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Version 3.6
Transformation of A&E, Acute Medicine
and General Surgery Services across Greater Manchester
Healthier Together Full Business Case
Edition 3.6 15/09/17
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Version 3.6
Document cover sheet
Document information
Draft 3.6
Document title: Healthier Together Full Business Case
Date: 15/09/17
Owner: Ed Dyson (GM SRO)
Author: NHS Transformation Unit
Version Editor Changes made Date
0.1 – 1.8
Mellanie Patterson Drafting 23/02/2017
2.0 – 3.0
Mellanie Patterson Addition of amendments suggested by sectors 15-31/03/2017
3.1 Jessica Boothroyd Updates to financial figures throughout report and appendices
09/05/2017
3.3 Lee Hay Addition of amendments 24/05/2017
3.4 Jessica Boothroyd & Lee Hay
Amendments and updates 12/09/2017
3.5 Lee Hay Formatting 13/09/2017
3.6 Lee Hay Programme plan update 14/09/2017
Version Reviewer Comments
1.9 Alex Heritage Review 23/02/2017
3.4 Clare Powell Review 12/09/2017
3.6 Clare Powell Review 15/09/2017
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Author’s Note
This business case has been produced to support the Greater Manchester application for national
capital funding to enable implementation of the Healthier Together model of care. The Heathier
Together Joint Committee will receive this business case at its 19 September meeting in order to:
- Receive assurance that the implementation plans remain consistent with the original
Healthier Together model of care as described in the Decision Making Business Case; and
- Provide GM level endorsement of the business case prior to onward submission in the
national capital allocation process.
This document contains commercially sensitive information relating to anticipated capital spend in
each sector. In the public facing version of this document, these capital figures will be redacted. The
grounds for this are to ensure appropriately competitive contractor procurement, and thereby
safeguard value for money.
Beyond September 2017, some business case content will require further development at sector
level. Specifically this includes:
Commercial case content. Due to the significant costs involved, Trusts did not commence
detailed design work at risk prior to the identification of a capital funding source.
Consequently, detailed design work did not begin in earnest until the 2017/18 financial year.
At the date of this business case, and following the identification of a capital source for the
programme, all sectors are working to develop detailed designs to support a full commercial
business case. It is expected that supporting commercial case content will be available for
the South East and Manchester and Trafford sectors by December 2017, with the North West
and North East sector commercial case content available early in 2018. The commercial case
within this September 2017 business case is therefore limited to a high level summary of the
physical capital requirements of the programme, the estimated costs of that requirement,
and how this will be financed.
Funding agreement finalisation. At the time of this business case, appropriate capital and
transitional funding sources have been identified to support the affordability of the capital
and transitional costs of implementation. Funding of the recurrent revenue implications has
been agreed in two sectors, whilst work continues to urgently complete and finalise these
agreements in the remaining two sectors. These agreements will then require ratification
through local Trust Boards and CCG Governing Bodies.
Organisation level financial statement impacts. Once funding agreements have been
finalised for all sectors, the impact on the prime financial statements will be calculated at
organisation level, and included in the sector appendices of the final business case.
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Contents 1 Executive Summary .................................................................................................................................. 8
1.1 Introduction ................................................................................................................................................... 8
1.2 Why are these service changes a priority for Greater Manchester? .............................................................. 9
1.2.1 General surgery ................................................................................................................................. 9
1.2.2 Emergency medicine ......................................................................................................................... 9
1.2.3 Acute medicine ............................................................................................................................... 10
1.3 Proposed model of care ............................................................................................................................... 10
1.4 GM Sector Overview .................................................................................................................................... 13
1.5 Proposed Benefits ........................................................................................................................................ 14
1.6 Value for money ........................................................................................................................................... 15
1.7 Financial Overview ....................................................................................................................................... 16
1.8 Interdependencies ....................................................................................................................................... 17
1.9 A phased implementation ............................................................................................................................ 17
1.10 Readiness Assessment .................................................................................................................................. 19
2 GM Strategic case - why the proposed changes are required .................................................................. 21
2.1 Background .................................................................................................................................................. 21
2.2 Case for change – Clinical priorities for GM ................................................................................................. 23
2.2.1 Emergency Medicine....................................................................................................................... 23
2.2.2 Acute Medicine ............................................................................................................................... 25
2.2.3 General Surgery .............................................................................................................................. 26
2.2.4 Supporting services - Radiology ...................................................................................................... 32
2.2.5 Summary ......................................................................................................................................... 32
2.3 Proposed model of care developments ....................................................................................................... 33
2.3.1 Overview of the new Model of Care - how will GM services operate differently ........................... 33
2.3.2 The high risk General Surgery model of care .................................................................................. 36
2.3.3 Paediatric General Surgery.............................................................................................................. 37
2.3.4 Emergency medicine and acute medicine model of care ............................................................... 37
2.4 Key support services..................................................................................................................................... 39
2.4.1 Critical Care ..................................................................................................................................... 39
2.4.2 Radiology ........................................................................................................................................ 40
2.4.3 North West Ambulance Service ...................................................................................................... 40
2.4.4 Compliance of the model of care with the outline model of care .................................................. 41
2.5 Proposed estate developments .................................................................................................................... 41
2.6 Proposed workforce developments ............................................................................................................. 42
2.7 Local sensitivities .......................................................................................................................................... 42
2.8 Implementation plan .................................................................................................................................... 44
2.9 Benefits ........................................................................................................................................................ 45
2.10 Interdependencies and enablers .................................................................................................................. 51
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2.10.1 Major Trauma ............................................................................................................................. 51
2.10.2 Diagnostic image sharing ............................................................................................................ 51
2.10.3 Record sharing ............................................................................................................................ 55
2.11 Risks.............................................................................................................................................................. 56
2.12 Approval and assurance of the “Decision Making Business Case” ............................................................... 58
2.13 Approvals and assurance .............................................................................................................................. 66
3 Economic Case – what is the preferred option and its implication .......................................................... 68
3.1 Introduction ................................................................................................................................................. 68
3.2 Longlisting and Shortlisting of options ......................................................................................................... 68
3.3 Appraisal of shortlisted options ................................................................................................................... 70
3.4 Refinement of the costs and benefits of option 4.4a ................................................................................... 74
3.5 Benefits ........................................................................................................................................................ 77
3.6 Sensitivity Analysis ....................................................................................................................................... 80
4 Commercial case – Financing the preferred option and procurement .................................................... 81
4.1 Introduction ................................................................................................................................................. 81
4.2 Physical capital requirement and cost of that requirement ......................................................................... 81
4.3 How this will be financed ............................................................................................................................. 83
5 Financial Case – cost implications of the preferred option ..................................................................... 85
5.1 Capital Costs ................................................................................................................................................. 85
5.1.1 Summary of capital requirements .................................................................................................. 85
5.1.2 Capital funding ................................................................................................................................ 86
5.1.3 Comparison to the DMBC ............................................................................................................... 86
Transitional Costs .................................................................................................................................................. 87
5.1.4 Non recurrent revenue costs .......................................................................................................... 87
5.1.5 IT costs of implementation (DataWell) ........................................................................................... 87
5.1.6 Residual stranded costs at non-hub sites ........................................................................................ 88
5.1.7 Non contracted pay costs ................................................................................................................ 89
5.1.8 Phasing of transitional costs ........................................................................................................... 89
5.1.9 Comparison to the DMBC ............................................................................................................... 90
5.2 Revenue Costs .............................................................................................................................................. 90
6 Management case .................................................................................................................................. 93
6.1 Programme Governance .............................................................................................................................. 93
6.2 Clinical Oversight of Healthier Together ....................................................................................................... 95
6.3 Programme resourcing ............................................................................................................................... 100
6.4 Project plan ................................................................................................................................................ 102
6.5 Change management ................................................................................................................................. 103
6.6 Management of benefits realisation .......................................................................................................... 104
6.6.1 Benefits realisation planning ........................................................................................................ 104
6.6.2 Clinical standards and baseline ..................................................................................................... 105
6.6.3 Progress monitoring ...................................................................................................................... 105
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6.7 Risk management ....................................................................................................................................... 107
7 Appendices .......................................................................................................................................... 111
7.1 Appendix 1: Manchester and Trafford Sector ............................................................................................ 111
7.1.1 Manchester and Trafford model of care ....................................................................................... 111
7.1.2 Manchester and Trafford estate requirements ............................................................................. 116
7.1.3 Manchester and Trafford sector workforce requirements ............................................................ 116
7.1.4 Manchester and Trafford Capital Costs breakdown ...................................................................... 116
7.1.5 Manchester and Trafford reconciliation to DMBC Capital figure .................................................. 117
7.1.6 Manchester and Trafford Revenue Costs ...................................................................................... 117
7.1.7 Manchester and Trafford Transitional Costs ................................................................................. 119
7.1.8 Manchester and Trafford Funding sources ................................................................................... 120
7.2 Appendix 2: North East Sector ................................................................................................................... 121
7.2.1 North East sector model of care ................................................................................................... 121
7.2.2 North East sector estate requirements ......................................................................................... 127
7.2.3 North East sector consultant workforce requirements ................................................................. 127
7.2.4 North East sector Capital Costs breakdown .................................................................................. 127
7.2.5 North East sector reconciliation to DMBC Capital figure .............................................................. 127
7.2.6 North East Sector Revenue Costs .................................................................................................. 128
7.2.7 North East Sector Transitional Costs ............................................................................................. 129
7.2.8 North East Sector Funding sources ............................................................................................... 129
7.3 Appendix 3: North West Sector .................................................................................................................. 130
7.3.1 North West sector model of care .................................................................................................. 130
7.3.2 North West sector estate requirements ....................................................................................... 135
7.3.3 North West sector workforce requirements ................................................................................. 135
7.3.4 North West sector Capital Costs breakdown ................................................................................ 135
7.3.5 North West sector interdependencies .......................................................................................... 135
7.3.6 North West sector reconciliation to DMBC Capital figure ............................................................ 136
7.3.7 North West sector Revenue Costs................................................................................................. 136
7.3.8 North West Sector Transitional Costs ........................................................................................... 137
7.3.9 North West Sector Funding sources .............................................................................................. 138
7.4 Appendix 4: South East sector .................................................................................................................... 139
7.4.1 South East sector model of care ................................................................................................... 139
7.4.2 South East sector estate requirements ......................................................................................... 144
7.4.3 South East sector workforce requirements ................................................................................... 145
7.4.4 South East sector Capital Costs breakdown .................................................................................. 145
7.4.5 South East sector reconciliation to DMBC Capital figure .............................................................. 145
7.4.6 South East Sector Revenue Costs .................................................................................................. 145
7.4.7 South East Sector Transitional Costs ............................................................................................. 147
7.4.8 Funding Sources ............................................................................................................................ 148
7.5 Appendix 5: North West Ambulance Service (NWAS) ................................................................................ 149
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7.5.1 The role of NWAS in the Healthier Together Model of Care ......................................................... 149
7.5.2 The Healthier Together transfer model ......................................................................................... 151
7.5.3 The impact on NWAS .................................................................................................................... 152
7.6 Appendix 6: Review of updated economic case against DMBC .................................................................. 157
7.6.1 Capital ........................................................................................................................................... 157
7.6.2 Revenue costs ............................................................................................................................... 157
7.6.3 Conclusion on DMBC decision ...................................................................................................... 160
7.7 Appendix 7: Anticipated efficiencies and valued benefits .......................................................................... 161
7.7.1 Purpose of this appendix .............................................................................................................. 161
7.7.2 Overview of anticipated efficiencies ............................................................................................. 161
7.7.3 Methodology used to quantify efficiencies................................................................................... 162
7.7.4 Impact of each efficiency by sector .............................................................................................. 165
7.7.5 Consolidated revenue benefits ..................................................................................................... 167
7.7.6 Risks to the quantification of the efficiencies anticipated ............................................................ 167
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1 Executive Summary
1.1 Introduction
In 2012, Health and Care Leaders across Greater Manchester (GM) identified the need to address
the variation in care and outcomes for patients across Greater Manchester. A formal programme of
change resulted in the 12 Greater Manchester CCGs supported by the GM Combined Authority
(GMCA) proposing changes to primary care, community care and some hospital services (A&E, Acute
Medicine and General Surgery).
Senior clinicians from across the conurbation designed new standards of care and, based on these, a
new model of care (or way of delivering services). A formal public consultation was completed
during 2014 resulting in the proposals being refined and communicated widely to all partners and
stakeholders.
Following a unanimous decision by GM CCGs to support the implementation of the programme on
the 15th of July 2015 a judicial review was then successfully defended. Healthier Together initiated
implementation in January 2017.
Healthier Together forms an integral part of the five year vision for GM, as articulated in the STP
document ‘Taking Charge Together’. This establishes a strategic narrative following engagement
with NHS commissioners, providers and local authorities, alongside best practice from national and
international experts, to identify five key areas for transformational change in GM (figure 1.1).
Figure 1.1
Healthier Together is now considered a key building block by the GM Health and Social Care
Partnership. It forms a core and integrated component of Devolutions “Theme 3” work programme,
entitled “Standardising Acute and Specialised Care”. As the first programme of scale to implement
since Devolution, it demonstrates GMs ability to make real regional change. Healthier Together now
underpins newer developments including the emerging Hospital Based Services Strategy and are
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complementary to the development of Central Manchester University Hospitals NHS Foundation
Trust and University Hospital of South Manchester NHS Foundation Trust into a Single Hospital
Service.
1.2 Why are these service changes a priority for Greater Manchester?
Healthier Together was initiated due to the unacceptable variations of care, and lack of compliance
with national standards that exist in Greater Manchester for General Surgery, Emergency Medicine
and Acute Medicine. The case for change (December 2013) highlighted the need to improve quality
and safety in these services and the development of the clinical standards supports this
improvement in order to improve outcomes.
Since the establishment of the CCG’s, the Association Governing Group (AGG) has taken on the GM
wide governance arrangements for strategic change programmes. In March 2017, the AGG endorsed
and supported:
A refreshed clinical case for change, which in light of more recent guidance is even more
compelling; and
A report on the developing sector models of care, and compliance against the original model
of care consulted upon. This report identified any variations to the original model of care,
and the rationale for any changes. None of the variations were determined to be either
significant or material.
1.2.1 General surgery
The case for change in general surgery is based on well evidenced variation in the standard of care
provided and resulting outcomes for patients.
The standard of care provided in Greater Manchester does not meet national clinical standards and
varies significantly; the number of emergency general surgery admissions, average length of stay,
compliance with key standards in National Emergency Laparotomy audit, access to diagnostics and
use of ambulatory care is different across each of our sites.
Since Healthier Together was introduced, our Trusts have now committed to participate in the
National Emergency Laparotomy Audit (NELA) in order to track performance and this indicates the
main challenges evident 3 years ago persist.
The case has recently been further strengthened by the continued reduction in access to radiology
workforce. Radiology is pivotal to delivery of high quality and timely general surgery, and is
particularly relevant in the high risk emergency and elective surgical populations.
Tackling variation in General Surgical outcomes to bring Greater Manchester in line with the best
hospitals in the UK will mean that we have the opportunity to save the lives of up to 300 residents of
Greater Manchester every year.
1.2.2 Emergency medicine
The NHS is experiencing unprecedented demand for urgent and emergency care; here in Greater
Manchester demand for emergency departments is increasing year on year and subsequently
departments are struggling to meet waiting time targets (see the chart below). Furthermore, there is
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significant variation in the attainment of quality and safety standards across our emergency
departments, due in main to shortages in medical and nursing staff and over-reliance on locum and
temporary staff.
Table 1.1: GM Quarterly Performance against the 95% National Standard (FY 16/17))
Organisation Q1 Q2 Q3 Q4
Bolton NHS Foundation Trust 82.3% 85.0% 80.1% 82.9%
Central Manchester University Hospitals NHS Foundation Trust 93.6% 93.0% 91.1% 90.2%
Pennine Acute Hospitals NHS Trust 85.7% 84.4% 79.7% 78.8%
Salford Royal NHS Foundation Trust 92.2% 87.8% 83.9% 79.8%
Stockport NHS Foundation Trust 82.1% 76.7% 75.3% 75.4%
Tameside And Glossop Integrated Care NHS Foundation Trust 90.4% 86.0% 82.3% 83.9%
University Hospital Of South Manchester NHS Foundation Trust 76.9% 90.8% 86.8% 87.7%
Wrightington, Wigan And Leigh NHS Foundation Trust 92.3% 91.2% 83.6% 83.0%
GM Average 87.8% 87.5% 83.7% 83.3%
National Average 90.3% 90.6% 87.9% 87.6%
1.2.3 Acute medicine
As seen Nationally, Greater Manchester has an increasingly frail elderly population and there is a
growing need for care for patients with acute medical presentations. However, across Greater
Manchester, there are different models of care and corresponding staffing models causing high
variation in outcomes for patients, shown through variation in length of stay and readmission rates
to Acute Medical Units (AMUs) between hospitals.
Not all sites can attain the quality and safety standards, including standards from the Society for
Acute Medicine which recommends 12 hours of consultant cover, 7 days per week. This may
contribute to further variation in care and outcomes in the evenings and weekends in individual
hospitals.
1.3 Proposed model of care
The aim of the HT programme is to deliver a clinically led transformation of acute services which
improves outcomes for patients; and which is operationally and financially sustainable. The
programme forms part of a wider GM strategy: “Taking Charge”, which through the devolution of
health and social care in GM, aims to standardise acute care across the region to improve services
for the benefit of patients.
All hospitals in Greater Manchester will make a series of improvements to the way that they deliver
Acute Medicine, A&E and General Surgery in order to deliver a step change in performance.
This means, for example, that all hospitals will introduce or expand:
Senior decision making at the front door – Consultant Cover will be increased to a minimum
of 12 hours (16 at a hub site where the higher acuity patients are received). Senior decision
making at the front door can significantly reduce admissions and length of stay.
Signposting to primary care and management of chronic attenders – All hospitals will
introduce a more consistent mechanism to manage these attendances.
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Use of alternatives to admission – Ambulatory care will be expanded, with A&E patients
seen on the day by the appropriate specialism for issues such as extremity fractures, chest
pain, shortness of breath and headaches rather than being admitted for lengthier ward
stays.
Management of frail elderly – All hospitals will introduce, if it does not already exist, a
multidisciplinary frail elderly assessment team that reaches into the Emergency Department
and Acute Medical Unit.
Timely diagnostics – All hospitals will set key performance indicators to track and manage
timely availability of diagnostics, with processes to ensure a 60 minutes turnaround for
standard emergency blood tests and the availability of a radiologist to review images 24/7.
The model of care will also concentrate high risk elective and all emergency general surgery from 9
sites onto 4 “hub” sites.
High acuity (very sick) patients requiring specialist care will be transferred and receive that care at a
hub that specialises in that type of care.
This allows the re-organisation of the workforce, which is currently overstretched over
multiple sites, in a more effective way.
Each hub site will collaborate with at least one other hospital in a “single service”, with staff
working as one team. This means that if a patient is transferred to a hub site for specialist
care, there are pathways and processes in place to do this seamlessly. Staff will also work
across sites in the single service, ensuring they continue to build both low acuity and high
acuity experience.
To concentrate high acuity patients onto our four hub sites, a number of capital investments
are proposed.
Since the Healthier Together decision significant work has been undertaken to assess
whether NWAS paramedics can identify emergency general surgical patients for immediate
conveyance to the general surgical hub sites. An extensive audit showed that these patients
do not present with symptoms that can be identified in an ambulance and as such these
patients will continue to be conveyed to the nearest A&E as they are now.
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Figure 1.2: Hospitals collaborating in Single Services (sector)
Further clarification on the Future Model of Care was provided to the four sectors in April 2016 by
the Chief Medical Officer and Clinical Champions; the sectors have since been developing local
models of care over the past 18 months.
An assurance process was established to ensure that the local implementation of HT complies with
the HT model and standards of care and that the implementation conditions and equalities
implementation conditions set out by the Committees in Common in July 2015 are met.
The stage 2 (Design of model of care and pathways) reviews were designed to achieve clinical
assurance, focusing on the design of the sector’s models of care, to ensure they will deliver the
standards and principles of the HT model of care.
The stage 2 review was split into three parts:
Stage 2a: Presenting the model of care (clinical teams);
Stage 2b: Actions and follow up on the model of care and presentation of the medical model
of care (clinical teams);
Stage 2c: Sector Senior Responsible Officer and Programme Director sign off.
Each sector has worked to develop detailed models of care that fit with the model outlined in the
DMBC, and meets the Healthier Together standards whilst addressing any emergent factors
potentially impacting the original model of care identified during the detailed design phase and
assured through the review process.
A key example is that in the DMBC it was envisaged that the North West Ambulance Service (NWAS)
would develop a pathfinder tool to determine the most appropriate place for patients to receive
their care. This assumption has been rigorously tested through audits as part of the assurance
process, with experts concluding there were not sufficient medical differentiators to identify
emergency general surgical patients (operative and conservatively managed) at pre-hospital stage.
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Therefore the current pattern of attendance for emergency general surgery patients is expected to
continue. Through the development of local care models, clinical pathways and A&E consultant
staffing levels have been iterated accordingly. For example, multiple non-hub sites have extended
the hours of A&E consultant presence to reflect anticipated demand, in addition to an increase in
General Surgical consultant presence at non-hub sites beyond a 3-4 hour hot clinic provision as
initially deemed suitable for such a site. The end result is more robust consultant level cover across
GM to ensure senior decision making and timely patient review.
Other examples include:
Better defining the activity codes that are considered to be “high risk” and producing local
pathways (such as ambulatory care) in order to refine the level of activity that will transfer
to the HT hub site in that sector;
Refining the outline estimates of implications for beds and capital at each site and, based on
that;
Refining the outline workforce modelling, to describe the numbers of staff and coverage that
will be provided within that sector;
Establishing a more detailed understanding of the volume of activity transferring to the hub
sites, in turn informing the on-site presence requirements to meet demand; and
The National Major Trauma Service specification requires consultant general surgeon response within 30 minutes. This enables the resident hubs to now become non-resident depending on their assessment of demand during the stage 2 review.
1.4 GM Sector Overview
The table below summarises the hub site investment in each sector:
Table 1.2: Summary of Capital Investment Required Within Each Sector
Sector Requirement
Manchester and Trafford 2 wards, 3 critical care beds, 1 theatre
At Central Manchester Foundation Trust, the hub site, the Trust will develop 2 wards to house both the
elective and non-elective activity that will transfer. The areas are currently in use by other services, which will
be decanted and rehoused to accommodate the new wards.
The Trust will also develop an additional emergency theatre in a shelled area in the existing main theatre
footprint to accommodate the additional non-elective/emergency activity and the semi-planned theatre lists
associated with the Ambulatory care service.
Critical care will be expanded by 3 beds in a shelled area of the newly created surgical high level
dependency/step down unit.
Existing Ambulatory Care space on both sites be reconfigured to facilitate the new Ambulatory Care model
(with extended patient assessment and opening into evenings and weekends). A small amount of additional
equipment will allow for a more comprehensive assessment and treatment to prevent unnecessary admission.
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Sector Requirement
There is a risk that an additional £200k of capital costs will be incurred. This is currently being assessed within
the sector.
North East Sector 2 wards, 4 critical care beds, 1 theatre
Pennine Acute Hospitals Trust, which operates 4 hospitals In the North East sector, will construct a new 2
storey building at first and second floor levels on the Royal Oldham hospital site to provide 2 surgical wards
and one theatre. It will also include a critical care ward (given that the additional critical care capacity required
cannot be incorporated within the current landlocked footprint).
North West Sector 2 wards, 6 critical care beds,
2 theatres (one elective and one non-elective)
Salford Royal Foundation Trust, which manages one hospital in Salford, has been selected as both a hub site for
Healthier Together and the single Major Trauma Centre for Greater Manchester. SRFT have already cleared
space for the erection of a new four storey building to allow for both the additional Healthier Together and
Major Trauma activity. This includes inpatient beds, critical care beds and two new theatres
South East Sector Equipping 1 ward, Equipping critical care beds
Equipping theatre, Expanding A&E
Expanded CT, Expanded Endoscopy
Stockport Foundation trust will create a larger, 6 bedded, Resus suite to accommodate the additional high
acuity demand, with the old space used to introduce 4 dedicated consultant-led Rapid Access Treatment
trolleys
The Trust will develop a two storey design which will minimise the potential for patients to have to wait in
corridor space, and increase clinical capacity, including an additional theatre
It will also rehouse some of the activity currently undertaken in the Cardiac Catheter and Pacing Lab, which
currently sits in the A&E footprint into the new theatre complex, allowing the development of a Frailty
Assessment Unit
1.5 Proposed Benefits
Once implemented, Greater Manchester will be at the forefront in providing high quality and safe
care through collaborative, networked working as described in the Five Year Forward View and the
Keogh Review1. l
For general surgery, the consolidation of high risk elective and emergency general surgery services
onto 4 “hub” sites will increase consultant presence at hub sites, improve access to theatres and
critical care and enable quality and safety standards to be met. For the vast majority of patients,
1 “Transforming urgent and emergency care services in England” http://www.nhs.uk/NHSEngland/keogh-review/Pages/about-the-review.aspx
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they will continue to present or be taken by ambulance to their local A&E, which could be a non-
surgical hub site; upon which clear protocols will be followed by the A&E medical staff.
Enacting these protocols in liaison with the consultant at the hub site, will ensure appropriate
transfer of patients, appropriate access to ambulatory care and the appropriate management of risk.
This will ensure demand across the sector is effectively managed. GPs will also have access to an
opinion from the consultant at the hub site, upon the need to refer a patient.
The demand for transfer of emergency patients has been estimated by sector, and used by the North
West Ambulance Service to determine the investment in additional vehicles required, which have
been incorporated into the business case. The demand for surgical ambulatory care services has
been estimated at between 20%- 30% of current admissions.
For emergency and acute medicine a recent review by ECIP (the Emergency Care Improvement
Programme) anticipates, if the model is completely, effectively and consistently implemented a
“significantly positive effect on flow and therefore performance” within GM A&Es2. We anticipate
significant improvements in:
Ambulance teams waiting with patients in corridors;
ED four hour waiting times and 12 hour “trolley waits”;
Diagnostics turnaround;
Admissions through ED (14% reduction in admissions, equivalent to 37,000 admissions cross GM)
General Surgery length of stay3;
Outcomes and mortality, with the opportunity to save up to 300 lives each year through General Surgery interventions alone;
Readmissions following ED, Acute Care or General Surgery care; and
Patient and staff satisfaction.
1.6 Value for money
Following the unanimous decision to implement the preferred service configuration option, sector
teams have worked to operationalise the clinical model and to refine costs. The economic case in
this business case has been updated to incorporate these revised costs and demonstrates that:
Doing nothing remains clinically unacceptable.
When compared to the do minimum option, the preferred option has a higher Net Present
Value and therefore demonstrates value for money.
2 February 2017 desktop review of Healthier Together standards. Performance uplift is heavily dependent on
the complete and consistent application of the model. ECIP have also suggested additional improvements that can enhance flow and waiting time performance, which will be built into the implementation. 3 Based on a comparison by each sector of each Trusts length of stay, by HES HRG code, to the upper quartile
nationally.
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Therefore the economic case demonstrates that the preferred option, as decided by the Joint
Committee in 2015, still demonstrates value for money at a GM level.
1.7 Financial Overview
The capital required to support the implementation of the programme is detailed above.
The transitional costs of implementation are set out below and in more detail in the financial case,
along with the funding sources identified.
Table 1.3: Transitional Costs
£’000
Manchester
and Trafford
sector
North
East
sector
North
West
sector
South
East
sector
NWAS GM PMO Total
Implementation Costs 153 380 1,250 130 1,913
Project Management 945 746 1,151 783 250 809 4,864
Workforce 2,088 1,792 250 4,130
Revenue consequences of
capital
728 1,063 1,791
TOTAL 3,186 1,854 5,256 1,163 250 809 12,518
In addition to the transitional costs above, there is a risk that stranded costs and non-contracted pay
costs will arise. These are further explained and quantified in the financial case, along with a
summary of potential funding sources identified should these costs eventuate.
The recurrent revenue impact of Healthier Together consists of:
Activity moves – impact at hub: This is the income relating to the general surgery activity
which is transferring from non-hub sites to hub sites, offset against the related operating
expenditure required to deliver that activity to current clinical standards.
Healthier Together Standards: This is the cost required to meet the Healthier Together
clinical standards, and includes consultant cost, other staff cost and some non-staff costs.
Revenue consequences of capital: This is the annual PDC and depreciation charges
associated with the capital investment required for the programme.
Ambulance costs: These are the costs of the additional ambulance conveyances from non-
hub to hub sites.
The recurrent revenue impacts by sector are set out in the table below.
Table 1.4: Recurrent Revenue Impact
Recurrent Annual Revenue Impact (£’000)
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Activity moves –
impact at hub
Healthier
Together
standards
Revenue
consequences of
capital
Ambulance Costs
Manchester and Trafford (1,561) 2,200 693 225
North East sector - 6,747 1,728 228
North West sector 1,569 3,197 2,073 148
South East sector 172 1,916 1,258 228
TOTAL 180 14,060 5,752 829
The funding agreements reached in relation to the capital, transitional and revenue impacts of the
programme are detailed in the Financial Case.
1.8 Interdependencies
The implementation of Healthier Together at Salford Royal Foundation Trust requires the
development of a new building to house additional inpatient beds, critical care beds and theatres.
The building will be partially funded through Healthier Together funding and partially funded
through a Major Trauma project, allowing Salford Royal to become the lead Major Trauma Centre
for Greater Manchester. Should the Major Trauma project not be funded, there is potential for the
cost of the Healthier Together capital build to rise.
Whilst there are some IT enablers that will support Healthier Together, including improved record
and image sharing, these do not affect our ability to go live and are considered to be enablers.
However, it is important that these enablers are developed during 2017/18 in support of activity
transfers.
1.9 A phased implementation
Whilst all of the hub sites require some capital investment to absorb 8,102 high acuity episodes
transferred from non-hub sites, the size of the investment and complexity of the work varies:
North East Sector: The sector will commence the delivery of ambulatory care and transfer of
high risk elective patients towards the end on 2017/18 over a 12 month. However,
consolidating high acuity care equivalent to 2,201 episodes at the hub site is dependent on a
capital build, at a proposed cost of £24.8m, which will be completed by c. April 2020.
North West Sector: Similarly, whilst the North West Sector can transfer a small cohort of
elective patients to the hub site and start the hub and non-hub site working together in a
collaborative single service in 2018, the sector will not be able to consolidate high acuity
activity equivalent to 1,260 episodes until a new build is complete in c. January 2020 at a
proposed cost of £18.5m. Given that the hub Trust requires a new building to accommodate
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both Healthier Together and Major Trauma, both schemes are co-dependent on the funding
of the similarly timed Major Trauma project (captured in a separate business case)4.
South East Sector: More immediately and at a lower cost, Stockport Foundation Trust can
expand its ED and theatre space, as described above, to absorb the additional demand,
equivalent to 2,388 episodes at the hub site by c. October 2018 at a much lower cost of
£9.9m
Manchester and Trafford Sector: Central Manchester Foundation Trust hub site can
reconfigure their existing space to accommodate 1,890 episodes at a cost of £10.2m by c.
December 2018.
This drives a phased implementation as outlined in the following roadmap5:
Figure 1.3: Implementation Roadmap
4 It is possible to build a new building to accommodate only Healthier Together. However there is a financial
benefit in consolidating the capital requirements of Healthier Together and Major Trauma. 5 Assuming approval of the business case in September 2017
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1.10 Readiness Assessment
The following table provides an assessment of whether the proposed changes are ready to
implement
Table 1.5: Programme Readiness
Readiness Complete?
Counterfactual
evidenced (scheme
avoids
operational/quality
harm)
Yes – see case for change in outline business case (“Healthier Together Decision
Making Business Case”) and this full business case. The clinical case was developed
through 80 GM clinical congresses/workshops assured by the National Clinical
Advisory Team (NCAT). The standards were recently re-tested for impact on 12 hour
waits with NHSIs Emergency Care Improvement Programme Team (ECIP).
Support to national
and GM strategic
objectives
Healthier Together supports the GM strategy “Taking Charge”, as a formal part of the
“Theme 3” workstream. It forms the cornerstone of the emerging Hospital Based
Services Strategy and a number of other programmes including the Single Hospital
Service for Manchester.
It also national strategic objectives:
It stretches across primary care, integrated care and acute care, with the primary care
element already increasing primary care access in order to reduce inappropriate
acute attendances
The acute workstream, for which capital funding is sought, ensures care is more cost
effective and appropriate by:
centralising high acuity care onto four specialist hub sites; and
making improvements to the way that care is delivered, such as expansion of
ambulatory care (with patients seen the same day in a clinic rather than
being admitted for lengthy stays on a ward).
The proposals are in line with the networked models of care described in the Five
Year Forward View and Keogh review.
Locally, Healthier Together underpins a number GM hospital based services strategies
for example the Single Hospital Service between University Hospital South
Manchester and Central Manchester Foundation Trust
Affordability
evidenced
The Outline Business Case, describes “affordability and value for money” and was
assessed by the ten Greater Manchester CCGs on the 15th of July 2015. The CCGs
took a unanimous decision to implement the changes.
Over 2015, Trusts have worked together to develop the detailed design and refresh
their financial estimates. These have not materially changed from the estimates
described in the Outline Business Case and are presented in this Full Business Case.
Greater Manchester will support transitional and recurrent revenue costs
NHS England
Assurance (inc. four
Completed in 2015 – Evidenced in the Outline Business Case
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tests)
Financial return Evidenced in the Economic Case
Outline Business Case
(“Decision Making
Business Case”)
signed off by GM
Agreed unanimously by all 12 CCGs as a “Committees in Common” in 2015
Can Demonstrate Best
Possible Value
The decision to implement Healthier Together was taken in July 2015 and therefore
preceded the Best Possible Value Framework. However, a coherent decision making
process was undertaken. The programme was assessed on the factors that are
included in the framework, for example, clinical effectiveness and safety, patient
experience, revenue costs and capital costs. The decision making process was
thoroughly tested when a full judicial review was successfully defended in January
2015
Full Business Case
signed off by GM
September 2017
Single Oversight
Framework
Trusts have modelled the impact on income and expenditure locally to support the 4
May central STP submission. In three sectors the programme will not impact on the
SOF metrics for any trusts in the sector. In the South East Sector, the hub site
(Stockport FT) anticipate that the increased use of agency staff during the transitional
period will adversely affect the SOF metrics of the Trust for one year only.
Ready to implement Trusts are ready to start phased implementation from quarter 2 2017.
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2 GM Strategic case - why the proposed changes are required
2.1 Background
Greater Manchester is a vibrant and dynamic conurbation with great potential for economic growth
and prosperity. However, the population of Greater Manchester has traditionally suffered some of
the poorest health in England. Good progress has been made in addressing the health challenges
posed by the burden of disease associated with social deprivation, poor mental health, cancers,
cardiovascular disease and poor lifestyle choices leading to problems of obesity, alcohol related
morbidity and smoking related disease. However, significant health inequalities remain.
In Greater Manchester we therefore face a significant challenge - and yet the current organisation
of hospital services in Greater Manchester is already unsustainable. A number of Trusts in Greater
Manchester are facing significant financial challenges. In addition, in many services a lack of
availability of suitably trained staff means that workforce is overstretched and failing to meet
national clinical standards.
These issues will only deepen as demand and costs continue to rise and budgets remain constrained.
In 2012, Health and Care Leaders across Greater Manchester (GM) identified the need to address
the variation in care and outcomes for patients across Greater Manchester. A formal programme of
change resulted in the 12 Greater Manchester CCGs supported by the GM Combined Authority
proposing changes to primary care, community care and some hospital services (A&E, Acute
Medicine and General Surgery).
A case for change was developed through 84 clinical congress/workshop sessions attended by over
370 clinicians. Clinicians also described a consistent cohort of standards that, if adopted across the
conurbation, would significantly reduce variation and improve performance and quality. Each of our
hospitals would need to change to meet these standards, and a new operating model was
developed.
The design work involved patients, carers and members of the public throughout, culminating in a
full public consultation of 2.8m people in the summer 2014. Over 29,000 residents formally
responded and many more attended events and heard about the proposals.
Table 2.11: 2014 Formal Public Consultation Summary
Leaflets delivered to all 1,250,000 households across Greater Manchester and Glossop
Over 450 engagement events and activities held in every district, attracting over 23,000 people
Almost 700 media articles generated across all platforms including TV, print, radio and internet
E-bulletins sent to over 90,000 people
Over 90 advertisements placed in newspapers
Over 150 outdoor adverts, posters and billboards, viewed over 21 million times
7 social media platforms accessed, engaging with over 8,500 people and organisations
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Over 1,000 bus adverts
Over 1000 radio adverts
Over 50,000 unique visitors to the Healthier Together website
Over 200,000 consultation documents distributed
Post-consultation, public feedback was collated into themes and considered by a number of
technical governance groups (for example, “Finance and Estates” and “Clinical Advisory”).
Every significant feedback theme was responded to in a comprehensive and publically available
Decision Making Business Case. For example, feedback suggested that travel data was out of date
and could be improved. This was captured in a Consultation Feedback Table and reviewed by the
Transport Advisory Group. A decision was then taken to update the data prior to decision making.
A full patient impact assessment was undertaken, and the reach of the consultation to protected
groups and the wider public was also assessed.
The Healthier Together Joint Committee (previously convened as a “Committees in Common”)
assessed the proposals and public response and unanimously agreed the implementation of
Healthier Together and the preferred hub sites in late 2015.
A subsequent judicial review, which was publically reported, was successfully defended.
Healthier Together initiated implementation in January 2017 and is now considered a flagship GM
programme, forming the cornerstone of the Health and Social care Partnerships strategy for hospital
based services (Theme 3). It seeks to ensure that decisions about services result in the delivery of
improved and equitable services for patients across GM and the wider area that GM hospitals serve;
and that these services are clinically and financially viable and sustainable across GM.
Healthier Together is an integral part of Theme 3, and there is a strong commitment to delivering
the Healthier Together outcomes. The clinical case for change for Healthier Together is strong, and
the programme has not only provided the basis for devolved working across GM, but the single
service model of care has laid the foundations for the development of new models of care within
Theme 3, and will provide a building block for the configuration of services.
It is also recognised however that the changed environment requires that this be done in a
pragmatic manner which allows for a continued interaction with broader service reconfiguration
plans so as to make Healthier Together more affordable. Theme 3 is placing a high priority on this
through the work to develop the hospital based services strategy. To strengthen the governance
arrangements, Healthier Together and Theme 3 activities are set to be unified through one common
governance structure.
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2.2 Case for change – Clinical priorities for GM
The Healthier Together programme was initiated in 2012 due to the unacceptable variations of care
and lack of compliance with national standards that existed in Greater Manchester (GM) for General
Surgery, Emergency Medicine and Acute Medicine.
2.2.1 Emergency Medicine
The NHS is experiencing unprecedented demand for urgent and emergency care. Here in Greater
Manchester demand for emergency departments is increasing year on year, and subsequently
departments are struggling to meet waiting time targets.
Table2.2: GM A&E Performance Against the 95% National Standards (FY 16/17) 6
Organisation Q1 Q2 Q3 Q4
Bolton NHS Foundation Trust 82.3% 85.0% 80.1% 82.9%
Central Manchester University Hospitals NHS Foundation Trust 93.6% 93.0% 91.1% 90.2%
Pennine Acute Hospitals NHS Trust 85.7% 84.4% 79.7% 78.8%
Salford Royal NHS Foundation Trust 92.2% 87.8% 83.9% 79.8%
Stockport NHS Foundation Trust 82.1% 76.7% 75.3% 75.4%
Tameside And Glossop Integrated Care NHS Foundation Trust 90.4% 86.0% 82.3% 83.9%
University Hospital Of South Manchester NHS Foundation Trust 76.9% 90.8% 86.8% 87.7%
Wrightington, Wigan And Leigh NHS Foundation Trust 92.3% 91.2% 83.6% 83.0%
GM Average 87.8% 87.5% 83.7% 83.3%
National Average 90.3% 90.6% 87.9% 87.6%
Table2.3: GM A&E Performance - Number of patients waiting >12 hours from decision to admit
Organisation Q1 Q2 Q3 Q4
Bolton NHS Foundation Trust 4 0 4 25
Central Manchester University Hospitals NHS Foundation Trust 0 0 0 0
Pennine Acute Hospitals NHS Trust 71 105 299 311
Salford Royal NHS Foundation Trust 0 0 7 0
Stockport NHS Foundation Trust 0 0 1 8
Tameside And Glossop Integrated Care NHS Foundation Trust 0 0 0 0
University Hospital Of South Manchester NHS Foundation Trust 15 1 0 1
Wrightington, Wigan And Leigh NHS Foundation Trust 0 0 0 0
GM Total 90 106 311 345
National Total 387 254 1257 1598
GM as a % of National 23.3% 41.7% 24.7% 21.6%
There is also significant variation in the attainment of quality and safety standards.
The summary table below shows the overall level of compliance across a selection of national
standards for urgent, acute and emergency medicine, based on a review by the National Clinical
Advisory Team in 2013.
6 Based on national NHS England statistics https://www.england.nhs.uk/statistics/statistical-work-areas/ae-
waiting-times-and-activity/statistical-work-areasae-waiting-times-and-activityae-attendances-and-emergency-admissions-2016-17/
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Table 2.4: National Clinical Advisory Team independent assessment of compliance of GM Trusts with national and GM A&E and Acute Medicine quality and safety standards, 2013
U&EM CMFT UHSM SRFT Bolton WWL Tameside Stockport Pennine
% Fully compliant 76% 76% 82% 70% 41% 43% 49% 59%
% Partially compliant 14% 14% 5% 3% 13% 19% 32% 16%
% Not evidenced 5% 8% 8% 5% 22% 22% 0% 3%
% Non-compliant 5% 2% 5% 22% 24% 16% 19% 22%
% Not applicable 0% 0% 0% 0% 0% 0% 0% 0%
A further review has now been undertaken to test whether clinical compliance remains an issue in
GM. The table below shows the results of a self-assessment, undertaken in 2016 by GM Trusts using
a different methodology (including a wider set of Healthier Together standards and a more detailed
approach). The table below, which should not be directly compared to the NCAT review, indicates
that GM Trusts report that they continue to face challenges consistently delivering national and GM
standards.
Table 2.5: Local self-assessment of compliance of GM Trusts with national and GM A&E and Acute Medicine quality and safety standards, 2016
U&EM CMFT UHSM SRFT Bolton WWL Tameside Stockport Pennine
% Fully compliant 28% 50% 48% 37% 52% 11% 15% 35%
% Partially compliant 46% 33% 46% 26% 22% 6% 28% 46%
% Not evidenced 26% 15% 4% 30% 15% 74% 42% 2%
% Non-compliant 0% 2% 2% 7% 11% 9% 15% 17%
% Not applicable 0% 0% 0% 0% 0% 0% 0% 0%
Where areas of non-compliance or partial compliance have been identified, these have fallen into
the following general themes:
Lack of defined pathways including ambulatory care systems;
Not meeting Radiology standards (24/7 access to Consultant led in house reports within 1
hour);
Insufficient multi-disciplinary care for the frail elderly;
In adequate access to support services essential for discharge; and
Insufficient intervention to reduce chronic attenders.
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Staffing standards are of particular concern:
The number of substantive, accredited A&E consultants within GM Trusts varies greatly, with
rotas often supplemented with inconsistent and expensive locum support.
Variation is not explained by differences in the demand dealt with by each A&E. Four Trusts
have an establishment below the College of Emergency Medicine guideline of 10 WTE. For
example the A&E at North Manchester A&E, part of The Pennine Acute Hospitals Trust, is a
large A&E which receives over 100,000 attendances a year. In 2016 the A&E service at the
site was operating with less than 3 WTE consultants. The fragility of the A&E service was
recognised in the Trust’s 2016 “Inadequate rating”7.
There are also gaps in consultant presence at times when demand is high. In most Trusts
consultant presence matches weekday demand in the daytime until 16.00- 17.00 but then
significantly reduces, despite demand continuing at a high level until at least 20.00-22.00.
Similarly during weekends, consultant staffing does not closely match demand.
Similarly there is a significant range in the number of substantive A&E middle grades with a
number of trusts are using consultants to fill middle grades rotas, putting further pressure
on consultants who are required to “act down”.
The chart below shows the GM consultant gap at the Outline Business Case (“Decision Making
Business Case”) stage.
Table 2.6: Consultant gap to meet minimum national standards at each site at DMBC stage (Autumn 2015)
Consultants 2015
Baseline
(WTE)
Requirement to meet national standards
(WTE)
Gap Autumn 2015
(WTE)
Emergency
Medicine
84.6 110.4 25.8
Some headway has been made in recruiting posts in preparation for the implementation of Healthier
Together, but it is still not possible to deliver national and GM standards at every site without
reconfiguring the service.
2.2.2 Acute Medicine
As seen nationally, Greater Manchester has an increasingly frail elderly population and there is a
growing need to care for patients with acute medical presentations. However, across Greater
Manchester:
there are different models of care;
there are different staffing models; and,
7 The Trust is now making significant improvements under the guidance of an Improvement Board and steer
from Salford Royal Foundation Trust and Central Manchester Foundation Trust
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there is variation in attainment of clinical standards, including standards from the Society for
Acute Medicine which recommends 12 hours of consultant cover, 7 days per week.
This variation contributes to high variation in: length of stay; readmission rates to Acute Medical
Units (AMUs) between hospitals; and patient outcomes.
2.2.3 General Surgery
Nationally, surgical morbidity and mortality rates for high-risk elective and emergency general
surgical patients compare unfavourably with international results, with evidence of higher mortality
and morbidity in these cohorts of patients.
Evidence of variation in surgical practice can be seen in published National Surgical Audit
Programmes:
National Emergency Laparotomy Audit (NELA) (2014 and 2015)
National Bowel Cancer Audit (2014, 2015 and 2016)
A number of national publications that incorporate GM data also demonstrate ongoing clinical
challenges:
Nuffield Trust, “Challenges and Opportunities in Emergency General Surgery”, 2016
NCEPOD, "Treat the cause", 2016
NCEPOD, " Time to Get Control", 2016
Variation in practice remains a priority for professional surgical bodies and this is recognised as
pivotal to improving surgical outcomes, including mortality. Evidence includes:
The National Bowel Cancer Audit Programme
The Association of Coloproctology of Great Britain and Ireland, “Resources for
Coloproctology Standards Summary”, 2015
The Association of Coloproctology of Great Britain and Ireland 2012: Ileal Pouch Registry
Report.
National Emergency Laparotomy Audit Programme 2014 onwards
NICE October 2016: Molecular testing strategies for Lynch syndrome in people with
colorectal cancer
General surgery is a surgical specialty that focuses on abdominal organs including oesophagus,
stomach, small bowel, colon, liver, pancreas, gallbladder and bile ducts, and sometimes
includes endocrine procedures such as operations involving the thyroid gland (depending on
local referral patterns). They also deal with diseases involving the skin, breast and soft tissue.
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Consistent quality improvement themes drawn from research include:
Identification of risk for patients, undergoing both elective and emergency8 procedures;
Understanding by clinical teams of “true” risk;
Standardising of clinical pathways, including the value of post-operative planned critical care
( Swart M, Carlisle JB, Goddard J Br J Anaesthesia 2017;118:100-104, Chana P, Joy M, Casey
N et al BMJ Open 2017;e014484); and
Making appropriate use of associated specialities such as radiology9
o The clinical workforce census (2016) describes a 51% increase in NHS outsourcing
spend 2104-2016 and 9% vacancy.
o Standards for Provision of a seven day acute care diagnostic radiology service (2015)
states that robust IT infrastructures should be in place to support image and report
sharing.
A recent study 5 of 69,490 high risk emergency general patients (including 19,082 who underwent
emergency abdominal surgery) admitted to 23 centres across Australia, England and the USA from
2007 to 2012 showed: 7 and 30 day mortality, readmission rates and length of stay were worse in
English units. Key features for the cohorts were:
Low intensive care unit bed ratios were associated with worse outcomes, including higher
post-operative mortality. Representing the increasing view that all major intra-abdominal
surgery patients would benefit from direct admission post operatively to critical care.
Having dedicated EGS teams cleared of elective commitments with formalised handovers
was associated with a significant improvement in 7 day mortality in the procedure sub-
group and a 22% improvement in long length of stay for EGS patients10.
In addition:
Across the UK emergency general surgery is delivered on many sites, each of which
undertakes a relatively small number of high risk cases. This model overstretches resources,
making the delivery of standards, such as the availability of senior decision makers,
challenging.
8 A number of papers have recently assisted in clarifying which emergency patient pathways would be
described as high risk (Nuffield Trust, 2016, commissioned by the Royal College of Surgeons, CEPOD 2016 “Treat the Cause”, NCEPOD 2016 “Time to get Control”, National Emergency Laparotomy Audit Programme) . 9 The Royal College of Radiologists London, Standards for Provision of a seven day acute care diagnostic
radiology service 2015; Provision of interventional radiology services 2014; Investing in interventional radiology
workforce: the quality and efficiency case 2014; Clinical Radiology workforce census 2016.
10 Chana P, Joy M, Casey N, et al. Cohort analysis of outcomes in 69 490 emergency general surgical admissions across an international benchmarking collaborative. BMJ Open 2017;7:e014484. doi:10.1136/bmjopen-2016-014484)
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Greater emphasis has recently been placed on the need to provide equity through the
provision of 7 day services in the NHS (Seven day services in hospitals: clarification of priority
clinical standards, NHS Improvement December 2016).
In Greater Manchester, performance for high-risk emergency and elective general surgery reflects
this national picture. Emergency general surgery is carried out in nine acute hospitals in Greater
Manchester with significant challenges, caused by variation in the number of consultant general
surgeons, anaesthetists and supporting diagnostic services available. The services are characterised
by the following features:
There is variation in the number of emergency general surgical admissions. The numbers
vary across GM from approximately 8 to 28 patients a day, of which only 2 to 7 patients
require an operation.
The average length of stay for non-elective general surgery patients varies significantly
across the GM footprint;
Variation persists in compliance with key standards in NELA: early input from senior
clinicians, timely antibiotic therapy, estimation of risk, timely access to theatre and post-
operative access to critical care.
The use of ambulatory care for surgical patients is not yet optimised. There is a negative
correlation between the number of admissions and the crude mortality rate for patients
aged 75 years old and above.
There are significant challenges in radiology within GM with variable access to 24/7 in house
diagnostic radiology reporting and delivery of interventional radiology. All radiology
departments in GM have reliance on outsourcing companies and this is increasing
particularly at night for emergency patients.
Trainee recruitment in General Surgery is falling with an inability to fill national training
posts in 2016.
The summary tables below shows high variation and low compliance with national clinical standards
across GM in 2013 and today.
Table 2: National Clinical Advisory Team independent assessment of GM Trust compliance against national and GM General Surgery quality and safety standards, 2013
GENERAL SURGERY CMFT UHSM SRFT Bolton WWL Tameside Stockport Pennine
% Fully compliant 68% 75% 68% 54% 32% 21% 54% 46%
% Partially compliant 21% 11% 32% 10% 14% 25% 32% 25%
% not evidenced 11% 7% 0% 29% 50% 50% 4% 29%
% Non-compliant 0% 7% 0% 7% 4% 4% 10% 0%
% Not completed 0% 0% 0% 0% 0% 0% 0% 0%
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As described above, a further review has now been undertaken to test whether clinical compliance
remains an issue in GM. The table below shows the results of a self-assessment, undertaken in 2016
by GM Trusts using a different methodology (including a wider set of Healthier Together standards
and a more detailed approach). The table below, which should not be directly compared to the NCAT
review, indicates that GM Trusts report that they continue to face challenges consistently delivering
national and GM standards.
Table 2.83: 2016 Local self-assessment of compliance against national and GM General Surgery quality and safety standards, 2016
11
GENERAL SURGERY CMFT UHSM SRFT Bolton WWL Tameside Stockport Pennine
% Fully compliant 39% 44% 23% 37% 50% 6% 23% 40%
% Partially compliant 50% 39% 37% 53% 39% 23% 52% 50%
% Not evidenced 8% 14% 34% 8% 2% 69% 21% 2%
% Non-compliant 3% 3% 6% 2% 9% 2% 4% 8%
% Not completed 0% 0% 0% 0% 0% 0% 0% 0%
Where areas of non-compliance have been identified, these have fallen into the following general
themes:
Timeliness of consultant surgeon review;
Formal pathways for unscheduled adult general surgical care;
Radiology standards (24/7 access to Consultant led in house reports within 1 hour);
Access to non-vascular and vascular interventional radiology ;
Sepsis and haemorrhage pathways;
Medicine for Care of the Older Person (MCOP) for patients over 70;
Profiling of surgical workload;
Reviews of surgical patient outcomes; and
Bed occupancy and flow of surgical patients within the system.
In addition to the issues identified there is also an opportunity to enhance perioperative pathways
by the introduction of ERAS+ (enhanced recovery from surgery), which reduced surgical length of
11
This is based on a self-assessment, overseen by the Healthier Together programme team and shared across Trusts via the Healthier Together Delivery Board
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stay by 3 days at Central Manchester Foundation Trust in 201612. This pathway has now been
adopted by the National Accelerator Programme as an initiative for widespread adoption.
As with A&E and Acute Medicine, general surgery staffing is overstretched and staffing standards are
of particular concern.
Table 2.9: Consultant gap to meet minimum national and GM quality and safety standards at each site under the current as-is model of care at Outline Business Case stage (Autumn 2015)
Consultants 2015
Baseline(WTE)
Requirement to meet national standards (WTE) Gap Autumn 2015 (WTE)
Surgery 75.8 130.0 54.2
Some headway has been made in recruiting posts in preparation for the implementation of Healthier
Together, but it is still not possible to deliver national and GM standards at every site without
reconfiguring the service.
The impact of this variation in standards and an overstretched workforce can be seen in National
Emergency Laparotomy Audit (NELA). NELA data, which, since Healthier Together has been
introduced, GM Trusts have now committed to report. The key areas of performance which
uniformly create challenges across GM are:
Review by a consultant surgeon within 14 hours of emergency admission to hospital;
Timely access to theatre;
Estimation of risk for all patients pre-operatively;
Direct supervision of all high risk patients surgery by a consultant surgeon and a consultant
anaesthetist; and
Immediate admission to critical care post-surgery for all high risk patients (p-possum
mortality risks of >5%).
The challenges for GM are reflected in high variation in 30 day mortality for patients undergoing an
emergency laparotomy, with some sites exceeding the national average of 11%. GM outcomes have
not improved since NELA began, which is at variance to the national picture which has seen a
reduction in mortality in some sites.
12 "Anaesthesia, 2017,”Impact of a peri-operative quality improvement programme on post- operative pulmonary complications"”
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Table 2.10: 30 day risk-adjusted mortality for patients between December 2013 and November 2015
2.2.3.1 Patients with Colorectal cancer
For patients with colorectal cancer in GM, a subset of general surgery, the number of cases in each
site is relatively small and varies from 72 to 140 patients per year (NBCOA 2016), of which up to 21%
have their major surgery carried out as an urgent/emergency case.
As with wider general surgery, GM standards and outcomes vary and are sometimes below the
national average:
The use of laparoscopic surgery is below the national average in GM (range 19% to 75%),
(National average 61%);
The proportion of patients staying in hospital > national average (5 days) is high in GM at
78% (range 69%-90%);
The average adjusted 90-day mortality rate in the GM network is 4.7% (range 1.5% - 7.8%),
which is higher than national average of 3.8%;
The average adjusted 2-year mortality rate in the GM network is 22.5% (range 13.8% –
42.9%), which is higher than National average 20.9%;
An average of 10.3% of patients are readmitted within 30 days (range 4.3% to 15.2%); and
The need for rescue following surgery, for example due to an anastomotic leak, is ~8% for
elective patients and 11% for emergency patients.
Provider 30 day mortality %
Wythenshawe Hospital 6.8
Stepping Hill Hospital 6.9
Manchester Royal Infirmary 8.4
North Manchester General Hospital 9.3
Royal Bolton Hospital 10.3
Royal Oldham Hospital 10.4
Salford Royal Hospital 11.0
Royal Albert Edward Infirmary 13.3
Tameside General Hospital 13.7
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2.2.4 Supporting services - Radiology
Radiology, a vital supporting service, similarly faces significant workforce challenges which will need
to be resolved to enable the improvement of A&E, Acute Medicine and General Surgery.
The current workforce challenge results in a heavy reliance for the majority of sites in GM on
outsourcing all or a significant element of their emergency workload for reporting. Outsourcing of
this type of work has been recently described by the Royal College of Radiology as being associated
with a risk of discrepancy greater than that recorded for in house reporting. Whilst in-house
consultants achieve a major discrepancy rate of 3.1%, outsourced reporting of CT scans for patients
proceeding to emergency laparotomy is associated with a major discrepancy rate of 12.7% (BrJRad
2016 Howlett et al.) The discrepancy rate would appear greatest in those patients having an urgent
or emergency CT Abdomen.
There is recognition that radiology has a manpower crisis and that different ways of working are
required to maximise productivity and improve quality. This has been described in a number of
publications including ‘Who Shares Wins-efficient collaborative radiology solutions. RCR Oct 2016’.
These publications support the development of network teleradiology IT platform across a clinical
network and this work is already being undertaken in other geographies such as East Midlands and
Liverpool. There is ongoing GM PACS reprocurement which supports this model.
In addition there are significant challenges in delivering resilient 7 day basic and intermediate non
vascular interventional radiology services across GM. The reasons for this reside in the level of
skillsets on some sites, numbers of radiologists and absence of on call radiologists out of hours on
many sites. Currently only 3 of the 9 sites can deliver a 7 day service. As a consequence delivery of
timely non-vascular intervention is variable, and delay may adversely impact patient outcomes.
With respect to vascular interventional radiology, GM is served by 2 teams of radiologists. One
(CMFT/UHSM) provide an extensive service to GM and further afield, but current numbers of
radiologists prevent this team from separating elective and emergency work. This team also provide
VIR services for elective activity on 4 sites. This means that currently only 3 of the 9 sites (2 of the
proposed 4 sectors) are compliant with the standards in NCEPOD 2016 “Time to get Control”
standards for gastrointestinal haemorrhage. This pathway integrates endoscopy, vascular
interventional radiology and general surgery. The expected incidence of upper GI haemorrhage in
GM is 150-450 cases per year in each hospital. 25% will be high risk and 50-60% will present out of
hours. Stratification of risk for individual patients is possible using endoscopic scoring system and
clinical features such as evidence of a re-bleed, systolic blood pressure at time of bleed and evidence
of other co-existing pathology.
2.2.5 Summary
The above evidence provides a continued compelling case to reconfigure A&E, Acute Medicine and
General Surgical hospital services that is fully supported by GM clinicians, providers and
commissioners. The other associated and related clinical services which should also be considered as
single services in the model are Critical Care and Radiology.
The above sections provide evidence of a continued strong clinical case for reconfiguring A&E, Acute
Medicine and General Surgical hospital services to address variation and improve outcomes for GM
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patients. This affirms the case for change developed through 84 clinical congress/workshop sessions
attended by over 370 clinicians in and endorsed by the Healthier Together Committee in Common in
July 2015.
2.3 Proposed model of care developments
The above evidence provides a compelling case to reconfigure A&E, Acute Medicine and General
Surgical hospital services that is fully supported by GM clinicians, providers and commissioners.
To reduce variation and achieve a step change in performance, commissioners worked with 380
senior clinicians and other stakeholders over a series of 84 clinical congresses and workshops to set a
series of 400 minimum standards, largely based on national standards from Royal Colleges, which
will be adopted uniformly. For example, every hospital will establish or expand ambulatory care.
They also designed, with input from patients, a new “model of care” or way of operating across GM
hospital sites to deliver those standards.
2.3.1 Overview of the new Model of Care - how will GM services operate differently
To meet a consistent set of minimum standards all hospitals in Greater Manchester will make a
series of improvements to the way that they deliver Acute Medicine, A&E and General Surgery in
order to deliver a step change in performance.
This means, for example, that all hospitals will introduce or expand:
- Senior decision making at the front door – Consultant Cover will be increased to a minimum
of 12 hours (16 at a hub site where the higher acuity patients are received). Senior decision
making at the front door can significantly reduce admissions and length of stay.
- Signposting to primary care and management of chronic attenders – all hospitals will
introduce a more consistent mechanism to manage these attendances.
- Use of alternatives to admission – for example ambulatory care will be expanded, with A&E
patients seen on the day by the appropriate specialism for issues such as extremity
fractures, chest pain, shortness of breath and headaches rather than being admitted for
lengthier ward stays.
- Management of frail elderly – all hospitals will introduce, if it does not exist, a
multidisciplinary frail elderly assessment team that reaches into the Emergency Department
and AMU.
- Timely diagnostics – all hospitals will set KPIs relating to timely availability of diagnostics,
with processes to ensure a 60 minute turnaround for standard emergency blood tests and
the availability of a radiologist to review images 24/7.
The scheme will also concentrate high risk elective and all emergency general surgery from 9 sites
onto 4 “hub” sites.
The design of the new model of care, which describes how our hospitals will operate to deliver new
standards of care, based on the following design principles:
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1. Hospital services will be provided locally whenever possible.
2. Hospital services will be provided at a site specialising in certain types of care (e.g. general
surgery) when needed.
3. Hospital services will be provided to a defined standard.
4. Care will be consultant delivered.
5. Services will be provided over seven days with no deterioration in service provision at the
weekends.
6. Sites will collaborate in delivery of the in scope services through the single services model in
their sector.
7. Within each sector one site will deliver the in-patient services for high risk elective and high
risk emergency general surgical adult patients.
8. Within GM, high risk patients with a medical or surgical pathology will where possible be
diverted directly to the most appropriate hospital site and will bypass their local A&E. For
some conditions these receiving A&Es will serve the GM population, for others there will be
a sector receiving A&E.
9. Sites undertaking high risk general surgery must have a co-located A&E.
10. Every site will have an Acute Medical Unit (AMU) and a Critical Care Unit (CCU).
Clinicians also agreed that hospitals should collaborate to deliver A&E, Acute Medicine and
General Surgery in networks, called “single services”. Within each network, one site would
become a hub that specialises in emergency and high risk general surgery. These hub sites will see
a larger number of patients each year from across a larger geography of Greater Manchester,
enabling them to become centres of excellence in caring for seriously ill patients.
Patients will have their diagnostics, low risk procedures and outpatients appointments at their local
sites (close to home where possible), with those patients assessed as requiring specialist care
transferred to the hub site.
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Figure 2.1: Hospitals collaborating in “single service” networks
To support this, ED, General Surgical, Anaesthetics and Critical Care staff will work in a single team
ensuring that effective working relationships are established. General Surgeons will rotate across the
single service network, ensuring that they continue to experience a range of higher and lower acuity
patients.
The picture below shows the single service network arrangement, formed over four “sectors”, that
was agreed by Greater Manchester CCGs on the 15th of July 2015.
Figure 2.22: Single service networks - "sectors"
Emergency Department - Self presenting surgical emergencies - Surgical presence in the Emergency Department
Emergency Department - Self presenting surgical emergencies - Access to surgical opinion from linked hospital treating high risk general surgical patients
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2.3.2 The high risk General Surgery model of care
The design of the Emergency general surgery model of care is summarised below:
GPs and Emergency Medicine will refer to local hot clinics/ambulatory care, where
appropriate; and when advice is needed from a senior surgeon outside of the times hot
clinic/ambulatory care is staffed locally, this is obtained from the general surgeon on duty at
the linked surgical hub site. To facilitate this, diagnostic tests may be undertaken locally,
with results shared with the general surgeon on duty in the linked hub site via the PACs IT
system.
Hot Clinics/Ambulatory care will be available locally to facilitate prompt semi-elective
admissions, with the patient initially being seen in A&E before being referred for a
procedure within the next 24-72 hours. This service should be provided for 3-4 hours per
day, 7 days per week.
For patients initially admitted on non-hub sites (for example onto the acute medical wards)
who then required a general surgical opinion; diagnostics should be undertaken on the non-
hub sites to facilitate clinical opinions being given by the general surgeon on duty in the
linked hub site via PACs.
All emergency general surgical patients will be admitted to sites specialising in emergency
and ‘high risk’ complex elective general surgery (surgical-hub sites); whether for
conservative management or a procedure.
The surgical hub site will deliver an increase in consultant presence for surgical assessment,
with the addition of a separate consultant available for undertaking Emergency General
Surgery 7 days per week, with the level of presence of both roles based on local demand.
There are four groups of emergency patients for which local pathways have been devised:
1. Patients requiring an inpatient emergency procedure – these should be transferred to the
surgical hub site
2. Patients requiring conservative inpatient ‘watch and wait’ management with a mortality of
>5% - these patients require significant surgical, diagnostic and associated service input and
as such should be transferred to the surgical hub site
3. Patients who are suitable for referral to a prompt semi-elective or elective pathway
including ambulatory care, hot clinic, outpatients, early elective lists
4. Patients requiring conservative inpatient ‘watch and wait’ with a mortality <5% who are not
suitable for referral to a semi-elective or elective pathway
The design of the elective general surgery model of care is summarised below:
‘High risk’ complex inpatient elective general surgery should be co-located with emergency general surgery.
Examples of ‘High risk’ complex patients to be managed at the surgical hub site include: patients scheduled for colorectal resections/interventions; patients undergoing high risk upper GI procedures and patients scheduled for a lower risk surgical procedure but with significant comorbidity.
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Co-location of emergency and high risk-elective surgery will allow for increased delivery of sub-specialised rotas.
The diagram below describes what this would Implementation of the model of care and standards
will improve patient care for patients like Lynda. This is illustrated below.
Figure 2.3: Example patient story
At 8pm at the A&E, Lynda is
assessed by the A&E consultant who is on shift. She examines
Lynda and arranges blood tests and scans
Lynda is prepared for theatre.
At 11pm Lynda is taken to theatre
for surgery where she is operated on
by a consultant General Surgeon and Anaesthetist
The results come back and the A&E
consultant suspects a general surgical condition and contacts the
single service General Surgical
Consultant who is working in the Royal Oldham
At 9pm Lynda is transferred to the
Royal Oldham where she is met by the General
Surgical Consultant and taken to the
ward before surgery.
Patient with a bowel obstruction, Lynda 69
Lynda is now seen by the
A&E consultant, not a junior member of
staff
Lynda is 69 and one evening she
develops vomiting, severe and worsening
stomach pain and so her husband
takes her to North Manchester
General A&E.
The A&E and General Surgical
consultants review the scans online
and discuss Lynda’s condition.
A bowel strangulation is
suspected.
After surgery Lynda recovers in an intensive care bed at the Royal Oldham and is
checked on by the General Surgical
consultant
Lynda’s test results are reviewed
straight away by the
specialistGeneral Surgical
Consultant
There is a another General Surgery
consultant ready to operate on Lynda, this
means no delay to Lynda’s operation and that other emergency
patients can still be assessed while she is in
theatre
Lynda is taken to
theatre only 4 hours
after leaving home
Because Lynda’s operation was done quickly none of her bowel had died and
the surgeon was able to repair the strangulation.
Because she was in Intensive Care, signs of an infection were spotted early and she
was given medication to stop her becoming really sick.
Lynda had her follow up outpatients close to home at North Manchester General
2.3.3 Paediatric General Surgery
The pathway for children is sometimes different to adults because, when children are particularly
sick, it is often better if they are cared for by a surgeon/team that specialise in paediatric care.
Salford Royal Foundation Trust, the hub site in the North West Sector, does not provide paediatric
services. Therefore the pathway for children, can be summarised as follows:
All children who are seriously ill with general surgical conditions, e.g. Generalised peritonitis,
Bowel obstruction, will be transferred to the Royal Manchester Children’s Hospital.
Children under 5 years old with serious illness, including suspected appendicitis will be
transferred to the Royal Manchester Children’s Hospital.
Children over 5 years old who require an admission for an acute general surgical condition
will be transferred to one of the four Healthier Together hub sites.
2.3.4 Emergency medicine and acute medicine model of care
The design of the elective general surgery model of care is summarised below:
All A&Es and Acute Medical Units will make changes to meet national and GM quality and
safety standards. For example:
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Senior decision making at the front door – consultant cover will be increased to a minimum
of 12 hours (16 at a hub site where the higher acuity patients are received). Senior decision
making at the front door can significantly reduce admissions and length of stay
Signposting to primary care and management of chronic attenders – all hospitals will
introduce a more consistent mechanism to manage these attendances.
Use of alternatives to admission – for example ambulatory care will be expanded, with A&E
patients seen on the day by the appropriate specialism for issues such as extremity
fractures, chest pain, shortness of breath and headaches rather than being admitted for
lengthier ward stays.
Management of frail elderly – all hospitals will introduce, if it does not exist, a
multidisciplinary frail elderly assessment team that reaches into the Emergency Department
and AMU.
Timely diagnostics – all hospitals will set KPIs relating to timely availability of diagnostics,
with processes to ensure a 60 minutes turnaround for standard emergency blood tests and
the availability of a radiologist to review images 24/7.
No A&E will close as a result of Healthier Together.
Every A&E will continue to open 24/7 (excluding the Urgent Care Centres in Trafford and
Rochdale).
Every A&E will have a minimum of 12 hours of consultant presence 7 days per week. These
A&Es will be co-located with low risk general surgical sites.
A&Es co-located with the four general surgical units that care for patients with life
threatening illnesses will have a minimum of 16 hours of consultant presence 7 days per
week.
A&Es will work in single service partnerships of A&Es with longer and shorter hours of consultation presence.
As well as evidence suggesting better outcomes for treatment of some high risk patients through conveyance to high risk sites, the other driver for A&E change is limited availability of emergency medical workforce. As such sectors have been requested to work collaboratively to ensure that A&E standards are met at all sites within the sector and to explore single service arrangements to provide greater resilience. Through the assurance of sector models of care, reviews have been undertaken to assess proposals to achieve the A&E and Acute Medical standards.
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Figure 2.4: A&E and Acute Medicine single service
Every hospital will have an Acute Medical Unit with 12 hours consultant cover, 7 days per
week
Acute Medical Units will be supported by a Critical Care Unit in each hospital.
In order to meet growing demand, an Acute Medical Unit (AMU) providing short term care up
to ~72 hours will be provided in every hospital in Greater Manchester which will provide care
to GM quality and safety standards, for the patients from the local community. This will
facilitate close linkages with local social care, primary care, family and carer support. The
service in each hospital will be consultant led, seven days per week. The units will work in
partnership with the Emergency Department to deliver rapid assessment, diagnosis and
treatment for patients with acute medical presentations; supported by seven day working
from social care, therapies and pharmacy.
To improve quality and safety standards, an investment in additional A&E and acute medical
consultants are required.
2.4 Key support services
2.4.1 Critical Care
Every hospital will have a Critical Care Unit. Surgical hub sites will be centres of excellence for critical
care patients arising from the services provided at those sites. Delivering a breadth of critical care
services across a sector. Non-hub sites will be centres of excellence providing critical care services to
patients in local area. Highly complex patients may require transfer to services at the specialist site.
Critical care units will continue to treat a variety of patients including acute medical, general
surgical and other patients who do not fall within the scope of Healthier Together.
General Surgery - Self presenting surgical emergencies - Surgical presence in the Emergency Department
General Surgery - Self presenting surgical emergencies - Access to surgical opinion from linked hospital treating high risk general surgical patients
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It is assumed that critical care capacity for general surgical patients will be reduced on non-
surgical-hub sites and increased on surgical-hub sites in line with changes in demand.
Critical care capacity will be maintained on every site for acute medical patients.
Critical care units on non- surgical hub sites will work with surgical hub site in single service
partnerships. Critical care doctors and some nurses will work across the critical care units
within the single service partnership to maintain skills.
2.4.2 Radiology
24/7 diagnostic reporting service at each site with 24/7 compliance to access of modalities.
Non-vascular interventional service to be provided 7 days per week at a sector level (at a
Greater Manchester level out of hours).
Vascular interventional radiology to be provided 24/7 days per week at a Greater
Manchester level through a network solution.
2.4.3 North West Ambulance Service
A number of pathways for emergency high risk patients are now fully embedded in Greater
Manchester through a partnership with NWAS:
Patients with Major Trauma
Acute myocardial infarction
Patients with a Stroke
Since the Healthier Together decision significant work has been undertaken to assess whether NWAS
paramedics can identify emergency general surgical patients for immediate conveyance to the
general surgical hub sites. An extensive audit showed that these patients do not present with
symptoms that can be identified in an ambulance and as such these patients will continue to be
conveyed to the nearest A&E as they are now.
Through the development of local care models, clinical pathways and A&E consultant staffing levels
have been iterated accordingly. For example, multiple non-hub sites have extended the hours of
A&E consultant presence to reflect anticipated demand, in addition to an increase in General
Surgical consultant presence at non-hub sites beyond a 3-4 hour hot clinic provision as initially
deemed suitable for such a site. The end result is more robust consultant level cover across GM to
ensure senior decision making and timely patient review. Aligned to this:
Work has been undertaken to assess feasibility of a pathway for shocked patients with upper
gastrointestinal haemorrage (GI bleed). National evidence suggests these patients require
endoscopy within 2 hours of their bleed. As such immediate conveyance and treatment to a
site capable of delivering this is essential. This additional pathway will be implemented as
part of Healthier Together.
There are other medical conditions for which timely expert interventions will have significant
patient benefits, such as shock due to infection. In these cases there will be benefit for
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patients being conveyed directly from out of hospital to the high acuity sites. Assessing the
feasibility of such a pathway is now necessary.
2.4.4 Compliance of the model of care with the outline model of care
On the 7th of March 2017 the CCG Association Governing Group confirmed that they had received
assurance that the detailed model of care, developed during 2016, is not materially different to the
model of care described in the outline Business Case.
2.5 Proposed estate developments
To accommodate the centralisation of high acuity demand at four hub sites, capital investment will
be required. The table below summarises the requirement.
Table 2.11: Capital requirements by sector
Sector Requirement
Manchester and Trafford 2 wards, 3 critical care beds, 1 theatre
At Central Manchester Foundation Trust, the hub site, the Trust will develop 2 wards to house both the
elective and non-elective activity that will transfer. The areas are currently in use by other services, which will
be decanted and rehoused to accommodate the new wards.
The Trust will also develop an additional emergency theatre in a shelled area in the existing main theatre
footprint to accommodate the additional non-elective/emergency activity and the semi-planned theatre lists
associated with the Ambulatory care service.
Critical care will be expanded by 3 beds in a shelled area of the newly created surgical high level
dependency/step down unit.
Existing Ambulatory Care space on both sites be reconfigured to facilitate the new Ambulatory Care model
(with extended patient assessment and opening into evenings and weekends). A small amount of additional
equipment will allow for a more comprehensive assessment and treatment to prevent unnecessary admission.
There is a risk that an additional £200k of capital costs will be incurred. This is currently being assessed within
the sector.
North East Sector 2 wards, 4 critical care beds, 1 theatre
Pennine Acute Hospitals Trust, which operates 4 hospitals In the North East sector, will construct a new 2
storey building at first and second floor levels on the Royal Oldham hospital site to provide 2 surgical wards
and one theatre. It will also include a critical care ward (given that the additional critical care capacity required
cannot be incorporated within the current landlocked footprint).
North West Sector 2 wards, 6 critical care beds
2 theatres (one elective and one non-elective)
Salford Royal Foundation Trust, which manages one hospital in Salford, has been selected as both a hub site for
Healthier Together and the single Major Trauma Centre for Greater Manchester. SRFT have already cleared
space for the erection of a new four storey building to allow for both the additional Healthier Together and
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Sector Requirement
Major Trauma activity. This includes inpatient beds, critical care beds and two new theatres
South East Sector Equipping 1 ward, Equipping critical care beds
Equipping theatre, Expanding A&E
Expanded CT, Expanded Endoscopy
Stockport Foundation trust will create a larger, 6 bedded, Resus suite to accommodate the additional high
acuity demand, with the old space used to introduce 4 dedicated consultant-led Rapid Access Treatment
trolleys
The Trust will develop a two storey design which will minimise the potential for patients to have to wait in
corridor space, and increase clinical capacity, including an additional theatre
It will also rehouse some of the activity currently undertaken in the Cardiac Catheter and Pacing Lab, which
currently sits in the A&E footprint into the new theatre complex, allowing the development of a Frailty
Assessment Unit
These final requirements have changed since the DMBC as further work has been undertaken to refine the estates needs at each Trust. The detailed of the changes are set out in Figure 51: ‘Capital Funding Reconciliation to DMBC’ in section 5.1. The total capital requirement of £63.3m is within 1% of the DMBC figure.
2.6 Proposed workforce developments
The table below summarises the workforce requirements by sector.
Table 2.12 Workforce requirements by sector
Consultant speciality Additional Consultants Required (WTEs)
Acute and Emergency Medicine 18.6
General Surgery 27.9
2.7 Local sensitivities
The following section outlines how local sensitivities to the Healthier Together plans have been
highlighted and shows how they are being managed and mitigated.
The Healthier Together public consultation attracted a wide range of views from the local population
and local organisations. A total of 22,541, consultation questionnaires were received in addition
to 658 responses to the residents survey from randomly selected residents; 95 written
submissions from individuals; 130 organised questionnaires; 894 pledges of support; 2,792
attendees of centrally organised public meetings; and 4 petitions with a total of 5,751
signatures.
An independent report on the formal consultation programme was commissioned and conducted by
Opinion Research Services (ORS) from Swansea University. The feedback from the consultation was
summarised into the following themes:
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Case for Change and Vision
Model of care
Transition and Implementation
Decision Making Processes
Data Queries (including travel and access issues)
Consultation Process
The feedback to the questions raised are summarised in Appendix to the Decision Making Business
Case.
In addition to pubic consultation feedback, an independent organisation, Mott MacDonald, assessed
and fed back both the positive and negative impacts of the proposals on protected groups. This
analysis was developed through desktop review, analysis and a programme of local engagement
events where equality and community group representatives were invited to share their views on
potential impacts and mitigating actions.
The Integrated Impact Assessment identified a number of mitigating actions that could be put in
place during implementation to mitigate the negative impacts of the proposals. An Equalities
Advisory Group has been established and one of the roles of this group is to review and advise on
the implementation of these mitigations. The group has reviewed the mitigating actions and
identified priority actions. These are outlined below:
Theme Equalities Implementation Conditions
Transition 1 Clear and regular communication is provided to staff and patients
2 Training and development of Single Service staff to better support patients with specific needs
Travel and Access
3 Coordinated transport planning and information on transport options is incorporated into Single Service implementation plans
4 An appraisal of priority access to car parking facilities at each Single Service hospital site is completed and reviewed by commissioners
5 An evaluation to appraise the extension of the volunteer driver scheme is completed
6 A common policy for travel reimbursement/set tariffs for taxis is established within each Single Service
7 Improved publicity of community transport schemes and travel voucher schemes to be provided
Service change
8 Patients are offered a choice of appointment times for elective care
9 An appraisal of flexible visiting times within a Single Service is completed in advance of any changes taking place
Monitoring 10 Commissioners will establish a monitoring/evaluation process to assess the progress of all IIA Implementation conditions
In addition, when the decision on the geography of the 4 single services in GM within the Healthier
Together model was taken on the 15th July 2015, a number of Implementation Conditions were set,
these included.
Implementation Conditions
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Programme Requirements
Condition 1 Regular data collection, review and monitoring is implemented
Condition 2 Structured process of peer review across GM
Condition 3 Establishment of a Greater Manchester Clinical Alliance
Condition 4 Joint appointments to Single Services
Condition 5 Appointment of GM clinical leadership for implementation
Condition 6 Formation of Single Service Research Hubs
Condition 7 Development of a GM governance framework
Condition 8 Formation of a CCG and Regulatory Body Alliance to support implementation
To ensure the implementation of Healthier Together aligns and meets these conditions, Greater
Manchester CCGs have commissioned the Transformation Unit to oversee the overall programme
plan and assure that local models of care comply with the Healthier Together model and standards.
2.8 Implementation plan
Whilst all of the hub sites require some capital investment to absorb 8,102 high acuity episodes
transferred from non-hub sites, the size of the investment and complexity of the work varies:
North East Sector: The sector will commence the delivery of ambulatory care and transfer of
high risk elective patients towards the end on 2017/18 over a 12 month. However,
consolidating high acuity care equivalent to 2,201 episodes at the hub site is dependent on a
capital build, at a proposed cost of £24.8m, which will be completed by c. April 2020.
North West Sector: Similarly, whilst the North West Sector can transfer a small cohort of
elective patients to the hub site and start the hub and non-hub site working together in a
collaborative single service in 2018, the sector will not be able to consolidate high acuity
activity equivalent to 1,260 episodes until a new build is complete in c. January 2020 at a
proposed cost of £18.5m. Given that the hub Trust requires a new building to accommodate
both Healthier Together and Major Trauma, both schemes are co-dependent on the funding
of the similarly timed Major Trauma project (captured in a separate business case)13.
13
It is possible to build a new building to accommodate only Healthier Together. However there is a financial benefit in consolidating the capital requirements of Healthier Together and Major Trauma.
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South East Sector: More immediately and at a lower cost, Stockport Foundation Trust can
expand its ED and theatre space, as described above, to absorb the additional demand,
equivalent to 2,388 episodes at the hub site by c. October 2018 at a much lower cost of
£9.9m
Manchester and Trafford Sector: Central Manchester Foundation Trust hub site can
reconfigure their existing space to accommodate 1,890 episodes at a cost of £10.2m by c.
December 2018.
The diagram below shows the overall roadmap.
Figure 2.5: Programme implementation roadmap
2.9 Benefits
The key objectives of Healthier Together is to deliver a clinically led transformation of acute services
that delivers better outcomes which is operationally and financially sustainable. The benefits from
achieving these objectives are set out below.
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Once implemented, Greater Manchester will be at the forefront in providing high quality and safe
care through collaborative, networked working as described in the Five Year Forward View and the
Keogh Review14.
Recent review by ECIP anticipates, if the model is completely, effectively and consistently
implemented a “significantly positive effect on flow and therefore performance” within GM A&Es15.
We anticipate significant improvements in:
Ambulance teams waiting with patients in corridors
ED four hour waiting times and 12 hour “trolley waits”
Diagnostics turnaround
Admissions through ED (14% reduction in admissions equivalent to 37,000 admissions cross
GM)
Length of stay (c. 1 day reduction in general surgery LOS16)
Outcomes and mortality – up to 300 lives saved each year through General Surgery
interventions alone
Readmissions following ED, Acute Care or General Surgery care
Patient and staff satisfaction
The expected benefits of the model of care are summarised below:
14
“Transforming urgent and emergency care services in England” http://www.nhs.uk/NHSEngland/keogh-review/Pages/about-the-review.aspx 15
February 2017 desktop review of Healthier Together standards. Performance uplift is heavily dependent on the complete and consistent application of the model. ECIP have also suggested additional improvements that can enhance flow and waiting time performance, which will be built into the implementation. 16
Based on a comparison of each Trusts length of stay, by HES HRG code, to the upper quartile nationally. This is likely to be a reasonable estimate; introduction of ERAS+, a pathway development that will be rolled out through Healthier Together, at CMFT in 2016 for all surgery patients reduced length of stay of by 3 days.
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Figure 2.6: Summary of Healthier Together improvements and how these drive benefits
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The diagram below provides additional detail on the benefits expected in relation to the emergency
care model of care and how these can be measured.
Figure 2.7: Emergency care model of care benefits
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A similar diagram below provides additional detail on the benefits expected in relation to the Acute
Medicine model of care and how these can be measured.
Figure 2.8: Acute Medicine Model of Care Benefits
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Finally, the diagram below provides additional detail on the benefits expected in relation to the
General Surgery model of care and how these can be measured.
Figure 2.9: General Surgery Model of Care Benefits
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2.10 Interdependencies and enablers
2.10.1 Major Trauma
The implementation of the Healthier Together programme is interdependent with the development
of a lead Major Trauma Centre for Greater Manchester at Salford Royal Foundation Trust (SRFT).
This is because SRFT are planning to build a new building to house both developments. If the Major
Trauma programme is not funded, the capital costs of the implementing in the North West Sector
may be significantly higher.
2.10.2 Diagnostic image sharing
Shared digital imaging and radiology provisions, with seamless access to radiological imaging
between the hub and non-hub sites is a critical component of fluid, cross organisational decision
making.
Currently the technology enabling the sharing of diagnostic imaging across GM, which is at the end
of its contract and is being re-procured, fails to realise this, with a proliferation of providers offering
fragmented and often manually intensive remote reporting services.
The Greater Manchester Clinical Advisory Group for Radiology is currently working towards the re-
procurement of an enhanced digital platform, “PACS”, seeking to maximise the effectiveness and
efficiency of digital imaging across GM. Whilst implementation of Healthier Together is not a direct
interdependency of the re-procurement, the opportunities and benefits the project offers are
significant and integral to the achievement of HT standards for Radiology.
The following table outlines key aspects of the standards and the level of interdependency between
PACS and HT:
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Table 2.11: Interdependency between Healthier Together and PACS re-procurement and upgrade explained
HT reference
Extract from HT standard Current position GM CIP contribution
R1a Hospital inpatients must have scheduled seven-day access to diagnostic services and consultant directed completed reporting • X-ray o Imaging available 24/7 within 1 hour for critical patients 12 hours for urgent patients 24 hours for non-urgent patients o A Radiology Consultant will be available 24/7 for advice if requested by a senior clinician.
This standard is being achieved variably across GM particularly for non-urgent patients.
Extensive use made of outsourcing arrangements.
Radiology consultant out of hours often ‘very remote’ lacking knowledge of GM services and processes.
Almost certain increases in demand combined with probable workforce shortages will increase pressure on ‘consultant directed completed reporting’.
Seamless out of hours image sharing across GM is a pre requisite for more developed local cover arrangements.
Allowing a wider pool of radiologists to work together will facilitate improved cover for specialist work.
Greater efficiency in reading of images, MDT preparation etc is essential to increase workforce flexibility to cope with rising demand and workforce shortages.
R1b Hospital inpatients must have scheduled seven-day access to diagnostic services and consultant directed completed reporting: • Computerised tomography (CT) o Imaging available 24/7 within 1 hour for critical patients, 12 hours for urgent patients 24 hours for non-urgent patients o Reporting provided within 1 hour for critical patients, 12 hours for urgent patients 24 hours for non-urgent patients
As above As above
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Version 3.6
R1c Hospital inpatients must have scheduled seven-day access to diagnostic services and consultant directed completed reporting: • Ultrasound (adults) o In routine working hours imaging and reporting by a suitable qualified practitioner available within 1 hour for critical patients 12 hours for urgent patients 24 hours for non-urgent patients o Outside of routine working hours Most emergency cases will require CT rather than US. If US is required then it should be discussed by the senior clinical team with the Radiologist on-call.
As above As above
R1d Hospital inpatients must have scheduled seven-day access to diagnostic services and consultant directed completed reporting: • Magnetic resonance imaging (MRI) o Reporting provided within 1 hour for critical patients 12 hours for urgent patients 24 hours for non-urgent patients
As above As above
R3 Digital PACS systems adhere to recognised standards allowing rapid transfer of images across GM of sufficient diagnostic quality to allow remote reporting. This will facilitate rapid management decisions.
Image transfer is possible – although highly inefficient – for planned care.
It is not possible out of hours thus hindering rapid management decisions.
There is currently limited capacity for high quality remote monitoring.
GMCIP will achieve this standard for elective and non elective patients. Improved diagnostic quality will be achieved.
UEAM38 When immediate outcome is dependent on imaging studies for all non elective radiographs a provisional report is available within 30 minutes and a definitive report within 1 hour.
By facilitating collaborative working across a wider pool of radiologists, it will more likely that the most urgent reporting timescales can be achieved.
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Version 3.6
UEAM37 Images must be available via digital PACS systems for review in ED, AMU and other clinical areas, such as ICU.
Within hospitals this might be achieved currently.
GM wide image sharing will facilitate this across multiple location including new clinical areas such as primary care.
UEAM43 24/7 Consultant radiologist available for advice The radiologist does not need to be on site but needs to be available 24/7 to view images on PACs and provide advice
Remote reporting not widely used, and where it exists, is restricted to that locality.
Seamless image sharing across GM will facilitate remote viewing particularly in an environment where the workforce is increasingly limited compared to the demand.
VIR6 Sites must ensure that PACS access to their individual service is immediately available to all radiologists in their network who provide an on-call interventional radiology service to their site.
Not currently compliant GM wide image sharing will facilitate this.
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The current outline business case for GM collaborative image sharing establishes a management
plan forecast to complete implementation by Q4 2018/19, with several finance options being
explored.
2.10.3 Record sharing
A second core enabler of Healthier Together is the ability to access patient records across an array of
providers and care settings, to optimise accurate and timely decision making. At present GM primary
and secondary care providers operate across a plethora of IT systems with variable compatibility,
and distinct lack of functionality with regards to the effective transfer of patient records.
The Greater Manchester Academic Health Science Network (GM AHSN) has established a
programme, which is an innovative digital infrastructure that enables doctors and care professionals
in Greater Manchester, East Cheshire and East Lancashire to share and view the patient and client
information they need, when they need it, to improve care.
It will provide Greater Manchester with a platform that supports better use of existing data and
enable GM to be at the forefront of modern healthcare, changing the health data landscape:
Figure 2.10: Datawell
For NHS Organisations, this will create a framework to simplify and enable easier sharing of data. To
do this a ‘node’ will be created in every participating organisation to which data will be added. These
nodes are designed to only allow sharing of data with other nodes and will validate all data requests
against ‘computable’ information sharing agreements. This allows all members to participate but
ensures that each member retains local control of how their data is used, and whom it is shared
with.
Funding for this or other similar solutions, is seen as a key enabler for Healthier Together, and other
transformation programmes, and will be sought through the GM Digital Fund where required.
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2.11 Risks
Key risks are detailed below:
Table 2.12: Risks
Key Risks Mitigating Factors
Workforce: Ability to recruit required number of consultants to deliver the HT standards Changes to working patterns with new model may ability to retain and recruit staff Impact of training requirements of junior medical staff due to HT impacting service provision at non-hub sites.
GM Workforce Reference Group to develop strategies focussing on key aspects of programme deliverables including recruitment, assessment of pipeline consultants within the GM system, terms and conditions and consistent application of policy and principles. Collaboration with Health Education England to ensure attractive training propositions for junior medical trainees across GM balanced with service stability for all sites. Established sector workforce and HR groups reviewing recruitment strategies linking to the wider GM picture, with robust staff communication and engagement strategies. Phased implementation plan across GM facilitates a sequential approach to recruitment where appropriate. GM review of clinical pathways to maximise efficient use of the workforce. Clinical Champions input to lead early engagement with staff groups, Unions, colleges etc. Readiness assessment focusing on cultural aspects of change, supplementary to systems and structural change requirements.
Radiology: Workforce challenges to delivery core requirements of HT Sub-specialty delivery of interventional radiology Existing reporting pressures
Radiology Clinical Advisory Group and Vascular Interventional Radiology sub groups established. with strong links to HT and pathway development, in additional to sectors developing local models to ensure 7 day delivery of level 1 competencies. Radiology standards agreed. Collaborative Image Sharing business case in development to enhance efficiencies and reporting capability. GM Workforce Group focussing on Radiology workforce requirements linked to wider Theme 3 requirements.
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Transfer of Patients: Potential clinical dis-benefit of double ambulance transfers of patients from a non-hub to a hub.
The potential dis-benefit of double ambulance journeys continues to be reviewed by the NWAS task and finish group with senior clinicians addressing any potential risks and issues. The evidence from NHS Lothian will continue to be explored in more detail as well as GM initiatives that transfer patients from a receiving A&E site to a specialist centre, such as Neurosurgery, Stroke, PCI, Major Trauma and existing Fairfield & Trafford models. NWAS business case provides sufficient capacity for the transfer of all patients from a non-hub to a hub site, using Optima modelling system to account for additional resources required. Similar models to Healthier Together exist such as NHS Lothian, where patients are transferred from an A&E receiving site to a specialist colorectal site for emergency laparotomy intervention, with excellent patient outcomes such as mortality rates for emergency laparotomy. Examples of existing pathways that transfer patients from one A&E to another, such as Fairfield model for emergency general surgery, Neurosurgery, Stroke, Major Trauma and PCI.
Delivery of standards & benefits Healthier Together standards and benefits of the programme not being achieved.
Benefits baseline completed in April 2017. Shared with sectors. Review and audit process to be developed and agreed with board linking to external independent support to facilitate process with use of audit data, hard copy evidence and peer review. Clinical Benefits dashboard developed and agreed via delivery board and reporting to commence from November 2017
Critical Care Compliance: Critical Care services in 2/4 sector hubs not being compliant with National Critical Care Guidance. This is due to workforce shortage of ICM consultants.
Compliance being managed by Critical Care Network across GM. Risk highlighted to AGG on 21st March 2017. Programme Team to liaise with CC Network.
Equalities: Risk that HT model creates inequity and fails to ensure patient voice heard through the planning and implementation stages.
Equalities advisory group established alongside the development of Integrated Impact Assessment (IAA) implementation condition with reporting function through the HT delivery board. Delivery of sector level equality impact assessments and patient voice groups and inclusion of patient in various working groups in addition to strengthening links with wider Theme 3 changes.
GI Bleed Patients: The risk that patients with life threatening gastrointestinal haemorrhage arriving in ED at non hub sites. Sectors not compliant with NICE/CEPOD standards.
NWAS medical pathfinder has GI haemorrhage included as indication for divert. GI Bleeds pathways under development and shared with sectors via Clinical Alliance. To be assessed as part of go-live plan and readiness asst. Clinical Lead to assure sectors approach. GI Bleeds workshop to be held following sector specific meetings on 26th October 2017
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Funding: Risk of failure to secure capital via national route Risk of lack of transitional funding to support implementation Stranded costs Risk of failure to agree recurrent revenue impact of delivering Healthier Together
The treasury allocated full capital request of £63m on 19 July 2017. Following GM approval the FBC will be submitted to national authorities for final approval and release of capital. The commercial case component will be completed now sectors are moving at risk ahead of the release of national funds through the procurement stages to complete the detailed design phase. Transformation Oversight Funding Group decision delivered on 28 June 2017 to support £17.2m and GM CCG monies to the value of £5.5m made available to support the transitional process. A large percentage of the TFOG funding supports any unmitigated stranded costs, with the expectation that organisations and sectors will work to mitigate their available assets. For example linking Theme 3 changes, looking to agreements around reciprocal activity flows, explore independent sector opportunities to deliver work referred to private sector back to the NHS, links with integrated programmes and wider estates strategies. Recurrent revenue agreements in place in two sectors, North West Sector expected to conclude imminently and the GM HSCP to support conclusion of negotiations in South East Sector. Funding oversight provided by the Finance Executive Group.
System Assurance: The system needs assurance, through the FBC that HT is affordable and deliverable (e.g. that workforce can be put in place) before funding and implementation is agreed
Production of a full FBC agreed with sectors. Governance process approved and Executive function process established. Production of accompanying paper to provide assurance on risks, funding, case for change and value for money to be presented at the Theme 3 executive and finance executive group prior to final approval at the Joint Committee.
2.12 Approval and assurance of the “Decision Making Business Case”
The Decision Making Business Case was ultimately agreed by, and documented the unanimous
decision of, the 12 Greater Manchester CCGs (15th of July 2015).
Prior to this approval, a number of other approvals and assurance processes were successfully
navigated:
The NHS England Investment Committee met on 7th of July 2015, giving the programme full
assurance to proceed with decision making
The Service Reconfiguration Oversight Group met on the 9th of June 2015 and
recommended the programme for assurance to the Investment Committee: “The OGSCR’s
recommends to the Investment Committee that the Greater Manchester CCGs’ are in a
position to make a considered decision. The Committee is recommended to approve the CCGs
moving to make a decision on the final service and site configuration through their
Committee-in-Common. It is also recommended that the ongoing requirement for assurance
of the implementation phase is considered alongside broader discussions about the
devolution of powers to Greater Manchester.”
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The Regional Management Team met on the 1st of June 2015, recommending the
programme to the Service Reconfiguration Oversight Group with the following statement:
“The North region confirms that the programme is fully aligned with the direction of travel
outlined in the 5 Year Forward View, and the development of single service models will
support the development of 7 day services in line with national policy.”
The Greater Manchester Joint Scrutiny Committee: The GM Health and Wellbeing Board
have expressed strong support for the Healthier Together programme, and its aims and
objectives as part of the wider Health and Social Care reform programme.
The Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny)
Regulations 2013 set out the responsibilities upon local authorities with regard to
consultations by the NHS. In summary, where a responsible person has under consideration
any proposal for a “substantial development of the health service in the area of a local
authority,” or for a “substantial variation in the provision of such service” the person must
consult the authority. Where a responsible person consults more than one local authority
those local authorities must appoint a joint overview and scrutiny committee for the
purposes of the consultation. Only that joint committee may make comments on the
proposal under the regulations, request provision of information, and request members or
employees of the responsible person to attend it to answer questions. These arrangements
were made and regular updates and sign offs undertaken throughout the Healthier Together
pre-consultation phase.
In addition, Healthier Together attended Greater Manchester Health and Wellbeing Boards
between September 2012 and decision making in July 2015.
Greater Manchester, Lancashire & South Cumbria Clinical Senate: In April 2014, the newly
formed Greater Manchester, Lancashire and South Cumbria Clinical Senate received a
commission by the Senior Responsible Officer for Healthier Together to provide clinical
advice to commissioners that would assure the recommendations made by the NCAT. The
group subsequently provided an Independent Clinical Review of Recommendations in June
2014, demonstrating significant progress; either partial or full completion of all outstanding
NCAT actions. Those that are partially completed relate to actions required in
implementation. Healthier Together then produced a subsequent report describing
completion of those actions.
National Clinical Advisory Team: NCAT assured the clinical programme work through an
informal and formal review of the Future Model of Care.
On the 17th December 2013, a panel of NCAT members undertook a formal review of the
model of care. The panel met with the Senior Responsible Officers for all three elements of
the programme, members of the Clinical Reference Group, Clinical Champions and members
of the Programme team. Presentations were given about primary care, integrated care and
the hospital elements of the programme. Following the panel the NCAT team endorsed the
model of care and provided a report to the Programme: “The unanimous opinion of the
NCAT panel is to strongly support the programme and to give clinical assurance that the
programme can proceed to public consultation. The panel offered strong approval of the
programme’s ambition, vision and scope together with an impressive public and clinician
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engagement. The commitment to the process of all the Local Authorities, Health and Well
Being Boards and all NHS Organisations is hugely impressive. It is the panel’s opinion that the
programme offers an approach and modelling that is an exemplar for the NHS and its
partners as they grapple with improving safety, value and sustainability in financially more
austere times.”
On the 11th September 2013, a panel of National Clinical Advisory Team (NCAT) members
had previously conducted an informal review. Panel members included:
Professor David Colin-Thomé chair and NCAT input into Primary Care, Long Term
conditions and unscheduled care;
Professor Kate Costeloe (Paediatrician);
Suzanne Truttero (Consultant midwife), and;
Mr Tony Giddings (General Surgeon).
The NCAT informal review report, sent to Greater Manchester on 27th September 2013
recommended that: “The panel expressed support for the ambition, scale and development
of the strategy and programme although there are specific issues to be addressed before the
formal NCAT review takes place prior to formal public consultation. The NCAT panel for the
formal review will include an expert in acute and emergency medicine.”
NCAT also independently assessed each Trust against national and GM standards, generating
a RAG rating and assessment that no GM Trusts is currently meeting all of the standards.
Department of Health, Health Gateway Review: The Health Gateway Review Process
provides all NHS and other health public sector organisations with confidential independent
peer review support for their projects and programmes. Supported by the Cabinet Office
and managed by the Department of Health, Health Gateway Reviews provide assurance to
programme and project owners that their project is on course to deliver the desired
outcomes, on time and within budget. Gateway Reviews are mandatory for all programmes
and projects being undertaken by NHS organisations that are assessed as high risk. A
Gateway Review is also required prior to public consultation when any service
transformation is proposed.
The programme completed a Stage 0 review in November 2012. The report recognised that
a good start had been made but identified the significant challenge and resource constraints
facing the programme at that time (now resolved). In relation to the clinical work forming
the foundation of the case for change and model of care the “confidence assessment”
comments: “A good start to the development of this Programme has been made with very
good work undertaken to provide clinically led and compelling cases for change across a
number of work streams, together with clear future service visions. There is clear clinical and
managerial consensus for the need to change and emerging clarity on the future service
visions.”
A third and final gateway review was undertaken in November 2014. The previous review focused on
the Programme’s readiness for public consultation. This Review followed the public consultation in
the period from July to October 2014, and was focused on the Programme’s readiness for making a
decision on options in July 2015.
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“The Review Team was impressed with the progress made by the Programme Team since the
last review. A robust Pre-Consultation Business Case was prepared and public consultation
was achieved despite a number of challenges. Numerous key stakeholders said that this
progress had been achieved because of the clear leadership of the Programme Team and the
commitment of team members. Although there were clear challenges within the public
consultation process, not least the pejorative interpretations of the nomenclature, there
were a number of aspects which we consider best practice.”
A confidence assessment of amber was given indicating that programme delivery is feasible.
All six recommendations were addressed before decision making commenced.
A further review was completed in March 2014, the purpose of which was to assess the
programme’s readiness for public consultation. The review recognised the progress made in
relation to developing the clinical standards, and also highlighted the work required to be
undertaken in advance of consultation. Seven key recommendations were made and a
confidence assessment of amber was given. The programme addressed all
recommendations before launching its public consultation.
NHS England: NHS England has distinct roles with regard to service change and specifically
the Healthier Together programme, they are: offering advice and ongoing assurance (on the
integrity and viability) of proposals as overseer of the local health system; and ensuring
alignment between change programmes and future strategy as a direct commissioner of
services.
The Pre-Consultation Business Case (PCBC) was approved by NHS England prior to
consultation. Monthly meetings were held between February and June 2014 to review the
Pre-Consultation Business Case and supporting documents. This involved information being
submitted to the Assurance Panel and questioning of the programme team where necessary.
A regular report was prepared by the Area Team Director to the National Service
Reconfiguration Oversight Group (SROG) detailing progress and adherence to the
aforementioned assurance criteria. NHS England’s assurance process identifies that
following consultation, “proportionate on-going NHS England oversight arrangements” will
be agreed with commissioners (Effective service change: a support and guidance toolkit,
NHS England, 2014). Post consultation, NHS England sought assurance of the following
elements:
1. That the consultation and subsequent analysis has been undertaken to best practice
standards and all views expressed have been properly taken account of;
2. That the resulting range of options developed by the CiC are strategically coherent from a
system point of view, and they align with NHS England’s views as a co-commissioner of
services for people in GM;
3. Of those options, those which are then progressed to the next stage (for a CiC decision)
remain within acceptable financial and quality parameters (as identified in pre-consultation
assurance), and the impact of each option (on organisations, sites and population groups)
has been fully assessed and is considered acceptable;
4. Any requirement for further consultation or engagement has been properly considered in
line with best practice;
5. Stakeholder handling plans are robust; and
6. The implementation framework is robust with risks properly mitigated.
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The Department of Health’s four tests for service change were applied at each stage (throughout
the programme lifecycle), the tests are: GP commissioner support; a solid clinical evidence base;
good engagement; and being mindful of patient choice. Assurance of these elements was
undertaken in a phased manner during the post consultation decision making phase of the
programme. NHS England and the CCGs’ Committees in Common agreed a timetable for the
assurance of these factors, and worked collegiately to deliver the evidence required. The six
elements of assurance were considered in a small number of phases as per the agreement
between NHS England and the Committees in Common. This approach was endorsed by the
OGSCR chair on 1 May 2015.
The diagram below summarises some of the evidence provided to NHS England.
Table 2.13: Summary of Evidence Provided to NHS England
1 Review of communications and engagement strategy
The Reach and Engagement Report outlines the approach taken during consultation to ensure that as
many people were engaged and made aware of HT proposals as possible. The report outlines how the
consultation was planned, in terms of branding and the key products which were used to share
information relating to the changes. It also details the approach to communications and marketing
activity (i.e. radio and local media), what materials were distributed and where for maximum impact, and
the different types of engagement events which were delivered across the Greater Manchester and
relevant boundary area footprint
2 Independent analysis of consultation feedback, including effectiveness of engagement with groups
with protected characteristics
The Consultation Feedback has been analysed by Opinion Research Services (ORS). ORS were appointed
by HT to facilitate aspects of the consultation process and to provide an independent report of the
formal consultation programme.
“As a research practice with wide-ranging experience of controversial statutory consultations across the
UK, ORS is able to certify that the formal consultation processes undertaken by Healthier Together has
been both intensive and extensive. Overall, ORS has no doubt that the exercise has been conscientious,
competent and comprehensive in eliciting the opinions of stakeholders and many members of the public.”
3 Audit trail demonstrating how feedback has been drawn into coherent themes of evidence to help
shape decision making
The Integrated Impact Assessment and accompanying appendices ensured that those involved in the
decision making on proposed changes to service configuration understood the impact these had on the
population it serves. In particular, attention was given to those groups and communities who may be
most vulnerable to changes. The IIA report also outlined mitigating actions which minimise the risk and
impact to them. The aim of the IIA was to explore the positive and negative consequences of different
options and produce a set of evidence-based, practical recommendations, which could then be used by
decision-makers to maximise the positive impacts and minimise any negative impacts of proposed
policies or projects.
4 Audit trail demonstrating feedback themes have been fully considered as evidence in developing the
range of options
The Consultation Feedback Themes explains how consultation feedback has been reviewed, grouped into
themes and responded to. The Lessons Learned Report collates both the stakeholder feedback and
internal team feedback post consultation process. The report outlines the range of lessons learned and
the subsequent actions taken in response to feedback - notably, a revision of the governance structure to
maximise stakeholder involvement during the decision making phase of the programme.
5 Options are described in terms that allow strategic coherence to be tested – at patient pathway and
organisational levels
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The Co-dependency Review Paper outlines service co-dependencies and those in scope of the Healthier
Together programme, bearing in mind that co-dependent services do not always need to be offered on
the same site. The report details work done both before and after consultation, outlining in particular the
work undertaken to respond to consultation feedback. An Independent Clinical Review Team has been
established for the purpose of assuring strategic clinical coherence. This process is set out in the agreed
Terms of Reference. This group collated detailing work on co-dependencies, organisational information
and site maps to understand the issues surrounding the services under review. An independent clinical
panel, made up of a bespoke group of clinical experts with professional credibility and independence,
reviewed the report and drew attention to any risks for further consideration before progressing their
proposals.
6 Proof that consideration has been given to prior commitments made by the NHS and commitments in
HT process hold true
Healthier Together has a very clear goal and set of commitments:
“We are committed to shifting resources from hospitals, allowing us to provide the right services for
people at home or closer to home. We are committed to people being seen more quickly by their GP, and
to helping people to help themselves, where they are able to.”
The Consultation Feedback Themes provides details of Healthier Together commitments which were
reinforced during and after consultation. For example, the promises that no A&Es would be closed as a
result of the Healthier Together programme.
7 Demonstrable sign-up from all commissioners (inc. NHS England) to options
Satisfied by the Department of Health’s 4 Tests: GP Commissioner Support (see element 15 of this table)
8 Evidence of aligned strategic intentions:
1. Alignment with specialised commissioning intentions
The scope of specialised commissioning within the context of Healthier Together is adult major
trauma.
2. Alignment with Caring Together (East Cheshire) and any other neighbouring programmes
Healthier Together can only align its strategic intentions with proposals which are in the public
domain. Therefore, at this point in time, it is not appropriate or possible to provide this
evidence.
9 Detailed supporting information for each option, allowing analysis of quality and financial implications
(to include modelling of activity, financial and workforce implications for each option)
A number of groups with representation from hospitals and Clinical Commissioning Groups (CCGs) across
Greater Manchester have been set up to provide challenge and assurance on the modelling
methodology:
Finance and Investment Group (FIG)
Data modelling and advisory Group (DMAG)
Estates & Infrastructure Group.
In addition, BDO LLP was commissioned to provide external oversight and assurance into the Healthier
together programme, specifically on the activity, financial, capital and workforce model. BDO have
worked with their partners EC Harris and Centre for Workforce Intelligence to provide this assurance.
The role of EC Harris was to assure the Estates and Capital infrastructure modelling, whilst the Centre for
Workforce Intelligence have reviewed and assured the workforce modelling.
10 Explanation of the interaction between the HT work and the Manchester Devolution work on overall
financial sustainability
Healthier Together is one of a number of key areas of Devolution work and Theme 3 which is currently
collaboratively directed and will be recognised as shared content in the GM Strategic Plan. A Devolution
Finance Group has been established to lead on the financial work required to support the development
of the Comprehensive Spending Review and the GM Strategic Plan for August 2015.
The plans will include:
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2015/16 will be the baseline year
High level modelling will to identify the likely position and gap over a five year period. The
work will be informed by clear principles that organisations can sign up to. It will show a GM
rather than locality level position. The principles and first cut of the model will be reviewed
at the Directors of Finance Meeting on 19 June 2015.
A review of the various plans and pieces of work in place
A view on what can be achieved through efficiencies and productivity improvements
(informed by benchmarking and national studies).
The strong platform for collective decision making within Healthier Together has been rolled out to
ensure clinically and financially sustainable acute and hospital based services will be delivered through
Devolution. The planning assumptions used for Healthier Together are consistency in terms of demand
and capacity planning with current service planning.
11 Demonstration that HT does not prejudice the ability to deliver an overall solution to Manchester’s
financial challenge
Financial Modelling - The PCBC referenced £22m of health economy savings, this has been re-tested
within this management report and adjusted to £20m. As the £22m was calculated on 2012/13 data, this
has been updated as per consultation feedback and consequently health economy savings have been
adjusted. As part of this work, the transition and capital investment costs required have also been
identified.
Links have been made with Chief Financial Officers and Local Authority Treasurers to develop a GM
Comprehensive Spending Review, which will calculate the full extent of the GM financial challenge.
Healthier Together is one programme of work which will contribute towards the narrowing of the
income/spending gap.
12 Impact assessment for each proposal, examining impact by organisation, specific sites, geographical
populations, groups of service users, groups with protected characteristics
This Integrated Impact Assessment report was produced by Mott MacDonald, with quality assurance
provided through an IIA Steering Group. The IIA evidence suggests that there are five protected
characteristic groups which have been identified as having a disproportionate need for the services under
review. They are: age (older people); disabled people; BAME groups; gender (both men and women) and
deprived communities.
In addition to the qualitative travel and access challenges which have been identified by stakeholders,
analysis has identified that older people (those over 65 years of age), and disabled people to a lesser
extent (3-4% and 1-2% respectively), are disproportionately impacted across all options compared to the
overall population impacted. Across both the Greater Manchester CCG catchment and the wider study
area, the proportion of the population from BAME groups impacted under each of the options is less
than the proportion of the overall population. A similar pattern can be seen for deprivation in the
Greater Manchester CCG analysis, however, when considering the wider catchment area, for those living
in deprived communities, the proportions impacted within three of the options (Options 4.4, 5.1 and 5.2)
are higher than the proportions of the overall population potentially impacted.
When considering travel impacts in relation to specific equality groups, there is little variation in the
proportions impacted compared with the overall population. For those that are impacted there is a
higher proportion, Options 4.2, 4.3, 4.4, 5.1 and 5.2 identify that there is a higher proportion of those
living in deprived communities who would experience an additional journey time of over 15 minutes
compared to the overall population.
13 Impact assessment for specialised services and future intentions
Within section 7.8 of the IIA a range of service impacts have been considered, some potentially positive
and some negative. Many of these have already been recognised by Healthier Together and its partners
and as a result work is already planned or underway to ensure that these impacts have been
appropriately considered prior to implementation. This will seek to minimise the likelihood of these
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impacts being realised.
Whilst these do not significantly vary within each option, the potential impacts relating to capacity of
hospital sites providing high risk general surgical care and ambulance services, and the resilience of
services are likely to be greater under the four sites options (Options 4.1, 4.2, 4.3 and 4.4). Achieving
workforce standards would have created more challenges under the five site options (Options 5.1, 5.2,
5.3 and 5.4).
14 Any requirement for further consultation or engagement has been properly considered in line with
best practice
Assured locally: To date, no responses or issues have been identified that would warrant further
consultation. Regular updates will continue with GM JOSC.
15 Stakeholder handling plans are robust
Assured locally: Healthier Together is working with local Healthwatch organisations to co-design an
engagement mechanism which enables patients, carers and members of the community across Greater
Manchester to provide assurance and inform implementation planning using patient experience and
knowledge of local services.
16 Implementation framework credibly demonstrates how proposals will be implemented, including
relationship between key organisation’s business plans and alignment with commissioner’s intentions.
Chapter 20 of the DMBC outlines the potential considerations for implementing Healthier Together, and,
incorporating relevant learning from other programmes. This chapter also puts forward a suggested
approach for implementation.
17 Ongoing compliance with DH’s four tests for service change:
1. Public and patient engagement test
Outlined in Chapter 3 of the DMBC
2. Patient Choice
The Patient Choice Report details how patient choice has been considered following feedback from
public consultation and also on the three in-hospital services- Emergency Medicine, General Surgery
and Acute Medicine. This has been considered by our Clinical and Patient Safety Group.
3. GP commissioner support
Terms of Reference for Healthier Together Committees in Common outlines how the Healthier
Together CiC are to be established and constituted, and voting and decision making arrangements.
4. Clinical evidence base
The Co-dependency Approach Paper outlines the relevant clinical considerations for the decision
making phase of the programme, alongside the Co-dependency Final
Independent Financial Assurance: An independent advisor, BDO LLP, assured the financial
analysis (and any updates made in response to public consultation feedback).
Independent Clinical Review of Co-dependencies: To support and assure the Healthier
Together Co-dependencies work an independent literature review was carried out by the
NHS Midlands and Lancashire Commissioning Support Unit. An independent clinical panel
was also convened to assure the review of co-dependencies undertaken by the programme
post consultation.
Assurance and approvals milestones are summarised below.
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Table 2.14: Assurance and approvals milestones
2.13 Approvals and assurance
Healthier Together is one of the largest clinical and quality improvement programmes in England,
including primary care, joined up care and hospital care. As such, it has been subject to extensive
assurance, scrutiny and oversight throughout its programme lifecycle. A myriad of GM groups have
convened to input to the FBC inclusive of:
Cost and efficiency principles developed by GM Programme Directors, 17th February 2017.
Cost and efficiency principles agreed by GM CFOs, 21st February 2017.
AGG endorsement of continued strength of the clinical case for change and model of care
compliance, 7th March 2017.
Finance Executive Group focus on core financial components of FBC, multiple dates.
Healthier Together oversight, Q1 2017/18.
In addition the following governance approval route has been established to confirm the various
elements of the FBC:
Theme 3 Executive – 12th September - to receive the FBC accompanying paper and a
briefing on any outstanding issues in relation to the local and national processes.
Recommendation: Theme 3 Executive, on behalf of the Theme 3 Board to ‘sponsor’ the GM
FBC.
NHS England strategic sense check 13 Feb 2014
NHS England Regional Director letter to Area Team Director detailing assurances required 1 May 2014
NHS England Assurance process (inputs included a Clinical Senate review and a Gateway
Team review) and formal assurance panel, chaired by Area Team Director
May - June 2014
Service Reconfiguration Oversight Meeting 3 June 2014
Extraordinary Service Reconfiguration Oversight Meeting 26 June 2014
Dame Barbara Hakin (National Director, Commissioning Operations) letter to CCGs
detailing assurance position
7 July 2014
Healthier Together Consultation Launch 8 July 2014
Regional Management Team Meeting 1 June 2015
Service Reconfiguration Oversight Group 9 June 2015
Investment Committee 7 July 2015
CCG Committees in Common 14 July 2015
67
Extraordinary FEG – 14th September – to receive the GM FBC and accompanying paper.
Recommendation: to confirm and assure the financial aspects of the GM FBC and agree any
further actions and / or amendments.
Joint Committee (as a ‘sub meeting’ to the existing JCB meeting) - 19th September - to
receive the GM FBC and accompanying paper. Recommendation: endorse the GM FBC and
reconfirm commissioner support for HT implementation.
68
3 Economic Case – what is the preferred option and its implication
3.1 Introduction
The purpose of this chapter is to describe the process that has already been followed to select a
preferred option for the configuration of services in “single service” networks. This includes:
the process undertaken to identify the long list of options and then reduce this to the short
list;
the options appraisal and governance processes undertaken in 2015 to select a preferred
option from the short list;
how costs and benefits have since been refined;
the net present value of the programme; and
how financial benefits will be monitored.
3.2 Longlisting and Shortlisting of options
At the Pre-Consultation Business Case stage a long list of seven key options in relation to the
configuration of single services was considered. These were:
‘Do nothing’
‘Do Minimum’ - All 10 hospitals increase their workforce to deliver the national and GM
clinical standards
Designate six hospitals as ‘specialist’ hub sites
Designate five hospitals as ‘specialist’ hub sites
Designate four hospitals as ‘specialist’ hub sites
Designate three hospitals as hub ‘specialist’ sites
Designate two hospitals as hub ‘specialist’ sites
Within each of these five specialist site options there were a number of sub-options depending on
which hospital would be the specialist site and which local hospitals would form the single service
along with the specialist hub.
It was agreed during the Pre-Consultation Business Case that due to the geography of the region and
the stated Healthier Together Principles:
Central Manchester University Hospitals, Salford Royal Hospital and Royal Oldham Hospital
would constitute three of the specialist sites.
Three specialist hospitals were too few for the hub and spoke single service model to work.
Six specialist sites were too many for the hub and spoke single service model to work.
69
The Pre-Consultation Business Case was signed off by the Healthier Together Committees in
Common (CiC), NHS England and the Greater Manchester Joint Overview and Scrutiny Committee.
The Decision Making Business Case (Outline Business Case) therefore considered four short listed
options:
Option 1 - ‘Do nothing’
Option 2 - ‘Do Minimum’ - All 10 hospitals increase their workforce to deliver the Healthier
Together clinical standards
Option 3 - Designate five hospitals as ‘specialist’ sites
Option 4 - Designate four hospitals as ‘specialist’ sites
Table 3.1: Summary of shortlisted options
Option Overview of options Reason for including
Option 1 Do nothing There are no changes to the clinical
model and the minimum clinical
standards are not delivered at any
provider hospital
As the control against which to
evaluate the other options.
Clinically this option is not
acceptable.
Option 2 All hospitals
deliver the
standards
This option would see all provider
trusts increasing the clinical workforce
to deliver the standards but would not
encourage cross Trust collaboration
Delivers the clinical benefits without
the need for reconfiguration.
Option 3 5 hub sites
deliver the
standards
This option designates 5 hospitals as
specialist sites, where workforce
would increase to deliver the
standards. The hub site would then
work collaboratively with other
neighbouring trusts to ensure all high
risk patients across Greater
Manchester could access appropriate
clinical care
Delivers the clinical benefits and
requires Trusts to collaborate in the
single service model. Recognises the
fact that recruiting staff at all sites is
not feasible, both from a recruitment
and recurrent cost perspective.
Option 4 4 hub sites
deliver the
standards
This option designates 4 hospitals as
specialist sites, where workforce
would increase to deliver the
standards. The hub site would then
work collaboratively with other
neighbouring trusts to ensure all high
risk patients across Greater
Manchester could access appropriate
clinical care
Delivers the clinical benefits and
requires Trusts to collaborate in the
single service model. Recognises the
fact that recruiting staff at all sites is
not feasible, both from a recruitment
and recurrent cost perspective.
70
3.3 Appraisal of shortlisted options
A significant amount of analysis and detailed modelling of the four shortlisted options (including four
sub-options for options 3 and 4) was undertaken, with sensitivity analysis. This considered:
Impact on the volume of activity transferred to the hub site;
Implications for the number of beds at all sites;
Implications for workforce requirements, based on ability to achieve key quality and safety
standards with projected activity;
Implications for estates when additional activity is transferred to the hub site;
Financial implications, including capital costs and revenue cost impacts;
An assessment of the transport and access impact for patients;
An assessment of public opinion, developed following feedback from a large scale Public
Consultation; and,
A risk assessment of each option.
The diagram below summarises the analysis.
Table 3.2 Capacity, estates, transport and financial impacts of options considered in Decision Making Business Case (OBC)
Option Activity and beds required
Estates requirement
Workforce Transport Financial Impact
Option 1 –
‘Do nothing’
No change No change No change No change No change
Option 2 – All
provider trusts
deliver the
standards
No change No change 99 additional
consultants
234 other staff
No change Capital cost £nil
Recurrent
revenue cost
£35.1m
Option 3 –
5 hub sites
deliver the
standards
Activity moves
to hub sites,
requiring
additional beds
and theatre
capacity at hub
sites
Capital
investment
required for
inpatient beds,
operating
theatres and
diagnostic
services at hub
site
54 to 56
additional
consultants and
130 other staff
No patient
would have
travel time in
excess of 45
minutes
Capital cost
£30m to
£64.6m
Recurrent
revenue cost
£10.3m to
£15.0m before
revenue cost of
capital
Option 4 – Activity moves Capital 42 to 44 No patient Capital cost
71
Options 3 and 4 had a number of sub-options for the different configurations of the single service
collaboration model, which is the reason for a range of capital and recurrent revenue impacts.
The diagram below describes some of the risks that were also taken into account.
Table3.2: Risks considered as part of the shortlisted options appraisal
4 hub sites
deliver the
standards
to hub sites,
requiring
additional beds
and theatre
capacity at hub
sites
investment
required for
inpatient beds,
operating
theatres and
diagnostic
services at hub
site
additional
consultants and
104 other staff
would have
travel time in
excess of 45
minutes
£35.8m to
£74.8m
Recurrent
revenue cost
£5.1m to £9.1m
before revenue
cost of capital
Option Risk Mitigation Conclusion
Option 1 –
‘Do nothing’
No improvement in
clinical standards.
Avoidable deaths would
not be reduced
Not applicable Not acceptable from a clinical
perspective
Option 2 – All
provider trusts
deliver the
standards
Trusts will not be able to
recruit all the required
staff
The recurrent revenue
cost of £35.1m would
make this option
unsustainable
Financially unsustainable
Option 3 –
5 hub sites
deliver the
standards
High risk patients would
have to travel further to
specialist site
Trusts will not be able to
recruit all the required
staff
For all options considered,
patient travel times were
limited to 45 minutes
New GM HR processes to be
set up to attract and recruit
more e.g. national
campaigns and joint
campaigns between
hospitals that struggle to
recruit and those that do
not
NPV (calculated on a cost
avoidance basis) ranged from
£89m to £98m over 20 years.
Option 4 –
4 hub sites
deliver the
High risk patients would
have to travel further to
specialist site
Trusts will not be able to
For all options considered,
patient travel times were
limited to 45 minutes
HR processes to be set up to
NPV (calculated on a cost
avoidance basis) ranged from
£113m to £128m over 20
years.
72
The net present value (NPV) of the options was calculated, including a separate NPV for each of the
sub-options considered within Option 3 and Option 4. The net present value for four sites was higher
than the net present value for five sites for all sub-options.
On 17th June 2015 the Healthier Together Committees in Common (CiC) voted unanimously for
Option 4: four single services. This decision was reached based on a variety of factors including
workforce considerations, affordability and value for money, public feedback, and travel and access.
Within Option 4 there were twelve sub-options dependent on which site was designated as the
fourth specialist site and then the configuration of the single services across Greater Manchester.
The table below sets out all twelve options.
Table 3.4: Sub-options within option 4
Option reference
Sub-option
Sub option reference
Specialist sites
Non-hub sites for A&E, Acute Medicine and General Surgery (but might be a specialist site for other services not in scope of Healthier Together)
4.1 1 4.1a Salford North Manchester
Central South Manchester and Trafford
Oldham Tameside and Stockport
Bolton Bury and Wigan
2 4.1b Salford North Manchester and Bury
Central South Manchester and Trafford
Oldham Tameside and Stockport
Bolton Wigan
3 4.1c Salford North Manchester and Wigan
Central South Manchester and Trafford
Oldham Tameside and Stockport
Bolton Bury
4 4.1d Salford Wigan
Central South Manchester and Trafford
Oldham Tameside and Stockport
standards recruit all the required
staff
recruit (as above) Option 4 is the preferred
option based on all factors
taken together.
73
Bolton Bury and North Manchester
4.2 5 4.2a Salford Bury and North Manchester
Central South Manchester and Trafford
Oldham Tameside and Stockport
Wigan Bolton
6 4.2b Salford North Manchester
Central South Manchester and Trafford
Oldham Tameside and Stockport
Wigan Bolton and Bury
4.3 7 4.3a Salford Bolton and Wigan
Central North Manchester and Trafford
Oldham Bury and Tameside
South
Manchester
Stockport
8 4.3b Salford Bolton and Wigan
Central North Manchester and Trafford
Oldham Bury
South
Manchester
Stockport and Tameside
4.4 9 4.4a Salford Bolton and Wigan
Central South Manchester and Trafford
Oldham Bury and North Manchester
Stockport Tameside
10 4.4b Salford Bolton and Wigan
Central Tameside and Trafford
Oldham Bury and North Manchester
Stockport South Manchester
11 4.4c Salford Bolton and Wigan
74
Central North Manchester and Trafford
Oldham Bury
Stockport South Manchester and Tameside
12 4.4d Salford Bolton and Wigan
Central North Manchester and Trafford
Oldham Bury and Tameside
Stockport South Manchester
On 15th July 2015 all 12 CCGs came together as a “Committees in Common” to select a preferred
option for implementation. CiC members received information and presentations for all the criteria
(Quality and Safety; Travel and Access; Transition; and Affordability and Value for Money). The
committee concluded that most of the criteria did not distinguish between the sub options; the key
differentiator between options was travel and access. In light of the evidence, CiC members voted
unanimously in favour of option 4.4a as the preferred option for implementation.
Table 3.5: Preferred sub-option
Option reference
Sub-option
Sub option reference
Specialist hub sites
Non-hub sites for A&E, Acute Medicine and General Surgery (but might be a specialist site for other services out of scope of HT)
4.4 9 4.4a Salford Bolton and Wigan
Central South Manchester and Trafford
Oldham Bury and North Manchester
Stockport Tameside
As the decision was taken in July 2015, a review of the options appraisal has been undertaken to
ensure the decision is still valid taking into account the updated figures and changes that have
happened in the intervening period. The conclusion of this review is that the figures which informed
the decision made at the time of the DMBC have not changed materially, meaning that the decision
made by the Committee in Common in July 2015 remains valid. On this basis it had been concluded
that option 4.4a is still the preferred option for the Healthier Together programme.
The details of this review are set out in Appendix 6.
3.4 Refinement of the costs and benefits of option 4.4a
Following the unanimous decision to implement option 4.4a, during 2016 sector teams have
conducted a detailed design phase to operationalise the clinical model and to refine cost estimates.
The updated figures, presented in the Executive Summary, are reconciled here to the Decision
Making/Outline Business Case.
75
Table 3.6: Reconciliation of updated cost estimates and Decision Making/Outline Business Case estimates
Cost Category DMBC £’000 FBC
£’000
Comment
Capital 63,330 63,347 Capital plans have been developed and refined since the
DMBC. Current capital costs are within 5% of the DMBC
figure.
Transitional – non-
recurrent revenue
11,550 12,519 These costs relate to implementation costs (£6,598k)
workforce costs (£4,130k) and revenue consequences of
capital (£1,791k). The revenue consequences of capital
have been included in the transitional figures but were
not envisaged or quantified at the DMBC stage.
In addition there is a risk of Non contracted pay costs of
£5,025k and stranded costs of a maximum of £18,490k
which have not been included on the basis that these
costs are expected to be partially or fully mitigated.
Revenue:
Income transferring to
hub sites
(40,630) (21,751) Refinements to the clinical model have impacted on the
activity transferring to the hub sites, with consequent
impacts on income and operating expenses. Operating costs at
hub sites
34,980 22,204
Net operating impact
on hub site
(5,650) 453
Consultant workforce
cost
8,926 4,880 A high estimate of consultant cost was used at DMBC
which has subsequently been refined to a more realistic
figure.
Other staff cost Not
quantified
8,202 The non-consultant workforce requirement was not
quantified in the DMBC, as the non-consultant cost
avoided is in proportion to the number of sites
designated as hub sites and therefore on a cost-
avoidance basis the non-consultant workforce cost
would not have impacted on the decision made.
Recurrent revenue
consequences of
capital
4,999 5,752 The DMBC estimate has been refined and reflects some
shorter asset lives driving a higher initial annual revenue
consequence of capital.
Ambulance costs Not
quantified
829 Recurrent revenue costs of ambulance transfers were
not quantified in the Decision Making Business Case, but
have since been developed following the subsequent
audit which proved that the anticipated pathfinder was
not viable.
76
The table below provides a breakdown of the refined and updated estimate of capital costs, with
funding sought centrally.
Table3.7: Capital Costs Quantum by Development
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
Further details are provided in the sector Appendices 1 to 4.
Revenue costs have also been further refined, including taking account an improved estimate of the
workforce requirements beyond Consultants. The current estimate of the Healthier Together
revenue impacts on the hub sites are summarised below, and set out in greater detail in the
Financial Case and in the sector appendices.
Table 3.8: Recurrent revenue costs (does not include any efficiency benefits)
Annual Revenue impact of HT £’000 MaT NES NWS SES GM TOTAL
Income transferring to hub sites (5,647) - (9,734) (6,370) (21,751)
Income adjustments with Commissioners
(861) - - 588 (273)
Total income transfers (6,508) - (9,734) (5,782) (22,024)
Operating costs 4,947 - 11,303 5,954 22,204
Consultant workforce cost 690 1,759 1,487 943 4,880
Other staff cost 1,196 4,988 1,710 309 8,202
Other stepped cost of implementation
314 - - 664 978
Revenue consequences of capital 693 1,728 2,073 1,258 5,752
Ambulance costs 225 228 148 228 829
Total gross annual revenue impact 1,557 8,703 6,987 3,575 20,822
At all sites, during the transitional period, there will be non-recurrent costs of implementation.
Refined and updated transitional costs are summarised below:
Table 3.9: Transition cost breakdown
MaT NES NWS SES NWAS GM PMO
Total
Implementation Costs 153 380 1,250 130 1,913
Project Management 947 746 1,151 783 250 809 4,685
Workforce 2,088 1,792 250 4,130
Revenue consequences of capital 728 1,063
1,791
TOTAL 3,188 1,854 5,256 1,163 250 809 12,519
77
This table does not include the stranded costs or non-contracted pay costs, on the basis that these costs are expected to be fully or partially mitigated.
There is a risk that stranded costs would arise if the loss of general surgery income at a non- hub site
could not be matched by the immediate removal of equivalent cost (for example, overhead costs).
Stranded costs over 3 years have been calculated (using a consistent methodology across Greater
Manchester) as being a maximum of £18.5m. Organisations will continue to work together at both
local and STP level to mitigate these costs as far as possible. Funding sources have been identified to
underwrite the majority of stranded costs should these eventuate. Greater Manchester is currently
reconfiguring more than half of its acute services under Devolution and there is genuine opportunity
to address this, although a residual risk remains that stranded costs could remain after the first three
years following the service transfers. Work will continue in the relevant sectors to ensure all
stranded costs are addressed within the first three years.
There is also a risk that non-contracted pay costs of up to £5.0m could be required non-recurrently
pending the substantive recruitment of new staff. This figure represents the maximum estimate of
the premium element of payments which may be required to secure appropriate staffing if providers
are unable to recruit substantively. It is expected that this risk will be partially mitigated through
both local and STP level action, and that any non-mitigated element will be funded locally in sectors.
3.5 Benefits
Following the refinement of the capital, revenue and transitional costs described above, the
programme Net Present Value has been recalculated.
As set out above, ‘do nothing’ is not a viable option as this would be clinically unsafe and does not
deliver the required clinical standards. The ‘Do Minimum’ option, (option 2 - All 10 hospitals increase
their workforce to deliver the national and GM clinical standards) is therefore the option against
which the economic benefit has been assessed. Once the initial investment phase is completed and
full implementation is completed, the annual impact of Healthier Together compared to the ‘Do
Minimum’ option is as follows:
Table 3.9: Annual Revenue Impact
Annual Revenue impact of HT £’000 MaT NES NWS SES GM TOTAL
Total gross annual revenue impact 1,557 8,703 6,987 3,575 20,822
Cost avoided (5,480) (12,615) (8,496) (6,414) (33,004)
Net annual revenue impact (3,923) (3,911) (1,509) (2,839) (12,182)
The costs avoided relate to the costs of additional consultants, their ‘close team’ and other staff at
the non-hub sites who would have been required to delivered the clinical standards at all 10 trusts
across Greater Manchester. The £33,004k of avoided cost is comprised of:
£24,802k of avoided cost relating to consultants and their close team
£8,202k of avoided cost relating to other staff costs
78
Consultants and their close team
The ‘consultants close team’ required to deliver the standards at all 10 trusts recognises the fact that
consultants do not work in isolation and is based on the following ratios:
• 0.30 WTE nurses per consultant
• 0.20 WTE admin staff per consultant
• 0.15 WTE junior medics (middle grades) per consultant
• 0.15 WTE junior medics (junior grades) per consultant
This methodology was used at the time of the Decision Making Business Case and has been adopted
for the benefit analysis, net present value calculation in this full business case. Applying this
methodology gives a recurrent revenue cost of £24,802k as the cost of the consultants and their
close team required to deliver Healthier Together standards at all sites.
Other staff costs
Implementing Healthier Together standards involves additional other staff (HCAs, nurses,
pharmacists) as well as consultants. These other staff costs were not quantified in the Healthier
Together Decision Making Business Case.
As sectors have commenced detailed implementation planning, they have now identified and
quantified the need for these additional staff. The recurrent revenue cost of these other staff totals
£8,202k per year, which is included in the recurrent revenue costs of the programme. To update the
counterfactual comparator for the benefit analysis and net present value calculation in this full
business case, this same value has been used as an approximation of the cost to deliver at all 10
sites. This is considered to be the most prudent approach, rather than trying to calculate a ‘fictional’
counterfactual figure. Adopting this approach understates the ‘do minimum’ position, and
consequently understates the Net Present Value and Return on Investment of the scheme.
Scheme benefits
The base NPV and ROI calculations include the following:
Capital costs of £63,347k;
The gross annual revenue impact as described above covering (consultant, staff costs and
other revenue costs) compared to the ‘Do Minimum’ case;
Non-recurrent revenue transitional costs of £12,519k;
the stranded costs of £18,490k; and
the non-contract pay costs of £5,025k.
79
The NPV of Healthier Together is therefore as follows:
Table 3.10: NPV
Net present value Gross £’m
Over 20 Years 103.9
Over 25 Years 137.1
Over 60 Years 283.0
This generates a discounted return on investment (ROI) as follows:
Table 3.11: ROI
Return on investment Return
Over 20 Years 2.2
Over 25 Years 2.5
Over 60 Years 4.2
Both the NPV and return on investment figures demonstrate that the Healthier Together clinical
model even including the risk of stranded costs and non-contract pay costs provides better value
than each Trust delivering the standards on their own.
The NPV calculations have not taken into account a number of non-valued benefits associated with
the new model of care to minimise the risk of double counting benefits with other on-going clinical
efficiency schemes across Greater Manchester. These are:
General surgery: reduction in length of stay.
General surgery: reduction in readmissions.
A&E: reducing admissions.
Less time for ambulance teams waiting with patients in corridors.
Decreased ED four hour waiting times and 12 hour “trolley waits”.
Improved diagnostics turnaround.
Improved outcomes and mortality – up to 300 lives saved each year through General
Surgery interventions alone.
Increased patient and staff satisfaction.
The potential benefits from these clinical efficiencies are set out and quantified where possible in
Appendix 7.
80
3.6 Sensitivity Analysis
In order to understand the sensitivity of the NPV and ROI on the key assumptions a best case and
worst case have been assessed.
Best case scenario
The assumptions in the ‘best case’ scenario are:
Only 50% of stranded costs are realised as other mitigating actions reduce these costs;
Staff costs of HT model are 25% lower than currently forecast.
In this case the NPV and ROI are as follows:
Table 3.12: NPV & ROI Best Case
Best case scenario NPV £'m
ROI
Over 20 Years 164.6 3.5
Over 25 Years 204.8 4.2
Over 60 Years 381.6 6.9
Worst case scenario
The assumptions in the ‘worst case’ scenario are:
capital costs are understated by 25%;
transitional costs 25% understated;
stranded costs exist at Tameside until 2026/27; and
staff costs to deliver Healthier Together are understated by 25%.
Table 3.13 NPV & ROI Worst Case
Worst case scenario NPV £'m
ROI
Over 20 Years 17.3 1.1
Over 25 Years 40.2 1.3
Over 60 Years 140.9 2.1
The sensitivities run in this ‘worst case’ scenario are considered to address all the major cost streams
and risks identified. The above calculation demonstrates that even under this scenario Healthier
Together still delivers a positive NPV, even over 20 years and delivers a positive return on
investment.
81
4 Commercial case – Financing the preferred option and procurement
4.1 Introduction
Due to the significant costs involved, Trusts did not commence detailed design work at risk prior to
the identification of a capital funding source. Consequently, detailed design work did not begin in
earnest until the 2017/18 financial year.
At the date of this business case, and following the identification of a capital source for the
programme, all sectors are working to develop detailed designs to support a full commercial
business case. It is expected that supporting commercial case content will be available for the South
East and Manchester and Trafford sectors by December 2017, with the North West and North East
sector commercial case content available early in 2018.
The commercial case within this September 2017 business case is therefore limited to a high level
summary of the physical capital requirements of the programme, the estimated costs of that
requirement, and how this will be financed.
4.2 Physical capital requirement and cost of that requirement
The physical capital requirement of the proposals in each sector is largely driven by the level of
general surgery activity transferring from non-hub sites to hub sites and constraints of the existing
estate and capacity in the sector.
Each hub site will require additional ward and theatre capacity to serve the additional general
surgery activity which will be met at the hub site. In the M&T and SES sectors, reconfiguration and
extension works are required to meet this requirement. In the NES and NWS, existing capacity
constraints require new buildings to house the additional wards and theatres required.
Table 4.1: Physical capital requirement in each sector
Sector Requirement
Manchester and Trafford 2 wards,
3 critical care beds
1 theatre
At Central Manchester Foundation Trust, the hub site, the Trust will develop 2 wards to house both the
elective and non-elective activity that will transfer. The areas are currently in use by other services, which will
be decanted and rehoused to accommodate the new wards.
The Trust will also develop an additional emergency theatre in a shelled area in the existing main theatre
footprint to accommodate the additional non-elective/emergency activity and the semi-planned theatre lists
associated with the Ambulatory care service.
Critical care will be expanded by 3 beds in a shelled area of the newly created surgical high level
dependency/step down unit.
Existing Ambulatory Care space on both sites be reconfigured to facilitate the new Ambulatory Care model
(with extended patient assessment and opening into evenings and weekends). A small amount of additional
82
Sector Requirement
equipment will allow for a more comprehensive assessment and treatment to prevent unnecessary admission.
There is a risk that an additional £200k of capital costs will be incurred. This is currently being assessed within
the sector.
North East Sector 2 wards
4 critical care beds
1 theatre
Pennine Acute Hospitals Trust, which operates 4 hospitals In the North East sector, will construct a new 2
storey building at first and second floor levels on the Royal Oldham hospital site to provide 2 surgical wards
and one theatre. It will also include a critical care ward (given that the additional critical care capacity required
cannot be incorporated within the current landlocked footprint).
North West Sector 2 wards
6 critical care beds
2 theatres (one elective and one non-elective)
Salford Royal Foundation Trust, which manages one hospital in Salford, has been selected as both a hub site for
Healthier Together and the single Major Trauma Centre for Greater Manchester. SRFT have already cleared
space for the erection of a new four storey building to allow for both the additional Healthier Together and
Major Trauma activity. This includes inpatient beds, critical care beds and two new theatres
South East Sector Equipping 1 ward
Equipping critical care beds
Equipping theatre
Expanding A&E
Expanded CT
Expanded Endoscopy
Stockport Foundation trust will create a larger, 6 bedded, Resus suite to accommodate the additional high
acuity demand, with the old space used to introduce 4 dedicated consultant-led Rapid Access Treatment
trolleys
The Trust will develop a two storey design which will minimise the potential for patients to have to wait in
corridor space, and increase clinical capacity, including an additional theatre
It will also rehouse some of the activity currently undertaken in the Cardiac Catheter and Pacing Lab, which
currently sits in the A&E footprint into the new theatre complex, allowing the development of a Frailty
Assessment Unit
The timing of the capital cost is anticipated to span 5 years. For MaT sector and SES the majority of
costs will be incurred in 2017/18. However, for NES and NWS, where significant new buildings will be
83
required, the capital cost will span a longer timeframe. This is set out in the table below and in the
sector appendices.
Table 4.2: Phasing of Capital Costs
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
4.3 How this will be financed
The following options have been considered for funding the developments described within this
business case.
Private Funding
Public Funding: PDC
Public Funding: Capital Investment Loan
Internal Cash Resources
A quantitative and qualitative assessment of each option is set out below.
Table 4.3: Assessment of funding options
Funding option
Description Other considerations Viable option
Private
Funding
3.5%
interest
Total annual
cost £2.2m
This would involve the hub site trusts
borrowing money from a private sector
partner such as a commercial bank or
through a commercial partner
Based on 2016/17 audited accounts for
the four hub site trusts:
Central Manchester Hospitals NHS
Foundation Trust reported a deficit for
the year of £94.7m.
Pennine Acute Hospitals NHS Trust
reported a deficit for the year of £2.4m
following receipt of £43.9m of non-
recurrent support.
Salford Royal NHS Foundation Trust
reported a surplus for the year of £9.9m.
Stockport NHS Foundation Trust
reported a deficit for the year of £6.3m.
The financial position of the trusts in
question and the length of the
programme payback period mean that
this option is likely to be difficult and
prohibitively time-consuming to access.
Given this, a private funding option is
not considered viable at this time due to
the imminent capital requirement to
support the planned go live dates
No
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Public
Funding:
PDC
3.5%
interest
Total annual
cost £2.2m
Public Dividend Capital is only available
in exceptional circumstances to support
capital investment in NHS trusts. Such
circumstances include where a trust has
a zero or low prudential borrowing limit
and/or where a major capital scheme
forms part of the financial recovery of
the trust. The DH reviews the policy on
providing exceptional PDC annually.
Assets that have been financed using
PDC are subject to a capital charge of
3.5% on average net book value
Hub site trusts would need to
demonstrate the capability to service the
loan and/or capital charges
Yes
Public
Funding:
Capital
Investment
Loan
4.0%
interest
Total annual
cost £2.4m
Capital Investment Loans – another
funding option available to the trusts is
through interest bearing Capital
Investment Loans accessed through NHS
Improvement, with final approval for
funds required coming from DH itself.
Unlike PDC, Capital Investment Loans
have a fixed repayment term and the
value of the asset is offset by the
outstanding principal value of the loan,
hence effectively removing the 3.5%
capital charge, to be replaced with the
principal and interest repayment profile
of the Capital Investment Loan. Market
testing indicates interest rates of around
4% are anticipated
Hub site trusts would need to
demonstrate the capability to service the
loan and/or capital charges
Yes
Internal
Cash
Resources
There are a number of potential options
available to the hub site trusts to fund
the investment from internal cash
resources. These include utilising
revenue surpluses, sales proceeds from
owned assets and working capital
Given the challenging financial position
of the hub site trusts and other estate
development plans, an internal cash
resource funding option is not
considered viable at this time
No
For the reasons described above, public funding is considered to be the only viable option for
funding the Healthier Together developments.
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5 Financial Case – cost implications of the preferred option
This following section describes the affordability and sources of budget funding for the preferred
option, 4.4a.
5.1 Capital Costs
5.1.1 Summary of capital requirements
The capital requirement for Healthier Together (HT) amounts to £63.3 million across Greater
Manchester. By sector, the breakdown of this cost is as follows:
Table 5.1: Breakdown of capital investment by sector
Sector Requirement
Manchester and Trafford 2 wards
3 critical care beds
1 theatre
At Central Manchester Foundation Trust, the hub site, the Trust will develop 2 wards to house both the
elective and non-elective activity that will transfer. The areas are currently in use by other services, which will
be decanted and rehoused to accommodate the new wards.
The Trust will also develop an additional emergency theatre in a shelled area in the existing main theatre
footprint to accommodate the additional non-elective/emergency activity and the semi-planned theatre lists
associated with the Ambulatory care service.
Critical care will be expanded by 3 beds in a shelled area of the newly created surgical high level
dependency/step down unit.
Existing Ambulatory Care space on both sites be reconfigured to facilitate the new Ambulatory Care model
(with extended patient assessment and opening into evenings and weekends). A small amount of additional
equipment will allow for a more comprehensive assessment and treatment to prevent unnecessary admission.
There is a risk that an additional £200k of capital costs will be incurred. This is currently being assessed within
the sector.
North East Sector 2 wards
4 critical care beds
1 theatre
Pennine Acute Hospitals Trust, which operates 4 hospitals In the North East sector, will construct a new 2
storey building at first and second floor levels on the Royal Oldham hospital site to provide 2 surgical wards
and one theatre. It will also include a critical care ward (given that the additional critical care capacity required
cannot be incorporated within the current landlocked footprint).
North West Sector 2 wards
6 critical care beds
2 theatres (one elective and one non-elective)
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Sector Requirement
Salford Royal Foundation Trust, which manages one hospital in Salford, has been selected as both a hub site for
Healthier Together and the single Major Trauma Centre for Greater Manchester. SRFT have already cleared
space for the erection of a new four storey building to allow for both the additional Healthier Together and
Major Trauma activity. This includes inpatient beds, critical care beds and two new theatres
South East Sector Equipping 1 ward
Equipping critical care beds
Equipping theatre
Expanding A&E
Expanded CT
Expanded Endoscopy
Stockport Foundation trust will create a larger, 6 bedded, Resus suite to accommodate the additional high
acuity demand, with the old space used to introduce 4 dedicated consultant-led Rapid Access Treatment
trolleys
The Trust will develop a two storey design which will minimise the potential for patients to have to wait in
corridor space, and increase clinical capacity, including an additional theatre
It will also rehouse some of the activity currently undertaken in the Cardiac Catheter and Pacing Lab, which
currently sits in the A&E footprint into the new theatre complex, allowing the development of a Frailty
Assessment Unit
5.1.2 Capital funding
The Greater Manchester Health and Social Care Partnership (GMHSCP) submitted a bid for the full
£63.3 million (alongside a capital bid of £30m for Major Trauma) to NHS England in May 2017.
In mid-July, the GMHSCP were informed that Greater Manchester has been awarded the full capital
requested for both the Healthier Together and Major Trauma programmes. This is made up partly of
STP funding and partly from DH Capital.
The receipt of capital funding is contingent on completion of an appropriate Full Business Case.
5.1.3 Comparison to the DMBC
The table below shows that the overall revised capital cost of HT is consistent with the estimate set
out in the Decision Making Business Case (DMBC), however there has been movement between the
sector requirements and this is described:
Table 5.2: Capital Funding Reconciliation to DMBC
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
87
Transitional Costs
5.1.4 Non recurrent revenue costs
Transitional (non recurrent revenue) costs relating to implementation have been categorised in the following manner:
Implementation Costs: This relates predominantly to preparatory works e.g. building design and site clearance.
Project Management: These costs have been calculated at both sector and GM level on a post by post basis.
Workforce: This relates to additional staffing required over and above 'business as usual' as the new clinical model embeds.
Revenue Consequences of Capital during transition: This is the PDC cost of the new builds in two sectors where the asset construction spans two financial years
Transitional costs of implementation totalling £11.7m will be funded by the Greater Manchester Transformation Fund. These are set out in the table below.
Table 5.3: Transitional Funding
£’000
Manchester
and
Trafford
sector
North
East
sector
North
West
sector
South
East
sector
NWAS Total
Implementation Costs 153 380 1,250 130 1,913
Project Management 945 746 1,151 783 250 3,875
Workforce 2,088 1,792 250 4,130
Revenue consequences of capital 728 1,063 1,791
TOTAL 3,186 1,854 5,256 1,163 250 11,709
In addition, Greater Manchester Project Management costs of £809k will be met through Greater
Manchester CCGs, bringing the total of non-recurrent revenue costs to £12,519k.
5.1.5 IT costs of implementation (DataWell)
IT costs relating to the implementation of DataWell have already been funded or are expected to be
met through the GM Digital Fund. As the DataWell IT solution is already being progressed across
Greater Manchester to support the provision of a number of different clinical services, the costs of
DataWell implementation have not been attributed to the Healthier Together business case.
88
5.1.6 Residual stranded costs at non-hub sites
During the transitional period, there is a risk that stranded costs will arise at non-hub sites. Stranded costs would arise if the loss of general surgery income at a non-hub site could not be matched by the immediate removal of equivalent cost (for example, overhead costs).
As the North East sector is one trust, no stranded costs are expected in this sector. This is on the basis that there will be no change in income and therefore no impact on corporate overheads, and that operating costs will be managed between hospital sites within the trust.
Stranded costs over 3 years have been calculated at the non-hub sites (using a consistent methodology across Greater Manchester) as being a maximum of £18.5m. This is set out in the table below.
Table 5.4: Stranded Costs
£’000 2017/ 18
2018/ 19
2019/ 20
2020/ 21
2021/ 22
2022/ 23
Total
Manchester and Trafford – UHSM NHS FT 398 1,673 1,992 - - - 4,062
North West Sector – Bolton NHS FT - - - 751 14 - 766
– Wrightington Wigan and Leigh NHS FT - - - 2,408 1,566 1,256 5,230
South East Sector – Tameside and Glossop Integrated Care NHS FT - 2,953 3,452 1,478 548 - 8,432
TOTAL 398 4,626 5,444 4,638 2,128 1,256 18,490
These costs have been calculated by applying a consistent methodology, which ignores the existing loss attributable to general surgery provision at non hub sites.
In the Manchester and Trafford sector, the stranded cost figures presented above assume full abatement of stranded costs two years after the merger of Central Manchester University Hospitals NHS FT and University Hospital South Manchester NHS FT.
Full mitigation within the timeframes envisaged is expected to present a significant challenge in the South East sector, due to the imminent timing of implementation and the quantum of fixed and overhead costs involved at Tameside and Glossop Integrated Care NHS FT.
Organisations will continue to work together at both local and STP level to mitigate these costs as far as possible, and over time these stranded costs are expected to work out of the system. Greater Manchester is currently reconfiguring more than half of its acute services under Devolution, providing genuine opportunity to mitigate stranded costs at acute provider sites.
Funding sources have been identified to underwrite the majority of stranded costs (up to £10.92m) should these materialise. This funding would be met by the Greater Manchester Transformation Fund (up to £5.46m) and Greater Manchester CCGs (up to £5.46m), with the remainder to be funded locally by the affected providers.
89
5.1.7 Non contracted pay costs
In addition to the transitional costs described above, there is a risk that non-contracted pay costs of up to £5.0m could be required non-recurrently pending the substantive recruitment of new staff. The maximum costs anticipated are set out below:
Table 5.5: Non Contracted Pay Costs
£’000 2017/ 18 2018/ 19 2019/ 20 2020/ 21 Total
North East Sector 666 1,997 1,548 - 4,211
North West Sector - 206 149 64 418
South East Sector - 277 119 - 396
TOTAL 666 2,480 1,816 64 5,025
The £5,025k represents the maximum estimate of the premium element of payments which may be required to secure appropriate staffing if providers are unable to recruit substantively. It is expected that this risk will be partially mitigated through both local and STP level action, and that any non-mitigated element will be funded locally in sectors.
This risk is most material in the North East sector where non contracted pay costs are estimated at up to £4.2m. Therefore, North East providers and commissioners are reviewing their implementation plans and are bringing forward the timing of their consultant recruitment.
Given existing workforce in the sector, the Manchester and Trafford sector do not anticipate difficulty in recruiting substantively. Consequently, no non contracted pay costs are expected in this sector.
5.1.8 Phasing of transitional costs
The phasing of the non-recurrent transitional costs (as set out in para 1.2.1 above) relating to implementation is summarised below. This table does not include the stranded costs or non contracted pay costs set out above, on the basis that these costs are expected to be fully or partially mitigated.
Table 5.6: Transition Costs Phasing
£’000 2017/ 18 2018/ 19 2019/ 20 2020/ 21 Total
Manchester and Trafford 1,542 770 874 - 3,186
North East Sector 753 373 158 570 1,854
North West Sector 1,865 2,306 1,086 - 5,256
South East Sector 532 631 - - 1,163
NWAS 250 - - - 250
Greater Manchester PMO 809 - - - 809
TOTAL 5,751 4,080 2,118 570 12,519
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5.1.9 Comparison to the DMBC
The table below compares the programme transitional costs of £12.52m above with the £11.55m of
transitional costs that were estimated in the Decision Making Business Case.
Table 5.7: Reconciliation of Transition Costs between Full Business Case and Decision Making Business Case (DMBC)
Revenue – Transitional £’000
DMBC FBC Commentary
IT Cost 1,000 - IT costs relating to the implementation of DataWell have
already been funded or are expected to be met through the
GM Digital Fund. As the DataWell IT solution is already being
progressed across Greater Manchester to support the
provision of a number of different clinical services, the costs
of DataWell implementation have not been attributed to the
Healthier Together business case.
Implementation Cost 6,000 6,598 In line with the DMBC. Relates to £1.91m of Implementation Cost and £4.68m of PMO costs across sectors and centrally.
Ambulance Cost 450 - Lower than the OBC - anticipated ambulance costs related to the development of the general surgery pathfinder. As this is no longer considered clinically viable, this development cost will not be incurred.
Workforce 4,100 4,130 In line with the DMBC.
Revenue Cost of capital 1,791 At DMBC stage revenue consequences of capital were valued but were not classified alongside other Implementation Costs.
TOTAL TRANSITIONAL COSTS AS ENVISAGED AT DMBC
11,550 12,519 There has been 8% increase from DMBC, due in the main to the inclusion of the revenue cost of capital figure, which has now been quantified.
5.2 Revenue Costs
The recurrent revenue impact of Healthier Together, when compared to current ‘Do Nothing’
provision, consists of:
Activity moves – impact at hub: This is the income relating to the general surgery activity
which is transferring from non-hub sites to hub sites, offset against the related operating
expenditure required to deliver that activity to current clinical standards.
Healthier Together Standards: This is the cost required to meet the Healthier Together
clinical standards, and includes consultant cost, other staff cost and some non-staff costs.
Revenue consequences of capital: This is the annual PDC and depreciation charges
associated with the capital investment required for the programme.
91
Ambulance costs: These are the costs of the additional ambulance conveyances from non-
hub to hub sites. These costs were not anticipated in the DMBC but have subsequently been
deemed to be necessary due to the non-viability of the anticipated clinical pathfinder
The recurrent revenue impacts by sector are set out in the table below, and are further
disaggregated and described in the sector appendices.
Table 5.8: Recurrent Revenue Impacts – Summary
Recurrent Annual Revenue Impact (£’000)
Activity moves –
impact at hub
Healthier
Together
standards
Revenue
consequences of
capital
Ambulance Costs
Manchester and Trafford (1,561) 2,200 693 225
North East sector - 6,747 1,728 228
North West sector 1,569 3,197 2,073 148
South East sector 172 1,916 1,258 228
TOTAL 180 14,060 5,752 829
Ambulance costs of £829k will be funded by commissioners as part of the GM ambulance
commissioning round.
In Manchester and Trafford and the North East sector, providers and commissioners have reached
agreement on the funding of the other recurrent revenue impacts. These agreements will require
ratification through local Trust Boards and CCG Governing Bodies following Greater Manchester
approval of the Healthier Together Business Case.
In the North West sector and in the South East sector, providers and commissioners have reached
partial agreement on the funding of the recurrent revenue impacts. Work continues to urgently
complete and finalise these agreements.
Healthier Together standards costs include consultant costs, other staff costs and some non-staff costs, and are further disaggregated below.
92
Table 5.9: Recurrent Revenue Impact
Recurrent Annual Revenue Impact (£’000)
Consultant
costs
Other staff
costs
Non staff costs TOTAL
Manchester and Trafford 690 1,196 314 2,200
North East sector 1,759 4,988 - 6,747
North West sector 1,487 1,710 - 3,197
South East sector 943 309 664 1,916
TOTAL 4,880 8,202 978 14,060
Comparison to the DMBC
The table below compares the recurrent revenue impacts to those envisaged in the Decision Making Business Case.
Table 5.10: DMBC costs
Cost Category DMBC £’000 FBC £’000 Comment
Consultant workforce
cost
8,926 4,880 A high estimate of consultant cost was used at
DMBC which has subsequently been refined to a
more realistic figure. In addition, baseline
consultant numbers have changed since the time
of the DMBC.
Other staff cost Not quantified
8,202 The non-consultant workforce requirement was
not quantified in the DMBC, as the non-
consultant cost avoided is in proportion to the
number of sites designated as hub sites and
therefore on a cost-avoidance basis the non-
consultant workforce cost would not have
impacted on the decision made.
Revenue consequences
of capital
4,999 5,752 The OBC estimate has been refined and reflects
some shorter asset lives driving a higher initial
annual revenue consequence of capital.
Ambulance costs Not quantified
829 Recurrent revenue costs of ambulance transfers
were not quantified in the Decision Making
Business Case, but have since been developed
following the subsequent audit which proved
that the anticipated pathfinder was not viable.
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6 Management case
The following section describes the management of the programme, including programme
governance; team management structure; resourcing and roles and responsibilities; programme
planning; risk management and benefits management.
6.1 Programme Governance
The programme governance was revised for implementation in October 2016 in response to the GM
H&SC Partnership changes and from February – June 2017 with the addition of the Healthier
Together Executive chaired by the Programme Sponsor (Chief Officer of the Greater Manchester
Health and Social Care Partnership, Jon Rouse). The delivery of Healthier Together is overseen by the
Healthier Together Delivery Board which is independently chaired, and reports into the Theme 3
Board, as part of the formal governance of the Greater Manchester Health and Social Care
Partnership.
The revision of the governance in October 2016 agreed the standing down of the Healthier Together
Joint Committee, with the Joint Commissioning Board (see wider Health & Social Care Partnership
Governance) taking over the role of future Greater Manchester commissioning decisions. Until such
time as the Joint Commissioning Board is legally constituted to take on this role, the Healthier
Together Joint Committee can be convened as required. The current governance structure for the
programme is summarised below:
Figure 6.1: Healthier Together Programme Governance
94
The Summary roles of the Healthier Together Governance Groups are described below: Table 6.1: Healthier Together Governance Groups
Group Membership Frequency Summary purpose
Theme 3 Board Theme 3 Executive Lead
Provider Executives,
Commissioner Executives,
Local Authority
Representative(s),
Finance and Estates
Representatives, GP
Provider(s), Patient
representative(s),
Clinical representative(s) ,
Other ‘Theme’ leads and
enabling work stream leads
Monthly Oversee and assure the development of a long term strategy for acute and specialised services (A&SS) across GM. Oversee and assure the development of the clinical model and associated strategies (workforce, estates, digital) to deliver the AS&S strategy. Oversee and assure the development of an options appraisal for the delivery of the A&SS strategy. Receive assurance that changes affecting hospital services are in line with the emerging strategy e.g. Healthier Together implementation.
Receive assurance that interdependencies between Theme 3 and the other Taking Charge Thematic Groups are managed.
HT Delivery
Board
CCGs & Providers
(including NWAS),
PMO reps (TU and sectors)
Monthly Forum for commissioners, providers and
sector leads to oversee delivery of the
agreed model of care.
Reporting and assurance of single service
(sector) progress.
Highlight and agree management of strategic
risks.
Highlight and agree issues that would benefit
from a ‘GM approach’.
Provide oversight for implementation
readiness.
GM Clinical
Alliance
HT Chief Medical Advisor,
Clinical Champions, Single
Service Clinicians, NWAS
Monthly Guardians of the Healthier Together model
of care and standards.
Oversee the development of consistent
patient pathways.
Assure clinical go-live readiness of each
single service.
Support the management of clinical risk
95
during implementation.
Reduce variation between single services by
sharing best practice.
Sector Governance
Each of the four sectors has been responsible for determining their own local governance and
reporting arrangements between the relevant provider and commissioner partners. As part of the
overall programme governance, each sector is required to report monthly, in writing, to the
Healthier Together Delivery Board via a standard status reporting template created for this purpose.
This status report covers the clinical, estate / capital, workforce, financial and communication /
engagement activities required to implement Healthier Together. This status report has been in
place since January 2015.
6.2 Clinical Oversight of Healthier Together
As part of the reconfiguration decision taken in July 2015, GM commissioners specified a number of
implementation conditions attached to the implementation of the programme. Two of the
conditions specified by commissioners related to clinical oversight of the programme:
Condition 3 - Establishment of a Greater Manchester Clinical Alliance
Condition 5 – Appointment of GM clinical leadership for implementation
These conditions have been addressed in the way the programme has been structured for
implementation. This is described below.
Appointment of GM clinical leadership for implementation
The following clinical leadership roles were appointed to in spring 2016 to support implementation
planning:
Healthier Together Chief Medical Advisor
Clinical Champion – A&E
Clinical Champion – Acute Medicine
Clinical Champion – General Surgery
Clinical Champion – Anaesthetics & Critical Care
Clinical Champion – Senior Nurse
Clinical Champion - Radiology
Clinical leadership has recently been reviewed for 2017 with the following agreed until 31 March
2018.
96
Table 6.2: Clinical Champion Resourcing
Clinical leadership for implementation Sessions / PAs per week
Chief Clinical Advisor 2
Emergency medicine Clinical Champion 0.5
Anaesthestics/Critical Care Clinical Champion 0.5
General Surgery Clinical Champion 1
Radiology Clinical Champion 1
Establishment of a Greater Manchester Clinical Alliance
The GM Clinical Alliance was established in February 2016, and clarification of its role was provided
to and endorsed by the HT Delivery Board in April 2016. The role of the Alliance is to ensure the
clinical effectiveness of the programme. Membership brought together the core Healthier Together
clinical team (Chief Medical Advisor and six Clinical Champions) with clinical leadership from the four
sectors. It has also brought together much wider clinical representation through sharing events and
clinical workshops.
The initial clinical approach included development of GM pathways for paediatric general surgery,
radiology and NWAS. GI haemorrhage was later identified as an interdependent service that also
required a unified approach. Clinical groups for each of these specialties were later established
Key outputs from the Clinical Alliance
The clarification of the model of care for general surgery was ratified by the 12 CCG leads and
representatives in April 2016. The paper was developed in order to provide clinically focussed
clarification of the definition of “high risk” general surgery, to support sectors in development of
their local model of care. To ensure the model was aligned with the latest clinical guidance it was
produced following review of the latest data and evidence from the National Bowel Cancer Audit,
National Emergency Laparotomy Audit and other sources to identify patients at highest risk using,
for example, trends in unscheduled returns to theatre. In addition, the clarification paper drew on
The Nuffield Trust’s definition of high risk case mix (Emergency General Surgery: Challenges and
Opportunities, 2013).
The National Emergency Laparotomy Audit (NELA) aligns well to the pathway and clinical standards
for general surgery and is be a key source of data to monitor progress against the standards and,
ultimately, realisation of the benefits. As is shown in the case for change there is a significant way to
go to meet the standards. Following the audit, GM results for years 1 and 2 were shared through
the Clinical Alliance. In audit year 3 a HT NELA dashboard was produced to encourage sharing of
data and best practice across GM in real time. The dashboard shows real-time performance against
some of the standards, supporting sector teams to monitor improvements in between annual audit
publication.
The Clinical Alliance has proven to be an impactful way to share the latest clinical guidance and best
practice. Through the Clinical Alliance other audit results have been shared for discussion and
97
identification of areas for improvement, including National Cardiac Arrest Audit (NCAA) and
National Bowel Cancer Audit (NBOCA). A variety of other best practice has been shared through
‘themes’ at the Clinical Alliance, for example guidance on Ambulatory Care and presentations from
sector leads whose ambulatory care provision was already showing demonstrable benefits.
Dedicated workshops were held around Colorectal MDTs and ERAS+ in December 2016. Colorectal
MDTs are to be established in all sectors by Quarter 1 2017/18. A common set of principles for
MDTs were agreed. Outputs and quantifiable benefits were also identified to facilitate progress
monitoring and shared best practice.
ERAS+ optimises pre-operative care for high risk elective surgery and colorectal cancer patients and
offers enhanced post-operative recovery in order to reduce complications and adverse outcomes
including mortality, longer length of stay or reduced long term survival rates. It has been projected
that reduced length of stay can result in £500k annual savings for large hospitals. Due to the link
with high risk general surgery Medical Directors agreed that Healthier Together would be an
appropriate vehicle to support delivery of ERAS+ in GM. Progress so far includes the establishment
of a GM Steering Group, development of the project plan and the first draft of the business case.
UHSM are expected to go live in April 2017, with six trusts to follow by January 2018.
Wider GM Clinical Sharing Events
The Clinical Alliance has hosted three wider sharing events, bringing together many more clinical and
programme representatives from all sectors with two purposes:
For sector HT teams share their local models of care and plans with each other,
For GM clinical leads to share guidance and GM models and pathways.
Three sharing events have been held so far. All three events were very well attended by sector
representatives including clinical staff, programme teams and other senior managers from all trusts
participating in Healthier Together.
On 18th August 2016 the first event was held focussed on sector general surgery models of
care.
On 8th December 2016 the second event focussed on sector medical models of care.
On 9th February 2017 sectors shared their progress and lessons learned. GM presentations
included proposed models for radiology, paediatric general surgery and GI haemorrhage plus
a presentation on developing a blended workforce for A&E.
On 5th May sectors participated in a sharing event for workforce models of care in general
surgery and clinical pathway design.
98
Clinical work-streams and sub-groups
Radiology
To ensure a coordinated approach to radiology services a single Clinical Champion was appointed to
provide guidance to both Healthier Together and the Collaborative Imaging Procurement Project
(CIPP). A single Radiology Clinical Advisory Group (CAG) was also established with the remit of
providing clinical guidance for both projects. Both projects and all GM trusts are represented on the
CAG, and they are supported by a single project manager from the TU.
The five work streams identified in the Scope of GM Radiology paper (approved by the Delivery
Board in July 2016) were:
Support the re-procurement of a PACS/VNA system for Greater Manchester;
Review the Healthier Together clinical standards for radiology;
Delivery of resilient radiology models in each sector to meet the Healthier Together
standards;
Deliver sector based non-vascular interventional radiology;
Deliver a pan Greater Manchester solution for vascular interventional radiology.
The first meeting took place in July 2016; the CAG are now a well-established group with good
engagement from all GM trusts and two sub-groups of the CAG were established to represent
interventional radiology.
The quality and safety standards pertaining to radiology were reviewed and re-written to align with
the NHS 7-day service standards. New clinical standards have been agreed for Vascular
Interventional Radiology (VIR) and Non-Vascular Interventional Radiology (NVIR) via the sub-groups.
These services were not included in the original Healthier Together standards but are now
recognised as pivotal to the pathway as they deliver life-saving interventions for sepsis and GI
haemorrhage. Trusts have completed self-assessment against the new clinical standards.
Consensus on core, intermediate and advanced/complex competencies for NVIR has been reached
and a review of the skills mix and competencies in GM has been completed. It has been established
that sector NVIR rotas will be necessary to ensure 7-day cover with an appropriate skills mix. A pan-
GM solution for VIR will now be delivered through the theme 3 vascular services reconfiguration.
Compliance with the clinical standards is likely to remain challenging, even in light of joint working.
Radiology services are under immense strain with workforce numbers failing to keep pace with the
increasing demand for scans and x-rays. The Royal College of Radiologists (RCR) workforce census
(2015) highlights what they call an “ongoing crisis” and notes that the North West has the highest
number of vacant posts in the UK. Workforce gaps are causing increasing reliance on outsourcing
(the cost in GM is estimated at £10m per year). In addition to cost there are some clinical risks
associated with outsourcing, including higher discrepancy rates, which have not been understood
until recently. In February 2016 the Radiology CAG were asked to participate in a Provider
Federation Board sponsored workshop to develop a GM vision for Radiology Services that would
maximise current capacity and create a more sustainable service. It is likely the role of the CAG will
99
be expanded creating to cover wider GM improvement initiatives ensuring a coordinated long term
strategy to meet increasing and conflicting demand.
Paediatric General Surgery
Post public consultation a co-dependency framework was developed, and paediatric general surgery
was identified as a co-dependent service with implications for the safe implementation of Healthier
Together. The co-dependency is related to paediatric general surgery services, calling upon Healthier
Together in-scope services, namely adult general surgery. It was concluded that paediatric general
surgery was moderately dependent on the Healthier Together in-scope services and as such would
require support from Emergency and High Risk Elective General Surgery (24/7) via a robust pathway
or on-call arrangement. It was agreed that robust pathways for paediatric general surgery would
have to be in place within a sector before any patient movement under the Healthier Together
programme.
A task and finish group was established in June 2016 with leads and key clinicians from the Strategic
Clinical Networks (SCN) and Senate – Greater Manchester, Lancashire and South Cumbria (NHS
England), the Children’s Surgery Operational Delivery Network and Healthier Together. Leads for
general surgery and anaesthesia joined the group, and input was obtained from the paediatric
radiology lead. The group have developed and agreed clinical standards for paediatric general
surgery, anaesthesia and radiology.
The group have now agreed the clinical pathways which specify when a child should be treated at the
tertiary site (RMCH), surgical hub site or other sites with a paediatric inpatient unit. The Partnership
Board have agreed that North West sector require an exception to the GM model as the surgical hub
(SRFT) does not have an inpatient paediatric unit. It is expected that the sector will make a decision
on which site will provide emergency paediatric general surgery by October 2017.
The group suggested that it would be valuable to have a Clinical Governance Board for paediatric
emergency general surgery, hosted by Royal Manchester Children’s Hospital (RMCH) to support the
effective delivery of these pathways and ensure care provided to children requiring emergency
general surgery meets the prescribed standards. As part of this, it has also been identified that an
educational group should be convened to look at what is required to build confidence and
competence outside of RMCH for emergency paediatric general surgery. These groups will be
composed of clinical representatives from specialities across each of the Healthier Together sectors
and will report into the Health and Social Care Partnership governance structure.
Gastrointestinal haemorrhage
A task and finish group for GI haemorrhage was established in November 2016 and brings together
consultant gastroenterologists and vascular interventional radiologists. The group is also supported
by the Clinical Champions for general surgery and critical care/anaesthesia.
The group was established to ensure that existing GI bleed units would not be destabilised by the
Healthier Together reconfiguration. In addition the group agreed it would be beneficial to develop
pathways and clinical standards to standardise the quality of services across GM.
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The group were also tasked with investigating the potential for an NWAS pathfinder to divert major
GI haemorrhage to the Healthier Together hub sites. In the A&E and NWAS model paper submitted
to the Delivery Board in October 2016 it was proposed that the streaming of patients directly to hub
site A&Es would commence with significant gastrointestinal haemorrhage.
The work of this group is ongoing, but draft clinical pathways and clinical standards have been
developed and are expected to be signed off imminently.
6.3 Programme resourcing
The Healthier Together Implementation team comprises a central programme team, a clinical team,
and sector teams. Within each sector, and NWAS, local programme teams have been established to
lead the implementation of the clinical models in their sector under the leadership of a sector
Programme Director. An oversight and assurance role is provided by the central programme team
using PRINCE2 methodology. The central team works closely with sector teams to ensure delivery
against plan and supports the Healthier Together Delivery Board.
The following Programme Management, clinical redesign and clinical lead resourcing has been
proposed to support the transition of services in 2017/18, and formed part of the bid to the
Transformation Fund:
Table 6.3: Greater Manchester Programme Resourcing
Role Total Days (17/18)
TU Director Oversight 52
Programme Director 156
Deputy Director 156
Senior programme management 208
Senior finance support 52
Project management 208
Analytical support 39
Administration and project support 104
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Additional clinical resourcing is summarised below:
Table 6.4: Clinical resourcing
2017/18 resourcing Sessions (PAs) per week PAs per month PAs per quarter Total
2017/18
GM Clinical Leadership
GM Clinical Lead 2 8 24 96
Emergency Medicine
Clinical Champion
0.5 2 6 24
Anaesthestics/Critical
Care Clinical Champion
0.5 2 6 24
General Surgery Clinical
Champion
1 4 12 48
Radiology Clinical
Champion
1 4 12 48
Each sector team has also put in place a suitable project team.
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6.4 Project plan
An outline of the high-level project plan, including its phases and sub-phases, is provided below.
Figure 6.2: Summary Programme Plan
Work area What (and who will lead this) Oct 17 Nov 17 Dec 17 2018 Q1
Funding Finalise revenue agreements
Complete commercial cases as required for central
approval.
Operational and
Clinical
Continue to service and support the Clinical Alliance
to exercise its clinical oversight duties, problem-
solving and dissemination of agree pathways and
protocols.
Support the development of ambulance Inter facility
transfer framework, pathways and protocols for
patient transfers with sectors and NWAS.
Support the Theme 3 GM Workforce Reference
Group to identify and support workforce strategies
for the delivery of HT.
Support sectors to develop robust clinical pathways
that meet the requirements of the model of care and
are operationally deliverable.
Benefits Monitoring Implement sector reporting dashboard for collecting
and presenting benefits.
Facilitate the development of an ongoing annual
audit process for HT standards.
Readiness and
Phasing
Assess compliance with implementation conditions
and equality commitments.
Complete readiness assessments for all sectors prior
to implementation.
Complete readiness assessment for NWAS.
Support sectors as required during ‘go live’
Communications Establish Communication and Engagement network
with GM Partnership support
Contribute to the development of a communications
plan for the implementation phase of HT
Agree the respective roles and responsibilities for the
TU and the Partnership in the delivery of
communications and engagement activities as
defined in the plan
Q2
From
2018
202/20
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6.5 Change management
The phased implementation plan will be directly supported both internally within the sectors and
externally by the core HT programme team, HT delivery board and Clinical Alliance. Key learning will
be identified following each milestone change and fed back through agreed assurance processes.
To supplement the change process, each sector will utilise the Mckinsey 7s model to ensure
thorough understanding of the interdependencies between the ‘Hard’ and ‘Soft’ elements of
change. It provides a holistic mechanism to review the interconnected dimensions as a way of
assessing the overall impact of change within an organisation.
In terms of applying the framework the following steps have been identified:
Step 1. Identify the areas that are not effectively aligned
Step 2. Determine the optimal organisation design
Step 3. Decide where and what changes should be made
Step 4. Make the necessary changes
Step 5. Continuously review the 7s
Figure 6.3: 7S Change Management Methodology
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6.6 Management of benefits realisation
6.6.1 Benefits realisation planning
Clinical benefits will be measured using the quality and safety standards plus the clinical outcomes
identified below.
Figure 6.4: Benefits Summary
The approach to managing the clinical benefits is illustrated as below, and a benefits realisation
template has been approved to be used to capture the pre-implementation baseline (step 4 in the
illustration).
Figure 6.5 Clinical Benefits
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6.6.2 Clinical standards and baseline
The evaluation approach was agreed in January 2016 and a decision was taken to carry out a full
audit at all participating sites to establish a baseline against which progress could be measured. The
baseline audit covered three areas:
1. Clinical standards, outcomes and activity
2. HR & Workforce
3. Equalities conditions
The baseline of performance against the Healthier Together Quality and Safety standards for general
surgery and urgent, acute and emergency medicine (UAEM) was the most complex of these
activities. Each provider trust was asked to submit a self-assessment against the standards and
evidence in support of this assessment.
The Healthier Together team used a combination of evidence submitted by trusts and national data
sources to establish current compliance. The team’s initial assessment of this evidence identified
that further work was required to provide a reliable 2016 baseline result that can be used to
measure progress as sectors move through the implementation phase. We also identified an
opportunity to streamline the assessment process going forward. The following actions were
recommended and endorsed by the Delivery Board:
Review of the Healthier Together clinical standards and evidence requirements by the
Clinical Champions. Prioritise ‘deal breaker’ or ‘go/no go’ standards that are key to safe,
successful implementation of Healthier Together.
Carry out independent clinical review of the baseline.
Utilise objective validated national data or local audits where possible to validate
performance against the clinical standards.
Review the evidence requirements to reduce the variation in approach.
Provide sectors with an opportunity to supplement their submission with additional
evidence to substantiate their 2016 self-assessment in order to make the baseline as
accurate as possible.
Subsequently the clinical standards to be monitored during implementation have undergone a
thorough review. Priority standards have been agreed for general surgery, acute and emergency
medicine. The evidence requirements and thresholds for compliance with these standards have
been reviewed, and external validated data and audit sources will be used to monitor progress
wherever possible.
6.6.3 Progress monitoring
To move towards more regular progress monitoring, an in-depth review of available national and
local audit data has been undertaken and trusts have been actively encouraged to participate in and
share data from relevant national audits including:
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National Emergency Laparotomy Audit (NELA)
Greater Manchester Critical Care and Trauma Network’s peer review report
Society for Acute Medicine Benchmarking Audit (SAMBA)
National Bowel Cancer Audit (NBOCA)
National Cardiac Arrest Audit (NCAA)
National Oesophago-Gastric Cancer Audit (NOGCA)
These audits (in particular the first three) are being actively used to assess progress against the
Healthier Together quality and safety standards. All relevant national audit results have been shared
and discussed through the GM Clinical Alliance and sector sharing events.
In order to assess progress against the general surgery standards on a real-time basis all GM sites
agreed to share access to the NELA database allowing us to produce more up-to-date data in the
form of a dashboard. In NELA audit year 3 we began producing a HT NELA dashboard to encourage
sharing of data and best practice across GM. The dashboard shows real-time performance against
the standards, supporting sector teams to monitor improvements in between annual audit
publication. The dashboard also summarises the previous year’s results in the table. Where
applicable these have been RAG rated to show the current level of performance against the agreed
thresholds for compliance. An example sector dashboard is shown below.
Figure 6.6: NELA dashboard examples
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6.7 Risk management
Risks are identified through the HT governance structure. Chairs and Project Leads for each project
stream are responsible for highlighting and escalating through the governance structure any risks
and issues that they become aware of. Additionally, existing risks will be monitored and all
reasonable attempts will be made to be mitigated.
Risks will be documented on an internal risk register document that will be used as directed by the
Programme Director by all members of the project team. The Programme Director will be
responsible for ensuring that the risk register is regularly completed and mitigating actions are
updated.
All risks will be given a rating of low, medium, high or very high, with the latter only being used
where a risk is deemed to be a potential risk to the continuation of the programme. All risks,
regardless of rating will be allocated a responsible governance group, dependent on the project
steam the risk is most related towards. All risks will be communicated to all stakeholders of the
programme as is relevant. Identified risks will cover all aspects of the programme, such as:
Clinical
Finance
HR & Workforce
Sector issues
Discussion of open risks will be a standing agenda item for all groups as above. Risks would be
communicated to groups through pre-meeting papers, sent a week in advance. Aside from Project
Sub-groups, the discussion of risks at each meeting will be documented through meeting minutes.
Meeting minutes will detail any action points in relation to open risks, including changing of scoring
or mitigating action. Additionally, meeting minutes will detail any newly identified risks.
The Programme Director will ensure that newly identified risks are recorded on the register weekly.
Each month, in the week prior to the HT Delivery Board, the Programme Team will undertake a
review of all risks.
Risks may also be identified through groups within the Implementation Programme governance
structure. It is expected that members of governance groups would be expected to raise any risks
relevant to their area of expertise.
Risks will also need to be managed within sector project teams. The expectation is where a sector is
aware of a risk within their sector, that may be relevant to other sectors or the Healthier Together
programme as a whole, the risk should be escalated to the Healthier Together Delivery Board using
the standard status report template and raised under the risk standing agenda item.
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Key current risks are detailed below:
Table 6.5: Summary of risks
Key Risks Mitigating Factors
Workforce: Ability to recruit required number of consultants to deliver the HT standards Changes to working patterns with new model may ability to retain and recruit staff Impact of training requirements of junior medical staff due to HT impacting service provision at non-hub sites.
GM Workforce Reference Group to develop strategies focussing on key aspects of programme deliverables including recruitment, assessment of pipeline consultants within the GM system, terms and conditions and consistent application of policy and principles. Collaboration with Health Education England to ensure attractive training propositions for junior medical trainees across GM balanced with service stability for all sites. Established sector workforce and HR groups reviewing recruitment strategies linking to the wider GM picture, with robust staff communication and engagement strategies. Phased implementation plan across GM facilitates a sequential approach to recruitment where appropriate. GM review of clinical pathways to maximise efficient use of the workforce. Clinical Champions input to lead early engagement with staff groups, Unions, colleges etc. Readiness assessment focusing on cultural aspects of change, supplementary to systems and structural change requirements.
Radiology: Workforce challenges to delivery core requirements of HT Sub-specialty delivery of interventional radiology Existing reporting pressures
Radiology Clinical Advisory Group and Vascular Interventional Radiology sub groups established. with strong links to HT and pathway development, in additional to sectors developing local models to ensure 7 day delivery of level 1 competencies. Radiology standards agreed. Collaborative Image Sharing business case in development to enhance efficiencies and reporting capability. GM Workforce Group focussing on Radiology workforce requirements linked to wider Theme 3 requirements.
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Transfer of Patients: Potential clinical dis-benefit of double ambulance transfers of patients from a non-hub to a hub.
The potential dis-benefit of double ambulance journeys continues to be reviewed by the NWAS task and finish group with senior clinicians addressing any potential risks and issues. The evidence from NHS Lothian will continue to be explored in more detail as well as GM initiatives that transfer patients from a receiving A&E site to a specialist centre, such as Neurosurgery, Stroke, PCI, Major Trauma and existing Fairfield & Trafford models. NWAS business case provides sufficient capacity for the transfer of all patients from a non-hub to a hub site, using Optima modelling system to account for additional resources required. Similar models to Healthier Together exist such as NHS Lothian, where patients are transferred from an A&E receiving site to a specialist colorectal site for emergency laparotomy intervention, with excellent patient outcomes such as mortality rates for emergency laparotomy. Examples of existing pathways that transfer patients from one A&E to another, such as Fairfield model for emergency general surgery, Neurosurgery, Stroke, Major Trauma and PCI.
Delivery of standards & benefits Healthier Together standards and benefits of the programme not being achieved.
Benefits baseline completed in April 2017. Shared with sectors. Review and audit process to be developed and agreed with board linking to external independent support to facilitate process with use of audit data, hard copy evidence and peer review. Clinical Benefits dashboard developed and agreed via delivery board and reporting to commence from November 2017
Critical Care Compliance: Critical Care services in 2/4 sector hubs not being compliant with National Critical Care Guidance. This is due to workforce shortage of ICM consultants.
Compliance being managed by Critical Care Network across GM. Risk highlighted to AGG on 21st March 2017. Programme Team to liaise with CC Network.
Equalities: Risk that HT model creates inequity and fails to ensure patient voice heard through the planning and implementation stages.
Equalities advisory group established alongside the development of Integrated Impact Assessment (IAA) implementation condition with reporting function through the HT delivery board. Delivery of sector level equality impact assessments and patient voice groups and inclusion of patient in various working groups in addition to strengthening links with wider Theme 3 changes.
GI Bleed Patients: The risk that patients with life threatening gastrointestinal haemorrhage arriving in ED at non hub sites. Sectors not compliant with NICE/CEPOD standards.
NWAS medical pathfinder has GI haemorrhage included as indication for divert. GI Bleeds pathways under development and shared with sectors via Clinical Alliance. To be assessed as part of go-live plan and readiness asst. Clinical Lead to assure sectors approach. GI Bleeds workshop to be held following sector specific meetings on 26th October 2017
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Funding: Risk of failure to secure capital via national route Risk of lack of transitional funding to support implementation Stranded costs Risk of failure to agree recurrent revenue impact of delivering Healthier Together
The treasury allocated full capital request of £63m on 19 July 2017. Following GM approval the FBC will be submitted to national authorities for final approval and release of capital. The commercial case component will be completed now sectors are moving at risk ahead of the release of national funds through the procurement stages to complete the detailed design phase. Transformation Oversight Funding Group decision delivered on 28 June 2017 to support £17.2m and GM CCG monies to the value of £5.5m made available to support the transitional process. A large percentage of the TFOG funding supports any unmitigated stranded costs, with the expectation that organisations and sectors will work to mitigate their available assets. For example linking Theme 3 changes, looking to agreements around reciprocal activity flows, explore independent sector opportunities to deliver work referred to private sector back to the NHS, links with integrated programmes and wider estates strategies. Recurrent revenue agreements in place in two sectors, North West Sector expected to conclude imminently and the GM HSCP to support conclusion of negotiations in South East Sector. Funding oversight provided by the Finance Executive Group.
System Assurance: The system needs assurance, through the FBC that HT is affordable and deliverable (e.g. that workforce can be put in place) before funding and implementation is agreed
Production of a full FBC agreed with sectors. Governance process approved and Executive function process established. Production of accompanying paper to provide assurance on risks, funding, case for change and value for money to be presented at the Theme 3 executive and finance executive group prior to final approval at the Joint Committee.
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7 Appendices
7.1 Appendix 1: Manchester and Trafford Sector
The following appendix provides sector level detail in support of the GM Business Case.
7.1.1 Manchester and Trafford model of care
Key highlights from the model of care are outlined below, followed by a summary table which
provides an assessment of different aspects of the local model of care against the Healthier Together
model.
Key highlights
Ambulatory care
Ambulatory care surgical pathways have been developed across the sector, with consensus
about the case mix suitable. These include: non-specific abdominal pain, biliary colic, mild
cholecystitis, abscesses, proctology, hernias, and simple diverticulitis. Plans are in place to
provide a 4 hour clinic, 7 days per week on both the non-surgical hub site (UHSM) and the
surgical-hub site (MRI).
ERAS+
ERAS+ optimises pre-operative care for high risk elective surgery and colorectal cancer
patients and offers enhanced post-operative recovery in order to reduce complications and
adverse outcomes including mortality, longer length of stay or reduced long term survival
rates. The ERAS+ programme is already in place at CMFT and due to the link with high risk
general surgery GM Medical Directors have agreed that Healthier Together would be an
appropriate vehicle to support delivery of ERAS+ in GM. A GM Steering Group has been
developed, with plans for the programme to be introduced in UHSM first, resulting in one
sector being complete.
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The following tables compare the plans which the sectors have developed for the implementation of the Healthier Together against the Healthier Together
model of care. It includes an assessment of variation against the different elements of the model. It should not be taken as a reflection of their current
compliance with the Healthier Together model.
Table 7.1.1: Summary of the model of care within the MAT sector
Healthier Together model Assessment Notes: Manchester and Trafford Sector
1. Emergency
General Surgery
All emergency high risk general surgical patients are
admitted to sites specializing in emergency and ‘high risk’
elective general surgery (surgical-hub sites). Each sector
should have a pathway in place for:
See below
High Risk Patients requiring an inpatient emergency general
surgical procedure should be transferred to the hub site:
- Emergency Laparotomy - Patients identified in the Nuffield 2016 paper on
Emergency General Surgery - NCEPOD 2016 “Treat the Cause” (Acute
Pancreatitis, calculus cholecystitis necessitating admission)
- NCEPOD 2016 “Time to Get Control” ( following stratification at therapeutic endoscopy and according to GM pathways)
All emergency general surgery patients requiring admission are to be
transferred to the surgical hub site (MRI).
Patients receiving certain categories of specialised care at UHSM to be
treated at UHSM.
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Healthier Together model Assessment Notes: Manchester and Trafford Sector
High risk patients requiring conservative inpatient ‘watch
and wait’ management - these patients require significant
surgical, diagnostic and associated service input and as such
should be transferred to the hub site or another GM hub site
in a networked model if determined by GM clinical pathway:
- As identified in Nuffield 2016 paper - NCEPOD 2016 “Treat the Cause” (Acute
Pancreatitis, calculus cholecystitis necessitating admission)
- NCEPOD 2016 “Time to Get Control” (following stratification at therapeutic endoscopy and according to GM pathways)
All emergency general surgery patients to be transferred to the
surgical hub site (MRI), is inclusive of Acute Pancreatitis and calculus
cholecystitis requiring an in-patient admission.
Patients receiving certain categories of specialised care at UHSM to be
treated at UHSM.
MRI is GM hub for Severe Acute Pancreatitis and VIR hub for variceal
bleeding.
MRI currently 1 of 2 VIR sites for non-variceal bleeding.
Patients who are suitable for referral to a prompt semi-
elective or elective pathway including ambulatory care, hot
clinic, outpatients, early elective lists.
Plan to meet standards at both sites within the sector.
Low risk patients requiring conservative inpatient ‘watch and
wait’ who are not suitable for referral to a semi-elective or
elective pathway.
Any emergency patient requiring overnight admission, regardless of
risk will be transferred to the surgical hub (MRI).
Patients receiving certain categories of specialised care at UHSM to be
treated at UHSM.
2. Elective
general surgery
A) All ‘high risk’ elective general surgery is undertaken a
surgical-hub sites. This includes:
a) All Patients with colorectal cancer b) All Patients with colorectal surgery for other
indications as identified in clarification paper (2016) c) Other high risk procedures as identified in the
clarification paper (April 2016) d) Patients undergoing a low risk procedure but
anticipated to require critical care post-operatively
All ‘high risk’ (complex) elective general surgery patients to be
transferred to the surgical hub site (MRI).
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Healthier Together model Assessment Notes: Manchester and Trafford Sector
due to their co-morbidities
Colorectal MDT process in place at a sector level, ready for
the transfer of high risk elective patients from April 2017
ERAS+ programme in place to support high risk elective
patients
CPET in place to provide estimation of risk pre-operatively
Plans are complete for the establishment of a Colorectal MDT in
preparation for the transfer of high risk elective patients to be
completed by November 2017. A successful test run of the Colorectal
MDT took place in March 2017, with the first formal Colorectal MDT
commencing April 2017.
ERAS + programme and CPET service already established in MRI.
All low risk elective surgery to be offered by all sites based
on local population requirements.
Low risk elective general surgery will be offered at both sites (MRI,
UHSM). Low risk elective activity at MRI for local population only.
3. General
surgical
workforce
a) Surgical hub site
• 24/7 assessment
• 14/7 operating (CEPOD)
MRI:
• 16 hour consultant presence on surgical hub site (until 00.00) with on-call following this. This is to accommodate Major Trauma Torso role.
• 12 hours consultant presence for operating on the surgical hub site.
The intention is for on-call provision for surgical hub and non-surgical
hub, for three sub-specialty consultant rotas, which includes
Colorectal.
Please note that advice on the provision of 24/7 presence for the
purposes of Major Trauma has changed. Please see section 2.
Assumed revised model on the non-hub sites
10 hours consultant presence including daily ambulatory care provision
Unpredictable on- call cover
UHSM
• 10 hours presence • Unpredictable on call
4. Emergency
Medicine
A&E consultant cover: 24/7 emergency medicine consultant presence at the surgical hub site
(MRI).
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Healthier Together model Assessment Notes: Manchester and Trafford Sector
workforce a) Surgical hub sites: minimum 16 hours/7 days, Major
Trauma Centre 24 hours
b) Non-surgical hub sites: minimum of 12 hours/ 7 days.
16 hours emergency medicine consultant presence at the non-surgical
hub site (UHSM).
5. Acute Medicine
workforce
Acute medical consultant cover:
Each site 12 hours consultant cover, 7 days per week
Plan in place to deliver workforce standards at both sites.
6. Critical Care a) Critical Care services meet national requirement to be a
closed service
CMFT and UHSM are compliant.
b) Provision of ERAS+ and CPET programme within the
sector
ERAS+ programme already in place at CMFT and plan in place for
development at UHSM.
7. Radiology a) 24/7 diagnostic reporting service at each site with 24/7
compliance to access of modalities
Current provision of on-call consultant radiologist on both sites 24/7
b) Non-vascular interventional service to be provided 7 days
per week at a sector level or GM
c) At least 1 site in GM to have a 24/7 NVIR rota
Current provision of non-vascular interventional rota available 7 days
a week.
d) Vascular interventional radiology to be provided 24/7
days per week at a GM level (network solution).
Current provision of 24/7 vascular interventional rota and a network
solution for Salford, Bolton, Wigan, Stockport and Tameside.
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The following section outlines the requirements for the delivery of this model of care:
7.1.2 Manchester and Trafford estate requirements
The table below summarises estates developments required to support the new model of care.
Table 7.1.2: Manchester and Trafford Estates
Requirements General Surgery improvements A&E improvements Acute improvements
Activity 225 elective patients move to hub site
1,665 non elective patients move to hub site
No estate development required in this sector
No estate development required in this sector
Inpatient beds 38 additional inpatient beds required at hub site – 2 wards
Critical Care beds
3 additional critical care beds required at hub site
Operating Theatres
1 additional emergency theatre
7.1.3 Manchester and Trafford sector workforce requirements
Additional consultant workforce is required in the sector to deliver the General Surgery clinical standards. The additional requirement is summarised in the table below.
Table 7.1.13: Manchester and Trafford Workforce
Numbers – WTE Baseline HT Requirement Recruitment required
Acute and Emergency
Medicine
32.0 29.0 2.0*
General Surgery 21.0 27.2 6.2
*2 WTE of additional consultants for medical Ambulatory Care are required due to the current
pressure on both A&E units within the sector. Current demand means that existing A&E consultants
do not have the capacity within their current job plans, to also cover the expansion in Ambulatory
Care required, as expected within the Healthier Together workforce model.
7.1.4 Manchester and Trafford Capital Costs breakdown
The commercial case above identified a capital cost budget for Healthier Together of £63m. Within the Manchester and Trafford sector, the capital cost is £10,160k. A breakdown of this figure is provided below.
Table 7.1.4: Manchester and Trafford Capital Investment
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
Table 7.1.5: Manchester and Trafford Capital Cost Timings
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
A risk of £200k has been identified by the sector in relation to capital costs and is being reviewed with a view to mitigating the risk or finding an alternative funding source.
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7.1.5 Manchester and Trafford reconciliation to DMBC Capital figure
This table shows that the revised capital cost of HT in the Manchester and Trafford sector is higher than the DMBC.
Table 7.1.6: Manchester and Trafford Capital Funding Reconciliation
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
7.1.6 Manchester and Trafford Revenue Costs
Revenue cost to commissioners
In the Manchester and Trafford sector, there will be an annual decrease in revenue cost to commissioners relating to Healthier Together of £861k. This is due to more patients being paid for under a lower ambulatory care tariff in the new model.
Revenue cost at hub sites
The following table outlines the recurrent revenue costs of Healthier Together at the sector hub site, the Manchester Royal Infirmary.
Table 7.1.7: Manchester and Trafford: Hub site Recurrent Revenue Cost to implement HT
Costs Total £’000
Total £’000
Income transferring to hub site (5,647)
Operating costs increase at hub site:
Surgical beds 2,050
Critical care beds 920
Support services 1,326
Joint working 314
Other costs 651 5,261
Consultant workforce additional cost 690
Other staff additional cost 1,196
Revenue consequence of capital (see below) 693
Ambulance costs 225
Total costs 2,418
In the Manchester and Trafford sector, it is anticipated that these revenue consequences will be fully
offset by the annual efficiencies anticipated by the programme, which are summarised below. The
methodology used to calculate these efficiencies is fully described in Appendix 7.
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Table 7.1.8: Potential efficiencies
£’000 General Surgery Length of stay
General surgery Readmissions
A&E Admissions Total revenue benefits
MAT £1,493 £388 £7,842 £9,723
There are risks to the recognition of these benefits in isolation for Healthier Together in the
Manchester and Trafford sector, notably:
Efficiencies relating to reducing A&E admissions have been assumed in isolation. Locality
schemes, which are at an emergent stage across Greater Manchester, also project A&E
efficiencies and consequently there is a risk that benefits may be double counted across the
system.
The business case for the Shared Hospital Service in the Manchester and Trafford Sector
(MAT) will be the means by which many of the efficiencies are delivered and there is a risk
that length of stay benefits may be double counted if both schemes go ahead. Further work
is required to establish the appropriate allocation of benefits.
Revenue consequences of capital
The total capital investment required in the Manchester and Trafford sector is £10,160k. This investment will have revenue consequences in terms of annual depreciation and either PDC dividend or interest on loans, depending on the source of finance. The forecast impact is as follows:
Table 7.1.9: Manchester and Trafford: Revenue costs of capital
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
Revenue costs at non-hub sites
Revenue costs at non-hub sites relate to the general surgery activity which has transferred to the hub site, where an element of the associated cost cannot be immediately removed at the non-hub (for example, overhead costs). These are ‘stranded’ costs.
Over time these stranded costs are expected to work out of the system. For example, reciprocal activity transfers driven by other system reconfiguration work currently in progress (including under Theme 3) are expected to make use of non-hub site capacity.
The following table outlines the annual stranded costs of Healthier Together at the sector non-hub site.
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Figure 7.1.10: Manchester and Trafford revenue costs at non-hub site
Costs Total £’000
Income loss 6,508
Costs of surgical beds saved (1,650)
Cost of critical care beds saved (802)
Support services costs saved (563)
Excess of income loss over costs saved (stranded costs) 3,493
Over the first 3 years of implementing Healthier Together the total stranded costs have been calculated at £4,062k
7.1.7 Manchester and Trafford Transitional Costs
Transitional costs relating to implementation have been categorised in the following manner:
Implementation Costs. This relates predominantly to preparatory works e.g. building design and site clearance
Project Management. These costs have been calculated at both sector and GM level on a post by post basis
Workforce. This relates to additional staffing required over and above 'business as usual' as the new clinical model embeds.
Agency Costs. There is a risk that the additional workforce required to deliver the Healthier Together clinical standards cannot be recruited to substantively. This figure represents the maximum estimate of the premium element of payments which may be required to secure appropriate staffing if providers are unable to recruit substantively.
Transitional funding has been requested from the Greater Manchester Transformation Fund in February 2017. The outcome of this request is expected in March 2017.
IT costs are not anticipated in the Manchester and Trafford sector due to existing working arrangements providing appropriate functionality to support Healthier Together data sharing, pending the outcome of the Single Hospital Services consultation.
Table 7.1.12: Manchester and Trafford Transitional Costs
Cost
2016/17 £’000
2017/18 £’000
2018/19 £’000
2019/20 Total £’000
Implementation Costs 5 61 87 153
Project Management 275 621 49 947
Workforce - 580 634 874 2,088
TOTAL 280 1,262 770 874 3,186
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An application to the Greater Manchester Development Fund has been made for £544.9k to cover the transitional costs already incurred in 2016/17 and forecast for quarter 1 2017/18. The balance of the transitional cost is covered by the Healthier Together application to the Greater Manchester Transformation
Fund.
7.1.8 Manchester and Trafford Funding sources
Capital funding is being sought from public funding sources, as described in the Commercial Case.
Transitional funding has been requested from the Greater Manchester Transformation Fund.
The recurrent revenue impact of the programme at the hub site is expected to be fully mitigated by the efficiencies anticipated by the programme.
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7.2 Appendix 2: North East Sector The following appendix provides sector level detail in support of the GM Business Case.
7.2.1 North East sector model of care
Key highlights from the model of care are outline below, followed by a summary table which
provides an assessment of different aspects of the local model of care against the Healthier Together
model.
Key highlights
Colorectal MDT
A Colorectal MDT is already in place with the sector (started in August 2015); this happens
each Friday where approx. 40 cases are discussed, supported by an MDT coordinator and
standardised proformas and processes. MDT clinical lead assists the process who manages
the meeting closely.
122
The following tables compare the plans which the sectors have developed for the implementation of the Healthier Together against the Healthier Together
model of care. It includes an assessment of variation against the different elements of the model. It should not be taken as a reflection of their current
compliance with the Healthier Together model.
Table 7.2.1: Summary of the model of care within the NE sector
Healthier Together model Assessment Notes: North East Sector
1. Emergency
General Surgery
All emergency high risk general surgical patients are admitted
to sites specializing in emergency and ‘high risk’ elective
general surgery (surgical-hub sites). Each sector should have a
pathway in place for:
See below
High Risk Patients requiring an inpatient emergency general
surgical procedure should be transferred to the hub site:
- Emergency Laparotomy - Patients identified in the Nuffield 2016 paper on
Emergency General Surgery - NCEPOD 2016 “Treat the Cause” (Acute Pancreatitis,
calculus cholecystitis necessitating admission) - NCEPOD 2016 “Time to Get Control” (following
stratification at therapeutic endoscopy and according to GM pathways)
All emergency general surgery to be transferred to the surgical hub
site (ROH).
High risk patients requiring conservative inpatient ‘watch and
wait’ management - these patients require significant surgical,
diagnostic and associated service input and as such should be
transferred to the hub site or another GM hub site in a
networked model if determined by GM clinical pathway:
All emergency general surgery to be transferred to the surgical hub
site (ROH). GM pathways agreed, inclusive of Acute Pancreatitis
and calculus cholecystitis requiring an in-patient admission.
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Healthier Together model Assessment Notes: North East Sector
- As identified in Nuffield 2016 paper - NCEPOD 2016 “Treat the Cause” (Acute Pancreatitis,
calculus cholecystitis necessitating admission) - NCEPOD 2016 “Time to Get Control” (following
stratification at therapeutic endoscopy and according to GM pathways)
Patients who are suitable for referral to a prompt semi-elective
or elective pathway including ambulatory care, hot clinic,
outpatients, early elective lists.
Models yet to be developed, however plans in place for
development of ambulatory care service in line with requirements.
Low risk patients requiring conservative inpatient ‘watch and
wait’ who are not suitable for referral to a semi-elective or
elective pathway.
Any emergency patient requiring overnight admission, regardless of
risk will be transferred to the surgical hub (ROH).
2. Elective general
surgery
A) All ‘high risk’ elective general surgery is undertaken a
surgical-hub sites. This includes:
a) All Patients with colorectal cancer b) All Patients with colorectal surgery for other
indications as identified in clarification paper (2016) c) Other high risk procedures as identified in the
clarification paper (April 2016) d) Patients undergoing a low risk procedure but
anticipated to require critical care post-operatively due to their co-morbidities
All ‘high risk’ elective general surgery patients to be transferred to
the surgical hub site (ROH).
b) Colorectal MDT process in place at a sector level, ready for
the transfer of high risk elective patients from April 2017
c) ERAS+ programme in place to support high risk elective
patients
d) CPET in place to provide estimation of risk pre-operatively
Colorectal MDT already in place within the sector.
CPET and ERAS+ agreed by the sector and included in model, not
currently in place.
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Healthier Together model Assessment Notes: North East Sector
All low risk elective surgery to be offered by all sites based on
local population requirements.
Low risk elective including day case will be provided across the
sector
3. General surgical
workforce
a) Surgical hub site
16/7 assessment
14/7 operating (CEPOD)
Unpredictable on-call cover
ROH
• 16/7 Consultant ward/assessment presence • 12.5/7 Consultant surgeon presence for emergency
operating
b) Assumed revised model on the non-hub sites
10 hours consultant presence including daily ambulatory care provision
Unpredictable on- call cover
NMGH:
• 12.5/7 consultant ward/assessment presence at non-surgical hub sites.
c) Fairfield General Hospital - Fairfield General Hospital is in the scope of HT for Emergency
Medicine and Acute Medicine service only i.e. not for General
Surgery. However, one of the standards under Urgent and Acute
Medicine UEAM18 states that:
“There must be on-site senior support at ST3+ level 24 hours per
day within the core specialties in Acute Medicine, Critical care,
Anaesthetics, General Surgery, Orthopaedics, Paediatrics &
Emergency Medicine”
It has been confirmed through discussions with the chief medical
advisor and the general surgery clinical lead in the North East
sector that this standard is not required to be met on the Fairfield
site.
Instead, existing arrangements will continue, which include
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Healthier Together model Assessment Notes: North East Sector
patients who present at Fairfield who need a general surgical input
being transferred to ROH. These pathways need development. This
negates the need for any further general surgical workforce at
Fairfield, as always intended in the HT model of care.
4. Emergency
Medicine
workforce
A&E consultant cover:
a) Surgical hub sites: minimum 16 hours/7 days, Major Trauma
Centre 24 hours
Plans in place to provide:
16 hours presence of emergency medicine consultant at ROH
b) Non-surgical hub sites: minimum of 12 hours/ 7 days. 12 hours cover at NMGH and FGH*.
*Note that the consultant workforce at NMGH is currently
assisted by a GM solution with support from SRFT and CMFT.
5. Acute Medicine
workforce
Acute medical consultant cover:
Each site 12 hours consultant cover, 7 days per week
Plan in place to deliver workforce standards but challenges exist in
gaining in-reach services support to acute medicine, e.g. cardiology,
respiratory, geriatric medicine.
6. Critical Care a) Critical Care services meet national requirement to be a closed service
Bury, North Manchester and Royal Oldham ICU currently meet
standards.
Royal Oldham HDU is currently not compliant. Action plan in place
to make the service compliant.
b) Provision of ERAS+ and CPET programme within the sector
GM Medical Directors and GM CCGs have agreed to the roll out of
ERAS+ across Greater Manchester. Sector has included these in
their model, not currently in place.
126
Healthier Together model Assessment Notes: North East Sector
7. Radiology a) 24/7 diagnostic reporting service at each site with 24/7
compliance to access of modalities
A radiology single service within the sector is proposed.
There will be challenges in meeting the Healthier Together
standards, as currently there is no provision of consultant on-call
overnight at the hub and non-hub sites, for no-interventional input.
(required for paediatric standards)
The diagnostic capability at ROH is not adequate to meet projected
demand with the need for another CT scanner.
b) Non-vascular interventional service to be provided 7 days
per week at a sector level or GM
c) At least 1 site in GM to have a 24/7 NVIR rota
d) Vascular interventional radiology to be provided 24/7 days
per week at a GM level (network solution).
A radiology single service within the sector is proposed.
Sector currently provides both a non-vascular and vascular
interventional service which is compliant with the standards. There
are challenges to the resilience of the workforce as currently does
not meet 1:6 rota national standards.
127
7.2.2 North East sector estate requirements
The table below summarises estates developments required in the sector to support the new model of care.
Table 7.2.2: North East sector Estates
Requirements General Surgery improvements A&E improvements Acute improvements
Activity 254 elective patients move to hub site
1,947 non elective patients move to hub site
No estate development required in this sector
No estate development required in this sector
Inpatient beds 47 additional inpatient beds required at hub site – 2 wards
Critical care beds
4 additional critical care beds required at hub site – a ward build is required to accommodate this because the current critical care space is landlocked
Operating theatres.
1 Operating theatre
7.2.3 North East sector consultant workforce requirements
Additional consultant workforce is required in the sector to deliver the Acute and Emergency Medicine and General Surgery clinical standards. The additional requirement is summarised in the table below.
Table 7.2.3: North East sector Workforce
Numbers – WTE Baseline HT Requirement Recruitment required
Acute and Emergency Medicine
17.2 24.7 11.4
General Surgery 14.0 18.0 4.0
7.2.4 North East sector Capital Costs breakdown
The Commercial case above identified a capital cost budget for Healthier Together of £63m. Within the North East sector, the capital cost is £24,837k. A breakdown of this figure is provided below.
Table 7.2.4: North East sector Capital Investment
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
Table 7.2.5: North East sector Capital Cost Timings
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
7.2.5 North East sector reconciliation to DMBC Capital figure
This table shows that the revised capital cost of HT in the North East sector is similar to that the DMBC.
128
Table 7.2.6: North East sector Capital Funding Reconciliation
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
7.2.6 North East Sector Revenue Costs
Revenue cost at hub sites
The following table outlines the recurrent revenue costs of Healthier Together at the sector hub site, the Royal Oldham Hospital.
Within the sector, minimum changes to net operating costs are anticipated due to the sites all forming part of the same trust.
Table 7.2.7: North East sector: Hub site Recurrent Revenue Cost to implement HT
Costs Total £’000
Income transferring to hub site -
Operating costs increase at hub site: -
Consultant workforce additional cost 1,759
Other staff additional cost 4,987
Revenue consequence of capital (see below) 1,729
Ambulance costs 228
Total 8,703
In the North East sector, it is anticipated that these revenue consequences will be partly offset by
the annual efficiencies anticipated by the programme, which are summarised below. The
methodology used to calculate these efficiencies is fully described in Appendix 7.
Table 7.2.8: Annual Efficiencies
£’000 General Surgery Length of stay
General surgery Readmissions
A&E Admissions Total revenue benefits
NES £542 £626 - £1,168
Revenue consequences of capital
The total capital investment required in the North East sector is 24,837k. This investment will have revenue consequences in terms of annual depreciation and either PDC dividend or interest on loans, depending on the source of finance. The forecast impact is as follows:
Table 7.2.9: North East Sector: Revenue costs of capital
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
Revenue costs at non-hub sites
129
As the North East sector is one trust, no stranded costs have been recognised at the non-hub sites in this sector. This is on the basis that there will be no change in income and therefore no impact on corporate overheads, and that operating costs should be able to be managed between trust hospital sites.
7.2.7 North East Sector Transitional Costs
Transitional costs relating to implementation have been categorised in the following manner:
Implementation Costs. This relates predominantly to preparatory works e.g. building design and site clearance
Project Management. These costs have been calculated at both sector and GM level on a post by post basis
Revenue Consequences of Capital during transition. This is the PDC cost of the new build as the asset construction spans two financial years.
Figure 7.2.10: North East sector Transitional Costs
Cost
2017/18 £’000
2018/19 £’000
2019/20 £’000
2020/21 £’000
Total £’000
Implementation Costs 380 380
Project Management 373 373 746
Revenue Consequences of Capital
during transition
158 570 728
TOTAL 753 373 158 570 1,854
There is a risk that non-contracted pay costs of up to £4.2m could be required non-recurrently pending the substantive recruitment of new staff. This figure represents the maximum estimate of the premium element of payments which may be required to secure appropriate staffing if providers are unable to recruit substantively. It is expected that this risk will be partially mitigated through both local and STP level action, and that any non-mitigated element will be funded locally in sectors.
7.2.8 North East Sector Funding sources
Capital funding is being sought from public funding sources, as described in the Commercial Case.
Transitional funding has been requested from the Greater Manchester Transformation Fund.
The recurrent revenue impact of the programme at the hub site is not expected to be fully mitigated by the efficiencies anticipated by the programme. Consequently sector commissioners and the sector provider are in the process of agreeing how recurrent revenue pressures will be funded.
130
7.3 Appendix 3: North West Sector
The following appendix provides sector level detail in support of the GM Business Case.
7.3.1 North West sector model of care
Key highlights from the model of care are outline below, followed by a summary table which
provides an assessment of different aspects of the local model of care against the Healthier Together
model.
Key highlights
Ambulatory care
Plans are in place for standardising the offer of ambulatory care at each site. Standard
pathways and criteria for common conditions to be developed, phased go live starting with
weekend service across all sites from April 2017.
Capital build
Through the Healthier Together programme and the Major Trauma programme for Greater
Manchester a four-storey new building with be erected at SRFT to accommodate the
additional activity from both programmes. This will include 3 wards, 7 critical care beds and
2 theatres.
131
The following tables compare the plans which the sectors have developed for the implementation of the Healthier Together against the Healthier Together
model of care. It includes an assessment of variation against the different elements of the model. It should not be taken as a reflection of their current
compliance with the Healthier Together model.
Table 7.3.1: Summary of the model of care within the NW sector
Healthier Together model Assessment Notes: North West Sector
1. Emergency
General Surgery
All emergency high risk general surgical patients are admitted to
sites specializing in emergency and ‘high risk’ elective general
surgery (surgical-hub sites). Each sector should have a pathway
in place for:
See below
High Risk Patients requiring an inpatient emergency general
surgical procedure should be transferred to the hub site:
- Emergency Laparotomy - Patients identified in the Nuffield 2016 paper on
Emergency General Surgery - NCEPOD 2016 “Treat the Cause” (Acute Pancreatitis,
calculus cholecystitis necessitating admission) - NCEPOD 2016 “Time to Get Control” (following
stratification at therapeutic endoscopy and according to GM pathways)
‘High-risk’ only emergency surgery patients will be transferred to
the surgical hub site (SRFT) with ‘low risk’ in-patients remaining at
both non-hub sites.
High risk patients requiring conservative inpatient ‘watch and
wait’ management - these patients require significant surgical,
diagnostic and associated service input and as such should be
transferred to the hub site or another GM hub site in a
networked model if determined by GM clinical pathway:
The model includes moving patients who require conservative
management in this category, to the surgical hub site or another
GM hub site according to GM pathways, inclusive of Acute
Pancreatitis and calculus cholecystitis requiring an in-patient
admission.
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Healthier Together model Assessment Notes: North West Sector
- As identified in Nuffield 2016 paper - NCEPOD 2016 “Treat the Cause” (Acute Pancreatitis,
calculus cholecystitis necessitating admission) - NCEPOD 2016 “Time to Get Control” (following
stratification at therapeutic endoscopy and according to GM pathways)
Patients who are suitable for referral to a prompt semi-elective
or elective pathway including ambulatory care, hot clinic,
outpatients, early elective lists.
Plan for ambulatory care to be offered across the sector (3-4 hours
per day, 7 days per week).
Low risk patients requiring conservative inpatient ‘watch and
wait’ who are not suitable for referral to a semi-elective or
elective pathway.
‘Low risk’ emergency activity to be retained at the non-hub sites as
long as contained within workforce modelling: Royal Bolton
Hospital (RBH) and Wrightington, Wigan and Leigh (WWL).
2. Elective
general surgery
A) All ‘high risk’ elective general surgery is undertaken a
surgical-hub sites. This includes:
a) All Patients with colorectal cancer b) All Patients with colorectal surgery for other
indications as identified in clarification paper (2016) c) Other high risk procedures as identified in the
clarification paper (April 2016) d) Patients undergoing a low risk procedure but
anticipated to require critical care post-operatively due to their co-morbidities
High-risk (complex) elective patients will be transferred to the
surgical hub site (SRFT).
b) Colorectal MDT process in place at a sector level, ready for
the transfer of high risk elective patients from April 2017
c) ERAS+ programme in place to support high risk elective
patients
d) CPET in place to provide estimation of risk pre-operatively
Discussions are taking place about the establishment of Colorectal
MDTs in the sector and introduction of ERAS+ programme/CPET.
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Healthier Together model Assessment Notes: North West Sector
All low risk elective surgery to be offered by all sites based on
local population requirements.
Low risk elective activity will be retained at the non-hub sites. Low
risk elective activity at SRFT for local population only.
3. General
surgical
workforce
a) Surgical hub site
24/7 assessment
14/7 operating (CEPOD)
SRFT:
• 24 hours consultant presence for surgical assessment • 14 hour consultant presence for undertaking Emergency
General Surgery *An additional 6 hour in-patient assessment role has been included
by the sector above the recommendations of the Chief Medical
Officer. Local provider to commissioner dialogue will be necessary
to support/challenge this role.
b) Assumed revised model on the non-hub sites
10 hours consultant presence including daily ambulatory care provision
Unpredictable on- call cover
WWL & RBH:
• 12 hours consultant presence due to the volume of patients expected on the non-hub sites
• Unpredictable on-call cover
4. Emergency
Medicine
workforce
A&E consultant cover:
a) Surgical hub sites: minimum 16 hours/7 days, Major Trauma
Centre 24 hours
SRFT to provide 24 hours of emergency medicine consultant
presence.
b) Non-surgical hub sites: minimum of 12 hours/ 7 days.
RBH and WWL to provide 16 hours of emergency medicine
consultant presence due to the volume of attendances on the non-
hub sites. This is on a background of the sector and GM having
major workforce issues in this area.
5. Acute
Medicine
workforce
Acute medical consultant cover:
Each site 12 hours consultant cover, 7 days per week
Plan in place to deliver workforce standards at all three sites but
challenges exist in meeting these currently.
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Healthier Together model Assessment Notes: North West Sector
6. Critical Care a) Critical Care services meet national requirement to be a
closed service
WWL and Royal Bolton are both compliant; Salford Royal has a plan
in place for compliance from 1st
April 2017.
b) Provision of ERAS+ and CPET programme within the sector
GM Medical Directors and GM CCGs have agreed to the roll out of
ERAS+ across Greater Manchester.
7. Radiology a) 24/7 diagnostic reporting service at each site with 24/7
compliance to access of modalities
A radiology single service within the sector is proposed. There will
be challenges in meeting the Healthier Together standards, as
currently there is no provision of consultant on-call overnight at the
hub and non-hub sites, required for paediatric standards.
b) Non-vascular interventional service to be provided 7 days per
week at a sector level or GM
c) At least 1 site in GM to have a 24/7 NVIR rota
A radiology single service within the sector is proposed.
There will be challenges in meeting the Healthier Together
standards, as currently there is no provision of non-vascular
interventional radiology at the weekend. It has been suggested that
a sector solution for providing weekend cover is explored
d) Vascular interventional radiology to be provided 24/7 days
per week at a GM level (network solution).
Vascular interventional radiology currently provided as part of
network solution with CMFT.
135
7.3.2 North West sector estate requirements
The table below summarises estates developments required in the sector to support the new model of care.
Table 7.3.2: North West sector Estates
Requirements General Surgery improvements A&E improvements Acute improvements
Activity 363 elective patients move to hub site
1,260 non elective patients move to hub site
No estate development required in this sector
No estate development required in this sector
In-patient beds 54 additional inpatient beds required at hub site – 2 wards
Critical Care beds
6 additional critical care beds required at hub site – 1 ward
Operating Theatres.
2 theatres (including 1 emergency theatre)
7.3.3 North West sector workforce requirements
Additional consultant workforce is required in the sector to deliver the General Surgery clinical standards. The additional requirement is summarised in the table below.
Table 7.3.3: North West sector Workforce
Numbers – WTE Baseline HT Requirement Recruitment required
Acute and Emergency Medicine
31.6 29.0 Already meeting the standards
General Surgery 32.8 41.5 8.7
7.3.4 North West sector Capital Costs breakdown
The Commercial case above identified a capital cost budget for Healthier Together of £63m. Within the North West sector, the capital cost is £18,450k. A breakdown of this figure is provided below.
Table 7.3.4 North West sector Capital Investment
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
Table 7.3.5: North West sector Capital Cost Timings
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
7.3.5 North West sector interdependencies
The implementation of Healthier Together programme is interdependent with the development of a lead Major Trauma Centre for Greater Manchester at Salford Royal Foundation Trust. This is because SRFT are planning to build a new building to house both developments. If the Major Trauma programme is not funded, the costs of the implementing in the North West Sector will be significantly higher.
136
7.3.6 North West sector reconciliation to DMBC Capital figure
This table shows that the revised capital cost of HT in the North West sector is lower than the DMBC figure, due to the co-location with the Major Trauma Centre described above.
Table 7.3.6 North West sector Capital Funding Reconciliation
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
7.3.7 North West sector Revenue Costs
Revenue cost at hub sites
The following table outlines the recurrent revenue costs of Healthier Together at the sector hub site, Salford Royal.
Table 7.3.7: North West sector: Hub site Recurrent Revenue Cost to implement HT
Costs Total £’000
Income transferring to hub site (9,734)
Operating costs increase at hub site: 11,303
Consultant workforce additional cost 1,487
Other staff additional cost 1,710
Revenue consequence of capital (see below) 2,073
Ambulance costs 148
Total 6,987
In the North West sector, it is anticipated that these revenue consequences will be partly offset by
the annual efficiencies anticipated by the programme, which are summarised below. The
methodology used to calculate these efficiencies is fully described in Appendix 7.
Table 7.3.8: North West sector annual efficiencies
£’000 General Surgery Length of stay
General surgery Readmissions
A&E Admissions Total revenue benefits
NWS £263 £669 £6,965 £7,897
Revenue consequences of capital
The total capital investment required in the North West sector is £18,450k. This investment will have revenue consequences in terms of annual depreciation and either PDC dividend or interest on loans, depending on the source of finance. The forecast impact is as follows:
137
Table 7.3.9 North West Sector: Revenue costs of capital
Costs Total £’000
Capital Investment 18,450
Revenue costs of capital
Depreciation 1,470
PDC Dividend 603
Total 2,073
Revenue costs at non-hub sites
Revenue costs at non-hub sites relate to the general surgery activity which has transferred to the hub site, where an element of the associated cost cannot be immediately removed at the non-hub (for example, overhead costs). These are ‘stranded’ costs.
Over time these stranded costs are expected to work out of the system. For example, reciprocal activity transfers driven by other system reconfiguration work currently in progress (including Devolution Theme 3) are expected to make use of non-hub site capacity.
The following table outlines the annual stranded costs of Healthier Together at the sector non-hub sites.
Table 7.3.10: North West sector revenue costs at non-hub sites
Costs 2019/20 £’000
2020/21 £’000
2021/22 £’000
Income loss 9,734 9,734 9,734
Operating costs saved (6,574) (8,154) (8,478)
Excess of income loss over costs saved (stranded costs)
3,160 1,580 1,256
Stranded costs of £5,996k are expected over the first three years of implementation, with £766k at the Royal Bolton Foundation Trust and £5,230k at Wrightington, Wigan and Leigh Foundation Trust.
7.3.8 North West Sector Transitional Costs
Transitional costs relating to implementation have been categorised in the following manner:
Implementation Costs. This relates predominantly to preparatory works e.g. building design and site clearance
Project Management. These costs have been calculated on a post by post basis
Workforce. This relates to additional staffing required over and above 'business as usual' as the new clinical model embeds.
Revenue Consequences of Capital during transition. This is the PDC cost of the newbuild as the asset construction spans two financial years
Transitional funding has been requested from the Greater Manchester Transformation Fund in February 2017. The outcome of this request is expected in March 2017.
138
Table 7.3.11: North West sector Transitional Costs
Cost
2017/18 £’000
2018/19 £’000
2019/20 £’000
Total £’000
Implementation Costs 1,250 1,250
Project Management 615 538 1,153
Workforce 1,344 448 1,792
Revenue consequences of capital 425 638 1,063
Total costs 1,865 2,306 1,086 5,256
There is a risk that non-contracted pay costs of up to £418k could be required non-recurrently pending the substantive recruitment of new staff. This figure represents the maximum estimate of the premium element of payments which may be required to secure appropriate staffing if providers are unable to recruit substantively. It is expected that this risk will be partially mitigated through both local and STP level action, and that any non-mitigated element will be funded locally in sectors
7.3.9 North West Sector Funding sources
Capital funding is being sought from public funding sources, as described in the Commercial Case.
Transitional funding has been requested from the Greater Manchester Transformation Fund.
The recurrent revenue impact of the programme at the hub site is expected over time to be fully mitigated by the efficiencies anticipated by the programme. Sector commissioners and the providers are in the process of agreeing how recurrent revenue pressures will be funded in the medium term.
139
7.4 Appendix 4: South East sector
The following appendix provides sector level detail in support of the GM Business Case.
7.4.1 South East sector model of care
Key highlights from the model of care are outline below, followed by a summary table which
provides an assessment of different aspects of the local model of care against the Healthier Together
model.
A&E capacity
Through the Healthier Together programme a two-storey expansion of Stepping Hill Hospital
A&E department is planned, with a £5.2 million capital investment proposed.
o This will see the creation of a 6 bedded Resus suite to provide the required additional clinical capacity to safely treat the anticipated increase in high acuity emergency surgery patients, but also provide the opportunity to reuse the existing Resus for 4 dedicated consultant-led Rapid Access Treatment trolleys. In addition to increasing the clinical capacity of the department, the expansion area will be a two storey design, providing additional operating space for the theatre complex situated above the Emergency Department.
o Expanding the complex by one theatre will not only provide much needed expansion capacity to future proof the complex in preparation for the subsequent phases of Healthier Together, but also provide the opportunity to rehouse some of the activity currently undertaken in the Cardiac Catheter Lab to the theatre complex.
o The Cardiac Catheter Lab is currently co-located in the footprint of the Emergency Department, alongside the Ambulatory Care Unit and with the relocation of services to the theatre complex, will provide the opportunity to develop a fully integrated Frailty Assessment Unit within the footprint of the Emergency Department.
o The development of a Frailty Assessment Unit would allow the Trust to adopt best practice for the management and treatment of frail, elderly patients.
Ambulatory care
Sector level pathway and protocols in place for ambulatory care; which will be delivered via
a 4 hour clinic, 7 days per week, on both the non-surgical hub site (TGH) and the surgical-hub
site (SFT). Pathways are in place for patients with: LIF pain (mild diverticulitis), RUQ pain
(mild cholecystitis / biliary colic), non-specific abdominal pain, RIF pain (clinically not
appendicitis). It is expected that 30% of emergency general surgical patients can be
managed in this manner.
North East Cheshire
Please note that arrangements for North East Cheshire patients aren’t included in the table
below, however, the latest commissioning intentions for East Cheshire CCG propose a
transfer of high risk General Surgery from East Cheshire Trust to Stockport, with the
expectation being that this will take place at some point in 2017/18. Options for the future
of East Cheshire Trust are to be considered between local partners and regulators over the
next six months and formal consultation will be scheduled as necessary.
140
The following tables compare the plans which the sectors have developed for the implementation of the Healthier Together against the Healthier Together
model of care. It includes an assessment of variation against the different elements of the model. It should not be taken as a reflection of their current
compliance with the Healthier Together model.
Table 7.4.1: Summary of the model of care within the SE sector
Healthier Together model Assessment Notes: South East Sector
1. Emergency
General Surgery
All emergency general surgical patients are admitted to sites
specializing in emergency and ‘high risk’ (complex) elective
general surgery (surgical-hub sites). Each sector should have
a pathway in place for:
See below
High Risk Patients requiring an inpatient emergency general
surgical procedure should be transferred to the hub site:
- Emergency Laparotomy - Patients identified in the Nuffield 2016 paper on
Emergency General Surgery - NCEPOD 2016 “Treat the Cause” (Acute
Pancreatitis, calculus cholecystitis necessitating admission)
- NCEPOD 2016 “Time to Get Control” ( following stratification at therapeutic endoscopy and according to GM pathways)
All emergency general surgery to be transferred to the surgical hub
(SFT).
High risk patients requiring conservative inpatient ‘watch
and wait’ management - these patients require significant
surgical, diagnostic and associated service input and as such
should be transferred to the hub site or another GM hub site
in a networked model if determined by GM clinical pathway:
All emergency general surgery to be transferred to the surgical hub
(SFT), inclusive of Acute Pancreatitis and calculus cholecystitis,
requiring an in-patient admission.
Therapeutic endoscopy not 24/7 currently in sector but action plan to
141
Healthier Together model Assessment Notes: South East Sector
- As identified in Nuffield 2016 paper - NCEPOD 2016 “Treat the Cause” (Acute
Pancreatitis, calculus cholecystitis necessitating admission)
- NCEPOD 2016 “Time to Get Control” (following stratification at therapeutic endoscopy and according to GM pathways)
deliver in place. Sector to be supported in meantime by MRI.
Patients who are suitable for referral to a prompt semi-
elective or elective pathway including ambulatory care, hot
clinic, outpatients, early elective lists.
Plan for 7 day access to ambulatory care across the sector.
Low risk patients requiring conservative inpatient ‘watch and
wait’ who are not suitable for referral to a semi-elective or
elective pathway.
All emergency general surgery to be transferred to the surgical hub
(SFT).
2. Elective
general surgery
All ‘high risk’ elective general surgery is undertaken a
surgical-hub sites. This includes:
a) All Patients with colorectal cancer b) All Patients with colorectal surgery for other
indications as identified in clarification paper (2016) c) Other high risk procedures as identified in the
clarification paper (April 2016) d) Patients undergoing a low risk procedure but
anticipated to require critical care post-operatively due to co-morbidities.
All High-risk (complex) elective patients plus any other elective
activity where the patient has a high risk condition (even if their
procedure is non-high risk) – as a basis for modelling, the Sector has
estimated based on the number of non-high risk procedure patients
staying longer than three days in the base year. Operationally, the
direction of such patients will be based on a standard risk
assessment.).
Colorectal MDT process in place at a sector level, ready for
the transfer of high risk elective patients from April 2017
ERAS+ programme in place to support high risk elective
patients
Discussions are taking place about the establishment of Colorectal
MDTs in the sector in preparation for the transfer of high risk elective.
The first combined meeting is to take place in May 2017. ERAS + and
CPET services being developed and included in their model.
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Healthier Together model Assessment Notes: South East Sector
CPET in place to provide estimation of risk pre-operatively
All low risk elective surgery to be offered by all sites based
on local population requirements.
Low risk short stay elective general surgery with expected stay of <3
days will remain at the non-surgical hub (TGH). All other elective
activity to be delivered at the surgical hub (SFT).
Low risk short stay elective general surgery to also be delivered at
(SFT) for the local population.
3. General
surgical
workforce
a) Surgical hub site
16/7 assessment
14/7 operating (CEPOD)
Unpredictable on-call cover
SFT:
• 13 hr./7 presence for surgical assessment • 12 hr./7 consultant surgeon presence for operating Chief medical officer and clinical champions have confirmed that this
level of cover is appropriate given the volume of patients within the
sector; subject to on-going activity analysis.
b) Assumed revised model on the non-hub sites
10 hours consultant presence including daily ambulatory care provision
Unpredictable on- call cover
TGH
• 10 hours consultant presence • Unpredictable on call
4. Emergency
Medicine
workforce
A&E consultant cover:
a) Surgical hub sites: minimum 16 hours/7 days, Major
Trauma Centre 24 hours
16 hours emergency medicine consultant presence at the surgical hub
site (SFT). Workforce issues continue.
b) Non-surgical hub sites: minimum of 12 hours/ 7 days.
12 hours emergency medicine consultant presence at the non-surgical
hub site (TGH)
5. Acute Medicine
workforce
Acute medical consultant cover:
Each site 12 hours consultant cover, 7 days per week
12 hours acute medical consultant presence at the non-surgical hub
site (TGH) and the surgical hub site (SFT).
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Healthier Together model Assessment Notes: South East Sector
6. Critical Care a) Critical Care services meet national requirement to be a
closed service
Stepping Hill and Tameside are compliant.
b) Provision of ERAS+ and CPET programme within the
sector
GM Medical Directors and GM CCGs have agreed to the roll out of
ERAS+ across Greater Manchester. Mode includes service on SFT site,
not in place yet.
7. Radiology a) 24/7 diagnostic reporting service at each site with 24/7
compliance to access of modalities
Stepping Hill is compliant. There will be challenges in meeting the
Healthier Together standards in Tameside with the number of
radiologists from February 2017. There is currently a network
arrangement in place for MR scanning.
b) Non-vascular interventional service to be provided 7 days
per week at a sector level or GM
c) At least 1 site in GM to have a 24/7 NVIR rota
A plan is in place for 7 day provision of non-vascular interventional
radiology.
d) Vascular interventional radiology to be provided 24/7
days per week at a GM level (network solution).
Vascular interventional radiology currently provided as part of
network solution with CMFT.
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7.4.2 South East sector estate requirements
The table below summarises estates developments required in the sector to support the new model of care.
Table 7.4.2: South East sector Estates
Requirements General Surgery improvements A&E improvements Acute improvements
Activity 205 elective patients move to hub site
2,183 non elective patients move to hub site
Provision of an additional
acute ward within “M”
Block at Stepping Hill
Hospital, reoccupying a
former clinical area
currently used as office
space, allowing location
of additional general
surgical beds, close to
Theatres in “D” Block.
Inpatient beds 34 additional inpatient beds required at hub site – 1 large ward
Critical Care beds
4 additional critical care beds required at hub site
Operating Theatres
Up to 9 sessions per week – 1 theatre
A&E capacity Additional emergency bays in A&E department
The related general surgery activity which will be transferring from Tameside to Stockport is broken down below.
Table 7.4.3: General Surgery activity transferring from Tameside to Stockport
Category Cholecystectomy CR Complex
CR Simple
Endo GS HPB No Proc Other UGI Complex
Total
Elective/Overnight/ High Risk 89 2 1 92
Elective/Overnight/ No Procedure (LOS >3 days) 11 11
Elective/Overnight/ Non High risk (LOS > 3 days) 11 52 1 29 2 5 2 102
Non Elective/ Overnight/Endoscopy 1 6 181 8 5 2 203
Non Elective/Overnight/High Risk
48 48
Non Elective/Overnight/No Procedure
1,292 1,292
Non Elective/Overnight/Non high risk
26 42 4 440 123 5 640
TOTAL 37 232 11 181 479 3 1,303 133 9 2,388
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7.4.3 South East sector workforce requirements
Additional consultant workforce is required in the sector to deliver the Acute and Emergency Medicine and General Surgery clinical standards. The additional requirement is summarised in the table below.
Table 7.4.4: South East sector Workforce
Numbers – WTE Baseline HT Requirement Recruitment required
Acute and Emergency Medicine
10.5 15.7 5.2
General Surgery 15.0 24.0 9.0
7.4.4 South East sector Capital Costs breakdown
The Commercial case above identified a capital cost budget for Healthier Together of £63m. Within the South East sector, the capital cost is £9,900k. A breakdown of this figure is provided below.
Table 7.4.5: South East sector Capital Investment
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
Table 7.4.6: South East sector Capital Cost Timings
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
7.4.5 South East sector reconciliation to DMBC Capital figure
This table shows that the revised capital cost of HT in the South sector is above the DMBC figure, for the reasons described in the table below.
Table 7.4.6: South East sector Capital Funding Reconciliation
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
7.4.6 South East Sector Revenue Costs
Revenue Cost to Commissioners
In the South East sector, there will be an annual increased revenue cost to commissioners relating to Healthier Together of £588k. This is due to an increase in post-operative critical care bed days in line with clinical standards. 90% of this additional cost relates to Tameside CCG patients and so will be borne by Tameside CCG.
The £588k is a cost to the sector as a whole, but represents additional income to the hub site.
Revenue cost at hub sites
The following table outlines the recurrent revenue costs of Healthier Together at the sector hub site, Stepping Hill.
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Table 7.4,7: South East sector: Hub site Recurrent Revenue Cost to implement HT
Costs Total £’000
Income transferring to hub site (6,370)
Operating costs increase at hub site 5,954
Consultant workforce additional cost 943
Other staff additional cost 160
Cost of joint sector working at hub site 271
Revenue consequence of capital (see below) 1,124
Ambulance costs 228
Total 2,309
In the South East sector, it is anticipated that these revenue consequences will be partly offset by
the annual efficiencies anticipated by the programme, which are summarised below. The
methodology used to calculate these efficiencies is fully described in Appendix 7.
Table 7.4.8: South East SectorAnnual Efficiencies
£’000 General Surgery Length of stay
General surgery Readmissions
A&E Admissions Total revenue benefits
SES - £365 £4,124 £4,489
There are risks to the recognition of these benefits in the South East sector, notably:
Efficiencies relating to reducing A&E admissions have been assumed in isolation. Locality
schemes, which are at an emergent stage across Greater Manchester, also project A&E
efficiencies and consequently there is a risk that benefits may be double counted across the
system.
Revenue consequences of capital
The total capital investment required in the South East sector is £9,900k. This investment will have revenue consequences in terms of annual depreciation and either PDC dividend or interest on loans, depending on the source of finance. The forecast impact is as follows:
Table 7.4.9: South East Sector: Revenue costs of capital
TABLE REDACTED FROM PUBLIC FACING DOCUMENT ON COMMERCIAL GROUNDS
Of the £1,258k total revenue consequences of capital in the sector, £1,124k relates to the hub site, with £134k incurred annually at the non-hub site.
Revenue costs at non-hub sites
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Revenue costs at non-hub sites relate predominantly to the general surgery activity which has transferred to the hub site, where an element of the associated cost cannot be immediately removed at the non-hub (for example, overhead costs). These are ‘stranded’ costs.
Over time these stranded costs are expected to work out of the system. For example, reciprocal activity transfers driven by other system reconfiguration work currently in progress (including Devolution Theme 3) are expected to make use of non-hub site capacity.
The following table outlines the annual costs of Healthier Together at the sector non-hub site, Tameside General Hospital.
Table 7.4.10: South East sector revenue costs at non-hub site
Costs Total £’000
Income loss 5,782
Operating costs saved (1,822)
Excess of income loss over costs saved (stranded costs) 3,960
Cost of joint sector working at non-hub site 542
Revenue costs of capital at non-hub site 134
Total 4,636
Resolution of stranded costs in the South East sector is a significant challenge given the hub site, Tameside General Hospital, which is a small district hospital with a new PFI build that attracts significant overhead costs. Applying the agreed stranded costs methodology over 3 years the value of stranded costs are £8,437k, however there is a risk that the assumed mitigation of costs in the later years will not materialise. Work is on-going to identify opportunities to mitigate the stranded costs.
7.4.7 South East Sector Transitional Costs
Transitional costs relating to implementation have been categorised in the following manner:
Implementation Costs. This relates predominantly to preparatory works e.g. building design and site clearance
Project Management. These costs have been calculated on a post by post basis
Workforce. This relates to additional staffing required over and above 'business as usual' as the new clinical model embeds.
Transitional funding has been requested from the Greater Manchester Transformation Fund in February 2017. The outcome of this request is expected in March 2017.
Table 7.4.11: South East sector Transitional Costs
Cost
2017/18 £’000
2018/19 £’000
Total £’000
Implementation Costs 130 130
Project Management 403 380 783
Workforce 250 250
TOTAL 533 630 1,163
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There is a risk that non-contracted pay costs of up to £400k could be required non-recurrently pending the substantive recruitment of new staff. This figure represents the maximum estimate of the premium element of payments which may be required to secure appropriate staffing if providers are unable to recruit substantively. It is expected that this risk will be partially mitigated through both local and STP level action, and that any non-mitigated element will be funded locally in sectors
7.4.8 Funding Sources
Capital funding is being sought from public funding sources, as described in the Commercial Case.
Transitional funding has been requested from the Greater Manchester Transformation Fund.
The recurrent revenue impact of the programme at the hub site is not expected to be fully mitigated by the efficiencies anticipated by the programme. Consequently sector commissioners and the sector provider are in the process of agreeing how recurrent revenue pressures will be funded. The diagram below sets out the recurrent revenue funding sources identified in the South East sector to date.
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7.5 Appendix 5: North West Ambulance Service (NWAS) As outlined in the main body of this business case, the principles of the Healthier Together Model of
Care are outlined below:
1. Hospital services will be provided locally whenever possible. 2. Hospital services will be provided at a site specialising in certain types of care (e.g. general
surgery) when needed. 3. Hospital services will be provided to a defined standard. 4. Care will be consultant delivered. 5. Services will be provided over seven days with no deterioration in service provision at the
weekends. 6. Sites will collaborate in delivery of the in scope services through the single services model in
their sector. 7. Within each sector one site will deliver the in-patient services for high risk elective and high
risk emergency general surgical adult patients. 8. Within GM high risk patients with a medical or surgical pathology will where possible be
diverted directly to the most appropriate hospital site and will bypass their local A&E. For some conditions these receiving A&Es will serve the GM population, for others there will be a sector receiving A&E.
9. Sites undertaking high risk general surgery must have a co-located A&E. 10. Every site will have an Acute Medical Unit (AMU) and a Critical Care Unit (CCU).
7.5.1 The role of NWAS in the Healthier Together Model of Care
A number of pathways for emergency high risk patients are now fully embedded in Greater
Manchester through a partnership with the North West Ambulance Service (NWAS):
Patients with Major Trauma;
Acute myocardial infarction; and
Patients with a Stroke. Since the HT decision to implement four single services across Greater Manchester for general
surgical services, significant work has been undertaken to assess whether NWAS paramedics can
identify emergency general surgical patients for immediate conveyance to the general surgical hub
sites. An extensive audit showed that these patients do not present with symptoms that can be
identified in an ambulance and as such these patients will continue to be conveyed to the nearest
A&E as they are now.
Aligned to this:
Work has been undertaken to assess feasibility of a pathway for shocked patients with upper
gastrointestinal haemorrhage (GI bleed). National evidence suggests these patients require
endoscopy within 2 hours of their bleed. As such immediate conveyance and treatment to a
site capable of delivering this is essential. This additional pathway will be implemented as
part of Healthier Together.
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There are other medical conditions for which timely expert interventions will have significant
patient benefits, such as shock due to infection. In these cases, there will be benefit for
patients being conveyed directly from out of hospital to the high acuity sites. Assessing the
feasibility of such a pathway is now necessary.
Consequently, plans for the transfer of high risk emergency general surgical patients from non-hub
sites to surgical hub sites have been made. Each sector has identified the expected volume of high
risk patients who will require transfer. Please see the diagram below which shows the four sectors
and the expected activity flows of emergency general surgical patients which for the region is
estimated as approximately 6,800 patients. These transfers will be in addition to the current NWAS
activity of conveyances to, from and between these hospital sites.
Figure 7.5.1: HT four single services for general surgery patients
1,665NEL
1,260 NEL
1,942 NEL
1,980 NEL
1,665NEL
1,260 NEL
1,942 NEL
1,980 NEL
1,665NEL
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7.5.2 The Healthier Together transfer model
In order to determine the impact of these additional transfers, the level of acuity of these general
surgical patients (identified as needing to transfer to the surgical hub site), have been categorised
into:
1. Patient needs urgent surgery: immediate destination is the operating theatre at the surgical
hub site;
2. Patient may need surgery within the next 24-48 hours: immediate destination is an ICU bed
at the Hub;
3. Patient may need surgery within the next 24-48 hours: immediate destination is an HDU bed
at the Hub; and
4. Patient may need surgery within the next 24 – 48 hours: immediate destination is a surgical
ward bed at the Hub.
It is proposed that clinicians use these simple categories to determine the level of response from NWAS. Clinical discretion is expected to be used with escalation through this framework under certain circumstances. It should be noted that there may be a very small number of patients who are too sick for transfer i.e. needs an immediate ‘life-or-death’ laparotomy, with features that make this very time critical. Therefore, there will be some circumstances where clinical expertise, theatre space and critical care capacity are immediately available at a non-Hub site and the balance of risk precludes inter-hospital transfer (at any level of priority). This would be an exception and require clinical justification.
It is expected that further detail on the logistics of these transfers will be developed as guidance for the sectors in preparation for implementation, this will cover for example: which communication channels will be used, which clinician phones which clinician within the single service, where in the hospital the ambulance should arrives at, how patients are booked in, what happens if the patient deteriorates on the journey etc.
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7.5.3 The impact on NWAS
Work was then undertaken to determine whether these categories of acuity could be mapped to the current NWAS framework for inter-facility transfers or whether a new framework specific to Healthier Together patients was required. The current framework used by the North West Ambulance Service to categorise patients who require transfer between facilities is outlined in the tables below.
Table 7.5.1: NWAS inter-facility transfer framework
Transportation choices for patients
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The Healthier Together clinical champions were able to map the categories of emergency general surgery patients requiring transfer (based on acuity), to
this current NWAS framework. The table below maps these categories to the NWAS priority of transfer/ required response time.
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Table 7.5.2: Healthier Together categories of patients mapped to NWAS inter-facility framework
HT
Category
Type of patient requiring transfer NWAS response Type of vehicle and
crew
Transferring clinicians required
1 Needs urgent surgery: immediate destination is the
operating theatre at the surgical hub site
P1
8 minutes
EMT2 or above
Junior doctor (Anaesthetics)
RGN
2 May need surgery within the next 24-48 hours: immediate
destination is an ICU bed at the Hub
P2
19 minutes
EMT2 or above Junior doctor (Anaesthetics)
RGN
3 May need surgery within the next 28-48 hours: immediate
destination is an HDU bed at the Hub
P3a
1-2 hours
EMT2/VAS/UCS Not normally required
Qualified HCP if: IV needs changing/
infusions, infusion controllers or
syringe pumps running
4 May need surgery within the next 24 – 48 hours: immediate
destination is a surgical ward bed at the Hub
P3b
Within 4 hours
VAS/UCS Not normally required
Qualified HCP if: IV needs changing/
infusions, infusion controllers or
syringe pumps running
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Analysis has been undertaken to split the total number of patients transferring to the surgical hub
site within a sector, into these four categories. This will be outlined below once modelling is
complete.
Table 7.5.3 Breakdown of activity
Sector Total volume of
non-elective
patients
transferring
(per annum)
HT Category 1:
Needs urgent
surgery:
immediate
destination is
the operating
theatre at the
surgical hub
site
HT Category 2:
May need
surgery within
the next 24-48
hours:
immediate
destination is
an ICU bed at
the Hub
HT Category 3:
May need
surgery within
the next 28-48
hours:
immediate
destination is
an HDU bed at
the Hub
HT Category 4:
May need
surgery within
the next 24 – 48
hours:
immediate
destination is a
surgical ward
bed at the Hub
Data source Sector data NELA data17
Sector data Sector data Sector data
Manchester
and Trafford
Sector
1,665 13
Totals are estimates based on national reports as
unable to use the sector data provided. North East
Sector
1,942 7
North West
Sector
1,260 29
South East
Sector
1,980 11
Total GM 6,847 60 365 3,285 3,650
This analysis has been combined with data on the time and day of presentation so NWAS have been
able to model the impact in terms of any additional vehicle requirement and associated workforce
implications.
This modelling has been undertaking using the Optima Predict system, which is a complete strategic
planning solution designed specifically for emergency services. It is a simulation based tool that
enables operations and planning personnel to model scenarios, through simulation of responses to
emergency incidents alongside sophisticated statistical and geospatial analysis.
The additional ambulance requirements for the Healthier Together activity, as per the OPTIMA
modelling were 3 x EA (Emergency Ambulance) resources, for 7 days per week, on a shift pattern of
10.00- 18.00 hours per day.
17 Based on last annual NELA audit (Year 2: 1st December 2014 - 30 November 2015), % of cases in
the <2 hours operative urgency category
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This was costed out by NWAS Finance as follows:
Table 7.5.4: Cost of required investment
Cost allocation 17/18 Annual cost
Pay Costs (Staffing including Relief and Clinical
Supervision)
£459,400
Annual Running Cost (Depreciation, Insurance,
Airwave, Sat Nav etc)
£158,700
Non Pay Costs (Vehicle lease, Medical & Surgical
Equipment, Fuel, Drugs, Consumables etc)
£55,000
Contribution / Overheads £156,200
Total annual cost of scheme £829,300
7.6 Appendix 6: Review of updated economic case against DMBC
The following appendix provides a detail review of the revised economic case compared with the
economic case as described in the DMBC to determine whether the option selected at the DMBC is
still the most appropriate option or whether the options appraisal needs to be re-opened.
7.6.1 Capital
The capital costs in the DMBC and the revised capital costs are as follows:
Table 7.6.1: Capital Cost in DMBC
£’000 DMBC FBC % Change Commentary
Capital 63,330 63,347 0.1% Consistent with the DMBC
The revised capital costs are within 5% of the DMBC figure, therefore this movement is not
considered material.
7.6.2 Revenue costs
The revenue costs fell into three main categories in the DMBC, namely:
Transitional costs
Additional cost of delivering the standards
Ambulance service costs To assess changes from the DMBC the costs have been reviewed under the same categories.
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Transitional costs
Table 7.6.2: Transitional Costs
Revenue – Transitional £’000
DMBC FBC Commentary
IT Cost 1,000 - IT costs relating to the implementation of DataWell have
already been funded or are expected to be met through the
GM Digital Fund. As the DataWell IT solution is already being
progressed across Greater Manchester to support the
provision of a number of different clinical services, the costs
of DataWell implementation have not been attributed to the
Healthier Together business case.
Implementation Cost 6,000 6,598 In line with the OBC. Relates to £1.91m of Implementation Cost and £4.68m of PMO costs across sectors and centrally.
Ambulance Cost 450 - Lower than the OBC - anticipated ambulance costs related to the development of the general surgery pathfinder. As this is no longer considered clinically viable, this development cost will not be incurred.
Workforce 4,100 4,130 In line with the OBC.
Revenue Cost of capital 1,791 At DMBC stage revenue consequences of capital were valued but were not classified alongside other Implementation Costs.
TOTAL TRANSITIONAL COSTS AS ENVISAGED AT DMBC
11,550
12,519 There has been 8% increase from OBC, due in the main to the inclusion of the revenue cost of capital figure, which has now been quantified.
This table does not include the stranded costs or non contracted pay costs, on the basis that these costs are expected to be fully or partially mitigated.
There is a risk that stranded costs would arise if the loss of general surgery income at a non- hub site
could not be matched by the immediate removal of equivalent cost (for example, overhead costs).
Stranded costs over 3 years have been calculated (using a consistent methodology across Greater
Manchester) as being a maximum of £18.5m. Organisations will continue to work together at both
local and STP level to mitigate these costs as far as possible. Funding sources have been identified to
underwrite the majority of stranded costs should these eventuate. Greater Manchester is currently
reconfiguring more than half of its acute services under Devolution and there is genuine opportunity
to address this, although a residual risk remains that stranded costs could remain after the first three
years following the service transfers. Work will continue in the relevant sectors to ensure all
stranded costs are addressed within the first three years.
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There is also a risk that non-contracted pay costs of up to £5.0m could be required non-recurrently pending the substantive recruitment of new staff. This figure represents the maximum estimate of the premium element of payments which may be required to secure appropriate staffing if providers are unable to recruit substantively. It is expected that this risk will be partially mitigated through both local and STP level action, and that any non-mitigated element will be funded locally in sectors.
Additional costs of delivering the standards
Table 7.6.3: Additional Costs of Standards
Cost Category DMBC £’000 FBC £’000 Comment
Consultant workforce
cost
8,926 4,880 A high estimate of consultant cost was used at
OBC which has subsequently been refined to a
more realistic figure. In addition, baseline
consultant numbers have changed since the time
of the DMBC.
Other staff cost Not quantified
8,202 The non-consultant workforce requirement was
not quantified in the OBC, as the non-consultant
cost avoided is in proportion to the number of
sites designated as hub sites and therefore on a
cost-avoidance basis the non-consultant
workforce cost would not have impacted on the
decision made.
Revenue consequences
of capital
4,999 5,752 The OBC estimate has been refined and reflects
some shorter asset lives driving a higher initial
annual revenue consequence of capital.
Total 13,925 18,834 The main reason for the increase is the inclusion
of the ‘Other staff’ costs which were not
quantified for the DMBC. Other revenue costs
are lower then forecast in the DMBC.
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Ambulance costs
Table 7.6.4: Ambulance Costs
Ambulance costs £’000 DMBC FBC % Change Commentary
Ambulance costs Not quantified
829 Not a change in scope, was never costed in DMBC. Narrative was included in DMBC which concluded the difference between the costs for 4 or site hub site would not be material and would not affect the decision. Cost has now been provided by NWAS for the proposed clinical model.
7.6.3 Conclusion on DMBC decision
From the review detailed above nothing has been highlighted that would indicate that the decision made at the time of the DMBC has changed by such a material amount that would mean that the decision made by the Committee in Common in July 2015 is no longer valid. On this basis it had been concluded that option 4.4a is still the preferred option for the Healthier Together programme.
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7.7 Appendix 7: Anticipated efficiencies and valued benefits
7.7.1 Purpose of this appendix
This appendix details the anticipated efficiencies expected as a result of the Healthier Together
clinical model, and explains how these efficiencies have been valued for the purposes of the
business case. The values are for illustrative purposes only and have not been included as benefits in
the economic case.
The appendix contains:
Overview of anticipated efficiencies
Methodology used to quantify efficiencies
o General Surgery Length of Stay
o General Surgery readmissions
o A&E admissions
Potential impact of each efficiency by sector
Risks to the quantification of the efficiencies anticipated
7.7.2 Overview of anticipated efficiencies
The key efficiencies anticipated as a result of the Healthier Together clinical model are summarised
below.
General surgery: reduction in length of stay. It is expected that length of stay will reduce for
general surgery patients due to improvements in clinical care, particularly the improved
availability of senior clinicians to assess, treat and discharge patients in a timely manner. Length
of stay for each in-scope HRG is expected to reduce to national upper quartile performance.
General surgery: reduction in readmissions. Improvements in clinical care are expected to lead
to a reduction in readmission rates for general surgery patients. Readmissions for each in-scope
HRG are expected to reduce to national upper quartile performance.
A&E: reduction in admissions. Improved availability of senior decision makers early in the
patient journey is expected to reduce avoidable admissions to national upper quartile
performance.
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7.7.3 Methodology used to quantify efficiencies
General Surgery length of stay
It is expected that length of stay will reduce for general surgery patients due to improvements in
clinical care, particularly the improved availability of senior clinicians to assess, treat and discharge
patients in a timely manner. The methodology followed to quantify this efficiency is set out below.
Identify typical spells
General surgery activity has been split into two types:
Typical spells. A typical spell is one where the spell length of stay is within the trim point for
the condition (HRG) being treated. In simple terms, typical spells tend to reflect an acute
phase of care.
Atypical spells. An atypical spell is one where the length of stay is greater than the trim point
(with a length of stay in excess of two standard deviations from the national median). These
spells are considered to be atypical with associated excess bed days. In simple terms, in many
cases the excess bed days reflect time in which the patient is no longer in the acute phase of
care but cannot be discharged for other reasons, often outside the control of the hospital,
such as lack of access to intermediate beds or a requirement for social care assessment. No
length of stay reductions are expected relating to atypical spells.
Compare length of stay by HRG for typical spells to national upper quartile performance
Typical spells have been identified by analysing 2015/16 general surgery activity at HRG level at each
provider. For each HRG by point of delivery, average typical spell length has been compared to
national 2015/16 top quartile performance for length of stay. (Specialist acute providers were
excluded when calculating national benchmarks.)
Where HRG length of stay at the local provider is currently higher than the national benchmark,
it is assumed that length of stay will reduce to benchmark once Healthier Together has been
implemented.
Where HRG length of stay at the local provider is currently lower than the national benchmark,
no change is expected.
This is illustrated by the diagram overleaf:
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Figure 7.7.1: Illustration of the methodology used to calculate efficiency improvements in Length of Stay for Typical Spells
Calculating Length of Stay efficiency improvements for Typical Spells
Best Performer e.g. 2 days
WorstPerformere.g. 6 days
Top Quartile
F
D
C
B
A
E
Lower QuartilesFor those spells with a LoS in the less than the
75th percentile, it is assumed LoS can be reduced to that of the 75th percentile (top quartile)
Top QuartileAssumed no
change in LoS
75th
Percentilee.g. 3 days
KEY:
Average LoS (days) for typical spells for the HRG in question
Hospital A
Hospital B
Hospital C
Hospital D
Hospital E
Hospital F
This methodology derives an anticipated total number of bed days saved for each provider.
Quantify the financial impact of the bed days saved
The impact of the reduction in general surgery length of stay is expected to be twofold.
Reduction in bed capacity required. Assuming 85% inpatient bed utilisation, the anticipated
bed days saved have been converted for each sector into an expected bed capacity saving. This
mitigates the capital requirements in the hub sites.
Recurrent revenue benefit. Each bed day saved will have a revenue benefit to providers. This
relates to staff time savings and also reductions in variable costs. The revenue impact is
estimated at £250 per day, based on the 2015/16 excess bed day tariff.
A number of sectors have made significant quantified improvements in general surgery length of
stay during 2016/17 as part of local CIPP initiatives. The bed days already saved through these
schemes have been removed from the calculations described above, to avoid double counting.
General Surgery readmissions
Improvements in clinical care are expected to lead to a reduction in readmission rates for general
surgery patients. The methodology followed to quantify this efficiency is set out below.
Calculate current local and national readmission rates
2015/16 activity data has been analysed by provider, POD and HRG to calculate emergency
readmission rates within 28 days of discharge from general surgery. Any combinations of
provider/POD/HRG containing small numbers, i.e. fewer than 5 spells, were excluded from this
analysis.
Compare readmissions by HRG to national upper quartile performance
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For each HRG by point of delivery, average readmission rate has been compared to national 2015/16
top quartile readmission rate. (Specialist acute providers were excluded when calculating national
benchmarks.)
Where HRG readmission rate at the local provider is currently higher than the national
benchmark, it is assumed that readmissions will reduce to benchmark once Healthier Together
has been implemented.
Where HRG readmission rate at the local provider is currently lower than the national
benchmark, no change is expected.
Quantify the financial impact of the bed days saved
The impact of the reduction in readmissions has been financially quantified by multiplying the
number of readmissions avoided by a low rate 2015/16 surgical tariff of £1,250.
A&E admissions
Improved availability of senior decision makers early in the patient journey is expected to reduce
avoidable admissions to national upper quartile performance. The methodology followed to quantify
this efficiency is set out below.
Calculate current local and national A&E admission rates
A&E admissions are defined as the percentage of emergency admissions via Type 1 A&E over the
total Type 1 A&E Attendances. Local provider performance for 2015/16 has been calculated using
this methodology.
National top quartile performance has been calculated based on 2015/16 data from acute providers
with a Type 1 A&E.
Compare local A&E admissions to national upper quartile performance
Current emergency type admissions at each provider were compared to expected admissions at
national upper quartile admissions rate. From this a number of avoidable admissions has been
derived for each provider.
Quantify the financial impact of the admissions avoided
The impact of the reduction in admissions has been financially quantified by multiplying the number
of admissions avoided by a low rate 2016/17 inpatient tariff for non-elective low level HRGs of £509.
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7.7.4 Impact of each efficiency by sector
General Surgery length of stay
Table 7.7.1: General Surgery Length of Stay
Sector Bed days saved Number of beds Recurrent Revenue Benefit (£’000)
MAT*** 6,216 20 £1,493
NES 2,260 7 £542
NWS* ? 2 £387
SES** - - -
TOTAL 10,410 30 £2,422
* The North West sector have calculated anticipated efficiencies locally using a different
methodology to that used in other sectors.
**The South East Sector have not quantified any length of stay efficiencies, and question whether
the new clinical model will lead to any change in length of stay.
*** In the MaT sector, the two organisations continue to be actively engaged in pulling together
cost benefits analysis, long term financial plans and the business case to deliver Single Hospital
Services (SHS) i.e. a merged organisation, and a Local Care Organisation (LCO) for Manchester.
Within these two programmes of significant change full consideration has been given to efficiencies
to deliver future financial plans, including efficiencies arising from LOS, early discharges and
admission avoidance. These efficiencies are planned to be delivered over a period of time
commencing 2018/19 i.e. post-merger.
Factoring in the impact of a new HT Ambulatory Care model at the non-hub site, which would avoid
unnecessary admissions needing to be transferred to the hub site, the net in patient activity to
transfer equates to approximately 38 inpatient general surgery beds. This equates to two additional
wards, one 24 bedded ward and the second ward within which 14 beds would be utilised for HT
activity. Applying efficiencies to just the HT activity transferring (starting May 2018) should, over
time, result in a requirement for 6 fewer beds. However the remaining requirement of 32 beds still
equates to two new wards, the second of which would eventually have only 8 beds utilised for HT
activity. CMFT has undertaken extensive exploratory analysis to ascertain whether 8 beds of surgical
activity could be accommodated within the existing bed capacity without impacting on current
operational delivery performance (thereby preventing the eventual need for a second ward build).
However, this has proved not to be possible.
As part of the wider application of the HT standards and expected efficiencies to the entire general
surgical activity at the hub site (not just that transferring from the non-hub), the potential total bed
reduction identified is 14.3 beds, realised over several years . This exercise has been undertaken
using the HT modelling of upper quartile LOS and bed occupancy of 85%. However, in the
meantime, on commencement of the activity transfer, a minimum of one full ward is required (24
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bedded) with an additional second ward also immediately required to deliver general surgical
services to patients utilising a minimum of 14 beds. It is recognised that over a period of time, due
to HT efficiency savings plus opportunities afforded from the wider LOC and SHS agendas, the overall
bed requirement is likely to reduce as described above however, at this time, in order to deliver the
HT standards and the new model of care, two new ward builds are required.
General Surgery readmissions
Table 7.7.2: General Surgery Readmissions
Sector Readmissions avoided Recurrent Revenue Benefit (£’000)
MAT 311 £388
NES 501 £626
NWS* 33 £10
SES 292 £365
TOTAL 1,137 £1,389
* The North West sector have calculated anticipated efficiencies locally using a different
methodology to that used in other sectors.
A&E admissions
Table 7.7.3: A&E Admissions
Sector Emergency admissions avoided Recurrent Revenue Benefit (£’000)
MAT 15,406 £7,842
NES* - -
NWS 13,684 £6,965
SES 8,102 £4,124
TOTAL 37,192 £18,931
*The North East Sector currently performs within the national top quartile for A&E emergency admissions, meaning there is no benefit to be expected from the HT clinical model relating to A&E admissions.
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7.7.5 Consolidated revenue benefits
The total revenue impact of the three valued benefits across the sectors is summarised below.
Table 7.7.4: Total Revenue Impact
£’000 General Surgery Length of stay
General surgery Readmissions
A&E Admissions Total revenue benefits
MAT £1,493 £388 £7,842 £9,723
NES £542 £626 - £1,168
NWS £387 £10 £6,965 £7,362
SES - £365 £4,124 £4,489
TOTAL £2,422 £1,389 £18,931 £22,742
7.7.6 Risks to the quantification of the efficiencies anticipated
There is a risk that the benefits anticipated by Healthier Together are also expected in other
schemes, leading to double counting.
Efficiencies relating to reducing A&E admissions have been assumed in isolation. Locality
schemes, which are at an emergent stage across Greater Manchester, also project A&E
efficiencies and consequently there is a risk that benefits may be double counted across the
system.
The business case for the Shared Hospital Service in the Manchester and Trafford Sector
(MAT), would provide the means by which many of the efficiencies would be realised,
therefore there is a risk that length of stay benefits may be double counted if both schemes
go ahead. Further work is required to establish the appropriate allocation of benefit.
