DUDLEY CLINICAL COMMISSIONING GROUP BOARD (PRIVATE) Date of Board: 31 March 2016 Report: Health Infrastructure Strategy TITLE OF REPORT: PURPOSE OF REPORT: AUTHOR OF REPORT: MANAGEMENT LEAD: CLINICAL LEAD: Health Infrastructure Strategy To present to Board the Health Infrastructure (Estates) Strategy Mr M Hartland, Chief Operating and Finance Officer Mr M Hartland, Chief Operating and Finance Officer Dr J Darby, Clinical Executive KEY POINTS: Update presented as at March 2016 following consultation and engagement with practices and localities Mixed approach to development proposed, incorporating new premises and increasing occupancy and utilisation of existing estate A number of key sites within the Borough identified Principles for Primary Care Transformation Fund proposed RECOMMENDATION: FINANCIAL IMPLICATIONS: WHAT ENGAGEMENT HAS TAKEN PLACE: ACTION REQUIRED: 1. To consider the request for Approval to Business Case for new developments in a. Kingswinford b. Gornal 2. To support the principle of increasing occupancy and utilisation of existing estate with long NHS leases/void costs 3. To agree the key sites as defined in 3.2 4. To approve the principles to be applied to Primary Care Transformation Fund bids. N/A to be confirmed at business case stage Via localities, individual practices and partners Decision Approval Assurance 1 P age
DUDLEY CLINICAL COMMISSIONING GROUP BOARD 31 MARCH 2016 HEALTH INFRASTRUCTURE STRATEGY 1.0 INTRODUCTION The Health Infrastructure Strategy Case for Change was presented to and approved by Board in September 2015. This paper, and accompanying strategy, updates Board on progress. 2.0 UPDATE The Health Infrastructure Strategy Case for Change was approved by the CCG Governing Body in September 2015. Since this point the CCG, supported by Capita, has undertaken continued consultation with localities, practices, partners and stakeholders. We were hoping to be in a position to present to Board at this point an estate strategy that described an infrastructure model for all of our 46 practices and community services that meets the needs of the new model of care we are implementing through the vanguard programme. Unfortunately, we are not in a position where we can do this. This is due to the mixed position primary care currently occupies with regard to the future model of primary care and individual practices position in this model. The attached strategy, therefore, describes the work completed to date, the enhanced case for change, and a summary of locality outputs at this point in time. The paper also described proposed criteria for Primary Care Transformation Fund bids, identification of key sites in the health economy and the need to ensure full occupancy and utilisation. The strategy does not present recommended procurement options for any proposed developments as these are presented to Board in a separate paper. 3.0 OUTCOMES The following outcomes have been identified to date. 3.1 New developments The Board agreed in September 4 principles for new developments: Proposed new developments must support the new mode of care To support a recommended joint list size of 20,000 30,000 patients. Minimum list size 15,000 To share back office functions within buildings To have a uniform, modular build enabling modification and expansion as required. The CCG has received request for 2 new developments 3.1.1 Kingswinford Moss Grove, Summerhill, Rangeways Rd and Kingswinford Medical Practice. It is proposed that this is a locality hub incorporating primary care, community services and diagnostics. The current list size for the 4 practices is 35,000. 2 P age
3.1.2 Gornal Lower Gornal Medical Practice and Castle Meadows Surgery. This is the colocation of two practices that would have MCP support services attached but not of the scale of a locality hub. The current list size of the 2 practices is approximately 14,000. At this point in time the CCG Board is not asked to give full approval for the schemes. The Board is asked to consider whether the schemes can be given Approval to business case stage. The format, structure and content of the business case is not known at this stage as this is dependent on the procurement route for the scheme (to be considered separately by Board), but all procurement routes require approval by Board to proceed with a business case. The business case will include the full details of the proposed development, including size, design, floor areas, services to be included, proposed locations, finances etc. Such business cases will be presented to Board at a future date for individual approval. 3.2 Key sites The implementation of the estates strategy does not necessarily rely on the development of new buildings. In the past 10 years there have been a number of new developments across the Borough procured through a number of procurement routes that have long leases that the CCG is required to underwrite. It is a fundamental premise of the strategy that a priority should be increased occupancy and utilisation of such buildings, thus reducing void costs and wasted expenditure for the CCG. A number of such sites have been identified across the health economy where focus will be on increasing occupancy and utilisation. This will result in moving services, where appropriate, into these underutilized facilities. This will be undertaken following standard consultation procedures and in conjunction with stakeholders, but is mechanism for achieving early opportunities from the use of estate. Such sites identified are: - Brierley Hill Health & Social Care Centre - Stourbridge Health and Social Care Centre - St James Medical Practice - Ladies Walk - Lion Health Note: not all of the above buildings have been procured with the intention of delivering community services (via OJEU); therefore the applicability of including community services is to be legally tested. Primary Care would not require such legal approval. 3.3 Primary Care Transformation Fund The CCG intends to fully utilise the ability to submit bids for funding from the NHS England Primary Care Transformation Fund to support the implementation of its Health Infrastructure Strategy. National criteria for the fund include: - Increased capacity fro primary care services out of hospital - Commitment to a wider range of services as set out in commissioning intentions to reduce unplanned admissions to hospital - Improving seven day access to effective care - Increased training capacity 3 P age
Submissions are to be submitted by the end of April 2016. It is proposed to support practices where bids are: 1. Aligned to the CCG estate strategy 2. Do not contradict the CCG estate strategy 3. Provide short-term support to practices prior to longer term development 4.0 CONCLUSION The CCG Health Infrastructure Strategy as at April 2016 is presented to Board for approval. It presents a phased approach to the implementation of the estate infrastructure required to deliver the MCP, and this is through a combination of new developments and increasing the occupancy and utilisation of existing estate. Engagement will continue with practices and localities, with the aim of progressing the implantation of the strategy through either of the mechanisms identified above. The strategy will be refreshed annually, with proposals for new developments presented to Board as requested and appropriate throughout the year. 5.0 RECOMMENDATIONS Board are asked: 5. To consider the request for Approval to Business Case for new developments in a. Kingswinford b. Gornal 6. To support the principle of increasing occupancy and utilisation of existing estate with long NHS leases/void costs 7. To agree the key sites as defined in 3.2 8. To approve the principles to be applied to Primary Care Transformation Fund bids. Mr M Hartland Chief Operating and Finance Officer March 2016 4 P age
Health Infrastructure Strategy March 2016 Matthew Hartland Chief Finance & Operating Officer Dudley CCG Health Partners
Executive Summary This planning document is the Dudley health economy s local Health Infrastructure Strategy (HIS) and represents Dudley Clinical Commissioning Group (DCCG) and its partners. Purpose of the DCCG HIS According to Department of Health figures (2014), the direct cost of the national healthcare estate is approximately 7 billion per annum making it the third-largest category cost for the NHS after staff and drugs. The estate, as an enabler for change, can and must deliver savings and reduce costs to meet the challenges of funding both the NHS and the wider health economy. There are considerable opportunities to achieve this in Dudley, which need to be driven by: A clear and concise clinical service strategy; More efficient operation and use of the estate and information technology; Improved efficiency, including value for money, in capital procurement and construction; and Adherence to best practice in land management, ensuring optimum solutions are implemented (including identification and disposal of surplus land). DCCG has therefore developed this Health Infrastructure Strategy (HIS) to support the delivery of its over-arching Strategic Plan for the local health economy. Development of the HIS is based on a robust methodology, with each stage focusing on the supply side (property) and the relevant demand side data (clinical service requirements). Phase 1 of the HIS incorporates primary care and community services. The HIS focuses on the five localities that make up the Dudley borough: Sedgley, Coseley & Gornal (SCG) Dudley & Netherton (DN) Kingswinford, Amblecote & Brierley Hill (KAB) Stourbridge, Wollescote & Lye (SWL) Halesowen & Quarry Bank (HQB) Phase 2 of the HIS will build on the outcomes of Phase 1 and incorporate other services that are key to the delivery of the New Model of Care for Dudley. This will therefore include estate/infrastructure requirements of: social care voluntary sector
public health wider community assets the impact the new model will have on acute/bed-based services (Russell s Hall, Corbett, Guest, Busheyfields and Ridge Hill). Inclusive development process This HIS is commissioner-led but benefits from a strong working relationship with the major providers in the area, through DCCG. Key stakeholders such as local authority representatives are involved in the planning process, ensuring that the wider public sector estate is considered and that decision-making processes are robust. The HIS development process has considered: priorities for each stakeholder; opportunities and risks for the estate as a whole; national and local contexts. Naturally, consideration has also been given to the interdependencies between acute and community health services. The early benefit of the HIS for all stakeholders will be one of cohesion for jointly realising estate solutions for the local area. It is anticipated that these can be delivered through current initiatives, such as the One Public Estate programme, which will enable great benefits to be derived for Dudley and should be positively encouraged. Challenges Primary care infrastructure across the Dudley borough faces a number of challenges. In many cases the current buildings and infrastructure fail to meet current and future needs. There are many examples of poor general practice facilities which do not support multi-disciplinary team working and contribute to a poor patient experience. Whilst there are examples of world-class primary care facilities, they are often used inefficiently. NHS England s Five Year Forward View calls for primary care to work at greater scale in facilities that enable teams from across health and social care to work together. As with many of the UK s boroughs, Dudley faces significant demographic growth as well as epidemiological pressures due to an aging population. In addition, there is substantial financial pressure within the local health economy. There is a significant saving requirement for Dudley by 2020/21 for all partners in the health and social care system, which means that finding ways to use existing resources more effectively is urgently needed. A recent survey of primary care and community estate has identified investment of approximately 40m is required in order to ensure the estate is fit for purpose to meet current needs. The majority of investment in the estate is derived from the estate not being functionally suitable which leads to ineffective utilisation. The spread of properties requiring significant investment is across all five localities.
Table 1. Investment Required to Achieve Estatecode Condition B 1 Facet Physical Condition Statutory Compliance Functional Suitability Space Utilisation TOTAL INVESTMENT Investment Required 13.53m 2.13m 21.32m 1.26m 38.24m The investment required in the estate over the next 10 years will only increase along with population, which is estimated to rise by approximately 2.6% per annum (demographic and nondemographic growth) from 312,900 in 2015 to 404,463 in 2025. This is illustrated in the following graph: Figure 1 Estimated Population Growth of Dudley Borough (assumption is being tested) 1 See https://www.gov.uk/government/publications/the-efficient-management-of-healthcareestates-and-facilities-health-building-note-00-08 for Estatecode published by the Department of Health, November 2014. This Health Building Note is split into two parts. Part A outlines how efficiencies in the running of land and property can be achieved. Part B provides more detailed advice about the active management of land and buildings used for healthcare services. Addendums (March 2015) providing guides to town planning for health organisations the healthcare system in England for local planning authorities.
Key strategic drivers The HIS takes account of key strategic drivers: National The NHS Five Year Forward View NCM Vanguard Programme Transforming Primary Care The Carter Review Implementing a strategic commissioning framework Working collaboratively with the public to both develop and utilise health and wellbeing effectively The Right Care initiative to identify local clinical priorities Local Promoting self-care, prevention and personal responsibility Developing joined up community hubs closer to home, for all Leading a sustainable health and care system, encompassing workforce, estates and IT Developing MCP 2 Improving quality Transforming commissioning Enabling work streams (such as IM&T) Reshaping delivery reducing community bed base but maintaining community hospitals as a core element of the estate Key considerations Key considerations for the health economy over the next five years include: Implementation of the Five Year Forward View Development and implementation of the MCP, supported by the NHS England Vanguard programme Integration of health, social care and mental health (supported by FYFV and Better Care Fund (BCF)) to improve patient experience and outcomes. Joint Strategic Needs Assessment (JSNA) priorities: growing elderly population and long-term conditions which increase acuity of care and also needs supportive independent living models of care, new cancer and specialist treatments, increase education on lifestyle choices and prevention. 2 NHS England s New Models of Care include the MCP Multi-specialty Community Practice
An affordable, sustainable local health and care economy which operates within finite resources and meets growing demand. Hospitals, health centres and care without walls combining to deliver integrated partnership working between agencies. Within this context, there is a strong rationale for DCCG taking control of the estate and rebalancing the NHS investment profile towards Out of Hospital (OoH) services. This is consistent with national and regional policies. The NHS England FYFV, the CCG s Five Year Strategic Plan, Commissioning Intentions and supporting Operational Plans are structured to meet this need. Supplementary funding streams are being identified to enable these changes, including NHSE Vanguard funding. Improving the estate and working together in shared facilities is fundamental to the way that care will be offered in the future. Services will be delivered from facilities where primary care practices can work together with their own access to on-site diagnostics, e.g., blood testing, ultra-sound, echocardiograms and MRI. Dudley CCG s six key principles Since inception, the following have informed the work of the CCG: Patient and public involvement The meaningful involvement of patients and public is of paramount importance. Throughout the NHS, the patient is usually the coordinator of their care. It is key that contact with healthcare professionals adds clinical value. The CCG believes this contact must be re-aligned, from a hierarchical dialogue expert to receptive patient, to a horizontal dialogue expert to expert. Patients/families are most knowledgeable about their symptoms, bodies and psychological and social state. This self-expertise remains an under-tapped resource that if accessed will transform healthcare and well-being. Supporting autonomous living is of paramount importance. However, when people do use healthcare Dudley CCG wants them to have clearer information about the quality of services in order to inform their choices; and also to be better able to share feedback as to whether services are working for them. Clinically-led health system The public register with their GP and it is through the coordination that their GP provides, that they are able to best access the healthcare that they need. So the future health system will be organised around this key relationship between patient and their GP: providing a personalised service. Similarly, all population-based healthcare will be commissioned on a registeredpopulation basis and will be organised in accordance with GP and CCG structures (so around practices, localities and borough-wide) in order to enable a clear, clinically-led approach to healthcare delivery.
Primary Care at heart The vast majority of care is either delivered by General Practice or is accessed through it. The success of primary care is therefore central to the future success of our health services locally. The CCG has developed a primary care strategy, supported by the Health and Wellbeing Board and NHS England. There are significant recruitment and retention challenges for primary care services so development of primary care infrastructure and workforce will be central components to on-going work the CCG wants Dudley to have a national reputation as the best place to work (for GPs along with their extended primary care and community staff). The CCG will continue to develop shared commissioning of primary care with NHS England in order to ensure that this can be achieved. A sustainable primary care system lies at the heart of the new care model. Working with partners in the CCG s communities The locality-based approach to the New Model of Care recognises the need to network GPs, patients and associated primary care/community services, social care and the voluntary sector in order to respond to the variable needs of different communities across the local population. Health inequalities can only be addressed through a jointly targeted community-based approach. The CCG will build partnership relationships through the organisation of all of its services for all of its populations based on clinical need. Focus on quality and continuous improvement The CCG will take a predominantly developmental approach to quality improvement that encourages transparency by all service providers to reduce variations in care and outcomes; and to aim for best practice performance. It will expect every service to be able to demonstrate the value and quality that it provides to patients. The CCG will utilise a continuous evaluation process that will ultimately ensure that we do not commission any service that cannot demonstrate value; and will actively promote those that can demonstrate best outcomes for patients. Live within available resources Dudley CCG will meet its financial responsibilities to address the reasonable needs of its population within available resources. This necessitates a drive for continuous efficiency and improvement given the economic constraints faced. The emphasis will always be to maximise the effectiveness and availability of front-line services. Likely efficiency savings A fundamental requirement of the estate review is to reduce the recurrent cost of estate in Dudley. Likely savings are based around two key factors: i. Potential disposals through consolidation/rationalisation and improved use of assets.
ii. This strategy aims to accommodate future services while avoiding unnecessary additional estate from being acquired. This will create effective future savings. The current cost of the healthcare estate in Dudley is estimated to be approximately 46m 3, split between different service types as follows: Table 2 Current Cost of Dudley Healthcare Estate Setting Value ( 'm) Primary Care 3.8 Community 10.2 Acute* 29.0 Mental Health and Learning Disabilities 3.0 Total 46 There is joint commitment from all partners to reducing the cost of estate and this will continue. Premises development approach The Board in September 2015 agree the following principles for the Health Infrastructure/Estates Strategy: 1. Multi-Specialty Community Provider All developments and service moves within existing estate should support the implementation of the MCP. 2. Minimum 15,000 population for primary care premises The smallest facility that services could be offered from will cater for a minimum of 15,000 patients. Larger facilities of over 30,000 patients could host on-site minor surgery units, multidisciplinary teams, outpatients, sexual health clinics, enhanced diagnostic services, social care and community learning environments with access to nutritionists, health coaches and voluntary community groups amongst others. 3 *Source: 14/15 PFI payments as per Dudley Group FT Published Annual Accounts
3.Shared back-office facilities Back-office functions to support primary care would be shared so that increased funding is available for clinical services. This environment will support new models of care, where multidisciplinary teams from across health and social care organisations work together. However, while a substantial number of practices still operate in isolation, it is only by working together that primary care practices will have the capacity to meet the demands of the future. 4. Uniform design To achieve value for money and efficiency in design a modular, standardised approach to design will be adopted. Infrastructure requirements Impact of transfer from acute to primary and community To ensure adequate access to essential services, relocation from expensive hospital sites of varying utilisation to community settings is necessary, particularly for outpatients. Therefore, the HIS provides capacity modelling that assesses the likely impacts on infrastructure requirements of hypothetical 15% and 30% transfers of outpatient activity from acute to primary and community sites 4. Outpatient activity is apportioned on the basis of locality populations; future demand is forecast in alignment with expected population growth based on ONS projections. Combining GP and outpatient activity modelling indicates the following Gross Internal Area requirement across Dudley CCG area based on 2026 projections: Based on 15% shift of outpatient activity: 15,574 m2 Based on 30% shift of outpatient activity: 16,829 m2 This equates to an additional 26 consulting/exam rooms across the borough by 2026, which would be incorporated into individual business cases as required. Key Sites Delivery of the estates strategy does not necessarily require the procurement and development of new buildings. There are buildings in the Borough previously procured through PFI, LIFT, 3PD or GP-owned that are either under-utilised or not appropriately structured for current healthcare services. 4 15% represents the minimum practicable shift from acute to primary and community settings; 30% the largest possible shift (and represents transformation on a scale that is recognised as challenging)
Some key sites must be retained for the provision of core health and care services; these sites largely choose themselves, through a combination of factors including geography/size /integration/co-location/ previous investment decisions. Key sites will be subject to ongoing review. They must be operated as efficiently and intensively as possible to maximise the use of expensive health assets. As a minimum, the HIS recognises the following primary care/community facilities as key sites: Brierley Hill H&SCC Stourbridge H&SCC St James Medical Practice Ladies Walk Lion Health Russell s Hall Corbett Guest Ridge Hill Busheyfields A key part of the future development of this strategy is the appropriate occupation and utilisation of these sites. They must be functionally suitable to support the new model of care and fully utilised to extract the value and investment in these buildings. Caution must be noted, however, that the inclusion of community services into buildings above needs to be tested legally as not have been through an OJEU procurement process. Current primary care position by locality It was originally intended to be able to present at this stage an estates solution for the Borough that supported primary care at scale, reduced cost, appropriate occupation and suitable for the delivery of the new care model in Dudley. Due to a number of factors, including GP practices being at differing points in defining the local model for primary care delivery, it is evident that a mixed, and phased, approach is required. The process to date has demonstrated that GP practices are in one of five categories: 1. Agreement with other practices to progress development of new premises 2. Willing to engage in further dialogue to explore potential for co-location 3. Require facilitation with neighbouring practices to engage in discussions of potential colocation 4. Require further information to see benefits of co-location/utilisation of key sites 5. Do not support primary at scale/not engaged in process.
The summary position by locality is identified below: Kingswinford, Amblecote & Brierley Hill (KAB) Locality The KAB locality contains 10 practices offering Primary Care services to approximately 86,000 patients from 12 locations. Four practices based in Kingswinford, with a list size of 33,500 patients, are currently engaged in discussions to co-locate in a Kingswinford hub. Dudley & Netherton (D&N) Locality The D&N locality contains 11 practices offering Primary Care services to approximately 55,000 patients from 11 locations. This locality contains a high number of small- and medium-sized practices, often based in close proximity to each other, including two practices who are colocated in a shared building. Some initial discussions have taken place between practices about potential further co-location, but there is currently limited appetite to take this forward. Sedgley, Coseley and Gornal (SCG) locality. The SCG Locality contains 9 practices, each operating from a single site and serving approximately 55,000 patients. Two practices, with a combined list size of approximately 14,000 patients, are in advanced discussions around co-location in a new-build development in the Gornal area. No other practices have shown a serious interest in premises changes at this stage. Halesowen & Quarry Bank (HQB) Locality The HQB locality contains 10 practices offering services to 54,000 patients across 13 sites. One practice has been involved in initial discussions about potential co-location as part of a scheme with practices in SQL locality, but there is currently no agreement on how this can be taken forward. Other practices have shown little appetite to be involved in any premises changes. Stourbridge, Wollescote & Lye (SWL) Locality The SWL locality is made up of 6 practices serving 65,000 patients from 8 sites. It includes 2 large practices with over 20,000 patients, one of which operates from 3 sites and has expressed an interest in a new-build to bring all services onto one site. Initial discussions have also taken place between three of the other practices about potential co-location, but there is currently no agreement on how this can be taken forward. Current options/considerations The HIS to date has identified the following options to progress the implementation of the CCG Estate Strategy to support both the new model of care and reduce the cost of existing estate:
1. New Premise Developments There have been two expressions of interest in developing new premises: I. Kingswinford Moss Grove, Summerhill, Rangeways Rd and Kingswinford Medical Practice. It is proposed that this is a locality hub incorporating primary care, community services and diagnostics. The current list size for the 4 practices is 34,000. II. Gornal Castle Meadows Surgery and Lower Gornal Surgery Co-location of two practices that would have MCP support services attached but not of the scale of a locality hub. The current list size of the 2 practices is upto 13,000 2. Early Opportunities for use of existing estate A number of opportunities are present for the potential utilisation of existing estate to support the aims of the strategy. These are predominantly aimed at better use of the key sites described above and facilitating delivery of primary care at scale in line with emerging models of care. 3. Primary Care Transformation Fund It is proposed to utilise the availability of central funds to pump-prime or provide support funds for the implementation of this strategy. 4. Branch closures It is likely that the CCG will receive applications from practices to close branch surgeries. These should be pursued through the normal processes of robust business case development and stakeholder consultation as prescribed by NHS England but if they meet the needs of the MCP development they should be supported from a strategic perspective.
Next steps This Health Infrastructure Strategy will be updated annually. The next iteration will include further developments in primary care alongside inclusion of public health, social care, hospital based acute care and other providers. Business cases for proposed developments will be presented to appropriate organisations Governing Bodies/governance structures as required during the year.
Figure 2 Dudley Overview Map