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Ref: Business Case Reference Version 5.0 24th July 2014

Business Case

Title Integrated Palliative Care Service

Responsible Manager Rachel Lissauer

Borough/Directorate Haringey/Commissioning

Sponsor/Clinical Lead Dr Kate Rees

Proposed Start and End Date

October 2014 – September 2017

Approval process

Date Outcome

Reviewed by Haringey Senior Management Team (SMT)

June 2014 Preferred Option was to deliver proposed service via a procurement waiver

Reviewed by Haringey CCG Clinical Cabinet (Clinical Model)

July 2014 Endorsement of clinical model

Reviewed by Haringey CCG Finance Committee

July 2014 TBC

Revision History

Version Revision Date

Summary of Changes

1.0 July 9th 2014 First Draft

2.0 July 14th 2014

Re-draft following meeting with NMUHT

3.0 July 16th 2014

McMillan funding confirmation / revised NMUHT costs

4.0 July 17th 2014

Changes to provider submitted costings and establishment data. Phasing of staffing provision and activity avoidance

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5.0 July 24th 2014

Updated following Finance and Performance Committee

Section 1: Description

Background

The purpose of this business case is to recommend a flexible and responsive 24 hour, 7 day a week Integrated Palliative Care Service for the local population of Haringey. Palliative care is the comprehensive care of those with serious or life-threatening illnesses. The focus of palliative care is on improving quality of life through the alleviation of pain and suffering. In 2013, HCCG identified Palliative Care as a key area for improvement and drafted a specification to address these service improvement challenges. Multi stakeholder liaison via the Palliative Care Steering Group has produced a proposal for an Integrated End of Life Service with North Middlesex University Hospital Trust (NMUHT) acting as the Lead NHS Provider. The proposal has been jointly prepared by the 5 partner organisations :

North Middlesex University Hospital Trust (NMUHT) (Lead)

North London Hospice (NLH)

Marie Curie Hampstead

Whittington Health (WH) an Integrated Care Organisation (ICO)

St Joseph’s Hospice Rationale Excellence in care for people at the end of life is one of the core challenges faced nationally in light of the aging population. For commissioners there is a potential win-win in finding the right combination of services to enable support for patients to die in their place of choice (usually home) whilst avoiding high cost of admissions and re-admissions to hospital Benchmarking exercises, carried out within the Steering Group through 2012 and 2013, revealed areas of good clinical practice but also highlighted key gaps in the service. Benchmarking data revealed:

Projected population growth in over 75s in Haringey over the next 10 years (16% increase projected 2014-2021)

Higher than average rate of death in hospital, 58.3% by comparison with London average of 55.6% (ONS data, see below)

High spend per hospital death (£2,250 compared with NCL average of £2,050), probably linked to higher length of stay in hospital than comparators

Rates of deaths in care homes that are significantly out of step with England average (ONS data, see below)

Deaths at home and in hospice that are in line with England average (ONS data, see below)

Benchmarking of service levels revealed:

Non-compliance with NICE Quality Standards for EoLC (Nov, 2011) due to lack of 24/7 access to palliative care nursing support, an insufficient multi-disciplinary team and lack of bereavement support

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Non-compliance with Commissioning Guidelines (Dec, 2011) which recommend 10-12 WTE clinical staff (medical and nursing) for a population of 225,000, together with social work / OT / physiotherapy input. Haringey have 5.6WTE medical and nursing staff and 0.3WTE social work input on a temporary basis.

Non-compliance with the early work carried out to prepare for End of Life Care Peer Review as part of the National Cancer Programme

Haringey palliative care service had fewer WTE staff overall than any other service in North Central London

In 2013 investment was made in District Nursing to develop a 24/7 service. Without this extension the palliative care offer for patients was compromised and the service was in breach of the NICE guidelines. St Joseph’s hospice was commissioned to provide 24/hr access to specialist palliative care advice for clinical staff (targeted particularly at District Nurses). A LES was also put in place to encourage GPs to use Co-ordinate my Care (an electronic record of the care plans that GPs make with patients when they are approaching end of life. Co-Ordinate my Care is a computer system that allows shared access to these plans between primary care and emergency / Out of Hours Services so that all partners know what plans are in place. These developments have been seen as a significant step forward. Monitoring of the District Nursing 24/7 service indicates that the primary use of the District Nursing service (which sees on average around 12 patients/wk between 12midnight and 8am) has been for palliative care. However, the short-staffing of specialist palliative care still left the service exposed. In 2013/14 the service experienced destabilisation as a result of staff retirements and the locum Consultant post becoming vacant. This exposed the vulnerabilities of a small service and resulted in some reports from GPs that the service had become more difficult for them and their patients to access. The Office of National Statistics (ONS) Report May 2014* provides the following data for Haringey and place of death for years 2010-2012 *(Metadata for the Clinical Commissioning Group Place of Death End of Life Care Profile National End of Life Care Intelligence Network PHE)

Table 1.0

Place of death (England wide)

Place of Death London wide

Place of Death

HCCG (ONS 2010-2012)

ONS Comment/rating

Actual ONS 2012

activity

Home 20.80% 20.90% 21.85% Not significantly different from England

250

Hospital 54.80% 55.65% 58.83% Significantly higher than England

673

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Care home 17.80% 14.40% 6.47% Significantly lower than England

74

Hospice 4.50% 6.80% 9.53% Not significantly different from England

109

Other 2.10% 2.30% 3.32% Not significantly different from England

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Haringey’s approach to commissioning EoLC In Haringey the approach that is taken to commissioning EOLC will be driven by the following:

A commitment to commissioning for outcomes. The focus will be on driving improvements measured on by outcomes that are quantifiable (e.g. proportion of deaths in hospital and home, deaths in place of choice) and in line with priorities of service users (e.g. experience of ability to plan care, freedom from pain, experience of quality of life)

A requirement to maximise productivity in the services being commissioned. Any model of care needs to be affordable. In the short term this means ensuring that the services commissioned to support patients dying at home or in their usual place of residence are less costly than a death in hospital. In the longer term there is a need to drive value by ensuring that outcomes are being improved whilst monitoring the full cost of care across a cycle (e.g. across the last year of life)

A recognition that positive outcomes will only be achieved where providers are connected, working clearly together across organisations, sectors and settings

This inter-connectedness will be underpinned by common access to electronic patient records (‘Coordinate my Care CMC’)

Effective working across organisations and sectors comes from objectives, culture and values that can be supported by organisational structures but will not inevitably be achieved by changing organisational structures

According to the Kings Fund, important factors for integrated EoL Care are:

Shared vision between commissioners and providers. This needs to be further reinforced by means of formal goals or objectives that are strategically set to ensure that they are most easily met by collaborative working. Essential to involve stakeholders to meet local needs.

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Building quality and outcomes into providers’ contracts is an important method of encouraging them to innovate and offer high-calibre, personalised services.

Commissioners to be informed and aware of what constitute appropriate outcomes in this area of care

Outcomes should be designated locally but be based on the NHS Outcomes Framework impact indicator ‘improving the experience of care for people at the end of their lives’ (Department of Health 2010c, p 24)

We are committed to applying these findings to our commissioning of End of Life Care through:

Stakeholder involvement in the development of the vision for the service. This stakeholder involvement will be significantly extended if the business case is approved through a series of stakeholder workshops particularly geared towards involving families and frontline staff in discussing the new service and how it can best meet their needs.

Stakeholder involvement in identification of outcomes and in setting the KPIs. There will be further involvement of stakeholders and of the wider clinical team as the specification is drafted.

We have set in place a robust system for monitoring and evaluating outcomes (detailed in the governance section).

Aims and Objectives Facilitation of preferred place of death and achievement of the quality indicators for End of Life Care are the main drivers behind attempts to create an integrated palliative care service in Haringey. Up to 74% of people say they would prefer to die at home

[1], but currently 58%

of people die in hospital[2]

. On average, people have 3.5 admissions to hospital in their last year of life, spending almost 30 days in bed in hospital

[3]..

Nationally an End of Life Care QIPP is in place which has set targets for improving the Death in Usual Place of Residence (DIUPR), reducing the number of hospital admissions of 8 days or more, which end in death and reducing the number of emergency admissions that end in death. Locally, the stakeholders involved in End of Life Care consider that there is scope to drive significant improvements in these outcomes for Haringey. An audit carried out at Whittington Health revealed:

In a 9 month period (June 2012 - Feb 2013) there were 12 admissions of less than 1 day for patients who died in hospital. The clinical audit found that 7 of these were potentially avoidable through improved planning, extended hours of service or alternative actions from District Nursing

In a 9 month period (June 2012 - Feb 2013) there were 37 admissions ending in death for patients with LOS of 8 days or more. 11 of these admissions (40%) were potentially avoidable.

Therefore, the aims that we have set for the service are:

An extension of End of Life Care specialist service. The service will become 7 day/wk and accessible via a single phone number. Whilst the service will still be restricted to those patients who need specialist management of their symptoms, the increased staffing complement will mean that the service can take additional patients onto its caseload.

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An improvement of 5% in the number of Haringey residents known to the specialist service who die in their preferred place of death.

A measurable improvement in the % of people closely affected by a death) who report:

1. A positive experience of communication and support 2. Timely access to suitable information 3. Good coordination of care 4. Services addressing their own needs 5. Cultural sensitivity in care needs 6. Good and suitable care around the time of death 7. Suitable referral and access to bereavement care

This will be monitored through a rolling audit carried out by the specialist palliative care service.

A reduction in the % of Haringey residents dying in hospital from 58% in 2010-12 to 56% (target for 2015/16).

A reduction in A&E attendances for those patients in the last year of life (18 attendances as minimum).

Reductions in the number of episodes of acute care for those in the last year of life.

An increase in the % of Haringey residents who die in Nursing & Care Homes. A target has not been set for this but will be defined through the process of developing the service specification.

A reduction in the number of hospital admissions of 8 days or more which end in death.

Scope

Table 2.0

Service level overlap but

not specifically within scope

Coordinate my Care (CMC) District Nurse Training

Hospices Care Homes

Nursing Homes

Outside of the scope of Service

Inpatient Palliative Care IP/OP and Day services at Hospices

Services for other CCGs Psychological Counselling

Generic EOLC provided by District Nurses Primary Care for end of life patients

Within the scope of the

Integrated Service

Specialist Palliative Care (CNS / Social Worker / Consultant)

Volunteers Palliative Care training

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Proposed Outline The integrated service will deliver 7 day a week 9am to 5pm service (with a scoping exercise around extending visiting hours to 8 am to 8 pm) to those at the highest level of need (Monday –Friday daytime) A Single Point of Access (SPoA) model will be established and staffed by a Clinical Nurse Specialist (CNS). The service will be accessible via dedicated phone and e-mail links and operate 5 days per week between 9 am and 5 pm At the weekends emergency referrals to specialist palliative care will be processed by the on-call CNS based at North London Hospice. The SPOA / Triage team will make an initial assessment based upon the patients ‘Coordinate my Care’ (CMC) electronic record and refer accordingly. In addition, an out of hours (24/7) advice line shall be provided to all professionals (for queries relating to any patients whether registered or not) and members of the public who are already known to the palliative care services. North Middlesex University Hospital (NMUHT) will act as Lead Provider. The Trust will therefore hold the contract with HCCG and will be accountable for the overall delivery of the outcomes identified in the service specification. NMUHT will provide a Consultant as Lead Clinician. This clinician will be responsible for establishing links with:

Care of the Elderly departments

Nursing Homes

Care Home project in the community

Coordinate my Care record systems

Advance Care Planning The Community Nurse Specialists (CNS) will be employed and managed by North London Hospice and based within Haringey. There will be a transfer of employment for those staff currently employed by Whittington Health. A dedicated Social Worker (1.5 WTE) resource will be employed by North London Hospice with a specific role including ‘loss and transition’. In addition to the core social work element of provision, there will also be a social worker responsible for the development of a comprehensive service including trained volunteers to work with people who are in the last year of life and their families who are undergoing loss or transition. This Volunteer Programme aims to reflect the ethnic mix of Haringey and is a joint venture between hospices. The team will work closely with GPs, District Nurses, local hospices and ambulance services

Benefits/Outcome Evaluation Investment in this scheme will come predominantly from the CCG’s contribution to the Better Care Fund. The Better Care Fund is specifically targeted towards

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providing 7 day/wk services where these services will impact on emergency admissions and improve discharge co-ordination. Investment in an integrated End of Life Care service is a close strategic fit with these aims and plans to extend the service formed part of the Better Care Fund Plan that was submitted in April and June 2014. All schemes funded as part of the Better Care Fund investment must deliver reductions in unplanned admissions and attendances and must demonstrate value for money. Regular monitoring of the End of Life Care service will be undertaken, primarily within the provider network, which will report into the End of Life Care Steering Group. There will also be evaluation of the End of Life Care service developments undertaken by Public Health as part of their role in evaluating the Better Care Fund schemes in order to inform yearly investment decisions. The service will aim to deliver the following quality and outcome indicators ; Outcome Indicators

An extension of End of Life Care specialist service from 350 patients/yr to no less than 400 patients / yr for 2015/16

An improvement of 5% in the number of Haringey residents known to the specialist service who die in their preferred place of death.

Baseline: proportion of patients known to palliative care service who die in place of choice (October 2013 – 2014) Numerator: number of families reporting patients’ ability to die in place of choice following questionnaire from Specialist Palliative Care service Denominator: number of patients on Specialist Palliative Care caseload

A measurable improvement in the % of people closely affected by a death) who report:

8. A positive experience of communication and support 9. Timely access to suitable information 10. Good coordination of care 11. Services addressing their own needs 12. Cultural sensitivity in care needs 13. Good and suitable care around the time of death 14. Suitable referral and access to bereavement care

This will be monitored through a rolling audit carried out by the specialist palliative care service.

A reduction in the % of Haringey residents dying in hospital from 58% in 2010-12 to 56% (target for 2015/16). This will be monitored via acute activity reporting / extracts with spell ending in death. This will be reported quarterly by CSU information analyst for End of Life Care Steering Group review. Baseline: Number of deaths in hospital for 2013/14 Numerator: acute activity report of admissions with spell ending in death Denominator: deaths for patients registered with Haringey GP:

Activity Targets

A reduction in A&E attendances for those patients in the last year of life (18 attendances as minimum). Evaluation will be based on cross

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referencing acute data with NHS number of patients on ‘Co-ordinate my Care’ (CMC) records (and/or on specialist palliative care team register). Numerator: A&E attendances Denominator: Deaths of patients registered with Haringey GP Review: Bi-annually (March and October 2015)

Reductions in the number of episodes of acute care for those in the last year of life. Numerator: Admissions to acute care (SUS data) Denominator: Deaths in patients registered with Haringey GP Review: Bi-annually (March and October 2015)

An increase in the % of Haringey residents who die in Nursing & Care Homes. A target has not been set for this but will be defined through the process of developing the service specification.

A reduction in the number of hospital admissions of 8 days or more which end in death. This will be reported through reviewing average LOS for episodes of acute care ending in death Review: Bi-annually (March and October 2015)

The proposed integrated service does not require a statutory public consultation Public engagement will take place via ‘Healthwatch’ and subsequent recommended actions from that group. The improvement and integration of existing services will be notified to service users via the CCG website and service user groups identified by ‘Healthwatch’ There will be a request for service user representation on the Palliative Care Steering Group as part of the proposed governance structure in Section 2.0

Options appraisal

Table 3.0 Several options have been considered:

1. Whether to use a procurement route to drive improvement in service 2. The staffing establishment required by the new service

The table below outlines the considerations involved in whether to use procurement or a value-based commissioning approach for the service.

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In March 2014 an options paper was considered by the CCG. The recommendation was to pursue a value based approach to commissioning on the basis that:

There is a high level of capability within our existing providers.

There is a strong risk that bringing a single provider or introducing a

Service Development Options

Advantages

Disadvantages

Do nothing : Continue service mapping

No use of CCG resource

Not currently not NICE Compliant EOLC Steering Group identified gaps in existing service provision

No Procurement : Service Review / Outcome based contract

Will drive innovation from within existing networks and build capacity across existing 3rd sector, statutory organisations etc Low likelihood of double running costs (e.g. funding palliative care acute provision and also a new service provider) Inclusive option, less likely to lead to fall-out from providers Captures the momentum to improve services Signals CCG commitment to focus on outcomes and invest in community service Will ensure continued focus on a service that has not been a priority

Will not create an opportunity to test the market and evaluate offers from outside providers Potential improvement is limited to ability of existing providers to improve services

Full Procurement

Drives innovation with longer period of time for consultation Likely to enable greater focus on outcome definition and monitoring

Longer lead time for mobilisation Existing provider network may either be firmly in place during this timescale (e.g. joint consultant appointment; better links between providers) or the process of networking might be threatened and held back by prospect of new, outside provider

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procurement process would create more hand-offs and boundaries into what should be a coordinated and integrated service.

Commissioners were therefore advised to test whether the provider network was able to produce a proposal for service delivery that had sign-up and commitment from all organisations. Procurement would be a fall-back option if stakeholders were not able to nominate a lead provider for the network. A specification was produced and the provider network did reach agreement on Lead Provider arrangements and a delivery model. The proposal from providers was received by the CCG on May 1

st 2014.

Advice has been sought from the CSU procurement team on the suitability of a procurement waiver. The briefing note quotes Monitor guidance which advises that:

“Commissioners need to make balanced judgments, taking account of a range of factors in the local circumstances. The guidance makes clear that choice and competition are just some of the tools available to commissioners to drive up the quality and efficiency of care provision. They won’t always be appropriate or the best levers, but it is right that commissioners should have the broadest set of tools available to them”.

The CSU briefing note sets out the following conditions that need to be satisfied in order for the CCG to consider ‘procuring services from the most capable providers’ [Regulation 5 of NHS Procurement Regulations] rather than going to the market.

A commissioner may decide to carry out a review of the provision of particular services in its local area in order to understand how those services can be improved in the interests of patients.

The review may involve extensive public consultation and engagement with existing and potential providers and other stakeholders. Reviewing available services and providers in this way is good commissioning practice and something that commissioners should consider doing as a matter of course.

In the context of a review, the commissioner is able to identify with

reasonable certainty those providers that are capable of providing the

services (or that are capable of developing the capacity / infrastructure to

do so) and to determine which provider (or providers) are most capable

of securing the needs of health care service users and of improving

services, and represent best value for money. In these circumstances, it

may be appropriate to negotiate directly with the providers in question.

The CSU briefing concludes that:

“In relation to the End of Life Care service the ‘procuring services from the

most capable providers’ is the preferred route where the requirements have

been met. In addition, the commissioner will also need to ensure that its

engagement with each of the prospective providers is consistent with its

obligation to act transparently and to treat providers equally under the

Procurement, Patient Choice and Competition Regulations. In particular, the

commissioner will need to ensure that potential providers have a reasonable

opportunity to express their interest in providing the services in question”.

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The recommendation here is that these conditions have been satisfied given

that:

All existing providers have formed part of the stakeholder consultation

and have had equal opportunities to input.

The provider proposal that has been developed has aimed to make use

of the capabilities and strengths of all partners. All providers will form

part of the new network and are therefore represented in the

governance structure

The existing providers (particularly given the three hospices involved in

Haringey) have unique capabilities in the provision of End of Life Care

Commissioners compared the costs proposed by the Haringey provider

network with those of a similar service provided by a third party in

Islington and found the proposed costs of the Haringey service to be

lower

The second set of considerations concerned the service model. The initial

provider proposal was discussed with the management and GP Commissioning

Lead for End of Life Care at the Steering Group. The service model was also

presented to the GP Clinical Cabinet for comment. Recommendations were

made for changes were received and have been reflected in this proposal.

The staffing establishment being proposed is considered to be the minimum to

provide a Single Point of Triage and a 7 day service. If MacMillan funding bids

are successful then the service model will have additional resource with which

to deliver the outcomes.

Dependency The monitoring of performance against established baselines requires access to detailed data returns from multiple providers. It is a dependency that NMUHT and WH ICO are able to report the same fields and to the same level of accuracy Action To report accurately this piece of work is dependent on a successful outcome from the current projects seeking to improve data reporting accuracy from WH

Section 2: Monitoring & Borough Governance Plans

Reporting and Governance Framework

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Assurance National Survey of Patient Activity Data for Specialist Palliative Care Services, Minimum Data Set for 2012 to 2013 (MDS) The National Council for Palliative Care (NCPC) June 2014

Data from this report confirms that nearly half the people receiving specialist palliative care in the community (46.2%) died in their own home – the place where most people say they want to die. This compares with just over 1 in 5 (21.8%) nationally

Section 3: Financial Information

Funding relating to existing Hospice services (including but not limited to; night sitting service, IP, OP and Day services) remains unaffected. These services form a vital part of the integrated service and are included within the proposed governance structure (Section 2.0) Clinical Nurse Specialists (CNS) previously employed by Whittington Health ICO are currently subject to a TUPE transfer to the North London Hospice (NLH). The relevant funding (PYE of approx. 300K) will be transferred at Month 8 at service commencement NMUHT as Lead Provider have submitted a cost and structure proposal. Additional Funding

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The core staff to deliver this service is considered to be;

7.5 WTE CNS

1.5 WTE Social Worker Any Block Payments made for this proposed service will be reconciled to an agreed timetable to ensure that funding reflects the actual staffing position so that the CCG is not funding vacant posts in the event of failure to recruit. MacMillan Cancer Support (MacMillan) has proposed that initial ‘pump priming’ funding for 2 supernumerary roles be made available If the MacMillan offer of funding is taken up it will fund the following posts

1.0 WTE CNS

1.0 WTE Social Worker The Macmillan funding offer will extend for a period of 2 years following service commencement. As this funding is non recurrent there is a CCG exposure to these unfunded posts from Year 3 onwards. Using the figures submitted in the original lead provider proposal the CCG commitment from Year 3 onwards would be approx. (at 2014/15 values)

CNS : £53,837

Social Worker : £47,000 Macmillan has stated that funding is not being offered to cover those roles that are considered to be a core health provision. Better Care Fund / Transformation Funding

To facilitate 7 day a week Palliative Care and to support the expansion of the dedicated Social Worker role within The integrated palliative care service there was an allocation of £290K from transformation funds in the BCF Activity Avoidance

The reasons for unplanned admissions in the last days of life are the absence of 24h response services, of timely access to advice and medication, and of prompt access to services in the community

[1,2]. All these areas are

targeted in the service developments. Potential savings of increasing the current service from 5 days to 7 days and the implications of single point of access and a multi-professional service have been calculated below. The following costing assumptions have been used in calculations relating to place of death (Source: Nuffield Trust:

Social Care & Hospital use at End of Life 2010) • Estimated death in hospital costs £6231 • Estimated home death would cost £4050, saving £2181 per death • Estimated hospice death average costs £4463, saving £1768 • Unable to estimate cost of death in care home To demonstrate cost savings from moving place of death out of hospital increase in the % of those dying in their preferred place of death who are already known to the specialist service and who have an Advanced Care Plan The current number of Haringey patients who are known to the specialist service and who have an ACP is approx. 350. The integrated service will aim to increase the number of people in Haringey accessing the specialist service and to assist an additional 5% of these service users to die in their preferred place of care. The

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estimated cost savings (FYE) is shown as Table 4.0 In addition to those Haringey patients who are known to the specialist service there are a significant number who die in hospital without accessing the specialist palliative care services. It is part of the role of the integrated service to improve multi agency co-ordination and communication to increase access to the specialist service and hence to increase the % of Haringey residents dying in their preferred place of death. We are only able to know the preferred place of death for patients who have an advanced care plan. This will therefore need to be audited by GPs or the specialist palliative care service. The current estimated number of Haringey patients who die in hospital but are NOT known to the specialist service and who DO NOT have an ACP is approx. 323 (673 total ONS reported deaths - 350 already known to the specialist service) The integrated service will aim to assist an additional 1% of these service users to die in their preferred place of care per year. The estimated cost savings (FYE) is shown as Table 4.0 (A) Table 4.0 Patients known to the Specialist Service

Percentage of deaths currently occurring in hospital (of those patients having an Advanced Care Plan) moved to alternative/preferred place of death

Number of deaths currently occurring in

hospital (of those patients having an

Advanced Care Plan) moved to

alternative/preferred place of death

Indicative cost saving if 100% of moved activity takes place at

Home

Indicative cost saving if 100% of moved activity

split : 50% at Home/ 50% in Hospice

5% 20 43,620 39,490

Table 4.0 (A) Patients not known to the Specialist Service

Percentage of TOTAL deaths currently occurring in hospital moved to alternative/preferred place of death

Number of TOTAL deaths currently

occurring in hospital moved to

alternative/preferred place of death

Indicative cost saving if 100% of moved activity takes place at

Home

Indicative cost saving if 100% of moved activity

split : 50% at Home/ 50% in Hospice

1% 4 7,088 6,417

In addition to the activity avoidance shown there is a likelihood that the enhanced service will additionally deliver a reduction in bed days though a reduction in spells and early supported discharge. These savings targets will be fully developed for the 2015/16 QIPP. Indicative figures are given below:

Table 5.0 A&E and NEL Admissions Avoidance

Potential Savings

Area Year 1 (PYE M11) Year 2 Year 3 +

A&E attendances ( £120) (Year 2 approx. 18 attendances)

£75 £2,126 £2,126

A&E admissions ( £1500) (Year 2 approx. 60 admissions)

£3080 £88,714 £88,714

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Total ** £3155 £90,840 £90,840 Savings calculations based on potential impact of moving from 5 day a week service to 7 day week palliative care service using assumptions of Bournemouth / Poole model. Bournemouth and Poole data has been analysed using HCCG demographics to compare like with li

Overall Financial Position Table 6.0 This Table is the initial provider proposal compared against the initial activity avoidance assumptions.

Cont’d

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Direct Cost : Salaries Band WTE Year 1 Year 2 Year 3

CNS (incl Clinical Nurse Specialist and

enhanced team leader at enhanced Band

7)

7 7.5 325,774 404,286 404,286

Year 1

4 x FYE CNS

1 x FYE enhanced CNS

2.5 PYE M8 onwards CNS

Team Manager 8 0.2 6,625 15,900 15,900 M8 PYE

Social Worker 1.5 17,625 70,500 70,500 M10 PYE

Medical Consultant 0.4 17,708 42,500 42,500 M8 PYE

Admin Support 1.2 14,333 34,400 34,400 M8 PYE

Salary costs Total 382,065 567,586 567,586

Travel 10,000 24,000 24,000 M8 PYE

Telephone 1,042 2,500 2,500 M8 PYE

Training & Supervision 3,125 7,500 7,500 M8 PYE

Med supplies & disposables 917 2,200 2,200 M8 PYE

Direct Costs : Other 15,084 36,200 36,200

HR, Payroll Cost 833 2,000 2,000 M8 PYE

Recruitment & Compliance 1,250 3,000 3,000 M8 PYE

Printing & Stationery 1,250 3,000 3,000 M8 PYE

Postage 417 1,000 1,000 M8 PYE

IT Support & Maintenance 2,083 5,000 5,000 M8 PYE

IT system and equipment year 1 20,000 0 0Laptops, phones

configued etc

Sundries 250 600 600 M8 PYE

Indirect Costs : Total 26,083 14,600 14,600

Rent and Rates 0.0 0.0 0.0

Furniture & Fittings (if hosted) 5,000 0.00 0.00 One off cost

Light & Heat 2,083 5,000 5,000 M8 PYE

Insurance 1,042 2,500 2,500 M8 PYE

Telephone Line Rental 417 1,000 1,000 M8 PYE

'Cost of increasing capacity of secure

connection''10,000 0 0

At Barrowell Green

'Annual Rental of increased capacity'' 2,083 5,000 5,000 At Barrowell Green

Equipment Maintenance 1,250 3,000 3,000 M8 PYE

Cleaning & Materials 1,042 2,500 2,500 M8 PYE

O/head & Prem Costs : Total 22,917 19,000 19,000

446,149 637,386 637,386

PYE M8

Year 1 Year 2 Year 3

382,065 567,586 567,586

300,000 300,000 300,000

82,065 267,586 267,586

15,084 36,200 36,200

26,083 14,600 14,600

22,917 19,000 19,000

146,149 337,386 337,386

146,149 290,000 290,000

- 47,386- 47,386-

6,568 131,811 131,811

6,568 84,425 84,425

O/head & Prem Costs : Total

(D) Additional Cost of Enhanced Service

(H) QIPP Savings (G-F)

(E ) From Transformation Funding

(F) Balance (D-E)

(G) Activity Avoidance Calculations (Year 1 PYE M11)

(A) Proposed Salary

(B) Existing Salary Funding

(C ) Additional Salary Costs

Direct Costs : Other

Indirect Costs : Total

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Section 4: Tracking the progress of the business plan

Milestone Plan

‘Rapid’ Procurement waiver agreed August 2014

Final agreement on Lead Provider Business Case via F&PC August 2014

Service specification agreed August 2014

Contract Variation confirmed August 2014

Service Commencement October 2014

Recruitment of additional CNS resource Nov / Dec 2014

Recruitment of additional Social Worker resource January 201

Risk Register Integrated EOLC Service Risk Register

Risk Description Risk Owner

Lead Committee

Inherent Risk Score

(Without Controls)

Existing Mitigation / Controls

How are we managing this risk? What are the Key Controls in place to prevent this risk from

occurring?

Assurance / Evidence

Who / Where can we gain evidence that these controls are

working effectively?

Residual Risk Score

(Current)

Delayed roll out of ‘Coordinate my Care’ training and usage

I = 3

L =3

9

Royal Marsden leading accelerated training Program me

CMC project lead confirmation via RMH of accelerated project timetbale

I =2

L =2

X4

TUPE of CNS to North London Hospice from WH ICO delayed

I = 3

L =3

9

Confirmation requested from NLH that a contingency is in place to prevent any break in service

NLH via Palliative Care Steering Group

I =3

L =2

6

Challenge to any Rapid Procurement award of contract / variation

I = 3

L =3

9

Formal position requested from CSU procurement

Simple procurement statement to address challenge

I =3

L =1

3

Clinical Governance & Quality

NMUHT as lead provider will hold responsibility for delivery of the contract to the required service specification. The structure in Section 2.0 ensures governance is applied to the following tiers:

Strategy and Performance

Operations

Monitoring NMUHT will report against a quality matrix reflecting required indicators and attainment levels. KPIs will be monitored quarterly or bi-annually (depending on the measure) at the Palliative Care Steering Group with input from: CCG commissioning, CCG performance lead, CCG Quality and the Lead provider An Integrated Performance Report will be submitted every 6 months to the Finance and Performance Committee (which may delegate responsibility for review to the QIPP Delivery Group). A full evaluation, based on the Performance Report, will be compiled by public health to inform BCF commissioning plans. The service will be subject to a Contract Variation as part of the existing NMUHT Contract and will therefore be managed via standard contract review meetings and enforced via all standard NHS contract levers

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Equalities Impact Having referred to the Equality Impact Assessment (EqIA) screening guidance will you be undertaking an EqIA? If yes, when will EqIA be carried out and who will do it?

Completed July 2014 following liaison with CSU

Integrated Equality Analysis EOLC July 9 DND.docx

Ref: Business Case Reference Version 5.0 24th July 2014 … Papers/20140730/… · Multi...

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