% 41.50% 38.00% 39.75% WL 33.33% 36.00% 36.00% 22.00% 29.00% H&F 33.33% 27.00% 22.50% 40.00% 31.25% 2016/2017 FYE H&F WL CL Total Drivers Current Investment (15/16) New Investment (16/17) Total Investment (16/17) 418,845 1,278,238 1,011,490 2,708,573 389,207 14,644 478,916 882,767 808,051 1,292,882 1,490,406 3,591,340 2015/2016 full year investment identified for SNRS resource 2016/2017 additional FYE investment for SNRS resource 2016/2017 full year investment for SNRS resource Gross Benefits (DTOC) - 83,176-133,081-153,413-369,669 Reduction in DTOCs Total Net Investment 724,876 1,159,801 1,336,993 3,221,670 Time Frame : April 2016 - Mar 2017 23

Option 4) Split based on DTOC activity: Financial Summary (2016-2017) The full year financial investments for 2016/17 are set below. This is an option that represents funding arrangements based on DTOC Activity (ICHT) Activity - 2 yr CCG Equal Split Activity Avg DTOC Ratio CL 33.33% 37.00% 41.50% 38.00% 39.75% WL 33.33% 36.00% 36.00% 22.00% 29.00% H&F 33.33% 27.00% 22.50% 40.00% 31.25% 2016/2017 FYE H&F WL CL Total Drivers Current Investment (15/16) New Investment (16/17) Total Investment (16/17) 418,845 1,278,238 1,011,490 2,708,573 1,017,691-488,143 353,219 882,767 1,436,536 790,095 1,364,709 3,591,340 2015/2016 full year investment identified for SNRS resource 2016/2017 additional FYE investment for SNRS resource 2016/2017 full year investment for SNRS resource Gross Benefits (DTOC) - 147,868-81,327-140,474-369,669 Reduction in DTOCs Total Net Investment 1,288,668 708,768 1,224,235 3,221,670 24 Time Frame : April 2016 - Mar 2017

Option 5) Combined averages split: Financial Summary (2016-2017) The full year financial investments for 2016/17 are set below. This is an option that represents funding arrangements based on an average of the three previous split options Activity - 2 yr CCG Equal Split Activity Avg DTOC Ratio CL 33.33% 37.00% 41.50% 38.00% 39.75% WL 33.33% 36.00% 36.00% 22.00% 29.00% H&F 33.33% 27.00% 22.50% 40.00% 31.25% 2016/2017 FYE H&F WL CL Total Drivers Current Investment (15/16) New Investment (16/17) Total Investment (16/17) 418,849 1,278,238 1,011,490 2,708,573 703,449-236,749 416,068 882,767 1,122,294 1,041,489 1,427,558 3,591,340 2015/2016 full year investment identified for SNRS resource 2016/2017 additional FYE investment for SNRS resource 2016/2017 full year investment for SNRS resource Gross Benefits (DTOC) - 115,522-107,204-146,943-369,669 Reduction in DTOCs Total Net Investment 987,319 1,036,039 1,198,313 3,221,670 25 Time Frame : April 2016 - Mar 2017

Governance approval timelines Ops Group Submission Date Meeting Date Central London TRG May 5 th May 13 th West London Ops May 8 th May 12 th H&F Ops May 8 th May 12 th F&P Submission Date Meeting Date Central London F&P May 18 th May 27 th West London F&P May 18 th May 26 th H&F F&P May 14 th May 26 th Governing Body Submission Date Meeting Date Central London GB June 29 th July 8 th West London GB July 13 th July 21 st H&F GB July 7 th July 14 th 26

Procurement timelines Issue advert & ITT documentation Bidder Briefing Event Deadline for the receipt of clarification questions ITT Submission DEADLINE ITT Bid evaluation stage Post procurement outcomes report CCG authorisation to award contract(s) Preferred Bidder initial notification and standstill period regarding Confirmation Contract signature Service mobilisation period Procurement advertised on Contracts Finder and all procurement documents made available to potential Bidders through the E-Procurement portal CCGs host a Bidder Briefing Event to ensure good understanding by Bidders of the service requirements and Procurement process following market testing Deadline for Bidders to submit clarifications to the CCGs Deadline by when Bidders must have fully completed and submitted their Bids this presumes 7 weeks (can be shortened / lengthened) Period when Bids will be evaluated and CCG clarification questions responded to by bidders. Evaluation panel individually review and score bids, followed by moderation event to agreed consensus scores and section of the Preferred Bidder(s) Preparation of report detailing the evaluation approach and outcome, with recommendation regarding award of contract CCG governance to consider post-procurement recommendation report regarding contract award. CCG authorise contract award. The expected dates when Bidders will be notified of the outcome of the evaluation and observance of the recommended Standstill Period The expected date for the signing of the Contracts between the CCGs and the successful Provider Period when the Preferred Bidder plans and delivers mobilisation activities to prepare for service commencement 27 Early August 2015 Mid to late August 2015 1 week before ITT submission deadline (see below) End of September 2015 Early October 2015 (allow 1 or 2 weeks), including Evaluation Panel Moderation meeting immediately toward end of this couple of weeks Mid October 2015 By end of October 2015 TBC pending meeting dates End of October 2015 From mid-november 2015 From November 2015 duration dependent upon mobilisation plan TBA with preferred bidder assume at least 3 or 4 months Full service commencement Date when commencement of the new Services expected 1 st April 2016 possible

itional slides APPENDIX 28

Levels of need & service categories/levels 29

National /ARU benchmarking summary data evidencing clinical & economic impact of SNRS The national benchmarking data set below supports both the clinical impact/outcomes (measurable functional gains), as well as the economic impact (measurable reduction in ongoing care) that specialist neuro-rehabilitation service make. 30

National /ARU benchmarking summary data evidencing clinical & economic impact of SNRS Source: UK Rehabilitation Outcomes Collaborative (UK ROC) 31