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Pre-Consultation Business Case for the Redevelopment of the St Pancras Hospital site and Mental Health Community Hubs
Version 9.1 26th June 2018
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Glossary of Terms
5YFV Five Year Forward View
A&E Accidents & Emergency
ALoS Average Length of Stay
CAMHS Child and Adolescents Mental Health Services
Capex Capital Expenditure
CBT Cognitive Behavioural Therapy
CCCG Camden Clinical Commissioning Group
CCG Clinical Commissioning Group
C&IFT Camden and Islington NHS Foundation Trust
CIM Capital Investment Manual
CIP Cost Improvement Plan
CMH Community Mental Health
CNWL Central and North West London NHS Foundation Trust
COIL Certificate Of Immunity from Listing
COO Chief Operating Officer
CQC Care Quality Commission
CSF Critical Success Factors
DHSC Department of Health and Social Care
DMBC Decision-Making Business Case
DQI Design Quality Indicator
EAV Equivalent Annual Value
EBITDA Earnings before Interest, Tax, Depreciation and Amortisation
EA10 Equalities Act 2010
EIA Equality Impact Assessment
FBC Full Business Case
FSRR Financial Sustainability Risk Rating
GB Green Book
GEM General Economic Model
GPs General Practitioner
HMHC Highgate Mental Health Centre
HMT HM Treasury
HOSC Health Oversight and Scrutiny Committee
HR & OD Human Resources & Organisational Development
I&E Income and Expenditure
IAPT Improved Access to Psychological Services
ICCG Islington Clinical Commissioning Group
ICT Information & Communication Technology
Term /
Abbreviation Definition
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IoMH Institute of Mental Health
IT Information Technology
ITFF Independent Trust Financing Facility
JHOSC Joint Health and Overview Scrutiny Committee
JHWS Joint Health and Wellbeing Strategies
JSNA Joint Strategic Needs Assessment
LCS London Clinical Senate
LoS Length of Stay
LTFM Long Term Financial Model
Moorfields Moorfields Eye Hospital NHS Foundation Trust
NCL North Central London
NHS FT NHS Foundation Trust
NHSE NHS England
NHSI NHS Improvement
NPC Net Present Cost
NLP North London Partnership
OBC Outline Business Case
OSC Overview Scrutiny Committee
PBMH Practice Based Mental Health
PCBC Pre-Consultation Business Case
PDC Public Dividend Capital
PIA Privacy Impact Assessment
PICU Psychiatric Intensive Care Unit
PID Patient Identifiable Data
PLACE Patient Led Assessment of the Care Environment
PPE Property Plant and Equipment
QIA Quality Impact Assessment
R&R Rehabilitation and Recovery
SAMH Services for Ageing and Mental Health
SMS Substance Misuse Service
SOC Strategic Outline Case
SoS Secretary of State
SPH St Pancras Hospital
STF Sustainability and Transformation Fund
STP Sustainability and Transformation Partnerships
the Trust Camden and Islington NHS Foundation Trust
the Trust Camden and Islington NHS Foundation Trust; the “Trust”
Two boroughs
The London Boroughs of Camden and Islington
UCL University College London
UCLH University College London Hospital
UCLP University College London Partners
VAT Value Added Tax
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Contents
Pre-Consultation Business Case for the Redevelopment of the St Pancras Hospital site and Mental Health Community Hubs 1
Foreword 7
Executive summary 9
1.1 Introduction 9
1.2 Case for change and care model 9
1.3 Governance 12
1.4 Stakeholder engagement 13
1.5 Finance case 14
1.6 Implementation 15
1.7 The Secretary of State’s four tests and NHSE’s bed test 15
1.8 Decision making and next steps 16
2 Introduction 17
2.1 Overview 17
2.2 PCBC objectives 17
2.3 Background 18
2.4 PCBC scope 18
2.5 Parties involved in the production of this PCBC 19
2.6 Proposal Development 19
2.7 PCBC structure 21
3 Context 23
3.1 The Population and Healthcare challenges 23
3.2 Background to the Trust and CCGs 24
4 Case for Change 27
4.1 Local Policy Framework 27
4.2 National Policy Framework 32
4.3 Regional Policy Framework 35
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4.4 Quality of Existing Estate 40
4.5 Limitations of Current Service Provision 41
5 Care model and expected benefit 43
5.1 Care Model 43
5.2 Expected benefit 56
5.3 Impact on service users and benefits 56
5.4 Changes to travelling times and distances 59
5.5 Public Sector Equality Duty 59
6 Governance 61
6.1 Governance structure for the consultation process 61
6.2 Roles and Responsibilities 62
6.3 Information Governance Issues 63
7 Stakeholder engagement 64
7.1 Legal Context 64
7.2 Pre-consultation engagement on the case for change 65
7.3 Options appraisal engagement 67
7.4 Applying pre-consultation engagement findings to options appraisal 70
7.5 Other pre-consultation engagement activity 71
7.6 Consultation Plan 71
8 Options development, analysis and evaluation process 76
8.1 Option development 76
8.2 Appraisal 1: Feasibility Study 77
8.3 Appraisal 2: Hurdle CSF 77
8.4 Appraisal 3: Qualitative CSF 79
8.5 Appraisal 4: Value for Money evaluation of options 81
8.6 Combined appraisal 83
8.7 Impact of the preferred option 84
9 Finance case 86
9.1 Introduction 86
9.2 Basis of preparation 87
9.3 Financial projections 87
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9.4 Impact on financial sustainability risk rating (FSRR) 101
9.5 Sensitivities 101
9.6 Conclusions 102
10 Implementation 104
10.1 Post consultation process 104
10.2 Programme management arrangements 104
10.3 Project implementation plan 108
10.4 Post project evaluation 110
10.5 Approvals process for investment by the Trust 110
11 The Secretary of State’s Four Tests 112
11.1 Test 1: Strong public and patient engagement 112
11.2 Test 2: Consistency with current and prospective need for patient choice 116
11.3 Test 3: A clear clinical evidence base 116
11.4 Test 4: Support for proposals from clinical commissioners. 117
11.5 NHSE’s Bed Closures Test 118
12 Decision making and next steps 119
Appendix Contents 120
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Foreword
North London Partners in Care share a vision for our community to be happier, healthier and
to live longer in good health. We have a collective agenda and a commitment to transform
the health and care services of North London. Our community has told us they want a more
joined up and integrated health and care system, they want care closer to where they live
and work, delivered by professional and compassionate health and care workforce.
We are united in our commitment to transforming care to deliver the best possible health
outcomes for our local population. This will be done by shifting our model of care so that
more people are cared for in ‘out of hospital’ settings, and through prevention, more
proactive care, and new models of care delivery, we can reduce the reliance on secondary
care and improve the way people access and receive care.
We want to improve overall mental health outcomes across North London and reduce
inequalities for those with mental ill health; enable more people to live well and receive
services closer to home and ensure that we are treating both physical and mental ill health
equally.
Our ambition is that unless someone requires highly specialised care, they will be able to
receive the care they need within North London, and not require an out of area placement.
By investing in community based care, we aim to reduce demand on the acute sector and
mitigate the need for additional mental health inpatient beds.
To deliver our vision, we have designed a programme of transformation for mental health
services based around these fundamental elements:
Supporting people with mental ill health to live well, enabling them to receive care in the least restrictive setting for their needs;
Raise mental health awareness to reduce stigma, ensuring that mental health is considered equally with physical health;
Reduce reliance on inpatient care and expand community provision to support more people to spend more time at home, rather than in hospital;
Ensuring more accessible and extensive mental health support is delivered locally within primary care services.
We are developing our services in the community to make sure that health and care will be
available closer to home for all, ensuring that people receive care in the best possible setting
at a local level and with local accountability. At the heart of the care closer to home model is
a ‘place-based’ population health system of care delivery which draws together social,
community, primary and specialist services underpinned by a systematic focus on prevention
and supported self-care, with the aim of reducing unplanned hospital admissions.
We believe that the changes proposed in this document provide an exciting opportunity to
deliver on our ambition to improve the mental health and reduce the health inequalities of
our communities. By delivering more care in community settings and working in a more
joined up and integrated way with our health, social care and voluntary sector partners, we
believe that we will be able to deliver better outcomes for our patients. By supporting people
closer to their homes and embedding services in the community, our teams can help prevent
people becoming unwell, or help them earlier so that they require fewer hospital referrals
and less crisis care.
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We know that services provided in the community for people who experience mental ill
health bring many benefits and better health outcomes. Community service are less
stigmatising and easier to access. People receiving their health care close to their homes
can continue to receive the support of their families, friends and local community, which we
know is vital to recovery. In order to realise our vision, we need to be able to provide more
specialist mental health services for all forms of mental health in the community, supporting
the work of our GPs and community teams, so that we can support earlier discharge and
reduce admissions and re-admissions.
Sometimes people will need specialist support provided in a hospital environment and it is
our aim that this is provided in environments that are safe, therapeutic and maintain
individual privacy. Where care is underpinned by strong, integrated community services,
people will be referred to hospital less often and will be discharged earlier following periods
of illness. By providing treatment in the least restrictive environment possible, fewer people
will be detained under the Mental Health Act and those that do can step down from a
hospital environment as soon as possible.
The community estate is key to delivering our vision. It can be brought together to help
achieve these synergies between services and sectors, supporting joint and multi-agency
working. The exact details of how all services may work together in the future is still to be
developed through co-production with service users and carers and creating the space in
Community Hubs is an enabler for this.
The care that we provide to patients must be underpinned by the best practice and we want
to be at the forefront of research developments to ensure that people who experience mental
ill-health are receiving the best care possible. By working with our academic partners, we
can ensure that every intervention is evidence based.
Helen Pettersen Angela McNab Accountable Officer Chief Executive Officer NCL CCGs Camden & Islington NHS Foundation Trust
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Executive summary
1.1 Introduction
The local health organisations are united in the commitment to transforming care to deliver
the best possible health outcomes for the population of Camden and Islington. The local
communities have voiced a need for a more joined up and integrated health and care
systems. This will be done by shifting the model of care so that more people are cared for in
‘out of hospital’ settings, and through prevention, more proactive care, and new models of
care delivery, reliance on secondary care can be reduced and improve the way people
access and receive care.
This Pre-Consultation Business Case (“PCBC”) assesses the opportunity to deliver better
outcomes for users of mental health services across Camden and Islington through the
development of a high quality and accessible estate. It sets out a way forward for formal
consultation on a preferred option which is demonstrably the best solution in terms of
benefits and value for money. The objectives of the PCBC are to:
Make the case for change for transformation and modernisation of the mental health services, delivered by Camden and Islington NHS Foundation Trust (“the Trust”) across its community estates, and specifically at the St Pancras Hospital (“SPH”) site, to set out proposals for the redevelopment of the estates required to enable the transformation;
Describe the clinically developed model of care and specification for:
The movement of community services into community hubs; and
The movements of in-patient services from SPH to another site.
Detail the process undertaken to engage the public, staff and other stakeholders in the pre-consultation phase and demonstrate how their feedback has shaped the development of the options as well as the proposed option to take forward;
Set out how the development of the preferred options is compliant with the Secretary of State for Health and Social Care’s (“SoS” or “Secretary of State”) four tests of service reconfiguration and NHS England’s “bed” test;
Make the case to Camden NHS Clinical Commissioning Group (“CCG”) (“Camden CCG”), Islington NHS CCG (“Islington CCG”) to commence public consultation on the preferred option.
The proposal set out in this document is to move the following:
Services being provided from SPH that are moving into the community hubs
Inpatient services being provided from SPH that are moving to another site that is 2.5 miles away from the current location; and
A limited range of other NHS services that are currently delivered from a variety of Trust sites which will move as part of proposals.
1.2 Case for change and care model
1.2.1 Context
The current Joint Strategic Needs Assessments (“JSNAs”) for Camden and Islington
produced by the respective Health and Wellbeing Boards outline a clear requirement for
sustainable and high quality mental health services in the area. Both Camden and Islington
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have significantly higher rates of mental health diagnosis than other London Boroughs.
Islington has the highest proportion of its population diagnosed with a psychotic disorder,
with Camden third highest nationally. The proposed reconfigurations reflect Health and Well
Being Board Strategies, which aim to:
Bring together partners to provide a holistic service to people with multiple complex
needs which include mental health problems;
Make sure the physical health needs of those with mental health conditions are
addressed effectively.
The Trust provides mental health services for people in the area. Almost 98% of services are
commissioned by Islington CCG in their role as lead commissioner with Camden CCG as an
associate commissioner.
The SPH redevelopment programme and development of mental health Community Hubs
enables an overarching transformation of the estate to enable effective delivery of the Trust’s
Clinical Strategy along with national and local health strategies through the development of a
range of health services and research facilities. It puts service users at the centre,
recognising there is a once in a lifetime opportunity to transform services across the London
Boroughs of Camden and Islington, building more visible, more accessible and more
integrated services for people locally alongside world class research driving the very best
practice.The vision for the community hubs is that service users and carers’ will have a
familiar, non-stigmatising, easily accessible place where they can access a variety of
services that promote holistic care.
Community services are being developed to make sure that health and care will be available
closer to home for all, ensuring that people receive care in the best possible setting at a local
level and with local accountability. At the heart of the care closer to home model is a ‘place-
based’ population health system of care delivery which draws together social, community,
primary and specialist services underpinned by a systematic focus on prevention and
supported self-care, with the aim of reducing unplanned hospital admissions.
Parity of esteem for mental health through modern estate and integration of care with
physical health is widely supported through national initiatives and within the local health
system. This is a rare opportunity to make a step change in converting that concept into
reality for service users in North Central London and is aligned to the wider Model of Care
and goals in the local Sustainability and Transformation Plan (“STP”).
To deliver the STP vision and the aims of the Five Year Forward View, a programme of
transformation has been designed with four aspects: Prevention, Service transformation,
Productivity and Enablers. The STP identifies the need to redevelop the estate at SPH, in
conjunction with other redevelopments, in order to enable a range of initiatives across North
Central London. Progress has been made against the STP plans through improving
community resilience, increasing access to primary care mental health services, developing
a women’s psychiatric Intensive Care Unit (“PICU”), investing in a community perinatal
service, investing mental health services delivered in A&E and increasing access to
psychological therapies.
The Trust’s sites vary widely in terms of their distribution, age, condition and suitability and
these “extensive differences” were noted in the 2016 Care Quality Commission (“CQC”)
inspection and whilst the 2018 inspection noted mitigations in place to address the concerns
raised previously the overall rating for Safety remained as “Required Improvement”. Part of
this is due to the inherent challenges of the estate such as visibility within the buildings.
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There is a potential time constraint on the ability to deliver the SPH transformation insofar as
August 2015 the Trust were successful in their application for a Certificate of Immunity from
Listing (“COIL”) that prevents the SPH site from becoming a listed building for five years.
1.2.2 Current and future care model
The Trust’s Care Model forms part of the broader NCL STP ‘stepped’ model of care for
mental health with goals around improved access to mental health services, improving the
acute mental health pathway and improving patient pathways through practice based mental
health teams and specialist care pathways. Following changes to the current care model, the
workforce requirement will change in line with the NCL STP under this proposal to achieve
portability, staff experience and career planning/development. Several initiatives have been
developed that are specific to mental health, in conjunction with other NCL STP
programmes, which include recruitment initiatives, rental initiatives development, and use of
new roles and up-skilling current staff.
The commercial structure around the payments to the Trust from the CCGs is such that
there would be no negative financial impact on the CCGs as a direct result of the proposed
service changes. The Trust currently has 235 beds (84 on the SPH site) used for acute
admissions, treatment of adults and older people. Over the last couple of years, the Trust
has experienced consistent pressure on its remaining beds and an increase in numbers of
people admitted and those treated by the Crisis system. The STP mental health work stream
is to a large extent based on reducing the demand for in-patient beds and meeting people’s
needs in the community. The Trust has undertaken a range of bed management initiatives
that has reduced admissions and bed utilisation, which in turn has reduced private sector
admissions and length of stay. Consequently, the CCGs and the Trust are confident that
maintaining the current bed base at 235, will be sufficient to meet demand in 2025.
1.2.3 Expected benefit
The service user benefits depend on the service they access:
Community based care: The relocation of some services to the Camden hub offers the opportunity to access services at a welcoming community based, non-acute setting.
Improved therapeutic environment: For inpatients at SPH, moving to a new facility ensures they receive care in a high quality, specialised building with modern facilities.
Parity of esteem for mental and physical health: Relocating to a newly built site that meets modern accessibility requirements, this will increase equality of access for users, staff and visitors. There will be a focus on supporting disabled service users with accessibility to the new site as identified in the Equality Impact Assessment.
Improved integration between acute and mental health services: It is expected that users transferring between mental health inpatient and acute facilities on the same site will receive a quicker and more streamlined transition.
Better working initiatives for staff: By developing new facilities and implementing the workforce plan as per the STP, the local health organisations are more likely to attract a higher quality staff by providing a high level of staff support.
Improved research opportunities: Leading to long term improvements in mental health care and outcomes.
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1.3 Governance
As the main commissioners’ of services, the changes to the clinical model and the
redevelopment of St Pancras Hospital, represent a substantial service change to Camden and
Islington CCGs.
Clinical Commissioning Groups (CCGs) are under a statutory duty to have regard to the NHS England guidance (“Planning, assuring and delivering service change for patients” – April 2018), which sets out how new proposals for change are tested through independent review and assurance by NHS England, taking into account the framework of Procurement, Patient Choice and Competition Regulations. The guidance sets out some of the key considerations for commissioners and their partners in designing service change including reconfiguration. The main tests that the proposals need to address are:
the government and NHS England’s key tests that should underpin service change proposals;
the strength of pre consultation business cases, clinical evidence and public involvement;
proposals having regard to relevant national guidance and complying with legislation;
the programme management that underpins the planning and delivery of schemes; and
deliverability on the ground and affordability in capital and revenue terms.
Programme Management
The consultation phase of the redevelopment of the St Pancras site is being overseen by the St
Pancras Hospital Redevelopment Oversight Group and led by the Chief Operating Officer of
Islington CCG. This group reports to both of the CCGs and provides assurance to NHS
England. The Oversight group is supported by three sub-groups; the Clinical Senate Liaison
Group, the Public Consultation Working Group and the Financial Modelling Group. This group
has overseen the development of the pre-consultation business case and the consultation
documents.
Pre-consultation business case, clinical evidence and public involvement
The CCGs and the Trust have taken the following steps to ensure that the documents produced
are fit for purpose and enable the CCGs to meet their statutory responsibilities.
1. NHS England (London Region) Head of Reconfiguration, providing direct advice to the St
Pancras Hospital Redevelopment Oversight group;
2. Islington CCG has taken legal advice on the adequacy of the Pre-consultation business
case and consultation documents;
3. Islington CCG has commissioned the Consultation Institute to assure the consultation
documents and methodology;
4. Camden Council and Islington Council’s respective Health and Care Overview and
Scrutiny Committees (“HOSC”) have been asked to review and comment on the
consultation methodology and documents prior to the commencement of consultation.
This is not part of their usual role, but both HOSCs have agreed to meet together to
review and comment on the documents to help us be confident that the documents and
process are the best that they can be;
5. The NHS England London Clinical Senate has been asked to provide advice on whether
the proposals for changes to inpatient and community mental health services:
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a) will enable improvements in clinical care and quality benefits for patients; b) are informed by best practice; c) align with national policy and are supported by STP plans and
commissioning intentions; d) Whether the proposals for developing community services will enable
delivery of more care in the least restrictive setting; e) Whether the approach of meeting the need for future inpatient demand by
further development of community mental health services is robust.
6. NHSI will need to provide assurance that the proposals for change will not unduly compromise the Trust’s financial position before going to consultation.
As a part of the proposed relocation, the Trust is not proposing to change the use, storage or accessibility of any Patient Identifiable Data it holds.
1.4 Stakeholder engagement
Under section 242 of the NHS Act 2006 and section 142Z of the Health and Social Care Act
2012, NHS Trusts and CCGs have a legal duty to make arrangements for individuals to
whom the services are being or may be provided, to be involved throughout the process. All
public consultations should adhere to the Gunning Principles.
1.4.1 Pre-consultation engagement on the case for change
The local health organisations have engaged with inpatient service users, community service
users, carers, staff and other stakeholders as part of pre-consultation engagement work for
the development of the plans. Pre-consultation engagement included service users and
carers, employees, GPs, the Camden and Islington HOSCs and other local stakeholders.
1.4.2 Options appraisal engagement
As part of the options development a series of meetings were held to get input and
understand the needs of stakeholders and patients. The following options appraisal
engagement was incorporated into the options appraisal process up to the point of selecting
the preferred option. Shortlisted options for inpatients included:
A1 – Do minimum - The Trust would carry out the minimum works necessary to improve the quality of their existing estate to enable the Trust to deliver a higher quality of care.
A2 – Re-provide inpatients at SPH - A new mental health inpatient facility would be built on the existing SPH site.
A3 – Re-provide inpatients at Whittington Hospital - The Whittington Hospital is located in Islington but on the border road between Camden and Islington to the North of both Borough’s. It is an acute hospital with land available for the Trust to build a new inpatient facility.
A4 – Re-provide inpatients at St Ann’s Hospital - St Ann’s Hospital was identified during the Strategic Outline Case (“SOC”) stage as having the potential to host a new inpatient facility for the Trust.
Each option had the same proposal for community services and other services which is why they are not explicitly mentioned under each option above. A summary of the areas considered following this engagement included:
The need for adequate consultation with service users, which would include the formal consultation process itself;
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Preference for inpatient beds to remain within or close to Camden;
Preference for inpatient beds not to shift to the St Ann’s site due to travel and accessibility issues;
Noting the proposed land disposal of the SPH site; and
Preference for the provision of appropriate services from the community hubs.
Following this the preferred option was agreed to be to move inpatient beds from SPH to a site in Camden and Islington, invest in community services through the two community hubs and bring researchers and academics together on a single site at SPH. The Whittington site was selected as the preferred option for inpatients and there has since been further engagement undertaken in the form of regular meetings with service users, carers, Trust staff and Joint Health Overview and Scrutiny Committee (JHOSC) updates.
1.4.3 Consultation Plan
In light of the service changes under this proposal, Camden and Islington CCGs are
proposing to run a public consultation for 12 weeks starting in July 2018 to September 2018.
As part of the formal consultation process, the group of stakeholders who will be engaged
will be widened. Accordingly, the range of methodologies will also be expanded to cover
targeted and ongoing engagement, across a range of channels. The concerns raised
through the pre-consultation engagements will be incorporated in the consultation as follows:
Consulting with current and ex-service users;
Keeping the provision of services within Islington or Camden;
Undertaking further travel time analysis;
Be clear about strategy of sale of NHS Resources; and
Opportunity to input on which services are provided in the Community Hubs.
The channels used to share the consultation and gather as many views as possible will
include website/online media, paper copies, public meetings, focus groups, staff
engagement, NHS provider roadshows, targeted interventions and local networks.
The CCGs have appointed an independent partner to evaluate the consultation responses
and analyse the results of the consultation. This will inform proposals in a Decision-Making
Business Case (“DMBC”) based on the consultation outcomes and will be the basis for the
CCGs final decision.
Following the closure of the consultation on 30th September 2018, the evaluation team will
have a period to analyse the results and present these to both of the CCG Governing Bodies
(“CCG GBs”). Camden and Islington CCGs will then make a decision on the redevelopment
proposals.
1.5 Finance case
As previously detailed, the amount of spending planned by both CCGs with the Trust will not
negatively change as a direct result of these proposals due to the contract arrangements in
place. The Trust receives a negotiated fixed amount per period from the CCGs to provide
services to the local population and this is not directly linked to the volume of service users,
unlike Payment by Results approaches used for many physical care services. Camden and
Islington CCGs have corroborated the financial information presented below with the Trust
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and have reached an agreed position, whereby the Trust takes the financial risk associated
with these proposals.
The capital receipt from the redevelopment of the SPH site is expected to be greater than the total capital cost of the transformation, due to the high value of estate at St Pancras. In the Trust’s Outline Business Case (“OBC”), a red book valuation has been undertaken as per NHSI and HM Treasury guidance which presents a prudent value. Therefore, the risk of not achieving a level of capital receipt to cover the costs of the redevelopment is low.
As above, there is no request for funding associated with this programme of work. There will,
however, be a requirement for interim financing arrangements for the Trust to manage the
timing of cash flows.
1.6 Implementation
Following the close of the consultation and decision-making process on the findings the
Trust will implement the proposal, factoring in considerations stipulated by the CCGs from
the consultation process.
The Trust has developed a robust programme management and governance structure which
ensures accountability through clear allocation of responsibilities, and provides assurance
through regular reporting, enabling quick identification and addressing any issues as they
arise. The Trust implementation team will comprise approximately 4-6 people on a whole
time equivalent (“WTE”) basis to be engaged at various points during the implementation.
The function requirements during the implementation include: Programme Director; Project
Director; Project Managers: Finance Support; HR and Workforce Support; Clinical Support;
and Administration.
An outline project plan is being worked up, that will set out the key milestones and which will
be updated on a regular basis as more information becomes available and the project
develops. There is also an existing risk management process in place for the Programme,
and this process will continue throughout the implementation and delivery phase of the
programme to ensure that risks are identified, monitored and where possible, mitigated.
NHSI also require Trusts to submit a Strategic Outline Case (SOC), Outline Business Case
(OBC) and Final Business Case (“FBC”) for approval for capital investment proposals of this
value.
1.7 The Secretary of State’s four tests and NHS England’s bed test
The 2014/15 mandate from the Secretary of State to NHS England, outlines that proposed
service changes should be able to demonstrate evidence to meet four tests before they can
proceed:
1) Strong public and patient engagement: There has been extensive stakeholder engagement to date as described in Section 7 of this document including presentations, discussions, surveys, meetings and emails. This will continue during the Consultation.
2) Patient choice: There will no change in the number of providers serving the local area,
whilst choice will be improved through the offer of fit for purpose mental health facilities for local service users.
3) Clinical evidence base: There is a clear case for change insofar as the existing estate
is ageing and inflexible with multiple ligature points and blind spots where staff cannot easily observe service users. A wide range of clinicians have been engaged and
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consulted throughout to ensure patient outcomes are central to plans with feedback showing a strong level of support. There is a clear clinical evidence base for the model of community services. For example, the community model for the practice based mental health teams in Islington has shown a 6% reduction in referrals to secondary care teams across Islington so far with further reductions expected. Service user experience and satisfaction has increased with 83% of people who completed a survey were likely to recommend the service to family or friends and 75% of people satisfied with the service that they had received. Similarly, the community model for the Integrated Practice Unit for Psychosis has made significant inroads into addressing physical health issues and won an award for Innovation in Mental Health.
As described in section 1.3, the Clinical Senate will also provide advice and feedback
prior to formal consultation commencing.
4) Support from clinical commissioners: Both CCGs support and have helped to
develop the proposals in this document. CCG Governing Body leads have been involved
in the process throughout alongside member GPs.
It is also noted that NHS England have also introduced an additional test but as it only
relates to circumstances where there are proposals to reduce bed numbers it is not
applicable here. For details of the analysis and modelling for bed numbers, please see
section 5.1.9
1.8 Decision making and next steps
Following consultation, the St Pancras Hospital Redevelopment Oversight Group will review
consultation responses received from members of the public and organisations. The St
Pancras Hospital Redevelopment Oversight Group is led by the Chief Operating Officer of
Islington CCG and the membership of the group includes commissioners from both CCGs,
communications specialist, the Director of Integrated Commissioning, London Borough of
Camden, as well as the Project Director from C&IFT. The St Pancras Hospital
Redevelopment Oversight Group will then consider the views of the participants and the
effect these may have on the decision-making process.
However, to give an indicative timeline, the programme expects the following milestones for
this process. These may be subject to change, as described above:
Formal public consultation – 5th July 2018 to 10th October 2018 (14 weeks).
External analysis of consultation responses – October 2018.
Final Decision-Making business case preparation – November 2018
Each CCG GB to consider the final Decision-Making business case document – November 2018
Each CCG GB make a decision on the final Decision-Making business case – November 2018
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2 Introduction
This section provides an overview of the purpose and development of the Pre-Consultation
Business Case (”PCBC”), as well as a description of the contents of the PCBC.
2.1 Overview
The local health organisations are united in the commitment to transforming care to deliver
the best possible health outcomes for the population of Camden and Islington. The local
communities have voiced a need for a more joined up and integrated health and care
systems. This will be done by shifting the model of care so that more people are cared for in
‘out of hospital’ settings, and through prevention, more proactive care, and new models of
care delivery, reliance on secondary care can be reduced and improve the way people
access and receive care.
This PCBC sets out the proposal to develop a fit for purpose and cost-effective service
transformation that delivers a high quality and accessible estate for patients with mental
health needs across the London Boroughs of Camden and Islington. The new estate,
combined with the service transformation, will enable Camden and Islington NHS
Foundation Trust (“the Trust”) to deliver high quality integrated health and social care
services, whilst supporting the Trust’s research objectives.
As set out in the Trust’s Estates Strategy, it is necessary to release value from the St
Pancras Hospital (“SPH”) site to enable the delivery of the broader transformation of mental
health facilities in the area.
This PCBC sets out a way forward for full public consultation on a preferred option which is
demonstrably the best solution in terms of benefits and value for money.
2.2 PCBC objectives
The objectives of this PCBC are to:
Make the case for change for transformation and modernisation of the current services delivered at the SPH site and the community sites of Greenland Road and Lowther Road and detail the proposal for redevelopment that enable these changes to happen;
Describe the clinically developed model of care and specification for the re-provision of:
Inpatient services from SPH to a new site at the Whittington Hospital;
The re-provision and alignment of some community services into newly developed community settings; and
Detail the services that are remaining on SPH, albeit in new facilities.
Detail the process undertaken with stakeholders to inform, develop and evaluate viable options for the redevelopment of the SPH site and re-provision of services elsewhere;
Detail the process undertaken to engage the public, staff and other stakeholders in the pre-consultation phase and demonstrate how their feedback has shaped the development and selection of the preferred option;
Set out how the development of the preferred options is compliant with the Secretary of State for Health and Social Care’s (“SoS” or “Secretary of State”) four tests of service reconfiguration and NHS England’s bed test;
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Make the case to Camden NHS Clinical Commissioning Group (“CCG”) (“Camden CCG”) and Islington NHS CCG (“Islington CCG”), to commence public consultation on the preferred option.
2.3 Background
The existing mental healthcare estate at SPH is not fit for purpose – it is in part converted
from Victorian workhouses and was simply not designed to meet modern health and safety
requirements or provide an optimal environment for delivering healthcare. The latest Care
Quality Commission (“CQC”) inspection published in March 2018 noted that the Trust had
sufficient mitigations in place to address the concerns raised previously. However, the
overall rating for Safety remained as “Required Improvement”. The previous The CQC report
(June 2016) highlighted that the Trust’s acute wards (for adults of working age) and
psychiatric intensive care units require significant improvement. This judgement was based
in part on the breach of guidance on single sex accommodation, the physical ward layout
which prevented staff observation of all areas and the presence of a number of ligature risks
that were insufficiently managed; with the risk either not consistently recognised or mitigated
or the unavailability of ligature cutters.
As well as failing to meet modern standards, the location itself is no longer fit for purpose as
it does not provide therapeutic value for people who may be resident for many weeks or
months. For example, the estate lacks space for physical activity, monitoring of service user
wellbeing is impeded by the layouts, and there are significant commercial developments in
the area surrounding St Pancras that infringe on the privacy and therapeutic environment of
service users.
Significant investment would be required to maintain and upgrade the current premises to
meet modern standards, and it would require significant disruption to services during a
transition period with several stages of decanting services from one site to another. Even
then, in some cases, the Trust would still be unable to satisfy the standards prescribed by
Department of Health best practice guidance (Health Building Notes).
The Trust has, however, identified an opportunity to transform the estate to provide a fit for
purpose, cost-effective, integrated, accessible estate to enable the delivery of high quality
health and social care services. This is set out in subsequent sections of this document.
2.4 PCBC scope
Islington CCG, Camden CCG and the Trust have carefully considered what needs to be
consulted on. It has been decided that the following services will be publicly consulted on:
Inpatient services being provided from SPH that are moving to another site that is 2.5 miles away from the current location;
Services being provided from SPH that are moving into the community hubs; and
A limited range of other mental health services that are currently delivered from a variety of sites which will move as part of proposals.
A complete list of the Trust’s services that are moving can be found in Appendix [1].
Services that are not moving will not form part of this consultation, but for completeness this document does set out the NHS services that will be staying on the SPH site.
The following NHS organisations who are currently providing services on SPH will continue
to do so in new buildings on the existing site:
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Royal Free NHS Foundation Trust; and
King’s Cross Surgery
London Central and West Unscheduled Care Collaborative.
Central North West London NHS Foundation Trust and University College London Hospital, who are currently providing services out of the South Wing building at SPH, will continue to do so from existing facilities:
All of these organisations have been consulted with as part of the production of PCBC and
will have the opportunity to feed into the consultation.
Trust services that are not provided on SPH site and are not moving, as well as back office support services will not form part of the consultation.
A complete list of other provider services that are staying at SPH can be found in Appendix [2].
2.5 Parties involved in the production of this PCBC
The PCBC has been produced following engagement throughout the process with the
following parties:
The local CCGs, specifically Camden CCG and Islington CCG;
The local Health Trusts, specifically Camden & Islington NHS Foundation Trust (“the Trust”);
London Health and Care Devolution;
Other primary care providers; including those on site (King’s Cross Surgery and London Central and West Unscheduled Care Collaborative); and
Local Authorities, specifically Islington London Borough Council and Camden London Borough Council including through the North Central London Joint Health Oversight and Scrutiny Committee (“JHOSC”), as set out in Section [7].
NHS England (“NHSE”);
2.6 Proposal Development
The Trust proposal set out in this document is to invest in new facilities for community
services provided on the SPH site, plus one site in Islington and one in Camden, whilst re-
providing the adult acute and rehabilitation inpatient facilities at SPH to a site adjacent to
Highgate Mental Health Centre (HMHC). These new facilities in Camden and Islington are
described as community hubs. The new facilities provided at the SPH site will also
accommodate a new Institute for Mental Health (“IoMH”) on behalf of Universities College
London (“UCL”).
Development of the proposed changes has been ongoing since early 2016 by the local
health organisations. This includes work on the pre-consultation activities, stakeholder
engagement and options development. Further detail of the options development is set out
in Section [8].
The SPH redevelopment programme and development of mental health Community Hubs
enables an overarching transformation of the estate to enable effective delivery of the Trust’s
Clinical Strategy along with national and local health strategies through the development of a
range of health services and research facilities. It puts service users at the centre,
recognising there is a once in a lifetime opportunity to transform services across the London
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Boroughs of Camden and Islington, building more visible, more accessible and more
integrated services for people locally alongside world class research driving the very best
practice. The opportunity is time limited because of the Certificate of Immunity from Listing
(“COIL”) that is set out in more detail in Section [4.1.3].
The SPH redevelopment programme is an opportunity to reshape the services themselves
delivering high class local, integrated care, meet leading 21st century standards in facilities
and develop a world class research institute.
As part of this transformation, the Trust will:
Build the community hubs, as part of the wider SPH transformation programme, where people can access local integrated health and social care;
Deliver innovative wellbeing and recovery services, with improved visibility with the local population, colleges, universities, and employers; and
Create an attractive setting that combines physical and mental health provision alongside a vibrant new development of residential, restaurant and leisure uses.
The SPH and Community Hubs programme will deliver:
1) Community hubs that support integrated care
The vision for the community hubs is that service users and carers’ will have a familiar, non-
stigmatising, easily accessible place where they can access a variety of services that
promote holistic care. There is a programme of transformation for mental health services
based around these fundamental elements:
Supporting people with mental ill health to live well, enabling them to receive care in the least restrictive setting for their needs;
Raise mental health awareness to reduce stigma, ensuring that mental health is considered equally with physical health;
Reduce reliance on inpatient care and expand community provision to support more people to spend more time at home, rather than in hospital;
Ensuring more accessible and extensive mental health support is delivered locally within primary care and other community services;
Community services are being developed to make sure that health and care will be available
closer to home for all, ensuring that people receive care in the best possible setting at a local
level and with local accountability. At the heart of the care closer to home model is a ‘place-
based’ population health system of care delivery which draws together social, community,
primary and specialist services underpinned by a systematic focus on prevention and
supported self-care, with the aim of reducing unplanned hospital admissions.
The plan is to develop community hubs as follows:
A 4 storey community hub at the Trust’s existing site in Greenland Road, in the London Borough of Camden; and
A 4 storey community hub at the Trust’s existing site at Lowther Road in the London Borough of Islington, replacing the existing building.
What this means for residents is that some services will move from their current locations and the final details for some of these services are yet to be fully determined. However, the local health organisations are confident that by co-locating clinical teams, giving access to joined-up care will have significant benefits for residents.
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The community initiative development is already underway in line with our STP plans
and will not wait for the opening of the new community buildings. The proposed
sequencing is as follows:
The Community Hubs will come into operation by June 2022
The In-patient block will come into operation December 2022
This will be followed by the development of the new health buildings on the St
Pancras site to open 2023
2) The SPH Site
The St Pancras Hospital site will be redeveloped to provide a total of 2,187m2 of
accommodation for the Trust including, out of a total current Trust occupied area of
12,117m2:
New community facilities that will include consulting rooms, meeting rooms, training facilities and the Recovery College. The Recovery College includes space for both clinical delivery and support facilities for the clinical teams;
In addition, a new Institute of Mental Health (“IoMH”) in partnership with University College London will provide an opportunity to improve mental health outcomes over the long term; and
New facilities for the other NHS services. 3) High quality inpatient facilities
A new build inpatient facility – located at Whittington Hospital (“the Whittington”). The inpatient facility will be a three storey new build surrounded by landscaped gardens with car parking available at our neighbouring Highgate Mental Health Centre (“HMHC”);
The new facility will have 84 single bed rooms, supported by 606 m2
of support space, an external courtyard or garden space and consulting rooms for each ward;
The new facility will be fully accessible, and present an attractive, therapeutic and welcoming environment for staff and service users; and
The facility will be designed to be future proof allowing reconfiguration in use as requirements change over the next decades.
2.7 PCBC structure
This PCBC was developed in line with the NHSE guidance “Planning, assuring and
delivering service change for patients” published on 1 November 2015 and the update in
March 2018, and HM Treasury Green Book guidance in relation to the capital investment
decisions involved to support that service change. It includes the following sections:
Executive summary: Summarises the key findings from the PCBC.
Introduction (this section): Provides an overview of the project’s objectives, background, scope, parties involved in the production and the proposal.
Context: This section sets the background of the parties involved, the current healthcare challenges faced by the commissioners and providers, and the commissioning arrangements between the CCGs and Trust.
Case for change: This section details the rationale and key drivers for changing the way services are delivered including from a national and local strategic context.
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Care model: This section sets out the model of care and details how the model of care is changing and the proposal facilitates delivery of this. It highlights the expected benefits and also how the model meets the needs identified in the Case for Change section.
Governance: This section documents the governance structure that has been put in place to ensure the consultation process is robust, accommodates relevant stakeholder views and who is responsible for making decisions and who is responsible for approvals.
Stakeholder engagement: This section sets out the engagement undertaken to date, how this has informed the consultation proposed and how the consultation will be run.
Options for consultation: This section documents the process for options generation and evaluation.
Finance case: This section sets out the financial impact of the selected option on the CCGs, Trust and any other relevant parties.
Implementation: This section sets out the practice steps needed to deliver the option identified in the Options for consultation, including project team, governance, risk management and timelines.
The SoS’s Four Tests: This section sets out how the consultation process has met the Secretary of State’s four tests and NHS England’s bed test.
Decision making and next steps: This section identifies next steps for the consultation process and wider development programme.
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3 Context
3.1 The Population and Healthcare challenges
The healthcare challenges set out below are in line with those presented in each of the
borough’s Joint Strategic Needs Assessments (JSNAs) and latest published Annual Report
and Accounts.
3.1.1 Health and well-being challenges in the borough of Islington
Islington borough is London’s fifth most deprived borough and the fourteenth most deprived in England, which contributes to poor health and wellbeing outcomes.
The borough is one of London’s most mobile populations with approximately 20% of residents entering and leaving the borough each year. This results with challenges in identifying health issues and monitoring improvement in health outcomes.
At least 44,000 people registered with a GP Practice in Islington have at least one long term condition such as diabetes. It is also assumed that many longer term conditions may be undiagnosed.
Islington has the highest prevalence of psychotic disorders in England, nearly double the national average. In addition, 10% of registered service users has a diagnosis of depression which is amongst the highest in London.
It is estimated that about 31,000 people in Islington suffer with depression or anxiety. The suicide rate has been reducing since 2001 and in 2011-2013 it was below the national average and slightly above the London average. The relatively younger population explains a lower prevalence of dementia.
Islington is the 14th most deprived Local Authority in England. The borough has a few small pockets of higher financial capability, with the rest of the population having low financial capability.
3.1.2 Health and well-being challenges in the borough of Camden
Camden is ranked the 15th most deprived borough in London (out of 33). Within Camden there are areas that are within the 10% most deprived areas in England. Poverty is a key determinant of poor outcomes in health and wellbeing and higher levels of deprivation are linked to numerous health problems such as chronic illness.
Camden has the third highest diagnosed prevalence of serious mental illness in the country and the 8th highest diagnosed prevalence of depression in London. One in seven GP registered adults in Camden have been diagnosed with one or more mental health conditions.
Camden experience a higher rate of alcohol specific hospital admissions than England and London. Three quarters of the adult population in Camden drink alcohol and of those who drink an estimated 34% drink at levels that cause risk of harm to physical and mental health.
Life expectancy in the borough of Camden is higher than the average life expectancy in London and England. While the life expectancy is higher, on average the last 20 years of their life is spent in poor health. There is also a stark difference in the life expectancy between the most and least deprived boroughs.
The JSNA’s published in October 2016 estimate that the population is due to rise by 9% over 10 years. Although older people make up a relatively small proportion of Camden’s
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population (approximately 11.5% are aged 65 and over), the highest percentage growth (41%) in the 10 years commencing 2016 will be seen in those aged 75 years and older, resulting with exacerbation of health challenges1.
3.2 Background to the Trust and CCGs
The services provided by the Trust are primarily commissioned by Islington CCG in their role
as lead commissioner for mental health services, with Camden CCG as a significant
Associate commissioner to the Islington CCG contract. This accounts for 98% of services
commissioned. As such, the Governing Bodies for both organisations will make the decision
about this proposal;
3.2.1 Islington NHS CCG
Islington CCG is the lead commissioner for mental health services provided by the Trust,
accounting for 98% of services commissioned.
Islington CCG has 33 member GP practices, serving a population of nearly 250,000. The
CCG spent a total of £329.6 million in 2016/17 and achieved an in year surplus of £9.7
million2.
The majority of the CCG’s services are provided by local NHS organisations such as
Whittington Health, Moorfields NHS Foundation Trust, Camden and Islington NHS
Foundation Trust, University College London Hospital NHS Foundation Trust and Royal Free
London NHS Foundation Trust. Services are also commissioned from not-for-profit
organisations based in the local community and other providers.
As part of taking forward the Haringey and Islington Wellbeing Partnership, the executive
management team of the CCG operates jointly with neighbouring Haringey CCG. The two
CCGs are led by a single Chief Operating Officer. Islington CCG received a “Good” rating at
the 2016/17 annual assessment.
3.2.2 Camden NHS CCG
Camden CCG is a significant Associate to the Islington CCG contract.
Camden CCG has 35 member GP practices and serves a slightly smaller population than
Islington of 280,000 residents. The CCG spent £371.7 million in 2016/17 and achieved an in-
year surplus of £476k3.
Similarly, for Camden CCG, the majority of services commissioned are provided by local
NHS organisations, including Camden and Islington NHS Foundation Trust, University
College London Hospital NHS Foundation Trust and Royal Free London NHS Foundation
Trust, Whittington Health and Moorfields NHS Foundation Trust. Camden CCG also
commissions services from not-for-profit organisations based in the local community and
other providers.
1 Camden JSNA 2015/16 (October 2016)
2 Islington CCG Annual Report and Accounts 2016/17
3 Camden CCG Annual Report and Accounts 2016/17
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3.2.3 Background to the Trust
The Trust provides mental health services for people with psychoses, complex psychological
conditions such as personality disorders, substance misuse, acute and crisis care, common
mental health disorders and dementia care. In addition, the Trust has a number of specialist
programmes such as mental health care for veterans living in London which is
commissioned by NHSE, this will not form part of this consultation as these services are not
moving, as set out in Section [2.4]. The Trust is the main provider of mental health services
for people living in Camden and Islington and also provides statutory social work and social
care services on behalf of the London Boroughs of Islington and Camden.
Services are provided for adults of working age, adults with learning difficulties and older
people in the London area, either in a community or inpatient setting. The Trust has
approximately 1,700 staff and provides services to approximately 30,000 people per year.
This includes a significant minority of people who are not local residents, but are temporarily
based here, such as students, asylum seekers and visitors to the capital.
Services at the Trust are managed in the following five operational divisions:
Acute and Crisis Care (Urgent care);
Recovery and Rehabilitation (Psychosis);
Services for Ageing and Mental Health (Older people and Dementia);
Substance Misuse Services (Alcohol and drugs);
Community Mental Health (Complex psychological and common mental health conditions).
The Trust does not provide child and adolescent mental health services (which is provided
by the Tavistock and Portman in Camden and Whittington Health in Islington) and has
relatively few specialist services.
The Trust is a member of University College London Partners (“UCLP”), one of the world’s
leading academic health science partnerships, and has a strong reputation for supporting
world-class quality research in to mental health.
The Trust has around 30 sites across Camden and Islington, as follows:
Inpatient beds are accommodated at two significant hospital sites in Camden (SPH and HMHC) providing 235 beds;
Community beds (residential) are provided across several sites, accommodating 78 beds;
Community clinical services are delivered from a number of buildings, spread across Camden and Islington.
The Trust’s Head Office is located at SPH, located within Camden. This occupies the former
St Pancras Workhouse and Infirmary and comprises 17 separate buildings and structures.
The site is located north of Kings Cross and St Pancras Station and west of the mainline
railway tracks. The Grand Union Canal is located just to the north and east of the site. St
Pancras Gardens forms the southern boundary to the site. In addition, the South Wing of the
hospital is located just to the south fronting onto St Pancras Way.
Adjacent developments around Kings Cross and St Pancras have transformed the area and
attracted significant inward investment. A number of large-scale housing developments, a
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feature of the regeneration of the area, overlook the site which is not seen as conductive to
mental health recovery.
The proposal is in line with the Trust’s 2016-2021 clinical strategy, which highlights some
particular demands on the estates of the Trust.
The focus of the Trust’s Clinical Strategy is to promote recovery, resilience and
independence via easy to access community-based services and specialist care-pathways.
This is based on:
Expanding capacity by integrating more staff into primary care and community settings;
Integrating physical and mental health;
Reducing the physical and psychological barriers to entry (through more local provision, better access for those with disabilities and more generally through greater awareness in the community);
Improving lives and wellbeing through wider integration of social and mental health support.
The Clinical Strategy is consistent with national policy and the North Central London (“NCL”)
Sustainability and Transformation Plan (“STP”), which aims to increase early intervention
and support through primary care, join up social care and health services and ensure mental
health has parity with physical health. This is outlined in further detail in the regional policy
case for change in Section [4] below.
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4 Case for Change
There are five categories of drivers for change to the current service delivery:
The local policy framework drivers for change – delivering on the objectives set out in the Trust’s clinical and estates strategies by providing more care in the community, developing research capabilities and leading on equality and diversity;
The national policy framework drivers for change – focusing on prevention, achieving parity for mental health and physical health care provision and integration of physical and mental care;
The regional policy drivers for changes – implementing the NCL STP plan;
The poor quality of existing estate at SPH; and
The limitations on the current service provision at SPH;
4.1 Local Policy Framework
4.1.1 The Trust’s Clinical Strategy
This proposal is in line with the Trust’s 2016-2021 clinical strategy, which highlights some
particular demands on the estates of the Trust.
The Trust’s Clinical Strategy represents a vision for the transformation of mental health and
substance misuse services. It is aimed at addressing the challenges for mental health
services of:
Increasing demand;
Historic underfunding in comparison with physical health services;
Difficulties with accessing timely interventions due to stigma; and
Poor awareness and services often not being joined up or accessible particularly for vulnerable communities.
The strategic priorities of the Trust are:
Early and effective intervention;
Helping people to live well; and
Research and innovation.
It focuses on increasing services based in primary care and the community, improving
access to services and integrating physical and mental health. The Clinical Strategy
recognises that health and wellbeing are shaped by individual characteristics, lifestyle
choices and environmental influences. So instead of attempting to ‘fix’ people and their
problems, or do things to them rather than with them, recovery-orientated services look at
individual needs and help people reach their potential. The Trust aims to provide services
that are accessible, person-centred and responsive to the often complex needs of
individuals. It is also recognised that the main determinants of health are socio-economic. In
order to promote good health, prevent ill health and reduce inequalities in health, the Clinical
Strategy promotes ongoing joint working with our partner organisations to act on the social
determinants that are likely to impair people’s health.
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A key component of the Clinical Strategy is the development of Practice Based Mental
Health. Practice-based teams work locally with GPs and other services in primary care.
Offering rapid assessments near to where people live, by senior clinicians who can make
decisions about treatments, access services in the community or, if needed, refer to our
specialist care-pathways. They will link people into the local community resources and
services as they are better placed to see people who won’t engage with secondary care
mental health services. They will support GPs in managing people with chronic mental
illnesses who are stable. Along with acute services, the practice-based teams are the entry
point into our specialist care-pathways.
Development of specialist care-pathways that deliver treatment and support to people with
similar needs due to mental illness is another priority. The focus of these services is to help
people achieve their recovery goals and link into their local social networks and community
resources. Access to these pathways is based on risk, intensity and the need for specialist
treatment.
The Trust has won awards for the development of an Integrated Practice Unit for people with
psychosis, which brings together partner organisations to improve the physical health of
those with psychosis. This is done with an aim to close the health inequality and lost years of
life for people with this condition experience. Bringing together all the providers who deliver
care to people with psychosis and coordinate their treatment and support will deliver a better
quality service and better outcomes, especially physical health outcomes.
Through community teams and work with partners, the Clinical Strategy sets out the vision to
offer high quality and comprehensive care and treatment. This is to ensure that service users
have access to high quality supported housing and are helped where necessary into
education and employment and to develop social networks. Community services and
support help people to continue their recovery and maintain their independence locally and
help reduce the length of time people need to spend in hospital, when they are very unwell,
to a minimum. The Trust is committed to offering world class, safe inpatient services in
therapeutic environments.
The focus of the Trust’s Clinical Strategy is to promote recovery, resilience and
independence via easy to access community-based services and specialist care-pathways.
It is clear that in order to meet this clinical vision, the Trust needs an estate that enables
Practice Based Mental Health to work locally and effectively with GPs and other services in
primary care. It also needs an estate that allows the early successes of Integrated Practice
Units to expand and bring physical health and mental health services together to meet health
in-equalities. The development of Community Hubs, rather than multiple sites for small
teams, allows a bringing together of services and providers to enable the coordination of
treatment to deliver care closer to people’s homes, a better quality service and better
outcomes. Finally, the Trust needs an estate that can provide a safe and therapeutic
environment to those requiring inpatient care.
The Clinical Strategy was approved and adopted by the Trust Board in November 2015. The
Clinical Strategy Programme Board was set up to oversee and monitor the delivery of the
Clinical Strategy.
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The Clinical Strategy is in line with the NCL STP, which aims to increase early intervention
and support through primary care, joined up social care and health services and ensure
mental health has parity with physical health.
4.1.2 The Trust’s Estate Strategy
The overarching aims of the Estate Strategy are to:
Provide modern, therapeutic mental health facilities across Camden and Islington;
Move more of our services into the community;
Build high quality, up-to-date, warm and welcoming inpatient facilities; and
Create world-class research facilities to help us deliver the very best care.
The Estates Strategy sets out the Trust’s vision for an overarching transformation of the
estate to enable effective delivery of national and local health strategies. It covers the period
2017 to 2022 and it is based on the Trust’s assessment of the present estate to establish the
scale of investment required to achieve the desired transformation. It has been developed in
consultation with Trust Clinicians and the Estates Team and was approved by the Board in
April 2017.
In summary, the Estates strategy:
Highlights the significant shortcomings of the present Trust estate and the need for wholesale estate change to meet service transformation;
Sets out an estate transformation strategy for the next five years that enables the intentions of the Trust’s Clinical Strategy to be delivered;
Illustrates the opportunity that exists through a comprehensive approach to the St Pancras site and wider estate to enable the creation of community hubs (buildings that bring together a range of services for mental and physical health and social care) in local settings across both boroughs, supporting the local CCGs’ and Local Authorities’ strategies for locally based services in defined geographical patches;
Creating centralised high quality clinical, education and research, facilities, integrated primary care and the development of key worker and social housing for staff and local communities;
Improving access for all to services both through the location of services and by addressing EA10 compliance – both of which are currently difficult to achieve within the existing estate; and
Improving the efficiency and environmental impact of buildings alongside critically ensuring we create environments that are therapeutic – supporting people’s wellbeing and recovery.
The Trust’s vision is:
“Our vision is to provide a fit for purpose, therapeutic, cost-effective, integrated and accessible estate which enables the delivery of high quality health and social care
services for our local population”
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4.1.3 Equality and Diversity Policy
The Trust’s Equality and Diversity Policy sets out how the Trust will demonstrate that it is
planning and delivering services in a fair and equitable manner to all sections of the
community, free from discrimination, and with dignity and respect.
Tackling health inequalities and social exclusion is an important priority for the Trust and it is
committed to taking positive steps to ensure fair and equitable access to services for all. As
a major provider of services, the Trust recognises the need to be pro-active so that it can
meet the changing needs of diverse communities, and provide fair access for all in an
environment where dignity, equality, diversity and human rights are respected and promoted.
In this respect, the proposed redevelopment will provide fit for purpose, accessible facilities
and support improved access to services for all users.
To support our commitment to equality and diversity, the Trust will:
a. Set and publish equality objectives;
b. Publish information annually on how we are meeting the public sector equality duties
(PSED) and our progress in this area;
c. Ensure that equality issues are considered as part of our everyday business, through
completion of equality analysis impact assessments for all business and policy reviews
and changes;
d. Seek opportunities to promote equality and diversity for our staff and service users;
e. Ensure that our services are as accessible and inclusive as possible, for all of our
service users;
f. Ensure that our service users know how to make a complaint or raise a concern if they
feel they have been discriminated against;
g. Ensure that our premises are accessible for staff and visitors.
Commitment to ensuring equality and diversity
The Trust recognises and celebrates the fact that each of the service users it supports and
every member of staff who works at the organisation, is a unique and valued individual with
different needs and aspirations.
In the 12-month period, the Trust embarked on an exciting new journey in relation to
integrating and embedding equality, diversity and inclusion into all areas of Trust business,
to ensure equality, diversity and inclusion becomes a ‘golden thread’ through all aspects of
the Trust’s business.
The Trust is now part of the Disability Confident Scheme, has become a Mindful Employer,
has trained staff to be mediators and is in the process of training staff at all levels to be anti-
bullying and harassment advisers. The newly established Disability Staff Network and
LGBT+ Staff Network are progressing, with commitment secured for the Trust to be present
at London Pride 2018.
Network for Change – our BME staff network - continues to grow. In the last year, the Trust’s
first Diversity Week at end of October 2017, showcased the rich abundance of cultures the
Trust has, culminating in an event which saw 70 plus staff members from the Trust
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attending, with guest speakers from NHS England, the Royal College of Nursing and C&I’s
Human Resources and Organisational Development Director giving the closing speech. In
addition, the Trust now has BME staff members trained to sit on interview panels in the
Trust.
The Women’s Psychiatric Intensive Care Unit (WPICU) has been officially launched – the
only such unit to offer this service across North Central London. The Recovery College is
delivering courses “Men and Masculinity (Trans inclusive)” and “Understanding Black and
Minority Ethnic (BME) Cultures and Mental Health”. The Trust has also launched rainbow
coloured NHS lanyards for staff, to reinforce the Trust’s cultural pillars and promote an
environment of openness in all the Trust's services.
With the launch of ‘Our Staff first’ strategy, the Trust has implemented career clinics, flexible
working Policy, themed HR and organisational development road shows, initiatives to
support internal career progression and has introduced a New Starters Buddying
Programme.
Priority actions for the 2018/19 will follow an equality delivery review that will involve
stakeholders and local communities.
Equality Impact Assessment
As part of the planning for the redevelopment of St Pancras Hospital, an Equality Impact
Assessment was undertaken, to ensure that all sections of our community would benefit
positively by the changes. The EIA has been completed in two parts, with the initial phase
completed prior to consultation and a second stage to be completed following the
consultation outcomes. The majority of vulnerable or protected groups identified as part of
the EIA have been judged as achieving greater equality, improved outcomes or increased
accessibility through the proposal. For example, both inpatient and community developments
will provide improved disabled access for service users, staff and visitors. For many other
groups, the purpose built facilities offer an improvement in therapeutic environment, access
to outdoor space and care delivered closer to home.
At this stage, the EIA has identified the potential increased travel time for some disabled
service users as the only vulnerable group that may experience a reduction in accessibility.
In order to minimise this risk, route planning to the new site will be provided and shared with
local community groups for individuals with disabilities.
4.1.4 Global Leader in research
The SPH site has a strategic importance due to its proximity to Kings Cross Station, Euston
Station and St Pancras Station representing a major national and international transport hub.
There is also a Health and Life Sciences Cluster around Euston and Kings Cross that
already includes The Trust, UCL, University College London Hospital NHS FT, the Francis
Crick Institute, the Wellcome Trust and the London BioScience Innovation Centre.
The Trust already has one of the strongest records and reputations in UK mental health
research. That is why the vision for the SPH site includes the establishment of an IoMH – in
partnership with UCL who have the highest number of mental health academic citations in
the UK – so that the Trust can build on this strength and be a world leader. For every £1
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invested in mental health research, economic benefits are estimated to be 37p4 per year in
perpetuity, so this is an initiative that supports not only better care for service users but also
the Mental Health Taskforce 5YFW (2016) objectives and broader economic sustainability.
4.2 National Policy Framework
Figure [4.1] summarises a number of relevant national policies and guidelines for mental
health and also for healthcare more broadly. These policies and guidelines have guided and
informed the proposal in a number of ways;
Services should be delivered to a local population footprint, rather than an organisational footprint;
Access to mental health must be improved to meet the rising demand for services;
Mental health must have parity of esteem to physical health to improve outcomes;
The barriers between primary and secondary care must be reduced to improve outcomes and reduce costs;
Services should be delivered as close to user’s homes as possible and supporting primary care;
The NHS Estate Policy highlights the importance of ‘the estate’ as an enabler to these changes.
Figure [4.1]: Key National Policy Frameworks
5 Year
Forward View
and New
Models of
Care
Improving mental health provision is a central theme in NHS England’s
2014 Five Year Forward View (“5YFV”) alongside mental health specific
policies, such as the Mental Health Growth Strategy and the NHS
Mental Health Policy, which sets out the need for change in how the
NHS delivers services in the future. The strategy includes a focus on
prevention, allowing people more control over their care, better use of
technology and so-called triple integration: between primary and
secondary care, between mental health and physical health and
between health and social care. The 5YFV suggests that mental health
outcomes can improve by better prevention, increasing early access to
effective treatments and crisis care and integrating care to reduce
mortality. It challenges the NHS to develop new models of care to better
provide for the needs of people and the increasing demand on health
services.
North London Partners in Health and Care (NLP) has produced a five-
year Sustainability and Transformation Plan (STP) which drives the
implementation of the 5YFV. This focuses on planning by place for local
populations rather than individual organisation’s.
Incorporating the STP plans, the Trust has developed an ambitious,
innovative and robust Clinical Strategy in line with the 5YFV, evidencing
4 Health Economics Research Group, Office of Health Economics, RAND Europe. Medical Research: What’s it worth?
Estimating the economic benefits from medical research in the UK. London: UK Evaluation Forum; 2008
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the Trust’s willingness to adopt new models of care to transform
outcomes. This includes using Practice-Based Mental Health Teams to
provide mental health services from local GP Surgeries; allowing
service users to be seen directly in Primary Care and facilitating early
diagnosis and intervention. Having Multidisciplinary Teams removes
organisational and specialty barriers between primary and secondary
care and also any perceived divisions between mental and physical
health.
The Trust have developed an ambitious, innovative and robust Clinical
Strategy in line with these principles from the 5YFV, evidencing the
Trust’s willingness to adopt new models of care to transform outcomes.
This not only aligns local planning to national policy, but supports
mental health specific guidance around increasing access to services
by reducing stigma, putting mental health within reach of local
communities and allowing access through primary care. This is often
referred to as getting ‘parity’ for mental health services and is important
to this case for change, as that is precisely what the SPH
redevelopment facilitates.
5YFV for
Mental Health
In January 2016 the UK Prime Minister announced proposals to
increase spending on mental health by £1bn. This was followed by the
publication of the ‘Five Year Forward View for Mental Health’ in
February 2016 from an independent national taskforce. Relevant areas
of growth for the Trust include:
Access – New access targets to reduce waiting lists and address the pressures between demand and current capacity. This has been announced in Early Intervention in psychosis and will extend into other areas.
Integration of physical health and mental health – Services which support integration with physical health care and acute Trust efficiencies such as comprehensive liaison services, specifically in A&E, but also including areas such as support to people with dementia to reduce Average Length of Stay (ALoS).
The Trust already provides services in these areas, and has evaluated
pilot projects to expand them in new models of delivery. It is therefore
expected that the Trust will be successful in extending its services in
this area in the next few years and this has formed part of the service
reconfiguration plans.
NHS Mental
Health Policy
The government plans to continue to prioritise improvements to mental
health services, building on the policy priorities of the last coalition
government. This was further reinforced by the Prime Minister’s
statement on 9 January 2017.
The government wants public services to reflect the importance of
mental health in their planning, putting it on a par with physical health.
This is often referred to as getting ‘parity’ for mental health services and
is important to this case for change as that is precisely what the SPH
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redevelopment will allow, particularly in enabling better access to
mental health services. The key priorities that are relevant to this PCBC
are:
Enabling better access to mental health services and shorter waiting times a priority for NHS England;
Making reducing mental health problems a priority for Public Health England, the new national public health service;
Making mental health part of the new national measure of wellbeing, so it is more likely to be taken into account when government creates policy;
Providing £400m between 2011 and 2015 to give more people access to psychological therapies - including adults with depression, and children and young people; and
Providing up to £16m of funding over four years for Time to Change, the campaign against mental health stigma and discrimination.
Other policies and frameworks that would affect the strategic decision
making of the Trust are:
The current national strategy for mental health in England: No Health without Mental Health.
A new national strategy up to 2020 for mental health in England is currently being developed by the Crisis Care Concordat, which the Trust signed up to in 2014 together with many of its partners in the two boroughs (Camden and Islington).
The CQC 2015 Report – Right Here Right Now.
Recent reports such as Transforming Care (2012) and the Confidential Inquiry into the Premature Deaths of People with Learning Disabilities (2013).
The Care Act 2014.
Guidance from The Department of Health states “the environment provided by acute mental health services is a crucial element in the delivery of positive therapeutic outcomes for service users, their safety and the safety of staff and the wider community.” The environment in which care is delivered is a dynamic of the care itself and plays a crucial role in supporting the delivery of higher-quality and more cost-effective care.
In particular, for mental health facilities, a superior and sympathetically designed therapeutic environment has the power to alleviate stress and provide comfort to peoples at times of acute distress and vulnerability. By continuing to deliver services in sub-par facilities, the Trust is failing to deliver an optimal service and the projected improvements to quality as laid out in the STP are unlikely to be achieved.
By moving a number of services currently provided at the SPH site to facilities in the community, the Trust will be able to increase access and provision to the local population. The associated reduction in cost of delivering services in the community also supports this strategy, allowing the CCGs to deliver better value services.
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NHS Estates
Policy
The Trust is required to reach an agreement on an outcome that works
in the interests of all interested providers, commissioners (local CCGs
and NHSE) and regulators (NHS Improvement). As above, the Trust
has already started this process through its bilateral agreements as
described in Section [4.5].
4.3 Regional Policy Framework
4.3.1 NCL STP (January 2017) background
The Camden and Islington CCGs are part of the grouping of commissioners and providers in
the North Central London region, which incorporates Barnet, Enfield, Haringey, Camden and
Islington health, social care and public health commissioners, as well as all NHS Providers in
the sub-region. This group is now referred to as North London Partners in Health and Care
(NLP).
North London Partners in Health and Care has worked together to develop a North Central
London (NCL) wide STP which sets out how local health and care services will transform
and over the next five years, build and strengthen local relationships and ultimately deliver
the Five Year Forward View vision. The STP Vision is as follows:
“Our vision is for North Central London to be a place with the best possible health and wellbeing, where no-one gets left behind”
A set of core principles to support delivery of the vision has been developed, along four
themes.
1. Prevention: increased efforts on prevention and early intervention to improve health and
wellbeing outcomes for the whole population, to reduce health inequalities, and help
prevent demand for more expensive health and care services in the longer term.
2. Service transformation: service transformation to meet the changing needs of the
population and bring care into the community, closer to home. This includes taking a
“population health” approach by strengthening the offering in the community by closely
integrating with primary care.
3. Productivity: identifying areas to drive down unit costs, remove unnecessary costs and
achieve efficiencies to ensure sustainability. For providers, this includes implementing
recommendations from the Carter Review and working together across organisations to
identify opportunities to deliver better productivity at scale.
4. Enablers: a focus on delivering capacity in key areas that will support the delivery of
transformed care across NLP. This includes digital, workforce, estates, and new
commissioning and delivery models.
4.3.2 NCL STP: Plan for Mental Health
The STP proposes a ‘stepped’ model of care supporting people with mental ill health to live
well, enabling them to receive care in the least restrictive setting for their needs. The aim is
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to reduce demand on the acute sector and mitigate the need for additional mental health
inpatient beds.
Figure [4.2]: Stepped Model of Care for Mental Health, NCL STP
Initiatives include:
Improving community resilience through specific initiatives supported by NHSE, such as helping service users get back into work, which have been shown to reduce cost and activity;
Increasing access to primary care mental health services: ensuring more accessible mental health support is delivered locally within primary care services;
Improving the acute mental health pathway: developing alternatives to admission by strengthening crisis and home treatment teams;
Developing a Woman’s Psychiatric Intensive Care Unit (“PICU”): ensure local provision of inpatient services to female service users requiring psychiatric intensive care, where currently there is none;
Investing in mental health liaison services: scaling up 24/7 all-age comprehensive liaison to more wards and Emergency Departments;
Investing in a dementia friendly NCL: looking at prevention and early intervention, supporting people to remain at home longer and supporting carers to ensure that we meet national standards around dementia.
In addition to the alignment with the STP plan indicated in Section [4.1], the reconfiguration of services directly addresses the building of community resilience, improving access to primary care mental health services and the development of a women’s PICU.
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The subsequent section set out the current model of care at the Trust and its relation to the
STP model of care in more detail.
4.3.3 Progress on STP mental health initiatives in Camden and Islington
There has been significant progress made in Camden and Islington since the STP was
written with the boroughs on track to deliver the STP mental health vision. The mental health
STP was driven by care models to improve patient outcomes, care and treat people in the
least restrictive environment, thus mitigating the need to expand the in-patient facilities.
4.3.3.1 Improving community resilience
Camden and Islington have implemented new employment schemes based on Integrated
Personal Support which is an evidence based type of employment support to help those with
mental health conditions back into work. These initiatives are specifically supported by NHS
England and have been shown to reduce activity, and also cost to, health services as people
gain employment.
Mental Health First aid is also widely rolled out to Camden and Islington Council and
voluntary sector services. This initiative is aimed at non-specialist front line services helping
them identify mental health concerns and support people to access mental health services.
Similarly, suicide prevention training is also being commissioned to support early
identification and intervention with people who may be at risk of suicide but not in contact
with mental health services.
4.3.3.2 Increasing access to primary care mental health services
The rollout and increased access to Practice Based Mental Health (“PBMH”) is a key part of
the CCGs vision and transformation strategy – specifically “ensuring more accessible and
extensive mental health support is delivered locally within primary care services”. This will
help the population get local, accountable care that is integrated with social, community and
specialist services. This will be underpinned by a systematic focus on prevention and
supported self-care, with the aim of reducing unplanned hospital admissions. In addition,
Camden and Islington CCGs are on target to increase access to IAPT services to 25% by
2021. Islington CCG has also invested in ‘integrated IAPT’ which specifically targets people
with long-term physical health conditions who may otherwise not recognise and come
forward for help with depression and anxiety associated with their conditions, but which
nevertheless make their condition more difficult to live with. Initially this will be targeted at
those with diabetes and chronic pulmonary respiratory disorder.
4.3.3.2.1 Improving the acute mental health pathway
Camden and Islington both have Crisis Home Recovery Teams that can respond to
individuals in the community who feel in crisis and without immediate support would need to
attend an Emergency Department. All acute admissions for mental health are agreed by the
Crisis Team to ensure that no one who could be supported at home or in a Crisis House is
admitted. There is also a 24-hour crisis line that the public and professionals can call to get
advice and support over the phone. Camden and Islington residents can also access Crisis
Houses across the boroughs to help avoid inpatient admissions where possible. These
teams will be reviewed in 18/19 to ensure that they are being efficiently used and working to
ensure that they are working to fully support people in the community, able to respond in a
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timely way, working closely with voluntary sector and social care; in order to support
people’s needs in the least restrictive setting.
Islington and Camden CCGs are early implementers of the Serenity Integrated Mentoring
(“SIM”) programme, which brings together police and care co-ordinators around a specific
cohort of patients who are repeatedly admitted to Health Based Paces of Safety under S136
of the Mental Health Act. In pilots elsewhere, this has resulted in a 50% decline in
attendance at Health Based Places of Safety and impacted on subsequent admissions.
4.3.3.3 Developing a Woman’s Psychiatric Intensive Care Unit (“PICU”)
In November 2017 the Trust launched an 11 bed Women’s PICU, which is a shared
resource for North London Partners; however, the majority of admissions will be from
Camden and Islington due to the higher acuity of need in these boroughs. The service is
already demonstrating significant improvement to patient care, not only are patients now
able to be provided with services in the NHS and within their local area enabling visits from
relatives and better joined up care, but length of stay has also reduced to an average of 27
days from previous average in the private sector of 45 days. It is too early to say but it is
hoped that this locally provided more joined up care, as well as reduced length of stay on the
PICU, will impact on the overall length of stay in in-patient care for these women.
4.3.3.4 Investing in mental health liaison services
The Trust provides mental health liaison services in UCLH, Royal Free London and
Whittington Hospitals which are the main Emergency Departments attended by Camden and
Islington residents. The services there operate 24/7 and provide in-reach to the wards to
support training of staff, early discharge and reduced re-admission. The services provided at
these hospitals can be described at meeting many of the Core 24 requirements. In addition,
a new mental health suite is being implemented in Whittington Hospital, which will provide a
safe and therapeutic environment for patients who have attended Emergency Departments
to be assessed and cared for prior to admission or discharge. It is expected that the mental
health suite will provide a calming environment which will support more people to be able to
access services at Crisis Houses, or in the community with support from community teams
and thereby reduce admissions to acute inpatient mental health settings.
4.3.3.5 New model of care for Child and Adolescents Mental Health Services (“CAMHS”) and perinatal services
The Trust does not provide CAMHS services and therefore this proposal will not impact on
CAMHS services. However, in 2016 the Trust launched a new Community Specialist
Perinatal Service. This service is a North London Partnership (NLP) resource and builds
upon the small services that were already operating in Islington, Camden and Haringey. The
new service works across maternity units and peripatetically in the community to support the
needs of pregnant women and those with babies under one-year-old. This multi-disciplinary
specialist service ensures that the top 3-5% of women with severe mental health needs are
provided with specialist care and support, to better anticipate potential decompensation of
mental health and to support better treatment in the community.
4.3.3.6 Investing in a dementia friendly NCL Islington and Camden achieve high rates of dementia diagnosis for their estimated dementia
population; the NHSE target is for two-thirds of those estimated to have dementia to have
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received a diagnosis. As of March 2017, Camden’s diagnosis rate was 75.4% and Islington’s
96.8%. This means that people in Camden and Islington can access support and services
early in their diagnosis thus reducing crisis and inpatient care and supporting more people in
their homes. The mental health for older people pathway will also be reviewed in 18/19 to
ensure that services are best supporting people’s needs.
4.3.4 The Health Estate as an Enabler
The STP states that:
“An important enabler of a number the initiatives are the redevelopment of both the Barnet,
Enfield and Haringey Mental Health Trust St Ann’s site and the Camden and Islington
Foundation Trust St Pancras site.”
Furthermore, the STP confirms that the proposed developments at the St Ann’s and St
Pancras sites would:
Transform the current inadequate acute mental health inpatient environments on both sites;
Provide more therapeutic and recovery-focused surroundings for service users and staff;
Improve clinical efficiency and greater integration of physical and mental health care;
Release estate across the Trusts, to enable development of community-based integrated physical and mental health facilities;
Develop world class research facilities for mental health and ophthalmology enabling practice to reflect the best evidence; and
Provide land for both private and affordable housing, as well as supported housing for service users and housing for key workers.
At a local level there is also alignment towards the health estate as an enabler for
broader transformation. Both Islington CCG and Camden CCG, have overarching visions to
improve access to appropriate and effective mental health services and to ensure services
are integrated to enable a much more seamless experience for service users. This vision will
be enabled through the provision of fit for purpose, cost-effective, integrated, accessible
estate which enables the delivery of high quality services. This is covered in more detail in
Section [4.5].
4.3.5 Links to Joint Strategic Needs Assessments (“JSNA”)
The current JSNAs for Camden and Islington produced by the respective Health and
Wellbeing Boards with input from the local authorities, CCGs and other public sector parties
further outline the requirements for a sustainable and high quality mental health service in
the area. Both Camden and Islington have significantly higher rates of mental health
diagnosis than other London Boroughs, with Islington holding the highest percentage of
psychotic disorder diagnoses and Camden 3rd on that list. This has significant impacts for
the overall health and wellbeing of residents across the boroughs; the Camden JSNA (2016)
reveals that of those receiving incapacity benefits in Camden, mental ill health and
behavioural disorders accounts for the largest proportion of claims. Consequently, the
proposals to dramatically improve the quality of services to promote recovery and outcomes
alongside improved access for users in the community are essential to meeting local needs.
“…a service model that systematically promotes integration of physical and mental health
across primary and secondary care services and including self-management is required.”
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Additionally, as articulated in the extract above from the Camden JSNA (2016) and, as
stated in the most recent Islington JSNA (2016) the strong link between mental and physical
health warrants a more joined up model of care that addresses mental and physical health
together; providing further support for a model that aligns these services.
4.3.6 Joint Health and Wellbeing Strategies (“JHWS”)
Both the Camden JHWS (2016) and the Islington JHWS (2017) identify mental health as one
of their key priorities to improve health and wellbeing in their Borough over the next few
years. There are similar strategies proposed in these documents to deliver this goal, such as
improving access to community based interventions and improving attitudes towards mental
health by developing understanding and reducing stigma. The proposed reconfigurations
reflect these broader strategies.
4.4 Quality of Existing Estate
4.4.1 CQC reports
The Trust delivers the majority of its care to residents in the London Boroughs of Camden
and Islington, including from its two acute sites at St Pancras Hospital (SPH) and the HMHC.
The sites vary widely in terms of their distribution, age, condition and suitability and these
“extensive differences” were noted in the June 2016 CQC report.
The report highlighted that the SPH acute wards and psychiatric intensive care units
required significant improvement. Therefore, it is a priority for the Trust to update the
facilities within which these services are delivered to enable better outcomes for service
users.
The latest CQC inspection published in March 2018 it was noted that the Trust had sufficient
mitigations in place to address the concerns raised previously. However, the overall rating
for Safety remained as “Required Improvement”. Furthermore, this most recent report
highlights the staffing difficulties facing the St Pancras site, with the vacancy rate of over
20% on all wards. This not only increases workload for staff but also increases the reliance
on agency and bank staff, which increases the likelihood of protocol not being followed and
staff training shortfalls.
4.4.2 Backlog maintenance
As may be expected, there is a considerable amount of backlog maintenance, particularly at
SPH, to the value of £10 million. Many of the buildings are inefficient, do not provide a
therapeutic inpatient environment, lack modern safety features and make it difficult to bring
together a full range of services (physical and mental health, and social care).
Beyond the £10 million of backlog maintenance, an estimate of approximately £175 million
has been quoted to re-provide services at the St Pancras site that meet modern standards.
A significant proportion (c.73%) of the Trust’s backlog maintenance requirement relates to
the SPH site.
4.4.3 Time bound opportunity
Critically, the opportunity to transform the mental health services in the area through the St
Pancras redevelopment is potentially time bound insofar as the Trust were successful in
their application for a Certificate of Immunity from Listing (COIL) and this is valid for a 5-year
period running to 2020. The importance of this to the scheme is that it means that no further
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buildings on the site can become listed in this period, enabling the Trust to consider
alternative uses for the current site.
4.4.4 Accessibility
In addition, whilst SPH does meet the Disability access requirements under Equalities Act
2010 (“EA10)”) compliance, the issues highlighted above, due to the age and consequent
design of the estate, leave room for improvement as they do not inherently meet the
requirements for all service users. Specifically, wheelchair users and people with sight loss
have relatively poor access, as the building is not designed to meet their needs. Similarly,
due to building design, lines of sight are compromised and additional systems have been put
in place to ensure patient safety.
4.4.5 Patient assessment
The 2016 Patient Led Assessment of the Care Environment (PLACE) scores, shown in
Figure [4.3], demonstrates the challenges the Trust has on the SPH site. This clearly
evidences that SPH needs improvements within the ‘Condition, Appearance and
Maintenance’ section and is a significant outlier on both the ‘Dementia Friendly’ and
Disability Access’ sections.
Figure [4.3]: 2016 PLACE assessment scores for SPH
Site Assessed
Cleanliness
2016
Food & Hydration
(Ward) 2016
Privacy, Dignity & Wellbeing 2016
Condition, Appearance & Maintenance 2016
Dementia Friendly
2016
Disability Access
2016
St Pancras Hospital
99.51% 86.26% 87.28% 91.4% 68.28% 65.57%
Average score C&I
99.51% 93.54% 89.43% 96.35% 82.07% 83.87%
National average
98.1% 89% 84.2% 93.4% 75.3% 78.8%
Comparative MH Trusts
99.6% 84.83% 96.24% 97.84%* 94.96% 93.32%
*SLAM spent a considerable sum in environmental works prior to the PLACE inspections
4.5 Limitations of Current Service Provision
4.5.1 Parity of esteem for mental health
Parity of esteem for mental health is widely supported as a concept across the health and
social care system, reflecting the fact that mental health can be more debilitating than most
physical conditions as well as the enormous social and economic costs of untreated
conditions (only 25% of those with depression are diagnosed).
Similarly, for inpatients that are admitted to the service at SPH, there is an associated
stigmatism with the facility which could be addressed through moving to a new, modern site
rather than staying at SPH. By exploring options to deliver inpatient facilities at a site that
also has physical health acute wards, there is an opportunity to develop closer collaboration
in meeting mental and physical health needs. This supports the wider new Model of Care as
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set out in Section [5] and STP goals for mental health provision that is integrated and viewed
as equal to physical health provisions.
4.5.2 Integration of care
This is a rare opportunity to make a step change in converting that concept into reality for
service users in North Central London. The proposal for the development of community hubs
brings the potential for significant strategic benefit for the broader health and social care
system as this hub will allow service users to have their physical and mental health
conditions considered on a single site through cross organisational working. The local health
organisations know that those living with psychosis on average die 20 years earlier than
average, but often this is due to poor management of preventable physical health and
wellbeing such as weight, diabetes and substance abuse. Further integrating care will
enhance the delivery of whole health and social care system transformation that is already
underway.
As this way of working is embedded across the community, there may also be opportunities
for workforce diversification, allowing staff to work more holistically than ever before with
service users. By bringing facilities and workforce together, collaborative working and
smoother transitions between services can achieved, which could not be achieved at SPH.
For example, an inpatient on a mental health ward could be visited on-site by a cardiologist
or diabetic nurse without significant travel or time delays. Similarly, an individual receiving
treatment on an acute ward may be recommended for swift assessment by a member of the
mental health team to best meet their needs.
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5 Care model and expected benefit
5.1 Care Model
The Trust’s Clinical Strategy 2016-2021 sets out the clinical model for services provided at
the Trust, both currently and in the future. This model has been designed to keep community
teams at the heart of service delivery; ensuring care is provided as close to patients’ homes
as possible. This model and its constituent parts are unchanged by the proposed
relocations, however its delivery will be greatly enhanced by the improved quality and
location of services, as evidenced below.
As described in the previous section, the Trust’s Care Model forms part of the broader NCL
STP ‘stepped’ model of care for mental health. This overarching model supports the focus of
services wrapped around individuals within their communities, with increasing levels of more
intensive, specialist care provided according to increasing need.
The development of a new inpatient facility 2.5 miles away from the existing site, alongside
new community facilities on the existing site and development of two new community hubs,
supports the improved delivery of the North Central London STP in a number of ways:
5.1.1 Improving facilities
Due to current inadequacy of the facilities at the St Pancras site, and the location of some
community services at this site, the Trust is unable to sufficiently deliver on a number of
aspects of the STP Model. This includes the delivery of high quality specialist services close
to home (Step 3) and elements of the more intensive levels that stipulate services should
support recovery at home and in the community (Step 4).
Furthermore, one of the enablers of the STP is the estates strategy, which lists the
redevelopment as key to delivering more therapeutic and recovery focussed surroundings.
5.1.2 Increasing access to mental health services
The STP’s focus on delivering more accessible and extensive mental health support within
primary care services is aligned to the planned roll out of the practice-based mental health
(PBMH) to all practices and increased access to Improved Access to Psychological Services
(IAPT) to 25% of the indicated population by 2021.
All Islington CCG registered patients are now able to access PBMH service. However, some
patients need to be seen at an alternative venue to their GP practice due to the limitations of
this estate. Camden CCG will expand their residents’ access to PBMH by building on their
current Team around the Practice model from 18/19, which too will add pressure on the
primary care estate.
Currently there are a high number of secondary care community teams located across
multiple sites, which includes some teams based on the St Pancras site. The development of
Community Hubs will allow the re-location of some of these services to more accessible
local sites for residents, away from hospital and closer to home. It also brings teams from the
same Division onto a single site, which improves closer working between professionals.
Community delivered services are expected to increase in levels of contact time with
patients as care is re-directed away from inpatient services, this requires a larger community
estate to accommodate additional activity.
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Service users will continue to have access the community services at new developed St
Pancras facilities, as well as services at the community hubs, giving services users greater
choice of where they wish to access services.
Community Hubs may also be able to bring opportunities for a wider range of in-reach work
for physical health services to patients with mental health to help improve accessibility to
physical health services.
5.1.2.1 Improvements to access within Camden
South Camden iCope (IAPT) and Assessment and Advice Team moving from St Pancras to Greenland Road;
South Camden Recovery Team to move into Greenland Road;
Community Recovery Service for Older People to Lowther Road in Islington (most patients are seen at home).
5.1.2.2 Improvements to access within Islington
Islington Practice Mental Health Team (where there is no capacity for patients to be seen at their GP practice) to move to Lowther Road;
Islington Assertive Outreach Team to move to Lowther Road;
Islington North iCope Team to move to Lowther Road;
Community Recovery Service for Older People to Lowther Road (most patients are seen at home).
5.1.2.3 Moves from St Pancras to sites other than the community hubs
Rivers Crisis House is likely to be moved off the St Pancras site, however plans for where this will be located are not finalised;
Pharmacy services to move to HMHC to support inpatients at both inpatient sites.
5.1.3 Improving the acute mental health pathway
The proposed relocation and development of Community Hubs does not involve the
provision of any extra inpatient beds, which aligns with the STP vision to develop
alternatives to hospital admission by strengthening crisis and home treatment teams. As part
of the acute pathway improvements, the STP also identifies the investment needed in
supported living arrangements, providing users with a supported, and longer term
arrangement for effective discharge.
5.1.4 Patient pathways
5.1.4.1 Practice Based Mental Health Teams PBMH based in primary care is a key component of the NCL STP, the Trust’s Clinical
Strategy and the CCG commissioning intentions. PBMH was piloted in Barnet and found to
reduce the need for referral to specialist care pathways by 60-65%. Subsequently it has
been operating across nine of the 33 practices in Islington for two years and has been rolled
out to all practices in 17/18, and across Camden from 18/19.
Service users are able to access locality based services, which include consultant
psychiatrists, psychologists, social workers and nurses. These services aim to:
Increase access to high quality assessment and early intervention;
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Provide a supporting role to GPs and primary care staff to help manage patients at the primary care level, avoiding deterioration of health and the need to refer to secondary services; and
Reduce demands on a range of secondary services including Crisis Teams, secondary care teams, and acute inpatient admissions.
Healthy London Partnership has commissioned an economic evaluation of PBMH models
used across London. Islington PBMH service will be one of the sites which is expected to
deliver its findings in summer of 2018. The economic evaluation will look at a range of
factors including the impact of the service on secondary care and acute bed utilisation.
PBMH also helps to reduce the stigma of accessing services specifically for mental health
and they have been found to be effective in managing mental health in Primary Care
settings. By continuing to invest in PBMH, more individuals requiring mental health services
can be identified and supported early on, thereby reducing the impact of undiagnosed and
untreated conditions on long term health and wellbeing. For the majority of service users,
PBMH will be the entry point to more specialist support, however other entry points include
the Urgent Care/Acute pathway and A&E.
PBMH complements IAPT services where people with common mental health services can
access care and support without the need to meet secondary care thresholds of care.
5.1.4.2 Specialist Care Pathways Service user access to specialist care pathways depends on a number of factors, including;
risk level, intensity of interventions required and the need for a specialist treatment only
available via these pathways. There are four divisions currently in place focused on
particular user cohorts and providing specialised, tailored support depending on user need
and these continue to be developed by the Trust.
Community Mental Health (CMH) Division;
Rehabilitation and Recovery (R&R) Division;
Services for Ageing and Mental Health (SAMH) Division;
Substance Misuse Service (SMS) Division.
In addition to these four divisions, the Trust also provides an Urgent Care/Acute Pathway
(Figure [5.1]) that service users may enter if they are experiencing a crisis in their mental
health. For some service users this may be their initial entry pathway to services. However,
service users on this pathway are moved as soon as possible onto less intensive and more
tailored pathways.
A service user will often move among or between pathways and specialist sub-divisions as
part of their therapeutic journey and teams work collaboratively across pathways to ensure
users are supported throughout by a team that knows and understands their needs.
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Figure [5.1] The Trust’s Clinical Model
5.1.5 Workforce
As the current care model moves to a focus on community provision of services, workforce
requirements will need to change in line with this. The NCL STP Mental Health Workforce
programme recognises that all NCL mental health providers will face the following key
issues:
Portability to enable staff to work across traditional boundaries (organisational and health and care settings);
Improving staff experience of providing care; and
Career planning/development to support a lifetime career in NCL.
To address these issues, there is a dependency on two other NCL, STP programmes:
Care closer to Home: to provide more care from integrated primary and community settings; and
Workforce: to ensure the workforce can meet the above expectations.
The aims of the programmes are:
To provide analytical support in designing the workforce elements across work streams to address the key issues above, including providing an understanding of the impacts and benefits of introducing new roles and ways of working;
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To provide a common approach to recruitment across the 10 NHS Trusts in North London Partners (NLP) which will cover common recruitment policy and processes that will support collaborative recruitment and retention initiatives for provider trusts; and
Enable ‘portability’ of staff between providers and into primary and community care settings.
To deliver these aims and address the issues, the NCL STP proposes a range of measures which will impact the workforce considered as a part of this proposal:
Recruitment initiatives
General STP workforce recruitment initiatives are:
The “CapitalNurse” (CN) programme is trialling a joint approach across NCL and NEL by giving an employment guarantee to all locally educated student nurses in September 2018. This will provide a core offer to all students including access to a CN branded preceptor ship programme. The NLP are keen to understand whether this approach would be of value to other staff groups.
There will be a joint approach and a common policy to facilitate collaboration in NCL to training Nursing Associates and using apprenticeships to grow the workforce.
NCL has led the way in identifying overseas educated nurses who do not have a UK registration but are working in support roles in the NHS and social care in NCL. Whilst the new funding arrangements at HEE mean that the funding approach will change this is a great route to identifying more new nurses.
The development of a shared staff bank in NCL.
Some mental health specific initiatives that are directly applicable to the Trust are:
International nurse recruitment from the Philippines.
Participating in local, London-wide and national careers fairs as well as engaging with local schools.
Streamlined recruitment process has improved time to hire and had a positive impact on our vacancy rate.
Retention initiatives:
A Retention Study is being conducted across the STP by IPSOS Mori, with the results available in May 2018. Once the retention issues have been identified initiatives can be designed and delivered to tackle those problems.
Reviewing flexible working and flexible retirement options and introducing new package of non-pay benefits for staff.
Buddy scheme for new starters.
Current action planning to address issues identified in staff survey.
Over 30 Quality Improvement projects focussing on staff wellbeing, reducing violence and aggression in wards, improving patient experience.
Identifying training needs across NCL in order to inform a programme of joint training that can be utilised across the STP. This has recently been done with Dialectical Behaviour Training running across NCL.
Training to be provided for adult MH colleagues in CAMHS and vice versa in order to enhance skills and enable a more joined up workforce across the sectors.
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Development and use of new roles:
Piloted nursing associates in 2017/18 and seeking to expand cohort in 18/19.
Working with Skills for Health to identify new roles/existing roles suitable to be adapted to our workforce and activities (e.g. advanced practitioner)
Working in partnership with Inclusion Barnet to identify roles, which benefit from being held by people with lived experience of mental health issues. This follows a two-year experience of employing community engagement workers who all have lived experience.
The development of Children and Young People crisis services that will work across NCL – a children and young people’s Out of Hours crisis team and bid to develop a new Health Based Place of Safety at Highgate Mental Health Centre (HMHC) – will create new roles and posts.
The potential devolution of Tier 4 CAMHS and the development of the acute care pathway across NCL will result in further enhancement of the workforce and create new roles by 2020/21.
Expansion of IAPT services is seeing a growing workforce that requires better career development and support.
Up-skilling current staff:
Recruited Physical Health Leads to improve skills of our mental health workforce.
Apprenticeship programme to enhance technical and management skills of staff.
Nursing associate and nurse degree apprenticeships commencing autumn 2018.
Dialectical behaviour therapy (“DBT”) training is being undertaken by 23 staff across NCL to further enhance the acute care pathway.
The development of a CAMHs out of Hours crisis team will create opportunities for staff to work in different settings and developing their skill set.
Opportunities are being explored to develop joint training across adult mental health and CAMHS in order to upskill staff in both sectors.
Mental Health First Aid Training for 200 non-mental health staff and current Peer Support Workers to be delivered by June 2018.
200 Primary Care and Social Care Staff to receive Suicide Prevention Training
A further 250 primary care and community staff will receive training through integrated IAPT programme.
In accordance with the care model, many staff at the Trust are already more community
based than they have been previously, and the preferred option does not call for any staff to
transfer out of the Boroughs of Camden and Islington.
These proposals are not expected to have negative impacts on the workforce. Any workforce
changes will be consulted on in-line with the Trust’s agreed Change Management Policy and
sufficient time will be allowed to ensure appropriate notice is given of any changes.
Furthermore, the Trust’s devolved structure encourages clinically led divisional autonomy,
within the Trust’s overarching policies, procedures and values. Each division will be
responsible for managing their workforce changes, supported by the Human Resources &
Organisational Development Team. The Trust Strategic Development Committee will have
oversight of workforce plans, with ultimate accountability being held by the Trust Board.
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Staff engagement sessions have been on-going since April 2017, to gather workforce views and listen to feedback. This has included engagement with clinical leads, senior managers, community staff, and ward staff, as well as open sessions that all staff members have been encouraged to attend. Whilst some members of staff would prefer to remain in their current working locations, there is wide acceptance that facilities are not as good as they should be and that the redevelopment programme is an opportunity to improve both service user experience and the working environment for staff.
5.1.6 Commercial principles
There is no activity shift expected between the different providers of the services being
consulted on.
In fact, the commercial structure around the payments to the Trust from the CCGs is such
that there would be no negative financial impact on the CCGs as a result of the proposed
service changes. This is because of the block grant payment mechanism which is set out in
more detail in Section [9].
5.1.7 Activity, Volume and Capacity Modelling
The table below sets out the overarching activity figures for the Trust over the period April
2014 to March 2017.
Figure [5.2]: Trust Total Activity and Admissions April 2012 to March 2017
2012/13 2013/14 2014/15 2015/16 2016/17
Admissions 1,216 1,316 1,315 1,397 1,363
Inpatient and Community Episode Caseload
(Total distinct patients)
20,020 21,567 22,584 23,274 23,823
The Trust currently has 235 beds (84 on the St Pancras Hospital site) used for acute
admissions, treatment of adults and older people.
Over the past decade or more, changes in the way mental health services are delivered
have consistently reduced the use of inpatient beds. The Trust has closed approximately
130 beds (acute and continuing care) in the past 10 years, through the development of
increased alternatives to hospital care and improvements to the arrangements and working
practices in inpatient care.
Over the last couple of years, the Trust has experienced consistent pressure on its
remaining beds and an increase in numbers of people admitted and those treated by the
Crisis system. This reflects both demographic growth and the nature of the local
demographic, which is highly transient and includes many people accessing mental health
services for the first time (and who therefore often require greater support). There has been
an increasing number of Overseas Visitors to the UK who require urgent and emergency
care, often resulting in an inpatient admission, before they can be re-patriated to their home
country.
In 2016, commercial advisors were commissioned by NCL STP to undertake bed modelling
for the area. The advisors predicted an increase in the overall requirement of inpatient beds
to increase from 236 to 268 in the Trust by 2021, an increase of 32 beds based on an 8%
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demographic growth if services remained as they were with no operational efficiencies or
clinical improvements. The advisors also suggested that if the STP mental health work
stream was delivered, it would remove the need for many of the additional inpatient beds
required estimating that the Trust bed base would need to increase to 246, a much smaller
growth of 10 beds.
The STP mental health work stream and progress on it in Camden and Islington is detailed
in section [4.4.2], these are to a large extent based on reducing the demand for inpatient
beds and meeting people’s needs in the community. In addition to this there have been a
range of changes to the Trust bed utilisation since the commercial advisors’ modelling as the
STP initiatives and Trust initiatives have advanced.
5.1.8 Trust initiatives on inpatient beds usage
In 2017, the bed situation specifically length of stay had worsened for Male PICU and acute
wards. Due to this and the already high length of stay for older people and rehabilitation
wards, the Trust embarked on an ambitious plan to reduce the length of stay of all of its
wards which is showing real progress and has enabled some significant changes.
The commercial advisors’ review detailed that the average length of stay in 2015 for acute
wards was around 49 days, and 55 for male PICU. The Trust acknowledged that they were
an outlier compared to other Trusts for length of stay, which contributed to high occupancy
levels and meant that they often had to use private beds to accommodate needs; this
included a length of stay for older adults of 135 days. The commercial advisor found that bed
occupancy was at 97-98% for acute and 99% for older adults, the Trust’s ambition is to
achieve 95% by March 2018.
To achieve the overall aim of 95% bed occupancy by March 2018 the Trust programme was
to:
Free up 12 beds across the system by 31 July 2017 to enable the opening of a Women’s PICU by 1 November 2017;
Fully utilise new community resource to step down some long staying rehabilitation patients by September 2017;
Reduce the number of people staying beyond the agreed median Length of Stay (LoS) by 50% by the end of 2017;
Convert 4 older people’s continuing care beds to acute beds by 31 March 2018.
This was achieved in a range of ways including:
Re-assessment of number of patients who were outliers in terms of LoS;
Closer links with Islington’s voluntary sector Crisis House to better utilise this service, the Trust is a partner in the newly re-commissioned service which started in April 2018;
Greater social care presence in acute wards to strengthen links to the community and supported accommodation to facilitate move on. The clinical strategy is in line with local social care plans for Camden and Islington Councils. Both Councils have introduced a Strengths Based Approach, which emphasises support for individuals to develop self – reliance, resilience and make greater connections with their community. Developing services that put community provision at the heart of our vision is in clear alignment with social care ambitions.
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Senior clinical review of patients to support reduction in LoS, including older adults with a target of reducing stays to 60 days;
Introduction of Red to Green which is a daily analysis of the treatment and care delivered to inpatients; red days being days where the treatment given could have been provided in the community. Therefore, working towards ensuring that every inpatient day is fully utilised and that patients are supported to discharge ensuring that they are treated in the least restrictive setting.
The Trust has made significant progress on these targets with the following having been
achieved:
Reconfiguration of bed base to allow the opening of an 11 bed women’s PICU in November 2018 (this included one bed closure due to the restrictions of the SPH estate);
Reduction in Continuing Health Care beds by four as planned, but increases acute bed base to support demand;
Increased flow to rehabilitation beds which in turn supports reduction in length of stay in acute beds;
Utilisation of all types of beds has reduced in the last year (Appendix [25])
Utilisation of acute beds has reduced from 99% to 96% in the last year;
Length of stay for acute beds for 17/18 is 67 days including PICU wards;
Utilisation of older adult beds has reduced from a high of 648 bed days in June 2017 to 502 in March 2018, a reduction of 33%
Length of stay for older adult for 17/18 is 118 days;
Utilisation of rehabilitation beds has reduced from 99% to 97% over the last year
Length of stay for rehabilitation for 17/18 is 721 days;
Occupied bed days (OBD) for private sector placement for acute care and PICU are now on a significant downward trajectory, following sharp peaks between July – Dec 20175, and are now on a zero trajectory by March 2021 (submission to NHSE) (Appendix [25])6;
Total OBDs for private sector placement acute and PICU placements fell from a high of 2065 in quarter three of 2017/18 to 330 in the following quarter;
New admissions have reduced from 591 to 474 between 15/16 and 17/18 representing a 20% reduction.
5.1.9 Refreshed bed modelling
Further bed modelling has been developed for the Trust which forecasts further in to the
future. In this updated bed modelling local demographic trends have been extrapolated into
short term and long term growth scenarios. The forecast suggests population growth of
8.29% in the years 2017 to 2025 with the population of Camden and Islington rising from
509,594 in 2017 to 551,855 in 2025.
5 This was due to closure of a 12 bedded acute ward during the re-configuration to women’s PICU, since opening of the PICU
(November 2017) both PICU and acute bed admissions to private sector have fallen to under 100 per month, compared
with highs of 500 (PICU) and 400 (acute) per month. 6 STP trajectory is not zero but C&I trajectory is and this is likely to be achieved ahead of schedule.
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Growth in Islington is forecast to be higher that Camden over this period (9.24% compared
to 7.43%). The trajectory of demographic growth from 2017 – 2025 on the projected bed
requirement in would be 254 beds from the current bed base of 235, with no mitigation of
efficiency or service development. In short there would be a requirement of 19 additional
beds.
The Trust has the second highest number of acute beds per head of population and is within
the upper quartile of mental health trusts for acute admissions and length of stay (Appendix
[24]). The Trust has around 70 beds more than the crude arithmetic mean of all Trusts. 40 of
these beds result from a higher than average propensity to admit. 30 of these beds result
from a higher than average length of stay.
There are some local factors that account for a proportion of this higher admission and
length of stay, such as the need for higher dependency bed usage, and for admissions of
people with a diagnosis of psychosis (above upper quartile for Cluster 10-16, and near to it
for Cluster 17). London similarly has much higher proportion of psychosis patients. However,
figures suggest that this may account for as many as 29 beds. There are high relative levels
of homelessness in Camden that analysis suggests could account for 8 beds, plus the
ongoing need of high levels of funded overseas visitors, again an additional 8 beds.
Thus 45 excess beds can be explained by clinical need, (from the identified 70), leaving
opportunity for improving bed utilisation that could result in bed savings of 25. This reflects
the difference between the existing and remodel of care figures, and mitigates against the 19
forecast additional beds demographic change suggest should the care model not change.
The Trust has around the median number of older adult beds per head of population and is
in the lowest quartile of mental health trusts for older adult admissions (Appendix [24]). Both
Camden and Islington have relatively young populations compared to London and England.
Length of stay in the Trust is fifth highest nationally and the longest in London. The Trust has
a much lower propensity to admit but a higher length of stay, with overall fewer than average
beds (circa 2 beds) per head of relevant population. Analysis suggests that the lower
propensity to admit accounts for 12 beds fewer than the mean, whilst the higher than
average length of stay accounts for about 10 beds. There is little to suggest any capacity to
reduce the bed base in this area7 and would need to reflect demographic growth in the
future.
With regard to rehabilitation beds there is a predicted growth of eight beds. However,
significant work has been done to reduce the length of stay for these patients including the
opening of a new resource which has allowed the opportunity for patients to step out of
rehabilitation that had previously had very long stays. Therefore, the need for additional beds
is mitigated, and a further review of rehabilitation across inpatient and community wards’ will
be undertaken in 2018/19 to ensure optimised care pathway to reduce length of stay where
possible.
The evidence above with regard to the progress made so far both in terms of delivery of the
STP and Trust initiatives suggests that this requirement will not be needed. For example,
7 Source: 2016 NHS Mental Health providers’ benchmarking club
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through earlier diagnosis and intervention; and greater support and capacity to enable
patients to receive care in the community, as well as continuation of the Length of Stay
project to absorb demand as admission and treatment length are reduced. Some of these
initiatives are difficult to quantify exactly, for example, there is yet to be an established
evidence base on the impact of PBMH on inpatient beds. However, this, combined with
initiatives in crisis services, is the prevailing good practice model and one being followed by
all mental health Trusts.
Consequently, the CCGs are confident that maintaining the current bed base at 235, will be
sufficient to meet demand in 2025, and the new build will actually allow one additional bed to
236 due to the removal of the estate compromise that saw one bed close in 2017. The
CCGs believe that this is a conservative proposal based on the clinical efficiencies
postulated within the STP, the service developments being delivered in the Trust’s Clinical
Strategy and improved practice that is already in track. These movements are set out in
more detail in Figure [5.3].
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Figure [5.3]: Bed modelling
Type of Bed Current Location No of Beds
(Feb 16)
No of Beds Predicted by STP due to demographic growth and
no service development
s (Feb 21) McKinsey
No of Beds Predicted in
STP with demographic growth and
Service Developments
(Feb 21) McKinsey Mitigation
Current No of beds (Feb
18)
No of Beds Predicted in OBC due to
8% demographic growth and
no community
developments (Feb 25 )
No of Beds Predicted in OBC due to demographi
c growth with Clinical
Strategy implemented community
developments (Feb 25)
Service Developments
Assumed / Delivered
(15/16) full year
data available
to McKinse
y
Assumptions are 13.3% demographi
c growth from 15/16 -
20/21 (5 years) steady
length of stay and
occupancy
As detailed in the STP
Increased CRHT Teams / Perinatal/Prima
ry Care
Service Development
s from Feb 17 include: Women's
PICU
N/A
As detailed in the
Clinical Strategy
Men’s PICU Total 12 13 13 12 13 12
Length of stay MPICU 55 89
Women PICU Total 0 0 10 11 12 11
Length of stay WPICU 36
Acute Total 152 173 140 140 151 130
Length of stay Acute 49 38 67
Older Adult Total 28 32 27 28 30 30
Length of stay Older Adult
135 37 118
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Rehabilitation Total 44 51 66 44 48 52
Length of stay Rehab 1103 721
Total number of beds
236 269 246 235 254 235
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5.2 Expected benefit
The benefit impact of the proposed development of facilities is focused around the improved
therapeutic environment for service users. This is in line with the current clinical strategy to
promote recovery, resilience and independence via easy access to community-based
services and specialist care-pathways.
The main benefits that have been identified are as follows:
Improve quality of care by enabling transformation of service models;
Support the delivery of the Trust’s clinical strategy and STP by increasing accessibility to community services;
To create fit for purpose, therapeutic inpatient wards;
Enable the Trust to fully comply with CQC requirements without the need for high numbers of adaptations – both hospital regulations and standards and statutory regulations;
Improve the Trust’s status as a research and development centre of excellence through e.g. better facilities and partnerships with other organisations;
Promote equality through improved access to ‘disability friendly’ facilities;
Improve sustainability through improved efficiency of facilities and enablement of better and more efficient care models;
Enable greater alignment of Trust services with the needs of service users through improved access to safer facilities;
Reduce stigmatisation of Mental Health service users by facilitating easy access to new facilities and open spaces;
Improve service user experience with the ability to access integrated physical and mental health services in line with the 5YFV and national NHS Mental Health strategy “No Health without Mental Health”;
Enable greater proximity to services for a high proportion of service users by locating services in Camden and Islington;
Attract and retain high quality staff by providing a high level of staff support including improved engagement and facilities;
Contribute to the local community by promoting community health services and improving staff’s workplace;
Support the movement or maintenance of the current location of others Trusts as set out in the STP; and
To allow the development of joint Mental and Physical health care by the proximity of the Whittington health site.
5.3 Impact on service users and benefits
Of the 25,000-30,000 people seen by the Trust on average per year, just under 9,000 were
seen at the St Pancras site last year. Of these 9,000 users, over half were visiting services
that will remain at the St Pancras site and so the number of users expected to be affected is
around 3,100 (see Figures below).
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Figure [5.3]: Affected service users by service - Inpatients
Name of service Proposed new location Number of service users affected (based on attendances 1 Jan-31Dec 2017)
Dunkley Ward (mixed sex with 4 learning disability beds)
New in-patient facility 165
Laffan Ward (mixed acute mental health)
New in-patient facility 168
Ruby Ward (female PICU)8
New in-patient facility 20
Rosewood Ward (female acute mental health)
New in-patient facility 115
Montague Ward (mixed high dependency rehab ward)
New in-patient facility 32
Sutherland Ward (mixed long-term complex care ward)
New in-patient facility 27
Total number of service users 527
Note: The Approved Mental Health Professional Service and Pharmacy services are addition
to those listed above that form part of the proposal (see Appendix [1]). However, these two
services support services listed above and are therefore covered in their numbers of service
users.
Figure [5.4]: Affected service users by service - Community
Name of service Proposed new location Number of service users affected (based on attendances 1 Jan-31Dec 2017)
Camden Mental Health Assessment and Advice Team
Camden Hub 720
Islington Practice Mental Health Team9
Islington Hub 15
Islington Assertive Outreach Islington Hub 101
South Camden Recovery Team Camden Hub 720
iCope North Islington Team Islington Hub 2,179
Community Recovery Service for Older People (Camden and Islington)
Islington Hub 99
South Camden iCope Camden Hub 2,450
Total number of service users 6,284
These users will see a number of significant benefits depending on the service they access:
5.3.1.1 Community based care Over two-thirds of the users likely to be impacted are attributed to the South Camden iCope
service, which is a low intensity service providing guided self-help interventions alongside
8 Part year effect opened in November 2017
9 Those not able to be seen in GP surgeries – figure based on March 18 only when full roll-out was achieved.
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psychological interventions such as Cognitive Behavioural Therapy (CBT). For these users,
the relocation of this service to the Camden hub offers the opportunity to access services at
a more welcoming community based, non-acute setting. This will not only provide easier,
more direct access to services but also reduce the stigma attached with accessing mental
health services.
5.3.1.2 Improved therapeutic environment For inpatients at the St Pancras site, moving to a newly built facility ensures they receive
care in a high quality, specialised building with state of the art facilities. The current site was
deemed unfit for purpose following a CQC report in June 2016, with some wards having
serious health and safety concerns, including ligature points and blind spots. The latest CQC
inspection published in March 2018 noted that the Trust had sufficient mitigations in place,
however the overall rating for Safety remained as “Required Improvement”. Furthermore,
this most recent report highlights the staffing difficulties facing the St Pancras site, with the
vacancy rate over 20% on all wards. This not only increases workload for staff but also
increases the reliance on agency and bank staff, which increases the likelihood of protocol
not being followed and staff training shortfalls.
By transferring these services to a purpose-built facility, critical safety improvements will be
seen alongside drastic improvements to the general therapeutic environment. For example,
the new site will improve on the poor quality of available outside space at the St Pancras site
and improve lines of sight for monitoring of patients.
5.3.1.3 Improved access When rated for disability access, the current site’s 2016 PLACE rating is a significant outlier
at only 65.57% accessible when compared to the national average of 78.8%, and the even
higher rating for comparative MH Trusts at 93.32% accessible. By relocating to a newly built
site that meets modern accessibility requirements, this will increase equality of access for
users, staff and visitors.
5.3.1.4 Parity of esteem for mental and physical health By co-locating the new purpose built facility alongside the Whittington Acute Hospital,
service users are able to receive specialist mental health treatment from the same site as
users of the acute physical health care service. This helps reduce the stigma attached to
mental health facilities and is a key aim of both the Trust and the STP clinical aims.
5.3.1.5 Improved integration between acute and mental health services In addition to the reduced stigma, by having mental health inpatient and acute facilities on
the same site, it is expected that users transferring between the two services will receive a
quicker and more streamlined transition. For service users being ‘stepped-up or stepped-
down’ from the acute pathway, there will be a minimal physical transfer required and this will
be able to occur more quickly between the two providers, improving treatment and service
user experience.
By continuing to deliver a model of care that is primary care and community focused, the
proposed relocation of some services does not impact upon the majority of service users’
access to services. The ongoing roll out of practice-based teams ensures all service users
are able to access mental health professionals and receive treatment and support close to
their homes.
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5.3.1.6 Better working initiatives for staff: By developing new facilities and implementing the workforce plan as per the STP, it is expected that the local health organisations are more likely to attract a higher quality staff by providing a high level of staff support including improved engagement and facilities. There will also be a naturally higher retention rate due to the higher quality buildings. 5.4 Changes to travelling times and distances Detailed travel time analysis has been undertaken from the centre of each partial post-code to the existing service and the new service location using the Transport for London travel tool. The analysis tables demonstrate the impact on services users and populations for the average change in travel times between distances using by differing modes of transport available for the journey for the following scenarios:
For all postcodes - a table showing the change in time due to relocation of beds from
St Pancras to the Whittington.
For Islington postcodes – a table showing change in time due to relocation of
community services from St Pancras to Lowther Road.
For Islington postcodes – a table showing change in time due to relocation of
community services from Manor Gardens to Lowther Road
For Camden postcodes – a table showing change in time due to relocation of
community services from St Pancras to Greenland Road.
Looking across all postcodes compared to travelling to St Pancras, around half of the
postcodes would have increased journey times to Whittington Hospital, a third little change
and around one fifth would have a shorter journey time.
The travel time analysis for movement between St Pancras and Lowther Road was generally
positive, indicating that over three quarters of Islington service users would have a shorter
journey. Two thirds of journeys between Manor Gardens and Lowther Road would be longer,
with one third of journeys shorter and a small percentage showing no difference.
The travel time analysis for movement between St Pancras and Greenland Road across
Camden postcodes was even more positive with around 80% of people experiencing a
shorter journey time and just 15% of journeys being longer.
The public consultation document will simplify the travel analysis for Islington and Camden
residents, give examples of travel routes, and provide a link to the full analysis so that
individuals can look up their own postcode against their likely site change, which will also
depend on condition treated.
5.5 Public Sector Equality Duty
The Equality Impact Assessment (EIA) process is designed to ensure that a project, policy or
scheme does not discriminate against any disadvantaged or vulnerable people or groups.
This ensures CCGs pay ‘due regard’ to the matters covered by Public Sector Equality Duty.
The EIA will be completed in two parts, with the initial phase completed prior to consultation
and a second stage to be completed following the consultation outcomes.
The initial phase EIA focused on:
How the services will impact on protected and vulnerable groups in the community;
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How the CCGs and providers must ensure equality and fairness in terms of access to these services- and appropriate provision for all patients based on their clinical, personal, cultural and religious needs; and
How the CCGs will work together with local providers and patients and carers to ensure a high quality of services that all patients can experience.
The majority of vulnerable or protected groups identified as part of the EIA have been judged
as achieving greater equality, improved outcomes or increased accessibility through the
proposal. For example, both inpatient and community developments will provide improved
disabled access for service users, staff and visitors. For many other groups, the purpose
built facilities offer an improvement in therapeutic environment, access to outdoor space and
care delivered closer to home.
At this stage, the EIA has identified the potential increased travel time for some disabled
service users as the only vulnerable group that may experience a reduction in accessibility.
In order to minimise this risk, route planning to the new site will be provided and shared with
local community groups for individuals with disabilities. Parking spaces for disabled service
users will be available on the current Highgate site of the Whittington Hospital.
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6 Governance
6.1 Governance structure for the consultation process
The consultation phase of the redevelopment of the St Pancras site is being overseen by the
St Pancras Hospital Redevelopment Oversight Group and led by the Chief Operating Officer
of ICCG (Figure [6.1]). This group is reporting to both of the CCGs in addition to providing
assurances to NHS England. NHSE representatives also have positions within a number of
the groups relevant to the redevelopment to ensure adherence to rigorous NHSE guidelines
for consultation. These arrangements are for the consultation phase only, with full project
governance details being set out in Section [9].
In order to proceed to public consultation, the process requires approval from the CCGs
Governing Bodies and NHSE. To support this decision, the CCG Governing Bodies will
review the proposed consultation document, consultation methodology (including the
Equality Impact Assessment (EIA) and Quality Impact Assessment (QIA)), financial
modelling and consider the response from the Clinical Senate. Camden and Islington Local
Authority’s Heath and Care Overview and Scrutiny Committees will be also be provided an
opportunity to review and comment on the consultation process prior to launch.
Figure [6.1] Public Consultation Governance Structure
A full break down of these consultation groups is provided below.
Figure [6.2] Membership of consultation groups
Group Lead Members Reporting to
St Pancras Hospital Redevelopment Oversight Group
Chief Operating Officer, Islington CCG
Transformation Programme Director, the Trust Islington CCG Camden CCG NHSE
CCG Governing Bodies and NHSE
Clinical Senate Liaison
Associate Director of Joint Commissioning for Islington CCG
Camden CCG Islington CCG Medical Director, the Trust NHSE
St Pancras Hospital Redevelopment Oversight Group
Public Consultation Working Group
Senior Engagement Manager,
Camden CCG Engagement Lead Head of Communications and
St Pancras Hospital Redevelopment
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Islington and Haringey CCGs
Engagement, the Trust Healthwatch Camden and Islington Service users
Oversight Group
Financial Modelling Work stream
Chief Finance Officer, North Central London CCGs
Trust Director of Finance – NHSE Finance lead
St Pancras Hospital Redevelopment Oversight Group
6.1.1 St Pancras Hospital Redevelopment Oversight Group
The overall redevelopment programme is managed by the St Pancras Hospital
Redevelopment Oversight Group and chaired by the Chief Operating Officer for Haringey
and Islington CCGs. This group has representation from the Trust, the CCGs (including
Engagement leads from each CCG) and NHSE. This group reports to CCG Governing
Bodies and in turn to NHSE.
6.1.2 Clinical Senate Liaison
The Clinical Senate Liaison group is led by the Associate Director of Joint Commissioning for
Islington CCG and is responsible for co-ordinating activities with the London Clinical Senate
(LCS). This group includes the CCG GP leads for Mental Health from Camden and Islington
and clinical representatives from CCGs, the Trust and NHSE. This group reports to the St
Pancras Hospital Redevelopment Oversight Group which in-turn reports to the NHSE locally
established Clinical Senate panel.
6.1.3 Public Consultation Working Group
The primary purpose of this group is to facilitate strong public engagement and ensure a
thorough and rigorous consultation is undertaken. All public consultation activities are being
managed by this group. The group is led by the Senior Engagement Manager for Islington
and Haringey CCGs and has support from the Camden CCG Engagement lead and the
Trust. Members from Healthwatch Camden and Healthwatch Islington and two service users
are members of this group. This group has inputted into the consultation document itself and
methodology.
6.1.4 Financial Modelling Work stream
This small working group consists of representatives from the Trust and NHSE and is led by
the Chief Financial Officer for the North Central London CCGs. This group is responsible for
providing financial insight and recommendations for funding of the redevelopment and also
report to the St Pancras Hospital Redevelopment Oversight Group.
6.2 Roles and Responsibilities
6.2.1 The CCGs
Approximately 98% of services provided at the St Pancras site are commissioned by
Islington CCG in their role as lead commissioner, with Camden CCG being a significant
Associate to the Islington CCG contract. As such, these CCGs will be the ultimate decision
making authority for the programme.
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6.2.2 The Trust
The Trust is leading on the SPH redevelopment proposal and working with stakeholders
such as NHSI, London Devo, NHSE, the Local Authorities, Service Users, staff and other
interested public bodies, including the CCGs to ensure plans are in line with individual
commissioner intentions and fit for purpose.
6.2.3 NHS England
NHSE are providing assurances and support at all levels of the programme, including
representation on many of the programme working groups.
6.3 Information Governance Issues
The Trust stores data about its patients that could identify each patient. This Patient
Identifiable Data (PID) can be classed as any information, electronic or paper format that
would allow a third party to identify the patient.
As a part of the proposed relocation, the Trust is not proposing to change the use, storage or
accessibility of any PID it holds. A Privacy Impact Assessment (PIA) screening questions
form was completed by the Trust (Appendix [4]) whereby the result indicated that a PIA was
not required.
The principal reasons include:
1. Trust staff will still be able to access data in the usual way via Care notes and N3 secure connection to digital records
2. Trust staff will still be able to access paper records through the Iron Mountain procedures
Should there be any changes to information privacy as a part of this proposal in the future;
the Trust will re-complete the PIA screening questions form to determine whether a PIA is
needed. The Trust’s Head of Information Governance and Security will be consulted closer
to the relocation to discuss shredding bins, privacy displays, and photocopier / scanner /
medical device locations.
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7 Stakeholder engagement
This section sets out the engagement that has been undertaken to date regarding the relocation of some services away from the St Pancras site and the development of community hubs. This includes the stakeholder groups who have been included as a part of the pre-consultation process, engagement activities undertaken and the findings from those activities. Moreover, it explains how this feedback has been used to develop the options detailed in Section [8] of this PCBC.
7.1 Legal Context
The requirements for Clinical Commissioning Groups to consult with patients and
stakeholders is set out in statute.
Regulation 23 of the Local Authority (Public Health, Health and Wellbeing Board and Health
Scrutiny) Regulations 2013, sets out the duty of health services to consult with Local
Authorities about any proposal for a substantial development of the health service in the
area of that local authority, or for a substantial variation in the provision of such service. The
Local Authority is entitled to make comments on the proposal to be consulted on. Paragraph
9 further sets out that the authority may report to the Secretary of State in writing where the
authority is not satisfied that consultation on any proposal has been adequate in relation to
content or time allowed or the authority considers that the proposal would not be in the
interests of the health service in its area.
Under section 242 of the NHS Act 2006 and section 142Z of the Health and Social Care Act
2012, NHS Trusts and CCGs have a legal duty to make arrangements for individuals to
whom the services are being or may be provided, to be involved (whether by being
consulted or provided with information or in other ways):
(a) in the planning of the commissioning arrangements by the group,
(b) in the development and consideration of proposals by the group for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them, and
(c) in decisions of the group affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact."
In order to meet these legislative requirements and the ‘four tests’ outlined in the Mandate
from the Secretary of State to NHS England and NHSE’s other tests, public involvement
must be an integral part of the service change process. Engagement should be early and on-
going throughout the process using a broad range of engagement activities.
The Clinical Commissioning Group (CCG) must make arrangements to secure that individuals to whom the services are being or may be provided are involved (whether by being consulted or provided with information or in other ways):
In the planning of the commissioning arrangements by the group;
In the development and consideration of proposals by the group for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them; and
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In decisions of the group affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact.
All public consultations should adhere to the Gunning Principles, which are:
Consultation must take place when the proposal is still at a formative stage;
Sufficient reasons must be put forward for the proposal to allow for intelligent consideration and response;
Adequate time must be given for consideration and response; and
The product of consultation must be conscientiously taken in to account.
7.2 Pre-consultation engagement on the case for change
The local health organisations have engaged with inpatient service users, community service
users, carers and staff as part of pre-consultation engagement work for the development of
the plans.
The local health organisations have met regularly as part of the Stakeholder Reference
Group, which is made up of senior representatives from the Trust, both CCGs and both
Councils. This group provides oversight and maintains responsibility for the pre-consultation
activities, consultation programme and implementation programme, including the review and
approval of business cases developed by member organisations. See Appendix [5] for a full
list of meetings conducted and pre-consultation engagement activities undertaken to date.
7.2.1 Pre-consultation engagement with service users and carers
The local health organisations have held a number of pre-consultation engagement events
to listen to the views of existing and previous service users and carer representation groups.
This has included:
The Trust’s medical director attending existing service user meetings to explain proposals and take questions;
The Nubian Service Users’ Forum and the Women’s Strategy Group are among the existing groups the Trust has engaged with;
A two borough community hubs event in March 2018, which attracted a diverse audience;
A Service User Alliance meeting on 31 March 2017; and
A Service User Conference on 13 April 2017.
At these meetings, senior leaders from the Trust provided information on the outline plan
and long list of options. Time was allocated for full debate, questions and feedback and this
has been logged and passed on for consideration. In addition, a survey was developed to
better understand the clinical and service priorities of service users in both the community
and inpatient settings. This was sent to all service users via email and copies were made
available in paper form at key meetings. Feedback from this survey is set out in Section [7.3]
below.
Some groups were asked to feedback on the positive aspects of the community services
they currently use, what could be improved, if they envisaged any problems if some
community services were based in the new hubs and if any problems were identified, what
the Trust could do to mitigate or minimise impact.
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Carers in both Camden and Islington have been given opportunities to hear more about the
proposals, to provide feedback and ask questions through a number of meetings throughout
2018. This includes the Islington Carers’ Hub and Camden Carers’ Hub. Healthwatch
Camden was also commissioned to attend the Camden and Islington carers meetings to
engage carers and listen to feedback.
Healthwatch interviewed 55 individuals comprised of current and former inpatients at SPH,
Highgate, staff and carers during February and March 2018.
7.2.2 Pre-consultation engagement with employees
Due to the potential workforce implications, the Trust have also completed initial
consultations with their staff and governors. This includes meetings with trade union
representatives and Governors and staff at key sites including St Pancras, HMHC, Lowther
Road and the Peckwater Centre.
Five clinical and technical design review workshops were also held to secure input from
approximately 30 clinicians on the optimal design of the estate in terms of both community
and inpatient facilities. See Appendix [5] for a full list of these meetings.
7.2.3 Pre-consultation engagement undertaken as a part of the STP
As a part of the STP process, a wide array of stakeholders was engaged that included CCG
Chairs, CCG Members, Clinical Cabinet, GPs, LINKs, Local Healthwatch, Local Authorities –
Health and Wellbeing Boards, Local Authorities – Lead Officers and Members, Provider
Trusts, OSC/JHOSCs and voluntary and community groups. Appendix [6] sets out how
these parties were engaged with and continue to contribute to the development and
implementation of the STP.
7.2.4 Pre-consultation engagement with GPs
The Trust’s Clinical Director and SPH programme director presented at a Camden CCG GB
seminar on 26 July 2017 and to Islington GB in July 2017. The Camden GB included the GP
chair of the locality meetings and an elected GP representative. The Islington GB includes
the GB Clinical Lead for Mental Health.
A written briefing was shared with Camden GPs in November 2017 and the medical director
is scheduled to present the Trust’s proposals at the CCG’s April 2018 locality meetings.
In March 2018 proposals were presented to the Islington GP Forum by the CCGs Clinical
Lead for Mental Health.
7.2.5 Pre-consultation engagement with the JHOSC
The London Boroughs of Camden and Islington are on the same committee of the North
Central London Joint Health and Overview Scrutiny Committee (“JHOSC”). The JHOSC
undertook a review of the SPH proposal in April 2017, September 2017 and March 2018.
At the 19 September 2017 JHOSC meeting, the redevelopment at the St Pancras site was
discussed, as part of the wider NHS Estates strategy. This meeting provided an opportunity
for the JHOSC to question and challenge current plans. A copy of the full minutes from this
meeting is in Appendix [7]. A summary of the points raised at this meeting includes:
Overall members welcomed the proposal to move inpatient facilities to the Whittington and agreed with the suitability of this site;
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Councillors would appreciate the opportunity to view the current site to assess the opportunities for Social Housing development and this was agreed at the meeting;
Following concerns raised that sale proceeds would be used for revenue spending, members were assured this would not happen;
The opportunity for surplus land to be used for GP surgery sites was raised as desirable;
Concerns were raise that the number of inpatient beds was not increasing. The Trust should ensure the justification for this is clear in the consultation; and
It was agreed that the Full Business Case would be presented to the JHOSC when appropriate.
The SPH Project Director presented at the JHOSC on 23 March 2018 with an update on the
SPH redevelopment project. The following was noted in the minutes which are yet to be
formally agreed:
It was agreed that further information would be provided at the June 2018 Camden and Islington OSCs by the Trust;
The London Estates Devolution team have been engaged and are being consulted but the SPH redevelopment would not require their approval;
It was agreed that the Chair of the Camden HOSC would be invited to the next SPH redevelopment programme board meeting, which for the first time would combine the separate boards of stakeholders and providers; and
There were no further concerns or issues raised about the proposal.
All review points raised by the JHOSC have been addressed and it should be noted that the SPH redevelopment is implementing the STP plan, to which the JHOSC contributed to.
7.2.6 Pre-consultation engagement with local people
The Trust has shared its proposals with local people through the St Pancras Community
Association and the Somers Town Neighbourhood Forum. Local people asked that
consideration is paid to what young people may need and the provision of jobs.
7.2.7 Pre-consultation engagement with other local stakeholders
The Trust has engaged with a number of local organisations including Healthwatch, Citizen’s
Advice Bureau, Voluntary Action Camden, the Old St Pancras Church, Octopus
Communities and the Holy Cross Centre Trust who provide support for people who are
socially excluded, for example, homeless.
7.3 Options appraisal engagement
As part of the options development (Section [8]), a series of meeting were held to get input
and understand the needs of stakeholders including health professionals, service users,
Local Authorities and the public (via Healthwatch meetings). The following options appraisal
engagement was incorporated into the options appraisal process, as set out in the next
section, up to the point of selecting the preferred option.
A brief summary of the options is set out below:
Re-provide inpatients at SPH;
Re-provide inpatients at Whittington site; or
Re-provide inpatients at St Ann’s Hospital.
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Each option had the same proposal for community services and other services as set out in Appendix [10] which is why they are not explicitly mentioned under each option above.
7.3.1 Overview
Key findings included:
Concerns over adequate consultation with service users;
Concerns over inpatient beds moving out of Camden;
Concerns over inpatient beds moving to St Ann’s site due to travel and accessibility issues;
Concerns over land disposal proposals of the SPH site; and
Concerns over the provision of appropriate services from the community hubs.
However, a consensus was reached on the preferred option: Moving the inpatient beds from St Pancras to a site in Camden or Islington, invest in community services through the two community hubs, build new facilities, and bring researchers and academics together on a single site at SPH. Specifically, the Healthwatch feedback indicated a unanimous agreement that the existing facilities at St Pancras Hospital are not fit for the purpose and the majority were in favour of the proposal.
7.3.2 Consulting with the service users
Local Healthwatch teams identified that service users felt strongly that there needed to be a
focus on consulting with current and ex-service users as part of the consultation.
7.3.3 Inpatient beds moving out of Camden
Concerns were raised in some service user groups about inpatient beds being moved away
from St Pancras and out of Camden – whether that be to Whittington Hospital or to St Ann’s
Hospital.
The ‘trade-off’, which reached a general consensus to be accepted by the majority of service
users, is that to resource the building of new warm, welcoming and therapeutic inpatient
spaces, beds would need to move from the high cost St Pancras site to one where a new
inpatient facility could be affordably built with additional revenue being directed towards
improving community services.
The Healthwatch engagement found a small minority said they would prefer to retain the
existing St Pancras Hospital. The central location and good transport links at St Pancras are
highly valued by many. However, depending on the specific circumstances for the individual,
a roughly equal number of respondents said a Whittington location would be easier for them
personally. Many people said they thought that the potential benefits of a new purpose built
hospital would outweigh any disadvantages associated with the re-location of the new site to
Whittington. The concerns about the Whittington location are almost exclusively related to
transport links and the walking distance to shops which in both cases are less convenient
than for St Pancras.
7.3.4 Inpatient beds moving to St Ann’s
Some service users with direct experience of the St Ann’s site raised concerns about the
possibility of inpatient beds moving there. There was concern mainly focused on the travel
challenges and general accessibility of the St Ann’s site. This concern is analysed in more
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detail through the travel analysis undertaken in Section [5.4] and also factored into the
options evaluation process in Section [8.4].
It was explained that the Trust would create its own buildings and deliver its own services. It
was also emphasised that the purchase of land at St Ann’s would be cheaper, enabling more
resources to be channelled into our community services. Relocating inpatient beds to St
Ann’s next to Barnet, Enfield and Haringey’s mental health inpatient site might allow for the
sharing of some facilities, such as an on-site gymnasium for example.
7.3.5 Land disposal proposal for SPH
Concerns were raised over the irreversible selling-off of ‘precious’ NHS resources, namely
the St Pancras site.
The mitigation includes the plan to offer some of the land to another NHS provider, as well
as sell a portion of the estate for the creation of affordable accommodation – with an element
being key-worker staff, potentially including Trust staff. It was explained that all existing
services remaining on the St Pancras site would no longer be viable beyond a certain point
in time, because without a substantial additional and continuing stream of finance it would
become unaffordable to either maintain and or replace existing St Pancras facilities to
ensure they were safe and fit-for-purpose.
7.3.6 Community care delivery
Service users highlighted confusion at the term “community hub”, confusing it with a
community centre. Part of the session was used to identify more suitable terms for the new
hubs. Going forwards, further engagement will be sought to define the community hubs in a
clear and consistent manner.
A need for a non-stigmatising and respectful environment that is considerate to different
cultures was highlighted. It was generally felt that more interventional services were required
to prevent a mental health crisis, namely a drop-in facility that is accessible to service users
so they have a place to go when they begin to feel unwell. It was felt that A&Es are
inappropriate and terrifying when suffering a mental health crisis with a preference for a
different “first port of call” option.
Equally, it was felt that more support is needed when an individual is out of crisis – which the
Trust needed to be more proactive rather than reactive. Although one service user stated
that some of the Trust’s proposed new locations could be more difficult for those with
mobility issues, if they did have to travel further, the majority view was that location was less
of an issue if services were good, improved and inclusive.
Some group members were particularly interested in the design of the buildings – asking that
they are Obsessive Compulsive Disorder friendly, not anxiety provoking in terms of design or
layout and present a more therapeutic environment with the right colours and plants. Others
said that there was a need to ensure the Trust had staff to support these new buildings –
people who have experience of the issues to talk to service users.
Most service users were generally positive about the proposed new facilities. The strongest
views were based on wanting services that were inclusive, resourced with knowledgeable
and compassionate staff and a non-stigmatising and welcoming environment. One service
user said: “Buildings need to feel more vibrant, don’t want to feel that we’re going to that
place”.
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7.4 Applying pre-consultation engagement findings to options appraisal
As part of the formal consultation process, the group of stakeholders who will be engaged
will be widened to include commentators and influencers such as local media, ward
councillors, NHS pressure groups and heritage bodies, as well as the wider local community,
including residents and businesses. Furthermore, Camden Healthwatch and Islington
Healthwatch will be commissioned to engage local people covering the nine protected
characteristics and other vulnerabilities. Accordingly, the range of methodologies will also be
expanded to cover targeted and ongoing engagement, across a range of channels, as
shown in Section [7.5.3]. Stakeholder mapping has been completed to ensure all interested
and relevant groups are captured.
The concerns raised through the pre-consultation engagement highlight the requirement for
full and contextual information to be provided alongside the options when undertaking the
formal consultation. Specific concerns raised will be incorporated in the consultation as
follows:
7.4.1 Consulting with current and ex-service users
The Trust’s Clinical Director will speak at all of the Trust’s service users’ groups to introduce the consultation, taking questions and letting people know how to fill it in (along with taking some hard copies).
Further targeted engagement using the consultation survey with service users across all five
of the Trust’s divisions – Acute, Services for Ageing and Mental Health, Recovery and
Rehabilitation, Substance Misuse Services and Community Mental Health. This will include
both current service users of inpatient services and community services.
7.4.2 Moving services out of Camden
This stresses the importance of ensuring the case for change is clear in all consultation
materials; emphasising not only the inadequate provision currently at the St Pancras site and
the premium paid on land there, but also the added value of the public pound when looking
at the alternative sites. The strategic case must be accessible to all stakeholders to ensure
this message is understood thoroughly.
Moving inpatient beds to the St Ann’s Hospital site in Tottenham, would mean moving them
out of the boroughs of Camden and Islington. The majority of pre-consultation engagement
activity points to individuals being not in favour of St Ann’s, saying it is a harder-to-reach
location for most people than the HMHC. We are therefore proposing we move the inpatient
beds to a new site at Whittington opposite the HMHC. This is consistent with the qualitative
scoring undertaken in Section [8] of the St Ann’s option and therefore will not form part of the
consultation.
7.4.3 Travel challenges
The concerns raised around travel times and access highlights the need for clear distance
and travel time information. To this end, travel analysis has been completed (see appendix
[3]) and provides interested parties the opportunity to understand the direct impact of a
move. This information will also be included in the consultation document and materials,
including publication on the CCGs and Trust’s websites.
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7.4.4 Sale of NHS Resources
This common concern is particularly emotive, and this issue must be handled sensitively
during the wider consultation to ensure the underlying strategy behind the move of some
services is clear. This also highlights that there should be some emphasis placed on the
number of services that will remain at the St Pancras site, alongside the proposed use of the
redeveloped space for NHS use; such as supported living accommodation, the Institute of
Mental Health and any space that will be utilised by other NHS healthcare providers.
7.4.5 Services in the Community Hubs
There will be opportunities for broader input on a range of issues. For example, to agree a
new name for the community hubs, ideas to generate this include a board where service
users can post suggestions and vote on a range of names. It will be a number of years
before community hubs opened, should the proposal go ahead, so there is ample time to
develop this with services users.
7.5 Other pre-consultation engagement activity
Following on from the above engagement activity, the Whittington site was selected as the
preferred option as set out in Section [8].
There has since been further engagement undertaken in the form of regular meetings with
service users, carers, Trust staff, JHOSC updates and meetings with NHSI and NHSE by the
local health organisations.
7.6 Consultation Plan
This section provides an outline of the plan for public consultation on the proposal. This plan
is in the process of review and is subject to change. The full consultation plan can be found
in Appendix [8].
7.6.1 Overview of the consultation plan
In line with statutory duties, both CCGs are required to involve the public on the redevelopment proposals, ensuring local people are given the opportunity to share their views on the redevelopment of the St Pancras Hospital site and all of the services affected. As the proposals represent a significant change in service provision, the CCGs have chosen to formally consult on the proposals.
The redevelopment of the site will affect the inpatient facility, the community services both on
the site and on additional Trust sites, along with NHS services which are delivered on the St
Pancras Site by other NHS Providers such as the Royal Free Hospital. A summary of
service changes can be seen in Section [1].
7.6.2 Summary of planned activities
In light of these plans, Islington CCG is proposing to run a public consultation for 12 weeks
starting in early July 2018 to the end of September 2018.
A draft consultation document, questionnaire and Frequently Asked Questions have been
developed and can be found in Appendix [9]. These will be finalised and approved by CCG
GBs in June 208. The consultation aims to:
Understand the views of the local community on the development of two new mental health community hubs, one in Camden and another in Islington.
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Understand the views of the local community on the relocation and development of new Camden and Islington NHS Foundation Trust mental health inpatient services from the St Pancras Hospital site to a site by HMHC and Whittington Hospital; and
The CCGs will speak to as many people in the local community as possible, ensuring they
hear from a wide range of service users of all of the services proposed for relocation, the
local community, local voluntary organisations and the two local Healthwatch as well as
other key stakeholders such as local Councillors and MPs.
7.6.3 Consultation communications and engagement channels
The channels used to share the consultation and gather as many views as possible are set
out in Figure [7.1].
Figure [7.1]: Communication channels for the consultation
Channels Implementation assumptions
Websites/online media A full consultation document containing a survey about the proposals will be available on Islington CCG, Camden CCG, and the Trust and Healthwatch websites. Prompts placed on the Trust social media channels will advise on how to leave feedback and join the public consultation meetings
Paper copies Copies of the full consultation will be available at each service affected by the St Pancras redevelopment, at other Camden and Islington Foundation Trust sites and upon request. Posters and leaflets in all 30 Trust sites will advise on the consultation and opportunities for feedback. Paper copies of the survey will also be available at each site. All paper publications will be in an easy to read format, with copies available in large print, easy read, community languages, braille and audio on request. There will be a dedicated telephone line for local people either requesting the consultation documents or any questions they may have.
Public meetings Held at easily accessible sites for people in Camden and Islington to discuss and provide feedback on the consultation. There will be a drop-in session with the Trust’s Clinical Director.
Focus groups Healthwatch Camden and Healthwatch
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Islington will be commissioned to undertake targeted research with groups that face barriers to accessing services and do not traditionally have their views heard in service redevelopment.
Staff Engagement Trust and CCG staff will be updated on the consultation via staff meetings and staff newsletters. GP member practices will also receive regular updates in GP forums, locality meetings and GP newsletters.
NHS Provider Roadshows Targeted engagement using the consultation document and survey with the services users of the other NHS providers affected by the proposed redevelopment.
Targeted Interventions Using the EIA to identify disadvantaged or vulnerable groups, the Trust will support the CCGs to consult with these groups.
Further targeted engagement using the consultation survey with service users across all five of the Trust’s divisions – Acute, Services for Ageing and Mental Health, Recovery and Rehabilitation, Substance Misuse Services and Community Health. This work will be carried out by Healthwatch Camden.
Local networks The consultation document and survey will be shared with local groups for distribution amongst their members, including Islington Patient and Community Groups, Trust Service User Groups, Patient representatives, local voluntary and community sector groups.
As mentioned in Section [7.4], following pre-consultation engagement feedback, the Trust’s
Clinical Director will attend all service user groups to introduce the consultation, and service
users across the Trust’s five divisions will be targeted with surveys.
7.6.4 Proposed consultation timeline
The table below (Figure [7.2]) provides an overview of the primary consultation activities and
communications planned.
Figure [7.2]: Timeline for Consultation Activities
Action
Lead Date
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Consultation documents and methodology sign off
Islington CCG Governing Body
June 2018
Camden CCG Governing Body
June 2018
Consultation documents and methodology reviewed by Camden and Islington Health and Overview Scrutiny Committees
ICCG and CCCG
June 2018
Public consultation goes live ICCG early July 2018 to end September 2018
Evaluation of responses External agency
October 2018
Results of consultation published and shared
Islington CCG, Camden CCG, the Trust and partners
November 2018
Final Business Case prepared
Islington CCG
November 2018
Consideration of Final Business case by Islington CCG Governing Body
Islington CCG
November 2018
Consideration by Camden CCG Governing Body
Camden CCG
November 2018
A decision is made by Camden and Islington CCGs on the final Business Case
Camden and Islington CCG
November 2018
The decision is communicated with the local community, HOSCs, Healthwatch and partners
Islington CCG / Camden CCG / The Trust
November 2018
7.6.5 Results, feedback and analysis
The CCGs will appoint independent partner (third party agent) to evaluate the consultation
responses and to analyse the results of the consultation. The partner will develop a process
and infrastructure that reassures stakeholders of the independent nature of the evaluation.
This will inform proposals in a Decision-Making Business Case (“DMBC”) that will validate
the consultation outcomes.
Following the closure of the consultation on in September 2018, the evaluation team will
have a period to analyse the results and present these to both of the CCG Governing
Body’s.
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Islington and Camden CCGs will then make a decision on whether to proceed with the redevelopment proposals and confirm this decision to NHS England and both OSCs for Islington and Camden.
The results will be available publicly, which will include, sharing on CCG and Trust websites
and sharing through other stakeholders’ networks, such as Healthwatch Islington and
Camden.
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8 Options development, analysis and evaluation process
This section sets out the range of options identified to address the objectives set out in the
Case for Change and documents the appraisal process used to evaluate these.
The local health organisations have developed a four-stage process (Figure [8.1]) for the
identification of a preferred option from a long list of options. This includes:
1. An initial feasibility study;
2. The development and application of a set of ‘hurdle’ Critical Success Factors (CSF)
to create a short list of options;
3. The development and application of a more detailed set of qualitative CSFs to
appraise short-listed options; and
4. A value for money assessment of the short-listed options.
The outcome of this process is to enable the local health organisations, through the St
Pancras Hospital Redevelopment Oversight Group, to determine preferred options for each
area that will be subject to full public consultation.
Figure [8.1]: Overview of option evaluation process
8.1 Option development
In advance of developing options for the St Pancras site, a process was run by the local
health organisations, incorporating service user input, to decide the appropriate setting for its
services; see a summary in Appendix [10]. This work concluded:
Set 1: Certain services, as set out in Appendix [10], should be provided in community hubs off site (including on existing Trust owned sites at Greenland Road and Lowther Road);
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Set 2: Other services, again as set out in Appendix [10], should be provided on the St Pancras site to maintain a presence in the area and to enable the Institute of Mental Health; and
Set 3: Inpatient services should be re-provided on or off site.
Therefore, all options to be developed, bar the ‘do minimum’ benchmark option, will include
the Set 1 services being provided off the St Pancras site and all options include the Set 2
services being provided on the St Pancras site. The key variable between options is
therefore the location of the re-provision of inpatient services (Set 3).
8.2 Appraisal 1: Feasibility Study
As lead comissioner, 98% of services provided at the SPH are comissioned by Islington
CCG, for the population of the London Boroughs of Camden and Islington, where the
majority of patients come from. Therrefore, the focus of the sites search was primarily within
the Camden and Islington boroughs to ensure continuity of provision, access for service
users and building on the support gained to date from the two councils for this propoal. This
is consistent with the pre-consultation engagement feedback receied as set out in Section [7]
which detailed concerns around time travel to a new location.
To allow the Trust to support its current cohort of service users effectively, sites were only
considered if they were within the boroughs of Camden or Islington, unless there was an
exceptional reason for their inclusion. For example, St Ann’s Hospital was included at
Strategic Outline Case (SOC) stage as it was identified that the Trust who owns that site
(Barnet Enfield and Haringey Mental Health Trust) had land available next to their existing
mental health facilities which are located approximately two miles away from the Islington
boundary.
The following types of site were considered:
Surplus council owned land in Camden or Islington;
Sites owned by other government bodies which are being decommissioned;
Sites owned by neighbouring NHS providers; and
Privately owned sites.
Following identification of the long list of options, these were then screened for viability and
site availability. This process was led by the Project Director and Transformation Programme
Director in dialogue with local stakeholders and real estate consultants, GL Hearn. This
assessment was presented to the Boards of the local health organisations for consideration
and approval as summarised in Appendix [11].
The Boards reviewed the proposed screening of the long list and validated the options to be
taken forward to the next stage of evaluation via the CSF process. A detailed description of
the options considered can be seen in Appendix [12].
8.3 Appraisal 2: Hurdle CSF
The purpose of Hurdle Critical Success Factors (CSFs) is to eliminate options that are not
able to satisfy any one of the three hurdles, using a binary pass/fail process. As such the
hurdle objectives are critical success factors that must be delivered for the project to
succeed. These were developed with service users and carers, and were enhanced
following pre-consultation engagement feedback around the need to minimise disruption for
any inpatients. Figure [8.2] sets these CSFs out in more detail.
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Figure [8.2]: Hurdle Critical Success Factors (CSFs)
# CSF Key points
1 CQC
requirements
The option provides a safe environment for service users and
staff. Facilities must as a minimum meet all CQC requirements,
and ideally exceed them.
2 Minimise service
user disruption
The option does not require inpatient facilities to be moved more
than once and minimises disruption to services users. This is
critical due to the nature of the services delivered.
3 Research and
development
The option supports and facilitates the creation and successful
operation of a research and development institute closely
integrated with a top research university.
The four options were then assessed against the three hurdle CSFs as shown below.
Figure [8.3]: Results of Hurdle CSF evaluation
# Option Name
Hurdle CSF
1
CQC
requirements
Hurdle CSF
2
Minimise
service user
disruption
Hurdle CSF
3
Research
and
development
Progressio
n to
qualitative
CSFs
A1 Do minimum with inpatients
For
comparison
only
A2
Re-provide inpatients at
SPH
For Net
Present
Cost (NPC)
comparison
only
A3 Re-provide inpatients at
Whittington
Yes
A4 Re-provide inpatients at St
Ann’s Hospital
Yes
As shown above, the following decisions were made about which options to take forward to
the qualitative CSF appraisal:
Option A1, (Do minimum with inpatients) is not a viable option on the basis that it failed to meet any of the hurdle criteria. However as this provides the baseline comparison it was progressed to the shortlist for evaluation purposes only as a benchmark for the other options in line with NHS capital business case requirements.
Option A2, (Re-provide inpatients at SPH), failed to meet the hurdles as it will cause significant disruption to service users during construction, particularly the large amount of heavy traffic movements and demolition that would be required. There is also concern that privacy and dignity could be compromised on St Pancras for inpatient services, as there are approved development plans around St Pancras are for tall residential blocks (up to 12 storeys) with balconies overlooking the site, and therefore over any inpatient
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facilities gardens or outdoor areas. In addition, the reduction in value of the St Pancras site under this option was found to make it the least affordable and to provide the worst value for money. This option will be considered in the quantitative analysis of net present costs for comparison purposes only in line with an approach agreed with NHS Improvement (NHSI).
Option A3, (Re-provide inpatients at Whittington), was progressed based on meeting all of the hurdle criteria.
Option A4, (Re-provide inpatients at St Ann’s Hospital), was progressed based on meeting all of the hurdle criteria.
8.4 Appraisal 3: Qualitative CSF
A total of nine further qualitative CSFs were jointly identified and agreed between the local
health organisations, service users and carers. These criteria were judged to be important to
the provision of mental health services but would not cause the project to be unachievable in
their own right.
Figure [8.4]: Qualitative Critical Success Factors (CSFs)
# CSF Key points
4 Quality of service
user care
The option enables the Trust to deliver the highest possible
standards of care quality to service users.
5 Aligned to
service user need
and supportive of
the clinical
strategy
The option enables alignment of clinical service location to the
needs of the population it serves.
The option supports the Trust and the wider STP objectives for
early intervention in community settings.
6 Destigmatise
mental health
The option enables services to be provided in a setting which
destigmatises mental health services, creating an attractive
welcoming environment for service users.
7 Promotes
equality
The option provides facilities which are accessible to all users
and helps to promote equality for service users, staff and wider
stakeholders.
8 Integrated care The option enables integration of mental health service provision
with other healthcare provision.
9 Located with in-
borough or close
to Camden and
Islington
The option provides new facilities which are based in either the
London Borough of Camden or the London Borough of Islington,
or if this is not possible, as close as possible to the Boroughs.
10 Support staff
wellbeing
The option supports staff health and wellbeing, including the on-
site provision of staff wellness services (e.g. fitness classes,
changing rooms and staff faith rooms).
11 Consistent with
the NCL STP
The option aligns with the plans set out in the STP and facilitates
delivery of the STP. It supports and enables wider plans for
other Trusts in NCL including proposed relocation of Moorfields
12 Consistent with
plans for local
community and
The option aligns with local authority and community plans for
place and area development, including the provision of housing
for local people, employment opportunities and environmental
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place
development
benefits
The agreed list of CSFs was evaluated by the local health organisations to establish the
appropriate weighting. It concluded that all CSFs should carry equal weighting as there were
no ‘mutually exclusive’ or ‘conflicting’ factors. The CSFs which were regarded as constituting
an absolute requirement were additionally designated as ‘hurdles’.
8.4.1 Application of the Qualitative CSF
The key themes from the quality assessment scoring workshops can be seen in Appendix
[13]. The scores across the workshops were averaged to establish a total overall ranking.
The detailed option scores arrived at during each workshop is also set out in Appendix [14].
The qualitative options evaluation was carried out by scoring each of the four options against
the CSFs, including the hurdles. The option scoring was carried out by the following three
groups, for which further information on the members is included in Appendix [15].
The Clinical Reference Group;
The Trust Board; and
The Trust Governors.
On each occasion the committees carrying out the scoring were briefed on the options under
consideration and provided with a summary of the options. The scoring was carried out in
small groups and the options were scored between 0 and 4, with 4 being the highest score.
This was done for the three Hurdle CSFs and the nine other CSFs (12 in total). The scores
were then averaged across the different groups to give an average score out of 48.
8.4.2 Pre-consultation feedback
As laid out in Section [7], the local health organisations completed a range of pre-
consultation engagement with key stakeholder groups, such as service user and carer
representative groups and Healthwatch teams since March 2017 and will continue to do so
throughout the pre-consultation phase. The findings of these preliminary consultations will be
used to further shape options, as a good indicator of user and public acceptability of options.
Of the three key themes identified during the consultation activities was a particular concern
over the accessibility of the St Ann’s site and also the potential loss of identity by moving
alongside another mental health Trust. The integrity of the service’s identity can be an
emotive and important factor for service users and staff. Consequently, when measuring the
St Ann’s site against the Whittington site, the Whittington site was preferred as a direct result
of pre-consultation engagement activities.
8.4.3 Summary qualitative evaluation of options
Overall, option A3 (rebuild at the Whittington) has the highest average score, and therefore
highest rank, leading it to being selected as the preferred option from a quality perspective.
The key drivers of this are:
Whittington is more accessible and geographically better located for service users, their families and staff;
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Whittington will deliver significant benefits to service users through delivering a better clinical environment and a more relaxed suburban community with green space;
Whittington has good transport connections;
The Whittington site is located close to the existing HMHC which provides opportunity for a stronger staff community and joint training;
The Whittington is an inpatient community hospital, with acute services and an A&E. This means that service users will benefits from comprehensive holistic care on one site;
Whittington is in the borough of Islington, with other current in-patient beds located at HMHC in the borough of Camden, and is therefore supported by both the local authorities and the STP; and
The Whittington site enables the construction of the Institute of Mental Health on the SPH site and maintains close links with the Community Hubs.
8.5 Appraisal 4: Value for Money evaluation of options
8.5.1 CCG impact
The financial appraisal was undertaken by the Financial Modelling Work stream that is led by
the Chief Financial Officer of the North Central London CCGs, (Section [6.1]). The impact
was found to not be significant as the commissioning arrangement between the CCGs and
the Trust is not one that is directly impacted by any changes in activity (such as Payment by
Results arrangements) and instead is based on an agreed settlement for providing mental
health services in the region (‘block’ payments). There is no change expected therefore in
the financial forecast of either of the CCGs as a result of these proposals.
8.5.2 Trust Impact
8.5.2.1 Economic assessment of options The quantitative evaluation of the options was carried out by KPMG and a specialist long
term financial model consultant (‘Assista’). They worked with the finance team from the
Trust to verify the current financial status of the Trust, as the starting point for the model.
The Trust’s finance department worked with Assista to understand what the income and cost
of providing services would be going forward, without any changes to the delivery model.
This analysis was based on information in the STP and the Trust’s understanding of future
funding and likely demand for the Trust’s services as described below.
They worked together to understand the implications of each options, including the do
minimum option. This included an evaluation of the risk that a forecast benefit was only
partially delivered or not delivered at all.
8.5.2.2 Outcome of quantitative assessment of options For the quantitative assessment, the project costs (capital, revenue and lifecycle), benefits and risks were calculated for the Trust cash flows under the different options in accordance with relevant guidance by independent technical consultants (Turner and Townsend (T&T)).
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8.5.2.3 Net present cost (NPC) assumptions The Department of Health and Social Care Template Generic Economic Model (“GEM”) was
used to generate the Net Present Cost (“NPC”) and Equivalent Annual Value (“EAV”).
8.5.2.4 Capital Costs The Trust and its technical consultants have developed a schedule of accommodation and
functional requirements based on the scope agreed with the board to deliver the vision and
consistent with the analysis of the bed requirement in Section [5.1.9] of the model of care.
This has supported the development of initial designs for the four options being considered
in this phase. The capital costs of all options have been developed by T&T and are
summarised in the figure below.
Option A1 (Do Minimum) has been based upon the latest estimate of backlog maintenance
which is attached at Appendix [16]; therefore, no specific additional capital has been
considered.
Figure [8.7]: Capital costs for each option
8.5.2.5 Operating costs and lifecycle An LTFM has been produced for each option that covers the period from 2017/18 to
2025/26. This was used as the basis of the operating cost assumptions for that period.
Beyond that period, it was assumed that costs were flat in real terms.
8.5.2.6 Quantifiable benefits The Trust has sought to quantify the public benefits that the proposed development will
deliver to the local and wider community as well as NHS. To do this, members of the project
team reviewed the benefits identified to set out those benefits that were able to be
quantified. The Trust worked through the list of potential benefits with input from clinicians
delivering the services.
Once benefits were identified as quantifiable, they were considered either as a reduction in
cost or an increase in income. Where benefits were reducing costs, full consideration was
given to the cost at present and to the impact that the change would have on that cost.
Where an additional income stream was identified this was valued based on past experience
Reconciliation of costs from LTFM to GEM Option A1 Option A2 Option A3 Option A4
£000sDo minimum
Reprovide IP
at SPH
Reprovide at
Whittington
Reprovide at
St Anns
Total incremental capital cost per LTFM - 124,345 135,845 117,693
Less: transitional fees capitalised - (4,852) (4,852) (4,852)
Less: land acquisitions - - (14,460) (4,000)
Less: decant costs - (589) - -
Nominal capital investment (nominal) - 118,904 116,533 108,841
Discount nominal to real (17/18 prices) - (10,036) (8,501) (7,923)
Less: Planning contingency (real) - (7,371) (7,555) (7,123)
Less: VAT (real) - (18,145) (18,005) (16,820)
Real capital investments (less contingency
and VAT) - 83,353 82,472 76,975
Discount real to NPC - (9,580) (8,228) (7,664)
Capital investment NPC per GEM - 73,773 74,243 69,311
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and current benchmarks. Once the benefit was identified the period when it is most likely to
have an impact was agreed an applied to the model, there were then discounted where
appropriate in the model.
Appendix [17] summarises the benefits identified, the value of those benefits and the key
assumptions associated with those benefits.
8.5.2.7 Net Present Cost summary The figure below sets out the outputs of the assumptions given above for the four options.
As described above, Option A1 and Option A2 are only provided for comparative purposes
as both have failed the Trust’s Hurdle CSFs.
Figure [8.9]: NPC calculations of the options
As shown above, Option A3 (rebuild at Whittington) has the lowest net present cost, slightly
ahead of Option A4 (rebuild at St Ann’s) and therefore is ranked as the preferred option from
a NPC perspective. Whilst the initial capital investment is slightly higher for this option the
operational savings delivered through co-location with both mental health and acute facilities
at the Whittington has driven this outcome (see benefits above).
8.6 Combined appraisal
The quality ranking has been averaged with the quantitative NPC ranking in the figure below.
This resulted in option A3 (build a new inpatient facility at Whittington) being identified as the
preferred option.
Net Present Cost (NPC) Option A1 Option A2 Option A3 Option A4
£000sDo minimum
Reprovide IP
at SPH
Reprovide at
Whittington
Reprovide at
St Anns
Property and opportunity cost 71,770 36,781 34,963 25,827
Initial capital investment - 73,773 74,243 69,311
Other capex - - - -
Lifecycle and business as usual capex 59,413 59,413 59,413 59,413
Total capex 131,183 169,967 168,619 154,551
Fees - 4,349 4,349 4,349
Total transitional costs - 4,349 4,349 4,349
Operating costs 3,078,767 2,978,245 2,958,380 2,973,361
Working capital adjustments (6,875) (7,616) (7,635) (7,635)
Total opex 3,071,893 2,970,630 2,950,746 2,965,727
Externalities - - - -
Total NPC (unadjusted) 3,203,076 3,144,946 3,123,715 3,124,627
Total Risk Adjustment 73,370 90,625 92,407 93,219
Trust total (risk adjusted) 3,276,446 3,235,572 3,216,121 3,217,846
Rank 4 3 1 2
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Figure [8.10]: Combined rankings of the Options
The option to build a new inpatient hospital facility on land vacated by the Whittington
Hospital is the preferred option from both the quantifiable and qualitative appraisal. Trust
clinicians also believe that the Whittington option delivers the closest alignment to the clinical
objectives of the STP and the Trust’s Clinical Strategy.
8.7 Impact of the preferred option
8.7.1 Quality Impact Assessment
A Quality Impact Assessment (QIA) process was developed and led by the Clinical Work-
stream Group for the preferred option to evaluate the impact on quality of care. This was
developed in partnership with clinicians at the Trust to ensure it provides an accurate
reflection of the changes to service delivery.
Specifically, the QIA of the proposed redevelopment will provide assurance that any
resultant reconfiguration services will not adversely affect the quality of service user care.
This is defined by NHS England as care that is clinically effective, safe and that provides as
positive an experience for service users as possible
8.7.2 Independent review
The Clinical Senate Liaison Group was established as part of the pre-consultation phase to
ensure proposals are independently reviewed and guided by NHSE Clinical Senate. Clinical
Senates provide independent strategic advice and guidance to commissioners and
stakeholders regarding healthcare provision. A request for advice from the London Clinical
Senate (LCS) was requested on 29 February 2018 by Islington CCG, with support from both
the Trust and Camden CCG. The LCS request sought guidance on:
Whether the change of environment will improve clinical care for inpatient and
community services;
Whether the proposals for changes to inpatient and community mental health
services:
Preferred option analysis Option A1 Option A3 Option A4
Do minimumReprovide at
Whittington
Reprovide at
St Anns
Quantifiable appraisal
Total risk adjusted NPC (£m) 3,276.4 3,216.1 3,217.8
Total risk adjusted EAC (£m) 121.0 118.8 118.8
Qualitative benefits (weighted scores)
Weighted benefits score 18 42 28
Quality points per EAC 0.149 0.354 0.236
Quantifiable appraisal 3 1 2
Qualitative appraisal 3 1 2
Points per EAC 3 1 2
Preferred option 3 1 2
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o will enable improvements in clinical care and quality benefits for patients
o are informed by best practice
o align with national policy and are supported by STP plans and commissioning
intentions;
Whether the approach ensuring the inpatient demand of population growth is
absorbed by the development of mental health community services.
The Local Clinical Senate will complete its work in June 2018. The recommendations will be shared with the CCG Governing Body’s for to ensure recommendations are addressed.
NHSE conducts a series of assurance tests including financial assurance which will be required before CCGs can launch the public consultation.
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9 Finance case
9.1 Introduction
The purpose of the financial case is to set out the impact of the preferred option on the
CCGs and Trust’s financial performance and position and to show the impact of the key
financial risks. This is important as it demonstrates the options being considered for
consultation are sustainable financially.
9.1.1 CCG impact
Contracts are in place between Islington and Camden CCGs and C&I until March 2019. The
CCG resource settlement runs through until 31 March 2021. Beyond 2020/21 growth
assumptions are not available. The assumption is that activity growth will be between 0.7%
and 1.7% across the two main CCGs between now and 2025/6. This is an average of +1.1%
per annum compound annual growth rate across the period.
CCG growth rates are as below:
FY 16/17 FY 17/18 FY 18/19 FY 19/20 FY 20/21
%age uplift %age uplift %age uplift %age uplift %age uplift
Camden 1.4 0.2 0.1 0 1.5
Islington 2.2 2.7 2.7 2.7 3.7
Camden’s average growth over the three remaining years is +0.5% per annum and Islington’s is +3.0% per annum, or an average of +1.7% across the two CCGs. The Trust’s growth assumption is based on a range of 0.7% to 1.7% per annum; which is less than CCGs growth assumptions. It is recognised that commissioners will fund different providers of mental health services at different rates of growth within their allocations, subject to overall compliance with the mental health investment standard. Both of the CCGs have reviewed the activity and financial modelling undertaken by the
Trust. The CCGs are assured that the underlying assumptions behind the activity and
income are consistent with their own projections, and the wider STP expectations.
Specifically, the Chief Financial Officer for both Camden CCG and Islington CCG
corroborated the financial information presented below with the Director of Finance for the
Trust. Most of the commentary in the section below therefore focuses on the impact on the
affordability of the proposals to the Trust as a provider – the Trust will see substantive
impacts on its cost base, balance sheet and cash flows as a result of the proposals in this
document.
9.1.2 Provider impact
The impacts of the proposals impact almost exclusively on the Trust in terms of providers
and therefore the system affordability of the proposals can be shown by setting out the
position for the Trust. This section sets out what those impacts are from a financial
perspective and that the preferred option is affordable for the Trust.
For the purposes of this analysis, affordability is defined as:
ensuring that the Trust has the cash required to complete the estates programme;
having sufficient cash to cover the Trust’s working capital requirement throughout the ten-year period (assumed to be two months of operating costs, circa £20.0m);
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the Trust being forecast to have a sustainable positive net surplus position by the end of the period considered; and
the Financial Sustainability Risk Rating (FSRR) will be at least 3 in all years when appropriate adjustments are made for the impact of bridge financing.
This section of the business case:
Shows the financial forecast of the investment case, with an analysis of the incremental impact against the baseline (do minimum) case;
Shows that the preferred option is affordable in the base case.
9.2 Basis of preparation
The projections in this section have been prepared on the following basis:
The Trust has completed NHSI’s 10-year Long Term Financial Model (LTFM). In line with the approach agreed with NHSI, 2016/17 was the outturn year used based on the forecast outturn at month 11 that had been submitted to NHSI. Separate models were populated for the baseline and the preferred option and a comparison of the outputs was used to assess the incremental impact.
The assumptions for the baseline case (do minimum) were based on a revised version of the Trust’s annual operating plan over the ten-year LTFM period.
The costs of the investment and associated operating and financing costs were obtained from the Trust’s facilities building cost model.
9.3 Financial projections
A series of assumptions have been used to forecast the Trust’s Income & Expenditure (I&E),
Balance Sheet and Cash Flow statements. These are set out in Appendix [18].
The figures presented in the financial case may differ from those presented in the economic
case due to discounting. The financial case figures are all nominal and not discounted,
whereas the economic case figures are discounted.
9.3.1 Income and expenditure
The Figure below sets out the Trust’s projected income and expenditure under the
investment case. This covers the period of construction (from 2018/19 to 2021/22) and the
following three years of steady state operations.
The incremental impact of the investment over the baseline is shown further below (the full
baseline income and expenditure is set out in Appendix [19]). A bridge is also included,
which shows the incremental impact of the investment on the first full year of operation
(2022/23).
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Figure [9.1]: Projected income and expenditure for the investment case
The projected investment case income and expenditure shows that:
Income growth is driven principally by the underlying growth in contractual income from clinical services (from the CCGs), with inflation accounting for 33% of the increase. This growth is partially offset by the assumed loss of £0.8m Sustainability and Transformation Fund (STF) funding from 2019/2020.
Pay costs are forecast to remain at £97.0m in 2017/18, due to the underlying growth being matched by the Trust’s CIP programme (3.2% of pay costs in that year). In subsequent years pay CIPs are projected at between 1.2% and 1.5%, thereby only partially offsetting the underlying pay cost growth. The investment is projected to reduce substantive and agency staff costs by £1.6m from 2021/22. Any increases above this amount in line with recent government announcements are assumed to be funded and it is therefore assumed would not have an impact on affordability. This will be modelled at FBC stage, but the assumptions are set out in appendix 17.
Non-pay costs are projected to fall from £29.0m in 2016/17 to £27.6m in 2017/18 due to recurrent CIP savings of £2.2m in other expenses (8.4% of other expenses). The CIP target for other expenses is £0.8m per year thereafter. The investment is projected to generate savings in other expenses of £3.5m in 2021/22, increasing to £4.4m in 2025/26).
An impairment of £8.2m is projected upon completion of the building works in 2021/22. This is the result of the requirement to change the valuation method of the new building from a cost basis to depreciated replacement cost upon its completion.
As shown above the Trust remains in surplus throughout the projection period except for two years:
2020/21: the £ (0.1) m deficit is projected due to the increased finance costs incurred during construction, with the benefits not being realised until the building is completed in the following year.
2021/22: the £ (7.1) m deficit is projected due to the one-off impairment charge described above.
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26
Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Income
Clinical income 108.4 108.0 109.4 110.2 111.7 112.8 113.9 115.0 116.1 117.2
Research & training 19.2 19.1 19.3 19.3 19.3 19.3 19.3 19.3 19.3 19.3
Other income 9.0 9.0 8.8 8.0 8.0 8.0 8.0 8.0 8.0 8.0
Total income 136.6 136.1 137.5 137.5 139.0 140.0 141.1 142.2 143.4 144.5
Operating costs
Pay (97.0) (97.0) (98.1) (99.6) (101.2) (101.8) (103.4) (105.3) (107.3) (109.4)
Non-pay (29.0) (27.6) (27.4) (27.1) (26.0) (23.1) (22.4) (21.7) (21.3) (20.8)
Total operating
expenses(126.1) (124.6) (125.4) (126.7) (127.3) (124.9) (125.8) (127.0) (128.6) (130.2)
EBITDA 10.5 11.5 12.1 10.8 11.7 15.2 15.4 15.2 14.8 14.3
Impairment - - - - - (8.2) - - - -
Depreciation &
amortisation(4.7) (5.2) (5.4) (5.4) (5.4) (6.4) (7.9) (7.9) (7.9) (7.9)
Financing 0.1 0.0 0.0 0.1 (3.5) (3.5) (3.2) (2.8) (2.4) (2.0)
PDC (4.3) (4.3) (4.7) (4.8) (2.9) (4.2) (3.9) (3.5) (3.1) (2.2)
Surplus/(deficit) 1.7 2.0 2.0 0.7 (0.1) (7.1) 0.4 1.0 1.4 2.2
£m
89
Figure [9.2]: Incremental impact of the investment on income and expenditure
£m 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26
Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Income
Protected revenue - - - - - - - - - -
Research & training - - - - - 0.0 0.0 0.0 0.0 0.0
Other - - - - 0.0 0.0 0.0 0.0 0.0 0.0
Total income - - - - 0.0 0.0 0.0 0.0 0.0 0.0
Operating costs
Pay - - - - 0.3 1.5 1.9 1.9 1.9 1.9
Non-pay - - - - 0.8 3.5 3.8 4.2 4.3 4.4
Total operating
expenses - - - - 1.1 5.0 5.7 6.1 6.2 6.3
Earnings before Interest, Tax,
Depreciation and Amortisation
(EBITDA)
- - - - 1.1 5.0 5.7 6.1 6.2 6.3
Impairment - - - - - (8.2) - - - -
Depreciation & - - - - - (1.0) (2.5) (2.5) (2.5) (2.5)
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amortisation
Financing - (0.0) (0.0) (0.1) (3.7) (3.6) (3.3) (2.9) (2.6) (2.1)
Public Dividend Capital (PDC) - (0.3) (0.6) (1.3) 0.5 (0.9) (0.7) (0.4) - 0.9
Surplus/(deficit) - (0.3) (0.6) (1.4) (2.0) (8.7) (0.8) 0.3 1.1 2.5
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The incremental impact of the investment on income and expenditure described above shows:
The investment is projected to generate a marginal increase in income (£30,000 per year) from research and development and other income.
Pay and non-pay cost reductions are described above.
The investment is projected to increase EBITDA by £6.3m (recurrently) by the end of the projection period.
The impairment relates to the revaluation of the new building, as described above.
Depreciation on the new building is projected to start from 2021/22, as the building is brought into use.
The investment is projected to cause an increase in financing costs throughout the construction and operating phases. This relates to the cost of financing the bridging loan described above in Figure [9.2]. This is a short term loan that could be substantially repaid within five years but to be prudent the Trust has modelled as having a ten-year term.
The net impact of the investment is a deficit through construction from 2017/18 and into the first year of full operation (2022/23). As loan repayments reduce the financing cost, the investment is projected to yield a surplus from 2023/24.
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Figure [9.3]: Net deficit/surplus bridge between the baseline and investment cases at 2025/26
The £ (0.3) m net deficit forecast in 2025/26 for the baseline case is significantly improved in the investment case to a £2.2m net surplus. As
noted above, the additional financing cost is expected to fall to nil from 2026/27, further improving the investment case position over the
baseline case.
9.3.2 Statement of financial position
The investment case statement of financial position is set out below, along with the incremental impact assessed against the baseline case (the
statement of financial position for the full baseline case is included in Appendix [20]).
£(0.3)m
£1.9m
£4.4m £(2.5)m
£(2.1)m
£0.9m £2.2m
£(1.0)m
-
£1.0m
£2.0m
£3.0m
£4.0m
£5.0m
£6.0m
£7.0m
£8.0m
Baseline case2025/26 deficit
Pay costs Non-pay costs Depreciation &amortisation
Financing PDC Investment case2025/26 surplus
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Figure [9.4]: Projected statement of financial position for the investment case
The investment case projected statement of financial position shows:
The property, plant and equipment balance is projected to increase significantly in the construction phase from 2017/18 to 2021/22. An impairment of the new building of £8.2m is projected in 2021/21 as set out in the assumptions above. The sale of the St Pancras site is projected to be phased between 2022/23 and 2025/26, reducing the property, plant and equipment balance significantly in each of these years.
The trade receivables balance is projected to remain fairly constant, as no significant changes in trade receivables days are assumed.
Cash is projected to remain above the Trust’s requirement of £20.0m, which is sufficient to meet its working capital requirements. Cash is discussed further in the following section.
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26
Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Property, plant and
equipment122.1 137.7 139.6 142.4 213.0 231.1 208.6 185.7 162.8 125.8
Trade receivables 12.7 12.7 12.8 12.6 12.5 12.6 12.7 12.8 12.9 13.0
Other current assets 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4
Cash and cash
equivalents44.0 24.9 23.7 21.8 76.1 37.5 47.7 58.9 70.5 97.0
Total assets 180.2 176.7 177.5 178.2 302.9 282.6 270.4 258.8 247.6 237.3
Trade payables (6.8) (6.9) (6.9) (7.0) (6.8) (6.1) (6.0) (5.9) (5.8) (5.7)
Loans: current - - - - (12.5) (12.5) (12.5) (12.5) (12.5) (12.5)
Other current liabilities (18.1) (12.4) (11.2) (11.2) (11.2) (11.2) (11.2) (11.2) (11.2) (11.2)
Loans: non-current - - - - (112.5) (100.0) (87.5) (75.0) (62.5) (50.0)
Other non-current
liabilities(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0)
Total liabilities (24.9) (19.4) (18.2) (18.2) (143.0) (129.9) (117.2) (104.6) (92.0) (79.4)
Net assets 155.3 157.3 159.3 160.0 159.9 152.7 153.1 154.2 155.6 157.8
PDC 60.3 60.3 60.3 60.3 60.3 60.3 60.3 60.3 60.3 60.3
Retained earnings 42.8 44.8 46.8 47.4 47.3 40.2 40.6 41.6 43.0 45.3
Revaluation reserve 52.2 52.2 52.2 52.2 52.2 52.2 52.2 52.2 52.2 52.2
Total equity 155.3 157.3 159.3 160.0 159.9 152.7 153.1 154.2 155.6 157.8
£m
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The fall in the trade payables balance of around £1.1m between 2017/18 and 2025/26 is driven by the reduction in other expenses which form part of CIP savings. There are no significant changes in trade payables days assumed over this period.
A loan of £125.0m is projected to be drawn down in 2020/21 (current element: £12.5m, non-current element: £115.5m). As noted in the assumptions table, £125.0m is the amount required for the Trust to maintain a minimum cash balance of £20m, required for working capital. As shown below the Trust’s cash balance presents an opportunity to optimise these loan arrangements to improve the net surplus position and this will be considered further throughout the Trust’s business case process as part of the commercial dialogue with the Independent Trust Financing Facility (ITFF). The £125.0 value is based on a prudent approach to the timing of payments to the Trust for the St Pancras site. It will be revised downward if payments could be made available earlier.
The capital receipt from the redevelopment of the SPH site is expected to be greater than this. In the Trust’s OBC, a red book valuation has been undertaken as per NHSI and HMT guidance which presents a prudent value. Therefore, the risk of not achieving a level of capital receipt to cover the costs of the redevelopment is low.
Figure [9.5]: Incremental impact on the projected statement of financial position
The incremental impact of the investment on the statement of financial position shows the following:
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26
Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Property, plant and
equipment- 15.4 17.9 34.9 106.8 126.3 105.1 83.5 61.9 26.2
Cash and cash
equivalents- (15.6) (18.8) (37.2) 13.7 (27.5) (19.7) (10.4) (0.2) 25.5
Total assets - (0.3) (0.9) (2.2) 120.6 98.7 85.4 73.0 61.7 51.7
Trade payables - - - - 0.2 0.8 0.9 0.9 1.0 1.0
Loans: current - - - - (12.5) (12.5) (12.5) (12.5) (12.5) (12.5)
Loans: non-current - - - - (112.5) (100.0) (87.5) (75.0) (62.5) (50.0)
Total liabilities - - - - (124.8) (111.7) (99.1) (86.6) (74.0) (61.5)
Net assets - (0.3) (0.9) (2.2) (4.3) (13.0) (13.8) (13.5) (12.4) (9.8)
Retained earnings - (0.3) (0.9) (2.2) (4.3) (13.0) (13.8) (13.5) (12.4) (9.8)
Total equity - (0.3) (0.9) (2.2) (4.3) (13.0) (13.8) (13.5) (12.4) (9.8)
£m
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The property, plant and equipment balance increases during the construction phase, subsequently falling as the St Pancras site is sold.
The negative impact on the cash balance is managed through the projected loan draw down, so that the Trust maintains sufficient cash for its working capital requirement.
The trade payables balance is projected to decrease by £1.0m as a result of the CIPs enabled by the investment that reduce other expenses.
Loans are drawn down and repaid.
Retained earnings is lower in the investment case, principally due to the additional financing costs (£21.1m), additional depreciation (£11.1m) and impairment of the new building (£8.2m), which is partially offset by the improved underlying cost base (£30.6m).
9.3.3 Cash flows
Figure [9.6] below sets out the sources and uses of funding for the proposal on the Trust for the scheme. It can be seen that the funding is
provided through a source of land value from SPH, Tottenham Mews and Trust reserves.
[Figure 9.6]: Source and uses of funds excluding external financing
Sources of funds Uses of funds
SPH Land value 95.4 Land receipt for Trust space 5.0
Tottenham Mews 12.0 Land purchase 14.5
Hanley Road 1.0 New inpatient facility 59.0
Trust reserves 32.0 Community hubs 40.6
SPH hub 16.4
Fees 4.9
Total 140.4 Total 140.4
Figure [9.7] below shows the cash flow statements for the investment case. The incremental impact of the investment against the baseline case
is shown on the following figure and the full baseline cash flow statement is included in Appendix [21].
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Figure [9.7]: Projected cash flow statement for the investment case
The cash flow statements show the following:
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26
Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Surplus from operations 10.5 11.5 12.1 10.8 11.7 15.2 15.4 15.2 14.8 14.3
Movement in working capital
(Inc)/dec in NHS trade
receivables(1.3) (0.0) (0.0) 0.1 0.2 (0.1) (0.1) (0.1) (0.1) (0.1)
(Inc)/dec in non-NHS trade
receivables1.2 - - 0.0 (0.0) (0.0) - - - -
(Inc)/dec in other receivables 0.3 - - - - - - - - -
(Inc)/dec in prepayments (0.2) - - - - - - - - -
Inc/(dec) in deferred income 0.2 - - - - - - - - -
Inc/(dec) in provisions (0.3) - - - - - - - - -
Inc/(dec) in trade payables 0.0 0.1 (0.0) 0.1 (0.2) (0.6) (0.1) (0.1) (0.1) (0.1)
Inc/(dec) in other payables (2.1) - - - - - - - - -
Inc/(dec) in accruals 2.7 (5.7) (1.2) - - - - - - -
Net cash inflow/(outflow)
from operating activities
11.1 5.9 10.8 11.0 11.6 14.4 15.1 15.0 14.6 14.1
Capital expenditure (4.2) (20.7) (7.3) (21.2) (76.0) (32.7) (4.5) (4.1) (4.1) (4.1)
Proceeds on disposal of PPE - - - 13.0 - - 19.1 19.1 19.1 33.2
Net cash inflow/(outflow)
from investing activities
(4.2) (20.7) (7.3) (8.2) (76.0) (32.7) 14.6 15.0 15.0 29.1
Dividends paid (4.1) (4.3) (4.7) (4.8) (2.9) (4.2) (3.9) (3.5) (3.1) (2.2)
Net interest (paid)/received 0.1 0.0 0.0 0.1 (3.5) (3.5) (3.2) (2.8) (2.4) (2.0)
Drawdown/(repayment) of
loans- - - - 125.0 (12.5) (12.5) (12.5) (12.5) (12.5)
Net cash inflow/(outflow)
from financing activities
(4.0) (4.3) (4.6) (4.8) 118.6 (20.2) (19.6) (18.8) (18.0) (16.6)
Net cash inflow/(outflow) 2.9 (19.1) (1.2) (1.9) 54.3 (38.6) 10.2 11.2 11.6 26.6
Opening cash balance 41.2 44.0 24.9 23.7 21.8 76.1 37.5 47.7 58.9 70.5
Closing cash balance 44.0 24.9 23.7 21.8 76.1 37.5 47.7 58.9 70.5 97.1
£m
97
Surplus from operations corresponds to the EBITDA shown in Figure [9.1].
Working capital movements are as described below. These show minimal projected movements in the working capital requirement, apart from accruals.
Capital expenditure includes the capital investment, as well as ongoing maintenance capped at between £2.3m and £2.7m per year.
Proceeds on the disposal of Property Plant and Equipment (PPE) includes the sale of Tottenham Mews (£12.0m) and Hanley Road (£1.0m) in 2019/20 and receipts relating to the sale of St Pancras of £19.1m each year from 2022/23 to 2024/25 and a final receipt of £33.2m in 2025/26.
The increase in interest costs relate to the financing of the bridge loan, which is due to be fully repaid by the end of 2025/26.
The projections show a minimum cash balance of £21.8m in 2019/20, which is sufficient to cover its working capital position.
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Figure [9.8]: Incremental impact of the investment on the cash flow statement
The incremental impact of the investment on the Trust’s cash flows over the baseline shows:
An improvement in surplus from operations, resulting from the CIPs that are enabled by the investment.
A slight decrease in trade payables, driven by the reduction in other expenses CIPs.
Capital expenditure relating to the investment.
Proceeds from the sale of the St Pancras site. Note that the sale of Tottenham Mews and Hanley Road in 2019/20 are assumed in both baseline and investment cases and therefore does not form part of the incremental impact.
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26
Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Surplus from operations - - - - 1.1 5.0 5.7 6.1 6.2 6.3
Movement in working capital
(Inc)/dec in non-NHS trade
receivables- - - - (0.0) (0.0) - - - -
Inc/(dec) in trade payables - - - - (0.2) (0.6) (0.1) (0.1) (0.0) (0.0)
Net cash inflow/(outflow)
from operating activities
- - - - 1.0 4.4 5.7 6.0 6.2 6.3
Capital expenditure - (15.4) (2.5) (17.1) (71.9) (28.6) (0.4) - - -
Proceeds on disposal of PPE - - - - - - 19.1 19.1 19.1 33.2
Net cash inflow/(outflow)
from investing activities
- (15.4) (2.5) (17.1) (71.9) (28.6) 18.7 19.1 19.1 33.2
Dividends paid - (0.3) (0.6) (1.3) 0.5 (0.9) (0.7) (0.4) - 0.9
Net interest (paid)/received - (0.0) (0.0) (0.1) (3.7) (3.6) (3.3) (2.9) (2.6) (2.1)
Drawdown/(repayment) of
loans- - - - 125.0 (12.5) (12.5) (12.5) (12.5) (12.5)
Net cash inflow/(outflow)
from financing activities
- (0.3) (0.6) (1.4) 121.8 (17.1) (16.5) (15.8) (15.1) (13.8)
Net cash inflow/(outflow) - (15.6) (3.1) (18.4) 50.9 (41.3) 7.8 9.3 10.2 25.7
Opening cash balance - - (15.6) (18.8) (37.2) 13.7 (27.5) (19.7) (10.4) (0.2)
Closing cash balance - (15.6) (18.8) (37.2) 13.7 (27.5) (19.7) (10.4) (0.2) 25.5
£m
99
The £125.0 million bridging loan (assumed to be ITFF) is projected to be drawn down in 2020/21 and repaid at £12.5m per year over 10 years by 2031.
The net impact on cash of the investment is projected to be a cash outflow in each year of the projections except 2020/21, due to the loan receipt, and in 2025/26, when the final payment for the St Pancras site is assumed to be received.
There is no assumed income statement impact from the disposals at this stage. The Trust will formally review this treatment at FBC stage once the development partner is identified as in the commercial case. This will not impact on affordability insofar as it does not impact on cash and would be treated as an exceptional item if a gain were recognised.
The principal factors of the investment that impact the cash balance at 2025/26 are illustrated in Figure [9.9] below.
Figure [9.9]: 2025/26 cash bridge from the baseline to the investment case
100
The main differences in cash between the baseline and investment cases arise from the following cumulative impacts:
Operating surplus: £30.6m, of which £21.0m relates to other expenses, £9.4m relates to reduced pay costs and £0.2m relates to additional income.
Capital expenditure of £131.0m is set out in the capital bridge above.
The drawdown of a £125.0m loan to bridge the temporary cash shortfall10.
Loans repaid of £62.5m.
10
The Trust have assumed a £125m facility is available at ITFF rates. There is a risk that this funding will not be available at the time it is needed or altogether which could delay the project
timescales.
£71.5m
£30.6m £(1.0)m
£(135.8)m
£90.4m
£(2.8)m
£125.0m
£(62.5)m
£(18.3)m
£97.1m
£(50.0)m
-
£50.0m
£100.0m
£150.0m
£200.0m
Baseline case2025/26 cash
Operatingsurplus
Workingcapital
differences
Capitalexpenditure
Proceeds ondisposal of
PPE
PDC dividendpaid
Loansdrawndown
Loans repaid Net interest Investmentcase 2025/26
cash
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Net interest paid increases by £21.1m, relating to the bridging loan described above.
9.4 Impact on financial sustainability risk rating (FSRR)
The financial sustainability risk rating (FSRR) is NHSI’s view of the level of financial risk a Trust is exposed to and is a therefore key metric to
consider for this transaction. Ratings go from 1 to 4, where 1 is the highest risk and 4 is the lowest risk.
The FSRR scores for the investment and baseline cases are set out in Appendix [22]. The FSRR calculation performed by the LTFM yield a
capital service cover risk rating of 1 for the investment case, as the bridge loan repayments are included in the debt service total
9.5 Sensitivities
The Trust has run a number of sensitivities to understand the impact of different risks on the project:
1. Construction programme delay by one year: This has an initial I&E and cash benefit, but worsens the position by 2025/26 as the benefits are also delayed.
2. Development/capital cost increase by 10%: This has a limited impact on the net surplus (decreasing it by £0.8m by 2025/26) but it reduces the forecast cash balance by £15.3m by 2025/26.
3. Land value at Whittington 50% higher: This has a limited I&E impact (decreasing it by £0.5m by 2025/26), but reduces forecast cash by £10.0m by 2025/26.
4. Land value at SPH 10% lower: This has a limited I&E impact (decreasing it by £0.4m by 2025/26), but reduces forecast cash by £11.6m by 2025/26.
5. Benefits delivered at 50% below plan: This reduces the recurrent net surplus by £3.8m £2.3m and cash by £16.6m at 2025/26.
6. Benefits delivered at 30% below plan: This reduces the recurrent net surplus by £2.3m and cash by £10.0m at 2025/26.
7. Recurrent CIP 30% lower than plan: This reduces the recurrent net surplus by £5.7m and cash by £21.3m at 2025/26.
8. Pay costs 5% higher than plan: This reduces the recurrent net surplus by £6.7m and cash by £40.2m at 2025/26. As this sensitivity is also considered in the baseline case analysis, it has no impact on the incremental impact of the transaction.
9. Pay costs 2.5% higher than plan: This reduces the recurrent net surplus by £3.4m and cash by £20.2m at 2025/26. As this sensitivity is also considered in the baseline case analysis, it has no impact on the incremental impact of the transaction.
The sensitivities set each have minimal or no impact on the forecast FSRR score when considered individually. A combined downside case will
be considered in the Trust’s FBC along with the impact on the FSRR, including the impact of delays in land receipts.
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9.6 Conclusions
The projections show that the Trust will have sufficient cash to implement the investment, while maintaining sufficient headroom for the working
capital requirement. The adjusted FSRR scores also imply an acceptable level of financial risk.
The projections require that a bridge loan of £125.0m is made available by the ITFF from 2020/21. The Trust will need to secure a commitment
on this loan or to make alternative funding arrangements in order to proceed with the investment.
There is no financial impact on any other parties, including both of the CCGs due to the block-payment contract provided to the Trust for the
delivery of mental health services.
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10
104
11 Implementation
This section sets out what happens after the consultation phase, namely, how the Trust
plans to manage the project and sets out in more detail the actions that will be required to
ensure the successful delivery of the scheme in accordance with best practice.
11.1 Post consultation process
Following the close of the consultation, the CCG Governing Body’s will consider the
responses to the consultation and be asked to give approval to the proposals (please see
the decision-making process as set out at the end of Section [7]). The Trust will implement
the proposal, having already factoring in considerations from the consultation process, as set
out in subsequent sections.
11.2 Programme management arrangements
The Trust has implemented a robust programme management and governance structure
which ensures accountability through clear allocation of responsibilities, and provides
assurance through regular reporting, enabling quick identification and addressing any issues
as they arise. This section describes the following programme management arrangements:
Programme management approach;
Project implementation budget;
Risk Management Arrangements; and
Benefits management.
11.2.1 Programme management approach
The Trust will follow the PRINCE2 principles in their approach to project management to
ensure the delivery of the project. This is the de facto standard in use in the public sector in
the UK.
Project implementation budget
The implementation costs for the project are expected to be £4.9m in nominal terms over the
project implementation period and are inclusive of costs associated with the programme
team, town planning and technical support.
11.2.2 Risk Management
The risk management strategy is in line with the HM Treasury Green Book and NHS
guidance for capital projects.
There is an existing risk management process in place for the Programme, and this process
will continue throughout the implementation and delivery phase of the programme to ensure
that risks are identified, monitored and where possible, mitigated. The overarching risk
management policy is based on an iterative process of:
Identifying and prioritising the risks to the achievement of the Programme aims and objectives;
Evaluating the likelihood of those risks being realised and the impact should they be realised;
105
Managing the risks efficiently, effectively and economically.
The Programme Office maintains the Risk Register for the Programme. Project risks
registers are maintained by the project manager/work stream lead and risks escalated where
necessary via reporting.
11.2.3 Programme governance structure
The key elements of the programme governance structure include:
A clear governance and delivery structure from operational work streams to the Trust
Board.
The structured relationship between programme management and delivery.
The interface between the Programme Board and its assurance mechanism.
The interface between the Trust Board and its assurance mechanism.
The programme governance structure surrounding this project is illustrated in the diagram
below:
Figure [10.1]: Project Governance Structure
The day to day development of the case is delivered by a series of project work streams
within which the membership will vary in line with the specific needs of the work stream and
the phase of the business case.
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Finance and Procurement
Lead: Director of Finance, the Trust or nominee
To monitor the development expenditure and advice on elements such as cash flow, VAT
and compliance with finance requirements. Procurement should advise on best practice for
contracts and equipping new schemes.
Workforce
Lead: Director of HR & OD, the Trust
Review the project for any impact on the workforce that creates change, and set out the
process for achieving this within the business case.
Estates
Lead: Director of Estates and Facilities, the Trust
To review the proposals for Estates issues and advise and provide solutions.
Operational
Lead: Chief Operating Officer, the Trust or nominee
To review the design proposals, advise on operation issues such as compliance and working
with Trust objectives and policies.
Clinical
Lead: Medical Director, the Trust or nominee
Review the clinical implications of the design proposals.
IM & T
Lead: Associate Director of ICT, the Trust
Review the design proposals against the Trust IT strategy and advice how this can be
best delivered.
Partnership
Lead: Transformation Programme Director, the Trust
To work closely with the Trust partners to keep them informed and understand and report on
any deliverables, groups include: On Site Partner, Stakeholders Holder Reference Group,
Council of Governors Site Development Working Group.
Communication
Lead: Head of Communications and Engagement, the Trust
To set out the communication strategy to deliver and monitor the plan. The Trust will be
subject to an ongoing duty to involve the public as it implements the decisions.
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11.2.4 Trust implementation team
The Trust implementation team will comprise approximately 4-6 people on a whole time
equivalents (WTE) basis to be engaged at various points during the implementation. The
function requirements during the implementation include:
Programme Director;
Project Director;
Project Managers:
Main Inpatient Build;
Community Projects;
St Pancras Hub and Disposal;
Finance Support;
HR and Workforce Support;
Clinical Support; and
Administration.
108
Figure [10.2]: Trust implementation team
Role 2017/18 2018/19 2019/20 2020/2021 2021/22 2022/23
Programme Management Office WTE WTE WTE WTE WTE WTE
Leadership 2 2 1 1 1 ¼
Management 1 ¼ 2 1 ¾ ½
Activity Modelling ½ ½
Financial 1 1 1 1 1 1
HR support ¾ ½ ½
Project Support 1 1 1 1 1 1
Total 4 ½ 5 ¼ 4 ¼ 5 ½ 5 ¼ 2 ¾
This proposed staffing profile for the implementation team has been informed by the recommendations of the Project Director based on
experience of similar schemes.
11.3 Project implementation plan
The key milestones for implementation are set out in Figure [10.3] below. These milestones will be updated on a regular basis as more
information becomes available and the project develops. For further details on the consultation phase and approval timeline, see Section [7.5].
Figure [10.3]: Project milestones
Date Key item
109
Date Key item
TBC Approval of OBC
TBC Go to market for Development Partner
TBC Appointment of Development Partner
TBC Planning application for new inpatient facility
TBC Planning application for community facilities
TBC Planning Application for SPH
TBC Completion of FBC
TBC Approval of FBC
TBC Construction of new inpatient facility completed
TBC Decant of inpatients into new inpatient facility
June 2022 Community hubs operational
February 2022 Redevelopment of SPH site begins
August 2023 SPH site operational (for C&I)
TBC Post project evaluation
11.4
110
11.5 Post project evaluation
The Trust has developed a high level post project evaluation plan which identifies the
mechanisms that would enable monitoring and review of performance at different stages of
the project. These are to be shared with and approved by the Trust at each key milestone.
A thorough and robust post project evaluation will:
Facilitate continual learning from the project to be implemented at subsequent
stages as well as future projects.
Ensure that the project adheres to the project plan/ milestones and review of project
risks
Enable measuring of project performance against project aims including the
realisation of benefits
Provide useful feedback and knowledge that can be shared with key stakeholders as
well as the NHS as a whole.
The key components of the Trust’s post project evaluation arrangements are:
A review of performance against Project Programme throughout the life of the
project;
A review of actual performance toward achieving the benefits detailed in the Benefits
Realisation Plan and confirmation that they have been met;
A review of project implementation to learn lessons for future; and
A review of the FBC capital and revenue costs to assess their robustness and
accuracy.
At the OBC stage, Design Quality Indicator (DQI) workshops have been conducted to review
and improve the design and construction approach based on input from a range of
stakeholders.
Going forward, service users, staff and the project team will be asked to evaluate the project
through the use of questionnaires, stakeholder consultation meetings, staff focus groups and
benefits realisation data.
The arrangements for the Post Project Evaluation will be established in accordance with best
practice. The Trust will identify responsibilities and resource requirements for management
of the Post Project Evaluation during the FBC development period, and Post Project
Evaluation will be an integral part of the post implementation operating model.
11.6 Approvals process for investment by the Trust
NHS Improvement require Trusts to submit a SOC, OBC and FBC for approval for capital
investment proposals of this value (i.e. >£50m). The SOC submitted to NHSI in November
2016 has already been approved, while the OBC was submitted in June 2017 and is
currently going through approvals with an open dialogue with NHSI. The FBC may take
between 3-6 months to gain approval. The process for approval of each case is shown in
figure [10.3].
111
Figure [10.3]: Capital Business Case Approval Process
Source: Capital Regime, Investment and Property Business Case Approval Guidance for
Trusts and Foundation Trusts, NHS Improvement, 2016.
HM Treasury Consultation with
DHSC
NHS Improvement Resources
Committee Approval
NHS Improvement
Board Approval DHSC Approval HM Treasury
Approval
112
12 The Secretary of State’s Four Tests
NHS England, in ‘Planning and delivering service changes for service users’ published in
December 2013, outlined good practice for commissioners on the development of proposals
for major service changes and reconfigurations.
Building on this, the 2014/15 mandate from the Secretary of State to NHS England, outlines
that proposed service changes should be able to demonstrate evidence to meet four tests:
1. Strong public and patient engagement;
2. Consistency with current and prospective need for patient choice;
3. A clear clinical evidence base; and
4. Support for proposals from clinical commissioners.
5. Bed closure test
Reconfiguration proposals must meet the four tests before they can proceed. These tests
are designed to demonstrate that there has been a consistent approach to managing
change, and therefore build confidence within the service, and with service users and the
public.
12.1 Test 1: Strong public and patient engagement
This test evaluates how service users and the public have been involved in the development of the proposals for the redevelopment of the St Pancras site and the development of the community hubs and relocation of some community services.
The extensive stakeholder engagement undertaken to date and that which is proposed over
the course of the project is laid out in detail in Section [7] of this document. The methods and
approaches for consultation have included presentations, discussions, surveys, meetings
and emails.
A summary of these activities includes;
15 Service User engagements;
5 Staff engagements;
5 Carer engagements;
5 for senior stakeholders;
2 Governor engagements;
5 Healthwatch engagements;
5 local community engagements;
1 local resident engagement.
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The figure below lists each of the committees who have considered the pre-consultation plan and associated engagement activities.
Figure [11.1]: Staff Engagement
Meeting/approach Date How were participants informed
Staff-side meeting 14 March 2017 Presentation and discussion
Peckwater Centre staff 28 March 2017 Presentation and discussion
Highgate Mental Health staff 04 April 2017 Presentation
St Pancras staff 05 April 2017 Presentation and discussion
Lowther Road staff 05 April 2017 Presentation and discussion
C&I Senior Leadership Team Meeting 24 April 2017 Presentation
St Pancras and Greenland Road staff 11 May 2017 Presentation
Highgate Mental Health staff 12 May 2017 Presentation
All-staff briefing 24 May 2017 Presentation
Email update for staff 02 February 2018 Update email
C&I staff briefing, Greenland Road 30 April 2018 Presentation
C&I staff briefing, St Pancras 01 May 2018 Presentation
C&I staff briefing, Lowther Road 03 May 2018 Presentation
C&I staff briefing, Highgate 04 May 2018 Presentation
Figure [11.2]: Service User and Carer Engagement
Meeting/approach Date How were participants informed
cBug, iBug, Nubian Users’ Forum, Women’s Strategy Group
24 March 2017 Presentation followed by Q&A session
Service User Alliance 31 March 2017 Presentation followed by Q&A session
Service Users’ Conference at St Pancras 13 April 2017 Presentation followed by Q&A session
cBug 25 April 2017 Discussion
Islington Carers’ Hub 28 April 2017 Discussion
Camden Carers’ Hub 19 May 2017 Discussion
iBug 27 June 2017 Discussion
Nubian Users’ Forum 18 July 2017 Presentation
Service User Alliance 22 September 2017 Discussion and Q&A session
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Briefing SMS Service Users at Margarete Centre 28 September 2017 Briefing
Frontline Service Users 02 November 2017 Discussion
Meeting of CPPEG 06 November 2017 Presentation
iCope Islington 15 November 2017 Discussion and Q&A
Carers’ Partnership Meeting 09 January 2018 Discussion and Q&A session
Healthwatch inpatient survey 24 January 2018 Verbally by Healthwatch and then asked a series of questions
Healthwatch inpatient survey 26 January 2018 Verbally by Healthwatch and then asked a series of questions
Healthwatch inpatient survey 30 January 2018 Verbally by Healthwatch and then asked a series of questions
Extraordinary Service Users’ Forum 02 February 2018 Update presentation followed by Q&A session
Islington Carers’ Meeting 06 February 2018 Verbally by Healthwatch and then asked a series of questions
Camden Carers’ Meeting 16 February 2018 Verbally by Healthwatch and then asked a series of questions
Previous inpatients Through March 2018 Verbally by Healthwatch and then asked a series of questions
St Pancras Redevelopment Consultation Review Group 07 March 2018 Papers and verbally
Two borough community hubs engagement event 15 March 2018 Presentation
Communications meeting with Paul Ware 19 March 2018 Verbally
Meeting with Paul Ware 18 April 2018 Verbally
Nubian Service Users' Forum 09 May 2018 Presentation
Figure [11.3]: Senior Stakeholder Engagement
Meeting/approach Date How were participants informed
Stakeholder Reference Group meeting 27 July 2016 Discussion
Stakeholder Reference Group meeting 05 October 2016 Discussion
115
Stakeholder Reference Group meeting 26 January 2017 Discussion
Stakeholder Reference Group meeting 27 February 2017 Discussion
Stakeholder Reference Group meeting 29 March 2017 Discussion
JHOSC 21 April 2017 Presentation
North Central London JHOSC 19 September 2017 Presentation
Stakeholder Reference Group meeting 24 October 2017 Discussion
Knowledge Quarter 01 November 2017 Presentation followed
Clinicians community hubs meeting 26 January 2018 Discussion
North Central London Joint Health Overview Scrutiny Committee
23 March 2018 Presentation
Stakeholder Reference Group meeting 24 April 2018 Discussion
Figure [11.4]: Governor Engagement
Meeting/approach Date How were participants informed
Council of Governors 09 May 2017 Presentation
Email update for governors 02 February 2018 Update email
C&I Council of Governors 08 May 2018 Presentation
12.2
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12.3 Test 2: Consistency with current and prospective need for patient choice
This test is to illustrate whether the proposed redevelopment will maintain the availability of
service user choice.
For most service users that currently access mental health services in the Borough of
Camden and Islington, the entry pathway will remain the same following the proposed
redevelopment. As the clinical model remains unchanged, with the majority of services
continuing to be delivered in the community and via primary care, the range of service user
choice is unaffected.
For service users of the inpatient facilities at St Pancras, the proposed changes will have
minimal impact on the choices available due to the fact that there is no change in the
number of providers serving the local area and the Trust’s own services are moving 2.5
miles further away. Currently the closest alternative provider of inpatient mental health is at
Gordon Hospital (operated by CNWL and 3.7 miles from St Pancras and 5.8 miles from the
Whittington site). In respect of the fact that many users of this service are admitted to the
facility under the Mental Health Act, the relocation would be insignificant in terms of impact
on patient choice.
In addition, the travel time identified, there should not be any services users that, following
the relocation of services to the Whittington site, would find the travel time an issue or that
their choice of provider has substantively diminished. This will be discussed further with
service users as part of the consultation phase following approval of the PCBC.
Patient choice would also be improved from a quality perspective as with the proposed
redevelopment, service users would have a purpose-built, higher quality, and safer facility
from which to receive care than is available currently. This increase in the quality is in line
with the CCGs and the Trust’s vision to deliver their vision of excellence; “We will continually
improve the quality and safety of service delivery, service user experience and improve
outcomes.”
12.4 Test 3: A clear clinical evidence base
This test is to demonstrate sufficient clinical evidence and clarity on the case for change.
This is clearly outlined in Section [4]. The independent verification of this case for change will
be gained through submission for consideration by the London Clinical Senate, engagement
with a range of clinicians as detailed below, and using reports from the CQC reports.
The model of care and proposals to relocate certain services have the support of the CCG
GP mental health leads and were developed by the Trust’s Medical Director and Director of
Nursing.
CQC Report
The Trust’s most recent CQC report was published in March 2018, where the Trust received
an overall rating of “Good”. The previous report, published in June 2016 identified the
deteriorating St Pancras Hospital site compared to the refurbished HMHC. Due to the ageing
and inflexible site at St Pancras, there is a clinical need to move service users to a site
without multiple ligature points and multiple blind spots from where staff cannot easily
observe service users. After publication of the 2016 report, the CQC was briefed on the
Trust’s plans to review the entire St Pancras estate.
117
London Clinical Senate
The St Pancras Redevelopment Oversight Steering Group contacted the London Clinical
Senate (LCS) for advice on:
Whether the change of environment will improve clinical care for inpatient and
community services
Whether the proposals for changes to inpatient and community mental health
services:
o will enable improvements in clinical care and quality benefits for patients
o are informed by best practice
o align with national policy and are supported by STP plans and commissioning
intentions
Whether the approach ensuring the inpatient demand of population growth is
absorbed by the development of mental health community services.
The LCS will provide the CCGs will feedback on the clinical case for the proposed service
changes. The CCGs will need to take account of these comments and include them in the
consultation document as appropriate. The CCGs responding to the LCS is part of the NHSE
assurance process of the CCGs approach to the consultation.
A wide range of clinicians have been engaged and consulted throughout the process to
ensure proposals have patient outcomes central to plans. There has been broad and varied
communication with a range of clinical staff, further details of which can be found in Figures
7.3 and 7.3. Of particular note are the GB Seminars, which the Trust presented the
redevelopment plans. CCG GB leads have been involved in the process throughout,
alongside the member GPs.
Furthermore, a meeting of clinical leads from the local health organisations was held on 26
January 2018 to discuss the community hubs. The Trust is scheduled to attend the Camden
GP locality meetings in April 2018 and Islington GPs were updated in March 2018. A number
of engagement events for Trust staff have been held at various Trust locations where
clinicians have attended. Trust clinicians also continue to be kept informed through existing
internal meeting structures.
Feedback provided demonstrated a strong level of support for the proposal with a consensus
that the changes identified would improve services for service users. A letter of support from
the Trust’s Director of Nursing, dated June 13th 2017, provides this assurance on behalf of
the clinicians at the Trust, stating that “considering the environmental challenges around
access, ligature management, the privacy and dignity of our service users and infection
control, we believe that the proposal reflects the collective view on how our local services
should be configured”. This can be found in Appendix [23].
12.5 Test 4: Support for proposals from clinical commissioners.
This test is to provide assurance that the proposals have the approval of local
commissioners.
Both of the CCGs have been involved and provided their support for the proposed
redevelopment as joint commissioners of the Trust. There have been a series of meetings to
118
brief all GP members of the CCGs, where they have had an opportunity to provide feedback
on the proposals. Formal and informal presentations and discussions have taken place at
several CCG Governing Body meetings, both public and private. The Chief Operating Officer
for Haringey and Islington CCG has led the engagement on behalf of Camden and Islington
CCGs and been the primary communicator to senior stakeholders. They also lead the St
Pancras Hospital Redevelopment Oversight Group, providing guidance over the
Consultation work stream and with representation from Camden CCG and Islington CCG.
Figure [11.5]:
Meeting/approach Date How were participants informed
Target audiences
Number of attendees/number of hits or users
Islington CCG Governing Body
September 2017
Presentation Governing Body
19
Islington GP Forum 22 March 2018
Presentation GPs 18
Islington CCG Governing Body seminar
11 April 2018
Presentation Governing Body
14
Camden CCG Governing Body seminar
25 April 2018
Presentation Governing Body
13
South Camden GP Locality meeting
11 April 2018
Presentation GPs 16
North Camden GP Locality meeting
12 April 2018
Presentation GPs 10
West Camden GP Locality meeting
13 April 2018
Presentation GPs 13
Islington CCG Governing Body
9 May 2018 Presentation Governing Body
18
Camden CCG Governing Body
9 May 2018 Presentation Governing Body
20
12.6 NHSE’s Bed Closures Test
From 1 April 2017, NHSE introduced a new test to evaluate the impact of any proposal that
includes a significant number of bed closures and to ensure commissioners are able to
evidence that one of the following three conditions have been met;
Sufficient alternative provisions have been made, such as increased GP or community services;
New treatments or therapies will reduce specific categories of admissions, or;
Where a hospital has been using beds less effectively than the national average, that there is a credible plan to improve performance without affecting patient care.
This test is only applied where the proposal includes plans to significantly reduce bed
numbers. As this proposal maintains the current inpatient bed provision following activity and
bed modelling, as outlined in further detail in section 5, this test is not applicable.
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13 Decision making and next steps
Following consultation, the St Pancras Hospital Redevelopment Oversight Group will review
consultation responses received from members of the public and organisations. The
committee will then consider the views of the participants and the effect these may have on
the decision-making process.
At this stage of the development of options, it is not possible to fully detail the timescales in
which decisions will be taken and when subsequent implementation could take place. This is
due to a number of factors, including:
The quantity and detail of consultation responses received, and timescales required to analyse those responses;
The consideration of consultation responses by the St Pancras Hospital Redevelopment Oversight Group and subsequent update of analysis and evaluation of options as required;
Camden and Islington CCGs, as the decision-makers, need to consider the consultation responses and make the decision about whether the proposals should go ahead;
The development of a decision making business case and confirmation by the St Pancras Hospital Redevelopment Oversight Group; and
The development of detail implementation plans between providers and commissioners on the basis of the decision made by the St Pancras Hospital Redevelopment Oversight Group.
However, to give an indicative timeline, the programme expects the following milestones for
this process. These may be subject to change, as described above:
Formal public consultation – July 2018 - October 2018 (14 weeks).
External analysis of consultation responses – October 2018.
The C&I CCGs will consider the responses to the consultation and agree whether the proposals to redevelop the St Pancras site and relocate in patient services should go ahead – November Governing Body meetings
Final business case preparation – November 2018
Each CCG GB to consider the final business case document – November 2018
Each CCG to make a decision on the final business case – November 2018
120
Appendix Contents
Appendix Number
Name
1 Trust services provided at SPH relocation summary
2 Other Provider’s services at SPH
3 Travel time report
4 Privacy Impact Assessment (PIA) screening questions form
5 Pre-consultation engagement meetings
6 NCL STP stakeholder engagement summary
7 JHOSC meeting minutes
8 Consultation plan
9 Consultation document, questionnaire and FAQs
10 Options development summary
11 Feasibility Study
12 Options considered
13 Qualitative assessment workshop summary
14 Qualitative assessment scoring
15 Qualitative scores of each option
16 Backlog maintenance
17 Quantifiable benefits
18 Trust’s Income & Expenditure assumptions
19 Baseline income and expenditure
20 Baseline statement of financial position
21 Baseline cash flow statement
22 Trust FSRR scores for the investment and baseline cases
23 Letter of support from the Trust’s Director of Nursing
24 Bed modelling benchmarking
25 Occupied Bed Days Trend Analysis
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Appendix 1 Trust services provided at SPH relocation summary
Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
ST PANCRAS
Dunkley Ward (16 bed mixed sex with 4 learning disability beds)
ACUTE
Laffan Ward (16 bed mixed acute mental health) ACUTE
Rosewood Ward (12 bed female acute mental health) ACUTE
Ruby Ward (11 bed female PICU) ACUTE
Montague Ward (14 mixed high dependency rehab ward)
R&R
Sutherland Ward (14 mixed long-term complex care ward)
R&R
Complex Depression, Anxiety and Trauma Service COMMUNITY
Camden & Islington Psychodynamic Psychotherapy Service
COMMUNITY
122
Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
Sexual Problems Team COMMUNITY
South Camden iCope COMMUNITY
Traumatic Stress Clinic COMMUNITY
NHS Transition, Intervention and Liaison Veterans’ Mental Health Service (formally known as LVS)
COMMUNITY
ADHD Team Attention Deficit Hyperactivity Disorder COMMUNITY
Adult Autism Clinic COMMUNITY
Camden Mental Health Assessment and Advice Team
COMMUNITY
Islington Practice Mental Health Team
COMMUNITY
South Camden Crisis Resolution Home Treatment ACUTE
Acute Day Unit (Jules Thorn) ACUTE
123
Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
The Rivers Crisis House (subject to separate review)
Approved Mental Health Professional Service ACUTE
Recovery College COMMUNITY
Pharmacy ACUTE
Clozapine Clinic COMMUNITY
HIGHGATE
Sapphire Ward (16 bed mixed acute mental health) ACUTE
Emerald Ward (15 bed mixed acute mental health) ACUTE
Opal Ward (16 bed mixed acute mental health) ACUTE
Jade Ward (16 bed mixed acute mental health) ACUTE
124
Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
Amber Ward (16 bed mixed acute mental health) ACUTE
Topaz Ward (16 bed acute mental health) ACUTE
Pearl Ward (14 bed mixed older people with mental illness)
SAMH
Highgate Day Centre R&R
Malachite Ward (16 bed mixed high dependency rehabilitation)
R&R
Coral Ward (12 bed male PICU) ACUTE
Garnet Ward (14 bed mixed dementia care) SAMH
Personality Disorder Therapies Team COMMUNITY
Personality Disorder Community Team COMMUNITY
Accommodation Team R&R
125
Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
GREENLAND ROAD
Camden Assertive Outreach Team R&R
Islington Assertive Outreach Team R&R COMMUNITY
Camden Early Intervention Team R&R
Islington Early Intervention Team R&R
Focus Homeless Outreach COMMUNITY
LOWTHER ROAD
North Islington Rehabilitation and Recovery Team R&R
Cornwallis Outreach Project R&R
Islington Mental Health Re-ablement Service R&R
PECKWATER CENTRE
126
Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
Camden Community Team SAMH
Camden Memory Service SAMH
Care Home Liaison Team SAMH
South Camden Recovery Team R&R
BLENHEIM COURT (NON-CLINICAL SITE)
Dementia Navigators SAMH
Home Treatment Team SAMH
Islington Community Mental Health Team SAMH
Islington Memory Team SAMH
Care Home Liaison Team SAMH
127
Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
MARGARETE CENTRE
South Camden Drug Centre SMS
ARLINGTON ROAD
Camden Alcohol Service SMS
THE HOO
North Camden Recovery Team R&R
DALEHAM GARDENS
North Camden Drug Service SMS
North Camden Recovery Centre R&R
SOUTHWOOD SMITH CENTRE
Accommodation Team R&R
128
Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
South Islington Recovery Team R&R
DRAYTON PARK
Islington Learning Disabilities Service COMMUNITY
MANOR GARDENS
iCope - North Islington Team
COMMUNITY
CAMDEN MEWS
Community Recovery Service for Older People - covering both Camden and Islington
SAMH
Mental Health Liaison Team ACUTE
OTHER SITES
Aberdeen Park R&R
Highview R&R
129
Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
Stacey Street (subject to separate review)
Raglan Day Centre SAMH
Whittington Hospital
Mental Health Liaison Assessment Team (ILAT),
Key:
Acute: Acute and Crisis Care (Urgent care)
R&R: Recovery and Rehabilitation (Psychosis)
SAMH: Services for Ageing and Mental Health (Older people and Dementia)
SMS: Substance Misuse Services (Alcohol and drugs)
Community: Community Mental Health (Complex psychological and common mental health conditions)
130
Appendix 2 Other Provider’s services at SPH
NHS Services & description of service Current address Future location
Rehabilitation inpatient wards (Central and
North West London Foundation Trust)
Provides treatment and support for patients
whose physical abilities have been reduced
through illness, such as a stroke, or a fall or a
musculoskeletal condition.
South Wing To remain in current
building
Evergreen Ward (University College London
Hospital)
A ward predominantly for care of the elderly
South Wing To remain in current
building
Kidney dialysis clinic (Royal Free Hospital) St Pancras
Hospital
To remain but in a
new building
Ophthalmology clinic (Royal Free Hospital) St Pancras
Hospital
To remain but in a
new building
GP out of hours service (London Central &
West Unscheduled Care Collaborative)
St Pancras
Hospital
To remain but in a
new building
Kings Cross GP Practice (AT Medics) St Pancras
Hospital
To stay but in a new
building
131
Appendix 3 Travel time report
Travel time change from postcode between major site changes using public transport
Changes are colour coded in the tables in the following way:
Green – a reduction in travel time of 5 minutes or more
Amber – a reduction in travel time of less than 5 minutes or an increase of up-to 5
minutes
Red – an increase in travel time of 5 minutes or more.
Camden postcodes Travel Times by TFL
Travel times (in minutes) from centre of Postcode to: Postcode St Pancras
Hospital Proposed site at
Whittington Hospital Net
change Greenland
Road Net
Change
WC1N 1 27 39 12 28 1
WC1N3 33 40 7 32 -1
WC1X9 29 44 15 32 3
NW1 0 8 35 27 9 1
NW1 1 10 36 26 16 6
NW1 2 22 34 12 16 -6
NW1 3 20 38 18 15 -5
NW1 4 39 47 8 29 -10
NW 1 7 21 30 9 6 -15
NW1 8 23 35 12 11 -12
NW1 9 16 38 22 14 -2
NW5 2 25 24 -1 16 -9
NW5 3 30 34 4 22 -8
NW5 1 30 17 -13 24 -6
NW3 1 35 38 3 26 -9
NW3 7 40 39 -1 31 -9
NW3 6 33 43 10 31 -2
NW3 5 40 42 2 31 -9
NW6 1 43 45 2 36 -7
NW6 2 41 42 1 35 -6
NW6 3 39 45 6 36 -3
NW6 4 41 47 6 32 -9
NW6 5 39 53 14 38 -1
NW2 3 47 49 2 47 0
NW3 3 35 39 4 26 -9
NW3 4 33 36 3 23 -10
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Islington postcodes Travel Times by TFL
Travel times (in minutes) from centre of Postcode to:
Postcode
St Pancras Hospital
Proposed site at Whittington Hospital
Net change
Lowther Road
Net change
EC1Y8 52 44 -8 37 -15
EC1V3 54 44 -10 37 -17
EC1R0 24 42 18 31 7
N17 39 43 4 26 -13
N18 38 68 30 55 17
N19 39 27 -12 30 -9
N10 56 48 -8 59 3
N11 46 53 7 36 -10
N12 37 30 -7 44 7
N13 57 70 13 50 -7
N14 47 62 15 39 -8
N51 35 46 11 28 -7
N52 43 47 4 30 -13
N78 32 43 11 2 -30
N79 29 39 10 26 -3
N 16 8 49 61 12 39 -10
N4 2 35 47 12 28 -7
N4 3 31 41 10 25 -6
N4 4 38 44 6 27 -11
N7 0 33 28 -5 31 -2
N7 6 33 32 -1 19 -14
N7 7 33 38 5 16 -17
N19 4 34 13 -21 27 -7
N19 5 29 21 -8 33 4
N6 5 36 29 -7 32 -4
N6 6 34 26 -8 51 17
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Travel time change from postcode compared to Lowther Road or Manor Gardens.
Islington postcodes
Travel Times by TFL
Postcode Lowther Road
Manor Gardens
Net change
EC1Y8 37 42 -5
EC1V3 37 43 -6
EC1R0 31 40 -9
N17 26 38 -12
N18 55 44 11
N19 30 13 17
N10 59 40 19
N11 36 41 -5
N12 44 41 3
N13 50 50 0
N14 39 47 -8
N51 28 15 13
N52 30 30 0
N78 2 17 -15
N79 26 15 11
N 16 8 39 35 4
N4 2 28 22 6
N4 3 25 18 7
N4 4 27 20 7
N7 0 31 9 22
N7 6 19 3 16
N7 7 16 9 7
N19 4 27 11 16
N19 5 33 18 15
N6 5 32 15 17
N6 6 51 26 25
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Map of Camden and Islington showing the main sites for proposed service change
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Appendix 4 Privacy Impact Assessment (PIA) screening questions form
Documenting here which of the screening questions are applicable to your initiative will help to draw out the particular privacy considerations that will help formulate your risk register later in the template. This will also assist in ensuring that the investment the organisation makes is proportionate to the risks involved: Remember! – imagine this initiative involved the use of your own information or that of a relative
Yes No Unsure Comments
i Is the information about individuals likely to raise privacy concerns or expectations e.g. health records, criminal records or other information people would consider particularly private?
☐ ☒ ☐ No change will be made to the way staff access patient information electronically. The Trust stores paper records in a central off-site facility.
ii Will the initiative involve the collection of new information about individuals?
☐ ☒ ☐ No new information will be collected.
iii Are you using information about individuals for a purpose it is not currently used for, or in a way it is not currently used?
☐ ☒ ☐ There are no changes to the way data is used.
iv Will the initiative require you to contact individuals in ways which they may find intrusive11?
☐ ☒ ☐ Stakeholders, including patients have been publically and privately engaged throughout.
v Will information about individuals be disclosed to organisations or people who have not previously had routine access to the information?
☐ ☒ ☐ There are no staff changes and data remains with the Trust.
vi Does the initiative involve you using new technology which might be perceived as being privacy intrusive e.g. biometrics or facial recognition?
☐ ☒ ☐ There are no new technologies used.
vii Will the initiative result in you making decisions or taking action against individuals in ways which can have a significant impact on them?
☐ ☒ ☐ No impact of the initiative on decision making.
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Appendix 5 Pre-consultation engagement meetings
Pre-consultation engagement activities – Service users and carers
Service User Engagement
24-Mar-17 cBug, iBug, Nubian Users’ Forum, Women’s Strategy Group
31-Mar-17 Service User Alliance
13-Apr-17 Service Users’ Conference at St Pancras
25-Apr-17 cBug
27-Jun-17 iBug
18-Jul-17 Nubian Users’ Forum
22-Sep-17 Service User Alliance
28-Sep-17 Briefing SMS Service Users at Margarete Centre
02-Nov-17 Frontline Service Users
06-Nov-17 Meeting of CPPEG to road-test Public Consultation document and survey
15-Nov-17 iCope Islington
24-Jan-18 Healthwatch inpatient survey
26-Jan-18 Healthwatch inpatient survey
30-Jan-18 Healthwatch inpatient survey
02-Feb-18 Extraordinary Service Users’
15-Mar-18 Community hubs engagement event
Pre-consultation engagement activities - Staff
Staff Engagement
14-Mar-17 Staff Side
28-Mar-17 Peckwater Centre staff
4-Apr-17 Highgate Mental Health staff
5-Apr-17 St Pancras staff
5-Apr-17 Lowther Road Staff
11-May-17 St Pancras and Greenland Road staff
12-May-17 Highgate Mental Health staff
24-May-17 C&I All-staff briefing
24-Jan-18
26-Jan-18
30-Jan-18
02-Feb-18 Email update for all C&I staff
Pre-consultation engagement activities – Broader Engagement
Broader Engagement
20-Mar-17 Islington and Camden Healthwatch
21-Apr-17 Joint Health Oversight Scrutiny Committee (JHOSC) (elected representatives from local Health Oversight Scrutiny Committees (HOSC))
28-Apr-17 Islington Carers’ Hub
09-May-17 Council of Governors
19-May-17 Camden Carers’ Hub
03-Aug-17 St Pancras Community Association
12-Sep-17 Islington Healthwatch
16-Sep-17 Voluntary Action Camden
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25-Sep-17 Camden Healthwatch
29-Sep-17 Service User Conference
17-Oct-17 Camden and Islington Healthwatch
01-Nov-17 Knowledge Quarter (DS)
08-Nov-17
07-Dec-17 Margie Butler, CEO at Camden Citizen’s Advice Bureau (MM)
14-Dec-17 Julie Parish, Operational Lead, Octopus Communities (MM)
15-Dec-17 Saul Gallick, Operational Lead and Sam Hopely, Chief Executive, Holy Cross Centre Trust (MM)
09-Jan-18 Carers’ Partnership Meeting
10-Jan-18 Somers Town Neighbourhood Forum
26-Jan-18 Clinicians community hubs meeting (Trust and CCG clinical leads)
02-Feb-18 Email update for governors
06-Feb-18 Islington Carers’ Meeting (Healthwatch)
16-Feb-18 Camden Carers’ Meeting (Healthwatch)
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Appendix 6 NCL STP stakeholder engagement summary
We have developed a governance structure to enable NHS and local government partners to
work together in new ways. The objectives of our governance arrangements are to:
Support effective collaboration and trust between commissioners, providers, political
leaders and the general public to work together to deliver improved health and care
outcomes more effectively and reduce health inequalities across the North London
system;
Provide a robust framework for system level decision making, and clarity on where
and how decisions are made on the development and implementation of the North
London STP;
Provide greater clarity on system level accountabilities and responsibilities for the
North London STP;
Enable opportunities to innovate, share best practice and maximise sharing of
resources across organisations in North London; and
Enable collaboration between partner organisations to achieve system level financial
balance over the remaining 3 years of the Five Year Forward View timeframe and
deliver the agreed system control total, while safeguarding the autonomy of
organisations.
The North London Programme Delivery Board oversees delivery of the plan. This is an
executive steering group made up of a cross section of representatives from across North
London. This group is specifically responsible for providing accountability for the
implementation of the workstream plans. Membership includes the Senior Responsible
Officers (SRO) of each workstream and SRO leads for CCGs, Providers and Local
Authorities.
Two subgroups provide advice to the Programme Delivery Board: the Health and Care
Cabinet (formerly the Clinical Cabinet) and the Finance and Activity Modelling Group.
The Health and Care Cabinet meets monthly to provide clinical and professional steer, input
and challenge to each of the workstreams as they develop. Membership consists of the five
CCG Chairs, the eight Medical Directors, clinical leads from across the workstreams, three
nursing representatives from across the footprint, Pharmacy and Allied Health Professions
representatives, a representative for the Directors of Public Health and representatives for
the Directors of Adult Social Services and the Directors of Children’s Services respectively.
The Finance and Activity Modelling Group is attended by the Finance Directors from all
organisations (commissioners and providers). This group currently meets fortnightly, to
oversee the finance and activity modelling of the workstream plans as they develop.
The workstreams are responsible for developing proposals and delivery plans in the core
priority areas and feed into the overarching governance framework. Every workstream has
its own governance arrangements and meeting cycles which have been designed to meet
their respective specific requirements, depending on the core stakeholders involved.
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The STP Advisory Board enables a collective partnership approach, and acts as the
‘sounding board’ for the implementation of the STP plans. The membership of this group
includes Local Authority leaders, NHS Chairs, and Healthwatch.
In addition to the above governance groups, CEOs and other relevant executive directors
and stakeholder representatives will meet quarterly for executive leadership events to enable
continued engagement and momentum, regular communication, and to assist with resolving
any programme delivery issues identified by the programme delivery board.
Follow this link to view a detailed governance handbook including the terms of reference for
all of the governance groups.
Link: https://adoddleak.asite.com/adoddlepublic/dpd/n9xeEI75ebM9H6bjyz
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Appendix 7 JHOSC meeting minutes
Meeting on 19th September 2017 Consideration was given to an amended presentation from the Camden and Islington Foundation Trust. Malcolm McFrederick, the Project Director, was the lead presenter. He explained that they
were not as far in the process for the St Pancras site as the Barnet, Enfield and Haringey
Mental Health Trust were for St Ann’s. They had submitted an outline business case to NHS
Improvement and were waiting for it to be approved. They were anticipating it would be
approved in October. If approval was granted, there would be a full CCG-led public
consultation.
Mr McFrederick highlighted that the existing buildings were not fit for purpose and it was not viable to bring the St Pancras buildings up to date. They wanted to see good and vibrant community facilities and mental health research taking place. A modern therapeutic environment would be good for patients and safer for staff. Inpatient beds would be moved from the St Pancras site and there would be two new ‘community hubs’. Mr McFrederick said there had been consultation with service user groups, CCGs and local councils. Members were informed that the preferred option of moving inpatient beds to the Whittington, establishing community hubs and bringing researchers and academics onto one site had been reached by considering it against 12 Quality Critical Success Factors. There were benefits from co-locating mental and physical health services. They had also researched the travel patterns of their patients, and had wanted to find a site which was easily accessible to those who used public transport and did not have a car. There was discussion about what would be in community hubs. There would be an office area, clinical space (for mental health services and for other health services), and a community space. The community space could include a café or gallery for service users to spend time in and for voluntary sector organisations to operate in. The Chair mentioned that the Adult Education strategy made mention of community hubs. She asked whether the Trust were working with Camden and Islington on this. Mr McFrederick said that they had spoken to Islington about this and would also speak to Camden in future. Trust officers said that they wished to align their plans for the surplus land in the St Pancras site with the borough’s plans for housing. Members asked how the redevelopment would fit in with wider STP matters. The Trust felt that community hubs would help with the linking of mental and physical health services. The Chair asked where the revenue from estates disposals would go. Mr McFrederick said that the sales proceeds would be used to fund the redevelopment plans. The Trust would be selling 80% of the St Pancras site and retaining 20%. Some of the land
would be used for housing and some would be used by Moorfields Eye Hospital.
Members sought clarification that sales proceeds would not be used for revenue spending. They were assured that this would not be the case.
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The Trust representatives were asked if a developer had been appointed. They said that this would take place after the outline business case was approved and would then go through the OJEU process. Members asked about the progress Moorfields were making in terms of their business case for locating on part of the St Pancras site. The Trust representatives said that the two bodies were working together in terms of the timing of their work and submissions. However, they were two distinct schemes and not integrated. Angela McNab, the Trust Chief Executive, confirmed that land which was surplus to Camden & Islington Foundation Trust requirements would be offered to other health bodies. Members said that there was pent-up demand for GP surgery sites in the area, and they hoped that some of the surplus land could be used for this. Councillor Connor asked if the number of beds would increase following the move of inpatient facilities from St Pancras to the Whittington. She was informed that they would not decrease, however there had been no indication from commissioners that they would purchase enough beds to allow for the creation of a whole new ward. She expressed disappointment at this and felt it was important to ensure there were more inpatient facilities available for mental health patients, as demand for these had not fallen. Members also wished to avoid patients having to be placed out of area. Officers said that, on average, the number of Camden and Islington patients who had to be placed outside of those boroughs was low. Ms McNab said the Trust had noted that people were being kept in beds here long than elsewhere and that they could be moved into intermediate care. Councillor Khatoon, who was a ward councillor for the area, addressed the meeting. She wanted to see consultation with local residents and attention given to how more social housing could be provided on the site and if employment opportunities could be created for local residents. Trust officers agreed to arrange an opportunity for Councillor Khatoon to have a walkabout around the site. Members expressed concern about the availability of key worker housing, and they felt that this was important to recruit and retain staff. Members welcomed the proposals to move beds to the Whittington and felt that it was a suitable site. They wished the final business case to come back to the Committee at a future date.
Meeting on 23 March 2018 – Draft Minutes
Malcolm McFrederick, the Project Director (Camden & Islington Foundation Trust), addressed members on the St Pancras hospital plans. He said that they were planning on selling their site and moving the inpatient facilities to the Whittington site. They were looking to develop two new hubs – on Lowther Road and Greenland Road – and they were considering whether a third site would be required. Mr McFrederick said that the Trust were going to go out for tender for a development partner. This could be on a long lease basis rather than for sale. The matter was also complicated by the fact the Department of Health had a historic interest in the site. Mr McFrederick explained that the site could possibly be sold to Moorfields Eye Hospital as a replacement for their old site. The Trust wanted to involve local communities in consultation on the future of the site. Mr McFrederick said that further information would come to both the Camden and Islington health scrutiny committees in June.
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Members asked whether London Estates Devolution would apply to the schemes. They were informed that they were not at the stage where estates devolution would apply. The Chair voiced concerns about the development board for St Pancras not meeting. Mr McFrederick said that the two development boards – one involving stakeholders and one involving providers – were being amalgamated. He assured the Chair that she would be invited to the next meeting.
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Appendix 8 Consultation plan
Consultation methodology: St Pancras Site Redevelopment
Islington Clinical Commissioning Group, together with Camden Clinical Commissioning
Group is leading a consultation on the proposals for the redevelopment of the St Pancras
Hospital site of which Camden and Islington NHS Foundation Trust is the landlord.
These changes will affect the inpatient facility and community mental health services
currently delivered on the site and on additional Trust sites. The other NHS services which
are delivered on the St Pancras Hospital Site by other NHS Providers such as the Royal
Free Hospital and a Camden GP practice will remain on the site. In some cases, these
services will be delivered in newly refurbished buildings, as part of the redevelopment
process.
In line with our statutory duties, the CCGs will consult on the redevelopment proposals, ensuring local people are given the opportunity to share their views on the services affected by the redevelopment of the St Pancras Hospital site. The statutory duties are:
Section 242 of the NHS Act 2006 states:
Each relevant English body must make arrangements, as respects health services for which it is responsible, which secure that users of those services, whether directly or through representatives, are involved (whether by being consulted or provided with information, or in other ways) in:
The planning of the provision of those services
The development and consideration of proposals for change in the way those services are provided, and
Decisions to be made by that body affecting the operation of those services
Section 14Z2 of the Health & Social Care Act 2012 states: The Clinical Commissioning Group (CCG) must make arrangements to secure that individuals to whom the services are being or may be provided are involved (whether by being consulted or provided with information or in other ways): a) In the planning of the commissioning arrangements by the group, b) In the development and consideration of proposals by the group for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them, and c) In decisions of the group affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact In light of these plans, Islington and Camden CCGs are proposing to run a public consultation for 12 weeks starting from 5h July to end of September 2018. A consultation document, questionnaire and Frequently Asked Questions have been developed. Aims of the Consultation:
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To understand the views of the local community on the relocation and development of new Camden and Islington NHS Foundation Trust mental health inpatient services from the St Pancras Hospital site to a site by Highgate Mental Health Centre and Whittington Hospital.
To understand the views of the local community on the development of two new mental health community hubs, one in Camden and another in Islington.
The CCGs, with support from Camden and Islington NHS Foundation Trust, will speak to as many people in the local community as possible, ensuring they hear from a wide range of service users of all of the services proposed for relocation, the local community, local voluntary organisations and Healthwatch’, as well as other key stakeholders such as local Councillors and MPs. Communications and engagement channels The channels we will use to share the consultation and gather as many views as possible are: General Population and Service Users:
A full consultation document with a survey about the proposals will be available on Islington Clinical Commissioning Group, Camden Clinical Commissioning Group, Camden and Islington NHS Foundation Trust and Healthwatch websites
There will be hard copies available of the above with a freepost addressed envelope at Camden and Islington Foundation Trust sites, on request
Posters/ flyers across the Trust’s 30 sites advertising the consultation
Prompts on social media, encouraging people to join one of the consultation meetings or provide their feedback online
Public meetings on 11th July, 19th July and 4th September 2018 at venues that are easily accessible to people in Camden and Islington
A drop-in session with C&IFT Trust Clinical Director - Vincent Kirchner
Sharing the consultation document and survey through our local networks, this includes to the Islington and Camden patient and community groups and Trust service user groups, our patient representatives and our local voluntary and community sector groups
Sharing information on the consultation through the GP newsletters and at the GP Forums
Sharing information on the consultation through our staff newsletters and at our staff briefings (CCGs and Trust)
Promoting the consultation survey to seek input from groups who traditionally face barriers to accessing services or having their voice heard Availability of the consultation document and survey questions in audio, braille, large print, easy read and in languages other than English, upon request.
There will be a dedicated telephone line for local people either requesting the consultation documents or any questions they may have.
Service Users Specific
It was felt strongly by the local Healthwatch and Service Users that there needed to be a focus on consulting with current and ex Service Users as part of the consultation. The points below specifically cover how we will work with service users:
Attendance (with Clinical Director Dr Vincent Kirchner) to speak at all of the Trust’s service users’ groups introducing the consultation, taking questions and letting people know how to fill it in (along with taking some hard copies)
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Further targeted engagement using the consultation survey with service users across all five of the Trust’s divisions – Acute, Services for Ageing and Mental Health, Recovery and Rehabilitation, Substance Misuse Services and Community Mental Health. This will include both current service users of inpatient services and community services. This work will be carried out by Healthwatch Camden and Islington with Trust service users.
Results, analysis and feedback
Camden & Islington Clinical Commissioning Groups will appoint an independent partner to evaluate the consultation process and analyse the results of the consultation. The partner will develop a process and infrastructure that reassures stakeholders of the independent nature of the evaluation. Following the closure of the consultation on 30th September 2018, the evaluation team will have a period to analyse the results and present these to Islington and Camden Clinical Commissioning Group Governing Bodies. Islington Clinical Commissioning Group will then make a recommendation on the redevelopment proposals to NHS England and Council Overview and Scrutiny Committees for Islington and Camden.
The results will be available publically, which will include, sharing on CCG and C&IFT websites and sharing through other stakeholders’ networks, such as Healthwatch Islington and Camden.
Decision making process
7. Proposed consultation timeline
Action
Lead Date
Consultation documents and methodology sign off
Islington CCG Governing Body
June 2018
Camden CCG Governing Body
June 2018
Consultation documents and methodology reviewed by Camden and Islington Health and Overview Scrutiny Committees
Islington CCG and Camden CCG
June 2018
Public consultation goes live Islington CCG 5th July 2018 to 10th October 2018
Evaluation of responses External agency October 2018
Results of consultation published and shared
Islington CCG, Camden CCG, the Trust and partners
November 2018
Final Business Case prepared
Islington CCG November 2018
Consideration of Final Business case by Islington CCG Governing Body
Islington CCG November 2018
Consideration by Camden CCG Governing Body
Camden CCG November 2018
A decision is made by Camden and Islington CCGs November 2018
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Camden and Islington CCGs on the final Business Case
The decision is communicated with the local community, OSCs, Healthwatch and partners
Islington CCG / Camden CCG / The Trust
November 2018
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Appendix 9
Consultation Document Transforming mental health services in Camden and Islington: Proposals for change to the Camden and Islington NHS Foundation Trust Estate Date: 4th July to 10th October 2018
St Pancras Hospital
Consultation Document A4 AMEND STAGE 6_25.06.18.pdf
NHS Camden and
Islington_survey amend stage 3 _25.06.18.pdf
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Appendix 10 Options development summary
Service Location Review by Camden and Islington Foundation Trust April 2017
Background
As part of the Outline Business Case one of the options under consideration is the
redevelopment of St Pancras with services moving to new community facilities funded
through the business case.
In order for the Trust to make a decision on the services to remain on St Pancras a process
was agreed with the board for criteria for services to be reviewed.
The criteria are noted below
CQC requirements met in full by facilities
Patient disruption must be minimised inpatients moved once only
Research and innovation supported alongside wider learning/ knowledge focus
Staff wellbeing supported
Enabling of the Sustainability and Transformation Plan (STP) ambitions
Enabling wider healthcare transformation across North Central London (NCL)
Affordability and value for money achieved
St Pancras site to be symbolic of our vision for mental health e.g. visibly
demonstrating integration, recovery, research etc.
Consideration of service user feedback that had been received to date
Workshops
Two workshops were arranged by Operations to be undertaken on the 24th and 31st March
2017, the attendees at these meetings were Clinical Directors, Consultants, Divisional
Directors and Service Managers, a full list of attendees can be seen in the Appendix 2.
The Outcome:
Stays at SPH Adult autism ADHD team London Veteran’s Service / traumatic stress clinic Medical education Head Quarters & Staff Facilities? Could be SPH / could be somewhere else (academic) Recovery College (Community feel) Sexual Problems Clinic Moves with inpatient Adult inpatient Inpatient rehabilitation and recovery service Volunteers Advocacy Moves to community
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Approved Mental Health Professionals Assessment and Advice Team Acute Day Unit (one of two facilities) Phlebotomy - building must have good access, as currently an issue Could go to community but want to be in one place Complex Depression Anxiety and Trauma Services (Acute Day Unit, Crisis House, Crisis Team) – Exists in Daleham Gardens – would be good to replicate for Rivers Crisis centre Community / mainly primary care – some admin ICOPE Psychological Therapies Service (Consider future need for TMS machines)
A full table is noted below of the preferences, along with comments made during the two
meetings.
The next stage
The work needs to be ratified by a number of groups before being presented to Executive for
agreement, so far it has been suggested that this is reviewed by the academics group held
at UCL, and the consultants group held at St Pancras.
In addition, Operations have been requested to review other services not currently provided
at St Pancras.
TRANSFORMING MENTAL HEALTH SERVICES IN CAMDEN AND ISLINGTON NHS FOUNDATION TRUST
The review output
CQC requirements met in full by facilities
Patient disruption must be minimised; inpatients moved once only
Research and innovation supported alongside wider learning/ knowledge focus
Staff wellbeing supported
Enabling of the Sustainability and Transformation Plan (STP) ambitions
Enabling wider healthcare transformation across North Central London (NCL)
Affordability and value for money achieved
St Pancras site to be symbolic of our vision for mental health e.g. visibly demonstrating integration, recovery, research etc.
Service
Adult Autism Diagnostic and Consultation Service
x x x x x x x
Adult inpatient services
x X x x x x x
Approved Mental Health Professionals Team (AMHPs)
x x x x x
Assessment and Advice Team
x x x x x
Attention Deficit Hyperactivity
x x x x x x
TRANSFORMING MENTAL HEALTH SERVICES IN CAMDEN AND ISLINGTON NHS FOUNDATION TRUST
Disorder (ADHD) Team
Camden and Islington Psychodynamic Psychotherapy Services
x x x x x
Complex Depression Anxiety and Trauma Service (CDAT)
x x x x x
ICOPE Psychological Therapies Service
x x x x x
London Veteran’s Service
x x x x x x x
Rehabilitation and Recovery Service – Inpatients
x X x x x x x
Sexual Problems Clinic
x x x x x
Acute Day Unit – x x x x x
TRANSFORMING MENTAL HEALTH SERVICES IN CAMDEN AND ISLINGTON NHS FOUNDATION TRUST
Jules Thorn
South Camden Crisis Team
x x x x x
The Rivers Crisis House
x X x x x x
Traumatic Stress Clinic
x x x x x
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The attendees
24th March 2017
Ian Griffiths Clinical Director Acute
Suzanne Joel Clinical Director SAMH
Gina Waters Consultant psychiatrist Acute
Liz McGrath Clinical Director SMS
Gillian Paterson Service Manager SMS
Dominic O’Ryan Clinical Psychologist STIS
Aisling Clifford Divisional Director Acute
Adele McKay Senior Service Manager Acute
Diana Brown Social Worker CDAT
Allison Arekion Service Manager CDAT
Matt Allin Psychiatrist RR R&R
Robert Murray Divisional Director R&R
Neill Wells Senior Service Manager R&R
Roger Evans Service Development Manager
Ops
Allison Arekion Divisional Director CMH
Ian Prenelle Clinical Director R&R
Chris Dunbar KPMG
Neil Turvey Project Director
Andy Stopher Acting Director of Operations
31st March 2017
Conor McIntyre Service Manager North Islington R&R
Druid Fleming Senior Service Manager North Islington R&R
Neill Well Senior Service Manager Camden R&R
Adele McKay Senior Service Manager Acute
James Wakefield Assistant Psychologist CDAT
Alison Areilion Service Manager CDAT
Emily van de Pol Divisional Director Community
Matt Allin Clinical Director SMS
Dominic O’Ryan Clinical Psychologist STIS
Andy Stopher Acting Director of Ops
Chris Dunbar KPMG
Lauren Oxley KPMG
Additional Comments
Acute
Acute all on one site would be preferable
Retain Crisis hub on St Pancras? 12 bed Crisis House
Acute day units - Doesn’t need to be on St Pancras, but does function better when collocated with inpatient acute.
In patient facility - Library for head office / back office?
Acute – could be some value in collocation (acute day units, crisis house, crisis team)
Acute day units – need large group rooms and consulting rooms Community Hubs
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CRTs – predominantly mobile working – need hot-desking space and car parking – need cars
Direction of travel is that crisis teams staffing might grow slightly
ADUs should not grow but should develop to do prevention / step down – join up with CRTs (acute service is currently 9-5)
Social housing to supported accommodation – (One Housing and Circle Housing) – currently there is a lack of move on/step down. Residential development could provide an opportunity for the Trust to incorporate MH focussed social housing/step down facilities.
East London has a step down unit with roadside exits (i.e. access directly from the street) – this represents the next level of step down housing.
Rehab wards remain with acute wards R&R
2 x EIS teams (need to be collocated)
2 x AOT teams (could be incorporated into community R&R teams)
Focus team – (should stay in Camden Town)
Community Rehab teams – May not need two – where do we co-locate? HOO?
HOO – currently difficult to maintain and a long way away. Could be an opportunity.
What do we do whilst rebuilding takes place? – Need a solution
Always need co-location for a particular cohort with long term needs (AOT and rehab)
Clinical strategy sees movement into GP surgeries but will be an ongoing need for central spaces for communication / to allow practice based teams to come together – all grades of staff, regular team meetings.
Technology will help, but it won’t eliminate the need for a ‘home’ space. Hot-Desking Reasons this might not work for specific teams / individuals:
Special physical / OH requirements
OH quiet space
Professions requiring dedicated space (i.e. Doctors need dedicated space – although could possibly hot desk within the dedicated area)
Confidentiality / noise distraction
Managers – confidential/sensitive discussions
Culturally inequitable if not required at all levels (i.e. including Executive) Other considerations
Lowther Road – pleased to see something being done with this
When you create community hubs – need to consider what happens to staff in the interim as interim accommodation costs can be expensive
154 Camden Mews – could we be doing more with that site? – we need the beds and the day service
Aged Mental Health:
“We are very happy with Peckwater in Camden” – very happy with it as a community site integrated with primary care and CNWL
In Islington we are happy with Brewery Road – but we don’t like that we can’t see patients there. D1 declined. Means Brewery Road could be a possible location for cheap back office space. Would mean we need another community site in Islington.
Southwood – not much opportunity to expand and surrounded by residential development.
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See most people in own homes – need some group rooms and clinic space (can be shared with other services)
Expect to slowly expand service over coming years. Substance Misuse
Holloway Road is not fit for purpose
Would be happy for substance misuse to be part of a larger community hub
Critical to have dispensing pharmacy in each hub
Would like to be more integrated with R&R teams
Key things to consider: 1. Future of Margaret Centre Site (HS2 / underutilised) 2. Redevelopment / alternative use of Holloway Road site 3. Daleham site – tenant (GP) dominates – could expand 4. Future of Grays in Road site? – should we keep it 5. Need more flexible space for day programmes / web based delivery 6. Do we want medically assisted detox beds (e.g. upstairs at Daleham?) –
commercial opportunity as no other providers of this service 7. Conference facilities would be beneficial (i.e. for 40/50 people to come together)
– could be provided within community hubs 8. Opportunity for community use of Conference facilities – come in and use (nice
quality) 9. Hubs should have a site coordinator / manager to make the building work 10. Section 75 review in Camden – currently don’t know the outcome but will impact
the role of social workers and level of integration – more focused space
Support social enterprises – support GP surgeries – link to physical care – currently no facilities for online therapy (either public / treatment room or social enterprise use)
We are not really engaging the younger population. Community Mental Health
We need to integrate with primary care, and also with other teams
Our services (CDAT, PD, traumatic stress) work across boroughs
ICOPE benefits in combining across boroughs (call centre / admin space)
More and more wanting to see patients within primary care space – but this is dependent on timescales for expanding GP estate / facilities
Many consultation rooms (high volume services)
Need group space
Need IT capacity / workstations Further comments for considerations
- ‘Where community services are located at the St Pancras site, it is positive when they can be easily accessed without passing through the hospital e.g. Camden iCope is easily reached via the new entrance. Clients can be deterred from engaging with community services if they find that attending the service means they are in contact with clients who are more unwell.
- Crisis teams at hospital locations: on occasion clients are anxious to attend a crisis service at a hospital due to fear of being sectioned. As such being in the community can help de-stigmatize.
- Crisis houses that are not so medicalised in appearance have received positive
feedback from clients.’
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Appendix 11 Feasibility Study
Option Name
Option Description Option Evaluation Option Outcome
Camden Council Site
Make use of council land which is either vacant or due to become vacant in the near future in the London Borough of Camden.
Camden Council has recently consolidated its estate and built a new head office near St Pancras. It has advised the Trust that is has no suitable land available.
Islington Council Site
Make use of council land which is either vacant or due to become vacant in the near future in the London Borough of Islington
Islington Council has confirmed that it has no suitable land available.
Pentonville Prison Site
Pentonville Prisons is located near to the western edge of the London Borough of Islington and is due to close in the near future.
The agent responsible for the redevelopment has confirmed they intend to make use of the land for residential development and the timetable is uncertain at this stage as the prison has no close date.
Holloway Prison Site
Holloway Prison is located just to the North of Pentonville Prison and was closed in 2016. The site may therefore be available in the near future.
The agent responsible for the redevelopment has confirmed they intend to make use of the land for residential development and the timetable for works is too short for this project as the prison is closed and negotiations on its redevelopment already well advanced.
Royal Free Site
The Royal Free’s main hospital site is located roughly in the centre of the London Borough of Camden. As the Trust would like to co-locate with an acute hospital Trust this would provide an ideal location.
The Royal Free is landlocked and has no surplus available space.
Moorfields Hospital Site (Moorfields)
Moorfields Eye Hospital NHS FT (Moorfields) is located in the south eastern corner of the London Borough of Islington. Moorfields is a specialist eye hospital.
Moorfields Eye Hospital has its own plans to relocate away from its current site at the North Eastern Edge of the City of London. Their project is reliant on a significant capital windfall
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Option Name
Option Description Option Evaluation Option Outcome
as a result of the sale and is therefore not a suitable site for the new inpatient facility.
University College London Hospital (UCLH)
UCLH’s main hospital is located in the south of London Borough of Camden. As the Trust would like to co-locate with an acute hospital Trust this would provide an ideal location. UCLH also has excellent links with University College London (UCL) for the development of a research centre.
UCLH is landlocked and has no surplus available space.
Vacant Private Sector Land
Any vacant private land of a suitable size that is identified in the area has the potential to be used to deliver the new hospital facility.
No private sector vacant land has been identified.
St Ann’s St Ann’s Hospital was identified during the SOC stage as having the potential to host a new inpatient facility for the Trust.
It is located in the London Borough of Haringey, but has been included as it was identified as the best site during the SOC stage and is a mental health Trust and is within two miles of the Islington border. There is land available to deliver the project and early discussions have taken place.
Whittington The Whittington Hospital is located on the border between Camden and Islington to the North of both Borough’s. It is an acute hospital with land available for the Trust to build a new inpatient facility.
The Whittington Hospital has land available as part of their ongoing capital strategy and is an acute hospital so has the potential to provide a full range of care for service users as part of the collaboration. It is also close to the existing Highgate mental health facility.
Do minimum
Under this option the Trust would carry out the minimum works necessary to improve the quality of their existing estate to enable the Trust to deliver a higher quality of care.
This option requires the minimum amount of capital as the land is available and buildings are already built.
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Option Name
Option Description Option Evaluation Option Outcome
Rebuild at SPH
A new mental health inpatient facility would be built on the existing SPH site.
The land at SPH is currently occupied by the Trust’s existing facilities and therefore these will need to be relocated or worked around while the new site is being built. However the land is the Trust’s to use as required.
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Appendix 12 Options considered
Inpatient options
Option name Option description and key observations
A1 Do minimum
(Continue to provide inpatient services in existing buildings).
The configuration of the SPH site will remain unchanged. We will continue to maintain the facilities.
As care will still be provided in old buildings, there will be a number of challenges with providing modern facilities.
Due to space constraints on the current site there will be no Institute of Mental Health and the ability to fundamentally transform care will be limited.
A2 Re-provide inpatients at SPH
A new inpatient facility will be built on the SPH site. This will provide a modern clinical space which is disability friendly and enable the Trust to deliver a safe service for service users and staff.
This would however be on a site that would offer limited ability to offer privacy and dignity to the inpatients. The only location available to enable the build (without the decant of one or two inpatient facilities) would be on the site adjacent to Granary Street, where a recent development scheme has achieved planning permission for up to 13 stories on the opposite side of the road, so this significantly reduces the value that can be realised from the site for reinvestment back into developing sustainable high quality facilities. In addition, the Trust is aware of development plans for the so called ‘Ugly Brown Building’ at the south of St Pancras of up to 12 stories directly overlooking the site, therefore a new inpatient facility could be overlooked in two directions, and only a double carriageway apart which is not seen as a desirable environment for delivering mental health inpatient services.
The inpatient facilities would also restrict the density of development adjacent to them, if inpatient facilities are to be delivered on the SPH site, to ensure the wellbeing of service users. The Trusts capital receipt will also be affected by the lower density.
The Trust would receive less capital receipt due to selling less land and less receipt because of the reduced density on the site; this results in a considerable reduction in the overall capital receipt for the site. This will undermine the Trust’s ability to deliver the requirements of this business case.
A3 Re-provide inpatients at Whittington Hospital
A new inpatient facility will be built adjacent to the Whittington Hospital in Archway, Islington. This will provide a modern clinical space that is disability friendly and enable the Trust to deliver a safe service for service users and staff.
Disruption to service users will be minimised during the
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Inpatient options
Option name Option description and key observations
construction phase as significant work will not commence at SPH until inpatients are moved to the new site.
The Institute of Mental Health can be delivered at the SPH site, but there will also be potential to sell some of the site for residential development, releasing funds for the rest of the project.
The new inpatient facility will continue to be located in the London Boroughs of Camden and Islington.
A4 Re-provide inpatients at St Ann’s Hospital
A new inpatient facility will be built adjacent to the St Ann’s Hospital, Haringey. This will provide a modern clinical space, which is disability friendly and enable the Trust to deliver a safe service for service users and staff.
Disruption to service users will be minimised during the construction phase as significant work will not commence at SPH until inpatients are moved to the new site.
The Institute of Mental Health can be delivered at the SPH site, but there will also be potential to sell some of the site for residential development, releasing funds for the rest of the project.
The new inpatient facility will not to be located in the London Boroughs of Camden and Islington.
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Appendix 13 Qualitative assessment workshop summary
Forum Date of Workshop Key themes
Senior Leadership Team
26 April 2017
Key themes from the Senior Leadership Team included:
The benefits of remaining in the London Boroughs of Camden and Islington to ensure they remain close to their communities was considered an issue for the St Ann’s site – particularly as transport links are not as good as for the other options. There should be good transport links for service users and staff.
Support for improved links between the community and inpatient services offered by the C&I.
There will be long term clinical benefits for service users from developing a new research facility
Whittington option allows for the co-location of a new Whittington Facility with the existing Highgate Mental Health Centre
Co-location with Whittington also provides acute and mental health care on the same site
Clinical Reference Group
25 April 2017
Key themes from the Clinical Reference Group included:
Refurbishing the existing facilities at SPH will not ensure they meet CQC guidelines and will continue to impact the care delivered to service users.
Travelling between St Ann’s and SPH would be a significant challenge for C&I personnel.
Staff wellbeing facilities can be incorporated into the new site, improving staff morale.
Council of Governors
9 May 2017 The council of governors identified:
The need to do more work to establish the impact on service users, staff and other stakeholders of increased travel to the preferred option chosen if moving from SPH. It was confirmed that further work on this will be completed as part of the FBC stage.
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Appendix 14 Qualitative assessment scoring
Option A1
Option A3
Option A4
Summary of comments made by each of the groups when scoring against the critical success factors
Do
minimum Whittingto
n St Ann's
CSF 1 0.8 3.9 2.4
The two new build inpatient facilities will meet CQC requirements. However, the St Ann’s option creates travel challenges for service users and staff due to limited public transport links and will make co-ordination between inpatient and community activity more difficult.
CSF 2 1.3 3.1 2.7
There will be significant disruption at St Pancras during the refurbishment work over an extended period of time. There will also be some disruption for service users during the transition to either St Ann’s or Whittington although for service users and their families when visiting St Ann's this will be more challenging due to the relative inaccessibility of the site.
CSF 3 1.7 3.9 2.8
The do minimum option does not make any land available for the new research facility. The new inpatient facility at St Ann’s would be considerably more remote from the research hub than an inpatient facility at Whittington.
CSF 4 1.1 3.9 2.6
Only new facilities can have a significant impact on the quality of care. Travel time for carers and family when visiting at St Ann's will have a significant impact on those individuals.
CSF 5 1.3 3.8 2.4
Only new facilities are aligned to the service user needs and enable the clinical strategy. Travel time for carers and family when visiting at St Ann's will have a significant impact on those individuals.
CSF 6 1.2 3.7 2.4
The current SPH cannot support the de-stigmatisation of mental health. Putting the new inpatient site next to an existing mental health site will allow the internal changes to be made but will not support the external perception, which would be supported by co-locating with the Whittington (an acute physical health hospital).
CSF 7 1.4 3.7 2.3
The ability to make changes to SPH to meet the requirements of the Equalities Act 2010 is limited. St Ann's is not as good for the service user cohort due to accessibility.
CSF 8 1.5 3.8 2.2 Whittington is the only site that provides the potential for an integrated whole person health solution (i.e. integrated physical and mental health).
CSF 9 4.0 3.4 1.2 St Ann's is out of area whereas SPH and
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Whittington are within the borough.
CSF 10
2.3 3.6 2.1
The is concern that staff travelling St Ann's will have a lifestyle impact due to the additional travel time. Whittington has the critical mass of staff to provide more support.
CSF 11
0.3 2.5 2.1
Do minimum, prevents delivery of the NCL STP as it continues to occupy SPH, it doesn't encourage community care and continues to provide care in substandard, high cost facilities. Whittington meets the STP most closely, while the St Ann's option is outside the borough.
CSF 12
0.7 2.7 2.6
Both Whittington and St Ann’s enable delivery of the local plans, in particular delivery of new housing. SPH in its current form does not allow housing on the land it occupies.
Overall Score
18 42 28 Option A3 (Rebuild at Whittington) has the highest score in the qualitative assessment and therefore is the preferred option. Overal
l Rank 3 1 2
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Appendix 15 Qualitative scores of each option
Senior Leadership Team and Board Scores
Critical Success Factor
Option A1
Option A3
Option A4
Notes
1) CQC requirements 1 4 2 Community inpatient link weaker at 3 compared to 2 due to location
2) Minimise service user disruption
1 3 3
3) Research and development
1 4 4 It was noted that a new research facility could not be constructed under option 1
4) Quality of service
user care 1 4 3
Again the community - inpatient link was emphasised, hence 2 scoring greater than 3
5) Aligned to service user need and supportive of the clinical strategy
1 4 3 Yet again the community - inpatient link was emphasised, hence 2 scoring greater than 3
6) De-stigmatise mental health
1 4 3
A view that option 3 creates a large mental health facility compared to a mental health facility collocated with physical health in option 2. Options 2 and 3 will both facilitate new facilities on the St Pancras site
7) Promotes equality 2 4 2 The accessibility of option 3 was a concern, as was the accessibility for the current buildings in Option 1
8) Integrated care 2 4 3 Option 2 provides colocation with physical health that the other options do not.
9) Located with in-borough or close to Camden and Islington
4 3 1
10) Support staff wellbeing
2 4 3 The effective creation of a larger mass of staff in option 2 gives this option the extra point
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11) Consistent with the NCL STP
1 3 3
12) Consistent with plans for local community and place development
1 3 3
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Council of Governors Scores
Critical Success Factor
Option A1
Option A3
Option A4
Notes
1) CQC requirements 0.4 3.7 2.1 St Pancras doesn't meet the criteria
2) Minimise service user disruption
0.8 3.2 2 St Ann's impact on friends and family travelling to see admitted patients
3) Research and development
2 3.8 2.4 St Pancras already undertakes this
4) Quality of service user care
1.4 3.8 1.8
5) Aligned to service user need and supportive of the clinical strategy
1.9 3.3 1.2 St Pancras is a good location, St Ann's is too far
6) De-stigmatise mental health
2.7 3.1 1.2 Whittington does put all our beds close together, and concentration of patients
7) Promotes equality 2.2 3 2
8) Integrated care 1.6 3.4 1.6
9) Located with in-borough or close to Camden and Islington
4 3.2 0.6 St Ann's is out of area
10) Support staff wellbeing
3.8 2.7 1.2 Don't need a building to support staff development, this is cultural, but longer travel could affect staff
11) Consistent with the NCL STP
0 0.6 0.2 Not all members of the group scored this CSF, which has distorted the average.
12) Consistent with plans for local community and place development
0.2 2 1.8 Some people will want to keep SPH beds
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Clinical Reference Group Scores
Critical Success Factor
Option A1
Option A3
Option A4
Notes
1) CQC requirements
1 4 3
New facilities will meet the criteria, existing unlikely too due to the age of the building and the lack of amenity space and the ability to put adequate accessibility into buildings designed in the C18th. Concern was noted that the location of St Ann’s would meet the accessibility criteria for service users due to the lack of close tube or train service directly to the site and it being only on one bus route
2) Minimise service user disruption
2 3 3
The greatest known disruption would be at St Pancras given the planning approvals around the site but also noting the other options also have building plans
3) Research and development
2 4 2
Under option 1 there will be no available space for an IoMH on the St Pancras site, as services will continue to be delivered in the same way. Locating Institute of mental health at St Pancras with easy link to Archway will be better than having our main facilities at St Ann’s due to the difficulty of access between the St Pancras and St Ann’s as whilst the nearest tube to St Ann’s is Seven Sisters a further walk of c20mins is needed to get to the site.
4) Quality of service user care
1 4 3
Only new facilities can ensure this criteria but travel difficulties to St Ann’s noted in scoring The travel relates to carers of those being in the trust premises, as St Ann’s is not as easy to get to as Archway which is accessible on buses as well as the tube for our Camden and Islington residents, whereas as St Ann’s is not on many bus routes is difficult to get to from Camden and Islington and only with substantial walking
5) Aligned to service user need and supportive of
1 4 3 As with the CSF above the same reasoning
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the clinical strategy
6) Destigmatise mental health
0 4 3
St Pancras Hospital does not achieve this in current layout, all options with community hubs improve this aside from St Ann’s being similar to St Pancras as being recognised as a specific mental health hospital site, not a general hospital site as the Whittington
7) Promotes equality
0 4 3 St Pancras has poor EA10 compliance new builds should be better but transport links to St Ann’s are poor
8) Integrated care 1 4 2
Only the Whittington options provides fully integrated care with inpatient and community hubs located within Camden and Islington, and the inpatient facilities co-located with acute facilities, whilst St Ann’s option will provide the community hubs, the inpatient facility is not located in Camden or Islington or on an acute site but a mental health site.
9) Located with in-borough or close to Camden and Islington
4 4 2 The 3rd option only has community hubs in borough, St Ann’s is close but not within
10) Support staff wellbeing
1 4 2
The new facilities can provide a higher level of staff wellbeing, but the score also reflects staff being isolated at St Ann’s
11) Consistent with the NCL STP
0 4 3 Only options 2 &3 support this and option 2 is more aligned to closer to home
12) Consistent with plans for local community and place development
1 3 3 Options 2 &3 enable this to be delivered at St Pancras
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TRANSFORMING MENTAL HEALTH SERVICES IN CAMDEN AND ISLINGTON NHS FOUNDATION TRUST
Building External Internal M&E External Internal M&E External Internal M&E External Internal M&E External Internal M&E Total Comments
Ash House - SPH 48,900 75,000 - - - - - 1,200 - 125,100£
Bloomsbury Building - SPH 211,931 13,600 75,000 - 50,000 - - 350,531£
Boiler House - SPH 35,300 100,000 100,000 - - - 235,300£
East Wing - SPH 100,000 300,000 47,950 - - 447,950£
Camley Centre/Estates Office - SPH - 300,000 50,000 - - - - - 350,000£
Jules Thorn Day Hospital - SPH - 44,348 - - - 150,000 200,000 394,348£
Gate House Building - SPH 58,132 75,000 75,000 16,650 - 27,650 - - 10,650 - 263,082£
Huntley Centre - SPH 350,000 97,951 100,000 - 10,100 - 558,051£
Former Kitchen - SPH - - - - - - 100,000 300,000 - - - - - 400,000£ Cost to bring building back to beneficial use
Former Mortuary Building - SPH - 50,000 50,000 - - - - - - - - 100,000£
North East Building - SPH 199,473 150,000 400,000 24,365 20,000 - - - - - 793,838£
North Wing - SPH - 114,201 - 11,700 200,000 - - 325,901£ This is RF cost under lease but shown to indicate extent of BLM
Post Room Building - SPH - 65,000 47,000 - - - - - - - 112,000£
Former Residence Building - SPH - 400,000 - 250,000 400,000 - 400,000 - - - 1,450,000£ Cost to bring building back to beneficial use
River Crisis House - SPH - - 1,800 20,000 - - - - - - 21,800£
South Wing - SPH 100,000 97,650 400,000 391,018 150,000 56,200 - 3,200 1,198,068£
The Well - SPH 36,305 1,276 1,225 - 4,000 1,739 6,344 - - 50,888£
West Wing - SPH 10,650 181,370 250,000 300,000 250,000 13,350 56,350 - 1,061,720£
SPH Site Infrastructure & Services 1,218,000 543,000 1,761,000£
HMHC M Block 100,000 47,760 3,500 550,000 7,000 - 20,000 - 728,260£
3-5 Daleham Gardens 8,140 7,678 2,850 10,469 20,000 - 6,962 3,500 - 5,441 15,000 - 80,040£
19 Aberdeen Park 4,600 2,940 7,540 2,226 10,000 4,475 15,088 600 - 350 - 47,819£
Camden Mews - 100,000 1,200 100,000 4,920 - - - 206,120£
154 Camden Road - - 100,000 1,200 - 4,780 - - - 105,980£
Drayton Park 7,872 - 1,400 50,463 2,320 5,090 - - - - 67,145£
Greys Inn Road 9,024 - - - - 2,850 - 2,120 - - 6,500 - 20,494£
Greenland Road 350 - 26,700 100,000 350,000 5,920 - - 15,000 - 497,970£
75 Hanley Road 60,000 300,000 100,000 - - 460,000£ BLM liability assuming retention
Hornsey Lane - - - - -£ Leased to third party - no residual BLM liability
The Hoo 20,000 150,000 110,298 14,000 2,800 100,000 9,900 41,807 20,222 5,000 3,850 200,000 677,876£
Holloway Road 5,784 3,698 2,830 614 1,000 - 2,943 780 - 33,582 2,500 - 53,730£
Lowther Road 19,100 100,000 350,000 1,200 6,500 780 477,580£
Margarete Centre - - 7,939 - - - - 50,000 50,000 107,939£
Southwood Smith Building 2,370 800 - - 62,660 10,730 527 - - - - - 77,087£
Stacey Street 13,557 5,868 2,050 2,987 3,500 3,435 209 15,000 - 28,681 - - 75,287£
Highview Residential - 3,000 1,600 - - 2,242 9,418 5,240 650 - - - 22,150£
Blenheim Court Brewery Road - - - - -£ Leased but no BLM liability beyond repairing covenants
Caledonian Road - - - - -£ Not owned by C&I - no BLM liability
Finsbury Health Centre - - - - -£ Not owned by C&I - no BLM liability
Raglan St - - - - -£ Not owned by C&I - no BLM liability
Hanley Gardens - - - - - - - - - - - - -£ Not C&I properties - no backlog liability
Highgate Road - - - - -£ Not owned by C&I - no BLM liability
Hunter Street - - - - -£ Leased building no residual BLM liability - possible vacation
Isledon Road - - - - -£ Not owned by C&I - no BLM liability
Manor Gardens - - - - -£ Leased but no BLM liability beyond repairing covenants
Netherwood St - - - - -£ Not owned by C&I - no BLM liability
Peckwater - - - - -£ Leased building no residual BLM liability - possible vacation
Simmons House - - - - -£ Leased and sublet - no residual BLM liability
Tottenham Mews - - - - -£ Derelict Building surplus to requirements - potential disposal
71,346£ 950,000£ 1,107,835£ 2,034,640£ 2,300,332£ 1,830,552£ 1,977,847£ 1,685,147£ 745,060£ 57,546£ 200,618£ 90,280£ 203,850£ 450,000£ -£ 13,705,054£
2,129,181£ 6,165,525£ 4,408,054£ 348,444£ 653,850£ 13,705,054£
St Pancras Hospital -£ 850,000£ 956,641£ 1,666,370£ 1,373,276£ 1,675,333£ 1,096,225£ 1,200,000£ 678,800£ 15,089£ 112,693£ 25,150£ 150,000£ 200,000£ -£ 9,999,578£
HMHC -£ 100,000£ 47,760£ -£ -£ 3,500£ 550,000£ -£ 7,000£ -£ -£ 20,000£ -£ -£ -£ 728,260£
Community Sites 71,346£ -£ 103,434£ 368,270£ 927,056£ 151,719£ 331,622£ 485,147£ 59,260£ 42,457£ 87,925£ 45,130£ 53,850£ 250,000£ -£ 2,977,216£
Total 71,346£ 950,000£ 1,107,835£ 2,034,640£ 2,300,332£ 1,830,552£ 1,977,847£ 1,685,147£ 745,060£ 57,546£ 200,618£ 90,280£ 203,850£ 450,000£ -£ 13,705,054£
Annual Total Annual Total Annual Total Annual Total Annual Total
Capital 2016/17 Capital 2017/18 Capital 2018/19 Capital 2019/20 Capital 2020/21
Appendix 16 Backlog maintenance
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Appendix 17 Quantifiable benefits
Type of Benefit Benefit
Option A1
Do Minimum
Option A2
Rebuild SPH
Option A3
Whittington
Option A4
St Ann’s Assumptions
Activity (less acute because more community intervention / early intervention / less duplication)
Quicker service user recovery frees up bed capacity and reduced cost (non-cash releasing, recurrent)
N/a £1.5m per annum (from 2023/24)
£1.5m per annum (from 2023/24)
£1.5m per annum (from 2023/24)
Improving the environment for service will mean they make a quicker recovery.
Identifying service users earlier, means that the severity of their conditions is reduced.
Reduced cost of physical healthcare through co-location of mental and physical healthcare services (non-cash releasing, recurrent)
N/a N/a £70k per annum (from 21/22)
N/a Costs of care for the Trust will reduce as a result of co-locating with an acute Trust.
Costs of service user transport will reduce
Staffing (reduced staff costs through less agency, more productive and happier staff)
Reduced agency staffing, so reducing cost, through improved staff working conditions and therefore retention (cash releasing, recurrent)
N/a £800k per annum
£800k per annum
£800k per annum
The new facility will improve staff morale.
The new facility will therefore encourage staff to stay in post, reducing vacancies and therefore agency staffing costs.
Reduced costs due to new build wards, with large bed capacity and better layout (cash releasing, recurrent)
N/a £800k per annum
£800k per annum
£800k per annum
Reducing the number of wards by one but maintaining the number of beds means that the number of senior staff required on each shift will reduce.
Reduced cost of staff training due to co-location of the site with other similar medical facilities (non-cash
N/a N/a £80k per annum (from
£80k per annum (from
By training staff in larger groups or being able to offer more training on site will
TRANSFORMING MENTAL HEALTH SERVICES IN CAMDEN AND ISLINGTON NHS FOUNDATION TRUST
releasing, recurrent) 2021/22) 2021/22) reduce costs.
Staff progression and therefore satisfaction will increase due to increased opportunity
Admin staff flexibly located to increase operational efficiency (non-cash releasing, recurrent)
N/a £100k per annum (from completion of the project)
£100k per annum (from completion of the project)
£100k per annum (from completion of the project)
Admin staff are more accessible to clinical staff, reducing inefficiency.
By making effective use of flexible working arrangements less space is required.
Overheads Operating costs of a new building are lower than those of an old building (cash releasing, recurrent)
N/a £1.8m per annum (from 2021/22)
£1.8m per annum (from 2021/22)
£1.8m per annum (from 2021/22)
Lifecycle cost report provided by T&T shows a significantly reduced costs from a more efficient new building.
Energy and utility costs (cash releasing, recurrent)
N/a £360k per annum (from 2021/22)
£360k per annum (from 2021/22)
£360k per annum (from 2021/22)
The new building will be more efficient due to using better building design / materials.
Renegotiation of existing FM contracts (cash releasing, recurrent)
N/a £575k per annum (from 2018/19)
N/a N/a Based on benchmarking data the existing FM costs can be reduced by renegotiating the contract.
Other Increased research income from working closely with the Institute of Mental Health (IoMH) (cash releasing, recurrent)
N/a £10k per annum (from 2021/22)
£10k per annum (from 2021/22)
£10k per annum (from 2021/22)
IoMH works closely with the Trust and therefore benefits from some research grants.
Sub-let consultancy rooms (cash releasing, recurrent)
N/a £20k per annum
£20k per annum
£20k per annum
2% of consultancy rooms sublet on a regular basis to enable the provision of other
TRANSFORMING MENTAL HEALTH SERVICES IN CAMDEN AND ISLINGTON NHS FOUNDATION TRUST
services.
Uptake of these rooms will be high.
Realisation of land proceeds from access community and hospital estate. (cash releasing, non-recurrent)
N/a £66.3m (between 2017/18 and 2026/27)
£90.4m (between 2017/18 and 2026/27)
£90.4m (between 2017/18 and 2026/27)
Land which is surplus to requirements in both the community estate and inpatient estate can be sold at market value to realise a financial gain
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Appendix 18 Trust’s Income & Expenditure assumptions
Area Assumption
Income Baseline and investment case
Contractual income from clinical services with Camden CCG and Islington CCG is assumed to grow at an average rate of 0.7% and 1.7% per year between 2016/17 and 2025/26 (before inflation).
Income from other contracts for clinical services is assumed to fall from £13.3m in 2016/17 to £11.7m in 2017/18 (an 11.5% decrease) and then grow by 0.8% per year (before inflation).
Non-contract activity income is assumed to remain at the 2016/17 level of £1.3m per year throughout.
Section 75 income is assumed to remain at £12.7m per year throughout.
A reduction in income reflecting the risk of funding from parity of esteem has been applied from 2019/20 at £0.7m, increasing to £1.9m by 2025/26.
STF funding has been assumed at £0.8m per year for 2016/17, 2017/18 and 2018/19. No funding has been assumed thereafter.
Investment case
The investment case is assumed to increase research and development and other revenue by £10k (from 2021/22) and £21k (from 2020/21) respectively.
Expenditure: Pay costs
Baseline and investment case
Activity growth is assumed to increase pay costs across all staff groups by 1.0% in 2017/18 and 0.6% per year thereafter.
Pay-related CIPs are assumed at 3.3% of total pay costs in 2017/18 and between 1.5% and 1.2% per year thereafter.
The impact of agenda for change (AfC) pay rates is assumed to be an annual increase of 1.2% in pay costs across all staff groups.
The cost associated with additional parity of esteem funding is assumed at 0.3% for 2019/2020, around 0.7% for 2020/21 and 0.5% per year thereafter.
Investment case
The investment is assumed to reduce spend on substantive nursing staff by £0.9m per year from 2021/22. This is a CIP plan to reduce the number of staff by one ward, made possible by the larger modern wards in the new building.
CIP plans to further reduce agency staff costs through: more efficient staff rotas, better staff retention and co-locating admin staff with community hubs is assumed to reduce agency costs by:
o £0.3m in 2020/21
o £0.6m in 2021/22
o £0.9m per year thereafter
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Area Assumption
Expenditure: Non-pay costs
Baseline and investment case
Activity growth is assumed to increase drug costs, clinical supplies and directly managed staff costs by 0.7% in 2017/18 and is assumed to have no further impact thereafter.
Parity of esteem funding is assumed to increase drug costs by 0.4% in 2019/20, 0.9% in 2020/21 and 0.6% thereafter.
Other expenses (general supplies, establishment costs, premises and plant costs and other costs) are assumed to fall slightly from £27.1m in 2016/17 to £27.4m in 2017/18 and in each year thereafter (before CIP and inflation).
Other expenditure CIPs are assumed to be achieved recurrently at £2.2m in 2017/18, with a further £0.8m assumed recurrently each year thereafter.
Investment case
The investment is assumed to reduce other expenses by £0.8m in 2020/21 and around £3.5m per year thereafter. This is the result of three CIP schemes:
o £1.8m from the reduced operating costs of the new building;
o £1.5m from reducing the length of stay (LOS) resulting from the improved therapeutic environment; and
o £0.4m from reduced energy costs of the new building.
Cost improvement plans
Baseline and investment case
The assumptions underlying the pay and non-pay CIPs are set out in the relevant sections above.
All CIPs are assumed to be recurrent.
No income CIPs are assumed.
CIPs are assumed at, as a percentage of operating expenditure:
o 4.1% for 2017/18
o 1.8% from 2018/19 to 2019/20
o 1.7% from 2020/21 to 2023/24
o 1.6% from 2024/25 to 2025/26
Investment case
The investment is assumed to generate pay cost savings of £1.8m by 2022/23, as set out in the pay costs section above.
Other expenses CIPs are assumed at £3.5m from 2021/22, as set out in the non-pay costs section above.
Interest expense
Baseline case
No interest costs are included in the baseline case.
Investment case
Interest costs under the investment case are assumed to be 2.9%.
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Area Assumption
Inflation Baseline and investment case
Inflation has been assumed at the following rates:
2018/19 2019/20 2020/21 2021/22 2022/23+
Income 0.1% 0.3% 0.3% 0.3% 0.3%
Pay costs 1.0% 1.0% 1.0% 1.0% 1.0%
Drug costs 3.5% 3.5% 3.5% 3.5% 3.5%
Other expenses 2.0% 2.0% 2.0% 2.0% 2.0%
Capex 3.0% 3.0% 3.0% 3.0% 3.0%
The above inflation rates are consistent with the Trust’s Sustainability & Transformation Plan (STP) assumptions
Note, in addition to the inflation rates above, the Trust has assumed a 1.2% AfC increase that whilst not technically inflation will compound with the inflation rates above to increase wages in cash terms.
Transitional support
The Trust has not assumed that it will receive any transitional support funding as part of its affordability assessment. Funding for the clinical transformation and estates strategy will be from land sales and internally generated reserves. As described above, due to the timing of the major cash flows (construction cost and land purchases coming before land sales), the Trust has assumed a bridging loan to ensure that it can maintain sufficient working capital over the LTFM period.
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Appendix 19 Baseline income and expenditure
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Appendix 20 Baseline statement of financial position
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Appendix 21 Baseline cash flow statement
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Appendix 22 Trust FSRR scores for the investment and baseline cases
The financial sustainability risk rating (FSRR) is NHSI’s view of the level of financial risk a trust is
exposed to and is a therefore key metric to consider for this transaction. The FSRR is a
combination of the following four metrics:
Liquidity: days of operating costs held in cash or cash equivalents
Capital servicing capacity: the degree to which the organisation’s generated income
covers its interest and debt repayments. Note that this may exclude repayment of
bridging debt at NHSI’s discretion (discussed further below).
Income and expenditure (I&E) margin: the degree to which the organisation is
operating a surplus/deficit with respect to its total operating and non-operating income.
Surplus/(deficit) is calculated before impairments and gains/losses on asset disposal.
Variance from plan in relation to I&E margin: the variance between a trust’s planned
and actual I&E margin.
Each of the metrics yields a score between 1 (greatest risk) and 4 (least risk). An overall FSRR
score is calculated from the average of the four metrics, although this is capped at 2 if one of the
metrics is a 1. Trusts that score a 1 or 2 may be subject to an investigation by NHSI.
The details of the FSRR calculations criteria are shown in Table F1 below.
Table F1: FSRR criteria
Notes:
The metrics are weighted equally (i.e. averaged), then rounded to produce a single FSRR
If the trust scores 1 on any metric, the overall rating will be capped at a 2.
The FSRR scores for the investment and baseline cases are set out in Tables F2 to F4 below.
The FSRR calculation performed by the LTFM yield a capital service cover risk rating of 1 for the
investment case, as the bridge loan repayments are included in the debt service total. This
significantly distorts the position as the Trust has sufficient cash to make these repayments as
1 2 3 4
Balance sheet
sustainabilityCapital service capacity (times) <1.25 1.25-1.75 1.75-2.5 >2.5
Liquidity Liquidity (days) <(14) (14)-(7) (7)-0 >0
Underlying
performanceI&E margin (%) <(1) (1)-0 0-1 >1
Variance from planVariance in I&E margin as % of
income<(2) (2)-(1) (1)-0 >0
Risk categoriesMetricFinancial criteria
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shown in the tables above. The LTFM itself provides an area where adjustments can be made to
reverse out the impact of bridge loan financing from the FSRR analysis and that is deemed
appropriate here. These repayments are excluded for bridge loans and the impact of this is
shown in Table F3 below.
Table F2: FSRR scores for the investment case (unadjusted)
As noted above, the inclusion of the bridge debt repayments as debt service in the capital service
capacity calculation causes this metric to become 1. Table F3 below presents the FSRR scores
after these payments have been excluded from the calculation.
Table F3: FSRR scores for the investment case (adjusted for debt repayments)
The adjusted FSRR shows an I&E margin rating of 2 in 2020/21, as the projections show a small
net deficit in this year of £(0.1)m. The overall rating remains at 3 for this year and at 4 for all
other years.
Table F4: FSRR scores for the baseline case
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26
Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Capital service capacity 3 4 4 3 3 1 1 1 1 1
Liquidity 4 4 4 4 4 4 4 4 4 4
I&E margin 4 4 4 3 2 3 3 3 3 4
Variance in I&E margin n/a 4 4 4 4 4 4 4 4 4
Overall FSRR n/a 4 4 4 3 2 2 2 2 2
Risk score
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26
Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Capital service capacity 3 4 4 4 4 4 4 4 4 4
Liquidity 4 4 4 4 4 4 4 4 4 4
I&E margin 4 4 4 4 4 4 3 3 3 2
Variance in I&E margin n/a 4 4 4 4 4 4 4 4 4
Overall FSRR n/a 4 4 4 4 4 4 4 4 4
Risk score
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26
Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Capital service capacity 3 4 4 3 3 3 3 3 4 4
Liquidity 4 4 4 4 4 4 4 4 4 4
I&E margin 4 4 4 3 2 3 3 3 3 4
Variance in I&E margin n/a 4 4 4 4 4 4 4 4 4
Overall FSRR n/a 4 4 4 3 4 4 4 4 4
Risk score
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Under the baseline case, the FSRR remains at 4 throughout, although the declining net surplus
position causes the I&E margin score to fall to a 2 by 2025/26.
The sensitivities set out in the previous section each have minimal or no impact on the forecast
FSRR score when considered individually. A combined downside case will be considered in the
FBC along with the impact on the FSRR.
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Appendix 23 Letter of support from the Trust’s Director of Nursing
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Appendix 24 Bed modelling benchmarking
On the graphs below, the Trust is identified as M11.
Adults
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Acute
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Length of Stay
2015/16 2017/18
Length of stay MPICU 55 89
Length of stay WPICU 36
Length of stay Acute 49 67
Length of stay Older Adult 135 118
Length of stay Rehab 1103 721
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Appendix 25 – Bed occupancy
Bed Occupancy
• Acute: Reduction approx. 3% • R&R: Reduction approx. 2% • SAMH:33% reduction in usage
Number of Out of Area Placements
(OAPs)
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• Reduction in ECR
• 5th April zero ECR bed