APPENDICES
1) Expected ways of working in the proposed new model of care 2) Further information on Health & Wellbeing 3) Further details on the “Home First” component of the model of care 4) Winter Plan 5) Beds analysis undertaken 6) MPFT Action Plan 7) Accessibility evidence 8) Equality Impact Assessment 9) Quality Impact Assessment 10) Quality metrics 11) Additional workforce information 12) Community beds modelling technical information 13) Wider community services technical information 14) Spotlight on care homes quality inspection 15) Pre-consultation engagement activities 16) Long list of options 17) Consultation Plan 18) Consultation Document 19) Consultation Analysis Plan 20) Letters of support 21) Return on Investment 22) Glossary
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Appendix 1: Expected ways of working in the proposed new model of care
How the care model integrates with the wider system The care model is designed to be well integrated and embedded into the wider health and care system, providing links with key sectors and services such as primary care, domiciliary care and acute provision. Where necessary, the service will make onward referrals to appropriate core services e.g. community matron, district nurse, Integrated Local Care Teams, community physiotherapy, social care maintenance packages or housing related support services and voluntary sector agencies to ensure that patients maintain this optimal level of functioning.
This integrated working will include: • Fully integrated multidisciplinary teams (MDTs) working together to achieve shared quality outcomes • Integrated working and agreed clinical pathways / policies with other services and organisations such as primary care, voluntary sector to ensure pathways of care are seamless • Robust links to specialist services / teams (e.g. frail and complex team and Long-Term Conditions team) to ensure access to prompt advice and support • Providing support to Care Homes both proactively and reactively, supporting clinical interventions, advice and guidance as required to ensure timely access to the services for those for whom a Care Home is considered their home setting.
The team will be expected to work across primary and secondary care, although much of the work will be carried out in a primary / community setting. The service will be expected to form close working relationships not only with individual general practices but other community services i.e. Community Specialist Teams, Integrated Local Care Teams (ILCTs) and Social Care.
Technology enabled care The service is designed to ensure patients have the right tools that they need to stay safe and well in their own home, building their independence to ensure that they can stay in their preferred setting of care. To maximise this opportunity the proposed care model operates on a principle of asset-based reablement, explicitly including technologically based solutions. To ensure this, the service will provide timely equipment and assistive technology with effective guidance about how to use it to enable people to remain in a home environment during the intermediate care episode.
We have a well-established track record of uptake of technology-enabled care in general practices across Staffordshire, with a focus on: atrial fibrillation, hypertension and diabetes type 2 pathways, encouraging practice teams and community pharmacies to extend their technology-enabled care applications. To this end a wealth of technologically based solutions will be deployed to achieve this, with available interventions being constantly re-assessed as new technologies and opportunities develop. Our current priorities for using technology in-line with our design principles include: Care Homes –using TECS to improve remote consultation between clinicians GP Forward View – online consultation; Patient Online; patient empowerment. This will enhance workforce effectiveness & productivity
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Upskilling NHS workforce to create digital clinical champions via action learning. This will be focused along specific long-term condition pathways (e.g. AF, hypertension, diabetes type 2, COPD, asthma) with relevant underpinning digital technology e.g. apps, social media, Flo telehealth, video consultation End of Life Care – using TECS to underpin effective and safe home-based care e.g. video consultation with attending palliative care nurse/hospice medic; or district nurse/GP Upskilling citizens/patients to utilise TECS to enhance empowerment/self-care + support for family/social carers e.g. via apps/remote medicines use reviews with pharmacists – minimise likelihood of deterioration of health condition/reduce likelihood of admission Support Discharge to Assess teams – with video consultation to GPs/community pharmacists Rollout of learning re competence/confidence/capability/capacity of general practice teams Practice and PPG Facebook pages to be used for messaging to invite participation in STP/CCGs’ consultation. Pages are also used to promote services, boost uptake of screening, post alerts (e.g. cyber security crisis). In addition, closed Facebook pages are used by clinicians to share information and discuss proposals.
Transforming the workforce
Implementing our proposed model of care will require a shift in how local community health and social care staff work and interact. We would expect the service to consider the following four aspects of workforce development as part of the model’s roll-out:
Updating current skill-mix capabilities Leadership Increasing capacity Developing career pathways
(a) Updating current skill-mix capabilities The transformation will require a significant work stream to understand and fully map the future workforce requirements of the service; this is a critical work stream which will need to take place in the imminent future as a priority for implementation, depending on the options selected within this PCBC. This work will need to define detailed job specifications and a revised skill-mix for the community services; this will also provide accurate costings.
The proposed model of care requires a shift from the current skill mix, with greater focus on removing cultural barriers that currently exist and reviewing the core competencies required to work in an integrated team. Front-line staff will need to shift towards a generalisation of skill-sets and competencies, moving towards the functionality necessary to deliver the care closer to home type working.
The mind-set of staff needs to be transitioned away from “I’m NHS” or “I’m social care” to being simply part of the team. Management ranks will be expected to manage service-lines outside of their traditional remit, more closely combining health and social care roles and responsibilities.
(b) Leadership Leadership is one of the most influential factors in shaping organisational culture and so ensuring the necessary leadership behaviours, strategies and qualities are developed is fundamental. Embedding new ways of working requires effective leadership at the frontline.
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There is an inherent need to overcome the preconceived notions on professional identities and integrated working. For this to become a reality the services will also need strong system leadership that is responsible for all facets of service delivery; they will be accountable for delivery of outcomes consistent with the agreed vision, values and strategies of the organisation.
(c) Increasing capacity Considering future demand projections, it will be necessary to increase service capacity iteratively to ensure that the projected benefits of the service are continually realised.
(d) Developing career pathways Currently the workforce is transitory and suffers from recruitment and retention crises – this can be tackled by providing greater structure to career pathways, ensuring clear lines of progression for staff, with options provided to up-skill into professional career pathways such as nursing and occupational therapy from more traditionally supporting grades.
ICT Outcome Matrix
Outcome area No Description Metrics Overarching 1 Reduction in the number of case managed patients (baseline per hub under development) Expected accessing unscheduled secondary care resulting in Outcomes a reduction in non-elective admissions; 2 Increase in the utilisation of pharmacy staff within (baseline and ambition to be agreed) Integrated Care Hubs to optimise medications for patients under case management, 3 Support for General Practice and the extended (QALY tool to be agreed and utilised) primary care team in the management of patients with Diabetes, Heart Failure and Respiratory conditions that makes patient care excellent and delivers individual patient outcomes in line with their management plans aligned with the new models of care, 4 Support General Practice in the incidence recording (baseline and ambition by hub to be of Diabetes, Heart Failure and Respiratory agreed) conditions so that the recorded incidence of LTCs is aligned with expected prevalence as suggested by local Public Health and NHSE utilising tools such as the GRASP tool, 5 Specialist integrated team knowledge and skills to (statistically significant sample audits of impact positively and be evident in the care plans care plans to be completed on a for patients being case managed, quarterly basis overlapped with NEL admissions and QALY tool outcomes) 6 Patients and the families of patients approaching (measured through PCCC outcomes) the end of life are cared for in line with their wishes in their preferred place of care, 7 Specialist teams contribute to and are active in the delivery of the single care plan
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Outcome area No Description Metrics 8 Identify and implement practices that empower (patient questionnaire and QALY tool patients so that they identify themselves as feeling outcomes) confident to manage their long term condition(s) including an increase in number of patients who identify themselves as feeling confident to manage their long term condition, 9 Increase the use of Technology to support patients (patient questionnaire before and to manage their own conditions after) Respiratory 10 Reduction in the number of patients presenting (monitored monthly through the Care outcomes with an exacerbation of COPD who are already Hubs overlapped with NEL admission diagnosed and under a management plan that are data) case managed through the Care Hub; 11 Minimum of 75% of patients who have a shared (statistically significant sample audits of management plan care plans to be completed on a quarterly basis) 12 90% of patients offered pulmonary rehab in line (monthly KPI including actual % take with NICE guidance up) 13 95% of patients offered the pneumococcal (monthly KPI including actual %take vaccination; up) 14 Reduction in the number of hospital readmissions (baseline per hub under development) 15 Increase the number of COPD patients who die in (quarterly,KPI – mechanism to capture their preferred place of death to be developed) 16 Develop and fully implement discharge bundles for (monthly KPI discharges back into ICT patients admitted with pneumonia and/or COPD and no of patients who are maintained in the community as a % of the total) 17 Enhancement of care for advanced disease (statistically significant sample audits of care plans to be completed on a quarterly basis to show changes for patients in the service for xxx months or longer) Diabetes 18 Improved CCG performance for the 8 care (baseline by CCG and ambition to be processes specifically for urine albumin and retinal agreed) screening; 19 % reduction in eye related procedures for (baseline by CCG and ambition to be ophthalmology; agreed) 20 % decrease in non-elective admissions with foot (baseline by CCG and ambition to be ulceration procedures; agreed) 21 Reduced primary care prescribing spend on (baseline by care hub and ambition to diabetes; be agreed) 22 Increased self-awareness and better understanding (measured through patient satisfaction of managing diabetes within the community surveys) 23 Increased number of people with holistic (QALY tool to be agreed and utilised personalised care plans to support and increase and patient survey)
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Outcome area No Description Metrics confidence to self-manage Heart Failure 24 To ensure that 100% of patients on practice HF (baseline by Hub to be determined and (HF) registers had a confirmed diagnosis. trajectory agreed) 25 Develop discharge bundles for patients admitted monthly KPI discharges back into ICT with heart failure delivered by the Integrated teams and no of patients who are maintained within the Care Hubs; in the community as a % of the total) 26 To ensure that 80% of patients are on appropriate (baseline by Hub to be determined and medical therapy and are titrated, or being titrated, trajectory agreed – to reported monthly to recommended dosages as tolerated (unless as a KPI) documented as contra-indicated) 27 To provide HF education and a continuing rolling (quarterly KPI – mechanism to capture to programme of education for all diagnosed patients be developed) 28 Increase the number of Heart Failure patients who (quarterly KPI – mechanism to capture to die in their preferred place of death be developed) Frailty 29 Through links with the falls service, deliver both a (baseline by Hub to be determined and reduction in non-elective spend on hip fractures trajectory agreed – to reported associated with a fall (per head of population over monthly as a KPI) 65) and a reduction in falls related admission rates (per head of population over 65); 30 Through links with the PCCC and Palliative Care (KPI to be developed) team, End of Life care will be anticipated and planned for, such that 100% of patients receive high quality co-ordinated end of life care; 31 XX% of patients will be supported to die in their (Monthly KPI measured through place of choice; documented preferred place of death v actual) 32 100% of identified patients are in receipt of an (statistically significant sample audits of Integrated Care and management plan; care plans to be completed on a quarterly basis) 33 100% of patients receive a Complex Geriatric Assessment; (Monthly KPI by hub) 34 Through the MDT approach to managing patients (baseline by Hub to be determined and with frailty, it is expected that 33% of admissions to trajectory agreed) acute care could be avoided. End of Life 35 To proactively identify all people considered to be in (statistically significant sample audits of the last year of life at an early stage, to be able to care plans to be completed on a give them pro-active person centred care in line with quarterly basis) preferences. 36 To offer every identified person the chance to have (Monthly KPI and statistically significant an advanced care planning discussion with the sample audits of care plans to be person of choice. completed on a quarterly basis) 37 To enable every person the opportunity to die in (statistically significant sample audits of their preferred place of choice. care plans to be completed on a
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Outcome area No Description Metrics quarterly basis) 38 Number and percentage of people with Preferred (monthly KPI) place of care/death recorded 39 Number and percentage of people who died in their (monthly KPI) recorded preferred place of choice 40 Number of patients dying in their usual place of (monthly KPI) Residence 41 To reduce number of non-elective admissions for (baseline and ambition to be agreed) those patients who die in hospital 42 Number and percentage of deaths in hospital (baseline and ambition to be agreed)
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Appendix 2: Further information on Health and Wellbeing 1.1 Predicted population change across localities
Each graph below outlines the relative percentage change in population expected for three age groups (0-14, 15-645, 65+) and by locality. Chart A1.1 – Stoke-on-Trent population profile 2014-2039
Chart A1.2– Newcastle-under-Lyme population profile 2014-2039
Chart A1.3 – Staffordshire Moorlands population profile 2014-2039
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1.2 Deprivation across localities
Stoke-on-Trent (North and South)
The map below shows differences in deprivation in this area The below chart shows the percentage of the based on national comparisons, using national quintiles population who live in areas at each level of (fifths) of the Index of Multiple Deprivation 2015 (IMD 2015), deprivation. shown by lower super output area. The darkest coloured Source: Public Health England Fingertips Report: areas are some of the most deprived neighbourhoods in Stoke-on-Trent - England. http://fingertipsreports.phe.org.uk/health- profiles/2017/e06000021.pdf
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Newcastle-Under-Lyme
The map below shows differences in deprivation in The below chart shows the percentage of the this area based on national comparisons, using population who live in areas at each level of national quintiles (fifths) of the Index of Multiple deprivation. Deprivation 2015 (IMD 2015), shown by lower super Source: Public Health England Fingertips Report: output area. The darkest coloured areas are some of Newcastle-Under-Lyme - the most deprived neighbourhoods in England. http://fingertipsreports.phe.org.uk/health- profiles/2017/e07000195.pdf
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Staffordshire Moorlands
The map below shows differences in The below chart shows the percentage of the deprivation in this area based on national population who live in areas at each level of comparisons, using national quintiles (fifths) deprivation. of the Index of Multiple Deprivation 2015 (IMD 2015), shown by lower super output Source: Public Health England Fingertips Report: area. The darkest coloured areas are some of Staffordshire Moorlands - the most deprived neighbourhoods in http://fingertipsreports.phe.org.uk/health- profiles/2017/e07000198.pdf England.
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1.3 Inequalities
Complex patients profile and Life Expectancy for Stoke-on-Trent CCG
The profile of complex patients within Stoke-on-Trent is older than within comparator CCGs, with the 80+ age bracket making up an increased proportion of complex patients in Stoke-on-Trent relative to statistical comparators. The below chart demonstrates the number of complex cases managed within the CCG area by age bracket. This chart shows that complexity significantly increases with age, with over 65% of complex cases within the CCG being associated with the 65+ age brackets.
Chart A1.4 - The number of complex cases managed within the CCG area by age bracket
Source: Stoke-on-Trent CCG NHS Right Care pack January 2017 https://www.england.nhs.uk/rightcare/wp- content/uploads/sites/40/2017/01/cfv-stoke-on-trent-jan17.pdf
The charts below compare the death rates in people under 75 (early deaths) between Stoke-on-Trent and the England average. The life expectancy in the most deprived areas is significantly lower than the England average for both men and women.
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Complex patients profile and life expectancy for North Staffordshire CCG
The profile of complex patients within North Staffordshire is older than within comparator CCGs, with the 80+ age bracket making up an increased proportion of complex patients in North Staffordshire relative to statistical comparators. The below table demonstrates the number of complex cases managed within the CCG area by age bracket. This table shows that complexity significantly increases with age within North Staffordshire, with nearly 70% of complex cases within the CCG being associated with the 65+ age brackets.
Chart A1.5 - demonstrates the number of complex cases managed within the CCG area by age bracket
Source: North Staffordshire NHS Right Care pack January 2017 https://www.england.nhs.uk/rightcare/wp- content/uploads/sites/40/2017/01/cfv-north-staffordshire-jan17.pdf
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Newcastle-Under-Lyme Life Expectancy
The below charts provide a comparison of the changes in death rates in people under 75 (early deaths) between Newcastle-Under-Lyme and the England average. It can be seen despite the lower rates of deprivation within Newcastle that the life expectancy is significantly lower than the England average for both men and women, with woman being having significantly lower life expectancy compared to the national average.
Staffordshire Moorlands Life expectancy
Life Expectancy at birth is 80.1 years (males) and 82.8 years (females). This equates to 4 years of extra life for males and over 1 year for females when compared with Stoke-on-Trent.
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Appendix 3: Further details on the “Home First” component of the model of care
Population covered by the proposed care model The proposed model covers patients over the age of 18 registered with a North Staffordshire or Stoke-on-Trent GP. South Staffordshire is out of scope. The entirety of the service is health commissioned with health working in partnership with social care to support ongoing assessment.
Admission avoidance To support the agenda of avoiding un-necessary admissions, the following timescales will be adhered to for proactive step-up care: Referrals for health based step-up to be assessed (face to face) within 2 hours of being notified by the Track and Triage team that patient meet criteria if urgent and within 4 hours if routine. First assessment will be by the most appropriate professional (ANP/ RGN/ Physiotherapist / OT). Patient will be accepted into the service with immediate interventions commenced in line with initial care plan within 4 hours. (2 hours represents the maximum backstop time, not target). Track and Triage and the Home First teams are expected to liaise to ensure patient is assessed sooner if clinically required e.g. patient in GP surgery not safe to go home and will otherwise be sent to emergency portal. Full assessment, final care plan, goals, planned completion date (completion of care programme) and planned post care programme arrangements will be in place within 72 hours of referral.
Discharge to assess To support the discharge to assess agenda, reducing the length of stay and delayed transfers of care, the following timescales will be adhered to: Within 1 hour of referral confirmation of referral and capacity to support will be provided and agreement of discharge time with Track and Triage Team. Initial visit will be arranged. Within 24 hours the first visit will be completed and care plan in place to ensure needs are safely managed whilst participating in short term support and interventions. Within 72 hours, initial decision point to determine next steps. Review will then be undertaken at days 7, 14 and 21 should patients remain on the service to ensure that patients are receiving the most appropriate level of care and are receiving active rehabilitation. Up to 6 weeks further ongoing review with flexible decision points determined by need with exit point agreed when individual has maximised their independence. Decisions will be managed within an inter- disciplinary decision framework.
Acceptance and exclusion criteria This proposed model will support all people over the age of 18 being discharged from hospital or as part of an admission avoidance plan within the population covered. Whilst accessible to the full over-18 population, a set of acceptance and exclusion criteria have been developed to ensure that the proposed model is accessed by those with the highest need. The acceptance criteria include: • Individuals must be over 18 years of age • People with sub-acute health needs that do not need an acute admission • People being discharged on specific pathways such as the orthopaedic pathway • People with complex health needs that may be eligible for NHS Continuing Health Care (CHC) funding to meet their needs and require a full assessment.
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• People that will benefit from short-term interventions to increase their independence linked to either health or social-care needs or both • People that may require assessment for long term care and support needs • Patients identified as ‘end of life’ will be supported if they have an urgent need for short term health or social care E.g. intravenous antibiotics for a chest or urinary tract infection to avoid hospital admission or carer breakdown • Patients with needs that require a level of intervention (either in terms of frequency, intensity or complexity) that cannot be met by core services with the overall goal being to prevent admission (to hospital or long-term care) or facilitate safe discharge • People that will benefit from enablement and rehabilitation • Identified as appropriate by the track and triage team in line with locally agreed arrangements / protocols • Directly from emergency portals, for example where patients present in a crisis with needs that can be safely managed in the community • Directly from Mental Health or Learning Disability services where a short term physical health need has been identified. • Residents in care homes (nursing and residential) • With a diagnosis of dementia (primary or secondary diagnosis) and coexisting physical health and / or social needs • Patients must agree to participate and agreement to care and support plan/goals • Individuals with evident long-term nursing home care needs will be directed to their place of choice following the DST process.
The exclusion criteria are:
• People under 18 years of age • Adults identified as having acute/unstable needs which cannot be managed within a community setting • Discharges that can be supported via more appropriate services e.g. Stroke – Early Supported Discharge • Patients who require longer term inventions and rehabilitation e.g. domiciliary care • Patients with needs that can be managed by commissioned core services. • Patients that require specialist inpatient rehabilitation such as stroke and neurorehabilitation • Patients with delirium or in an acute phase of functional mental illness (e.g. acute psychosis, acute depressive episode) with no other needs. Close links to existing mental health services/ professionals will be required for those patients with complex multiple needs. • Patients not medically manageable in a community setting or where environmental issues prevent safe management of healthcare needs (in these instances bed based IC should be considered first) • Maternity and paediatric patients
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Appendix 4: Winter Plan
West Staffordshire A&E Delivery Board
Winter Plan 18/19
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Version Date Update 1.1 22/06/2018
1.2 11/07/2018 AEDB Feedback amendments
Contents 1. Introduction ...... 20 2. Background ...... 20 3. West Staffordshire Local Context & Winter Review ...... 21 4. Plan Interdependencies ...... 21 5. Outcomes of the Plan ...... 21 5.1. Simplified Access Points ...... 21 5.2. Integrated Approach Urgent & Emergency Care...... 21 5.3. Working together as one Healthcare System ...... 21 5.4. Wider System Delivery ...... 21 5.5. Hospital Front door ...... 22 5.6. Hospital Flow ...... 22 6. Governance ...... 23 7. PMO & Monitoring ...... 23 8. Winter Plan Key Performance Indicators ...... 25 9. Escalation Planning ...... 25 10. System on Call Arrangements ...... 26 11. Adverse Weather Plans ...... 28 12. Influenza Strategy ...... 28 13. Outbreak Plans ...... 29 14. Communication ...... 30 14.1. Cascading Advanced Warnings and Focus on High Risk Groups ...... 30 14.2. Nursing Homes & Care Agency Communications Plan ...... 31 Page 18 of 287
15. Capacity and Demand Modelling ...... 31 15.1. UHNM Bed Modelling ...... 31 15.2. Achievement of A&E Performance ...... 34 15.3. Reduction in Stranded Patients Plan ...... 35 15.4. Midlands Partnership NHS Foundation Trust (MPFT) Bed Modelling ...... 35 15.5. MPFT Community Services ...... 36 15.6. North Staffordshire Combined Healthcare (NSCHT) ...... 38 15.7. Staffs County Council Nursing Home Capacity ...... 39 15.8. Stoke City Council ...... 39 15.9. CCG Capacity ...... 41 15.10. West Midlands Ambulance Service (WMAS) Capacity ...... 41 15.11. Staffordshire Doctors Urgent Care (SDUC) Capacity ...... 41 15.12. Primary Care Capacity ...... 42 16. Surge Plan ...... 42 16.1. Additional UHNM Bed Capacity ...... 42 17. Workforce Planning ...... 43 17.1. UHNM Workforce Planning ...... 43 18. Risks to the Staffordshire Winter Plan ...... 46 19. Finance ...... 47 20. Conclusion ...... 47
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1. Introduction
The West Staffordshire urgent care system has faced challenges for a number of years, consistently failing to deliver the 4 hour target,
Winter 2017-18 has been recognised as one of the worst on record for the Staffordshire and Stoke on Trent system, resulting in poor experiences and outcomes for patients.
The STP commissioned Fusion 48 to review the 2017-18 Winter Plan and their report concludes that the system clearly did not work together to develop a coherent and deliverable plan. Key findings and recommendations were:
Use the STP framework for planning to ensure strategic objectives and programmes link
• Avoid long lists of winter schemes (there were c 100)
• Adopt a more segmented approach to planning and use targeted KPIs
• Improve consistency of planning across the STP footprint
• Agree clear and consistent information flows
The UEC system has acknowledged the report findings and has embraced the opportunity to ensure the lessons learned are in place for this year’s plan.
This document sets out the Winter Plan (the Plan) for West Staffordshire based populations, and describes how partners in the health and social care economy are planning to ensure that our services can best meet the anticipated emergency demands
The success of this plan requires a whole system approach and effective partnership working.
It will be crucial that all partners understand their role in supporting and delivering this plan. This year the planning has started earlier and is led through the STP, more emphasis placed on a whole system planning process rather than individual organisations undertaking planning in isolation.
2. Background
It is an expectation of all partners and regulators that an effective plan is constructed and tested for the winter period 2018/19. The West Staffordshire Accident and Emergency Delivery Board (WSA&EDB) must be assured that all commissioner and provider plans evidence individual organisational and system wide resilience and congruence.
The Winter Plan (the Plan) has been formed via the employment of best practice and lessons learned from recent winter periods. Delegates from all key stakeholders have been engaged in the formation of the Plan and compliance will be the responsibility of all WSA&EDB members, in collaboration with their respective organisation.
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3. West Staffordshire Local Context & Winter Review
The 2018/19 winter plan has been developed to ensure the following areas are addressed: The system have reviewed winter and agreed that the following are a priority;
Clear and tangible plans to close anticipated bed deficit (escalation) Reduction in Stranded & Super Stranded Patients Reduction in Length of Stay 7 Day Services Reduction in MFFD Green to Go Community Service provision including domiciliary care Reduction in Ambulance conveyance to ED Increase Access to Primary Care (including OOH)
4. Plan Interdependencies
The Plan has a number of interdependencies and should be read in conjunction with; The Staffordshire Escalation Plan, The Local Heath Resilience Partnership Influenza Plan, National adverse weather plans, Emergency Department (ED) Recovery Plan Individual organisational plan (e.g. Business continuity, incident response, infection prevention etc).
5. Outcomes of the Plan
The Winter Plan aims to support the delivery of the following outcomes that are identified in the STP:
5.1. Simplified Access Points Simplify access to urgent and emergency care for people so they get the right advice and help when they need it, therefore reducing pressure within the system and leading to an improved patient experience and outcome.
5.2. Integrated Approach Urgent & Emergency Care Provide a fully integrated Urgent and Emergency Care Offer which will include consolidation of Minor injuries, Walk-In-Centres, GP urgent, NHS111, and increase rapid response & community Urgent Care Diagnostics.
5.3. Working together as one Healthcare System Provide the framework, systems and processes to enable all system partners to work together to deliver robust and cohesive demand and capacity planning.
5.4. Wider System Delivery Focus on proactive support to homes to reduce avoidable attendances and admissions to hospital, timely and simple discharge pathways and a partnering approach to market management which will result in sustained, high quality care home provision
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5.5. Hospital Front door Ensure that the management of A&E is optimised, including GP Streaming to deliver 95% 4 hour performance, zero 12 hour breaches, and achieve the ambulance handover target.
5.6. Hospital Flow Ensure that patients flow through the hospital and receive the right care at the appropriate time and discharged timely. This will include implementation of SAFER bundles, Reduction of Stranded & Super Stranded patients, appropriate bed base and reduction of ambulance conveyance to ED.
5.7. Hospital Discharge Flow Ensure that the correct internal hospital processes and support services are in place to ensure that patients can be discharged from hospital in a safe and timely manner. The key to this is ensuring joined up health and social care is available within the community and primary care. This will include implementation Discharge to Assess (D2A), trusted assessor and reviewing Continuing Healthcare (CHC) assessments.
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6. Governance
Winter planning is a sub-work-stream within the STP Urgent and Emergency Care (UEC) Governance structure; forming part of the Working Together as One Health and Care System work-stream. The Senior Responsible Officer for STP UEC is also the Senior Responsible Officer for Winter Planning for the Pan Staffordshire footprint.
Fig 1: STP Governance Structure
7. PMO & Monitoring
The Programme Management Office will coordinate and continuously monitor the winter plan, the team consists of:
CCG Director of Commissioning and Operations; CCG Deputy Director of Strategic Commissioning;
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Staffordshire Urgent Care Team.
The PMO worked collaboratively with the following partners to produce the Winter Plan: University hospital of North Midlands (UHNM); Midland Partnership Foundation Trust (MPFT); Staffordshire County Council (SCC); Stoke City Council (Stoke CC); North Staffordshire Combined Healthcare Trust (NSCHT); West Midlands Ambulance Service (WMAS); Staffordshire Doctors Urgent Care (SDUC); Primary Care; Voluntary Services.
Weekly conference calls will take place with all partners in order to develop the plan, test assumptions and monitor through winter using recommendations from Fusion 48 evaluation and KPIs developed to monitor the outcomes of the plan. The PMO (Staffordshire Urgent Care Team) will report, track and monitor KPIs and where necessary escalate to senior leaders.
To further ensure that the system partners and the associated plans are effective, a multi-agency desktop exercise will be undertaken in September 2018. The desktop exercise will use realistic scenarios to evaluate the plans led by the Regional Capacity Management Team and Staffordshire Urgent Care Team.
The focus of the test will be: Flow; Bed capacity; Community capacity; Understanding the potential impact of flu; Ensuring Actions within the Escalation Plan reflect SMART Methodology and are outcome based.
Fig 2 Example of monitoring dashboard
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8. Winter Plan Key Performance Indicators
The programme has identified a set of key metrics which will enable the success of the winter plan to be monitored.
These metrics are as follows (Targets and methods of measurement are provided in brackets where known):
Ambulance arrivals and delays *; A&E 4 Hour Wait (90% from 30th September 2018, moving to 95% by March 2019); Number of patients LoS >7 days and as a percentage of all occupied beds *; Number of patients LoS >21 days and as a percentage of all occupied beds *; Bed occupancy rate (95%) *; Escalation beds open during the winter period (plan vs. actual) *; Number of Medically fit for Discharge (MFFD) patients (plan vs. actual); Delayed Transfers of Care (DTOC) rate (3.5%).
A number of these metrics will be monitored nationally on a daily basis (marked *) by NHS England as part of their winter monitoring arrangements. This data is published weekly, which will enable almost real-time monitoring to take place.
For those metrics not available on a weekly basis, the system will work set up information flows to be able to source as near as real time data that is available.
9. Escalation Planning
The WSA&EDB wholly recognises that the system will experience fluctuations in demand across the winter period and partners have constructed models to forecast demand and plans to support response.
A programme of very senior leadership will be set up across the system to facilitate the best possible planning prior to peak periods of demand that includes; appropriate staffing levels and senior level command and control Page 25 of 287
across the system at peak times and weekly CEO calls will facilitate timely response to pressures within the system.
The Staffordshire Escalation Action cards (Appendix 3) set out the procedures across the LHE to manage day to day variations in demand as well as the procedures for managing significant surges by having a clear escalation and de-escalation plan based on 4 levels.
There are predicted periods of surge and, on occasion, surges will occur, due to external factors such as cold weather, social economic and regional occurrences, power cuts, etc.
The plan details clear actions aligned to specific triggers for each level for each organisation contributing to a shared risk management approach across the system. These escalation cards all align and complement the system as a whole, focusing on specific problems encountered at each escalation level (1-4). During periods of surge, escalation quickly reaches level 3/4. The response is then to focus on specific issues to de-escalate and manage the surge. The escalation cards have been tested as a system and have subsequently been revised to assure that the correct actions are taken by the correct organisations to produce a measureable output. This will enable the system leadership to monitor effectiveness and address any inadequacies or short falls in response
The Staffordshire Escalation Plan, on call arrangements and Emergency Preparedness Resilience and Response (EPRR) mechanisms all enhance the resilience of the system by means of detailing the responsibilities and key actions for partners to enact and return the system to a stable position.
During the conference calls, partners will be asked to confirm that they have fully enacted their actions included in the Staffordshire Escalation Plan and if there are any residual risks or issues associated to them, this is to also include any workforce actions such as cancelling meetings. Should system partners not be assured regarding the completion of the actions, this will be escalated immediately to the CCG executive on call tier.
10. System on Call Arrangements
The system has a long established mechanism for on call across all key partners, which is further complemented by the Escalation Management System (EMS) and Staffordshire Escalation Plan (Appendix 3). The response element (Action Cards) of the plan is determined by the EMS level and is refreshed bi-annually.
Daily conference calls (MADE) are undertaken to identify and respond to the pressures in the system, actions are formulated and responses are collated by the CCG. In the event that the system experiences significant/sustained pressure issues these are escalated to the Executives (Gold) of each organisation by their silver counterpart. UHNM will continue internal Sit Rep throughout the day on both acute sites to manage flow where the WMAS Halo, Complex Discharge, Social Care and Mental Health Operational Leads will be invited to attend to support a single site view of flow and actions required to next sit rep. Fig. 3: MADE membership attendance by level of escalation
Organisation EMS EMS Level EMS Level 3 EMS Level 1 2 Level 4 UHNM (RSUH and County) CCG
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MPFT Staffordshire County Council Stoke County Council NSCHT
Fig. 4: Frequency of MADE calls by level of escalation
Monday to Friday EMS Level 09.30 1230 1600 1 2 3 4
It is each Silvers responsibility to keep their Gold informed of any risks or issues that need escalating. During the call the attendees will collectively decide if there are any strategic issues that need to be escalated to the CCG Gold on Call. At level 4 and any other instances that require a Gold call will be decided and chaired by CCG Gold with all gold partners attending.
Each provider has detailed their internal on call arrangements within their plans to ensure there is coverage
Fig. 5: Internal on call arrangements by organisation
Organisation Silver Gold CCG – Pan Staffordshire Senior Managers On-Call Directors On-Call Staffordshire Doctors Urgent Care Operational On-Call Exec On Call Clinical On-Call VCL On Call Manager Developing Exec On Call (national coverage) MPFT On Call Manager Directors On-Call (North Staffs, South Staffs, Shropshire) UHNM On Call Manager Directors On-Call Staffs CC Care Commissioning Lead Director of Health and Care (deputy lead commissioner for (deputy Care commissioning brokerage) lead) Stoke CC NSCHT Exec on Call WMAS Strategic Operational Cell Gold Commander
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11. Adverse Weather Plans All key partners across the health and social care economy have organisation specific adverse weather plans which focus on the maintenance of service delivery and the safety of staff. These plans are fully tested and the NHS plans are assured via the EPRR Core Standards Assessment Process.
All plans fully reflect the Cold Weather Plan for England, are evoked via the command and control structures and encompass specific communication arrangements. This ensures that a consistent approach is applied across the economy. The Cold Weather Plan for England specifies the levels as:
Level 0: “Year round planning” and the Making the Case companion document may be more of relevance to public health professionals, Health and Wellbeing Boards (HWB), local authority chief executives and elected members; Level 1: “Winter preparedness and action” and the Making the Case companion document will be of relevance to all professional groups, particularly front line health and social care professionals; Levels: 2-4 “Severe winter weather is forecast through to national emergency” are more reactive in nature and include snow and ice as well as severe cold weather and may be particularly relevant to emergency planners and responders.
Via the EPRR route, partners receive weather warnings from the Meteorological Office and in the event of weather related incident affecting business continuity, a health cell (membership from the Local Health Resilience Partnership) will be established to coordinate the response.
At a local level, plans detail proactive communications (internal and external), staff briefings to ensure services are coordinated, flexible working, mutual aid, the use of the voluntary sector and specialised transport arrangements.
12. Influenza Strategy
The National Influenza Plan is a key prevention item for the winter and sets out a coordinated and evidence based approach to planning for and responding to the demands across England, taken from the lessons learnt during previous Influenza episodes. It provides the public and healthcare professionals with an overview of the coordination and the preparation for the Influenza season and signposting to further guidance and information.
The National Influenza Plan encompasses the responsibilities for NHS England, Public Health England, Local Authorities, providers, CCGs, General Practitioners and enacts the National Influenza Vaccination programme.
The Local Flu Plan supports the coordinated and evidence based approach to planning and responding to the demands of flu across Staffordshire supported with a Commissioning for Quality and Innovation (CQUIN). A Staffordshire Influenza MOU is in place to ensure partnership working to support all aspects of the local health economy for example if there was a flu outbreak in a care home they would receive support from Public health and MPFT with assessment and vaccination.
In 2018/19 the plan aims to ensure that:
Vaccination is actively offered to 100% of all those eligible groups; Vaccination of at least 75% of those aged 65 years and over;
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Vaccination of at least 75% of healthcare workers with direct patient contact; Improving uptake for those in clinical risk groups, particularly for those who are at the highest risk of mortality from flu but have the lowest rates of vaccine uptake, such as those with long-term liver and neurological disease, including people with learning disabilities or children, a minimum uptake of 40% has been shown to be achievable in pilots conducted to date. As a minimum uptake levels between 40% and 60% to be attained and uptake levels should be consistent across all localities and sectors of the population; Providing direct protection to children by extending the annual flu immunisation programme and also cutting the transmission of flu across the population; Monitoring flu activity, severity of the disease, vaccine uptake and impact on the NHS; Prescribing of antiviral medicines in primary care for patients in at-risk groups and other eligible patients under NHS regulations and in line with NICE guidance; Providing public health information to prevent and protect against flu; Managing and implementing the public health response to incidents and outbreaks; Ensuring the NHS and PHE are well prepared and have appropriate surge and resilience arrangements in place during the flu season.
All Staffordshire providers attained the 75% level in 2016/17 for flu vaccination.
In addition each provider has reviewed their flu plans and included additional actions within their own organisations plans:
Fig. 6: Additional actions within organisational flu plans
Organisation UHNM Monthly Flu Steering Group in order to plan, deliver and review flu programme Embedding of a “check and prompt” process to help protect patients with LoS greater than 30 days SDUC Reviewing option to deliver their own internal flu vaccination clinics MPFT Will encourage staff to have flu vaccinations with drop-in clinics, communications, increasing number of vaccinators Work with primary care to vaccinate housebound patients All in patients and new admissions through winter at community hospitals and Brighton House will be offered vaccination Stoke CC Communication re precautionary measures and symptoms of flu to care providers and direct payment advisory services Staffs CC – Public Health Target care homes to all residents are offered flu vaccination Encourage care homes to enable and promote flu vaccinations Encourage brokerage staff to have the flu vaccination NSCHT Coordinate own campaign supported by Team prevent Training to commence in Aug 18 for peer vaccinators WMAS Deliver flu vaccinations at various locations Train paramedics to administer the vaccination Aiming 80% uptake by 31st December 2018 Trust engagement vehicle mobilised to locations not served by paramedics to ensure mobile flu clinics are available
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13. Outbreak Plans
All provider organisations have robust plans for the prevention and management of outbreaks, predominantly led by Infection Prevention Teams. The plans have been tested, applied to respond to live issues and supported by clinical teams with on-site presence and on call availability.
Outbreaks have the potential to significantly preclude system flow and whilst the system does have effective plans and a degree of side room capacity, this remains a significant risk.
All relevant staff are comprehensively trained in infection prevention and in the event of staff sickness having a material effect on a service; a clinical prioritisation process will be applied, supported with mutual aid agreements.
14. Communication
The Winter Communications Campaign on behalf of all six CCGs is aligned to the National Stay Well campaign and the STP Communications Plan. The strategy includes:
Focus on social & digital; Pan Staffordshire coordinated approach including all commissioners and providers; Utilising Patient Participation Groups to share information within their local communities.
Providers have organisation-specific communication plans which complement the system- wide plan. All existing communication channels will be used to target the groups most vulnerable over winter to ensure that people who are most at-risk of preventable emergency admission to hospital are aware of and, where possible, are motivated to take, actions that may avoid admission this winter.
The campaign will ensure that:
There is a consistent identity to promote the range of services available to patients/service users (focussing on clinically appropriate alternatives to 999 and ED); Patients/service users are made aware that 999 and ED are for life-threatening/serious issues only; Patients/service users are made aware that NHS 111 is the most effective service for non-life threatening/serious issues; Self-care and prevention is fully promoted.
A communications escalation card has been developed and will be included in the set of escalation cards for the first time this year.
14.1. Cascading Advanced Warnings and Focus on High Risk Groups
In addition the communication arrangements across the system, partners have specific plans in place to communicate to those patents/service users identified as at a heightened level of risk, due to the winter period. Activities include work with rural communities, high volume users, vulnerable patients/service users, patients/service users with long term conditions and sourcing support from the voluntary sector.
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System partners also receive alert information from a number of agencies (e.g. Civil Contingencies Unit, Police, Meteorological Office etc.), which are used to proactively plan and effectively respond via the EPRR arrangements.
The Community Provider will ensure that the intervention work with High Volume Users is intensified over the Winter Period, to ensure that the clinical condition of this cohort of patients is optimised and they are supported appropriately. This will reduce ED attendances and non-elective admissions.
14.2. Nursing Homes & Care Agency Communications Plan
15. Capacity and Demand Modelling UHNM and University Hospitals Derby and Burton (UHDB) – Queens Site both conducted a thorough activity review in order to establish their modelling for winter, separately they both concluded that the capacity required for winter 2018/19 was the baseline plus 10% uplift and growth. This was presented at a demand and capacity meeting attended by all stakeholders and it was agreed collectively that this assumption should be applied to all organisations modelling.
All Providers were asked to demonstrate an understanding of their demand and capacity over the winter months and provide an organisational winter plan. The plan must include;
Additionality and phasing of escalation Workforce Model to support 7 day working, senior decision making and escalation capacity 7 day working Christmas, New Year and Easter period Options for further surge capacity if required
15.1. UHNM Bed Modelling
In line with National mandates from NHSi and NHSE the Trust has been asked to model its Winter bed requirements utilisng a 95% occupancy rate
UHNM currently have a budgeted baseline of 1249 beds however with 2.3% growth this equates to 1420. They require an additional 171 beds. No phasing has been applied to the additionality however the expectation is that the demand will increase throughout winter and the peak in demand of 171 beds will be experienced in January 2019, there is also the expectation that this demand will remain throughout Februray and March, however if it does reduce the escalation beds can be closed.
The Trusts growth figures are based on a detailed bottom-up analysis of local dempgraphics and morbidity, recent experience and known capacity constraints. The detail of their modelling is included in their plan (Appendix 6), the key points to note are;
The plan assumes MFFDs will continue at 208 beds Assume two week loss of elective activity due to winter pressures
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A&E has an underline growth of 4.1%. 2017/18 outturn included activity which will in 2018/19 be undertaken via the Urgent Care Centre and therfore not included in the UHNM activity Includes approved service developments but not ones waiting approval
UHNM’s bed base total is 1491 with 1295 beds at Royal Stoke and 196 beds at County Hospital. The winter modelling has been based on the General and Acute bed stock (1249 – RSUH = 1057, County = 192) therefore removing maternity, paediatrics and critical care.
Fig. 7: Winter Bed Modelling
Bed Modelling Beds Core Funded 1249 Capacity required with 2.3% growth and agreed uplift of 10%, (Note: UHNM applied 11.1%) 1420
Calculated Gap 171
15.2. Summary Position The table below provides a summary postion of the capacity system partners have commteed to bring on line to mitigate the anticipated gap throughout the winter period (subject to agreement as detailed within this document). Assunptions applied to this plan are:
There is no variation in the calculated bed gap throughout the winter period Due to the variance in LoS it is antiipated that every 4 community beds will release 1 acute bed. Community cpacity has not been converted to “bed” days but will be seen as supporting the achievement of the MFFD target. A 10% uplift in all Bed Stock both community & acute; A 10% uplift in community & mental health services; Reduction of Stranded patients & Super Stranded.
Fig 8: Summary Position
October November December January February March Commentary -171 -171 -171 -171 -171 -171 Baseline deficit in acute beds
+30 30 30 30 30 30 Beds released through efficiencies (stranded/S&T) +25 25 25 25 25 Phase 1 County Capacity Opened +63 63 63 63 63 Bradwell Hospital capacity Acute Beds Acute mobilised +41 41 41 Phase 2 County Capacity Opened -141 -53 -53 -12 -12 -12 Running Total Additional CCG commissioned Care +13 13 13 13 13 13
Home Capacity
Beds unity Comm +19 19 19 19 19 19 Efficiencies within CH/CG beds
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+22 22 22 22 Scotia Ward 10 beds and Milford Ward 12 Beds (MPFT) +10 10 10 10 SCC additional care home capacity +4 4 4 4 Ward 4 (NSCHT ) +5 5 5 Stoke City Council +3 3 3 Scotia Day Case Unit (MPFT) -133 -45 -36 +7 +7 +7 Running Total applying 1:4 ratio All figures below represent increase above baseline on a monthly basis – these figure is not cumulative + 140 +280 hours + 420 Hours + 561 561 Hours 561 Hours Additional HF Capacity above
hours Hours baseline baseline baseline + 394 hours 394 hours 394 hours 394 hours SCC Re-ablement/POLR +564 hours +990 hours +899 hours +525 +814 hours + 938 Stoke Domiciliary Care hours hours +704 +1279 hours 1713 hours 1854 1769 2893 Running Total – increased hours hours hours hours home care capacity
CommunityServices 47 85 114 123 118 193 Conversion into number of patients supported (based on av 15 hour per PoC)
Delivery of schemes will be ensured through the governance process detailed above.
15.3. Detailed Plans - UHNM
Within the appended plan UHNM indicate that efficiencies within the Simple and Timely discharge figures will be achieved by changes to the acute flow model which will be phased in from August. It consists of 4 work streams:
ED; Assessment flow; Wards; Discharge.
25 escalation beds will be opened at County (Ward 1) with a fully dedicated MDT available including Social Workers to ensure continuity of care and flow. The ward will open in a phased manner from November and will be managed by UHNM. At times of escalation senior presence will support the ward to ensure flow is maintained to free up capacity. Clear escalation processes will be in place to ensure patients who become delayed are expedited.
63 escalation beds will be opened at Bradwell in a phased manner from November to meet winter demand. When opened for winter it will be managed by UHNM with a dedicated MDT including Social Workers. A workforce plan is being developed to ensure the ward is as prepared as possible for opening. Whilst the ward is open senior CCG presence will be available to support flow and assist with any specific delays. MADE events will be run at peak times. Clear escalation plans will be devised to ensure system leaders can support the unblocking of strategic issues raised.
Phase 2 is the opening of a further 41 beds at County Hospital in January. A number of ward areas at County have been identified as being able to be brought back into use:
Ward 6 – 19 beds;
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AAU – 7 beds; Discharge lounge – 3 beds; HDU – 12 beds.
UHNM will manage the beds and at times of escalation senior presence will support the ward to ensure flow is maintained to free up capacity. Clear escalation processes will be in place to ensure patients who become delayed are expedited. As the ward areas targeted by this scheme are being brought back into use and are not up to current standards there may be some capital costs associated with getting them back into a useable state.
Fig. 9: Plans to reduce bed deficit
UHNM Bed Deficit -171 Simple and Timely 30.0 Phase 1 Escalation Beds 25.0 UHNM within existing estate (County) Bradwell 63.0 Recommissioned and managed by UHNM Additional capacity involving estate modifications (From Phase 2 Escalation Beds 41.0 January at County) Total Scheme Effect 159 Net System Position -12.0
Other UHNM Acute Flow Enablers to support escalation Oct – March 2018:
Acute Flow Model Programme: end to end improvement flow focus: July 2018; Review of NCEPOD capacity RSUH – improve NEL surgery access and reduce LOS, ring fence elective capacity; Acute Floor Model RSUH ED: AMRAU pilot August, full model October 2018; Bradwell Model RSUH: November, 2018; Med Fit/IDT Model County: January – April 2019; Value Stream Mapping COPD pathways: multi stakeholder teams. High Intensity user admission avoidance with out of hospital pathway.
15.4. Achievement of A&E Performance
The Trust are planning to achieve 90% by September 2018 by redesigning flow through majors to allow greater in- reach, and then 95% by March 2019 will be dependent on maintaining sufficient capacity at Royal Stoke and in community services to ensure flow. A&E internal plan includes:
Review of A&E 4 hour breaches and reasons with a view of targeting specific pathways; Review Emergency Department floor template to maximise flow for admitted pathways; Speciality doctors ingress into A&E to ensure greater in-reach from bed based specialities; County site plan will achieve 88% by September 2018 and 95% by March 2019; Plan to achieve 95% target in both minors and paediatrics at RUSH by September 2018 to achieve the 90% overall target, this will then be sustained;
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The Trust’s detailed winter plan describes the actions that will be taken during winter to support achieving the A&E target; this includes escalation bed capacity schemes. These are also discussed in section 3 – winter planning; Leek & Haywood walk-in centres, UTC and the emergency eye clinic are included in the A&E numbers. These will all exceed 95% performance; A sustainable and agreed MFFD/G2G plan to achieve the 118/59 target prior to winter period.
15.5. Reduction in Stranded Patients Plan
15.5.1. Acute Beds
A 25% reduction in bed days associated with long stay patients must be achieved which equates to the equivalent reduction of 75 acute beds. UHNM, CCG, County Council and MPFT are working closely to support and this will be delivered through the following actions;
15.5.2. Community Beds
MPFT have defined stranded patients as those in a bed for more than 28 days. The following actions will be taken by the trust:
Daily board rounds; Weekly MDTs in escalation beds; Weekly review of stranded patients; Daily conference calls across community and bed based services; Planned monthly MADEs across services.
Reduction in DTOCs is closely aligned to this work stream; there is an agreed trajectory between partners. DTOCs calls are held through the week they are chaired and tracked by the CCG and Staffordshire County Council to ensure strategic issues are escalated in a timely manner and actioned to support management of flow and a reduction of DTOCs.
15.6. Midlands Partnership NHS Foundation Trust (MPFT) Bed Modelling The trust provides 102 community beds in West Staffordshire and has calculated that an additional 25 beds are required. At the moment 10 escalation beds from winter 2017/18 remain open but the trust will be closing this capacity by 31st July 2018 and further detail is included in their plan. Scotia ward is expected to open on the 3rd December 2018, however the Trust recognise that this capacity may be required prior to the planned start date and have confirmed that they will require a two week lead in time to mobilise to ensure that the infrastructure is in place for safe and suitable care.
Staffing will increase to support the extra beds and a discharge lounge will be in operation from September 2018 to April 2019 at the community hospital for all patients being discharged home.
Fig. 10: MPFT Bed Model and Escalation Bed Phasing
Current Rehabilitation Bed Capacity Location Bed Base Escalation Capacity Comments
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Brighton House 25 Chatterley 25 Grange 32 Jackfield 20 Scotia In Patient Ward 10 Milford Ward 12 Scotia Day Case Unit 3 Total 102 25 (24% uplift)
Phasing of Winter Bed Capacity Month Baseline Extra Beds Opened Total Comments Oct-18 102 0 102 Nov-18 0 102 Dec-18 22 124 Scotia & Milford Jan-19 3 127 Scotia Day-case Feb-19 0 127 Mar-19 0 127
15.7. MPFT Community Services MPFT will aim to deliver an additional 10% uplift of commissioned home first hours. This will be an additional 561 care hours across Staffordshire, below details the phasing of this additionality. Note: there are challenges in delivering the existing commissioned hours, therefore there are a number of risks to increasing to this level within the timescales:
Fig. 11: Phasing of additional hours
Phasing of Winter Home First Capacity Month Baseline Extra Hours (Weekly) Total Comments Oct-18 140 5750 Nov-18 280 5890 Dec-18 420 6030 5610 Jan-19 561 6171 Feb-19 0 6171 Mar-19 0 6171
The additional capacity will be delivered through the following key actions:
continued implementation of the long-term plan to provide the required number and skill mix of staff needed both immediately and to ensure sustainability in the future; improvements in productivity to extract as much value as possible from available spending (currently well in progress via wok with Meridian Productivity Ltd to increase staff / patient face-to-face time). Page 36 of 287
Other activities to increase delivered hours could include the following. Funding of any additional costs incurred would need to be agreed:
to outsource any capacity gaps through sub-contract arrangements (pass through cost arrangement to be agreed); paid overtime to Home First workers.
15.7.1. Social Care Capacity In terms of the additional capacity for social care assessment, MPFT will look to provide 7 day a week cover where discharge to assess is not embedded (ie the out of county hospitals and some additional support into Queen’s), in addition to this MPFT would look at additional capacity to work on a Monday and a Friday to ensure the appropriate level of flow is maintained. There are also some additional capacity requirements around the beds; any expansion of social care assessment function, for it to be successful and provide effective 7 day flow, is dependent on LA Brokerage and care homes admitting patients 7 days a week.
Any increase in capacity, bed based or community will require additional resource to respond to demand. MPFT has a responsibility in the assessment of the social care needs of individuals at:
UHNM (RSUH & County) Queens Hospital, Burton Good Hope Walsall Royal Wolverhampton Russells Hall
There are some differences in the current provision of social care. In the north there is 7 day assessment cover in the acute hospital. In the south the provision remains on a Monday-Friday basis. Over winter, the plan is to increase the Social Care presence making the service more responsive to the needs of partners (the exact requirement will be confirmed following further discussions with HR and finance. This will need to be contractually agreed and funded via Commissioners).
The additionality can be in place from the 1st October and is to be signed off by WSA&EDB including source of funding. Operational teams have been consulted on the potential 7 day service request. The options to deliver a 7 day service could be through a Management of Change (further detail included in workforce planning section) or is to increase as follows;
Fig 12: Additional Staffing
Area Staff Required Cannock 3 x wte Social Workers (B6) 7 day working/D2A beds Stafford 2 x wte Social Workers (B6) To enhance D2A/D2A beds North 3 x SCAs 1 x Advanced SW (B5 To enhance Home First Service and B7)
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15.7.2. Therapies
MPFT are undertaking a review with AHP’s to strengthen the current provision. There are currently different models in place across services in relation to therapies. To ensure effective flow and improved outcomes for patients, any increase in service provision also requires an increase in therapy resource. This will include weekend therapy provision.
There is 7 day therapy support in Home First and Brighton House but currently more limited weekend therapy support at the Haywood which will need further review.
There are two options proposed by the Trust;
Option 1
1 OT and 1 Physio to provide weekend cover at the Haywood
Option 2
2 WTE OT’s and 2 WTE’s provide weekend cover for the Haywood and CCG beds allowing cover for sickness and AL
This additionality could be delivered through a management of change with existing staff or recruitment of locum cover.
15.7.3. Haywood Walk-in-Centre Historically in times of pressure extending the WiC opening times have been requested due to patients waiting for it to open. To meet demand the trust intends to extend the opening hours until midnight and to open at 8am on a Saturday and a Sunday.
15.7.4. Mental Health
The Trust plans to increase mental health cover at County Hospital for ED and wards and increase the services for older people mental health to support admission avoidance both from 5 day coverage to 7 day coverage. Both increases require confirmation of funding.
Specialist mental health nurses to in reach into care homes to avoid admissions to both acute and mental health trusts. In addition the service will support patients in D2A beds
15.8. North Staffordshire Combined Healthcare (NSCHT)
NSCHT have provided a winter plan (Appendix 9) that details the 10% uplift and phasing for several services that they provide. This includes;:
Mental health liaison that will be an all age, all hours service by December 2019; Page 38 of 287
Enhanced outreach service supporting community teams and care homes including the development of a trusted assessment with some care homes; Crisis/home Treatment; Ward 4 with 4 escalation beds.
The Trust have identified actions that will support flow across the system from a mental health perspective, some of these are:
Proactively pull patients; Dedicated mental health liaison worker on elderly care to support discharges; Focus on LoS and DTOCS on Ward 4; Proactive engagement with AEC.
15.9. Staffordshire County Council
Detail of Staffordshire County Council approach to winter is included in their plan. There will be clear leadership line of sight and performance reporting mechanism in place across their health and social directorate. Some of their key actions outlined are:
Ensure delivery of funded home based Discharge to Assess (D2A) capacity; Increase the supply of pre-purchased temporary step down nursing beds; Address the supply of home care in the hardest to serve areas of the county; Ensure sufficient brokerage capacity to manage increases in discharge numbers.
SCC is negotiating the provision of the 10% additional Home first D2A hours with the existing providers, in the context of under-delivery against commissioned hours.
Additional nursing home beds will be purchased to support dementia flow as temporary placements when permanent care becomes restricted. The capacity will be split 50/50 East and West.
SCC have completed mobilisation of a tender for home care, however there still remains a need for a further increase and this will be a priority. The Moorlands is the most challenging area to source home care and SCC will continue to contract manage the providers in this area and a supra-rural rate has been planned for the most rural areas, with a bidding process, target for delivery from October 2018.
15.10. Stoke City Council
Stoke City council are committed to ensuring the required additionality of step down/pre-purchased beds available through winter. They will utilise the joint contract effectively to ensure best use of resource.
Domiciliary Care provision has been modelled and is provided within the Stoke CC winter planning document
(Appendix 12).Using previous year demand they expect the full 10% increase to be required in November, however they have been unable to get Home First data which is required to fully understand demand. Page 39 of 287
Fig. 12: Planned domiciliary care provision (table)
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Hours 10,835 11,127 10,792 10,672 11,739 11,515 10,620 11,328 11,615 11,320 Per (Actual) Week
Fig. 12b: Planned domiciliary care provision (chart)
12,000
11,500
11,000
10,500
10,000
9,500
9,000
Predicted Hours Per Week (2018/19) Hours Per Week (2017/18)
They will share the level of demand expected with the agencies so that they can prepare for the additional ask for resource during winter.
Additional capacity has already been generated in the current market through jointly commissioned capacity between the CCG and Stoke-on-Trent City Council. The partners have commissioned nine block purchased rotas across a number of providers and this has ensured that there has been additional capacity in the market.
The City Council is committed to continuing to work with the CCG to increase the numbers of rotas in order to meet the increasing demand and allowing timely move on of packages of care onto more long-term maintenance packages.
Each rota of care increases capacity by 91 hours per week. From the demand modelling, it is anticipated that there will be an escalation from October that will, at its peak, require 10 additional rotas to offer the appropriate support through Winter.
Monitoring services are being formulated that will give clear oversight as to the actual requirement ensuring that we are able to meet demand requirements efficiently and without over-purchasing.
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The City Council are committed to putting in place the required additionality of step-down/pre-purchased beds and utilising the joint contract effectively between CCG and Stoke-on-Trent City Council in a controlled way that makes best use of available resource.
Additionally there are some early estimates of Bed Deficit calculations, however, these will need to be modified to reflect CCG declared pressure and understand what further additionality Stoke-on-Trent City Council may need to explore.
15.11. CCG Capacity
Staffordshire CCGs will be commissioning additional beds to support the winter period in care home market by 10% to support the continued flow this equates to 13 beds above the 132 baseline. The CCGs will also ensure that the wrap around cover required is also commissioned to maintain flow. The contracts will also reflect the need to adopt trusted assessor and a seven day service which reduces any delays in patient transfers throughout the winter period.at are in place with the care homes ensure that a 7 day service is provided.
In addition to this the CCGs will also drive the achievement of the contracted level of stays within the community bed bases (28 days LoS Rehab/Assessment patients, 31 LoS patients with EMI needs). There will also be a focus on achieving a 25% reduction in stranded/super stranded patients emulating the processes successfully implemented by UHNM. By driving through these efficiencies it is anticipated a further 19 beds will be delivered from October 2018.
15.12. West Midlands Ambulance Service (WMAS) Capacity
WMAS have provided detail of their expected demand within their plan (Appendix 15). Typically there is 4.5% increase year and year with a 10% growth in December and January. The Trust has developed a strategic plan with early investment for robust plans in place to ensure that during winter there is the maximum number of staff available and they can meet the demand expected.
The Trust has a strong Command and Control structure to ensure resource is managed effectively. An additional Duty Senior Commander will be based in headquarters as it has been proven in the previous two years that it is beneficial to have extra senior leadership on site.
WMAS will meet the additionality through recruitment of more staff, ensuring timely replacement of vehicles to enable a temporary increase in the fleet for the busiest months, increased call takes and ambulance fleet assistants.
15.13. Staffordshire Doctors Urgent Care (SDUC) Capacity
SDUC are undertaking statistical forecasting using Erlang C modelling techniques specifically focusing on key dates throughout December and January where increases in seasonal activity are anticipated. The forecasts will be agreed and signed off by the regional management team with finalised forecasts provided by early October 2018. Please see workforce planning section for more detail on how the additionality will be provided. Page 41 of 287
15.14. Primary Care Capacity
Extended Access will be in place from 1st September 2018 and this will result in the following:
North Staffordshire CCG – 230 additional 15 minute appointments per week; Stoke on Trent CCG – 304 additional 15 minute appointments per week.
This will improve access for the population by providing additional time slots across evenings and weekends.
Nursing Homes will be supported by primary care in an aim to reduce the need for emergency response and promote timely referrals to other services. This will be achieved through the following:
Zoning of practices to specific homes; Networking with the locality with statutory and voluntary services; Quarterly information sharing opportunity with homes; Strong links with both GP practices and care homes.
16. Surge Plan
As part of business continuity and contingency planning UHNM has to plan for expected and un-expected surges in demand. Part of the surge plan will focus on the bank holiday periods and the recorvery:
Christmas; New Year; Easter.
UHNM are consulting on a revised command and control rota for winter. Final details to be confirmed following HR review.
MADE calls will continue to be held 3 times each day through winter with all organisations supporting through senior leadership input, coordinated through UHNM. In the event that the system experiences significant/sustained pressure, issues will be escalated to the senior leaders and regulators.
Providers have included their own specific actions to respond to surge in their winter plans
16.1. Additional UHNM Bed Capacity
A number of options are being persued by the Trust:
The Trust is seeking planning permission to install 2 modular wards on site in time for January 2018, although this is a very expensive option; The Trust is seeking Department of Health funding to develop the Trent building to provide an additional 25 beds from January 2019 and 75 beds by the winter of 2019/20. It is in discussion with NHSI and the STP as to how this can be funded.
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17. Workforce Planning
17.1. UHNM Workforce Planning
UHNM have reviewing staffing establishments and have rolled out the Safer Care Tool that allows a review of staffing requirements on a shift by shift basis dependent on patient acuity. There is a national shortage of nurses however UHNM vacancy rates are below the national average. They continue to promote the use of internal nurse bank rather than agency.
The detail of the trusts workforce planning is included within their Operational Plan (Appendix 6), including process for assurance, identifying the challenges risks and how these are mitigated.
The Workforce required for the additionality proposed will be drafted as part of the phased enabler work for RSUH and County, it is currently being scoped and this will be adjusted against last year’s workforce outturn.
17.2. MPFT Workforce Planning
To provide 7 day working for services over winter will require a change in service provision. Before any consultation commences the Joint Staff Partnership need to be notified, this is too late for July and there is no JSP in August, so a separate meeting will need to be convened. There would also need to be a comprehensive Equality Impact Assessment on the staff groups affected.
Below is a proposed timescale based upon a start date of 1st October for 7 day working:
(Please note this will be for AHP and Social Work roles)
Fig. 13: MPFT plan for moving to 7 day working
Date Activity Commence consultation with affected staff and w/c 23th July 2018 Trade Unions Close consultation on proposed seven day 27th August 2018 working. Consider representations and queries. w/c 27th August 2018 Response to the Consultation and issue any changes. 30th August 2018 Issue letters advising changes to contract 1st October 2018 Seven day working pattern commences
Recruitment remains challenging around the Home First service and nursing posts given the competition from other NHS organisations and private providers. The Trust continues to work with the external recruitment provider to expedite the selection process for those successful applicants going through the employment checks process. Rolling adverts are being utilised to aid a speedier recruitment and selection process, and recruiting managers are requested to review/interview candidates as and when applications are made rather than waiting for specific closing dates and pre-scheduled interview programmes.
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The Trust will be visiting a number of Job Fairs at Universities over the coming months in order to seek to attract newly qualified nursing staff to work at the Trust. The service does not currently utilise bank staff in the Home First workforce and options around this are being explored within the Care Groups. The pool of flexible workers, both qualified and unqualified registered at the former SSSFT Trust will increase the availability of workers to the service going forwards to cover any sickness absence, this is not something that has previously been available.
The Trust will also look to increase the availability of flexible workers through an internal recruitment campaign whilst being mindful of the working time directive and the health and wellbeing of staff already employed in a full time role within the Trust. An advert for flexible Health Care Support workers is currently live on NHS Jobs and there are plans to expand the number of adverts across all professional groups in order to address agency spend.
The Trust will be tapping in to the national nursing recruitment campaign launched on the 4th July to celebrate the 70th Birthday of the NHS and using the Careers social media accounts and the expertise of the Trust’s Communication Team to point candidates towards the employment opportunities within the Trust. In addition to the above opportunities for employment within the Home First service are being promoted through leisure centres radio across the County, and we are looking to use the information screens in doctors surgeries, that will enable us to target the areas with most need.
The learning and development programme is being reviewed and revised, including the time allocated for shadowing in some areas where this is appearing to be more lengthy, to ensure that the workers are available at the earliest opportunity, whilst having the correct skills to undertake their duties safely. The Trust are in discussions with an NHSi approved care agency and exploring opportunities for them to be able to provide domiciliary workers to the Trust under a master vend arrangement, these discussion are also part of a wider remit to expand the existing master vend arrangement for all clinical roles across the new Trust ensuring we engage workers at the most competitive rates wherever possible.
Retention has been identified as an issue within the Home First workforce one of the main reasons cited is the shift patterns, these are being re-visited by the E-Rostering Team, together with Meridian and operational managers to see if there is a more efficient and effective roster that can be implemented that better supports the work life balance of the workers and therefore aids retention of their skills whilst recognising the needs of the service. Exit data and Listening Into Action data will be examined over the next few months to establish any other areas of dissatisfaction and an Organisational Development plan developed based on the results.
The contract with the outsourced recruitment provider SBS ends in October, moving the recruitment and selection process to an in-house service will give greater control and flexibility over the recruitment process and allow for team resources to be flexed to meet demands in recruitment to posts.
Information is collated on a weekly basis and vacancies monitored through the Programme Board, a specific Workforce Workstream, reporting in to the Programme Board is being established to support the recruitment, development and retention of this workforce and more closely monitor progress towards a full establishment.
17.3. NSCHT Workforce Planning
Ward 4 will actively support admissions and discharges across 7 days linked to the 7 day functionality of the enhanced Outreach service. Where care homes express concerns around admitting patients at weekends Outreach will offer full transitional support. Page 44 of 287
Outreach service operates over 7 days from 8am-8pm. There will be 7 day support on site at Royal Stoke to support the Discharge to Assess pathway and enable transition to provider services.
Mental Health Liaison operates 24/7 at the Royal Stoke for adults and older people, with a core hours service for children and young people under the ae of 16. By December 2018 there will be 24/7 provision for all age ranges.
Access/ Home Treatment Service operates 24/7
17.4. Stoke CC Workforce Planning
Stoke CC will monitor the ongoing demand and are committed to being flexible to meet requirements of demand and continue to explore the viability of seven day working across assessment capacity and supporting teams.
The Commissioning staff will communicate with providers over the coming weeks to ensure that a full list is formulated of providers who will work seven days and what the working patterns will be over winter.
This will be shared with Social Work colleagues to improve speed of placements and keep referrals targeted to then aid egress from hospital for residents or users of domiciliary care.
This list will be modified throughout winter and we will also monitor referral rates at weekend and over the bank holidays to not only ensure that we know where referrals can effectively made, but also in order to shape our response to seven day working internally.
Stoke CC will be able to see the availability of staff over Christmas and New Year, and any existing capacity on rotas will be able to be utilised. However, new capacity will not be able to be brought on line by asking staff to work who previously had leave agreed, without effective financial investment to ensure that they are fairly remunerated.
17.5. SCC Workforce Planning
Brokerage capacity will increase during winter to support the extra demand:
Fig. 14: Brokerage capacity over winter 2018/19
Brokerage Oct Nov Dec Jan Feb Mar FTE 7 7 8 9 8 8
In additional 2 FTE can be added a short notice from the wider team to support peak demand. There is also an option for temporary recruitment if there is significant absence within the brokerage team.
During November to March extension of the brokerage team into weekend will be tested alongside support to the implementation of a Trusted Assessor model (implemented by MPFT). Brokerage will focus on timely moves to a targeted number of key homes and home care providers, and on engagement with the families.
While the Council will promote 7 day assessments and discharges across all care homes with which it contracts, due to the nature of many providers and the balance of supply and demand, the winter plan is not premised on achieving equal flow into all care homes on each day of the week. Page 45 of 287
The Trusted Assessor model is focused on those care homes that are most frequently used to support hospital discharge (due to their capacity, price and other elements of market position).
Similarly, in terms of 7 day access into home care, the contractual requirements to support restarts of packages can be triggered 7 days a week. For new referrals, the Council’s approach is to prioritise flow 7 days a week into its key strategic home care partners – MPFT and Nexxus (who are contracted to a Provider of Last Resort role as well as a provider of D2A and reablement) and 9 other providers who are contracted on a capacity block basis across the county. In addition, 7 day access to Pre-Purchased Rotas (for Moorlands, as set out in the previous section) is being prioritised by the Council.
17.6. WMAS Workforce Planning
WMAS have no vacancies (including paramedics). They have a low utilisation of bank staff and the lowest level of sickness in the country. The Trust is completing early recruitment of new staff to ensure training is complete and they are operational for the festive period.
To maximise capacity there will be no non-urgent/non-mission critical meeting in headquarters between December 14th and January 9th.
All officers must book on duty with the EOC so that they are able to respond to incidents when the closest vehicle, all managers with a blue lighted care will make themselves available throughout winter. The Trust has agreed key dates where all operationally qualified managers make themselves available:
Dec – 14, 15, 16, 17, 21, 22, 23, 24, 26, 27, 28, 31, Jan – 1, 2, 3, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15
17.7. SDUC Workforce Planning
SDUC are currently recruiting for all clinical and operational roles in line with their winter staffing requirements. The training programme will be completed in autumn to ensure all staff are available to work frontline across the winter period.
Annual leave allowance has been reduced during the winter months and in addition they have implemented an organisation wide annual leave embargo between 20th December and 14th January 2019.
18. Risks to the Staffordshire Winter Plan
The plan takes into account the review from previous years winters and where possible has mitigated aginst the key identified risks.
The following are key risks identified across the health economy. There are plans being executed to mitigate the risks going into winter;
Workforce Availablity Activity exceeding planned capacity Unprecedented impact from Flu Impact of conclusion of the domicilary care procurement in February 2019 on Home First capacity
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Impact of the closure of escalation beds on community services ARP Spring Review – changes to be implemented prior to September 2018
19. Finance The system have worked collaboratively to ensure that the finance plan for winter is agreed. The Acute capacity will be transacted through the use of PbR and excess bed days. The Social care commissioners will be agreeing the relevant payment mechanisms with their respective providers and CCGs will be commissing an additonal 10% care home capacity.
20. Conclusion To complete at the end by CCG
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Appendix 5: Beds analysis undertaken The community beds situation in North Staffordshire and Stoke-on-Trent In order to support urgent care flow through the acute hospital, historically a significant number of patients were discharged from an acute bed into a community bed in a community hospital or a care home. This approach developed due to a number of factors, some of which are detailed below:
A bed dependency culture in the north of the County where there is a disproportionate number of community beds, which are too often the default discharge destination; Utilisation of the Community Hospitals in the South as Acute overflow due to issues in discharging patients who are Medically Fit for Discharge (MFFD); Patients being assessed within the Acute setting at an early stage of their admission when their physical or mental health is not at a point where an accurate assessment can be made; Too many frail patients being admitted, decompensating and becoming complex discharges requiring high levels of care; A lack of understanding of the community services available to discharge and the level of care that can be provided; Variation in commissioned services across Staffordshire and varying levels of investment to support discharge; A demand and capacity mismatch leading to patients being placed in services other than those they have been assessed for, which creates blockages within the system; Risk averse decisions that prevent people going straight home when they could do so.
The use of and reliance on community beds in the North of the County has not changed significantly over the last three years (between the period of 2014-2017) despite investments in community services. Evidence from the National Intermediate Care Audit over the last three years demonstrates that North Staffordshire CCG and Stoke- on-Trent CCG have nearly three times as many community beds per capita than the average, three times as many admissions to community beds and spend three times as much on community bed based care. Utilising the benchmark data from the 2017 National Intermediate Care Audit, North Staffordshire CCG and Stoke-on-Trent CCG should have a total of 98 – 120 beds. Despite the community bed capacity, A&E performance over the last three years has not improved and remains amongst the worst in the country.
The consequence of the historic approach to discharge is that the system fills capacity rather than meet need, particularly when the system is under pressure and other capacity is not available which is often the case. This results in significant numbers of patients who are not able to access services promptly, or who are discharged to a bed for assessment or discharge either remaining in the acute trust as a MFFD delay, or being moved into a community bed to wait for the service they actually need.
Why this situation needs to change
The evidence suggests that patients who unnecessarily stay in hospital beds are much more likely to deteriorate medically; their personal preferences are also most frequently to go home, if the option is available. National Best Practice studies by the Emergency Care Intensive Support Team (ECIST) and our local studies (called Point Prevalence) tells us that ideally, 90% of patients who are currently situated in community beds should be instead treated within their preferred setting of care – their home.
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The CCGs thought this would be too much of a step-change in our system due to the traditionally high number of community beds, so the CCGs agreed with UHNM, SSOTP and the Local Authorities to model along the lines of a 70% home and 30% commissioned rehabilitation bed model split. What number of beds are needed?
We therefore wanted to understand how many rehabilitation beds we would need to keep patients safe and make sure that they would receive the care they need, preventing deconditioning through having an unnecessary stay in a hospital bed and ensuring that there are treated in their preferred care setting.
How we came to an answer
To answer this question, we assessed information from UHNM (Royal Stoke) about the number of patients who were within community beds who needed support to return home, over and above what community services traditionally provide. Patients over the period September 2016 to March 2017 were considered. These are the patients who needed bed based assessments such as rehabilitation or assessment for bed based care. These are known as ‘complex discharge’ patients. 146 patients per week were analysed. A detailed breakdown of how we did this research and the assumptions that were used is provided at the end of this paper. The answer from the modelling was 132 beds.
What did the data tell us?
The data showed us where complex discharge patients had gone to from the acute setting. Traditionally, 50% of these patients went to a community hospital or care home bed and 50% had gone home with a home care package to help them with personal tasks or intermediate care package such as nursing and therapy support. During the period covered by the study the number of patients who had been treated with a home care package increased, on average, to 60%. For the modelling the target of 70% of complex discharge patients had gone home with a home care package was assumed. Since February 2018 the 70% home care target has been achieved.
How have things changed?
Currently 132 community beds have been temporarily closed to move the bedded care closer in line with the recommendations from national best-practice and our own research. When we had 264 beds in Community Hospitals, prior to the temporary closures, there were 2,758 community care hours where 183 patients could be supported. The care model has evolved to provide care closer to home, and in the appropriate setting, through the Home First service.
What is Home First?
Home First is provided by MPFT and is delivered from people’s home setting, from either their home or their care home, to provide reablement for patients. This includes washing, dressing and help with personal tasks – essentially helping people to remain and be independent after a period of acute illness.
Since the introduction of Home First the number of community care hours for Intermediate Care, Reablement and Palliative Care has increased by 125% from 2,758 to 6,200 at any one time which allows 413 patients to be supported (230 more than previously). This means that under the new care model of Home First, more patients can be better supported, preventing unnecessary medical deterioration whilst also being within their preferred setting of care – their home. Services are continually working to improve patient experience and quality of care. Page 49 of 287
Plans to explain this will be covered in the PCBC. There are challenges in delivering the service and a robust action plan is in place to improve flow and to ensure that staff are retained to deliver the capacity in full.
Within the Home First model the average wait for people to be moved from acute services at the hospital to their home setting is currently 1 day. Patients are not moved into another bed in the interim which avoids unnecessary disruption to these patients and their recovery.
Detail for how the bed modelling was undertaken
Below we have detailed how the modelling to understand the bed capacity required was undertaken: 1. How the model calculates the number of weekly referrals – it uses a weekly average of Acute referrals from September 2016 to March 2017. 2. Proportions of each referral group between Home based (70%), commissioned beds and nursing / residential / other bed based (30%): - Of the remaining 30%: 70% are Commissioned beds and 30% are nursing / residential / other bed based.
This assumption has manifested in reality with the 70:30 ratio occurring after the implementation of Home First:
% of discharges to home or community / nursing beds
80% 70% 60% 50% 40% 30% 20% 10% 0%
% bed % home
3. Proportions of referrals for community beds by type of community bed Rehab/Assessment (90%) and EMI (10%).
4. The weekly referrals are multiplied by 52.14 weeks to give annual referrals. Next the average LOS is applied to each community bed type to give total number of occupied bed days.
a) Rehab / Assessment beds, the average length of stay (D2A) was 28 days, the commissioned length; b) EMI beds, the average length of stay was 34 days.
5. The total number of occupied bed days is divided by average occupancy and 365 days to give total number of beds required for each community bed type.
a) Rehab / assessment (116) and EMI (16).
6. Each community bed type is added together to give the total number of beds required (132).
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What is happening now?
Currently a PCBC is being drafted to formally assess and consult on how to best move to a more permanent community bed solution for North Staffordshire and Stoke-on-Trent. This PCBC will assess the viability of multiple scenarios including re-opening all 264 beds, maintaining the status quo and a variety of options for consolidating the bed base in-line with the Home First model of care.
Projecting forwards it is likely that increased community bed capacity will be needed at various points, both due to demographic and non-demographic growth and any un-predicted surge in demand, e.g. a bad flu season. It is proposed that additional escalation capacity be made available to ensure flexible reaction to this; there are several potential options currently available for this e.g. Care Homes is the only viable option for flexing capacity. It is expected that any increase in this respect will be considerably less than the current 264 bedded model as per the modelling undertaken.
Community beds further sensitivity
Further sensitivity analysis, regarding length of stay and assumed bed utilization has been undertaken to understand impacts across the various scenarios. The outputs of these are presented in the tables below.
Core assumptions
For context, the baseline assumptions (relating to the original 132 beds baseline) are presented below.
Length of Stay
Year 0 1 2 3 4 5 Financial Year 17/18 18/19 19/20 20/21 21/22 22/23 Rehab / Assessment bed 28 28 28 28 28 28 EMI 34 34 34 34 34 34
Bed Occupancy
Year 0 1 2 3 4 5 Financial Year 17/18 18/19 19/20 20/21 21/22 22/23 Rehab / Assessment bed 95% 92% 92% 92% 92% 92% EMI 95% 92% 92% 92% 92% 92%
The NPV for each option when compared to the Do Nothing is:
Baseline Option Option Description NPV compared with Do Nothing
Do Nothing Do Nothing Do Nothing £0 132 Bed Baseline Option 1 Haywood Only £174,495,819
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132 Bed Baseline Option 2 Haywood and Leek £161,651,817 132 Bed Baseline Option 3 Haywood and Longton £171,549,199 132 Bed Baseline Option 4 Haywood and Cheadle £176,919,340 132 Bed Baseline Option 5 Haywood and Bradwell £172,454,697 132 Bed Baseline Option 6 Haywood and Care Homes £210,266,537
Sensitivity analysis
92% Occupancy:
33 days Length of Stay at the original bed occupancy assumptions (i.e. 92% in Year 5) results in a bed requirement of 152 in 17/18 increasing to 163 beds in 22/23.
For each option the beds are reconfigured to meet the new bed requirement. The estimated Net Present Value compared to the Do Nothing shows that Option 6 is still the clear preferred option.
Baseline Option Option Description NPV compared with Do Nothing
Do Nothing Do Nothing Do Nothing £0 132 Bed Baseline Option 1 Haywood Only £149,109,445 132 Bed Baseline Option 2 Haywood and Leek £136,314,116 132 Bed Baseline Option 3 Haywood and Longton £146,211,498 132 Bed Baseline Option 4 Haywood and Cheadle £151,581,639 132 Bed Baseline Option 5 Haywood and Bradwell £153,977,257 132 Bed Baseline Option 6 Haywood and Care Homes £195,712,457
95% Occupancy:
When the occupancy of 95% is maintained for all the five years the bed requirement in 22/23 decreases by five to 158.
The estimated Net Present Value shows that the Option 6 is still the preferred option.
Baseline Option Option Description Cost Category NPV compared with Do Nothing
Do Nothing Do Nothing Do Nothing Discounted Costs for NPV £0 132 Bed Baseline Option 1 Haywood Only Discounted Costs for NPV £155,336,413 132 Bed Baseline Option 2 Haywood and Leek Discounted Costs for NPV £142,541,084 132 Bed Baseline Option 3 Haywood and Longton Discounted Costs for NPV £152,438,466 132 Bed Baseline Option 4 Haywood and Cheadle Discounted Costs for NPV £157,808,607 132 Bed Baseline Option 5 Haywood and Bradwell Discounted Costs for NPV £153,977,257 Page 52 of 287
132 Bed Baseline Option 6 Haywood and Care Homes Discounted Costs for NPV £199,165,747
Appendix 6: MPFT Action Plan
Notes
2 per Coordinator on duty each week. each duty on Coordinator 2per
managers. To be implemented with immediate effect. immediate with implemented be managers.To
Flow chart shared with all CCG commissioned beds beds commissioned CCG all with shared chart Flow
inform therapies. inform
48 hours from admission to CCG Bed. System in place to to place in System Bed. CCG admission to from 48hours
[email protected] [email protected]
hours escalated to service manager. service to escalated hours
Time scale set for acceptance. Not responded within two two within responded Not acceptance. for set scale Time
to cover leave etc. leave cover to
Contingency in place to ensure consistent approach in place place in approach consistent ensure to place in Contingency
CDS.
Action in place for flow to review demand for beds through through beds for demand review to flow for place in Action
Database completed. To track dst progress track To Databasecompleted.
for update on actions now in place. in now actions on update for
Every 48 hours a telephone call to the homes, S care etc. etc. care homes,S the to call a telephone 48 hours Every
issuesidentified.
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the CCG beds. CCG the
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place.
call to the homes, S care etc. for update on actions now in in now actions on update for etc. care homes,S the to call
All patients reviewed at MDT's. Every 48 hours a telephone a telephone 48 hours at MDT's. Every reviewed patients All
attended all MDT's with county S care and Lead nurse Lead and care S county MDT's all with attended
Open
Status
ongoing
ongoing
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on target on
on target on
27/07/18
completed
completed
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Action Owner Action
Sue Ball Ball Sue
Sue Ball Sue
Sue Ball Sue
Mountford-Fone
Sue Ball/Clare Ball/Clare Sue
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Katie Dirn Katie
Lisa Lawton Lisa
Lyn Charlton Lyn
Lisa Lawton Lisa
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01/08/18
01/08/18
Deadlinedate
30th July 201830th July
2018
1st September 1stSeptember
30th July 201830th July
2018
31stAugust
30th July 201830th July
30th July 201830th July
30th July 201830th July
30th July 201830th July
30th July 201830th July
30th July 201830th July
30th July 201830th July
30th July 201830th July
30th July 201830th July
End July 2018 July End
July 10th 2018July
End July 2018 July End
2018
August1st
Action Description Action
responsive within agreed time frames frames time agreed within responsive
staff are accountable for the beds and and beds the for accountable are staff
discussions with managers to ensure named named ensure managersto with discussions
based services monthly services based
Internal made events happening at all bed bed at all happening events made Internal
all MDT's all
Rota in place for senior leadership to over see see over to leadership senior for place Rota in
to panel each week each panel to
Target set for number of DSTs to be submitted submitted be DSTs to of number for set Target
identified patient requires checklist requires patient identified
Implement standard process to follow when when follow to process standard Implement
patients
Identify times scales for assessment - new assessment new - for timesscales Identify
Group net account for CCGbeds for account net Group
Group net account for flow hub staff hub flow for account net Group
within 1 hour within
asked to accept or escalate for a TA review a TAreview for escalate or accept to asked
Places identified and homes provided with PP with provided homes and identified Places
bed within 1 hour within bed
All PP's to be reviewed and identified for CCG CCG for identified and reviewed PP'sbe All to
discharges through CDS. through discharges
match against discharges and potential potential and against match discharges
Flow to review the demand list every hour and and hour every list demand the review to Flow
actions for the day the for actions
Coordinators to update shared action log of all all of log action shared update to Coordinators
updates on patients within the CCG beds. CCG the within patients on updates
Flow to contact the homes every 48 hours for for 48 hours every homes the contact to Flow
CCG beds. Haywood. beds. CCG
To provide contact details for the new flow flow new the for details contact provide To
Implement robust time lines for escalations. for lines time robust Implement
Meeting with therapy manager and leads. and manager therapy with Meeting
Meet with and support CMF CMF support and with Meet
Attend all MDt's all Attend
26/07/18
26/07/18
26/07/18
26/07/18
23/07/18
26/07/18
25/07/18
25/07/18
23/07/18
23/07/18
23/07/18
23/07/18
24/07/18
23/07/18
11/07/18
11/07/18
Forum date Forum
Forum
Flow Team Flow
Flow Team Flow
Flow Team Flow
spread sheet spread
Co coordinators coordinators Co
beds
CCG commissioned commissioned CCG
CCGBeds
CCGBeds
Flow
Flow team Flow
Matron
Daily flow Daily
spread sheet spread
Co coordinators coordinators Co
Flow CCG Hub CCG Flow
beds
CCG commissioned commissioned CCG
Team meeting meeting Team
leads month leads
Meet with Therapy Therapy with Meet
identified
All beds with DST's with beds All
stranded patients. stranded
all units with with units all
beds
CCG commissioned commissioned CCG
The management of tasks assigned to individuals/project leadsof individuals/project to assigned tasks management The
Projector
Workstream
staff staff
Named social care care social Named
month
internally every every internally
MADE events MADEevents
MDT
leadership at each at each leadership
Senior clinical clinical Senior
DST time scales time DST
Checklist/DST
Therapies
communication
communication
Flow CCG Flow
Flow
Flow
DST daily update daily DST
Stranded patients Stranded
review MDT review
Attend all homes to to homes all Attend
beds
Processes across the the across Processes
Therapy Provision Provision Therapy
Review of DST's of Review
patients patients
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Understanding beds Understanding
9
8
7
6
5
4
3
2
1
DefinitionLog:of Action
20
19
17
16
15
14
13
12
11 10 Ref Appendix 7: Accessibility Evidence
Off peak bus travel times for community beds
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Community hospitals car parking information
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Hub options car parking information
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Appendix 8: Equality Impact & Risk Assessment The Future of Local Health Services in Northern Staffordshire
OWNERSHIP & CONTROL Organisation: North Staffordshire & Stoke on Trent Clinical Commissioning Groups Assessment Lead: Associate Director, Anna Collins Directorate/Team responsible for the assessment: Communication & Engagement Board Member responsible for the assessment: Accountable Officer, Marcus Warnes Date of commencing the assessment: 8th June 2018 Date for completing the assessment: Ongoing to completion of formal consultation Version: Draft v.3 Peer Reviews: “The Public Consultation should include seeking feedback which considers what reasonable adjustments would help people with disabilities and enabling fair access and take-up of local hospital and community services. This Equality Impact & Risk Assessment (EIRA) provides an overview of our current understanding of how CCGs can build on the existing targeted engagement with the various diverse populations and their associated health challenges of both Stoke-on-Trent and North Staffordshire. It recognises our ‘due regard’ legal responsibilities under the Public Sector Equality Duty (PSED) to provide an audit trail of our deliberate consideration of people from groups protected by the Equality Act 2010, in all our planning and decision making. The EIRA captures how CCGs are taking ‘due regard’ in the Future of Local Health Services and the Pre Consultation Business Case in their planning and decision making. We evidence what we are doing to meet the PSED and how our approach to commissioning of healthcare services is inclusive of people from local protected characteristic groups. The Public Consultation will seeking feedback from diverse communities to consider the reasonable adjustments would help people with disabilities and enable fair access and inclusion to local hospital and community services”. Equality & Inclusion Business Partner – Midlands and Lancashire Commissioning Support Unit
“Firstly it’s great that this piece of work has been undertaken, that it’s using a process which has been designed to be compliant with the legislation and by a person who knows what they are doing.
However, the real issue ensuring that this desk research under goes sensitivity testing with local PC groups and even more importantly that there is a meaningful discussion of its findings by decision makers during the option development phase.
I see there is time scheduled for the latter and I recall that you have a plan for the former whereby the EA is to be reviewed by your local Equalities Advisory Group. This is good stuff”.
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The Consultation Institute
Sign Off: CCGs Joint Governing Body 18th June 2018
BACKGROUND The health and social care needs of the North Staffordshire and Stoke-on-Trent population are changing. People are living longer with increasing long-term conditions, requiring ongoing support and management. This is putting a significant strain on our services and the sustainability of the health system.
Given these pressures, we need to think differently about how we provide services closer to home, and in particular for adults with high clinical needs (such as multiple long term conditions and/or significant frailty) who are at risk of unnecessary or inappropriate admission to acute hospitals. Our community hospitals provide both bed-based services and wider non-bed based services including outpatient care, minor injuries, day case and, x-ray.
Our focus is on ensuring the greatest health benefit from these resources which will allow patients to manage their own conditions and access care from home. We are engaging with the public and local stakeholders to develop proposals to meet these aims, including what the future role of our community hospitals and associated services should be.
The draft model of care we have developed for our community services aims to meet the needs of the local population and deliver the right care in the right setting. This is consistent with the NHS Five Year Forward View, the GP Five Year Forward View and the Five Year Forward View for Mental Health. We believe the range of services within our communities, including community hospitals, can make a significant contribution to the development of new local care models. This should lead to better outcomes for patients and provide more sustainable services.
The clinical case for change along with the viable solutions to the problems described are clearly articulated in the Pre-Consultation Business case which has been developed with clinicians, providers, patients and other key stakeholders.
By designing a model of care closer to home, this PCBC focusses on community-based services across North Staffordshire and Stoke-on-Trent. Specifically, we consider the proposed way forward for community-based care covering:
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• The bed configuration for community services Adult Intermediate Rehabilitation Service Beds (AIRS beds); and • Our proposals to integrate and expand existing wider community services into Integrated Care Hubs. STAKEHOLDERS WHO MAY BE AFFECTED BY THE PROPOSALS In developing our approach and considerations the approach has been to ensure that no-one receives less favourable treatment due to their personal circumstances, i.e. the protected characteristics of their age, disability, sex (gender), gender reassignment status, sexual orientation, marriage and civil partnership status, race, religion or belief, pregnancy and maternity status. Appropriate consideration will also be given to gender identity, socio-economic status, immigration status and the FREDA principles of the Human Rights and health inclusion groups – where there are local concerns. An overarching consideration in the proposals has been to reduce health inequalities and improve patient outcomes.
It is considered that the following groups of people all have the potential to be positively or negatively affected by the proposals:- Patients, service users Carers or family General Public Staff Partner organisations PROTECTED GROUPS INVOLVED IN THE EQUALITY IMPACT ASSESSMENT
The North Staffordshire and Stoke on Trent CCGs have undertaken substantial engagement with a wide range of stakeholders and the public since it commenced pre consultation in 2014. This on-going dialogue has informed the development of this Case for Change. A stakeholder mapping exercise was undertaken with the Local Equality Advisory Forum (LEAF) on 23rd May 2018 to inform the Consultation Plan. This is provided at Appendix 1. It was cross referenced against the CCGs database of organisations representing protected groups. This will ensure that the appropriate organisations and individuals are consulted in an accessible and appropriate way that meets their needs. A comprehensive stakeholder list is provided as Appendix 3 of the Consultation Plan. Representatives of people with the protected groups will be asked to provide feedback on a regular basis on the Equality Impact assessment through the CCGs Local Equality Advisory Forum (LEAF). The group meets bi-monthly and acts as a group of critical friends to give feedback from the perspective of groups including older people, race & ethnicity, LGB&T+, Disability (learning disability, deafness and disability support are represented), faith, pregnancy & maternity, homelessness, asylum seekers &
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refugees & gypsy/traveler.
LEAF representatives were involved in the Options Development and Appraisal Reference Groups. EVIDENCE USED FOR ASSESSMENT
The following evidence has been considered as part of the Equality Impact Assessment
Local Service Usage data equality monitoring data • Joint Strategic Needs Assessment • Local Health Inequalities data • Demographic data and Office of National Statistics projections
A summary of local health needs and equality data is provided as Appendix 2 and more detail can be found by following the links below. Staffordshire Moorlands Data Pack Newcastle & District Data Pack Stoke North Data Pack Stoke South Data Pack
• The shortlist of options was developed against accessibility assessment criteria which was co- produced with stakeholders and considered:- • Travel time & transport routes with subsidised transport • Digital Technology - skype, telephone conversations, apps • Equity of service based on local need • Electronic patient records to be available to all Health and Social Care • Waiting times • GP opening hours – extended hours • Out of Hours • Car parking • Outpatient clinic availability • IT – linking care records across organisations • Communication: Speak plainly, Health literacy, Patient centered language
HEALTH INEQUALITIES Complex patients profile and Life Expectancy for Stoke-on-Trent CCG
• The profile of complex patients within Stoke-on-Trent is also older than within comparator CCGs, with the 80+ age bracket making up an increased proportion of complex patients in Stoke-on- Trent relative to statistical comparators. The below chart demonstrates the number of complex cases managed within the CCG area by age bracket. This chart shows that complexity significantly increases with age, with over 65% of complex cases within the CCG being associated with the 65+ age brackets. Chart A1.4 - The number of complex cases managed within the CCG area by age bracket Page 59 of 287
Source: Stoke-on-Trent CCG NHS Right Care pack January 2017 https://www.england.nhs.uk/rightcare/wp- content/uploads/sites/40/2017/01/cfv-stoke-on-trent-jan17.pdf
The charts below compare the death rates in people under 75 (early deaths) between Stoke-on-Trent and the England average. The life expectancy in the most deprived areas is significantly lower than the England average for both men and women.
The positive impact on health outcomes and reducing health inequalities are that the better access patients have to the right care for their acute needs and long term health conditions, the lesser the need will be for admissions to hospital and the greater the level of management of conditions, thus improving quality of life. Greater accessibility also leads to reduced anxiety and an improved patient experience.
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COMMUNITY REHABILITATION BEDS Currently, 175 Adult Intermediate Rehabilitation beds are provided from the 5 community hospitals plus additional capacity in the care home setting. 184 of the rehabilitation beds are temporarily closed.
In addition, a broad range of community based services are spread across a variety of settings including community hospitals and GP Practices. The Services are currently commissioned from the Midlands Partnership Foundation Trust (MPFT) and from individual nursing and residential homes.
The short list of options for community beds is presented below:-
Older people, who require rehabilitation and reablement support, following an illness or injury, are often admitted to a community hospital bed, particularly following an acute hospital episode.
The current model of care can cause ‘decompensation’ for elderly patients as well as being clinically and financially unsustainable:
Improving quality of care: Caring for older people in a hospital bed can be detrimental to such an extent that it can outweigh the benefit of care received due to the extent of physical, psychological, cognitive and social ‘deconditioning’.
Improving the sustainability of the workforce: The majority of community beds are provided from single stand-alone wards across 5 community hospitals which face continual workforce resilience Page 61 of 287
challenges.
Improving service effectiveness and efficiency: The mind set of health and social care is still too often hospital bed first, although people want to remain in their own home whenever possible. They are often cared for ‘at levels of care’ which are higher than required to meet their needs. Not only is this not what most people want it is also resource inefficient and increases the risk of iatrogenic (health and care induced) harm.
Proposed future models: The default care setting for all patients should be the place they call home as this can significantly improve the quality of care received (due to a reduced likelihood of decompensation). The proposed service change would see those people who are medically fit for discharge (MFFD) receiving reablement and rehabilitation support in a community hospital bed NHS care home bed or at home.
Travel times and accessibility for patients, whilst analysed, are of lesser consequence in this scenario as patients would be ambulated by Community Transport Services from an acute setting to Community Hospital or Care Home.
THE IMPACT ON WIDER COMMUNITY SERVICES
The options developed are considered against a Do-Nothing scenario where wider community services are largely provided from existing community hospital sites within a locality.
To identify the potential solutions that could address our case for change and ability to deliver our clinical model, we have considered three ways that the provision of community services could be organised in our localities. We have considered the options in terms of:
The set of services required to deliver our model of care; How many hubs could be developed; and Where the hubs could be located.
The services to be delivered from the hubs, as defined in the clinical model, have been developed based on key principles which align to national and local strategies; including:
Provision of services at scale; Community centered care; Undertaking a Multi-Disciplinary Team approach; Extended Access to GP practices;
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Coordination of cross-sector services; and Delivering a holistic service based on patient needs.
To develop the appropriate set of hub services, significant engagement across a large number of organisations took place.
There are two possible permutations for the number of community services hubs across the localities. The first is having the same number of hubs as there are existing community hospitals within the localities (i.e. five, with two in the Moorlands) or alternatively considering a hub per locality (four).
Existing or alternative sites could deliver the wider community services across localities. As such, the options consider the provision of services across the existing community hospital sites as well as an alternative provision (new sites).
Details of current services provided from the Community Hospitals have been published on the CCGs websites and were presented and considered as part of the Options Development process.
The Impact of Travel on Disadvantaged Groups
Analysis has been undertaken to consider the average change in patient travel time and distance from the current configuration of beds (with temporary closures in effect) and previous configuration (prior to temporary closures) across each of the six options That is, we looked at how long it would take on average a patient to travel to their closest site in the current and previous configurations (post and pre temporary closure) and compare this against what the time would be under each of the six options
Our analysis shows that on average, the additional average travel time across each option is less than 10 minutes – though this doesn’t into account traffic conditions. This is not expected to have an impact on quality of care received. In order to mitigate the impact of this on disadvantaged groups we will:-
Continue to work with local authority partners to discuss additional transport provision Commission additional community transport services as part of implementation plan Discuss these mitigation’s and other suggestions as part of formal consultation with disadvantaged groups
Though noting that we have to go through a process to procure care homes, the estimates show that if care homes were procured locally, there will be a more beneficial (smaller) change in travel time
Bus routes
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Analysis of bus routes across the various sites suggests there is a range of between 65 – 92 minutes to travel between the hospital sites on average at peak times (8am), with the Haywood being the most accessible
In terms of drive times, the average range across the hospitals is much smaller, between 21 – 29 minutes at peak times (8am)
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Off peak bus travel times for community beds
NHS Care Homes – Travel Impact Analysis
The table below shows the total average travel times and distances between the scenarios of: a) Haywood Hospital plus Bradwell Hall, Hilton House, Adderley Green and Farmhouse care homes b) Haywood Hospital plus Bradwell Hall and Adderley Green care homes
For each scenario, the average, median and 80th percentile travel times and distances are shown, as well as the difference in each of these metrics from the current configuration of community hospital and care home beds.
On average, using two care home settings rather than four, would increase average drive times across the population by 0.6 miles (2 minutes) from what the system currently has in place. For 80% of the population, the change in travel time would be 0.1 miles (0.5 minutes) There would be no change in the median travel time.
Above the 80th percentile, the travel times would increase by 1.5 miles (5.6 minutes) which suggests that the 20% of the population living furthest away from these sites would be affected the most, however given the magnitude of the change in times and distances, the changes are unlikely to be significant.
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Total Travel Difference from current
Distance Time (mins) Distance Time (mins) (Miles) (Miles)
4 Care Homes + Haywood 80th %ile 4.4 14.4 0.0 0.0
Median 2.4 8.9 0.00 0.00
Average 3.3 10.7 0.02 0.07
2 Care Homes + Haywood 80th %ile 4.9 17.2 1.5 5.6
Median 3.2 11.7 0.0 0.0
Average 3.8 12.8 0.6 2.1
Difference 80th %ile 0.6 2.9 1.5 5.6
Median 0.8 2.8 0.0 0.0
Average 0.5 2.1 0.6 2.0
Parking
The Haywood Hospital is the only site that charges for car parking.
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Community hospitals car parking information
The table below shows that Haywood has the most parking spaces available per community bed, suggesting it is the most accessible of the five hospitals.
Crucially, the table highlights the non-clinical space available and the relative challenges across the sites (excluding the Haywood). This is an important consideration in relation to understanding ‘best fits’ to support future demand for community services.
Table 1: Size and capacity of estates
Site No. of parking Clinical space Non-clinical Parking spaces per spaces available (m2) space (m2) bed available
Haywood 322 10,172 6,512 4.2
Leek 98 2,915 1,814 2.7
Cheadle 99 2,871 1,710 2.1
Bradwell 179 2,758 1,399 2.8
Longton 38 1,667 1,349 1.0
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Integrated Care Hubs
The proposed hub services have been developed against a number of principles
Provision of services at scale Community centered care Multi-Disciplinary Team approach Extended access to GP practices Coordination of cross sector services Holistic and based on patient needs
Travel time
Given that the hubs are going to be new and there isn’t a clear ‘as-is’ comparator to assess accessibility against, we have narrowed our analysis to look at the average travel time and distance to the possible hub locations within each locality.
Bus Routes
Analysis of bus routes across the various sites suggests that: In Stoke South the range in bus times from the existing community sites to the two possible hub locations is 6 – 8 minutes, for car travel it is 3 – 8 minutes Page 68 of 287
In the Moorlands, the range in bus times to travel between the existing community sites and other hub locations is between 65 – 75 minutes , drive time ranges between 22 – 24 minutes (excluding times between the existing Leek site and the Knivedon site)
In Newcastle, there bus travel between the existing community hospital site and the Milehouse Lift is c.25 minutes, whereas by car it is c6 minutes
Public travel (Bus) at peak times from localities to hub locations
Source: Google Maps
Car Parking
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The short list of options for the wider community services is presented below:-
EQUALITY IMPACT AND RISK ASSESSMENT
Negative Impact Positive Impact Age Rehabilitation Beds Rehabilitation Beds Potential Impact identified from data The majority of older people will be cared and feedback to date. Concerns arose for at home rather than having to travel to over available social care capacity and an inpatient hospital setting. This would the impact upon older people in have a positive impact on carers too who Staffordshire and Stoke-on -Trent. would also not have to travel to visit their There is a possibility that some carers loved ones. and family members may have to Care for the elderly patient in the place they travel further due to the removal of call home can greatly improve the quality of community hospital beds but the overall impact on travel is that on care received and the outcomes achieved. average more would have to travel Continuity, and therefore remaining at less as the majority of patients will be home, is key for all patients particularly treated in their own home. dementia patients, in order to limit The potential impact on some carers confusion and associated distress. and family members in accessing Improved dignity would be helped if the public transport may be negatively affected by the reduction in patient remained in their own home. community transport Reduced exposure to communal acquired There is a greater risk of isolation for infections would be helped if the patient patients and carers would need to remained in their own home. include more voluntary sector Again being in a familiar place - treated at organisations to support socialisation. home, would minimise the feeling of Page 70 of 287
disorientation or loneliness
Hubs The views of the community should be taken into consideration for the most appropriate location of the hubs. Any transferral of services will be required to be the same or better than currently provided; otherwise there will be a negative impact.
Disability Potential impact on people with Access needs to be considered whether this is in mobility impairment from reduced relation to existing sites or new sites. The sites access to services. are required to be DDA compliant, including Fire, Health and Safety compliant, parking facilities and easily available by public transport. Communicating the changes including the re- location of current services may be difficult for some people.
Gender There needs to be an assured level of The delivery of care at home or in a place Reassignment / staff competency in caring for this called home helps people to retain their Transgender independence, confidence and therefore protected characteristic in a person wellbeing as opposed to being treated in an centred way. unfamiliar hospital setting. Retention of independence helps patients to remain in their place of usual residence for longer. Continuity is key for all patients particularly patients who are transgender or who have chosen gender reassignment.
Pregnancy and An acknowledgement needs to be Not specifically identified Maternity made with regard to family members, who are informal carers, particularly a female who may be pregnant, that ‘The welfare and wellbeing of the family which is supporting the relative will always be considered. Religion or Belief There needs to be an assured level of Care for patients will be personalised to ensure staff competency in caring for this it meets all their medical, nursing and personal protected characteristic in a person care needs. centred way. Care provided at home will be closer to the place of worship. Assurance that patients personal beliefs will be taken into consideration i.e.(jabs/injections and care planning) Page 71 of 287
Particular consideration required to the End of Life Care Plans. Care Planning will also take into account any personal preferences of patients such as beliefs. Dignity and respect are a core component of care planning for patients within these services and decisions about care are taken in partnership with the patient, their family and, or carers to ensure an appropriate approach
Race Health Information leaflets in Currently patients from BAME Communities community beds and hubs need to be may need to make advanced appointments readily available to people in a range (not just GPs) to ensure that if required, of common languages. interpreting services can be arranged which Cultural awareness and sensitivity to could more easily be achieved through the hub the diverse needs of people within the CAB or Vol Sector services community, e.g. at end of life care where many of the BAME community Assurance is required that staff have cultural cultures and traditions require open awareness and sensitivity to the diverse needs access for visiting family members. of people within the travelling community, e.g. Care Plans to have specific references at end of life care where many community on how to respond to the patient and cultures and traditions require open access for their cultural traditions. visiting family members.
The model of providing support closer to home will have a more positive take up from the Traveller Community.
Sex (Gender) Different gender bed provision bust be Census 2011 figures highlight that men and adhered to in community beds. women are equally represented
Sexual Recognition and understanding of Not specifically identified Orientation same sex couples and Next of Kin arrangements. Ensure partners are not excluded. Include in the Care Plan process. Ensure people are treated with dignity and respect.
Marriage and Marriage & Civil Partnership is a Many married older couples rely heavily on Civil Partnership protected characteristic in terms of each other as the main carer, friend and companion. Intermediate Care Service teams work-related activities and NOT will include the spouse in decisions about care service provision planning for relatives. The delivery of care at home or in a place called home helps people to retain their independence, confidence and therefore
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wellbeing as opposed to being treated in an unfamiliar hospital setting. Retention of independence, patients will be able to remain in their place of usual residence for longer. Vulnerable & Rurality With the new proposals, because more people Deprived Consideration must be given to will be cared for at home or in intermediate accessibility of services for patients in care beds within their own communities, travel Communities areas of the Staffordshire Moorlands will be significantly reduced. and Newcastle-under-Lyme The use of cross border facilities will assist in reducing negative impacts of rurality and poverty in terms of ability to visit.
Homeless The concept of providing care at home Services based on a hub and spoke model may could mean that the care needs to be be easier to access. An engagement exercise provided in a hostel. But without a home this proposal may have a with homeless people was undertaken in negative impact on those without a summer 2017 and separate services are home. currently being commissioned to meet their There needs to be awareness and health needs. training given to staff to enable them
to have the skills needed to respond to issues that are not every day occurrences.
Carers Informal Carers - Informal carers must be With the new proposals, because recognised and their needs responded to, to more people will be cared for at home ensure there is continuity of care for their or in intermediate care beds within cared for. They need more respite particularly their own communities, travel will be young carers significantly reduced for carers. Equally as a result of more people Choice - People need to remain in control with being cared for at home there will be choice. For example, family carers don’t want less disruption to the carer’s routine paid carers coming in at 7am or 11pm at night. and their loved ones will retain their Don’t want different carers on different days. independence, confidence and therefore wellbeing for longer. Carers Information - When people register as a Integrated care planning will respond carer they should be provided with relevant to personal preferences of patients as carers information at the hub rather than well as family and carers views to having to seek it out for themselves e.g. carer’s ensure that an appropriate approach allowance, attendance allowance, NHS to care is taken. transport reimbursement costs.
ENSURING LEGAL COMPLIANCE
Current service delivery Proposal Mitigation
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All larger providers are required to The Consultation Plan aims to engage The CCGs will engage with submit annual equality compliance with local representatives from all 9 representatives from local protected reports reflecting requirements protected groups to ensure they have groups to request their feedback on (e.g. EDS; NHS England mandated a voice in informing the decisions any adverse impacts arising from standards) in the NHS National about future service delivery. Options contained in the PCBC. Standard Contract 2018-19. The service will be accessible to all and The identified providers will be Contract Managers send this available regardless of age, race, expected to submit monthly data on information to the Equality & gender, gender reassignment, sexual performance against agreed (KPIs). Inclusion Business Partner for orientation, disability, religion or Performance data will be provided to content check This should belief, pregnancy maternity and the contract monitoring meetings, evidence that providers are breastfeeding mums. which will be responsible for meeting the PSED and most Equity of Access, Equality and Non- monitoring performance against the importantly, how they are using Discrimination is included in the NHS service specification. The provider this monitoring data such as standard contract for providers will provide through disaggregated complaints and workforce profiles, under service condition 13. equality monitoring data on patient to improve fair access to The re-designed service will offer satisfaction experience. As included information, services and premises opportunity for patients and carers to with in the standard NHS contract (and any employment give any feedback on barriers (FFT). opportunities) for local people encountered by protected group The service specifications will include from groups protected by the patients / carers to ensure fair access a local service user survey which will Equality Act 2010. Provider to information, services, premises, and request demographic information as workforce data should annually any employment opportunities. evidence how it reflects the a default requirement (provides the communities they serve and the option for patients / primary carers support available to staff. This data to declare) to enable feedback to be should be available to be viewed analysed to ascertain who is taking by the public and lead up the services and differential commissioner on provider website satisfaction levels. – ‘How we are meeting the PSED’ and evidencing ‘due regard’ of people from groups protected by the Equality Act 2010 and health inclusion groups under the H&SC Act 2012. PROMOTE EQUALITY OF OPPORTUNITY
Community services to be By bringing together services under a Periodic requirement to offer the delivered from the hubs have been single specification for integrated care option to patients and carers to commissioned separately. Fair teams (hubs) it is envisaged that it will complete a satisfaction with access to information and services support further reductions in services survey with equality was a key element. duplication improving multi monitoring included (within service professional communication and a spec).
more streamlined pathway. Page 74 of 287
Foster Good Relations Foster Good Relations Between Foster Good Relations Between Between People People People
The Joint Strategic Needs Consideration will be given to the local The CCGs work strategically to Assessment highlights local issues issues identified within the report and influence the Health & Wellbeing based on the analysis of the patient / carer feedback received, Board and inclusion within the JSNA information available. It identifies when designing integrated care for North Staffs and for Stoke-on- where needs are not being met services. Trent localities, Health Needs describing these as themes for Assessments which focus specifically action. It is a particularly useful on the healthcare needs and health tool for local commissioners as it inequalities of local people from provides a wealth of quantitative groups protected by the Equality Act and qualitative data that clearly 2010. describes the key issues for the local population.
EXPECTED OUTCOMES Benefits to patients There is consensus across North Staffordshire and Stoke-on-Trent that if we do not redesign and transform services to improve quality, using the available resource as efficiently as possible, our population will experience poorer health outcomes as a direct result. There are a set of key principles that sit behind the implementation of providing care closer to home as outlined below:
The model will be based upon a pull by community not push by acute; Clinical governance will sit with the community provider No assessments for on-going care needs will carried out in an acute bed (unless by clinical exception); The full implementation will ensure that more people go home with a reduction in the number of patients going into a bed based rehabilitation service; Pathways and principles across Northern Staffordshire will be aligned to ensure equity of provision.
Improving the quality of care
Caring for elderly patients in the place they call home can greatly improve the quality of care received and the outcomes achieved. Evidence suggests that caring for older people in a hospital bed can often outweigh the benefits of care received due to decompensation. Emergency Care Improvement Programme reported that the negative impact of bed rest in older people is as follows:
In the first 24 hours:
Reduction in muscle strength of 2-5%; Reduction in circulating volume by up to 5%;
In the first 7 days:
Reduction in circulating volume by up to 20%; Page 75 of 287
Loss of muscle strength 5-10%; Reduction in functional residual capacity (FRC) of 15-30%; Negative impact upon skin integrity
Two separate studies have shown that 10 days in a hospital bed (acute of community) leads to the equivalent of 10 years ageing in the muscles of people over 80.
Improving the delivery of services
The default care setting for all elderly patients should be the place they call home. Our local engagement has told us that this is not only what people want but it can also improve outcomes and be a more effective use of available resources.
Historically, the number of beds within Northern Staffordshire has led us to a position where patients have been cared for at a level higher than required to meet their needs. This is not an efficient use of resources and also leads in many cases to a longer length of stay and a higher likelihood of entering long term care.
It is however acknowledged that some patients upon discharge will have needs that place them beyond the thresholds to be cared for safely at home. The CCGs will continue to commission a significant number of beds to support patients requiring a higher level of care and/or requiring an assessment for longer term 24 hour care needs. These beds will be commissioned in line with the clinical need of this cohort of patients.
The integration of services and a flexible workforce will support the maximisation of capacity within the community and will reduce the numbers of handoffs between services therefore positively impacting upon individual patients experience
Through the new model of care patients will receive the right level of support, by an appropriately skilled workforce, in a timely way and for a time limited period. The model will also maximise independent living and actively support people to return to optimal levels of functioning.
The clinical model was iterated with stakeholders, generating support amongst staff, the public and key stakeholders. To release capital to fund this new care model, 132 community beds were temporarily closed. These temporary closures were aligned with modelling the CCG had conducted around demand in North Staffordshire and Stoke-on-Trent and the emerging care model.
Elements of the new care model include: Developing the Home First model; and Significantly increasing the hours of community care by 25%. Providing wrap-around services based on patient need in the Integrated Care Hubs
HOW OUTCOMES WILL BE MONITORED, REVIEWED, EVALUATED AND PROMOTED
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The revised service specifications for Home First and Integrated Care Services will be outcome focused. A number of quality requirements and key performance indicators will be developed to ensure that quality and safety of services are not compromised and are included in the specification
The Providers will be expected to submit monthly data on performance against agreed KPIs. Performance data will be provided to the contract monitoring meetings, which will be responsible for monitoring performance against the service specification.
The providers will provide through the quality accounts information on patient satisfaction experience.
HUMAN RIGHTS
The Stage 1 Equality Impact and Risk Assessment identified that there was no requirement to carry out a stage 2 Human Rights Assessment
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RISK ASSESSMENT Risk level Consequence level RARE 1 UNLIKELY 2 POSSIBLE 3 LIKELY 4 VERY LIKELY 5 1. Negligible 1 2 3 4 5 2. Minor 2 4 6 8 10 3. Moderate 3 6 9 12 15 4. Major 4 8 12 16 20 5. Catastrophic 5 10 15 20 25 Consequence Score: Likelihood Score: Risk score = consequence = 4 x likelihood = 3 12
Any comments / records of different risk scores over time (e.g. reason for any change in N/A scores over time):
EQUALITY IMPACT AND RISK ASSESSMENT AND ACTION PLAN
Risk identified Actions required to reduce / Resources Action Owner Target eliminate negative impact required date Proposal to change Consult with people with Consultation and Comms and Oct service provision has not protected characteristics who engagement plan. Engagement 2018 undergone due process may be directly or indirectly with evidence of affected by the proposal. To show following due regard understanding of the issues that ‘Brown’ principles and may affect protected groups in risk of legal challenge relation to the proposal. through Judicial Review. Not considering re- Governing Body to consider how Consultation Comms & Jan shaping services following the proposals will be analysis Engagement 2019 feedback from implemented following feedback stakeholders received
ONGOING MONITORING AND REVIEW OF EQUALITY IMPACT RISK ASSESSMENT The equality impact assessment action plans will be monitored through Governing Body meetings held in public
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Equality Delivery System: The Goals and Outcomes of the Equality Delivery System Tick Objective Narrative Outcome box(s) below 1. The NHS should 1.1 Services are commissioned, procured, Better health achieve designed and delivered to meet the health needs outcomes improvements in of local communities patient health, 1.2 Individual people’s health needs are assessed public health and and met in appropriate and effective ways patient safety for 1.3 Transitions from one service to another, for all, based on people on care pathways, are made smoothly comprehensive with everyone well-informed evidence of 1.4 When people use NHS services their safety is needs and prioritised and they are free from mistakes, results mistreatment and abuse 1.5 Screening, vaccination and other health promotion services reach and benefit all local communities 2. The NHS should 2.1 People, carers and communities can readily Improved improve access hospital, community health or primary patient access accessibility and care services and should not be denied access on and experience information, and unreasonable grounds deliver the right 2.2 People are informed and supported to be as services that are involved as they wish to be in decisions about targeted, useful, their care useable and 2.3 People report positive experiences of the used in order to NHS improve patient 2.4 People’s complaints about services are experience handled respectfully and efficiently 3. The NHS should 3.1 Fair NHS recruitment and selection processes A representative increase the lead to a more representative workforce at all and supported diversity and levels workforce quality of the 3.2 The NHS is committed to equal pay for work working lives of of equal value and expects employers to use the paid and equal pay audits to help fulfil their legal
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non-paid obligations workforce, 3.3 Training and development opportunities are supporting all taken up and positively evaluated by all staff staff to better 3.4 When at work, staff are free from abuse, respond to harassment, bullying and violence from any patients’ and source communities’ 3.5 Flexible working options are available to all needs staff consistent with the needs of the service and the way people lead their lives 3.6 Staff report positive experiences of their membership of the workforce 4. NHS 4.1 Boards and senior leaders routinely Inclusive organisations demonstrate their commitment to promoting leadership should ensure equality within and beyond their organisations that equality is 4.2 Papers that come before the Board and other everyone’s major Committees identify equality-related business, and impacts including risks, and say how these risks everyone is are managed expected to take 4.3 Middle managers and other line managers an active part, support their staff to work in culturally supported by the competent ways within a work environment free work of from discrimination specialist equality leaders and champions
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Equality Impact and Risk Assessment Checklist
Scope Yes/No
Have I made the reader aware of the full scope of the proposal and do I understand the Yes current situation and what changes may occur?
Legal
Have I made the reader aware of our organisation’s legal duties with regard to Equality Yes & Diversity and are they documented?
ACTION: raise discussion at Governing Body
Has the relevance of these duties pertaining to this item been outlined explicitly and Yes documented?
Have I explained how in this area we currently meet our Public Sector Equality Duties Yes and how any change may affect this?
Information
Have I seen sufficient research and consultation to consider the issues for equality Yes groups? (this may be national and local; demographic, numbers of users, numbers affected, community needs, comparative costs etc)
Have I carried out specific consultation with affected groups prior to a final decision In Plan being made?
Has consultation been carried out over a reasonable period of time i.e. no less than six In Plan weeks leading up to this item?
Have I provided evidence that a range of options or alternatives have been explored? In Plan
Impact
Do I understand the positive and negative impact this decision may have on all equality Yes groups?
Am I confident that we have done all we can to mitigate or at least minimise negative Yes impact for all equality groups?
Am I confident that where applicable we considered treating disabled people more YesPage 81 of 287 favourably in order to avoid negative impact? Any negative feedback would be
considered to avoid any potential negative impact where appropriate
Am I confident that where applicable we allowed an exception to permit different N/A treatment ( i.e. a criteria or condition) to support positive action
Have I considered the balance between; proposals that have a moderate impact on a Yes large number of people against any severe impact on a smaller group.
Highlighted within feedback received
*Wider Budgetary Impact (where applicable)
Within the wider context of budgetary decisions did I consider whether an alternative Yes would have less direct impact on equality groups?
Within the wider context of budgetary decisions did I consider whether particular Yes groups would be unduly affected by cumulative effects/impact?
Transparency of decisions
Will there be an accurate dated record of the considerations and decisions made and Yes what arrangements have been made to publish them?
Governing Body will be held in public and minutes published.
Due regard
Did I consider all of the above before I made a recommendation/decision? Yes
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Appendix 1
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Appendix 2
Local Health Needs & Equality Assessment
Staffordshire Moorlands Newcastle & District Stoke North Stoke South Asthma, Cancer, Coronary Heart Asthma, Coronary Heart Disease, COPD, Diabetes, Dementia, Depression, Coronary Heart Disease, Diabetes Disease, Depression, Diabetes, Depression, Diabetes, Obesity and Hypertension, Obesity Peripheral Mellitus and Hypertension are of Epilepsy, Obesity and Stroke are of Stroke are of high prevalence in the Arterial Disease and Serious Mental high prevalence in the Longton high prevalence in the Staffordshire Newcastle localities than of England. Health Conditions are of high locality. Moorlands locality than of England. •Newcastle under Lyme performs prevalence in the Stoke North locality •Stoke on Trent has a high number of •Staffordshire Moorlands performs poorly compared to England in GCSE than of England. deprived neighborhoods, performing poorly compared to England in results, violent crime, smoking at time •Stoke on Trent has a high number of particularly poorly in GCSE results, breastfeeding, excess winter deaths, of delivery, breastfeeding and alcohol deprived neighborhoods, performing violent crime, obesity, smoking, recorded diabetes and smoking at admissions. particularly poorly in GCSE results, infant mortality and life expectancy. time of delivery. •Appointments at Bradwell Hospital violent crime, obesity, smoking, infant •More appointments at Longton •Leek Hospital is attended by patients are attended by patients from areas of mortality and life expectancy. Cottage are attended by patients from more least deprived areas than varied deprivation. •More appointments at Haywood from a deprived area than patients most deprived. •58% of appointments are attended by Hospital are attended by patients from from the least deprived areas. •Cheadle Hospital is attended by females, the majority of which are a deprived area than patients from the •62% of appointments are attended patients from more least deprived aged 50+. least deprived areas. by females and the majority of which areas than most deprived. •The over 70s will see the largest •59% of appointments are attended by are aged 50+. •For leek and the north-moorlands population increase over the next 5 females, the majority of which are aged •The over 70s will see the largest area, Male and Female appointments years. 50+, though the Walk In Centre population increase over the next 5 are attended fairly equally and the age •Audiology, Dermatology, ENT, MSK, appointments are attended more so by years. distribution of service users is also well Rheumatology, Physiotherapy have the patients under 50 years of age. •MSK, Rheumatology, Physiotherapy distributed amongst the 10 year age most appointments attended at •The over 70s will see the largest have the most appointments groups. Bradwell Hospital. population increase over the next 5 attended at Longton Cottage •For Cheadle and the south- •40% of appointments are attended by years. Hospital. X-Ray activity not available moorlands area, 61% of appointments patients living within 3 miles of •Elderly Care, Neurology, at this time.
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are attended by females, the majority Bradwell Hospital. The Rash Clinic Rehabilitation, Rheumatology and Walk •67% of appointments are attended of which are aged 50+. (Dermatology) has wider geography of In Centre form the majority of care by patients living within 2.5 miles of •The over 70s will see the largest patients attending; 12% travelling over provided at Haywood hospital. Longton Cottage Hospital. population increase over the next 5 7.5 miles. •53% of appointments are attended by •60% of service users recorded they years. •40% of service users recorded they patients living within 5 miles of were married or in a civil •For Leek, 57% of service users were married or in a civil relationship. Haywood Hospital. Nearly 20% of relationship. recorded they were married or in a •Just over 42% stated their religion as appointments are attended by patients •Just over 60% stated their religion civil relationship. 70% for Cheadle. either CofE, Roman Catholic or over 7.5 miles or outside of as either CofE, Roman Catholic or •68% stated their religion as either Christian. 43% did not state their Staffordshire. Christian. 30% did not state religion. CofE, Roman Catholic or Christian. religion. •30% of service users recorded they •92% of service users stated British •For Leek, 56% of service users stated •62% of service users stated British as were married or in a civil relationship. as their ethnicity. British as their ethnicity, with 38% not their ethnicity. 35% did not state their 51% did not state. stating their ethnicity. For Cheadle, ethnicity. •Just over 32% stated their religion as 96% of service users stated British as either CofE, Roman Catholic or their ethnicity Christian. 61% did not state their religion. •57% of service users stated British as their ethnicity. 40% did not state their ethnicity.
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Appendix 2: The scale of the challenge – Health and Wellbeing
Section summary
This section outlines the current population and demographic profile of North Staffordshire and Stoke-on-Trent CCGs. There is an ageing population and increased prevalence of long term illnesses and complexity of conditions compared to national averages. Our community services were designed to cope with the burden of shorter term illnesses and for individuals who were in general, less frail when they sought help. To meet the changed demographic demands for care and make sure people’s outcomes continue to improve, we must reconsider the way in which care is provided.
2.1.1 The local population The resident population of both North Staffordshire and Stoke-on-Trent CCGs is just over 479,400. The population is expected to grow by c.0.3% per annum, more slowly than the English average of 0.8%.1
Population growth of North Staffordshire and Stoke-on-Trent CCG compared to national average 2
0.9% 0.8%
0.7% 0.6% 0.5% 0.4% 0.3%
% Population % change 0.2% 0.1%
0.0% 2015 2016 2017 2018 2019 2020 Year North Staffordshire CCG Stoke on Trent CCG England
Whilst population growth is more constrained, 13% of the local population is aged over 75, compared to the national average of 10%.3 This older population will grow significantly, by 8.4% in the next 5 years7. The two CCGs comprise three localities, with key population differences described below.
1 Source: Office for National Statistics: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/overviewof theukpopulation/july2017 2 Office for National Statistics: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/datas ets/2014basednationalpopulationprojectionstableofcontents Page 86 of 287
Population figures for each CCG by locality 7
North Staffordshire Stoke-on-Trent (North Newcastle-under - Staffordshire and South) Lyme Moorlands
Age 0-14 19,900 14,700 48,500
Age 15-74 96,200 72,600 186,200
Age 75 and over 11,600 10,600 18,800
Total 127,900 98,000 253,500
2.1.2 Stoke-on-Trent current population profile (North and South Stoke) The total population of Stoke is 252,000 and is estimated to grow to 256,000 by 2020. The current population profile of Stoke-on-Trent is broadly in-line with national averages, but with a proportionately larger young population.
Population Profile of Stoke-on-Trent
Predicted population of Stoke-on-Trent, compared to national figures 4
Males Females Persons
Stoke-on-Trent (population in thousands)
3 ONS Population Statistics https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/populatio nestimatesforukenglandandwalesscotlandandnorthernireland 4 Public Health England Fingertips Report: Stoke-on-Trent - http://fingertipsreports.phe.org.uk/health- profiles/2017/e06000021.pdf Page 87 of 287
Population (2015) 125 126 252
Projected population (2020) 128 128 256
% people from an ethnic background 14.1% 14.8% 14.5%
Dependency ratio (dependants / working population) x 100 61.0%
National figures for predicted population5
Males Females Persons
England (population in thousands)
Population (2015) 27,029 27,757 54,786
Projected population (2020) 28,157 28,706 56,862
% people from an ethnic background 13.1% 13.4% 13.2%
Dependency ratio (dependants / working population) x 100 60.2%
2.1.3 Staffordshire Moorlands current population profile The total population for Staffordshire Moorlands is 98,000 and predicted to rise to 99,000 by 2020. The population is significantly older than the national average, with substantially fewer young adults. As the population of Staffordshire Moorlands ages, it is expected that there will be further increases relative to the national average particularly for over 75s.
Population profile of Staffordshire Moorlands
5 Public Health England Fingertips Report: Stoke-on-Trent - http://fingertipsreports.phe.org.uk/health- profiles/2017/e06000021.pdf Page 88 of 287
Predicted population of Staffordshire Moorlands 6, compared to national (Table 4)
Males Females Persons
Staffordshire Moorlands (population in thousands)
Population (2015) 48 50 98
Projected population (2020) 49 50 99
% people from an ethnic background * * 1.6%
Dependency ratio (dependants / working population) x 100 71.0%
2.1.4 Newcastle-Under-Lyme current population profile The total population for Newcastle-Under-Lyme is 127,000 and is predicted to rise to 129,000 by 2020. Newcastle-Under-Lyme is broadly in-line with national population profiles.
Population profile of Newcastle-under-Lyme
Predicted population of Newcastle-under-Lyme 7, compared to national (Table 4)
Males Females Persons
6 Public Health England Fingertips Report: Staffordshire Moorlands - http://fingertipsreports.phe.org.uk/health- profiles/2017/e07000198.pdf 7 Public Health England Fingertips Report: Newcastle-Under-Lyme - http://fingertipsreports.phe.org.uk/health- profiles/2017/e07000195.pdf
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Newcastle-Under-Lyme (population in thousands)
Population (2015) 63 64 127
Projected population (2020) 65 65 129
% people from an ethnic background 3.5% 2.9% 3.7%
Dependency ratio (dependants / working population) x 100 60.2%
An ageing population is more likely to have long term conditions, be frail and develop various complexities. Data on patient complexity also suggests that for the over 80s, in both Stoke-on-Trent and North Staffordshire, patients are more complex than in similar areas.8 Local NHS services therefore need to be prepared to meet the extra health care needs of an older population, for long periods of time, to the end of life. This has particular implications for community services provision within Stoke-on-Trent and North Staffordshire due to the relatively older populations.
2.1.5 Prevalence of illnesses by CCG The health of people in North Staffordshire and Stoke-on-Trent is generally worse than the UK average. There is a higher prevalence of many conditions compared to English averages, particularly depression, diabetes, hypertension and obesity.
Prevalence of conditions across North Staffordshire and Stoke-on-Trent compared with England, 2017 9
8 NHS Right Care pack January 2017 https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2017/01/cfv-stoke- on-trent-jan17.pdf and https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2017/01/cfv-north- staffordshire-jan17.pdf 9 2017 QOF prevalence data from gpcontract.co.uk https://www.gpcontract.co.uk/browse/05G/17 Page 90 of 287
Prevalence of health conditions in Stoke-on-Trent CCG
Stoke-on-Trent has higher prevalence rates than England for nearly every condition, particularly for smoking prevalence, hypertension, depression and obesity. This prevalence of Long-Term Conditions (LTCs) places additional strain on community services within Stoke-on-Trent.
As summarised in the figure above, the Stoke-on-Trent Joint Strategic Needs Assessment (JSNA)10 presents further areas where Stoke-on-Trent’s health status is lower than the national average:
Despite a younger population, only 48% of adults report they are physically active compared with 57% for England; The rate of admissions for alcohol-related harm in Stoke-on-Trent is high (1,058 admissions per 100,000 people compared to 647 across England); Stoke-on-Trent has some of the highest rates of alcohol related hospital admissions in the country and hospital costs alone exceed £13 million per year. They are also rising more quickly: admissions rose 23.7% in 2017 in Stoke-on-Trent, compared with 6.8% in England; Self-harm rates increased substantially in Stoke-on-Trent between 2012/13 and 2015/16; and 20.3% of adults in Stoke-on-Trent smoke, compared to 15.5% in England.
Prevalence of health conditions in North Staffordshire CCG
North Staffordshire also has higher prevalence rates than England for nearly every condition, especially hypertension, depression and obesity.
While the North Staffordshire JSNA11 highlights some areas that are similar or better than the England average (e.g. problem drug users), Newcastle-Under-Lyme and Staffordshire Moorlands generally have worse health status relative to the national average:
Diabetes prevalence is high, with 7.1% of adults in Newcastle-Under-Lyme and 7.5% in Staffordshire Moorlands recorded in 2014/15 (compared to 6.4% across England); Admissions for alcohol-related harm in Newcastle-Under-Lyme are high, with 881 admissions per 100,000 people (compared to 647 across England); There is much higher smoking at the time of childbirth than average (14% of mothers smoke, compared 10.6% nationally); and Admissions for self-harm are substantially higher (233.1 compared with 196.5 per 100,000 in England).
2.1.6 Deprivation Poverty and deprivation are key determinants of poor health outcomes. Higher levels of deprivation are linked to many health problems, including the prevalence of long-term conditions. Overall deprivation across the area is below the national average, but the picture varies by locality and within localities12.
10 Source Stoke-on-Trent Joint Strategic Needs Assessment - http://webapps.stoke.gov.uk/jsna/ 11 Staffordshire Joint Strategic Needs Assessment – https://www.staffordshireobservatory.org.uk/publications/healthandwellbeing/yourhealthinstaffordshire.aspx#.Ww03zu4vy po Page 91 of 287
Stoke-on-Trent is the 16th most deprived local authority area in England. More than 30% of the City’s population live in areas classed in the 10% most deprived in England, with only one-in-six of the population in areas ‘better than the England average’; The population in Newcastle-Under-Lyme is less deprived than the English average, though there are pockets of high deprivation, particularly around the town centre; and While Staffordshire Moorlands is relatively affluent (and less deprived than the national average), it has pockets of high deprivation in some urban areas. 9% of its population (80,500 people in 2013) lives in the most deprived fifth of areas nationally.
2.1.7 Health inequalities The local joint strategic needs assessments13 14 demonstrate health inequalities across CCGs, as well as within localities. They show that health indicators for Newcastle-Under-Lyme and Staffordshire Moorlands are near the national average, whilst those for Stoke-on-Trent are below average for both males and females:
Life Expectancy at birth in Stoke-on-Trent is 76.4 years (males) and 81.0 years (females). Both are lower than the national average (79.2 years for males and 82.9 years for females). The rate of infant mortality was the highest in England between 2013 and 2015; Despite lower deprivation within Newcastle-Under-Lyme, life expectancy is near the national average of 79.2 years for males and 82.9 years for females. Life Expectancy at birth in Newcastle- Under-Lyme is 78.6 years (males) and 82.9 years (females); and Life Expectancy at birth is 80.1 years (males) and 82.8 years (females) across Staffordshire Moorlands, similar to the national averages (79.2 years for males and 82.9 years for females). This equates to four years of extra life for males and over one year for females, when compared with Stoke-on-Trent.
12 [See Annex section 1.2 Stoke-on-Trent CCG NHS Right Care pack January 2017 https://www.england.nhs.uk/rightcare/wp- content/uploads/sites/40/2017/01/cfv-stoke-on-trent-jan17.pdf Source: North Staffordshire NHS Right Care pack January 2017 https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2017/01/cfv-north-staffordshire-jan17.pdf 13 Stoke-on-Trent Joint Strategic Needs Assessment – http://webapps.stoke.gov.uk/jsna/ 14 Staffordshire Joint Strategic Needs Assessment – https://www.staffordshireobservatory.org.uk/publications/healthandwellbeing/yourhealthinstaffordshire.aspx#.Ww03zu4vy po Page 92 of 287
Appendix 9:: Quality Impact Assessment
Title of Scheme The Future of Local Health Services in Northern Staffordshire CCGs covered by the scheme: North Staffordshire CCG & Stoke-on-Trent CCG Commissioning Lead for scheme: Head of Strategic Commissioning Senior Manager/Executive Sponsor: Director of Strategy, Planning & Performance
1.0 Brief description of scheme: The health and social care needs of the North Staffordshire and Stoke-on-Trent population are changing. People are living longer with increasing long-term conditions, requiring ongoing support and management. This is putting a significant strain on our services and the sustainability of health system.
Given these pressures, we need to think differently about how we provide services closer to home, and in particular for adults with high clinical needs (such as multiple long term conditions and/or significant frailty) who are at risk of unnecessary or inappropriate admission to acute hospitals. Our community hospitals provide both bed based services and wider non-bed based services including outpatient care, minor injuries, day case and, x-ray. Our focus is on ensuring the greatest health benefit from these resources which will allow patients to manage their own conditions and access care from home. We are engaging with the public and local stakeholders to develop proposals to meet these aims, including what the future role of our community hospitals and associated services should be.
The draft model of care we have developed for our community services aims to meet the needs of the local population and deliver the right care in the right setting. This is consistent with the NHS Five Year Forward View, the GP Five Year Forward View and the Five Year Forward View for Mental Health. We believe the range of services within our communities, including community hospitals, can make a significant contribution to the development of new local care models. This should lead to better outcomes for patients and provide more sustainable services. The clinical case for change along with the viable solutions to the problems described are clearly articulated in the Pre-Consultation Business Case (PCBC) which has been developed with clinicians, providers, patients and other key stakeholders.
The default care setting for all elderly patients should be the place they call home. Our local engagement has told us that this is not only what people want but it can also improve outcomes and be a more effective use of available resources.
Historically, the number of beds within Northern Staffordshire has led us to a position where patients have been cared for at a level higher than required to meet their needs. This is not an efficient use of resources and also leads in many cases to a longer length of stay and a higher likelihood of entering long term care.
It is, however, acknowledged that some patients upon discharge will have needs that place them beyond the thresholds to be cared for safely at home. The CCGs will continue to commission a significant number of beds to support patients requiring a higher level of care and/or requiring an assessment for longer term 24 hour care needs. These beds will be commissioned in line with the clinical need of this cohort of patients.
The integration of services and a flexible workforce will support the maximisation of capacity within the community and will reduce the numbers of handoffs between services therefore positively impacting upon individual patients’ experience
Through the new model of care patients will receive the right level of support, by an appropriately skilled workforce, in a timely way and for a time limited period. The model will also maximise independent living and actively support people to return to optimal levels of functioning.
There are a set of key principles that sit behind the implementation of providing care closer to home as outlined below: The model will be based upon a pull by community not push by acute; Clinical governance will sit with the community provider; No assessments for on-going care needs will carried out in an acute bed (unless by clinical exception); The full implementation will ensure that more people go home with a reduction in the number of patients going into a bed based rehabilitation service; and
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Pathways and principles across Northern Staffordshire will be aligned to ensure equity of provision.
The PCBC focusses on community-based services across North Staffordshire and Stoke-on-Trent. Specifically, the proposed way forward for community-based care covering: The bed configuration for community services Adult Intermediate Rehabilitation Service Beds (AIRS beds); and Our proposals to integrate and expand existing wider community services into Integrated Care Hubs.
This quality impact assessment has therefore been separated into two sections to mirror the proposed changes.
2.0 Intended Quality Improvement Outcome/s: There is consensus across North Staffordshire and Stoke-on-Trent that if we do not redesign and transform services to improve quality, using the available resource as efficiently as possible, our population will experience poorer health outcomes as a direct result.
Caring for elderly patients in the place they call home can greatly improve the quality of care received and the outcomes achieved. Evidence suggests that caring for older people in a hospital bed can often outweigh the benefits of care received due to decompensation.
The NHS Emergency Care Improvement Programme (ECIP) reported that the negative impact of bed rest in older people is as follows: In the first 24 hours: In the first 7 days: Reduction in muscle strength of 2-5%; Reduction in circulating volume by up to 20%; Reduction in circulating volume by up to 5%; Loss of muscle strength 5-10%; Reduction in functional residual capacity (FRC) of 15-30%; Negative impact upon skin integrity
Two separate studies15 have shown that 10 days in a hospital bed (acute or community) leads to the equivalent of 10 years ageing in the muscles of people over 80.
The overall aim of the Integrated Care Teams is to improve outcomes for people, create access to better, more integrated care outside of hospital, reduce unnecessary hospital admissions and enable effective working of professionals across individual Care Hubs. • Support for General Practice and the extended primary care team in the management of patients with Diabetes, Heart Failure and Respiratory conditions that makes patient care excellent and delivers individual patient outcomes in line with their management plans aligned with the new models of care. Specialist integrated team knowledge and skills to impact positively and be evident in the care plans for patients being case managed. • Patients and the families of patients approaching the end of life are cared for in line with their wishes in their preferred place of care. Specialist teams contribute to and are active in the delivery of the single care plan. Identify and implement practices that empower patients so that they identify themselves as feeling confident to manage their long term condition(s) including an increase in number of patients who identify themselves as feeling confident to manage their long term condition,
3.0 Methods to be used to monitor quality impact: The West Staffordshire Urgent Care Board will monitor the impact on the health economy’s urgent care system. Revised service specifications for Home First and Integrated Care Services will be outcome focused and a number of quality requirements and key performance indicators will be developed to ensure that quality and safety of services are
15 Gill et al (2004) studied the association between bedrest and functional decline over 18 months. They found a relationship between the amount of time spent in bed rest and the magnitude of functional decline in instrumental activities of daily living, mobility, physical activity and social activity. & Kortebein P, Symons TB, Ferrando A et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontal A Biol Sci Med Sci. 2008;63:1076-1081
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not compromised. This information will be monitored at Clinical Quality Review Meetings in accordance with the CCG’s Quality Strategy and reported to contract monitoring meetings which are responsible for monitoring performance against the service specifications.
4.0 The bed configuration for community services Adult Intermediate Rehabilitation Service Beds Historically Adult Intermediate Rehabilitation beds were provided from 5 community hospital – Bradwell, Cheadle, Haywood, Leek Moorlands and Longton Cottage; providing a capacity of 264 beds. Since 2015 a number of the rehabilitation beds have been temporarily closed and additional capacity has been commissioned in the care home setting; providing a capacity of 132 beds. During this period the clinical model has iteratively changed developing both the home first model – providing reablement care in people home/care home – and significantly increasing the hours of community care by 25%.
The options contained within the Pre Consultation Business Case based on a sustained change to the clinical model all maintain a capacity of 132 beds. Following discussion at the Expert Panel held on 12th June 2018 the ‘provisional preferred option’ to allow a flexible bed capacity based upon patient need was Option 1 – Haywood & Care.
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Area of Impact Questions Description of Impact (Positive /negative/Unchanged) & Risk Rating Mitigation Strategy & Quality Could the proposal impact positively Rationale Monitoring Arrangements L C R Beds or Negatively on any of the following? o The duty to secure continuous Positive. CCGs set out their expectations of outcomes, Pre-existing Future procurements will formalise current improvement in the quality of the quality standards and planned monitoring arrangements risk on CCG’s incentivised agreements with care homes to healthcare commissioned (Health through contracts with providers. Prior to any changes to risk register: 3 increase staffing to support 7 day admissions. and Social Care Act 2008 Section commissioned services, service specifications and outcome x 3 (Amber) 139)? focused key performance indicators will be revised and Should the CCGs be required to commission standardised. short term (unexpected surge) care home bed capacity based on patient need, the CCG The CCGs will commission Midlands Partnership NHS will utilise a dynamic procurement system Foundation Trust (MPFT) as the lead provider for all (ADAM) to procure the beds. The ADAM community beds including any care home provision. The system is currently utilised by continuing monitoring of community beds (including care homes) will healthcare to appropriately procure take place through a new additional subgroup of MPFT’s placements based on the patient’s care Clinical Quality Review Meeting. This will allow focused needs, taking into account known quality discussion of disaggregated information specific to the outcomes, admission restrictions, etc. proposed changes.
Learning from experience, as part of any procurement exercise to award subcontracts with care homes, joint (CCGs, MPFT, and local authorities) announced and
DUTY OFQUALITY DUTY unannounced site visits will take place prior to any contracts being awarded. The CCG will only allow MPFT to subcontract to care home providers with a CQC rating of ‘Good’.
The quality monitoring of care homes of care homes in general (where the CCG does not have a contract in place) is undertaken by the relevant local authority. There are 147 care homes in North Staffordshire & Stoke-on-Trent. Those homes that have been inspected by the CQC have been rated as follows: 1 ‘Outstanding’, 94 ‘Good’, 40 ‘Requires Improvement’ and 2 ‘Inadequate’. Pan-Staffordshire CCGs are working in partnership with Staffordshire County Council & Stoke-on-Trent City Council to support quality Page 96 of 287
Area of Impact Questions Description of Impact (Positive /negative/Unchanged) & Risk Rating Mitigation Strategy & Quality Could the proposal impact positively monitoringRationale and improvement within care homes including Monitoring Arrangements Beds or Negatively on any of the following? an ‘Improvement & Responsive Team’. Forums to share information take place monthly at the CCG led Nursing Home Quality Assurance & Improvement Group and local authority led Quality & Safeguarding Information Sharing Meeting.
Staffordshire County Council and Staffordshire CCGs have developed the ‘Provider Failure Standard Operating Procedure’ which sets out procedures and responsibilities for meeting the needs of patients in the event of a closure of a care home. o Commitment to the public to Unchanged. Demand and capacity modelling utilising Pre-existing However, the CCG retains a Red Risk on its continuously drive quality UHNM exit strategy plans for complex discharges (e.g. risk on CCG’s risk register concerning the potential impacts improvement as reflected in the where clinicians wanted to discharge the patient to based risk register: 4 of urgent care performance pressures on rights and pledges of the NHS on need) and assuming an occupancy level of 95% (to allow x 5 (Red) patients (risk rating reflected in previous Constitution? for flexibility and surge) has been undertaken and signed off column). It is recognised that it is likely that o Strategic partnerships and shared by health economy stakeholders of the West Staffordshire increased community bed capacity will be risk? Urgent Care Board. needed at various points, both due to demographic and non-demographic growth The proposed modelling which delivers the shift required and any unpredicted surge in demand. It is from bed based capacity to home based capacity, 132 beds proposed that additional escalation capacity (77 intermediate/reablement and 55 assessment), is based be made available to ensure flexible reaction upon achieving a 70% target for patients going home with to predicted surge (e.g. winter planning) and 30% transferring to a community hospital or care home bed unexpected surge. dependent upon their needs.
Within the Home First Model the average wait for people to be moved from acute services at the hospital to their home setting is currently 1 day. Patients are not moved into another bed in the interim which avoids unnecessary disruption to these patients and their recovery. Further, over time the unmet demand for North Staffordshire and Stoke has reduced from 109 patients equating to 456 bed days lost on 2/11/2017, to 84 patients equating to 252 bed days lost on 22/2/2018, to 66 patients equating to 151 bed Page 97 of 287
Area of Impact Questions Description of Impact (Positive /negative/Unchanged) & Risk Rating Mitigation Strategy & Quality Could the proposal impact positively daysRationale lost on 7/6/2018. Monitoring Arrangements Beds oor NegativelyThe duty toon protect any of thechildren, following? Positive. Since September 2016 the CCGs have N/A N/A young people and adults? commissioned community beds within care homes. During this period three homes have come under the Large Scale Enquiry procedure due to concerns about the care delivered. The CCGs were a partner in the multi-agency response on both occasions. Our main learning from these occasions has been an increased awareness of the gap in professional leadership expertise locally within the care home sector, to support staff within the homes with care planning, assessments and delivery.
To address this gap and strengthen local support, the CCGs will commission MPFT as the lead provider for all community beds including any care home provision. MPFT will be responsible for the management and the clinical and therapy input into the commissioned bed base under the D2A pathway and will also provide medical oversight into the beds. In addition, and learning from experience, MPFT will also provide clinical leadership, have responsibility for ensuring that robust staffing models are in place over seven days and that care is delivered to the standards set out within the service specification. This will ensure that all community beds are subject to the same clinical governance arrangements and oversight.
Due to the layout of the wards within the community hospitals the beds are not suitable as placements for patients with EMI nursing assessment needs. Specialist nursing homes with the relevant expertise provide the best environment for the care of this cohort of patients. o Tackling health inequalities and Unchanged. Implementing the Home First Model the CCG N/A N/A focusing resources where they are will commission community services based on patient need. needed most? The CCGs have increased community care hours by 125% to 6,200 at any one time allowing 413 patients to be
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Area of Impact Questions Description of Impact (Positive /negative/Unchanged) & Risk Rating Mitigation Strategy & Quality Could the proposal impact positively supported.Rationale Monitoring Arrangements Beds or Negatively on any of the following? A separate Equality Impact Assessment (EIA) has been undertaken by the CCGs which will be reviewed following the completion of formal consultation in January 2019. The EIA incorporates substantial engagement with a range of stakeholders and the public. Further, a stakeholder mapping exercise was undertaken with the Local Equality Advisory Forum (LEAF) on 23rd May 2018 to inform the Consultation Plan. This was cross referenced against the CGC’s database of organisations representing the protected groups and will ensure that the appropriate organisations and individuals are consulted in an accessible and appropriate way that meets their needs.
The main areas highlighted by the EIA for consideration are frailty and accessibility. o The implementation of evidence Unchanged. N/A N/A based practice? o Improvements in care pathway(s)? NHS Five Year Forward View, NHS England, 2014 o Reduction of unwarranted variations in care? High impact change model: Managing transfers of care o Full adoption of Better Care, between hospital and home, NHS England, Local Better Value metrics? Government Association, 2015.
NICE Guideline 27: Transition between inpatient hospital settings and community or care home settings for adults
EFFECTIVE with social care needs, 2015.
NHS England’s Quick Guide: Discharge to Asses and benefits for older, vulnerable people. o Clinical leadership? Unchanged. The CCGs, led by the CCG’s Medical Director o Clinical engagement? and Clinical Director, have undertaken clinical engagement with the GP Federation, Northern Alliance Board, GP Members and West Midlands Clinical Senate. Feedback has
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Area of Impact Questions Description of Impact (Positive /negative/Unchanged) & Risk Rating Mitigation Strategy & Quality Could the proposal impact positively beenRationale incorporated into the development of the Pre Monitoring Arrangements Beds or Negatively on any of the following? Consultation Business Case. o The ability to review quality Unchanged. Refer to ‘duty to secure continuous improvements through core improvement’ above. clinical quality indicators supported by good information? o Promotion of self-care? Unchanged. The model of care is based upon clinical best practice and feedback from engagement events. Home is the preferred setting for health and care interventions. One of the key design principles is that people will self-care to live well and independently in their own homes and where they need support this will be provided by family, friends, community and public bodies in the health economy. Further, patients will feel empowered and self-care and management is promoted. Patients can make informed choices about their care and take responsibility for their own health and wellbeing through rehabilitation and supported self-management. o Self-reported experience of Unchanged. Throughout 2015 North Staffordshire & Stoke- N/A N/A. patients and service users? on-Trent CCGs undertook extensive engagement on a new (Response to national/local model of care, known as ‘My Care, My Way – Home First’, surveys/complaints/PALS/incident which aims to support patients to remain fit and well and s)? supported within their own homes without the need for an admission to a hospital bed. The full report is available
here: http://www.northstaffsccg.nhs.uk/my-care-my-way. The feedback from the public and other stakeholders was that patients benefit from being – and prefer to be – at home and support the proposed model of care in principle.
EXPERIENCE However, stakeholders want: Assurance that there is capacity in community services to support the model; To be sure about the future of community hospitals; Effective support for every spouse/family/carer; To know it will be carefully implemented and patients will be followed up in the community;
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Area of Impact Questions Description of Impact (Positive /negative/Unchanged) & Risk Rating Mitigation Strategy & Quality Could the proposal impact positively Rationale To know the investment is in place to support the Monitoring Arrangements Beds or Negatively on any of the following? changes.
Further engagement has reiterated the above findings and concerns around quality of care home quality of care. o Patient choice? Unchanged. The decision of the requirement for a complex discharge is made by the discharging clinician(s). This process is not changed by the consultation. o Accessibility of services? Unchanged. Analysis has been undertaken to consider the average change in patient travel time and distance from the current configuration of beds (with temporary closures in effect) and previous configuration (prior to temporary closures) across each of the six options. That is, we look at how long it would take on average a patient to travel to their closest site in the current and previous configurations (post and pre temporary closure) and compare this against what the time would be under each of the six options. Our analysis shows that on average, the additional average travel time across each options is less than 10 minutes – though this doesn’t into account traffic conditions. This is not expected to have an impact on quality of care received. Though noting that we have to go through a process to procure care homes, the estimates show that if care homes were procured locally, there will be a more beneficial (smaller) change in travel time. o Compassionate and personalised Unchanged. CCGs set out their expectations of outcomes, care? quality standards and planned monitoring arrangements through contracts with providers. o Patient safety and preventable Unchanged. During Multi-Agency Discharge Events (MADE) N/A N/A harm? in in March & June 2018 point prevalence audits of patients
o Reducing healthcare acquired within community beds (community hospital & care homes) infections? have demonstrated that all of the 118 (March) and 101 SAFE (June) patients were appropriately placed within assessment beds e.g. all patients required an assessment of future need. This reduces the risk of deconditioning and
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Area of Impact Questions Description of Impact (Positive /negative/Unchanged) & Risk Rating Mitigation Strategy & Quality Could the proposal impact positively exposureRationale to healthcare acquired infections. Monitoring Arrangements Beds oor NegativelyClinical workforce on any of capacity the following? Unchanged. Nationally and locally workforce recruitment N/A N/A (recruitment & retention), and retention remains a key challenge within both NHS and capability and competency? private providers. Health & social care partners in the health economy are working together within the Sustainability & Transformation Partnership (STP) to address recruitment and retention in Staffordshire.
In March 2018 22.58% of shifts at Community Hospitals were below the agreed staffing levels, 31% agency usage and limited success in recruiting to positions over a two year period. NHS Benchmarking concurs with local expert provider advice that an ideal ward size is 20 patients per ward (i.e. total of 40 allowing for male and female), with a good mix of side rooms and bays. This allows a good use of the area, a good staffing ratio, and allows for absences to be managed safely. Further, learning from local incidents a site should have a minimum of 2 wards to support flexibility to maintain safer staffing levels. Further, dependent upon the community hospital sites chosen there are environmental layout challenges which increase nurse/healthcare support worker numbers required to maintain safe staffing.
Currently there is a pressure on primary care where care home beds are situated in multiple areas due to the requirement to provide medical support. Moving towards a reduced number of sites with clinical governance and oversight provided by MPFT.will strengthen the clinical model and reduce the impact upon primary care.
Creation of the Home First Team has led to movement of staff from other community nursing staff. Whereby opportunities have been presented for staff to be promoted and move within the health economy. However, overall the need to recruit into the health economy remains.
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5.0 Our proposals to integrate and expand existing wider community services into Integrated Care Hubs. The service will be delivered through localities and primary care hubs moving forwards under a multi-disciplinary approach, utilising risk stratification to identify those patients requiring proactive management and support across a team of specialist nurses, therapists, mental health professionals, pharmacists and social care professionals supported by the overarching governance of specialist consultants where required. The service will be led through strong clinical management within primary care. It is expected that the response to the requirements will be developed through the three Alliance Boards covering Staffordshire.
The service will support and integrate with wider community services in the timely and effective management of patients including district nursing, specialist nursing, specialist therapies, community matrons and social care provision. The team will where appropriate bring in the expertise and enhanced support of teams such as the Home First service to avoid inappropriate admission to secondary care and to support patients to remain independent at home for as long as possible. The service will also place a close focus upon supporting patients to self-manage their own condition(s).
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Area of Impact Questions Description of Impact (Positive Risk Rating Mitigation Strategy & Quality - Could the proposal impact positively or /negative/Unchanged) & Rationale Monitoring Arrangements L C R Hubs Negatively on any of the following? o The duty to secure continuous improvement Positive. The introduction of Integrated Care N/A N/A in the quality of the healthcare Teams (ICTs) will improve outcomes for people, commissioned (Health and Social Care Act create access to better, more integrated care 2008 Section 139)? outside of hospital, reduce unnecessary hospital admissions and enable effective working of professionals across individual Care Hubs.
The ICTs will also be measured against a set of outcomes which are benchmarked against best practice and have been signed off through the Clinical Leaders Group in addition to a set of overarching deliverables to secure continuous improvement which are as follows:
Reduction in the number of case managed patients accessing unscheduled secondary care resulting in a reduction in non-elective
QUALITY admissions; Increase in the utilisation of pharmacy staff within Integrated Care Hubs to optimise
medications for patients under case DUTY OF DUTY management Support for General Practice and the extended primary care team in the management of patients with Diabetes, Heart Failure and Respiratory conditions that makes patient care excellent and delivers individual patient outcomes in line with their management plans aligned with the new models of care Support General Practice in the incidence recording of Diabetes, Heart Failure and Respiratory conditions so that the recorded incidence of LTCs is aligned with expected prevalence as suggested by local Public
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Health and NHSE utilising tools such as the GRASP tool, Specialist integrated team knowledge and skills to impact positively and be evident in the care plans for patients being case managed, Patients and the families of patients approaching the end of life are cared for in line with their wishes in their preferred place of care, Specialist teams contribute to and are active in the delivery of the single care plan, Identify and implement practices that empower patients so that they identify themselves as feeling confident to manage their long term condition(s) including an increase in number of patients who identify themselves as feeling confident to manage their long term condition, Increase the use of Technology to support patients to manage their own conditions o Commitment to the public to continuously Positive. The model of care will deliver co- N/A N/A drive quality improvement as reflected in the ordinated, quality and integrated care for our rights and pledges of the NHS Constitution? frail population and patients with long term conditions in particular, aligned with primary care.
MPFT as a provider are committed to named teams supporting system integration and work is underway to commence implementation of the workforce against population sizes, demographics and risk stratified cohorts to ensure capacity meets demand and care is delivered closer to home.
The model will also ensure that patients have the ability to exercise their right to choice as outlined
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within the NHS Constitution. o Strategic partnerships and shared risk? Positive. The ICT will be the delivery vehicle for N/A N/A the new model of care and will form part of a larger infrastructure including locality working, GP Federations, Local Health Economy Clinical Networks and Alliances. There will also be a requirement to work in partnership with wider public sector organisations including district councils, fire and safety, housing associations and the voluntary sector to ensure supportive communities and healthy promoting environments are promoted, developed and optimised. The teams will where appropriate bring in the expertise and enhanced support of teams such as the Home First service to avoid inappropriate admission to secondary care and to support patients to remain independent at home for as long as possible.
It is expected that the service will be delivered through an integrated approach across services and providers, facilitated and driven forwards by Alliance Boards across Staffordshire.
It is expected that relevant staff from the following organisations will sit within the scope of ICTs – MPFT;; UHNM; Combined Healthcare; Voluntary Sector; Local Authorities; Primary Care.
There is a risk around staffing within primary care and GP recruitment which is picked up in the overarching STP work plan around the GP 5 year forward view and recruitment and retention plan. o The duty to protect children, young people Unchanged. There will be a duty to work with N/A N/A and adults? the wider public sector organisations to ensure supportive communities and healthy promoting CONFIDENTIAL – DRAFT FOR DISCUSSION – SUBJECT TO MULTI REVIEWS AND ENGAGEMENT
environments are promoted for good physical and mental health wellbeing across all age life course. o Tackling health inequalities and focusing Positive. The ICT will form an integral part of N/A N/A resources where they are needed most? primary care based clinical services and will work in partnership with GP practices and communities to provide the right nursing and social care services to GP patients in the right way and at the right time.
Workforce modelling is being developed taking into account population sizes, deprivation and risk stratified lists to ensure appropriate service provision is wrapped around populations at a specialist team level supporting an MDT approach to the care of patients with long term condition and frailty and those requiring specialist end of life care. It is also expected that the ICTs will deliver proactive case finding and management for individuals at risk of admission or readmission to hospital, through the use of risk stratification. The purpose of this is to agree with the individual a planned ‘shared care’ approach which stabilises the individual’s condition and prevents further unnecessary admissions and/or supports earlier discharge, The teams will also be arranged in such a way that they can deliver timely, responsive and anticipatory advice to the wider Primary Care Team in support of the safe clinical management of patients in the community based on specialist clinical judgement and patient need. o The implementation of evidence based Positive. N/A N/A practice? NICE Guidance – Respiratory; Diabetes; Heart Failure, End of Life Care
EFFECTIVE BCF 2017 – 19 Policy Framework, Condition
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3. Health and Social Care Integration agenda GP 5 Year Forward View Mental Health 5 Year Forward View NHS 5 Year Forward View o Improvements in care pathway(s)? Positive. The service will be delivered through N/A N/A localities and primary care hubs moving forwards under a multi-disciplinary approach, utilising risk stratification to identify those patients requiring proactive management and support across a team of specialist nurses, therapists, mental health professionals, pharmacists and social care professionals supported by the overarching governance of specialist consultants where required. The service will be led through strong clinical management within primary care. The ICT will support and integrate with wider community services in the timely and effective management of patients including district nursing, specialist nursing, specialist therapies, community matrons and social care provision. The team will where appropriate bring in the expertise and enhanced support of teams such as the Home First service to avoid inappropriate admission to secondary care and to support patients to remain independent at home for as long as possible. The service will also place a close focus upon supporting patients to self- manage their own condition(s). The ICT will contribute to the delivery of the prevention and self-help agenda for patients under their care, promoting the uptake of services such as the flu vaccine, pneumococcal vaccine, signposting to weight loss, cancer screening programmes and smoking cessation. o Reduction of unwarranted variations in care? Positive. The ICTs will deliver the formulation of N/A N/A a single, holistic care plans, owned by primary
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care, which pulls together all clinical and social care and voluntary sector contributions and recognises the role the patient/carer has in managing their own care throughout their lifetime. This will recognise multi-morbidity factors to ensure a holistic approach to addressing a patients needs are met. Recognition needs to happen at all points of contact for an older person including physical and mental health, social care and the voluntary sector, and wider place based services. To achieve this there needs to be an emphasis on training the wider workforce and community teams and facilitating them to refer into a specified pathway e.g. frailty.
Provide parity of esteem between mental and physical ill health for by reducing rates of depression, anxiety and self-harm in patients and by increasing the rates of access to psychological therapies for patients with comorbid depression and long term conditions. o Clinical leadership? The service will be led through strong clinical N/A N/A management within primary care.
The role of the Alliance Boards will be key to ensure that services, irrespective of responsible Provider are delivered in a co-ordinated and efficient manner.
It is expected that the governance of the model will be driven through the Alliance Boards with organisations working together to develop an accountability model as part of the service specification. o Clinical engagement? Further engagement is required with the N/A N/A Alliances, Community Services clinical team leads
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on the implementation plan and programme roll out for areas scoped within the programme. A steering group and formal governance structure is in place to drive this forward. o Full adoption of Better Care, Better Value Positive. The implementation of the ICTs is N/A N/A metrics? expected to have a positive impact on the BCBV metrics – managing long term conditions in the community resulting in less demand in secondary care; providing alternatives for urgent care admissions; reduction in the dependency of people on domiciliary care services and care homes. o The ability to review quality improvements Positive. Enhanced - a number of overarching N/A N/A through core clinical quality indicators expected outcomes with measurements are supported by good information? included alongside specific outcomes and measurements for key areas of activity – respiratory; diabetes; heart failure; frailty; end of life.
Sample audits of care plans will be undertaken on a quarterly basis.
The service will be expected to utilise a set of QALY tools as part of the KPI dataset.
Patients and the families of patients approaching the end of life care for in line with their wishes in preferred place of care will be measured through PCCC outcomes. o Promotion of self-care? The ICT will deliver a service that supports self- N/A N/A care and patient education which will equip patients and their carers with the tools they need to understand and manage their own long term conditions.
There will also be a focus on the utilisation of appropriate technology such as ‘My COPD’ to
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support patients in managing their own conditions. o Self-reported experience of patients and Patient satisfaction surveys will be undertaken on service users? (Response to national/local patient’s views of managing their long term surveys/complaints/PALS/incidents)? conditions in the community, e.g. diabetes, use of technology to manage conditions.
Use of QALYs tools will also inform the analysis of patient experience. o Patient choice? Positive. The aim is where possible for teams to N/A N/A be in one place, in one building and one team wrapped around general practice and the locality. Patients will also be free to choose the most appropriate place to receive their care from across Staffordshire and Stoke on Trent. o Accessibility of services? Parity of esteem will be provided between N/A N/A mental health and physical ill health by reducing rates of depression, anxiety, self-harm in patients and by increasing the rates of access to psychological therapies for patients with co- morbid depression and long term conditions.
EXPERIENCE Travel analysis has been undertaken based upon current provision and proposed options for the location of Hubs which has demonstrated minimal impact. o Compassionate and personalised care? ICTs will reach into residential and nursing homes N/A N/A to support patients to remain in their place of residence by wrapping services around the populations, supporting advanced care planning and delivering services to support patients at the end of their life.
The ICT will deliver person centred outcomes in a timely manner through the development of personalised care plans across health and social care.
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o Patient safety and preventable harm? Unchanged. N/A N/A o Reducing healthcare acquired infections? Unchanged. N/A N/A o Clinical workforce capacity (recruitment & The ICT will consist of a multi-disciplinary team N/A N/A retention), capability and competency? made up of community nursing, Specialist Long Term Conditions Nurses, Specialist Physiotherapists, voluntary sector input, social care, primary care, mental health and pharmacist support with a strong link to prevention and proactive management.
The service will support the education and skills development programme of the wider primary SAFE care team in reaction to the specialist management of patients with Long Term Conditions and frailty to share learning and best practice.
The service aims to maximise the use of trained pharmacy staff in the management of patients with long term conditions.
There are concerns around the retention and recruitment of community nursing
Commissioning Lead Name: Gemma Smith Designation: Head of Commissioning Date: 18/06/2018 Quality Support Name: Lee George Designation: Head of Quality Date: 18/06/2018 Executive Name: Zara Jones Designation: Director of Strategy, Planning & Performance Date: 18/06/2018
Date Reviewed by QIA Panel: Tuesday 19th June 2018 Decision: Approved with conditions: o QIA to be updated and reviewed by a further Panel following the completion of formal consultation. o Lead Provider & subcontracting contract and quality monitoring arrangements to be further developed and included within updated QIA.
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Appendix 10:: Quality metrics for community beds and services. Community beds
Clinical Effectiveness
New patients have the following undertaken on admission:
Continence Assessment
Falls Risk Assessment
Nutrition & Hydration Risk Assessment
Record of prescribed & administered medicines
Tissue Viability Risk Assessment
Existing patients have assessments reviewed monthly or sooner if there is a change in need:
Continence Assessment
Falls Risk Assessment
Nutrition & Hydration Risk Assessment
Record of prescribed & administered medicines
Tissue Viability Risk Assessment
Care plans reflect patient need and risk assessments
Patient Experience
Friends & Family Test:
• % of patients would recommend
• % of patients would not recommend
• Sample size
Number of complements received
Number of formal complaints received
Number of complaints referred onto the Ombudsman
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Patient Safety
Number of slips, trips and falls resulting in harm
Number of pressure ulcers acquired in your care by grade:
Number of medication incidents
Number of outbreaks (infection prevention & control)
Number of serious incidents reported
Number of deaths
NHS Safety Thermometer
• % No Harm
• % No New Harm
Residents deemed not to have capacity have had a Mental Capacity Assessment completed and consideration for Deprivation of Liberty evidenced
How many safeguarding notifications have been made?
How many CQC notifications have been made?
Workforce
Number of occasions <2 RNs on duty between 8am – 8pm
% days lost (sickness and absence)
% staff have had an appraisal in past 12 months
Number of shifts covered by agency staff
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Wider Community services quality metrics
Overarching Expected Outcomes
• Reduction in the number of case managed patients accessing unscheduled secondary care resulting in a reduction in non-elective admissions;
• Increase in the utilisation of pharmacy staff within Integrated Care Hubs to optimise medications for patients under case management;
• Support for General Practice and the extended primary care team in the management of patients with Diabetes, Heart Failure and Respiratory conditions that makes patient care excellent and delivers individual patient outcomes in line with their management plans aligned with the new models of care;
• Support General Practice in the incidence recording of Diabetes, Heart Failure and Respiratory conditions so that the recorded incidence of LTCs is aligned with expected prevalence as suggested by local Public Health and NHSE utilising tools such as the GRASP tool;
• Specialist integrated team knowledge and skills to impact positively and be evident in the care plans for patients being case managed;
• Patients and the families of patients approaching the end of life are cared for in line with their wishes in their preferred place of care;
• Identify and implement practices that empower patients so that they identify themselves as feeling confident to manage their long term condition(s) including an increase in number of patients who identify themselves as feeling confident to manage their long term condition;
• Increase the use of Technology to support patients to manage their own conditions.
Respiratory outcomes
• Reduction in the number of patients presenting with an exacerbation of COPD who are already diagnosed and under a management plan that are case managed through the Care Hub
• Minimum of 75% of patients who have a shared management plan
• 90% of patients offered pulmonary rehab in line with NICE guidance
• 95% of patients offered the pneumococcal vaccination
• Reduction in the number of hospital readmissions
• Increase the number of COPD patients who die in their preferred place of death
• Develop and fully implement discharge bundles for patients admitted with pneumonia and/or COPD
• Enhancement of care for advanced disease
Diabetes
• Improved CCG performance for the 8 care processes specifically for urine albumin and retinal screening
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• % reduction in eye related procedures for ophthalmology
• % decrease in non-elective admissions with foot ulceration procedures
• Reduced primary care prescribing spend on diabetes
• Increased self-awareness and better understanding of managing diabetes within the community
• Increased number of people with holistic personalised care plans to support and increase confidence to self- manage
Heart Failure (HF)
• To ensure that 100% of patients on practice HF registers had a confirmed diagnosis
• Develop discharge bundles for patients admitted with heart failure delivered by the Integrated teams within the Care Hubs
• To ensure that 80% of patients are on appropriate medical therapy and are titrated, or being titrated, to recommended dosages as tolerated (unless documented as contra-indicated)
• To provide HF education and a continuing rolling programme of education for all diagnosed patients
• Increase the number of Heart Failure patients who die in their preferred place of death
Frailty
• Through links with the falls service, deliver both a reduction in non-elective spend on hip fractures associated with a fall (per head of population over 65) and a reduction in falls related admission rates (per head of population over 65)
• Through links with the Primary Care Commissioning Committee and Palliative Care team, End of Life care will be anticipated and planned for, such that 100% of patients receive high quality co-ordinated end of life care;
• 100% of identified patients are in receipt of an Integrated Care and management plan
• 100% of patients receive a Complex Geriatric Assessment
• Through the MDT approach to managing patients with frailty, it is expected that 33% of admissions to acute care could be avoided
End of Life
• To proactively identify all people considered to be in the last year of life at an early stage, to be able to give them pro-active person centred care in line with preferences
• To offer every identified person the chance to have an advanced care planning discussion with the person of choice
• To enable every person the opportunity to die in their preferred place of choice
• Number and percentage of people with Preferred place of care/death recorded
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• Number and percentage of people who died in their recorded preferred place of choice
• Number of patients dying in their usual place of residence
• To reduce number of non-elective admissions for those patients who die in hospital
• Number and percentage of deaths in hospital
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Appendix 11: Additional details of workforce
Community inpatient
After temporary bed closures
Staff in Budgeted Post Organisation Name Staff Group Role FTE FTE Brighton House Additional Clinical Services Health Care Support Worker 0 0.85333 Healthcare Assistant 14.52 12.47 Helper/Assistant 1.40 0.61 Administrative and Clerical Clerical Worker 1.00 1.87 Allied Health Professionals Physiotherapist 1.00 0.00 Estates and Ancillary Housekeeper 0.00 0.56 Nursing and Midwifery Registered Sister/Charge Nurse 2.00 2.00 Staff Nurse 8.88 4.55 Brighton House Total 28.80 22.90
Staff in Haywood Hospital Budgeted Post (May-18) Staff Group Role FTE FTE 447 Haywood Broadfield Add Prof Scientific and Ward_G03047 Technic Clinical Psychologist 1.00 0.00 Assistant/Associate Additional Clinical Services Practitioner Nursing 1.00 1.00 Counsellor 1.00 0.00 Healthcare Assistant 21.63 18.80 Helper/Assistant 1.00 0.00 Administrative and Clerical Clerical Worker 2.00 1.01 Allied Health Professionals Dietitian 0.00 1.00 Physiotherapist 1.00 0.00 Speech and Language Therapist Specialist Practitioner 1.00 0.80 Estates and Ancillary Housekeeper 1.00 1.00 Nursing and Midwifery Registered Sister/Charge Nurse 6.69 6.80 Staff Nurse 8.61 6.40 447 Haywood Broadfield Ward_G03047 Total 45.93 36.81 447 Haywood Additional Clinical Services Assistant/Associate 0.00 1.00
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Chatterley Practitioner Nursing Ward_G03045 Healthcare Assistant 23.91 18.42 Administrative and Clerical Clerical Worker 2.03 2.23 Estates and Ancillary Housekeeper 0.95 0.00 Nursing and Midwifery Registered Sister/Charge Nurse 6.69 10.94 Staff Nurse 10.32 3.44 447 Haywood Chatterley Ward_G03045 Total 43.90 36.03 447 Haywood Grange Assistant/Associate Ward_G03044 Additional Clinical Services Practitioner Nursing 0.00 1.00 Healthcare Assistant 24.34 24.21 Administrative and Clerical Clerical Worker 3.40 1.80 Estates and Ancillary Housekeeper 0.80 0.00 Nursing and Midwifery Registered Sister/Charge Nurse 4.85 11.35 Staff Nurse 16.01 8.09 447 Haywood Grange Ward_G03044 Total 49.40 46.45 447 Haywood Jackfield Assistant/Associate Ward_G03043 Additional Clinical Services Practitioner Nursing 0.00 1.00 Healthcare Assistant 15.87 14.05 Administrative and Clerical Clerical Worker 1.00 2.10 Estates and Ancillary Housekeeper 0.64 0.64 Nursing and Midwifery Registered Sister/Charge Nurse 6.69 5.00 Staff Nurse 8.61 3.55 447 Haywood Jackfield Ward_G03043 Total 32.81 26.34 447 Haywood Sneyd Assistant/Associate Ward_G03046 Additional Clinical Services Practitioner Nursing 1.00 0.00 Health Care Support Worker 5.04 2.20 Healthcare Assistant 9.68 11.36 Administrative and Clerical Clerical Worker 1.00 1.00 Estates and Ancillary Housekeeper 0.67 0.64 Nursing and Midwifery Registered Sister/Charge Nurse 6.69 6.25 Staff Nurse 9.83 9.57 447 Haywood Sneyd Ward_G03046 Total 33.91 31.03 447 Scotia Inpatient Assistant/Associate Ward_G03064 Additional Clinical Services Practitioner Nursing 0.00 1.00 Healthcare Assistant 5.12 4.24 Administrative and Clerical Clerical Worker 1.22 0.80 Estates and Ancillary Housekeeper 0.80 0.32 Nursing and Midwifery Registered Modern Matron 0.00 1.00 Page 119 of 287
Sister/Charge Nurse 6.69 4.60 Staff Nurse 5.20 3.00 447 Scotia Inpatient Ward_G03064 Total 19.03 14.96 Grand Total 224.98 191.62
Reablement recruitment shortfall and use of agency staff: Spring 2018
Stoke (North and South)
In Stoke-on-Trent, community-based services are working with fewer staff in post than budgeted for. This is most notable within the reablement team, which is operating with only 54% of planned capacity and reliant heavily on overtime and agency working. Table below compares the actual workforce with the establishment (number of staff that the Trust has budgeted to have in post). Organization Name Position Title Budgeted FTE Staff in Post FTE Clinical Assessment Team - Stoke Administrative Team Leader 1.0 1.0 Advanced Practitioner 2.0 1.0 Clinical Team Leader 1.0 1.0 Clinical Triage Practitioner 0.0 0.0 Community Matron 1.0 1.0 End of Life Clinical Champion 0.8 0.8 Nurse Coordinator FOH 1.0 1.0 Nurse Practitioner 0.8 4.0 Occupational Therapy Technical Instructor 2.6 2.6 Palliative Care Lead 1.0 1.0 Physiotherapist 1.8 1.8 Physiotherapy Technical Instructor 0.6 0.6 Physiotherapy Technician 0.9 0.9 Secretary 1.0 1.0 10.6 8.2 Senior Occupational Therapist 3.0 3.0 Staff Nurse 1.0 1.0 Team Leader 1.0 1.0 Total for Stoke CAT 31.1 30.9 Reablement - Stoke Reablement worker 96.5 52.5 Total staff for Stoke 127.6 83.4
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Reablement recruitment tracking for Stoke-on-Trent
Stoke ( Est. = 96.5 ) 140 120 Vacancy / Gap (after 100 additional working)
80 Recruited / Pending Start
WTE 60 Overtime + Agency 40
20 Actual In Post 0 Establishment
Week Commencing
Staffordshire Moorlands
Staffordshire & Moorlands has fewer recent recruitment challenges across the Reablement and Clinical Assessment Teams, with both working with at least 87% of planned capacity.
Organization Name Position Title Budgeted FTE Staff in Post FTE Clinical Assessment Team - Moorlands Administrator 0.9 0.9 Advanced Practitioner 1.0 1.0 Advanced Social Work Practitioner 0.4 1.0 End of Life Clinical Champion 2.0 1.0 Occupational Therapy Assistant Practitioner 1.0 1.0 Physiotherapist 1.0 1.0 Physiotherapy Technical Instructor 0.6 0.6 Physiotherapy Technician 1.0 1.0 Senior Nurse Co-ordinator 4.5 4.0 Senior Occupational Therapist 1.8 0.8 Senior Physiotherapist 1.8 1.8 Social Care Assessor 3.4 3.4 Social Worker 0.9 0.0 Team Leader 1.0 1.0 Total for Moorlands CAT 21.3 18.6 Reablement - Moorlands Reablement worker 54.4 49.4 Total staff for Moorlands 75.7 68.0 The reablement service has been recruiting heavily and, once posts are filled, will significantly reduce the reliance on overtime and agency use.
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Newcastle-under-Lyme
Newcastle-Under-Lyme’s Reablement and Clinical Assessment Teams are working at over 84% of expected capacity. The reablement team has increasingly moved away from reliance on overtime and agency working and towards filling full-time posts (see table below).
Organization Name Position Title Budgeted FTE Staff in Post FTE Clinical Assessment Team - Newcastle Administration Apprentice 1.0 0.0 Administrator 1.0 1.0 Advanced Practitioner 1.0 1.0 Advanced Practitioner - Physiotherapist 1.0 1.0 Clinical Team Leader 0.0 1.0 End of Life Clinical Champion 3.8 1.8 Occupational Therapist 1.0 1.0 Occupational Therapy Assistant 1.6 1.0 Occupational Therapy Assistant Practitioner 0.6 0.6 Physiotherapist 2.8 2.7 Physiotherapy Technical Instructor 0.6 1.2 5.7 5.5 Senior Occupational Therapist 1.8 1.8 Senior Staff Nurse 0.9 0.9 Social Care Assessor 3.8 3.8 1.0 1.0 Team Leader 1.6 1.0 Total for Newcastle CAT 29.1 26.3 Reablement - Newcastle Reablement worker 66.8 56.4 Total staff for Newcastle 95.9 82.7
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Reablement recruitment tracking for Newcastle-under-Lyme for 2018
Newcastle ( Est. = 66.8 ) 80 70 60 Vacancy / Gap (after additional working) 50 Recruited / Pending Start
40 WTE 30 Overtime + Agency 20 10 Actual In Post 0 Establishment
Week Commencing
Five year growth and WTE requirement data is included in separate excel file.
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Appendix 12; Community beds modelling technical annex
1.1 This document
The aim of this technical annex is to provide further detail on the activity and financial modelling to support the PCBC. It outlines:
The assumptions used for modelling of the 132 bed baseline; Overarching modelling approach undertaken to inform the affordability analysis; and Supporting data and assumptions used in the modelling.
The information presented below, as well as the modelling approach and subsequent outputs have been led by North Staffordshire and Stoke-on-Trent CCGs and Midlands Partnership NHS Foundation Trust (MPFT).
1.2 Modelling approach
1.2.1 Overall approach
The diagram below shows the approach for modelling the activity (20 year bed profile) and the finance outputs.
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1.3 Activity modelling approach
1.3.1 132 bed baseline
For the 132 bed baseline, the assumptions and methodology used in the CCGs’ original modelling were used, as shown below.
For this model, most of the original assumptions are consistent between Year 0 (2017/18) and Year 5 (2022/23) except target utilisation, which reduces from 95% in 2017/18 to 92% for 2018/19 onwards.
For sensitivity analysis, two other bed baselines were generated: 126 beds and 136 beds.
126 beds baseline – two assumptions changed:
o Reduced average length of stay for rehabilitation and assessment beds from 28 days to 27 days; and
o Reduced average length of stay for EMI beds from 34 days to 30 days.
136 beds baseline – the target utilisation in 2017/18 reduced from 95% to 92%, and again to 89% in 2018/19.
1.3.2 Growth assumptions
The number of beds increase from the initial 132 bed baseline for five years based on demographic, non-demographic and intervention assumptions.
a) Demographic growth
The population for both North Staffordshire and Stoke on Trent CCGs is increasing, creating additional demand for community beds. To analyse the additional demand, ONS population predictions for the two CCGs was used. The main patient cohort to use community beds are older than 70, so only those patients were used for the analysis. Table 1: Demographic growth used in the modelling. (Source: Population projections by single year of age – clinical commissioning groups, 2014 based, Office of National Statistics)
2017 2018 2019 2020 2021 2022 2023
North Staffordshire 33,700 35,300 36,200 37,000 38,100 38,800 39,400 CCG (70+)
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2017 2018 2019 2020 2021 2022 2023
Stoke on Trent CCG 32,100 33,000 33,800 34,700 35,300 35,700 36,200 (70+)
Total 65,800 68,300 70,000 71,700 73,400 74,500 75,600
% change 3.8% 2.5% 2.4% 2.4% 1.5% 1.5%
Some figures are based on different timescales, and needed to be rebased: for example, demographic growth conversion from calendar years to financial years: for 2018/19 demographic growth the 2018 value is used.
Since the original analysis was completed, the ONS data has been refreshed (using 2016 data). With the update, in 2023 the total population for 70+ in the two CCGs was 74,100 as such there is no impact on the modelling outputs.
b) Non-demographic growth
Non-demographic growth comes from increased expectation and demand for healthcare services, changes in disease profile, improved access to care and any other pressures on services which are not accounted for through demographic growth.
As there were no non-demographic growth assumptions specifically available for community services, the CCG’s assumed that GP Referrals from the acute would be an appropriate proxy for this.
Table 2: Demographic growth used in the modelling. (Source: Activity growth Staffordshire STP has been directed to apply by NHSE for 18/19 by point of delivery).
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
GP Referrals 0.8% 0.8% 0.8% 0.8% 0.8% 0.8%
c) Interventions
Interventions from the CCGs have reduced non-elective (NEL) admissions to help to reduce demand for community beds. It has been assumed that for 2018/19 onwards, future NEL interventions will mitigate any demographic growth so the overall impact from demographic growth will be zero. Table 3: Intervention assumptions to reduce demographic growth. NEL admissions in 2017/18 data from Secondary Uses Service (SUS).
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Interventions -6.3% -2.5% -2.4% -2.4% -1.5% -1.5%
d) Overall growth to be used in the modelling
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The estimated demographic growth is added to the non-demographic growth (sources outlined above) and reduced by the interventions to give an overall total for growth which is used in the modelling.
Table 4: Overall growth to be used for modelling the bed requirements.
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Demographic growth 3.8% 2.5% 2.4% 2.4% 1.5% 1.5%
Non-demographic 0.8% 0.8% 0.8% 0.8% 0.8% 0.8% growth
Interventions -6.3% -2.5% -2.4% -2.4% -1.5% -1.5%
Total -1.7% 0.8% 0.8% 0.8% 0.8% 0.8%
The growth is then applied to the 2017/18 baseline figures to calculate the bed requirement for Year 5, 2022/23. This growth results in:
Do Nothing bed requirement increasing from 264 (in 2017/18) to 275 (in 2022/23). For the Do Something options, the 132 beds baseline increases to 138. Do Something initial estimated 132 bed baseline increases to 142 beds in the same timeline.
1.2.3 Timelines
The high level timeline and phasing of options used in the modelling, as defined by the CCGs is presented below. The major activities, where applicable to options, are:
Reopening a second site through refurbishment works and eradicating any moderate and low backlog maintenance; Selling any unused sites (note land receipts are not used in the final calculations though they are included in the sensitivity analysis); and Building any additional beds at the Haywood Hospital.
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April April April April April 2018 2019 2020 2021 2022
Construction Any sites Additional bed Option 1: PCBC FBC begins on new sold capacity at Haywood complete complete wards at assumed Haywood open Only Haywood during 20/21 by summer 2021
Construction Any sites Additional bed Option 2: PCBC FBC Leek reopens begins on new sold capacity at Haywood and complete complete mid FY 19/20 wards at assumed Haywood open Leek Haywood during 20/21 by summer 2021
Construction Any sites Additional bed Option 3: Longton PCBC FBC begins on new sold capacity at Haywood and reopens mid complete complete wards at assumed Haywood open Longton FY 19/20 Haywood during 20/21 by summer 2021
Construction Any sites Additional bed Option 4: Cheadle PCBC FBC begins on new sold capacity at Haywood and reopens mid complete complete wards at assumed Haywood open Cheadle FY 19/20 Haywood during 20/21 by summer 2021
Any sites Option 5: Bradwell PCBC FBC sold Haywood and reopens mid complete complete assumed Bradwell FY 19/20 during 20/21
Any sites Option 6: PCBC FBC sold Haywood and complete complete assumed Care Homes during 20/21 Source: CCGs, MPFT
For the Do Nothing option it was assumed that all sites would reopen halfway through FY 2019/20 with no sites sold or new beds built at Haywood.
For each Do Something option, the following profiles were applied to respective major activities.
Table 5: Table for the profiles for each majority activity for Option 1 Haywood Only.
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Capital Expenditure for 0% 0% 0% 0% 0% 0% reopening any sites* Land Receipt to sell Bradwell, Cheadle, Leek and 0% 0% 0% 100% 0% 0% Longton Capital Expenditure for 0% 0% 8% 70% 22% 0% additional beds at Haywood * for option 1 no sites are reopened. Source: CCGs, MPFT
Table 6: Table for the profiles for each majority activity for Option 2: Haywood and Leek.
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Capital Expenditure for 0% 0% 100% 0% 0% 0% reopening Leek
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2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Land Receipt to sell Bradwell, Cheadle and 0% 0% 0% 100% 0% 0% Longton Capital Expenditure for 0% 0% 8% 70% 22% 0% additional beds at Haywood Source: CCGs, MPFT
Table 7: Table for the profiles for each majority activity for Option 3: Haywood and Longton.
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Capital Expenditure for 0% 0% 100% 0% 0% 0% reopening Longton Land Receipt to sell 0% 0% 0% 100% 0% 0% Bradwell, Cheadle and Leek Capital Expenditure for 0% 0% 8% 70% 22% 0% additional beds at Haywood Source: CCGs, MPFT
Table 8: Table for the profiles for each majority activity for Option 4: Haywood and Cheadle.
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Capital Expenditure for 0% 0% 100% 0% 0% 0% reopening Cheadle Land Receipt to sell 0% 0% 0% 100% 0% 0% Bradwell, Leek and Longton Capital Expenditure for 0% 0% 8% 70% 22% 0% additional beds at Haywood
Table 9: Table for the profiles for each majority activity for Option 5: Haywood and Bradwell.
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Capital Expenditure for 0% 0% 100% 0% 0% 0% reopening Bradwell Land Receipt to sell 0% 0% 0% 100% 0% 0% Cheadle, Leek and Longton Capital Expenditure for 0% 0% 0% 0% 0% 0% additional beds at Haywood Source: CCGs, MPFT
Table 10: Table for the profiles for each majority activity for Option 6: Haywood and Care Homes.
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2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Capital Expenditure for 0% 0% 0% 0% 0% 0% reopening any sites* Land Receipt to sell Bradwell, Cheadle, Leek and 0% 0% 0% 100% 0% 0% Longton Capital Expenditure for 0% 0% 0% 0% 0% 0% additional beds at Haywood * for option 6 no sites are reopened. Source: CCGs, MPFT
1.2.4 Bed Configuration for each option
For modelling purposes, the CCG had to define the number of beds by site and financial year across each of the options (including the Do Nothings).
For 2017/18 and 2018/19 the bed configuration options are the same because the MPFT estate assumptions do not begin until 2019/20. For 2017/18 there are 15 beds at Leek as 15 beds was the average number of beds for the financial year: at the start of 2017/18 36 beds were available; this reduced to 18 in August 2017 and became 17 at the time of closure in October 2017.
The tables below show the total number of beds for each option at each site and year taking into account the community beds growth, financial year sites reopen and any additional bed capacity at Haywood. For years 2023/24 onwards the bed configuration is assumed to be the same as 2022/23.
Table 11: 2017/18 – 2022/23 bed configuration by site for the Do Nothing option.
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Bradwell 63 63 63 63 Cheadle 48 48 48 48 Haywood (AIR) 77 77 77 77 77 77 Leek 15 36 36 36 36 Longton 40 40 40 40 Care Homes 63 77 4 6 9 11 Total Beds 155 154 268 270 273 275 Number of beds required 264 266 268 270 273 275 Difference to requirement -109 -112 0 0 0 0 Source: Number of beds CCG, timings
Table 12: 2017/18 – 2022/23 bed configuration by site for Option 1: Haywood Only.
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Bradwell Cheadle
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Haywood (AIR) 77 77 77 77 142 142 Leek 15 Longton Care Homes 63 77 58 59 Total Beds 155 154 135 136 142 142 Number of beds required 132 137 138 139 141 142 Difference to requirement 23 17 -3 -3 1 0
Table 13: 2017/18 – 2022/23 bed configuration by site for Option 2: Haywood and Leek.
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Bradwell Cheadle Haywood (AIR) 77 77 77 77 107 107 Leek 15 36 36 36 36 Longton Care Homes 63 77 23 23 Total Beds 155 154 136 136 143 143 Number of beds required 132 137 138 139 141 142 Difference to requirement 23 17 -2 -3 2 1
Table 14: 2017/18 – 2022/23 bed configuration by site for Option 3: Haywood and Longton.
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Bradwell Cheadle Haywood (AIR) 77 77 77 77 102 102 Leek 15 Longton 40 40 40 40 Care Homes 63 77 19 19 Total Beds 155 154 136 136 142 142 Number of beds required 132 137 138 139 141 142 Difference to requirement 23 17 -2 -3 1 0
Table 15: 2017/18 – 2022/23 bed configuration by site for Option 4: Haywood and Cheadle.
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Bradwell Cheadle 48 48 45 45 Haywood (AIR) 77 77 77 77 97 97
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Leek 15 Longton Care Homes 63 77 11 11 Total Beds 155 154 136 136 142 142 Number of beds required 132 137 138 139 141 142 Difference to requirement 23 17 1 0 1 0
Table 16: 2017/18 – 2022/23 bed configuration by site for Option 5: Haywood and Bradwell.
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Bradwell 61 61 63 63 Cheadle Haywood (AIR) 77 77 77 77 77 77 Leek 15 Longton Care Homes 63 77 Total Beds 155 154 138 138 140 140 Number of beds required 132 137 138 139 141 142 Difference to requirement 23 17 3 -1 -1 -2
Table 17: 2017/18 – 2022/23 bed configuration by site for Option 6: Haywood and Care Homes.
2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Bradwell Cheadle Haywood (AIR) 77 77 77 77 77 77 Leek 15 Longton Care Homes 63 77 61 62 65 65 Total Beds 155 154 138 139 142 142 Number of beds required 132 137 138 139 141 142 Difference to requirement 23 20 0 0 1 0
1.4 Finance modelling approach
Total finance costs are made up of recurrent and non-recurrent (capital expenditure) costs.
1.4.1 2017/18 baseline recurrent costs
To calculate the baseline costs the following cost categories were used:
Direct – Staff and general medical and surgical equipment;
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Indirect – Transport, catering, portering, indirect hospital support etc.; Estates – deprecation, cost of capital, other; Corporate – medical directorate, finance, corporate workforce etc.; Additional Haywood costs – Indirect P2P, Other Corporate Support services, Indirect Admin etc.
The data used in the modelling relating to these cost types was provided by MPFT for the year 2016/17, a 1% inflation assumption was applied to convert to 2017/18 prices.
The direct costs were calculated by using Jackfield as a proxy at £61,600 per bed per year (data provided by MPFT). The Jackfield ward was chosen based on MPFT’s assumption that if another site was reopened, it would follow the Jackfield’s workforce model.
Table 18: Total recurrent costs for each site if they were open in 2017/18, MPFT data.
Haywood Cost per bed Bradwell Cheadle Leek Longton Total (AIR)
Number of beds 63 48 77 36 40 264
Total 17/18 Direct Costs £3,881,812 £2,957,571 £4,744,437 £2,218,178 £2,464,643 £16,266,641
Total 17/18 Indirect Costs £1,575,299 £791,036 £2,105,932 £1,103,751 £944,241 £6,520,259
Total 17/18 Estate Costs £368,392 £220,029 £1,314,793 £166,022 £323,721 £2,392,957
Total 17/18 Corporate £241,643 £182,596 £933,474.48 £583,889 £221,845 £2,163,448 Costs
Total 17/18 Costs £6,067,146 £4,151,233 £9,098,636 £4,071,840 £3,954,450 £27,343,305
17/18 cost per bed £96,304 £86,484 £118,164 £113,107 £98,861 £103,573
17/18 cost per bed per day £264 £237 £324 £310 £271 £284
Corporate Overheads % by 4% 4% 10% 14% 6% site For future years it is assumed that corporate overheads are a site specific percentage of the total direct, indirect and estate costs.
1.4.2 Recurrent cost growth
Two main factors grow the recurrent costs per year: inflation and cost elasticity to activity.
a) Inflation
The costs are categorised and inflated each year by the 2017/18 and 2018/19 National Tariff Payment System produced by NHS England and NHS Improvement as shown in the table below. Figures beyond 2018/19 are assumed to be the same as 2018/19.
Table 19: Inflation for each category between 2018/19 and 2022/23 (Source: National Tariff Payment System, NHSE and NHSI). Page 133 of 287
Cost Category 2018/19 2019/20 2020/21 2021/22 2022/23
Pay 2.1% 2.1% 2.1% 2.1% 2.1% Drugs 2.1% 2.1% 2.1% 2.1% 2.1% Non Pay 2.1% 2.1% 2.1% 2.1% 2.1% Other Operating Costs 2.1% 2.1% 2.1% 2.1% 2.1% Capital Expenditure 2.9% 2.9% 2.9% 2.9% 2.9% Corporate Overheads* 0.0% 0.0% 0.0% 0.0% 0.0% *Corporate Overheads are not inflated but are an allocation added to each site as shown in Table 18.
b) Cost Elasticity
Cost elasticity assumptions are included in the modelling to account for varying profiles of cost – activity changes. For example, semi-fixed costs (which have a 70% cost elasticity) would increase by 7% relating to a 10% increase in activity, whereas variable costs (with an elasticity of 100%) would increase by 10%.
Table 20: Cost elasticity for each category (source CCGs and MPFT).
Cost Elasticity Category Cost Elasticity
Fixed 0% Semi-fixed* 70% Variable 100% Corporate Overheads 0% *For semi-fixed 70% was chosen as it was cross-referenced with other business cases e.g. Shaping a Healthier future NWL PCBC and West North East Cumbria PCBC.
c) Allocation
The final step to grow the costs is to allocate the inflation and cost elasticity categories to each cost line as shown in the tables below.
Table 21: Inflation and cost elasticity categories allocated to each direct cost line.
Direct Cost Sub Category Subjective Description Inflation Cost Elasticity to Activity
Pay Nurse band 6 Pay Semi-fixed Pay Nurse band 2 Pay Semi-fixed Pay Agency Nursing: Band 2 Pay Semi-fixed Pay Nurse band 7 Pay Semi-fixed Pay Nurse band 5 Pay Semi-fixed Pay Admin & Clerical band 2 Pay Semi-fixed Bank Helthcr Assistnt Pay Pay Semi-fixed Spclng Pay Ancillary band 2 Pay Semi-fixed Non Pay Drugs Drugs Variable Non Pay Med & Surg Equip General Non Pay Variable
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Non Pay Staff Uniforms & Clothing Non Pay Variable Non Pay Protective Clothing Non Pay Variable Non Pay Printing Costs Non Pay Variable Non Pay Stationery Non Pay Variable Non Pay Mobile Phones Non Pay Variable Table 22: Inflation and cost elasticity categories allocated to each indirect cost line.
Site Specific Inflation Cost Elasticity to Activity
Transport Other Operating Costs Semi-fixed Outpatients Other Operating Costs Semi-fixed Catering Other Operating Costs Semi-fixed Domestics Other Operating Costs Semi-fixed Laundry Other Operating Costs Semi-fixed Portering Other Operating Costs Semi-fixed Chaplaincy Other Operating Costs Semi-fixed Baclofen Other Operating Costs Semi-fixed Hairdressing Other Operating Costs Semi-fixed Laundry Other Operating Costs Semi-fixed Chaplaincy Other Operating Costs Semi-fixed CLRN Other Operating Costs Semi-fixed
Community Hospital Specific Inflation Cost Elasticity to Activity
Patient Flow Team Other Operating Costs Semi-fixed Community Hospitals CCMT Other Operating Costs Semi-fixed Hospitals Airs Medics Other Operating Costs Semi-fixed Complex Assesment Team Other Operating Costs Semi-fixed Hospitals Management Team Other Operating Costs Semi-fixed Administration Other Operating Costs Semi-fixed Specialised Management Team Other Operating Costs Semi-fixed Haywood AIRS Admin Other Operating Costs Semi-fixed Haywood Central Functions Other Operating Costs Semi-fixed Infection control Other Operating Costs Semi-fixed
Community In-Reach Inflation Cost Elasticity to Activity
Dietetics Other Operating Costs Semi-fixed Continence Other Operating Costs Semi-fixed End of Life / Palliative Care Other Operating Costs Semi-fixed Tissue Viability Other Operating Costs Semi-fixed Podiatry Other Operating Costs Semi-fixed Adult SALT Other Operating Costs Semi-fixed
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Haywood and Leek Indirect Costs Inflation Cost Elasticity to Activity
INDIRECT 1: Indirect Admin Other Operating Costs Semi-fixed INDIRECT 2: Indirect Hospital Other Operating Costs Semi-fixed Support INDIRECT 3: Indirect Other Other Operating Costs Semi-fixed INDIRECT 4: Indirect P2P Other Operating Costs Semi-fixed INDIRECT 5: Indirect Pharmacy Other Operating Costs Semi-fixed INDIRECT 6: Indirect CIP Other Operating Costs Semi-fixed
Table 23: Inflation and cost elasticity categories allocated to each estate cost line.
Estate Costs Inflation Cost Elasticity to Activity
CORPORATE 3: Corporate Capital Other Operating Costs Semi-fixed (Depreciation) CORPORATE 3: Corporate Capital Other Operating Costs Semi-fixed (Cost Of Capital) CORPORATE 4: Corporate F&E - PFI Other Operating Costs Semi-fixed CORPORATE 4: Corporate F&E - LIFT Other Operating Costs Semi-fixed CORPORATE 4: Corporate F&E - Other Operating Costs Semi-fixed Other
d) Recurrent Cost growth for each option
For each site the 2017/18 costs provided by MPFT are then grown by the inflation and cost elasticity assumptions as agreed by MPFT.
Table 24: Annual recurrent costs between 2017/18 – 2022/23 for each site for the Do Nothing Option
Source: MPFT for 2017/18 costs and growth assumptions for years 2018/19 – 2022/23 Bradwell 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £0 £0 £4,093,157 £4,203,109 £4,316,015 £4,431,955 Indirect Costs £0 £0 £1,660,600 £1,704,967 £1,750,520 £1,797,290 Estate Costs £0 £0 £388,340 £398,716 £409,368 £420,306 Total (excluding £0 £0 £6,142,097 £6,306,791 £6,475,903 £6,649,550 Corporate) Corporate £0 £0 £244,628 £251,188 £257,923 £264,839 Overheads (4.0%) Total Bradwell £0 £0 £6,386,726 £6,557,979 £6,733,826 £6,914,390 Recurrent Costs
Cheadle 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £0 £0 £3,118,596 £3,202,368 £3,288,392 £3,376,728
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Indirect Costs £0 £0 £833,870 £856,149 £879,023 £902,509 Estate Costs £0 £0 £231,944 £238,141 £244,503 £251,036 Total (excluding £0 £0 £4,184,410 £4,296,658 £4,411,919 £4,530,273 Corporate) Corporate £0 £0 £184,055 £188,993 £194,062 £199,268 Overheads (4.4%) Total Cheadle £0 £0 £4,368,465 £4,485,651 £4,605,981 £4,729,541 Recurrent Costs
Haywood (AIR) 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £4,744,437 £4,871,880 £5,002,748 £5,137,133 £5,275,129 £5,416,834 Indirect Costs £2,089,826 £2,145,661 £2,202,988 £2,261,847 £2,322,278 £2,384,323 Estate Costs £1,302,029 £1,336,816 £1,372,533 £1,409,204 £1,446,854 £1,485,511 Total (excluding £8,136,292 £8,354,358 £8,578,269 £8,808,183 £9,044,261 £9,286,668 Corporate) Corporate £834,743 £857,115 £880,087 £903,675 £927,896 £952,766 Overheads (10.3%) Total Haywood (AIR) Recurrent £8,971,035 £9,211,473 £9,458,356 £9,711,859 £9,972,157 £10,239,434 Costs
Leek 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £924,241 £0 £2,338,947 £2,401,776 £2,466,294 £2,532,546 Indirect Costs £1,103,751 £0 £1,163,518 £1,194,604 £1,226,521 £1,259,291 Estate Costs £166,022 £0 £175,011 £179,687 £184,488 £189,417 Total (excluding £2,194,013 £0 £3,677,477 £3,776,068 £3,877,304 £3,981,254 Corporate) Corporate £314,615 £0 £527,339 £541,476 £555,993 £570,899 Overheads (14.3%) Total Leek Recurrent £2,508,628 £0 £4,204,815 £4,317,544 £4,433,297 £4,552,153 Costs
Longton 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £0 £0 £2,598,830 £2,668,640 £2,740,327 £2,813,940 Indirect Costs £0 £0 £995,371 £1,021,965 £1,049,269 £1,077,303 Estate Costs £0 £0 £341,250 £350,367 £359,728 £369,339 Total (excluding £0 £0 £3,935,451 £4,040,972 £4,149,324 £4,260,582 Corporate) Corporate £0 £0 £220,779 £226,699 £232,778 £239,019 Overheads (5.6%) Total Longton £0 £0 £4,156,230 £4,267,671 £4,382,102 £4,499,602 Recurrent Costs
Do Nothing 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Recurrent Costs £11,479,663 £9,211,473 £28,574,592 £29,340,704 £30,127,363 £30,935,120
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Table 25: Annual recurrent costs between 2017/18 – 2022/23 for each site for Option 1
Source: MPFT for 2017/18 costs and growth assumptions for years 2018/19 – 2022/23 Haywood (AIR) 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £4,744,437 £4,871,880 £5,002,748 £5,137,133 £9,728,160 £9,989,486 Indirect Costs £2,089,826 £2,145,661 £2,202,988 £2,261,847 £2,322,278 £2,384,323 Estate Costs £1,302,029 £1,336,816 £1,372,533 £1,409,204 £1,446,854 £1,485,511 Total (excluding £8,136,292 £8,354,358 £8,578,269 £8,808,183 £13,497,292 £13,859,321 Corporate) Corporate Overheads £834,743 £857,115 £880,087 £903,675 £1,384,755 £1,421,897 (10.3%) Total Haywood (AIR) Recurrent £8,971,035 £9,211,473 £9,458,356 £9,711,859 £14,882,047 £15,281,217 Costs
Leek 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £924,241 £0 £0 £0 £0 £0 Indirect Costs £1,103,751 £0 £0 £0 £0 £0 Estate Costs £166,022 £0 £0 £0 £0 £0 Total (excluding £2,194,013 £0 £0 £0 £0 £0 Corporate) Corporate Overheads £314,615 £0 £0 £0 £0 £0 (14.3%) Total Leek £2,508,628 £0 £0 £0 £0 £0 Recurrent Costs
Option 1 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Recurrent Costs £11,479,663 £9,211,473 £9,458,356 £9,711,859 £14,882,047 £15,281,217
Table 26: Annual recurrent costs between 2017/18 – 2022/23 for each site for Option 2
Source: MPFT for 2017/18 costs and growth assumptions for years 2018/19 – 2022/23 Haywood (AIR) 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £4,744,437 £4,871,880 £5,002,748 £5,137,133 £7,330,374 £7,527,289 Indirect Costs £2,089,826 £2,145,661 £2,202,988 £2,261,847 £2,322,278 £2,384,323 Estate Costs £1,302,029 £1,336,816 £1,372,533 £1,409,204 £1,446,854 £1,485,511 Total (excluding £8,136,292 £8,354,358 £8,578,269 £8,808,183 £11,099,506 £11,397,123 Corporate) Corporate Overheads £834,743 £857,115 £880,087 £903,675 £1,138,754 £1,169,288 (10.3%) Page 138 of 287
Total Haywood (AIR) Recurrent £8,971,035 £9,211,473 £9,458,356 £9,711,859 £12,238,260 £12,566,411 Costs
Leek 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £924,241 £0 £2,338,947 £2,401,776 £2,466,294 £2,532,546 Indirect Costs £1,103,751 £0 £1,163,518 £1,194,604 £1,226,521 £1,259,291 Estate Costs £166,022 £0 £175,011 £179,687 £184,488 £189,417 Total (excluding £2,194,013 £0 £3,677,477 £3,776,068 £3,877,304 £3,981,254 Corporate) Corporate Overheads £314,615 £0 £527,339 £541,476 £555,993 £570,899 (14.3%) Total Leek £2,508,628 £0 £4,204,815 £4,317,544 £4,433,297 £4,552,153 Recurrent Costs
Option 2 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Recurrent Costs £11,479,663 £9,211,473 £13,663,171 £14,029,403 £16,671,557 £17,118,564
Table 27: Annual recurrent costs between 2017/18 – 2022/23 for each site for Option 3
Source: MPFT for 2017/18 costs and growth assumptions for years 2018/19 – 2022/23 Haywood (AIR) 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £4,744,437 £4,871,880 £5,002,748 £5,137,133 £6,987,833 £7,175,547 Indirect Costs £2,089,826 £2,145,661 £2,202,988 £2,261,847 £2,322,278 £2,384,323 Estate Costs £1,302,029 £1,336,816 £1,372,533 £1,409,204 £1,446,854 £1,485,511 Total (excluding £8,136,292 £8,354,358 £8,578,269 £8,808,183 £10,756,965 £11,045,381 Corporate) Corporate £834,743 £857,115 £880,087 £903,675 £1,103,611 £1,133,201 Overheads (10.3%) Total Haywood (AIR) Recurrent £8,971,035 £9,211,473 £9,458,356 £9,711,859 £11,860,576 £12,178,581 Costs
Leek 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £924,241 £0 £0 £0 £0 £0 Indirect Costs £1,103,751 £0 £0 £0 £0 £0 Estate Costs £166,022 £0 £0 £0 £0 £0 Total (excluding £2,194,013 £0 £0 £0 £0 £0 Corporate) Corporate £314,615 £0 £0 £0 £0 £0 Overheads (14.3%) Total Leek Recurrent £2,508,628 £0 £0 £0 £0 £0 Costs
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Longton 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £0 £0 £2,598,830 £2,668,640 £2,740,327 £2,813,940 Indirect Costs £0 £0 £995,371 £1,021,965 £1,049,269 £1,077,303 Estate Costs £0 £0 £341,250 £350,367 £359,728 £369,339 Total (excluding £0 £0 £3,935,451 £4,040,972 £4,149,324 £4,260,582 Corporate) Corporate £0 £0 £220,779 £226,699 £232,778 £239,019 Overheads (5.6%) Total Longton £0 £0 £4,156,230 £4,267,671 £4,382,102 £4,499,602 Recurrent Costs
Option 3 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Recurrent Costs £11,479,663 £9,211,473 £13,614,586 £13,979,530 £16,242,678 £16,678,183
Table 28: Annual recurrent costs between 2017/18 – 2022/23 for each site for Option 4
Source: MPFT for 2017/18 costs and growth assumptions for years 2018/19 – 2022/23 Cheadle 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £0 £0 £3,118,596 £3,202,368 £3,082,868 £3,165,682 Indirect Costs £0 £0 £833,870 £856,149 £879,023 £902,509 Estate Costs £0 £0 £231,944 £238,141 £244,503 £251,036 Total (excluding £0 £0 £4,184,410 £4,296,658 £4,206,394 £4,319,227 Corporate) Corporate £0 £0 £184,055 £188,993 £185,022 £189,985 Overheads (4.4%) Total Cheadle £0 £0 £4,368,465 £4,485,651 £4,391,417 £4,509,212 Recurrent Costs
Haywood (AIR) 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £4,744,437 £4,871,880 £5,002,748 £5,137,133 £6,645,293 £6,823,804 Indirect Costs £2,089,826 £2,145,661 £2,202,988 £2,261,847 £2,322,278 £2,384,323 Estate Costs £1,302,029 £1,336,816 £1,372,533 £1,409,204 £1,446,854 £1,485,511 Total (excluding £8,136,292 £8,354,358 £8,578,269 £8,808,183 £10,414,425 £10,693,638 Corporate) Corporate £834,743 £857,115 £880,087 £903,675 £1,068,468 £1,097,114 Overheads (10.3%) Total Haywood (AIR) Recurrent £8,971,035 £9,211,473 £9,458,356 £9,711,859 £11,482,892 £11,790,752 Costs
Leek 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £924,241 £0 £0 £0 £0 £0 Indirect Costs £1,103,751 £0 £0 £0 £0 £0
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Estate Costs £166,022 £0 £0 £0 £0 £0 Total (excluding £2,194,013 £0 £0 £0 £0 £0 Corporate) Corporate £314,615 £0 £0 £0 £0 £0 Overheads (14.3%) Total Leek Recurrent £2,508,628 £0 £0 £0 £0 £0 Costs
Option 4 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Recurrent Costs £11,479,663 £9,211,473 £13,826,822 £14,197,510 £15,874,309 £16,299,964
Table 29: Annual recurrent costs between 2017/18 – 2022/23 for each site for Option 5
Source: MPFT for 2017/18 costs and growth assumptions for years 2018/19 – 2022/23 Bradwell 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £0 £0 £3,963,216 £4,069,677 £4,316,015 £4,431,955 Indirect Costs £0 £0 £1,660,600 £1,704,967 £1,750,520 £1,797,290 Estate Costs £0 £0 £388,340 £398,716 £409,368 £420,306 Total (excluding £0 £0 £6,012,156 £6,173,359 £6,475,903 £6,649,550 Corporate) Corporate £0 £0 £239,453 £245,873 £257,923 £264,839 Overheads (4.0%) Total Bradwell £0 £0 £6,251,609 £6,419,233 £6,733,826 £6,914,390 Recurrent Costs
Haywood (AIR) 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £4,744,437 £4,871,880 £5,002,748 £5,137,133 £5,275,129 £5,416,834 Indirect Costs £2,089,826 £2,145,661 £2,202,988 £2,261,847 £2,322,278 £2,384,323 Estate Costs £1,302,029 £1,336,816 £1,372,533 £1,409,204 £1,446,854 £1,485,511 Total (excluding £8,136,292 £8,354,358 £8,578,269 £8,808,183 £9,044,261 £9,286,668 Corporate) Corporate £834,743 £857,115 £880,087 £903,675 £927,896 £952,766 Overheads (10.3%) Total Haywood (AIR) Recurrent £8,971,035 £9,211,473 £9,458,356 £9,711,859 £9,972,157 £10,239,434 Costs
Leek 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £924,241 £0 £0 £0 £0 £0 Indirect Costs £1,103,751 £0 £0 £0 £0 £0 Estate Costs £166,022 £0 £0 £0 £0 £0 Total (excluding £2,194,013 £0 £0 £0 £0 £0 Corporate) Corporate £314,615 £0 £0 £0 £0 £0 Overheads (14.3%)
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Total Leek Recurrent £2,508,628 £0 £0 £0 £0 £0 Costs
Option 5 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Recurrent Costs £11,479,663 £9,211,473 £15,709,965 £16,131,091 £16,705,983 £17,153,824
Table 30: Annual recurrent costs between 2017/18 – 2022/23 for each site for Option 6
Source: MPFT for 2017/18 costs and growth assumptions for years 2018/19 – 2022/23 Haywood (AIR) 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £4,744,437 £4,871,880 £5,002,748 £5,137,133 £5,275,129 £5,416,834 Indirect Costs £2,089,826 £2,145,661 £2,202,988 £2,261,847 £2,322,278 £2,384,323 Estate Costs £1,302,029 £1,336,816 £1,372,533 £1,409,204 £1,446,854 £1,485,511 Total (excluding £8,136,292 £8,354,358 £8,578,269 £8,808,183 £9,044,261 £9,286,668 Corporate) Corporate £834,743 £857,115 £880,087 £903,675 £927,896 £952,766 Overheads (10.3%) Total Haywood (AIR) Recurrent £8,971,035 £9,211,473 £9,458,356 £9,711,859 £9,972,157 £10,239,434 Costs
Leek 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Direct Costs £924,241 £0 £0 £0 £0 £0 Indirect Costs £1,103,751 £0 £0 £0 £0 £0 Estate Costs £166,022 £0 £0 £0 £0 £0 Total (excluding £2,194,013 £0 £0 £0 £0 £0 Corporate) Corporate £314,615 £0 £0 £0 £0 £0 Overheads (14.3%) Total Leek Recurrent £2,508,628 £0 £0 £0 £0 £0 Costs
Option 6 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Recurrent Costs £11,479,663 £9,211,473 £9,458,356 £9,711,859 £9,972,157 £10,239,434
1.4.3 Capital Expenditure to reopen sites
Table 31: Required capital expenditure to reopen each site
Eradicate moderate Additional work Total Capital Option number for Site and low risk backlog required to reopen Expenditure to site reopens maintenance site reopen each site
Bradwell Option 5 £1,431,000 £100,000 £1,531,000
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Cheadle Option 4 £1,130,000 £500,000 £1,630,000
Leek Option 2 £797,500 £2,202,500 £3,000,000
Longton Option 3 £100,000 £500,000 £600,000
Source: ERIC, for ‘additional work’ column i.e. MPFT…
Bradwell has the largest backlog maintenance to eradicate of all four sites; however, the site needs the least amount of work to reopen as only known derogations require fixing.
Cheadle has a smaller backlog maintenance compared with Bradwell but it is still second highest out of all four sites and requires £0.5m to improve the lift, kitchen and other works.
Leek requires the largest capital expenditure to reopen the site (£3m) and make it clinically safe. It is unviable in its current state, the physical condition and statutory compliance is the poorest out of all sites. On space utilisation it is the worst site. In functional suitability Leek Moorlands is significantly failing, there are flow difficulties with very narrow corridors forced on the layout by the old buildings. Wards have wooden floors and there is a high degree of dislocation of ward spaces. Ward design is very old fashioned and does not follow current infection control best practice.
For Longton the combined expenditure is the lowest, with fire escapes and other remedial work required before the site can reopen.
1.4.4 Capital Expenditure to increase bed capacity
For capital spend to increase capacity, costs were generated from discussions with the Quantity Surveying and Project Management consultancy and based on the Building Cost Information Service (BCIS) indices. The costs are middle range based on the best descriptor within the BCIS indices for the proposed development. It has been assumed that any capital expenditure to increase the number of beds is located at Haywood.
Table 32: Breakdown of the capital expenditure per m2 to increase bed capacity
Capital expenditure / Cost Category Description % m2 The current quartile price for build cost is Build Cost £3,000/m2, however, due to the PFI the build cost - £3,900 is 30% higher: £3,900/m2.
Externals % of the build cost 10% £390
Design fees % of the build cost and externals 12% £515
Furniture and % of the build cost and externals 15% £644 Equipment
IT % of the build cost and externals 5% £215
Total capital expenditure before contingency and VAT £5,663
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% on the total capital spend before contingency Contingency 5% £283 and VAT
Total capital expenditure before VAT £5,946
VAT % on the total capital spend before VAT 20% £1,189
Total capital expenditure / m2 £7,135
It is assumed that a 20 bed ward would require 1,100m2 floor area (MFPT data). It is assumed that if more than 20 beds are needed, these would increase by five beds at a time.
The tables below show the breakdown of the required capital expenditure to increase bed capacity at Haywood for the relevant options (options 5 and 6 do not require additional bed capacity at Haywood as there is sufficient capacity at Bradwell and Care Homes respectively).
Table 33: Breakdown of the build costs for additional beds at Haywood for each option
Option 1: Option 2: Option 3: Option 4: Option 5: Option 6: Haywood Haywood and Haywood and Haywood and Haywood and Haywood and Only Leek Longton Cheadle Bradwell Care Homes Number of beds required at 142 107 102 97 77 77 Haywood for 2022/23 Current capacity at Haywood 77 77 77 77 77 77
Additional beds required 65 30 25 20 0 0 Size required (m2): 1,100m2 3,575 1,650 1,375 1,100 - - per 20 bed ward Current quartile £3,900 £13,942,000 £6,435,000 £5,362,500 £4,290,000 - - build cost Externals 10% £1,394,250 £643,500 £536,250 £429,000 - - Design fees (on 12% £1,840,410 £849,420 £707,850 £566,280 - - above) Furniture and Equipment (on build 15% £2,300,513 £1,061,775 £884,813 £707,850 - - costs) IT (on build costs) 5% £766,838 £353,925 £294,938 £235,950 - - Total (before Contingency and £20,244,510 £9,343,620 £7,786,350 £6,229,080 - - VAT) Contingency 5% £1,012,226 £467,181 £389,318 £311,454 - -
Total (excluding VAT) £21,256,736 £9,810,801 £8,175,668 £6,540,534 - -
VAT 20% £4,251,347 £1,962,160 £1,635,134 £1,308,107 - -
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Total including VAT £25,508,083 £11,772,961 £9,810,801 £7,848,641 - -
1.4.5 Depreciation and Capital Charges
For the five year total expenditure analysis the impact of capital costs are included in the form of depreciation and capital charges, as opposed to recognising total expenditure as it is incurred (in line with agreed accounting policies).
a) Depreciation
For all capital expenditure the assumption provided by MPFT Finance is straight line depreciation for 25 years. This aligns with the useful life for buildings where the minimum is 21 years and maximum is 85 years16.
Each instance of in year spend is depreciated over a 25 year period, as shown in the Option 1 new beds at Haywood.
Table 34: In year capital spend for building new beds at Haywood in Option 1
Total in year 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Total spend
Option 1 £0 £0 £2,040,647 £17,855,658 £5,611,778 £0 £25,508,083
Table 35: Depreciated values for in year capital spend for building new beds at Haywood in Option 1
Depreciated value Overall in year Start Date In year value Finish Year over 25 years depreciation
2017/18 £0 £0 2042/43 £0
2018/19 £0 £0 2043/44 £0
2019/20 £2,040,647 £81,626 2044/45 £81,626
2020/21 £17,855,658 £714,226 2045/46 £795,852
2021/22 £5,611,778 £224,471 2046/47 £1,020,323
2022/23 £0 £0 2047/48 £1,020,323
Total £25,508,083 £1,020,323
b) Capital Charges
Capital Charges have also been applied to any capital expenditure incurred.
16 Note 18 Revaluations of property, plant and equipment, p84, Staffordshire and Stoke on Trent 2017/18 Annual Report Page 145 of 287
To calculate the in year capital charges:
capital spend within each period has been added to the annual opening balance of assets relevant depreciation for the year has been subtracted to give an annual closing balance for net assets. A capital charge of 3.5%17 has been applied to the average of the opening and closing balances.
Table 36: Calculating Capital Spend for building new beds at Haywood in Option 1
Category 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23
Opening £0 £0 £0 £1,959,021 £19,018,826 £23,610,281 Balance In year £0 £0 £2,040,647 £17,855,653 £5,611,778 £0 additions Minus £0 £0 -£81,626 -£795,852 -£1,020,323 -£1,020,323 depreciation Closing £0 £0 £1,959,021 £19,018,826 £23,610,281 £22,589,958 Balance Capital Charge @ £0 £0 £34,283 £367,112 £746,009 £808,504 3.5% The capital charges are then added to the annual total expenditure as shown in section 1.5.1.
1.5 Affordability evaluation
There are three core metrics used for the affordability evaluation: five year total expenditure, Capital expenditure and Net Present Value.
1.5.1 Five year total expenditure
The total expenditure over the five year period (2018/19 – 2022/23) is estimated to understand the relative increase in expenditure for the system across the options. The total expenditure is comprised of three cost components:
Total recurrent costs at each site, which includes direct cost per bed, indirect costs, estates costs and corporate costs;
Total capital expenditure required (reopen sites, eradicate moderate to low backlog maintenance and increase number of community beds at Haywood), has been depreciated. The depreciation and capital charges are included; and
Care Homes bed costs, which are the recurrent costs to run each care home bed and does not include any winter escalation or Brighton House.
Table 37: Five year total expenditure and annual expenditure for 2018/19 – 2022/23 for Do Nothing
Total Costs Cost Category 2018/19 2019/20 2020/21 2021/22 2022/23 between
17 HM Treasury Green Book Page 146 of 287
2018/19 and 2022/23 Total Recurrent £128,189,253 £9,211,473 £28,574,593 £29,340,705 £30,127,363 £30,935,119 Costs Total Capital Expenditure £1,081,760 £0 £270,440 £270,440 £270,440 £270,440 Required Capital Land Receipts £0 £0 £0 £0 £0 £0 received
Capital Charge £752,499 £0 £113,585 £222,437 £212,972 £203,506
Care Homes £6,109,995 £4,215,519 £229,937 £362,151 £570,388 £731,999 Beds Costs
Total Net Costs £136,133,507 £13,426,992 £29,188,555 £30,195,733 £31,181,163 £32,141,064
Table 38: Five year total expenditure and annual expenditure for 2018/19 – 2022/23 for Option 1
Total Costs between Cost Category 2018/19 2019/20 2020/21 2021/22 2022/23 2018/19 and 2022/23 Total Recurrent £58,544,952 £9,211,473 £9,458,356 £9,711,859 £14,882,047 £15,281,217 Costs Total Capital Expenditure £2,918,125 £0 £81,626 £795,852 £1,020,323 £1,020,323 Required Capital Land Receipts £0 £0 £0 £0 £0 £0 received Capital Charge £1,955,909 £0 £34,283 £367,112 £746,009 £808,504
Care Homes £11,110,767 £4,215,519 £3,334,092 £3,561,155 £0 £0 Beds Costs
Total Net Costs £74,529,752 £13,426,992 £12,908,357 £14,435,979 £16,648,379 £17,110,045
Table 39: Five year total expenditure and annual expenditure for 2018/19 – 2022/23 for Option 2
Total Costs between Cost Category 2018/19 2019/20 2020/21 2021/22 2022/23 2018/19 and 2022/23 Total Recurrent £70,694,168 £9,211,473 £13,663,171 £14,029,403 £16,671,557 £17,118,564 Costs Total Capital Expenditure £1,826,827 £0 £157,673 £487,316 £590,918 £590,918 Required Page 147 of 287
Capital Land Receipts £0 £0 £0 £0 £0 £0 received Capital Charge £1,236,627 £0 £66,223 £268,136 £438,812 £463,456
Care Homes £6,925,906 £4,215,519 £1,322,140 £1,388,247 £0 £0 Beds Costs
Total Net Costs £80,683,528 £13,426,992 £15,209,208 £16,173,103 £17,701,287 £18,172,939
Table 40: Five year total expenditure and annual expenditure for 2018/19 – 2022/23 for Option 3
Total Costs between Cost Category 2018/19 2019/20 2020/21 2021/22 2022/23 2018/19 and 2022/23 Total Recurrent £69,726,450 £9,211,473 £13,614,586 £13,979,530 £16,242,678 £16,678,183 Costs Total Capital Expenditure £1,218,356 £0 £55,395 £330,097 £416,432 £416,432 Required Capital Land Receipts £0 £0 £0 £0 £0 £0 received Capital Charge £819,053 £0 £23,266 £160,937 £305,827 £329,023
Care Homes £6,454,534 £4,215,519 £1,092,203 £1,146,813 £0 £0 Beds Costs
Total Net Costs £78,218,393 £13,426,992 £14,785,449 £15,617,377 £16,964,937 £17,423,638
Table 41: Five year total expenditure and annual expenditure for 2018/19 – 2022/23 for Option 4
Total Costs between Cost Category 2018/19 2019/20 2020/21 2021/22 2022/23 2018/19 and 2022/23 Total Recurrent £69,410,078 £9,211,473 £13,826,822 £14,197,510 £15,874,309 £16,299,964 Costs Total Capital Expenditure £1,158,685 £0 £90,316 £310,078 £379,146 £379,146 Required Capital Land Receipts £0 £0 £0 £0 £0 £0 received Capital Charge £783,237 £0 £37,933 £166,585 £280,886 £297,834
Care Homes £5,511,791 £4,215,519 £632,328 £663,944 £0 £0 Beds Costs
Total Net Costs £76,863,790 £13,426,992 £14,587,398 £15,338,116 £16,534,341 £16,976,943
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Table 42: Five year total expenditure and annual expenditure for 2018/19 – 2022/23 for Option 5
Total Costs between Cost Category 2018/19 2019/20 2020/21 2021/22 2022/23 2018/19 and 2022/23 Total Recurrent £74,912,336 £9,211,473 £15,709,965 £16,131,091 £16,705,983 £17,153,824 Costs Total Capital Expenditure £244,960 £0 £61,240 £61,240 £61,240 £61,240 Required Capital Land Receipts £0 £0 £0 £0 £0 £0 received Capital Charge £170,400 £0 £25,721 £50,370 £48,227 £46,083
Care Homes £4,215,519 £4,215,519 £0 £0 £0 £0 Beds Costs
Total Net Costs £79,543,215 £13,426,992 £15,796,926 £16,242,701 £16,815,449 £17,261,147
Table 43: Five year total expenditure and annual expenditure for 2018/19 – 2022/23 for Option 6
Total Costs between Cost Category 2018/19 2019/20 2020/21 2021/22 2022/23 2018/19 and 2022/23 Total Recurrent £48,593,279 £9,211,473 £9,458,356 £9,711,859 £9,972,157 £10,239,434 Costs Total Capital Expenditure £0 £0 £0 £0 £0 £0 Required Capital Land Receipts £0 £0 £0 £0 £0 £0 received Capital Charge £0 £0 £0 £0 £0 £0
Care Homes £19,909,214 £4,215,519 £3,506,545 £3,742,231 £4,119,472 £4,325,446 Beds Costs
Total Net Costs £68,502,492 £13,426,992 £12,964,902 £13,454,090 £14,091,629 £14,564,880
Table 44: Output of the five year total expenditure (2018/19 – 2022/23)
Five year total Option 1: Option 2: Option 3: Option 4: Option 5: Option 6: expenditure Do Nothing Haywood Haywood and Haywood and Haywood and Haywood and Haywood and (2018/19 – Only Leek Longton Cheadle Bradwell Care Homes Page 149 of 287
2022/23)
Recurrent Costs at £48,593,279 £58,544,952 £53,186,359 £52,420,845 £51,655,332 £48,593,279 £48,593,279 Haywood Recurrent Costs at Other £79,595,974 £0 £17,507,810 £17,305,605 £17,754,746 £26,319,057 £0 Site(s) Total Capital Expenditure £1,081,760 £2,918,125 £1,826,827 £1,218,356 £1,158,685 £244,960 £0 Required (Depreciated) Capital £752,499 £1,955,909 £1,236,627 £819,053 £783,237 £170,400 £0 Charges
Land receipts £0 £0 £0 £0 £0 £0 £0
Care Homes £6,109,995 £11,110,767 £6,925,906 £6,454,534 £5,511,791 £4,215,519 £19,909,214 Beds Costs Total five year £136,133,507 £74,529,752 £80,683,528 £78,218,393 £76,863,790 £79,543,215 £68,502,492 expenditure Increase in total expenditure compared £67,631,015 £6,027,260 £12,181,036 £9,715,901 £8,361,298 £11,040,723 £0 with top- ranked Option
Rank 7 2 6 4 3 5 1
The total expenditure summed across the five year period has the same rankings as the for the increase in annual expenditure between 2018/19 and 2022/23.
Option 6 has the smallest five year total expenditure. This is driven through:
Care home beds (£1,000 / week / bed) being cheaper than CCG commissioned care beds (c.£2,000 / week / bed);
The consolidation of recurrent costs at one site (hospital site); and
There being no capital requirements (due to the PFI at the Haywood, and any capital expenditure for care home beds already being captured in their running costs).
All options improve on the Do Nothing option. The Do Nothing option ranks the worst across the options, with the largest five year total expenditure. This is driven through the additional capital expenditure estimated to be required to
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reopen all sites, plus the associated recurrent costs compared with the other options which are has recurrent costs from two sites.
1.5.2 Capital Expenditure
Capital expenditure is for any option required to increase bed capacity, eradicate moderate and low risk backlog maintenance and any additional work to reopen the site.
The below table sets out the overall Capital Expenditure values used for the Net Present Value calculations, it represents the overall cost of any additions as opposed to the depreciation and capital charges referenced in the five year total expenditure.
Table 45: Total Capital Expenditure required for each option
Total Capital Option 1: Option 2: Option 3: Option 4: Option 5: Option 6: Expenditure Do Nothing Haywood Haywood and Haywood and Haywood and Haywood and Haywood and for each Only Leek Longton Cheadle Bradwell Care Homes option Number of additional 0 65 30 25 20 0 0 beds required at Haywood Increase number of £0 £25,508,083 £11,772,961 £9,810,801 £7,848,641 £0 £0 beds Reopen site and eradicate £6,761,000 £0 £3,000,000 £600,000 £1,630,000 £1,531,000 £0 backlog maintenance Total Capital £6,761,000 £25,508,083 £14,772,961 £10,410,801 £9,478,641 £1,531,000 £0 Expenditure
Rank 3 7 6 5 4 2 1
Option 6 has no capital requirement as extra bed capacity would be provided by care homes (as opposed to requiring additional beds on the community hospital site). Further, given the PFI and its coverage of backlog, there is no cost with eradicating it for this option.
Option 1 would need an additional 6 5 beds at a cost of £25.5m. This cost is depreciated over 25 years increasing the recurrent cost by £1.0m per year.
For Options 2 to 5, capital expenditure is required to eradicate moderate and low risk backlog maintenance, with the most significant at Leek (given the relative condition of the site as outlined in the case for change). In addition, for options 2 to 4 there are capital costs associated with the increased bed capacity required at Haywood (this does not apply to Option 5 given the Bradwell has sufficient capacity).
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The Do Nothing option is ranked third because the only capital expenditure required is to reopen all the sites. Reopening all the sites requires £1.1m lower capital expenditure than building a 20 bed ward at Haywood.
1.5.3 Net Present Value
The Net Present Value (NPV) allows possible long term investments to be compared against each other by considering the relative time value of money (i.e. supporting understanding the difference between the present value of cash inflows and outflows). This supports an understanding of which Option supports the best level improvement, against the Do Nothing, over a 20 year planning horizon.
In estimating the NPV, recurrent spend for the open sites, care home bed spend and required capital expenditure are accounted for.
Please note only the cash outflows were considered and compared with the Do Nothing option. Depreciation, capital charges and inflation are all removed and the cash outflows are discounted by 3.5% per annum as part of Treasury’s guidance over the 20 years.
The following tables show the Net Present Cost for each option broken down by total recurrent costs, total capital expenditure required, land receipt and care home bed costs.
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Table 46: Net Present Cost breakdown for Do Nothing
Years Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 TOTAL 11 – 20 Cost Category (£m) (£m) 2028/29 - 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2037/38
Total Recurrent Costs -£528.587 -£11.235 -£8.830 -£26.796 -£26.960 -£27.126 -£27.293 -£26.690 -£26.690 -£26.690 -£26.690 -£26.690 -£266.898
Total capital -£6.761 £0.000 £0.000 -£6.761 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 expenditure required Capital land receipts £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 received
Care Home Beds Costs -£17.467 -£3.285 -£4.015 -£0.209 -£0.313 -£0.469 -£0.574 -£0.574 -£0.574 -£0.574 -£0.574 -£0.574 -£5.735
Total Net Costs -£552.815 -£14.520 -£12.845 -£33.766 -£27.273 -£27.595 -£27.866 -£27.263 -£27.263 -£27.263 -£27.263 -£27.263 -£272.633
Discounted Costs for Net -£394.942 -£14.520 -£12.410 -£31.520 -£24.599 -£24.048 -£23.463 -£22.179 -£21.429 -£20.704 -£20.004 -£19.327 -£160.739 Present Cost
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Table 47: Net Present Cost breakdown for Option 1
Years Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 TOTAL 11 – 20 Cost Category (£m) (£m) 2028/29 - 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2037/38
Total Recurrent Costs -£260.398 -£11.235 -£8.830 -£8.892 -£8.954 -£13.535 -£13.625 -£13.022 -£13.022 -£13.022 -£13.022 -£13.022 -£130.218
Total capital -£25.508 £0.000 £0.000 -£2.041 -£17.856 -£5.612 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 expenditure required Capital land receipts £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 received
Care Home Beds Costs -£13.400 -£3.285 -£4.015 -£3.024 -£3.076 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000
Total Net Costs -£299.306 -£14.520 -£12.845 -£13.956 -£29.886 -£19.147 -£13.625 -£13.022 -£13.022 -£13.022 -£13.022 -£13.022 -£130.218
Discounted Costs for Net -£221.348 -£14.520 -£12.410 -£13.028 -£26.955 -£16.685 -£11.472 -£10.593 -£10.235 -£9.889 -£9.554 -£9.231 -£76.774 Present Cost
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Table 48: Net Present Cost breakdown for Option 2
Years Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 TOTAL 11 – 20 Cost Category (£m) (£m) 2028/29 - 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2037/38
Total Recurrent Costs -£295.809 -£11.235 -£8.830 -£12.883 -£12.968 -£15.139 -£15.237 -£14.635 -£14.635 -£14.635 -£14.635 -£14.635 -£146.345
Total capital -£14.773 £0.000 £0.000 -£3.942 -£8.241 -£2.590 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 expenditure required Capital land receipts £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 received
Care Home Beds Costs -£9.698 -£3.285 -£4.015 -£1.199 -£1.199 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000
Total Net Costs -£320.281 -£14.520 -£12.845 -£18.024 -£22.408 -£17.729 -£15.237 -£14.635 -£14.635 -£14.635 -£14.635 -£14.635 -£146.345
Discounted Costs for Net -£234.162 -£14.520 -£12.410 -£16.825 -£20.211 -£15.450 -£12.830 -£11.905 -£11.503 -£11.114 -£10.738 -£10.375 -£86.282 Present Cost
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Table 49: Net Present Cost breakdown for Option 3
Years Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 TOTAL 11 – 20 Cost Category (£m) (£m) 2028/29 - 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2037/38
Total Recurrent Costs -£287.723 -£11.235 -£8.830 -£12.771 -£12.856 -£14.679 -£14.775 -£14.172 -£14.172 -£14.172 -£14.172 -£14.172 -£141.718
Total capital -£10.411 £0.000 £0.000 -£1.385 -£6.868 -£2.158 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 expenditure required Capital land receipts £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 received
Care Home Beds Costs -£9.281 -£3.285 -£4.015 -£0.991 -£0.991 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000
Total Net Costs -£307.415 -£14.520 -£12.845 -£15.147 -£20.714 -£16.837 -£14.775 -£14.172 -£14.172 -£14.172 -£14.172 -£14.172 -£141.718
Discounted Costs for Net -£224.295 -£14.520 -£12.410 -£14.140 -£18.683 -£14.673 -£12.440 -£11.529 -£11.139 -£10.762 -£10.398 -£10.047 -£83.554 Present Cost
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Table 50: Net Present Cost breakdown for Option 4
Years Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 TOTAL 11 – 20 Cost Category (£m) (£m) 2028/29 - 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2037/38
Total Recurrent Costs -£281.921 -£11.235 -£8.830 -£12.953 -£13.039 -£14.318 -£14.412 -£13.809 -£13.809 -£13.809 -£13.809 -£13.809 -£138.089
Total capital -£9.479 £0.000 £0.000 -£2.258 -£5.494 -£1.727 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 expenditure required Capital land receipts £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 received
Care Home Beds Costs -£8.447 -£3.285 -£4.015 -£0.574 -£0.574 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000
Total Net Costs -£299.846 -£14.520 -£12.845 -£15.785 -£19.106 -£16.045 -£14.412 -£13.809 -£13.809 -£13.809 -£13.809 -£13.809 -£138.089
Discounted Costs for Net -£218.925 -£14.520 -£12.410 -£14.735 -£17.233 -£13.982 -£12.134 -£11.234 -£10.854 -£10.487 -£10.132 -£9.789 -£81.414 Present Cost
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Table 51: Net Present Cost breakdown for Option 5
Years Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Cost Category 11 – 20 TOTAL (£m) (£m) 2028/29 - 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2037/38 Total Recurrent -£298.122 -£11.235 -£8.830 -£14.734 -£14.829 -£15.057 -£15.155 -£14.552 -£14.552 -£14.552 -£14.552 -£14.552 -£145.521 Costs Total capital expenditure -£1.531 £0.000 £0.000 -£1.531 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 required Capital land receipts £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 received Care Home -£7.300 -£3.285 -£4.015 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 Beds Costs
Total Net Costs -£306.953 -£14.520 -£12.845 -£16.265 -£14.829 -£15.057 -£15.155 -£14.552 -£14.552 -£14.552 -£14.552 -£14.552 -£145.521
Discounted Costs for Net -£222.487 -£14.520 -£12.410 -£15.183 -£13.375 -£13.121 -£12.760 -£11.838 -£11.438 -£11.051 -£10.677 -£10.316 -£85.796 Present Cost
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Table 52: Net Present Cost breakdown for Option 6
Years Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Cost Category 11 – 20 TOTAL (£m) (£m) 2028/29 - 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2037/38 Total Recurrent -£183.172 -£11.235 -£8.830 -£8.892 -£8.954 -£9.017 -£9.081 -£8.478 -£8.478 -£8.478 -£8.478 -£8.478 -£84.776 Costs Total capital expenditure £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 required Capital land receipts £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 £0.000 received Care Home -£71.328 -£3.285 -£4.015 -£3.181 -£3.233 -£3.389 -£3.389 -£3.389 -£3.389 -£3.389 -£3.389 -£3.389 -£33.891 Beds Costs
Total Net Costs -£254.500 -£14.520 -£12.845 -£12.072 -£12.187 -£12.406 -£12.470 -£11.867 -£11.867 -£11.867 -£11.867 -£11.867 -£118.667
Discounted Costs for Net -£185.578 -£14.520 -£12.410 -£11.269 -£10.992 -£10.811 -£10.499 -£9.654 -£9.327 -£9.012 -£8.707 -£8.413 -£69.964 Present Cost
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Table 53: 20 Year Net Present Value for each option
Five year total Option 1: Option 2: Option 3: Option 4: Option 5: Option 6: expenditure Do Nothing Haywood Haywood and Haywood and Haywood and Haywood and Haywood and (2018/19 – Only Leek Longton Cheadle Bradwell Care Homes 2022/23) Total Recurrent -£528,586,999 -£260,397,547 -£295,809,500 -£287,723,304 -£281,920,662 -£298,121,994 -£183,172,440 Costs Total Capital Expenditure -£6,761,000 -£25,508,083 -£14,772,961 -£10,410,801 -£9,478,641 -£1,531,000 £0 Required Capital Land Receipts £0 £0 £0 £0 £0 £0 £0 received Care Homes -£17,466,900 -£13,399,980 -£9,698,040 -£9,280,920 -£8,446,680 -£7,299,600 -£71,327,520 Beds Costs Total Costs (excluding -£552,814,899 -£299,305,609 -£320,280,501 -£307,415,025 -£299,845,983 -£306,952,594 -£254,499,960 inflation) Discounted Costs for Net -£394,942,126 -£221,348,249 -£234,161,751 -£224,294,869 -£218,924,728 -£222,487,428 -£185,577,532 Present Cost Net Present Value compared to £0 £173,593,877 £160,780,374 £170,647,257 £176,017,397 £172,454,697 £209,364,594 the Do Nothing Option
Rank 7 3 6 5 2 4 1
Similar to the previous affordability analysis strands, Option 6 has the best rank across the options. There is clear gap between Option 6 and the other options; the improvement between Option 6 and Do Nothing is £32.3m higher than the other options – driven by it having the lowest recurrent costs across the options and no additional capital expenditure requirements.
Options 1 – 5 also are favourable to the Do Nothing, though not as highly as Option 6. Option 4 is ranked second for NPV as the additional recurrent costs and capital expenditure to run the two sites is lower than the additional capital expenditure required at The Haywood Only for all the additional community beds.
Finally, Option 2 has the lowest NPV compared to the Do Nothing option due to the second highest recurrent costs and second highest capital expenditure required when discounted.
1.5.4 Affordability Evaluation Summary
Table 54: Totals and ranking for the three core metrics used for the affordability evaluation.
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Five year total Option 1: Option 2: Option 3: Option 4: Option 5: Option 6: expenditure Do Nothing Haywood Haywood and Haywood and Haywood and Haywood and Haywood and (2018/19 – Only Leek Longton Cheadle Bradwell Care Homes 2022/23) Total five year £136,133,507 £74,529,752 £80,683,528 £78,218,393 £76,863,790 £79,543,215 £68,502,492 expenditure
Rank 7 2 6 4 3 5 1
Total Capital £6,761,000 £25,508,083 £14,772,961 £10,410,801 £9,478,641 £1,531,000 £0 Expenditure
Rank 3 7 6 5 4 2 1
Net Present Value compared to £0 £173,593,877 £160,780,374 £170,647,257 £176,017,397 £172,454,697 £209,364,594 the Do Nothing Option
Rank 7 3 6 5 2 4 1
1.5.5 Sensitivity Analysis
The Expert Group identified three areas for sensitivity analysis to be focus on, these area: Weekly care home bed cost and annual cost growth; Receiving land receipts; and Changing the 132 bed baseline to 126 and 136 bed baselines.
a) Weekly care home bed cost and annual cost growth
Originally the weekly cost per care home bed, provided by the CCG, was £750, inflated by the average UK inflation of the last 12 months – 2.8%. These figures were tested with MPFT and it was agreed with MPFT to increase the weekly cost per care home bed to £1,000 (2017/18 prices), inflated by 5% per year. The increase in the cost assumptions were to capture any capital expenditure and the premium added due to small demand.
This was discussed with stakeholders during the technical group meeting and sensitivity analysis was agreed to be performed on the care home bed costs. The care home bed costs are one of the main drivers for Option 6 (Haywood and Care Homes) being top-ranked in every criteria for the affordability analysis.
In this section of the sensitivity analysis two tests were performed on the weekly care home bed cost and annual cost growth to determine the increases required for each assumption so Option 6 is not top-ranked for five year total expenditure and Net Present Value.
The first test is to increase the weekly care home bed cost while keeping the annual cost growth consistent.
Table 55: The increase in care home bed costs needed for Option 6 to not be ranked first for five year total expenditure and Net Present Value criteria
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% increase in weekly cost Current weekly care home New weekly care home Affordability Criteria required for Option 6 not bed cost bed cost to be rank 1
Five year total expenditure £1,000 £1,580 58%
Net Present Value £1,000 £1,766 77%
The test concludes that the weekly care home bed must increase over 50% (and double the original weekly care home bed assumption) before Option 6 is not top-ranked: this improves the robustness of the cost assumption provided by MPFT.
For the second test, the weekly care home cost is kept consistent and the annual cost growth is increased until Option 6 is not top-ranked for the five year total expenditure criteria.
Table 56: The annual increase in care home bed cost needed for Option 6 to not be ranked first for five year total expenditure and Net Present Value criteria
% increase in annual cost Current weekly care home New weekly care home Affordability Criteria growth required for bed annual cost growth bed annual cost growth Option 6 not to be rank 1
Five year total expenditure 5% 18% 260%
Net Present Value N/A as NPV calculations exclude inflation
The outcome of the second test shows the annual cost growth for weekly care home beds would have to triple from the current assumption before Option 6 is not the top-ranked option for five year total expenditure.
Both test shows that large increases in care home cost assumptions are required before Option 6 is not the top-ranked option for affordability.
b) Receiving Land Receipts
For the next sensitivity test, land receipts are now included in the analysis.
The affordability and Net Present Value evaluations assumed that no sites were sold due to moving the community beds as identified in each option.
The value for each site was provided by the Trust, taken from the external valuer’s report as at 31st March 2018.
Table 57: Land values for each site for sensitivity analysis
Bradwell Cheadle Haywood (AIR) Leek Longton
£1,795,000 £715,000 £3,325,000 £1,300,000 £435,000
It is assumed that Haywood is not to be sold in any of the options. The table below shows the sites which would be sold for each option and the land receipt received.
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Table 58: Total expenses between 18/19 and 22/23 which includes land receipts and changes to the options ranking
Total expenses Change to Option between 18/19 original Sites assumed Change Option Rank Description and 22/23 with affordability to be sold in Rank land receipts analysis
Do Nothing Do Nothing £136,133,507 £0 None 7 -
Bradwell, Option 1 Haywood Only £67,296,817 £4,245,000 Cheadle, Leek, 2 - Longton Bradwell, Haywood and Option 2 £74,750,593 £2,945,000 Cheadle, 5 - Leek Longton Haywood and Bradwell, Option 3 £72,560,896 £3,810,000 4 - Longton Cheadle, Leek, Haywood and Bradwell, Leek, Option 4 £71,901,911 £3,530,000 3 - Cheadle Longton Haywood and Cheadle, Leek, Option 5 £76,645,143 £2,450,000 6 - Bradwell Longton Bradwell, Haywood and Option 6 £61,834,311 £4,245,000 Cheadle, Leek, 1 - Care Homes Longton
Including land receipts into the affordability analysis had no impact to the ranking of options for five year total expenditure and Option 6 remains the top-ranked option.
The land receipts were next included in the 20 year Net Present Value analysis.
Table 59: 20 year Net Present Value including land receipts compared with Do Nothing and changes to the options ranking
20 year NPV including land Change to original Change in Option Option Description Rank receipts compared NPV analysis Rank with Do Nothing
Do Nothing Do Nothing £0 £0 7 -
Option 1 Haywood Only £177,422,624 £3,828,747 3 -
Option 2 Haywood and Leek £163,436,596 £2,656,221 6 -
Haywood and Option 3 £174,083,658 £3,436,401 5 - Longton Haywood and Option 4 £179,201,255 £3,183,858 2 - Cheadle Haywood and Option 5 £174,664,457 £2,209,760 4 - Bradwell
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Haywood and Care Option 6 £213,193,341 £3,828,747 1 - Homes
Including land receipts into the net present value analysis had no impact to the ranking of options for five year total expenditure and Option 6 remains the top-ranked option.
c) Changing the 132 bed baseline to 126 and 136 bed baselines
The 132 bed baseline was produced from referrals, length of stay and utilisation assumptions. To test the sensitivity of the baseline and if it affects the rankings two new baselines were used: 126 and 136 bed baselines.
To calculate the 126 bed baseline: the Length of Stay for Rehabilitation / Assessment beds is reduced by from 28 days to 27 days and EMI beds are reduced from 34 days to 30 days.
To calculate the 136 bed baseline: the Length of Stay is the same as the 132 bed baseline but the target utilisation decreases from 95% to 92%.
Please note that the Do Nothing option is not affected by the different baselines as all the sites are reopened and there are 264 beds available.
Table 60: Affordability and ranking for each option for the different baselines
Total expenses Total expenses Total expenses between 18/19 between 18/19 between 18/19 Option Option and 22/23 for Rank and 22/23 for Rank and 22/23 for Rank Description 126 bed 132 bed 136 bed baseline baseline baseline
Do Nothing Do Nothing £136,133,507 7 £136,133,507 7 £136,133,507 7
Option 1 Haywood Only £71,541,817 2 £74,529,752 2 £75,061,482 2
Haywood and Option 2 £77,695,593 5 £80,683,528 6 £81,272,743 6 Leek Haywood and Option 3 £76,370,896 4 £78,218,393 4 £79,948,046 4 Longton Haywood and Option 4 £75,431,911 3 £76,863,790 3 £77,887,898 3 Cheadle Haywood and Option 5 £79,095,143 6 £79,543,215 5 £80,030,838 5 Bradwell Haywood and Option 6 £66,079,311 1 £68,502,492 1 £68,747,239 1 Care Homes
Option 6 is still top ranked for all three baselines. The only change in ranking is where Options 2 and 5 (Haywood and Leek and Haywood and Bradwell) swap rankings for the 136 bed baseline compared with 132 bed baseline due to the increase capital expenditure required for the extra beds at Haywood for Option 2.
Table 61: Net Present Value and ranking for each option for the different baselines
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20 year NPV 20 year NPV 20 year NPV compared with compared with compared with Option Option the Do Nothing Rank the Do Nothing Rank the Do Nothing Rank Description option for 126 option for 132 option for 136 bed baseline bed baseline bed baseline
Do Nothing Do Nothing £0 7 £0 7 £0 7
Option 1 Haywood Only £185,665,010 2 £173,593,877 3 £173,164,047 3
Haywood and Option 2 £172,851,508 6 £160,780,374 6 £160,301,872 6 Leek Haywood and Option 3 £176,969,925 4 £170,647,257 5 £164,420,289 5 Longton Haywood and Option 4 £180,366,594 3 £176,017,397 2 £173,273,899 2 Cheadle Haywood and Option 5 £175,976,081 5 £172,454,697 4 £171,405,342 4 Bradwell Haywood and Option 6 £216,220,909 1 £209,364,594 1 £208,672,346 1 Care Homes
Option 6 is unaffected by any change in baselines, remaining top ranked. Haywood and Cheadle (option 4) improves its ranking from the 126 bed baseline to 132, because Haywood only requires five additional beds between the baselines compared to Haywood and Cheadle. Increasing the baseline from 132 and 136 beds improves the ranking for Haywood and Bradwell as no additional capital expenditure is required compared with Haywood and Longton, which goes down a ranking.
For the final sensitivity the corporate overheads were removed from the Net Present Value calculations as the corporate overheads would be the same for each option.
Table 62: Corporate overheads removed for the Net Present Value calculations for each option and compared against original Net Present Value analysis
20 year NPV including land Change to original Change in Option Option Description Rank receipts compared NPV analysis Rank with Do Nothing
Do Nothing Do Nothing £0 £0 7 -
Option 1 Haywood Only £163,542,651 £10,051,226 3 -
Option 2 Haywood and Leek £154,860,560 £5,919,814 6 -
Haywood and Option 3 £160,398,613 £10,248,644 5 - Longton Haywood and Option 4 £164,832,430 £11,184,967 2 - Cheadle Haywood and Option 5 £160,646,415 £11,808,282 4 - Bradwell
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Haywood and Care Option 6 £194,490,659 £14,873,935 1 - Homes
Removing corporate overheads in the Net Present Value calculations had no impact to the ranking of options and Option 6 remains the top-ranked option.
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Appendix 13: Wider Community Services Technical annex
Hub Capex Model
Overview
To compare the financial viability associated with each potential hub option across the four localities a high-level capital expenditure model has been developed. This model compares the initial capital costs as well as the discounted present value, in terms of total costs, for each hub option across a 20 year time horizon (2018/19 – 2037/38).
Limitations
Due to the limited data availability and timelines the analysis outlined below is subject a number of material limitations. To account for the uncertainty arising from these limitations the outputs of this analysis have been presented as a range. A list of limitations and their expected impacts has been outlined below:
Data accuracy. The data provided to support this analysis has not been validated in any way and as such any inaccuracies in this underlying information will cause model estimates to differ from reality.
Data availability. The analysis has been built on a limited amount of data that in many cases was either incomplete or not available. To work around these issues assumptions have been developed with a range of local stakeholders using national guidance where applicable. Although every attempt has been made to validate these assumptions they may still vary from reality.
Extrapolation of data. In many cases full information across sites was not available. As a result gaps were filled by extrapolating information from other sites. This means the analysis will not account for site specific effects that could have material impacts in both the capital and lifetime costs of an option.
High level analysis. Recurrent and non-recurrent costs have primarily been estimated on a per m2 basis (based on assumptions provided by local system estate leads) and have not been adjusted for site specific factors. To develop more robust cost estimates additional bottom up analysis is required regarding; spatial requirements, floor space, site specific constraints and costs.
Local Improvement Finance Trust (LIFT) charges. Forecast LIFT building service charges have been estimated and extrapolated on a per m2 basis (based on information provided by local system estate leads). These estimates do not include items such as service change charges which could materially increase costs.
Inclusion of benefits. This analysis is primarily focused around the cost implications of each of the hub location options identified. As such, any income effects that may improve the financial viability of an option have not been captured.
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Methodology
To estimate the discounted present value of each estate option (within a locality) the following steps have been undertaken:
1. Service definition. For the local health and care system to determine the total floor space requirements for each hub option it was first necessary to define a list of services that would be offered. Engagement with CCG and MPFT leads resulted in a service list outlined below, which is to be offered homogenously across all locality hubs.
Table 1: Hub Level Service Lists
Service Stoke South Moorlands Newcastle Stoke North
Continence ✓ ✓ ✓ ✓
Diabetes ✓ ✓ ✓ ✓
Diabetes Education Type 1 ✓ ✓ ✓ ✓
Domiciliary Physiotherapy ✓ ✓ ✓ ✓
End of Life / Palliative ✓ ✓ ✓ ✓
Falls - Responder ✓ ✓ ✓ ✓
Falls - Specialist ✓ ✓ ✓ ✓
Heart Failure ✓ ✓ ✓ ✓
Home First ✓ ✓ ✓ ✓
Home Oxygen ✓ ✓ ✓ ✓
ILCT: Community Matrons ✓ ✓ ✓ ✓
ILCT: District Nursing ✓ ✓ ✓ ✓
OT ✓ ✓ ✓ ✓
Physiotherapy ✓ ✓ ✓ ✓
Podiatry ✓ ✓ ✓ ✓
Respiratory ✓ ✓ ✓ ✓
Specialist: Long Term Conditions - ✓ ✓ ✓ ✓ Diabetes Type 2 (Education)
Specialist: Long Term Conditions - ✓ ✓ ✓ ✓ Pulmonary Rehab
Tissue Viability / Wound Care - ✓ ✓ ✓ ✓ Community Nursing
2. Floor space requirements. Once the service list had been defined it was then important to determine the scale at which these services would be provided and then the implications in terms of floor space requirements. Due to
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limitations around data completeness an initial high-level assumption of 1,900m2 of floor space was used across all hub options (assumption provided by MPFT and agreed with the CCG). Floor space adjustments were then made to account for varying population sizes and acuity across each of the considered localities. To do this a number of methods were considered:
a. Need Weighted Population. To reflect the varying population sizes and healthcare requirements, locality level need weighted population estimates were used to estimate variations in floor space requirements. Source: NHS England Technical Guide to CCG Allocations 17/18 (Document C – General and Acute need estimates)
b. Acuity Weighted Population. Locality level populations were risk stratified and the number of patients considered as medium to high acuity were compared to estimate variations in floor space requirements Source: CCG Provided – Medium to High Risk Stratified Patients.
c. Medium to High Acuity Patients (65+). This approach reflects that of the Acuity Weighted Population, however, the comparison was refined to the population aged 65+. Source: CCG Provided – Medium to High Risk Stratified Patients.
The output of these approaches is presented below:
Table 2: Locality Floor space Requirements
Due Locality Floor space Req. (m2) to the Scenario Stoke South Moorlands Newcastle Stoke North
Base 1,900 1,900 1,900 1,900
a) Need Weighed Population 1,900 1,346 1,900 2,413
b) Moderate / High Risk Patient 1,900 1,236 1,900 1,900
c) Moderate / High Risk Patient (65+) 1,900 1,387 2,023 2,307
Chosen Scenario 1,900 1,346 1,900 2,200* similarity between estimates across each of the approaches the Need Weighted Population was employed. However, based on engagement with MPFT estates leads a revision was made in the example of Stoke North. This revision incorporated a c.10% efficiency factor to account for economies of scale and room sharing in a larger development
3. Available or Unutilised floor space. For each of the proposed hub options a figure for the current sites unutilised floor space was estimated. These figures were obtained through a combination of publicly available data (HEFS ERIC 16/17 site level data), trust provided data (PCC Unit Allocations 2018) and confirmed with MPFT and CHP estate leads.
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4. Additional floor space requirements. Available or unutilised floor space across each of the hubs was then compared to the estimate floor space requirement for each hub outlined in the table above. Where the required floor space exceeded the available floor space within an option an additional floor space requirement was estimated which represents the magnitude of the difference between these two figures (e.g. Required Floor space = 1,900m2, Available Floor space = 1,300m2, then Additional Floor space Requirement = 600m2).
5. Cost Implications. Based on previous discussion with the CCG and MPFT options were matched up with appropriate cost items based on whether they involved refurbishing existing estate, building new estate or expanding current LIFT developments. The table below summarises which cost items were applied to each option:
Table 3: Hub Level Applied Cost Items
Locality Option Refurbishment Rebuild LIFT expansion
1a. ETTF ✓ Stoke South 1b. Meir LIFT * ✓
2a. Leak Community ✓
Moorlands 2b. Kniveden ✓
2c. Cheadle Community ✓ ✓
3a. Bradwell Community ✓ ✓ Newcastle 3b. Milehouse LIFT * ✓
Stoke North 4a. Haywood Community ✓
Capital Expenditure
For each of the strategies outlined above the total capital ask has been estimated in line with the methodology outlined in the Healthcare Costing Premises Guidance (HPCG 2010) OBC forms. This approach first estimates ‘Departmental Cost’ which capture the raw new build and refurbishment costs associated with the proposed floor space and then applies a series of uplifts to account for furnishing, equipment, non-works costs as well as contingencies.
Figure 1: HPCG 2010: OBC Cost Form
Cost Allowance / Total Cost Space and Construction Requirements PUBSEC GIA / m2 m2 Allowance New Build Adaption of existing accomodation for alternative use Upgrading of existing accomodation for current use TOTAL DEPARTMENT COSTS (LINE 1 of Cost form below)
Project cost estimates OGSR Cost Excl. VAT £'s Cost Incl. VAT # Cost Heading use only VAT £'s 20% £'s 1 Departmental Costs 2 On Costs 3 Works Costs Total 4 Provisional location adjustment 5 Sub Total 6 Fees Land 7 Non-Works Costs Other 8 Equipment Costs 9 Planning Contingencies on £ 10 Total (for approval purposes) 11 Optimism bias 12 Sub-total including Optimism bias 13 Inflation assumptions 14 FORECAST OUTTURN BUSINESS CASE Page 170 of 287
The formulas below outline how each of the key subtotals (rows highlighted grey) are estimated:
1. Initially Departmental Costs, which represent the costs associated with constructing the unfurnished shell of the building, are estimated:
퐷푒푝푎푟푡푚푒푛푡푎푙 퐶표푠푡푠푖 = 푅푒푓푢푟푏𝑖푠ℎ푚푒푛푡 퐶표푠푡푖 + 푅푒푏푢𝑖푙푑 퐶표푠푡푖
Where:
푅푒푏푢𝑖푙푑 퐶표푠푡푖 = 퐴푑푑𝑖푡𝑖표푛푎푙 퐹푙표표푟푠푝푎푐푒 (푚2)푖 ∗ 푁푒푤 퐵푢𝑖푙푑 퐶표푠푡 퐴푙푙표푤푎푛푐푒/푚2푖
푅푒푓푢푟푏𝑖푠ℎ푚푒푛푡 퐶표푠푡푖 = 푈푛푢푡𝑖푙𝑖푠푒푑 퐹푙표표푟푠푝푎푐푒 (푚2)푖 ∗ 푅푒푓푢푟푏𝑖푠ℎ푚푒푛푡 퐶표푠푡 퐴푙푙표푤푎푛푐푒/푚2푖
2. Subsequently Works Costs, which reflect the total build costs for both the building shell and site are estimated by incorporating ‘On Costs’:
푊표푟푘푠 퐶표푠푡푠 푇표푡푎푙푖 = 퐷푒푝푎푟푡푚푒푛푡푎푙 퐶표푠푡푠푖 ∗ (1 + 푂푛 퐶표푠푡푠 푈푝푙𝑖푓푡푖)
3. Total (for approval purposes) is then estimated based on the following approach:
푇표푡푎푙푖 = (퐷푒푝푎푟푡푚푒푛푡푎푙 퐶표푠푡푠푖 ∗ (퐸푞푢𝑖푝푚푒푛푡 퐶표푠푡 푈푝푙𝑖푓푡푖) + 푊표푟푘푠 퐶표푠푡푠 푇표푡푎푙푖 ∗ (1 + 퐹푒푒푠 푈푝푙𝑖푓푡푖 + 푁표푛 푊표푟푘푠 퐶표푠푡푠 푈푝푙𝑖푓푡푖) ) ∗ (1 + 푃푙푎푛푛𝑖푛푔 퐶표푛푡𝑖푛푔푒푛푐𝑖푒푠푖)
4. Forecast Outturn Business Case is estimated by then applying an optimism bias:
퐹푂퐵퐶 푇표푡푎푙푖 = 푇표푡푎푙푖 ∗ (1 + 푂푝푡𝑖푚𝑖푠푚 퐵𝑖푎푠푖)
The table below provides additional detail on the variables included within the equations above along with the source from which values have been obtained. It is also worth noting that these variables fully align with those outlined and defined within the HPCG (2010) and as such row references which relate to this document have been included for transparency:
Cost Item Description Source/s
(1) New Build Cost Accounts for the raw construction costs of MPFT & CHP Estates Leads Allowance developing the additional space requirement. DH HPCG 2010 These costs are applied on a per m2 basis PUBSEC Cost Indices
(1) Adaption of This accounts for the total costs incurred in MPFT & CHP Estates Leads Existing refurbishing existing estates such that they DH HPCG 2010 accommodation for would be suitable to provide hub services. alternative use These costs are applied on a per m2 basis PUBSEC Cost Indices
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(2) On Costs This assumption is relates to costs associated MPFT & CHP Estates Leads with site access e.g. roads and walkways and is DH HPCG 2010 applied to (1) Departmental Costs NHS England PAU
(6) Fees Fees are associated with services provided by MPFT & CHP Estates Leads professionals associated with the planning, DH HPCG 2010 development and construction and legal fees associated with the build. This uplift is applied NHS England PAU to the estimated (3) Works costs
(7) Non- Works Costs Non-works costs are included as an allowance Local Estates Leads to cover costs associated with land purchases, DH HPCG 2010 decant costs, decommissioning costs along with any statutory and/ or local authority charges. NHS England PAU This uplift is applied to the estimated (3) Works costs
(8) Equipment Costs This assumption is included as an allowance for Local Estates Leads the supply of group 2 equipment along with DH HPCG 2010 costs associated with group 3 and 4 equipment (as defined in HPCG 2010). This uplift is applied NHS England PAU to (1) Departmental costs.
(9) Planning Planning contingencies are included to cover Local Estates Leads Contingencies the most likely risks associated with the project, DH HPCG 2010 such as cost overruns in the build contract, claims for NHS England PAU disruption and loss, and expenses and claims for additional professional fees. This uplift is applied to the subtotal of (3) Works costs, (6) Fees, (7) Non-works costs and (8) Equipment costs
(11) Optimism Bias In line with HMT Green Book an optimism bias Local Estates Leads is included to counteract the known tendency DH HPCG 2010 of project costs to be underestimated, particularly at the preliminary planning stages. NHS England PAU This uplift is applied to (10) Total for Approval Purposes HMT Green Book
Net Present Cost (NPC)
A 20-year NPC was estimated for each of the options to provide a view on the long term value of each option. Under this method costs non-recurrent costs, which are paid in full in the initial year (2018), are combined with recurrent costs, which unless otherwise stated, are paid throughout the time horizon. To account for the time value of money all future costs are adjusted to account for a discount factor of 3.5% per year. As a result, capital costs incorporated into LIFT contracts are considered and as such this metric has been used for the overall affordability scoring of each option. The equation below outline how the 20-year NPC’s for each option have been estimated:
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1 푁푃퐶 = 퐶푎푝𝑖푡푎푙 퐸푥푝푒푛푑𝑖푡푢푟푒 + ∑푡=20( (퐹푙표표푟푠푝푎푐푒 푥 (푅푢푛푛𝑖푛푔 퐶표푠푡 + 퐿퐼퐹푇 푅푒푠𝑖푑푢푎푙 + 푖 푖 푡=0 (1+퐷푖푠푐표푢푛푡 퐹푎푐푡표푟)푡 푖 푖푡 푖푡 퐿푒푎푠푒 푃푙푢푠푖푡) + 푆푡푟푎푛푑푒푑 퐶표푠푡푖푡)
The table below provides a description of each of the cost items included in the equation above:
Table 5: Recurrent NPC Cost Items
Cost Item Description Source/s
Running Cost Represents hard and soft facilities maintenance HEFS ERIC 16/17 site cost combined with financing costs. These costs level data are applied on a per m2 basis
Stranded Costs* Reflects the opportunity costs of not utilising LIFT 2018 LIFT Annual estates within a locality. This figure is Finance Summaries apportioned based on contract length and 2018 LIFT Annual current CCG usage of LIFT property Utilisation Summaries
LIFT – Lease Plus This cost reflects the proportion of the lease 2018 LIFT Annual payment associated with the repayment of initial Finance Summaries build costs. As such, after a 20 year duration or 2x 2018 LIFT Annual return these are removed from the subsequent Utilisation Summaries recurrent costs. These are applied on a per m2 basis
LIFT - Residual This cost reflects the fees relating to facilities 2018 LIFT Annual management, maintenance and security and are Finance Summaries paid through the duration of this analysis. These 2018 LIFT Annual are applied on a per m2 basis Utilisation Summaries
Sensitivity analysis
Once base estimates of Capital Expenditure and NPC for each of the option were estimated a set of sensitivities were developed to account for the inherent uncertainty associated with a number of the variables. These sensitivities were based on flexing values of:
6. Build Costs. Sensitivity analysis was undertaken to reflect the range of assumptions provided by local and national stakeholders as well as from national guidance. Estimates of raw builds costs per m2 varied from £2,800/m2 (Provided by local system estates leads) to c.£3,200/m2 (based on the Department of Health’s 2010 Healthcare Premises Costing Guidance (HPCG) and Public Sector Build Cost Indices (PUBSEC)). As such, this range was included as the upper and lower sensitivities with a mid-point of £3,000/m2included (Provided by local and national estate leads).
7. Refurbishment Costs. Refurbishment costs for each scenario were estimated using a consistent assumption that they constituted 74% of build costs (outlined by estate leads in the local system). As such, utilised refurbishment cost assumptions were £2,368/m2 for the high scenario, £2,220/m2 for the mid scenario and £2,072/m2 for the low scenario.
8. On Costs. To reflect uncertainty around the potential costs associated with building roads and access into each of the sites the on cost assumption was varied across scenarios. Based on input from local stakeholders an
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assumption of a 20% uplift was used for the low and mid scenarios and an assumptions of 30% was used for the high scenario (as per national stakeholder input).
Additional sensitivity analysis was also included to understand the implications of potential land release across each of the hub locations.
Modelling assumptions
An exhaustive list of the assumptions used in this analysis along with the sources underpinning them is outlined in the table below. Where assumptions vary by sensitivity these values have been included within the table along with a description of why:
Table 6: Modelling assumptions, descriptions and sources
Value Assumption Description Source/s Lower Mid Upper Bound Bound Bound To reflect the uncertainty around the underlying build MPFT & CHP Estates (1) New Build costs a range of sensitivities Leads Cost have been included. The lower Allowance per £2,800 £3,000 £3,200 estimate is based on DH HPCG 2010 m2 stakeholder input and the upper based on DH HPCG and PUBSEC Cost Indices PUBSEC
Accounts for the cost of MPFT & CHP Estates refurbishing and repurposing Leads (1) existing estate such that it is Refurbishment £2,072 £2,200 £2,368 DH HPCG 2010 Cost functionally suitable for its new role PUBSEC Cost Indices
To reflect that the majority of hubs are being located on existing sites, which would be MPFT & CHP Estates expected to incur lower works Leads (2) On Costs 20% 20% 30% costs a 20% assumption has be DH HPCG 2010 used in the low and mid NHS England PAU sensitivities. A more conservative 30% has been used in the upper. MPFT & CHP Estates A range of assumptions have Leads been included with the higher (6) Fees 18% value associated with PFI / LIFT DH HPCG 2010 builds NHS England PAU
This assumption is held (7) Non- Local Estates Leads 5% constant across all hub options Works Costs DH HPCG 2010 and sensitivities Page 174 of 287
Value Assumption Description Source/s Lower Mid Upper Bound Bound Bound NHS England PAU
This assumption is held constant across all hub options Local Estates Leads (8) Equipment and sensitivities. If existing 15% DH HPCG 2010 Costs equipment is to be used across each of the hubs this figure NHS England PAU could be adjusted downward Local Estates Leads This assumption is held (9) Planning DH HPCG 2010 Contingencies 10% constant across all hub options and sensitivities NHS England PAU
MPFT & CHP Estates This assumption is held Leads (11) Optimism Bias 10% constant across all hub options DH HPCG 2010 and sensitivities PUBSEC Cost Indices
The level of risk sharing between system and private investors when considering Risk Share 30% LIFT contracts. Using this the Local Estates Leads system would face 30% of total build costs when entering a LIFT style arrangement
A cap has been imposed on the Capital maximum capital repayment MPFT & CHP Estates 200% repayment for initial capital costs of a LIFT Leads project. (5% ROI, 20yr contract)
Tax rate to be paid on specify VAT 20% HMRC cost items
The rate used to discount future benefits and costs in HMT Treasure Green Discount Rate 3.5% order to trade off the value Book attaches to the present consumption
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Value Assumption Description Source/s Lower Mid Upper Bound Bound Bound The average floor space required to deliver the specified hub services to the local populations
Required floor Note: This figure represents 1,900m2 MPFT Estates Leads space the average hub size, this figure has been adjusted based on population need for the Moorlands and Stoke North localities (as outlined in 2. Floor space requirements)
Accounts for the hard and soft FM costs associated with HEFS ERIC 16/17 £60 - 90 running NHS estate. Figures Running Cost / m2 available for the local area MPFT & CHP Estates have been extrapolated across Leads all sites (where applicable)
Preferred Hub Configuration
To ensure clarity, in terms of the total capital requirement for the preferred hub configuration a full breakdown of capital workings across each of the selected hubs has been included below. These outputs are based upon the mid sensitivity.
Figure 2: Stoke South – Longton ETTF OBC Cost Form 1a. Longton ETTF
Cost Allowance / Total Cost Space and Construction Requirements PUBSEC GIA / m2 m2 Allowance New Build 1,900 £3,000 £5,700,000 Adaption of existing accomodation for alternative use £2,220 £0 Upgrading of existing accomodation for current use £0 TOTAL DEPARTMENT COSTS (LINE 1 of Cost form below) 1,900 £3,000 £5,700,000
Project cost estimates OGSR Cost Excl. VAT £'s Cost Incl. VAT # Cost Heading use only VAT £'s 20% £'s 1 Departmental Costs 5,700,000 1,140,000 6,840,000 2 On Costs 20.0% 1,140,000 228,000 1,368,000 3 Works Costs Total 6,840,000 1,368,000 8,208,000 4 Provisional location adjustment 0 0 0 5 Sub Total 6,840,000 1,368,000 8,208,000 6 Fees 18.0% 1,231,200 1,231,200 Land 0 0 0 7 Non-Works Costs Other 5.0% 342,000 68,400 410,400 8 Equipment Costs 15.0% 855,000 171,000 1,026,000 9 Planning Contingencies on £ £9,268,200 10.0% 926,820 185,364 1,112,184 10 Total (for approval purposes) 10,195,020 1,792,764 11,987,784 11 Optimism bias 10.0% 1,019,502 203,900 1,223,402 12 Sub-total including Optimism bias 11,214,522 1,996,664 13,211,186 13 Inflation assumptions 0 0 0 14 FORECAST OUTTURN BUSINESS CASE 11,214,522 1,996,664 13,211,186 Page 176 of 287
Figure 3: Moorlands – Leeke (Rebuild) OBC Cost Form
2a. Leeke (Rebuild)
Cost Allowance / Total Cost Space and Construction Requirements PUBSEC GIA / m2 m2 Allowance New Build 1,346 £3,000 £4,038,000 Adaption of existing accomodation for alternative use £2,220 £0 Upgrading of existing accomodation for current use £0 TOTAL DEPARTMENT COSTS (LINE 1 of Cost form below) 1,346 £3,000 £4,038,000
Project cost estimates OGSR Cost Excl. VAT £'s Cost Incl. VAT # Cost Heading use only VAT £'s 20% £'s 1 Departmental Costs 4,038,000 807,600 4,845,600 2 On Costs 20.0% 807,600 161,520 969,120 3 Works Costs Total 4,845,600 969,120 5,814,720 4 Provisional location adjustment 0 0 0 5 Sub Total 4,845,600 969,120 5,814,720 6 Fees 18.0% 872,208 872,208 Land 0 0 0 7 Non-Works Costs Other 5.0% 242,280 48,456 290,736 8 Equipment Costs 15.0% 605,700 121,140 726,840 9 Planning Contingencies on £ £6,565,788 10.0% 656,579 131,316 787,895 10 Total (for approval purposes) 7,222,367 1,270,032 8,492,399 11 Optimism bias 10.0% 722,237 144,447 866,684 12 Sub-total including Optimism bias 7,944,603 1,414,479 9,359,083 13 Inflation assumptions 0 0 0 14 FORECAST OUTTURN BUSINESS CASE 7,944,603 1,414,479 9,359,083
Figure 4: Newcastle – Bradwell OBC Cost Form
3a. Bradwell
Cost Allowance / Total Cost Space and Construction Requirements PUBSEC GIA / m2 m2 Allowance New Build 522 £3,000 £1,566,000 Adaption of existing accomodation for alternative use 1,378 £2,220 £3,059,160 Upgrading of existing accomodation for current use £0 TOTAL DEPARTMENT COSTS (LINE 1 of Cost form below) 1,900 £2,434 £4,625,160
Project cost estimates OGSR Cost Excl. VAT £'s Cost Incl. VAT # Cost Heading use only VAT £'s 20% £'s 1 Departmental Costs 4,625,160 925,032 5,550,192 2 On Costs 20.0% 925,032 185,006 1,110,038 3 Works Costs Total 5,550,192 1,110,038 6,660,230 4 Provisional location adjustment 0 0 0 5 Sub Total 5,550,192 1,110,038 6,660,230 6 Fees 18.0% 999,035 999,035 Land 0 0 0 7 Non-Works Costs Other 5.0% 277,510 55,502 333,012 8 Equipment Costs 15.0% 693,774 138,755 832,529 9 Planning Contingencies on £ £7,520,510 10.0% 752,051 150,410 902,461 10 Total (for approval purposes) 8,272,561 1,454,705 9,727,266 11 Optimism bias 10.0% 827,256 165,451 992,707 12 Sub-total including Optimism bias 9,099,817 1,620,157 10,719,974 13 Inflation assumptions 0 0 0 14 FORECAST OUTTURN BUSINESS CASE 9,099,817 1,620,157 10,719,974
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Figure 5: Stoke North – Haywood OBC Cost Form
4a. Haywood
Cost Allowance / Total Cost Space and Construction Requirements PUBSEC GIA / m2 m2 Allowance New Build 300 £3,000 £900,000 Adaption of existing accomodation for alternative use 1,900 £2,220 £4,218,000 Upgrading of existing accomodation for current use £0 TOTAL DEPARTMENT COSTS (LINE 1 of Cost form below) 2,200 £2,326 £5,118,000
Project cost estimates OGSR Cost Excl. VAT £'s Cost Incl. VAT # Cost Heading use only VAT £'s 20% £'s 1 Departmental Costs 5,118,000 1,023,600 6,141,600 2 On Costs 20.0% 1,023,600 204,720 1,228,320 3 Works Costs Total 6,141,600 1,228,320 7,369,920 4 Provisional location adjustment 0 0 0 5 Sub Total 6,141,600 1,228,320 7,369,920 6 Fees 18.0% 1,105,488 1,105,488 Land 0 0 0 7 Non-Works Costs Other 5.0% 307,080 61,416 368,496 8 Equipment Costs 15.0% 767,700 153,540 921,240 9 Planning Contingencies on £ £8,321,868 10.0% 832,187 166,437 998,624 10 Total (for approval purposes) 9,154,055 1,609,713 10,763,768 11 Optimism bias 10.0% 915,405 183,081 1,098,487 12 Sub-total including Optimism bias 10,069,460 1,792,794 11,862,255 13 Inflation assumptions 0 0 0 14 FORECAST OUTTURN BUSINESS CASE 10,069,460 1,792,794 11,862,255
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Appendix 14:: Spotlight on Quality Inspection
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Appendix 15: Engagement activity
The following table provides an indication of the breadth and depth of engagement with staff, clinicians, politicians, locally elected members, Overview & Scrutiny Committees, patients, carers, campaign groups, people with protected characteristics and the general public that we have undertaken with set piece pre-consultation activity. This has been supported by editor briefings, media releases newsletters, spotlight briefing documents and updated web content to provide feedback on the views gathered and how we have taken them into consideration.
Step 1: Identify The consultor needs to identify all the possible solutions it should consider in the process. Gather views Possible from a range of stakeholders: what solutions do they think will work? Solutions
Method Purpose Output Consideration
Public 25 Sepr 2017 To test the Recorded notes of table Used to develop the Involvement Test Event presentation content discussions format for listening and table group events Community Reference discussion format of Groups, Healthwatch the pre-consultation volunteers & Patient events Congress Members
18 Attendees
Public Listening Event To provide an update Photographed Output used to 16 Oct2017 Leek on the process thus flipcharts published on develop long list 111 Local residents & far, current situation, website stakeholders discuss criteria and Independent Analysis 9 Nov 2017 Haywood services at community by the Centre for 42 Local residents & hospitals – now and in Health and stakeholders the future Development (CHAD*) 14 Nov 2017 Longton 22 Local residents & stakeholders 23 Nov 2017 Bradwell 49 Local residents & stakeholders 29 Nov 2017 Cheadle 82 Local residents & stakeholders
December 2017 Leek local Results fed into survey Options Development Organised by Karen Event Bradley MP 536 responses
Oct – Dec 2017 CCG Online Results fed into survey Options Development Event
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146 responses
Political Stoke-on-Trent City Council Meeting in public & Scrutiny of process Engagement 18 October 2017 minuted Adults & Neighbourhoods
Overview & Scrutiny Committee
MPs Briefing Fully Parly Hub briefing provided 23.06.17 29.09.17 Adjournment in HoC 23.10.17 called by Gareth Snell 24.11.17 MP 26.01.18
15 Nov Newcastle Borough Briefing re: Bradwell Councillors’ Listening event Leader, OSC Chair, Chair of Save Bradwell Hospital
6 Nov Staffordshire County Meeting in public & Council minuted
Healthy Staffordshire All Cllr event offered as Select Committee part of paper
Parish Councillors 28th Nov Market stall & survey 2017 Leek Moorland
Stoke-on-Trent City Council
Adults and Neighbourhoods OSC
st 21 Sept Committee Paper
th 18 Oct Committee Paper Results fed into
th Options Development 20 Nov Committee Paper Event th 7 Dec All Councillors Listening event
7th Dec Councillors’ To provide an update Notes taken and fed Results fed into Listening event on the process thus into overall feedback Options Development far, current situation, Event Healthy Staffordshire discuss criteria and Select Committee HOSC services at community Page 182 of 287
members hospitals – now and in the future
28th February 2018 Lobby Discussion with MPs Attended by Dr Lorna Visits to Community Groups visit to about beds at Clarson and feedback Hospitals to meet with Westminster Community Hospitals received was used to campaign groups inform visits to arranged for Community hospitals Independent Chair of STP Sir Neil McCay
CCG Patient PPI Steering Group To provide an update Minuted Results fed into Networks on the process thus Options Development 31 October 2017 far, current situation, Event 31st October 2017 discuss criteria and services at community 19th December 2017 hospitals – now and in the future 27th March 2018
29th May 2018
Healthwatch Healthwatch Stoke 14 Nov To provide an update Notes taken and fed Results fed into Involvement Listening event - Stoke on the process thus into overall feedback Options Development far, current situation, Event discuss criteria and services at community hospitals – now and in the future
Healthwatch Staffordshire To provide an update Survey circulated Included in survey on the process thus amongst members responses and used to far, current situation, inform Options discuss criteria and Development Event services at community hospitals – now and in the future
Voluntary Sector 15 Dec VAST To provide an update Results fed into Involvement on the process thus Options Development Voluntary sector event far, current situation, Event discuss criteria and services at community hospitals – now and in the future
Equality Groups 20 December LEAF To provide an update Results fed into on the process thus Options Development Listening event far, current situation, Event Representatives of discuss criteria and services at community Page 183 of 287
protected characteristic hospitals – now and in groups the future
23rd May LEAF – To discuss key groups Stakeholder map Used to inform stakeholder mapping and methods to updated and key Consultation Plan workshop consult with groups identified organisations representing diverse communities and protected characteristics
Clinical December GPs’ Locality Briefing and feedback Engagement Meetings sought
20 December 2017 Presentation & SF to liaise and arrange Northern Alliance Board feedback agenda item
11 January 2018 GP Presentation & Presentation & Federation feedback feedback
18th January 2018 GP Presentation & Results fed into Members Event feedback Options Development Event
31 January 2018 West Presentation on Midlands Clinical Senate extended scope
January – March 2018. To discuss proposals Proposals received Results fed into Clinical engagement visits for locality provision of from each locality technical expert events to GPs by Dr Lorna Clarson Integrated Care Services
STP Monthly Health & Care To provide updates on Discussions fed into Transformation Board progress and critical path and meetings plus weekly calls alignment with STP tactical delivery on progress of consultation process development of PCBC
8th May 2018 Visit by West Briefing and visit to Presentation & Used to inform options Midlands Clinical Senate community hospitals feedback development & PCBC
21st May 2018 Visit to West Briefing and Presentation & Used to inform options Midlands Clinical Senate investigation into feedback development & PCBC
Stage 2 review clinical case for change
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Step 2: Long List The consultor needs to check which of the possible solutions is viable. A proposal is only viable if it meets of Viable agreed essential criteria. Essential criteria are ‘must have’ attributes that can include safety Solutions requirements, regulatory requirements and the total amount of money available. These are generally the elements that are stipulated requirements for the consultor. The output of Step 2 is a long list of viable proposals.
Method Purpose Output Consideration
23rd January 2018 To consolidate and Criteria assessment and All data packs, Options Development feedback what people long list analysis presentations and said during Step 1; feedback published on 90 stakeholders services and themes, website. Newsletter Representatives from consider local health produced and provider organisations, needs analysis data distributed to key local councils, general packs and define and networks, used to practice and the voluntary develop criteria inform Step 3 viable sector, as well as patient solutions representatives
14th February 2018 Independently Feedback about patient The CCGs learned a Options Appraisal facilitated by the choices and priorities great deal from the Consultation Institute considered from a discussions and it was 60 Stakeholders to consider different single location and clear that there are Representatives from scenarios for each of whole geography different needs in each provider organisations, the five community perspective area. local councils, general hospitals. Services Outputs used to inform practice and the voluntary considered included development of sector, as well as patient community beds, solutions to be representatives urgent treatment considered by Execs centres, diagnostics and expert groups such as x-ray and ultra sound and dementia services.
20 March 2018 Internal To discuss the Long list of options Used to inform Execs Meeting scenarios for technical expert group consideration by and develop shortlist community hospital location
25th April 2018 Strategic To consider: PCBC Minuted for next Programme Board Timeline update, meeting Solutions Chief Execs of NHS, Local Development Progress Authorities & STP members , Work stream Updates, Estates Model - Work stream
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Use of Technology, Procurement plan, Financial Model, Challenges and Issues, Strategic risks and mitigation
Step 3 Short List The consultor needs to narrow its list of viable proposals to those that best meet the stated objectives of Viable Solutions: the change programme. This can be achieved by assessing each of the viable proposals against desirable criteria. Desirable criteria are those elements of the proposals over which the consultor has influence. The choice elements of a decision.
Method Purpose Output Consideration
Commissioners’ To screen out the You Said – We did Published on website Assessment of public suggestions which are and in newsletter 31st feedback either not within the May 2018 CCGs gift to commission or are not viable due to external factors such as national guidance, estates capacity, service capacity.
2nd May 2018: Information To provide Reference Presentation & Q&A Used to inform 10th Briefing Group participants May Reference Group with information to
make an informed contribution to the options evaluation process.
10th May 2018 Options Consolidation
Reference Group
Step 4: Ranked The output of the process is information to present to the decision making body information that informs Shortlist and influences their decision on which proposals to include as options in a public consultation. It provides detailed information on the reasons for discarding each of the possible solutions that don’t make it into the consultation document.
Method Purpose Output Consideration
Apply Essential 16th May - Experts’ To evaluate long list Minuted Used to inform Criteria Assessment against hurdle criteria. Reference group desirable criteria assessment of options
Apply Desirable 25th May Options Present how the Weightings and scoring To inform Governing
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Criteria Evaluation by Reference Expert Group of shortlisted options Body decision Group developed a short list, including presentation
of the emerging evidence. Assessment of short list of options against the desirable criteria.
30th May Feedback to To feedback outputs Presentation & open Used to inform Reference Group from scoring of discussion. Notes taken technical expert shortlist against meeting on 12th June desirable criteria and capture further options for consideration and address concerns.
1st – 10th June Online Open question to Comments evaluated Used to inform feedback check with general by theme technical expert public whether all meeting on 12th June options have been considered.
12th June Informal Cabinet To discuss shortlisted Minuted To inform Governing Stoke-on-Trent City Council proposals and process. Body decision
13th June Informal cabinet To discuss shortlisted Minuted To inform Governing Staffordshire County proposals and process. Body decision Council
12th June Technical experts Detailed evaluation of Minuted To inform Governing evaluation shortlist using financial Body decision land estates data alongside public sensitivity analysis of options.
12th June Patient Congress Present how the Weightings and scoring To inform Governing Expert Group of shortlisted options Body decision developed a short list of options, including presentation of the emerging evidence. Assessment of short list of options against the desirable criteria.
26th June 2018 To receive and PCBC and supporting PCBC submitted for consider the PCBC for consideration by NHS
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Extraordinary Governing approval for documents England Body submission to NHS England.
*The Centre for Health and Development (CHAD) was established as an innovative partnership between Stoke-on-Trent City Council, Staffordshire County Council and Staffordshire University. Its purpose is to contribute to the reduction of health and social inequalities and improve the health and wellbeing of our local population through carrying out high quality translational and internationally recognised research
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Appendix 16:: Long list of options Community beds
No consolidation (5 sites): the number of community beds across the 5 sites reverts to before the temporary closures
# # Sites Beds Site combination
1 5 264 Longton, Leek, Cheadle, Bradwell, Haywood
Full consolidation (1 site): 132 beds consolidated across 1 single site
# # Sites Beds Site combination
2 1 132 Longton
3 1 132 Leek
4 1 132 Cheadle
5 1 132 Bradwell
6 1 132 Haywood
7 1 132 Care Home
Partial consolidation (2 site) – 132 beds consolidated across 2 sites
# # Sites Beds Site combination
8 2 132 Longton, Haywood
9 2 132 Longton, Cheadle
10 2 132 Longton, Leek
11 2 132 Longton, Bradwell
12 2 132 Longton, Care Home
13 2 132 Haywood, Cheadle
14 2 132 Haywood, Leek
15 2 132 Haywood, Bradwell
16 2 132 Haywood, Care Home
17 2 132 Cheadle, Leek
18 2 132 Cheadle, Bradwell
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19 2 132 Cheadle, Care Home
20 2 132 Leek, Bradwell
21 2 132 Leek, Care Home
22 2 132 Bradwell, Care Home
Partial consolidation (3 site) – 132 beds consolidated across 3 sites
# # Sites Beds Site combination
23 3 132 Longton, Haywood, Cheadle
24 3 132 Longton, Haywood, Leek
25 3 132 Longton, Haywood, Bradwell
26 3 132 Longton, Haywood, Care Home
27 3 132 Longton, Cheadle, Leek
28 3 132 Longton, Cheadle, Bradwell
29 3 132 Longton, Cheadle, Care Home
30 3 132 Longton, Leek, Bradwell
31 3 132 Longton, Leek, Care Home
32 3 132 Longton, Bradwell, Care Home
33 3 132 Haywood, Cheadle, Leek
34 3 132 Haywood, Cheadle, Bradwell
35 3 132 Haywood, Cheadle, Care Home
36 3 132 Haywood, Leek, Bradwell
37 3 132 Haywood, Leek, Care Home
38 3 132 Haywood, Bradwell, Care Home
39 3 132 Cheadle, Leek, Bradwell
40 3 132 Cheadle, Leek, Care Home
41 3 132 Cheadle, Bradwell, Care Home
42 3 132 Leek, Bradwell, Care Home
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Partial consolidation (4 site) – 132 beds consolidated across 4 sites
# # Sites Beds Site combination
43 4 132 Longton, Haywood, Cheadle, Leek
44 4 132 Longton, Haywood, Cheadle, Bradwell
45 4 132 Longton, Haywood, Cheadle, Care Home
46 4 132 Longton, Haywood, Leek, Bradwell
47 4 132 Longton, Haywood, Leek, Care Home
48 4 132 Longton, Haywood, Bradwell, Care Home
49 4 132 Longton, Cheadle, Leek, Bradwell
50 4 132 Longton, Cheadle, Leek, Care Home
51 4 132 Longton, Cheadle, Bradwell, Care Home
52 4 132 Longton, Leek, Bradwell, Care Home
53 4 132 Haywood, Cheadle, Leek, Bradwell
54 4 132 Haywood, Cheadle, Leek, Care Home
55 4 132 Haywood, Cheadle, Bradwell , Care Home
56 4 132 Haywood, Leek, Bradwell, Care Home
57 4 132 Cheadle, Leek, Bradwell, Care Home
Partial consolidation (5 site) – 132 beds consolidated across 5 sites
# # Sites Beds Site combination
58 5 132 Longton, Haywood, Cheadle, Leek, Bradwell
59 5 132 Longton, Haywood, Cheadle, Leek, Care Home
60 5 132 Longton, Haywood, Cheadle, Care Home, Bradwell
61 5 132 Longton, Haywood, Care Home, Leek, Bradwell
62 5 132 Longton, Care Home, Cheadle, Leek, Bradwell
63 5 132 Care Home, Haywood, Cheadle, Leek, Bradwell
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No consolidation (6 site) – 132 beds consolidated across 6 sites
# # Sites Beds Site combination
64 5 132 Longton, Haywood, Cheadle, Leek, Bradwell, Care Home
Wider community services
Locality Refined
One hub, As is from existing Longton hospital site Stoke South One hub: Hub services delivered from new site (ETTF) with Longton hospital site repurposed (Longton) One hub: Hub services delivered from Meir LIFT with Longton hospital estate repurposed
Two hubs: As is from existing hospital community sites
Two hubs: Hub services delivered from new site (Kniveden) and Cheadle existing community hospital site
Two hubs: Hub services delivered from existing Leek community hospital site and new Cheadle site Moorlands One hub: Hub services delivered from existing Leek hospital site with Cheadle hospital site (Leek, Cheadle) repurposed
One hub: Hub services delivered from new site (Kniveden) with Cheadle hospital site repurposed
One hub: Hub services delivered from existing Cheadle hospital site with Leek hospital site repurposed
One hub: Hub services delivered from existing Bradwell hospital site Newcastle One hub: Hub services delivered from Milehouse LIFT with Bradwell hospital estate Bradwell repurposed
One hub: Hub services delivered from existing Haywood hospital site Stoke North One hub: Hub services delivered from Middleport LIFT with Haywood hospital site Haywood repurposed
Community beds
Clinical Effectiveness
New patients have the following undertaken on admission:
Continence Assessment
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Falls Risk Assessment
Nutrition & Hydration Risk Assessment
Record of prescribed & administered medicines
Tissue Viability Risk Assessment
Existing patients have assessments reviewed monthly or sooner if there is a change in need:
Continence Assessment
Falls Risk Assessment
Nutrition & Hydration Risk Assessment
Record of prescribed & administered medicines
Tissue Viability Risk Assessment
Care plans reflect patient need and risk assessments
Patient Experience
Friends & Family Test:
• % of patients would recommend
• % of patients would not recommend
• Sample size
Number of complements received
Number of formal complaints received
Number of complaints referred onto the Ombudsman
Patient Safety
Number of slips, trips and falls resulting in harm
Number of pressure ulcers acquired in your care by grade:
Number of medication incidents
Number of outbreaks (infection prevention & control)
Number of serious incidents reported
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Number of deaths
NHS Safety Thermometer
• % No Harm
• % No New Harm
Residents deemed not to have capacity have had a Mental Capacity Assessment completed and consideration for Deprivation of Liberty evidenced
How many safeguarding notifications have been made?
How many CQC notifications have been made?
Workforce
Number of occasions <2 RNs on duty between 8am – 8pm
% days lost (sickness and absence)
% staff have had an appraisal in past 12 months
Number of shifts covered by agency staff
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Wider Community services quality metrics
Overarching Expected Outcomes
• Reduction in the number of case managed patients accessing unscheduled secondary care resulting in a reduction in non-elective admissions;
• Increase in the utilisation of pharmacy staff within Integrated Care Hubs to optimise medications for patients under case management;
• Support for General Practice and the extended primary care team in the management of patients with Diabetes, Heart Failure and Respiratory conditions that makes patient care excellent and delivers individual patient outcomes in line with their management plans aligned with the new models of care;
• Support General Practice in the incidence recording of Diabetes, Heart Failure and Respiratory conditions so that the recorded incidence of LTCs is aligned with expected prevalence as suggested by local Public Health and NHSE utilising tools such as the GRASP tool;
• Specialist integrated team knowledge and skills to impact positively and be evident in the care plans for patients being case managed;
• Patients and the families of patients approaching the end of life are cared for in line with their wishes in their preferred place of care;
• Identify and implement practices that empower patients so that they identify themselves as feeling confident to manage their long term condition(s) including an increase in number of patients who identify themselves as feeling confident to manage their long term condition;
• Increase the use of Technology to support patients to manage their own conditions.
Respiratory outcomes
• Reduction in the number of patients presenting with an exacerbation of COPD who are already diagnosed and under a management plan that are case managed through the Care Hub
• Minimum of 75% of patients who have a shared management plan
• 90% of patients offered pulmonary rehab in line with NICE guidance
• 95% of patients offered the pneumococcal vaccination
• Reduction in the number of hospital readmissions
• Increase the number of COPD patients who die in their preferred place of death
• Develop and fully implement discharge bundles for patients admitted with pneumonia and/or COPD
• Enhancement of care for advanced disease
Diabetes
• Improved CCG performance for the 8 care processes specifically for urine albumin and retinal screening
• % reduction in eye related procedures for ophthalmology
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• % decrease in non-elective admissions with foot ulceration procedures
• Reduced primary care prescribing spend on diabetes
• Increased self-awareness and better understanding of managing diabetes within the community
• Increased number of people with holistic personalised care plans to support and increase confidence to self-manage
Heart Failure (HF)
• To ensure that 100% of patients on practice HF registers had a confirmed diagnosis
• Develop discharge bundles for patients admitted with heart failure delivered by the Integrated teams within the Care Hubs
• To ensure that 80% of patients are on appropriate medical therapy and are titrated, or being titrated, to recommended dosages as tolerated (unless documented as contra-indicated)
• To provide HF education and a continuing rolling programme of education for all diagnosed patients
• Increase the number of Heart Failure patients who die in their preferred place of death
Frailty
• Through links with the falls service, deliver both a reduction in non-elective spend on hip fractures associated with a fall (per head of population over 65) and a reduction in falls related admission rates (per head of population over 65)
• Through links with the Primary Care Commissioning Committee and Palliative Care team, End of Life care will be anticipated and planned for, such that 100% of patients receive high quality co-ordinated end of life care;
• 100% of identified patients are in receipt of an Integrated Care and management plan
• 100% of patients receive a Complex Geriatric Assessment
• Through the MDT approach to managing patients with frailty, it is expected that 33% of admissions to acute care could be avoided
End of Life
• To proactively identify all people considered to be in the last year of life at an early stage, to be able to give them pro- active person centred care in line with preferences
• To offer every identified person the chance to have an advanced care planning discussion with the person of choice
• To enable every person the opportunity to die in their preferred place of choice
• Number and percentage of people with Preferred place of care/death recorded
• Number and percentage of people who died in their recorded preferred place of choice
• Number of patients dying in their usual place of residence
• To reduce number of non-elective admissions for those patients who die in hospital
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Appendix 17 Consultation Plan
The Future of Local Health Services in Northern Staffordshire Consultation Plan This consultation plan was developed using NHS England guidance ‘Planning and Delivering Service Changes for Patients’ (March 2018), the Cabinet Office principles for public consultation (November 2013) and the Consultation Charter (The Consultation Institute 2017)
Feedback on the Consultation Plan was sought from the PCBC Steering Group on 20th June 2018 and feedback was provided from NHS England on 19th June. All comments have been incorporated into the Plan. Staffordshire Healthy Select Committee and Stoke-on-Trent Adults & Neighbourhoods Committee were asked to comment on the plans. Neither Overview & Scrutiny Committee requested any changes.
Purpose In accordance with the National Health Service Act 2006: section 13Q (NHS England), 14Z2 (CCGs), Clinical Commissioning Groups have a duty to make arrangements to involve patients in: the planning of commissioning arrangements the development and consideration of proposals for changes in the way those services are commissioned/provided which would have an impact upon the range of services available or the manner of their delivery; and decisions affecting the operation of those commissioning arrangements/services which would have such an impact.
Definition:- “Consultation is the dynamic process of dialogue between individuals or groups, based upon a genuine exchange of views, with the objective of influencing decisions, policies or programmes of action”. The Consultation Institute
The purpose of this Consultation Plan is to provide an overview of how the CCGs will make arrangements to meet the above duty in line with the definition and the principles to be followed in implementing those arrangements.
In addition, this plan seeks to fulfil the CCGs’ statutory duties under the Equality Act 2010 which requires us to demonstrate how we are meeting our Public Sector Equality Duty and how we will give due regard to the nine protected characteristics of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, sexual orientation.
We will ensure that any unforeseen impact on protected groups are minimised and that Overview and Scrutiny Committees are fully consulted as part of the process. An overview of the CCGs’ legal duties is provided as Appendix 1. Aims The aims of the consultation are:- To inform people about how the proposals have been developed To describe and explain the options for the Future of Local Health Services in Northern Staffordshire To understand people’s preferences on the proposals To ensure that a diverse range of voices are heard which reflect the communities involved in the consultation To understand the responses made in reply to our proposals and take them into account in decision-making To give patients and the public the opportunity to put forwards their own proposals about how services might be arranged to meet local need. To ensure that the consultation maximises community involvement and Page 197 of 287
complies with legal requirements and duties
Our Consultation Mandate
It is recognised Best Practice that a public consultation requires a Consultation Mandate. This mandate was discussed by the PCBC Steering Group on 23rd May 2018 and again revised and agreed on 20th June 2018.
North Staffordshire and Stoke-on-Trent Clinical Commissioning Groups (CCGs) will involve clinicians, statutory bodies, MPs, Local Authority Leaders and elected members, service providers, patients, people from diverse communities and carers in the development of high quality, clinically sustainable, viable solutions for the provision of local health services in Northern Staffordshire.
The proposals on the configuration of local health services to be provided in the areas of Newcastle, Stoke-on-Trent and Staffordshire Moorlands to meet local health needs will undergo formal public consultation during 2018 and will meet the strategic aim to continue to commission safe, accessible, services to improve the health and wellbeing outcomes and meet the clinical needs of the people of Stoke-on-Trent and North Staffordshire.
The scope of the consultation will include the provision of rehabilitation beds and community based services provided from integrated care hubs.
Principles The proposals contained in the final Pre-Consultation Business Case will be subject to formal public consultation. The Gunning Principles will be applied rigorously and the CCGs’ will :-
be open minded and not pre-determine any decisions. The options developed for the future provision of local health services have been co-produced with members of the public and stakeholders. The proposals are underpinned by data analysis of local health needs, current service provision and demand, health inequalities data and travel analysis.
ensure that the people involved will have enough information to make an intelligent choice and input into the process of option development. Throughout the pre-consultation period, relevant information and supporting data has been made available in a variety of formats including website, newsletter, media relations, briefings and this has been promoted through social media and partner networks. The pre-consultation and formal consultation process have undergone an Equality Impact Assessment to ensure that everyone has been given an opportunity to participate in the process should they choose to do so.
make sure that enough time is given for people to make an informed decision and provide feedback. In line with HM Government Code of Practice on Consultation, the consultation will last for at least 12 weeks with consideration given to longer timescales if identified as a requirement during the process.
evidence how decision-makers have taken public opinion into account and will provide feedback to those consulted. The CCGs will make sure that there is enough time to analyse the feedback and report through the appropriate governance structure before giving feedback to the consultees.
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Equalities
It is not just a legal requirement but also the right thing to do to make sure that the consultation process reaches all those who have an interest in the proposals and that they are empowered and enabled to get involved.
The consultation process has been subject to an equalities impact analysis to confirm that the process for consultation and decision-making is fully compliant with our legal duties under the 2010 Equality Act and the NHS Act 2006 (as amended) and that we are taking account of people’s protected characteristics.
Consultation information will be made available on request in different formats and languages. Statistical analysis reveals the Polish and Urdu are the two most prevalent spoken languages in Northern Staffordshire following English and so every effort will be made to provide material on request.
The CCGs websites are AA compliant and use Google Translate (47 languages) read aloud software, large format and text only display.
The Equality Impact Assessment reveals that the two protected groups most likely to be affected by the proposals and options for consultation are older people and people with a disability. Particular attention will be paid to groups identified such as the Pensioner’s Convention, Age UK, Saltbox Older People’s Engagement Network (OPEN), Disability Solutions, the Local Equality Advisory forum and support groups for people with long term conditions such as Breathe Easy and Diabetes UK. Early contact with the Carers Forum has already been made. In response to the Stoke-on-Trent Adults & Neighbourhood’s Overview & Scrutiny Committee, Residents Associations firmly feature in the planned activity. Reasonable adjustment and support will be made to make sure that For example, a workshop will be held with ASIST Advocacy services, a group of people with learning disability which will be facilitated by their trained support workers and by working with the Citizen’s Advice Bureau’s Deafinitequality we will conduct a focus group in British Sign Language.
All larger scale public events will be held in accessible locations and all participants will be asked to specify any particular needs to allow them to meaningfully participate for which reasonable adjustment will be made. BSL interpretation will be provided at community events should it be required.
Steps will be taken to ensure that BME groups are represented in the cross section of consultees by going to places of worship and social groups.
By far the hardest to reach group is the working well and in order to reach people aged 30 – 50 who work during the day, we will work in partnership with the Chambers of Commerce to identify and visit the 10 largest employers in the area to seek the views of staff.
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Key Messages In developing the narrative which will be used to ensure that people have enough information to express informed preferences during the consultation, the following core messages will run throughout:-
There is a compelling case for proposing changes in the configuration of local health care services and we will describe this using plain language. We will address the concerns raised through previous pre-engagement that:- o Investment has been made in community services o Patient safety will not be compromised There is clinical and partner support for the model This is an opportunity to influence the provision of local health services
We will include the NHS England requirement that from 1 April 2017 local NHS organisations will have to show that significant hospital bed closures, subject to the current formal public consultation tests, can meet one of three new conditions before NHS England will approve them to go ahead:
Demonstrate that sufficient alternative provision, such as increased GP or community services, is being put in place alongside or ahead of bed closures, and that the new workforce will be there to deliver it; and/or Show that specific new treatments or therapies, such as new anti-coagulation drugs used to treat strokes, will reduce specific categories of admissions; or Where a hospital has been using beds less efficiently than the national average, that it has a credible plan to improve performance without affecting patient care
Spokespeople The narrative, case for change and options delivery will be clinically led in order to engender trust and confidence and to reinforce the message that patient safety and outcomes are at the forefront of the case for change.
These responsibilities will be shared between the Medical Director and the Clinical Director for Partnerships & Engagement and will be supported by the Accountable Officer as required.
Lay members for Patient and Public Involvement will be called upon to bring the patient voice into the room and allays any public concerns from a lay perspective.
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Methodology
The foundation of the formal consultation will be a public facing version of the PCBC developed as a public consultation document and supporting Issues Paper. These will be written in plain language and will be widely distributed in digital and hard copy format to organisations and individuals, inviting comments using a feedback form included within the document and supported by an online survey to replicate the questions asked in the Consultation Document.
We will operate on a principle of inside-out so that staff and clinicians are the foundation of the views gathered to understand views on opinions about how the model would be implemented and delivered.
There will be a digital version of the document hosted on a microsite developed specifically for the Future of Local Community Hospitals and all social media, newsletters and other channels will push people to a web-based survey.
A series of public events, one in each locality will be arranged where people can hear about the proposals, discuss how the proposals will affect them and give feedback. These events will be delivered at fully accessible venues and meet audio/visual standards. They will be facilitated and recorded as part of the formal consultation process.
An ongoing dialogue about the activity will take place via press releases, social media posts and radio interviews.
Video briefings from key spokespeople will be used on the website to clearly explain the options in a personable way.
Employees, GP members, Patient’s Congress, PPGs and ‘Our NHS’ patient members will be included in the process via newsletters, briefings and being invited to attend the engagement events.
Due regard to the needs of people with protected characteristics will be made in the approach to engagement, accessibility of the engagement process and when considering future options. Every effort will be made to ensure that engagement with protected groups takes place through organisations which represent those groups. Equality monitoring data will be gathered (although optional for participants to provide) through the survey.
Public facing consultation document
The underlying principles will be that:
The public consultation document will set out the case for change, information about the options and proposals and how they were developed, and how people can give their feedback. Our information will be consistent and clear and will take levels of health literacy into account We will reach out to people where they are, where possible, through focus groups and interviews We will make the information relevant to local groups – we will be clear about what the proposals mean for each geographical area and for each group of people taking account of their interests, diverse needs and preferences We will monitor and evaluate the process consistently including capturing feedback and comments from events, meetings, discussions and individual responses to the consultation.
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Governance Oversight of the implementation and delivery of the Consultation Plan will be via the Joint Health Overview & Scrutiny Committee, CCGs Communication & Engagement Committee and Governing Bodies.
Stakeholder Analysis A Stakeholder mapping workshop was undertaken by the CCGs’ Patient and Public Involvement (PPI) Steering Group on 27th March 2018 The resulting stakeholder map identified with whom we should consult and the most appropriate method for reaching them and is outlined in Appendix 2.
The Local Equality Advisory Forum (LEAF) discussed the most appropriate groups and organisations representing diverse communities with protected characteristics with whom we should consult on 23rd May 2018. The resulting list of stakeholder groups is provided as Appendix 3.
Timescales It is proposed that subject to NHS England approval, the twelve week consultation period will commence on Monday 10th December 2018 October and close on Sunday 17th March 2019.
Budget All non-pay related activity will be delivered as part of the Local Provider Framework and Contract with the Midlands and Lancashire Commissioning Support Unit with Associated thresholds and key performance indicators.
Additional budget will be required for:-
Venue hire and refreshments Print Translation and interpretation services
Evaluation Formal public consultation differs from engagement in that we are asking for responses to a specific set of proposals, rather than a general exploration of issues and ideas. This influences the way we set out the consultation document and the way we seek feedback. The consultation document will set out each proposal in a balanced way with supporting information. A feedback form will be included in the document asking for people’s views on each option. This will include a space where people can suggest other options or make other comments. The feedback form will also be available as a document for use in group discussions, forums or other events and will be made available on line for people to make responses electronically if they prefer.
A consultation response email will be established to respond to simple requests for information e.g. requests for the consultation document or basic information about the process. This will not be a mechanism of capturing feedback but providing information or signposting. Recording feedback and analysis
The information collected through survey (paper and online) will be anonymous.
A record of each engagement event will be made, contemporaneous notes will be taken, but no reference will be made to participants by name.
The names of organisations which participate will be recorded.
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Minutes of formal meetings, including Health Overview & Scrutiny Committees will be recorded and included in the analysis.
Letters sent to the CCGs from MPs, Councillors, partners and the public will be recorded, responded to and acknowledged in the analysis of feedback.
Online and written petitions will be acknowledged in the analysis in accordance with the CCG petition policy.
The CCGs will allow sufficient time to record and analyse the consultation feedback, publish a report of themes and sentiment and will give the suggestions made due consideration in developing recommendations for consideration by the Governing Bodies.
Support for the hosting of the feedback and analysis of the responses will be provided by the Midlands and Lancashire Commissioning Support Unit. Their Consultation Analysis Plan is available separately to this document.
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Appendix 1
Legal Duties
NHS Constitution
We will adhere to the ideals of the NHS Constitution (2016), which sets out the principles, rights and values of the NHS which is to provide a comprehensive service, available to all. We will communicate how we are performing against the pledges set out in the Constitution.
NHS Five Tests for reconfiguration The five tests set out that proposed service changes should be able to demonstrate evidence of:
Test One: Strong public and patient engagement; Test Two: Consistency with current and prospective need for patient choice; Test Three: A clear clinical evidence base; and Test Four: Support for proposals from clinical commissioners. Test Five: New patient care tests These tests are designed to demonstrate that there has been a consistent approach to managing change, and therefore build confidence within the service, and with patients and the public.
Patient & Public Involvement
The Health and Social Care Act 2012 introduced significant amendments to the NHS Act 2006 and supports two legal duties, requiring CCGs and commissioners in NHS England to enable:
• patients and carers to participate in planning, managing and making decisions about their care and treatment, through the services they commission;
• the effective participation of the public in the commissioning process itself, so that services provided reflect the needs of local people.
Under Section 242(1B) of the NHS Act (2006), we are required to ensure that the public and our patients are informed, involved and consulted in the following areas:
• In planning the provision of services
• In the development and consideration of proposals for change in the way services are provided
• In any decisions to be made affecting the operation of services
Political
We will consult the Local Authority Health Overview & Scrutiny Committee as we are considering proposals which constitute:-
a substantial development of the health service in the area, or a substantial variation in the provision of a service. This is underpinned by S244 of the NHS Act 2006 (as amended), and explained further by the Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013.
As art of this requirement, the CCGs are keen to implement a ‘no surprises’ approach to ensuring that all elected members are fully appraised and involved in the consultation process, and as such, are able not only to make an informed contribution to the consultation in their own right but to support their constituents in doing so if requested to.
As the proposals affect five community hospitals in more than one local authority area, in accordance with the Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013, which are aimed at supporting local authorities to discharge their scrutiny functions effectively, the CCGs’ governing body in common on 5th December 2017 agreed that under Part 4 Health Scrutiny by Local Authorities, regulation 30 (5), local authorities should appoint a joint health scrutiny committee where a ‘responsible person’ (in our case the CCG) informs affected local authorities that it has under consideration a proposal which would affect more than one local authority area. The regulations require the relevant local authorities to form a joint scrutiny panel known as a mandatory joint scrutiny panel.
The CCG considers that requesting Staffordshire County Council and Stoke on Trent City Council to establish a mandatory joint scrutiny panel is the best way of obtaining a view on the set of proposals on which we intend to formally consult.
Equality
We have a legal duty under the Equality Act (2010) to promote equality through the services we commission and establish processes to hear the voices of local people irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status.
We will pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population and will make sure that people who lack capacity are supported and empowered to have their say.
We will meet our statutory duty to have due regard to the need to
eliminate discrimination, advance equality of opportunity foster good relations To 'have due regard' means that in making decisions and in its other day-to-day activities a body subject to the duty must consciously consider the need to do the things set out in the general equality duty.
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The Equality Delivery System (EDS) was developed in 2011 to help the NHS understand how equality can drive improvements and strengthen the accountability of services to patients and the public. Equality lies at the heart of CCG business to deliver better outcomes for patients and communities and better working environments, which are personalised, fair and diverse.
To understand what is and is not working for patients and communities, we will ensure that:-
• all participation activity reaches communities and groups with distinct health needs and those who experience poor health outcomes. • we consider how to reach people that experience difficulties accessing health services or have health problems that are caused or affected by their socioeconomic circumstances. • people who have characteristics that are protected under the Equality Act 2010 are integral to all participation and measures taken to enable patients to participate in their own health are designed in a way which meets individual needs. • we will commission services to diagnose, treat and improve both physical and mental health.
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Appendix 2
Consultation schedule Patients How When
Workforce Staff events and pop-up consultation displays will be held for Arrangements to be made and dates service provider’s staff. Clinical engagement will take place with to be confirmed following formal the LMC, GP Federation, Locality Leads, Alliance Boards, STP sign off of the Consultation Plan Clinical Leaders Group and provider Governing Bodies. All staff will be encouraged through their internal comms channels to participate in public events and use the online survey. Local residents, carers, patients & stakeholders Public consultation event x 5. One to be held in each area Arrangements to be made and dates Online consultation document. to be confirmed following formal Patient interviews at community hospitals and in clinics. sign off of the Consultation Plan Face to face interviews at Christmas shopping centres. Media coverage and social media amplification Healthwatch (Staffs and Stoke) Workshop with volunteers Arrangements to be made and dates to be confirmed following formal sign off of the Consultation Plan Patient Congress Agenda item for workshop style discussion Arrangements to be made and dates to be confirmed following formal sign off of the Consultation Plan PPGs Localities ‘Your’ Voice Newsletter, PPG Protected area of website. PPGs to Arrangements to be made and dates be encouraged to circulate consultation document amongst to be confirmed following formal patients at Practice. sign off of the Consultation Plan People with protected characteristics Targeted engagement with groups identified by LEAF eg Arrangements to be made and dates Page 207 of 287
Deafness Association, Asist, Gypsy Traveller Network, Religious to be confirmed following formal groups, Disability Forum, LGBT Networks, Maternity Support sign off of the Consultation Plan Group. Distribute consultation document, share link to online survey and attend meetings. Arrange focus groups and conduct face to face interviews.
Public/Patient CCG Membership Newsletter to 3500 stakeholders to highlight different Arrangements to be made and dates opportunities to get involved to be confirmed following formal sign off of the Consultation Plan Residents Associations Write to RAs with invitation to participate in public events or Arrangements to be made and dates offer bespoke workshops to be confirmed following formal sign off of the Consultation Plan Carers Forum Workshop style session at their meeting Arrangements to be made and dates to be confirmed following formal sign off of the Consultation Plan Care Homes Invitation to offer focus groups / interviews with staff / patients Arrangements to be made and dates to be confirmed following formal sign off of the Consultation Plan Attendees from previous events/engagement Newsletter to highlight different opportunities to get involved Arrangements to be made and dates to be confirmed following formal sign off of the Consultation Plan Voluntary sector providers and organisations Bespoke workshop for VAST and offer to attend member Arrangements to be made and dates groups meetings to be confirmed following formal sign off of the Consultation Plan Campaign Groups Invitation to attend public events. Bespoke relationship Arrangements to be made and dates meetings are required to be confirmed following formal sign off of the Consultation Plan Businesses (the working well) Chambers of Commerce newsletter and dip sample top 10 Arrangements to be made and dates
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employers to consult staff during working day to be confirmed following formal sign off of the Consultation Plan Political MPs Personal letter with guidance for how they can involve Arrangements to be made and dates constituents and updates at regular Bi-monthly Briefing to be confirmed following formal sign off of the Consultation Plan Health Overview & Scrutiny Committees Joint HOSC Arrangements to be made and dates (HOSCs) to be confirmed following formal sign off of the Consultation Plan Health & Wellbeing Boards (Staffs & Stoke) Agenda item on committee meeting Arrangements to be made and dates to be confirmed following formal sign off of the Consultation Plan Councillors (County, City, Borough, District, Write to Councillors to brief them and invite to public events Arrangements to be made and dates Town & Parish ) to be confirmed following formal sign off of the Consultation Plan Clinical GP membership/practices Attend Locality meetings. GP Newsletter Arrangements to be made and dates /Localities/Federations to be confirmed following formal sign off of the Consultation Plan Local Medical Councils (LMC) North and South Letter Arrangements to be made and dates to be confirmed following formal sign off of the Consultation Plan Alliance Boards Agenda Item at Meeting Arrangements to be made and dates to be confirmed following formal sign off of the Consultation Plan STP/TWB team / Health and Care Agenda item at meetings Arrangements to be made and dates Transformation Board to be confirmed following formal / STP Clinical Leaders Group sign off of the Consultation Plan
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NHS Provider organisations (Exec Teams/Staff) Vis internal comms channel, through STP Comms network Arrangements to be made and dates to be confirmed following formal sign off of the Consultation Plan Private Sector providers (e.g. Newsletter update with links to consultation and involvement Arrangements to be made and dates OOHs/111/Patient Transport/Virgin Care) opportunities to be confirmed following formal sign off of the Consultation Plan Local Pharmaceutical Committee (LPC) North Newsletter update with links to consultation and involvement Arrangements to be made and dates and South opportunities to be confirmed following formal sign off of the Consultation Plan Pharmacists/ Opticians/Dentists Newsletter update with links to consultation and involvement Arrangements to be made and dates opportunities to be confirmed following formal sign off of the Consultation Plan Partners Public Health England (PHE) Newsletter update with links to consultation and involvement Arrangements to be made and dates opportunities to be confirmed following formal sign off of the Consultation Plan Social Care Newsletter update with links to consultation and involvement Arrangements to be made and dates opportunities to be confirmed following formal sign off of the Consultation Plan Housing Associations Newsletter update with links to consultation and involvement Arrangements to be made and dates opportunities to be confirmed following formal sign off of the Consultation Plan Fire & Rescue/ Police Newsletter update with links to consultation and involvement Arrangements to be made and dates opportunities to be confirmed following formal sign off of the Consultation Plan
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Appendix 3
Protected Groups
Organisation Age Disability Gender Marriage & Pregnancy Race Religion Sex Sexual Reassignment Civil & Maternity or Orientation Partnership Belief Action for Blind People √ Action for Children √ √ Action on Hearing Loss √ Adsis (Alcohol & Drug Services √ in Staffordshire) Age UK (North Staffs) √ Alzheimer's Society √ √ (Staffordshire) Apostolic Praise Centre √ Approach (for older people with √ √ Dementia) Arch (North Staffs) √ √ √ √ √ √ √ Arthritis Care √ √ Asha North Staffs √ √ Asist - Reach √ √ Aspire Housing Beth Johnson Foundation √ √
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Breathe Easy (British Lung √ √ Foundation) Changes ( Mental Health) - √ North Staffs & Stoke Changes ( Mental Health - √ √ young people) Citizens Advice - Newcastle √ √ √ √ √ √ √ √ √ Citizens Advice - Stoke √ √ √ √ √ √ √ √ √ Citizens Advice - Cheadle √ √ √ √ √ √ √ √ √ Citizens Advice - Leek √ √ √ √ √ √ √ √ √
City Central Mosque √ √
Community Council of √ √ √ √ √ √ √ √ √ Staffordshire Community Drug & Alcohol √ Service (CDAS) Crossroads Care (North √ √ Staffordshire) Deafinequality √
Deaflinks Staffordshire √
Deafvibe √
Diabetes UK North Staffs √ √ Volunteer Group Disability Solutions √ Dyslexia Association of √ Staffordshire EngAGE Forum √ √ Page 212 of 287
Equality & Diversity - Staffs Uni √ √ √ √ Ethnic Minority Team √ √ √ Gaylife/Galaxy Youth √ √ √ Gillaninoormasjid Mosque √ √ Guru Nanah Sikh Temple √ √ Healthwatch Staffordshire √ √ √ √ √ √ √ √ √ Healthwatch Stoke on Trent √ √ √ √ √ √ √ √ √ Improving Maternity Services in √ Staffordshire Keele (LGBT) √ √ √ Let's Make Jam WI √ √ Mencap √ Mind (North Staffs) √ Moorlands HomeLink √ √ National Ankylosing Spondylitis √ Society Staffordshire Autistic Society √ Netmums (North Staffs) √ New Leaf √ North Staffordshire Polish Day √ Centre North Staffs African Caribbean √ Association North Staffs Carers √ North Staffs Carers (includes √ young carers groups) North Staffs Orthotics √ Campaign Page 213 of 287
OLGBT Stoke & N Staffs (Older √ √ √ √ LGBT group) / Consortium of LGB&T community sector organisations Pandas √ Pensioners Convention √ RNIB √ Royal British Legion √ √ √ √ √ √ √ √ √ Saltbox - OPEN √ √ √ Salvation Army, Stoke √ √ √ Sanctuary/Trans Staffordshire √ √ Sanctus St Marks √ √ Staffordshire & Stoke on Trent √ Dementia Alliance Staffordshire Afghan √ Association Staffordshire Buddies √ Staffordshire Council of √ Voluntary Youth Services Staffordshire Housing √ √ √ √ √ √ √ √ √ Association Staffordshire Pink Link √ √ Staffs Cancer LGBT √ Staffordshire Women's Aid √ √ Stoke Expert Citizens √ Stoke Gujarati Samaj √ Stoke Hindu Temple √ √
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Stoke Polish Catholic Centre √ √ Stoke-on-Trent Pride √ √
Stoke Recovery Service / √ AddAction Support Staffs (Staffordshire √ √ √ √ √ √ √ √ √ Moorlands) Trans Staffordshire √ The Carers' Hub √ VAST (voluntary sector - Stoke √ √ √ √ √ √ √ √ √ on Trent & North Staffs) Voices of Stoke √ √ √ √ √ √ √ √ √ YMCA √ √ √
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Appendix 18: Consultation Document
DRAFT CONSULTATION DOCUMENT
The Future of Local Health Services in Northern Staffordshire
VERSION: 17 DATE: 10.09.18
CONTENTS
What is this consultation about? What is consultation? Who is conducting this consultation? Why should you read this consultation document? Introduction Why do services need to change? Understanding what people need How we developed our options for change What we are consulting on o Options for integrated care hubs o Options for community hospital and NHS care home beds How you can have your say What happens next? Glossary Consultation Questionnaire
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WHAT IS THIS CONSULTATION DOCUMENT ABOUT?
The health and social care system in North Staffordshire and Stoke-on-Trent faces many challenges. This document describes some of the changes we need to make to address these challenges and make sure we can provide high quality health and social care services that meet the health needs of local people within our finite budget.
The document explains how some health and care services in Newcastle, Stoke-on-Trent, and the Staffordshire Moorlands could change. We look at two key areas:
• We aim to join together key services in the community through ‘integrated care hubs’ which would wrap services around each patient and allow them to get the care they need closer to home. We would be able to better manage long term conditions and keep people out of hospital.
• We have looked at how we can best use our community hospitals and care homes. We want to make sure that people have the right care when they need it after a hospital admission and can get back to normal as soon as possible. Evidence shows patients are likely to get well sooner if they can be sent home quickly. Most people would prefer to be treated at home if it was possible.
We believe the suggested model of care and options in this consultation document will help us offer safe, easy-to-reach services that improve local people’s health and wellbeing and meet their medical needs.
WHAT IS CONSULTATION?
Consultation aims to inform the decisions made by the Clinical Commissioning Group. It invites people to give their views on proposed changes to NHS services. The themes from the consultation helps decision makers provide services that meet patients' needs and offer the best value for money.
By law, the NHS must involve the public and local organisations when developing services or considering big changes to the way they are provided. This legal duty is found in the NHS Act 2006, which was amended in the Health and Social Care Act 2012.
Public involvement is an important part of health service decision making. Your views matter and will be considered alongside clinical, financial and practical factors. The results of public consultation do not represent a vote or a veto over any proposals for change.
We will provide a variety of ways for you to give your feedback and we will make this as accessible as possible. Should you wish to respond to a survey, come to a meeting or see us in your community, we will respect your views and you will remain anonymous unless you tell us that you are responding on behalf of an organisation.
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All of the feedback and opinions we receive will be written into one report and we will public this within 12 weeks of the consultation closing.
We will spend some time considering what we are told and the information will be considered by our Governing Bodies when they make their decisions. This meeting will be held in public and we will publish all of the relevant documents on our websites.
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WHO IS CONDUCTING THIS CONSULTATION?
North Staffordshire and Stoke-on-Trent Clinical Commissioning Groups (CCGs) are legally responsible for this consultation.
These two organisations are responsible for deciding which service providers receive NHS money and they commission (buy) most NHS care, including community, mental health and hospital-based services in Northern Staffordshire. They have a legal duty to involve local people in decision making when proposing to make large changes to services.
CCGs are led by their GP members which means that all decision making is informed by clinical experts. Together, the two CCGs serve approximately 500,000 people across Stoke-on-Trent, Newcastle-under-Lyme and the Staffordshire Moorlands.
The outcome of this consultation will be reported to the governing bodies of both clinical commissioning groups, who meet together and they will consider the feedback before taking any decisions. Whilst the two bodies meet together to consider the whole geography, they can still take separate decisons for Stoke-on-Trent and North Staffordshire as they are separate legal entities.
WHY SHOULD YOU READ THIS CONSULTATION DOCUMENT?
If you live in North Staffordshire or Stoke-on-Trent, it is important that you read this consultation document. It sets out options for change which may affect you or your family and friends.
The NHS believes there can, and will be, a bright future for health and care services delivered in this area. For this to happen, we need health and social care services that work together more effectively, we need to work within our budget, and we need to develop safe, quality services that are delivered from appropriate buildings and attract the right staff.
We serve a population of 479,000 people, which is growing by 0.3% annually – somewhat lower than the English average of 0.8%. Our population is less active, smoke more and have higher rates of alcohol-related harm than the national average. Overall deprivation across our area is below the national average, but there are variations between locality and within localities. As an example, Stoke-on-Trent is one of the most deprived local authority areas in England. This is reflected in our population having slightly lower life expectancy than average. We need to address these health inequalities.
We also need to make some changes to the way services are delivered. If we don’t, we won’t be able to continue to provide the right services into the future. This is what we mean when we say our health and care services need to be “sustainable”.
The content of this document may have a particular impact on people who use community hospitals in this area and on their carers and relatives. We will be consulting these people, and many others, because the proposed changes will be of particular interest to them.
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In this consultation document, we outline our preferred options, but any decision about service change will take into account the results of this consultation.
Please take the time to read this consultation document and let us know what you think. Your views will help us to decide how we should develop health and social care for the future.
You can read more about our broader strategy for health and care on our website https://www.healthservicesnorthstaffs.nhs.uk. You will find several documents there, including the Pre-Consultation Business Case, which provides more detail on how we have developed our proposed model of care and the options for change that we want to involve people in.
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INTRODUCTION
The health and social care needs of people in our area are changing. We are living longer with more long-term health conditions. This is putting a strain on local services and the future of the health system.
Given these pressures, we need to think about how we can provide services closer to home. This will help avoid unnecessary admissions to hospital.
The NHS delivers a wide range of community services to patients, often in their own home or in the local community. We want people to get the maximum benefit from our community based services. This is why we have been talking to the public, patients, medical colleagues and other experts about what the future role of the community hospitals and community services should be.
We have developed a model of care and options for where we should place community services in North Staffordshire and Stoke-on-Trent. It aims to give people the right care in the right setting.
We believe the right mix of community services to meet local needs which are accessible and of high quality standards can improve health outcomes.
This consultation document explains why we need to make changes to our community services and community hospitals.
We will conduct this consultation programme in an open-minded, constructive and transparent way. All voices will be heard, and all feedback will be considered.
WHY DO SERVICES NEED TO CHANGE?
Health and social care services in North Staffordshire and Stoke-on-Trent face some challenges that we must address to make sure patients get the high-quality care they deserve.
These challenges are:
Health and wellbeing The health of people in North Staffordshire and Stoke-on-Trent is generally worse than the UK average. Many conditions - particularly depression, diabetes, hypertension and obesity are more common here. People in our area are less active, smoke more and have higher rates of alcohol- related harm than the national average.
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We also have a higher number of older people (over 75s) living here than in other parts of England. Those older people tend to have more long- term, complicated illnesses than the national average.
Poverty and deprivation Higher levels of poverty and deprivation are linked to many health problems. Stoke-on-Trent is the 16th most deprived local authority area in England. Nearly one in three of the city’s residents live in areas that are among England’s most deprived.
The population of Newcastle-Under-Lyme is less deprived than the English average, but there are pockets of high deprivation, particularly around the town centre. Staffordshire Moorlands is relatively affluent but has pockets of high deprivation in some urban areas.
Care and quality Health services in North Staffordshire and Stoke-on-Trent are generally safe and well-led, but there has been a focus on treating people in hospital for too long.
Clinical evidence suggests people get well sooner if they can be sent home more quickly, and most prefer to be treated at home if it is possible. Good community-based services help reduce the need for hospital-based care.
North Staffordshire and Stoke-on-Trent have more community beds than the national average, meaning more patients are being treated in hospital unnecessarily, or are sent from a general hospital bed into a community hospital bed for further assessment or to wait for the service they need.
We have started to make changes, but more needs to be done because people are still being admitted to hospital unnecessarily - particularly in Stoke-on-Trent.
Workforce We have found it difficult to hire and retain enough NHS workers to staff community hospital beds in North Staffordshire and Stoke-on-Trent.
Other pressures facing the NHS across England are starting to be felt locally, including: an ageing workforce the impact of Brexit on nurse supply from Europe fewer people applying for nurse training recruiting difficulties low staff morale
Staffing issues risk the quality and safety of care and mean we need to use locums and agency workers, which costs more and can affect the quality of care, because patients may not see the same doctor twice.
We have made some progress. The introduction of our Home First service, which aims to give more care at home and in the local area, needed more generalist staff rather than specialists. This has helped address some, but not all, of our staffing difficulties.
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Providing a full and skilled community-based workforce in North Staffordshire remains a challenge. We need to maintain the good progress we’ve made.
Finance The health and care system in North Staffordshire and Stoke-on-Trent is currently spending far more money than it receives. This cannot continue. We must live within our means. We must act to make our local health and care system sustainable.
The local Sustainability and Transformation Plan, published in 2016, estimated that the local health and care system would face a funding gap of £542m by 2020/21 if it failed to respond to the challenges it faces. This funding gap is caused by a rise in the number of people being admitted to major hospitals, duplication of services, inflation and increased spending because of our ageing population. Since this plan was published, the financial position has worsened.
Several programmes are in place to improve our financial position, but more needs to be done. We must transform community services to secure our financial future.
Our buildings We intend to deliver community services from buildings that are easy to travel to, safe, fit-for-use and cost-effective. Well-designed buildings play an important part in ensuring high quality care, a good patient experience and better patient outcomes. Well-designed facilities also provide a healthier environment for staff to work in and help reduce running and maintenance costs.
Like many NHS buildings across the country, our community hospitals are in varying conditions. Many need significant investment before they can be used. Leek Moorlands and Longton Cottage hospitals have Victorian buildings that were constructed before the NHS was even created in 1948.
The only community hospital that does not have a large backlog of maintenance work and is fit-for-use is Haywood Hospital, where most of the building was constructed between 1995 and 2004.
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UNDERSTANDING WHAT PEOPLE NEED
In October 2017, we started speaking to people about the care they receive and how we could better deliver community services that would better meet their changing health needs.
This process aimed to:
Provide meaningful information, so people had enough understanding to get involved in the process Gather information and listen to ideas Use the feedback provided to develop the proposal for this stage of formal consultation
We gathered opinions in various ways. We made sure that we were easy to reach. We wanted to hear and understand the full range of views in our area.
To develop our proposed model of care, we spoke to more than 500 people. These people included members of the public, patients, carers, medical staff, and local and national politicians. We told them about the process and kept them updated. We also offered them the chance to be involved in developing options for the new care model and how they would be evaluated.
We gathered public opinion using a variety of different means to make sure that we were accessible and able to hear the opinions of a range of stakeholders including clinicians, staff, politicians, patients, the voluntary sector and representatives of diverse communities.
We made sure everyone involved had enough information and time to make an informed decision and share their feedback. We gave presentations at meetings and workshops. We also used an online survey to gather views on which services could be offered at each location. We kept people updated through a monthly newsletter.
All presentations, briefing materials, data packs and the content of the pre-consultation can be found on a special website that we are using https://www.healthservicesnorthstaffs.nhs.uk
Emerging themes from discussions
Despite some concerns about how effective and safe providing community-based care would be, and how the new model would be implemented, the idea of bringing care out of a hospital and closer to where people live was broadly accepted.
The key feedback was:
Patients benefit clinically and mentally from being at home Patients prefer to be at home There was support for the model, in principle, which is detailed in the next section of this document Page 224 of 287
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THE MODEL OF CARE
The conversations we had with the public, patients, medical colleagues and other experts inspired us to come up with a new care model. A care model is a carefully planned approach to improving patients’ health.
We believe our new care model will address the needs local people told us about by making sure they get the right care in the right place. This will help secure our local health system’s future.
We know the NHS in North Staffordshire and Stoke-on-Trent faces some big challenges, but we think there are some exciting opportunities. We plan to lead a process that creates something special. A new approach to community-based care that improves patients’ outcomes and gives them access to the care they need near home. No more long and unnecessary hospital stays. This new model of care is designed for all adults aged over 18 but is particularly geared towards supporting people with high clinical needs who are most at risk of hospital admission, such as adults with multiple long-term conditions.
We want to prevent people getting poorly wherever possible and will work with patients to help them help themselves. We will also be working with GPs in Primary Care to maintain the health of people who are generally well.
Our aims
We want to create a new way of offering community-based care that:
Helps people recover quickly when they are ill so they can be independent again as soon and safely as possible Reduces how long people spend in a major hospital Allows people to live with and manage their health conditions more effectively Gives people the choice of dying at home if that is what they want
This approach is based on 10 principles that came from our meetings with local people, as well as our knowledge of the best clinical practice nationally and internationally, and the NHS’ General Practice Forward View.
These principles are:
1. Home is the preferred setting for care whenever possible 2. Care should be patient-centred 3. Patients should feel confident and supported to manage their own illnesses 4. The providers of health and care should work together to improve people’s outcomes 5. Care should be planned and proactive Page 226 of 287
6. Care should be delivered by medical professionals who have different expertise working together 7. The care model should use “trusted assessors” to make initial decisions about the care that people need 8. Strong professional leadership is a must 9. Staff should feel empowered 10. People should only go into hospitals when they really need to
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Putting the Patient at the Centre
Our new approach would involve teams of medical experts with a mix of skills and expertise working in local neighbourhoods, or ‘localities’, to help people with conditions stay healthy.
GP surgeries would work with teams made up of nursing and adult social care workers, members of the voluntary sector, and community mental health professionals. These “integrated care teams” would support frail, older people as well as those living with long-term conditions, such as asthma, diabetes, heart failure and kidney disease. The aim is to stop a health crisis by spotting any changes in a patient’s health and giving them the care they need quickly.
Integrated care teams
Across Staffordshire, people who are frail or have several long-term health conditions are supported by nurses and social care workers. This is a form of “integrated care”. Integrated care puts the patient’s specific needs at the centre of everything that is done for them. It is coordinated or joined up so medical professionals with different expertise can work together to identify the best options for the patient.
We want people to benefit from integrated care teams whenever they seek medical advice or support in their community – whether they’re contacting their GP surgery, a voluntary organisation or social care provider.
As the diagram below shows, we want these teams to “wrap” care around vulnerable patients. These teams will let people know about the services they need and help them access them.
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Some specialist services, such as cardiac rehabilitation or physiotherapy, need to be delivered on a broader scale to make sure they are cost- effective, but on a small enough scale that they meet local people’s needs. We will develop four hubs where patients can get the care they need closer to home. These “integrated care hubs” will be in Newcastle-under-Lyme, Stoke North, Stoke South and the Staffordshire Moorlands. They will allow health and care professionals the chance to deliver care side-by-side and to discuss a patient’s changing needs.
Specialist integrated care hubs
We don’t think patients should have to travel to a large hospital to get specialist health and social care. Our new care model will create four “integrated care hubs” where patients, particularly those who are vulnerable and frail, can get the care they need.
By creating these new bases, we can meet local patients’ needs while keeping costs down. They would also take pressure off major hospitals. The hubs would be located in:
Staffordshire Moorlands Newcastle-under-Lyme The north of Stoke-on-Trent The south of Stoke-on-Trent
The specialist teams based at these four hubs will work closely with local GPs. We think this will help improve working relationships between primary care, the voluntary sector, community-based services and specialist services.
The exact services and medical professionals at each hub will depend on local needs. But they would be key care and support centres for people with dementia or those who are old and frail. Other teams based there could include the community diabetes team, the respiratory team, the cardiac rehabilitation team, the long-term conditions support team, the community mental health team and the cancer support team, as well as district nurses.
The care will be delivered in the same way at each hub. This should ensure every community has equal access to the same opportunities.
You can read more about the way these hubs would operate in our Pre-Consultation Business Case (PCBC), which is on our website: https://www.healthservicesnorthstaffs.nhs.uk
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How it would work – case studies
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HOW WE DEVELOPED OUR OPTIONS FOR CHANGE
Since October 2017, we have been looking in detail at the concerns and feedback people have shared with us. Their feedback has shaped the design of our proposed model of community-based care. It has also helped us to identify options for providing high-quality, affordable and lasting community-based care to people in our area. These options should tackle the challenges we outlined earlier.
The diagram below shows the process that we went through to come up with the options for change. The options are outlined later in this document.
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First, we developed two long lists of options based on people’s feedback. One looked at the number of community beds we would need and where they could be. We started with a list of over 60 options.
The second set of proposals looked at where we could locate hubs offering wider community services. These long lists were based on the views and feedback we received from the public, politicians, medical professionals and others.
We worked hard to make sure that the proposals met the five tests set out by NHS England and we were particularly careful to make sure that the proposals were clinically safe and based on evidence and research.
Then we worked with local people, with our partners and clinicians to develop a set of criteria we could use to shorten the list. We would not want to consult on anything that couldn’t be delivered, so a group of experts from the health community and local authorities narrowed down the options. They did this by assessing if they were affordable, in line with local and national health strategies and would deliver safe and quality care to patients in the future. They used a scoring method which is explained in more detail in the PCBC.
We set up a reference group of key people, which included senior medical and local authority representatives as well as patients and Healthwatch. The group met five times to narrow down and score the options according to criteria the group felt were most important.
These criteria included service quality, waiting times, how easy the facilities were to reach, car parking and whether the services met local health needs. Again we asked people to score the options and the results are available in the PCBC.
The West Midlands Clinical Senate considered the proposals and the process we had been through to make sure we were not proposing to do anything that would be unsafe and that we would be making improvements for patients. Members of the Senate came to visit us and they considered the model of care from a clinical perspective. The first time we met with them, they made recommendations which we made sure we had addressed. They published their final opinion of our proposals [here]
We kept people updated about the process we were going through in a regular newsletter and we published everything on our website.
NHS England are assured that we have been thorough in the way we have developed the proposals and we have worked with the Consultation Institute to make sure that we have followed best practice along the way.
The Pre-Consultation Business Case was considered by the CCGs’ Governing Bodies at a meeting held in public to create a final shortlist of options for both community hubs and beds which we are now consulting on.
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WHAT WE ARE CONSULTING ON
In the introduction to this document, we described some of the challenges facing health and social care in North Staffordshire and Stoke-on-Trent. We also explained some of the ways we could address these challenges through the new model of care.
Some of our proposals involve changing the way we provide local services and where they are based, so public consultation is important and necessary to inform our decisions.
These changes would affect:
- Wider community services - NHS community based beds - Some specialist services
In this section of the document, we summarise the options for change. We will also tell you which is the preferred option and why but this doesn’t mean that we have made any decisions. .
You can find more detailed information about each of these options, the case for change, the potential impact of different options and how we assessed the options for change by reviewing documents, such as the Pre-Consultation Business Case Equality Impact assessment and Quality Impact Assessment on our website - www.healthservicesnorthstaffs.nhs.uk.
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INTEGRATED CARE HUBS
We aim to create four bases, called “integrated care hubs”, where people can get specialist health and social care close to home. These hubs would be based in Newcastle under Lyme, Stoke North, Stoke South and Staffordshire Moorlands. The hubs would mean patients, particularly those who are old or frail, will no longer need to travel to a large hospital for support.
We now want to know where, within these areas, you think the hubs should be.
We have narrowed down a long list of 13 options to a short-list of eight. These eight include one, two or three options for each of the hubs. These choices were put together by thinking about what the needs of local people, the services we need to deliver from the community hubs, how many hubs should be developed and where they should be located.
All of the options have been developed having considered:
Meeting the health needs of local people Delivering high-quality care Whether they would work in the future Accessibility (travel times and distances, public transport links). Costs
INTEGRATED CARE HUBS: STOKE SOUTH OPTIONS
A proposal to keep the Longton Cottage Hospital was not included in the final short list as it would be too expensive to make it safe and fit for purpose. The options for the location of an integrated care hub in the South of Stoke-on-Trent are:
Option 1A:
A hub could be based in Longton with services delivered from a new site built to meet the needs of local people. The purpose built facility would be built alongside a new GP facility that is being funded by the NHS Estates, Technology and Transformation Fund - a multi-million-pound investment in general practice facilities and technology across England. This is our Preferred option
Advantages Disadvantages We would deliver an “integrated care This option would require a large hub” from a new building, which would amount of building work, which would Page 235 of 287
be designed to suit local people’s cost between £6.89 million and £9.64 needs. million. As it would be a new purpose built It would take a while to build the new facility, we could offer a higher quality facility of care could be expected than at Longton Cottage Hospital would no Option 1B. longer be required The site would be easily reached by car and bus. It is marginally quicker for people in the area to reach than Option 1B.
Option 1B:
A hub could be delivered from the building at Meir Primary Care Centre.
Advantages Disadvantages We would provide specialist care The Meir site would need some services from an “integrated care hub”, building work to make sure it is suitable at Meir Primary Care Centre on for the hub’s needs. This work would Weston Road. cost between £880,000 and £1.23 The hub would be easily to reach by million. car and bus. Longton Cottage Hospital would no This is a cheaper option than 1A. longer be required
INTEGRATED CARE HUBS: STAFFORDSHIRE MOORLANDS OPTIONS
As outlined in the Pre-Consultation Business case, following the first process of scoring the options for the Staffordshire Moorlands, the Technical Group recommended that further analysis of new options be undertaken. A proposal to develop a completely new site in Leek scored comparatively well in terms of the capital investment that would be needed. However, appropriate land or estate would need to be purchased to enable the development. This reduced the deliverability of this option. There was a lack of detail available about a potential site, funding, ownership and logistics meant that this option was removed from the proposals.
We know that there is a great deal of public feeling about both Leek & Moorlands and Cheadle Community hospitals but the population size means that we need to decide on the best single location for the integrated care hub to serve the people of Staffordshire Moorlands. We have considered several options and would welcome your feedback on them as we need to know which would be the most acceptable to local people. Page 236 of 287
Option 2A: Leek Refurbish
We could refurbish the current hospital estate to turn it into a community hub.
Advantages Disadvantages Leek Community Hospital would be The site would be more difficult for the people retained in its current form which is of Cheadle to reach. important to local people . This would require significant internal building The hub would be easily to reach by modification to improve accessibility; for car and bus. example widening of corridors, repositioning of fire escapes and reconfiguration of clinical space.
Option 2A: Leek Rebuild
An option to rebuild the current Leek & Moorlands Community Hospital would involve building a new hub on the location of the existing Leek Community hospital site.
Advantages Disadvantages We would deliver an “integrated care The site would be more difficult for the hub”, as we described earlier, from a people of Cheadle to reach. rebuilt, state of the art Leek Moorlands MPFT would need to use other existing Community Hospital. buildings to accommodate services The grade 2 listed aspect of the whilst build works are undertaken on Hospital would be retained. the Leek site. This would be a short The hub would be easily to reach by term problem. car and bus. a new build would be more financially sustainable and would future proof the model of care in Leek
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The scoring undertaken highlighted the relative high ranking of the Rebuild Leek option and as such its status as the provisional preferred option.
Technical Group scoring of the option, showed benefits were based upon:
Accessibility. The hub would be on the existing Leek community site, which the Technical Group scored considered the best for accessibility Quality. As the option would be a new build, it would be developed to be fit for purpose and as such addresses some of the quality concerns with the proposal to refurbish the Hospital
The Reference Group scored the option of a hub at the Leek Hospital site as the highest and so a hub at the Leek Community Hospital would align to this preference
The rebuild of Leek Hospital would ensure that existing NHS assets are maximised; rather than selling the site to buy a new site in Leek town centre.
This option is cheaper than Option 2C and costs around the same as Option 2B. Quality of care is expected to be similar to Option 2B and Option 2C.
This is our Preferred option
Option 2B:
One hub with services delivered from a new site (Kniveden)
Advantages Disadvantages We would deliver an “integrated care The option would require a large hub”, as we described earlier, from amount of building work upfront, which Kniveden, which would be designed to would cost between £4.88 million and suit the hub’s specific needs. £6.83 million. This option is less easy to get to by car The quality of care is expected to be and bus. similar to Option 2A and Option 2C
Option 2C:
A hub with services delivered from Cheadle Community Hospital
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Advantages Disadvantages We would deliver an “integrated care Cheadle Community Hospital is an old hub”, as we described earlier, from the building and would need some existing Cheadle Community Hospital maintenance work before it could site on Royal Walk. reopen as a hub. This would cost The hub would be easy to reach by car between £3.9 million and £4.8 million. and bus. We would no longer need Leek Quality of care is expected to be similar Moorlands Community Hospital to Option 2A and Option 2B. This option is cheaper than Option 2B.
INTEGRATED CARE HUBS: NEWCASTLE-UNDER-LYME OPTIONS
Option 3A:
One hub with services delivered from Bradwell Community Hospital.
Advantages Disadvantages We would deliver an “integrated care The building is old, so we would need hub” from Bradwell Community to do some building work to make this Hospital. happen. This work would cost £5.89 The hospital is easy to reach by bus million and £7.54 million. and car, and sits in pleasant grounds.
This is our Preferred option
Option 3B:
One hub with services delivered from the NHS building at the Milehouse building at Millrise Village on Lymebrook Way,
Advantages Disadvantages We would deliver an “integrated care We would need to invest between hub from the more modern Milehouse £0.95 million and £1.32 million to make which is where some GP practices are this happen. already located.
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INTEGRATED CARE HUBS: STOKE NORTH OPTION
Option 4A:
One hub with services delivered from Haywood Community Hospital.
Advantages Disadvantages We would deliver an “integrated care This option would initially cost us hub” from Haywood Community between £6.6 million and £8.2 million. Hospital, as we described earlier, from a site that is modern and fit-for-use. The hospital is easily accessible by bus and car.
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COMMUNITY HOSPITAL AND NHS CARE HOME BEDS
Currently, people access community services at five hospitals across North Staffordshire and Stoke-on-Trent. These are Haywood Hospital, Leek Moorlands Hospital, Longton Cottage Hospital, Cheadle Hospital and Bradwell Hospital.
The conditions of these hospitals vary. Leek and Longton Hospitals have Victorian buildings that were not designed for modern healthcare and would need significant investment before they could be fit for use.
Haywood Hospital is the newest of the buildings – it was built between 1995 and 2004. It is the most suitable for delivering modern community healthcare, has the most parking and is the easiest to travel to. It also has the most space, which is important when it comes to finding somewhere that can host a range of services.
In the financial year 2015/16, Staffordshire and Stoke-on-Trent had 264 community hospital rehabilitation beds across its sites – far more than similar areas. It struggled to hire enough skilled workers to staff them.
We think too many people are having rehabilitation care from hospital beds when they could have stayed at home or had their treatment in the community.
Patients’ health tends to go downhill quickly if they stay in a hospital bed when they are well enough to go home. Some of our most frail and vulnerable patients live in care homes, and evidence suggests they are admitted to hospital too often and stay there too long.
Options
While our new approach is centred on developing wide-ranging, out-of-hospital services, we know there will be times when people will need to be assessed, or treated, in a community hospital or care home bed.
As outlined in the Our proposed model of care, North Staffordshire and Stoke-on-Trent will need approximately132 beds in this new approach with an ability to flex the numbers up and down a little when we need to. To help you to understand how we got to this number we have written a document [append spotlight on beds]
We want to know where you think these beds should be.
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We have narrowed down a list of 63 options to six for this consultation. These options were put together by looking at how many beds may be required how many sites they could be delivered from and which sites could be used. You can find out more about how we reduced the options in our Pre- Consultation Business Case on our website: https://www.healthservicesnorthstaffs.nhs.uk
The options include a mix of existing community hospitals and care homes. Care homes could be used to provide short-term support. We would put safety measures in place to make sure that the care given meets our high standards. You will see that all options look to use Haywood Hospital – that is because it is modern and fit-for-use.
‘Doing nothing’ is not an option because it would not address unnecessary hospital admissions and prolonged inpatient stays.
All six options will offer care in more modern settings, will last into the future and are cost effective. Most importantly, they will help patients get home sooner and recover quicker.
Community hospital beds: Option 1 To provide all 132 beds at Haywood Community Hospital.
What does this option mean for patients?
We would deliver all assessments and short-term care to people in beds at Haywood Hospital. This is the most modern and fit-for-use community hospital in the area. Patients could expect a pleasant setting, which is easy to reach by bus and car. There is plenty of parking. For quality care, this option ranked highest in our analysis. We would need to expand the site to add an extra 65 beds for this option, which would cost around £1.02 million.
Community hospital beds: Option 2
Option 2 involves providing 77 at Haywood Community Hospital and 55 at Leek Moorlands Community Hospital.
Patients would receive assessments in 55 beds at Leek Moorlands Community Hospital. Any short-term inpatient care would be delivered in the beds at Haywood Community Hospital.
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What does this option mean for patients?
Haywood Community Hospital is the most modern and fit-for-use community hospital in the area. Patients can expect pleasant surroundings there. Both sites are easy to get to by bus and car. Leek Moorlands is an older building so we will need to spend £3 million to make it safe and ready to reopen.
Community hospital beds: Option 3
Option 3 involves providing 132 beds. This includes 77 at Haywood Community Hospital and 55 at Longton Cottage Hospital.
Patients would receive assessments in 55 beds at Longton Cottage Hospital. Any short-term inpatient care would be delivered to patients in the beds at Haywood Community Hospital.
What does this option mean for patients? Haywood Community Hospital is the most modern and fit-for-purpose community hospital in the area. Patients can expect pleasant surroundings there. Both sites are easy to get to by bus and car. Longton Cottage Hospital is one of the oldest community hospitals in our area so we would need to do some building work before it could be reopened. However, the work required is not as extensive as Option 2. We would need to invest £600,000 to reopen it.
Community hospital beds: Option 4
Option 4 involves providing 132 beds. This includes 77 at Haywood Community Hospital and 55 at Cheadle Community Hospital.
What does this option mean for patients? Care would again be shared across two sites. Haywood Community Hospital, as the most modern community hospital, offers pleasant surroundings for treatment. Both sites are easy to get to by bus and car, with plenty of parking. Cheadle Community Hospital is an older building. It is the second most expensive to reopen, after Option 2, because of the building work it needs. It will cost £1.63 million to reopen the Cheadle site. Page 243 of 287
Community hospital beds: Option 5
Option 5 involves providing 132 beds. This includes 77 at Haywood Community Hospital and 55 at Bradwell Community Hospital.
What does this option mean for patients?
Again, Haywood Community Hospital is the most modern and fit-for-purpose community hospital in the area. Patients receiving short-term care there can expect to be in pleasant surroundings. During our pre-consultation discussions, some people were worried that Bradwell Community Hospital would be more difficult to access than other sites. However, our analysis shows the average travel time by car to the hospital is in line with the other options. Both sites can be accessed by bus and car. Bradwell Community Hospital has space for the beds we need but, as it is an older building, we would need to invest £1.5 million in building work to get it reopened.
Community hospital beds: Option 6
Option 6 involves providing 132 beds. This includes 77 at Haywood Community Hospital and the remainder as NHS-commissioned beds in local care homes.
We would provide care from 77 beds at Haywood Community Hospital. The other 55 beds would be commissioned by the NHS from local care homes rated ‘good’ or ‘outstanding’.
What does this option mean for patients?
This is the only option that includes care home beds. It is the closest option for local people, in terms of travel time and distance – by car and bus. It is also the cheapest option - Haywood doesn’t need any building work and has no recurring costs. We would need to pay around £4.3 million per year by 2022/23 for care home costs. People have told us they are concerned about the quality of care at care homes. We have plans to make sure we can uphold high NHS standards if this option is chosen.
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Preferred option Our preferred option is Option 6. We believe this option offers the best balance of cost, ease of access, its alignment with NHS strategy and the quality of services it promises.
Using our scoring method, Option 6 came out on top. It scored highest in all criteria apart from ‘quality of care’. We have listened to concerns about care quality at care homes and identified ways to make sure high NHS standards are met and maintained should this option be chosen. You can find out more about these options, as well as our scoring system, in the Pre-Consultation Business Case on our website: https://www.healthservicesnorthstaffs.nhs.uk
Specialist services delivered by specialist consultant’s clinics (Tier 4 Services)
As part of the proposals for change in the Staffordshire Moorlands, it is proposed that some services currently provided from Leek Moorlands Community Hospital be moved to Royal Stoke Hospital. This is because they have small numbers of people using the services and there are issues with waiting times. The CCGs consider that the provision of these Tier 4 services which are specialist services delivered by specialist consultants clinics would not be viable because this precious resource needed to be co-located within the acute trust at UHNM side by side with the specialist diagnostic equipment required for these procedures to be undertaken safely.
This was discussed as part of the Pre-consultation activity and was fed back to consultees via the ‘You Said, We Did’ document. As such, in line with the STP plans around planned care, it is proposed that Tier 4 services will no longer be delivered from the hub locations. The Healthy Staffordshire Select Committee was asked to consider whether they consider this to be a substantive variation which they confirmed and as such these proposals to relocate services will be included in the scope of the consultation. The services and associated activity levels are as follows:
Services that it is proposed will not operate out of Hubs that are currently delivered from Leek Moorlands Hospital community hospital
Tier 4 Services: UHNM Consultant led Leek Moorlands Hospital
Colorectal 110
Dermatology 773
Nephrology 107
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Neurology 193
Trauma and Orthopaedic Surgery 121
General Surgery 264
(NB data shows contacts per year not patients per year which will be fewer as a single patient may have several contacts during a year) HOW YOU CAN HAVE YOUR SAY
We welcome all responses to this consultation.
We have developed a consultation plan based on our equality impact assessment and what we know about our local people and our stakeholders. We will be targeting certain groups of people to make sure that we have heard voices from across the north of Staffordshire. We will of course, also be encouraging NHS and partner staff, clinicians and politicians to respond to this consultation. To help us with this we have undertaken stakeholder analysis and we will be checking along the way to make sure that we have representatives of all groups in the responses.
You can respond by completing the questionnaire at the end of this document. Simply tear off the questionnaire, complete it and send it to:
Freepost Plus RTAA-XTHA-LGGC, Communications, Heron House, 120 Grove Road, Stoke-on-Trent ST4 4LX
There is no need to use a stamp.
Alternatively, you can visit the consultation website and fill in the questionnaire online. https://www.healthservicesnorthstaffs.nhs.uk/
Details of upcoming consultation activities, background documents and more information about this consultation can be found on the consultation website.
If you would like hard copies of the documents, alternative formats or help to complete the survey, please let us know.
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If you would like to receive our regular electronic newsletter with updates on different activities please email [email protected] and we will add you to the mailing list.
WHAT HAPPENS NEXT?
This consultation will run for 12 weeks from 5th December 2018 to 13th March 2019.
The responses received during the consultation will be analysed independently. The independent report will be published within 12 weeks of the consultation ending. The report will be presented to the North Staffordshire and Stoke-on-Trent Clinical Commissioning Groups for consideration before any decisions on service change are taken.
Once the Governing Body has made their decisions, we will be letting everyone know the outcome than the hard word to implement the changes will begin and we will keep you update don our progress.
The decision making process will be assured by NHS England and the Consultation Institute.
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GLOSSARY
Care Quality Commission - the independent regulator of all health and social care services in England.
Clinical Commissioning Groups - GP-led groups responsible for planning and commissioning hospital and community health services in their local area. Commissioning involves deciding what services are needed for a wide variety of local people and making sure they are provided. There are 195 across NHS England.
The Consultation Institute – a UK-based, not-for-profit organisation that offers expert advice and guidance on public consultation and engagement.
West Midlands Clinical Senate - a non-statutory advisory body covering the West Midlands. It offers independent, strategic advice and guidance to health commissioners and other stakeholders to help them make the best decisions for the people they represent.
Care
Community care – the care people receive close to home or in the home, typically from health visitors, district nurses or physiotherapists.
Integrated care – care that puts the patient’s needs at the centre of everything that is done for them. It is coordinated care that encourages medical professionals to work together to identify the best options for the patient. The aim is to avoid care being disjointed, confused, duplicated or delayed.
Primary care - the advice, care and treatment people receive from their GP.
Services
Social care services – practical help offered to people who have an illness, disability, are old or on a low income. Support ranges from community activities to help at home.
Home First – a service that supports people’s healthcare needs at home. It helps people avoid unnecessary hospital stays or to leave hospital sooner. The aim is to help people be as healthy and independent as possible.
NHS plans
Sustainability and Transformation Plan – multi-year NHS health plans built around the needs of local people in a specific place.
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Five Year Forward View – a document that sets out a clear direction for the NHS until 2020, showing why change is needed and what it will look like.
General Practice Forward View – a document that outlines the challenges facing general practitioners and the general practice service in Britain, and plans to tackle them. It commits to an extra £2.4 billion a year to support these services by 2020/21.
NHS Estates, Technology and Transformation Fund - a multi-million pound investment in general practice facilities and technology across England between 2015/16 and 2019/20. It is part of the General Practice Forward View’s commitment to more modernised buildings and better use of technology to improve general practices services for patients.
Emergency Care Improvement Programme – a clinically-led programme that offers intensive practical help and support to 40 urgent and emergency care systems across England. The aim is safer, faster and better care for patients.
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CONSULTATION QUESTIONNAIRE
This questionnaire is in two parts. Part One looks at the options for change described in this consultation document and Part Two is about your personal circumstances. You don’t have to answer the questions in Part Two but, if you are able to do so, it would help us to better understand the impact of any potential service changes upon different groups of people.
Could you please begin by giving us your postcode leaving out the last two letters. For example, if your postcode is CA19 4QS, enter “CA194”; if it is CA28 7AA, enter “CA287” This means that we know which area you live in but we cannot identify your home. It will help us to make sure that we have gathered enough views from people in each area as we will review this throughout the consultation period.
The first half of my post code is:
Part One
Question 1 We would create four specialist integrated care hubs in Staffordshire Moorlands, Newcastle-under-Lyme, Stoke North and Stoke South so patients can get the care they need closer to home .Thinking about this proposed approach, please indicate your overall feeling below.
Strongly Disagree Neither agree Agree Strongly agree disagree nor disagree
Please include any comments you may have on this approach below (optional):
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Integrated care hubs
Question 2 We have explained a number of options for the future provision of integrated and expanded community services in Stoke South, Stoke North, Staffordshie Moorlands and Newcastle. Each option proposes the location of the hub in each area. To remind you, we have shaded our preferred option for each location.
Please indicate how you feel about each option by ticking the relevant boxes below.
Locality Option Strongly Disagree Neither Agree Strongly disagree agree agree nor disagree Stoke South 1a Hub services delivered (Longton) from a new purpose built site in Longton 1b Hub services delivered from MEIR Tell us which is your preferred option Staffordshire 2a Hub services delivered Moorlands refurbish from the existing but (Leek, refurbished Leek Cheadle) Moorlands Community Hospital 2a Hub services delivered Rebuild from a rebuilt facility at the existing Leek hospital site 2b Hub services delivered Kniveden
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2c Hub services delivered from existing Cheadle hospital site Tell us which is your preferred option Newcastle 3a Hub services delivered Under Lyme from existing Bradwell (Bradwell) hospital site 3b Hub services delivered from Milehouse Tell us which is your preferred option Stoke North 4a Hub services delivered (Haywood) from Haywood hospital
You may also wish to offer alternative ideas of your own.
Stoke South:
Staffordshire Moorlands:
Newcastle:
Stoke North:
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Community rehabilitation hospital beds
Question 3a
We have outlined six options for the future provision of community hospital beds in North Staffordshire and Stoke-on-Trent. Please indicate how you feel about each option by ticking the relevant boxes below.
Strongly Disagree Neither Agree Strongly disagree agree agree nor disagree Option 1 Provide all beds at Haywood Community Hospital Option 2 Provide beds at Haywood Community Hospital and Leek Moorlands Community Hospital Option 3 Provide beds at Haywood Community Hospital and Longton Cottage Hospital Option 4 Provide beds at Haywood Community Hospital and Cheadle Community Hospital Option 5 Provide beds at Haywood Community Hospital and Bradwell Community Hospital Page 253 of 287
Option 6 Provide beds at Haywood Community Hospital and the remainder as NHS commissioned beds in local care homes
Question 3b Please tell us which is your preferred option for community beds and why. You may also wish to offer alternative ideas of your own.
Question 3c Option 6 would see 55 beds being provided in local care homes. During the pre-consultation process, some people were worried about the quality of care at these homes. We would only commission from NHS care homes with strict quality checks and rated ‘good’ or ‘outstanding’ by the Care Quality Commission and would introduce close quality checks. We have written a document to explain this (appendix spotlight). Would this alleviate any concerns you may have about this option?
I would still have concerns My concerns would be alleviated a little This would somewhat alleviate my concerns I would support this option if these checks were put in place
Question 4 As part of the proposals for change in the Staffordshire Moorlands, it is proposed that some specialist services currently provided from Leek Moorlands Community Hospital with small numbers of people using the services and long waiting times be moved to Royal Stoke Hospital. This would mean that specialists could better meet patient needs and clinic space could be freed up to provide community based services. Please indicate your strength of feeling for this proposed change below. Page 254 of 287
The disadvantage of this proposal would be the additional travel time and inconvenience of accessing specialist services from UHNM.
Strongly Disagree Neither Agree Strongly disagree agree nor agree disagree colorectal
dermatology nephrology neurology Trauma & orthopaedics general surgery
Question 5 How do you think the options contained in this consultation document will particularly affect you?
Question 6 How would you normally travel to your local NHS hospital?
[OPTION BOX – own car, on foot, public transport, taken by friend, taken by relative, other]
Question 7 Do you have any concerns about being able to travel to or access any services? What would need to happen to make this less of a concern for you?
Question 8 Do you have any other views you wish to share with us on the ideas described in this consultation document?
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Part Two – About You
We would like to understand more about you so that we can be sure we have received responses from the range of different people in our diverse community and so that we can better understand the background to your responses (for example, where you live in relation to your nearest hospital). You can help us by completing this part of the consultation questionnaire but this is entirely voluntary.
Have you read the consultation document?
Yes No
What is your age?
Five year ranges 16-80 then 80+
What is your gender?
Male – Female – Prefer not to say
Is your gender different to that assigned to you at birth?
Yes – No – Prefer not to say
Are you married or in a civil partnership?
Yes – No – Prefer not to say
What is your sexual orientation?
Heterosexual Gay woman/lesbian Gay man Bisexual Prefer not to say If other, please write in:
What is your religion or belief? Page 256 of 287
No religion or belief Buddhist Christian Hindu Jewish Muslim Sikh Prefer not to say If other religion or belief, please write in:
What is your ethnicity?
Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the appropriate box
White English Welsh Scottish Northern Irish Irish British Gypsy or Irish Traveller Prefer not to say
Any other white background, please write in:
Mixed/multiple ethnic groups White and Black Caribbean White and Black African White and Asian Prefer not to say Any other mixed background, please write in:
Asian/Asian British Indian Pakistani Bangladeshi Chinese Prefer not to say Any other Asian background, please write in:
Black/ African/ Caribbean/ Black British African Caribbean Prefer not to say Any other Black/African/Caribbean background, please write in:
Other (please write in):
Do you consider yourself to have a disability or long term health condition?
Yes No Prefer not to say
If you wish to give further information, please do so here: Page 257 of 287
Do you have caring responsibilities? If yes, please tick all that apply
None Primary carer of a child/children (under 18) Primary carer of disabled child/children Primary carer of disabled adult (18 and over) Primary carer of older person Secondary carer (another person carries out the main caring role) Prefer not to say
Are you currently pregnant?
Yes – No – Prefer not to say
Do you have a child under 24 months?
Yes – No – Prefer not to say
]A[ppApp
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Appendix 19: Consultation Analysis Plan The Future of Local Health Services: North Staffordshire and Stoke-on-Trent Consultation Analysis Plan
Client: North Staffordshire CCG and Stoke-on-Trent CCG Date of Issue: August 2018
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Table of Contents Aims and main deliverables ...... 3 Consultation services – main elements ...... 3 Consultation survey: uploading, testing and hosting and IG statement preparation ...... 3 Designing consultation document ...... 3 Consultation survey data entry, processing and analysis ...... 4 Correspondence: logging, reading, analysing and reporting ...... 4 Consultation report of findings ...... 4 Consultation meetings...... 4
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Aims and main deliverables Aims
Consultation support services for the North Staffordshire and Stoke-on-Trent CCG’s future of local health services consultation. Main deliverables
Uploading and hosting of the consultation survey and preparation of IG statement. Design of consultation document with a tear-off consultation survey. Analysis, including open response coding and tabulation of all consultation survey questions (28 questions including 7 open questions). Collation, reading, coding of 20 correspondence items received (i.e. letters and emails). Production of a final report of findings including feedback from the consultation survey and correspondence and also including introduction, background and engagement methodology. Attendance at weekly consultation project meeting and arranging and attending a mid-point review meeting and post consultation review meeting.
Consultation services – main elements Consultation survey: uploading, testing and hosting and IG statement preparation
The Engagement, Involvement and Insight specialists will read the PCBC document and upload, host and internally test the survey ready for online launch. Once the online survey is ready to go ‘live’ a URL link will be available to embed and post on social media to promote the survey. Appropriate privacy impact assessment will be completed and the questionnaire will have information governance statements in place, to meet GDPR 2018 requirements. A reporting link will be available throughout the consultation period to continually review responses to the survey in real time.
Designing consultation document
Upon receipt of the consultation document content, our in-house Campaigns, Creative & Digital team will work with you to identify your preferences around the look and feel of the consultation document. Once identified, our designers within the team will use the foundations of your preferences to design an engaging public facing consultation document. They will also use these guidelines to develop a ‘tear-off’ paper version of the survey which will sit at the back of the consultation document. Please note
This proposal assumes the designed consultation document will be no more than 40 pages in length, 32 pages providing information around the consultation and 8 pages for the tear-off paper survey. We have allocated 40 hours of design time to produce the consultation document and tear-off paper survey. If any further time is required, we will ask you to confirm you are happy for us to proceed before continuing. The allocated design time encompasses the time to create an initial draft of the consultation document and tear-off survey, followed by two sets of amendments. Any further rounds of amendments will then incur additional charge.
3
Consultation survey data entry, processing and analysis
Open questions (qualitative responses) will be read and coded. Every response from every question will be read and coded against a coding frame of key themes. The coding frame will be developed from the responses received (and not predetermined) so that no theme is hidden or not considered. During the coding of open questions exemplar quotations will be identified for insertion into the consultation report of findings. All questions will be tabulated against the 9 protected characteristics and by geography (using postcode data supplied). Scope has been provided to read and code up to 1,750 open responses from questions within the questionnaire. This has been calculated based on submission of 500 surveys and assuming the completion of half of the 7 open questions on average per survey.
Correspondence: logging, reading, analysing and reporting
Scope has been provided to receive and manage 20 items of correspondence. Over 20 items will be charged per item of correspondence received (see costs for further details). We expect these to be in the form of letters and emails from all stakeholders. Time has been provided to receive and log each item. Each item will be read and coded using the coding frames developed to analyse the open questions in the main survey. Appropriate quotations will also be identified for use in the consultation report of findings.
Consultation report of findings
The consultation report of findings will be structured to reflect the scale of the consultation, including identification of the key stakeholders (see example of the report structure). This report will; o Contain charts and graphs summarising the responses to the questions. o Highlight key differences between sub-groups (please note: these will not be significance tested). o Contain quotes for key themes to bring the essence of what was being said to life. The report will 20 – 30 pages, followed by the appendices This can be produced using your standard reporting template or ours. Deliverables Consultation report
Introduction and background Engagement methodology Profile of respondents Feedback from the online survey Feedback from the correspondence Appendices End of consultation review
Consultation meetings
Time has been provided for the following meetings: A mid-point review. We will structure, arrange and attend a mid-point review meeting. Appropriate material will be provided to review the promotion and engagement with the consultation. An end of consultation review meeting. We will structure, arrange and attend an end of consultation review meeting. Focus will be on ensuring that all stakeholders have been engaged, discuss any consultation governance queries and how to address these and the next steps to the production of the consultation report of findings.
4
Attendance at a weekly consultation catch-up teleconference. We can use this time to provide advice and guidance during the consultation. We have provided time to attend two meetings either side of the consultation period.
5
Contact:
E: [email protected] M: 07702 683 832
E: [email protected] M: 07919 175 711
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Appendix 20: Letters of support
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Appendix 21 Return on Investment (ROI)
Overview This annex explores the potential activity and length of stay benefits associated with the development of the hubs. In order to develop a view of these benefits we have sought to triangulate various sources of evidence. This annex demonstrates that:
1. The hubs could significantly reduce over reliance on hospital based services, particularly for the frail and elderly population; 2. These benefits could translate to significant system cost savings, supporting the affordability of the hubs; and 3. In order to breakeven, only a small quantum of the overall benchmarked opportunity needs to be achieved. The remainder of this annex sets out:
. Our approach and outputs of the top-down analysis; . Relevant precedent and benchmarking; and . The core assumptions behind the activity undertaken
Top-down benchmarking approach Based on discussions with clinicians it has been identified that the hubs should positively impact A&E attendances, non-elective admissions and length of stay; reducing the reliance on hospital services from both a volume, self-management and patient outcomes perspective. This is the core premise of the transformation of the care delivery model, the reason the changes are being proposed. To understand baseline performance across these metrics, and therefore opportunity, top-down benchmarking has been conducted in the following areas.
9. A&E Attendances Benchmarking. To estimate the opportunity in Accident and Emergency Attendances the proportion of unnecessary A&E attendances has been compared against the average and top quartile of a peer group of 10 trusts (selected based on the Trust Peer Finder tool). Source data: NHS Digital - Unnecessary A&E Attendances tool (16/17 HES data) and NHS Trust Peer Finder
10. Non-Elective (NEL) Activity Benchmarking. To estimate the opportunity in non-elective admissions, the number of admissions per 10,000 population, for each of the two CCGs, has been compared to the average and top quartile of peers across 10 CCGs. To convert this to a cost saving, reference costs for UHNM have been applied to the volume of admissions saved. The total cost saving is then scaled to take account of fixed and semi- fixed costs. This is undertaken by assuming costs breakdown; fixed costs (20%), semi-fixed (60%) and variable costs (20%). All fixed costs are assumed to remain, 70% of semi-fixed costs and all variable
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costs are assumed to be saved. This approach means we focus on the potential system cost savings, rather than income saving under PbR tariff. Source data: 16/17 Monthly Activity Return & 15/16 Reference Costs (HRG level)
11. Non-Elective and Elective (EL) Length of Stay (LoS) Benchmarking. Opportunities relating to LoS are estimated by comparing the average length of stay for University Hospitals of North Midlands NHS Trust to a peer group (of all non-teaching acute trusts) at a HRG level. A large peer group was required here to overcome small sample biases and any currencies with less than 5 units of activity are not included within the benchmarking analysis. Cost savings are then estimated using cost elasticities obtained through statistical benchmarking, this analysis shows that the bed element of an admission cost is c.60% and c.40% for elective and non-elective bed days respectively. Source data: 15/16 Reference Costs (HRG level)
Top-down benchmarking outputs The table below sets out the top-down opportunity available from achieving top-quartile performance across the four metrics considered. The tables present the total opportunity of all patients were considered, as well as further analysis below this table which outlines the relative impacts for the cohort of patients being targeted (over 65s with LTCs sub-groups).
TABLE 63: TOP-DOWN OPPORTUNITY ANALYSIS
Point of Unit Activity Total Cost Top Quartile Activity Cost Impact Delivery Year 5 (m) Opportunity (%) Impact (m)
A&E Attendances 165,616 £32.3 0.0% - -
NEL Spells 56,377 £185.3 14.0% 7,893 £16.1
NEL Bed days 271,446 £74.1 23.6% 64,061 £17.5
EL Bed days 42,325 £28.3 19.5% 8,253 £5.5
SOURCE: BASED ON A LITERATURE REVIEW OF SIMILAR CARE MODELS AND THEIR PUBLISHED IMPACTS. IT IS NOTED THAT THE VARIANCE BETWEEN THE OPPORTUNITY ANALYSIS FOR LENGTH OF STAY HERE AND IN SECTION 2.2 IS THAT THIS ANALYSIS IS BASED ON A MORE DETAILED POD AND SPECIALTY BREAKDOWN WHICH DEMONSTRATES A LARGER OPPORTUNITY. THE NON-ELECTIVE BENCHMARKING IS THE SAME AS SECTION 2.2.
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As outlined in the main body, Section 4.5.10, the break-even requirement is a total reduction in non-elective admissions of c.3.2%, relating to 1,800 spells. The analysis above demonstrates that there is significantly greater opportunity, compared to this breakeven point.
Whilst this analysis is useful to demonstrate that the breakeven point should be achievable, the care model will primarily target the over 65s with long term conditions. The impacts for this cohort are outlined in further detail below.
Point of Unit Activity Total Cost Top Quartile Activity Cost Impact Delivery Year 5 (m) Opportunity (%) Impact (m)
A&E Attendances 47,257 £9.7 0.0% - -
NEL Spells 23,407 £100.9 14.0% 3,277 £8.8
NEL Bed days 140,489 £38.3 23.6% 33,155 £9.1
EL Bed days 21,906 £14.7 19.5% 4,272 £2.9
Based on the size of this cohort and higher unit cost, the breakeven reduction required for this patient group is:
1. Non-elective admissions. If we focus just on non-elective admissions, a 5.3% reduction would be required, relating to c.1,250 spells. This highlights that less than half of the total benchmarked opportunity (14% - c.3,280 spells (c.£8.8m)), as highlighted in the table above, would need to be achieved to balance the affordability of the hubs. 2. Wider impacts. The table above demonstrates the impact of a number of wider impacts for the over 65s with LTC cohort, this includes a c.23.6% NEL beddays opportunity to upper quartile which relates to c.£9.1m. If we assume the care model could have wider impacts on length as well, the improvement required across this cohort does fall to reach breakeven. Moreover, we would only need to achieve c.16% of the total benchmarked opportunity to top-quartile for the over 65s; translating to a reduction of only 2.3% in non-elective admissions, 3.8% in NEL LoS and 3.2% EL LoS.18
The estimated c.1,250 spells reduction required for the over 65s with long term conditions cohort translates
18 Given the large elective opportunity estimated from the top-down analysis, elective length of stay benefits have also been included in this analysis. This is supported by the precedent presented later in this section which demonstrates length of stay opportunities from similar interventions in other systems.
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to an approximate 26 reductions per hub per month required for the hubs to breakeven. This is significantly lower than the aspirational reduction of c.48 per hub, per month (outlined in section 3.5.2) which is based on the care model being implemented (further information on benefits outlined in section 6.4.7). This again depicts that the breakeven requirements of the hubs are not significant when compared to the top-down opportunity, precedent and aspirational impacts of the care model.
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Precedent for impacts from literature We have undertaken a literature review to understand the impact of similar clinical models on the frail and elderly population. The literature shows that there is a large opportunity to reduce non-elective admissions, length of stay and A&E attendances. This supports the top-down analysis, suggesting that the opportunities to breakeven or exceed breakeven are achievable.
TABLE 64: SELECTED PRECEDENT
Populati Interventio Overview on POD Metric Impact Source n cohort Discharge to Assess interventions in Sheffield found lead Frail and Estimated from Monitor, Moving care closer to to a reduction in the Discharge Elderly, EL, 40% LoS home (2015). A strategy for urgent care length of Stay for to Assess LTC, MH NEL reduction transformation in Birmingham Frail and Elderly population sub group Discharge to assess leading to reduction Discharge Frail and 13% https://www.ncbi.nlm.nih.gov/pubmed/20091507 in non-elective NEL LoS to Assess Elderly reduction inpatient length of stay impacts Integrated service Admissi Integrated 30% https://www.stockport- solution delivered ons, neighbourh 15% reduction together.co.uk/application/files/3614/6943/4316/ through a MCP NEL, attenda ood teams most at Business_case_- provider developed AE nces delivered risk 50% _Stockport_Together_Overview_Design_Business_ from general from a hub reduction Case.pdf practice focussing LoS
19 t
on prevention at scale, transformation of out of hospital care. Step change in Integrated Service redevelopment: Integrated whole system Dementi Admissi 40% dementia system for NEL services for people with dementia. Mersey Care a ons reduction prevention dementia NHS Trust (2012) Impact of a new Triage and emergency Rapid admission avoidance Mean LoS Elderly https://academic.oup.com/ageing/article/43/1/11 system for older Geriatric NEL LoS reduced by Assessmen 6/23376 people on length of 18.16% t Team stay and same-day (TREAT) discharges Impacts of disease management Improved programmes on Frail and Admissi 24% preventativ NEL https://www.ncbi.nlm.nih.gov/pubmed/21323617 population with Elderly ons reduction e care heart disease and diabetes
SOURCE: BASED ON A LITERATURE REVIEW OF SIMILAR CARE MODELS AND THEIR PUBLISHED IMPACT
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Return on Investment (ROI)
The return on investment across the possible hub configuration has been estimated to better understand its affordability. The analysis builds on the possible non-elective reductions outlined above. The two scenarios estimated below relate to the achievement of a conservative 10%, and a more ambitious achievement of 15% reduction in admissions for the 65+ LTC cohort.
The financial estimates for these two scenarios have been obtained through combining Reference Cost data for University Hospital North Midlands (UHNM), to obtain unit costs for non-elective admissions, with Commissioner data to apportion out cost and activity for the cohort in question, and with cost split (fixed, semi-fixed and variable) and cost elasticities to reflect actual cost savings in response to activity reductions.
The achievement of these activity reductions has been phased and present a maximum activity reduction of 5% per year against the baseline position. Note the forecast cost savings outlined below have been based on 16/17 costs, grown in line with cost inflation of 2.1% per annum.
As we can see from the ‘in-year’ cost savings the full 10% non-elective admission reduction is achieved by year 2 (20/21). The 10% reduction is assumed to apply to the original estimated baseline year for all subsequent years (though note in-year savings against the baseline position grow in line with cost inflation). Likewise, the 15% non-elective admission reduction is realized in full by year 3 (21/21) and in- year savings subsequently grow in line with cost inflation only.
The cumulative savings reflect the total difference in costs between the projected baseline and each of the scenarios (i.e. a sum of the in-year savings against the baseline position, where a 10% non-elective activity reduction will generate a recurrent in-year cost saving)
Table 1: Cost Reductions across years 1 - 5
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Table 2: Cost Reductions across years 6 – 10
Based on the profiles outlined above, after 5 years cumulative savings of c.£27.1m and c.£36.2m would be achieved against the baselined for the 10% and 15% sensitivities respectively. After 10 years these cumulative savings would be c.£60.2 and c.£86.0m
These returns are considered against the investment of the hubs, more specifically this relates to the capital expenditure associated with the development of the hubs. The approach and assumptions underpinning these costs are outlined in more detail in the main body. The costs are outlined in the table below.
Table 3: Hub estimated capital expenditure
Combining these elements, two ROIs have been estimated:
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Under the more conservative scenario of a 10% non-elective admission reduction the ROI is -39.9% after 5 years and 33.4% after 10 years. The payback period is 7 years 9 months (2026/27) this is the point where the revenue benefits exceeds capital costs.
Under the more ambitious scenario of a 15% non-elective admission reduction the ROI is -19.8% after 5 years and 90.6% after 10 years. The payback period is 6 years (2024/25) this is the point where the revenue benefits exceeds capital costs.
Other benefits
The PCBC identifies a number of other system and patient benefits that do not release direct financial savings to the CCG, but improve quality of care , patient experience and outcomes. A number of these are described below and benchmarked below against comparator peers.
A&E attendances
As set out in the case for change, performance against the 4 hour target in A&E at UHNM is challenged, with among the lowest in the country and against its comparator peers. As summarised in the Figure below.
A&E performance
90% 85% 80% 75% 70% 65% 60% 55% 50% May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18
Benchmarked trusts UHNM England average
SOURCE: BASED ON A LITERATURE REVIEW OF SIMILAR CARE MODELS AND THEIR PUBLISHED IMPACTS. IT IS NOTED THAT THE VARIANCE BETWEEN THE OPPORTUNITY ANALYSIS FOR LENGTH OF STAY HERE AND IN SECTION 2.2 IS THAT THIS ANALYSIS IS BASED ON A MORE DETAILED POD AND SPECIALTY BREAKDOWN WHICH DEMONSTRATES A LARGER OPPORTUNITY. THE NON- ELECTIVE BENCHMARKING IS THE SAME AS SECTION 2.2.
A&E performance is likely to be driven by a number of factors, including delayed discharges and limited acute care bed capacity. In order to improve A&E performance there is a currently a relatively high number of zero day inpatient admissions, as set out in the table below.
Table 4: Number of zero day inpatient non-elective emergency admissions at CCG, comparator and national level 2017/18
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Zero day inpatient non elective emergency admissions CCG % Rate per 100,000
NHS North Staffordshire CCG 41.6% 5,117 NHS Stoke-on-Trent CCG 44.6% 6,211 Comparator trusts (weighted 30.9% 3,622 average) England 30.5% 3,112
The new model of care is likely to reduce the level of A&E attendances through referral to Track and Triage for suitable patients by WMAS, rather than conveyance to A&E; as illustrated in the example in section 3.5.1 of the business case.19 This is in turn should contribute to:
An improvement in A&E performance; and A reduction in zero day inpatient non-elective admissions. Excess bed days
As set out in the top down analysis, there is an opportunity to reduce length of stay. This is further supported by an assessment of excess bed days. The table below sets out that there is a significant opportunity to improve in this regard.
Excess bed days per 1000 population: North Staffordshire and comparator CCGs
Excess bed days Excess bed day rate per % to upper quartile CCG total (17/18) 000 population performance
NHS North Staffordshire 8,582 35.3 43% CCG NHS Stoke-on-Trent CCG 12,475 39.8 49%
Weighted average 37.8 47% The Home First model will facilitate earlier discharge of patients in acute hospital beds, building on the Discharge to Assess approach, and providing a fully rounded package of intensive home-based support.
Based on reference costs from 2016/17, approximately £14.5m in excess bed day payments were made. The financial analysis has not included this potential. Moreover, NHS England has issued guidance
19 Examples of this have been demonstrated through similar models eg Tower Hamlets WEL Integrated Pioneer Scheme, which demonstrated 15% NEL reductions and 2 A&E attendances avoided per non-elective admission avoided and Stockport Together (30% reduction in A&E attendance). A further evidence base is provided in Transforming urgent and emergency care services in England Safer, faster, better: good practice in delivering urgent and emergency care, NHS England: https://www.england.nhs.uk/wp-content/uploads/2015/06/trans- uec.pdf 24
indicating that systems should work collectively to reduce excess bed day payments and reinvest these resources, at the discretion of the system, in service improvements across the spectrum of providers.
The focus on DTOCs indicates a steady reduction in the number of patients classed as DTOCs, as well as the bed days lost, since a high in Q4 2016/17. In 2017/18, there were 24,449 delayed days across the NHS and social care at UHNM, equating to 5% of occupied beds (3.6% in comparator trusts and 4.4% nationally. Achieving the national target of 3.5%, including through Home First, would reduce the number of delayed bed days by 7,442 bed days and free up 20.4 beds per year. It will also contribute to the reduction of stranded and super stranded patients (26% target reduction), the rate of which is largely in line with national benchmarking.
Figure: Stranded and super stranded patients at UHNM 2017/2018 and Q1 2018/19
Stranded and Super Stranded Patients University Hospital of North Staffordshire NHS Trust 25000 0.6
20000 0.5 0.4 15000 0.3 10000 0.2
5000 0.1 Excess Excess Bed Days 0 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June July 2017-18 2018-19 Stranded 7+ Super Stranded 21+ % Stranded 7+ % Super Stranded 21+
When assessing the specific reasons for delayed transfers of care, Staffordshire LA and Stoke on Trent are notable outliers for reasons of “awaiting completion of assessment” and “awaiting care package in own home” based on data from Q4 2017/18. As there was a marked rise in delays nationally in 16/1720 across these two domains, this makes these differences more notable. This confirms the rationale to move towards patients remaining at home where clinically appropriate while awaiting an assessment for either a longer term package of care or an assessment for 24 hour care as a means to reduce DTOCs.
20 Awaiting care package in own home increased by 45% and awaiting completion of assessment increased by over 10%. Parliamentary briefing: Delayed transfers of care in the NHS, 2017 25
Figure: Reason for delayed discharge by local authority, number of delayed days per 100k population Q1 2017/18
Reason for delayed discharge number of delayed days per 100,000 population Q1 2017/18
450
400
350
300
250
200
150
100
50
0 Awaiting Awaiting Awaiting Awaiting Awaiting Awaiting care Awaiting Patient or Disputes Housing – Other completion of public funding further non- residential nursing home package in community family choice patients not assessment acute NHS home placement or own home equipment covered by care placement or availability and NHS and availability adaptations Community Care Act
Staffordshire Stoke-On-Trent UA England
End of life care
The provision of integrated care, including palliative care services that are based around patients’ needs and wants should mean that patients approaching the end of life are cared for in line with their wishes whilst in their preferred place of care. More patients in North Staffordshire die in hospital than in their comparator CCGs or nationally, in the table below. The CCGs have both set a target that the number of patients who die in hospital should decrease to be in line with national levels by June 2019. However, as more patients receive end of life care in their home, or usual place of care, a step change will be required to remain in line with national trajectories (Figure below).
Table: % of patients who die in hospital by CCG, comparator CCGs and nationally
Area % of patients who die in hospital
NHS North Staffordshire CCG 50.3%
NHS Stoke on Trent CCG 52.7%
Comparator CCGs 47.2%
England 46.9%
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Figure: Deaths in hospital
Deaths in hospital - national and local trends 65.0%
60.0%
55.0%
50.0%
45.0%
40.0% 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
England North Midlands North Staffordshire CCG Stoke on Trent CCG
Limitations
The top down opportunity estimation presented in this paper should be considered in light of a range of limitations which are outlined in detail below:
Top-down analysis. The estimated opportunities outlined have been developed using a top down methodology. That is, publicly available data has been utilised to perform national and peer group benchmarking which informs the estimated opportunity. Further bottom-up analysis could be undertaken in the future to test and triangulate these estimates.
Data. The data used has come from publicly available sources and has not been validated.
Assumptions. The analysis includes a number of assumptions, from a review of literature and stakeholder engagement. These could be further tested in future work.
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Appendix 22: Glossary AIRS Beds Adult Intermediate Rehabilitation Service Beds BME Black and Minority Ethnic BCIS Building Cost Information Service CHAD Centre for Health and Development CQC Care Quality Commission COPD Chronic Obstructive Pulmonary Disease CAT Clinical Assessment Team CAGR Compound Annual Growth Rate CCG Clinical Commissioning Group CHC Continuing Healthcare DST Decision Support Tool DTOC Delayed Transfer of Care D2A Discharge To Assess ADAM Dynamic Procurement System ENT Ear Nose and Throat EMI Elderly Mentally Infirm ECIST Emergency Care Intensive Support Team EDS Equality Delivery System EIA Equality Impact Assessment ETTF Estates and Technology Transformation Fund ERIC Estates Return Information Collection FTE Full Time Equivalent FRC Functional Residual Capacity FNC Funded Nursing Care GP General Practitioner HEFS Hospital Estates and Facilities Statistics IMD Index of Multiple Deprivation ICA Integrated Care Area ICR Integrated Care Record ICTs Integrated Care Teams KPI Key Performance Indicator LSE Large Scale Enquiry LOS Length of Stay LAs Local Authorities LEAF Local Equality Advisory Forum LIFT Local Improvement Finance Trust LMC Local Medical Committee LTCs Long-Term Conditions LSOA Lower Layer Super Output Area MFFD Medically Fit for Discharge MADE Multi-Agency Discharge Events MDT Multi-Disciplinary Team NAIC National Audit Intermediate Care NPC Net Present Cost NPV Net Present Value 28
NEL Non-Elective Admission OT Occupational Therapy OPEN Older People’s Engagement Network OSC Overview and Scrutiny Committee PPG Patient Participation Group PCBC Pre-Consultation Business Case PCCC Primary Care Commissioning Committee PFI Private Finance Initiative QALY Quality Adjusted Life Year QIA Quality Impact Assessment RNs Registered Nurses SRO Senior Responsible Officer SSSFT South Staffordshire and Shropshire Healthcare Foundation Trust SSOTP Staffordshire and Stoke-on-Trent Partnership NHS Trust STP Sustainability & Transformation Partnership tCI The Consultation Institute MPFT The Midlands Partnership NHS Foundation Trust TUPE Transfer of Undertakings Protection of Employment – Transfer to another employer UHNM University Hospital of North Midlands NHS Trust VAST Charity in Staffordshire promoting the voluntary and community sector AA Compliant Web Content Accessibility Guidelines WMAS West Midlands Ambulance Service
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