CCG GOVERNANCE BOARD EXECUTIVE SUMMARY SHEET

CCG Governance Board Agenda Item 7.2 DATE: 14 th November 2017 CCG GOVERNANCE BOARD EXECUTIVE SUMMARY SHEET TITLE OF PAPER: EXECUTIVE RESPONSIBLE: Telford and Wrekin Wound Healing Service Fran Beck Contact Details: Ext: Email: fran.beck1@hnhs.net AUTHOR (if different from above) Anna Hammond Contact Details: Ext: Email: annahammond@nhs.net CCG OBJECTIVE: To improve commissioning of effective, safe and sustainable services, which deliver the best possible outcomes, based upon best available evidence. For Information For decision For performance monitoring Wound care in Telford and Wrekin (T&W) is an area with an unfunded gap. The current wound care provision is unsustainable, cost inefficient, lacks specialist input and does not provide high quality care for complex wound patients. EXECUTIVE SUMMARY FINANCIAL IMPLICATIONS: This paper aims to: 1. Describe the current service provision and the need for change 2. Discuss a range of options to address identified issues along with the associated benefits, cons and costs of each option 3. Gain approval for the commissioning of the most appropriate option to deliver high quality complex wound care in the most cost efficient way whilst creating capacity to further implement neighbourhood working, a key priority area for the CCG Providing a dedicated complex wound healing service will cost 846,655 per year once fully implemented in financial year 2020/21. Savings associated with providing such service are generated from areas including reduced formulary spend, reduced A&E follow up appointments and most significantly increased capacity of Community Nursing and Primary care for focus on long term conditions and admission avoidance. Total net savings in the region of 533,454 per year are anticipated at full implementation; these savings are based on conservative estimates and have been risk adjusted. Further analysis on the costs associated with providing a dedicated complex wound healing service are ongoing to ensure the most cost efficient design and delivery. 1

EQUALITY & INCLUSION: PATIENT & PUBLIC ENGAGEMENT: LEGAL IMPACT: CONFLICTS OF INTEREST: Once approved and dependent on the option selected by PPQ a Equality Impact Assessment will be completed and processed using the CCGs approval process. This proposal builds on previous patient engagement which has found services should be delivered close to patients home by those most suitably trained to support patients to a rapid recovery. Once approved and dependent on the option selected by PPQ further more specific patient engagement on the delivery mechanism for the service will be undertaken. No legal implications anticipated None identified RISKS/OPPORTUNITIES: Risks: - Not Implementing the service will; Prevent the implementation of Neighbourhood working, mean poor quality of care is not addressed and the current funding gap is not addressed - Short term financial pressure to CCG with savings not realised until the third year of operation - The innovative nature of the service makes accurate demand planning a challenge and could lead to an under or over resourced service Opportunities: - Improved outcomes and patient experience - Close an area with unfunded gap via an expanded service to cover all primary and community nursing wound care activity RECOMMENDATIONS: The CCG Governance Board are asked to: Review the service proposal and other options for improved complex wound care Approve one of the discussed options to deliver high quality complex wound care in the most cost efficient way whilst creating capacity to further implement neighbourhood working, a key priority area for the CCG 2

Business Case Telford and Wrekin Wound Healing Service Executive Summary The following business case provides a comprehensive proposal for the commissioning of a dedicated complex wound 1 care community hub, as well as other resource efficient and cost effective options to improve the quality of care for patients with complex wounds. It will outline the benefits, risks and expected savings from mobilising such service. The business case serves to address unfunded work in primary care as well as creating capacity to implement neighbourhood working which is a key priority area for the CCG. Wound care in Telford and Wrekin (T&W) remains an area with an unfunded gap. Healing rates for complex wounds are poor and the current wound care provision does not meet patient needs. The Tissue Viability Service deliver 3 clinics per week to both T&W CCG and Shropshire CCG, all of which fall outside the T&W border, furthermore there is very limited capacity to support healthcare professionals through upskilling. Patients currently receive care from a combination of Practice and Community Nurses, whose expertise do not lie in complex wound care and whose time could be valuably spent on a wide range of other clinical areas, particularly long term conditions. The average length of treatment time for complex wounds by Practice Nurses is 80 weeks, for Community Nurses 17 weeks (table 1) and for best practice, 12.1 weeks 1, suggesting that when complex wound care is delivered by specialists healing rates are quicker. Quicker healing rates are expected to improve patient experience and reduce costs associated with dressing changes and staff capacity. Furthermore, a dedicated service with an appropriate skill mix would allow for a more cost-effective service than the current provision. A significant indirect benefit of complex wound care specialist teams would be in freeing up Practice Nurses and Community Nurse time to focus on other areas of care, such as the proactive care of patients living with long-term conditions helping to keep them safe and well out of hospital. The innovative nature of the service makes accurate demand planning a challenge this is in part due to; incomplete data from GP practices and setting projections based on faster healing rates. For these reasons a conservative model has been developed which mitigates the risk of underestimating costs by using current activity numbers, conservatively moving to an activity model based on expected prevalence (see appendix C). This allows for the true costs for the service to be established as a starting position but may overestimate costs (and therefore underestimate savings) once the service is fully operating and delivering reduce healing times. 1 For the purposes of this piece of work, COMPLEX is defined as: Non-healing (i.e. not healed within 4-6 weeks as rough guide) and a number of problems present. NON-COMPLEX is defined as: Short term/simple healing, takes less than 4 weeks to heal, can be undertaken by Practice Nurse in 10 minute appointment. 3

1.0 Local context Wound management for T&W patients is currently provided within all 16 GP practices by Practice Nurses, in addition to the community provision from Community (District) Nurses with limited support from the specialist Tissue Viability service. A community wound care audit provided data on the scope of complex wounds currently managed in the community by Practice and Community Nurses (table 1). This suggests that 63.5% of complex wounds are managed by Community Nurses and the remaining 36.5% by Practice Nurses. Nationally, 86.7% of wound care is delivered by Community Nurses, demonstrating that in T&W more can be done to increase care delivered within communities. Table 1; A community wound care audit illustrating current scope of complex wound care (Data provided to Telford and Wrekin CCG 17-21 July 2017) Practice Nurse Direct Patient Contact Community Nurse Direct Patient Contact Number of complex wound appointments per working week Monday -Friday Number of complex wound patients seen per working week Monday- Friday Average number of minutes per complex wound treatment Unquantified 420 244 Unquantified 18 30 Average number of minutes spent on complex wounds per week Length of time the complex wound has been treated for by Practice or Community Nurse 4,392 (73 hours, 12 minutes)* Range 4-702 weeks Average 80 weeks 12,600 (210 hours) Range 4-122 weeks Average 17 weeks *Due to not being able to quantify how many times the 244 patients attend the practice for wound care each week the assumption of 1 attendance per patient per week has been made to estimate weekly demand and time spent on complex wound care by Practice Nurses. Please see section 7 risks for further discussion. 4

2.0 Reasons for change Increasing Demand and Changes to Ongoing Care The issue of wound care is significant. The British Medical Journal estimated that there are 2.2m UK patients with a wound, expected to rise by 2% per year and costing between and 4.5bn and 5.1bn. A large proportion of these wounds will need to be managed over an extended period of time due to their complexity, and consequently place additional pressure on cost and demand. As hospitals aim to discharge patients following operations as soon as appropriate, post-operative wound care and dressings carried out within acute care settings is increasingly shifting to community settings. Consequently, GP practices picking up this activity are losing Practice Nurse capacity that could be valuably spent on other areas of essential primary care, such as caring for Long Term Conditions (LTCs). Similarly, Community Nursing teams are becoming increasingly utilised by wound care as opposed to delivering case management and collaborative care planning. In order to keep patients with long term conditions safe, well, and ultimately out of hospital, it is imperative that the capacity is available within Primary Care and Community Nursing to deliver true risk stratification and case management. Better use of limited specialist capacity Due to the small size of the current Tissue Viability Service, there is very limited capacity for the service to support healthcare professionals in managing patients with complex wounds. The service comprises of three WTE clinicians to serve the population of the two CCGs. They currently deliver three Tissue Viability clinics per week all of which fall outside the T&W border and are therefore of limited access to T&W CCG complex wound patients. British Healthcare Trades Association (BHTA) has identified a need for more Tissue Viability Nurses (TVNs) championing accountability for wound care, particularly in the primary care setting due to the increasing vulnerable population. Improving the Quality of Care Whilst some wound care activity is appropriate to be undertaken within GP practices (non-complex), complex wound care requires more specialist care and when delivered by specialists, evidence informs us that healing rates can average at 12.1 weeks 1 which is 84% quicker on average than if treated by a Practice Nurse and 29% quicker than if treated by a Community Nurse in T&W. Moreover, healing rates (for leg ulcers in particular) have been reported at 60% higher using a specialist team approach to wound care 1. Data from the community would care audit highlighted that a large number of patients have been attending their practice multiple times per week for several years with a non-healing wound, resulting in thousands of appointments and a poor experience for the patients. Although the audit only provided complex wound care data for Practice Nurses, it is likely that patients are also seen by the GPs at some point during their complex wound care resulting it both GP and Practice Nurse capacity being spent on complex wounds. Therefore, faster healing not only improves quality, it also generates cost efficiencies through reduced dressing changes and wound care appointments. 5

Aligning with Neighbourhood Working Aside from bringing care closer to home and into communities, there is a need to address social isolation for patients affected by complex wounds and develop community resilience. Wounds can be a contributing factor to increased stress, negative moods, pain, depression and social isolation, all of which can have a major personal and social impact on patients, reducing their quality of life. A series of studies 3 have indicated that stress and anxiety may be linked to increased wound-related pain at dressing change, and consequently compromised healing rates. A dedicated complex wound care community hub will contribute a solution to these problems by bringing patients into a clinic environment, linking them to other groups within their communities and subsequently reduce reliance on other services. Wound Care links to Diabetes & Sepsis Outcomes for patients with diabetes are poor and performance is significantly worse than both peers and national benchmarks. T&W have one of the highest diabetes related amputation rates in the country (9th highest nationally). Wounds in diabetic patients heal slowly due to reduced blood flow, and if cared for inappropriately can quickly develop complications such as infection. It is estimated that 80% of diabetes related amputations are preventable. Furthermore, statistics show that 70% of amputees die within 5 years. Research indicates that amputation wound healing outcomes can be maximised by specialist wound care and multidisciplinary team working by more than 50% 4. The cost and frequency of diabetes associated amputations for T&W is increasing each year. In the financial year 14/15 there were 32 cases costing 204,075, by 15/16 this had increased to 39 cases costing 245,246 and the most recent 16/17 data shows a steeper increase to 50 cases costing 360,196. Therefore, between the financial year 15/16 and 16/17 there was a 28% growth in diabetes associated amputations and a 47% associated cost increase. Sepsis is a rare but a serious complication of infection, which without quick treatment can lead to multiple organ failure and death. Poor wound dressing techniques and unhygienic conditions may increase the risk for wound infection, which can result in sepsis. NICE guidance recognises the link between sepsis and wound healing; listing people with any breach of skin integrity as having increased risk. As well as the detrimental implications for patients, the costs for T&W CCG on treating sepsis are increasing significantly with acute contract over performance of 325,000 at month four of 2017/18. In order to deliver the required improvements in wound care provision in T&W, a range of options have been developed. These include: 1. Do nothing; continue with current arrangements 2. Enhance current Community Nurse service to include wound care appointments currently managed by Practice Nurses 3. Commission a dedicated wound healing service for the management of complex wounds 4. Develop a Local Enhanced Service (LES) for GP practices to deliver complex wound care These options and their pros and cons are explained in detail in section 6. The remainder of this document assumes options 3 is the preferred options and describes the service model and associated savings of this option. 6

3.0 Proposal for commissioning of a complex wound care community hub service 3.1 Service overview The proposed complex wound care service will provide wound care for complex wounds, nonhealing wounds (4-6 weeks as standard but a degree of flexibility is required on an individual patient basis) and non-complex chronic wounds in local wound care hubs within the four neighbourhoods. Each hub will require; 1 Wound Care Practitioners 1 Band 5 Nurse Each hub will offer; 167 appointments per week 105 of these appointments are from the current complex wound care Community Nursing Domiciliary provision 61 of these appointments are from current complex wound care Practice Nurse activity 1 appointment to cover A&E follow up wound care The total staff required to deliver the 668 appointments per week for this service; 15 WTE Band 4 Wound Care Practitioner 5 WTE Band 5 Community Nurse 1 WTE Band 2 Admin 1 WTE Band 7 Team Leader 0.2 WTE Band 8B clinical lead These totals include cover for annual leave, sickness, CPD and training days 3.2 Demand and capacity In order to establish demand and capacity for a wound healing service an audit of practice nurse complex wound healing activity was undertaken alongside research on expected prevalence for the CCG and evidence of wound healing rates in a best practice service. Building on the evidence it is anticipated that the reductions in healing time will reduce demand for appointments and release capacity; at this stage it is hard to establish the trajectory for reduced overall demand. Furthermore, the role of a Wound Care Practitioner is relatively innovative and therefore recruitment timelines are hard to accurately establish. It is therefore suggested that this service is implemented through a phased approach; Phase 1, the transfer of Practice Nurse Activity and Phase 2, the domiciliary complex wound healing service that will be delivered by wound care practitioners instead of by Community Nursing. The innovative nature of the service makes accurate demand planning a challenge this is in part due to; incomplete data from GP practices and setting projections based on faster healing rates. For these reasons a conservative model has been developed which mitigates the risk of underestimating costs by using current activity numbers, conservatively moving to an activity model based on expected prevalence (see appendix C). This allows for the true costs for the service to be established 7

as a starting position but may overestimate costs (and therefore underestimate savings) once the service is fully operating and delivering reduce healing times. 4.0 Cost of complex wound care community hub service The total cost of implementing the service once fully implemented is 846,655 per year. Based on the phasing described above the annual costs are as follows in Table 2: Table 2; Annual costs service costs 2017/18 2018/19 2019/20 2020/21 Annual Cost 199,903* 796,370 830,521 846,655 *Assuming the business case is approved this allows a three month implementation period with service commencement in January incurring a quarter of the annual cost of the first full year of the service. Please see appendix A for full breakdown of service costs. 5.0 Investment Appraisal There are a number of direct and indirect savings associated with commissioning this service that will provide a return on investment to the CCG. A summary of the savings which includes risk adjustments is included in table 3 below. Direct savings: Reduced formulary spend through standardisation, reduced waste and reduced growth Based on data validated by the Tissue Viability Specialist team (Appendix C), 21% of wound care is complex wound care. T&WCCG formulary spend for all complex and non-complex wound care in 2016/17 totalled 711,943. A conservative assumption could be that 21% of the total spend on wound care formulary is on complex dressing formulary equating to 149,508, of which; 126,165 is from FP10 prescriptions by GPs, Practice Nurses or care homes ( 517 per patient based on the 244 seen each week by Practice Nurses) 23,343 is from Amcare related from Community Nurses ( 55 per patient based on 420 patients seen by Community Nursing) Amcare acts as a large store of wound care formulary whereby nurses can go online and order the products needed at each stage of wound healing. This allows for standardisation by limiting the choice of formulary to the most suitable and affordable products and, in addition, reduced waste as unused products can be used as needed for the care of other patients. Furthermore, In the last 4 financial years, formulary spend through Amcare has remained steady whereas FP10 Prescription spend has increased year on year, with the most significant increase of 24% ( 144,188) between years 2015/16 and 2016/17. By transferring the Practice Nurse complex wound care patients to a community hub model and therefore Amcare, prescription formulary will be adhered to, waste will be reduced and the current significant growth in spend will be mitigated, saving a total of 143,007 per year. 8

Reduced Formulary spend through faster healing time; Wounds that heal faster require less dressings reducing spend on formulary. The extent of these savings are not modelled at this time but as healing rates are likely to significantly improve (from 80 weeks for Practice Nurses to potential best practice of 12.1 weeks) there are likely to be subsequent formulary savings in addition to the above. If healing times are faster and consequently require 50% (assumed figure) less dressings, an additional saving of 68,035 can be expected. Reduced wound related diabetes amputation rate Reaserch 1 & 4 suggests that a reduction of between 42% and 70% is reasonable through use of dedicated wound care teams. Based on current amputation rates and 17/18 diabetes related amputation HRG cost ( 6,691) this could save the CCG up to 234,185 (70% reduction). Please note there is an additional Diabetes project that also has QIPP savings associated with reduced amputation rates of c. 60k for 18/19 taking this into account, project CCG savings are 174,185. Fewer A&E follow up appointments In 2016/17, 26,948 was spent on 218 instances where A&E follow-up attendances can be reasonably attributed to wound care. This is made up of; (1) The main treatment received (Treatment 1) classified as wound and dressing care ( 1,199) (2) The patient recorded as receiving Guidance/advice as treatment 1, and having wound/dressing care under treatment 2 ( 25,749). These follow up appointments can t be confirmed as due to poor wound care in primary settings. However, they would be within remit of the proposed complex wound care community hub should patients be referred or made aware that an alternative to secondary care is available. Transferring this secondary care activity to the new service would therefore save the CCG 26,948. Reduced PbR based costs associated with Wound Care & Wound Healing NEL Hospital Admissions Research suggests that 27 50% of acute hospital beds are likely to be occupied on any day by patients with a wound. It is likely that moving complex wound care to specialists will contribute to reduced wound care related admissions; this may include sepsis as described above. Outpatient follow-up appointments It is expected that post-operative complex wound care would shift from secondary settings to the community complex wound care hubs. The financial impact for these two areas is not yet quantified due to data coding, however a benefit will be seen in overall contract performance; this is estimated to be c. 100,000 Indirect savings: Increased capacity of Community Nurses - By removing complex wound care from Community Nurses, 9.3-10.5 WTE of capacity will be released. This time could then be dedicated to proactive management of patients with long term conditions and in doing so prevent 860 NEL admissions. CCG analysis has identified that the average cost of avoidable admissions is 2,090. The means that the admission avoidance saving opportunity presented through the wound healing service and released community nursing time is 1,798,023 per year. Increased capacity of Primary Care - Based on the recent audit, around 6 hours per week for a large (10,000 pop) GP Practice and 3 hours for a small (5,000 pop) GP Practice is spent providing care to complex wounds. It is likely that additional time is also spent by GPs supporting patients with complex wounds. Removing complex wound care from general practice will release much needed capacity that may be utilised for caring for patients with LTCs. Whilst the financial benefit of this cannot easily be quantified it is likely to support the reduction in non-elective admissions that form part of neighbourhood working. 9

Table 3; Benefits associated with fully implemented complex wound community hub service Direct savings Formulary spend through standardisation, reduced waste and reduced growth Formulary spend through faster healing time and less dressings Total Saving Opportunity Risk Adjustment* Risk Adjusted Saving 143,007 0.8 114,406 68,035 0.6 40,821 Reduced diabetes amputations 174,185 0.6 104,511 A&E follow up appointments 26,948 0.8 21,558 NEL Admissions & Outpatient follow up appointments associated with poor wound care and wound healing 100,000 0.2 20,000 Notes on Risk Adjustments The current community nursing provider use Amcare and have seen reduced cost and reduced growth, this can be easily managed and monitored. Evidence of reduction in product usage from improved healing rates is limited, however the reduction in healing time is significant and this can be easily managed and monitored. Evidence of the link between wound care and amputations is clear; however there are a number of other factors which can affect amputation rates. This activity can be easily monitored and the contract can be managed to ensure this activity shifts to the wound healing service. There are clear links between wound healing and reduced NEL admissions and outpatient follow-ups however current coding makes this difficult to monito and measure. Direct Savings Total 512,175 301,296 Indirect savings Increased capacity of Community Nurses for the management of LTCs reducing Non-elective admissions (Supported by increased Primary care Staff capacity) 1,798,023 0.6 1,078,813 There is assurance that the released community nursing time will be utilised on admission avoidance activities and these will prevent non-elective admissions. However, there is still some risk that activity may not reduce to the same level because the acute capacity may be used for other conditions, until the capacity is taken out of the system. Direct & Indirect Savings Total 2,310,198 1,380,109 * Risk Adjusts are based on the validity of the saving assumptions and evidence combined with the anticipated ablility and assurance that savings can be released to the CCG as follows; 80% - Robust evidence with strong assurance and mechanisms in place to ensure costs are removed 60% - Robust evidence with limited assurance and mechanisms in place to ensure costs are removed 40% - Some evidence with strong assurance and mechanisms in place to ensure costs are removed 20% - Some evidence with limited assurance and mechanisms in place to ensure costs are removed 10

5.1 Phasing of Costs and Savings Table 4; Annual cost, savings and net impacts of the suggested service 2017/18 2018/19 2019/20 2020/21 Annual Cost* Risk Adjusted Savings^ Net Impact on Cost 199,903 796,371 830,521 846,655 0 353,328 449,742 1,380,109 199,903 443,043 380,779-533,454 *Assuming the business case is approved, a three month implementation period will begin with service commencement in January, incurring a quarter of the annual cost of the first full year of the service. ^The direct savings values have been profiled based on achieving a third of the total benefit in 18/19, two thirds in 19/20 and full risk adjusted savings in year 20/21. Indirect savings have been modelled based on the proposed service implementation plan associated with option 3. 6.0 Options The following options are discussed in the table 3 below; 1. Do nothing; continue with current arrangements 2. Enhance current Community Nurse service to include wound care appointments currently managed by Practice Nurses 3. Commission a dedicated wound healing service for the management of complex wounds 4. Develop a Local Enhanced Service (LES) for GP practices to deliver complex wound care 11

Table 5; Options Table Option Pros Cons 1. Do nothing; continue with current arrangements 2. Enhance current Community Nurse service to include wound care appointments currently managed by Practice Nurses Increased Practice Nurse Capacity of up to 6 hours per week for a large GP Practice and 3 hours for a small GP Practice at full implementation of service Improved wound healing rate for those patients currently cared for by Practice nurses, but not to optimal rates Inefficient service delivery resulting in slow healing rate (up to 82% longer than best practice) at high cost Opportunity to increase capacity for neighbourhood working missed and subsequent increase in NEL admissions for patients with LTCs Unsustainable service as demand continues to increase with limited capacity Poor use of Practice Nurse time and Community Nurse time Cost inefficient workforce Funding gap remains for complex wound care, with the risk the GPs may withdraw from unfunded activity Opportunity to improve community resilience missed and reduce social isolation missed Poor wound care management, quality of care and patient experience Potential increase in wound infection and subsequent cost through treatment with drugs or surgery Increased amputation rates Financial Investment of 387,398 required with no opportunity for future savings Inefficient service delivery resulting in slow healing rate (up to 48% longer than best practice) at high cost Opportunity to increase capacity for neighbourhood working missed and subsequent increase in NEL admissions for patients with LTCs Unsustainable service as demand continues to increase with limited capacity Poor use of Community Nurse time; where a dedicated wound healing service could be delivered by lower cast staff (Cost inefficient workforce) Opportunity to improve community resilience missed and reduce social isolation missed Poor wound care management, quality of care and patient experience Potential increase in wound infection and subsequent cost through treatment with drugs or surgery 12

3. Commission a dedicated wound healing service for the management of complex wounds PREFERRED OPTION 4. Develop a Local Enhanced Service (LES) for GP practices to deliver complex wound care Net savings of 533,454 delivered upon full service implementation Improved quality of care and patient experience with up to 84% faster wound healing rate Increased capacity of Practice Nurse and Community Nurse time for neighbourhood working reducing NEL admissions for patients with LTCs Sustainable service able to meet increases in demand More cost-efficient workforce through skills mix, utilising Band 4 Wound Care Practitioners with Community Nurse clinical oversight Funding gap addressed in Primary Care Improved community resilience and reduced social isolation Increased integration with current Tissue Viability Service whose expertise can upskill wound care practitioners and enable collaborative care planning that may result in a 50% improvement in outcomes and less wound complications Opportunity for specialist career development Funding gap addressed General Practice remunerated for complex wound care Financial Investment of 846,655 with full return on investment not delivered until the third year of service operation Minimal increase initially in Community Nurse capacity to support a reduction in NELs through neighbourhood working until Phase 2 Potential for service misuse by patients with non-complex wound Financial Investment of c 390,000 (Based on Oxford CCG LES costs applied to T&W CCG) based on projected activity levels Inefficient service delivery resulting in slow healing rate (up to 82% longer than best practice) Opportunity to increase capacity for neighbourhood working missed and subsequent increase in NEL admissions for patients with LTCs Unsustainable service as demand continues to increase with limited capacity Poor use of Practice Nurse time; where a dedicated wound healing service could be delivered by lower cast staff (Cost inefficient workforce) Opportunity to improve community resilience missed and reduce social isolation missed Poor wound care management, quality of care and patient experience Potential increase in wound infection (sepsis) and subsequent cost through treatment with drugs or surgery Practices may not wish to undertake the LES Increased amputation rates 13

7.0 Risk Analysis The following represents the mayor risks to the project. Risk: Score (premitigation): Mitigation: Not agreeing the Business Case will: - Prevent the implementation of Neighbourhood working (Corporate risk) - Mean poor quality of care is not addressed (Quality risk) - Mean the current funding gap is not being addressed (financial risk) 15 Likelihood = 3 Severity = 5 Ensure Business Case is robust to include all benefits to patients, practices and health economy Short term financial pressure to CCG with savings not realised until the third year of operation 15 Likelihood = 3 Severity = 5 Further explore opportunities to reduce service costs and expedite full service roll out and associated savings The innovative nature of the service makes accurate demand planning a challenge and could lead to an under or over resourced service 12 Likelihood = 4 Severity = 3 Set clear activity planning assumptions based on worst case initial costs and test these during implementation as part of an agreed activity and demand review process that allows for a degree of flexibility until demand is more accurately established. 8.0 Conclusion Appropriate care pathways, with close follow up and monitoring by relevant members of the wound care team can substantially improve clinical outcomes and reduce unnecessary morbidity and mortality. Lengthy wound care healing time causes unnecessary distress and pain for the sufferer as well as being costly to the NHS in terms of capacity, complications and formularies. It is essential that alternative care options to the current model are considered to ensure the most efficient use of resources to deliver the best possible care to patients. It is recommended that the CCG provides investment for option 3, a standalone dedicated Wound Healing Service for Telford and Wrekin to ensure that quality outcomes for patients are maximised and that care is delivered in the right place, by the most appropriate clinician, first time. 14

Appendix A- Financial Model (Option 3) Details Complex Care Wound Clinic Pay Costs Annual Hours WTE Annual Cost/WTE Year 1 Annual Cost Year 2 Annual Cost Year 3 Annual Cost Band 8B Clinical Lead 7.50 0.20 67,857 13,571 14,447 7,500 Band 7 Team Lead 37.50 1.00 45,802 45,802 47,780 49,960 Band 5 Community Nurse 37.50 5.00 31,625 158,123 166,324 175,040 Band 4 Wound Care Practitioner 75.00 15.00 52,256 391,924 408,558 417,107 Band 2 Admin 37.50 1.00 20,069 20,069 20,840 21,787 Total Pay Costs 22.20 629,489 657,949 671,394 Non Pay Costs Training 6,000 6,000 6,000 Travel 24,192 24,192 24,192 Mobile phones 3,960 3,960 3,960 Indirect Costs/Overheads 132,729 138,420 141,109 Total Cost 166,881 172,572 175,261 Total Annual Cost 796,370 830,521 846,655 Exclusions; Costs of premises are included within this proposal where arrangements can be made with appropriate local providers for available clinic space. These discussions have yet to take place. However, if capital costs are required (for example adaptations to Newport Cottage Care Centre), these fall outside of the scope of this proposal and additional external funding would be required. Costs of patient dressings or treatments would not be the responsibility of SCHT. Appropriate systems would be developed to facilitate refunds of invoices received by SCHT to be paid by Telford and Wrekin CCG. 15

Spend Appendix B- Formulary spend through Amcare and FP10 systems FP10 prescription formulary spend; Financial Year Spend % Increase in spend from previous year 2013/2014 387,468 2014/2015 421,900 8 2015/2016 452,610 6 2016/2017 600,784 24 Amcare formulary spend; Financial Year Spend % Increase in spend from previous year 2013/2014 103,114 2014/2015 117,060 11 2015/2016 107,128-9 2016/2017 111,159 3 Figure 1; Amcare Spend on Wound Care per financial year Amcare Spend per Financial year 120,000 115,000 110,000 105,000 100,000 95,000 2013/2014 2014/2015 2015/2016 2016/2017 Year 16

Appendix C; Percentage non-healing (complex) wounds and healing wounds as validated by TVS team References 1. MANAGING WOUNDS AS A TEAM, Moore et al, 2014. Available at http://ewma.org/fileadmin/user_upload/ewma.org/project_portfolio/ewma_documents/ AAWC_AWMA_EWMA_ManagingWoundAsATeam_FINALdoc.pdf (last accessed 10.09.17) 2. How a nurse-led centre improved complex wound healing rates, Julie Penfold, 2017. Available at http://journals.rcni.com/doi/pdfplus/10.7748/phc.27.5.8.s8 (last accessed 10.09.17) 3. Psychological aspects of wound care: implications for clinical practice, 2014. Available at https://www.jcn.co.uk/files/downloads/articles/04-2014-psychological-aspects-of-woundcare.pdf (last accessed 10.09.17) 4. Critical elements to building an effective wound care center, Kim et al, 2013. Available at http://www.jvascsurg.org/article/s0741-5214(12)02711-5/fulltext (last accessed 10.09.17) 5. Are your wound management choices costing you money? Tracey Morgan, 2015. Available at https://www.jcn.co.uk/files/downloads/articles/jcn-08-2015-07-wound-managementchoices-costs.pdf (last accessed 10.09.17) 17