Enclosure 8

STRATEGIC SERVICE DEVELOPMENT PLAN

2008/2009

To be reviewed July 2009

1. INTRODUCTION

The Strategic Service Development Plan (SSDP) sets out the framework for development of primary and community care services in Stoke on Trent. It outlines the PCT response to the White Paper “Our Health, Our Care, Our Say” and the 2007 Lord Darzi Next Stage Review of the NHS. It also sets out the development of the community component of the Fit for the Future (FftF) strategy and the service model being developed within Stoke-on-Trent.

The PCT Board have agreed that the SSDP will be reviewed annually. This is the update of the 2007/8 SSDP which was approved by the Trust Board in July 2007. The intentions and commitments made in the July 2007 SSDP have not changed, however during the past year, a number of new national and local policies and initiatives, such as the Overarching Vision for the local health economy, the PCT Assurance Framework which underpins Fit for The Future and the national Lord Darzi recommendations for service development, have emerged which will impact on the way ahead for services as described in the 2007 SSDP. Where this is the case, these have been highlighted in the plan. The PCT is in a good position to respond to these initiatives as the SSDP and Fit for the Future developments are in line with and in advance of emerging national direction.

The PCT formally consulted on the SSDP between January and April 2007 the results of which were considered by the Board in May 2007. The final SSDP, published in July 2007, reflected the outcomes of the consultation. The main themes and concerns raised can be viewed in the consultation evaluation report on the PCT website at www.stokepct.nhs.uk

Considerable work has been carried out in the last year on the recommendations from the consultation and in particular on the ongoing public engagement in the development process. A clear process has been agreed with the Stoke Health Overview and Scrutiny Committee for the development of individual schemes who have supported a process of local active engagement on each scheme rather than a formal consultation for each scheme. Detailed public engagement is therefore being carried out, an example of which is for the planned development in Cobridge.

The PCT is a partner within a LIFT (Local Improvement Finance Trust) company which covers Northern Staffordshire. The LIFT is the PCTs major vehicle for the development of new primary and community care centres. Within LIFT, the PCT is a part of a legal Strategic Partnering Agreement consisting of the following organisations:

Stoke On Trent PCT North Staffordshire PCT

North Staffordshire Combined Healthcare NHS Trust

Newcastle Borough Council

Stoke on Trent City Council

Staffordshire County Council

What does the SSDP mean for patients?

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http://www.stokepct.nhs.uk/

The PCTs overall aim is that access to services is improved and that patients and users are seen in the most appropriate place.

The new centres and services will be developed so that:

- they improve geographical access;- they increase the range of locally based specialities;- they can be accessed in a more flexible and timely manner.

For example, patients with diabetes may currently have to visit the consultant, GP, practice nurse, podiatrist and dietician at different times and in different locations. Many of the new centres will enable the establishment of “one stop” services so that the person can see all the professionals involved with their care at one visit. The service could also link to the Expert Patient Programme and the local Diabetes UK group. This model could be developed for other long-term conditions such as coronary heart disease and respiratory disease

A referral from the GP in future would mean that a patient is seen at one of the centres either by a consultant or by a GP with a special interest in that condition. Or the outpatient visit following an admission to hospital could well take place more locally. Other outpatient follow-up, such as physiotherapy, could also be provided at the centres.

When planning and commissioning new services in the centres the PCT will also review whether there is a need for these to be provided in the evenings or at weekends to improve access.


2. THE CITY OF STOKE-ON-TRENT

2.1 The city and its key aims

The city of Stoke-on-Trent is located in the north of the West Midlands region and is a unitary Local Authority. Stoke-on-Trent City Council is responsible for a range of local services, including social services. In October 1st 2006, Stoke on Trent Primary Care Trust was created which shares the same geographical boundaries as the City Council. The PCT is responsible for commissioning all health services for its 247,000 population.

Stoke-on-Trent has been identified as a pathfinder city (one of only 9 cities in the country) for housing market renewal. This involves a programme of significant housing redevelopment over the next decade in specific areas across the city. These ‘areas of major intervention’ are the focal point of detailed planning to improve the housing stock and the services for the community. The process of regeneration is being led by an organisation called RENEW which works closely with the City Council.

Stoke-on-Trent City Council launched a community strategy in 2004 which outlines the main areas of improvement needed for the city and aims to make Stoke-on-Trent:

a Healthier City a Safer City a Wealthier City a Greener City a Learning City a City With a Strong Sense of Community

Through the Local Strategic Partnership, the PCT is committed to working with its partners to help deliver this shared vision and in particular to ensure that Stoke-on-Trent does become a healthier city.

2.2 The health of the population

Each year, the Director of Public Health for the PCT produces an annual report on the health of people living in Stoke-on-Trent. It outlines the progress being made in improving the major health outcomes experienced by the residents of the city.

In general the health of people in Stoke-on-Trent is improving but that improvement is not sufficiently fast enough to close the gap between Stoke-on-Trent and the rest of the country. In fact, the gap appears to be getting bigger.

Improvements in life expectancy and reductions in infant mortality are key areas which will make the most difference to overall health in Stoke on Trent.

There is a well established link between deprivation and ill health. In 2006, the City Council published its neighbourhood renewal strategy. It described the neighbourhoods within the city ranking them against various deprivation indicators with health as a specific indicator. It then brought all the factors together to show the overall outcome. Appendix 1 indicates the position of the various areas within the city in the Local Index of Deprivation for 2006. This shows that the neighbourhoods with the poorest scores on health deprivation and disability are:


Burslem Abbey Hulton Cobridge/Forest Park BentileeShelton North and EtruriaNorthwoodBlurton and NewsteadMiddleport and Longport SmallthorneLongtonMeir North Hanley East and Joiners SquareMeir South BradeleyBerryhill and Eaton Park

2.3 Integrating planning

In order to improve the integration of local planning and service provision the PCT, the City Council, Staffordshire Police and other bodies have agreed that services will increasingly be organised in five neighbourhoods across the city. These areas are:

North Tunstall, Chell, Packmoor, Norton, Bradeley, Burslem North.

West Burslem South including Longport, Middleport, Hanley (City Centre), Etruria, Shelton, Cobridge, Sneyd Green.

East Bentilee, Abbey Hulton, Bucknall, Baddeley Green, Milton, Smallthorne.

South East Longton, Meir, Weston Coyney, Blythe Bridge.

South West Fenton, Blurton, Hartshill, Trentham, Stoke

It should be acknowledged that there will be services that must still be organised on a wider basis either due to low numbers of users or because there is a scarcity of specialist workforce skills. Establishment of the neighbourhood “hubs”, as described in Section 5 will create a network of services across the city improving access to these services and patients will be able to choose the centre which will be the most appropriate for delivery of their care.

Within this framework organisations will be able develop services which respond to the needs of the local population. For the PCT this has led to the general alignment of the Practice Based Commissioning clusters with the neighbourhoods.

Working in partnership with the local authority and others is fundamental to improving the health and well being of the people in Stoke-on-Trent and the PCT will take every opportunity to develop premises in conjunction with partners.



3. MODERNISING SERVICES IN STOKE-ON-TRENT

3.1 National Strategic context

In January 2006, the government White Paper called “Our Health, Our Care, Our Say” outlined how health services are expected to develop over the next decade. The document identifies 5 key areas for change:

more personalised care services closer to people’s homes better co-ordination with local councils increased patient choice a focus on prevention rather than cure

Put simply, the White Paper expects local PCTs to show how they will move as many services as possible and appropriate from the hospital (acute) setting into the community where they can be provided close to where people live. Due to changes in clinical skills and technology, services can increasingly be delivered at a local level. Any services which do not require the high levels of intervention that the acute hospital provides should be delivered in the community. It is important to note that services that are best provided in hospital will continue to be provided there.

The White Paper also states that local organisations need to ensure better integration of services, particularly across health and social care. This includes coordination and integration of voluntary sector and private sector agencies (e.g. nursing and residential homes), as well as social services and health services.

More recently Lord Darzi has spearheaded a national programme of work to look at the redesign of care across eight clinical pathways and set out significant investment for areas, such as Stoke on Trent, where ratios of GPs to patients are unacceptably high. The West Midlands Strategic Health Authority has launched a regional strategy for health improvement ‘Investing for Health’ and the Northern Staffordshire health economy has set out its Overarching Vision for service development within the area. All of these reinforce and move forward the strategic intentions within ‘our Health Our Care Our say’.

In early 2008 the PCT produced a framework for the development of Primary Care services – in particular for General Practice services. This sets out plans to achieve excellence in Primary Care and improve the detection and diagnosis of disease. Whilst this will reduce level of unmet health need it may also increase the impact on service provision in primary care services. This will need to be taken account of in the planning of individual service and premises developments

3.2 Local reasons for change

3.2.1 Impact of the Fit for the Future (FFtF) Strategy

The Fit for the Future (“FftF”) strategy published in 2000 set out a vision for a major shift of services into primary and community settings linked to the development of a new acute hospital to replace the Royal Infirmary and City General Hospitals and a new community hospital to replace the Haywood, Stanfield and Westcliffe Hospitals. The business case sets out specific targets for the transfer of services to primary care settings to ensure that the new hospital which, as a consequence, will have


fewer beds, can meet the demands for its services when it is fully open in 2012/2013

Outpatients

By 2012/2013 of a projected 280,000 first and follow-up consultant-led outpatient attendances, 43% will be delivered in community settings. For Stoke-on-Trent provision has been planned for 64,000 outpatients of which approximately 14,000 are new referrals and 50,000 are follow ups.

There are assumptions about the mix of outpatient transfers. For example it is assumed that all outpatient activity related to diabetes is delivered in the community; all activity related to cardiothoracic surgery is delivered in the hospital.

The PCT is also making provision for other outpatient services that are not included in the above numbers, such as sexual health services and TB clinics as well as for others such as the INR (warfarin) clinics and those run by other professionals such as nurses and physiotherapists.

The business case does not identify who will deliver these services; some may be delivered through clinicians with a special interest; others through University Hospital North Staffordshire (UHNS) staff working in new ways in new locations; others through the Independent Diagnostic and Treatment Centres or Primary and Community service providers

Intermediate Care

With the development of services since the publication of the FftF strategy the opportunity has been taken to reassess the level of intermediate care services that are needed to support the proposals. The assumption for 2012/13 is that there will be a demand for an additional 45 intermediate care beds and 49 home-based intermediate care places to be in place within Stoke on Trent. This is building upon the existing investment in these services. It will provide the opportunity for health and social care integration of intermediate care services through the Healthy Communities and Older Peoples section of the Local Area Agreement.

Urgent Care

Urgent care services are being redesigned in conjunction with North Staffordshire PCT with the aim of ensuring that only those people that require admission to an acute hospital bed are admitted. New care pathways are being set up for improved intervention in primary care and a new Primary Care Urgent Care service adjacent to Accident and Emergency at UHNS was established in 2007.

Further initiatives to include extension of diagnostic services in community hospitals and the development of Primary Care Assessment Centresand locality-based minor injury units are under development within the City.

3.2.2 GP recruitment and retention

The GP is usually the first point of contact with the NHS and improvements to both the recruitment of GPs and practice premises will build confidence in local services.


It has been historically difficult to recruit GPs to practices in Stoke-on-Trent and the City has been identified as being in the 15% most under doctored areas in the country as measured by number of GPs per patient. This means that GPs are often dealing with a higher list size than desirable. During 2007 the PCT was allocated additional funding to open 2 brand new GP practices to improve access and reduce the number of patients per GP in the local area. The location of these is in line with areas outlined for priority improvement in the SSDP.

In Stoke-on-Trent, there is a significant number of GPs who could retire in the next 5 - 10 years. For those in inadequate premises, succession planning is key as the PCT is unlikely to let new service contracts to GPs in sub-standard or unsuitable premises.

Over time the new medical school will produce doctors who will remain in the local area. This will assist in the numbers that are available and who, more importantly, have trained within the existing practices in Stoke-on-Trent. Whilst there is still work to do, recruitment is not as big a risk as it was three to five years ago.

3.2.3 Recruitment, training and retention of other primary care clinicians

Although premises alone do not solve recruitment problems, there is evidence that a modern infrastructure and services does help to attract new GPs to an area. A better quality of working life in a modern building is cited as one of the reasons GPs select a practice. A further factor is the ability to work with the wider primary care team based in the premises to provide extended primary care services. Being able to enable individual GPs to develop their own specialist activities, which in turn extends the range of services available in a practice for its patients is also important.

Alongside supporting GP recruitment and retention there is a parallel need to train, recruit and develop other primary care clinicians. To do this more suitable teaching and training premises are needed in the City and it is essential that the premises create a suitable learning environment for the students with the appropriate facilities being in place. The new premises are being built with the ability to provide flexible teaching and training.

3.2.4 Condition of GP premises, health centres and clinics

Overall the quality of the current primary and community care infrastructure is poor. The PCT’s clinics and health centres are generally over 30 years old and either require significant investment or replacement as they are not designed to deliver new styles of service or, in certain cases, to meet current clinical guidelines.

Although some practices have invested in modern premises many GPs and their staff still operate from inappropriate converted residential accommodation that does not meet current guidelines, does not support the development of the primary care team and is not capable of being brought up to 21st century standards.

Until recently investment in premises had been limited but the PCT has now opened three brand new centres in Packmoor, Fenton and Shelton under the LIFT programme and a joint centre with the City Council in Bentilee. Building of the new community hospital on the Haywood site has started.


3.2.5 Other primary care contractors

3.2.5.1 Dentistry

The new dental contract was implemented on 1st April 2006. For the first time, this gives the PCT the ability to commission services where they are most required. A Dental Development Plan is in place which highlights current provision and the ongoing need to improve access to regular routine care in the City. This has informed the Oral Health Commissioning Strategy which is being considered by the Trust Board in July 2008.

In terms of premises, there are a number of current premises that are not, or will not be, fit for purpose in the future. The PCT will seek to support improvements and also explore the possibility of co-location with other services where there is a need to improve both premises and access to NHS dentistry.

3.2.5.2 Pharmacy

The PCT has a Pharmaceutical Needs Assessment which indicates that all areas of the city appear to be adequately served in terms of standard pharmaceutical provision (e.g. dispensing of prescriptions). However, in line with the recent White Paper, the PCT wishes to expand the role of Community Pharmacies, increasing their involvement in advice and basic disease management.

The PCT wishes to improve ease of access to community pharmacy services for patients and will seek to co-locate community pharmacies with new premises developments where this is felt to be appropriate. This should also improve the joint working between the Pharmacy and GP practices, resulting in improved quality and a better patient experience. These new premises should also support pharmacies in increasing the range of services they will provide for patients.

3.3 Other factors

3.3.1 RENEW and housing developments

The RENEW programme is reshaping the provision of housing within the city with significant movements in the location of new developments. This is coupled with other housing developments that fall outside the RENEW agenda, for example on the Royal Infirmary hospital site when this is released. In certain of these areas the primary care infrastructure is either non-existent currently or, whilst present, does not have the capacity to deal with a greater number of patients. The people living in these areas will be a mix of those relocating within Stoke-on-Trent and those who are attracted to the city on the back of these developments. Whilst the internal movement means that some practices may lose patients this will help to move their lists towards more appropriate size rather than necessarily releasing resource to be used elsewhere. The PCT will need to take this factor into account when determining its future developments.


4. THE MODEL OF CARE

To respond to the changing agenda the PCT is developing services based upon a four tiered model of care which has been adopted across the local health economy.

Tier 1 - Self-Help and Prevention Services

This level is about health promotion, prevention of ill-health and supporting individuals to manage their own conditions. It is about the provision of information, interventions and support in a variety of ways. It does not lie within the remit of one group of staff to deliver this and services may be provided from a number of community locations or even at home.

Services at Tier 1 are aimed towards particular individuals, conditions or geographical areas and typically focus on health and well-being, both physical and mental, as well as the maintenance of people within their own home environment. Services may include exercise programmes, weight management, Expert Patient Programme self management of long term conditions; Health Trainers and screening services. Interventions may also include providing information to the general public, patients or carers.

Tier 2 - Primary Care and Community Services

This tier of services includes those that have traditionally been delivered in primary care in the community. Over the past twenty years, GPs, dentists, pharmacists, optometrists, community nursing and therapy staff have been undertaking a wider range of activities within local centres. GPs for example offer services which now include minor surgery, diagnostics such as blood tests, electrocardiographs (ECGs) and follow up of patients after surgery (e.g. removal of sutures). Over the next decade, this range of services will expand further, particularly in the management of long term conditions and identifying and managing those at risk of suffering from a long term condition.


Tier 1 – Self Help & Prevention

Tier 2 – Primary Care & Community Services

Tier 3 – Specialist Primary & Community

Tier 4 – Acute Services

More people are living longer with chronic conditions such as diabetes, respiratory problems, heart disease etc. as well as mental health problems such as depression. It is not necessary for people with these conditions to visit the hospital as a matter of routine now. GPs and other primary care services are undertaking more and more work in primary care to help people manage at home. GPs, nurses, therapists and other primary and community staff are also specialising in particular conditions such as diabetes so that they can help patients to manage their condition more effectively.

Tier 3 – Specialist Primary and Community Services

This Tier describes the provision of specialist services in a primary care setting such as outpatients, intermediate care, rehabilitation, specialist nursing and therapy services and diagnostic services. The emphasis at tier 3 is on those services that previously would have been provided in the acute setting but should be based in the community.

Primary and community care services will need to be capable of responding to this change in emphasis. One of the major changes will be that, unless there are very positive reasons for remaining in the hospital’s care, follow up treatment after admission to hospital, will be delivered in the community, whereas in the past this would have been delivered at the hospital.

Due to changes in skills and technology, diagnostic tests that once were provided by the hospital can now be carried out at Tiers 2 and 3 and it is expected that this trend will continue into the future. For example, the need for an ultrasound scan used to mean a visit to the hospital; new equipment plus staff training means that this can now be done in a primary care centre. There will still be a need for referral to the hospital for certain tests but the follow up may be provided locally.

Tier 4 – Acute Services

This Tier describes services which will continue to be provided in acute hospitals due to the complexity of care needed or specialist skills and facilities required.

The University Hospital of North Staffordshire with its range of secondary and tertiary services will continue to be the main acute hospital used by people from Stoke-on-Trent. However, as patients become more aware of the possibilities under the Patient Choice policy they will choose to use other hospitals over a wider geographical area.

5. MODEL OF SERVICE DELIVERY


The PCT will develop its services based upon the Neighbourhood Management Areas. This framework of 5 areas will enable the PCT and its partner organisations to plan, commission and deliver services at a more local level than they currently do. In order to do this, the PCT is following a “hub and spoke” model of facilities within each area. This means each of the 5 areas will have one facility which delivers Tier 3, services locally and will also have a range of facilities to deliver Tier 2 and Tier 1 services

Establishment of the “hubs” will create a network of Tier 3 services across the city improving access to these services. Patients will be able to choose the centre which will be the most appropriate for delivery of their care.

The PCT has developed a primary care strategy which gives a clear commitment to improving the quality of all services. This expands on the service model set out in this SSDP and sets out how the PCT in conjunction with Practice-based Commissioning Clusters (PBC) will commission high quality Tier 1, Tier 2 and Tier 3 services for the local population. This document, together with other related strategies will inform the approach to be adopted in service commissioning.

The hub and spoke model has three levels and is described in Diagram 1 and Table 2. The relationship of centres to the tiered model of care is shown in Diagram 2.

5.1 Level 3 – Locality Centres

The PCT are commissioning 5 centres that will form “hubs” within the network of services to be developed. These centres will sit between the services provided by the Level 2 centres (described below) and acute hospital services. Although Level 3 centres may have GP services in them, the emphasis will be upon Tier 3 services based in the community and serving a larger population of between 50,000 and 100,000. The reasons behind this may include:

The need to have sufficient numbers of patients to support the development of the service;

The need to have inpatient beds in some centres that have the full range of support required;

The need to use specialist staff skills effectively coupled with a relatively low number of patients;

The level of investment required in equipment and the need to ensure that it is fully used.

The following examples demonstrate how this may work.

The PCT will establish outpatient services in the community. To ensure that these can run on a planned and regular basis will need a consistent level of patient referrals which will come from a larger population. So, for example, the centre in Shelton will be the base for follow up appointments after orthopaedic surgery with the medical input either from a GP with a special interest (GPSI) or a consultant orthopaedic surgeon.

The PCT is developing its inpatient beds for intermediate care either to support patients being discharged from the acute hospital or for patients that are taken ill at home but do not need admission to the acute hospital. The beds need to have the support of the appropriate nursing, therapy and medical staff and thus the centre needs to be of a certain size.


To date, nail surgery has been carried out by podiatrists in the hospital when it could be done in the community with appropriate provision. There are about 600 referrals per year or 12 per week. It is thus more practical to base the staff and equipment in one location.

New diagnostic technology is increasingly easy to deploy but needs to be fully used. To support any investments we shall be looking at diagnostic services covering a minimum population.

The ‘hubs’ are being commissioned as follows:

North – Haywood Hospital This is currently being redeveloped and will include a range of inpatient and outpatients specialist services, diagnostics, intermediate care and ambulatory care services and out-patient facilities. The new hospital will open in May 2009.

East – Bentilee District Centre This opened in February 2007 and provides Tier 3 services for a population of up to 50,000 people and Tier 2 services for the local population. There will be a range of out-patient services available at the centre and provision of extended diagnostics is currently being planned.

South East – Longton Hospital This will continue to provide a range of services including in-patient beds for intermediate care, out-patient and rehabilitation facilities and diagnostic tests such as X-Ray and audiology. Depending on the outcome of consultation on the Older People’s Health and Social Care strategy, the nature of use of beds and other accommodation may change over the coming years; however Longton Hospital will continue to provide a range of services for people living in the south of the City. Longton Hospital will be developed as the opportunity presents.

South West – to be determined There are currently no premises within this neighbourhood management area suitable for delivering Tier 3 services, although some limited out-patient facilities are available in the new centre at Fenton. Given that the south-east of Stoke-on-Trent includes the most affluent areas of the city, this will not be a priority for the next 5-6 years. The PCT will then consider the future replacement of Hanford Health Centre and Stoke Health Centre and will be work will work with the City Council to identify a suitable development for the South West area.

West –Cobridge The hub at Cobridge is being developed on the Elder Road site. The centre will deliver Tier 3 services including an Integrated sexual health service and TB services and will bring together three GP practices in the locality to deliver Tier 2 services The Outline Business Case for the scheme is currently being prepared for consideration by the Board.

With the completion of the Bentilee, Shelton and Haywood developments, capacity for over 50,000 of the planned 64,000 outpatient transfers from UHNS, will be in place by the end of 2009/10. With the development of the Level 3 centre at Cobridge, the PCT will deliver its overall capacity requirements in advance of the opening of the new acute hospital.

5.2 Level 2 – Primary Care Centres

Level 2 centres will primarily deliver Tier 2 services. The new Level 2 centres at Fenton and Shelton bring together a number of GP practices under one roof together with other community health services commissioned by the PCT. This means that a wider range of services can be provided in one place for more people.


The PCT will continue to bring together smaller practices into one building. This will make it possible to provide a wider range of services than before as practices can share skills, equipment and facilities. Practices will, however, retain their own identity within the building. By doing this, other health services such as district nursing, podiatry, physiotherapy, dentistry and community mental health services can also be brought to these Level 2 centres. In most cases there will be a pharmacy either in, or close to the centre. The centres will help deliver a wider range of services closer to where people live. Although some people may have to travel a little further than they do now to see their GP, this should be balanced by the wider range of services provided at the new centres.

The PCT will develop a number of these centres across the city over the next 5-6 years, in line with the redevelopment plan for the main hospital. To ensure that the new centres can support the above range of services it will be expected that there is a minimum of 8,000 patients registered with the practices that are involved moving to a maximum of 18,000 to 20,000 registered patients so that the new Level 2 centres are still within the local neighbourhood. There may be a greater number of people resident in the area but registered with other practices and they may access some of the services.

This model means that the PCT will not invest in new buildings serving a population of less than 8,000 registered patients unless there are particular exceptional circumstances. It will also not support the development of new small and single-handed practices working in isolation from colleagues. Although the practices may remain as individual organisations they will be co-located with other services.

In addition to the range of services that will be offered at the centres the PCT will also look at the times that services are available to patients. The current approach to delivering services no longer reflects the way that we live and work today. We must therefore not only ensure that our services are located closer to patients but that the times that our premises are open vary to enable patients to have appointments that meet their needs.

Although the above descriptions have concentrated upon the provision of health services the PCT will be looking to work with other agencies, such as the Local Authority to develop facilities and to be able to offer a wide range of services within them..

Shelton Primary Care Centre and Fenton Health Centre have already been developed as level 2 centres. In determining the location and the priority of additional Level 2 primary care centres that will be needed the PCT has taken the following factors into consideration:

The deprivation and health indicators for a given area. The PCT uses the Local Index of Multiple Deprivation and the specific health deprivation index for this together with morbidity data provided by the Directorate of Public Health;

The sustainability of the current premises and services within a given area in terms of capacity (including physical capacity, fitness for purpose, need to move services out of hospital etc) and their ability to cope in the short to medium term with changes;

The intention to bring smaller practices together under one roof to create larger centres with a wider range of services with a minimum of 8,000 registered patients;

The geography of the city to ensure that travel distances are acceptable for the local population coupled with a review of public transport access.

These criteria will also be used to determine the priority for future proposals.


Following the public consultation in 2007, the PCT prioritised the following areas for the development of new Level 2 Centres

Abbey Hulton, Burslem, Longton North, Longton South and Meir.

These were agreed as priorities based on the criteria shown in Table 1, particularly in relation to the level of deprivation in a given area and the sustainability of the practices. A specific priority order for development of these schemes was not set out as the PCT must retain a balance between priorities and deliverability.

The PCT has been able to progress the Meir scheme during 2007. A site has now been acquired and the PCT is developing an Output Based Specification for this scheme in conjunction with the clinical services and patients in the area

During 2007 The PCT also undertook to re-look at the potential for re-developing the existing plan for a development in Tunstall to replace the current health centre and this work is ongoing.

Table 4 shows examples of services which may be provided at the level 2 and level 3 centres.

5.3 Level 2a - Children’s Centres and the Extended Schools Network

The Children’s Centres that have been established in the city over the past few years are an important link in the primary care network. The strategy for children’s services envisages the development of integrated inter-agency working within a particular geographical locality rather than around specific GP lists. This should apply to universal services such as health visiting and community midwifery with other more targeted services such as psychology and speech and language therapy being either fully integrated in some areas or delivering part time in others according to the level of need in the local population. We shall be working with partners to develop integrated Family Support Services with a particular focus on early support in the 0-4 age group.

As the children become older the focus will shift to the extended schools network where the Children’s Centres will facilitate access to services at primary school level although there may be direct links for the secondary schools. Access to some advice or open access services for example on healthy lifestyles (e.g. sexual health, drug and alcohol use) will be available from a wider range of outlets where young people attend such as youth centres or sports centres.

Links with other agencies will be forged through integrated working in localities through Children’s Centres, Extended Schools and other local outlets.

5.4 Level 1 Centres

Level 1 centres are those which house either single or multiple GP practices but at which no other community health services are provided. They are typically located in local communities close to their registered patients to ensure good geographical access to medical services. The majority of Level 1 developments will be replacements for existing outdated or unsuitable premises. Patients using these centres would access the closest Level 2 and Level 3 centres for other services.

In developing new Level 1 centres, the PCT will support re-development of either single large practices with a minimum of around 8,000 patients or the co-location of multiple small practices, with a combined minimum of around 8000 patients. Bringing together


small practices will help to reduce the isolation of GPs and to develop a wider range of services.The PCT will not force the merger of practices but where opportunities present it will support the creation of larger practices.

To ensure all Level 1 GP practices have a fair opportunity to develop their services in modern, fit for purpose premises and that a transparent process is followed to determine the priority for these, the PCT will develop a set of criteria and a selection process which reflects the principles in this SSDP. The process and criteria will be in place by the end of September 2008 and expressions of interest sought for commencement in 2009/10.

The PCTs aim is to commence at least one new L1 development annually for the next 5 years commencing 2009/10.

During 2007 the PCT received additional national funding to open 2 new GP Practices and a GP-led health and well being centre. The GP-led Centre will provide access for as many people as possible and provide a mix of appointments and some unscheduled services.

The new GP practices, which will be located in the Meir and Middleport/Burslem areas will provide extended opening hours and a wider range of services over and above those of most current GP practices. This is in accordance with the priorities identified in the SSDP consultation last year and enables the PCT to accelerate the SSDP programme already in place as well as complement the Primary care Framework. The location of the GP Led Health Centre is yet to be determined.

It is anticipated that the Meir practice will be open by January 2009 and the Middleport / Burslem practice will open in autumn 2009.

5.5 Implications of the Model of Service Delivery

Workforce

The workforce implications of implementing new models of care outlined in Our Health, Our Care, Our Say and in local strategies such as Fit for the Future are significant as more services are provided in community settings and out of community premises. Plans for the workforce are an integral part of the planning of all pathways and this is overseen by the Fit for the Future programme management approach. It should be pointed out that in many cases, it may be that the same health professionals will provide services – just in a more accessible location for the population.

Information Management & Technology (IM & T)

PCT IM & T strategies have been developed to respond to central direction and the overall changes in IM &T procurement and delivery.

All of the new buildings will be provided with network cabling to the appropriate standard which is capable of responding to the changing provision of services supporting initiatives such as on line booking of appointments, touch screen technology for patient registration and transmission of diagnostic results. The networking is also compatible with existing systems in GP practices.

The configuration of IM&T within Northern Staffordshire means that users can sign onto the system from any location for users from any of the Trusts and have the potential to share data including e-mail.

With this model in place remote support to any location can be offered, and users can access their account from any location.


As the Level 3 centres will operate as a network, so that patients can choose the centres most convenient to them, the IM& T systems will need to link. They will also need to link to the systems used by the specific service providers.

All Tier 3 Centres will be equipped to provide access to diagnostic services. The specifics of the diagnostics required will depend on the agreed services for the Centre but buildings will be able to facilitate this and provide diagnostic services as necessary.

6. ACCESS, CAPACITY AND ACTIVITY

6.1 Access to services

The Level 3 centres will accommodate the majority of services to be transferred to secondary to primary care. It is vital that, in making these changes, the PCT plans for the right services to be provided in the right place at the right time to meet patient needs.

To aid this planning, the PCT has looked at the numbers and home postcodes of outpatients attending University Hospital North Staffordshire (UHNS) during 2007/8 and the types of specialties patients were attending hospital for.

Using this information the PCT has mapped the numbers against the level 3 hub locations and access times based on using public transport (based on average travel times using data from www.transportdirect.info) to inform where services could be located. This will reduce the miles and average time that people currently travel to access outpatient services, for example

Patients living in the Hanley area will be able to access outpatient services either at Cobridge within 13 minutes, or at Bentilee within18 minutes or at Haywood within 11 minutes compared to a travel time of 33 minutes to UHNS


http://www.transportdirect.info/

Patients living in the Bentilee area will be able to access outpatient services either at Bentilee within 10 minutes, or at Cobridge within 35 minutes, or at Haywood within 37 minutes, compared to a travel time of 50 minutes to UHNS

Patients living in the Longton and Meir areas will be able to access services at Longton Hospital within 12 minutes or at Bentilee within 31 minutes, compared to a travel time of 49 minutes to UHNS

Patients living in the Haywood area will be able to access services at Haywood Hospital within 17 minutes or Cobridge within 20 minutes or Bentilee within 40 minutes, compared to UHNS which takes 60 minutes

The PCTs aim is to ensure that patients can receive services in community locations, and where possible to have a choice of level 3 centre to attend which is convenient to them.

6.2 Premises Capacity

In planning the new facilities, a number of underlying assumptions have been made, these are that:

All services transferred from secondary to primary care will require clinical treatment rooms

Planning should allow for a level of unmet need Premises should be fit for purpose for years to come Patients should be able to access a range of ‘one stop’ services within the Level 3

centres A significant number of General Practices will be replaced Future configuration of GP practices may change as GPs retire Facilities for clinical teaching and training purposes should be included as

standard

The new developments are being planned to enable maximum flexibility both in their construction and room usage. All of the premises incorporate teaching facilities for staff and have sufficient accommodation to locate additional staff and services.

The following planning rules are being used in the development of facilities. These form the core requirements for all services:

Buildings are designed to accommodate longer and more flexible opening hours with the expectation that buildings will be used for 3 clinical sessions per day, rather than the traditional two (morning and afternoon).

There will be maximum shared and flexible room usage. To aid this appropriate decontamination facilities will be provided to ensure that rooms can be used for a variety of services,

Clinical room usage will be planned to maximum capacity usage based on best practice benchmarking on numbers of patients/session/hour

There will be shared reception and waiting areas on each floor where there are clinical services

Office space will be shared based on the number of people likely to be in the building at any one time, not the number of staff. Sufficient office space will be provided for clinicians to do administrative work away from clinical rooms, to ensure that clinical rooms can be fully utilised for direct patient care.


Workstations – All workstation facilities are standardised with full access to all technology so staff can work from any desk.

All patient areas will be standardised and fully equipped in terms of IT equipment, desks, trolleys, treatment couches, etc. Building users will only be able to bring additional medical equipment


Diagram 1 Layout of centres

Diagram 2 Relationship between Tiers of Care and Levels of Facility

Tiers of care which may be provided at each centre

Level 3 Centre

Level 2Centre

Level 1Centre

Tier 3

Tier 2

Tier 1


NORTH

Haywood

Hospital EAST

Bentilee

District

Centre

WEST

Cobridge

SOUTH

WESTTo be Identified

SOUTH

EASTLongt

onHospi

tal

Pri

m-

aryCareCentre

Pri

m-

aryCareCentre

Pri

m-

aryCareCentre

Pri

m-

aryCareCentre

Pri

m-

aryCareCentre

Pri

m-

aryCareCentre

Pri

m-

aryCareCentre

Pri

m-

aryCareCentre

Pri

m-

aryCareCentre

Pri

m-

aryCareCentreUH

NS

GP

GP

GP

GP

GP

GP

GP

GP

GP

GP

GP

GP

GP

GP

GP

GP

GP

GP

GP

GP

Table 1 Risk factors considered in prioritising schemes

Risk Criterion Local Multiple Deprivation

Index

Health Deprivation

Index

Forecast GP

retirement

Impact of housing development

Aggregation of small

practices

Current patient list

Condition of existing

premises*

Proposed Level 2 Centre

Abbey Hulton High (5th) High (2nd) High Low Yes 7463 Category C

Burslem High (1st) High (1st) High High No Expansion of

existing practice

5950 Category C

Longton North Medium (22nd) High (10th) High Low Yes 10590 Category C

Longton South Medium (22nd) High (10th) High Low Yes 18239 Category C

Meir High (4th) High (11th) High Low Yes 18172 Category C

*Existing Condition- Estmancode uses Categories A to D where Category A is the “Best”


Table 2A possible configuration for primary care estate in 2013/14.

Neighbourhood Area

Tier 3 Specialist primary care centres

(Hubs)

Tier 2 Primary Care Centres

(Main Spokes)North

population47,468

Haywood Hospital Burslem Health CentreTunstall

West (includes the City Centre)

population34,690

Cobridge Shelton Primary Care CentreHanley

East

population45,524

Bentilee Neighbourhood Centre Abbey Hulton

South East

population52,736

Longton Hospital Meir Longton NorthLongton South

South West

population60,218

To be agreed Fenton Primary Care CentreHanfordStoke


Table 4 Examples of services to be delivered from the proposed level 2 & 3 centres

Service Level 3 Haywood Hospital

Level 3 Longton Hospital

Level 3 Bentilee Centre

Level 3 Cobridge

Level 3 South West Hub

Level 2 Primary Care Centres

Intermediate Care Beds

Yes – 28 Yes - 27 No No No No

Rehabilitation beds Yes No No No No NoGP practice(s) No No Yes Yes Yes Yes

Existing secondary care Outpatients

Yes Yes Possibly No No No

Secondary to primary care transfers

Yes- 22,000 Number to be Agreed

Yes - 18,000 Yes – 12,000 Number to be agreed Yes – 12,000 (at Shelton)

X Rays Yes Yes Yes Yes Possible NoOther diagnostics e.g. ultrasound, echocardiography

Yes, as appropriate

Yes, as appropriateYes, as appropriate Yes, as appropriate Yes, as appropriate Yes, as appropriate

Therapy services Yes Yes Yes Yes Yes Yes

Relocation of other UHNS transferred services

Yes Yes Yes Yes Yes Yes – as appropriate


7. TIMESCALES AND IMPLICATIONS FOR AFFORDABILITY

This section outlines the current financial position of the PCT and its future resource assumptions; financial affordability of the proposed Level 3, Level 2 and Level 1 schemes and affordability solutions. The PCT is currently in the process of developing a number of centres which will be completed over the next three years..

7.1 Financial Stability

The PCT has a secure financial base, a recurrent surplus in excess of £7m and an agreed financial plan for 2008/09 targeting a £4.5m surplus whilst also setting a contingency reserve of £2m. The PCT’s revenue resource limit will be in the region of £437 million in 2008/09 and its longer term financial planning model includes provision for the financial consequences of Fit for the Future to 2012/2013 and the likely effects of the LIFT programme covering the same period.

Incorporated into its longer term financial model is the potential for reduced future years' growth assumptions. This ‘downside’ modelling identifies growth as low as 4%, which would severely test the PCT’s ability to fully develop its SSDP intentions in the short-term. To protect against this, the PCT as part of its financial planning processes for 2008/09 earmarked a level of resource identified as a SSDP ‘sinking fund’. This resource (£0.6m) is protected recurrently and is available on a non recurrent basis to support the wider Local Delivery Plan targets and investments.

The PCT’s own capital resource limit is supplemented by funds to enable premises purchases, acquisition of land, site preparations and demolitions. Private finance, agreements with Stoke City Council and the LIFT programme will secure replacement of significant parts of a poor condition community and primary care estate facilitating transformation of services as outlined in this SSDP. The PCT is confident about its ability to deliver the schemes because of its partnership with Prima 200 Ltd, the North Staffordshire LIFT Company, and the exclusivity agreement that exists between the parties. This does not preclude GPs as independent contractors from pursuing their own premises developments.

7.2 Financial Analysis of Level 3 Schemes

The PCT has secured funding for services development at the Haywood Hospital and the Bentilee Centre; it is planning to invest from its future years' growth into services to be provided from Longton Hospital and Cobridge.

Haywood Hospital services will be fully operational in 2009/10. The net additional cost of services / facilities is £1.9m with funding secured from the PCT’s sinking fund reserve (£1.8m) and other commissioners.

Bentilee Neighbourhood Centre opened in February 2007, the net additional costs of services/facilities commissioned/applicable for use by the PCT were provided for in the PCT’s Local Delivery Plan for 2007/08.

Cobridge Community Health Centre Outline Business Case will include details of services to be provided and sources of funding. These will include transfer of existing GP practices and PCT premises revenue budgets and Payment by Results (PBR) funding transfers supporting secondary to primary care shift. The net additional costs of services/ facilities commissioned/ applicable for use by the PCT will be provided for in the LDP.

Other developments require further work on the service specifications before cost estimates can be derived – these costs will be provided for in the LDP.

7.3 Financial Affordability of Level 2 Schemes/tt/file_convert/588881031a28ab34788b734f/document.doc 25

The PCT is planning to invest from its future years' growth into services to be provided from premises in Abbey Hulton, Burslem, Meir, Longton North and Longton South. These developments will all feature as part of the PCT’s LIFT programme.

The development of these premises will give rise to an annual revenue cost greater than the current spend on the premises being replaced. This will partly be the product of replacing old for new but will also be partly due to expanding capacity in primary care as we move closer to providing more care closer to home. Output-based specifications for the schemes have not yet been prepared and the PCT will need to develop full business cases to show the affordability of these developments. Whilst new premises funding must compete with other priorities in the LDP the PCT should be bold in its ambition and maximise the number of new premises being developed in order to make the much needed and radical improvement to the estate.

The revenue flow to support these developments can be maximised through consideration of the following:

o Proceeds from disposal of PCT-owned premiseso Financial support for write offs (e.g. where the sales (usually open market value)

income is lower than the asset value on the PCT’s books)o NHS growth funding levels and utilisation of the SSPD Sinking Fundo Delivery of savings plans to secure re-investment opportunities o Availability of transfer funding accompanying transferred serviceso Income from tenants including GP rents and other third parties o Grants from other agencies, including pharmacy premia

There is also a further opportunity for the PCT to consider to support the programme of community and primary care services development, as described below, which would maximise the opportunity to commence schemes more rapidly.

Currently, as the PCT estate is redeveloped, the old premises are sold off where surplus to requirements. The sales income is a capital receipt and cannot therefore be transferred to meet revenue costs (e.g. rent on new premises) and, until the premises are sold, the PCT continues to pay capital charges. An alternative option exists whereby the PCT could dispose of a share in its current estate in advance of new developments, thus releasing equity which could be used to meet on-going revenue costs.

Discussions have been taking place with the LIFT Company about the potential for using the capital asset contained within the current estate to pump-prime the development programme outlined in this SSDP. Over time, the current estate will be replaced by new buildings and will transfer out of the direct ownership of the PCT (although the PCT is a shareholder in LIFTCo and thereby continues to “own” a proportion of the new premises).

One option is to create a joint venture (JV) company which would purchase the current PCT estate and then, over time, reprovide that estate with new buildings. The joint venture could be structured in such a way that the PCT retains up to 60% ownership through a preference share. The sale of the estate into the joint venture company would release capital which could then be used to offset on-going revenue commitments. The current estate would be rented back to the PCT until such time as it was replaced by new buildings. This would avoid the payment of capital charges on the current buildings, although the PCT would incur some (much reduced) capital charges on its shareholding

Examples elsewhere

The Government is set to introduce a requirement for all NHS organisations to comply with International Financial Reporting Standards (IFRS), effective from April 2009. One of the more significant issues contained within these proposals is the potential for some PFI arrangements to be ‘on Balance Sheet’. Should this be the case, this negates any benefit arising from /tt/file_convert/588881031a28ab34788b734f/document.doc 26

savings in capital charges, as organisations would immediately become liable for 3.5%, payable against its asset base. Whilst further detailed guidance is awaited, the PCT expects LIFT arrangements to remain ‘off Balance Sheet’; this is because of the different structure of LIFT arrangements as compared with PFI deals. One significant difference is what happens at the end of the initial lease term; typically LIFT arrangements include an option that would allow ownership of the asset to revert back to the PCT, however, PFI arrangements tend not to include such options and interest in the asset tends to accumulate over the life of the initial lease. This difference in approach is likely to result in different accounting treatment between LIFT and PFI arrangements.

The PCT needs to gain advantages from this approach. There are a number of reasons to consider this option which include:

The PCT is no longer responsible directly for the estate but can consider this as part of the services that it needs to commission. However, in the proposed company structure the PCT has control over how the estate is redeveloped;

The transfer of the property can be used to pump prime new developments;

Where the properties will not be replaced in the short term the PCT can gain access to capital through the JV company;

There is flexibility about the disposal of the estate with the opportunity for redevelopment to the benefit of the PCT;

A positive cash flow to the PCT will be generated.

7.4 Financial Affordability of Level 1 Schemes

The PCT is currently developing a process and criteria by which to determine a priority for development of level 1 schemes. Future updates to the Local Delivery Plan (starting 2009/10) will include £100k provision each year for Level 1 schemes. Table 3 shows the sources and applications assumed for each development.


Table 3 Table projecting the sources and applications assumed for developments

Level 2 & Level 3 schemes

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 Rec Non Rec Non Rec Non Rec Non Rec Non Rec Non Rec NonFenton & Packmoor 650 Shelton 505 605 6 500 Packmoor 192 LIFT - General 163 500 250 Milehouse (PCT contribution) 47 Scheme 5 200 400 Scheme 6 50 200 Cobridge 600 800 Scheme 8 50 200 Meir 200 800 Scheme 10 150TOTAL 355 0 500 505 1255 256 547 250 600 650 1000 200 800 150

Level 1 schemes 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 Rec Non Rec Non Rec Non Rec Non Rec Non Rec Non Rec Non


TOTAL 100 100 100 100Note: New Meir and Burslem/Middleport Darzi practices not included at this stage

Appendix 1

Local Index of Deprivation April 2006 Source: Knowledge Management Unit, Stoke-on-Trent City Council

TotalScoreNeighbourhood

Burslem 117.79Forest Park 107.60Bentilee 106.72Meir North 100.96Shelton North and Etruria 96.92Abbey Hulton 96.80

Chell Heath 94.32Meir South 93.82Hanley East and Joiners Square 91.12Northwood 87.01Middleport and Longport 86.41Smallthorne 80.15Blurton and Newstead 77.13Fenton 73.64Tunstall 72.78

Fegg Hayes and Great Chell 71.15Norton and Ball Green 70.05Stanfield and Little Chell 69.71Shelton South 69.57Dresden and Normacot 69.55Boothen 68.19Longton 64.64


Weston Coyney East 63.34Goldenhill 61.32Fen Park 60.74Bucknall and Townsend 58.18Trent Vale 57.85Burslem Park 57.16Hollybush 56.44Berryhill and Eaton Park 55.25Cliff Vale and Basford 54.48Birches Head West 54.27Hanford 51.88Sneyd Green 50.49Oxford and Brindley Ford 49.81

Bradeley 46.45Norton East 42.08Hartshill West 41.89Weston Coyney West 38.22Penkhull and Hartshill 37.65Meir Hay 34.04Lightwood 26.61

Milton and Baddeley Green 26.17Packmoor and Turnhurst 20.67Trentham West 17.62Meir Park 11.15Birches Head East 10.57Trentham East 5.15Trentham Ley 3.65


Health & Medicine

Enclosure 8