decision handbook - future focused finance · decision charter rfl nhs foundation trust 01/06/18...

DECISION HANDBOOKRoyal Free London NHS Foundation Trust

The future provision of endoscopy services for

patients within the RFL Group

futurefocusedfinance.nhs.uk

SITUATION

• The service in the RFL group is delivered by two trusts (RFL and NMUH) in 3 locations across the area - a 4th location, Barnet, offers

an in-patient and emergency service only. Current activity equates to 4 rooms at RF and CF and 3 rooms at NM.

• Demand for endoscopy services is growing by at least 7% per annum and will continue to grow with an aging population and national

health screening programmes e.g. bowel screening over the next 10 years

• Despite both trusts fully utilising its resources there is no capacity at the RF or NM sites and only limited capacity at the Chase Farm site

(which has been earmarked for the RF immediate growth) so there is an urgent need to create capacity

• The NMUH service is only surviving by using the Chase Farm surgi-centre – this short-term solution ends July 18.

• The only site that has JAG accreditation is Chase Farm (this could be placed in doubt if other group sites do not gain JAG)

• There is no capacity for increased private practice (RF site) + the growth of specialist therapeutic endoscopy

COMPLICATION

• Both trusts are now partly reliant on the insourcing providers or use of waiting list initiatives to achieve waiting times and targets

• Alternative technology will not materially cap demand (and may lead to an increase) in this 10 year timeframe

• There is no alternative model being considered elsewhere by commissioners

• We have defined exactly which procedures (high risk of mortality / require anaesthetic support etc.) need to take place on an acute site,

other hospital sites or in the community and which procedures can take place safely at the weekends.

• There will be additional capacity demand pressures if the full HPB service transfers from UCH – estimate = 1 additional room

OBJECTIVES

• To achieve JAG accreditation on all sites

• To provide the capacity required to meet the projected demand for a safe and timely endoscopy service for the next 10 years

• To provide the capacity required to develop an academic infrastructure and expand the group’s endoscopy reputation for outstanding

research and specialist work

• To achieve best possible value for service users (considered in term of outcomes, patient experience, safety, timeliness and cost)

• To achieve a solution for the future staffing of the expanded service (terminate in-sourcing arrangements)

• To provide capacity on the Royal Free site to meet the increased demands for private practice

CONSTRAINTS

• Lack of NHS capital in the system – alternative funding streams / partners must be explored and identified

• Commissioner and provider affordability

• Patients willingness to travel long distances for treatment (when there may be closer alternatives)

• All sites need to move to full 7 day working with associated changes / challenges to current work patterns

• National lack of NHS endoscopy staff to be able to meet the future demand / long training periods e.g.. nurse endoscopists

• Must be acceptable to all stakeholders including patients, staff and commissioners

DECISION CHARTER

RFL NHS Foundation Trust01/06/18 Version 4.2

The future provision of endoscopy services for patients within the RFL Group

DECISIONThe group needs to decide on the future configuration of endoscopy services for patients within the

RFL Group that offers the best value to service users and taxpayers

1Decide on the remit / depth of the work stream i.e. RFL Group v the wider NCL / STP (Commissioner sign-off

needed

2Decide on the activity mix – activity that MUST be on an acute site (complex, specialist, private practice etc.)

vs another NHS site or diagnostic hub

3 Decide value objectives and value measures

4 Decide set of available solution options

5 Decide preferred option(s) to work into full service specification(s)

6Decide on service configuration i.e. days/hours of working and how will the service be staffed in the future –

NHS or a mix of an NHS / insource / private model

7 Decide on funding options and potential partnership working

8 Decide on interim and final working / partnership arrangements

1


RFL Group that offers the best possible value to service users and taxpayers

2

3

4

5

6

7

8

DECISION STEPS

RFL NHS Foundation Trust The future provision of endoscopy services for patients within the RFL Group 01/06/18 Version 4.2

OU

TC

OM

ES

CARE

OUTCOMES

• Mortality rates

• Unplanned admissions

• Known deaths within 30 days of endoscopic procedure

• Unplanned admissions within 8 days of an endoscopic procedure

USER

EXPERIENCE

• Accessibility for patients

• PROMs

• Quality of environment

• Separate paediatric facilities

• Travel times

• Patient survey responses (FFT etc.)

• Patient survey responses by site

• Potential to provide separate paediatric facilities

SAFETY /

QUALITY

• JAG accreditation

• Availability of anaesthetics support

• National waiting time targets

• Achievement of JAG accreditation

• Proportion of procedures on sites with appropriate anaesthetics

support

• Performance against national diagnostic target

RE

SO

UR

CE

S

REVENUE COSTS

• Cost per scope

• Marginal cost per scope

• Scalability (+/-)

• Lowest cost setting

• Ranked by cost of options

• Ability to add / remove rooms and associated cost

CAPITAL COSTS • Capital costs • Ranked by cost of options



VALUE COMPONENT VALUE CRITERIA VALUE METRICS

RFL NHS Foundation Trust The future provision of endoscopy services for patients within the RFL Group

VALUE MEASURES

01/06/18 Version 4.2



R Recommend A Agree P Perform I Input D Decide

RAPID® is a registered trademark of Bain & Company Inc.


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Decide on the remit / depth of the work stream i.e. RFL Group v the wider NCL / STP (Commissioner sign-off needed)

D R I I I I

Decide on the activity mix – activity that MUST be on an acute site v another NHS site or diagnostic hub

D R I I I

Decide value objectives and value measures

D R I I I

Decide set of available solution options

D R A I I I I I

Decide preferred option(s) to work into full service specification(s)

D R I I I A I I I

Decide on service configuration + how will the service be staffed in the future – NHS or mix of NHS / insourcing / private

D R I I I I I

Decide on funding options and potential partnership working

D R I I I

Decide on interim and final working / partnership arrangements

D R I P P P P

1

2

3

4

5

6

7

8

01/06/18 Version 4.2

Decide remit of

the work stream

Decide on

activity mix

Decide value

objectives and

value measures

Decide set of

available

solution options

Decide preferred

option for full

spec

Decide service

configuration +

staff model mix

Decide funding

options /

partnerships

Decide on

interim and final

arrangements



Consult with Clinical

leadership and

finance leads from

other trusts

Consult with STP

RFL Exec steer

on implications of

potential HPB

transfer

Explore primary

care alternative

options

Sign off from RFL

Group Board

Sign off from

Commissioners

Gather service

information from RFL

sites

Gather service

information from

NMUH

Gather potential

private practice

activity

Confirmation of

endoscopy growth

– internal +

CCG’s

Sign off from RFL

Clinical leadership

Sign off from

NMUH Clinical

leadership

Gather expert input

and engage relevant

stakeholders

Describe

objectives, define

values and

constraints

Define value

measures in line

with endoscopy

strategy

Review evidence

and produce

summary

Document long list of

options

Ascertain broad

estimates of

capital costs

Collect and

assess data /

activity mixes

Review and

sense check

assumptions

Create and

communicate

options shortlist

Agree decision

pass/fail value criteria

Gather expert

input and engage

relevant

stakeholders

Assess priorities

in terms of value

and risk

Generate and

communicate

recommendation

Service Line costing

(full income) for all

sites to be updated

Consultation with

all sites / staff

groups

Develop phased

implementation

plan

Financial analysis

work – options

appraisal

Discussions with

potential

providers –

market analysis

Develop

workforce plan –

staff consultations

Outline business

case

Final business

case

Negotiation with

current insourcing

providers

Liaison with

decontamination

provider

Liaison /

communication

with all sites

Staff consultation

exercise

Create benefits

realisation plan

1

2

3

4

5

6

7

8


KEY ACTIONS

01/06/18 Version 4.2

CRITERIA CRITICAL STEPS CHOICES CONSIDERED COMMITTEES

• Consensus between

stakeholders about remit of

project

• Understanding of which

organisations will be participating

in the decision (CCGs, providers,

other NHS orgs)

• Elements in and out of scope

clearly identified and understood

• Consult with local CCGs and STP

• Consult with service Leads of

other NCL trusts

• RFL Exec steer on potential HPB

transfer from UCLH

• Explore primary care alternatives

• Which organisations should be

involved in the decision?

• Is there appetite for STP wide

work?

• Do we need to address potential

future group members

requirements?

• What are our activity planning

horizions?

• How quickly does the decision

need to be made?

• CCG’s / STP

• RFL Group Board

• RFL GEC

• RFL Group Services and

Investment committee

• NMUH Exec

COMMUNICATION CLOSURE VALUE TOOLS

• Agreed scope of work to be

summarised in a ‘dialogue 1’

(RFL Business case process) of

the decision and presented to

relevant stakeholders

• Stakeholders informed as per

communication strategy

• Scope agreed by RFL Group

Board and decision to proceed on

that basis

• BPV framework

• RFL business case and decision framework

• NHS Right Care data

Decide on the remit / depth of the work stream i.e. RFL Group v the wider NCL / STP (Commissioner sign-off needed)1

1 2 3 4 5 6 7 8

RRAPID ROLES RFL Group BoardEndoscopy business

case sponsorn/a

Executive committees,

Service leadsD A I


6CS

01/06/18 Version 4.2


• There should be consensus

between stakeholders around

expected growth in endoscopy

• There should be consensus

between stakeholders around the

activity mix and the potential

options for configuration as a

result (including split between

diagnostic/therapeutic endoscopy

and necessary levels of on-site

anaesthetic support)

• Gather current information from

RFL sites

• Gather current information from

NMUH sites

• Gather potential private practice

activity demand

• Obtain confirmation of endoscopy

growth projections from CCG /

National bodies ?

• Sign off from both RFL and

NMUH clinical leadership

• How much growth in activity is

expected over the agreed period?

• What procedures are carried out

and what settings can they be

provided in?

• What are the best practice

guidelines?

• Are there alternative options for

provision, such as primary care

hubs?

• CCGs / STP

• BPV workshop and evaluation

teams


• Agreed scope of work to be

summarised as ‘dialogue 1’ of the

decision and presented to


• Activity mix agreed by relevant

stakeholders and incorporated

into ‘dialogue 1’

• Stakeholders informed as per

communication strategy

• External assessments of expected growth in endoscopy:

− Scoping the Future. An evaluation of endoscopy capacity across the

NHS in England', Health Services Management Centre at the

University of Birmingham and the Strategy Unit at NHS Midlands and

Lancashire Commissioning Support Unit

− 'Modelling Potential Changes in Gastro-Intestinal Endoscopy Activity

in London between 2013/14 and 2019/20', Midlands and Lancashire

CSU

Decide on the activity mix – activity that MUST be on an acute site v another NHS site or diagnostic hub2

1 2 3 4 5 6 7 8

RRAPID ROLES Endoscopy workshopEvaluation working

groupn/a Service leadsD A I


6CS

01/06/18 Version 4.2


• The objective of the decision

should be to maximise value for

service users (in terms of clinical

outcomes, patient experience

and safety)

• There should be access to

sufficient evidence and data to

assess metrics

• It should be straightforward /

practical to collect evidence and

data

• Value criteria and metrics should

be sufficient to enable robust

evaluation

• Measures should be in line with

trust goals + endoscopy strategy

• Gather expert input and engage


• Describe objectives, define value

and constraints

• Define value measures in line

with RFL Group goals

• Define value measures in line

with RFL endoscopy strategy

• Review evidence and produce

summary document

• What value components, criteria

and metrics reflect the objectives

set out in the decision charter?

• What data sources are readily

available?

• Who should be involved in the

evaluation?

• CCG / STPs

• RFL GEC

• NMUH Exec


• Project sponsor to inform RFL

and NMUH Boards

• Ensure rationale behind

identifying the best value

configuration for future

endoscopy services is widely

disseminated

• Agreed value measures to be

included in ‘dialogue 2’ of the

decision and presented to

relevant stakeholders.

• Engage / inform stakeholders as

per communication strategy

• BPV value generation tool and BPV data sources library

• Patient Reported Outcome Measures (PROMS)

• JAG accreditation standards

Decide value objectives and value measures3

1 2 3 4 5 6 7 8

RRAPID ROLES Endoscopy workshopEvaluation working

groupn/a CCGs, Service leadsD A I


6CS

01/06/18 Version 4.2


• Options considered must be

realistically affordable and

available in the timescales set out

• Options must be comparable

according to agreed Value

Measures

• Options must consider risk to

patient experience

• Options must consider potential

impact to users of current space

if relocation of others has to be

considered

• Options must consider

practicalities of cross site working

• Seek best practice, evidence or

ideas for option set

• Document long list of options

• Collect and assess current and

future forecast growth evidence

• Obtain outline capital costs

• Review and sense check

assumptions

• Create and communicate options

shortlist

• Where to look for best practice

and replicability?

• How to gauge patient impact?

• What hurdle criteria could be

used to eliminate options which

are unrealistic?

• RFL GEC

• NMUH Exec

• RFL Group Board

• RFL Asset Management Group


• Stakeholders to be kept

appraised of options considered

• Full list of viable options

incorporated into ‘dialogue 2’

documentation

• ‘Dialogue 2’ including long list of

viable options presented to RFL

group board

• BPV decision framework and value generation tool

Decide set of available solution options4

1 2 3 4 5 6 7 8

RRAPID ROLESEndoscopy BPV

workshop

Evaluation working

groupNMUH Board

Patient groups, CCGs,

Service leadsD A I


6CS

01/06/18 Version 4.2


• The recommended option should

maximise value, as evaluated by

the agreed scoring framework

• In the event of multiple shortlisted

options, they must all address the

fundamental decision, as outlined

in the decision charter, and have

a reasonable prospect of being

delivered within the known

constraints

• Agree ‘hurdle criteria’ for options

• Gather expert input and engage


• Assess priorities in terms of risk

and value

• Generate and communicate

recommendation

• Can the options be delivered

within the known constraints

(workforce, time, financial)?

• Is there sufficient flexibility in the

option to adapt to ?

• There are cost implications of

working up full services

specifications – are we confident

that the option(s) in question are

viable?

• RFL GEC




teams

• RFL Group board


• Presentation of ‘dialogue 2’ to

GEC, GSIC and group board

• Communication of shortlisted

options to wider stakeholders

• RFL Group board approves the

option(s) shortlisted in ‘dialogue

2’ for full development


• BPV data sources library

Decide preferred option(s) to work into full service specification(s) 5

1 2 3 4 5 6 7 8


case sponsorCCGs MultipleD A I


6CS

01/06/18 Version 4.2


• Service configuration must aim to

maximise value

• There should be clear

understanding of the transitional

and steady-state requirements

• Timing and sequencing of any

reconfiguration should be clear

• Site and service co-

dependencies must be

considered and ensure all sites

are sustainable

• Service line costing (full income)

for all sites to be updated

• Consultation with all sites / staff

groups

• Develop phased implementation

plan

• What options are there for

reconfiguring the workforce?

• How will the location of any

potential development change

the workforce requirements.

• Are there ways to minimise any

associated risks?

• Would a partnership include

staffing?

• RFL GEC




teams

• RFL Group board


• Staff communication and

consultations as required

• Stakeholders informed of

progress and potential options

• Full business case (‘dialogue 3’)

produced for consideration by

relevant stakeholders and

decision by RFL group board.

• JAG specifications

• Staff consultations

• Union consultation

Decide on service configuration + how will the service be staffed in the future–NHS or mix of NHS/insourcing/private6

1 2 3 4 5 6 7 8


case sponsorn/a MultipleD A I


6CS

01/06/18 Version 4.2


• The funding arrangements must

be affordable for the trust over

the life of the project.

• Risk should be shared

appropriately between partner

organisations

• Contractual arrangements must

be able to be agreed within the

necessary timescales to allow the

project to be delivered

• Financial analysis work – options

appraisal

• Discussions with potential

providers – market analysis

• Develop workforce plan – staff

consultations

• Final business case

• What funding options are

available?

• Can RFL fund the investment

itself or is a partnership required.

• What form might a partnership

take?

• Are the proposed funding

arrangements affordable?

• Are they aligned with the trust’s

long term financial strategy?

• Is the trust assured that any

partner can deliver our

requirements?

• RFL GEC




teams

• RFL Group board


• Conversations with potential

external partners

• Staff communication and

consultations as required

• Stakeholders informed of

progress and potential options




ultimately decision by RFL group

board.

• Alternative contracting / partnership forms


Decide on funding options and potential partnership working7

1 2 3 4 5 6 7 8


case sponsorn/a MultipleD A I


6CS

01/06/18 Version 4.2


• Deliverability of proposals (cost

and timing)

• Consideration of impact on other

services within the hospital and

the wider local area

• Negotiation with current

insourcing providers

• Liaison with decontamination

provider

• Liaison / communication with all

sites

• Staff consultation exercise

• Create benefits realisation plan

• Are we happy to enter into

contractual agreements at this

point?

• Are all parties aware of and

happy with the arrangements?

• Have all necessary consultations

been carried out?

• RFL GEC




teams

• RFL Group board


• Communication with all

stakeholders, as outlined in the

communications strategy and

included in ‘dialogue 3’ of the

business case




decision by RFL group board

• Plans effectively communicated

to all necessary parties prior to

implementation


Decide on interim and final working / partnership arrangements8

1 2 3 4 5 6 7 8


case sponsorn/a

Executive committees,

Service leadsD A P


6CS

01/06/18 Version 4.2

Decision Calendar

2017 2018

Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct

Decide remit of the work

stream

Decide on activity mix

Decide value objectives and

value measures

Decide set of available

solution options

Decide preferred option for

full spec

Decide service configuration

+ staff model mix

Decide funding options /

partnerships

Decide on interim and final

arrangements

DECISIONThe group needs to decide on the future configuration of endoscopy services for patients within the RFL Group that offers

the best possible value to service users and taxpayers

1

2

3

4

5

6

7

8


DECISION TIMELINE

01/06/18 Version 4.2

Care outcomes will be

maintained or improved in

the face of significantly

increasing demand

Achieving JAG accreditation

and meeting national waiting

times target on all our sites

will ensure our services

remain safe.

User experience will be

improved by providing

access to services where

they are needed and in high

quality facilities.

Investing in appropriate

facilities will result in a

sustainable service and

deliver best possible value.

The RFL group strategy is

supported by the

investment, which is aligned

to meeting growing demand

across NCL.

• Without increasing out

endoscopy capacity we

will not be able to fully

meet the demand for

endoscopy in the area,

which will likely impact on

our overall care

outcomes.

• Demand for therapeutic

endoscopy is limited by

capacity. Additional

capacity will allow us to

develop and grow the

world-class elements of

our service.

• Additional capacity for

specialist work could lead

to greater research

activity, which is

associated with improved

care outcomes.

• Patient and staff

experience will be

improved by modern and

well designed facilities.

• Sufficient capacity will be

beneficial, in terms of

outcomes and

experience, both staff and

patients.

• User experience will be

improved by facilities

which are suitably located

to serve the needs of the

catchment population.

• JAG accreditation is the

gold standard for

endoscopy provision and

indicates that a service is

both safe and well run.

• Meeting national waiting

time targets will reduce

the risk of delays to

patient treatment,

potential harm and

potentially improve

outcomes through early

diagnosis and

intervention.

• Suitable investment in

infrastructure will ensure

that the service is able to

meet rising demand and

improve future flexibility.

• Investing in a timely

manner and managing

growing demand

effectively will provide a

better value over the life

of the investment.

• Depending on the agreed

scope of the project, there

may be capacity available

for increasing the

proportion of specialist

work carried out or

increasing private patient

procedures.

• Significant growth in

endoscopy is expected

across NCL

• Investment will support

the existing hospitals in

the group and build in

some flexibility to

accommodate future

members.

• Expansion of endoscopy

services supports national

priorities for cancer and

bowel screening.

Case for change: Investing in an expanded endoscopy service is worthwhile as it will allow the trust to cope with growth in demand and efficiently

manage services. This will allow the trust to maintain excellent care outcomes, user experience and ensure that services are clinically and financial

sustainable. Additional capacity could also facilitate growth in specialist therapeutic endoscopy, research and private patient treatment.


VALUE BUILDING

01/06/18 Version 4.2

PRIMARY

ASSERTIONSUB-ASSERTION

EVIDENCE

AVAILABLE

FURTHER EVIDENCE

TO BE GATHEREDMETRICS TARGET

CA

RE

OU

TC

OM

ES

Care outcomes will be

maintained or

improved in the face of

significantly increasing

demand

• Without increasing

our endoscopy

capacity we will not

be able to fully meet

the demand for

endoscopy in the

area, which will

likely impact on our

overall care

outcomes.

• Demand for

therapeutic

endoscopy is limited

by capacity.

Additional capacity

will allow us to

develop and grow

the world-class

elements of our

service.

• Additional capacity

for specialist work

could lead to greater

research activity,

which is associated

with improved care

outcomes.

• Demand and

capacity modelling

indicates the trust is

already close to

capacity.

• Consultant base has

indicated desire to

grow therapeutic

and specialist

endoscopy.

• Bowel screening

service has yet to

be implemented and

will increase

diagnostic activity

and subsequent

procedures.

• Monitoring of

existing capacity

and waiting times.

• Review of

requirements for

specialist

endoscopy growth.

• Further assessment

of impact of bowel

screening

programmes.

• Known deaths

following endoscopy

• Unplanned

admissions

following endoscopy

• Maintain or improve

outcomes against

17/18 baseline for

both measures.


EVIDENCE LOG

01/06/18 Version 4.2

PRIMARY


EVIDENCE

AVAILABLE

FURTHER EVIDENCE


US

ER

EX

PE

RIE

NC

E

User experience will

be improved by

providing access to

services where they

are needed and in high

quality facilities.

• Patient and staff

experience will be

improved by modern

and well designed

facilities.

• Sufficient capacity

will be beneficial, in

terms of outcomes

and experience,

both staff and

patients.

• User experience will

be improved by

facilities which are

suitably located to

serve the needs of

the catchment

population.

• Patient experience

scores, FFT

(Friends and Family

test) and local data.

• Endoscopy

performance data.

• Staff surveys and

feedback.

• PROMs scores to

be gathered.

• Patient opinions of

travel times and

environment to be

sought, either by

questionnaire or

from patient groups.

• Staff input into

design phase.

• Accessibility for

patients

• PROMs

• Quality of

environment

• Separate paediatric

facilities

• Travel times should

not increase

significantly for the

majority of patients.

• PROMs scores

should be

maintained or

improved.

• Staff and user

perception of the

quality of

environment should

improve.

• The option should

be able to meet best

practice guidelines

for separate

paediatric facilities.


EVIDENCE LOG

01/06/18 Version 4.2

PRIMARY


EVIDENCE

AVAILABLE

FURTHER EVIDENCE


SA

FE

TY

/ Q

UA

LIT

Y

Achieving JAG

accreditation and

meeting national

waiting times target on

all our sites will ensure

our services remain

safe.

• JAG accreditation is

the gold standard

for endoscopy

provision and

indicates that a

service is both safe

and well run.

• Meeting national

waiting time targets

will reduce the risk

of delays to patient

treatment, potential

harm and potentially

improve outcomes

through early

diagnosis and

intervention.

• JAG is the national

accrediting body for

endoscopy and their

standards provide a

comprehensive

evaluation of the

safety and quality of

the service.

• National standards

are set based on a

variety of evidence

to ensure that

patients are treated

in a timely fashion.

• Current RFL

performance against

JAG expectations.

• Current RFL waiting

time target

performance.

• Self-evaluation of

endoscopy units

against JAG

framework.

• Continued

performance

monitoring.

• Timing of JAG

accreditation

• Availability of

anaesthetics

support

• National waiting

time targets

• All units JAG

accredited by 2020.

• All sites with

suitable

anaesthetics

provision.

• Maintain or improve

performance against

national waiting time

targets.


EVIDENCE LOG

01/06/18 Version 4.2

PRIMARY


EVIDENCE

AVAILABLE

FURTHER EVIDENCE


RIS

K

Investing in

appropriate facilities

will result in a

sustainable service

and deliver best

possible value.

• Suitable investment

in infrastructure will

ensure that the

service is able to

meet rising demand

and improve future

flexibility.

• Investing in a timely

manner and

managing growing

demand effectively

will provide a better

value over the life of

the investment.

• Depending on the

agreed scope of the

project, there may

be capacity

available for

increasing the

proportion of

specialist work

carried out or

increasing private

patient procedures.

• Activity modelling

and growth

projections

• Timely investment

will reduce the

likelihood of failing

to meet national

targets and

therefore a

reduction in the risk

of potential

safety/quality

issues.

• Strong evidence to

suggest that

outcomes are

improved in services

with staff performing

suitable numbers of

procedures.

• Evidence to suggest

that patient

outcomes are better

in units undertaking

clinical research.

• Self-evaluation of

endoscopy units

against JAG

framework.

• Continued

performance

monitoring.

• Timescales for

implementation

• Delivery capability

• The option can be

delivered within

timescales which

minimise the risk of

quality and/or safety

concerns.

• The option can be

delivered within the

known financial and

workforce

constraints, and with

a prudent view of

future constraints.


EVIDENCE LOG

01/06/18 Version 4.2

PRIMARY


EVIDENCE

AVAILABLE

FURTHER EVIDENCE


ST

RA

TE

GIC

FA

CT

OR

S

The RFL group

strategy is supported

by the investment,

which is aligned to

meeting growing

demand across NCL.

• Significant growth in

endoscopy is

expected across

NCL

• Investment will

support the existing

hospitals in the

group and build in

some flexibility to

accommodate future

members.

• Expansion of

endoscopy services

supports national

priorities for cancer

and bowel

screening

• Activity projections

are for the whole

London region and

indicate similar

levels of growth.

• NMUH also need to

consider investment

in additional

endoscopy facilities

• RFL and NMUH

have both indicated

that they have

limited endoscopy

capacity available.

• Analysis of available

numbers from other

local trusts suggests

that more providers

will find themselves

requiring additional

endoscopy capacity.

• Activity increases as

a result of the

national bowel

screening

programme will

need to be

accommodated.

• Updates of activity

projections as

required.

• Continued

discussion with

NMUH about activity

levels.

• Bowel screening

growth impact to be

validated.

• Activity of potential

group members to

be reviewed.

• Addresses group

endoscopy

requirements over

the next 10 years.

• Aligns with the

trust’s private

patients strategy.

• Aligns with STP

expectations for

endoscopy provision

within NCL.

• Meets the group

endoscopy

requirements with

some flexibility to

accommodate and

future changes.

• Aligns with and

provides capacity

for private patients.

• Aligns with the NCL

STP growth

expectations and

strategic

programmes.


EVIDENCE LOG

01/06/18 Version 4.2

CRITERIA IMPORTANCE (%) RATIONALE SCORING

OU

TC

OM

ES

• Mortality rates

• Unplanned admissions

• Accessibility for patients

• PROMs

• Quality of environment

• Separate paediatric facilities

• Timing of JAG accreditation

• Availability of anaesthetics support

• National waiting time targets

10%

10%

15%

10%

10%

10%

10%

15%

10%

Will the option maintain or improve performance

against key JAG outcomes?

Will the option be as accessible for our population?

Will PROMs be maintained or improved?

Will the quality of environment be improved?

Can the option provide separate paediatric areas?

When will JAG accreditation be achieved?

Will there be appropriate anaesthetics support?

Will we be able to meet / maintain waiting targets?

Options generally scored 1-5 on the following

basis:

5 Significant/definite improvement

4 Some/possible improvement

3 Maintained

2 Some/possible deterioration

1 Significant/definite deterioration

Full details of definitions of scores were made

available to the BPV workshop.

RE

SO

UR

CE

S

• Cost per scope

• Marginal cost per scope

• Scalability (+/-)

• Lowest cost setting

• Capital costs

40%

20%

10%

10%

20%

Do the costs offer the best possible value?

Is there the option to scale the facilities up or down

in the future?

Cost options ranked by relative cost

Scalability scored 1-5:

1 No scalability

3 Good scalability but with high cost/risk

5 Full scalability with reasonable cost/risk

RIS

K • Timescales for implementation

• Delivery capability

25%

25%

Are the timescales reasonable?

Are we capable of delivering the option?

Scored 1-5 on a similar basis to outcomes. Full

details of definitions of scores were made


ST

RA

TE

GIC

FA

CT

OR

S • Addresses group endoscopy

requirement for next 10 years

• Aligns with PPU strategy

• Aligns with STP expectations for

endoscopy provision within NCL

20%

10%

20%

Does the option address the projected activity

requirements?

Is the option aligned with other strategies in the

organisation and across the STP?

Scored 1-5 on a similar basis to outcomes. Full

details of definitions of scores were made


RFL NHS Foundation Trust The future provision of RFL endoscopy services

SCORING RATIONALE

01/06/18 Version 4.2

At the end of decision step 5 a set of options were presented to the RFL group board for shortlisting. As there were significant costs associated with the full planning and financial analysis it was agreed that an initial evaluation should be carried out on the outcomes, risks and strategic factors. The BPV evaluation group recommended that a full specification should be worked up for options 2 and 3.

VALUE COMPARISON

Value component (i) Value component (ii) Value criteria Weighting % Option 1 Option 2 Option 3 Option 4 Option 7

Outcomes Care outcomes Known deaths following endoscopy 10% 2 4 4 3 1

Outcomes Care outcomesUnplanned admissions following

endoscopy10% 2 4 4 2 1

Outcomes User Experience Accessibility for patients 15% 2 4 3 3 1

Outcomes User Experience PROMs 10% 1 4 3 3 1

Outcomes User Experience Quality of environment 10% 2 5 4 4 3

Outcomes User Experience Separate paediatric facilities 10% 1 4 3 3 2

Outcomes Safety/quality Timing of JAG accreditation 10% 1 4 4 3 2

Outcomes Safety/qualityAvailability of appropriate anaesthetics

support15% 2 4 4 2 2

Outcomes Safety/qualityAchieve national waiting time standards

for diagnostics10% 1 5 4 4 2

VALUE 100% 1.6 4.1 3.5 3.0 1.7

Risk Timescales for implementation 25% 2 3 3 3 2

Risk Delivery capability 25% 3 3 3 2 1

Strategic factorsAddresses group endoscopy

requirement over next 10 years20% 1 4 4 3 3

Strategic factorsAligns with the trust's private patients

strategy10% 1 5 4 3 1

Strategic factorsAligns with STP expectations for endoscopy provision within NCL

20% 2 4 3 2 1

RISK + STRATEGIC FACTORS 100% 1.8 3.8 3.4 2.8 1.6

RFL NHS Foundation Trust The future provision of endoscopy services for patients within the RFL Group 01/06/18 Version 4.2

1

ROYAL FREE HOSPITALS NHS FT

BPV FEEDBACK

Stakeholders WHAT WENT WELL? WHAT DIDN’T GO SO WELL? WHAT COULD BE IMPROVED?

Provider(s) Clinicians

1. Useful in understanding the methodology and processes

2. Clear framework for decision making to achieve best value based on clinical outcomes.

3. Helped hone focus on what to influence and what value means

4. Wide stakeholder involvement, no mixed messages – strengthened governance and transparency.

1. Difficult for external sites to attend and contribute

2. Decision making complex, role of decision makers not clear – needed more clarity.

3. Lack of understanding of the process

4. CCG did not clearly articulate the value expected from commissioners and potential trade off not explored.

5. Lack of patient input

1. More time for the process 2. More involvement from other

sites 3. Clearer expectation of each

stakeholder 4. Better guidance for workforce

planning 5. Guidance needed for patient

involvement


2

CCG representatives

1. Clearly driven process 2. Sessions well facilitated

1. Not 100% clear what the level of CCG involvement was or what input was required from CCG’s

1. Clearer expectations of CCG’s

3


Provider(s) Corporate / Divisional Mgt

1. Got a multidisciplinary team approach inc commissioners and different sites

2. Got all parties together 3. Good buy-in from all parties 4. Good structure to BPV process 5. Good structure to identify the

options 6. The background to the decision

was explained well 7. Helped define the decision 8. Willingness to use tools and

methods presented 9. Project team understood the

purpose of BPV methodology 10. Gave credibility to the decision 11. Concentrated minds on

important issues 12. Ability to transfer to business

case process 13. Outputs well received by senior

management 14. Project management

1. Not sure on commissioner role-- were they at the right level ?

2. Interaction with commissioners was not right

3. Pressure of other commitments from senior decision makers / owners

4. More info as to why I was in the room and what were the expectations of me

5. Endoscopy had already completed much of the work – the process would work better if involved right from the start

6. Some repetition as the process started after the business case

7. BPV template a bit too clunky and bureaucratic

8. Some difficulty tailoring elements of BPV process despite RAPID

9. The RAPID decision making process was not clear (perhaps

1. Would work better with more

time i.e. from the start 2. Use BPV throughout the whole

process 3. Wider knowledge of BPV

throughout the trust 4. Improve understanding of

RAPID/ Decision Charter / Evaluation Framework for all parties (not just Mgt)

5. Dedicated project manager to lead - more time

6. Need to find a systematic way to do this at greater pace and without heavy reliance on two individuals

7. Some of the questions discussed in BPV sessions are being repeated in trust committee’s - would a final facilitated session between project team and approving body help ?

8. Codify how BPV elements are

4

15. External facilitation 16. Good to have commissioners at

table – made us think slightly differently

17. Small break out groups were helpful for more informal clarification / questions

18. Useful to have North Midd present – engagement / sharing of strategy

due to the speed we were working at)

10. In part we didn’t get well enough into the decision roles

11. At times a lack of clear ownership of the decision despite RAPID

12. At times it felt a bit repetitive as we had undertaken quite a bit of work prior to commencing the BPV process

merged with RFL’s dialogue process

9. Needed better patient involvement and feedback – either direct or via questionnaire / or?

10. Need to identify CCG Champion at the start of the process – fully involve them so they understand the BPV process and the importance of their involvement

11. Patient co-design 12. Commissioner ability to

influence 13. Timing of when we started on

the BPV journey

decision handbook - future focused finance · decision charter rfl nhs foundation trust 01/06/18...

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