Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group Governing Body Meeting
Date: Tuesday 3rd April 2018
Time: 1.30pm
Location: Vassall Centre, Gill Avenue, Downend, BS16 2QQ
Agenda item: 7.1
Report title: Rehabilitation, Reablement and Recovery, in South Gloucestershire
Report Author: Dave Jarrett, Area Director, South Gloucestershire
Report Sponsor: Lisa Manson, Director of Commissioning
1. Purpose The purpose of this paper is to update the Governing Body on progress in relation to the South Gloucestershire 3Rs Programme, which set out a vision for the provision of rehabilitation, reablement and recovery services, and to seek approval for the proposed way forward and next steps.
2. Recommendations The Governing Body is asked to APPROVE the following:- - The preferred option to deliver a new model of care for rehabilitation, reablement and recovery services for the people of South Gloucestershire, including:
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o A centre of excellence for intensive rehabilitation in 40-50 beds co- located within a new build residential/nursing home facility at Frenchay (70-80 units in total, subject to planning permission) o An enhanced primary and community care hub (subject to completion of the full business case), co-located with a new build residential/nursing home facility at Thornbury (70-80 units, subject to planning permission). This would include a dedicated frailty unit offering a ‘one-stop shop’ proactive service for frail and older people to keep them as healthy and independent as possible, alongside a 6-10 bedded unit providing short term support for people to avoid or recover from hospital admission. o Reinvestment in rehabilitation support for people in their own homes - The CCG retains the option to flex the number of beds by purchasing short term additional capacity on either site - Clinical service provision is delivered through the reprocurement of Adult Community Health Services (separate programme) - The CCG seeks to partner with South Gloucestershire Council and agrees to request that the Council acts as lead commissioner for the new build residential/nursing home facilities required.
3. Background South Gloucestershire CCG previously consulted on the future of services at Frenchay and Thornbury. A decision was taken in 2015 to commission community rehabilitation beds on both sites to meet the needs of the population. At the same time South Gloucestershire Council made clear its intention to commission residential/nursing home beds and extra care housing facilities on the two sites.
A process was established whereby the existing community provider (Sirona health and care) would work with an external funding partner to develop detailed proposals for integrated health and social care provision, including extra care housing, at Frenchay and Thornbury. For a variety of reasons, however, the work did not progress at the pace expected.
In December 2017 the Governing Body took the decision to discontinue the Sirona led development of the Frenchay and Thornbury sites as it could not legally offer the contract length Sirona required to make the scheme successful.
This delay was understandably disappointing for stakeholders who had been waiting for a number of years to see the new sites developed. As a result the CCG committed to an immediate review in order to confirm both the commissioner requirements in light of population need and to ensure a modern model of care,
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and further to this to enable us to restart a process that would give a clear timeline for delivery.
In January 2018 Attain was appointed to support the CCG in reviewing options for next steps. Attain worked closely with the CCG, South Gloucestershire Council, North Bristol NHS Trust and other partners to come to a preferred option, which is described below. The preferred option remains broadly consistent with the vision for health and care services described in the original 3Rs consultation.
The detailed report is attached.
4. Background 4.1 The 3Rs Programme The 3Rs programme aims to improve rehabilitation, recovery and reablement services for adults of Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups (BNSSG CCG).
The objective of the 3Rs is to develop capability and capacity in the community so that people with complex needs spend less time in hospital following an acute admission. There is a strong emphasis on maintaining people at home with community beds providing a platform for achieving this.
The 3Rs programme has been developed for the South Gloucestershire population but sits within a wider programme for improving rehabilitation, recovery and reablement services for adults across Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group.
Overall, key system partners are determined to provide a flexible model of care that enables patients to recover and sustain independence as soon as possible following hospital treatment. Care would be provided in modern and high quality settings that are most appropriate for their need, with an emphasis on returning people home as soon as they are able. Getting people home as soon as possible after an episode of care is important to prevent decompensation and keep them as healthy, well and independent as possible.
The independent report from Attain attached at Appendix 1 sets out an appraisal of South Gloucestershire’s 3Rs programme with reference to the national and local BNSSG context, and national and international examples of best practice.
Further to this it describes the preferred procurement option for the delivery of the overall model of care including the delivery of efficient, effective and high quality
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bedded services for community bedded rehabilitation and bed-based complex care.
4.2 Current Situation The implementation of 3Rs to date has involved improvement to existing services through redesign and investment.
It has included enhancements to service at home through investment in additional nurses, therapists and other staff in the community teams.
Currently it also includes 70-80 community beds provided through a combination of the Skylark Unit in Yate and Henderson Ward at Thornbury Hospital both operated by Sirona, supplemented by capacity purchased on short term contracts at a number of local nursing homes.
This capacity includes both the ‘pathway 2’ beds for people requiring active rehabilitation and the ‘pathway 3’ beds for people identified as likely to require long term care.
This fragmented delivery across multiple sites prevents patients moving between pathways, limits access to therapy input and increases length of stay.
In addition the current capacity operates primarily on a ‘step down’ model providing community support following an acute stay, and there is a lack of ‘step up’ support to prevent admission to hospital.
4.3 BNSSG CCGs and SGC working together. Subject to full Council support, South Gloucestershire Council (SGC) is committed to working jointly with BNSSG CCG to commission an integrated health and care approach to providing support, care and housing for older people.
For older people specifically, SGC has a strategic aim to enable the delivery of ExtraCare accommodation as an effective housing with care solution, along with additional residential/nursing home care. By offering a mixed model of residential/nursing home and NHS community care on a single site we can offer the best and most targeted support for individual’s needs. Services will be able to flex to respond to individuals as their needs change, and ensure at all times a focus on enabling and empowering people to maintain their highest possible level of independence.
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The current sites at the old Frenchay Hospital and Thornbury Hospital offer significant opportunity to progress this ambition, and remain the preferred option for the CCG.
4.4 Options for Improvement The options appraisal covers three dimensions:
• Model of Care • Estates • Procurement
A preferred overall approach was reached through an appraisal of each option in each dimension against a set of criteria covering three domains: System Sustainability, Person-Centred and Ease of Implementation.
Inherent within these domains were the two key principles of:
(i) Appropriateness - in line with population requirements and national policy including RightCare (ii) Affordability – delivering best value within the resources available.
4.5 The Preferred Option The preferred option is firstly to provide a more efficient model of care by facilitating a greater proportion of patients treated through Pathway 1 (home- based care) and achieving upper quartile performance in length of stay in bedded capacity. In parallel to develop a rehabilitation centre of excellence at Frenchay and 6-10 ‘step up’ beds at Thornbury with the developments at both sites co- located with a nursing home and ExtraCare housing and a new build for an Enhanced Primary and Community Care Centre.
Frenchay - A new build containing 40 to 50 core community rehabilitation beds on the vacant hospital site. The rehabilitation beds would be co-located with additional 36 care home beds including dementia nursing units and Local Authority commissioned ExtraCare Housing of 50-80 units. This would be adjacent to the current Brain Injuries Rehabilitation Unit (BIRU), with the potential for creating a BNSSG ‘Centre of Excellence’ for Rehabilitation.
Thornbury - Two new build schemes.
(i) A new build for an Enhanced Primary and Community Care Centre - includes integrated primary and community services providing holistic and comprehensive care, including General Practice, Frail Elderly and Mental Health.
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(ii) A new build for co-located Local Authority commissioned services, including 6- 10 NHS funded core beds within a new Nursing Care home of c 80 units (including dementia care) and 50-80 units of Extra Care Housing.
Both sites would involve NHS land sale: North Bristol NHS Trust (NBT) at Frenchay and Thornbury.
The preferred approach for procurement is in two parts:
1. Clinical service provision is delivered through the reprocurement of Adult Community Health Services (separate programme) 2. The CCG seeks to partner with South Gloucestershire Council and requests it to act as lead commissioner for the new build care home facilities required.
It is important to note that in transitioning to the new services and whilst there is further detailed work required to finalise the model of care overall, the CCG will continue to purchase non-core beds on short-term contracts through current arrangements as needed.
4.6 Benefits The proposed service model at Frenchay allows patients to move seamlessly between pathways, accessing the appropriate level of therapy intervention for their need in a purpose built facility, reducing length of stay for the individual patient, and maximising the opportunity for patients to return to their original care setting. This centralisation of 3Rs bedded capacity would facilitate delivery of the optimal model of care. A single core facility should encourage recruitment and retention of highly skilled and trained clinical staff (nursing and therapy).
The bedded care at Thornbury provides flexibility for ‘step up’ care from community and primary care as well as step down care from the acute providers.
The approach is consistent with the national ‘RightCare’ model and, with commitment to further refine the local approach, provides a good basis for improving health and care for local people.
4.7 Next Steps The overall success of the programme requires whole system commitment and collaboration to deliver the efficiency and effectiveness improvements within the preferred option. In progressing this option a number of next steps have been identified and recommended to build confidence in delivery of the preferred option. These are divided into three areas:
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1.Preparation for procurement: this includes securing efficiencies in current community contracts; seeking agreement from South Gloucestershire Council to act as lead commissioner and undertake the required procurement; public engagement and consultation; clarifying the patient cohort; further affordability assessment; and decisions on releasing land for the development.
2. Procurement process: a) Clinical service provision delivered through the reprocurement of Adult Community Health Services (separate programme). b) The CCG seeks to partner with SGC and request it to act as lead commissioner for the new build care home facilities required. Establish a multi-agency project team to manage the process.
3. Further efficiency and effectiveness improvements: this includes refining how the interface between the 3Rs pathways can enable flexibility in meeting need; improving patient flow throughout all parts of the system; and co-ordinating care throughout the network of services.
5. Financial/resource implications The CCG currently purchases 70 Pathway 2 and Pathway 3 beds across a variety of locations in South Gloucestershire. The length of stay of these patients exceeds national best practice length of stay in both P2 and P3. As the beds are in a mixture of locations it is not possible for patients to move between the pathways as their rehabilitation needs change.
The proposed beds will be funded from the decommissioning of the existing bed complement and reducing length of stay. It is not expected that any savings will be generated as there will need to be investment in Pathway 1 capacity to ensure that there is optimum balance between the pathways.
Funding has been secured to complete a Formal Business Case for the development of an integrated primary and community care facility in Thornbury. This will be monitored and approved through the Primary Care Commissioning Committee.
6. Legal implications All procurement must be undertaken in line with procurement law and EU regulations. The CCG will not undertake any procurement for the Nursing and Extra Care Housing Provision, which is the responsibility of the Local Authority.
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The development of a Primary Care facility will be in accordance with the Primary Care regulations.
7. Risk implications Key risks and mitigations previously identified are set out below.
Description of risk Mitigating actions Mitigated Risk score Likelihood x impact 1 Delay in procurement Additional spot purchasing will be 2x1=2 timetable undertaken 2 Low number of bids that Significant market engagement 1x2=2 prevents effective undertaken to understand appetite of outcome in delivering a market nursing home 3 NBT Land sale value Negotiation with NBT and partners to 2x3=6 ensure all commitments can be met
8. Implications for health inequalities An Equality Impact Assessment has been completed and was previously reviewed and accepted by the Governing Body. There have been no changes to this assessment.
9. Implications for equalities (Black and Other Minority Ethnic/Disability/Age Issues) There are no specific implications for equalities arising from the recommendations of this report.
10. Consultation and Communication including Public Involvement The development of the options has relied on National best practice and has been based on previous public engagement. Further public engagement to design the detailed model of care within a specification for services will take place as part of the community services procurement.
10 . Appendices Appendix Full report
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Glossary of terms and abbreviations
Glossary of terms and abbreviations
Pathway 1 Patients who are discharged home, to be assessed to understand their rehabilitation needs.
Pathway 2 Patients who are discharged to a residential setting, to be assessed to understand their rehabilitation needs and to receive active Rehabilitation.
Pathway 3 Patients who have been identified as likely to require long term care.
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Bristol, North Somerset & South Gloucestershire CCGs
3Rs Programme: Options Appraisal & Strategic Outline Case for South Gloucestershire
March 2018 Contents
SECTION PAGES 1 Executive Summary 3
2 Strategic Context 8 3 Case for change • Current situation 15 • Drivers for change 33 4 Options appraisal • Criteria 40 • List of options: Efficiency gains; Estates; and Procurement 46
5 Preferred option 68
7 Appendix 85
2 Executive Summary 1. Introduction The 3Rs programme aims to improve rehabilitation, recovery and reablement services for adults of Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups (BNSSG CCGs). The objective of the 3Rs is to develop capability and capacity in the community so that people with complex needs spend less time in hospital following an acute admission. There is a strong emphasis on maintaining people at home with community rehabilitation beds providing a platform to achieve this. Overall, key system partners are determined to provide a flexible model of care that enables patients to recover and sustain independence as soon as possible following hospital treatment. Care would be provided in settings that are most appropriate for their need, with an emphasis on returning home as soon as able. E.g. private / academic This appraisal of the South Gloucestershire 3Rs programme sets out to describe the preferredMore complex procurement burns, option for the delivery of the overall model of care including the delivery of efficient, effective andENT, high craniofacial, quality cardio, bedded services for community bedded rehabilitation and bed-based complex care . The approach undertakenrespiratory is as follows : • Support CCGs to determine the best way forward for meeting the community health objectives of the 3Rs programme for South Gloucestershire. • Provide the CCGs with a framework for future commissioning intentions of the 3Rs programme. • Build on the substantial work carried out to date, but also take advantage of an opportunity to take a new look at current and future requirements without reinventing the wheel. • Involve engagement with commissioners and providers.
2. Drivers for Change It is recognised that the system is under challenge with all organisations facing operational and financial pressures: • Rising demand and stretched system capacity • Newly merged CCGs jointly procuring service • Fragmented patient pathways • Land set aside for sale and/or development • Cost pressures and needing the money to go further • Improving outcomes for patients
3 Executive Summary
3. Current Situation With an ageing population, there is an expectation that frail older people will be the predominant users of 3Rs services. Key observations are: • In South Gloucestershire there are 20 community beds at Thornbury Hospital, which is no longer fit for purpose, and a further 30 beds in interim accommodation on the top floor of a residential/nursing home in Yate. In addition there are 26 beds (including 19 that are separately funded through the Better Care Fund), which are provided through a mix of independent providers on short-term contractual arrangements. • The fragmented delivery prevents patients moving between pathways and limits access to therapy input • The majority of the work is considered to be ‘step down’ (community support following post-acute stay). 4. Financial Envelope for 3Rs in South Gloucestershire E.g. private / academic More complex burns, • The total annual budget for 3Rs provision in South Gloucestershire is £6.0m. ENT, craniofacial, cardio, respiratory 5. BNSSG CCGs and SGC working together. • South Gloucestershire Council (SGC) is committed to working jointly with BNSSG CCG to commission an integrated health and care approach to providing support, care and housing to older people. • For older people specifically, SGC has a strategic aim to enable the delivery of ExtraCare accommodation as an effective housing with care solution, along with additional residential/nursing home care. • The current sites at the old Frenchay Hospital and Thornbury Hospital offer significant opportunity to progress this ambition, and remain the preferred option for the CCG. 6. Options for Improvement This options appraisal covers three dimensions Model of Care efficiencies, Estate opportunities and Procurement. A preferred overall approach was reached through an appraisal of each option in each dimension against a set of criteria covering three domains: System Sustainability, Person-Centred and Ease of Implementation. Inherent within these domains were the two key principles of (i) Appropriateness - in line with population requirements and national policy including RightCare and (ii) Affordability – delivering best value within the resources available.
4 Executive Summary
7. The Preferred Option The preferred option is firstly to provide a more efficient model of care by facilitating a greater proportion of patients treated through Pathway 1 (home-based care) and achieving upper quartile performance in length of stay in bedded capacity. In parallel to develop a rehabilitation centre of excellence at Frenchay and 6-10 ‘step up’ beds at Thornbury with both sites co- located with a nursing home and ExtraCare housing and a new build for an Enhanced Primary and Community Care Centre.
Frenchay - A new build containing 40 to 50 core community rehabilitation beds on the vacant hospital site. The rehabilitation beds would be co-located with additional 36 care home beds including dementia nursing units and Local Authority commissioned ExtraCare Housing of 50-80 units. This would be adjacent to the current Brain Injuries Rehabilitation Unit (BIRU) with the potential for creating a BNSSG ‘Centre of Excellence’ for Rehabilitation.
Thornbury - Two new build schemes. (i) An enhanced primary and community care hub in a new build (subject to completion of the full business case), co-located with a new build residential/nursing home facility at Thornbury (70-80 units, subject to planning permission). This would include a dedicated frailty unit offering a “one-stop shop” proactive service for frail and older people to keep them as healthy and independent as possible, alongside a 6-10 bedded unit providing short term support for people to avoid or recover from hospital admission.
Both sites would involve NHS land sale: North Bristol NHS Trust (NBT) at Frenchay and at Thornbury.
5 Executive Summary
The preferred approach for procurement is in two parts : A. Clinical service provision is delivered through the reprocurement of Adult Community Health Services. (separate programme) B. The CCG seeks to partner with SGC and request it to lead as commissioner for the new build care home facilities required, linking in with NBT.
It is important to note that, in transitioning to the new services and whilst there is further detailed work required to finalise the model of care overall, the CCG should continue to purchase non core beds on short-term contracts through current arrangements as needed.
8. Benefits
The proposed service model on Frenchay allows patients to move seamlessly between pathways: accessing the appropriate level of therapy intervention for their need in a purpose built facility; reducing length of stay for the individual patient; and maximising the opportunity for patients to return to their original care setting. This centralisation of 3Rs bedded capacity would facilitate delivery of the optimal model of care for the population of South Gloucestershire. A single core facility should encourage recruitment and retention of highly skilled and trained clinical staff (nursing and therapy).
The bedded care at Thornbury provides flexibility for ‘step up’ care from community and primary care. The approach is consistent with the national ‘RightCare’ model and, with commitment to further refine the local approach, provides a good basis for improving health and care for the people of South Gloucestershire.
9. Affordability
It has been difficult to undertake an affordability appraisal of the preferred option due to current data quality. However, given the current budget is based on less than optimum outcomes and inputs with a heavily weighted bed base (90% of the overall 3Rs budget for South Gloucestershire) it is assumed that the running costs for the proposed new configuration should be at least cost neutral.
6 Executive Summary
10. Next Steps The overall success of the programme requires whole system commitment and collaboration to the efficiency and effectiveness improvements within the preferred option. In progressing this option 11 next steps have been identified and recommended to build confidence in delivery of the preferred option. These are divided into three areas: Preparation for procurement This includes securing efficiencies in current community contracts; seek agreement from South Gloucestershire Council to undertake procurement as lead; public engagement and consultation; clarifying the patient cohort; further affordability assessment; and decisions on releasing land for the development. Procurement process This covers: a) Clinical service provision is delivered through the reprocurement of Adult Community Health Services (separate programme). b) The CCG seeks to: • Partner with SGC and request it to perform the role as lead commissioner for the new build care home facilities require • Establish a multi-agency project team to manage the process. Further efficiency and effectiveness improvements This includes refining how the interface between the 3Rs pathways can enable flexibility in meeting need; improving patient flow throughout all parts of the system; and co- ordinating care throughout the network of services.
7 Strategic Context Context (1)
The 3Rs programme is focused on improving rehabilitation, recovery and reablement services to adults in Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups (BNSSG CCGs) catchment populations. The primary objectives of the 3Rs programme in South Gloucestershire are: • To develop capability and capacity in the community for the South Gloucestershire population so that people with complex needs can receive additional support in the community • To reduce likelihood of being admitted to a hospital or time in hospital following an acute admission.
The South Gloucestershire CCG element of the programme has been organised into two phases with support of South Gloucestershire Council: E.g. private / academic 1. Focused on services at patients’ homes and community inpatient servicesMore. complex burns, - increasing the capacity and capability of community services throughENT, craniofacial, a combination cardio, of redesign respiratory and additional investment. - includes enhancements to services at home and to the NHS community inpatient services (discharge to assess capacity) at Southmead Hospital (Elgar House), at Thornbury Hospital, and commissioned via a number of local nursing homes. 2. Commenced in 2015 and focuses on longer term sustainability. - includes plans for new services and potentially new health and care facilities located on existing NHS sites at Frenchay or Thornbury. The CCGs continue to develop their options for providing enhanced primary care facilities at Thornbury to support local needs integrated with care housing.
9 Context (2)
The development of both phases was led by Sirona care & health working in partnership with their commissioner, South Gloucestershire CCG, and North Bristol NHS Trust (NBT) up until December 2017. NBT is the owner of the land at both Frenchay and Thornbury (the latter with NHS Property Services) which had previously been agreed as the preferred locations for the proposed health and social care facilities:
“There is agreement in principle with NBT that land at both sites will continue to be reserved for this purpose until commissioners’ work is concluded etc.” (BNSSG board papers, Nov 2017) E.g. private / academic Progress to date More complex burns, The second phase has suffered from a number of delays and the option to mobiliseENT, craniofacial, new facilities cardio, via the Sirona contract is no longer viable. In December 2017 BNSSG CCGs agreed that the Sironarespiratory-led approach be terminated. At this time the decision was made to undertake an options appraisal to progress the objectives of the 3Rs programme, from which a way forward would be agreed in April 2018.
It is recognised that the system is under challenge with provider organisations facing pressures. It is critical that a robust and rigorous approach is adopted that considers a holistic system-wide approach, aligning with the aims of the 3Rs programme. Success of the programme itself is linked to the system vision of out-of-hospital care provision that facilitates improved system-wide patient flow.
10 Scope
To complete the options appraisal and strategic outline case for the South Gloucestershire 3Rs programme the approach undertaken is as follows: • Supports CCGs to determine the best way forward for meeting the community health objectives of the 3Rs programme for South Gloucestershire. • Provides the CCGs with a framework for future commissioning intentions of the 3Rs programme • Builds on the substantial work carried out to date, but also take advantage of an opportunity to take a new look at current and future requirements without reinventing the wheel. • Takes into account the ongoing work being conducted across the system. • Involves engagement with commissioners and providers. E.g. private / academic More complex burns, ENT, craniofacial, cardio, Our approach respiratory • Analytics using updated CCG demand and capacity modelling and finance information • Evidence of best practice drawing from international, national and local sources of information where appropriate • Stakeholder engagement including site visits • Fortnightly steering group meetings
Interdependencies There are also interdependencies with existing or planned work by individual organisations and workstreams within the Sustainability and Transformation Plan (STP) and with system partners, e.g. South Gloucestershire Council, and the impact on their services and commissioning requirements. These may impact on what information is made available to our project team and planned outputs. For example, these may include other services that intersect with 3Rs or are provided either by the same provider or on the same estate, and where one service can act as a catalyst to support the delivery of another as part of a broader health and social care facilities.
11 Project plan Through the Steering Group, we agreed the following programme of work in preparation for the CCGs’ Governing Body on the 3rd April 2018.
JAN FEB MAR APR
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10
Mobilisation Stakeholder engagement
Activities Stakeholder mapping Data Data Data analysis & modelling request collection Preferred option Options development & appraisal development
Detailed review Final editing of Drafting of report (model of care, benchmarks, assumptions) report
Key Meetings Governing Commissioning Governing Body Executive Group Body
Weekly Progress Reports Reporting Risk Log SRO sign-off SRO approval of PID of final draft report
Stakeholder map Options Project Community Strategic appraisal and deliverables bed model for Outline Project plan preferred scenario testing Case option report PID
= project milestones
12 Commissioner engagement The key themes from our engagement with commissioners is shown below:
CCGs Local Authority
• South Gloucestershire • South Gloucestershire Council • Bristol • North Somerset
- Planned merger of CCGs on April 2018. - Alignment on need for understanding what - Alignment on STP vision and movement towards additional capacity is required in the region, both more integrated care and enhanced primary care on for community beds and nursing and residential Thornbury. care homes. - Understanding of need for deeper analysis on - Vision to potentiate market for extra-care housing capacity utilisation and service performance across and residential and nursing care homes. interdependent services to enable improved - Preference for new community health build with co- efficiencies and delivery of person-centred care. located ExtraCare housing and residential and nursing care homes.
13 Provider engagement The key themes from our engagement with providers is shown below:
Community & Social Care Acute
• Sirona care and health – incl. site visits • North Bristol NHS Trust • South Bristol Community Hospital visit • South Gloucestershire Council – adult social services
- Commitment to providing future services and - Alignment on STP vision and continued support of supporting the system. 3Rs programme. - Variation on levels of rehabilitation potential of - Commitment to support community provision to patients between community providers and lack of ensure seamless handoffs and care closer to home. clarity in detailed understanding of patient cohorts e.g. some beds used as interim placements whilst - Integrated discharge team in place. waiting permanent care home. - Significant winter pressures on acute beds. - Assurance that the preferred option should not lead - Opportunity for closer clinical collaboration to to any cost shift between health and social care enhance early discharge planning - Opportunity for sharing of best practice across - Intention to dispose of both Frenchay and providers. Thornbury sites - Opportunity for closer working with acute, primary care, mental health and third sector.
14 Case for change: Current situation 3Rs Service Model and Principles
The objective of the 3Rs model is to develop capability and capacity in the community so that people with complex needs spend less time in hospital following an acute admission. Emphasis is on maintaining people at home with community beds providing a platform to achieve this. The model has included enhancements to service at home through investment in additional nurses, therapists and other staff in the community teams. Currently 3Rs provision in South Gloucestershire includes community beds at the Skylark Unit in Yate, at Thornbury Hospital and in a number of local nursing homes. Community services including beds are to be operated at scale for BNSSG with a flexible approach to allow bed numbers to be flexed over time. The CCG plans to minimise the proportion of funding tied to long term agreements and maximise use of existing fit for purpose capacity e.g. South Bristol Community Hospital.
Original objectives of the 3Rs • Supporting the long term delivery of the 3Rs model of care which although focused on care at home, envisages an ongoing requirement for an element of community inpatient capacity • Providing modern, fit for purpose accommodation for community inpatient services to replace existing facilities which are either temporarily available (Elgar and now Skylark) or no longer fit for purpose (Henderson Ward) • Locating the community inpatient beds at accessible locations within the boundaries of South Gloucestershire (local people, Councillors and MPs regard Frenchay as an accessible location for South Gloucestershire population) • Utilising the NHS land at Frenchay and Thornbury, locations that are strongly preferred by local stakeholders, particularly in the case of Frenchay because of expectations arising from previous explicit commitments made by the local NHS to develop health and social service provision there following the closure of the acute hospital • Increasing dementia care home and extra care housing provision for South Gloucestershire and promoting an integrated approach by co-locating these developments with NHS services • Enabling flexible use of health and care beds by operating these from a single integrated facility
16 Current situation: 3Rs pathways
• Establishment of the Discharge to Assess (D2A) services has been built upon existing rehabilitation, recovery and reablement services pathways for 3Rs services. Key points are: • There are three D2A pathways in the 3Rs services: – PATHWAY 1 (P1) Home with package of care – PATHWAY 2 (P2) Community bed – PATHWAY 3 (P3) Complex care (bed-based) • Although not quantified, it is clear that the majority of the work is ‘step down’ and responds to community support post-acute stay. • The 3 current community providers provide 3Rs services in different ways, which has meant that fully standardised comparable data is not yet possible. Further analysis on more comparable pathway level data will support the next stage of work. • However, recent changes in pathways and data recording (Q3 & Q4 2017/18) mean these will be improved. • In South Gloucestershire the number of episodes (based on referrals) of care in 2017 (calendar year) for each pathway is as follows: P1 1195; P2 652; and P3 217. • Contract variations along with contract extensions with current providers. • Referrals, pathway details (e.g. 1 vs. 1+ in NS) and handoffs between acute and community providers also vary between the 3 catchment populations. • The pathways are commissioned and funded as follows: - P1 and P2 are commissioned directly by BNSSG CCG - P3 is ‘jointly’ commissioned using Better Care Fund, with beds procured by CCG and Councils
17 BNSSG provider site map – Pathway 2 The map below shows the distribution of sites offering P2 D2A services across BNSSG. For South Gloucestershire, there are four locations. Thornbury Elgar Frenchay
SMT
Yate NBT SMT BC Deerhurst NSCH UHB EBICC B CCMHA SBRC SBCH WGH
Key SBCH = South Bristol Community Hospital MHA = Methodist Homes B = Beeches SBRC = South Bristol Rehabilitation Centre SMT = St Monica’s Trust EBICC = East Bristol Intermediate Care Acute Sirona BCH NSCP Other CC = Cedar Care Centre BC = Brunel Care
18 DRAFT – IN CONFIDENCE Current 3Rs provision
As of March 2018, this is the current 3Rs services provision for the BNSSG system: South Gloucestershire CCG Bristol CCG North Somerset CCG 282,100 population 463,700 population 215,700 population 53,600 (19%) over 65s 61,100 (13%) over 65s 52,100 (24%) over 65s (32% BNSSG ^65 pop) (37% BNSSG ^65 pop) (31% BNSSG ^65 pop)
North Community Weston Sirona Bristol University Other – Somerset health CCG General care & health Communi- Hospitals Community provider Hospital ty Health Bristol managed Partnership Total
5,668 Pathway 1 2,600 slots per year 2,184 slots per year 884 slots per year (50 slots per week) (42 slots per week) (17 slots per week) (109)
50 core beds 213 Pathway 2* 122 beds 34 beds** 7 beds on short term contracts beds
19 beds on short term 38 Pathway 3 19 beds 0 beds contracts beds
P2 bed details: South Gloucestershire - 20 beds at Thornbury Hospital (Henderson ward) & 30 beds in Skylark at The Meadows Residential home, Yate; Bristol - 41 beds at South Bristol Community Hospital managed by University Hospitals Bristol & 44 beds managed by Bristol Community Health in various locations; and North Somerset - 7-9 beds at Cleveland Community Hospital. All remaining beds including P3: in various locations in residential/nursing care homes.
* Although some beds are defined for stroke rehabilitation only, they are often used as P2 due to system flow pressures **Capacity is variable, the upper limit of available beds has been taken (16-25 beds).
19 Current estates position
In South Gloucestershire, there have been recent changes to where Sirona is providing 3Rs services to its catchment population. As of February 2018, community beds for P2 care are provided on Henderson ward at Thornbury hospital and in Skylark in The Meadows, Yate. P3 care are provided within a number of care homes at various locations. • Thornbury hospital is an old Victorian building and Henderson ward’s layout is typical of a traditional acute ward layout of bed bays and three single rooms. The site is no longer fit for purpose to provide the quality of services that Sirona is committed to. • Skylark occupies a floor in the newly built residential care home of The Meadows. All rooms are single occupation only with en-suite bathroom and corridors wide enough for staff to transfer patients and beds as required. The floor also includes access to stairs for physiotherapy sessions and kitchen for occupational therapy support. The facility is more conducive to providing a less medicalised environment which is more suited to 3Rs services. • Both sites have day rooms for patients to socialise and communicate outside of their beds/rooms.
Of note: Bristol provides P2 services in the LIFT scheme building of South Bristol Community Hospital. This build is fitted and designed as a large community hospital and there are a number of other medical facilities provided on site. P3 care is provided in a number of care homes at various locations. North Somerset has rehabilitation beds for P2 services in recently refurbished Clevedon Community Hospital as well as an equivalent level of care provided within Uphill ward on Weston Acute Hospital NHS Trust.
20 Current 3Rs budget
Financial Envelope for D2A pathways • The total annual budget for 3Rs provision in South Gloucestershiire is £6.00m and for each pathway: - Pathway 1 £601k - Pathway 2 £4.4m - Pathway 3 £973k (CCG £409k and SGC £594k) • Due to the block contract arrangement, spend for 2017/18 equals budget to date. • Funding of pathways is either directly from CCG budget or in the case of Pathway 3 via the Better Care Fund (BCF).
Pathway Capacity £m £ per slot/bed TOTAL BUDGET FOR 6.01 3RS IN S.GLOS Pathway 1 2,600 slots 0.60 231 Funded by CCG Pathway 2 57 beds 4.44 77,951 includes support costs Funded by CCG Pathway 3 includes support and 19 beds 0.97 51,229 case management Funded by BCF costs
21 Current contracting position
All existing contracts with each community provider are block contracts for adult community services that include delivery of 3Rs services.
South Gloucestershire CCG Bristol CCG North Somerset CCG
Sirona Bristol Community North Somerset care & health Health Community Community (also provides Provider (also provides adult Partnership Children’s community Learning Disabilities (includes Children’s and adult Learning services) community services) Disabilities services)
March 2019 September 2019 March 2021 £18.8m pa £43m pa £24.5m pa Contract End & Contract termination Contract termination Contract termination Information date 30/03/2019,, date 30/09/2019, date 30/03/2021, initial contract term (3 initial contract term initial contract term (5 years), 2 year contract (3+2) years), 2 year contract extension option (1+1) extension option
22 South Gloucestershire Council
Current commissioning Intentions • South Gloucestershire Council (SGC) is committed to working jointly with BNSSG CCG to commission an integrated health and care approach to providing support, care and housing to older people. Their vision’s aim is for people to have the same access to the same quality of care services, whatever their support need and wherever they live. • For Older People specifically, SGC has a strategic aim to enable the delivery of ExtraCare accommodation as an effective housing with care solution for older people. Underpinning this commitment is the provision of a wider choice of tenure to match the increasing demographic change of older people in South Gloucestershire. • SGC aimed to deliver 700 additional housing units by 2016 which was not achievedE.g. private as some/ academic earmarked sites did not deliver as anticipated. Per site they estimate 50-80 units for ExtraCare housingMore complex (ECH) burns, and the equivalent of additional capacity of a nursing care home through the provision of 36 units ofENT, nursing craniofacial, care cardio, on each sites which should including provision of nursing care for people with dementia. respiratory Housing for Older People • ECH is one important component of a continuum of housing designed to meet the needs of an ageing population where care and support needs can be focussed into individual housing developments as required. ECH design and location should enable individuals to live in self-contained flats or chalets within an environment that promotes privacy, comfort, support and companionship. The accessible environment of ECH and not just the care provision is a significant factor in enabling people to live more independently, increasing socialisation and community involvement and improving nutrition and wellbeing. • In policy CS20, provision is made for ECH as one form of housing to meet the needs of an ageing population. The council envisages a continuing need for ECH and will therefore encourage the development of its market. • ECH will be regarded as a model of housing that combines independent housing with flexible levels of care and support. Schemes might incorporate purpose-built, self-contained and accessible rented, shared ownership, or leasehold accommodation.
23 Best Practice summary NHS Benchmarking Half of providers are achieving the average or better and top 25th centile providers perform at 21 days or less. Average Length of Stay (%) Average Occupancy Rates (%) 80 Pathway 2 ALOS (Days) 100 Mean Avg: 70 90 86.8% Summer Winter
60 S Glos. 32.1 28.7 80 National Target: 85% Unexplained inconsistency across 70 50 seasons 60
40 50
30 Mean Avg: 27.8 days 40
30
20 Average Rates Occupancy(%)
20 Average Length of Stay (Days) Stay of Length Average th 10 Top 25 centile providers perform at 10 21 days or less 0 0
ALOS in community bed-based care in BNSSG is higher than Community provision across BNSSG consistently reports the 2017 NHS Benchmarking average across providers of 27.8 occupancy rates of close to 100% with Q3 17/18 South days (Responses = 267 providers). Of note, 2012 NHS Gloucestershire at 93%. This is higher than the national Benchmarking average was 27 days across 124 community target of 85% and the mean average for bed-based bed-based providers. provision.
Source: NHS Benchmarking, NAIC – Providers, Bed-based Activity – Average Length of Stay (Days), 2017. Responses = 267 providers. NHS Benchmarking, NAIC – Providers, Bed-based Activity – Average Occupancy Rates (%), 2017. Responses = 248 providers. 25 Community rehabilitation models of care BNSSG CCGs intentions are to move to shorter ALOS with faster access to 3Rs post-acute discharge, towards top 25th centile national performance. The following are examples that have achieved this (details are found in the Appendix): • Barking & Dagenham, Havering & Redbridge CCGs launched a programme to address issues of inefficiency and increasing demand facing their community services in 2014. The CCGs agreed targets for providers of general and complex rehabilitation, 21 and 28 days respectively (based on data from NHS Benchmarking and other pilots). At the time ALOS was 29 days, with cases going up to 40+ days. By end of year their provider, North East London NHS Foundation Trust, recorded ALOS of 19 days for general rehabilitation. Latest quality reports indicate that ALOS on general rehabilitation wards has remained within 21 days target, with 2018 figures published as 20.4 days despite other pressures. • West, North & East Cumbria Success Regime wanted to examine what the future for their community hospitals should be. During 2016 they conducted analysis on productivity within community hospitals, to establish current impact of previous initiatives and identify opportunities for further improvement. In the period 2007 – 2010 there was an intense focus on improving productivity and quality in community hospitals. As a result: – Overall admission numbers to community hospitals doubled – Length of stay (LOS) reduced in every hospital (average of 9 days fewer) – Overall there was an 80% increase in the ‘throughput per bed’ Between 2010 and 2013 admission numbers stayed more or less steady with a small further reduction in ALOS of 1.3 days and 5% increase in throughput. By 2016 there was an additional 14.8% reduction in readmissions with length of stay rising to 21 days in community hospitals due to external system pressures. • Leicestershire NHS Trust is a case study of how to deliver more care closer to home by increasing the proportional split between P1 and P2 pathways. The Trust consolidated their varied pathways into an increased split of 70% P1 activity and 30% P2 activity. As a consequence of successfully implementing this shift towards home care, the Trust was able to improve their patient flow and DTOC pressures on the system.
26 Supportive elements to models of care (1)
These supportive elements to community rehabilitation models looked at by RightCare optimal pathway for frail elderly is relevant to 3Rs provision: 1. Appropriate Post Acute Care 2. Prevention focus
1. Appropriate Post Acute Care initiatives tend to include: • Discharge planning with MDTs • Home-based packages and care packages within 24 hrs of referral to Adult Care and support • Appropriate step up and step down home based and bed based rehabilitation and reablement • Engagement with voluntary sectors to support frail elderly who live alone 2. Prevention focus initiatives tend to include: • Risk stratification • Identification, case management and care coordination of high risk cohorts (involving close working with primary care) • Admissions avoidance • Falls Prevention
Source: NHS RightCare scenario: The variation between standard and optimal pathways (2018) https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2018/02/claras-story- multimorbidity-summary-slide-pack.pdf
27 Supportive elements to models of care (2) Frailty – Sub-optimal and optimal pathways
No prevention Pillar to post Too late
• Reactive • Traditional treatment • Damage done • No education • Many wards • Too much reliance on • No third sector • Too much time acute care
in bed optimal pathwayoptimal - No risk profiling Inappropriate Insufficient home
and identification acute care care support Sub
Prevention focus Fast Appropriate
• Proactive • Bespoke treatment • Support mechanisms in • Education • Little time in bed place • Third sector • Greater understanding of • Trusted system need • Happier and healthier experience ptimal pathway ptimal Risk profiling and Great acute care O Great home care identification 2 support
28 Technical best practice: estates
• Department of Health’s Health Building Note 11-01 Facilities for primary and community care services (2013) states: • The need to maximise flexibility and adaptability by incorporating the following strategies: - use generic patient/client contact spaces; - limit the number of specialist spaces; - standardise room sizes and position of built-in equipment; - consider future engineering service requirements at the outset; - consider flexible and adaptable forms of construction; - develop a modular approach to planning and construction; - provide space for future expansion, if relevant
29 Technical best practice: technology
Patient flow management software can be used to:
• Make visible the status of patients being managed by a central contact centre which coordinates referrals between Independent Living Teams (ILT) covering health (Community Nursing, Physiotherapy, Occupational Therapy etc.), support (Re-ablement Services) and a Discharge Hub within the local acute hospital. • Determine capacity at each community hospital and in each community nursing and therapy teams in real time. • Efficient, effective and auditable communication from Contact Centre to teams
The technology enables future phases of model of care development: • A discharge hub giving community services visibility to pro-actively in-reach and plan ahead for managing discharges from the acute setting • Neighbourhood Teams to better manage activities in the community targeted at admission avoidance and quicker discharge from the surrounding acute providers • A single view of Assessment Placements across the county enabling proactive management of step down from an acute setting while assessing the most appropriate next stage of care.
Source: Cambio Patient Flow Manager, Lincolnshire Community Health Services Case Study. Website: http://cambiopfm.co.uk/casestudy/lincolncommunity, accessed March 2018.
30 Technical best practice: procurement • Monitor’s (Now NHS Improvement) Substantive 3Rs Areas for Improvement guidance on the Procurement, Patient Choice and Current CCG procurement policy is due to be updated Competition Regulations, in particular Regulation as part of the merger with a new version to be released 3, obliges the CCGs to act transparently and in April 2018. Our observations noted the following: proportionately, and to treat providers equally and • The document is out of date and does not reflect in a non-discriminatory way. A procurement latest legislation/national policy (2015). process should be compliant with the treaty principles of EU regulations: Transparency; Equal • It makes several references to The Public treatment and non-discrimination; Proportionality; Contracts Regulations 2006. The Public Contracts and Mutual recognition. Regulations 2006 has been superseded by The Public Contracts Regulations 2015; • A compliant, transparent procurement process can • No mention of the different procurement routes discharge these obligations and be the enabler for available e.g. Open, Restricted, Competitive the required transformational change as opposed Dialogue, Accelerated, Competitive Procedure to any direct award that may have a high likelihood with Negotiation, The ‘Innovation Partnership’ of challenge. Procedure. • There is a requirement for the CCGs to make • Many of the policy documents referred under arrangements for providers to express their ‘NHS Policy’ are no longer valid, particularly after interest in providing services. If the CCGs were to the introduction of the NHS (Procurement, Patient adopt a non-competitive option it would breach Choice and Competition) (No 2) Regulations 2013. these regulations. • There are several references to NHS • Integrated Support and Assurance Process (ISAP) – Commissioning Board, which is now NHS England. CCGs need to be aware of ISAP and it is recommended that the Key Lines of Enquiry (KLOE) are utilised as a checklist for commissioners at each stage of the process.
31 3Rs Areas for Improvement
In comparison to the RightCare recommendations, there are opportunities for improvement in South Gloucestershire which would enable the system to achieve the optimal level of care for patients.
With an increasing ageing population there are opportunities to improve the existing model of care: • Efficiency improvements towards top 25th centile provider performance. • A system-wide population health approach incorporating risk stratification • Case management and care coordination by cohort identification to prevent deterioration of at risk groups • Better balance of ‘step up’ and ‘step down’ care with integrated pathways between primary and mental health care in addition to acute care • Improved coordination of voluntary sector to provide flexible support and capacity to holistic home care • Outcomes based frameworks for commissioning and providers • Improved utilisation of assistive technology • Fit for purpose estates • Updated procurement policy and process
32 Drivers for change Drivers for change There are six key drivers for change which help build a strong case for shaping the provision of the 3Rs programme across BNSSG. Each driver looks from a number of different perspectives including the patient, staff, providers and the system.
Rising demand and stretched system capacity Improving outcomes for Improving patients effectiveness (sustained health for pathways improvement and recovery) Drivers for change Cost pressures Land set aside and needing for sale to make the and/or money go development further
Newly merged CCGs jointly procuring service
34 Population Analysis: growth (and age) With an ageing population, the three CCGs are facing similar trends of increasing growth rates in over 65 year olds. This compares to a declining growth rate for under 65 year olds. The increased growth in the over 65 year old cohort will lead to increased demand for both step up and step down intermediate care. In relation to planning 3Rs services frail older people are expected to be the predominant users.
3.00% Over 65 years old population projected numbers and % of total BNSSG 2.50%
2018 2021 2030 % increase 2.00% 2018 - 30 S Glos. 53,600 56,600 68,900 28 1.50% (32%) Bristol 61,100 63,300 74,500 22 (37%) 1.00%
N Som. 52,100 55,000 66,900 28 PopulationGrowth Rates (%) (31%) 0.50% TOTAL 166,800 200,900 236,200 26 (mean) (100%) 0.00% Source: Office for National Statistics, 2014-based Subnational population projections, Table 2: Local authorities and higher administrative areas within England; 5 year age groups, Persons. Financial Year Website: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigratio n/populationprojections/datasets/localauthoritiesinenglandtable2, accessed City of Bristol, North Somerset, South Gloucestershire, Total, Total, February 2018.
35 Projected Post-Acute Care Referrals Projected 10,000
9,000 • 25% of emergency admissions for over 65 year olds require post-acute care (National Audit for 8,000
Intermediate Care, 2012) . 7,000 • Emergency admissions could increase from under 30,000 a year in 2016/17 to over 35,000 6,000 admissions per year in 2029/2030 for BNSSG – opportunity for integrated urgent care approach. 5,000 • Projected increase in emergency admissions are 4,000 conservative given that emergency admissions
have been growing at significantly faster than Referrals topost acutecare 3,000
population growth. 2,000 • The projected number of referrals into post-acute care (unmet demand) would rise from ~7,300 in 1,000 2017/18 to ~9,200 in 2029/30. Current - configuration of services will need to adapt to meet the increases in demand. Financial Year
Bristol CCG North Somerset CCG South Gloucester CCG
Projected Emergency Admissions Calculation: Emergency Admissions by financial year, multiplied by, 1 plus population growth rates for financial year. Post Acute Care Referrals Calculation: 25% assumption multiplied by historic and projected Emergency Admissions by financial year. Sources: NHS Benchmarking, National Audit of Intermediate Care, 2012. NAIC use a 25% assumption taken from the paper ‘An estimate of post acute intermediate care need in an elderly care department for older people, Young J, Forster A, Green J, 2003’; Emergency Admissions – BNSSG, Urgent Care Dashboard v10, February 2018. Population Growth Rates - Office for National Statistics, 2014-based Subnational population projections, Table 2: Local authorities and higher administrative areas within England; 5 year age groups, Persons. Website: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/datasets/localauthoritiesinenglandtable2, accessed February 2018. 36 Current and Projected Emergency Admissions It is important to understand rates of growth for emergency admissions as it currently heavily influences availability of capacity and patient flow into the 3Rs services. Applying the population growth rate to historic emergency admissions for over 65 year olds demonstrates that emergency admissions could increase from just under 30,000 a year in 2016/17 to over 35,000 admissions per year in 2029/2030. Note that the projected increase in emergency admissions is conservative given that emergency admissions have been growing at significantly faster than population growth. 40000
35000
30000
25000
20000
15000 Emergency Admissions 10000
5000
0 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2028/29 2029/30 (FOT) Financial Year
Bristol CCG North Somerset CCG South Gloucester CCG Projected Emergency Admissions Calculation: Emergency Admissions by financial year, multiplied by, 1 plus population growth rates for financial year. Sources: Emergency Admissions – BNSSG, Urgent Care Dashboard v10, February 2018. Population Growth Rates - Office for National Statistics, 2014-based Subnational population projections, Table 2: Local authorities and higher administrative areas within England; 5 year age groups, Persons. Website: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/datasets/localauthoritiesinenglandtable2, accessed February 2018. 37 Other factors to consider: Delayed Transfer Of Care in Acute providers DTOCs in acute providers heavily influences the utilisation of beds across the system and therefore impact on availability of community beds for P2 and P3 services. During winter, only WAHT has managed to meet the target set for DTOCs as a proportion of bed base.
DTOCs as a proportion of bedbase (%)
10.0% 9.0% 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Nov 02 Nov 09 Nov 16 Nov 23 Nov 30 Dec 07 Dec 14 Dec 21 Dec 28 Jan 04 Jan 11 Jan 18 Jan 25 Nov 02 Nov 09 Nov 16 Nov 23 Nov 30 Dec 07 Dec 14 Dec 21 Dec 28 Jan 04 Jan 11 Jan 18 Jan 25 Total 5.4% 6.0% 5.8% 5.8% 4.5% 5.2% 4.4% 4.3% 6.7% 6.0% 5.2% 6.2% 5.8% UHB 6.7% 8.7% 8.7% 8.7% 5.6% 6.3% 6.5% 6.5% 8.0% 7.1% 6.7% 7.6% 8.3% NBT 5.0% 5.9% 5.0% 5.1% 4.9% 5.1% 3.9% 4.4% 7.1% 6.7% 5.8% 7.2% 6.1% WAHT 4.4% 1.6% 3.6% 3.2% 1.6% 3.6% 2.4% 0.4% 3.2% 1.6% 0.4% 0.4% 0.4% Target 3.8% 3.8% 3.8% 3.8% 3.8% 3.7% 3.7% 3.7% 3.7% 3.6% 3.6% 3.6% 3.6%
Source: BNSSG, Discharge Dashboard, Reporting period 26/10/2017 – 25/01/2018.
38 Summary of demand and current capacity
Projections show rising demand and the gap between community bed capacity and the number of referrals is going to increase unless provision and configuration are transformed for home-based and community beds. There is likely to be future shortage of capacity under current model of care.
Shortage of capacity for community beds (P2) from 2023/24 10000
9000
8000
7000
6000
5000
4000
NumberReferrals of 3000
2000
1000
0 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2028/29 Financial Year Unmet demand - home-based care (Referrals)
Unmet demand - complex care beds (Referrals)
Unmet demand - community beds (Referrals)
Capacity - community beds (Referrals; 95% occupancy + current ALOS)
Capacity - community beds and complex care beds (Referrals; 95% occupancy + current ALOS)
39 Options appraisal: Criteria Criteria development
In developing criteria to assess each option against for provision of 3Rs services and capacity requirements, we have looked at the following objectives that align with the vision of 3Rs programme: • To meet the evolving needs of the BNSSG catchment populations • To provide an improved patient experience • To provide a safe and sustainable 3Rs services • To improve efficiencies and quality outcomes • To be sustainable, flexible and resilient
We have developed 10 criteria across three domains of System Sustainability, Person-Centred and Ease of Implementation. Inherent within these criteria are: o APPROPRIATENESS: In line with national policy (incl. RightCare), these criteria support the desire of the CCGs to deliver care that is appropriate to the needs of the individual i.e. right care, right time, right place. In particular, integrated coordinated care, 3Rs model and multidisciplinary working all enable delivery of appropriate care for the population that a preferred option must provide. o AFFORDABILITY: With a system under considerable financial strain and regulator pressure, it is vital that the preferred option gives value for money and delivers effective care, it is not expected that any savings will be generated.
41 Criteria for appraisal: 3 domains
SYSTEM SUSTAINABILITY PERSON-CENTRED EASE OF IMPLEMENTATION
Consistent with vision for co- ordinated pathways and Supports 3Rs model of care Timescales integrated care
Supports council’s intentions Ease of access Resource required
Optimises multi disciplinary Fit for purpose estates Political and public interest working Value for money/contributes to
deficit controls Weighting 40% 35% 25%
42 Criteria for appraisal: System sustainability
SYSTEM SUSTAINABILITY Each option is assessed against below details:
• Supports BNSSG vision for system Consistent with vision for co- • Aligns with STP aims ordinated pathways and • Enables seamless care delivery irrespective of care setting, professional integrated care and organisation • Facilitates partnership working • Meets SGC commissioning intentions for ECH Supports council’s intentions • Aligns with existing commitments to current/planned residential care home sites • Suitable for high quality care delivery Fit for purpose estates • Promotes good care outcomes • Creates a positive patient/staff experience • Positive impact on health and care system Value for money/contributes to • Is/close to cost neutral deficit controls • Does not negatively impact on another organisation’s budget/future spend Weighting 40%
43 Criteria for appraisal: Person-centred
PERSON-CENTRED Each option is assessed against below details: • Allows for rehabilitation, recovery and reablement service delivery • Develops capability and capacity in the community for the South Supports 3Rs model of Gloucestershire population so that people with complex needs can care receive additional support at home or in the community • Provides opportunity for enhanced services and new health and care facilities if appropriate • Availability of beds at right time for right level of care • Locally accessible via private and public transport Ease of access • Located in areas of need i.e. where frail elderly population expected to rise
Optimises multi- • Allows for integrated care delivery disciplinary working • Co-location with residential/nursing home care and ExtraCare housing Weighting 35%
44 Criteria for appraisal: Ease of Implementation
EASE OF IMPLEMENTATION Each option is assessed against below details:
• Implementable within 2 years (by April 2020) Timescales • Supports system-wide efficiency improvements within 1 year
• Costs Resource required • People – procurement/design + build/programme/clinical expertise
• Aligns with existing public commitments Political and public interest • Supports and strengthens local communities
Weighting 25%
45 List of options: Efficiency Buildings Procurement
Long list of options for 3Rs services
EFFICIENCY ESTATES PROCUREMENT
1 Shift more care to Pathway 1 Frenchay: new build for A number of options were & Reduce ALOS in beds community rehabilitation beds; reviewed and after stakeholder Thornbury: new build for engagement the preferred Enhanced Primary and Community approach is: Health Centre & ‘Step Up’ beds
2 Reduce ALOS in beds Skylark + Another site A. Clinical service provision is delivered through the re- Split core 3Rs beds procurement of Adult 3 Shift more care to Pathway 1 Frenchay + Thornbury: community Community Health Services. (separate programme) rehabilitation beds on both sites B. The CCG seeks to partner with with Thornbury Enhanced Primary SGC and request it to lead as and Community Health Centre commissioner for the new build 4 Do Nothing Thornbury: all community care home facilities required, rehabilitation beds with Enhanced linking in with NBT. Primary and Community health centre 5 Elgar at Southmead Acute Hospital
6 Do Nothing
47 Options for Efficiency Efficiency Gains and/or Activity Shifts Options: Efficiency Gains and/or Activity Shifts
1: Reduce ALOS & Shift more to Pathway 1 2: Reduce ALOS Phase 1 18/19 target = 25 days P2; 35 days P3 Phase 1 18/19 target = 25 days P2; 35 days P3 Phase 2 20/21 target = 21 days P2; 30 days P3 Phase 2 20/21 target = 21 days P2; 30 days P3 • P1 Slots Capacity: Increase+ • P1 Slots Capacity: Same • P2 Bed Capacity: Same/decrease • P2 Bed Capacity: Same/decrease • Proportional shift P1:P2 = 70:30 • P3 Bed Capacity: Same/decrease • P3 Bed Capacity: Same/decrease
3: Shift more to Pathway 1 4: Do Nothing • ALOS: Same • ALOS: Same • P1 Slots Capacity: Increase • P1 Slots Capacity: Same • P2 Bed Capacity: Same/increase • P2 Bed Capacity: Increase • Proportional shift P1:P2 = 70:30 • P3 Bed Capacity: Increase • P3 Bed Capacity: Increase
Note: All efficiency gains to be modelled at 95% occupancy (current CCG planning target)
49 Efficiency Gains and/or Activity Shifts Options against criteria PREFERRED OPTION Key Strongly meets criteria 1 2 3 4 Meets criteria Shift more to Does not meet criteria Shift more to Pathway 1 Reduce ALOS Do Nothing Pathway 1 Not applicable & Reduce ALOS
SYSTEM SUSTAINABILITY Consistent with vision for co-ordinated pathways and integrated care
Supports council’s intentions
Fit for purpose estates
Value for money/contributes to deficit controls PERSON-CENTRED
Supports 3Rs model of care
Ease of access
Optimises multi disciplinary working EASE OF IMPLEMENTATION
Timescales
Resource required
Political and public interest
50 Efficiency Gains and/or Activity Shifts Option 1 - Reduce ALOS & Shift more to Pathway 1
Phase 1 18/19 target = 25 days P2; 35 days P3 Benefits: Phase 2 20/21 target* = 21 days P2; 30 days P3 • Greater capacity in the community due to • P1 Slots Capacity: Increase+ phased more efficient use of beds • More home-based care due to increase in P1 • P2 Bed Capacity: Same/decrease slots by c.1 slot per week, within current • Proportional shift P1:P2 = 70:30 contracted capacity • P3 Bed Capacity: Same/decrease • No increase in the community bed base as demand is met by additional home-based care. Assessment • Efficiency improvements release capacity for • With shift towards more home-based care and flexible use to accommodate unusual pressures increased efficiencies in bed-based care, this option aligns with vision of 3Rs model and integrated Risks: multidisciplinary, person-centred care. • Prior commitment to increase community bed • More efficiency will release capacity that creates numbers is not met better value for money, enabling better access to the • Ability to shift patients across pathways might right level of care appropriate for patient needs. not be feasible without understanding current • A phased approach to achieving the reduced ALOS is cohort needs in detail per pathway deliverable by April 2020 but will require a focused • High increase in home-based care reliant on team involving collaboration across health and social support and coordination with other services care teams.
Option 1 strongly meets several criteria and is the PREFERRED OPTION.
*Note: targets based on evidence of 21 days for general rehabilitation and 28 days for complex rehabilitation. Since there is less clarity on patient cohort and rehabilitation potential of current P3 caseload, a conservative target of 30 days has been proposed, pending further clinical analysis.
51 Efficiency Gains and/or Activity Shifts Capacity required for Pathway 2 South Gloucester View Option 1: Reduce average length of stay (ALOS) and shift more activity from P2 to P1: 17/18 Current ALOS 30 days; Phase 1 18/19 ALOS target 25 days; Phase 2 20/21 target 21 day
Bed requirements from option impact based on bed days 80 Current ALOS P2 to 70 30 days P1 shift
60
50
40 35-45
beds No. beds of 30
20
10
0 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2028/29 Financial Year
Key for ALOS 34 days 30 days 25 days 21 days 17 days 14 days
Once efficiencies are achieved on target, P2 bed capacity requirement will be 35-40 to provide adequate episodes of care.
52 Efficiency Gains and/or Activity Shifts Capacity required for Pathway 3 South Gloucester View Option 1: Reduce average length of stay (ALOS) and shift more activity from P2 to P1: 17/18 Current ALOS – 38 days; Phase 1 18/19 ALOS target 35 days for P3; Phase 2 20/21 target 30 days P3
Bed requirements from option impact based on bed days 20 Current 18 ALOS 38 days 16
14 12-14
12 beds
10
No. beds of 8
6
4
2
0 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2028/29 Financial Year
Key for ALOS 40 35 30 28 25
Once efficiencies are achieved on target, P3 bed capacity requirement will be 12-14 to provide adequate episodes of care.
53 Efficiency Gains and/or Activity Shifts Option 2 - Reduce ALOS
Phase 1 18/19 target = 25 days P2; 35 days P3 Benefits: Phase 2 20/21 target = 21 days P2; 30 days P3 • Greater capacity in the community due to • P1 Slots Capacity: Same phased more efficient use of beds • Efficiency improvements release capacity for • P2 Bed Capacity: Same/decrease flexible use to accommodate unusual pressures • P3 Bed Capacity: Same/decrease • No increase in the community bed base
Assessment Risks: • With increased efficiencies in bed-based care, this • Prior commitment to increase bed numbers is option aligns with vision of 3Rs model and not met integrated multidisciplinary, person-centred care. • Reduction in ALOS not realised due to pressures • More efficiency will release capacity that creates from other sectors better value for money, enabling better access to • P1 utilisation not optimised for more people to the right level of care appropriate for patient needs. receive care in the home rather than in • A phased approach to achieving the reduced ALOS is community beds deliverable by April 2020 but will require a focused team involving collaboration across health and social care teams. Option 2 is DISCOUNTED. Whilst it strongly meets some criteria, it does not enable the vision of more care closer to home or more efficiency and better flow in the 3Rs services.
*Note: targets based on evidence of 21 days for general rehabilitation and 28 days for complex rehabilitation. Since there is less clarity on patient cohort and rehabilitation potential of current P3 caseload, a conservative target of 30 days has been proposed, pending further clinical analysis.
54 Efficiency Gains and/or Activity Shifts Capacity required for Pathway 2 South Gloucester View Option 2: Reduce average length of stay (ALOS): 17/18 ALOS 30 days. Phase 1 18/19 ALOS target 25 days; Phase 2 20/21 target 21 day
Bed requirements from option impact based on bed days 90 Current 80 ALOS 30 days 70
60
50 42-50 beds
40 No. beds of
30
20
10
0 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2028/29 Financial Year
Key for ALOS 34 days 30 days 25 days 21 days 17 days 14 days
Once efficiencies are achieved on target, P2 bed capacity requirement will be 42-50 to provide adequate episodes of care.
55 Efficiency Gains and/or Activity Shifts Capacity required for Pathway 3 South Gloucester View Option 2: Reduce average length of stay (ALOS): 17/18 ALOS – 38 days. Phase 1 18/19 ALOS target 35 days for P3; Phase 2 20/21 target 30 days P3
Bed requirements from option impact based on bed days 20 Current 18 ALOS 38 days 16
14 12-14
12 beds
10
No. beds of 8
6
4
2
0 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2028/29 Financial Year
Key for ALOS 40 days 35 days 30 days 28 days 25 days
Once efficiencies are achieved on target, P3 bed capacity requirement will be 12-14 to provide adequate episodes of care.
56 Efficiency Gains and/or Activity Shifts Option 3 – Shift more activity to Pathway 1
• ALOS: Same Benefits: • P1 Slots Capacity: Increase • Increased P1 activity means more patients can • P2 Bed Capacity: Same/increase receive home-based care • Proportional shift P1:P2 = 70:30 • More home-based care due to increase in P1 slots by c.1 slot per week, within current • P3 Bed Capacity: Increase contracted capacity
Assessment Risks: • With shift towards more home-based care, this • ALOS remains above best practice targets and option aligns with vision of 3Rs model and integrated potentially reflects inefficiency in current bed use multidisciplinary, person-centred care. that will continue to impact service delivery • The shifting of activity can be achieved by April 2020 • There will be a potential shortage of community with minimal, but without reduction in ALOS there beds by 28/29 that may require future build in a remains the need to increase capacity to meet future financially constrained system, without demand that will require longer timescales and more improving efficiencies resource. • Ability to shift patients across pathways might • However, without creating more efficiency to release not be feasible without understanding current capacity there will be difficulty in enabling better cohort needs in detail per pathway access to the right level of care appropriate for • High increase in home-based care reliant on patient needs and ensuring value for money. support and coordination with other services
Option 3 is DISCOUNTED. It fails to meet enough criteria and does not address future demand and capacity needs.
57 Efficiency Gains and/or Activity Shifts Option 4 – Do Nothing
• ALOS: Same Benefits: • P1 Slots Capacity: Same • This option requires additional capacity at • P2 Bed Capacity: Increase current levels of efficiency - commitment to increase bed numbers is met • P3 Bed Capacity: Increase
Risks: Assessment • ALOS remains high and potentially reflects • Although the current delivery of 3Rs services is in inefficiency in current bed use line with vision of 3Rs model and integrated • There will be a potential shortage of multidisciplinary, person-centred care, this option community beds by 28/29 that may require fails to address the future needs of the population. future build in a financially constrained • It does not create efficiency to enable better access system, without improving efficiencies to the right level of care appropriate for patient • Home-based packages do not change to meet needs or ensure value for money. demand; could lead to an undersupply of home-based care packages
Option 4 is DISCOUNTED. It fails to meet enough criteria and does not address future demand and capacity needs - the current way of working must be changed.
58 Options for Estates Estates Options: Estates for 3Rs beds
1: Frenchay: new build for community rehabilitation beds; 2: Skylark + Another site Thornbury: new build for Enhanced Primary and Community Health Centre & ‘Step Up’ beds • Current 30 bedded location in Meadows, Yate (currently 2 year lease agreement - alternative site once lease ends) • • Integrated community health and care Co-located with residential home care • • Co-located with residential/nursing home care with no core health Another site for remaining capacity requirements beds • Core bed capacity with flexible use of co-located facilities
3: Frenchay + Thornbury: community rehabilitation beds 4: Thornbury: all community rehabilitation beds on both sites with Thornbury Enhanced Primary and with Enhanced Primary and Community health Community Health Centre centre
• 2 site split - 2 new builds for community beds: • 1 site – 1 new build for community beds - Frenchay as integrated health and care hub co-located • Co-located with primary care new build – opportunity for with residential home care integrated primary and community care hub - Thornbury as integrated primary and community hub co- • Core bed capacity with flexible use of co-located facilities located with primary care new build
5: Elgar 6: Do Nothing
• Use 30+ bedded base at Southmead acute site • Keep current configuration • Co-located with acute services • Capacity for Pathway 2: Same bed numbers • Redesign model of care to meet demand without new build
Detailed impact on other potential sites described in preferred option
60 Estates
Options against criteria PREFERRED OPTION Key Strongly meets criteria 1 2 3 4 5 6 Meets criteria
Does not meet criteria Skylark + Frenchay + Do Frenchay Thornbury Elgar Another Thornbury Nothing Not applicable
SYSTEM SUSTAINABILITY Consistent with vision for co-ordinated pathways and integrated care
Supports council’s intentions
Fit for purpose estates
Value for money/contributes to deficit controls PERSON-CENTRED
Supports 3Rs model of care
Ease of access
Optimises multi disciplinary working EASE OF IMPLEMENTATION
Timescales
Resource required
Political and public interest
61 Estates Option 1 – Frenchay: new build for community rehabilitation beds; Thornbury: new build for Enhanced Primary and Community Health Centre & ‘Step Up’ beds • Frenchay single site new build for core community beds • Thornbury Enhanced Primary and Community Health Centre • Co-located with ECH and residential/nursing home care with no core health beds • Core bed capacity with flexible use of co-located facilities to accommodate increases in demand and flexible commissioning of supplementary beds at Thornbury dependant on need Benefits: • Involves NBT land sale • Provides required capacity in fit for purpose facilities • It delivers core and flexible bed base for responsiveness to meet needs Assessment • A new build facility on for beds on Frenchay site • This option provides opportunity to have a new build for all core meets previous commitments community beds that is designed to meet patient needs and services’ • Enables new build for Primary and Community health requirements, aligning with vision of 3Rs model and system vision for centre on Thornbury alongside LA requirements. integrated multidisciplinary, person-centred care. • Co-location with residential/nursing home care lends • Beds co-located with residential and nursing care home capacity itself to potential for more integrated care enables council intentions and person-centred care in a lower acuity • Build on this site supports NBT desire to sell land setting. Risks: • Creating a single site may lead to better clinical safety, governance • Cost and resource requirement for new build may not and improved outcomes and also leads to economies of scale that yield overall savings and will require time before provide value for money. services can be operationalised • Opportunity to provide integrated health and care and become • Location may not be close to demand Centre of Excellence for Rehabilitation services at FRENCHAY, • No core beds on Thornbury may be politically especially with proximity of Brain Injury Rehabilitation Unit for challenging due to prior expectations. specialist neurorehabilitation • Other community demands not met • THORNBURY developed as Primary and Community Health Centre adjacent to LA Extra Care Housing and Nursing Home beds Option 1 strongly meets several criteria and is the PREFERRED OPTION. 62 Estates
Option 2 – Skylark + another site
• Current 30 bedded location in Meadows, Yate (currently 2 year lease agreement - alternative site once lease ends) +? • Co-located with residential home care • Another site for remaining capacity requirements
Assessment Benefits: • This option makes use of existing operational facility (since • Co-location with residential/nursing home care lends February 2018) that is co-located with residential and nursing itself to potential for more integrated care care home units, which would lessen need for time and • Easy to implement since one site is already operational resources. (for limited term) • It is not designed for 3Rs services but has been adapted to suit patient needs, aligning with vision of 3Rs model and system Risks: vision for integrated multidisciplinary, person-centred care. • Not a long-term option as SGC forecasts the need for • However, it is only a short-term option due to lease this capacity as its originally intended use within the arrangement and any extension would not meet council local market after lease ends intentions. The Meadowws was enabled to meet forecast • Prior commitment to other sites is not met capacity requirements in SGC’s Better Support for Older People • Separating care delivery across multiple sites will Strategy. After the lease term a new site would need to be impede best clinical governance, safety, outcomes and found to transfer patients to. economies of scale. • An additional site (similar/new build) would need to be agreed • Too early to ascertain cost-benefit and patient to host the remaining capacity requirements. outcomes over long-term for similar estate
Option 2 is DISCOUNTED because Skylark is not available for long term use and split site solution is not preferred.
63 Estates Option 3 – Frenchay + Thornbury: community rehabilitation beds on both sites with Thornbury Enhanced Primary and Community Health Centre
• 2 site split - 2 new builds for community rehabilitation beds: - Frenchay as integrated health and care hub co- located with ECH and residential home care - Thornbury as enhanced primary and community care centre co-located with ECH, residential home care and with primary care new build Benefits: • Provides required capacity in fit for purpose facilities • It delivers core and flexible bed base for responsiveness Assessment to meet needs • This option provides opportunity to have new build facilities that • Enhanced primary and care services to optimise out of are designed to meet patient needs and services’ requirements, hospital care aligning with vision of 3Rs model and system vision for integrated • New builds on sites meets previous commitments multidisciplinary, person-centred care. • Co-location with residential/nursing home care lends • Co-location with residential and nursing care home capacity itself to potential for more integrated care supports council intentions. • Build on this site supports NBT desire to sell land • Providing high quality skilled rehabilitation across two sites may affect patient outcomes, lower any efficiency gains and reduce Risks: economies of scale. • Separating care delivery across multiple sites will • Delivering two new builds will require more time and resource. impede best clinical governance, safety, outcomes, efficiencies and economies of scale. • Having two new builds may increase system overheads. Option 3 is DISCOUNTED. Whilst it meets some criteria, a • Resource requirement for new build may more costly multi-site delivery may be more costly to run and impact and will require time before services can be fully on achieving best outcomes. operationalised
64 Estates Option 4 – Thornbury: all community rehabilitation beds with Enhanced Primary and Community health centre
• 1 site – 1 new build for community beds • Co-located with primary care new build – opportunity for integrated primary and community care hub • Core bed capacity with flexible use of co-located facilities • Involves demolition of current estate • Involves NBT/NHS PS land sale
Assessment Benefits: • Provides opportunity to have a new build that is designed to • Provides capacity to meet future requirements meet patient needs and services’ requirements, aligning with • Core vs. flexible bed base allows for responsiveness to vision of 3Rs model and system vision for integrated future system/model of care changes i.e. designed to multidisciplinary, person-centred care. meet needs • Co-location with residential and nursing care home capacity • Meets political and public appetite supports council intentions and person-centred care in a lower • Honours earlier commitments acuity setting. • Integrated with residential/nursing home care • Creating a single site may lead to better clinical safety, governance and improved outcomes and also leads to Risks: economies of scale that provide value for money. • Cost of build may not yield overall savings • Site will require time and resources associated with transfer of • Complexity of joint primary and community build patients to a temporary alternative setting and demolition of • Increased cost and time for demolition of old build Victorian build before new build. • Will require cost and time of relocating current services during building phase
Option 4 is DISCOUNTED. It fails to meet enough criteria strongly. It leads to no health beds on Frenchay and is more complicated to deliver overall. 65 Estates Option 5 – Elgar
• Use 30+ bedded base at Southmead acute site of North Bristol NHS Trust • Co-located with acute services
Assessment Benefits: • Provides capacity to meet future requirements within existing • Easy to implement since site is already operational for build that has previously provided 3Rs services acute care • Allows for seamless transition to post-acute care • Less cost to system without new build • Lacks opportunity for co-location with residential and nursing care home capacity due to being on acute site and so does not Risks: support council intentions or person-centred care in a lower • Risk of using capacity to cope with acute bed acuity setting. pressures • Creating a single site may lead to better clinical safety, • It may continue an acute patient experience during governance and improved outcomes and also leads to 3Rs service delivery that it less integrated with other economies of scale that provide value for money. care services. • Site will require time and resources associated with need to • Prior commitment to other sites is not met refurbish to become fit for purpose. • Location may not be close to demand • Seen as less appealing given previous attempt at using site for 3Rs • Not fit for purpose – requires refurbishment • Does not support NBT desires to sell land
Option 5 is DISCOUNTED. Although it may be easier to deliver a refurbished build, it fails to meet most other criteria. 66 Estates Option 6 – Do Nothing
Thornbury
• Keep current configuration SMT Yate NBT SMT • Capacity for Pathway 2: Same bed numbers BC Deerhurst NSCH UHBEBICC B CCMHASBRC SBCH • Redesign model of care to meet demand without WGH new build
Assessment Benefits: • The current delivery of 3Rs services fails to address the future • Option allows time for system-wide review and needs of the population and does not support the vision of 3Rs standardisation of BNSSG 3Rs services services and integrated multidisciplinary, person-centred care in • It provides opportunity for system-wide efficiency fit for purpose estates. gains before commitment to estates • It does not enable efficiency for better access to the right level • Opportunity to consider integrated model of care that of care appropriate for patient needs or ensure value for money supports both ‘step down’ and ‘step up’ care. in the long-term. • It misses the opportunity for co-location with residential and Risks: nursing care home capacity that would support council • Safety and governance issues of using estates that are intentions and person-centred care in a lower acuity setting. not fit for purpose and patients in multiple sites • Although no time and resources will be required in the short- • Prior commitment to other sites is not met term, there will be future need for improved sites that meet • Does not enable 3Rs or system vision population requirements. • Does not support NBT desires to sell land
Option 6 is DISCOUNTED. It fails to meets enough criteria and does not address future capacity needs - the current way of working must be changed.
67 Preferred option This section describes: The preferred option for Pathways 2 & 3 Wider system impacts Recommended next steps to deliver Preferred option for 3Rs services model
EFFICIENCY ESTATES PROCUREMENT
Improve efficiency across 3Rs • Integrated Health and Care Hub • Single BNSSG Adult pathways to facilitate greater at Frenchay, co-located with new Community Service including proportion of patients treated care home delivering nursing 3Rs (facilitated by BNSSG through Pathway 1 (home- dementia capacity and an Adult Community Services Re- based care) and aim to achieve ExtraCare Housing scheme. Procurement) upper quartile performance in • Enhanced Primary and • New multi-agency project length of stay from 30 days to Community Care Centre at team to be established that 21 days in bedded capacity Thornbury providing extended will oversee procurement and services (Frailty/Mental Health/ delivery. CCG recommended Outpatient services) with 6-10 to request that SGC leads the ‘step up’ beds, co-located with project team. new care home delivering nursing dementia capacity and an ExtraCare Housing scheme.
69 DRAFT – IN CONFIDENCE Preferred Option for 3Rs Service Model (1)
Frenchay Thornbury • New build for bedded facility to include: • New build for Enhanced Primary and - A) 40-50 core beds (P2 and P3) Community Care Centre - B) Additional 36 care home beds including - Integrated primary and community care dementia nursing units co-located with services providing holistic and 3Rs beds comprehensive care - C) Co-located with local authority - Provision of extended services including commissioned ExtraCare Housing 50-80 frailty and mental health units • New build for co-located Local Authority • Facilitates NBT land sale commissioned services • Opportunity to provide integrated health and - New nursing care home c.80 units (up to care and become centre of excellence for 36 of which would be dementia nursing) rehabilitation services – co-located with Brain - ExtraCare Housing units: 50-80 units Injury Rehabilitation Unit (specialist • Includes 6-10 ’step up’ beds neurorehabilitation opportunity) • Maintain flexible use of capacity in Thornbury to accommodate transition to optimum length of stay and increases in demand • Facilitates NBT and NHS PS land sale
This preferred option includes flexibility to purchase additional beds on a short-term basis to accommodate unusual pressures.
70 Preferred Option for 3Rs beds (2) Context • The statement of commissioner requirements issued in 2015 for 3Rs procurement did not specify bed numbers but invited the providers to consider how the 3Rs model of could be implemented in a sustainable way, with an emphasis on supporting people at home wherever possible. • South Gloucestershire CCG previously consulted on the future of services at Frenchay and Thornbury. A decision was taken in 2015 to provide community rehabilitation beds on both sites to meet the needs of the population. At the same time South Gloucestershire Council made clear its intention to commission residential/nursing home beds and extra care housing facilities on the two sites. • A process was established whereby the existing community provider (Sirona health and care) would work with an external funding partner to develop detailed proposals for integrated health and social care provision, including extra care housing, at Frenchay and Thornbury. For a variety of reasons, however, the work did not progress at the pace expected. • In December 2017 the Governing Body took the decision to discontinue the Sirona led development of the Frenchay and Thornbury sites as it could not legally offer the contract length Sirona required to make the scheme successful. • This delay was understandably disappointing for stakeholders who had been waiting for a number of years to see the new sites developed. As a result the CCG committed to immediately undertake a review that would both confirm commissioner requirements in light of population need and to ensure a modern model of care, and enable us to restart a process that would give a clear timeline and date for delivery. • In January 2018 Attain was appointed to support the CCG in reviewing options for next steps. Attain worked closely with the CCG, South Gloucestershire Council, North Bristol NHS Trust and other partners to come to a preferred option, which is described below. The preferred option is in line with the output from the original 3Rs consultation.
71 Preferred Option for 3Rs beds (3) Improving efficiency and future capacity • The CCG has recently reviewed projected demand and capacity for 3Rs with reference to latest available NHS benchmarking date, and including consideration of progress made in other health systems since 2015. This analysis takes account : - Opportunities to increase the proportion of care delivered at home (which all else being equal will reduce the bed requirement) and the projected growth in demand. - Opportunities to move to an optimum level of rehabilitation care (which would reduce bed requirement at current levels of need and increase capacity for additional episodes of care • The analysis supports a core 3Rs bed requirement in the range of 40 to 50 core rehabilitation beds with 6-10 beds to be used flexibly for ‘step up’ . • The preferred option is to provide all of the core rehabilitation beds on the Frenchay site – this would enable concentration of resources and expertise for the South Gloucestershire population. It provides good access for the whole population and offers an opportunity for further synergies by locating the rehabilitation beds alongside the existing specialist rehabilitation services (BIRU), effectively creating the basis for a centre of excellence for rehabilitation. • In addition to this core capacity, the CCG would provide 6-10 ‘step up’ beds at Thornbury and budget for the potential need to purchase short-term additional 3Rs episodes according to need. • Further detailed affordability analysis is required. However, at this stage, it is assumed that the proposed new configuration should be at least cost neutral. • The preferred approach for procurement is in two parts (Lots). Firstly that the CCG commissions the services as part of its overall intention to procure a single comprehensive community service across BNSSG. In parallel, SGC could be asked to lead the procurement of building requirements, with the CCG in support.
72 Preferred Option for 3Rs Service(4) Intentions for Thornbury site • In addition to the 6-10 ‘step up’ beds at Thornbury, the CCG has worked with NHS England and local provider organisations to develop a vision for future primary care and community services for Thornbury. • The work undertaken to date has identified the opportunity for a new purpose-built primary and community care facility, providing a modern and adaptable environment which can support future service models and accommodate the expected population growth in the local area. Replacing the current cramped and outdated premises, the new facility would become the nucleus for a dynamic new enhanced primary and community health and care mode that achieves a sustainable reduction in reliance on acute hospital services. • Using ETTF funding external consultant support has been commissioned to progress the development of an option appraisal and draft outline business case for future primary care and community infrastructure requirements with reference to the national and local priorities arising from the General Practice Forward View. Innovations in primary care are occurring across the South West region and include enhanced primary care hubs offering Urgent Visiting services, collaborative cluster models and technology adoption. • Work to date has included consideration of community and hospital outpatient activity currently in poor quality buildings on the Thornbury Hospital site and the potential for co-locating community mental health teams currently in separate accommodation in the town. It has also identified the land requirements for a new facility based on a range of potential premises requirements and consideration has been given to the local sites that are available to facilitate a development of this type. • The likely preferred option would be to develop on part of Thornbury Hospital site, subject to confirmation of the other functions to be accommodated there. • The current total registered population of Thornbury town and surrounding villages is approximately 30,000 of which approximately 21,000 are registered with the three Thornbury town centre practices. An increase in registered patients of 17% is forecast by 2027 as a result of population growth arising from a combination of demographic change and planned and potential housing growth. • The Capita options appraisal and the first draft of the outline business case is due to be completed by April 2018.
73 Affordability of the Preferred Option
It has been difficult to undertake an affordability appraisal of the preferred option due to current data quality. However, given the current budget is based on less than optimum outcomes and inputs with a heavily weighted bed base (90% of the overall 3Rs budget for South Gloucestershire) it is assumed that the proposed new configuration should be at least cost neutral. The 3Rs services are costed via block contract and it has not been possible to identify an overhead cost which could be compared against the potential charge for new facilities made by future developer. The preferred future model for commissioners is to purchase episodes of care based on competitive price per episode. However, current financial modelling for community services is built on the annualised cost of care and associated beds. Therefore, at this stage it is only possible to produce a future potential cost envelope for 3Rs services based on changes to capacity requirements in the preferred efficiency option. A premium for overheads at new build will need to be estimated once current overheads within adult community services contract is established. Although we have provided this comparison of future against current cost, it comes with a major caveat that it does not include the premium that is likely to be applied by a developer for a new purpose built facility.
CURRENT ANNUAL FUTURE ANNUAL FINANCIAL FINANCIAL ENVELOPE ENVELOPE FOR PREFERRED OPTION
Core Core + Flex
£6.0m £3.8m £2.2m £5.0m £1m
Analysis is based on 18/19 indicative financial envelope, which suggests that the future configuration of services based on the Remaining budget could allow preferred option should be at least cost neutral. for premium of new build
Source: BNSSG CCG Indicative budget for 3Rs services. 74 Procurement
Suggested procurement timeline for services
Apr ‘20
Apr ‘19 Sept ‘19 Sept ‘20
Apr ‘21 Sept Sept ‘18
Bristol Community Health: Direct Award* Adult community & Learning Disabilities
North Somerset Community Partnership: Adult & Children’s community services Single integrated provider contract for Adult community services Sirona (incl. 3Rs +/- LD) 5-10 years care & health: Contract extension* Adult community Sirona care & health: Direct Award* Learning Disabilities
*All new contracts/extensions include updated service specification that aligns with future single provider contract e.g. new build requirement, outcomes measures etc.
75 Integrated Support and Assurance Process (ISAP) for procurement • Over the last few years there have been a number of high profile contracts that have failed relatively quickly after award e.g. Hinchinbrook Hospital (Circle), Suffolk Community Services (Serco), Cambridge & Peterborough Adult Community Services (UnitingCare) which have placed High Value Complex Contracts into more scrutiny by politicians, public and the media. • ISAP is a relatively new NHS England/NHS Improvement scrutiny process to provide assurance around “novel and complex” contracts: – Long-term, high-value models would fall within scope – It involves checkpoints at four different stages – from planning through procurement and contract award to service mobilisation
• The CCGs will need to ensure that sufficient time is allowed in Programme development to take into consideration the production of a business case that responds/tests to the requirements contained within the above, which is likely to form the basis of any central approval to proceed. • Contact should be made with NHSE/NHSI before project commencement to inform the timeline.
76 Preferred Option for 3Rs beds (5) Next Steps The success of the programme requires a whole service approach and collaboration with all key stakeholders to plan, prioritise, deliver changes and inform the future investment programme. In progressing this option we have identified 10 next steps to build confidence in delivery of the preferred option. These are described in in 3 domains: (1) preparation for procurement, (2) procurement process (3) further efficiency and effectiveness improvements Preparation for procurement By when
1. Build efficiencies into current community contracts: Align all current contracts for community provision across BNSSG to a 2020 end point to enable procurement of a single BNSSG community service. • Shift to 70/30 ratio for P1/P2 • Shift to 25 day ALOS for P2 by September 2018 and 21 days Sept 18 • Shift to 35 day ALOS for P3 by September 2018 and 30 days Sept 18 Sept 19 2. Seek agreement with SGC to move forwards with procurement in partnership and set up programme board May 18 3. Public engagement and consultation: Rollout stakeholder communications and engagement plan further to previous 3Rs consultation (in line with IRP recommendations) Changes to service configurations and estates taken to public consultation, if required Spring 18 4. Clarify patient cohort: Undertake a clinical audit of all P1, P2 and P3 current cases to ensure further clarity of case mix to inform further refinement of the overall model and continue to seek similar benchmarked systems and review their operational models (through 3Rs steering group) Spring 18 5. Affordability assessment: Further cost analysis of the preferred option to agree the affordable budget for the new model July 18 6. Release land: Agree arrangements with NBT and NHSPS for releasing land at Frenchay and Thornbury for development of the new health and care facilities. July 18
77 Preferred Option for 3Rs beds(6) Next Steps (continued)
Procurement process By when
7. Commence the procurement of a single BNSSG community service, incorporating 3Rs requirements to be introduced from April 2020. As part of this transition – develop outcomes-based commissioning with Sept 18 contractual/performance levers for improving efficiency, capacity and affordability: Led by BNSSG CCG in partnership with SGC 8. Commence the procurement of new buildings on Frenchay and Thornbury with the intention of the new developments available for use in 2020/21: SGC to be asked to lead in partnership with BNSSG CCG and NBT. NOTE: This would require sourcing suitable interim arrangements for the current 20 beds at Sept 18 Thornbury and phasing development to minimise disruption to primary care and outpatient services on the site. Further improving efficiencies and effectiveness By when 9. Improve patient flow through the system: • System patient flow mapping and analysis e.g. following frequent flyers across the system to understand barriers and trigger points. • Align data capture within contracts to allow for ‘realtime’ planning assumptions to be applied to programme development. Sept 18 • Create standardised pathways and processes across system incl. handovers and medical cover to ensure greater efficiencies and optimise RightCare principles. • Use of risk stratification (at cohort level) to lead to predictive population modelling that supports detailed planning and implementation 10. System-wide bed analysis (across all sectors) – to determine true bedded capacity, performance incl. Dec 18 utilisation 11. Consider increasingly co-ordinated of model of care that offers more seamless integrated care, covering acute, community, primary care and mental health Dec 18
78 Risks and Mitigations
Risks Mitigations • Delivering the ALOS reductions to 21 days • A transition plan which includes reducing ALOS to target. ensure that patients are in the most appropriate • Inability to close spot purchase beds and setting. patients continue to placed across the area. • A clear operating policy for the use of spot • Patients remain in an acute environment too purchasing beds to ensure patients are in the long, and Elgar ward remains open for patients requiring rehabilitation. most appropriate settings for their needs and the acute providers are supported appropriately. • Patients remain inappropriate setting and unable to access appropriate rehabilitation. • An explicit budget identified for rehabilitation, which is monitored monthly and appropriate • Patients cannot be discharged from an acute setting in a timely way. mitigations taken to manage within resources available. • Costs of rehabilitation cannot be contained with the budget either in terms of bed numbers or • A clear commissioning statement confirming the costs. purchase the number of nursing home beds. • A developer is not identified for the Frenchay • Multi-agency project team established to oversee and Thornbury sites. procurement and delivery • NBT land sale value
Adjacent opportunities System requirements
As a part of this project we have assessed the wider opportunities presented by an integrated service across all 3 CCGs, or those that complement e.g. reducing acute beds to fund shift to community care. There are a number of increased efficiency gains to adopt a similar approach for the whole BNSSG system, with impact on future beds.
Key system elements that would support a successful outcome of the chosen option are: • Fully integrated health and care • Patient flow improvements by integrated pathways and collaborative working across all organisations • Timely and effective assessment, care planning and coordination (discharges and transfers) • Patient and public involvement • Enhanced primary care delivery is integral
81 Efficiency Gains and/or Activity Shifts Capacity required for Pathway 2 BNSSG View Option 1: Reduce average length of stay (ALOS) and shift more activity from P2 to P1: Phase 1 18/19 ALOS target 25 days for P2 and 35 days for P3; Phase 2 20/21 target 21 days P2 and 30 days P3
Bed requirements from option impact based on bed days Current ALOS 300 34 days P2 to P1 shift 250
200
150 140-150
beds No. beds of 100
50
0 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2028/29 Financial Year
Key for ALOS 34 days 30 days 25 days 21 days 17 days 14 days
Once efficiencies are achieved on target, P2 bed capacity requirement will be c.140-150 to provide adequate episodes of care.
82 Efficiency Gains and/or Activity Shifts Capacity required for Pathway 3 BNSSG View Option 1: Reduce average length of stay (ALOS) and shift more activity from P2 to P1: Phase 1 18/19 ALOS target 25 days for P2 and 35 days for P3; Phase 2 20/21 target 21 days P2 and 30 days P3
Bed requirements from improved average length of stay (bed days) 50
45 Current ALOS 39 days 40
35 28-34 30 beds
25
No. beds of 20
15
10
5
0 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 2026/27 2027/28 2028/29 Financial Year
Key for ALOS 40 35 30 28 25
Once efficiencies are achieved on target, P3 bed capacity requirement will be c.28-34 to provide adequate episodes of care.
83 Efficiency Gains and/or Activity Shifts Potential impact example if preferred option for efficiency gains was applied to Bristol
What if Bristol capacity follows same principle as South Gloucestershire
+/- Change from After Before current E.g. private / academic More complex burns, ENT, craniofacial, cardio, P1 slots 2,964 884 respiratory 2,080
P2 beds 46 122 -76
P3 beds 21 19 +2
Total beds 67 141 -74
84 Appendix Best practice details Community length of stay (1)
Barking & Dagenham, Havering & Redbridge CCGs • In 2014 the CCGs jointly established a programme to address issues of inefficiency and increasing demand facing their community services, “Making intermediate care better”. • The programme included rollout of trialled services such as the Community Treatment team and the Intensive Rehabilitation service. Both services had the aim of reducing acute hospitalisation, supporting discharge from community beds and maintaining independence of patients. • Their approach was to work closely with providers by: - Designing care around patients, making sure that they receive the right care, in the right place, at the right time - Ensuring that different services ‘talk’ to each other reducing inefficiencies in care - Supporting people to live well and independently for as long as possible - Locating support and care services in, or as close to peoples homes as possible - what patients said they wanted - Ensuring intermediate care services and the health and social care system is ‘future proof’ and able effectively to manage increasing demand and need, not only today, but in years to come - Delivering services that are efficient and provide value for money • The CCGs agreed targets for providers of general and complex rehabilitation, 21 and 28 days respectively (based on data from NHS Benchmarking and other pilots). At the time ALOS was 29 days, with cases going up to 40+ days. • The main provider of intermediate care is North East London NHST Foundation Trust (NELFT), who after successfully introducing these services in 2014, recorded ALOS as 19 days for general rehabilitation. • Latest quality reports indicate that ALOS on general rehabilitation wards has remained within 21 days target, with 2018 figures published as 20.4 days despite other pressures. Community length of stay (2) West, North & East Cumbria Success Regime • In realising the vision for their wider clinical services strategy, WNE Cumbria success regime wanted to examine what the future for their community hospitals should be. During 2016 they conducted analysis on productivity within community hospitals, to establish current impact of previous initiatives and identify opportunities for further improvement. • In the period 2007 – 2010 there was an intense focus on improving productivity and quality in community hospitals. As a result: - Overall admission numbers to community hospitals doubled - Length of stay (LOS) reduced in every hospital (average of 9 days less) - Overall there was an 80% increase in the ‘throughput per bed’ • Between 2010 and 2013 admission numbers stayed more or less steady but there was been a small further reduction in LOS of 1.3 days and throughput per bed increased by a further 5% . • Between 2013- 2016: 14.8% reduction in readmissions - There has been a significant increase in length of stay to 21 days in community hospitals with significant numbers of delayed transfers of care. - Increased proportion of step down patients 75-80% over the last 12 months reflecting significant bed pressures in the acute trust and on community based services (home care, reablement and community health provision). Leicestershire NHS Trust The Trust identified challenges resulting from 56 different discharge pathways, meaning too often patients were put onto the wrong pathway and overprescribed packages of care, associated with long lengths of stay. Following a reduction to 5 discharge pathways, around 70% of patients are discharged through pathways 1 ‘Home with existing support’. A whole system change in how the hospital approaches health and social care has seen the Trust move from amongst the worst 10% of national DTOC performance to sustaining DTOC levels that place them amongst the top 2.5% of systems.” Sources: Health Catalyst (2014), https://www.healthcatalyst.com/success_stories/reducing-length-of-stay-in-hospital; WNE Cumbria Community Hospitals Preferred Option Rationale and Vision (2016) http://www.wnecumbria.nhs.uk/wp-content/uploads/2016/09/APPENDIX-H-Community- hospitals-vision-and-proposals-May-2016.pdf; Leicestershire NHS Trust, case study, Department of Health, December 2017 https://www.parliament.uk/documents/commons-committees/public-accounts/Correspondence/2017-19/correspondence-dh-annual-report- accounts.pdf
Community length of stay (3)
El Camino hospital, California, USA • A core pillar of the hospital is keeping patients safe; however, leaders recognized that they faced some major challenges in living up to this when looking into ALOS. This was due to: - Complexity of implementing a multi-layered, multidisciplinary approach to improving the patient discharge process; and - Identifying what issues were contributing the most to increased LOS so that they could be addressed • To address this issue, they adopted a patient-centred approach to tackling LOS reduction that involved multidisciplinary cooperation, leadership and organisational buy-in and alignment, and additional resources to enhance discharge care coordination, along with detailed analytics of data, processes and protocols. • This innovative, systematic approach resulted in not only a better than anticipated reduction in average LOS (ALOS) of 7.8 percent, but also: - 14.8% reduction in readmissions - 55% reduction in healthcare acquired conditions - 32% reduction in incidence of AHRQ patient safety indicators - $2.2 million projected annual cost savings • Barriers they identified and were able to overcome included - Starting discharge planning at admission - Implementing multidisciplinary care coordination rounds - Communicating and coordinating across the continuum of care to prevent readmissions - Making the appropriate resources available e.g. care coordinators and discharge planners • Now the focus is on further improvement by incorporating palliative care services; adding geriatric psychiatry into the program to address emotional and social needs and aid in making decisions about end-of-life care and quality of life; and exploring new technology to better monitor patients at home Sources: Health Catalyst (2014), https://www.healthcatalyst.com/success_stories/reducing-length-of-stay-in-hospital; Community model of care Canterbury District Health Board, New Zealand • Facing an ageing population and a system approach that was no longer felt to be able to deliver sustainable services to its population, the leadership were catalysed after the 2010 earthquake to re-examine what could the future look like and establish initiatives to deliver their vision. • A key initiative was the Community Rehab Enablement and Support Team (CREST). It was created with the aim of: - Reducing LOS once in hospital - Reducing the chances of readmission; and - Delaying admission to aged residential care. • The 2010 earthquake sped up roll-out of this service to cope with the immediate loss of beds. Case managers’ roles were established to ‘pull’ patients out of hospital and agree goals with patients (that were holistic i.e. not just medical). • A number of benefits were realised: - Community support workers were pulled out of low-value spend on patients that no longer needed support but had not been reassessed and their support was switched to those in greater need with the aim of reducing reliance on residential care by keeping people in their own homes (boosted by creation of CREST). - Indicators show the combination of efficiency in the hospital and better preparation of patients in the community is producing more effective activity. Christchurch Hospital used to be regularly in gridlock with no available beds and patients backing up into ED. During 2012 bed occupancy reached 100% only once (and very briefly). Additionally, some specialty follow-up outpatient appointments dropped by nearly 40%. - Between 2006/07 and 2011/12 the level of hospital resources devoted to acute medical conditions declined in Canterbury relative to the rest of the country, while access to elective surgery increased, demonstrating substantial medium-term shift of resources away from acute hospital care and towards community and arranged care. • Leadership has stated that high accountability for agreed outcomes and performance targets (development of system wide outcomes framework) – allows everyone to see how they contribute and moves away from measuring inputs. Appropriate post-acute care (1) NHSE Menu of Opportunities initiatives + NHSE Safe, Compassionate Care
Opportunity Description Post Discharge • Discharge planning process from admission through to discharge, (redesign efficiency and effectiveness) • Agreeing pathways of care post discharge (D2A, Intermediate care including rehabilitation and reablement, End of Life, Care Homes and domiciliary care) • Development of pathways, resources and shifts of care settings i.e. reduction in acute costs and increase of more care in community delivery Good discharge planning • Patient, carers and families are involved in decision making from admission. and post-discharge support • Discharge to an older person’s normal residence should be possible within 24 hours, seven days a week – unless continued hospital treatment is necessary. • Older people should only be discharged from hospital with adequate support and with respect for their preferences. • Older people being admitted following an urgent care episode should have an expected discharge date set within two hours. • There is a hospital based multi-disciplinary team located at the front door of the hospital integrated with the community team focused on the facilitation of discharge. • Care packages to support discharge should be available within 24 hours of referral to Adult Care and Support. • Adequate and timely information must be shared between services whenever there is a transfer of care between individuals or services. • When preparing for discharge, older people and carers should be offered details of local voluntary sector organisations, other sources of information, practical and emotional support including information on accessing financial support and reablement services. • Voluntary sector services should be available to provide a ‘welcome home’ service for frail older people who live alone 7 days a week Source: NHSE, Menu of Opportunities, 2017. NHSE, Safe, Compassionate care for frail older people using an integrated care pathway, 2013.
Appropriate post-acute care (2) NHSE Menu of Opportunities initiatives + NHSE Safe, Compassionate Care
Opportunity Description Good rehabilitation and • Adequate and flexible provision of step -p and step-down home-based and bed-based rehabilitation reablement after and reablement services with enough capacity and responsiveness to meet the needs of everyone acute illness or injury who might benefit. • Shared assessment frameworks across health and social care should lead to a personalised care plan for each individual, where the individual and their carers are key participants in any decision made. • Contracting and commissioning of services is done not on the basis of time periods and tasks, but on the outcomes desired for the person. • Workforce required for home-based rehabilitation and reablement services should include an appropriate skill mix including nurses, therapists, social workers and community psychiatric nurses, voluntary and community groups, led by a senior clinician.
Source: NHSE, Menu of Opportunities, 2017. NHSE, Safe, Compassionate care for frail older people using an integrated care pathway, 2013.
Frailty MDT case study NHS Camden CCG Overview: • The Hub MDT has been working across Camden since 2013. It brings together clinicians and practitioners who work with patients with the most complex needs who require care and support from a range of specialists. These patients might be severely frail and a risk to themselves or others due to their physical and/or mental health. • Referrals to the MDT for 2015/16 were about 25% higher than expected.The average number of referrals per week was 21.3 in 2015 and 18.3 in 2016. • In July 2016, Camden CCG also successfully piloted North Locality MDT meetings, to support GP practices in this area of Camden manage moderately frail and complex patients. These were launched in the West and South Locality areas in September and October.
Outcomes: • The most recent analysis showed a 27% reduction in A&E attendances by patients who had used the service. The cost of emergency admissions also lessened and the number of emergency bed days decreased. • In Camden, people aged over 75 have said that they want to spend more time in their homes. After Hub MDT management an average of 74% of patients spent the same time or more at home, despite being complex patients.
Sources: Camden CCG https://gps.camdenccg.nhs.uk/service/frailty-mdt-hub; NEJM, http://catalyst.nejm.org/time-spent-at-home-a-patient-defined-outcome/ https://gps.camdenccg.nhs.uk/cdn/serve/topic-downloads/1473954494-0d8970bff6af23424f81bcbaee0adac4.pdf?dl=1 http://www.camdenccg.nhs.uk/downloads/our-work/Our-performance/NHS-Camden-CCG-Case-study-Frail-and-Elderly- MDT-10-Feb-2017.pdf
Frailty care models (1) South Devon and Torbay Frailty Hub & Dorset Frailty Toolkit South Devon and Torbay Frailty Hub Overview: • The hub provides services for the top 2% of high risk patients (around 1,000) with the aim of supporting people to live and age well, with multi-agency wraparound support. It integrates the reactive and the proactive (the virtual ward) care of the most frail by building on the already established complex care hub. • There is a single point of contact and a single-assessment document with all members of the multi- disciplinary team (MDT) having access to the patient’s records. • Joint health and social care co-ordinator posts have been created. Newton Abbot GPs have been providing a seven day service since the end of October 2014. They are fully mobile, have access to every patient’s records and are able to print out prescriptions from their cars. A GP with special interest in frailty has been in post since September 2014 and is running daily MDT meetings to discuss complex patients. There is support from a geriatrician and the MDT includes palliative care. Outcomes aimed for: • Improved experience of care for patients and their carers – using ‘I’m Still Me’ • ‘I statements’, collected by Senior Voice and Healthwatch • Reduced avoidable emergency admissions and A&E attendance • Reduction in permanent admissions to care homes (national indicator) • Reduction in temporary admissions to care homes (local indicator) • Primary care contacts for elective admissions Dorset has a frailty toolkit for identification, assessment and care planning of frail patients (see link)
Sources: South Devon and Torbay Frailty Hub, https://www.local.gov.uk/sites/default/files/documents/case-study-south- devon-an-644.pdf Dorset Frailty Toolkit - https://www.clahrc-wessex.nihr.ac.uk/img/casestudies/Tool%20Kits%20JN20857.pdf Frailty care models (2) International evidence Overview: • International research and reports have shown that care and support for older people, whether formal or informal and family care, focuses on the care of long‐term conditions and on integrated health and social care. • In most countries the dominant framework for care and support for older people is ‘ageing in place’, enabling older people to remain in their own homes for as long and as independently as possible. Even in countries with a history of making residential and nursing home care available, the current move (influenced by philosophical and economic reasons) is to support older people at home for as long as possible, with residential care being used as a last resort towards the end of life.
Integrated care for older people • An international study of integrated health and social care concluded that a starting point should be a clinical service model designed to improve care for older people. Integrated care is a process that must be led, managed and nurtured over time. Initiatives often have to navigate and overcome existing organisational and funding silos. • For older people with complex health and social care needs, integrated care often means a single point of entry – designating a case manager who helps with assessing needs, sharing information, and co‐ordinating care delivery by multiple formal and informal caregivers.
Sources: Centre for Policy on Ageing (2014), https://www.ageuk.org.uk/Documents/EN-GB/For-professionals/Research/CPA- International_care_and_support_of_older_people.pdf?dtrk=true; Goodwin et al (Kings Fund, 2014), Providing integrated care for older people with complex needs: Lessons from seven international case studies Falls prevention case studies RightCare
1. Fallsafe Care Bundle - North East & North Cumbria – Three hospital trusts have introduced an improvement programme to embed the Royal College of Physicians (RCP) guidelines for preventing falls in hospital. 2. Targeted Case Finding – Wandsworth – An update to Wandsworth Clinical Commissioning Group (CCG) Board on progress in developing and implementing services and initiatives aimed at early identification of patients at risk of developing osteoporosis. 3. Toolkit for general practice in supporting older people living with frailty - NHS England – A toolkit for GPs, practice nurses and the wider primary care workforce to support the case finding, assessment and case management of older people living with frailty. 4. Improving bone health & fracture prevention – Academic Health Science Network - North East & North Cumbria – A project to reduce morbidity and mortality associated with fragility fractures
Sources: North East and North Cumbria, http://www.ahsn-nenc.org.uk/wp-content/uploads/sites/3/2015/08/FallSafe-Case-Study- 031016.pdf Wandsworth CCG, https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2017/12/falls-fragility-fractures-pathway-v18.pdf NHS England, https://www.england.nhs.uk/wp-content/uploads/2017/03/toolkit-general-practice-frailty.pdf North East and North Cumbria, http://www.ahsn-nenc.org.uk/wp-content/uploads/2015/01/AHSN-Presentation-Bone-Health- Programme.pdf Prevention focus (1) NHSE Menu of Opportunities initiatives – Admissions Avoidance, Risk Stratification, Identification + Falls Prevention
Opportunity Description Community Geriatrician The Community Geriatrician service will ensure consultant level clinical leadership for frail and vulnerable people within population who are at risk of hospital admission and require a consultant led comprehensive assessment. The assessment will lead to an individualised plan of care that will enhance patient experience through interventions appropriate to their care needs.
Scope/Interdependencies
This project sits within the scope of the wider integrated community services and frail elderly work and as such has links and interdependencies with other care co-ordination projects (i.e. polypharmacy risk stratification, care co-ordination and case management) Integrated Care Integrated Care Practitioners in Primary Care. Work with older people whose long term health conditions Practitioners (LTCs) are affecting their sense of wellbeing and putting them at risk of unplanned hospital admission. Working as part of the GPs’ Multi-Disciplinary Teams will work alongside people to help them identify and achieve goals that will improve their sense of wellbeing. Reducing Emergency Implementation of the reactive care pathway through integrated admission avoidance and proactive care admissions for complex frail through the implementation of Connect approach – integrated neighbourhood teams, risk stratification, elderly shared care planning, MDT review and case management. Includes Interface Geriatrics.
Focus on those patients who are high users of acute services by focusing through the monthly GP practice based MDTs on putting into place care plans for these patients working with interface geriatricians where needed.
Source: NHSE, Menu of Opportunities, 2017. Prevention focus (2) NHSE Menu of Opportunities initiatives – Admissions Avoidance, Risk Stratification, Identification + Falls Prevention
Opportunity Description Proactive Model - Join up and enhance locality based health and care services to ensure people manage their own health Integrated Neighbourhood and social care and access the right support when needed. This will include roll out of integrated locality Teams and Neighbourhood teams across whole of CCG, fully functioning primary care MDTs with specialist support and wrap around Networks neighbourhood networks for support LTC Stratification Implementation and utilisation of risk stratification tools in General Practice to ensure identification of patients with LTC and ‘frequent flyers’; service provision designed to support individuals with high utilisation of acute services.
Frail and Elderly - General Pilot admission avoidance schemes within groups of practices. Evaluate these schemes, assess the Practice Admissions benefits, and then roll-out further or cease. Examples include care home based matrons and a community Avoidance Scheme paramedic.
Reducing emergency *UTI / catheter admissions admissions *PCE - Stroke prevention *PCE - Frailty Admissions
Frailty Telehealth Expansion of the delivery of health-related services and information via telecommunications taking advantage of new and emerging technologies. The first stage of the project will be to scope which areas will be explored further. Savings would be expected to arise from earlier intervention to minimise entry into the acute sector and provide more health support in the community.
Source: NHSE, Menu of Opportunities, 2017. Prevention focus (3) NHSE Menu of Opportunities initiatives – Admissions Avoidance, Risk Stratification, Identification + Falls Prevention
Opportunity Description Falls Prevention Working with the County Council and district councils to understand what more can be done (e.g. Cold Call Alarms). Considering the use of volunteers alongside the Falls programme with care homes. Considering a process in terms of running the Falls scheme by using an 'Ask, Assess, Act' approach. Will save via reduced attendance and admission at acute. Falls To provide a 365 day 24hr/7day response service to people who have fallen or are at risk of falling in non- injury situations, in their current place of residence. Falls prevention and early The aim of the service is to reduce the number of falls and ensure effective treatment and rehabilitation intervention in the community. Plans to increased investment in medication reviews in patients' homes as well as continuation of the home exercise and classes programmes to reduce the risk of falls.
Source: NHSE, Menu of Opportunities, 2017. Prevention focus (4) Wellbeing for complex needs Opportunity Description Healthy active ageing and • Influenza and pneumococcal pneumonia vaccination. supporting Independence • Adequate treatment for ‘minor conditions’ which may limit independence. • Support to maintain healthy lifestyle – regular exercise, not smoking, reducing alcohol consumption, healthy eating and preventing obesity Living well with simple or • Personalised care planning and shared decision-making is a universal offer for all those aged 75 stable long-term conditions and over with one or more long-term condition. • Treatment and management of long-term conditions in older people is optimised and there is no discrimination on the basis of age alone. • The use of assistive technology is part of the menu of options in place for patients to effectively self-manage their long-term condition. Living well with complex • Systematic, targeted case-finding. This includes using risk stratification, electronic comorbidities, dementia • case-finding tools and screening within primary and community settings. and frailty • Proactive comprehensive geriatric assessment (CGA) and follow-up. • An identified keyworker who acts as a case manager and coordinator of care across • the system. • General practices monitor hospitalisation and avoidable ED attendances regularly and determine whether alternative care pathways might have been more appropriate. • Carers are offered an independent assessment of their needs and signposted to interventions to support them in their caring role. • Opportunities to participate in exercise are available to frail older people. • Frail older people have access to services to prevent falls. • A comprehensive service for those with dementia must be available and accessible. • Services are available to reduce polypharmacy in frail older people.
Source: NHSE, Safe, Compassionate care for frail older people using an integrated care pathway, 2013. Prevention focus (5) Rapid response
Opportunity Description Rapid support close to • Single point of access available to facilitate access to community services to manage crisis at home home in crisis with specialist opinion and diagnostics. • A comprehensive geriatric assessment initiated rapidly, within four hours of referral, 8am to 8pm, seven days a week. • Ambulatory emergency pathways with access to multi-disciplinary teams should be available with a response time of less than four hours for older people who do not require admission but need ongoing treatment. • Mental health services should contribute with specialist mental health assessments if appropriate. • An interface or community geriatrician service is available to provide expert clinical opinion, clinical support and supervision to community teams and domiciliary care when needed to housebound patients. • Rapid access ambulatory clinics available in acute and community hospital settings for the provision of rapid access to specialist advice from the multi-disciplinary team. • A personalised care plan including emergency contingency plan, advanced care plan and the facility to allow a natural death order (if clinically appropriate) is in place and can be accessed by the patient and all services involved in their care and support.
Source: NHSE, Safe, Compassionate care for frail older people using an integrated care pathway, 2013. Procurement best practice examples (1) Below is a summary of similar procurements that have been delivered across the country:
Procurement Client CCG Service Aim Value Route Bedfordshire Competitive “Mental Health, • Redesign and integrate Mental Health Services £289m CCG Dialogue Learning Disability • Improved quality and improved health outcomes & Adolescent” • Increased capacity and reduce gaps in provision
Greater Competitive “Integrated • Right Care, Right Place, Right Time £285m Huddersfield Dialogue Community • Self managed care, early intervention, proactive/ co CCG and Services - Care produced care planning, North Kirklees Closer To Home” • Carer support and engagement with carers and community CCG culture • Building Community capacity, reduced demand on acute / non elective sector services • Value for Money and local incentive schemes
North East Restricted “Integrated Out of • Design, development, and implementation of their £250m Essex CCG Hospital Services – ambitious ‘Care Closer to Home’ programme, which aims to Care Closer to transform the delivery of integrated out of hospital health Home” and social care Luton CCG Competitive “Community • To ensure every child and young person has a healthy start £230m Dialogue Mental Health” in life • The reduction in health inequalities • Healthier and more independent adults and older people.
Procurement best practice examples (2)
Procureme Client CCG Service Aim Value nt Route Hull CCG Open “Community • Integrated service transformation working where all organisations £160m Services” work together as one system with a number of significant service changes: • Urgent Care • Better Care • Community Hubs • Outcome Based Commissioning
East Riding of Competitive “Community • Requirement to re commission Community Services to focus on £136m Yorkshire Dialogue Services” integration and patient outcomes • Desire to integrate services and improve quality of service through updated specifications and Outcome based models
Luton CCG Restricted “MSK” • Increased integration with other local services such as GPs, local £5.5m psychological therapy services and the local Acute Trust with good care coordination processes • Delivery of packages of care that move patients swiftly along an evidenced based pathway (with stepped approach and one-stop services where possible or appropriate)
103 Pre-procurement best practice approach
A systematic approach needs to be adopted by the CCGs, which should embed modern commercial approaches in health and social care to deliver better value for the public and achieve transformation through:
Combining decision making and delivery activity supported by nationally agreed/accepted best practice processes, frameworks and tools Early communication with providers, to provide clarity on levels of market activity and to ensure capture of innovative solutions Focusing on significant clinician/stakeholder involvement to provide the platform for an informed approach to commercial decision making Aligning the needs of the public, patients, environment, commissioner, provider market, and relationships. Simply, the more engagement the CCGs have with the current and potential market the better, both before the commercial process has commenced and also once the commercial process has gone ‘live’ (in-process). See following tables that provide an understanding of the various market engagement and route to market options available, moving from pre-procurement phase to procurement commencement, outlining the advantages and risks associated with of how each option would need to be managed.
Pre-procurement Checklist
Phase 1 Phase 2 Phase 3 Phase 4 1 Strategy 2 Mobilise 3 Baseline 4 Pre- Development Procurement
Establish System / Identify project team Review all relevant Financial Envelope and Commissioning Vision and individual CCG contracts and assumptions defined responsibilities aligned with High Level Incentive Consider Collaborative Procurement Plans Ways of Working Stakeholders Scheme agreed identified and needs Cross check relevant Establish Current Basic Contract populated incorporated in plans Commissioning Plans Procurement Practice to Contract Plans Contract Model Selected / Contractual Communication and Commitments Reporting protocols Benchmark Workforce Requirements all/designated outlined including TUPE Governance Confirm Budgets / services to national arrangements and IMT Requirements High Level Spend / standards Segmentation Board Leads / SRO mapped out Check performance Financial impact – e.g. Estates / Premises Consider Commercial criteria to national funding streams to included/required Interventions tables deliver project Equipment and supplies Complete High Level Is the spend analysis Mobilisation plan Timeline and its conclusions produced and Complete Prior complete Detailed Project Plan formally agreed by Information Notice / including EQIA stakeholders Assess any service Commissioning links to local Specifications and Engage with NHSI Intentions QIPP,STP,and provider outcomes defined regarding ISAP CIPS Market Engagaement Procurement engagement examples (1)
Phase Market Engagement Options Advantages Risks/Considerations Pre- Issue a Prior Information Notice (PIN) Notice + Wide ‘signal’ to suppliers of contracting - Limited discussion and sharing of ideas Procurement authority’s future plan - Resources required to hold One to One PIN notice published on various public sector + Allows market to plan for the future sessions platforms (such as Contracts Finder) as well as OJEU (capacity/strategy) and could be used to ‘signal’ to interested + One to One session with interested organisations of the contracting authority’s intent to suppliers/providers procure or partner. + Suppliers/providers more likely to be open and discuss ideas in these One to Help interested organisations plan and also can One sessions reduce the overall minimum timescale associated + Allows (pre-procurement) innovative with a given procurement route. solutions to be discussed + Can reduce overall timescale associated with chosen procurement route later Pre- Request for Information (RFI) + It can provide intelligence on potential - Service models may have not been Procurement suppliers/providers interested in worked up or fully defined therefore Suppliers/providers are issued with an overview of delivering services and also helps to service specifications may not be the commissioning aim and are asked to provide shape and design service models available to potential suppliers/providers feedback. + The intelligence gathered can also help - Resources required to hold One to One (justify) the identity of an appropriate sessions One to One sessions with suppliers/providers can be procurement route for delivery of - Limited discussion and sharing of ideas incorporated into the RFI exercise. future services.
Usually the timescale associated with this is around 4 – 6 weeks. Pre- Market Engagement + Provides intelligence on potential - Requires increased consistent Procurement suppliers/providers interested in message/information Market engagement forum with suppliers to seek delivering services. views and options for the delivery of specific services. + Allows sharing of ideas and promotes - Resource intensive discussion Timescales = 4 – 6 weeks + Provides an opportunity to promote potential collaboration between potential suppliers
106 Procurement engagement examples (2)
Phase Market Engagement Options Advantages Risks/Considerations Pre- Market Engagement & Stakeholder Engagement + Provides powerful intelligence about - Resources required to hold Procurement potential suppliers/providers interested Workshops Combination of market engagement and stakeholder in delivering services. - suppliers/providers may be unwilling engagement by holding 1 or 2-day event workshops + Allows sharing of ideas and promotes to participate in group workshops as which could include; potential suppliers/providers, discussion potential competitors are in current suppliers/providers, patient groups, local + Forum to collate a range of information attendance. authority etc. from a variety of stakeholders in one coordinated event. Each workshop could have a theme with rich + Opportunity to review current services. discussion between service users, patient/public + Opportunity to gain views from patient groups, current suppliers/providers and other groups/stakeholders relevant stakeholders on delivery of proposed new + Provides an opportunity to promote services potential collaboration between potential suppliers/providers
In Process Potential Bidder Events + Potential bidders can formally raise - Critical that all interested parties are specific clarifications to help them provided with the same level of Bidder Events are held following the commencement understand if the opportunity is right for information during the procurement of the formal procurement process them process, so all information provided, + Allow potential bidders to obtain a more points of discussion, etc. from any in depth understanding of the bidder event must be made available to procurement requirements and provide all a further opportunity to stimulate - Consistent message/information – market interest. limited opportunity to modify procurement aspects – this needs to be in line with Regulation 41 of the Public Contact Regulations 2015
107 Recommended routes to market (1) Based on preferred option, the following table outline the various routes to market, with Competitive Dialogue, Structured Dialogue and Invitation to Tender being the more suitable routes. Route Main Features/Characteristics Advantages / Disadvantages Potential to Use Competitive For strategic, high value, high risk requirements + Flexible approach to complicated Suitable approach to seek Dialogue where the contracting authority is unable to produce procurements ideas/innovation from a complete ITT/requirement specification without + Increases competition and encourages Market. discussing its needs in detail with suppliers/providers innovation (through a series of managed ‘dialogue sessions’). - Very resource intensive to carry out Resource intensive and best used when contracting dialogue phase authority is seeking innovation. - Innovative approaches may vary making Healthcare procurements increasingly using this it difficult to evaluate bids on a like for procurement route to move to ‘outcomes’ based like basis specifications with increased focus on patient needs - Risk to equal treatment of Complex healthcare requirements examples suppliers/providers of same dialogue is (Community Services, Mental Health) not undertaken with necessary rigor – big area of challenge if not managed well Timescale: Minimum 12 months (more likely up to 18 - Large ‘sunk’ costs for bidders who are months) not successful in the process (may put them off next time) Structured Where it can be robustly demonstrated that only one + Flexible approach to complicated Suitable approach to seek Dialogue provider has expressed an interest following the contracts ideas/innovation from publication of a PIN (with call for competition) Provider(s) Provides assurance to the CCG that the Most Capable Provider will be selected - Very resource intensive to carry out Bidders can ask for further information dialogue A fully developed and priced bid based on an agreed - Dialogue limited to one provider entity contractual position (rather than multiple providers as per the All issues that need to be negotiated are fully Competitive Dialogue procedure) addressed and concluded during the dialogue Timescale: Minimum 12 months
108 Recommended routes to market (2)
Route Main Features/Characteristics Advantages / Disadvantages Potential to Use Variation to Used where there may be technical reasons that + Relatively simple and quick Could only be used where existing mean there is only one provider(s) who could provide + Defined patient needs, quality is ensured contractual relationship service contracts the service(s) (and improved) exists. without The existing contracts would need to have variation competition ability built into it and careful not to exceed into - Does not test the market for innovation materiality of scope/value or cost
Timescale: Less than 1 month Single Tender Where it can be robustly demonstrated that only one + A quick process that saves resources and Highly unlikely to exist Action provider(s) is capable of providing a particular time involved in running a tender given the service required. service(s), there is no requirement to put a contract out for competitive tender or for reasons of extreme - Does not test the market for innovation urgency or cost Consideration of impact of procurement on pathway - Potential of successful challenge if integration unbeknownst to the CCG, there were indeed other capable providers. Invitation to Restricted Procedure - suitable for: + By restricting the number of Specification needs to be Tender (ITT) Large market available for competition suppliers/providers participating at the relatively detailed, Patient/population need identified tender stage, the contracting authority’s although some elements Specification, outcomes and KPI’s generally costs can be lower and the time spent in of innovation can be determined pre-procurement but can be refined evaluation may be less than under the introduced through during preliminary stages. open procedure. appropriate ITT questions + The restriction in the number of and testing. Timescale: 6-9 months’ minimum tenderers can assist in avoiding unnecessary costs related to suppliers/providers that are not suitable. This can also result in more interested suppliers/providers that submit better quality tenders, thereby facilitating more effective competition. - Longer than Open procedure due to the need for pre-qualification stage - Minimum number of pre-qualified supplier may be necessary to proceed to second stage of the process 109 Bob Deans & Dr Shirani Rajapaksa [email protected] [email protected]