Clinical Chair: Dr Andrew Parson 1 Chief Officer: Dr Angela Bhan

South East London Sector

A meeting of NHS Bromley CCG Governing Body 11 July 2013

ENCLOSURE 3

End of Life Business Case

SUMMARY:

As part of the ProMISE Programme, Bromley CCG is proposing the commissioning of an End of Life Care Model which facilitates and supports people in their last year of life and affords them the opportunity to die with dignity in their “normal place of residence”, rather than in an acute setting. In Bromley approximately 2,600 deaths are recorded each year, with circa 80% of those coded as expected deaths from chronic conditions; predominantly cancer, respiratory or cardiovascular disease. Bromley also has a higher than average number of deaths from dementia. Of those total deaths, 56% die in hospital. Comparatively however, those referred via St Christopher’s Hospice tend to die at home, with only 20% dying in hospital. Whilst the quality and cost issue exists in 2013, these will be further compounded as the over 65 years population grows by 14% by 2021. Activity data currently indicates that people in their last year of life tend to be admitted twice, preceding the point of admission when they die, with admission via A&E. Both unplanned admission costs and A&E admission will be charged under PbR, costing the CCG approximately £15,636,400 per annum. Bromley CCG therefore proposes a model of an End of Life Care Coordination Centre to include out of hours advice centre, focussing on a single point of entry, as set up with Bromley Healthcare and coordination of care for the last year of life. Patients will be case found and the centre will receive referrals leading to an anticipated improvement in home death rates for the benefit of patients and their families and reducing hospital admission in the final year of life . KEY ISSUES:

A key issue for the Governing Body’s consideration is the recommendation that this service be offered to St Christopher’s Group without recourse to procurement. Presently End of Life services are provided routinely by various agencies; notably domiciliary carers via London Borough of Bromley Social Services, St Christopher’s Hospice and Harris Hospiscare providing in-patient care, home care and a range of outpatient and day care services, Community services provided by Bromley Healthcare.

Clinical Chair: Dr Andrew Parson 2 Chief Officer: Dr Angela Bhan

The current annual Bromley CCG investment in specialist end of life services is detailed below:

St Christopher’s Hospice o Contract £1,198,684 o CQUINS £17,496

Harris Hospiscare with St Christopher’s o Contract £714,097 o CQUINS £10,711

Care Home project – funded by a separate Service Level agreement o Contract £59,388

It should be noted that the payment from the CCG covers between one-third to one-half of the actual annual cost of the services provided to Bromley residents by the St Christopher’s Group. The remaining cost of the service is currently covered by the London Borough of Bromley within the Social Care budget.

Rationale for the waiver

The St Christopher’s Group already provides an excellent range of local End of Life Care services in Bromley

The service design is a reconfiguration of existing services, not a material change to the way in which services are presented to the “user” via pathway redesign or resource change, as supported by the waiver against completion of section 242 (NHS Act of 2006). Only the introduction of an out of hours coordination centre would be an addition to the service provision.

The costings for the care coordination centre demonstrates value for money, comparable with that of the Croydon service and charges the CCG for only the cost of the day service provision (including staff costs, IT training and marketing) with the out of hours service subsumed by St Christopher’s and Partners.

Significant patient and carer participation has contributed to the development of this model, as identified in Section 6 of the Full Business Case)

End of Life Care would be more fragmented if another specialist palliative care provider entered the market

There is currently no alternative local, specialist provider with significant experience already established in the area that could provide immediate service provision with limited infrastructure and startup costs.

St Christopher’s Hospice, LBB Carers and community staff have demonstrable capacity and experience that can be quickly adapted to develop this integrated service approach.

St Christopher’s is already well networked with local providers and agencies to support the integrated approach, with pace and scale

The organisation has both an intellectual capital and unparalleled experience with specialist end of life care in the Bromley area

80% of bereaved carers (VOICES-hospices survey respondents) consistently say that the care

Clinical Chair: Dr Andrew Parson 3 Chief Officer: Dr Angela Bhan

St Christopher’s Group home care patients receive is ‘exceptional’ or excellent’

The 5 CCG Cluster contract with St Christopher’s Hospice expired on 31st March 2013 and is being rebased in year, with the provision of a new 3 year contract to be discussed in September 2013.

OVERALL RISK ASSESSMENT

See Section 10 of business case attached

COMMITTEE INVOLVEMENT:

ProMISE Programme Board

Strategy Planning Group

Clinical Executive

Clinical Advisory Group

PUBLIC AND USER INVOLVEMENT:

See section 6 of Business Case attached

IMPACT ASSESSMENT:

See Appendix 5 of Business Case attached RECOMMENDATIONS:

The Governing Body is asked to:-

Approve the business case and agree to the recommendation that the waiver of the single tender requirement and the award of the contract for this service to St Christopher’s Group

ACRONYMS

CCG – Clinical Commissioning Group CQUIN – Commissioning for quality and innovation LBB – London Borough of Bromley QIPP – Quality Innovation Productivity and Prevention

DIRECTORS CONTACT:

Name: Meredith Collins E-Mail: Meredith.collins@bromleyccg.nhs.uk Telephone: ext. 2723

AUTHOR CONTACT: Name: Kate Dawes E-Mail: kate.dawes@bromleyccg.nhs.uk Telephone: 07841 707684, ext. 2675

1

For the Attention Of Bromley CCG

ProMISE Board

Agenda Heading End of Life Care - Service Enhancement

Date 17th June 2013

Consideration of Project Principles Insert

cross (x)

Scale and pace √

Patient engagement x

Joint working (JSNA, Wellness agenda etc.) √

Using best practice √

Developing appropriate commissioning to imbed the business case √

Date for Post Implementation Review July 2014

Report Author Kate Dawes, Programme Manager

Date 17th June 2013

Contact Details Kate.Dawes@bromleyccg.nhs.uk

Senior Sponsor Meredith Collins, Director of Healthcare System Reform

Signed off by Name Signature Date

Programme Board Paul White

Finance Lucy Cole

Informatics Sarah Osborn

Project Management

Chris Evennett

Pathway Redesign TBC

IT N/A

HR N/A

2

1 Business Case History

1.1 Document Location This document is only valid on the day it was printed.

The source of the document will be found at this location: Strategic Programmes\Promise integrated

care\end of life.

1.2 Revision History Date of this revision: 08.05.2013

Date of next revision:

Date of further revision: 12.4.13 following discussions at SPG

Revision

date

Previous

revision date

Summary of Changes Changes

marked

08.05.2013 08.05.2013 First cut of the CCG business case

1.3 Approvals This document requires the following approvals.

Signed approval forms should be filed appropriately in the project filing system.

Name Signature Title Date of

Issue

Version

Meredith Collins

1.4 Distribution This document has been distributed to:

Name Title Date of Issue Version

ProMISE Programme Board

Clinical Advisory Group

Strategic Planning Group

3

2 Table of contents

Item Page

3 Executive summary 4

4 The case for change 5

5 Current service provision for specialist end of life care 6

6 Consultation with residents, users & stakeholder groups 7

7 Proposed solution 8

8 Financial modelling 10

9 Options for the way forward 13

10 Risk 13

11 Performance monitoring 13

Appendix 1 Description of services provided by the St Christopher’s Group 15

Appendix 2 A visual outline of the Bromley End-of-Life Care Partnership 16

Appendix 3 Financial model costings 17

Appendix 4 Market Management, Redesign and Procurement Assessment Tool

18

Appendix 5 Equality Impact Assessment 22

4

3 Executive Summary

As part of the ProMISE Programme, Bromley CCG is proposing the commissioning of an End of Life

Care Model which facilitates and supports people in their last year of life and affords them the

opportunity to die with dignity in their “normal place of residence”, rather than in an acute setting.

The proposed model integrates well within the wider strategic paradigm for Coordinate My Care and

NHS 111.

In Bromley approximately 2,600 deaths are recorded each year, with circa 80% of those coded as

expected deaths from chronic conditions; predominantly cancer, respiratory or cardiovascular disease.

Bromley also has a higher than average number of deaths from dementia. Of those total deaths, 56%

die in hospital. Comparatively however, those referred via St Christopher’s hospice tend to die at

home, with only 20% dying in hospital. Whilst the quality and cost issue exists in 2013, these will be

further compounded as the over 65 years population grows by 14% by 2021.

Activity data currently indicates that people in their last year of life tend to be admitted twice,

preceding the point of admission when they die, with admission via A&E. Both unplanned admission

costs and A&E admission will be charged under PbR, costing the CCG approximately £15,636,400 per

annum.

Bromley CCG therefore proposes a model of an End of Life Care Coordination Centre to include out of

hours advice centre, focussing on a single point of entry, as set up with Bromley Healthcare and

coordination of care for the last year of life. Patients will be case found and the centre will receive

referrals. Key components of the service will be provision of:

Nurse specialist assessment, including

advance care planning conversations

Key workers

Coordinate my care registers

Three monthly reassessment

Organising Marie Curie nursing

Coordinate Medical equipment

Support links in to community services

for integrated approach

Rapid response to patient’s who’s

conditions have changed

Provide personal care services for up

to 6 weeks for PRU discharges

Cost for the provision of this service is estimated at £243,000, with additional community costs for

alternative community care stay costs (to acute provision) at £188 per day. The St Christopher’s Group

has fully disclosed the costs of this service, which passes on only the resource costs for the day staff,

with out of hours staff costs and margins excluded. (Appendix 3).

Scenario modelling has ascertained the savings and costs below dependent on the number of hospital

deaths to be avoided. It is anticipated that the most likely scenario (scenario 3) will achieve net savings

of £321,000.

Scenario Reduction in emergency admissions @£3,987 LOS 8 days

Reduction in prior admissions @£1716 LOS 2 days

Reduction in A & E attendances @£311

Cost of alternative community care for both stays @£188 per day (LOS 10 days)

Cost of new Centre

Net Savings

Best case 305 305 610 3050 days

£1,216K £523K 189K £573K £243K £1,112K

5

Worst case 52 52 104 520 days

£207K £89K £32K £98K £243K £9K

Most likely *

179 179 357 1790 days

£714K £307K £111K £337K £243K £552K *Please note that changes to figures as presented to the Clinical Executive have not been checked by finance,

but relate to a midpoint of best and worst cases, which have been ratified by Finance.

4 The case for change

The demographic challenge

The London Borough of Bromley has an estimated population of 312,580 people1, with a higher than

average older population and approximately 2,600 deaths each year. Of these 20 – 25% will die

suddenly, leaving 80% dying predominantly of cancer, respiratory or cardiovascular disease. Bromley

also has a higher than average number of death from dementia, 21% as opposed to a national average

of 17.3%. This is statistically significant as end of life care has been shown to be more challenging for

dementia patients and they experience a lower rate of home deaths and, in general, poor end of life

care.

The palliative care needs of Bromley residents are likely to increase in time as it is estimated that the

population will grow by 14% by 2021; this is faster than the UK average growth of 9% for the same

time period. This population growth is coinciding with demographic changes occurring across the UK

as a result of the ageing baby boom population which will mean that the number of people residing in

Bromley that will require end of life services is set to increase rapidly over the coming years.

Opportunities to improve the quality of the service

Bromley also faces a unique challenge for the palliative care needs of its ageing population and there

is some evidence that residents are currently not satisfied with the level of care that they are receiving

1. NHS England’s outcomes benchmark and support packs show that Bromley is one of the worst

performing areas in England in terms of patients rating of the out-of-hours GP provision.

Identification of end of life care patients is important in ensuring they receive the right co-ordinated

care from all different service and that their care preferences are recorded and communicated to the

variety of care providers that they may encounter. For this reason many areas have begun to keep End

1 End of life care intelligence network, Bromley Local Authority profile, 2012

6

of Life Care registers of patients who are nearing the end of their life. There is evidence to show that

Bromley may not be recording their palliative care patients effectively. This is supported by the data

shown below:

Source: Marie Curie End of Life Atlas

The chart shows that Bromley has much lower percentages of deaths recorded on a palliative care

register than the other boroughs in South East London. This includes both deaths with and without

palliative care needs. Of the 56% of people in Bromley who die in hospital, there is an imbalance in

terms of diagnosis. Over a five year period, people with cancer were much less likely to die in hospital

than people with other conditions. (43% cancer and 65% other conditions), suggesting more needs to

be done.

The Results of the first national VOICES survey of bereaved people showed that SE London had

comparatively low results for the majority of the end of life measures. Research shows us that if given

the choice, most people would prefer to die at home and the least preferred place of death is in

hospital. Rates of hospital deaths in Bromley remain round 56% with only 36% dying in their own

home (incl. care homes) 1. The major limitation of the current end of life provision is not being able to

exploit the benefits (both financial and human) which derive from early referral and the potential for

more integrated and coordinated health and social care. Amongst these are:

Avoidance of hospital admissions

A smooth and speedy transition from hospital to home

Increasing further patient and carer satisfaction

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Bexley

PCT

Bromley

PCT

Greenwich

Teaching

PCT

Lambeth

PCT

Lewisham

PCT

South

East

London

Total

Southwark

PCT

UK Total

% of deaths with PC need on a PC register % of ALL deaths on palliative care register

7

A link to a wider population which offers the added value of community engagement and of a bespoke volunteer programme

The benefits of getting ‘all care in one go in one place’ – a ‘one stop shop’ approach. We know that working with multiple agencies saps people’s care giving capacity and energy. Also the benefits of one key person knowing someone’s ‘story’ – patients and carers not having to repeat themselves

5 Current service provision for specialist end of life care

End of life care is of course provided routinely by local health and social care providers, but specialist

palliative care services are provided by the St Christopher’s Group from two sites – one in Sydenham

and the other in Orpington. These services include in-patient care, home care and a range of

outpatient and day care services. These are detailed in appendix 1.

In 2011 the St Christopher’s Group had 472 referrals in Bromley North and 490 referrals in Bromley

South. Patients receive 24 hour advice and visiting service and have access to an extensive specialist

multi-disciplinary team. The St Christopher’s Group reverse the trend of where Bromley residents die

with only 20% of their caseload dying in hospital and 54% of their caseload dying at home/care home.

Using a validated outcome measure, St Christopher’s Index of Patient Priorities (SKIPP), levels of

satisfaction with the care provided have remained consistently at over 80%.

The annual Bromley CCG investment in specialist end of life services is detailed below:

St Christopher’s Hospice

Contract £1,198,684

CQUINS £17,496

Harris Hospiscare with St Christopher’s

Contract £714,097

CQUINS £10,711

Care Home project – funded by a separate Service Level agreement

Contract £59,388 per year

It should be noted that the payment from the CCG covers between one third to one half of the actual

annual cost of the services provided to Bromley residents by the St Christopher’s Group.

6 Consultation with residents, users and stakeholder groups

8

St Christopher’s has worked in partnership with Bromley Health Care, London Borough of Bromley and

Marie Curie to develop this proposal. Other key partners are still in negotiation and include GPs,

PRUH, Carers Bromley, Age UK, Oxleas and residential and nursing homes.

Specific consultation is documented below:

Report commissioned by BHC relating to feedback from recently bereaved carers of people

who had died of a non-malignancy and had not been under the care of St Christopher’s. 2011

QUALYCARE gathered bereaved relatives views of care in three London boroughs. The Public

Health department in Bromley were part of a research study being carried out by the Cicely

Saunders Institute at King’s Hospital.

User Forums’ at St Christopher’s and HarrisHospice held regularly and frequently.

SKIPP (St Christopher’s Index of Patient Priorities) which demonstrates the impact of the

difference it makes patients when their care is co-ordinated by St Christopher’s.

Bromley End of Life Strategy Group- Nursing Director of St Christopher’s has membership and

is Vice Chair.

Feedback questionnaire to service users of various parts of the service, specifically Patients

receiving the Community Support Volunteer service and those receiving social care and night

sitting service, looking at

o Perceived reliability and helpfulness of worker

o Dignity and respect

o Responsiveness to individuals’ needs

o Communication (and coordination of care)

7 Proposed solution

This is a proposal to radically redesign the end of life pathway in Bromley offering a new commitment

to end of life care in the local community.

What will the service look like?

The Bromley End-of-Life Care Partnership:

1. A new End of Life Care Co-ordination to include an out of hours

advice service:

This will be hosted and managed by the St Christopher’s Group and will focus on referral into a

single point of entry (SPE) already set up with Bromley Health. The details of anyone who is on or

eligible to be on the GSF/CMC registers will be forwarded to the co-ordination centre (details

below). The centre will ensure that health and social care services do not work in silos and that the

9

patient and family experiences timely and co-ordinated care.

How will it work in practice?

Case-finding the extra 800 patients - this will be achieved in the following ways:

From those referred into the St Christopher’s reablement hospital discharge pilot

From the St Christopher’s Group Clinical Nurse Specialists who currently attend Primary

Care/GSF/Nursing Home meetings. These meetings are fundamental to achieving ‘joined-

up’ care. The CNS’s will case-find the non-specialist population via these meetings

The St Christopher’s Group will shortly be launching a palliative heart failure service across

Bromley. This is a research study/service evaluation and will be working with Bromley

Health, the CCG and the PRUH. Academic support is being provided by the Cicely Saunders

Institute, Kings College London University. This new service will be able to identify another

group of people in the last year of life

The St Christopher’s Group works closely with Bromley Health and will be re-configuring

services in line with the newly developing Integrated Teams. Within this they will also

have contact with the specialist nurses in COPD and Heart Failure who will be another

source of case identification

More specifically the new centre will:

Each referral to the co-ordination centre will have an assessment by a nurse experienced in

end of life care. This will be agreed as a joint visit with a district nurse or community matron,

for example, if they are already involved with the referred patient. The assessment will

include a medical/nursing assessment, medication review, advance care planning and

conversations concerning preferred place of care/death and whether to attempt

cardiopulmonary resuscitation. A carers assessment will also be completed.

Following the assessment a decision will be jointly made to the appropriate key worker. This

decision will be made in consultation with the nurse attending the joint assessment

The co-ordination centre will therefore ensure that all patients referred will receive the

appropriate care package and professional support at the right time

Patients’ details will be entered, with their consent, onto the CMC register and the register

will be kept up to date

The centre will ensure feedback to primary care GSF meetings of the clinical picture of their

patients by centre staff or via one of the partners

Once on the ‘hub’ (co-ordination centre) register the hub nurses will reassess the patient 3

monthly either together with the named key worker or by telephone

10

The centre will ensure the delivery of a personal care service up to six weeks for discharges

from the PRUH and continued personal care for CC1 patients (One year pilot project funded

by the Reablement Board)

For patients who are receiving social care from a domiciliary agency, the ‘hub’ will have

regular contact to optimise joined up delivery of care and to encourage social carers to

feedback any concerns or changes they have observed in the patients. Training will be

offered by the ‘hub’.

The centre will organise Marie Curie night nursing

The centre will have a direct link with MEDIQUIP equipment services and will administrate

the ordering of equipment for patients referred to ensure people can access the right

equipment as quickly as possible

The centre will have strong links to Bromley Health services, including community nursing

and therapists to ensure the delivery of care is integrated

The centre will have a strong link to the Local Authority and Social Services and OXLEAS

(regarding the management of end stage dementia) to ensure all the appropriate services

are involved

The centre will work directly with the St Christopher’s Group specialist community services

and ensure that patients are referred into these services at the appropriate time

St Christopher’s is developing extensive support in the community via a bespoke volunteer

support service. The centre will have access to this

The centre will be able to respond rapidly to patients whose condition has changed and a

reassessment needed

A diagrammatical representation of the new model is shown in Appendix 2

What are the expected outcomes of the new service?

The outcomes of the new service:

1. In the first year of operation the new service is expected to achieve a home death rate of

50% for those who are referred to the co-ordination centre.

2. National data has demonstrated that most people in their last year of life have an average of

3 hospital admissions. This would be monitored with the expectation that in Bromley the

11

average would fall to around 2 admissions or less

3. Validated outcome tools (i.e. SKIPP and VOICES) to monitor satisfaction and impact of the new centre.

There are three areas of impact for SKIPP - a) Quality of Life b) Organisational impact c) Presence or absence of symptoms

VOICES is an assessment of impact of the service as opposed to a specific QOL.

It is anticipated that 75% of patients referred to the centre would rate the difference the

services provided by the centre to have made a positive impact.

4. After accounting for the necessary investment in additional community services, significant

net savings will be made on the hospital commissioning budget. See section 8 below.

** All outcomes will be measured by St Christopher’s Hospice, as part of the monthly contract

management and performance monitoring with Bromley CCG. In addition the outcomes will be

monitored for the next 3 years by the ProMISE Programme team and included within the balanced

scorecard.

8 Financial modelling

Key assumptions

There are four key assumptions that underpin the financial modelling for the business case. These are

as follow;

1. The proposed service aims to reduce the number of people who die in hospital. This is expected

to impact primarily on the number of deaths following a medical emergency admission.

Each year there are approximately 2600 deaths in Bromley, of which 1455 people die in hospital

(56%). This is slightly higher than the national average of 54.5%. (Source “End of Life Intelligence

Network 2012”). However, where care is coordinated by St Christopher’s Hospice, only 20% of their

patients die in hospital. Whilst it is appreciated that the services offered by St Christopher’s Hospice

will not be suitable for all patients, the opportunity exists to enable more people to die in the

surroundings of their choice, which is usually at home or in a community setting.

To assess the potential to reduce the number of people dying in hospital, the business case focuses on

those people whose death only followed an emergency medical admission, to remove trauma and

surgically related admissions that are unlikely to be affected by the proposed service model. Of the

1455 hospital deaths, 1044 of these were medical emergency admissions. St Christopher’s currently

receives around 800 referrals a year for Specialist Palliative Care in Bromley, and only 20% (160) of

“their” patients die in hospital. If we assume all the 160 St Christopher’s Hospice patients are part of

the 1044 deaths following a medical emergency admission, there is a pool of 884 remaining patients

who could benefit from the expanded service.

12

Because of the innovative nature of this proposal, there is no direct evidence on which to assess how

many more people could be cared for outside of hospital if this service was commissioned, although a

roughly similar approach has been developed in Somerset which has achieved a hospital death rate of

only 7%, albeit for a much smaller cohort of patients.

In order to calculate the savings associated with a person’s last hospital admission, the 50th percentile

tariff value has been used. (Appendix 3)

2. It is common for people in their last year of life to make several trips to hospital. It is assumed

that one additional hospital admission will be saved prior to the patient’s last admission.

For each admission when the patient dies, there are typically two previous hospital stays within the

last year of life. An examination the same 1044 cohort of medical patients shows there were a further

2025 inpatient episodes. For the purposes of the model, one additional admission is presumed saved

by the new service. Once again, in order to assess the most likely tariff savings, the 50th percentile

tariff has been used. (Appendix 3)

3. The A & E costs associated with the both admissions will also be avoided.

The model assumes a reduction of two inpatient episodes per patient, described in 1 and 2 above.

Associated with both admissions will be an A & E attendance. Once again the 50th percentile tariff has

been chosen as the most appropriate to calculate the potential savings. (Appendix3)

4. Additional service provision in the community for both social care and nursing

The cost of providing alternative packages of community care for both admissions detailed above will

be funded using some of the savings generated from the acute commission budget. Again, using the

same 50th percentile corresponding to the admissions, the two associated lengths of stays of have

been used to build the community care costs. (Appendix 3)

These patient-specific costs, along with the fixed cost of running the 24hr co-ordination centre

(£243,000) are set against the hospital tariff savings to highlight the affordability of the service model

and scale of financial savings.

The scenarios

As discussed above, given the innovative nature of the project there is little robust information to

quantify the expected reduction in the number of people dying in hospital. Therefore three different

scenarios have been calculated to show the potential range of savings.

Best case

In this scenario it is assumed that Bromley CCG matches the best overall hospital death rate in England

of 42.2% which would require a reduction of 305 admissions, reducing the medical emergencies that

resulted in death from 1044 down to 739.

Worst case

In this scenario, it is assumed that the service has marginal impact, reducing the number of people

dying in hospital by only 52 per year, and reducing the medical emergency admission death rate from

1044 to 992.

13

Most likely

In this scenario the mid-point point between the above two scenarios and assumes a reduction of 179

people dying in hospital and therefore a medical emergency admissions death rate of 865. (1044-179)

The table below calculate the potential savings for each scenario.

Scenario Reduction in emergency admissions @£3,987 LOS 8 days

Reduction in prior admissions @£1716 LOS 2 days

Reduction in A & E attendances @£311

Cost of alternative community care for both stays @£188 per day (LOS 10 days)

Cost of new Centre

Net Savings

Best case 305 305 610 3050 days

£1,216K £523K £189K £573K £243K £1,112K

Worst case 52 52 104 520 days

£207K £89K £32K £98K £243K £9K

Most likely *

179 179 357 1790 days

£714K £307K £111K £337K £243K £552K

*Please note that changes to figures as presented to the Clinical Executive have not been checked by finance,

but relate to a midpoint of best and worst cases, which have been ratified by Finance.

Additional service “in kind” benefits

St Christopher’s is also committed to adding a number of costs ‘in kind’ to the project. The project will

have management support from a Lead Senior Nurse for the first year based at the St Christopher’s

Group, who will provide operational and clinical leadership to the Bromley Care Partnership and will

act as a liaison point between individual organisations on operational issues Services in-kind will also

include a bespoke trained volunteer service to support the Social Care aspect of the project, and

access to the dynamic Social Programme at the Anniversary Centre/Caritas Centre. It is assumed that

this role will no longer be required in following years, as the post will support initial set up in the first

12 months.

St Christopher’s also intends to cover premises and back-office costs for the first year of the project.

Any future costs for these aspects of the service will be renegotiated with the St Christopher’s Group

as part of future planning. However, it is expected that this cost will continued to be funded by St

Christopher’s Hospice.

14

9 Options for the way forward

Option 1 Do nothing

This option is easily discounted as the main quality and financial benefits of this service proposal would not be met

Option 2

Tender for the enhanced specialist services.

Option 3

Negotiate a contract variation with the existing provider/s

Preferred option

A market management and procurement assessment has been completed (appendix 4) suggesting option three is the right approach on the basis that:

The St Christopher’s Group already provides an excellent range of local End of life services in Bromley

The integrated service design has an estimated value of £242,603, approximately 13% of the existing £1.923m contract with St Christopher’s Hospice, Harris Hospiscare and the Care Home Project, including both contracts and CQUINS.

The service design is a reconfiguration of existing services, not a material change to the way in which services are presented to the “user” via pathway redesign or resource change, as supported by the waiver against completion of section 242 (NHS Act of 2006). Only the introduction of an out of hours coordination centre would be an addition to the service provision. (13% of the total contract value).

End of Life care would be more fragmented if another speciality palliative care provider entered the market

There is currently no alternative local, specialist provider with significant experience already established in the area that could provide immediate service provision. St Christopher’s Hospice, LBB Carers and community staff have demonstrable capacity and experience that can be quickly adapted to develop this integrated service approach.

St Christopher’s is already well networked with local providers and agencies to support the integrated approach, with pace and scale

The organisation has a both an intellectual capital and unparalleled experience with specialist end of life care in the Bromley area

80% of bereaved carers (VOICES-hospices survey respondents) consistently say that the care St Christopher’s Group home care patients receive is ‘exceptional’ or excellent’

The 5 CCG Cluster contract with St Christopher’s Hospice expired on 31st March 2013 and is being rebased in year, with the provision of a new 3 year contract to be discussed in September 2013. Bromley is looking to extricate itself from this arrangement with this service enhancement, which further endorses our recommendation for single tender waiver.

10 Risks

15

Impact Proba-

bility

Risk Owner Mitigation

M M Christopher’s unable to sufficiently

influence the role of the Domiciliary

care worker

KD Robust integration and operational

plan with Memorandum of

Understanding and integration

understood

M M Performance management will be

diluted due to multi-providers

KD Robust balance scorecard and

contract management to be

established with contract

11 Performance Monitoring

The CCG and St Christopher’s will evaluate the project using quantitative and qualitative methods,

making use of well-established tools where possible. Performance will be monitored every six weeks

and will be included within the CCG contract management reviews.

Quantitative methods:

No. of patients referred

No. of patients whose details are entered onto CMC

No. of patients assessed, of whom no. discharged from hospital

No. of patients who die at home/care home/ in hospital/in hospice.

Total no. of hospital admissions during contact period.

No. of patients receiving support from Community Support Volunteers

Qualitative methods:

1. A range of validated tools e.g. SKIPP and VOICES dependent on which services the patient

has received

2. Patients receiving the Community Support Volunteer service will be asked to complete a

short feedback questionnaire (already in use) about this service

3. Patients receiving social care and night sitting service and their informal carers will be asked

to complete a short feedback questionnaire covering the following:

- Perceived reliability and helpfulness of worker

- Dignity and respect

- Responsiveness to individuals’ needs

- Communication (and coordination of care)

16

4. Summary of ad hoc feedback received (compliments/complaints/comments)

17

Appendix 1

Description of services provided by the St Christopher’s Group

In patient care:

Admission 24 hours a day, 7 days a week to 48 bedded unit

Immediate admission for emergency referrals

Expert symptom control

procedures such as blood transfusion, epidural & intrathecal pain management, ascetic taps

Treatment of lymphoedema arising from the illness

A small number of beds for respite care for patients with specialist palliative care needs

Excellent facilities for patients and families including overnight accommodation for family

Home care:

A visiting service 24 hours, 7 days a week, working closely with GPs and community nurses

Clinical nurse specialists who operate as key workers, coordinating care at home and

supporting primary care

Patients can be seen at home or in the clinic suite at either site

Access to the full range of multi-professional teams and clinics in the hospice

Clinical nurse specialists trained as advanced practitioners & qualified as independent prescribers

Day and outpatient care on both sites – Anniversary Centre (St C’s) and Caritas Centre (Harris):

A spacious social centre with a cafe, hairdressing salon and a suite of consultation,

interview/group rooms

Individual and group sessions run by the physiotherapy team in the rehabilitation gym (circuit

training, fatigue and breathlessness group and Pilates)

A planned day in the Centre with support from the multi-professional team

Bathing facilities for people who need help or who want help at hand should they need it

Support with information needs including a wide range of free information leaflets written

specially for our patient group

Complementary and arts therapies

A social programme for the patients and the community

Care Home project – funded by a separate Service Level agreement

A consultancy service

A visiting service for patients with specialist palliative care needs

Nurse facilitators working with care homes to implement the Gold Standards Framework

A lymphoedema service:

A Bromley wide service for people with both primary and secondary lymphoedema

18

Appendix 2

A visual outline of the Bromley End-of-Life Care Partnership

19

Appendix 3

Costings used in the financial model

Potential saving associated with reducing deaths in hospital

Procedure and Diagnosis driven - medical emergency admissions over 65s

Percentile Episodes Tariff Ave Length of Stay

25% 261 £2874 3

50% 522 £3,987 8

75% 783 £4,940 17

100% 1044 11.8

Procedure driven only - medical emergency admissions over 65s

Percentile Episodes Tariff Ave Length of Stay

25% 56 £2,180 4

50% 112 £5,655 12

75% 168 £7,882 30

100% 224 14.8

Diagnosis driven only - medical emergency admissions over 65s

Percentile Episodes Tariff Ave Length of Stay

25% 205 £3,042 3

50% 410 £3,987 9

75% 615 £4,615 26

100% 820 11

In patient episodes one year prior to the deceased admission

Percentile Episodes Tariff Ave Length of Stay

25% 205 £664 O

50% 410 £1,716 2

75% 615 £3,846 9

100% 2015

20

A&E attendances one year prior to the deceased admission

Percentile Episodes Tariff Attendances

25% 254 £178.93 1

50% 507 £311.65 2

75% 761 £493.52 3

100% 1014

Costs of community care to prevent hospital admissions:

Estimates costs of additional home care

Daytime Personal care

packages

Ave 3 visits of one hour

2 staff per visit

Cost per hour: £13.38

Night visits

Ave 3 hours of

care per night

Staff cost per

hour £11.00

Community care

District nurse, drugs,

equipment

£75 per day

Totals

Costs for

one day

£80.22 £33.00 £75.00 188.22

Costs for

10 days

£802.2 £330.00 £750.00 £1882.2

Fixed costs of the new co–ordination service:

End of Life Care co-ordination Centre based at St Christopher’s Group – NEW COST PAID TO ST CHRISTOPHER’S GROUP

3 x FTE’s Band 7 CNS £153,090

2 x FTE’s Admin £59,513

IT/training/marketing £30,000 (one-off costs year one – future costs to be negotiated as project progresses beyond first year)

Full cost per annum £242,603

21

Appendix 4

Market Management, Redesign and Procurement Assessment Tool

Disease Group End of Life Care

Disease Sub-group Cancer, COPD, Heart Failure etc

Prepared by Chris Evennett/Kate Dawes

Date 15th

May 2013

Assessment (see guidance notes for further explanation of the assessment questions)

Criteria Assessment question Answer Justification

Quality Is it a quality service

currently?

Yes. The service offered by St Christopher’s Hospice is well respected and performs well in patient surveys, particularly when

compared with the provision of end of life care provided by exiting providers.

Establishing another specialist end of life service would make it more complicated to integrate care between the various

agencies, particularly as the business model emphasis the need for better coordination of care

Availability Are there other

providers in the market?

No There are no other local providers of specialist end of life care. The service model dictates that the specialist provider must

be locally based to establish the seamless communication networks

Capacity Is additional capacity of

sufficient quality

required?

No Only a limited amount of additional community care capacity will be spot purchased to enable more people die in their

own homes.

Commerciality Is the contract

commercially sound?

The contract would benefit from more specific KPIs to ensure that more people died in the setting of their choice.

Next steps proposed:

It is proposed to negotiate a contract extension with St Christopher’s Hospice to deliver this enhanced service. (Scenario 6)

Scenario 1 Scenario 2 Scenario 3 Scenario 4 Scenario 5 Scenario 6 Assessment Criteria Scenario 7 Scenario 8 Scenario 9 Scenario 10

Yes Yes Yes Yes Yes Yes QUALITY No No No No

Yes Yes Yes No No No AVAILABILITY Yes Yes No No

Yes No No Yes No No CAPACITY Yes No Yes No

Yes No Yes No COMMERCIALITY

Tender Monitor

Engage /

Renegotiate

Stimulate /

Tender Monitor

Engage /

Renegotiate OUTCOME Tender Redesign

Redesign /

Stimulate Redesign

Outcomes Description

Tender Reprocure service

Monitor Ongoing contract monitoring

Engage/

Renegotiate

Engage with existing provider /

renegotiate contract

Stimulate

Stimulate existing provider and

market

Redesign

Redesign of clinical pathway /

service delivery

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Appendix 5

End of Life Business Case Procurement Paper

Purpose of the Paper The purpose of this paper is set out the rationale for seeking a single tender waiver for procurement of an End of Life service within Bromley, contrary to NHS England Procurement route of open tender. Existing provision Presently End of Life services are provided routinely by various agencies; notably domiciliary carers via London Borough of Bromley Social Services, St Christopher’s Hospice and Harris Hospiscare providing in-patient care, home care and a range of outpatient and day care services, Community services provided by Bromley Healthcare. The current annual Bromley CCG investment in specialist end of life services is detailed below:

St Christopher’s Hospice Contract £1,198,684 CQUINS £17,496

Harris Hospiscare with St Christopher’s Contract £714,097 CQUINS £10,711

Care Home project – funded by a separate Service Level agreement Contract £59,388 per year

It should be noted that the payment from the CCG covers between one-third to one-half of the actual annual cost of the services provided to Bromley residents by the St Christopher’s Group. The remaining cost of the service is currently covered by the London Borough of Bromley within the Social Care budget. Rationale for the waiver

The St Christopher’s Group already provides an excellent range of local End of life services in Bromley

The integrated service design proposed has an estimated additional value of £242,603, equating to approximately 13% of the existing combined £1.923m contract with St Christopher’s Hospice, Harris Hospiscare and the Care Home Project, including both contracts and CQUINS.

The service design is a reconfiguration of existing services, not a material change to the way in which services are presented to the “user” via pathway redesign or resource change, as supported by the waiver against completion of section 242 (NHS Act of 2006).

The costings for the care coordination centre demonstrates value for money, comparable with that of the Croydon service and charges the CCG for only the cost of the day service provision (including staff costs, IT training and marketing) with the out of hours service subsumed by St Christopher’s and Partners.

Significant patient and carer participation has contributed to the development of this model, as identified in Section 6 of the Full Business Case)

End of Life Care would be more fragmented if another speciality palliative care provider entered the market

There is currently no alternative local, specialist provider with significant experience already established in the area that could provide immediate service provision. St Christopher’s Hospice, LBB Carers and community staff have demonstrable capacity and experience that can be quickly adapted to develop this integrated service approach.

St Christopher’s is already well networked with local providers and agencies to support the integrated approach, with pace and scale

The organisation has both an intellectual capital and unparalleled experience with specialist end of life care in the Bromley area

80% of bereaved carers (VOICES-hospices survey respondents) consistently say that the care St Christopher’s Group home care patients receive is ‘exceptional’ or excellent’

The 5 CCG Cluster contract with St Christopher’s Hospice expired on 31st March 2013 and is being rebased in year, with the provision of a new 3 year contract to be discussed in September 2013.

Recommendation It is recommended that there is sufficient mandate for single tender waiver, as identified by local procurement resources, in accordance with the Bromley Procurement Policy and that of NHS England (formerly NHS Commissioning Board) http://www.england.nhs.uk/wp-content/uploads/2012/09/procure-brief-5.pdf