full business case · there is also the necessity to assess value for money when proposing a...
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Full Business Case Cardio-Respiratory Community Service
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Project name Cardio-Respiratory Community Service
Unique reference
Clinical lead Irem Patel (Consultant Respiratory Physician) and Raquel Delgado (GP clinical lead)
Implementation lead Julie Scrivens (Out of Hospital Clinical Pathway Lead for Planned Care) – Hammersmith and Fulham CCG
Date approved
Signature
Name
Role
Counter signature (if applicable under detailed scheme of delegation)
Date
Signature
Name
Role
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Document Information
Document Name Cardio-Respiratory Community Service Full Business Case for NHS Hammersmith & Fulham Finance and Performance Committee
Version v.6
Status Draft
Author Jen Goddard
Date created June 2015
Date last amended
Version Control
Version Release date Description of changes
1-5 11th
June 2015 Internal CCG changes, with commercial section advice from Shared Business Services
6 12th
June 2015 Removed duplicate text in section 5
Revision History
Version Date Reviewer name Role
1-5 11th
June 2015 Jen Goddard Greg Reide
Planned Care Programme Manager NHS SBS – NHS Shared Business Services
6 17th
June 2015 Jane Wilmot Members of Steering Group Ops Team – H&F exec
Revisions from H&F Exec team, clinicians on steering group and lay member included within Business Case
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Contents:
Number Title Page
1. Strategic objectives and drivers for change
2. Proposed change (business option/solution)
3. Options appraisal
4. Commercial considerations
5. Financial case
6. Funding source
7. Overall plans for implementation
8. Timescale
9. Risks
10. Stakeholder engagement
11. Recommendations
12. Questions to be addressed by F&P
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SECTION 1: Strategic Objectives and Drivers for Change
Provide the reason(s) why change is needed, based on what is known now. These may be opportunities, challenges or problems that
need to be addressed.
Introduction The purpose of the business case is to evidence the case for change for Cardiology and Respiratory services commissioned by Hammersmith and Fulham CCG, and sets out the proposal to decommission the existing Community Respiratory service and procure a Cardio-Respiratory Community Service for Hammersmith and Fulham CCG. The business case details proposed clinical provision, projected activity shifts, and the benefits to be realised both operationally and financially across Hammersmith and Fulham. Cardiorespiratory refers to the heart (cardio) and the lungs (respiratory), which work together to transport oxygen throughout the body. Cardiorespiratory fitness, also called aerobic capacity, is the ability of the lungs, heart and circulatory system to supply the body with the oxygen it needs to maintain a physically active lifestyle. Cardiorespiratory conditions can restrict the ability to breathe in enough air and deliver enough oxygen to the body when needed, with common symptoms including coughing, wheezing and shortness of breath. Cardiovascular disease (CVD) is an umbrella term for all diseases of the heart and circulation, including heart disease, stroke, heart failure, atrial fibrillation etc. Lung disease is an umbrella term that covers a broad range of respiratory diseases, such as acute respiratory infections, bronchitis, emphysema, asthma, and chronic obstructive lung disease (COPD). In England:
There are an estimated 7 million people living with cardiovascular disease (CVD) in the UK
Cardiovascular disease causes more than a quarter of all deaths in the UK, or around 160,000 deaths each year
Coronary Heart Disease is the UK's single biggest killer1
Diseases of the respiratory system accounted for 1 in 5 deaths in the UK in 2006
Respiratory disease cost the UK £6.6 billion in 2004 – £3.0 billion in NHS care costs, £1.9 billion in mortality costs and £1.7 billion in morbidity costs
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National Drivers for change
Over recent years, the NHS has been increasing its focus on improving the provision, access and quality of care provided outside of an acute hospital setting. The White Paper ‘Our Health, Our Care, Our Say’
3 outlined the ambition to create a
fundamental shift of care from hospitals to more community-based settings and this was reiterated by Lord Darzi in ‘Our NHS, Our Future’
4 with the principle to ‘localise where possible, centralise where necessary’.
The most recent NHS England Guidance (2013) highlights that in order to meet the needs of our population, it is not possible to maintain the current duplication and fragmentation of care which drains resources and does not offer consistently high quality and cost effective care. The guidance states that; ‘without transformational change in how services are delivered, a high quality, yet free at the point of use health service will not be available to future generations.’
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The NHS Five Year Forward View (October 2014) further emphasises the need to break down barriers in how care is provided; with far more care delivered locally, supported by specialist centres for more complex needs. The provision of more Cardio-Respiratory care in the community is a step towards meeting this objective of care closer to patients and
1https://www.bhf.org.uk/research/heart-statistics (accessed 12th May 2015) 2The burden of Lung Disease, 2nd edition (2006) https://www.brit-thoracic.org.uk/document-library/delivery-of-respiratory-care/burden-of-lung-disease/burden-of-lung-disease-2006/ (accessed 12th May 2015) 3Department of Health (2006) Our Health, Our Care, Our Say 4Department of Health (2007) Our Health, Our Future 5NHS England (2013) Planning and Delivering Service changes for Patients
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primary care and will have significant benefits; providing a more convenient service to patients and helping to relieve the pressure on secondary care services, focusing the most complex Cardiology and Respiratory diagnostics and treatment in secondary care.
Local Drivers for change
The local drivers underpinning the need to transform clinical services in the borough of Hammersmith & Fulham include:
The residents of Hammersmith & Fulham borough have changing health needs, as people live longer and live with more chronic diseases – putting pressure on health care provision.
We need to have more planned and integrated care, provided earlier to our population in settings outside of hospital. Patients do not always need to receive hospital based care and alternative community and primary care based services can often be delivered closer to home and be more cost effective and centred around the patient
Capacity within our acute hospital providers is constrained and this is adversely impacting referral to treatment waiting times for patients, indicating that services need to be provided differently to ensure the best clinical outcomes
Variation in both quality and access and standards must improve ensuring that services are centred around the patient
Providing a value for money service that achieves clinical and financial sustainability
GP and patient feedback Currently in H&F there is no Community based Cardiology service provision and another local driver for change has been feedback from both GPs at GP network meetings, from patients, and through different survey responses. A sample of survey responses are listed below, in the majority there was positive support for the proposed Cardio-Respiratory Community service development:
“I believe a joint Cardiology and Respiratory Community Service in H&F would benefit us and reduce the current waiting time in terms of waiting for different referrals and outpatient clinics” – H&F patient
“This sounds like it would be an excellent service and very useful - depending what would be available. We don’t have a community heart failure nurse anymore” – H&F GP
“A heart failure community nurse specialist who is able to do house visits would be invaluable and I believe is really needed within the borough” – H&F GP
“Excellent idea, most patients overlap with both and are comorbid and many medication interactions arise in the gap between cardio and resp - and we are left as GPs trying to rationalise these! Also useful for newly presenting patients who could have either system causing their symptoms” – H&F GP
Public Health data
There is also strong Public Health evidence specific to Hammersmith and Fulham that demonstrates we have worse outcomes when benchmarked against London (and in some cases the whole of England) for certain cardiovascular and respiratory disease indicators. Public Health England have published data on the following
6:
Between 2011-13 Hammersmith & Fulham’s age-standardised mortality rate for Cardiovascular disease for under 75s is 95.5 per 100,000 that benchmarks us as red or “worse” than both the London and England average, however we have no community based service to address management or prevention of cardiovascular disease
Emergency COPD admissions in H&F were 1.99 per 1,000 population in 2012/13 which is “worse” than London and “similar” compared to England.
Between 2011-13, there were 350 estimated deaths from causes attributable to smoking per 100,000 people
6http://fingertips.phe.org.uk/
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in H&F. This is “worse” than England or London
Value for Money
There is also the necessity to assess value for money when proposing a business case. Cardiology has a high outpatient spend, within the top five specialties for the CCG in 14/15 at £1.43m (including first, follow up and procedures, all sources of referral, all providers). For Respiratory in 14/15 the CCG spent £721k on outpatients (including first, follow up and procedures, all sources of referral, all providers). H&F CCG also spent £1.1m in 13/14 on the Community Respiratory Service as part of the block contract with CLCH. The proposed procurement of a new Cardio-Respiratory Community service gives a real opportunity to assess value for money of current provision, and to drive efficiency savings. This project will help to:
• Empower individuals, carers and families so they can be proactive in their own care • Continuously improve services including quality through close working with providers,
commissioners, patients and service users • Shift activity from unplanned to planned care, ensuring care can be provided in the most
appropriate setting, closer to home through primary and community services and minimising acute episodes of care - in line with the Shaping a Healthier Future programme
• Achieve the financial obligations and other statutory/legal duties of the CCG
Current Cardio-Respiratory services Cardiology services There is currently no cardiology specific Community service provision in H&F. Cardiology outpatient attendances predominantly take place at Imperial (61%) and Chelsea and Westminster (21%) as part of current acute contracts. Inpatient activity (elective including daycase and non-elective) also predominantly takes place at Imperial (69%), Chelsea and Westminster (15%), and the Royal Brompton (6%). Respiratory services Currently, Central London Community Healthcare NHS Trust (CLCH) is commissioned by H&F to deliver a Community Respiratory service which assesses treats and monitors patients with respiratory illness such as chronic obstructive pulmonary disease (COPD), asthma and bronchiectasis. The service carries out the following:
• spirometry (basic lung function) testing • pulmonary rehabilitation • disease education for self-management • support with managing 'flare-ups' of COPD • chest clearance • medication reviews and advice on medication use • support for patients after discharge from hospital • assessment / review of home oxygen therapy • hospital at home admission avoidance • community respiratory assessment unit (CRAU) offering full diagnostics • COPD hotline 9.00 to 20.00, Monday to Friday
CLCH is moving towards service line reporting and CLCH has given £1.1m as the cost of the current Community respiratory contract. All other respiratory outpatient attendances are funded under the acute contracts in the main with Imperial (54% Outpatient activity), Chelsea and Westminster (19% Outpatient activity), and Royal Brompton (19%). Local audits have demonstrated that most of the outpatient activity that remains in secondary care at Imperial is inappropriate for the Community Service (i.e. two week waits, or red flags for the Community Service such as ILD-interstitial lung disease). Inpatient activity (elective including daycase, and non-elective) is also funded via the acute contracts, in the main with Imperial (67%), Chelsea and Westminster (18%), and the Royal Brompton (9%). The Commissioning for Value: Pathways
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on a Page Pack (Nov 2014)7 published by Public Health England with NHS England outlines that H&F spend on non-
elective COPD and asthma admissions is significantly worse when compared to the average of ten similar CCGs. There is therefore scope for strengthening service models and pathways for respiratory services.
SECTION 2: Proposed change (business option / solution)
Describe what the proposed project would deliver i.e. what would be done to fix the problem and deliver the change.
The remainder of this paper sets out a proposal to establish a Cardio-Respiratory Community service for Hammersmith & Fulham CCG, to be provided in locations across the area, achieved through a single procurement, with the potential to have a single provider if this proves to be the most economically advantageous and clinically effective solution. The priorities will be to ensure that:
Access for the H&F CCG patient population is optimised;
Clinical safety and quality is prioritised in the procurement process;
Cost savings are achieved and economies of scale are achieved where appropriate; and
The specifications are evidence based and meet all relevant national guidelines.
Key features of the Cardio-Respiratory Community service:
Improve patient satisfaction through delivering a quick, accessible and high quality service;
Consultant led and appropriately staffed;
Provide the clinical triage routed via a ‘one stop shop’;
Carry out clinically appropriate outpatient procedures;
Manage more urgent cases – within a maximum of two weeks (2 week waits for suspected cancer are excluded from scope);
Sustainability – to improve the knowledge of NHS health professionals around the management of Cardiovascular and Respiratory diseases through the development and implementation of education programmes and virtual clinics for GPs, nurses and other practitioners on the agreed clinical pathway;
More appropriate clinical direction of referrals to the acute setting, so only patients who need to be seen in the acute setting are referred;
Improve the education of patients regarding self-management of their conditions;
Reduce and maintain waiting times for assessment to a maximum of four weeks;
Improve communication and ensure the transfer of care is managed appropriately between specialist and primary care;
Provide better value for money due to a more cost effective use of resources;
Improve the management of cardiovascular and respiratory disease through implementation of national and best practice guidelines, e.g., NICE, Care Closer to Home etc;
Improve patient choice by providing an alternative to acute hospital care;
Be available to all adult patients who are registered with a GP in H&F CCG
The service would be compliant with SystmOne, or a system that is interoperable with SystmOne, to enable transfer of patient data between community, primary, and secondary care where required and in keeping with Data Protection regulations.
The key principle of the service will be joint working, with the service operating as an integrated Cardiology and Respiratory service. It will provide regular joint diagnostic clinics, multidisciplinary team case reviews, and joint or co-located community clinics at the same time to provide joined-up care for patients with breathlessness of unknown origin, and/or comorbid cardiology and respiratory illnesses. For example:
7Commissioning for Value: Pathways on a Page – Hammersmith & Fulham CCG (Nov 2014) Public Health England with NHS England
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The service will provide pulmonary rehabilitation and cardiac rehabilitation clinics in the community. These classes will cover a range of ages and abilities to ensure all patients with a cardiac or respiratory rehabilitation need are able to access appropriate classes. The service will also have named respiratory and cardiology nurses for each GP network, and one specialist breathlessness nurse supporting all five GP networks. The service will provide support to H&F GP networks in delivering the Out of Hospital (OOH) contracts, specifically ambulatory blood pressure monitoring, ECG and Spirometry. The key aim of the service is to ensure patients are managed seamlessly along their symptom pathways to ensure positive patient outcomes. The service specification is attached in Appendix 1 for information (attached separately).
SECTION 3: Economic Case
This section must be completed in conjunction with the CCG Head of Finance.
Some projects will have benefits that are not cash releasing but are never-the-less an important consideration in the decision to make an
investment.
In this section list and, as far as possible, quantity all of the non-cash releasing benefits for the options that you have considered. The
option that has the greatest economic benefit should be strongly considered to be the preferred option, although other factors can be
taken into consideration in the next section. Detailed calculations should be shown as an appendix to this document.
3.1 The financial benefits of providing a Community Cardio-Respiratory service are expected as follows; i. Provides more efficient and targeted use of clinical resources (achieved through specialist triage of
referrals and multidisciplinary working),
Cardiocause
Patient presents
with shortness of
breath
Joint diagnostic clinic – ECG, spirometry (or review of tests performed in primary care),
ECHO, BNP
Resp
cause
Cardiologyservice
management
MDT for patients with
co-morbidities
or complexity
Respiratory
service
management
Joint rehabilitation services covering a range of abilities
lifestyle change/psychological therapies
Patient presents with
known/identified
Cardio condition
Patient presents with
known/identified
Resp condition
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ii. Reduces the number of secondary care outpatient attendances predominantly in Cardiology (due to assessment and management in the community or earlier discharge from secondary care to the community service),
iii. Reduces the number of referrals to secondary care as a result of activity delivered in the community, up-skilling of GPs in primary care and early intervention through timely access,
iv. Secondary care no longer receives inappropriate referrals or referrals without documented preliminary investigations,
v. Clinical triage of referrals will support patients receive the right care first time;
vi. Multidisciplinary approach to care, bringing together Cardiologists and Respiratory physicians, will allow patients to get more coordinated care, reducing the number of interventions needed, and being managed along symptom pathways;
vii. Achieves better value for money (VFM), in line with CWHHE’s Quality, Innovation, Productivity and Prevention (QIPP) agenda
3.2 The qualitative benefits of providing a Community Cardio-Respiratory service include;
i. Early diagnosis and intervention in primary care and a greater focus on prevention and self-care through care planning,
ii. Development of local care pathways and referral process within the community service, iii. Provides education, information and advice to support and up skill GPs, promoting confidence to manage
a higher number of patients within primary care before onward referral, or under shared care arrangements,
iv. More patients will be diagnosed and treated within the community in convenient and accessible locations with a reduction in the number of referrals to secondary care,
v. Efficient and targeted use of clinical resources, vi. A greater focus on joint care planning with patients and support for patients to care for their conditions
more effectively; vii. Shared Decision Making between patients and clinicians on treatment options will allow more patient
centred care; viii. Avoidance of unnecessary delays or waits for secondary care appointments, ix. Better signposting and cross referral to relevant services x. Provides access and onward referral to specialist Cardiology, Respiratory and other related services where
necessary.
3.3 Table 1 below illustrates the Value for Money (“VFM”) achievable from the procurement of the new service.
Table 1 : Current and Illustrative Reduced Tariff Costs
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3.4 The expected savings on tariff are expected through:
Reduced cost of provision of care in the community through lower capital and overhead costs;
A more effective use of skills mix;
Multi-disciplinary working to ensure patients access the right professional first time;
Competitive pressures through open procurement of services.
The financial benefit of providing a Community Cardio-Respiratory service, when combined with the qualitative factors detailed in 3.2 supported by the comprehensive re-design of service model and structure provide strong support to allow the Community service to be procured as per the preferred option in Section 4.
SECTION 4: Options Appraisal
In this section please describe the options that are available for achieving the desired outcome. This should include: a summary of the
economic assessment of the various options (as above), details on how the options were evaluated, why they were discounted and the
process by which the selection process was followed. This should include factors such as financial; legal or reputational risk criteria that
impacted these decisions.
It must evidence that alternative approaches were considered, evaluated and dismissed for sound reasons.
The options appraisal should include the formal evaluation of “doing nothing”.
Following review of this paper, Finance and Performance (F&P) Committee is asked to consider the following options relating to:
Three service commissioning options (Option 1-3)
Three payment options (Section 4, Option A-C) Service Options: We have set out three service options, the emerging preferred one of which is Option 3. Option 1 and Option 3 have
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been costed. Option 1: Do nothing (costed below in section 6) There is no formal mandate to redesign the CCG’s current Community Respiratory service. However, in keeping with the strategic direction of travel and the potential cost saving and enhanced quality and access benefits to patients from care closer to home, the CCGs all wish to commission services in the Community. The do nothing option will mean the continuation of no cardiology service provision in the community Option 2: Continue current Community Respiratory service and procure a separate heart failure or cardiology service The other option apart from “doing nothing” is to continue with our current Community Respiratory Service and procure a Community Cardiology service separately. It is felt that this option would not achieve the benefits of integrating the two specialties in the community such as a streamlined patient journey and faster access for correct treatment. Additionally this option would not achieve the same potential economies of scale as an integrated Cardio-Respiratory service. Furthermore, carrying out formal procurement has cost implications, and the expense would be larger proportionally if only a Cardiology service were procured. Option 3: Procure a new Cardio-Respiratory Community Service in H&F Under this option, a specified Cardio-Respiratory community based service would be commissioned to start in April 2016 using a single stage open procurement process. Based on similar services elsewhere (NHS West London CCG and NHS Central London CCG), evidence shows this to be achievable with minimal infrastructure requirements enabling providers to use existing estate. A strong market appetite is evident for these services, and undertaking procurement will attract value for money and innovative service delivery proposals. Option 3 is the recommended option for approval.
SECTION 5: Commercial Considerations
Outline all of the commercial considerations in taking forward this project. This should include as a minimum:
Procurement route
TUPE implications
Premises
Contracting mechanisms (including proposed payment mechanism)
Length of contract
Exit strategy
Legal implications
Procurement Route Following advice from the procurement support service supplier, NHS Shared Business Services (SBS), the preferred procurement route is a single stage open tender procedure under Part B of the Public Contract Regulations 2006. This route has the twofold benefit of ensuring that inappropriate bidders are deselected from the process and reducing the procurement timeline. This is achieved by running the Pre-Qualification Questionnaire (PQQ) and Invitation to Tender (ITT) concurrently, thereby condensing the whole process into a shorter time period. This is considered to be the most cost effective and timely option – for the Bidder and market. This has been informed by market engagement which has indicated a relatively small number of potentially interested bidders i.e. no requirement necessary to have a shortlisting process during the procurement. Other procurement options considered: An Any Qualified Provider (AQP) route for procurement was considered and has been used elsewhere for commissioning Community services, but it was discounted here due to:
Loss of potential economies of scale
Challenges relating to ensuring good governance;
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Challenges relating to the sustainability of the Community service;
Challenges relating to clear patients pathways; and
Additional capacity which would be required to manage multiple contracts. Existing contractual obligations and notice period required As we anticipate that the CCG will move approximately 80% of first and follow-up cardiology activity and no further respiratory outpatient activity (our base case scenario) this would represent a significant portion of the existing provider services. There is a contractual obligation which requires CCGs to give a minimum of six months’ counting and coding notice. The contracting support team will be notified that notice is likely to be required, pending sign off from the CCG’s relevant approval board. If Option 3 is agreed and a procurement is started, notice will need to be served to the current incumbent (CLCH) for the current Community Respiratory Service as per the obligations of standard NHS contracts. A standard de-commissioning notice is 6 months within this contract. Following agreement of the business case a de-commissioning notice can be issued. TUPE As a significant proportion of first and follow up appointments (especially Cardiology) could be transferred from the secondary care setting into the Community, there is likely to be a sufficient volume to warrant a TUPE transfer of current staff into the new service. TUPE workforce data will be requested from existing providers for inclusion in the Invitation to Tender as soon as possible. The onus is on bidding organisations to seek their own independent legal advice as to whether TUPE applies. Premises Premises may be mandated by the CCG, utilising existing space in current premises in multiple sites across each the H&F borough to allow equity of access for patients. The running of these sites will be considered when costing the contract. The provider will be responsible for ensuring each location where services are to be provided meets with Care Quality Commission (CQC) regulations. This process can take between six to twelve weeks from the date a contract is awarded. The provider will also be responsible for the lease of the premises and for facilities management of the building, plus cleaning and maintenance. Indicative costs will be provided in the procurement documentation. Each provider will also need to consider whether the new Cardio-Respiratory Community service would ideally be co-located with other related services. Contracting and payment options: An NHS Standard Contract is proposed for a three year period, with an option to extend for an additional period of two years, subject to the quality standards being achieved. The exit strategy will be in keeping with standard NHS Contract terms. There is a wide range of contracting options to consider. Fewer contracts are expected to result in the highest cost savings through greater economies of scale. Typically one contract with one provider equates to approximately £4,000 per year in management costs. This means that an increase in the number of contracts managed will likely require a corresponding increase in resource for the contract management team. Pricing Structure Differing payment options exist, as described below. This business case is recommending that option (C), a contract based on PbR/Tariff (i.e. cost and volume) is adopted. The options considered are:
Option A – Straight block contract This option funds a pre-agreed level of activity based on historical performance and predicted future need. Typically a 10% over/under activity threshold may be set. This would mean that any underperformance up to 10% is not paid for and any over performance up to 10% is not paid for. This option presents a risk to the commissioner of underperformance and no incentive for the provider to over perform. As a new service, there are uncertainties on the precise volume of activity that will be delivered in the Community Service. Therefore the risk of adopting a block contract approach is considered too great and is not recommended.
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Option B – Contract on PBR/Tariff with a minimum income guarantee This option funds the provider on a cost and volume basis (as with Option C) with a set price for first and follow up appointments, and diagnostics. The price would be set through competitive procurement, with a clear signal to the market that the maximum price must be lower than 80% of current tariff price, if it can be demonstrated this is viable for providers in the financial case. To support attractive offers from the market, including small/medium sized organisations, the perception of activity risk can be managed by the commissioners by setting a minimum income guarantee for an initial transition period (up to 12 months). The minimum income guarantee would be set at a pre-agreed lower level of expected activity (a ‘down-side’). Activity delivered over this threshold would be paid at a local tariff price. Based on the expectation of activity transfer to the Community Service, it is reasonable to set a minimum income guarantee at 30% of the planned activity. Minimum income guarantees are used to support the management of risk where activity requirements are unknown/untested and the market requires some form of assurance to attract sufficient interest. The specification includes a ‘Single Point of Access’ function, which will enable the provider of the Community service to channel referrals to the Community service as clinically appropriate. In this instance however, it is felt that a minimum income guarantee is not required as there is sufficient interest for this service, and substantial community activity volumes in Respiratory to be a low risk to potential service providers. Option C – 100% of contract on PbR/Tariff (or cost and volume) With this option, the provider receives an amount per case with no minimum or maximum guarantee of payment or activity. There is no minimum income guarantee for the provider and no maximum budget for the commissioner. The PQQ element of the procurement will seek to assess the financial risk of any bidders bearing in mind this information.This contract value will be subject to a 10% performance based element, using KPIs within the quality schedule, to include meeting waiting times and patient experience. This is the recommended option.
Recommendation
Option C, a cost and volume contract based on PbR/Tariff is recommended. A 10% performance based element will include meeting waiting time KPIs in addition to patient experience.
Proposed Tender Rate The tender value will stipulate that bids are expected to be no greater than 80% of PbR tariff, and only proposals that set out a tariff lower than this will be considered. Potential for price reviews will be built into contracting arrangements with the selected provider. Contract Details An NHS Standard Contract is proposed for a three year period (with the option to extend for a further two years) subject to the quality standards being achieved. The exit strategy will be in keeping with standard NHS Contract terms. For the benefit of this business case, financial forecasting has been projected over a three year contractual term. Legal considerations The standard NHS Contract will be legally binding and close adherence to the procurement process will ensure that any contract awarded will not be subject to successful challenge. IT The provider will be expected to ensure the appropriate IT systems are in place and fully interoperable with SystmOne and absorb these costs in full in their bid. While a quote will be provided to Bidders as an indicative guide (the CCG has obtained a quotation from The Phoenix Partnership (TPP) dated 26
th March 2014 to the value of £61,277 for a 200 user
license), bidders will need to conduct their own due diligence. The providers will be asked to include costs for SystmOne in their bids. The new Community Cardio-Respiratory service will require continuity of patient record (electronic and paper, between GP, Community service and hospital service).
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SECTION 6: Financial Case
This section must be completed by the CCG Head of Finance.
1) Current spend and activity ACUTE CARDIOLOGY The activity and cost by the largest providers for acute based cardiology outpatient first (OPFA) and follow up (OPFU) activity for 13/14 and 14/15 is below:
Changes were made to the counting of diagnostic cardiology procedures between 13/14 and 14/15 and hence the cardiology procedure point of delivery (OPPROC) is only shown below for 14/15 - 65% i.e. the majority is diagnostic ECG:
Firs t
Attendances
Firs t
Attendances
Cost of Fi rs t
Attendances
Cost of Fi rs t
attendances
2013/14 2014/15 2013/14 2014/15
IMPERIAL 1,710 1,237 £377,786 £196,995
CHEL WEST 439 352 £94,189 £80,274
EALING 132 140 £31,938 £34,004
OTHER 65 71 £10,546 £10,809
BROMPTON 39 50 £8,112 £10,366
Grand Total 2,385 1,850 £522,571 £332,448
Fol low up
Attendances
Fol low up
Attendances
Cost of Fol low
up Attendances
Cost of Fol low
up attendances
2013/14 2014/15 2013/14 2014/15
IMPERIAL 1,037 1,085 £129,966 £87,777
CHEL WEST 411 456 £43,525 £46,053
EALING 189 152 £22,325 £16,987
OTHER 95 128 £11,245 £13,354
BROMPTON 208 136 £4,914 £805
Grand Total 1,940 1,957 £211,975 £164,976
Total
Attendances
Total
Attendances
Cost of Total
Attendances
Cost of Total
attendances
2013/14 2014/15 2013/14 2014/15
IMPERIAL 2,747 2,322 £507,752 £284,772
CHEL WEST 850 808 £137,714 £126,327
EALING 321 292 £54,263 £50,991
OTHER 160 199 £21,791 £24,163
BROMPTON 247 186 £13,026 £11,171
Grand Total 4,325 3,807 £734,546 £497,424
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The total cost of all acute Cardiology outpatient attendances and procedures in 14/15 was £1.43m for H&F. This includes activity at all providers, and from all referral sources e.g. GP referrals plus other referrals such as internally generated referrals. ACUTE RESPIRATORY The activity and cost by the largest providers for acute based respiratory outpatient first (OPFA) and follow up (OPFU) activity for 13/14 and 14/15 is below:
All activity in the Respiratory procedure point of delivery (OPPROC) for 2014/15 is shown below. 81% of this is for complex lung function testing which would not be removed from the acute contract, and hence the respiratory OPPROC point of delivery is not considered in further analysis.
Total
Procedures
Cost of Total
Procedures
2014/15 2014/15
IMPERIAL 4,063 £880,387
CHEL WEST 159 £28,779
EALING 67 £16,911
OTHER 43 £9,606
Grand Total 4,332 £935,683
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The total cost of all acute Respiratory outpatient attendances and procedures in 14/15 was £721k for H&F. This includes activity at all providers, and from all referral sources e.g. GP referrals plus other referrals such as internally generated referrals. COMMUNITY RESPIRATORY Outlined below is the activity that took place in 2014/15 in the Community Respiratory Service for H&F:
There were 6,700 attendances in 14/15 of which 75-80% were follow ups. The attendances include:
Disease Management clinics
Consultant clinics
Community Respiratory Assessment clinics
Physio attendances
Pulmonary Rehab attendances
02 assessment attendances The service line cost in the CLCH contract for this service line in 14/15 was £1,115,126. TOTAL ACTIVITY/COST The total cost of acute cardiology outpatient activity, acute respiratory and community respiratory activity (outpatients and procedures) in 2014/15 was £3.27m. 2) Changes to activity flows Under Option 1 outlined in Section 4, i.e. the “Do Nothing” option – all activity would remain in the same place as outlined above. Under Option 3 outlined in Section 4, i.e. the commissioning of a new Cardio-Respiratory Community service – the table below shows the expected transfer in activity from acute providers, that could be seen by the new Cardio-Respiratory community service, as agreed by the Steering Group, involving Lead clinicians:
Total
Procedures
Cost of Total
Procedures
2014/15 2014/15
IMPERIAL 394 £86,967
CHEL WEST 30 £7,410
OTHER 17 £3,111
Grand Total 441 £97,488
Service - Reporting Line Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15TOTAL
14/15
14/15
ANNUAL
PLAN
14/15
VARIANCE
FROM PLAN
%
VARIANCE
Community Respiratory 558 604 534 651 628 639 669 586 478 536 547 270 6,700 6,939 -239 -3%
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The above is based upon the following assumptions:
14/15 data
Shifts apply to all new and follow up attendances at all providers (procedures excluded) not just GP referred attendances
Assume shift of 80% of all acute Cardiology outpatients to community
Assume no shift of acute Respiratory (as majority is already in the community)
Assume shift of 80% of Cardiology diagnostics to the community
No activity shift: respiratory procedures (these are complex lung function tests which will stay in the acute sector)
First to follow up (FFU) ratios will also be reviewed as activity shifts take place to ensure that patients are being appropriately discharged from either secondary or community settings, with appropriate care plans. The expected FFU ratios will be reflected in contracting arrangements. Specialist clinical opinion was sought on the above assumptions, and input from a Cardiology consultant was that the diagnostic baseline data in North West London is generally not plausible, and for H&F although the overall quantum was fairly accurate the split of diagnostics was specifically underestimating the number of Echo and 24 hour ECGs required. The following table shows the estimated diagnostic percentages required for the total number of Cardiology OP attendances, and how this translates into required diagnostic activity numbers. These figures below are used going forward in costing the service.
19
3) Cost of the new service This section analyses three different approaches to costing the new service:
1) Bottom up costing of the service 2) Benchmarking with similar services run by other CCGs 3) Costing shifted activity at 80% of tariff
1) Bottom up costing
To ensure that the service is financially viable prospect for potential providers, a bottom up costing exercise has been undertaken to ensure that the the notional costs of providing the service can be covered by tariff price, and also tariff price with a 20% discount. This has been calculated by assessing the number of clinics required and costing up the associated pay and non-pay costs. A summary is shown below. This indicates that even at 80% tariff and ensuring the service is staffed to run 52 weeks a year, it is a viable prospect for providers, making an estimated profit of approximately £164k.
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2) Benchmarking analysis
This section has been redacted due to the commercially sensitive nature of the benchmark information. 3) Indicative costs and savings to the CCG at 80% tariff Option 1 below outlines the “Do Nothing” situation forecasted forward three years, where all activity remains in the same place as it is currently. Option 3 below outlines the costs and proposed savings of the new Cardio-Respiratory community service. They assume a contract price equivalent to 80% of current average PbR acute tariff is applied to forecast Community Cardiology activity levels, with 14/15 actual baseline, growth of 3%, and the tariff deflator as stated. A 20% efficiency factor is also applied to the community respiratory activity in the new service as it is felt by the contracts team this service line does not represent value for money in the current CLCH contract.
Out of Hospital Services The cost of the new service above has currently not been adjusted i.e. reduced to take into account flows of activity out of Secondary and Community care into the proposed Out of Hospital Services for 16/17. The services have not yet commenced in 15/16 and therefore, the actual ramp up in terms of how much activity will run through these services is not yet clear. With Spirometry there are also queries related to the specification and whether appropriate delivery can currently take place in primary care, or whether this needs splitting into two levels, review and diagnosis. QIPP savings have already been planned for some of the OOH services before they commence and ramp up, and this is noted here to highlight the potential for double count of savings. For H&F the 2015-16 QIPP plan for OOH ECG contains planned reduction of 865 (ECG activity) with saving value of £167k, when real values are available these can be factored into the above. 4) What is the upper affordability limit? The upper affordability assumed cost of the new Cardio-Respiratory Community service across a three year contract is estimated at £6,196,292 based on the above calculations.
21
SECTION 7: Funding source
Outline all sources of funding for the project including non-recurrent, recurrent and capital.
Consider the application route for sources of funding that are outside CCG allocations, for example, capital requirements.
The table in part 3 of Section 6 outlines that the projected funding for the new service is £6,196,292 in total over three years. This will be funded comprised in part by the existing recurrent Community Respiratory service funding over three years of £3,586,338, and the remainder of the budget required will be covered by existing acute funding arrangements. It is estimated that through activity shift and associated tariff negotiation £991,441 of savings across the three years could be released to the CCG.
Project costs for personnel to manage the procurement will come from existing CCG budgets
SECTION 8: Overall Plans for Implementation and timescales
This section builds on the resources and cost of delivery section included in the project mandate.
Outline the resources and timescales required to deliver all phases of the project. Consider procurement cost, legal costs, project
management time, the completion of capital bids, stakeholder engagement, equipment and overheads. These costs should also be
included in the non-recurrent costs in the financial case.
Also consider the cost of slippage in delivery of the project and the inclusion of a contingency.
An advert signalling an intention to procure the new Cardio-Respiratory Community service, together with a Memorandum of Information, is planned for publication on Contracts Finder and EU Supply Portal in late July 2015 subject to Governing Body approval in July 2015. Potential Bidders will be invited to a Market Engagement Event to take place in August 2015. The next stage of the procurement is then to issue a Pre-Qualification Questionnaire (PQQ) and an Invitation to Tender (ITT) to the market. Following evaluation of Bids, contracts will be awarded by individual CCGs (subject to Governing Body approval). The procurement timetable is presented below:
Activity H&F CCG
Finance and Performance Committee approval 30 June 2015
Governing Body (GB) Business Case approval 14 July 2015
Notice to current providers 15 July 2015 (dependent on GB approval)
Advert for Market Event Late July 2015
Publication of MOI and draft specification Early August 2015
Advert for procurement Early August 2015
Publication of Invitation to Tender (incl PQQ) Early August 2015
Bid response deadline (7 weeks) End September 2015
Evaluation and internal approval process During October 2015
Approval of Preferred Bidder by Governing Body November 2015
Contract Award – notify bidders and standstill period Following November 2015 GB approval
Mobilisation Post standstill until 31st
March 2015
Service Commencement 1 April 2016
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SECTION 9: Risks
Build on the key risks identified in the project plan to provide an initial risk register to be used at the commencement of the project. This
will become the live risk register and will form a separate document. Include a detailed list of risks, scores and mitigations in the appendix
of this document.
Table - Overview of risks and mitigating actions
Description of risk L C Score Mitigating actions
Expected savings are not achieved because the volume of activity expected to transfer to the is not achieved; this may be related to Consultant to Consultant referrals bypassing the Community service
2 3 6 Market research indicates that 80% activity transfer of Cardiology is achievable. This can be facilitated by referral management and the Single Point of Access function. The CCG will need to ensure that its referral management process is effective. Engagement with local GPs will need to take place to make them fully aware of the service offering and referral options.
Expected savings are not achieved because the price expected for the Community service is not achieved.
2 3 6 Market research has set the expectation for cost assumptions modelled in the business case and a maximum 80% of PbR will set in the advert
The procurement timetable slips reducing the cost savings in 2015/16 due to scale and complexity
4 3 12 Early conversations with the Procurement team indicate that a tender at this scale may incur delays; the process will need to be tightly managed and will warrant dedicated resource at key periods.
The acute trusts are destabilised and quality is impacted because outpatient Cardiology and Respiratory services cross-subsidise other specialisms
2 2 4 While this is clearly important, the strategic direction of Shaping a Healthier Future means that the transfer of care to out of hospital settings needs to be carefully managed. Engagement has taken place with local trusts and a clear expectation is set on the planned procurement.
Total costs escalate because capacity isn’t reduced in acute trusts
3 3 9 We will stipulate that acute trusts will be required to hold their waiting times as activity transfers out so that activity can be reduced. On-going monitoring of activity in both
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SECTION 10: Stakeholder Engagement
Include here a summary of the stakeholder engagement plan, highlighting particular interdependencies. This should be a summary of the
communication plan to support project delivery.
8 http://www.hammersmithfulhamccg.nhs.uk/news-and-publications/news/2015/03/views-needed-on-community-respiratory-services-in-
hammersmith-and-fulham.aspx
hospital and the Community service will need to take place.
Insufficient high quality providers submitting tenders
1 4 4 The procurement will be advertised appropriately to ensure that all capable providers are aware of the opportunity to tender. Strong interest has already been signalled from the market.
Lack of suitable premises 2 4 8
H&F CCG to liaise with premises lead to ensure clarity over availability and suitability.
General stakeholder engagement A variety of methods were used to ensure stakeholder and patient involvement in planning this service. These included:
CCG presentation at the Charing Cross Cardiac Club
Heart Health Talk at the Community Champions meeting at the Old Oak Community Health Centre
GP survey distributed via e mail and online at Survey Monkey
Patient survey – tweet sent out with the link to the survey at Survey Monkey and also put on the CCG website8
Views on service specification requested from local support groups such as Breathe Easy and CCG lay member
Review of patient experience feedback from the current Community Respiratory service (PREMS) As outlined in Section 1 there was positive support for the proposed Cardio-Respiratory Community service development. Further engagement will take place ahead of concluding the procurement of services, and onus will be put upon the successful bidder to engage with patients whilst mobilising the service. Market engagement An expression of interest was put to the market in February 2015 and six response questionnaires were received, including two from large local providers, indicating sufficient market interest. A separate bidders’ information event is planned for the service in August 2014. The aim of the bidders’ event is to gauge the level of interest, clarify the commissioning intentions and procurement timeline of the service and to respond to appropriate queries ahead of the Qualifying Process. This event will be supported by NHS Shared Business Services (SBS). Full public consultation was considered but not seen as necessary as the service is in part a continuation of one that is already running and the service re-design has had patient user feedback.
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SECTION 11: Recommendation
Include here an outline of the key decisions that the reviewer (s) of this business case are required to make.
The Cardio-Respiratory Community Service steering group recommend that procurement for the Cardio-Respiratory
service, using a single stage open tender approach, commences with immediate effect to enable a contract to be
awarded in with service start date of April 2016. A further recommendation is made that a remuneration model based
on payment by local tariff with a minimum income guarantee for the first 12 months is adopted.
13: KEY DECISIONS REQUIRED BY FINANCE AND PERFORMANCE COMMITTEE:
The Finance and Performance Committee are asked:
Item Agreement from F&P committee is sought on the following:
Outcome of F&P discussion
1 To agree the procurement for a Community Cardio-Respiratory Service can commence immediately in line with the attached specification
2 To agree the current Community Respiratory service run by CLCH can be decommissioned immediately, giving the incumbent provider six months’ notice
3 To agree the proposed methodology of a single stage open tender route to enable contracts to be awarded from April 2016 onwards.
3 To agree the proposed cost and volume payment method for an estimated contract with an upper affordability limit of £6,196,292 for 3 years, a model based on locally agreed tariff
Following agreement of the Business Case by the Finance and Performance Committee, it is planned to be taken to the
July 2015 Governing Body for approval.
Interdependencies following service commencement include;
H&F GPs, Practice Nurses and Practice Managers
H&F GP Federation
Consultants in secondary care
Other CWHHE CCGs
Diagnostic services
Acute Settings – Chelsea & Westminster NHS Foundation Trust, Imperial College Healthcare Trust, Royal Brompton & Harefield NHS Foundation Trust
Other long term conditions services e.g. Diabetes
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APPENDIX 1 – Draft Service Specification
Service Specification
No.
Service Cardio-Respiratory Community Service
Commissioner Lead Julie Scrivens – Lead for Planned Care
Provider Lead TBC
Period 1st April 2016 – 31
st March 2019
Date of Review
1. Population Needs
1.1 National/local context and evidence base
National context
Diseases of the heart and circulatory system cause more than a quarter of all deaths in the UK,
accounting for around 160,000 deaths each year. The most common of these diseases, coronary heart
disease (CHD) is the UK’s single biggest killer, CHD is responsible for around 73,000 deaths in the UK
each year, an average of 200 people each day, or one every seven minutes. There are almost 2.3
million UK residents living with CHD, and its treatment costs the NHS nearly £2 billion each year9.
Local context
Hammersmith and Fulham is a small, but densely populated borough in West London. The population is
unusual in that it has a large proportion of young working age residents, high levels of migration in and
out the borough, and ethnic and cultural diversity. The principle cause of premature and avoidable death
in Hammersmith and Fulham is cancer. However this is followed closely by cardiovascular disease
(which includes heart disease and stroke). A significant number of people also die from COPD. Public
Health England outline the following statistics:
Between 2011-13 Hammersmith & Fulham’s age-standardised mortality rate for Cardiovascular disease for under 75s is 95.5 per 100,000 which benchmarks the borough as “worse” than both the London and England average
Emergency COPD admissions in H&F were 1.99 per 1,000 population in 2012/13 which is “worse” than London and “similar” compared to England.
Between 2011-13, there were 350 estimated deaths from causes attributable to smoking per 100,000 people in H&F. This is “worse” than both England and London
Public Health England’s Commissioning for Value Insight Packs (Nov 2014) suggests there are
significant opportunities for improvement in terms of both quality and spending for heart disease and
COPD in Hammersmith, hence the move towards developing a Cardio-Respiratory Community service.
The Cardio-Respiratory Community service will provide person centred care through a co-ordinated and
integrated approach to cardiovascular and respiratory prevention and management. High quality
outcomes that matter to patients will be delivered in easily accessible community locations across the
9 British Heart Foundation – Cardiovascular Disease Statistics. Accessed at https://www.bhf.org.uk/research/heart-statistics (Feb 2015)
26
Hammersmith & Fulham catchment area. Recent policy documents issued by the Department of Health
and by Healthcare for London have emphasised the benefits of shifting services into the community1011
,
and Lord Darzi12
has promoted the shift of activity into the community setting with responsive NHS care
that is:
Fair – equally available to all, taking full account of personal circumstances and
diversity
Personalised – tailored to the needs and wants of each individual, especially the
most vulnerable and those in greatest need
Effective – focused on delivering outcomes for patients that are among the best
in the world
2. Outcomes
2.1 NHS Outcomes Framework Domains & Indicators
Domain 1 Preventing people from dying prematurely
Domain 2 Enhancing quality of life for people with long-term conditions
Domain 3 Helping people to recover from episodes of ill-health or following injury
Domain 4 Ensuring people have a positive experience of care
Domain 5 Treating and caring for people in safe environment and protecting them from avoidable
harm
2.2 Locally defined outcomes
By providing faster access for patients with respiratory or heart conditions to specialist care within a community or home environment, and improved integrated care management between secondary and primary care and community specialist professionals, the following outcomes are expected:
Improved early diagnosis of cardiac and respiratory conditions
When diagnosed, people get high quality information on the illness and on the services available, both at diagnosis and throughout the course of their care
Optimised medical management of patients with cardiac and respiratory conditions in primary care and the community
Improved access for patients by delivering services closer to home and by increasing the number of investigations carried out during a single appointment, therefore reducing the need for multiple visits to a variety of locations
Minimised disease progression via: o Improved early identification - so that people recognise the symptoms of their cardiac or
respiratory condition and seek assessment and advice from healthcare professionals. o High-quality care and support following diagnosis – by developing an organised and
proactive multidisciplinary approach to the management of cardiac and respiratory illness, including both chronic and acute care.
Improved access to end of life care services and equity in care provision
Increase patient and carer satisfaction with their access and quality of care
10
Our health, our care, our say: a new direction for community services, 2006. Accessed at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/272238/6737.pdf (Feb 2015)
11 Health Inequalities and Equality Impact Assessment of ‘Healthcare for London: consulting the capital’, 2008. Accessed at
http://www.apho.org.uk/resource/item.aspx?RID=52757 (Feb 2015)
12 Our NHS Our Future: NHS Next Stage Review- Interim report, 2007. Accessed at
http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_079087.pdf (Feb 2015)
27
Increased understanding of public, patients and carers regarding lifestyle changes which can improve their health and wellbeing
Shift of appropriate cardiology and respiratory outpatient activity from hospital into community services
3. Scope
3.1 Aims and objectives of service
3.1.1 Aims of the service
The overarching aim of the service is to provide a high quality, consultant-led integrated community
cardiology and respiratory service to the residents of the Hammersmith & Fulham CCG. The service
aims to deliver an accessible, efficient, cost-effective service managing the majority of diagnostics and
outpatient activity within primary and community care settings. The service supports the Out of Hospital
ambitions of the CCG for the development of integrated pathways of care across health and social care,
transforming care pathways by shifting care from acute to community and primary care settings where
appropriate, avoiding hospital admissions if appropriate, and improving early discharge.
In addition, the integrated service will aim to provide the following outcomes common to all community
health services:
ensure that users of the service have a positive experience of care
ensure effective integrated care and communication between relevant health professionals
improve symptom control, function and quality of life for all patients, through self-management as far as possible
reduce/eliminate waste and poor quality care, and strengthen affordability and value
Outcomes matter to patients, and this service will aim to ensure patients with heart or lung conditions can
live active, well and independent lives.
Respiratory specific aims
The Service will seek to improve the quality of patient care, manage the risks of hospital admissions and
repatriate clinically appropriate cases from acute outpatients into a community care setting where it is
clinical appropriate.
The respiratory specific aims include:
ensuring timely and accurate diagnosis and severity assessment in people with respiratory conditions
increasing the proportion of people with COPD who are diagnosed with quality assured spirometry
ensuring prompt, optimal management and integrated care for all patients in line with evidence-based guidance, providing:
o responsible respiratory prescribing including oxygen therapy o specialist care closer to home o admission to hospital when required o early, structured and assisted discharge of COPD patients when appropriate o early reablement post exacerbation
ensuring effective management of co-morbidities, optimisation of therapy and treatment of tobacco dependence as appropriate
minimising the impact of the disease through faster and more effective treatment of exacerbations in the most appropriate or patients’ preferred setting
planning care case by case to increase the patient time spent with optimal functioning out of hospital
support for patients with planned transitions of care either from hospital to home or home to hospital
delivery of a Home Oxygen Assessment and Review Service ensuring all patients prescribed
28
oxygen are assessed yearly including with home visits and have ongoing community review to ensure a higher standard of clinical treatment and improved outcomes, through more effective and speedier diagnosis, ongoing education and risk assessment and long term follow up
support patients reaching the end of life (and their carers) with advance care planning to support preferred place of care and preferred place of death discussions
decreasing the number of people dying prematurely from respiratory illness
reducing the number of patients that smoke by providing smoking cessation as an integral part of the service e.g. all staff in the service are level 2 or 3 trained, and supporting primary care with smoking cessation
The service will focus on the following key areas:
Supporting diagnoses in Primary Care through virtual clinics (i.e. no patient in attendance, GP and consultant work through the management of both routine and complex patients together), education and support
Supporting primary care via telephone and e mail
Management of complex cases in community via consultant-led community clinics
Case load management Redirection of acute outpatient referrals into community
Identification and management of stable and acute patients, including effective response to exacerbations
Running a pulmonary rehabilitation program (offered within 4 weeks of discharge where appropriate following non-elective admission for respiratory condition)
Health promotion and facilitation of self-management
Integration with existing services – a non-exhaustive list to include; social care, community matron, IAPT, primary care mental health teams, CIS+, care navigators
Triage of respiratory referrals (and cardiology referrals) through a combined single point of access
Providing an urgent advice phone line for rapid response services to prevent admissions where possible (8am – 8pm)
Providing home Oxygen assessments and reviews
Supporting patients in the community with end stage respiratory disease and their carers
Cardiology specific aims
The cardiology specific aims include:
Providing a high quality cardiology service within the community providing assessment, diagnosis, and management of patients in need of non-invasive cardiovascular assessment and treatment
Putting in place a “one stop” service that can incorporate diagnostic testing and treatment during a single visit (where appropriate)
To manage patient care in the most clinically appropriate setting, following a patient centred pathway with access to specialist care closer to home where required activity
To provide a cardiology service that is responsive to the needs of patients
To provide fast, equitable access to treatment in an environment convenient to patients
To provide quick opinions and treatment plans for the referring clinicians; the aim is to diagnose and refer back to the GP with a detailed management plan, and follow up only as appropriate
To provide education and support to GPs to enable them to manage their patients with cardiac conditions “in-house”
To improve health outcomes through earlier diagnosis and treatment of common cardiology conditions
To support patients, and their carers, with end stage cardiac failure in the community
3.1.2 Objectives of the service
Strategic objectives
To reduce the cardiovascular and respiratory contribution to health inequalities
29
To reduce overall mortality attributable to cardiovascular or respiratory disease
To provide a seamless pathway between community, primary care and secondary care services
Cardio-Respiratory Programme objectives
To deliver consultant-led cardiology services in the community, including management of heart failure, arrhythmia, complex or uncontrolled hypertension, stable but sub-optimally controlled angina, diagnosis and management of valve disease, and cardiac rehabilitation
To deliver consultant-led respiratory services in the community, including management of COPD, asthma, and bronchiectasis.
To deliver training and education, incorporating advice and guidance services, to local GPs
To improve the quality of cardiology and respiratory services in primary and community care
3.2 Service description/care pathway
3.2.1 Joint working
The key principle of the service will be joint working, with the service operating as an integrated
Cardiology and Respiratory service. It will provide regular joint diagnostic clinics, multidisciplinary team
case reviews, and joint or co-located community clinics at the same time to provide joined-up care for
patients with breathlessness of unknown origin, and/or comorbid cardiology and respiratory illnesses.
For example:
The service will provide joint pulmonary rehabilitation and cardiac rehabilitation clinics in the community.
These classes will cover a range of ages and abilities to ensure all patients with a cardiac or respiratory
rehabilitation need are able to access appropriate classes. The service will also have named respiratory
and cardiology nurses for each GP network, and one specialist breathlessness nurse supporting all five
Cardiocause
Patient presents
with shortness of
breath
Joint diagnostic clinic – ECG, spirometry (or review of tests performed in primary care),
ECHO, BNP
Resp
cause
Cardiologyservice
management
MDT for patients with
co-morbidities
or complexity
Respiratory
service
management
Joint rehabilitation services covering a range of abilities
lifestyle change/psychological therapies
Patient presents with
known/identified
Cardio condition
Patient presents with
known/identified
Resp condition
30
GP networks. The service will provide support to H&F GP networks in delivering the Out of Hospital
(OOH) contracts, specifically ambulatory blood pressure monitoring, ECG and Spirometry.
The key aim of the service is to ensure patients are managed seamlessly along their symptom
pathways to ensure positive patient outcomes. This service is intended very much to be run
jointly across the two specialties. However for clarification purposes outlined below are specifics
related to service provision for each specialty.
3.2.2 Cardiology specific service provision
The community cardiology service will be a consultant led service, supported by a multidisciplinary team
of specialist community nursing and allied health professionals including (non-exhaustively) respiratory
and cardiac nurses, clinical psychologists, physiotherapists, rehabilitation team, community pharmacists.
The service forms a significant component of delivering integrated cardiology services working with
primary care, community nursing services, and local acute hospitals. It will build on established links with
related services to help offer a borough wide network of initiatives aimed at reducing the prevalence and
impact of CVD. The service will be primary care facing and seek to proactively support primary care
improvement and support GPs to appropriately clinically manage patients in primary care in line with
locally agreed thresholds and protocols.
Primary Care:
The service will liaise closely with primary care colleagues providing: o Specialist support for primary care with the management of patients with atrial fibrillation,
coronary heart disease, heart failure, established hypertension, valve disease, palpitations, atypical chest pain, post exacerbation review, and episodes of related cardiovascular conditions
o Supporting primary care to take the initial steps in diagnosing patients o Virtual clinics to facilitate skill transfer to GPs by working through standard and complex
patient management using real patients as case studies o Support for patients to self-manage, including through medicines management with the
support of a community pharmacist o Management of acute episodes related to cardiovascular conditions o Post exacerbation review o Written materials on cardiovascular conditions and local support groups o Referrals as appropriate to other services
Community Care:
The service will provide: o Consultant led service with community outpatient clinics as appropriate o One stop joint cardiology and respiratory diagnostic assessment o Management of housebound patients via domiciliary visits o Community based Cardiac rehabilitation (joint with respiratory rehab) o Psychological support where the underlying cardiac condition is responsible for the
psychological distress o Early supported discharge and discharge management o Development of management and care plans, and ensuring these plans are shared with
primary care; o Advice and guidance via email, and other means of communication (telehealth, telephone,
skype, online consultation) to primary care o Training, education, and support to primary care in the identification, diagnosis, and
management of cardiovascular conditions, and working with the GP Federation to achieve these goals
o End of life management o A named cardiology nurse for each GP network, and one specialist breathlessness nurse
supporting all five GP networks
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Secondary/Tertiary Care:
The service will liaise closely with secondary/tertiary care colleagues providing onward referral for: o Acute admissions for cardiovascular conditions; o Inpatient cardiac rehabilitation; o Specialised outpatient treatment (e.g. heart surgery) o Management of patients aged <35 years o Management of severe cases of arrhythmia, hypertension, heart failure, or angina
The community cardiology service will provide:
A triage service for all cardiology referrals (excluding acute episodes)
Direct access diagnostics for local GP referrals to include echo, ECG, 24 hour ECG, and 24 hour blood pressure monitoring, interpretation and reporting
Assessment (including all diagnostics) and treatment plans for the following: o Arrhythmia and specifically atrial fibrillation o Complex or uncontrolled hypertension o Heart failure o Stable sub-optimally controlled angina o Chest pain o Advice and guidance for primary care on the assessment, diagnosis, and management of
cardiac conditions o Cardiac rehabilitation services
The detail of these service elements is outlined below:
Triage
For all referrals from GPs, community services, and hospitals, provision of:
Review of all referrals within 48 hours by a suitably qualified clinician
Triage of referrals to the most appropriate service, based on agreed levels of care across primary, community, and secondary care
Booking of appointments for the community cardiology service, offering routine referrals and appointments within 20 days and more urgent referrals an appointment within 7 days
Onward referral to secondary care as appropriate
Information back to referrers within 72 hours of referral with outcome of triage facilitated by IT as far as possible. Where outcome of triage is to manage in primary care, this information will include advice and guidance on the management of the patient.
Diagnostic Services
For patients presenting to general practice with palpitation, atrial fibrillation, hypertension etc. provision
of:
24 hour ECG reporting
Echocardiography
24 hour ambulatory blood pressure monitoring
home based blood pressure monitoring
other event monitor as appropriate
email/web-based advice on need for further specialist assessment and/or investigation
treatment plan
Consultant–led one-stop clinics
32
Clinics provided by a Consultant with specialist interest in: o Chest pain o Palpitation / arrhythmia / atrial fibrillation o Hypertension
Access to 12 lead ECG, 24 hour ECG monitoring or other event monitoring, 24 hour blood pressure monitoring, echocardiography (24 hour monitoring to be undertaken prior to Consultant clinic appointment) where not previously undertaken
Any necessary onward referral to hospital based care for further investigation and/or specialist follow-up to be in place
Treatment Plan
Heart failure management service
The service will provide a heart failure management service to patients with diagnosed heart failure that
adheres to British Heart foundation guidelines. The service will provide the following:
Close working with rapid response services (Community Independence Service Plus – CIS+) to prevent hospital admissions and improve patient pathways. This will include provision of an on-call function during core hours for immediate advice and guidance, and follow up patient visits within 48 hours, and for housebound patients within 48 hours
Case management, including home visits for patients with diagnosed heart failure – potentially joint visit with primary care
Review of all investigations with Consultant Cardiologists
Patient assessment including all diagnostics tests (blood tests, ECG, spirometry, echocardiography, exercise testing), where not already carried out in primary care
Integrated working with community nursing teams and referrals to community nursing team when appropriate
Work with primary and secondary care where appropriate to ensure appropriate management plans are in place post discharge
Palliative management plans that enable the majority of cardiac patients to have their end of life care managed in their homes.
Maximise the use of appropriate telemonitoring, especially for housebound patients. Patient helpline for patient and GP advice
Arrhythmia management service
The service will provide an atrial fibrillation management service and a rapid access arrhythmia service,
providing diagnostic investigations for palpitations, syncope and pre-syncope. This will include:
Routine blood testing, ECG, 24-72 hour ECG monitoring, echocardiography (if necessary), exercise testing (if clinically indicated) and cardiomemo fitting (if necessary).
Initial consultation with a Specialist Arrhythmia Nurse for risk stratification and organising appropriate investigations including placement of cardiac monitors.
Review of all investigations with Consultant Cardiologists
Telephone-call reassurance for appropriate patients
Chronic AF management
Chronic chest pain service
The aim of this service is to coordinate with the rapid access chest pain service and to manage patients with chronic cardiac chest pain who, despite optimal revascularisation (i.e. where revascularisation is either incomplete or impossible to achieve e.g. high operative risk and who consequently have ongoing angina), have persistent recurrent symptoms. This will include:
Community clinic assessments
Review of all investigations with Consultant Cardiologists
Case management e.g. optimisation of medication for patients with moderate to severe chest pain
Close liaison with pain specialists, Chronic Pain Clinic, psychology and psychiatric services
Rapid initiation of psychological therapy for those patients where anxiety/psychological issues are
33
significantly impacting on symptoms
Treatment via exercise physiology and some minor cardiac physiology input
Appropriate onward referral to IAPT
Advice and support to General Practice:
The service will be primary care facing and seek to proactively support primary care improvement
including services delivered under out of hospital services such as 24 hour blood pressure monitoring
and ECG testing. This will include:
Supporting diagnosis of patients ECG interpretation and blood pressure monitoring and training etc. to support delivery of the OOH services
Support appropriate GP referral behaviour and assist them to navigate through the system, by signposting appropriate services outside this Community Cardio-Respiratory service
Clinical management through a variety of methods e.g. MDT case discussions, e mail etc.
Treatment Plan
Cardiac rehabilitation
Offer cardiac rehabilitation for those discharged from secondary care in line with NICE and British Heart
Foundation guidance including to:
Actively identify and refer all patients who are potentially eligible for cardiac rehabilitation and encourage participation
Manage referral and recruitment of patients to cardiac rehabilitation programme
Comprehensive assessment of patients referred for cardiac rehabilitation
Develop individualised patient care plans in line with NICE guidance and British Association for Cardiovascular Prevention and Rehabilitation standards and core components
Deliver comprehensive cardiac rehabilitation programmes in line with the British Association for Cardiovascular Prevention and Rehabilitation standards and core components, including exercise, education, risk factor management and social and psychological support
Deliver programmes in a range of settings, including patient’s homes
Conduct final assessment
Discharge and transition to long-term management
Where appropriate, work closely with respiratory rehabilitation providers to join programmes and improve patient pathways where possible
The service will offer “person centred” rehabilitation plans, agreed with each patient individually, providing
high quality, evidence-based care. The service will include:
An holistic approach to needs assessment encompassing clinical, social, emotional, financial and family/ carer requirements and leading to agreement on an individual care plan for each patient
A flexible allocation of resources, ensuring that the rehabilitation programme can be adjusted according to individual patient need whilst acknowledging guidance
Recognition that patient needs vary and rehabilitation should be tailored to the patient
Partnership with local volunteers supporting patients
The ability to offer individual and home based rehabilitation where required
The Prime Contractor shall ensure the service delivered meets the standards outlined within current
SIGN Guidance and supported by the British Association for Cardiovascular prevention and
Rehabilitation (BACR) and offers, as a minimum, the following core components:
Health promotion
Physical activity and exercise
Diet and weight management
Treatment for tobacco dependence
Education
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Pathophysiology and symptoms
Occupational factors
Sexual dysfunction
CPR
Risk factor management Blood pressure, lipids and glucose assessment
Psychological Psychological and quality of life assessment and self-management strategies.
Discussion of social, financial and vocational aims
Cardio-protective drug therapy and implantable devices Use of cardio-protective drug therapy
Awareness of impact the device will have on patients, carers and family
Information on device parameters
Referral protocol to specialist services for support
Long-term management strategy
On-going support and continuity of care is essential. Information from the service will be sent to
the patients GP for inclusion onto the CVD register.
Support should include: physical activity, weight management and all other secondary prevention
interventions and education
Supporting carers and relatives in the life of a person with a long-term condition.
Cardiac and heart failure nursing
NOTE: This list is only a guide and is not exhaustive. The commissioner will welcome proposals from
providers who are able to offer more broadly based “pre-habilitation” services which support the CCG’s
aims of reducing obesity, increasing levels of physical activity and promoting healthier lifestyles.
This service offer will be reviewed annually to ensure the service continues to offer the most up-to-date
and evidence-based interventions available for patients with cardiac conditions.
The service will be delivered from a range of settings (including gyms) and offered under different options
to maximise engagement. Patients may repeat the programme should they wish to.
3.2.3 Respiratory specific service provision
The Community Respiratory Service will provide a multidisciplinary, community-based clinical service for
people who have a long term respiratory illness, predominant those with airways disease (COPD,
Asthma, Bronchiectasis). The service will develop and deliver a system of specialist respiratory nursing
and physio support for networks of GP practices to facilitate and support early identification, evidence
based diagnosis, responsible respiratory prescribing and high value chronic care, anticipatory care and
case management, reablement and support at the end of life.
The model of service delivery is outlined below. In general the diagnoses of COPD and asthma will be
undertaken primarily within Primary Care. Where a diagnosis is indeterminate, advice will be available
from the consultant-led community team via advice and guidance, or direct referral. If the patient is
complex or has an acute episode then referral to and management in community or hospital based care
may be appropriate. When the patent is stable, the general expectation is that primary care will be
clinically responsible for the patient’s treatment and on-going management. The service will be primary
care facing and seek to proactively support primary care improvement and support GPs to appropriately
clinically manage patients in primary care in line with locally agreed thresholds and protocols.
Primary Care:
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The service will liaise closely with primary care colleagues providing: o Specialist support for Spirometry (for patients with expected COPD or asthma) undertaken in
accordance with the conditions of the CWHHE Out of Hospital scheme for Spirometry; and also providing diagnosis for complex diagnostic spirometry
o Supporting practices to case-find undiagnosed COPD and asthma in symptomatic smokers o Measurement of oxygen saturation for patients with COPD; o Specialist support where relevant following primary care annual reviews of patients with
COPD and asthma; o Development of care plans in partnership with patients;
Community Care
The service will provide: o Consultant led service with consultant outpatient clinics as appropriate o One stop joint cardiology and respiratory diagnostic assessment o Breathlessness MDTs o Breathlessness/COPD/Heart failure patient hotline available 8am-8pm and with weekend
cover o Assessment, treatment and management of patients with asthma, COPD, respiratory
infections, pneumonia, bronchitis, bronchiectasis and other appropriate respiratory conditions; o Working jointly with primary care to effectively manage housebound patients with complex
COPD, asthma, and bronchiectasis; o Level 1 and 2 oxygen assessment and management; o Pulmonary rehabilitation (joint for patients with heart failure/breathlessness where
appropriate)and physiotherapy o Psychological support (including but not limited to the management of depression and/or
anxiety related to the patient’s condition/s); o Sputum clearance and specialist physiotherapy review for patients with bronchiectasis o Early supported discharge and discharge management of patients from secondary care,
including co-ordination of step down care for all appropriate patients and delivery of COPD discharge bundles prior to discharge;
o Development of management and care plans and dissemination of plans to primary care; o Advice line to provide timely support to community service rapid responders; o Advice and guidance via email for primary care o Training, education, and support to primary care in the identification, diagnosis, and
management of COPD, asthma, and bronchiectasis; o Responsible respiratory prescribing across primary and secondary care o Supporting patients reaching the end of life, and their carers, with advance care planning to
support preferred place of care and preferred place of death discussions o A named respiratory nurse for each GP network, and one specialist breathlessness nurse
supporting all five GP networks
Secondary/Tertiary Care:
The service will liaise closely with secondary/tertiary care colleagues providing onward referral for: o Acute admissions for respiratory illness; o Inpatient pulmonary rehabilitation and physiotherapy; o Non-invasive ventilation assessment and management o Specialised outpatient treatment (e.g. lung surgery, respiratory failure) o Management of severe cases of COPD, asthma, and bronchiectasis o Interstitial Lung Disease
The community service is expected to provide the following core respiratory services:
Triage of all referrals for respiratory illness from Hammersmith & Fulham CCG GP practices, community providers, and secondary care, through a single point of access
Non-complex lung function testing (spirometry) where the GP is unclear, restricted or unable to
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provide
Early assessment, treatment and review in the community (via community clinics and domiciliary care) for COPD, asthma, bronchiectasis and assist with the management of interstitial lung disease, including the management of acute exacerbations.
Development and/or updating of care plans, in conjunction with patients and GPs.
Pulmonary rehabilitation.
Psychological assessment, treatment and support.
Education for patients and support for self-management.
Education for healthcare professionals in primary and secondary care.
Advice and guidance for GPs in the diagnosis and management of respiratory illness, via email.
Close working with local specialists in secondary care (e.g. respiratory and cardiology consultants) to improve patient pathways.
Close working with rapid response services to prevent hospital admissions and improve patient pathways. This will include provision of an on-call function during core hours for immediate advice and guidance, and follow up patient visits within 48 hours.
Reduced length of stay and post-admission secondary care outpatient referrals via active working with the inpatient and intermediate care teams to identify patients who could be discharged to the community with or without intermediate care support.
Optimised pharmacological & non-pharmacological management of patients in conjunction with their GP
Home oxygen assessment and reassessment to facilitate the provision of LTOT and AOT; monitoring of all patients on home oxygen concentrators.
In addition to these core respiratory services, the following general services will also be provided:
Care co-ordination between Primary Care and Secondary Care ensuring constant communication and accurate record keeping (i.e. care plans)
Attendance at multidisciplinary meetings when required
Maintenance of good communication with Patients’ Groups, including seeking patients’ feedback twice a year
Support for family and carers
Facilitation of transport for patients, by linking with existing transport providers
Link to tools for identification such as Putting Patients First
3.2.4 Integrated Care Pathway
The following referral pathway will be followed:
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A detailed process for the single point of access for clinical triage will also be put in place.
3.2.5 Staffing
It is expected that the service will be fully-staffed throughout the contract with the appropriate skill mix of
clinicians, managers, and administration staff. Any staff vacancy must be reported to the Commissioner
as part of monthly monitoring or as the potential vacancy arises (including long term sickness and
maternity). Vacancies are likely to impact on service delivery and must be dealt with pro-actively.
Cover arrangements (e.g. filling posts that are vacant) will be paid for by the provider.
The service is expected to comprise a multidisciplinary team of professionals including but not limited to:
Cardiac & Respiratory Consultants
Cardiac & Respiratory specialist nurses
Cardiac & Respiratory physiotherapists
Cardiac & Respiratory physiologists
Cardiac & Respiratory psychologists
Specialised pharmacy support
It is expected that the workforce of the service will have appropriate disease specific competencies, but
will also seek to develop new skills around the clinical management of conditions within the adjoining
pathway.
3.2.6 Accessibility/acceptability
The service is expected to provide both planned and unplanned access to the service to support patients
at risk of exacerbation and to intervene to support patients at the early stage of exacerbation.
Days and hours of operation are open to local determination to meet patient needs but as a minimum,
services will be provided Monday to Friday 9am to 5pm. The service will need to demonstrate how
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working with local urgent care services and other community services, they will effectively meet the
needs of unstable patients 7 days a week, 24 hours a day given that the community service will only
operate in their defined contracted hours. This will involve partnership working with local urgent care
services and other community services.
Patient education and pulmonary rehabilitation should be offered across the week (Monday to Saturday)
during the day and early evenings to improve access.
The service will be provided from community sites that provide coverage across the Hammersmith and
Fulham CCG area. This will include as a minimum one location in the north, one location in the centre,
and one location in the south of the catchment area.
The provider will have choice over the location of service delivery, but these must satisfy the following
criteria:
Within the borough of Hammersmith and Fulham (ideally with three locations serving the north, middle and south of the borough)
Service delivery sites must be easily accessible via public transport i.e. on a bus route (bus stop nearby) and with parking nearby, and also parking for blue badge holders
There should be step free access to all locations where the service is provided with enough space for a wheelchair user to manoeuvre around the premises, and also with an accessible toilet
The service provider must comply with all CQC fundamental standards, including those related to premises and equipment for all the sites that the service is provided at
The service must demonstrate how they will ensure equality of access for all patients meeting the duties
of the Equalities Act 2010 for protected characteristics including but not limited to age, gender, disability,
race, religion and sexuality, including where appropriate, positive outreach to patients and case finding.
The service will provide appropriate and timely interpreting/translation services and information in other
languages and formats where necessary, for those who do not speak English or who use British Sign
Languatge
We will expect the provider to provide accessible and high quality transport for patients based on the
national guidelines and eligibility for Patient Transport Services.
3.2.7 Response time and prioritisation
Immediate response for sudden illness (e.g. acute exacerbation). Initial response will be via the rapid response team (RRT). The RRT would contact the community respiratory service for advice and to arrange follow up. Where follow up is required, this should be done on the same day or the next working day
For urgent referrals, patients will be contacted within 48 hours of receipt of referral, and will be offered an appointment within 7 working days
For routine referrals, patients will be contacted within 5 working days of receipt of referral, and will be offered an appointment in the Community Service within 20 working days at clinic or at home for those patients who are housebound
All patient appointments will be allocated/offered by the single point of access booking function within 48 hours
All referrals should be offered an appointment that is compliant with the 18 week referral to treatment
pathways.
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For reporting back to GPs, the service will provide reports that are received by the referring GP:
For direct access diagnostics, within 7 working days
For urgent referrals, within 48 hours of the patient’s appointment
3.2.8 Discharge
Patients will be discharged from the service when:
They are seen as a one off encounter (e.g. for a spirometry test) or seen in the community clinic and discharged back to the care of their GP
They have completed an agreed intervention (e.g. pulmonary rehabilitation) All patient discharges should be planned and discussed with the patient and the service to which the
patient is to be discharged. Patients should be informed of contact details of the community team and
emergency out of hours services if further medical assistance is required.
A discharge letter should be sent within 1 week of discharge to primary care, along with a copy given to
the patient where appropriate.
3.2.9 Medicines Management
The service must be able to describe the systems and processes they will have in place to ensure safe
and effective prescribing and medicines management.
The service is required to adhere to the management of respiratory guidelines agreed through the North
West London Collaborative Medicines Management committee. Where new evidence emerges or the
providers would like the guidelines to be reviewed, providers are asked to work closely with the
Collaborative medicines management team and submit a business case with supporting evidence to the
CCG.
The outcome of medication optimisation will be to improve the quality of life for all patients and reduce
the risk of hospital admissions – e.g. timely initiation of COPD rescue packs for exacerbations. These
medicines may either be prescribed by a suitable qualified prescriber within the team or in conjunction
with the patient’s GP.
Providers should have a comprehensive policy on the ordering, safe storage, handling, prescribing and
dispensing of medicines approved by their Drug and Therapeutics Committee (or equivalent). If not
covered under the general medicines policy the following areas must have separately approved policies:
The use and disposal of patients own medicines
Self-administration of medicines by patients
Use of unlicensed medicines and medicines used for unlicensed indications
Interacting with the pharmaceutical industry
Prescribers should adhere to the NWL Integrated Formulary and should not seek to avoid restrictions by
asking GPs to prescribe non-formulary medicines. Antibiotics should, in the main, be prescribed from the
preferred list.
Where there is a choice of medicines which would be equally suitable for the patient, the most cost-
effective choice should be prescribed/recommended. This includes prescribing/recommending medicines
by generic name except where this is clinically inappropriate.
Providers should prescribe in accordance with all relevant local, national and professional guidance
including National Service Frameworks, NICE Technology Appraisal Guidance and relevant Health
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Service Circulars and Guidance, Executive Letters and Audit Commission reports.
Providers will demonstrate compliance with any relevant Central Alerting System alerts NPSA and MHRA
safety alerts and notices.
Providers will have a process in place to report Adverse Drug Reactions via the ‘Yellow Card’ system
All medicines used or prescribed are included within the service price unless they are specifically stated
to be excluded.
If medicines are required they should be prescribed by the Provider and given to the patient at their
appointment. Full and complete information on medicines provided should be provided to the patient’s
GP within 14 days to enable repeat prescriptions to be issued.
It is the responsibility of the Provider to prescribe a medicine on an on-going basis if:
It is unlicensed; or
It is included in the ‘Red List’ of medicines where responsibility for prescribing remains with the consultant
Where a GP feels they do not have sufficient experience of the medicine to take clinical responsibility for prescribing it
Ideally, informed consent for the use of licensed medicines outside of their licensed indications should be
obtained from patients before the prescription is written. Where there is a substantial body of evidence to
support the use of a licensed medicine outside of its licence, the GP may be asked to prescribe.
When a medicine requires specialist monitoring, the GP may be asked to prescribe only if the following
conditions are met before shared care takes place:
The patient's condition is stable; and
The agreement of the patient's GP is sought prior to the transfer of prescribing; and
The GP is sufficiently informed and able to monitor treatment, identify medicine interactions and adjust the dose of any medicines as/if required by shared care; and
Resources are available to ensure (where required) the safe administration of any specialist medication in the community e.g. IV therapy. This would usually be agreed with the community nursing services.
All individual consultations are required to include a discussion of ‘how to use prescribed medicines and
devices’. This should be supported by the provision of information leaflets or online
websites/manufacturer device videos as appropriate. The Provider will ensure that any potential issues of
medicine adherence (medicine taking) are considered and addressed.
When the patient is discharged from the service (or after episodes of care as appropriate) information
should be provided to the GP including:
Details of any medicines that have been stopped, the reason why the medicine has been prescribed and the intended duration of any new medicine
Any adverse reactions or allergies
Appropriate contact details where the GPs can communicate any issues
Any special arrangements made with Community Pharmacists or Community Nurses to supply/administer medicines
The providers will be required to monitor and audit internal prescribing as good practice and provide a
report to the CCG every six months
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3.3 Population covered
The service is provided to a specific local district that includes the London Borough of Hammersmith and Fulham. Adult people accessing services must be registered with a GP within the boundaries or otherwise deemed to be the responsibility of NHS Hammersmith and Fulham. Home visits will be provided where appropriate if patients are resident within the borough.
3.4 Any acceptance and exclusion criteria and thresholds
Exclusion Criteria
Patients under 18 years of age
Suspected cancer/two week waits
Acutely unwell patients. These patients should be admitted to hospital via usual channels, not via these services
Red flags: pleural effusion, known diagnosis of ILD, rapid progression of symptoms, sleep service, and TB
Days/Hours of operation
Community Service Hubs should ideally operate 8am-8pm
Early supported discharge – should run seven days a week
Referral route
A secure nhs.net email address for the single point of access for triage into the community service should be available
Referral to the early supported discharge program will occur through liaison with secondary care after appropriate assessment.
Referral to the Rapid Response Service will take place through use of a dedicated telephone number
Response time and prioritisation
Acute care service Early review at home (within 48-72 hours) for patients discharged from hospital after a respiratory exacerbation, for those who live within the borough
All patient appointments will be allocated by the single point of access booking office within 48 hours
3.5 Interdependence with other services/providers
The community service will be required to work in a multidisciplinary way with other critical parts of the
system including primary care, community nursing services, acute hospital providers, and the community
and voluntary sector to provide services to patients in the most appropriate setting across Hammersmith
and Fulham. As a community service it is critical that good working relationships are formed with open
dialogue between secondary and primary care colleagues; as well as colleagues from respiratory
community services to ensure that patients receive the best care in the most appropriate setting. The
service will work closely with:
Primary care, including Out Of Hospital service providers, providing spirometry and other direct access diagnostics
H&F GP Federation
Anti-coagulation services
Community nursing services (RRS, Case management)
CIS+
Acute sector
Mental health providers
Diagnostic services
Dietetics
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Smoking cessation
Social services
Occupational therapy and rehabilitation services
Expert patient programmes
End of life care services
Out of hours services
Psychological services, including IAPT and health psychology services
Community and voluntary sector providers
3.5.1 Psychological therapies
If the patient requires psychological support for mild or moderate anxiety and depression, or other
psychological distress associated with their cardiology or respiratory condition then the patient should be
assessed and treated by a clinical psychologist within the team. If the patient requires psychological
support for an unrelated condition (e.g. bereavement) they should be referred to the local IAPT service.
The provider will be required to deliver psychological therapies in line with respective service and
reporting requirements of the CCG. Activity will be expected to contribute towards meeting the IAPT
targets for each CCG. Where a patient may require structured psychological support the patient should
be referred into the appropriate service within Hammersmith and Fulham.
3.6 Equipment
The provider will provide all equipment, including that which enables the service to provide
echocardiogram reports and management plans in accordance with the BSE standards and minimum
data set. All equipment will be suitable for use in community settings and for housebound patients, or
those with mobility issues.
Equipment that enables Tissue Doppler assessment is not compulsory, but would be advantageous
3.7 Information Technology (IT)
To facilitate transfer of information between the community service and primary care, the community service will use the SystmOne operating system, or a system that is interoperable with SystmOne, using a secure N3 connection for transfer of patient identifiable data. The provider should work with primary care to ensure consent is agreed on both sides to share information and record it on the system. The provider will install and maintain IT systems that enable secure storage and transfer of information
between providers in the care pathway. This will include, but is not limited to:
Computer hardware, software, and networking that are secure and used only for clinical case management purposes.
Use of NHS.net mail to ensure the secure transfer of patient information.
Training for all staff in information governance and confidentiality and maintain levels of information governance training as required through mandatory and statutory training programmes
Ensuring controls for access to systems are managed effectively in line with national standards for registration (and smartcards where appropriate) so that permissions are allocated and withdrawn as necessary, and the provider can demonstrate compliance with role based access to patient recoards
With specific regard to diagnostics, the following conditions apply:
Sonographers and clinicians recording diagnostics will have immediate access to a Consultant Cardiologist opinion on results of tests/images. This is to ensure that if a serious condition is identified while taking the echocardiogram that requires urgent attention; a senior opinion can guide immediate action.
Reports and management plans can be sent to the referring GP by secure electronic means.
Secondary care clinicians are able to view images, and not just reports.
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The provider will work with the CCG and other parties involved in the care pathway to improve the use of
information in support of patient care. This may include participation in audits.
4. Applicable Service Standards
4.1 Applicable national standards (e.g. NICE)
NICE Clinical Guidance CG101: Chronic Obstructive Pulmonary Disease: Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care
NICE Quality Standard QS10: Chronic Obstructive Pulmonary Disease Quality Standard
An Outcome Strategy for People with Chronic Obstructive Pulmonary Disease (COPD) and Asthma In England (Department of Health, 2011)
Equality and Excellence: Liberating the NHS (White Paper, 2010)
Our Health, Our Care, Our Say (White Paper, 2006)
Commissioning a Patient Led NHS (Department of Health, 2005)
National Service Framework for Older People (2001)
National Service Framework for Long Term Conditions (2005)
Clinical Commissioning Policy: The Use of Hyperbaric Oxygen Therapy (2013)
NICE Clinical Guidance CG108: Chronic Heart Failure
NICE Clinical Guidance CG180: Atrial Fibrillation – The Management of Atrial Fibrillation
NICE Clinical Guidance CG127: Hypertension
NICE Clinical Guidance CG 126: Management of Stable Angina
NICE Quality Standard QS9: Chronic Heart Failure Quality Standard
NICE Quality Standard QS28: Quality Standard for Hypertension
NICE Quality Standard QS21: Quality Standard for Stable Angina
Cardiovascular Disease Outcome Strategy: improving outcomes for people with or at risk of cardiovascular disease (March, 2013)
Equality and Excellence: Liberating the NHS (White Paper, 2010)
Our Health, Our Care, Our Say (White Paper, 2006)
Commissioning a Patient Led NHS (Department of Health, 2005)
National Service Framework for Older People (2001)
National Service Framework for Long Term Conditions (2005)
4.2 Applicable standards set out in Guidance and/or issued by a competent body (e.g. Royal
Colleges)
British Thoracic Society Guidelines
Primary Care Respiratory Society UK Guidelines
British Cardiovascular Society Guidelines
British Association for Cardiovascular Prevention and Rehabilitation standards
Primary Care Commissioning Good Practice Guides for commissioning
Royal College of Physicians - National Review of Asthma Deaths (2014)
4.3 Applicable local standards
The GPs will be required to act in line with appropriate Governance arrangements in the delivery of this
enhanced service, including Standards of Better Health, NICE guidance, Professional Competencies for
Independent Contractors, Clinical Audit and Review Procedures, Information Governance Arrangements,
Patient and Public Involvement, Equality and Human Rights. The service will undertake regular audit
review on an annual basis (quarterly for the first year) and report to the Hammersmith & Fulham CCG.
Governance Requirements
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Clinical Accountability
Whilst the overall clinical responsibility of the Service User resides with the registered GP, the Provider
shall be clinically responsible for the episode of care that is administered to the Service User. Further,
the Provider shall be responsible, and accountable, for all aspects of the work of its Staff, including the
management of Service Users, in accordance with the GMC, Health Professionals Council and
Chartered Society of Physiotherapists codes of ethics and rules of professional conduct.
5. Applicable quality requirements and CQUIN goals
5.1 Applicable Quality Requirements (See Schedule 4 Parts [A-D])
5.2 Applicable CQUIN goals (See Schedule 4 Part [E])
The KPIs listed below are indicative and will be agreed in detail as part of the contractual agreements
with the provider.
Performance
Indicator
Indicator Threshold Method of
Measurement
Frequency of
Monitoring
Clinical
Effectiveness
% of patients managed by the service without onward referral to secondary care
Monitor in
year one, set
target in year
two/three
Provider
performance
report
Monthly
% of new patients with a score of
MRC3 and above who are offered
pulmonary rehabilitation if
appropriate
100% Provider
performance
report Monthly
% of patients receiving supported discharge and respiratory follow up following hospital admission for a respiratory exacerbation
100% Provider
performance
report
Monthly
% of new patients who have been offered review of inhaler technique
95% Patient survey
Joint audit with
primary care
Annual
Reduction in % of patients experiencing exacerbation of respiratory conditions (HRG codes of non-elective admission to be agreed)
TBC A&E
attendances
Patient survey
Joint audit with
primary care
Annual
% of patients who are offered referral to pulmonary rehabilitation assessment
95% Provider
performance
report
Monthly
% of patients who are referred to pulmonary rehabilitation and complete full programme (completion criteria to be agreed)
50% Provider
performance
report
Monthly
Number of emergency cardiology or respiratory admissions into acute trusts for patients that have
Targets for
improvement
to be set
Clinical audit
undertaken
directly with
Monthly
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been seen by the service
following
establishment
of baseline
primary care
Hospital (SUS)
data on
unplanned
admissions
% patients providing feedback immediately post appointment
80% Validated
Patient
questionnaire
tool
Annually
% of hypertension patients whose blood pressure is stabilised after one year (providing no cardiac event)
85%
Audit
undertaken
jointly with
primary care
Annual
% of patients with atrial fibrillation who are rate controlled and on appropriate anti-coagulation medication
95% Audit
undertaken
jointly with
primary care
Annual
% of patients who are referred to cardiac rehabilitation assessment
95%
% of patients who are referred to cardiac rehabilitation and complete full programme.
50% Provider
performance
report
Monthly
Smoking cessation – number of smokers referred into the service who quit smoing
TBC Provider
performance
report
Monthly
Patient satisfaction TBC Audit Monthly
Access
Patients are discharged with a plan of care.
100%
Provider report of number of discharges and care plans.
Monthly
Referrals are reviewed, triaged and accepted or redirected within 2 working days.
100% Provider Performance Report
Monthly
Patients are offered an appointment within 48 hours of receipt of referral.
100% Provider Performance Report
Monthly
Routine patients are seen within 20 days of referral.
100% Provider Performance Report
Monthly
Urgent patients are seen within 7 days of referral.
100% Provider Performance Report
Monthly
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GP support
and
education
Discharge summaries of non-
urgent patients are sent to GPs
within one week of appointment.
100%
Provider
Performance
Report
Monthly
GP education sessions/virtual
clinics delivered across all
practices
80% Provider
Performance
Report
6 monthly
Primary care feedback to be
collected and reviewed including
self-assessment of GP
competency
TBC Audit TBC
Number of telephone advice
episodes offered to GPs in respect
to clinical management within
primary care and referral to
secondary services
Number Provider
Performance
Report
6 monthly
Number of email advice episodes
offered to GPs in respect to
clinical management within
primary care and referral to
secondary services
No. Provider
Performance
Report
6 monthly
Service
Productivity
DNA rates are kept low to ensure
the service is working to capacity. <10%
Provider
Performance
Report
Monthly
% of patients discharged from the service whose episode of care is not complete (drop outs)
<10%
Provider
Performance
Report Monthly
Vacancy rates are kept low to
ensure the service is working at
capacity.
<12% Provider
report. Monthly
Clinical audit
Internal prescribing adheres to the
NWL Integrated Formulary. 95%
Provider report
of audit of
internal
prescribing.
6 monthly
Commissioner/Community/Primary
care joint audit to review
effectiveness of service
TBC Audit 6 monthly
6. Location of Provider Premises
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The Provider’s Premises are located at:
The provider will have choice over the location of service delivery, but these must satisfy the following
criteria:
Within the borough of Hammersmith and Fulham (ideally with three locations serving the north, middle and south of the borough)
Service delivery sites must be easily accessible via public transport i.e. on a bus route (bus stop nearby) and with parking nearby, and also parking for blue badge holders
There should be step free access to all locations where the service is provided with enough space for a wheelchair user to manoeuvre around the premises, and also with an accessible toilet
The service provider must comply with all CQC fundamental standards, including those related to premises and equipment for all the sites that the service is provided at
7. Individual Service User Placement