Transformation of A&E, Acute Medicine and General Surgery Services across Greater Manchester ...

167 Pages·2017·3.88 MB·English

by  Patterson Mellanie

Transformation of A&E, Acute Medicine
and General Surgery Services across
Greater Manchester

Healthier Together Full Business Case

Edition 3.6
15/09/17

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Version 3.6
Document cover sheet

Document information
Draft 3.6
Document title: Healthier Together Full Business Case
Date: 15/09/17
Owner: Ed Dyson (GM SRO)
Author: NHS Transformation Unit

Version Editor Changes made Date
0.1 – Mellanie Patterson Drafting 23/02/2017
1.8
2.0 – Mellanie Patterson Addition of amendments suggested by sectors 15-
3.0 31/03/2017
3.1 Jessica Boothroyd Updates to financial figures throughout report and 09/05/2017
appendices
3.3 Lee Hay Addition of amendments 24/05/2017
3.4 Jessica Boothroyd & Amendments and updates 12/09/2017
Lee Hay
3.5 Lee Hay Formatting 13/09/2017
3.6 Lee Hay Programme plan update 14/09/2017

Version Reviewer Comments
1.9 Alex Heritage Review 23/02/2017
3.4 Clare Powell Review 12/09/2017
3.6 Clare Powell Review 15/09/2017
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Author’s Note

This business case has been produced to support the Greater Manchester application for national
capital funding to enable implementation of the Healthier Together model of care. The Heathier
Together Joint Committee will receive this business case at its 19 September meeting in order to:
- Receive assurance that the implementation plans remain consistent with the original
Healthier Together model of care as described in the Decision Making Business Case; and
- Provide GM level endorsement of the business case prior to onward submission in the
national capital allocation process.
This document contains commercially sensitive information relating to anticipated capital spend in
each sector. In the public facing version of this document, these capital figures will be redacted. The
grounds for this are to ensure appropriately competitive contractor procurement, and thereby
safeguard value for money.
Beyond September 2017, some business case content will require further development at sector
level. Specifically this includes:
 Commercial case content. Due to the significant costs involved, Trusts did not commence
detailed design work at risk prior to the identification of a capital funding source.
Consequently, detailed design work did not begin in earnest until the 2017/18 financial year.
At the date of this business case, and following the identification of a capital source for the
programme, all sectors are working to develop detailed designs to support a full commercial
business case. It is expected that supporting commercial case content will be available for
the South East and Manchester and Trafford sectors by December 2017, with the North West
and North East sector commercial case content available early in 2018. The commercial case
within this September 2017 business case is therefore limited to a high level summary of the
physical capital requirements of the programme, the estimated costs of that requirement,
and how this will be financed.
 Funding agreement finalisation. At the time of this business case, appropriate capital and
transitional funding sources have been identified to support the affordability of the capital
and transitional costs of implementation. Funding of the recurrent revenue implications has
been agreed in two sectors, whilst work continues to urgently complete and finalise these
agreements in the remaining two sectors. These agreements will then require ratification
through local Trust Boards and CCG Governing Bodies.
 Organisation level financial statement impacts. Once funding agreements have been
finalised for all sectors, the impact on the prime financial statements will be calculated at
organisation level, and included in the sector appendices of the final business case.
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Contents
1 Executive Summary .................................................................................................................................. 8
1.1 Introduction ................................................................................................................................................... 8
1.2 Why are these service changes a priority for Greater Manchester? .............................................................. 9
1.2.1 General surgery ................................................................................................................................. 9
1.2.2 Emergency medicine ......................................................................................................................... 9
1.2.3 Acute medicine ............................................................................................................................... 10
1.3 Proposed model of care ............................................................................................................................... 10
1.4 GM Sector Overview .................................................................................................................................... 13
1.5 Proposed Benefits ........................................................................................................................................ 14
1.6 Value for money ........................................................................................................................................... 15
1.7 Financial Overview ....................................................................................................................................... 16
1.8 Interdependencies ....................................................................................................................................... 17
1.9 A phased implementation ............................................................................................................................ 17
1.10 Readiness Assessment .................................................................................................................................. 19
2 GM Strategic case - why the proposed changes are required .................................................................. 21
2.1 Background .................................................................................................................................................. 21
2.2 Case for change – Clinical priorities for GM ................................................................................................. 23
2.2.1 Emergency Medicine....................................................................................................................... 23
2.2.2 Acute Medicine ............................................................................................................................... 25
2.2.3 General Surgery .............................................................................................................................. 26
2.2.4 Supporting services - Radiology ...................................................................................................... 32
2.2.5 Summary ......................................................................................................................................... 32
2.3 Proposed model of care developments ....................................................................................................... 33
2.3.1 Overview of the new Model of Care - how will GM services operate differently ........................... 33
2.3.2 The high risk General Surgery model of care .................................................................................. 36
2.3.3 Paediatric General Surgery.............................................................................................................. 37
2.3.4 Emergency medicine and acute medicine model of care ............................................................... 37
2.4 Key support services..................................................................................................................................... 39
2.4.1 Critical Care ..................................................................................................................................... 39
2.4.2 Radiology ........................................................................................................................................ 40
2.4.3 North West Ambulance Service ...................................................................................................... 40
2.4.4 Compliance of the model of care with the outline model of care .................................................. 41
2.5 Proposed estate developments .................................................................................................................... 41
2.6 Proposed workforce developments ............................................................................................................. 42
2.7 Local sensitivities .......................................................................................................................................... 42
2.8 Implementation plan .................................................................................................................................... 44
2.9 Benefits ........................................................................................................................................................ 45
2.10 Interdependencies and enablers .................................................................................................................. 51
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2.10.1 Major Trauma ............................................................................................................................. 51
2.10.2 Diagnostic image sharing ............................................................................................................ 51
2.10.3 Record sharing ............................................................................................................................ 55
2.11 Risks.............................................................................................................................................................. 56
2.12 Approval and assurance of the “Decision Making Business Case” ............................................................... 58
2.13 Approvals and assurance .............................................................................................................................. 66
3 Economic Case – what is the preferred option and its implication .......................................................... 68
3.1 Introduction ................................................................................................................................................. 68
3.2 Longlisting and Shortlisting of options ......................................................................................................... 68
3.3 Appraisal of shortlisted options ................................................................................................................... 70
3.4 Refinement of the costs and benefits of option 4.4a ................................................................................... 74
3.5 Benefits ........................................................................................................................................................ 77
3.6 Sensitivity Analysis ....................................................................................................................................... 80
4 Commercial case – Financing the preferred option and procurement .................................................... 81
4.1 Introduction ................................................................................................................................................. 81
4.2 Physical capital requirement and cost of that requirement ......................................................................... 81
4.3 How this will be financed ............................................................................................................................. 83
5 Financial Case – cost implications of the preferred option ..................................................................... 85
5.1 Capital Costs ................................................................................................................................................. 85
5.1.1 Summary of capital requirements .................................................................................................. 85
5.1.2 Capital funding ................................................................................................................................ 86
5.1.3 Comparison to the DMBC ............................................................................................................... 86
Transitional Costs .................................................................................................................................................. 87
5.1.4 Non recurrent revenue costs .......................................................................................................... 87
5.1.5 IT costs of implementation (DataWell) ........................................................................................... 87
5.1.6 Residual stranded costs at non-hub sites ........................................................................................ 88
5.1.7 Non contracted pay costs ................................................................................................................ 89
5.1.8 Phasing of transitional costs ........................................................................................................... 89
5.1.9 Comparison to the DMBC ............................................................................................................... 90
5.2 Revenue Costs .............................................................................................................................................. 90
6 Management case .................................................................................................................................. 93
6.1 Programme Governance .............................................................................................................................. 93
6.2 Clinical Oversight of Healthier Together ....................................................................................................... 95
6.3 Programme resourcing ............................................................................................................................... 100
6.4 Project plan ................................................................................................................................................ 102
6.5 Change management ................................................................................................................................. 103
6.6 Management of benefits realisation .......................................................................................................... 104
6.6.1 Benefits realisation planning ........................................................................................................ 104
6.6.2 Clinical standards and baseline ..................................................................................................... 105
6.6.3 Progress monitoring ...................................................................................................................... 105
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6.7 Risk management ....................................................................................................................................... 107
7 Appendices .......................................................................................................................................... 111
7.1 Appendix 1: Manchester and Trafford Sector ............................................................................................ 111
7.1.1 Manchester and Trafford model of care ....................................................................................... 111
7.1.2 Manchester and Trafford estate requirements ............................................................................. 116
7.1.3 Manchester and Trafford sector workforce requirements ............................................................ 116
7.1.4 Manchester and Trafford Capital Costs breakdown ...................................................................... 116
7.1.5 Manchester and Trafford reconciliation to DMBC Capital figure .................................................. 117
7.1.6 Manchester and Trafford Revenue Costs ...................................................................................... 117
7.1.7 Manchester and Trafford Transitional Costs ................................................................................. 119
7.1.8 Manchester and Trafford Funding sources ................................................................................... 120
7.2 Appendix 2: North East Sector ................................................................................................................... 121
7.2.1 North East sector model of care ................................................................................................... 121
7.2.2 North East sector estate requirements ......................................................................................... 127
7.2.3 North East sector consultant workforce requirements ................................................................. 127
7.2.4 North East sector Capital Costs breakdown .................................................................................. 127
7.2.5 North East sector reconciliation to DMBC Capital figure .............................................................. 127
7.2.6 North East Sector Revenue Costs .................................................................................................. 128
7.2.7 North East Sector Transitional Costs ............................................................................................. 129
7.2.8 North East Sector Funding sources ............................................................................................... 129
7.3 Appendix 3: North West Sector .................................................................................................................. 130
7.3.1 North West sector model of care .................................................................................................. 130
7.3.2 North West sector estate requirements ....................................................................................... 135
7.3.3 North West sector workforce requirements ................................................................................. 135
7.3.4 North West sector Capital Costs breakdown ................................................................................ 135
7.3.5 North West sector interdependencies .......................................................................................... 135
7.3.6 North West sector reconciliation to DMBC Capital figure ............................................................ 136
7.3.7 North West sector Revenue Costs................................................................................................. 136
7.3.8 North West Sector Transitional Costs ........................................................................................... 137
7.3.9 North West Sector Funding sources .............................................................................................. 138
7.4 Appendix 4: South East sector .................................................................................................................... 139
7.4.1 South East sector model of care ................................................................................................... 139
7.4.2 South East sector estate requirements ......................................................................................... 144
7.4.3 South East sector workforce requirements ................................................................................... 145
7.4.4 South East sector Capital Costs breakdown .................................................................................. 145
7.4.5 South East sector reconciliation to DMBC Capital figure .............................................................. 145
7.4.6 South East Sector Revenue Costs .................................................................................................. 145
7.4.7 South East Sector Transitional Costs ............................................................................................. 147
7.4.8 Funding Sources ............................................................................................................................ 148
7.5 Appendix 5: North West Ambulance Service (NWAS) ................................................................................ 149
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7.5.1 The role of NWAS in the Healthier Together Model of Care ......................................................... 149
7.5.2 The Healthier Together transfer model ......................................................................................... 151
7.5.3 The impact on NWAS .................................................................................................................... 152
7.6 Appendix 6: Review of updated economic case against DMBC .................................................................. 157
7.6.1 Capital ........................................................................................................................................... 157
7.6.2 Revenue costs ............................................................................................................................... 157
7.6.3 Conclusion on DMBC decision ...................................................................................................... 160
7.7 Appendix 7: Anticipated efficiencies and valued benefits .......................................................................... 161
7.7.1 Purpose of this appendix .............................................................................................................. 161
7.7.2 Overview of anticipated efficiencies ............................................................................................. 161
7.7.3 Methodology used to quantify efficiencies................................................................................... 162
7.7.4 Impact of each efficiency by sector .............................................................................................. 165
7.7.5 Consolidated revenue benefits ..................................................................................................... 167
7.7.6 Risks to the quantification of the efficiencies anticipated ............................................................ 167

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1 Executive Summary
1.1 Introduction
In 2012, Health and Care Leaders across Greater Manchester (GM) identified the need to address
the variation in care and outcomes for patients across Greater Manchester. A formal programme of
change resulted in the 12 Greater Manchester CCGs supported by the GM Combined Authority
(GMCA) proposing changes to primary care, community care and some hospital services (A&E, Acute
Medicine and General Surgery).
Senior clinicians from across the conurbation designed new standards of care and, based on these, a
new model of care (or way of delivering services). A formal public consultation was completed
during 2014 resulting in the proposals being refined and communicated widely to all partners and
stakeholders.
Following a unanimous decision by GM CCGs to support the implementation of the programme on
the 15th of July 2015 a judicial review was then successfully defended. Healthier Together initiated
implementation in January 2017.
Healthier Together forms an integral part of the five year vision for GM, as articulated in the STP
document ‘Taking Charge Together’. This establishes a strategic narrative following engagement
with NHS commissioners, providers and local authorities, alongside best practice from national and
international experts, to identify five key areas for transformational change in GM (figure 1.1).
Figure 1.1

Healthier Together is now considered a key building block by the GM Health and Social Care
Partnership. It forms a core and integrated component of Devolutions “Theme 3” work programme,
entitled “Standardising Acute and Specialised Care”. As the first programme of scale to implement
since Devolution, it demonstrates GMs ability to make real regional change. Healthier Together now
underpins newer developments including the emerging Hospital Based Services Strategy and are
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complementary to the development of Central Manchester University Hospitals NHS Foundation
Trust and University Hospital of South Manchester NHS Foundation Trust into a Single Hospital
Service.
1.2 Why are these service changes a priority for Greater Manchester?
Healthier Together was initiated due to the unacceptable variations of care, and lack of compliance
with national standards that exist in Greater Manchester for General Surgery, Emergency Medicine
and Acute Medicine. The case for change (December 2013) highlighted the need to improve quality
and safety in these services and the development of the clinical standards supports this
improvement in order to improve outcomes.
Since the establishment of the CCG’s, the Association Governing Group (AGG) has taken on the GM
wide governance arrangements for strategic change programmes. In March 2017, the AGG endorsed
and supported:
 A refreshed clinical case for change, which in light of more recent guidance is even more
compelling; and
 A report on the developing sector models of care, and compliance against the original model
of care consulted upon. This report identified any variations to the original model of care,
and the rationale for any changes. None of the variations were determined to be either
significant or material.
1.2.1 General surgery
The case for change in general surgery is based on well evidenced variation in the standard of care
provided and resulting outcomes for patients.
The standard of care provided in Greater Manchester does not meet national clinical standards and
varies significantly; the number of emergency general surgery admissions, average length of stay,
compliance with key standards in National Emergency Laparotomy audit, access to diagnostics and
use of ambulatory care is different across each of our sites.
Since Healthier Together was introduced, our Trusts have now committed to participate in the
National Emergency Laparotomy Audit (NELA) in order to track performance and this indicates the
main challenges evident 3 years ago persist.
The case has recently been further strengthened by the continued reduction in access to radiology
workforce. Radiology is pivotal to delivery of high quality and timely general surgery, and is
particularly relevant in the high risk emergency and elective surgical populations.
Tackling variation in General Surgical outcomes to bring Greater Manchester in line with the best
hospitals in the UK will mean that we have the opportunity to save the lives of up to 300 residents of
Greater Manchester every year.
1.2.2 Emergency medicine
The NHS is experiencing unprecedented demand for urgent and emergency care; here in Greater
Manchester demand for emergency departments is increasing year on year and subsequently
departments are struggling to meet waiting time targets (see the chart below). Furthermore, there is
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significant variation in the attainment of quality and safety standards across our emergency
departments, due in main to shortages in medical and nursing staff and over-reliance on locum and
temporary staff.
Table 1.1: GM Quarterly Performance against the 95% National Standard (FY 16/17))

1.2.3 Acute medicine
As seen Nationally, Greater Manchester has an increasingly frail elderly population and there is a
growing need for care for patients with acute medical presentations. However, across Greater
Manchester, there are different models of care and corresponding staffing models causing high
variation in outcomes for patients, shown through variation in length of stay and readmission rates
to Acute Medical Units (AMUs) between hospitals.
Not all sites can attain the quality and safety standards, including standards from the Society for
Acute Medicine which recommends 12 hours of consultant cover, 7 days per week. This may
contribute to further variation in care and outcomes in the evenings and weekends in individual
hospitals.
1.3 Proposed model of care
The aim of the HT programme is to deliver a clinically led transformation of acute services which
improves outcomes for patients; and which is operationally and financially sustainable. The
programme forms part of a wider GM strategy: “Taking Charge”, which through the devolution of
health and social care in GM, aims to standardise acute care across the region to improve services
for the benefit of patients.
All hospitals in Greater Manchester will make a series of improvements to the way that they deliver
Acute Medicine, A&E and General Surgery in order to deliver a step change in performance.
This means, for example, that all hospitals will introduce or expand:
 Senior decision making at the front door – Consultant Cover will be increased to a minimum
Organisation Q1 Q2 Q3 Q4
of 12 hours (16 at a hub site where the higher acuity patients are received). Senior decision
Bolton NHS Foundation Trust 82.3% 85.0% 80.1% 82.9%
making at the front door can significantly reduce admissions and length of stay.
Central Manchester University Hospitals NHS Foundation Trust 93.6% 93.0% 91.1% 90.2%
Pennine Acute Hosp italSsi gNnHpSo sTtriunsgt to primary care and management8 o5f. 7c%hronic8 a4t.t4e%nders 7–9 A.7l%l hospi7ta8l.s8 w%ill
Salford Royal NHS Founidnatrtoiodnu cTeru as mt ore consistent mechanism to ma9n2a.g2e% these8 a7t.t8e%ndanc8e3s.9 % 79.8%
Stockport NHS Foundation Trust 82.1% 76.7% 75.3% 75.4%
Tameside And Glossop Integrated Care NHS Foundation Trust 90.4% 86.0% 82.3% 83.9%
University Hospital Of South Manchester NHS Foundation Trust 76.9% 90.8% 86.8% 87.7% 10
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Wrightington, Wigan And Leigh NHS Foundation Trust 92.3% 91.2% 83.6% 83.0%
GM Average 87.8% 87.5% 83.7% 83.3%
National Average 90.3% 90.6% 87.9% 87.6%