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Executive Summary This business case identifies the potential to deliver enhanced patient benefits through the creation of a Limited Liability Company to provide nursing and therapy services to the PCT through a Specialist Personal Medical Services (SPMS) contract. The company will be structured such that it remains within the NHS family, with secure NHS terms and conditions for staff. Benefits will be e expertise of our staff and throug on. Patients will benefit from improved access to integrated and co-ordinated care, tailored to their needs and delivered as clos ional and flexible approach to com o Local Education Authorities), and governance.

achieved through innovation in service delivery to maximise thh a very different culture to improve recruitment and retenti

e to home as possible. It would operate a highly professmissioners (to GP practices, to Localities, to Acute Trusts, tdemonstrate robust clinical leadership, corporate and clinical

Central Surrey Healthcare will ensure the robust supply of nursing and therapy services to enable health promotion; self managed dmission avoidance as part of the Better Healthcare Closer to Hom insey financial strategy

care, new care pathways and ae clinica the McKl strategy and

The proposal has been developed over a number of workshops with 35 senior nurse and therapy staff representatives. The group identified the vision, values and services that it would like to develop and assessed the business models to enable this to happen. The preferred model, a Limited Company operating with SPMS contracts is a new option for the NHS and this proposal is the first of its kind. The benefits of a Limited Company include organisational stability, culture shift and responsiveness to need. Briefing events have been held with over 250 of the current 713 nursing and therapy staff. The PCT’s Staff Side has been involved throughout the process. Initial consultation with stakeholders and commissioners in the wider community has taken place. Commitment and support for the project is high. Further work is required to manage risks and produce a full business case. A detailed transition plan will be implemented.

Jo Pritchard MA BSc DipHV,RGN Tricia McGregor BSc (Speech & Language pathology), MRCSLT

Central Surrey Healthcare Development of a Limited Company to provide nursing and therapy services under a Specialist

PMS Contract

Outline Business Case

June 2005

Central Surrey Healthcare Ltd Outline Business Case

June 2005 1


Executive Summary This business case identifies the potential to deliver enhanced patient benefits through the creation of a Limited Liability Company to provide nursing and therapy services to the PCT with a Specialist Personal Medical Services (SPMS) contract. The company will be structured such that it remains within the NHS family, with secure NHS terms and conditions for staff. Benefits will be achieved through innovation in service delivery to maximise the expertise of our staff and through a very different culture to improve recruitment and retention. Patients will benefit from improved access to integrated and co-ordinated care, tailored to their needs and delivered as close to home as possible. It would operate a highly professional and flexible approach to commissioners (to GP practices, to Localities, to Acute Trusts, to Local Education Authorities), and demonstrate robust clinical leadership, corporate and clinical governance. Central Surrey Healthcare will ensure the robust supply of nursing and therapy services to enable health promotion; self managed care, new care pathways and admission avoidance as part of the Better Healthcare Closer to Home clinical strategy and the McKinsey financial strategy The proposal has been developed over a number of workshops with 35 senior nurse and therapy staff representatives. The group identified the vision, values and services that it would like to develop and assessed the business models to enable this to happen. The preferred model, a Limited Company operating with SPMS contracts is a new option for the NHS and this proposal is the first of its kind. The benefits of a Limited Company include organisational stability, culture shift and responsiveness to need. Further work is required to manage risks and produce a full business case. The initial high level risk assessment will be further developed together with a detailed transition plan. Briefing events have been held with over 250 of the current 713 nursing and therapy staff. The PCT’s Staff Side has been involved throughout the process. Initial consultation with stakeholders and commissioners in the wider community has taken place. Commitment and support for the proposal is high.

June 2005 2


Contents

Page

Value Proposition 3 - 9

The Limited Company 10 - 11

Integrated Governance 12 - 14

Service Delivery 15 - 17

Financial Plan 18 - 20

Staff and Stakeholder Engagement 21

Next Steps 21

Communication 22

Recommendation and Issues for the Board 22

Frequently asked questions 23

Appendices

A. Demonstration of Value Proposition 24 - 28

B. Options Study - Corporate Entities 29 - 33

C. Business Case Generation Process 34 - 36

D. Corporate Governance – Drivers and Options 37

E. SWOT Analysis 38

F. Risk Assessment 39 - 40

G. Support 41

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1. Value Proposition

1.1 Proposal EEMS PCT, like all PCTs, has a dual responsibility both as a strategic commissioner of healthcare for patients but also as a direct provider of community services. This dual role creates significant internal tensions as the objectives of the two roles may conflict e.g. in pursuit of financial balance. The separation of these two roles offers clear benefits by allowing the PCT to focus on its role as a commissioner and on the strategic development of the local health economy. The independent provider role gives a more obvious voice to the provision of community services and supports the development of a plurality of providers. Further benefits will be realised: The formal contractual relationship created by the commissioner/provider split will

clarify commissioning intentions and improve performance management A clearer relationship with other providers similar employment model to the other

primary care providers The focus on a pure provider role offers greater consistency for patients and staff as the

NHS enters yet another phase of re-organisation. To deliver these benefits, nursing and therapy teams at EEMS PCT are proposing the establishment of a Limited Company, Central Surrey Healthcare, to provide high quality nursing and therapy services. The business will focus on the development and provision of a range of services in home, community and hospital settings. and the recruitment and retention of high calibre staff The development of Central Surrey Healthcare will achieve: A dynamic organisation whose core business is the provision of high quality nursing and

therapy services. A more responsive and flexible organisation with which commissioners, including GP

commissioning teams wish to work (see Appendix G). The focus on service delivery will help to recruit and retain staff, along with:

• A philosophy and culture that values and motivates staff through their involvement in decision making and by incentivising performance; and

• A strong commitment to professional development and education and training, Improved management and co-ordination of care will enable the delivery of the PCT’s

strategic plans e.g. Better Healthcare Closer to Home The establishment of Central Surrey Healthcare will deliver cost savings as the benefits of integrating some services are realised. It is considered that there will be a reduction in overheads as this Company is intended to be “lean and mean” with self-managed teams to enable more responsive, patient-focused decision making. The development of Central Surrey Healthcare is in line with both the national and local drivers for change which can be summarised as: DH review of PCT functions as part of a ‘Fit for Purpose’ review (clear indications that

PCT’s are unlikely to provide services - Nigel Crisp quoted in HSJ 16th June 2005) .

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Development of practice based commissioning and payment by results. Government promotion of patient choice and plurality of provision. Requirement for visible, accountable organisations for the range of services provided. New contracting framework developed by the Department of Health for this purpose. National and local strategies dependence on enhanced primary and community care, the

promotion of self care and a health promoting NHS. A particular focus on role redesign, care pathways and long term conditions.

The legacy of past changes and current financial service issues have resulted in low morale and a demotivated workforce. Radical change is required. Co-ownership of the Limited Company enables a total change in culture and “stands the best chance of realising enthusiasm, energy, expertise and innovation, of creating the ownership, urgency and momentum for rapid service improvement” (J. Griffiths – Appendix G letter). Appendix A presents the detail undertaken to identify what the Limited Company can achieve and why it is best placed to do this. The background to the development of the outline business case and the process to identify the staff’s preferred business model are included as Appendices B and C. National policy teams have been involved in the development of this proposal to ensure that good practice elsewhere is followed and to consider the widest range of options available to the nursing and therapy teams. The Department of Health primary care policy leads, professional leads and the National Association of Primary Care have been particularly helpful and have advised that the proposed development is in line with national policy and given their support. The proposal has the support and backing of the different commissioners (described in Chapter 9 and Appendix G)

1.2 Values

One of the key values for Central Surrey Healthcare is for the staff to feel that they are part of the team ……” just imagine a workforce that wants to come to work knowing they can help patients and really make a visible contribution. That feel valued and cared for, and have the same vision and objectives as their leaders” Staff want an organisation that:-

Really understands local needs Provide services that commissioners wish to choose for their patients Holistic and linked to other services A culture of service to the community Clear mission, clearly articulated Quality at its core - Quality of service, quality of care, quality of management Robust and reliable Protects and nurtures the small, important specialist services

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1.3 Short-term goals Active participation in EEMS PCT’s financial recovery plan, including demand

management and modernisation of emergency and intermediate care services Play a full part in the implementation of the ‘Better Healthcare Closer to Home’ strategy

for Local Care Hospitals, community clinics a Critical Care Hospital and enhanced primary care services, as well as the recommendations emerging from the McKinsey review Development of 24/7 services to prevent admissions and support discharges on any day

and at any time. Implementation of proposed managed care pathways Improvements to patient access to services

1.4 What will be different?

Responsiveness to patients Services explicitly designed around patient needs Improvement in patient information literature developed in conjunction with

patient groups Customer (Patient and commissioner) surveys and action on feedback Development of 24hr , 7 day a week services Performance managed by the PCT to oversee the quality of care

Quality of care In order to compete in the market-place, win business and expand, Central

Surrey Healthcare will focus strongly on the needs of its commissioners Central Surrey Healthcare will have strong incentives to focus on improved

services, including integrated care pathways, health promotion and self-care to drive down inappropriate usage of health care, prevention of unnecessary admissions to hospital and inappropriately long stays in hospital

The company will have a key role in developing strategic partnerships to expand primary and community care, in investing in new technology, in developing services in people’s homes, GP surgeries, community centres and local care hospitals

It will build on close links with GPs, social services, pharmacists, public health staff and voluntary and community organisations

Leadership and management A vigorous dynamic organisation focused on nursing and therapy services will

help to recruit and retain staff, with a strong focus on professional development and education and training

Model of co-ownership which genuinely empowers staff within a formal constitution. Evidence from companies operating large scale co-ownership (e.g. John Lewis Partnership) demonstrate lower staff turnover rates than their competitors and a very high level of commitment to service change and delivery

For a member of staff the culture and function of the organisation will feel very different. (see Appendix A)

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Managed Care Pathways

The incentives of co-ownership in a multi-disciplinary organisation will drive through significant improvement to care pathways.

Key benefits includes improving self referral to reduce GP time, co-ordinated care with single points of access, reduced waiting times, reduces numbers of patients being passed around the system.

Examples of new and effective care pathways for children with disabilities, patient with back pain, patient with a long term condition are included.

1.5 Critical Success Factors The organisation will be successful if it can demonstrate

Improved ability to recruit staff and retain staff The early implementation of managed care pathways e.g. people with long term

conditions, children with disabilities, hospital avoidance programmes The establishment of a 24 hour 7 days a week nursing and therapy service Demonstration of increased numbers of patients being supported by the

community teams with corresponding decreased usage of acute hospital bases services

Ability to respond quickly to commissioner requests for service changes Improved access to services Reduction in demand on GP’s workload Better Healthcare Closer to Home strategy implements Achieving all the above within financial resources

1.6 Examples of proposed care pathways

Stroke patient Patient with backpain Child with disabilities

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Stroke Patient

Current pathway Proposed Pathway

Locality commissioners/PCT have commissioned a stroke unit as per the NSF and CSH provide an integrated approach to care within an agreed care pathway

Patient’s local acute hospital has not stroke unit

H

Patient collapses at home.

Wife dials 999

After some treatment patient is transferred to a medical bed

Patient receives medical care plus therapy input

After some discussion and mixed messages to his family about his recover, patient is discharged home after 4 months

Rehab/therapy is provided in the community and patient is referred to these services

Ambulance takes patient to A&E

As patient improves he manages to get a space on the stroke focus area where his needs are looked after in a slightly more co-ordinated ways

ome after 18 weeks

Patient collapses at home Wife dials 999

Patient spends 1 week in acute unite and is then medically stable

During this week meetings have been held with the family and patient and rehab key worker appointed

At the end of the 1st week patient transfer to the community based stroke unit with agreed rehab goals planned for 6 weeks.

With the key worker managing the rehabilitation and ongoing planning the patient and family are ready for discharge home 6 weeks later

Rehab continues at home where the patient is in the ideal environment to relearn lost skills with the support of his friends and family

Ambulance takes patient direct to acute stroke unit

Home after 7 weeks

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PATIENT WITH BACK PAIN Current Pathway

Consultant Orthopaedic

Or Rheumatologist

GPSI Pain ClinicPhysi

o

Surgery

GP

Diagnostic e.g. X-Ray, MRI

Surgical Appliances

Multiple referrals and waits apatient is passed between and among services

s

Inappropriate use of services

Musculo Skeletal Centre Triage over phone or drop in clinics

Changes to care pathway are managed by the centre

Patient self Refers

Future Pathway

ESP and

Diagnostics

ConsultantFor

Surgery

BiomechanicalPodiatry or

Surgical appliances

Physio

Psychologist Pain Clinic

Reduced GP time Reduced referrals and waits Reduced use of 2˚ care In built pathway Learning Overall a shorter Cohesive patient journey

June 2005 9


June 2005 10

CHILDREN’S DISABILITIES

PAEDIATRICIAN

IRRESPECTIVE OF AGE/CURRENT NEED REFERRALS TO:-

GP HV Dental Podiatry Social Care RESPITE

•ONE POINT OF ENTRY •CHILD CENTRED •Team managers pathway and review referrals

INITIAL CO- ORDINATED

ASSESSMENT

IMMEDIATE CO-ORDINATED INTERVENTION

PLANNED CO-ORD INTERVENTIONS UPTO 2 YEARS AHEAD

CHILDREN WITH DISABILITIES TEAM

PAEDIATRICIAN/GP/SELF REFERRAL /OTHER REFERRER

Proposed Pathway Current Pathway

Physio Speech & Language Dietetics Occupational Therapy Education

A young couple move into the area from London. Their 2½ year old daughter has a syndrome that results in a range of complex needs affecting a number of different areas of her development. Matters are complicated by the fact that both parents are profoundly deaf and their first language is British Sign Language. The little girl had over 20 professionals involved in her care in London. Each of these contacted their local counterpart who in turn had to communicate with the mother, mostly by text message. The SLT in Epsom phones to make an appointment to see the family – the day she offers is in a week where the family already have appointments on 4 days that week…….. What a difference a co-ordinated and planned service would make………


2. The Limited Company Detailed work was undertaken with advisors from the Department of Health and management consultants as to the business models available for consideration. Appendix B describes in detail the options available, those selected for further scrutiny and the option appraisal process. The Reference Group considered several options but with the express objective of staying within the NHS family. This could be achieved by:

developing a separate directorate in the PCT: dividing into locality structures within the PCT: or creating a separate provider unit outside of the PCT for the delivery of nursing

and therapy services.

There were also a range of options regarding the separate provider unit. However, several options could not be pursued either due to a lack of legislative framework or to insufficiently developed local partnerships at present. The preferred option was identified as the establishment of a limited company which could use the new contracting opportunities through Specialist Personal Medical Services. The company could be:

a wholly owned subsidiary of the PCT; or be wholly owned by the employees e.g. nursing and therapy staff

The Limited Company with employee ownership option was chosen by the representative staff group as it was considered to offer:

organisational stability in an ever changing NHS professional leadership and focus flexibility to respond to new developments, commissioners, patient needs change in culture thus increasing staff involvement and motivation opportunity to move to formal contracts, as with primary and secondary care value for money

The chosen option protects NHS pensions and terms and conditions and will operate as a ‘not for profit’ organisation

2.1 Establishment Central Surrey Healthcare will be established as a not for profit private Limited Company and will be owned by its shareholders. There are various options under consideration as to how the shares will be held. The shareholders can be the staff employed by the Company, who can pay a nominal amount (ie £1) for a share in the company. Shares will only be held by employees during the course of their employment and will be transferred back to the company on leaving employment with Central Surrey Healthcare. Alternatively shares can be held in Trust with a Board of Trustees. Those eligible for shareholding of the Company could be:

Employees of the company Shareholding will cease when a member of staff leaves the organisation.

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Consideration needs to be given as to representation of partner organisations, for example GPs, social services managers. the potential for conflict of interest will be avoided by ensuring that shareholders

are not involved in the commissioning of services.

The shareholders will meet at least once annually to approve the annual report and accounts of the company and the appointment of Auditors, and discuss the company’s forward plans for service development. The Company will be registered with Companies House and will be subject to the full range of responsibilities set out in company law. These include the duties and responsibilities of directors, the rights of shareholders and the requirement for annual audited accounts and other reporting responsibilities. The Board of Directors will be accountable to the staff, the co-owners of the company for ensuring that it develops in way that is consistent with the needs of its local community of stakeholders, and that it carries out its work in a way that is compliant with its objects. Partners/shareholders will have the right to be nominated as executive directors, to receive information about the company’s activities and to be consulted on service improvement. The Company will establish and maintain a register of its partners/shareholders. There will be no limit on the number of people who can register as partners/shareholders if they meet the eligibility criteria.

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3. Integrated Governance

3.1 Corporate Governance NHS governance has been defined by the Audit Commission as “the systems and processes by which health bodies lead, direct and control their functions in order to achieve organisational objectives and by which they relate to their partners and the wider community.” Governance arrangements for all Boards, private and public sector, have been strengthened in recent years in the light of the Cadbury Report (1992), the Turnbull Report (1999), and the Higgs Report (2003). The governance arrangements for Central Surrey Healthcare will be developed in accordance with the Institute of Directors’ Standards for the Board, which are derived from all three reports, and include:

1. Clarity over which matters are reserved to the Board for decision 2. Timely information 3. A formal, transparent procedure for the appointment of new directors 4. Appropriate training for directors 5. The role of the company secretary 6. A clearly accepted division of responsibilities between the chair and the managing

director/chief executive, to ensure a balance of power and authority, so that no one individual has unfettered powers of decision

7. Independent non-executive directors comprising not less than one third of the board In addition, three crucial public service values must underpin the work of the NHS, and therefore of Central Surrey Healthcare:- Accountability Probity (and honesty and integrity) Openness

Central Surrey Healthcare’s Board meetings will be held in public, any conflicts of interest of Board members will be detailed and registered, and the company will fully comply with Section 11 of the Health and Social Care Act 2001 as regards consulting the Overview and Scrutiny Committee, and patients and the public on services planning and operation as well as in the development stage of proposals for change. There are four strands of NHS governance which can be brought together into an integrated governance framework: Clinical governance Risk management Controls assurance Financial and corporate governance

Central Surrey Healthcare will follow Department of Health guidance on all aspects of governance. Learning will be sought from other companies of similar size/turnover.

June 2005 13


Trustees/Non Executive Directors

The range of options open to the Company for Governance arrangements will be explored during the transition period. The Company will need to ensure that it has a robust but cost effective structure. The various models presented in Foundation Trusts and the proposed community interest companies will be among those researched.

Constitutional issues

The company will have:

A Memorandum and Articles of Association Standing Orders and Standing Financial Instructions

These documents will include: The requirement to focus on the promotion of the health of and the delivery of care

to NHS patients The application of clinical and service quality standards The duty of partnership with other NHS and social care bodies The duty to participate in the education and development of NHS staff The financial duties under which the company will operate The provision of management information

3.2 Clinical Governance Central Surrey Healthcare will establish a robust system of accountability for

continuously improving the quality of services and safeguarding high standards of care. An environment will be created in which excellence in clinical care will flourish. Systems will be in place for all 7 pillars of clinical governance using identified clinical governance leads as champions.

1. Clinical Effectiveness: Evidence based practice will be at the core of service

delivery 2. Risk Management: Robust systems including the use of datix will be in place to

develop a culture where risk is understood, monitored and minimised and where staff learn from mistakes. A full list of regulatory requirements and registrations will be covered in the full business case including health and safety standards.

3. Education and Training: Continuing professional development will be key to extending skills and establishing new roles

4. Patient and Public Involvement: In an environment of increasing patient choice Central Surrey Healthcare will place a high value on involving patients, public and stakeholders in service design and development.

5. Using Information: Central Surrey Healthcare will continue to use RIO, further developing its use and function. Caldecott principles will be adhered to.

6. Clinical Audit: Settings standards and monitoring and evaluating performance against them as an opportunity to develop will be essential.

7. Staffing and Staff Management: Central Surrey Healthcares most valuable resource is its staff. Their wellbeing will be paramount and Improving Working Lives practice plus standard would be achieved. The impact of co-ownership will be critical to recruitment and retention.

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Central Surrey Healthcare will need to consider whether Clinical Governance Services can be provided from another organisation e.g East Elmbridge and Mid Surrey PCT via a Service Level Agreement to ensure that support is received from an appropriately sized department. It would also be of benefit to reduce the amount of unnecessary change during the establishment of the company.

An appropriate structure would be established which will ensure involvement in

governance at all levels throughout the organisation and which will seek to integrate the different strands of governance into an integrated framework.

The Company will expect to be subject to some form of regulatory inspection process (not yet legally required but DH looking at this).

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4. Service Delivery Central Surrey Healthcare will deliver services specifically to meet the requirements of its commissioners and the patients and clients they serve. In the current health economy the Better Healthcare Closer to Home strategy is one of the most significant drivers and encompasses a wide range of key national targets. Also key are the emerging results and news from the work of McKinseys across the SHA. 4.1 Better Healthcare Closer to Home Better Healthcare Closer to Home is the overarching strategy for the Primary Care Trust. Its focus on maximising the potential of prevention and health promotion, of self-care, of care in the home, in primary and community services, and in Local Care Hospitals fits closely with Central Surrey Healthcare’s vision. The Company will play a key role in the delivery of the Better Healthcare Closer to Home. Key areas for involvement include: The implementation of the Unscheduled Care Strategy for urgent care and same day care, with the aim of meeting the target of reducing unnecessary acute hospital admissions by 25% per annum

Screening of all patients Urgent treatment centre at Epsom Pathway co-ordination Intermediate care hospital – emergency nurse practitioners Supporting the direct referral process from expert patients, carers, GPs, ambulance

service, other community services The Same Day Care Strategy to reduce A&E attendances by 50%

‘Minor A&E’ attendances managed by community clinicians Improved management of long-term conditions (reduced admissions, reduced length of stay, more co-ordinated patient pathways through care and case management, use of the expert patient programme)

Diabetes COPD Stroke Rapid access chest pain service

Estate rationalisation strategy

To ensure optimal use of GP premises, community clinics and Local Care Hospitals

4.2 Service delivery structure The organisation of service delivery will need to reflect three key themes:

The supply of appropriately skilled staff supported by strong professional leadership.

This will be the core of the organisation to ensure recruitment, retention, skill mix and competency

Delivering services around users to enable integration and multidisciplinary teams around care pathways

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Providing services that fit with the location/ and Locality working with

commissioners and GP organisations Overarching these themes will be the need to ensure value for money, financial viability and competitiveness with a business culture

4.3 Staffing The Company will employ a range of nursing and therapy staff, registered and unregistered together with support and administrative staff. The current head count (reflecting the historical moratorium) enforced vacancy levels for the above staff is:-

Team Head count Nursing Teams 474 Therapy Teams 240 Total 713

The historical funded establishment/head count is higher than this but difficult at this stage to quantify. Community Dental Services have been full involved in the workshops and considering being part of the Company. The nature of their service also lends its self to other options which are also being considered. Family planning services are considering whether they would be better placed with health promotion as part of a sexual health service. Since the Board meeting in January, some services have joined the PCT e.g. prison healthcare, some mental health services. These services may be very appropriate for inclusion and will be discussed on a case by case basis. There are a number of other staff/support services that are essential to service delivery e.g. clinical governance, HR, complaints, finance, information, pay roll etc. All these services will need to be identified and evaluated to determine the best option. Options that could be considered may depend partly on the percentage usage between commissioning and providing. Potential options include: a). service remains with PCT and Central Surrey Healthcare has a Service Level Agreement

to receive the service from the PCT b) service transfers to Central Surrey Healthcare with a Service Level Agreement for any

services the PCT requires c) Central Surrey Healthcare opts to purchase a service from a new provider

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4.4 Leadership and management Central Surrey Healthcare will have a management structure which will build on the need for strong professional leadership, a focus on business skills, high calibre financial acumen and the development and maintenance of good relationships with our commissioners. The management costs will be kept as low as possible to ensure maximum possible investment in our staff and a culture that supports and enables the staff. 4.5 Skills and competencies All staff will receive statutory and mandatory training and will undertake continuing professional development and clinical supervision. Service innovation will require the development of appropriate skills and competencies. The opportunities provided by Agenda for Change will be harnessed.

4.6 Employment Staff transferring into the organisation will be covered by TUPE arrangements. Continuous service, which determines eligibility for rights and benefits, will be preserved. Once established the company will recruit and employ its own staff aided by governance arrangements that will reinforce high standards of employment practice. The culture of co-ownership and the innovative styles of service delivery is expected to improve recruitment. In this area, once staff join the organisation there is a high degree of stability.

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5. Financial Plan

5.1 Central Surrey Income Currently the services to be included in Central Surrey Healthcare have a total budget allocation of nearly £30m; this represents less than 10% of the PCT’s total resource limit of £314,283,000. Income from the service is sourced mainly from the PCT, but includes income from other organisations and central allocations from the Department of Health.

PCT Financial Allocations 1% Prisons

Central Services 3%

Prescribing 12%

Primary Medical Services 12%

10% Community Services Primary Care Development Fund 1%

Commissioning 60%

PCT Central Services 1%

Current Sources of Income for Central Surrey Healthcare

2004/5 PCT Funded 20,676,985 RNCC 3,692,623 Continuing Care - Adults 2,548,578 Continuing Care - Children 787,933 SWELOC 324,678 Local Education Authority 231,415 Epsom & St Helier 1,583,533 Central SH LTD 29,845,745

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What will it cost to set up? Initial start up costs still need to be worked through, especially with regards to actual service being provided, premises and location of services, management costs etc. These will be identified as part of the Transition Plan. Risks Risks arise around the uncertainty of the cost of Management Costs (i.e. support of the PCT), rental of premises and equipment. Uncertainty around whether the service is fully funded in its current form. Financial instability can arise if Commissioners and independent organisations cease to contract with the Limited Company. Given the current problems with service provision and the challenges of moving to limited company, serious consideration needs to be given to a phased support plan over an agreed period of time. This will need to include a plan to manage redundancy risk. Management Costs The overall costs of the support services provided by the PCT with regards to Management Input, Finance, Information, Human Resources and Procurement need to be discussed in detail with the PCT. The Company will look to use shared services wherever possible and appropriate.

Value for Money An understanding of the value for money of the services provided by the Company will need to be developed with the commissioners. This will not just describe the costs of the services but what new and innovative services can be delivered across care pathways.

The company will consider joint ventures with other local health and social care providers (for example GP providers) and Public Private Partnership arrangements with other organisations.

Information

The nursing and therapy services input data onto the RIO information system. This system is relatively new to the PCT and still needs considerable work for it to deliver the level of information that both the commissioners and providers require. Discussions with the PCT’s information analysts suggest that the RIO system should be retained by Central Surrey Healthcare as it has been developed to meet the Department of Health requirements and has the potential functionality to enable it to be adapted to meet the needs of the business. By continuing to use the PCT systems, Central Surrey Healthcare will be “future-proofed” against developments in the national program and Connecting for Health. Coding will be developed in line with national policy and is likely to be to the SNOMED standard

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It will be essential to ensure that reports are produced as required to meet the differing needs of commissioners, including statutory requirements, as well as enable both managers and staff to understand activity levels and the outputs of the services. The system must supplement and support the business processes and staff of Central Surrey Healthcare, and assist in the improved delivery of patient care. As yet there is little work being undertaken by the Department of Health on the definition of outputs in community services (a necessary precursor to developing a national tariff). Interest in involvement has been expressed to senior staff within the Department of Health’s Policy Unit to ensure that work is not undertaken in isolation. Maintaining RIO and using the PCT’s information services will also ensure full engagement in developments around ‘Connecting for Health’

5.2 Capital Assets The ownership of NHS Estates can only transfer between NHS statutory bodies e.g. NHS Trusts. In the case of new NHS organisation e.g. PCT’s in 2002, establishment orders include arrangement to transfer assets. Central Surrey Healthcare Ltd is a ‘within the NHS family’ as it has an SPMS contract and is not for profit enabling access to NHS Pensions and Terms of Conditions. However it is not an NHS body, it is a separate legal entity. As such assets (buildings) cannot be transferred to it. Buildings will therefore remain with the PCT and service/financial agreements will need to be developed to enable the company to continue to operate from current premises. The ownership of equipment, furniture and other items will need to be discussed particularly where this has been a gift to the health service. Legal advice may need to be sought. Issues regarding depreciation, replacement costs will be discussed with the PCT and with auditors. 5.3 Trust Funds Legal advice will need to be sought on the transfer of clinical trust funds.

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6. Staff and Stakeholder Engagement 6.1 Staff It is important that there is broad support from staff affected by new proposal. Staff newletters, a series of staff briefings and regular attendance at Staff Side meetings have ensured regular communication with as many staff as possible. The 35 staff representatives on the Reference Group have ensured that their colleagues have been kept up to date as issues have been discussed and decisions made. Over 230 staff have been seen at the briefing sessions held over the last few weeks.

6.2 Stakeholders/Commissioners

A series of meetings has been held with commissioners and other stakeholders. It was not felt appropriate to consult with patients directly at this early stage. Chris Phipps, the Patient and Public Involvement Chair, has been a member of the Steering Group A table (Appendix G) identifies the stakeholder visited and their response to the proposals.

7. Next Steps The Transition period will require a robust and detailed plan of work which will be overseen by an Implementation Steering Group chaired by the Chief Executive. The Governance process will be paramount. The most critical step is the appointment of suitable leadership for the development of the proposal. The identified lead will need to establish a project team. The work streams will include Human resources identify staff, transfer arrangements, formal

consultation Finance identify budgets, contract currency,

overheads, SLAs etc Cash flow plan, financial plan

Establishment of the Company Preparatory legal advice, establish company corporate identity, accommodation.

Information information needs, infrastructure audit, RIO functionality, Information governance

Organisational development Principles to underpin organisational structure and culture, appoint shadow senior management structure/governance structure

Capital Assets Equipment, leases, depreciation on asses, discussions with auditors,

Communications Communication plan, marketing plan Governance arrangements Business plan, risk assessment

June 2005 22


8. Communication A newsletter has been produced every few weeks to ensure that staff are kept up to date with developments and are aware as to the names of their Reference Group members. It is proposed to continue this Newsletter during the Transition period as well as hosting a series of Briefing events and workshops to examine the issues presented by the development of the Company. Staff will have a formal 12 week period of consultation on their transfer to Central surrey Healthcare which will be undertaken by the PCT’s Human Resource department. The staff side representatives have been involved through out the process and the Chair has been a member of the Reference group and has attended the majority of the briefing events. A communications strategy will be developed to ensure the involvement of patients, public, staff, commissioners and stakeholders.

9. Recommendations for the Board Applications for Foundation Trust status are assessed on the following areas.

Responsiveness to patients Quality of care Leadership and management Commitment and support of staff Partnership working and stakeholder support Financial position Human resources strategy

Central Surrey Healthcare identifies the potential to deliver benefits in all the areas.

The Board is asked to Agree that the preferred option for nursing and therapy services for the PCT

is for a Limited Company to be established which will hold Specialist Personal Medical Service contracts with the PCT.

Agree to support further work to deliver the preferred option including assessment of the impact on the PCT and a detailed financial analysis.

Authorise that a Transition Plan (identifying necessary resources) be developed which will be agreed and then overseen by the Implementation Steering Group.

Support the PCT in proceeding with formal consultation with the nursing and therapy teams concerning transition and transfer arrangements.

June 2005 23


Frequently Asked Questions Q Why haven’t you balloted staff on the proposal? A A group of 35 senior staff have been closely involved in the development process and

the option appraisal. All staff have been given the opportunity to learn about the options and the reasons for change. The Staff Side have given all staff the opportunity to express any concerns. All these processes show staff support.

Staff Side is formally contacting staff to enable them to determine the level of staff support.

Q Why aren’t there fully-developed proposals for clinical governance? A Because these will form part of the Full Business Case and need to be developed by the

shadow Chief Executive and Board. Clinical governance is flagged as a crucial issue in the proposal and staff are enthusiastic about a clinical governance system designed around their needs and those of the localities.

Q` Doesn’t this proposal increase risk to the PCT? A As with the development of practice based and locality commissioning, risk and

opportunity go together. As with locality commissioning, risks will be minimised through the development of a strong governance structure and clear accountability for the performance of the new organisation. The aim is to provide every reassurance to the PCT that will be able to minimise risk while harnessing the latent enthusiasm and commitment of staff which the development work has uncovered.

Q What do you need to get the company of the ground? A A transition plan is being developed. We need interim leadership, together with strong

human resources and financial support. Q How will this proposal help the PCT’s financial recovery plan? A The development process has uncovered, not surprisingly, a lack of clear financial

information and lack of financial understanding amongst staff. The establishment of a separate organisation with strong staff ownership will very substantially increase the financial awareness and commitment of staff.

Q Are you likely to need to pay Corporation Tax and /or VAT ? A Corporation Tax is only payable if any profits are paid out as dividends or clearly seen as

profit to the company. If a linked charity was established profits could be donated to the charity and any Corporation Tax liability avoided.

VAT is not chargeable on medical services and so should not be applicable to the services provided by the Company. The requirement to pay VAT is not influenced by the legal status of the organisation.

June 2005 24


Appendix A

Demonstration of Value Proposition

Analysis of Drivers for Change

Change in PCT’s role - to one of strategic commissioning, accountability, partnership development and support

1. With the introduction of practice-based commissioning, PCTs are increasingly delegating

commissioning to GP practices in localities 2. GP practices are in turn setting up more formal locality organisations, such as EDICS. 3. Development of a plural market 4. It is increasingly anomalous for PCTs, as strategic commissioning organisations, to be

managing directly nursing and therapy services – they are now the only services locally without an independent organisation

5. Other Trusts and companies in the area want a nursing/therapy organisation in the health care market place to do business with

6. It does not make sense for GPs to be contracting with the PCT for nursing and therapy services that their patients need – when those same GPs are accountable to the PCT for both commissioning and service delivery.

7. Movement towards a tariff based economy 8. Contestability.

Impact of Patient Choice

The focus of government policy is to promote patient choice alongside collaboration and partnership

Patient choice requires strong provider organisations The public, other providers and commissioners need visible, accountable organisations

for the range of services required EEMS nursing and therapy services have a wide range of commissioners in addition to

the PCT itself: acute trusts, other PCTs, South West Elective Orthopaedic Centre, Surrey County Council Children’s Services, local Education Authorities and potentially others in the future such as prisons, voluntary organisations, Boroughs and mental health providers

Appropriate forms of contract and organisation have been developed by the Department of Health

Specialist PMS is a type of PMS Contract especially suitable for nursing and therapy

services: it does not require a list of registered patients All types of PMS can set up a limited company.

June 2005 25


Service development

National and local strategies depend on enhanced primary and community care, the

promotion of self-care, and a health-promoting NHS supporting full engagement by people in their health

A particular focus on role redesign, care pathways and long-term conditions

All these policies and strategies require a strong organisation for nursing and therapy services.

June 2005 26


Services Currently Provided The PCT’s nursing and therapy teams provide a range of services which have been developed in part as a response to commissioners’ requirements and historically because of the different approaches of the organisations that contributed to the development of the PCT, which were:

Epsom and St Helier NHS Trust Surrey Oaklands (previously Kingston and District Community Trust)

Surrey & Sussex Healthcare NHS Trust Croydon & Surrey Downs NHS Trust

Services Provided Commissioners

District Nursing EEMS PCT Health Visiting EEMS PCT School Nursing EEMS PCT Public Health Nursing – breast feeding advisor,

EEMS PCT

Child Protection – specialist team EEMS PCT Specialist Nursing – continence, respiratory, Parkinsons’ , Multiple Sclerosis

EEMS PCT

Intermediate Care EEMS PCT Inpatient – rehabilitation EEMS PCT Continuing care assessment – adults and children Free Nursing Care assessments

EEMS PCT East Surrey PCT

Paediatric home nursing EEMS PCT Physiotherapy EEMS PCT

SWELEOC Epsom & St Helier

Occupational therapy EEMS PCT SWELEOC Epsom & St Helier NHS Trust

Speech & Language therapy EEMS PCT Surrey County Council Epsom & St Helier NHS Trust

Dietetics EEMS PCT Epsom & St Helier NHS Trust

Podiatry EEMS PCT Epsom & St Helier NHS Trust

Neuro – rehabilitation EEMS PCT

June 2005 27


Outline Plans for Human Resources Management Support for service development and organisational goals: links between service

development strategy and HR strategy, listening to staff and involvement of staff in plans for shaping services

Consideration of wider system reform HR mainstreamed across organisational strategies Aim to be model employer: o high-quality working environments o flexible working and child care o innovative recruitment strategies o learning and development not only for own staff but wider health care system

Staff and stakeholder involvement will shape the final HR strategy Participatory working culture Pursuit of Investors in People accreditation Improving Working Lives status Continue to access Strategic Health Authority Workforce Development support and

funding.

June 2005 28


Staff Vignette Working in healthcare now and in the future Sarah is an experienced senior district nurse who has worked in the NHS for 15 years. She has three children still at school and is juggling the demands of a challenging job with a busy family life. During her NHS career her employer has changed several times as a result of organisational change, Trust mergers and service transfers. She increasingly feels that the constant change is forced on her and is struggling to see the benefit for her or her patients. More recently the financial difficulties in the health system in her area have resulted in a vacancy freeze. She is now expected to cover an increasingly impossible caseload or agree to reduce services to patients and she finds both of these unacceptable. She has some ideas about how her service could work better but the pressure on services is so great that there is no time for service development. Staff are more frequently ill and this places a further burden on the remaining team. An additional pressure is the increasing number of patients being discharged home from hospital much earlier. Sarah regularly comes into work to find that although her diary is already full there are several urgent new referrals and she is left trying to cope. It takes half the morning to sort out the new referrals some of which were inappropriate anyway. She doesn’t understand why her team are expected to take on more and more work without appropriate staffing. The neighbouring trust has just had a new post funded and they pay higher London weighting. Sarah is very loyal to her patients and her colleagues and likes working so near to home. However she is now seriously considering whether it is time to move on…….. In the future with Central Surrey Healthcare Sarah is an experienced senior district nurse who has worked in the NHS for 15 years. She has three children still at school and is juggling the demands of a challenging job with a busy family life. She is a co-owner/partner in Central Surrey Healthcare. As a partner she has signed up the roles and responsibilities she will play in the organisation. She knows that her contribution directly affects the performance of the company and her ability to derive benefits from it. The ethos of the company is unlike anything else she has experienced in the NHS and as partners have worked to improve the effectiveness of services she has received an increasing number of benefits. She feels increasingly loyal to the business and is thriving on the genuine co-ownership. She finds that staff are enthusiastic to make changes to services and see a direct relationship between their efforts and the impact this can have on their patients and themselves. Sarah is an elected member of the clinical council and represents partners’ views on key policy decisions. Like all staff she knows exactly what the business is there to do and is up to date on how the business is going. She knows the detail of the contract that has been signed between Central Surrey and the local GPs and has up to date information on the monitoring of the contract. She is fully aware of the pathway that has been agreed and as a result there are only occasional emergencies enabling Sarah to plan her caseload more efficiently. Sarah finds the communication in Central Surrey Healthcare really helpful and the open culture promotes a climate of learning. Even tough the pressures of work can still be challenging Sarah finds that everyone always seems to find a way to make it work. One of Sarah’s colleagues is moving to Manchester soon and she is not surprised that two of her friends in a nearby Trust are already asking her about the vacancy……

June 2005 29


Appendix B

Options Study - Corporate Entities Option Considerations As part of option to

further review Part of PCT as provider arm

Advice from the SHA and Department of Health suggests that not a long term option. PCT will need to separate .commissioner v provider functions. Likely to be able to remain with for 2-3 years

YES

Community NSH Trust No legislative framework in place to allow development as was replaced with establishment of PCTs. Policy advisors at DoH state focus on new opportunities. Unlikely to revisit legislation to support cone community Trust’s establishment

NO

Care Trust Supported in national guidance and being developed where unitary .authorities and co-terminus organisations. Surrey County Council not considering in near future. Proposed model must build in flexibility to allow changes if become an option

NO

Children’s Trust Surrey County Council has considered options but at present is only considering our relation to a commissioning today and with a limited remit i.e. disabilities, paediatric therapies, CAMH. No plans to develop Surrey wide provider Trust due to size and complexities of the area.

NO

Community Interest Company

Community Interest Company will provide a legal framework to develop Community Interest Companies model, such as social enterprise models, which have been considered in recent time. However the Regulation was only appointed in April 2005 so development on this has not yet started. It is expected that the good practice aspects of this model be embraced and considered as part of option in the future.

NO

Foundation Trust Not available for community services at present NO Limited Company A separate legal entity.

Can operate SPMS contracts and so enable NHS Pensions and Terms and Condition to be secured

YES

Partnership or other arrangement with GP Limited Company

Discussed with GP colleagues. Due to the size and complexities of the nursing and therapy services was not considered an option by the Partnerships or Limited Companies within the PCT.

NO

Re-integration with Acute service provider

PCT has 3 main acute providers….No single obvious choice. Not in line with BHCH. Historical evidence re benefits is week.

NO

June 2005 30


Organisational options considered

1. Locality model within EEMS PCT

Staff would continue to be directly managed by the PCT, and would be divided according to the three Locality Commissioning Groups under Locality Managers. This would align staff with the Locality Commissioning process agreed to support practice-based commissioning. It would not clearly separate out the PCT’s commissioning and provider responsibilities.

2. Arms-length business unit within EEMS PCT

Nursing and therapy services and staff would become a separate unit or directorate within EEMS PCT, with a business/general manager, and internal service-level agreements with the Localities. The services and staff would continue to be the direct responsibility of the PCT, and the PCT Chief Executive would remain the accountable officer. This option creates an artificial commissioner/provider split.

3.Wholly-owned subsidiary of NHS body – EEMS PCT or other

A Limited Company whish has one share which is held by an NHS body e.g. the PCT. Decisions and policy changes would be made by the Board The Company would be owned by the NHS body and would not therefore have its own membership or separate accountability.

4. SPMS Limited Companies for nurses and therapists separately The companies would be separate legal entities, owned by members, which would be responsible for contract delivery. The companies would have SPMS contracts with the PCT. Chief Executives and Boards of Directors would run the companies on behalf of members. The companies would be within the NHS family.

5. SPMS Limited Company for nursing and therapy staff

As 1.4 but a single company for all nursing and therapy staff.

6. Private company – Alternative PMS An option designed by the Department of Health for commercial providers and the voluntary sector. Similar to an SPMS Limited Company but would not be able to ensure NHS terms and conditions of service for staff.

June 2005 31


t

Option Appraisal

An option appraisal was undertaken by the Reference Group on April 25th 2005. The options appraised were the six listed above in Sections 5.1- 5.6. Hurdle Criteria The option appraisal set the following hurdle criteria which had to be met by all options:

• Engagement of stakeholders1 o All the options would enable strong engagement of stakeholders

• Staff training and development2 o All the organisational options would enable a strong focus on staff training and

development • Patient and public involvement3

o All the options would enable even greater accountability to the local community and enhanced opportunities for patient and public involvement

• Protection of staff terms and conditions (including NHS pensions) o Under all options, existing terms and conditions will be preserved and staff will

have access to the NHS pension scheme and associated benefits on the same basis as NHS employees.

• Deliverability within time frame o No differences could be identified in the ability to deliver any of the

organisational options by March 2006. The Alternative PMS Private Company option did not meet the hurdle criterion for protection of NHS staff terms and conditions.

Other assessment criteria Nine other criteria were used: Integrated care pathways (three inter-rela ed criteria)

Promoting and facilitating pathway development from prevention to palliative care, including the ability to innovate and provide flexible solutions Providing appropriate skills and staff levels to resource pathways Promoting interdisciplinary and inter-agency communication and working

1Engagement of Stakeholders 2 Staff training and development 3 Although engagement of stakeholders, staff training and development, and patient and public involvement were set as hurdle criteria to be met by all organisational options, further analysis during the development of this OBC has suggested that the limited company option would, in fact, promote stronger performance on all three of these important criteria.

June 2005 32


f

Protection and development of specialist services Specialist services such as nursing for respiratory conditions, Parkinsons’ or Multiple

Sclerosis, or speech and language therapy, are very important to the future development of primary, community and intermediate care and need to provide for a wide geographical area. Which of the organisational options offers the best likelihood of protecting and developing these services?

Recruitment and retention o staff One of the greatest current threats to the effective delivery of community and

intermediate care services is the difficulty in recruiting staff, partly because of close proximity to London PCTs which can offer higher salaries This criterion therefore concerned the relative focus of the different organisational

options on nursing and therapy services, how far staff would have ownership of service improvement processes, and parity of organisational status with other health care providers Which organisational option would be best able to offer new rewards and incentives

and explore innovative ways of working in partnership with staff to deliver local services?

Value for money Improve value for money, efficiency and competitiveness by a strong focus on

financial viability, detailed costing of services, financial transparency and accountability At present, the cost of services provided by nursing and therapy staff is not clearly

understood and therefore awareness of the importance of financial management is limited – which organisational option would achieve the greatest improvement in this undesirable situation?

Efficiency and competitiveness See ‘value for money’ above

Future proofing Which of the organisational options would be most flexible and able to adapt to

rapidly-changing NHS policies and processes, whilst providing a secure future for staff?

Robust leadership and governance There is a well-established association between strong managerial and clinical

leadership and improved delivery of services, recruitment and retention of staff and strong financial management. Which of the organisational options would be likely to provide strong leadership and governance?

June 2005 33


Option Appraisal - Scores

Individual’s scores added together within groups

Locality Model

PCT Directorate

Wholly owned subsidiary

SPMS Ltd Co within NHS Nurses, Therapist

SPMS Sep Ltd Co for diff. Prof groupings

Group 1 104 124 126 182 171

Group 2 61.5 87 112 158 125.5

Group 3 105 132 169 200 181

Group 4 83 112 110 152 153

Group 5 107 114 144 229 177

Total 461 569 661 921 808

The highest scoring option was for an SPMS Limited Company for all nursing and therapy staff, with SPMS Limited Companies for nurses and therapists separately being the second preferred option. It is perhaps worth stressing that the Chief Executive of the Limited Company would be the Accountable Officer – this transfer of financial accountability is not achieved by any of the other organisational options

June 2005 34


Appendix C

Business Case Generation Process

In September 2004 a discussion paper on the future of commissioning was presented by the Chief Executive to the PEC and Board. The paper, Developing Commissioning in Surrey and Sussex, made reference to the newly issued guidance on Practice Based Commissioning and the requirement to devolve commissioning to GP practice or locality level where requested by April 2005. The paper highlighted the need for the PCT to respond at some speed to the changes and to ensure that whole system reform could be achieved through new commissioning models. The paper also made reference to the potential development of Specialist Personal Medical Service (SPMS) contracts to support service delivery. SPMS is defined in the Department of Health guidance issued in December 2003 Sustaining Innovation through New PMS Arrangements, which came into force in April 2004. The paper was one of a series which described a re-structure of the current management within the PCT to enable the proposed commissioning model to be developed. The proposals also included re-structuring the way in which the PCT’s provider services were managed. It was suggested that they be divided into three groupings in the three proposed locality areas. The proposals for the provider services met with concern from staff and stakeholders. The Board agreed in January 2005 that a review should be undertaken of the future options for the provision of nursing and therapy services with a focus on exploring the Specialist PMS contractual route. The preferred option was to be presented to the Board in the summer. A series of workshops has been held with a Reference Group, thirty five senior nurses and therapists, to explore the various employment models and the business content. A strong emphasis was placed on understanding the needs of commissioners and the service improvements required by national and local strategies and policies that staff wished to see made.

June 2005 35


. Advice and consultancy input has been sought from the Department of Health, the National Association of Primary Care, professional bodies and

a

Terms of Reference for Project Aim

Undertake action requested by The Board on the 11th January to support the PCT’s nursing and therapy staff to examine “the potential of SPMS (Specialist Personal Medical Services) for nursing and therapy staff”.

Objectives

• Assess the advantages and disadvantages to stakeholders (particularly staff and commissioners) of the use of SPMS contracts for the provision of nursing and therapy services.

• Involve staff and stakeholders in discussions throughout the process to ensure ownership of the outcome.

• Identify the range of employment models available – both where SPMS

contracts possible and compare with those where SPMS not an option.

• Identify the preferred employment model • Present the outcomes as an outline business case and recommendations for

consideration to the PCT Board in July – option appraisal and initial analysis of the processes needed to establish a robust new organisation.

Project Sponsor: Alan Kennedy Project Team: Tricia McGregor, Jo Pritchard,

Management consultant support –
other gencies.
June 2005 36


Reference Group The Reference Group included senior nurses and representation from specialist nursing, therapy leads for the five therapy areas plus specialist areas; the Chair of Staff Side; training and development; health promotion and community dentistry. The Group developed a vision as to the services that staff wished to provide, the way in which they wished to be employed and the values that they held as essential when considering future employment models. The options for future employment and the complexities of different contractual routes were explored in some detail. The workshops culminated in a review of options, the work to date and an option appraisal on April 25th 2005.

Steering Group Once the Reference Group had identified a preferred option a steering group was established. The purpose of the Steering Group has been to oversee the development of the Outline Business Case. Membership of the Steering Group: Alan Kennedy (Chair) – Chief Executive Tricia McGregor – Director of Therapies Malachy McNally – Director of Finance Iain McNeil – Medical Director/Director of Service Delivery

Maurice Nicholls – Non Executive Director Chris Phipps – Public & Patient Involvement Forum Jo Pritchard – Director of Nursing & Primary Care Clare Tanner – Director of Human Resources

Commitment and support of staff One of the main advantages of the preferred option is that it should enable nursing and therapy staff to have more control over the improvement of services, harnessing their creative energy and expertise, be they clinical staff or managers. It is therefore essential that staff are fully committed to the preferred option. They have been heavily involved in the work undertaken so far.

Thirteen staff briefings were held across the PCT and were attended by over 230 staff. Staff were given a summary of the work by the Reference group, the context in which this has happened and the detail of the preferred option for future employment. Questions were asked both at the briefing sessions and in writing. These questions have been recorded and answers given in one of the newsletters that have been sent to staff at regular intervals. The themes and issues raised are listed in Appendix H.

Stakeholder Meetings Considerable effort has been made to meet with current and potential future stakeholders to discuss the proposals. Meetings have included acute Trust chief executives, neighbouring PCTs, the Head of Children’s Services, the lead for Adults and Community care, Borough and District Chief Executives, representatives from all the PCT’s emergent locality commissioning groups, the Strategic Health Authority and the Department of Health. All have been extremely supportive of the proposal (Appendix G). The GP commissioners have been clear that they require a robust supply of nursing and therapy service in the future and that this is the most appropriate route to achieve both current service provision but more importantly enable them to undertaken more radical system changes as outlined in Better Care Closer to Home.

June 2005 37


Appendix D

Corporate Governance – Principles

Corporate governance is the process by which company objectives are established, achieved and monitored. It is concerned with the relationships and responsibilities between the board, management, shareholders and other relevant stakeholders within the legal and regulatory framework. The company will adhere to corporate governance principles of responsibility, accountability and transparency. Responsibility of directors, who approve the strategic direction of the organisation within a framework of prudent controls and who employ, monitor and reward staff. Accountability of the board to shareholders, who have the right to receive information on the financial stewardship of the business and exercise power to reward or remove the directors, entrusted to run the company. Transparency of information with which meaningful analysis of the company and its actions can be made. The disclosure of financial and operational information and internal processes of management oversight and control will enable stakeholders to understand the organisation. Further, the company will adopt an inclusive ‘stakeholder’ approach with responsibilities and accountability – not just to employees/shareholders – but to the wider community in general.

June 2005 38


Appendix E

SWOT Analysis of Business Case As an additional check, a SWOT analysis was undertaken of the preferred option of an SMPMS Limited Company.

Strengths

o Make a major contribution to service development in line with Better Healthcare Closer to Home

o Focus explicitly on the needs of a range of commissioners

o Focus on financial clarity and value for money – accountability

o Greater managerial clarity and transparency to patients and the public

o Increase the value placed on nursing and therapy services by parity of organisational status

Weaknesses

o Further organisational change for staff o Start-up costs o Investment in management needed o Detailed costing of services required o Interim management and transition

plan needed o Adds to management workload at a

time of multiple priorities for the PCT

Opportunities

o To create a dynamic, exciting organisation in which staff want to work – recruitment and retention

o Become a flagship organisation in the EEMS health care system

o National policy for services o National policy for PMS options o Practice-based commissioning and

consequent changes in PCT role o Act as a strong base for strategic

partnerships, e.g. for children’s trusts, and with GP organisations

Threats

o Need strong stakeholder commitment, especially in short-term, for successful launch

o PCT’s underlying financial position o Implications for PCT management

roles o Need to establish strong working

relationships with Localities and GP provider organisations

Overall, it is considered that the strengths and opportunities outweigh the weaknesses and threats, but concerns around organisational change for staff and financial viability will need explicit attention and strong management through the next few months

June 2005 39


June 2005 39

Appendix F

Risk AssessmentStrategic Risk Register and Assurance Framework

SPMS Outline Business Case Projected Risks if the Board supports the proposals on 6th July 2005

Principle Objective Responsible Person

Principle Risk. Description of strategic Risk or Opportunity

Current Risk Rating

Key Controls. Assessment of

Controls. Gaps in Controls

Current progress.

Blockages to achieving progress

Sources of Positive

Assurance & Results (e.g.

report)

Gaps in Assurance

Summary of Management Plan

1. Financial balance Malachy McNally

Alan Kennedy

Prices not reflecting the costs of the service. Changes in DoH funding regime i.e. RNCC allocation Agreement of appropriate overhead supporting local currencies. Restructuring costs arising from negotiated changes to pathways and services (Cos. Decision then borne by Co. If due to commissioning Process borne by commissioner) Obtaining an Employing Authority Number to ensure NHS Pensions/Terms and Conditions

20 Negotiation with commissioners – highlighted – Full Business Case DoH confirmation of EA No.

2. Development of Full Business Case (Finance Dept. issues)

Malachy McNally

Resource capacity to support the development of Full Business Case. Sufficient information to assess activity undertaken Identification of contract currency – local prices or national tariff. Depreciation on equipment/assets

16 Identification of resource and regular review of capacity Business Case development Negotiation with PCT commissioners and DoH


June 2005 40

3. Development of Full Business

Case (HR Issues)

Clare Tanner

Insufficient HR capacity to support Project Director during transition period. Time to identify staff eligible and not eligible for TUPE and consult on transfer. Appointment of Chair in time to then appoint Chief Executive Lack of appropriate policies and procedures for new organisation to support staff

20

4. Development of Limited Company on 01.04.06

Alan Kennedy

Limited Company not established Project Director not appointed No professional leads identified to take forward project, for both nursing and therapies, during transition period

16 Leads appropriate

5. Employers moving to use shared services

If Limited Company does not go down shared service route will not implement ESR

6. Integrated Governancearrangements in place

Iain McNeil Insufficient development of Governance framework to include: Clinical Governance Risk Management Corporate Governance Financial Information No internal or external controls to measure quality of service provision

20 Clear framework developed and communicated to staff/commissioners and key stakeholders Structures in place

7. To ensure robust IT and system support

Surrey HIS/Matt Holton

Failure to deliver adequate IT services to support the business function of the SPMS company

15 SLA required between the PCT and Surrey HIS. SLA required between SPMS company and Surrey HIS SLA to be monitored

8. To engage and gain

support/commitment of stakeholders

Project Director

Potential lack of support from staff, public and other stakeholders

12 Workshops, staff consultation and stakeholder events


Appendix G

Support Stakeholders Comments/ responses Support for

proposal Sutton & Merton PCT An obvious way forward. Will watch with interest

Yes East Surrey PCT No obvious concerns. See why staff are supportive. Yes Epsom Ewell and Banstead commissioning GP

Want a secure supply of nursing and therapy staff and see this to be way forward.

Yes

E Elmbridge – lead GP – Dr Kearsey

Concerned at low morale, recruitment of staff. wants close working in future

Yes

Leatherhead GPs Dr Claridge Dr Barr ( no representative group to meet)

Concerned at any threat to continuity of services. Want more provision and see similar model to GP’s as positive.

Yes

Dorking GPs Concerned about current responsiveness to needs. Supportive of concept.

Yes

Kingston Hospital NHS trust Director of Nursing cannot see any reasons not to support. wish to maintain and improve communication

Yes

Epsom & St Helier Hospitals NHS Trust

Chief Executive and directors supportive in principle. Like focus on culture changes and outputs. Would take to their Board.

Yes

Surrey & Sussex Healthcare NHS Trust

No concerns. Consider it be an exciting model. Yes

Surrey County Council – Children’s Services

Likes proposals and pleased that in line with developments within Children’s Services. No Children’s trusts planned but can align teams

Yes

Surrey County Council - Adults and Community Care

No obvious difficulties resented Opportunity to work on intermediate care `services

Yes

Borough & District Councils Heather Kerswell David Smith

Enthusiastic support. Benefits of sole focus on services. Wish to ensure ongoing involvement in LSPs

Yes

Strategic Health Authority – lead nurse and lead therapist Ginny Colwell Amanda Allen

Supportive and enthusiastic. Keen to engage in ongoing work.

Yes

Letters received: Dr Tim Richardson Dr Sue Kearsey Jenny Griffiths

June 2005 41

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