Business Case Authorisation Cover Sheet Section A Business Case Details Business Case Title: Directorate: Division: Sponsor Name Consultant in Anaesthesia and Pain Medicine Medicine and Rehabilitation Direct Care Dr M Cooper, Consultant Anaesthetist/Dr J Cowan, Clinical Lead Signed General Manager/Director: Date: March 2012 Section B Consideration of Other Services Medical x Theatre Nursing x Ward Nursing x Occupational Therapists Imaging x Pathology Orthotists Physiotherapists Pharmacy Admin/Secretary x Estates Corporate Section C Director Approval of Business Case (see note 1) Signed Director of Operations: Date: Signed Director of Finance: Date: Signed Director of Nursing: Date: Signed Director of Estates: Date: Section D Executive Approval (see note 1) Approved Held back Rejected If approved funding source: Reserves New Income Other Comments: Signed by Executive Director Date: Executive Directors present at Board: 1
Finance HR Operations Nursing SECTION 1: EXECUTIVE SUMMARY (see note 2) Demand on the pain service at the RNOH has continued to grow within the hospital and it provides a service to both patients referred directly to the chronic pain service and also to support surgical patients during their inpatient stay. This continued increase in demand for the service requires the department to increase its consultant capacity. This has recently been demonstrated through the use of an unfunded Locum Consultant. Anaesthetics Changes within the theatre service are needed to improve capacity and deliver the theatre components of the Inpatient Project. This will require additional anaesthetic consultants to provide the additional work. Appointment of part time anaesthetists can be difficult, therefore, this post will enable the appointment of a full time anaesthetist who will be able to cover the developments in this service and provide a dual role that is of sufficient interest to prospective candidates. Pain Management The RNOH Pain Management Department provides a high quality service when measured against similar sized services nationally. We offer a range of treatment modalities from interventional techniques to cognitive behaviour therapy-based pain management programmes. The service is truly multi-disciplinary and multi-faceted with input from several related medical disciplines including rheumatology, rehabilitation and psychiatry. The department has a short waiting list for assessment and therapy and is compliant with the NHS requirements in this respect. These strengths have made the service successful and respected, both regionally and nationally, resulting in increasing numbers of referrals. Over the last year the number of referrals to the chronic pain service increased by 23%. This correlates to 615 referrals in November / to 758 in November /11. Until early 2011, this additional work was being undertaken as additional sessions by existing Consultants. However a locum post has shown that the demands of the service have a clear need for the third post. The addition of a new Consultant with sessions within, Chronic Pain with Anaesthetics is needed to allow the chronic pain service to cope with its current referral rate. The Anaesthetic Department at RNOH provides consistent high quality service to medical and surgical teams in the operating theatres and the Alan Bray Unit. Consultants in this department also run a specialist respiratory support service for spinal injury patients and the acute pain management service. The specialist nature of the care given to patients at RNOH necessitates direct Consultant involvement in nearly all cases. There is a requirement for further Consultant sessions within this department at present. The Clinical Lead Consultants in the Anaesthetic and Pain Management Departments have agreed to the creation of a combined post comprising 7 sessions in chronic pain management and 3 sessions in anaesthesia. SECTION 2: CURRENT SERVICE (Service summary, history activity, finances) The Chronic Pain Team includes 2 Chronic Pain Consultants namely Dr J Berman (JB) and Dr R Zarnegar (RZ),1.6wte (both full time but one consultant is 0.4wte in anaesthesia), 2 Chronic Pain Specialist Nurses, 0.2wte Consultant Psychiatrist, 1.0wte Clinical Fellow, 2.0wte Secretaries and 1.0wte Administration Assistant. Since August 2011 there has been a Locum Consultant covering the capacity required and this role is currently extended until April 2012. Patients are seen by a variety of these specialists and the Consultants (both pain and psychiatry) and the CNS all hold independent clinics. One Consultant (RZ) has sessions to run the pain management programme, the other (JB) is the Consultant Clinician to the active back programme and is a member of the integrated back unit. Chronic Pain Consultant activity has been steadily 2
increasing over the past few years (see Chart 1 and 2) with the team undertaking increased clinics to see patients to the detriment of non-direct patient care activities. Chart 1: Cumulative waiting list 300 250 200 150 <5 weeks 5-12 weeks 13-18 weeks 19-26 weeks > 26 weeks 0 50 0 06/11/20 06/03/20 06//20 06/11/20 06/03/20 06//20 06/11/20 06/03/20 06//20 06/11/20 06/03/2011 06//2011 06/11/2011 Chart 2 monthly referral rates - 6 month rolling mean 90 80 70 60 number of patients 50 40 30 6 month mean 20 0 Fe b- Ap r- Ju n- Au g- Oc t- De c- Fe b- Ap r- Ju n- Au g- Oc t- De c- Fe b- Ap r- Ju n- Au g- Oc t- 6 months to end of: De c- Fe b- Ap r- Ju n- Au g- Oc t- De c- Fe b- 11 Ap r- 11 Ju n- 11 Au g- 11 Oc t- 11 The table below shows a year on year increase in activity that has been supported by the existing Consultants over the past three years. 3
Table 1 Activity 20/ 20/ 20/11 2011/12 forecast New 566 615 758 932 FU 1,262 1,241 1,766 1,864 N:F ratio 2.23 2.02 2.33 2.00 It is anticipated that the forecast number will in reality exceed 962 new patients as the same growth has been assumed from / to /11 (23%) and 1924 follow up cases if the new to follow-up ratio is assumed to drop to 2. The new to follow up ratio can be seen to be below the Trust target. Overcoming Current Capacity Constraints As well as the increased clinics undertaken by the current establishment of Consultants, it has also been possible to introduce CNS-led telephone follow-up clinics for appropriate patients; this has had a great impact on the efficiency of the pain service over the last 15 months. More recently, the current Specialist Nurse has also been seeing patients face-to-face for follow-up appointments in a parallel clinic with a Consultant (JB). There is potential to expand the nurse led clinics to further increase the efficiency of the service and with the imminent recruitment of the second CNS it is anticipated that this will be provided. The third Consultant would enable the existing Consultants to release clinic sessions to provide the necessary non-direct patient care professional activities and also increase their support to current inpatients. An example of the job plan for the new post is shown on Page 7. One of the existing Consultants will also be undertaking training in paediatric pain management to provide expertise in this nationally under-resourced specialty. The aim is to provide on-site provision for RNOH patients and eventually to help develop the RNOH as a centre of excellence in this field. The provision of a third Consultant will go part of the way to release time for this new activity in its initial stages. Example Job Plan: 7.5 sessions direct clinical care 2.5 sessions SPA Consultant AM PM Estimated hours Monday Pain list/ Pain clinic (Stanmore) alt Admin 7.30-16.00 Tuesday MDT, Admin, SPA (pain) Pain List 9.00-17.30 Wednesday SPA (Pain) SPA (Anaesthetic) 7.00-18.00 4
Thursday Theatre (Anaesthetic) Theatre (Anaesthetic) 9.00-16.00 Friday Clinic (Bolsover) Clinic (Bolsover) 8.30-16.30 40h week Plus on call commitments to be agreed. SECTION 3: REASONS FOR CHANGE There has been a steady increase in the number of patients requiring chronic pain management both from the increasing number of surgical patients seen in the Trust and from the local community. This steady increase has been maintained within the service for several years, but to the detriment of being able to deliver a sustained and educational role to the Trust in line with Clinical Governance needs. Delivering a sustainable service within the department requires that a third Consultant is appointed to support the changes outlined in this paper. There are likely to be changes in the way chronic pain management services are commissioned in the future. The services provided to patients at the RNOH are more specialised and unlikely to be undertaken without support from the department. Routine chronic pain management may be considered for alternative routes of care. This is likely to involve a specialist working alongside an alternative professional, although it is unclear how this will function. It is anticipated that the established service at the RNOH would be a contender to provide such support in the future, given the specialist knowledge and competence of its practitioners. It is also recognised that for those procedures, for which there is research to support the outcomes, there will need to be an identified provider. The RNOH s current reputation and current waiting times lends itself to taking such activity forward. SECTION 4 OPTIONS APPRAISAL (What are the different options that have been considered for delivery of the new initiative must always have a do nothing option and say why it should be discounted, if at all) Option 1 Do nothing Our present service has been built over the years to respond to the needs of patients referred to the chronic pain service for assessment and treatment. Our staff have risen to a variety of challenges as both numbers of patients, professionals and organisations involved in the delivery of this service has grown. Presently the following services are provided to patients: 1. Assessment and complex symptom control (physical, psychological and emotional) where this cannot be managed elsewhere. 2. Outpatient services. 3. Day case treatments 4. Chronic pain management. A full multi-professional team is available to all RNOH patients. Historically, the services have fully utilised the majority of clinical time although in recent years multi-professional care has increased. 5
This option perpetuates the existing service provision and structure. The team would continue to provide advice and support for patients and other professionals. The service operates 9am-5pm 5 days a week. The cost of this option makes no change to the budget. Advantages Maintains the status quo Affordable Disadvantages 18 weeks Trust target might be compromised and waiting times and length of list increase Existing delays for some patients in pain relief and symptom control would remain without possible solutions Not consistent with national, regional and local plans Current structures and practices appear inflexible A fragmented service that is difficult for patients and carers to use Not a timely and responsive service Not sustainable Doing nothing is not a realistic option for an organisation that is founded on quality of care. Patient care, reputation and funding would be put at risk. We have an increasing number of re-referrals. The implication of this is that we would find it hard to reduce our follow-up ratios, but the waiting list for these is growing. We are only maintaining our waiting list for new patients with the use of a locum at present. Our procedure waiting list is also very long. The do nothing option would actually result in all the waiting lists growing to unacceptable levels in a matter of weeks. The only other solution would then be a very tight referral criteria, making the service difficult to access by those making what we would consider to be appropriate referrals. In other words, the service would be in danger of collapsing if we did nothing. Option 2 Increasing Chronic Pain Service sessions only This option would mean an increase in the establishment for pain of a 0.45wte Consultant per year. This change would ensure the chronic pain service could meet its increased demands and this would also allow for some ongoing growth of this service. There would not be any change to the way services are delivered or to the types of service delivered as described in option 1. There may be some increase in the work for other professionals but this can only be described as small as the service would be continuing its integrated approach to chronic pain management currently being delivered. In addition a key objective would be for the service to develop a paediatric interest to support the potential demand in this specialist field. Advantages Improved outcomes for patients. Reduction in inappropriate and/or unwanted hospital admission for patients due to uncontrolled pain resulting in calls to 999 and out-of-hours GP services. Support for patients to achieve their goals. Improvement in access and management on the existing pathways of care and associated interventions available for patients. Focus on improving standards of care in line with evidence based practice Some development of new services and income streams but not the development of the planned paediatrics service Consistent with national, regional and local plans 6
Disadvantages A challenging way ahead that comes with risks Inability to flexibly provide support to all service demands Additional staff costs Poorer field of candidates if the only option was a part time job with solely pain sessions Option 3 Appointment of a new Consultant with 7 chronic pain sessions and 3 anaesthetic sessions This option would focus on improving the efficiency of the referral to treatment chronic pain pathway. The third Consultant would enable the existing Consultants to release clinic sessions to provide the necessary non-direct patient care professional activities and to increase their support to current inpatients. One of the existing consultants will also be undertaking training in paediatric pain management to provide expertise in this nationally under-resourced specialty. The aim is to provide on-site provision for RNOH patients and eventually to help develop the RNOH as a centre of excellence in this field. The provision of a third Consultant will go part of the way to release time for this new activity in its initial stages. The appointment would mean the department can sustain its short waiting list for assessment and therapy and is compliant with the ongoing demands of commissioning in this respect. It will mean that the service can sustain its successes and maintain its respect both regionally and nationally resulting in increasing numbers of referrals. It will ensure that the work undertaken by the recently appointed locum post, which has shown that there has been an increased demand on the service, will be met. Advantages Improve the service and care access to our patients Potential for more effective use of resources Consistent with national, regional and local plans A coordinated service that is easy for patients to use and understand A timely and responsive service Delivery of 18 weeks Cover arrangements of service Increased support for chronic patients on the wards Development of new services and income streams including the paediatric service Opportunity to favourably position the RNOH with future commissioners and get ahead of any potential competition Disadvantages Additional cost offset by the increased activity undertaken by the service Comparison of Options Option 1 is ineffective and not sustainable long-term. Option 2 provides an effective service but is unlikely to be delivered and will not meet the responsibilities of the Trust. Option 3 provides an improved service and meets the needs of our patient demands. The service will therefore be sustainable for the future and enables us to be the hospital of choice for these patients. Preferred Option Option 3 is preferred. It will provide improved outcomes for patients and present an opportunity for the RNOH. 7
4.2 Recommended proposal Timetable and deliverability Executive Committee approval Feb 2012 Trust Board approval March 2012 Advertisement April 2012 Interviews & recruitment May 2012 Start date July 2012 Recommendation The approval of this post will allow continuing provision of high-volume specialist care to meet increasing patient demand will maintain the chronic pain service at the RNOH as a centre of clinical excellence will allow further development of education, research and audit to improve patient care The post is self-financing. SECTION 5 RISK ASSESSMENT Refer to Section 4 above; Risk of Not Proceeding: An inability to develop the service in line with the needs of other clinical services within the RNOHt, including the recruitment of new Consultant Surgeons The profile of the RNOH would be adversely affected if specialist work were required to go elsewhere due to a lack of capacity Clinical Governance requirements would not be met Waiting times for Chronic Pain will increase Significant risk to the new to follow-up ratio being increased due to unnecessary appointments being made for patients to be seen by a more senior clinician Lack of access to training for medical and nursing staff There will be a need to reduce the demand on the service and restructure referrals There will be ongoing pressure to meet the administration requirements for the service SECTION 6 COST BENEFIT ANALYSIS OF ALL OPTIONS - The RNOH has a model for financial calculations which must be used, but this section should also describe the financial case in text Pain Management There are currently 3 to 5 requests for the Pain Team to visit patients on wards per week and they are currently able to see most of these patients but with some difficulty due to support and time constraints. If the other patients were also seen and each patient was to reduce their bed day by one per treatment, this would enable the RNOH to save by reducing the spend by 350 per patient and increase the income through additional activity. In addition the service will also provide an ability to deliver the necessary service required by the Chronic Management Team; ability to meet the NHS Plan waiting time targets and NICE guidelines; improved patient satisfaction and access to service; enhanced reputation for the RNOH as a world class leader in treating patients with complex orthopaedic conditions, to support specialty departments to carry out research and teaching. ability to support delivery of continued excellent clinical standards by a dedicated, highly motivated, specialised consultant group opportunity to support extended days in theatres to maximise the use of the valuable resource 8
improved discharge for patients and provide greater capacity to increase activity. Anaesthetics The anaesthetic service does not provide an income directly to the RNOH. The funding for this post arises from the increased activity that is able to be undertaken where a general anaesthetic is required. This may be within the Theatre complex, Radiology Department or other areas within the RNOH. The funding may also be used to support the extended lists project that is being introduced in theatres. 6.2 Workforce effect on staff of change, how does the proposal affect the workforce requirements As the Direct Clinical Care programmed activities are already established and in place, there would be no additional on costs for other departments including outpatients and Theatres. The business case will enhance recruitment & retention opportunities and provide an opportunity for succession planning within the department. 6.3 Equipment any new equipment needed or use of existing equipment affected There will be no additional equipment required 6.4 Consumables/ Maintenance effect on consumable costs, usage or maintenance There will be additional impact on consumables as shown in Section 7. There will be no additional maintenance costs associated with this case. 6.5 Accommodation changes in consumable usage No changes are anticipated through acceptance of this business case and no impact on theatre scheduling is expected. 6.6 Income changes in income The directly attributable increase in income from this post reflects the existing services that are provided by the current locum. The new timetable is expected to continue to facilitate the forecasted activity (see table 1 in section 2) which equates to 174 new patients, 98 follow-up patients. In addition it will be possible for radiological income to be maximised as the additional GA sessions will allow more flexible use of radiological diagnostics requiring a GA. An example of this is that the anaesthetic component of the post will enable additional interventional general anaesthetic CT guided radiofrequency ablations. This income assumption is shown in the financials. Income and savings The financial case demonstrates that funding for the post will in part be provided through more flexibility to complete general anaesthetic demand for ablations and partly through the continuation of existing work being undertaken within the pain department. The procedures being undertaken would not be transferable to a community facility under the revised commissioning rules. These procedures are essential in maintaining a quality of life for many patients. Whilst there are risks to the chronic pain service from the future of commissioning it is likely that the criteria for referral and the need to support more specialist work is the focus. The department expanding will provide the flexibility to support such work in a timely way in the future. In addition allowing the team sufficient time to see patients on the wards prior to being discharged will enable patients to initiate their pain treatment and care at an earlier stage. The patients are currently inpatients under surgical teams and by enabling the pain team to improve their access to these patients will reduce bed days and allow patients to initiate their post-surgical pain care at an earlier stage. 9
7.0 Financial Summary Preferred Option WTE/ Activity Recurrent Cost inc VAT Income Outpatient new 174 32,016 Outpatient follow-up 98 9,604 Injections 70 50,540 * GA Radiofrequency Ablations (3 per week 27 weeks) 81 81,000 Non-Recurring Costs inc VAT Total Income 173,160 Pay Interventional GA CT Radiofrequency Ablations Consultant Radiologist including On-Call 0.13 14,600 Band 6 Radiographer 0. 4,200 Band 6 ODP 0. 4,200 Band 2 0. 2,300 Anaesthesia & Pain Consultant Pain including On-Call 0.75 84,200 Consultant Anaesthetics 0.25 28,0 Secretary B4 0.75 22,200 Total Pay Costs 159,800 Non-Pay Consumables for injections 5,000 Consumables for ablations 2,700 Total Non-Pay Costs 7,700 Net Contribution Gain/(Loss) 5,660 Note GA Ablations only cost for 27 weeks as at present there is not enough activity to cover a full 40 weeks.