DATE: 25 July 2013

Title Community Clinics Business Care

Recommended action for the governing body

That the Governing Body:

Approve the Community Clinic Business Case noting

Community Clinics redesign represents £805k

recurrent QIPP saving opportunity

Approve procurement of new Community Clinic

intermediate services via the Any Qualified Provider

model

Note Quality & Safety subgroup to approve

Community Clinic Service Specifications

Executive Summary

Community Clinics represent a redesign of existing health economy services and look to introduce an intermediate tier of consultant-led provision between Primary Care and Secondary Care for non-complex treatment. Community Clinics will provide non-complex care in community settings hence act as a filter to ensure only appropriate patients are referred into existing Secondary Care provision as well as provide more cost-effective care. Community Clinics are proposed to be developed for Dermatology, Minor Surgery, Gynaecology and Urology as these areas are clinically appropriate for redesign of services and in addition represent areas where there is significant acute spend greater than the national average. In order to prevent the development of Community Clinics creating ‘over-capacity’ in the wider health economy a transformational CQUIN has been negotiated into 2013/14 contracts to ensure appropriate capacity reductions are undertaken in Secondary Care to mirror additional capacity in community settings the redesign scheme will achieve. Any Qualified Provider (AQP) is the preferred model of procurement of the new tier of provision as this will give greater choice and contestability to the Bexley health economy. Service Specifications for Dermatology, Minor Surgery,

ENCLOSURE: I Agenda Item: 74/13

Governing Body (Public) Meeting

Gynaecology and Urology are currently being finalised. The Quality & Safety Subgroup meeting on 18th July 2013 will review the Service Specifications to ensure they meet appropriate Clinical Governance criteria in order to assure non-complex treatment undertaken in non-hospital settings may be done so safely and effectively. Community Clinics, subject to Governing Body approval and procurement timetable, are planned to go live from December 2013.

Which objective does this paper support?

Patients: Improve the health and wellbeing of people in Bexley in partnership with our key stakeholders

X

People: Empower our staff to make BCCG the most successful CCG in (south) London

X

Pounds: Delivering on all of our statutory duties and become an effective, efficient and economical organisation

X

Process: Commission safe, sustainable and equitable services in line with the operating framework and which improves outcomes and patient experience

X

Organisational implications

Key Risks (corporate and/or clinical)

Potential to introduce additional capacity into wider economy (though CQUIN mitigates against this) Referral Management process continues to refer into existing Secondary Care services rather than filter into new Community Clinic provision

Equality and Diversity

None identified

Patient impact

Potential to improve patient care.

Financial

Opportunity for cost savings and efficiencies.

Legal Issues

None identified.

NHS constitution

Supports the CCG’s duties under the NHS Constitution.

Consultation (Public, member or other)

Outline details reviewed at held at 21May Patient Council event. Detailed Community Clinic review required Sep13 Patient Council

Audit (Considered / Approved by Other Committees / Groups)

Finance Working Group approved Draft Business Case 09Jul13 Quality & Safety Group review due 18Jul13

Communications Plan As included per Appendix 4 of Business Case

Author Neil Hales

Clinical Lead Dermatology: Dr Anna Malone Minor Surgery: Dr Ravi Muthukaluvan Gynaecology: Dr Aleks Fox & Dr Shradda Karkare Urology: Dr Pandu Balaji

Executive Sponsor Sarah Valentine

Date 10 July 2013

PMO Reference: Name of Proposal: Community Clinics Business Case Version: 1.02 Issue Status: Draft: Approved by Finance Working Group 09 July 2013 To be reviewed by Quality & Safety Group 18 July 2013 Date Last Updated: 10 July 2013 Author: Neil Hales

5

Contents List

1.0 DISTRIBUTION LIST 1.1 DISTRIBUTION LIST AND PROJECT TEAM 1.2 ISSUE AND AMENDMENT RECORD

3 3

2.0 EXECUTIVE SUMMARY 2.1 DEVELOPING COMMUNITY CLINICS FOR BEXLEY 2.2 HOW COMMUNITY CLINICS WILL OPERATE 2.3 POTENTIAL LOCATIONS FOR COMMUNITY CLINICS WITHIN BEXLEY 2.4 KEY FEATURES OF THE NEW COMMUNITY CLINICS SERVICE 2.5 ASSUMPTIONS 2.6 RISKS 2.7 KEY STAKEHOLDERS 2.8 COMMUNICATIONS

7 8 13 14 15 15 16 16

3.0 SUPPORTING INFORMATION 3.1 SCOPE 3.2 CRITICAL SUCCESS FACTORS 3.3 DEPENDENCIES 3.4 CONSTRAINTS 3.5 APPROACH 3.6 TIMESCALES 3.7 QUALITY CONTROLS & AUDIT

17 24 24 25 25 26 27

4.0 SERVICE OPTIONS 4.1 OPTION 1 – DO NOTHING 4.2 OPTION 2 – RE-WORK PATHWAYS WITH EXISTING PROVIDERS 4.3 OPTION 3 – TRANSFORMATIONAL CHANGE VIA PROCUREMENT OF COMMUNITY CLINICS 4.4 SUMMARY AND RECOMMENDATIONS 4.5 PROCUREMENT OPTIONS 4.6 RECOMMENDED PROCUREMENT OPTION AND SUGGESTED TIMETABLES 4.7 EQUALITY IMPACT ASSESSMENT 4.8 QUALITY IMPACT ASSESSMENT 4.9 PRIVACY IMPACT ASSESSMENT AND INFORMATION GOVERNANCE CONSIDERATIONS

28 28 29 30 31 31 32 32 32

5.0 COST ANALYSIS 5.1 CURRENT COST & ACTIVITY AND CALCULATION OF SAVINGS

33

6.0 COMMUNITY CLINIC - SERVICE SPECIFICATIONS 6.1 DERMATOLOGY 6.2 MINOR SURGERY 6.3 GYNAECOLOGY 6.4 UROLOGY

36 36 36 36

7.0 APPENDICES

1 EVIDENCE BASE 2 SUGGESTED IMPLEMENTATION TIMETABLE INCORPORATING AQP PROCUREMENT 3 RISK REGISTER 4 COMMUNICATION AND ENGAGEMENT PLAN 5 EQUALITY IMPACT ASSESSMENT 6 QUALITY IMPACT ASSESSMENT 7 DEVELOPING COMMUNITY CLINICS - PATIENT LEAFLET (TBC) 8 DEVELOPING COMMUNITY CLINICS – CLINICAL COLLEAGUES UPDATE

37 38 39 42 44 46 48 51

6

List 1.1 Distribution List Refer to Scheme of Delegation to identify who should review the Business Case

Role Name Position

Owner Sarah Valentine Director of Commissioning

Reviewers Charles O’Hanlon Assistant Director of Transformation & Redesign

Philippa Robinson Interim Projects Manager

Clinical Leads Dr Anna Malone Clinical Lead - Dermatology

Dr Ravi Muthukaluvan Clinical Lead - Minor Surgery

Dr Aleks Fox & Dr Shradda Karkare

Clinical Leads - Gynaecology

Dr Pandu Balaji Clinical Lead - Urology

Finance Lead Theresa Osborne Chief Finance Officer

Finance & Information Support Richard Brailey Projects Finance Manager

Quality reviewer David Parkins (tbc) Head of Quality 1.2 Issue/Amendment Record

Status Version Release Issue Date Reason For Issue/Changes Made

Draft 1.00 05/07/13 Draft Business Case Completed

Draft 1.01 08/07/13 Amended for SV comments as follows: 2.2.4 para 4: (services) should be provided between 8 – 8 Monday to Friday, - previously ‘Monday to Saturday’ 2.2.4 para 5: In order to ensure as wide a coverage of the Bexley population as possible new Community Clinic services should be developed across the localities of Clocktower, Frognall and North Bexley, - previously ‘within each locality’

7

Draft 1.02 09/07/13 Amended following Finance Working Group 9Jul13 feedback as follows: NEW SECTION 2.2.4 Referral process – Treatment Access Policy and Individual Funding Requests process Whilst it is incumbent on the Patient Management Centre triaging referrals for non-complex care to the Community Clinics and in addition Secondary Care clinicians referring patients to such services, Community Clinic providers will remain responsible for adhering to CCG commissioning policy including specifically the CCGs Treatment Access Policy (TAP) and process for Individual Funding Requests (IFR). Although Community Clinics are designed to undertake non-complex treatments there may be some patients who require lower acuity / complexity procedures which are still subject to the TAP and IFR policies. Procedures undertaken which do not comply with TAP and IFR policies will not be funded. Section 2.2.4 to 2.2.7: renumbered to take into account above.

10/07/13 2.2.4 (now 2.2.5) para 1: ...Service Specifications shown in Section 6 provide details of individual specialties requirements...including requirement for providers to ensure sufficient clinical equipment is available to perform Minor Surgery and that such equipment is maintained clinically fit for purpose via regular planned and preventative maintenance as appropriate.

8

10/07/13 NEW SECTION: 2.2.6 Comparing Secondary Care to new Community Clinics provision The purpose of the new Community Clinics service or intermediate tier of provision is to provide care to the same high standards as in Bexley’s acute hospitals portfolio in a non-hospital or community setting. With that in mind the Community Clinic pricing model has been calculated to ensure the only difference between a patient who had previously been treated in hospital for a non-complex operation and a patient having the same care in the new Community Clinic would be the lower Community Clinic price. A minimum 30% reduction has been factored into the pricing model for Community Clinics which reflects the significant reduction in overheads that naturally make hospital-based costs more expensive in comparison. All other aspects of care however remain the same as Community Clinic prices includes the cost of supporting elements such as diagnostics, pharmacy and pathology. The Community Clinic therefore represents a like for like service with non-complex care currently available in acute hospitals but one which is both more cost-effective and convenient for Bexley residents as services will be established in community locations hence closer to patients homes.

10/07/13 Section 2.2.6 – 2.2.8 renumbered to take into account the above

9

10/07/13 2.3.2 final para: negotiate specific arrangements to ensure viability from a clinical/technical perspective including....

o Ensure sufficient

appropriate

clinical

equipment is

available to

undertake Minor

Surgery

o Ensure such

equipment is

maintained

clinically fit for

purpose and

subject to

appropriate

regular planned

and preventative

maintenance

10/07/13 2.4 Key features of the new Community Clinic service.... Reduces diagnostic costs by enabling greater community provision hence more accurate / appropriate onward referral to secondary care should this be clinically merited: Added: Embeds diagnostic costs within Community Clinic prices to ensure care is commissioned to the same clinical appropriateness as in Secondary Care but in a more cost effective community setting

10/07/13 6.0 Added: Note: Service Specifications – to follow. Service Specifications are to be reviewed at the Qualify & Safety Subgroup meeting on 18

th July 2013

to ensure compliance with Clinical Governance processes and provide assurance that care may be delivered safely and effectively from non-hospital premises.

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2. Executive Summary

2.1 Developing Community Clinics for Bexley Community Clinics are being developed as part of the CCGs wider QIPP plan to address specialties where benchmarked Acute spend is significantly greater than the national average. Community Clinics for Dermatology, Minor Surgery, Gynaecology and Urology will address these high levels of spend by migrating care from Acute to Community settings. The Community Clinic model is predicated on Consultant-supervised non-complex care being provided in non-Acute sites. This mirrors similar redesign of services in many health economies where less complex treatments may be performed away from traditional acute hospital sites. Most local examples of such redesign are seen in Greenwich, Bromley and Croydon. The creation of such an Intermediate level of care between Primary Care and Secondary Care fulfils the wider health agenda of bringing Care Closer to Home (Our Health, Our Care, Our Say) as well as offering a financial benefit to the CCG via sub-tariff pricing. The intermediate tier of care created by the Community Clinics will become a key element of healthcare delivered for Bexley residents and in time will develop into the first choice referral for all non-complex care in Dermatology, Minor Surgery, Gynaecology and Urology. Referral protocols as specified in each specialty’s Service Specification and associated work with existing referral management processes will ensure non-complex care, subject to patient choice, is diverted into the new Community Clinic provision. Equally, new Community Clinic providers are required to operate fast-track referral processes to ensure any urgent or cancer cases they receive either in error or referrals received in good faith but which require acute care, are re-routed back to existing acute hospital services. This Business Case recommends procurement of the new Community Clinics is undertaken via the Any Qualified Provider (AQP) model in order to ensure greater choice and contestability within the Bexley health economy. New Community Clinic services are expected to start during December 2013 with the full momentum of services being achieved during the final quarter of 2014/15. It is recognised that introducing an additional layer of capacity in non-acute settings could lead to faster throughput of patients and consequentially financial pressure rather than cost saving. In order to mitigate against this a key dependency is the Transformational CQUIN negotiated into the 2013/14 acute contract with Bexley’s main provider South London Healthcare NHST. The Transformational CQUIN, which is valued at £731k annually, will be withheld unless key capacity reductions in existing acute provision are undertaken to dovetail the on-set of new capacity via the Community Clinics procurement. A further protection to the CCG in terms of ‘over-capacity’ being introduced into the system is that under the recommended AQP procurement, new providers have no guarantee of income or activity volume. We will also need careful monitoring of the AQP services to ensure that we have not just introduced new demand, and specific KPIs regarding patients to be treated or returned to primary care will be introduced (these will sit alongside the Treatment Access Policies).

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2.2 How Community Clinics will operate 2.2.1 Services provided Community Clinics are not looking to replicate the entire gamut of services provided by existing acute hospital provision. They are to form an intermediate service, sitting below Secondary Care, which will treat non-complex patients only in the areas noted below. Further details of elements of care governed by the Community Clinic redesign process is noted under individual Service Specifications for each of the 4 selected specialties at Section 6. The following non-complex treatments are intended to be undertaken by Community Clinics:

Dermatology - Cryotherapy / cryosurgery - Skin therapies Minor Surgery (subject to Clinical Lead confirmation) - Cysts - Excision of abcesses - Haemorrhoids - In-growing toenails - Lipoma - Vasectomy Gynaecology - Colposcopy - Cervical polyp removal - Complex coil fitting / removal - Dysmenorrhea - Menorrhagia - Pessary changes - Suspected fibroids Urology - Haematuria - Lower urinary tract symptoms - Recurrent urinary tract infections - Urinary incontinence

Intermediate provision provided by the Community Clinics will act as a filter to:

Minimise inappropriate & costly referrals into Secondary Care

Treat patients requiring non-complex care including minor surgery or where appropriate diagnostic

investigations pertaining to the above areas

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2.2.2 Referral process – receiving referrals from inception of service in December 2013 Bexley CCG operates a referral management process known as the Patient Management Centre (PMC). All non-urgent referrals from Bexley GPs are currently referred to the PMC which then undertakes:

clinical triage to determine onward referral to Secondary Care, and

the offer of choice of provider to the patient.

A critical success factor for the new Community Clinics is that the referral management process actively streams non-complex patients into the new Community Clinics rather than offering Choice of a secondary care provider. This will of course be dependent on several bidders being approved AQP status, i.e. a sufficient critical mass of providers illustrates perceived robustness of service choice whereas only one provider may be perceived as an ‘experimental’ option. It is not the intention of the Community Clinics to deny patients choice of providers of treatment. The opposite is true in that a range of existing Secondary Care choice options should be supplemented by the new Community Clinic provision. A key dependency for Community Clinics is however that they receive enough critical mass of referrals for non-complex care to be viable. As such both referring GPs and the referral management process within the PMC need to offer patients the choice of AQP provider (rather than the choice of secondary care provider). On-going monitoring will be necessary at PMC level of the Choices being taken by patients. 2.2.3 Referral process – receiving referrals from April 2014 Current Commissioning Intentions, i.e. for 2013/14 are predicated on migrating approximately 25% of current spend above national average from secondary care to the new intermediate AQP services. The opportunity for Community Clinics to migrate non-complex care from existing acute provision however is much greater. It’s estimated that 25% of all specialty elective activity currently seen in secondary care within Dermatology, Minor Surgery, Gynaecology and Urology could be undertaken in the new intermediate tier. The percentage transfer opportunity ranges by specialty with up to 60% of Dermatology activity possible to be undertaken in a setting other than a traditional hospital. This represents a much greater QIPP redesign opportunity however new services coming online will need time to bed-down and mobilise before they can provide sufficient capacity to effect larger scale changes. Development of Community Clinics from December 2013 onwards therefore represents a first phase in the wider creation of intermediate AQP provision for non-complex treatments. 2013/14 Commissioning Intentions have been predicated on relatively small reductions in existing acute capacity. From April 2014 onwards however intermediate provision can become more mainstreamed, i.e. greater tranches of activity decommissioned from existing secondary care providers during 2014/15. The overall aim of the Community Clinic redesign is to migrate a majority or in some instances all non-complex activity from current Secondary Care provision. In order to facilitate this 2014/15 Commissioning Intentions will reflect the increased use of AQP Community Clinics provision and necessary corresponding reductions in acute capacity. This is in line with the requirements from the TSA regarding reducing the reliance on secondary care providers. As developed for the 2013/14 contract round, consideration will need to be given to whether a further Transformational CQUIN is adopted in 2014/15 to facilitate necessary capacity reductions in acute settings. Moreover the current (SE London) Treatment Access Policy and Commissioning Intentions within 2014/15 acute contracts will need to be amended to specify non-payment for non-complex activity that continues to be undertaken in traditional acute hospital settings as the capacity reductions are agreed. This will act as a further mechanism to ensure the intermediate tier of Community Clinics is fully utilised. 2.2.4 Referral process – Treatment Access Policy and Individual Funding Requests process

13

Whilst it is incumbent on the Patient Management Centre triaging referrals for non-complex care to the Community Clinics and in addition Secondary Care clinicians referring patients to such services, Community Clinic providers will remain responsible for adhering to CCG commissioning policy including specifically the CCGs Treatment Access Policy (TAP) and process for Individual Funding Requests (IFR). Although Community Clinics are designed to undertake non-complex treatments there may be some patients who require lower acuity / complexity procedures which are still subject to the TAP and IFR policies. Procedures undertaken which do not comply with TAP and IFR policies will not be funded. 2.2.5 Service delivery Section 2.3 below highlights that Community Clinics must be delivered from premises which are Care Quality Commission accredited for Minor Surgery. Service Specifications shown in Section 6 provide further details of individual specialties requirements including requirement for providers to ensure sufficient clinical equipment is available to perform Minor Surgery and that such equipment is maintained clinically fit for purpose via regular planned and preventative maintenance as appropriate. However, the main ethos of the redesign is care must be delivered by suitability accredited individuals under the supervision of a Consultant Specialist. Other economies adopting the community / intermediate model have typically used GPs with a Special Interest (but this is a historic model not suited to the current procurement and AQP environment). Bexley’s requirement, in order to enable safe and efficient services which are fully compliant with appropriate clinical governance processes, is for new community / intermediate service providers to offer a minimum of 4 clinical sessions per week, 1 of which must be delivered by a Consultant Specialist. Services, i.e. the minimum of 4 clinical sessions per week, should be provided between 8 – 8 Monday to Friday as this gives potential providers more scope in terms of developing future services and is consistent with the move to develop services operating outside normal working office hours (noted in Everyone Counts). In order to ensure as wide a coverage of the Bexley population as possible new Community Clinic services should be developed across the localities of Clocktower, Frognall and North Bexley. The CCG recognises that coverage across the locations for 4 specialties could be delivered by a combination of different provider bids. Its recognised that optimum coverage across Bexley can only be achieved however if new providers look to bid for services covering all 3 localities. This will be taken into account as part of the AQP evaluation process should this preferred procurement method be adopted. 2.2.6 Comparing Secondary Care to new Community Clinics provision The purpose of the new Community Clinics service or intermediate tier of provision is to provide care to the same high standards as in Bexley’s acute hospitals portfolio in a non-hospital or community setting. With that in mind the Community Clinic pricing model has been calculated to ensure the only difference between a patient who had previously been treated in hospital for a non-complex operation and a patient having the same care in the new Community Clinic would be the lower Community Clinic price. A minimum 30% reduction has been factored into the pricing model for Community Clinics which reflects the significant reduction in overheads that naturally make hospital-based costs more expensive in comparison. All other aspects of care however remain the same as Community Clinic prices includes the cost of supporting elements such as diagnostics, pharmacy and pathology. The Community Clinic therefore represents a like for like service with non-complex care currently available in acute hospitals but one which is both more cost-effective and convenient for Bexley residents as services will be established in community locations hence closer to patients homes.

14

2.2.7 Onward referral to Secondary Care As Community Clinics represent an intermediate level of care below traditional acute hospital services the onward referral of patients requiring either more complex or more urgent care into Secondary Care provision is of paramount importance. As part of the bidder evaluation process potential providers will be required to describe their systems and processes to enable fast onward referral into Secondary Care and associated monitoring to receive assurance from providers that such referrals are seen within 2 weeks. Onward referral for more urgent or complex patients will need to be undertaken immediately. Key Performance Indicators will be developed within successful bidders contracts to identify and measure the level of onward referral into Secondary Care is within expected parameters. This will ensure the Community Clinic continues to present an added-value element within the overall Bexley health economy and guard against it introducing another layer of cost without corresponding treatment. 2.2.8 Direct listing within Secondary Care As the Business Care represents the introduction of a further level of health provision following initial GP referral a further element of the new Community Clinics service is the ability to ‘direct list’ patients for treatment in Secondary Care. The ability to direct list patients in existing hospital provision should be reserved for care more complex than can be delivered in the new community settings. Further information on direct listing is built into individual Service Specifications however it is recognised that the ability to direct list patients for treatment from new Community Clinics into hospital treatment lists will depend greatly on successful bidders developing appropriate protocols with existing hospital providers. Community Clinics will have the clinical capability to direct list if they are a consultant-led process and it will depend on the consultants providing the leadership within the community AQP providers. This will need to be considered and evaluated as part of the bidding process/ Some patients will require interventions too complex to be seen in the Community Clinic and too complex for direct listing of treatment hence the provision in 2.2.5. Community Clinics ability to direct list into existing hospital provision will represent a more integrated pathway for those patients requiring more complex care as well as ensuring additional costs, i.e. a further ‘first’ outpatient attendance in Secondary Care are avoided. This principle is aligned with the COBIC (see later) principles of commissioning integration across the traditional care settings and breaking down the existing boundaries. COBIC is the Health & Care Revolution that is striving to revolutionise health and social care for patients, their families and friends, and for taxpayers. It is designed to:

Catalyse improvements – in the quality and length of people’s lives

Create Conditions in which doctors, nurses and their organisations can redefine the way health and

social care is delivered

Shift the Focus – from disease groups or professional groups to outcomes that matter to individuals and

populations

Improve the Value – obtained for the money spent on health and social care by incentivising better

outcomes rather than activity.

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2.2.9 Follow Up care Follow Up care and specifically the number of expected follow ups for the less complex interventions undertaken in Community Clinics will vary by specialty and specific details are enclosed in the Service Specifications at Section 6. The chart below describes current 1

st Outpatient to Follow Up attendance based on Bexley’s main provider South

London Healthcare NHST.

As Community Clinics are designed to undertake less complex interventions the follow-up requirement for patients will be much lower than that seen in a traditional hospital setting. In recognition of this the 1

st Outpatient to Follow Up attendance for new Community Clinic providers will be

limited to a maximum 1:1 ratio.

Community Clinics QIPP

First to Follow Up ratios

Per 1314 baseline - Bexley CCG @ South London Healthcare NHST

Specialty First Follow UpOutpatient

Procedure

Dermatology 3,684 6,334 2,692 1 to 2.5

General Surgery 3,972 7,174 1,238 1 to 2.1

Gynaecology 2,468 3,412 1,660 1 to 2.1

Urology 1,806 3,172 382 1 to 2.0

Total 11,930 20,092 5,972 1 to 2.2

Ratio

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2.3 Potential locations for Community Clinics within Bexley 2.3.1 Bexley location Bexley CCG is co-terminus with the London Borough of Bexley which is located in South East London and immediately borders Kent to its south and east.

2.3.2 Potential locations in Bexley Community Clinics must be sited within Bexley boundaries with preference for successful bidders to ensure maximum coverage for Bexley’s 232,000 residents by placing a facility in or near each of the 3 localities:

Clocktower

Frognall

North Bexley

Specific sites to be used for Community Clinics are not limited to existing Primary Care estate the market will determine via its offers which locations they will be able to provide services from.

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It is incumbent on any potential bidder / provider to:

ensure the site(s) included within their (AQP) bid are fit for purpose and most critically, are Care Quality

Commission (CQC) accredited (or will become CQC accredited prior to service commencement) for

provision of Minor Surgery

negotiate appropriate rental/lease agreements with owners of suitable estate, where necessary, to

ensure provision of a Community Clinic service is viable, e.g. to cover:

o rent

o rates

o heat

o light

o electricity

o IT systems

o telephony

negotiate specific arrangements to ensure viability from a clinical/technical perspective including:

o N3 connectivity for Choose & Book

o IT compatibility to enable ‘direct listing’ into Secondary Care providers where appropriate

o Ensure sufficient appropriate clinical equipment is available to undertake Minor Surgery

o Ensure such equipment is maintained clinically fit for purpose and subject to appropriate

regular planned and preventative maintenance

Note: Premises which do not hold CQC accreditation for provision of Minor Surgery prior to service commencement will fail the Any Qualified Provider evaluation process. 2.4 Key features of the new Community Clinics service The main features of the new service, which are captured in greater detail in individual Service Specification shown in section 6, are:

Increased patient satisfaction through improved access, shorter waits, delivering high quality within a value for money framework

A service that is delivered closer to the patients within community and primary care settings.

A pathway that enables hospitals to focus on the services that only they can provide

A cost effective service that: o reduces elective costs via re-provision in sub-tariff community services o reduces hospital out-patient activity due to reduction in inappropriate referrals o reduces overall out-patient activity via defined 1

st to Follow Up ratios reflective of lower level

complexity / case mix seen in non-acute services o reduces diagnostic costs by enabling greater community provision hence more accurate /

appropriate onward referral to secondary care should this be clinically merited o Embeds diagnostic costs within Community Clinic prices to ensure care is commissioned to the

same clinical appropriateness as in Secondary Care but in a more cost effective community setting

Reduced waiting times in wider health economy as acute hospitals see more appropriate patients and non complex care is seen in new community provision

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2.5 Assumptions The principal assumptions which underpin this business case are:

The current project plan, though challenging, is achievable and will utilise pre-identified additional procurement support for the Any Qualified Provider evaluation should Governing Body adopt this recommended approach

Clinical leads will secure a consensus among GP colleagues about the appropriate use of the new service

Key groups and decision making bodies will meet within the timeframes set out in the project plan

The proposed service model will attract interest from suitably qualified providers

Sufficient locations are available within the Bexley geographical area which are either is CQC Minor Surgery accredited or could achieve such accreditation prior to contract commencement on 1 December 2013

Following negotiation with suitably qualified providers, the mobilisation and transition will proceed as planned

Existing Acute providers will continue to provide non-complex care post the 1 December 2013 start date, but transfers from secondary care to Intermediate Care will commence at that point for all suitable new referrals (see next bullet)

Clinical Triage by the Patient Management Centre (Referral Management process) or similar successor organisation as appropriate must play an active role in diverting Acute referral to the Intermediate service provided by the Community Clinics where such clinical triage deems that appropriate

Dissemination and education where appropriate on revised pathways is required in order to promote the use of Community Clinics as a ‘first choice’ for non-complex care

There will be no legal challenges or other external causes of delay to the project, as no slippage is built into the plan for any such contingency

If any conflicts of interest arise, remedial actions are taken swiftly to negate these 2.6 Risks The principal risks identified are as follows, and a more detailed project risk register is attached as Appendix 3:

The new service does not meet patients’ needs

The new service is not acceptable to local GPs

The new service increases overall capacity within the local health economy (though a Transformational CQUIN has been adopted to ensure capacity reduction in SLHT mirrors additional Community Clinic capacity when brought online

The new service does not filter inappropriate referrals away from Secondary Care as intended but acts as a further stage of treatment elongating patients journeys and overall costs - (the GP referral systems with the PMC will be designed to mitigate against this together with KPIs on expected onward referral into Secondary Care will be specified to guard against this)

The new model does not attract interest from suitably qualified providers

Slippage in the timescale for the CCG’s sign off of the procurement brief, business case, service specification or other key documents

Slippage in the procurement timescale

Slippage in the mobilisation timescale

Existing providers reduce capacity before the new service is ready to come into operation – this will need to be carefully managed through the mobilisation

There is delay as a consequence of external challenge (unlikely if recommended AQP procurement is adopted)

The CCG does not devote sufficient clinical, managerial, business intelligence or procurement support to the project

QIPP targets are not achieved due to delays within the above

Adverse impact on CCG reputation The project planning aims to mitigate these risks, although timescales are very tight.

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2.7 Key stakeholders Key stakeholders are:

2.8 Communications

There is a detailed communications and engagement plan (attached as Appendix 3) which sets out how the Redesign Team will communicate both with the stakeholders identified above, whose support is crucial, and with other external audiences including:

Local Medical Committee

Individual voluntary organisations and self-help groups

Other local CCGs

Commissioning Support Unit The plan also covers internal communication within the CCG.

CCG All Bexley GPs Nurse Practitioners, Nurses and Health Care Assistants Bexley Practice Managers Governing body members Patient Council members CCG Chief Officers and staff involved with quality, safety and finance. CCG Communications Team

Other NHS bodies Secondary Care Other local CCGs Clinical Networks

Other partners Bexley Health Limited (Patient Management Centre (referral management) provider)

Political Leader, London Borough of Bexley Health Overview & Scrutiny Chair Health Overview & Scrutiny members Other councillors Local MPs Local Medical Committee

Statutory body partners LB Bexley Chief Executive Relevant Director at LB Bexley Health & Well-Being Board members

Patient representative groups

Bexley Health Watch Relevant voluntary and self-help groups (tba) PPGs Patient Groups

Community CE, Chair and Coordinator of BVSC Community forums

Media Locals – News Shopper, Bexley Times, Mercury, CCG website

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3. Supporting Information

3.1 Scope of service The development of Community Clinics, representing an intermediate tier between existing Primary Care and Secondary Care healthcare provision, impacts on all of Bexley’s 232,000 local residents, their immediate families and carers. Bexley currently spends over £9.9m each year in providing elective care in those specialties highlighted as being suitable for a Community Clinic development. These are:

Dermatology £752k

General Surgery £4,609k

Gynaecology £2,478k

Urology £2,152k

There are over 11,000 elective operations undertaken in the above specialties annually for Bexley residents. In addition to the above Bexley’s main acute provider South London Healthcare NHST sees over 5,000 outpatient procedures per year for the CCG. 3.1.1 Local Demographics

Key aspects of Bexley’s population which may impact on the provision of healthcare are:

Bexley’s population is growing and significant growth is predicted to at least 2026

The % of elderly people is also predicted to grow

Levels of obesity are high and levels of physical activity low

Levels of smoking and potentially harmful drinking are high

Although overall the Borough is less deprived than the average for England, 8% of the Bexley population lives in the most deprived areas nationally

Although unemployment is in line with the England average, a lower % of Bexley residents have professional, technical or managerial jobs

Recent changes to the housing benefit system are likely to result in further inward migration to Bexley from other parts of London

3.1.2 Current Minor Surgery elements provided in the Community Existing commissioning arrangements provide the following Minor Surgery or related aspects within the local Bexley community currently:

Minor Surgery DES

GPwSI in Minor Surgery

GPwSI in Dermatology

GPwSI Vasectomy service The Minor Surgery DES is commissioned nationally by NHS England and will not be affected by the development of Community Clinics, i.e. these will be a separate entity. Current GPwSI services have migrated from previous PCT arrangements and will operate during 2013/14. These existing contracts will be terminated as the Community Clinics procurement provides a new model for GPwSI services to operate within beyond 2013/14.

21

In order to ensure current GPwSI providers have sufficient time to engage in the process of developing Community Clinics as well as honouring existing 2013/14 local contractual arrangements, the proposed Any Qualified Provider model procurement will operate with 2 windows. Each window lasts for 6 weeks from initial advertisement to closing date for submission of AQP bids. The first AQP window, subject to approval of this Business Case by the Governing Body, will close in late September with a view to new services starting from 1

st December 2013.

A second AQP window will close in late January with a view to new services starting on 1

st April 2014.

Further details are noted in Section 4.6 Recommended procurement option. Any future windows for these services will need to be determined post the initial AQP procurement process by determining the range and breadth of the suppliers approved, and the need for any further providers of services. 3.1.3 Current Secondary Care services Bexley commissions a full range of Secondary Care to ensure that the CCG’s obligation to ensure and promote choice is met; and that local residents have access to the full range of elective and non-elective care. Main current providers are:

South London Healthcare NHS Trust

Dartford & Gravesham NHS Trust

Guys & St Thomas’s NHS Foundation Trust

Kings College University Hospitals NHS Foundation Trust

Lewisham Healthcare NHS Trust

It should be noted that at time of writing South London Healthcare NHS Trust (SLHT) is currently undergoing dissolution as part of the Trust Special Administrator process. SLHT services will continue to be provided from its existing sites noted below. The providers noted in brackets will undertake the majority of healthcare activity from 1

st October 2013 when final dissolution of SLHT is currently envisaged:

Princess Royal University Hospital (Kings College University Hospitals NHS Foundation Trust)

Queen Elizabeth Hospital, Woolwich (Lewisham Healthcare NHS Trust)

Queen Mary’s Hospital, Sidcup (Dartford & Gravesham NHS Trust)

22

3.1.4 The case for change – current spend on Acute services

The graphic below highlights benchmark data noting Bexley CCG spend on Elective Activity compared to national average as defined by the Audit Commission PbR Benchmarker Tool (https://pbrbenchmarker.audit-commission.gov.uk).

Benchmarking data shows the combined Elective variance from national average in Dermatology, General Surgery, Gynaecology and Urology is £3,997k.

The ethos behind the Community Clinic QIPP is to migrate non-complex care from Acute to Community settings where clinically appropriate to do so. For planning purposes it was estimated the introduction of Community Clinics could reduce current variation from national average spend on Elective activity by c. 25%. This recurrent reduction in Acute spend of £939k rises to £1,340k when accompanying outpatient assumptions are factored in. £1,340k has been deducted from contract baselines of major acute providers in the 2013/14 contract round, predicated on the new Community Clinics commencing in October 2013. The majority impact of £1,058k or 79% is with South London Healthcare NHST (SLHT).

Bexley CCG - All Providers - Elective Activity

Q3 1213 Benchmarked Acute Spend

Ratio

Observed Expected Variance Observed Expected Variance

Dermatology £751,480 £223,300 £528,190 1,208 359 849 3.37

General Surgery £4,609,350 £2,582,980 £2,026,380 4,449 2,493 1,956 1.78

Gynaecology £2,478,070 £1,449,190 £1,028,880 2,754 1,611 1,143 1.71

Urology £2,151,610 £1,737,120 £414,490 2,885 2,329 556 1.24

Total £9,990,510 £5,992,590 £3,997,940 11,296 6,792 4,504

Source: Audit Commission PbR Benchmark data

£ Spend Activi ty

£0

£500,000

£1,000,000

£1,500,000

£2,000,000

£2,500,000

£3,000,000

£3,500,000

£4,000,000

£4,500,000

£5,000,000

Dermatology General Surgery Gynaecology Urology

Observed

Expected

23

Through discussion with Clinical Leads however the QIPP opportunity in Dermatology, Minor Surgery, Gynaecology and Urology could be much greater by ensuring that this new intermediate tier of care provided by Community Clinics is adopted as a first choice referral instead of treatment in hospitals. Its estimated an average of 25% of all current elective activity in these 4 areas could be re-routed into Community Settings. 3.1.5 HRG chapter breakdown of significant variation from national average HRG data analysed from the Audit Commission PbR Benchmarker explores the £3.9m spend in excess of national average further, focusing on the Top 10 HRG spend and variance areas. An adjustment has been made in respect of General Surgery where it is known that clearance of Gastric Bypass (weight loss surgery) backlogs accounted for an inflated benchmarked position in HRG chapter FZ during 2012/13. Regardless of this adjustment of £483k, Bexley spend across General Surgery, together with, Dermatology, Gynaecology and Urology as highlighted below, remains exceptionally high.

Based on the higher spending HRG chapters alone, noted above, the variation from national average remains at £3.2m higher in the 4 targeted areas for development of Community Clinics in Bexley.

Extract: https://pbrbenchmarker.audit-commission.gov.uk/

Bexley Care Trust

Admitted Patient Care -- Elective Activity

12 months to Q3 2012/2013

--All Specialties/Treatment Areas--

--All Providers--

Bexley CCG - Top 10 HRG Chapter spend

Rank Treatment Area Specialty

% of PCT

Spend Actual

National

Average Variance Ratio Actual

National

Average Variance Ratio

1 FZ - Digestive System Procedures and Disorders General Surgery 17.2 6,112 4,860 1,251 1.26 7,625 6,245 1,380 1.22

Exception FZ04B - Very Major Stomach or Duodenum Procedures w ithout Major CC (Gastric Bypass) 571 88 483 6.50 103 16 87 6.5

Revised FZ - Digestive System Procedures and Disorders less Gastric Bypass 5,541 4,772 769 1.16 7,522 6,229 1,293 1.21

2 MA - Female Reproductive System Procedures Gynaecology 6.58 2,338 1,465 873 1.6 2,754 1,350 1,404 2.04

3 LB - Urological and Male Reproductive System Procedures and Disorders Urology 7.41 2,632 2,144 488 1.23 3,226 2,610 616 1.24

4 QZ - Vascular Procedures and Disorders General Surgery 3.72 1,321 927 394 1.42 1,170 551 619 2.12

5 JA - Breast Procedures and Disorders General Surgery 3.37 1,198 829 369 1.44 957 578 379 1.66

6 BZ - Eyes and Periorbita Procedures and Disorders Ophthalmology 5.15 1,830 1,522 308 1.2 2,341 2,041 300 1.15

7 JC - Skin Surgery Dermatology 2.8 994 732 263 1.36 1,520 989 531 1.54

8 PA - Paediatric Medicine Paediatrics 2.44 868 734 134 1.18 594 511 83 1.16

9 DZ - Thoracic Procedures and Disorders Respiratory 2.55 908 784 124 1.16 663 582 81 1.14

10 CZ - Mouth Head Neck and Ears Procedures and Disorders ENT 6.16 2,188 2,077 111 1.05 2,243 2,028 215 1.11

Top 10 HRGs

Dermatology, General Surgery, Gynaecology and Urology 14,025 10,870 3,155 1.29

Variance after accounting for Gastric Bypass backlog is £3.2m or 29% higher spend across all providers than the national average

£000

£000s spend Activity

24

3.1.6 Specific HRG breakdown by specialty Individual HRGs are broken down further to highlight specific areas of high spend in Bexley.

Dermatology - JC

Rank Treatment Area

% of PCT

Spend Actual

National

Average Variance Ratio Actual

National

Average Variance Ratio

1 JC15Z - Skin Therapies level 3 1.92 683 370 313 1.85 1,262 684 578 1.85

2 JC - Skin Surgery 2.8 994 732 263 1.36 1,520 989 531 1.54

3 JC05C - Minor Skin Procedures category 3 without CC 0.09 32 14 18 2.33 31 13 18 2.33

4 JC01B - Major Multiple Skin Procedures with Intermediate CC 0.05 17 7 10 2.42 3 1 2 2.42

5 JC27Z - Nursing Procedures & Dressings 1 0.04 13 5 8 2.48 21 8 13 2.48

6 JC20Z - Electrical and other invasive therapy 3 0.01 5 1 4 5.30 5 1 4 5.3

7 JC06B - Minor Skin Procedures category 2 with Intermediate CC 0.02 6 2 4 2.59 4 2 2 2.59

8 JC04C - Intermediate Skin Procedures without CC 0.12 42 39 3 1.08 40 37 3 1.08

9 JC06A - Minor Skin Procedures category 2 with Major CC 0.01 5 2 3 2.24 1 0 1 2.24

10 JC05A - Minor Skin Procedures category 3 with Major CC 0.01 3 1 2 2.57 3 1 2 2.57

£000s spend Activity

General Surgery - FZ

Rank Treatment Area

% of PCT

Spend Actual

National

Average Variance Ratio Actual

National

Average Variance Ratio

1 FZ - Digestive System Procedures and Disorders 17.2 6,112 4,860 1,251 1.26 7,625 6,245 1,380 1.22

2 FZ04B - Very Major Stomach or Duodenum Procedures without Major CC 1.61 571 88 483 6.50 103 16 87 6.5

3 FZ61Z - Diagnostic Endoscopic Procedures on the Upper GI Tract with biopsy 19 years and over 1.28 456 335 121 1.36 1,125 827 298 1.36

4 FZ03A - Diagnostic and intermediate procedures on the upper GI tract 19 years and over 0.81 289 192 97 1.51 694 461 233 1.51

5 FZ53Z - Therapeutic Colonoscopy 19 years and over 0.7 249 172 77 1.45 406 280 126 1.45

6 FZ12C - General Abdominal - Very Major or Major Procedures without CC 0.43 154 95 59 1.62 72 45 27 1.62

7 FZ64Z - Combined Upper and Lower GI Tract Diagnostic Endoscopic Procedures with biopsy 0.28 100 77 24 1.31 149 114 35 1.31

8 FZ11B - Large Intestine - Major Procedures without Major CC 0.26 93 59 34 1.58 39 25 14 1.58

9 FZ05A - Major Stomach or Duodenum Procedures 2 years and over with CC 0.21 73 42 31 1.73 19 11 8 1.73

10 FZ46C - Malignant Large Intestinal Disorders with length of stay 0 days 0.17 60 31 29 1.93 198 103 95 1.93

General Surgery - JA

Rank Treatment Area

% of PCT

Spend Actual

National

Average Variance Ratio Actual

National

Average Variance Ratio

1 JA - Breast Procedures and Disorders 3.37 1,198 829 369 1.44 957 578 379 1.66

2 JA07B - Major Breast Procedures category 2 with Intermediate CC 0.75 265 162 103 1.63 135 83 52 1.63

3 JA07C - Major Breast Procedures category 2 without CC 0.67 238 190 48 1.25 125 100 25 1.25

4 JA14Z - Free Perforator Flap Breast Reconstruction 0.33 119 35 84 3.36 17 5 12 3.36

5 JA06Z - Major Breast Procedures category 3 0.32 114 94 20 1.21 39 32 7 1.21

6 JA12B - Malignant Breast Disorders with Intermediate CC 0.31 112 37 74 3.01 328 109 219 3.01

7 JA09B - Intermediate Breast Procedures without CC 0.25 90 83 7 1.08 80 74 6 1.08

8 JA09D - Intermediate Breast Procedures with Intermediate CC 0.18 62 38 24 1.63 48 29 19 1.63

9 JA12C - Malignant Breast Disorders without CC 0.08 29 23 5 1.23 84 68 16 1.23

10 JA12A - Malignant Breast Disorders with Major CC 0.05 18 4 14 4.51 36 8 28 4.51

General Surgery - QA

Rank Treatment Area

% of PCT

Spend Actual

National

Average Variance Ratio Actual

National

Average Variance Ratio

1 QZ - Vascular Procedures and Disorders 3.72 1,321 927 394 1.42 1,170 551 619 2.12

2 QZ14A - Vascular Access except for Renal Replacement Therapy with CC 0.48 170 24 146 7.06 306 43 263 7.06

3 QZ14B - Vascular Access except for Renal Replacement Therapy without CC 0.51 183 59 124 3.09 391 126 265 3.09

4 QZ13A - Vascular Access for Renal Replacement Therapy with CC 0.24 87 46 41 1.89 65 34 31 1.89

5 QZ13B - Vascular Access for Renal Replacement Therapy without CC 0.11 39 8 31 5.05 30 6 24 5.05

6 QZ15B - Therapeutic Endovascular Procedures with Intermediate CC 0.66 234 209 25 1.12 53 47 6 1.12

7 QZ04Z - Extracranial or Upper Limb Arterial Surgery 0.2 72 54 17 1.32 20 15 5 1.32

8 QZ17C - Non-Surgical Peripheral Vascular Disease without CC 0.07 24 8 16 3.07 40 13 27 3.07

9 QZ17B - Non-Surgical Peripheral Vascular Disease with Intermediate CC 0.09 32 17 15 1.88 22 12 10 1.88

10 QZ02A - Lower Limb Arterial Surgery with CC 0.26 93 86 8 1.09 14 13 1 1.09

£000s spend Activity

£000s spend Activity

£000s spend Activity

Gynaecology - MA

Rank Treatment Area

% of PCT

Spend Actual

National

Average Variance Ratio Actual

National

Average Variance Ratio

1 MA - Female Reproductive System Procedures 6.58 2,338 1,465 873 1.60 2,754 1,350 1,404 2.04

2 MA23Z - Lower Genital Tract Minor Procedures - Category 2 1.52 539 75 464 7.17 1,007 140 867 7.17

3 MA05B - Lower Genital Tract Minor Procedures without CC 0.72 256 30 227 8.67 477 55 422 8.67

4 MA08Z - Upper Genital Tract Laparoscopic / Endoscopic Major Procedures 0.54 192 137 55 1.40 86 61 25 1.4

5 MA06Z - Open Major Upper and Lower Genital Tract Procedures with malignancy 0.47 166 117 50 1.43 44 31 13 1.43

6 MA10Z - Upper Genital Tract Laparoscopic / Endoscopic Minor Procedures 0.41 147 93 54 1.58 190 120 70 1.58

7 MA12Z - Resection and ablation procedures for intra-uterine lesions 0.36 129 104 25 1.24 156 125 31 1.24

8 MA03B - Lower Genital Tract Major Procedures without CC 0.17 60 47 13 1.28 29 23 6 1.28

9 MA02Z - Lower and Upper Genital Tract Complex Major Procedures 0.16 55 42 14 1.33 19 14 5 1.33

10 MA12B - Resection and ablation procedures for intra-uterine lesions without CC 0.13 45 32 14 1.43 54 38 16 1.43

£000s spend Activity

25

Left unabated the excessive spend in the above 4 specialties will continue to cause the CCG significant financial problems. Through discussion with Clinical Leads however several areas of non-complex care can be migrated from current hospital sites to Community settings which will start to address the high spend, i.e. by providing in a more cost-effective environment. In addition to the above the CCG is working with its health economy partners as part of the Trust Special Administrator process for South London Healthcare NHST as to whether current levels of activity are appropriate. This 2-pronged approach will look to address the high variation in acute spend seen in Bexley. This Business Case concentrates only on the development of Community Clinics however, i.e. forming a mechanism to ensure care is diverted into more cost-effective settings when non-complex care is required.

Urology - LB

Rank Treatment Area

% of PCT

Spend Actual

National

Average Variance Ratio Actual

National

Average Variance Ratio

1 LB - Urological and Male Reproductive System Procedures and Disorders 7.41 2,632 2,144 488 1.23 3,226 2,610 616 1.24

2 LB14E - Bladder Intermediate Endoscopic Procedure 19 years and over 0.54 193 155 37 1.24 930 749 181 1.24

3 LB15C - Bladder Minor Procedure 19 years and over without CC 0.36 128 86 42 1.49 317 212 105 1.49

4 LB25C - Prostate Transurethral Resection Procedure without CC 0.31 109 75 34 1.45 66 45 21 1.45

5 LB04B - Kidney Major Endoscopic Procedure without CC 0.3 106 49 57 2.17 45 21 24 2.17

6 LB27Z - Prostate or Bladder Neck Minor Endoscopic Procedure - Male, w ith LOS 1 day or less 0.26 92 53 39 1.74 213 122 91 1.74

7 LB32C - Penile Conditions and Minor Procedures 18 years and under 0.24 85 44 41 1.93 105 55 50 1.93

8 LB22Z - Laparoscopic Bladder Neck Procedures - Male 0.24 85 44 41 1.95 19 10 9 1.95

9 LB12Z - Bladder Intermediate Open Procedure 0.18 65 30 36 2.20 36 16 20 2.2

10 LB02A - Kidney Major Open Procedure 19 years and over with Major CC 0.15 54 20 34 2.65 6 2 4 2.65

£000s spend Activity

26

3.1.7 Changing pathways to ensure Community Clinics are utilised Bexley are currently developing a series of clinical pathways which describe key actions on GP assessment and treatment options for onward referral into more specialised care. An example of the current Bexley pathway for Menorrhagia is noted below.

Subject to the Governing Body’s approval of the Community Clinics Business Case, existing and developing pathways will be amended in order to highlight the range of services to become available in the new Community Clinics as the first Choice to all patients with the relevant conditions. As part of the wider engagement plan and upon contract award, revised pathways incorporating services covered, details of the new Community Clinic providers and their locations within Bexley, will be added to all Bexley pathways as the Choice offer for our patients.

27

Revised pathways will also be shared with existing Secondary Care clinicians in order to ensure that, where appropriate, Secondary Care triage process and / or consultant review may also act as a further mechanism for referral into the new Community services. But the aim is to avoid patients being seen in Secondary Care where they should have been referred directly into the Intermediate Care services (to avoid duplication of costs) 3.2 Critical success factors The critical success factors which will determine whether the new service is successful and has met its objectives are:

Timely mobilisation of new service

Acceptability to patients and quality of patient experience as measured by regular surveys and other measures such as Focus Groups where appropriate

Acceptability to the CCG’s member practices in quality of intermediate provision hence confidence in referring patients to it

Maintenance and improvement of clinical outcomes

Achievement of financial savings via migration from Acute to more cost-effective Community model

Reduction in existing Acute Hospital capacity to mirror new Community Clinic capacity coming online

A full set of detailed Key Performance Indicators (KPIs) will be developed as part of the Any Qualified Provider procurement evaluation process 3.3 Dependencies The main dependencies associated with this proposal are:

Availability of suitably qualified and experienced professional staff to deliver the service model

Availability of suitable estate for potential bidders / providers to use within Bexley which either has or will have CQC accreditation for Minor Surgery prior to service commencement

Availability of the CCG’s internal supporting departments to undertake the work within the critical timelines

Availability of (pre-secured) additional Any Qualified Provider procurement resource to lead the CCGs AQP evaluation and contract award process

The CCG financially supporting the proposal and the associated work streams involved

The CCG’s ability to pro-actively manage GP referrals and introduce a method of managing non-compliance

The effectiveness of clinical triage process within the referral management process (Patient Management Centre) to ensure non-complex referrals are diverted to the Community Clinics

Timeliness of appropriate capacity reductions from major acute hospital providers to mirror CCG Commissioning Intentions

Effectiveness of Transformational CQUIN negotiated to enforce above capacity reductions at South London Healthcare Trust, Dartford & Gravesham, Kings, Lewisham and Guy’s & St Thomas’

Appropriate and meaningful engagement with patients and local communities throughout the planning and mobilisation period

28

3.4 Constraints

The project will be subject to the following constraints:

Patient safety is paramount and must be maintained throughout the transitional period and by the new model of service

Requirement for a contribution to the overall QIPP saving plan for the CCG, 2013/2014

Robust cross organisational relationship management across primary and secondary care will be required to ensure new services are fully utilised and quickly embedded into the health economy

Legal parameters for procuring a Prime Contractor model without external challenge

Timing of pertinent meetings to enable ratification. This will have to be managed during an tight procurement timeline during mid to late summer

Maintenance of commercial confidentiality 3.5 Approach This service redesign is predicated on the introduction of new intermediate services provided in community settings. The development of Community Clinics is a consultant-led mechanism which will enable non-complex care to be seen safely and effectively via Minor Surgery Suites developed in community settings. This principle and approach is aligned with the COBIC (see later) principles of commissioning integration across the traditional care settings and breaking down the existing boundaries. COBIC is the Health & Care Revolution that is striving to revolutionise health and social care for patients, their families and friends, and for taxpayers. It is designed to:

Catalyse improvements – in the quality and length of people’s lives

Create Conditions in which doctors, nurses and their organisations can redefine the way health and

social care is delivered

Shift the Focus – from disease groups or professional groups to outcomes that matter to individuals and

populations

Improve the Value – obtained for the money spent on health and social care by incentivising better

outcomes rather than activity.

As the recommended approach is introduction of new providers this is required to go through a formal procurement process. Procurement options and a preferred method of procurement, i.e. via Any Qualified Provider, are noted further in Section 4.6. The following summarises how the redesign meets the objectives of the QIPP agenda:

Quality: improve patient access by providing care closer to patients homes and improve the integration of care

Innovation: transformational change via development of Community settings for some elements of traditional Acute care, i.e. migration of non-complex patients away from hospital sites

Productivity: migration of non-complex activity from Acute settings will ensure Acute Hospital resources are targeted at ‘Acute appropriate’ care hence link naturally to ongoing Acute Cost Improvement Programmes in addition to this representing a more cost-effective process for the CCG

Prevention: intermediate tier of care will act as a filtering mechanism for non-complex care which when seen quicker than overall Acute waiting times could prevent exacerbation of some illnesses

29

3.6 Timescales The procurement of this service will be completed by December 2013. The key milestones are:

Milestone Date Outcome

Director of Commissioning to sign off business case and procurement brief

08 July 2013 Reviewed

Finance Working Group to sign off business case and procurement brief

09 July 2013 Draft Approved

Executive Management Committee to note and discuss business case and procurement brief

16 July 2013 Awaiting review

Quality & Safety Group to sign off business case 18 July 2013 Awaiting review

Governing Body to sign off business case and procurement brief 25 July 2013

Provider Engagement event advertised 25 July 2013

Provider Engagement event held 15 August 2013

Any Qualified Provider (AQP) offer published on Supply2health.nhs.uk and start of formal procurement process

29 August 2013

AQP offer open on Supply2health Notice Board for 3 weeks 20 September 2013

Providers to complete AQP applications 27 September 2013

DH & CCH evaluation process commences 01 October 2013

Initial CCG Evaluators meeting 02 October 2013

DH Compliance evaluation concludes 15 October 2013

CCG online evaluation by Evaluators concludes 17 October 2013

CCG Evaluators moderation meeting 22 October 2013

Clarification questions to Providers 22 October 2013

Providers replies to clarification questions 25 October 2013

Final AQP evaluation completed 25 October 2013

Consensus meeting 29 October 2013

Outcome letters to providers 31 October 2013

Draft contract and schedules prepared 01 November 2013

Contract Award completed 15 November 2013

Provider mobilisation runs from 01 November to 29 November 29 November 2013

Service commencement 01 December 2013

30

3.7 Quality Controls and Audit 3.7.1 Contract management The national standard acute contract 2013/14 will be used for all successful bidders under the proposed Any Qualified Provider model. A full set of Key Performance Indicators (KPI’s) will be integrated into the service specification. From contract signature, throughout the mobilisation/transition period and the duration of the contract, the CCG will hold monthly meetings with the successful contractors. It will be the responsibility of the successful contractors to monitor quality and delivery of service provision of any sub-contractors. Monitoring will extend to the impact of the service on acute activity to test assumptions, i.e. overall Acute elective activity with Dermatology, General Surgery (Minor Surgery), Gynaecology and Urology should fall. The service model, i.e. migration of non-complex care into community settings, has been used in a number of health economies across a range of specialties including the 4 elements within the proposed redesign / procurement. Given the nature of the proposed Any Qualified Provider procurement, i.e. no guaranteed volumes or payment, financial risk sits with the successful provider alone. However, the CCG will need to monitor closely the uptake on these services to ensure that we have not created a new tier of requirements that were previously met within Primary Care settings (i.e. GMS and PMS contracts). 3.7.2 Joint service review The contract between the CCG and the successful AQP contractors will also set out arrangements for quarterly Joint Service Review meetings. 3.7.3 Governance The contract(s) will form a part of the CCG’s overall monitoring process which is supported by the Commissioning Support Unit.

31

4. Service Options

The possible options are:

Option 1 - “Do nothing” – maintain status quo, continue with current arrangements; continue with current service provision arrangements

Option 2 – Develop pathways with existing providers to ensure inappropriate referral into Secondary Care is reduced

Option 3 –Transformational change achieved via development of Intermediate tier of care delivered in Community settings

4.1 Option 1 – Do nothing No advantages have been identified. Disadvantages are:

Deterioration in patient experience as pressure builds on existing Acute services due to continued levels of inappropriate referral or care that could be delivered in alternative settings

Potential deterioration in clinical outcomes as existing Acute services become overloaded

Increase in waiting times

Less integration of care

Less patient centred care

Additional costs to CCG

Adverse impact on QIPP delivery and overall financial position This option is therefore incompatible with the CCG’s strategic objectives, commissioning intentions and QIPP plans; and is discounted from further consideration. 4.2 Option 2 – Develop pathways with existing providers to ensure inappropriate referral into Secondary Care is reduced Advantages are:

Full compliance with Trust Special Administrator recommendations for South London Healthcare NHS Trust

Acts as mechanism to effect some clinical changes

Reduces inappropriate referral and reduces outpatient costs

Partial achievement of CCG QIPP delivery and overall financial position Disadvantages are:

Transformational change and realisation of significant savings not possible as existing Acute cost base remains largely similar

Contractual levers would be required to prevent activity throughput increasing as inappropriate activity reduces

Less integration of care

Partial delivery of QIPP delivery and overall financial position

32

4.3 Option 3 – Transformational change achieved via development of Intermediate tier of care delivered in Community settings Advantages are:

Maximises scope to achieve savings and achieve QIPP delivery and overall financial position

Provides a mechanism to reduce inappropriate referral to Secondary Care,

Reduces Outpatient costs via promotion of One Stop Shop methodology hence fewer follow ups

Reduces Elective activity costs by migrating care from Acute to Community settings

Offers more cost-effective treatment option for large proportion of current Acute activity

Offers greater choice and contestability into the NHS market

Fulfils wider CCG vision of developing Care Closer to Patients Homes

Use of AQP model widens number of available providers but without any guaranteed volumes / income hence no CCG risk

AQP model must be advertised nationally as well as promoted locally hence offers opportunity for new providers to enter the Bexley economy

COBIC compliant (i.e. transformational, new outcomes, and also financial VFM) Disadvantages are:

Requires considerable commissioning and procurement input to progress AQP procurement

Development of new Community Clinic services may take time to become embedded as a default service

Traditional referrals into Acute providers may continue for non-complex care hence risk of under-utilisation of new services (though this should be mitigated by clinical triage at PMC filtering non-complex Acute referrals into Community Clinic provision)

33

4.4 Summary and recommendations The impact of these 3 options can be summarised as follows:

Recommendation - The recommended option is option 3.

Inappropriate activity continues to

overburden Acute providers Treatment may be undertaken away from

Acute settings where clinically appropriate Treatment may be undertaken away from

Acute settings where clinically appropriate

No risk as continuation of existing service

Re-worked pathways would share same

clinical safety provision, i.e. Care Quality

Commission accreditation for Minor Surgery

Care Quality Commission accreditation for

Minor Surgery will prevent inappropriate

Community settings being adopted

Overall waiting times elongated due to

inappropriate activity Re-worked pathways could offer elements of

activity closer to patients homes Care is delivered closer to patients homes

Signifcant variation in Acute spend from

national average is not addressed

Some achievement of QIPP via development

of Community options from local Acute

providers

Achievement of QIPP via development of

Community options and longer term adoption

of more cost-effective intermediate care

Care Closer to Home agenda not adhered to Potential to achieve Care Closer to Home

Agenda via re-worked pathways Care Closer to Home Agenda achieved

AQP procurement not utilised to widen offer

of patient choice AQP procurement not utilised to widen offer

of patient choice

AQP offers greater choice and contestability

with no associated guaranteed volume/costs

to CCG

Care is not delivered closer to patients

homes Re-worked pathways could offer elements of

activity closer to patients homes Care is delivered closer to patients homes

No risk as continuation of existing service Potential anti-competitive / procurement law

challenge from non-local providers

Established NHSE authored AQP procurement

process would negate legal challenge re

selection of new providers

Continuation of existing service so unlikely

delivery risk

Partial in-year delivery risk as re-worked

pathways would take time to become

embedded

Partial in-year delivery risk as Community

Clinics would take time to become embedded

/ become first option for non-complex care

Key

Significant barrier to achievement of goal

Barrier to achievement of goal

Partial achievement of goal

Achievement of goal

Delivery

Clinical

Strategy - national

Patient experience

Financial

Strategy - local

Legal

Option 1: Option 2: Option 3:

Do nothing Develop pathways with existing providersTransformational change achieved via AQP

procurement of Intermediate / Community tier

34

4.5 Procurement options There are several procurement options available within the NHS. During any planned procurement key consideration must be given to the overarching principles of public procurement activities which are:

Transparency

Proportionality

Non-discrimination

Equality of treatment

Possible procurement routes for the development of Community Clinics are:

Any Qualified Provider

Competitive Tendering

o Open Procurement

o Restricted Procurement

o Competitive Dialogue

4.6 Recommended procurement option Any Qualified Provider (AQP) is the preferred procurement vehicle as this represents the best way to increase choice and contestability in the Bexley health economy when introducing a new tier of healthcare. The AQP model gives most financial protection to the CCG as there are no guaranteed volumes of activity or financial pre-commitment. Interested providers / bidders will develop new services at their own risk though the significant risk and reward aspect of the scheme, i.e. the scale of potential income for new providers, should ensure there are significant numbers of suitably qualified providers to ensure the establishment of Community Clinics becomes both a viable and preferable alternative for the treatment of non-complex care for Bexley residents. Bexley’s location in London and the national nature of the AQP process should ensure interest in the intermediate tier development from a potentially wide audience of healthcare providers. The AQP model may also encourage local Primary Care and Secondary Care clinicians to form alliances or joint ventures to bid to provide Community Clinics. The AQP model gives the best opportunity for a range of providers to look to provide Community Clinics and as such competition, at reduced costs to the CCG, is expected to be driven up. 4.6.1 AQP windows for developing Community Clinics Two windows are proposed for the Any Qualified Provider procurement process. The first window, intended to open mid-August and conclude in late September, subject to Governing Body approval of this Business Case, will focus on potential providers wishing to establish new Community Clinics from December 2013.

35

A further AQP window will open mid-January concluding in late February. The purpose of the second window is 2-fold:

Firstly, this represents an opportunity for existing Minor Surgery community provision such as CCG

GPwSI contracts to continue provision within the new Community Clinics framework. Current 2013/14

CCG GPwSI contracts are as rolled over from the former Bexley Care Trust and will conclude on 31st

March 2014.

Secondly, an additional AQP window recognises the intermediate tier of care created by provision of

Community Clinics will develop over time. The initial start-up of new services will begin in December

2013 but a further AQP window allows potentially a greater range of providers to enter the Bexley

economy as the intermediate tier starts to bed down as the first choice for non-complex care for Bexley

residents. The second AQP tranche will therefore coincide with a greater level of decommissioned

activity from existing Secondary Care providers to reflect the intended shift from Acute to Community

provision for non-complex interventions.

Any future windows for these services will need to be determined post the initial AQP procurement process by

determining the range and breadth of the suppliers approved, and the need for any further providers of services.

4.6.2 Suggested AQP timetable to deliver new Community Clinic services from Dec 2013 Appendix 2 shows the anticipated timetable required to deliver new Community Clinic services from December 2013. This is subject to the Governing Body a) approving this Business Case, and b) approving the recommended Any Qualified Provider procurement model 4.7 Equality Impact Assessment A preliminary Equality Impact Assessment has been undertaken which is noted under Appendix 5. The expected outcome of the redesign scheme is positive with improved access generated from the Community Clinics scheme

4.8 Quality Impact Assessment

A preliminary Quality Impact Assessment has also been carried out. This indicates that the impact of the project will be positive. The details of this are given at Appendix 6. 4.9 Privacy impact assessment and information governance considerations

A preliminary Privacy Impact Assessment has been carried out. The CCG will not, as a consequence of this project, hold or process any patient identifiable data; nor have any other information governance issues of concern been identified.

36

5. Cost analysis

5.1 Current costs & activity and calculation of minimum level savings Section 3.1 describes the scope for potential changes in the delivery of care within Dermatology, General Surgery, Gynaecology and Urology. The HRG analysis highlights key areas of current spend above national average based on Audit Commission PbR Benchmark data. Further specialty specific data detailing procedure level activity within such HRGs and the ability to undertake such treatment in a community setting is described in more detail in individual Service Specifications noted under Section 6. The following tables highlight minimum savings the CCG could expect however under the Community Clinics redesign predicated on the following key assumptions:

all Outpatient Procedures migrate from Secondary Care to the new Community Clinics

existing Daycase transfer assumptions from Secondary Care to Community Clinics

o 50% Dermatology

o 25% Gynaecology and Urology

o 20% General Surgery

maximum 70% cap applies to current Secondary Care prices when re-provided in Community Clinics

(though some procedures will be priced less than this)

a 1 to 1 first outpatient to follow up attendance ratio is applied reflecting the nature of the non-complex

care to be undertaken in Community Clinics

The table below summarises the impact of the above and minimum savings these would represent for the CCG via the migration of current Secondary Care activity to Community Clinics:

Summary

Saving £

Transfer of Secondary Care outpatient procedures £239,292

Transfer of Secondary Care daycases £315,272

Reduced follow ups in Community Clinics £112,628

Reduction in Outpatient costs in Community Clinics £137,820

Total minimum saving by migrating to Community Clinics £805,012

37

5.1.1 Analysis of minimum savings from Community Clinics migration Shifting all existing outpatient procedures from Secondary Care to Community Clinics represents the easiest transition as there is no requirement on pathway agreement, i.e. these represent non-complex interventions which are already been done outside of the main acute apparatus.

Applying Clinical Lead assumptions on elements of daycase care that could migrate into Community Clinics shows the following additional saving:

Outpatient Procedures

Per 1314 baseline - Bexley CCG @ South London Healthcare NHST

Specialty

No. Opd

Prox

Current

Secondary

Care Value

£

Average

price £

Maximum

Community

Clinic price

£

Minimum

Saving £

Dermatology 2,692 £271,294 £101 £71 £81,388

General Surgery 1,238 £201,638 £163 £114 £60,491

Gynaecology 1,660 £223,526 £135 £94 £67,058

Urology 382 £101,182 £265 £185 £30,355

Transfer of Secondary Care outpatient procedures

Minimum saving £239,292

Daycases

Per 1314 baseline - Bexley CCG @ South London Healthcare NHST

Specialty

No.

Daycases

Current

Secondary

Care Value

£

Average

Price £

Potential %

to transfer

to

Community

Clinic

Community

Clinic

Daycases

Maximum

Community

Clinic price

£

Antiticpated

Saving £

Dermatology 980 £564,354 £576 50% 490 £403 £84,653

General Surgery 2,924 £1,851,964 £633 20% 585 £443 £111,118

Gynaecology 1,832 £1,122,958 £613 25% 458 £429 £84,222

Urology 1,460 £470,388 £322 25% 365 £226 £35,279

Transfer of Secondary Care daycases

Minimum saving £315,272

38

As previously noted in Section 3.1 the current first to follow up ratio is circa 1:2.2 whereas provision within Community Clinics would reduce to a maximum 1:1. In order to calculate the follow up outpatient saving this would present the table below shows the impact on 1

st

to F/up ratio when migrating all outpatient procedure codes from Secondary to Community.

The table below expands on this to show the follow up outpatient saving that would arise from reduction in first to follow up ratio down to 1:1.

A further saving is generated when calculating the reduced outpatient price calculated for patient seen in Community Clinics. This is set as a maximum of 70% of existing national tariff price.

First to Follow Up ratios

Per 1314 baseline South London Healthcare NHST with Opd procedure removed

Specialty First Follow UpOutpatient

Procedure

Outpatient

Procedure

Dermatology 3,684 6,334 2,692 1 to 2.5 - 1 to 1.7

General Surgery 3,972 7,174 1,238 1 to 2.1 - 1 to 1.8

Gynaecology 2,468 3,412 1,660 1 to 2.1 - 1 to 1.4

Urology 1,806 3,172 382 1 to 2.0 - 1 to 1.8

Total 11,930 20,092 5,972 1 to 2.2 1 to 1.7

Ratio Ratio

Orignal Revised

Outpatient savings 1

Follow Up ratio impact on SLHT baseline for Opd procedure migration to Community Clinics

Specialty

Community

Clinic

Daycases

Current

Follow Ups

Reduction to

1: 1 ratio

Follow Up

Tariff

Follow Up

Opd Savings

Dermatology 490 1 to 1.7 842 352 £69 £24,320

General Surgery 585 1 to 1.8 1,056 471 £101 £47,615

Gynaecology 458 1 to 1.4 633 175 £81 £14,190

Urology 365 1 to 1.8 641 276 £96 £26,503

Minimum saving

Reduced follow ups in Community Clinics £112,628

Revised

Outpatient

1st:F/up rate

Outpatient savings 2

Per Community Clinic transfer assumptions

Specialty FirstFollow

UpTariff 1st

Tariff

F/up

Cost if

treated in

Secondary

Care

Comm

Clinic

1st

Comm

Clinic

F/up

Comm

Clinic cost £Saving £

Dermatology 490 490 £112 £69 £88,690 £78 £48 £62,083 £26,607

General Surgery 585 585 £191 £101 £170,762 £134 £71 £119,533 £51,228

Gynaecology 458 458 £138 £81 £100,302 £97 £57 £70,211 £30,091

Urology 365 365 £177 £96 £99,645 £124 £67 £69,752 £29,894

Minimum saving

Reduction in Outpatient costs in Community Clinics £137,820

39

6. Service Specifications

Note: Service Specifications – to follow Service Specifications are to be reviewed at the Qualify & Safety Subgroup meeting on 18

th July 2013 to ensure

compliance with Clinical Governance processes and provide assurance that care may be delivered safely and effectively from non-hospital premises. 6.1 Community Clinic Service Specification - Dermatology

6.2 Community Clinic Service Specification – Minor Surgery

6.3 Community Clinic Service Specification - Gynaecology

6.4 Community Clinic Service Specification - Urology

40

Appendix 1

The evidence base

The proposals set out in this Business Case are principally informed by the following publications:

Our Health Our Care Our Say - Department of Health Policy Document 2006

Everyone Counts – NHS England Policy Document 2012

Bexley Joint Strategic Needs Assessment 2011

Protecting and Promoting Patients Interests: the role of Sector Regulation – Department of Health Policy

Paper 2011

NHS England guidance for CCGs Managing Conflicts of Interest March 2013

Monitor consultation document Substantive guidance on the Procurement, Patient Choice and Competition

Regulations May 2013

Care Quality Commission – The Essential Standards (of Quality and Safety)

Procurement Guide For Commissioners of NHS-funded Services 2010

Any Qualified Provider guidance – www.supply2health.nhs.uk

Audit Commission Payment by Results national benchmarking data 2012/13

(https://pbrbenchmarker.audit-commission.gov.uk/)

Bexley CCG Commissioning Intentions 2013/14

SLHT baseline 2013/14

Trust Special Administrator recommendations for South London Healthcare NHS Trust

41

Appendix 2 Suggested implementation timetable incorporating Any Qualified Provider procurement

MJSB/AQP/National

SupportHub

Pre 21Jun elements 21-Jun-13 28-Jun-13 05-Jul-13 12-Jul-13 19-Jul-13 26-Jul-13 02-Aug-13 09-Aug-13 16-Aug-13 23-Aug-13 30-Aug-13 06-Sep-13 13-Sep-13 20-Sep-13 27-Sep-13 04-Oct-13 11-Oct-13 18-Oct-13 25-Oct-13 01-Nov-13 08-Nov-13 15-Nov-13 22-Nov-13 29-Nov-13 06-Dec-13

Service Identification and

confirmation

(24 May)

Market assessment, service

provision, utilization and requirement

(14Jun)

Finance

Working Group

sign off EMC

(9Jul)

Quality & Safety

Group sign off

EMC (18Jul)

Governing Body

approval of

scheme and

procurement via

AQP (25Jul)

Locality

meetings - North

Bexley /

Frognall (18Jul)

Locality

meeting -

Clocktower

(25Jul)

Patient Council engagement event

(21May)

Notification to existing Providers via

QIPP decommissioning plans

(31Mar)

Provider

Engagement

Event (16Aug)

Document

submission

()

Publish Offer on

S2H

Thurs 29 Aug

DH AQP places

Provider

Applications on

S2H for Evaluation

(Tues 01 Oct)

Initial Evaluators

meeting

Weds 02 Oct

Moderation

meeting

Tues 22 Oct

Clarification

questions to

Providers

Tues 22 Oct

Provider replies

Fri 25 Oct

Consensus

Meeting

Tues 29 Oct

Outcome letters

to Providers

Thurs 31 Oct

.

Service Commencement

Mon 01 Dec

-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Week ending on Friday: NHS Bexley CCG Community Clinics - Window 25 July 2013

Commissioner Planning Phase

Planning, Market Assessment, Provider Assessment, Specification Drafting, Advert onSuppl2Health,Provider and Commissioner Events,

(ongoing prior to timeline - complete 16 Aug)

Contract Award Phase

(Completion 15 Nov)

Commissioners agree:

1. Offer

2. Qualification Document

3. Specification

4. Evaluators

(complete )

Notice board open for 3 weeks

(closes 20 Sept)

Providers complete AQP Application Form on S2H

(offer closes 27 Sept)

DH Compliance Evaluation

(completion Tues 15 Oct)

Provider Mobilization & Service Commencement (Completion 29Nov)

Weeks from Offer being posted>

Provider assessment and engagement

(16 Aug)

Specification Identification and Approval

(09 July)

Advertizement on S2H of Commisioner Intention and Provider &

Commissioner Events (25Jul subject to GB sign-off)

Commissioner Evaluation of Section 5

completion 01 Nov

On line evaluation by Evaluators

complete Thursday 17 Oct

Financial Evaluation

complete Fri 25 Oct

CfH IM&T Evaluation

complete Fri 25 Oct

Contract Preparation

Draft contract and schedules

prepared

by Friday 01 Nov

Appendix 3

Community Clinics Risk Update – May2013

(Dermatology / General Surgery / Gynaecology / Urology)

Risk Scoring Matrix

Likelihood

Rare Unlikely Possible Likely Almost Certain

Impact 1 2 3 4 5

5 Catastrophic 5 10 15 20 25

4 Major 4 8 12 16 20

3 Moderate 3 6 9 12 15

2 Minor 2 4 6 8 10

1 Negligible 1 2 3 4 5

Risks Impact Likelihood Risk Mitigating Actions Risk after Mitigation (1-5)

1 (low) to 5(high) I x L

Robustness of data i.e. underlying data quality issues which would lessen the existing variances from benchmarked national average

5 3 15 Reviewed with SLHT, DVH, GST and CSU as part of 1314 contract development. There are known variances in General Surgery for Bariatric activity but the QIPP opportunity has been deliberately targeted as much lower than benchmarked position to ensure QIPP target is more viable.

10 (5x2)

Are suitable premises available from which a Community Clinics could be operated from

5 2 10 Initial view was to undertake review of all Primary Care estate to establish suitability of premises for Minor Surgery to be undertaken. Previous plans have included use of Erith Hospital and larger practices such as Albion Surgery have been assessed however as CCG does not own estate the Service Specification will specify what constitutes suitable premises for Community Clinics to be undertaken

5

(5x1)

Ability to encourage GP’s to work differently and adopt a new model of community delivery.

5 3 15 Effective communications strategy that incorporates GP engagement. Engagement with GP community on Pathway development has already begun with 5 of 20 new pathways being launched on 13May13. As Community Clinic services develop such pathways will be refined to include elements of care which should be seen in Community Clinics first prior to consideration

10

(5x2)

for referral into an Acute setting

Failure to identify activity appropriate to transfer from acute into the community setting.

4 1 4 Review learning from economies who have successfully transitioned care from Acute to Community settings.

Review SUS data to highlight volume of activity to transfer.

Given the high level of spend above national benchmarks and lack of existing Community provision in Bexley this is seen as low risk.

4

(4x1)

Resistance of Providers around repatriation of this element of the work into community settings

5 3 15 Clear commissioning intentions outlining service changes at both corporate and clinical level within SLHT, DVH and GST.

Clinical resistance is expected to an extent however transformational CQUIN (1% of total 2.5% CQUIN) has been developed to ensure clinical buy-in over the operation of new Community Clinic services to ensure repatriation is effective from the new services start-up

10

(5x2)

Failure to engage GPs and other referrers sufficiently to ensure a new Community Urology Clinic has enough critical mass to be viable.

5 3 15 Effective communications strategy with all stakeholders (primary and secondary care). Links to clinical engagement with providers detailed as a requirement in SLHT CQUIN (above) and developing Pathway work commenced May13 with Bexley GPs

10

(5x2)

Public expectations don’t change and there is a widespread view that you get treated for illness at hospital rather than in community settings.

4 3 12 Ensure service spec defines need for providers to identify innovative ways of ensuring their protocols involve changing patient expectations.

Patient engagement events factored into comms plan

Voluntary sector organisations have outlined ways that they can help change patient expectations

8

(4x2)

Availability of GPwSI or other appropriate clinical professional

4 2 8 GPwSI model preferred as this would leave existing clinical resource in Acute settings however a Hospital Consultant Outreach model or Consultant overseeing model in a hub and spoke mechanism may be operated. These may vary by specialty dependent on interested parties from both local consultant body and GPs looking to develop Community Clinics element.

It is expected however that there would be sufficient interest from peripheral health economies as well as potentially national organisations to ensure there is enough clinical resource to effect the migration from Acute to Community Clinics care

4

(4x1)

Introducing extra capacity within the community setting without reducing the acute capacity could manifest as a financial pressure

5 3 15 Needs to be carefully managed as part of a commissioning intentions/contract setting process for 13/14 hence inclusion of the 1% Transformation CQUIN.

This will however remain a risk as its key that provider capacity is tapered off to reduce at the same time the Community Clinics activity comes on stream to ensure double running of activity is minimised.

10

(5x2)

Appendix 4 Communications and engagement plan Background and introduction: the purpose of the plan The CCG places great emphasis on communicating effectively with its member practices and with the people of Bexley as well as with all other stakeholders. This plan sets out how the communications and engagement strand of the project will be managed effectively. Our broad aims are:

To communicate right message to the right people at the right time

To help keep everyone informed so the benefits of the new Community Clinics can be communicated

To aid delivery of new service through effective communication

Our project-specific objectives are:

To provide key messages explaining the work being undertaken

To explain specific information about the new service model

To ensure that stakeholders are presented with a balanced view on changes being made

To identify and support key spokespeople to deliver the message

Dependencies

The successful delivery of this communication and stakeholder engagement plan will be dependent on:

Acknowledgement and agreement by all partners that a consistent and transparent approach to communication and engagement any audience is essential. Understanding that stakeholders have differing awareness, information needs and accessibility issues.

Patient group engagement in service redesign

GP engagement

Timely delivery of communications to stakeholders

Ensuring commissioning communication channels are used effectively to ensure a wide pool of potential providers.

Robust project management and reporting with clear deadlines to ensure the delivery of a whole system service redesign

Key Messages

The overall aim is to communicate to the different audiences that development of an intermediate level of care via the Community Clinics will:

facilitate migration of patients requiring non-complex care from Acute hospitals to Community settings

achieve CCG wider health agenda objectives of providing care closer to patients homes

offer a cost-effective alternative to Acute referral

provide greater level of healthcare choice via the AQP model

Communications channels

The following communication channels are used to communicate with our stakeholders.

Stakeholder group Channels

CCG All Bexley GPs Nurse Practitioners, Nurses and Health Care Assistants Bexley Practice Managers Governing body members Patient Council members CCG Chief Officers and staff involved with quality, safety and finance.

Letter, emails, meetings Staff newsletter, staff briefing GP newsletter, emails, GP zone, Q&As GP newsletter, emails, Q&As Emails Email, written briefing, Q&As

Other NHS bodies

Secondary Care clinicians Secondary Care management team Other local CCGs Clinical Network London Ambulance Service

Email, written briefing

Political Leader LB Bexley HOSC chair HOSC members Other councillors Local MPs LMC

Written briefing,1:1 briefing (if necessary) Written briefing, 1:1 briefing (if necessary) HOSC meeting Written briefing, 1:1 briefing (if necessary)

Statutory body partners

LB Bexley CE LB Bexley Director(s) Health & Wellbeing Board members

Written briefing Written briefing Written briefing

Patient representative groups

Bexley Health Watch Relevant voluntary and self-help groups (tba)

PPGs

Patient Groups

Written briefing, Q&As, engagement meeting Written briefing, Q&As, engagement meeting

In PPG newsletter

Written briefing, Q&As, engagement meeting

Email; 1:1 briefing

Some of the above, especially leaders of patient groups may require a 1:1 briefing

Community CE, Chair and Coordinator of BVSC

Community forums

Written briefing, Q&As

Written briefing

Media Locals – News Shopper, Bexley times, Mercury

Reactive statement drafted

Appendix 5 Equality impact assessment

Equality Impact Assessment

Does the scheme affect one of the following groups more or less favourably than another?

If yes, explain impact and any valid legal and/or justifiable exception

Age Consider and detail (including the source of any evidence) across age ranges on old and younger people. This can include safeguarding, consent and child welfare.

All Community Clinic services are designed with an open age-range hence by definition are not intended to favour any age group more than any other. Older patients are more prone to some health issues such as incontinence hence the Urology clinic for example may see older patients however clinics are designed for all ages.

Disability Consider and detail (including the source of any evidence) on attitudinal, physical and social barriers.

None identified.

Sex Consider and detail (including the source of any evidence) on men and women (potential to link to carers below)

The Gynaecology Community Clinic is specifically for female patients only.

Gender reassignment (including transgender) Consider and detail (including the source of any evidence) on transgender and transsexual people. This can include issues such as privacy of data and harassment.

None identified.

Marriage and civil partnership Consider and detail (including the source of any evidence) on people with different partnerships.

None identified.

Pregnancy and maternity Consider and detail (including the source of any evidence) on working arrangements, part-time working, infant caring responsibilities.

The impact of the proposals will be positive as the Community Clinic redesign makes care more accessible to patients.

Race Consider and detail (including the source of any evidence) on difference ethnic groups, nationalities, Roma gypsies, Irish travellers, language barriers.

The service model aims to bring services closer to home thus improving geographical access and seeking to engage groups in the population who are traditionally considered “hard to reach”.

The service recommendations will be intended to apply equally to all groups protected under equality and anti-discrimination legislation. However, if during development, it becomes apparent that specific recommendations might be required for specific groups, subgroup analysis of the evidence will be undertaken where possible.

Religion or belief Consider and detail (including the source of any evidence) on people with different religions, beliefs or no belief.

None identified.

Sexual orientation Consider and detail (including the source of any evidence) on heterosexual people as well as lesbian, gay and bi-sexual people.

None identified.

Carers Consider and detail (including the source of any evidence) on part-time working, shift-patterns, general caring responsibilities.

As part of the wider agenda of Community Clinics improving access for all patients requiring non-complex care the proposals will be positive.

Other identified groups Consider and detail and include the source of any evidence on different socio-economic groups, area inequality, income, resident status (migrants) and other groups experiencing disadvantage and barriers to access.

None identified.

Is the impact of the scheme likely to be negative? If so, can this be avoided? Can we reduce the impact by taking different action?

The expected outcome of the scheme is positive with improved access intermediate tier services.

Appendix 6 Quality impact assessment

Stage 1 - proforma

Scheme Details:

Scheme Title / Name Clinical Leads

Management Lead Sponsor

Community Clinics QIPP Dermatology - Dr Anna Malone Minor Surgery - Dr Ravi Muthukaluvan Gynaecology - Dr Aleks Fox & Dr Shradda Karkare Urology - Dr Pandu Balaji

Neil Hales Project Manager

Sarah Valentine Director of Commissioning

The CCG plans, subject to final Governing Body approval, a transformational redesign of existing Acute Hospital services by developing Community Clinics to undertake non-complex treatments. Community Clinics will operate as an intermediate level of care between current Primary Care and Secondary Care services. The scheme forms part of the CCGs 2013/14 QIPP plan and procurement of new providers for what is a new service is recommended to be undertaken via the Any Qualified Provider model.

Answer positive/negative in each area. If Negative, score the impact, likelihood and total in the appropriate box. If score ≥10 insert “Yes” for full assessment

Area of Quality

Impact question P/N Impact

Likeli-hood

Score Full Assessment required

Duty of Quality

Could the proposal impact positively or negatively on any of the following - compliance with the NHS Constitution, partnerships, safeguarding children or adults and the duty to promote equality?

Positive

Patient Experience

Could the proposal impact positively or negatively on any of the following - positive survey results from patients, patient choice, personalised & compassionate care?

Positive

Patient Safety

Could the proposal impact positively or negatively on any of the following – safety, systems in place to safeguard patients to prevent harm, including infections?

Positive

Clinical Effectiveness

Could the proposal impact positively or negatively on evidence based practice, clinical leadership, clinical engagement and/or high quality standards?

Positive

Prevention Could the proposal impact positively or negatively on promotion of self-care and health inequality?

Positive

Productivity and Innovation

Could the proposal impact positively or negatively on - the best setting to deliver best clinical and cost effective care; eliminating any resource inefficiencies; low carbon pathway; improved care pathway?

Positive

Expected Quality Metric outcomes (success criteria)

Signature: Designation: Date:

Please describe your rationale for any positive impacts here: The project is clinically led and the service specifications will be required to be approved by the Quality & Safety Working Group prior to formal Governing Body approval. The aims of the project of direct relevance to the Quality Impact Assessment are:

quality of service will be assured from non-complex care being undertaken in CQC accredited facilities in a Consultant-Supervised service

patient experience should be particularly enhanced as non-complex treatment will be made available in community settings and therefore more likely closer to their homes

waiting time for non-complex care is expected to be lower in community provision than compared to existing secondary care services

patient safety will be assured from provision of care within Care Quality Commission premises – this is a pass/fail element of the AQP procurement evaluation process

the proposals should further develop clinical effectiveness and engagement as its pre-requisite for the Community Clinic model for Consultant Specialists and General Practitioners and other health professionals to work together in a Consultant-Supervised environment

developing services in the community will help to address health inequalities as access barriers to health are lessened

Community Clinics represent an improved and more efficient pathway for non-complex treatment for which patients have less overall waiting time due to no longer ‘queuing’ in the same hospital system with more complex patients

Sub-tariff pricing as settings are away from Hospital bases represent more cost effective delivery of care

Metric – these need to be measurable Expected impact

Patients and carers empowered and supported in the community

Positive. The new service is predicated on bringing care closer to patients homes and will provide greater health infrastructure in localities/communities within the Bexley health economy

High quality, timely and appropriate referral from primary care

Positive. The new service will provide a mechanism for patients to be seen sooner in the community, treated in CQC accredited environments and alleviate the burden on existing secondary care provision

Access and waiting times Positive. The new service will reduce the current level of inappropriate referral to secondary care hence have an overall beneficial effect on overall waiting times. In addition patients will typically be seen much sooner in community settings as well as access being improved considerably as Community Clinics will be established on a locality basis.

Clinical outcomes Positive. The AQP model will provide an environment for improved outcomes and quality of service by creating a health economy with increased choice and contestability

Patient experience Positive. The project aims to redefine existing pathways in order that referral into community services rather than to traditional hospital settings is seen as the first choice for a significant portion of non-complex care.

Resilience and sustainability of new model including workforce planning issues

Positive. The new service will create a greater variety of (AQP) providers which are required to work with a Consultant Specialist ‘in control’ of the service. The volume opportunity to transfer from acute to community settings is significant hence should provide a viable base from which new Community Clinics will be developed and sustained for the longterm.

Facilitation of inter-professional and inter-organisational working and shared learning

Positive. Inter-professional shared working and learning is a key element of the new service as its Consultant-led. The introduction of Community Clinics will change the existing commissioner / provider dynamics as a greater range of providers will mean existing power-base of main providers will be diluted. As part of this dilution local providers will be encouraged to work more closely with the CCG to jointly develop pathways to ensure retention of more complex elements of care which the new intermediate tier / Community Clinics could not treat.

Neil Hales (electronically) Project Manager 05 July 2013

Appendix 7

Developing Community Clinics – Patient Leaflet (TBC)

Developing Community Clinics in Bexley

Overview

Bexley Clinical Commissioning Group (CCG) serves a population of 232,000 people and encompasses both deprived and

affluent areas. Bexley’s population, including the groups most likely to be high users of health services, is growing. The CCG’s

vision is for local people to stay in better health for longer, with the support of good quality integrated care available as close

to home as possible; backed up by accessible, safe and expert hospital services.

Bexley intends to undertake a procurement to develop Community Clinics as part of the wider health agenda of bringing

patients care closer to home. Community Clinics will form an intermediate tier of care between Primary Care and Secondary

Care. This will facilitate the migration of non-complex Acute care into Community settings and in addition provide a

mechanism to ensure only appropriate referrals are seen in Acute Hospitals.

Community Clinics are currently being developed for:

Dermatology

Gynaecology

Minor Surgery

Urology

What are the benefits of Community Clinics ?

As technological advances are made more and more care traditionally seen in a hospital can be seen safely and effectively in

non-acute or non-hospital settings. These include locations such as local GP practices.

The ability to now treat some patients away from hospital means care can be delivered closer to patients’ homes. Delivering

more care in such Community settings allows easier access for patients as well as being more cost effective.

Moving care where appropriate into Community settings assists local acute hospitals also as this means they may concentrate

on delivering more complex care. There is also a wider benefit of overall hospital waiting times reducing as less patients are

seen in a hospital setting.

Bexley are looking to mirror successful Community or ‘Intermediate’ services developed in the wider NHS. Local examples of

where similar Community services have been developed include, Bromley, Greenwich and Croydon.

What types of services will be provided in the Community Clinics ?

Community Clinics are designed to deliver non-complex treatments. These include treatments for:

Skin therapies

Vasectomy

Ingrowing toenail

Urinary problems

Menstrual problems

Some of the above services may already be provided by local GPs. The development of Community Clinics envisages the

majority of non-complex treatments will be seen in premises in the Bexley area rather than being referred to Acute Hospitals.

Who will provide Community Clinics and where will they be based ?

The CCG, subject to approval by its Governing Body, is looking to adopt the “Any Qualified Provider” model. Any Qualified

Provider or AQP, is a national procurement process hence clinicians interested in providing care for Bexley patients need not

currently live or work in the local area.

The CCG is committed to delivering care closer to patients homes though hence Community Clinics must be sited within the

Bexley area.

Providing care in a safe environment is of paramount importance and as part of the AQP evaluation process new healthcare

providers must specify their premises are compliant with Care Quality Commission regulations for Minor Surgery.

How will this affect me ?

When patients see their GP at present, they are given a choice of hospital should the GP decide they need to be seen by a

Consultant Specialist. Community Clinics will present a further option for GPs to refer patients to for non-complex care. Care

will be provided by Consultant-led teams which means treatments may be undertaken by health practitioners such as a GP

with a Special Interest, under the supervision of a Consultant Specialist.

Developing Community Clinics will mean non-complex care can be delivered in locations such as local GP practices and Health

Centres hence visits to hospital for some non-complex care will become less frequent.

How will this affect local hospitals ?

Community Clinics are designed to supplement the provision of NHS services locally. In addition to providing capacity for non-

complex treatments to be seen in the Community Clinics will work closely with existing NHS hospitals also to ensure patients

always receive the most appropriate care in the most appropriate setting at all times. Some patients for example may be

referred to a Community Clinic but upon clinical assessment or triage its determined they need to be seen within a local

hospital provider.

When will the Community Clinics start ?

Community Clinics in Dermatology, Gynaecology, Minor Surgery and Urology are planned to start in December 2013, subject

to approval by the CCG Governing Body.

What happens next ?

The CCGs Governing Body will meet in July 2013 where a Business Case for development of the new Community Clinics will be

presented.

Subject to the Governing Body approving the development of Community Clinics the following timetable will then be

followed:

August 2013 Opportunity to develop Community Clinics in Bexley advertised via ‘Any Qualified Provider

(AQP)’ national advert

September 2013 Interested clinicians/providers submit AQP application

October 2013 CCG reviews applications and selects AQP providers

December 2013 New Community Clinics open

Appendix 8

Developing Community Clinics – Clinical Colleagues update (TBC)

Developing Community Clinics in Bexley

Overview

Bexley Clinical Commissioning Group (CCG) is developing Community Clinics currently due to start in December 2013.

Community Clinics will act as an intermediate stage of care between Primary Care and Secondary and are designed to ensure

non-complex patients are less frequently referred into Acute settings as they may more appropriately be seen in premises to

be established nearer patients homes. The CCG will be procuring providers for the new Community Clinics via the Any

Qualified Provider process.

Community Clinics are currently being developed for:

Dermatology

Gynaecology

Minor Surgery

Urology The following services will be provided in the Community Clinic / intermediate tier:

Dermatology - Cryotherapy / cryosurgery - Skin therapies Minor Surgery (subject to Clinical Lead confirmation) - Cysts - Excision of abcesses - Haemorrhoids - In-growing toenails - Lipoma - Vasectomy Gynaecology - Cervical polyp removal - Complex coil fitting / removal - Dysmenorrhea - Menorrhagia - Pessary changes - Suspected fibroids Urology - Haematuria - Lower urinary tract symptoms - Recurrent urinary tract infections - Urinary incontinence

The introduction of Community Clinics will be a step-change in the way non-complex care is treated in Bexley. The CCGs

expectation is that as the clinics develop they will become the default referral for non-complex care in order to reduce the

burden on local Acute Hospitals.

All Bexley GP referrals are currently triaged via the Patient Management Centre (PMC). The PMC will triage non-complex

referrals to the Community Clinics as they become established from December 2013, i.e. patients will be offered a first choice

of attending a local Community Clinic rather than attending an Acute Hospital.

Community Clinics are required to have Care Quality Commission accredited Minor Surgery Suites from which to operate.

Although other health professionals may be involved in some aspects of the delivery care Community Clinics are a consultant-

supervised service.

Community Clinics are required to operate a minimum of 4 clinical sessions per week, 1 of which must be consultant-led.

Any referral deemed too complex for a Community Clinic to treat within a non-acute setting will be referred into Secondary

Care.

Community Clinics Service Specifications also ensure any urgent or cancer referral received in error is fast-tracked through to

the appropriate Secondary Care service.