Business Case Template

Business Case Template Project Name Community MSK Service Review SRO (Sponsor) Clinical responsible officers Financials verified by Peter Crutchfield Chair Dr Ruth O Hare Clinical lead Dr Andy Goodstone Neil Shadbolt Project Start date 6 June 2013 Project completion date 7 December 2013 1. EXECUTIVE SUMMARY This paper sets out a proposal to review community based Musculoskeletal (MSK) services within Central London CCG. It is anticipated that the new service to be provided will have the following objectives: Provide clinical assessment, treatment and clinical leadership within a comprehensive consultant led community service which actively promotes integration with local secondary care providers Provide a single point of access to MSK services Enhance the management of patients within the community, and actively manage the demand for secondary care services ensuring patients access the most appropriate settings of care Ensure the successful completion of packages of care, reducing the number of patients requiring referral for invasive secondary care treatment Provide patient centred direct access MSK physiotherapy in a convenient location Deliver a maximum waiting time of 10 working days from the data of receipt of the referral letter to the first appointment for urgent patients Monitor direct referrals to secondary care and work with acute hospital providers to ensure that non red flags are returned to the GP or sent to the community provider Increase conversion rates from outpatient attendances to surgery through more appropriate referrals to acute hospital providers Provide early assessment and interventions for chronic pain Enhance education around Musculoskeletal conditions for both healthcare professionals and patients Encourage best practice around MSK treatment and condition management Establish effective working relationships with relevant interfacing services e.g. Fit for work Successfully deliver excellent clinical outcomes and a positive patient experience deliver savings in line with QIPP plans Improve patient access to MSK services by establishing a community based service and improve the patient experience through improvement in patient satisfaction Reduce inequalities in access to and outcomes from MSK services Develop measures for service improvement and report outcomes of actions taken as a result, especially around patient experience and clinical outcomes

2. DECISION SUMMARY The Board is asked to make the following decisions. 1. To agree procurement of a consultant led multidisciplinary community MSK service (fully integrated with our local secondary care providers) for the ENTIRE NHS Central London CCG geographical area. 3. PROJECT DESCRIPTION The purpose of this review is to define the future of community based musculoskeletal (MSK) services within Central London CCG. Recommendation focuses on procurement of a consultant led multidisciplinary community MSK service which is fully integrated with our local secondary care providers. It is anticipated that the new Multidisciplinary Clinical Assessment and Treatment Service (MCATS) for musculoskeletal conditions will include single point of access, physiotherapy, osteopathy, acupuncture, pain management offering joint injections and patient self-management. It is expected that patients will benefit from innovated practices such as the introduction of patient self-referral, peer group support and access to a health psychologist to improve life management skills. The successful service provider will work closely and build positive relationships with all healthcare providers within the MSK pathway to treat patients in a community based setting. It will aim to meet the health needs of the local population as well as shift unnecessary hospital outpatient attendances to a community setting. It is the intended that through this integrated approach, measurable outcomes will be: Improved access to assessment and treatment for MSK conditions locally Reduction in the number of unnecessary referrals to secondary care outpatient clinics Improved surgical conversion ratio locally Improved quality of MSK services provide in a primary care setting, including general practice Integrated care pathway reflects NICE guidelines Improved patient satisfaction Reduced risk of long term sickness absence and loss of employment for MSK patients Increased levels of satisfaction of service users and fewer complaints The community MSK service will be a consultant led multidisciplinary team including Extended Scope Practitioner, Physiotherapist and Osteopathic input. It will deliver integrated triage and assessment (direct and non direct), disease management and treatment including physiotherapy, osteopathy, join injection therapy and pain management, as well as patient and refer education, all in line with NICE and DH guidance. The community service will introduce new innovative ways of managing MSK conditions especially rheumatology and pain management. It is anticipated that these will have a positive impact on patients and their families in terms of their well-being both in terms of introducing better support networks and reducing dependency on prescribed medication. The service will exclude Red Flags which are to be agreed with the provider and commissioner in line with NICE and the MSK outcomes framework. The community MSK service will provide support, training and advice to GP practices in terms of diagnosis and treatment. Health inequalities will also be addressed with the aim of reducing late presentation, and a reduced likeliness of referral to hospital, elective surgery and unplanned hospital admissions among socially disadvantaged patients. Appendix 1 provides a more detailed overview of the proposed service from the clinical perspective. Page 2 of 16

4. CONTEXT 4.1 BROADER STRATEGIC CONTEXT In 2006 the Department of Health published released The Musculoskeletal Services Framework which sets out evidence of best practice and recommends actions for change to improve MSK services nationally. Demand for musculoskeletal services is high: nationally, MSK conditions generally comprise around 30 per cent of all primary care consultations. In terms of expenditure, MSK conditions are the fifth highest are of spend in the NHS. Musculoskeletal (MSK) conditions are common, and are a major cause of ill health, pain and disability. It is estimated that nearly one quarter of adults and around 12,000 children are affected by long standing MSK problems. Musculoskeletal conditions are the most common reason for repeat consultations with a GP. The prevalence of MSK conditions generally rises with age and, since the number and proportion of older people in the population is projected to increase in future, so the number of people with MSK conditions will also rise. There are over 200 MSK conditions affecting millions of people, including arthritis, back pain and osteoporosis. The key conditions included in MSK services are Osteoarthritis Rheumatoid arthritis Osteoporosis Fibromyalgia Spinal/neck pain Ligament injuries Sprains and strains Overuse injuries Chronic pain management The recent Marmot review outlined the economic case for tackling and supporting disability given the increasing proportion of the future working age population who, in the absence or intervention, would be living with a disability. Recent statistics show that MSK is the most commonly reported type of work-related illness. The Westminster JSNA (2012) identifies MSK as a significant cause of disability and Westminster Health and Wellbeing Strategy prioritises worklessness and promoting good health through good quality work, with a specific requirement of commissioners relating to job retention. It should be noted that a recent Government proposal, in response to Health at Work an independent review of sickness absence, recommends the establishment of a health and work assessment and advisory service to make occupational health advice more readily available to employers and employees. The new service will be delivered in 2014 and include: State-funded assessment by occupational health professionals for employees who are off sick for four weeks or more; Signposting to appropriate interventions including Universal Jobmatch, an online jobsearch service for those employees who are able to work, but unlikely to return to their current employer; Case management for those employees with complex needs who require on-going support to enable their return to work It is acknowledged that GPs play a key role in helping an individual back to work; improving education on health and work for healthcare professionals is identified as a key priority. Central London CCG has two service providers for community MSK Services. Healthshare Limited provides a service to eight GP practices located in the South of the borough whilst Central London Community Healthcare covers the rest of the geographical area. Both services offer general MSK intervention such as Physiotherapy and Osteopathy as well as a community musculoskeletal clinical assessment, triage and treatment service. Referrals are triaged with patients being seen and treated within the community service or being referred onto other appropriate services. Following triage, the following options are available: Referral to diagnostics (x-ray, MRI, ultrasound scanning, blood tests) Diagnosis and treatment by an Extended Scope Practitioner (ESP), including prescribing of any Page 3 of 16

medication required for two weeks (or such shorter period for a full course of medication as appropriate) and soft tissue and reticular injections Referral to the physiotherapy, osteopath or pain management services provided by the community musculoskeletal clinical assessment, triage and treatment service Referral to the physiotherapy, osteopathy or pain management services provided by the community musculoskeletal clinical assessment, triage and treatment service Referral to other primary care services, for example podiatry Referral back to the GP with advice regarding treatment in general practice Referral to secondary care outpatient services (orthopaedics, rheumatology, pain management) subject to patient choice As stated above, MSK conditions are associated with high expenditure. Table 1 identifies outpatient acute activity over the previous three financial years for NHS Central London CCG. Table 1: NHS Central London CCG Outpatient Activity & Cost All referral sources: SLA providers only Activity Cost Year Speciality name OPFA OPFUP OPPROC OPFA OPFUP OPPROC 2010-11 TRAUMA & ORTHOPAEDICS 4,431 7,789 126 765,341 815,306 13,127 1,593,774 2010-11 PAIN MANAGEMENT 714 1,499 26 165,638 171,904 6,488 344,029 2010-11 RHEUMATOLOGY 1,118 4,171 33 350,044 539,696 5,656 895,396 6,263 13,459 185 1,281,023 1,526,906 25,270 2,833,199 Year Speciality name OPFA OPFUP OPPROC OPFA OPFUP OPPROC 2011-12 TRAUMA & ORTHOPAEDICS 4,165 7,945 62 718,327 827,348 7,752 1,553,427 2011-12 PAIN MANAGEMENT 817 1,451 278 191,730 174,644 68,417 434,792 2011-12 RHEUMATOLOGY 1,086 4,510 28 338,397 568,125 6,899 913,421 6,068 13,906 368 1,248,454 1,570,118 83,068 2,901,640 Year Speciality name OPFA OPFUP OPPROC OPFA OPFUP OPPROC 2012-13 TRAUMA & ORTHOPAEDICS 3,935 7,242 91 671,868 750,803 12,108 1,434,779 2012-13 PAIN MANAGEMENT 744 1,130 217 178,510 140,169 44,420 363,100 2012-13 RHEUMATOLOGY 893 3,932 55 277,529 504,136 14,568 796,233 5,572 12,304 363 1,127,908 1,395,108 71,096 2,594,113 The existing community services have obviously contributed to reducing the dependency on secondary care provision within NHS Central London CCG. However, it is envisaged that more opportunity exists in delivering more services in a community based setting. Table 2 identifies Healthshare activity and cost over the previous two financial years. Table 2: Total Healthshare Activity and Cost for NHS Central London CCG Healthshare Activity during Healthshare Activity during Team Referred To Description April 2011 to March 2012 April 2012 to March 2013 First 2,686 2,707 Follow Up 6,554 6,346 Total 9,240 9,053 Attendance Type Contract 11/12 Contract 12/13 Tariff ( ) Annual Cost ( ) Tariff ( ) Annual Cost ( ) Pain Management Trauma and Orthopaedics Rheumatology USG Injections 31.73 57.14 280,000 10,000 31.73 57.14 274,465 17,142 Total Contract Value 290,000 291,607 Page 4 of 16

At inception of the community contract with Healthshare Ltd, a tariff price of 33.50 was agreed however due to the over activity in year one it was negotiated that the provider would reduce the unit cost for each activity by 5%, to 31.73 for all attendances with exception of USG injections. Moreover, the contract moved from a cost per case model to a block contract, giving the provider a guaranteed financial income and Westminster PCT financial assurance. Whilst tariff price is clearly shown above, it should be noted that other costs associated with the service are absorbed separately; notably facility management (circa 27,406 representing negotiated position for 2011/12) and EMIS ( 3,847). Facility management includes both premises and administration expenditure. Taking into account these extra costs, tariff price (assuming USG injection tariff remains fixed) increases to 35.34. Table 3 shows CLCH activity and cost over the same time period. Please note that the contract is historically Westminster PCT; contact value for NHS Central London CCG has been apportioned based on calculated usage which was circa 68.9%, the remainder of which is allocated to QPP and others. The activity represents number of contacts. Table 3: Total CLCH Activity and Cost for NHS Central London CCG Team Referred To Description CLCH contacts during April 2011 to March 2012 CLCH contacts during April 2012 to March 2013 DEFAULT UNKNOWN 3 5 NULL 683 540 MSK Central Booking Office 65 53 MSK Classes 0 4 MSK Linnet Outpatients 4,542 4,418 MSK Lisson Grove Outpatients 3,635 3,837 MSK Soho Outpatients 1,404 2,002 MSK Spinal ESP 399 417 MSK Stowe Class 1,137 716 MSK Stowe Lower Limb ESP 323 410 MSK Stowe Outpatients 7,913 7,498 MSK Upper Limb ESP 502 416 Total 20,606 20,316 CLCH Service - Westminster PCT Contract 11/12 Contract 12/13 - MSK pathways 500,887 484,602 Musculo-Skeletal Physiotherapy 786,739 761,161 1,287,627 1,245,763 CLCH Service - NHS CLCCG Contract 11/12 Contract 12/13 - MSK pathways 344,939 333,724 Musculo-Skeletal Physiotherapy 541,793 524,178 886,732 857,902 Average cost per contact 43.03 42.23 The following shows expenditure for inpatient admissions over the same period. Page 5 of 16

MSK Inpatient Activity: Number of admissions MSK Inpatient Cost Year HRG Sub chapter Daycase Elective ordinary Elective admissions Non Elective admissions Elective admissions Non Elective admissions Regular day admission Non Elective Total admissions Year HRG Sub chapter Daycase Elective ordinary Regular day admission Non Elective Total admission cost 2011/12 Musculoskeletal Disorders 365 27 481 873 2011/12 Musculoskeletal Disorders 259,552 31,502 665,523 956,577 2011/12 Orthopaedic Non-Trauma Procedures 606 363 86 1055 2011/12 Orthopaedic Non-Trauma Procedures 1,216,209 1,768,448 231,700 3,216,357 2011/12 Orthopaedic Reconstruction Procedures 1 23 13 37 2011/12 Orthopaedic Reconstruction Procedures 11,090 262,510 161,782 435,382 2011/12 Orthopaedic Trauma Procedures 35 43 482 560 2011/12 Orthopaedic Trauma Procedures 90,447 132,292 1,618,669 1,841,408 2011/12 Spinal Surgery and Disorders 54 58 303 415 2011/12 Spinal Surgery and Disorders 70,871 275,045 717,483 1,063,399 Grand Total 1,061 514 0 1365 2940 Grand Total 1,648,169 2,469,797 3,395,157 7,513,123 Year HRG Sub chapter Daycase Elective ordinary Elective admissions Non Elective admissions Elective admissions Non Elective admissions Regular day admission Non Elective Total admissions Year HRG Sub chapter Daycase 2012/13 Musculoskeletal Disorders 327 20 128 247 722 2012/13 Musculoskeletal Disorders 181,404 18,450 442,955 642,809 2012/13 Orthopaedic Non-Trauma Procedures 468 321 1 83 873 2012/13 Orthopaedic Non-Trauma Procedures 996,719 1,595,694 277,423 2,869,836 2012/13 Orthopaedic Reconstruction Procedures 3 32 9 44 2012/13 Orthopaedic Reconstruction Procedures 33,409 373,238 121,780 528,427 2012/13 Orthopaedic Trauma Procedures 39 50 645 734 2012/13 Orthopaedic Trauma Procedures 101,882 165,704 1,539,204 1,806,790 2012/13 Spinal Surgery and Disorders 52 64 6 180 302 2012/13 Spinal Surgery and Disorders 55,645 296,302 389,081 741,028 Grand Total 889 487 135 1164 2675 Grand Total 1,369,059 2,449,388 0 2,770,443 6,588,890 Elective ordinary Regular day admission Non Elective Total admission cost Activity reduction between 2012/13 and 2011/12-265 Cost change between 2012/13 and 2011/12-924,233 Percentage reduction -9% Percentage reduction -12% Notes: The cost of a regular day admissions is agreed on a local basis between the commissioner and the provider. A zero cost is shown in the table above as we currently don t have a record of all the local costs for each provider. No regular day admissions were recorded during 2011/12, possible change coding. Page 6 of 16

4.2 NWL-SPECIFIC CONTEXT The review of community MSK provision is clearly stated within NHS Central London CCG Commissioning Intentions 2013/14 and aligns to our Out of Hospital Strategy which was published in May 2012. The strategy covers the period 2012-15 and describes plans to transform delivery of community-based services in order to align with Shaping a Healthier Future, which is the NWL strategy for reconfiguration of hospital services. It is envisaged that mobilisation of a new community MSK service will demonstrate that NHS Central London CCG is improving services for patients in line with the Operating Framework for the NHS in England 2012/13. The improvement to community MSK services for our patients will ensure compliance to the four key themes identified in the Operating Framework; namely: putting patients at the centre of decision making in preparing for an outcomes approach to service delivery, whilst improving dignity and service to patients and meeting essential standards of care; completion of the last year of transition to the new system, building the capacity of emerging clinical commissioning groups (CCGs) and supporting the establishment of Health and Wellbeing Boards so that they become key drivers of improvement across the NHS; increasing the pace on delivery of the quality, innovation, productivity and prevention (QIPP) challenge; and maintaining a strong grip on service and financial performance, including ensuring that the NHS Constitution right to treatment within 18 weeks is met. With respect to Health and Wellbeing Priorities, improving community MSK provision will ensure that services are moved closer to home and a new service will demonstrate adherence to QIPP; Quality patients feeling supported to manage their condition helping people to recover from illness or injury without acute intervention improvement of patient experience Innovation refinement of current service specification to promote innovation development of new ways of working which promotes integration of health services introduction of educational programmes centred around the patient provide access to a health psychologist to improve life management skills Productivity reduce overall MSK expenditure especially centred around rheumatology increase efficiency within a community service to ensure patients are treated quicker and closer to home Improve surgical conversion ratio Prevention Education of patients to manage their condition Early assessment and interventions for chronic pain Improve the quality of assessment and initial diagnosis to reduce the risk of deteriorate Page 7 of 16

5. OPTIONS APPRAISAL The following table identifies the options which have been identified following a clinical review of all existing MSK provision within NHS Central London CCG geographical area. Option Description Advantage Disadvantage 1. Do Nothing Service provided by Healthshare Ltd to GP practices in South Locality continues until 6 th December 2013 Continues to meet strategic goals in the short term Healthshare Ltd contract ceases 6 th December 2013 which will impact patients Risk to clinical benefits associated with the service due uncertainty for the future 2. Procurement of a consultant led multidisciplinary community MSK service (fully integrated with our local secondary care providers) for ONLY those practices in the South Locality who have Healthshare Ltd as their current community MSK providers Review and improve current service specification and MSK pathway to reflect current DH and NICE guidelines Single point of access for both acute and community referrals Improvement to patient outcomes Reduce the number of unnecessary referrals to secondary care outpatient trauma and orthopaedic / pain services Commitment to Out of Hospital strategy and community MSK Service is transparent Risk to delivery of QIPP Not having a fully functioning community MSK service in place could potentially add cost pressures on other services and an increase in acute sector usage Transactions costs will need to be identified and absorbed Once procurement starts, stringent timelines will need to be adhered to Participating clinicians and support staff will need to provide commitment during the whole procurement process Multiple providers may cause confusion amongst patients or clinicians Additional advertising costs may need to be identified to promote alternative service providers Continues to meet strategic goals Evaluation process will be scrutinised therefore an impartial evaluation panel Multiple contracts may result in additional contract management costs Page 8 of 16

3. Procurement of a consultant led multidisciplinary community MSK service (fully integrated with our local secondary care providers) for the ENTIRE NHS Central London CCG geographical area which will add to the creditability of the tender process Cost savings associated with the reduction in acute activity are realised with expansion and redesign Patients benefit from innovation whether it be increased access or a more holistic service Review and improve current service specification and MSK pathway across entire NHS Central London CCG geographical area to reflect current DH and NICE guidelines Single point of access for both acute and community referrals Improvement to patient outcomes Reduce the number of unnecessary referrals to secondary care outpatient trauma and orthopaedic / pain services Commitment to Out of Hospital strategy and community MSK service is transparent Continues to meet strategic goals Provides an opportunity to increase competition thereby increasing choice Evaluation process will be scrutinised therefore an impartial evaluation panel which will add to the creditability of the tender process Cost savings associated with the reduction in acute activity are realised with expansion Transactions costs will need to be identified and absorbed Costs associated with AQP are potentially higher than those associated with a standard procurement process Once procurement starts, stringent timelines will need to be adhered to Participating clinicians and support staff will need to provide commitment during the whole procurement process Page 9 of 16

and redesign Patients benefit from innovation whether it be increased access or a more holistic service Retendering the community MSK service across the entire geographical area will introduce economies of scale for potential bidders which will have a financial benefit for NHS Central London CCG 6. BENEFITS Procurement of a consultant led multidisciplinary community MSK service which is fully integrated with our local secondary care providers will have a number of benefits: Streamline MSK provision within NHS Central London CCG Enhance patient experience and satisfaction Improve education of assessment and treatment Improve community MSK provision Reduce unnecessary hospital attendances Increase effectiveness of care plans Introduce innovation associated with the diagnosis and treatment of MSK conditions Demonstrate financial savings and VFM through a reduction of acute expenditure and introduction of economies of scale for community provision Improve patient well-being and that of their families Benefit realisation will be captured in a number of ways: Regular performance monitoring - community and secondary care settings Patient satisfaction surveys, patient user groups, complaints, etc Reduction in healthcare associated costs (e.g. secondary care, prescribing, etc) Successful interventions with respect to fit for work service reduction in long term sickness In terms of shifting activity from secondary care, it has been identified a community MSK service would impact Rheumatology; financial analysis is shown below. Anecdotal evidence would suggest that other clinical areas (e.g. trauma and orthopaedics) would also benefit but further information would be needed to identify potential savings and therefore have been omitted from this business case. Page 10 of 16

RHEUMATOLOGY % Reduction for 13/14 0% Consortium POD Activity 12-13 Cost 12-13 2013-14 Baseline (2012-13 Activity Baseline + Demographic factors.4% + Acute 3.0%) 2013-14 Baseline Cost (National Acute Tariff Deflator 1.5%) 2013/14 Reduction Activity 2013/14 Reduction Cost CL CCG OPFA 893 277,529 923 282,661 0 0 OPFU 3,932 504,136 4,066 513,457 0 0 OPPROC 55 14,568 57 14,837 0 0 Total 4,880 796,233 5,046 810,955 0 0 Consortium % Reduction for 14/15 10% 2014-15 Baseline (2013-14 Activity Baseline + Demographic factors.4% + Acute 3.0%) 2014-15 Baseline Cost (National Acute Tariff Deflator 1.5%) 2014/15 Reduction Activity 2014/15 Reduction Cost POD OPFA 955 287,887 95 28,789 CL CCG OPFU 4,204 522,951 420 52,295 OPPROC 59 15,112 6 1,511 Total 5,217 825,950 521 82,595 Consortium % Reduction for 15/16 15% 2015-16 Baseline (2014-15 Activity Baseline + Demographic factors.4% + Acute 3.0%) 2015-16 Baseline Cost (National Acute Tariff Deflator 1.5%) 2015/16 Reduction Activity 2015/16 Reduction Cost POD OPFA 889 264,035 133 39,605 CL CCG OPFU 3,913 479,408 587 71,911 OPPROC 55 13,821 8 2,073 Total 4,856 757,264 728 113,589 Consortium % Reduction for 15/16 15% 2016-17 Baseline (2015-16 Activity Baseline + Demographic factors.4% + Acute 3.0%) 2016-17 Baseline Cost (National Acute Tariff Deflator 1.5%) 2016/17 Reduction Activity 2016/17 Reduction Cost POD OPFA 782 228,685 117 34,303 CL CCG OPFU 3,439 415,017 516 62,253 OPPROC 48 12,014 7 1,802 Total 4,269 655,716 640 98,358 Total Reduction over 3 yrs Consortium POD Activity Cost OPFA 345 102,697 CL CCG OPFU 1,523 186,459 OPPROC 21 5,386 Total 1,889 294,542 Page 11 of 16

7. REQUIRED INVESTMENT The current expenditure and activity for Musculoskeletal (MSK) conditions are identified in section 4 above. It is acknowledged that the existing community baseline needs to be maintained and, in accordance with our Out of Hospital Strategy, expanded to meet the needs of our local population. The MSK community budget will be maintained in order to deliver a new consultant led multidisciplinary community MSK service and support the procurement process. The total value of community budget is 1,265,000 Procurement support is provided by North West London Commissioning Support Unit; procurement support is part of their core offer. 8. COMMERCIAL A restricted tender process will be undertaken in which potential providers are required to complete a prequalification questionnaire (PQQ) to show that they have sufficient experience and resources to meet the needs of the procurement opportunity. Following evaluation, the Invitation To Tender (ITT) documentation will be issued and leads to evaluation, interview and contract award. Please note that only providers who are short-listed at the PQQ stage will be invited to submit a tender. It is anticipated that the entire process will take between 6 and 9 months. The risks associated with the procurement, contractual negotiations and mobilisation are embedded within Section 9. It should be noted that TUPE is likely to apply The following table sets out a summary of this process and an indicative timetable: Process Start date Closing Date/Completion Governing Body Approval 5 th June 5 th June Completion of procurement PID; agreement of MOI, PQQ & ITT documentation 6 th June 2 nd July MSK Community Service Advert published MOI & PQQ 3 rd July 24 th July PQQ submission 24 th July 24 th July PQQ Evaluation 25 th July 6 th August ITT documents finalised 7 th August 13 th August Invitation to Tender issued Bidder Clarification Stage 14 th August 14 th August 11 th September 12:00pm midday 4 th September 17.00hrs Page 12 of 16

Bidder s Day 29 th August 29 th August Tender Evaluation 12 th September 22 nd October Successful Bidder s Presentations and Interviews 8 th October 8 th October Evaluation Panel Final Meeting 22 nd October 22 nd October Prepare and agree ratification and debrief documents 23 rd October 30 th October NHS Central London CCG board approval to award contract 6 th November 6 th November Appointment of preferred bidder 7 th November 7 th November Standstill period 8 th November 18 th November Contract Award and Contract signed 25 th November 25 th November Mobilisation and transition period 26 th November 6 th December New Service Begins 7 th December Appendix 2 provides a more detailed GANTT chart. 9. PROJECT RESOURCING NHS Central London CCG has a dedicated clinical lead for MSK, Dr Andy Goodstone. Procurement support will be provided through North West London Commissioning Support Unit. During the procurement process, NHS Central London CCG will monitor progress through the Programme Delivery Board which is supported by the Transformation Support Team. Following the start of service delivery, North West London Commissioning Support Unit will take responsibility for on-going contract management. 10. STAKEHOLDER ENGAGEMENT Key stakeholders were identified at the start of the clinical review process. These include: NHS Central London CCG GP s Patient representatives from NHS Central London CCG user panel Dr Alan Hakim, Consultant in Rheumatology and Acute Medicine Patient with a chronic MSK condition Current community providers, Healthshare Ltd and CLCH Clinical engagement has taken many forms ranging from individual meetings, written correspondence as well as telephone discussions. Engagement culminated in a stakeholders event was held on 20th May 2013 which invaluable in developing the service specification. Formal public consultation will not be required as there will not be a significant change to service delivery for patients. Page 13 of 16

11. GOVERNANCE AND MONITORING Clear governance structures exist within NHS Central London CCG that will oversee development of the new community MSK service. The service specification has been reviewed under the direction of a special interest group led by our clinical MSK lead, Dr Andy Goodstone. Development of the business case has included contributions from finance and information teams, as appropriate. Reporting of the findings and recommendations are presented to the TRG (Transformational Redesign Group) who will: scrutinise and challenge the recommendations ensure recommendations reflect and promote: clinical quality access and safety reduction in health inequalities innovation evidence based practice adhere to NHS Central London CCG objectives Following formal TRG recommendation, Finance and Performance Sub Committee will review the business case before it can obtain final authorisation from the CCG governing body. Once approval has been granted, North West London Commissioning Support Unit will be instructed to start the procurement process. It must be noted that monitoring will be achieved through the Programme Delivery Board and supported by the Transformation Support Team which is an integrated PMO function of the CCG. Monitoring will continue during service mobilisation with the identification of key milestones. It must be noted that the Programme Delivery Board provides strategic and clinically informed leadership to oversee delivery. It will report to the Finance and Performance Sub Committee to whom it is also accountable. Following contract award and the start of service delivery, monitoring will continue via KPI s; these will focus on a number of areas including activity and financial performance, quality, patient satisfaction and improving clinical outcomes. Monitoring of contractual KPI s will be supported by North West London Commissioning Support Unit. It is envisaged that by adopting this approach, NHS Central London CCG will: improve controls and assurance relating to the delivery of the community MSK service identify roles and responsibilities linked to successful delivery provide consistent and intelligent programme and performance management display a greater pace of delivery through consistent application of PMO tools and methodologies and dissemination of lessons learned improve benefits realisation through earlier risk mitigation display ownership and improved governance Page 14 of 16

12. RISKS AND RISK MITIGATION Identified Risk Category Mitigating actions Current status Differing timescales for termination of current service providers Contracting Healthshare Ltd currently operates under a standard NHS community contract which will end 6 th December 2013. CLCH are subject to a notice period which may not align to the Healthshare Ltd contract date. Where timescales are unavoidable different, work will be undertaken with providers to: Awaiting project approval before instructing North West London Commissioning Support Unit to procure new service and issue termination notice, if appropriate. Investigate contract end alignment Phased mobilisation plan for preferred supplier starting with South locality Ensure minimal impact upon project implementation Monitoring success/ failure Contracting Project status and updates will be reported through the appropriate channels. Monthly monitoring of the contract against planned activity and finance will take place from service commencement date. Internal governance being developed. Lines of reporting from North West London Commissioning Support Unit procurement team to be confirmed. TUPE Contracting TUPE is likely to apply as existing community service. Engage with the current providers and potential bidders in order to communicate. Engage with existing providers to identify staff affected. GP engagement is lost Engagement Ensure continuous dialogue with our member practices through locality meetings and regular bulletins. Dr Andy Goodstone has been appointed as the named clinical lead. Special interest group has been established to engage with stakeholders. Loss of stakeholder engagement Engagement Ensure that there is continuous dialogue with stakeholders via patient user group. Special interest group has been established to engage with stakeholders. Confirmation of financial envelope Finance Confirmation of CLCH budget required due to transfer of Queen Park and Paddington to West London CCG. Finance contacted to determined named lead. Financial model to be tested. Financial envelope to be confirmed by finance lead; will include procurement costs. Lack of financial advice/ input to project Finance Confirmation of a financial lead for the project. Finance contacted to determined named lead. Financial model to be tested. Estate costs Finance Service specification will reflect that any estate cost will be the responsibility of potential bidders. Financial model must reflect potential estate costs in order ensure that the service is sustainable. Page 15 of 16

Shift in hospital activity is not achieved Finance Mitigating actions include: Working with the acute providers and Patient Referral Service (PRS) to direct patients into the triage service Changes to acute contract in order to decommission planned activity and introduce contract levers to ensure patients cannot be seen without an assessment via the MSK triage service Promote the service and ensure that regular monitor of GP referral activity Engagement has commenced with stakeholders. Financial model must reflect planned shift in activity. No interested providers Procurement Continuous dialogue with stakeholders and carry out market testing exercise. Dialogue with key stakeholders has commenced. Procurement timescales are delayed Procurement Ensure that the project has a confirmed responsible owner engaged and supporting the project. Dr Andy Goodstone has been appointed as the named clinical lead. Delays to procuring a provider results in service gap Service provision Confirm procurement expertise early on and determine project timescales including contingency planning. Awaiting project approval before confirming North West London Commissioning Support Unit procurement support. There is no adequate space for service delivery Service provision Identifying service delivery model including estates early on in the project planning process. Existing clinics are likely delivery points for a new community service Incentives associated with service delivery and the financial value Service provision Service specification will be developed to ensure incentive targets as SMART. Financial envelope to be confirmed by finance lead; will include procurement costs. 13. OVERALL TIMELINE / SEQUENCE FOR IMPLEMENTATION Under terms and conditions of the existing NHS community contract for Healthshare Ltd, a further extension of the contract is not permitted. The contract will continue until 6th December 2013; section 8 provides an indicative timetable for the procurement and mobilisation of a replacement service. Appendix 2 represents this indicative timetable within a GANTT chart. 14. RECOMMENDATION TO PURSUE The preferred option is to procure a consultant led multidisciplinary community MSK service for the ENTIRE NHS Central London CCG geographical area option 3. There are a number of reasons for this recommendation. From a clinical and patients perspective, one provider delivering community MSK services across NHS Central London CCG will: Provide a consistent and clear pathway Introduce financial savings through improving productivity and efficiencies Reduce unnecessary hospital outpatient appointments into a community setting closer to home Page 16 of 16