Project name Community Musculoskeletal Service

Unique reference

Clinical lead Clare Jarman

Implementation lead Julie Scrivens

Date approved

Signature

Name

Role

Counter signature (if applicable under detailed scheme of delegation)

Date

Signature

Name

Role

Business Case

i

Document Information

Document Name Community Musculoskeletal Service Business Case

Version v.22.0

Status Draft

Author Julie Scrivens

Date created 28/09/2014

Date last amended 11/06/2015

Version Control

Version Release date Description of changes

v.0.1 – v.0.9

24/09/14 – 02/02/15

Further development

v.10.0 – v.16.0

06/02/14 – 12/02/14

Further development with CL and Ealing CCG

v.17.0 – v.21.0

13/03/15 – 16/04/15

Further development with Ealing CCG

v.22.0 – v.24.0

27/05/15 – 29/06/15

Update of contract options following H&F Ops Group meeting and update to financial modelling

Revision History

Version Date Reviewer name Role

v.0.1-v.0.9

24/09/14 Julie Scrivens & Jess Simpson & CWHHE MSK Steering Group

HF CCG Commissioners and CWHHE MSK Steering Group

v.10.0 – v.16.0

06/02/14 – 12/02/15

Julie Scrivens, Jess Simpson, Jatinder Garcha, Jacky Wallbridge

HF, CL, Ealing CCG Commissioners & HF Planned Care Clinical Lead

v.17.0 31/03/15 Jacky Wallbridge Ealing CCG Commissioner

v.18.0 07/04/15 Jacky Wallbridge Ealing CCG Commissioner

v.19.0 08/04/15 Jacky Wallbridge Ealing CCG Commissioner

v.20.0 – v.21.0

08/04/15 – 16/04/15

Jess Simpson H&F CCG Commissioner

v.22.0 – v.24.0

27/05/15 – 29/06/15

Jess Simpson H&F CCG Commissioner

ii

Contents

SECTION 1: Strategic Objectives and Drivers for Change ....................................................1

SECTION 2: Proposed change (business option / solution) ..................................................5

SECTION 3: Economic Case .................................................................................................8

SECTION 4: Options Appraisal .............................................................................................9

SECTION 5: Commercial Considerations ............................................................................ 11

SECTION 6: Financial Case ................................................................................................ 17

SECTION 7: Funding source ............................................................................................... 20

SECTION 8 : Overall Plans for Implementation and timescales .......................................... 21

SECTION 9: Risks ............................................................................................................... 22

SECTION 10: Stakeholder Engagement ............................................................................. 24

SECTION 11: Recommendation .......................................................................................... 25

1

SECTION 1: Strategic Objectives and Drivers for Change

Provide the reason(s) why change is needed, based on what is known now. These may be opportunities, challenges or problems that

need to be addressed.

1.1 Introduction

The purpose of this business case is to evidence the case for change for Musculoskeletal services commissioned by Hammersmith & Fulham and Ealing CCGs, and sets out the proposal to decommission existing services and procure a Community Musculoskeletal Service as agreed by the CWHHE Collaborative Working Groups. It will detail clinical provision, projected activity shifts and the benefits to be realised both operationally and financially across Hammersmith and Fulham and Ealing CCG. Musculoskeletal disorders comprise a heterogeneous collection of more than 200 separate conditions, including acute trauma, recurrent conditions and long term conditions. Musculoskeletal conditions affect bones, joints, muscles and spine, as well as rarer autoimmune conditions. Musculoskeletal conditions interfere with people’s ability to carry out their normal activities. Common symptoms include pain, stiffness and a loss of mobility and dexterity1.

In England:

16.5 million people have back pain2

8.5 million people have peripheral joint pain3

4.4 million have moderate or severe osteoarthritis4

650,000 have inflammatory arthritis1

400,000 women aged over 80 years have osteoporosis1

200,000 people have osteoporotic fractures each year5

“Osteoarthritis… is the single largest cause of pain and disability in this country [and] is a generally unrecognised public health priority.” Professor Dame Sally C Davies, Chief Medical Officer for England, 20131 The Global Burden of Disease, UK Health Dataset 2010 shows that people live with musculoskeletal disorders for more years of their lives (Years Lived with Disability – YLD) than any other condition. Falls were the second leading cause of YLDs and have increased in absolute terms by 32% (95% UI 14–50) from 1990 to 20106.

1.2 National Drivers for Change

1.2.1 Over recent years, the NHS has been increasing its focus on improving the provision,

1 Arthritis Research UK. Musculoskeletal Health. A Public Approach. Chesterfield: ARUK; 2014.

http://www.arthritisresearchuk.org/~/media/Files/Policy%20files/2014/public-health-guide.ashx 2 Clinical Standards Advisory Group for Back Pain. Back pain report of a CSAG Committee on Back Pain. London: HMSO, 1994.

3 National Clinical Guideline Centre. Osteoarthritis Care and management in adults. London: Royal College of Physicians, 2014.

http://www.nice.org.uk/guidance/cg177/resources/cg177-osteoarthritis-full-guideline3 4 Arthritis and Musculoskeletal Alliance. Standards of Care for people with Inflammatory Arthritis. London: Arthritis and Musculoskeletal

Alliance, 2004. http://arma.uk.net/wp-content/uploads/pdfs/ia06.pdf 5 National Osteoporosis Guideline Group. Osteoporosis. Clinical Guideline for Prevention and Treatment. Shefield: University of Sheffield,

2008. http://www.shef.ac.uk/NOGG/NOGG_Executive_Summary.pdf 6 Murray CJL, et al. UK health performance: findings of the Global Burden of Disease Study 2010. Lancet 2013;381(9871):997-1020.

http://dx.doi.org/10.1016/S0140-6736(13)60355-4 and http://viz.healthmetricsandevaluation.org/gbd-compare/

2

access and quality of care provided outside of an acute hospital setting. The White Paper

‘Our Health, Our Care, Our Say’7 outlined the ambition to create a fundamental shift of care

from hospitals to more community-based settings and this was reiterated by Lord Darzi in

‘Our NHS, Our Future’8 with the principle to ‘localise where possible, centralise where

necessary’.

1.2.2 The most recent NHS England Guidance (2013) highlights that in order to meet the needs of our population, it is not possible to maintain the current duplication and fragmentation of care which drains resources and does not offer consistently high quality and cost effective care. The guidance states that; ‘without transformational change in how services are delivered, a high quality, yet free at the point of use health service will not be available to future generations’9.

1.2.3 The NHS Five Year Forward View10 further emphasises the need to break down barriers in how care is provided; with far more care delivered locally, supported by specialist centres for more complex needs. The provision of more MSK services in the community is a step towards meeting this objective of care closer to patients and primary care. This has significant benefits; providing a more convenient service to patients and helping to relieve the pressure on secondary care services, focusing the most complex MSK diagnostics and treatment in secondary care. Patient feedback from other similar community services indicates high satisfaction by patients for community alternatives to hospital outpatient care.

1.2.4 Demand for musculoskeletal services is high and has increased over the decade, particularly in the last 3 years: nationally, MSK conditions generally comprise around 30 per cent11 of all primary care consultations. Musculoskeletal disorders (MSDs) have consistently been the most commonly reported type of work-related illness since records began. An estimated 8.3 million working days (full day equivalent) were lost through MSDs in GB in 2013/14 (approximately 550,800 working days lost in CWHHE per year, based on this national estimate). There are currently 7467 people in the boroughs of CWHHE claiming incapacity benefit due to a musculoskeletal disorder, based on national figures. Within the NHS, half of sickness absence is caused by MSDs12.

1.2.5 Arthritis Research UK estimates that there are approximately 10 million people living with long term musculoskeletal pain in the UK. Applying this national estimate locally suggests that at least 178,300 adults living in CWHHE may be affected by long standing musculoskeletal problems (such as arthritis) that limit everyday activities, with older people and women particularly affected.

1.3 Local Drivers for Change

1.3.1 The local drivers underpinning the need to transform clinical services in the borough of Hammersmith & Fulham include:

The residents of Hammersmith & Fulham have changing health needs, as people live longer and live with more chronic diseases – putting pressure on health care provision.

Under our current model of care, we need to have more planned and integrated care, provided earlier to our population in settings outside of hospital. Patients do not always need to receive hospital based care and alternative community and primary care based

7 Department of Health (2006) Our Health, Our Care, Our Say

8 Department of Health (2007) Our Health, Our Future

9 NHS England (2013) Planning and Delivering Service changes for Patients

10 http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

11 NHS Institute for Innovation and Improvement – 2009. Delivering Quality and Value Focus On: Musculoskeletal Interface Services

(England). 12

Hse.gov – Musculoskeletal disorders (MSDs) in Great Britain

3

services can often be delivered closer to home and be more cost effective and centred around the patient

Capacity within our acute hospital providers is constrained and this is adversely impacting referral to treatment waiting times for patients, indicating that services need to be provided differently to ensure the best clinical outcomes

Variation in both quality, access and standards must improve ensuring that services are equitable and centred around the patient

Providing a value for money service that achieves clinical and financial sustainability.

1.3.2 Shaping a Healthier Future and Out of Hospital (OOH) Strategy’s

Central London, West London, Hammersmith & Fulham, Hounslow and Ealing (CWHHE) CCGs are currently delivering an ambitious OOH programme intended to ensure that patients are at the centre of care, with the registered GP providing, managing and coordinating the care received. A key aspiration in delivering CWHHE CCG’s Out of hospital strategic and commissioning intentions is to increase the proportion of care that is planned but also to simplify the existing pathways with more of the diagnostics and decision making carried out in community settings. The community musculoskeletal service is one of a number of planned care services that is to be commissioned as part of this development.

1.3.3 Current Provision of MSK care within the CWHHE CCGs

There is currently a mixed provision of MSK services within the CWHHE CCGs comprising of hospital based or hospital-run services in community clinics, community run services and some practice based services. This has led to wide variation in provision of care between CCGs in inner North West London.

1.3.4 Collaborative Working Across Central London, West London, Hammersmith and Fulham, Hounslow and Ealing CCGs (CWHHE)

In October 2013 CWHHE elected to work together in collaboration and engaged Finnamore management consultants to undertake a review of MSK services. This work was continued by two multi-disciplinary groups; one operational and one clinical that included CWHHE clinicians, commissioners, acute and community providers, patient representatives and volunteer organisations. The groups met regularly and benefitted from the commitment of these members from February 2014 until early September 2014 resulting in a large piece of collaborative service re-design work. The outputs of this fully inclusive re-design work were:

Collaborative Service Specification

Core MSK clinical pathways

A single referral form with a minimum data set

Agreed key performance indicators (KPIs)

Agreed data reporting requirements This has been presented to and agreed by; the collaborative Chief Officer, each CCG Chair and Managing Director, and to a series of various internal meetings across the CCGs, such as the Patient Safety, Quality & Risk Committee. In our Commissioning Intentions, we signalled that CCGs in the CWHHE collaborative intended to commission a Community MSK service that meets the population needs and, as far as possible, is standardised across North West London.

4

1.3.5 The Evidence Base considered in this work includes:

The Musculoskeletal Services framework DH 2006, which sets out evidence of best practice and recommends actions for change to improve MSK services nationally. The vision of the MSK Services Framework is to fully utilise the skills and expertise of clinicians appropriately to improve patients outcomes through a more actively managed patient pathway

NICE Guidance [CG177], Osteoarthritis: The Care & Management of Osteoarthritis in Adults. Feb 2014

NICE Guidance, Rheumatoid Arthritis: The Management of Rheumatoid Arthritis in Adults. Feb 2009

National Service Frameworks where applicable (Long Term Conditions, Older People)

Healthcare Commission – Core Standards

Healthcare Profession Council Standards

The Chartered Society of Physiotherapy – Core Standards and Service Standards

Evidence suggests that a service that can provide quick access and effective treatments can improve patient outcomes and avoid patient conditions from becoming chronic13.

Evidence nationally that prior to MSK triage services being introduced; up to 70% of all secondary care Orthopaedic referrals were inappropriate14.

1.4 Current MSK services in Hammersmith & Fulham

1.4.1 Community Physiotherapy and Clinical Assessment and Treatment Services (CATS) H&F CCG currently commissions a community MSK service comprising of GP direct access physiotherapy, CATS, and pain management from Ealing Integrated Care Organisation (ICO). The physiotherapy arm of the service consists of generic clinics for any uncomplicated MSK condition, especially first episodes of back and neck pain. The CATS service offers specialist and pre-operative assessment, investigations, advice and onward referrals (e.g. to podiatry).

1.4.2 Chronic Pain Services

Presently Hammersmith & Fulham commissions a community chronic pain service from Ealing ICO. The service provides clinically appropriate multidisciplinary input for patients with chronic and problematic pain where there is a high degree of confidence that there is not an untreated or undiagnosed pathology as the source of pain. Psychosocial issues associated with the presentation should be mild to moderate, and patients are seen on a group or individual basis in the community. The service does not accept direct GP referrals, with all patients needing to be seen by CATS in the first instance.

1.4.3 Rheumatology Services

Rheumatoid arthritis is a multi-system disorder, affecting an estimated 1109 people in Hammersmith & Fulham15. Early confirmation of the diagnosis by a specialist is recommended as early treatment within three months of the onset of symptoms can significantly reduce joint damage. For people with established disease, NICE recommends that a named member of the multidisciplinary team (e.g. specialist nurse) should be responsible for co-ordinating care and access to therapy. Rheumatoid arthritis is associated with increased risk of co-morbidities such as hypertension, ischaemic heart disease,

13

Department of Health – 2006. The Musculoskeletal Services Framework – A Joint Responsibility: Doing it differently (England). 14

NHS Institute for Innovation and Improvement – 2009. Delivering Quality and Value Focus On: Musculoskeletal Interface Services (England). 15

NICE, 2009. Rheumatoid Arthritis Costing Template – Implementing NICE Guidance

5

osteoporosis and depression. NICE recommends that screening for co-morbidities, poor disease control and side-effects of medication should occur in primary care16. Presently all of Hammersmith & Fulham’s Rheumatology services are within secondary care.

1.4.4 Hammersmith & Fulham IAPT Service

The Hammersmith & Fulham IAPT (Improving Access to Psychological Therapies) service offers support for common mental health problems such as depression, anxiety and panic through a programme called Back On Track. This service is provided by a partnership between West London Mental Health NHS Trust, West London Centre for Counselling and Mental Health Matters. Back On Track is for people who are resident in Hammersmith & Fulham or are registered with a GP in Hammersmith & Fulham. Patients can be referred by a health professional or self-refer by phone or online, this service is not currently integrated directly with the community pain or MSK service.

SECTION 2: Proposed change (business option / solution)

Describe what the proposed project would deliver i.e. what would be done to fix the problem and deliver the change.

2.1. The CCG wishes to commission a Community Musculoskeletal (MSK) Service for their local

adult GP registered population to ensure continuity of service provision across CWHHE in line with the comprehensive MSK Review that has been completed with commissioner, provider and patient involvement across CWHHE.

2.2. The MSK service is an alternative to hospital-based outpatient services where non-complex

acute and chronic conditions can be seen for clinical assessment, diagnostics and treatment in a community setting. This is in line with CWHHE’s Out of Hospital strategy and strategic commissioning intentions to ensure that high quality care is delivered as close to the patient’s home as is appropriate.

2.3. The service specialties that are included within the Service scope are:

Community MSK physiotherapy services;

Outpatient orthopaedic services;

Outpatient rheumatology services; and

Chronic MSK pain management services. 2.4. The most critical element of this service is that it will offer a patient centred experience

where patients can access high quality care locally in a professional and welcoming environment. Patients should be able to access treatment quickly, via a single point of access, and receive treatment from the initial visit where possible (‘one-stop service model’). The service will accept referrals from GPs, hospital MSK departments and self-referrals for physiotherapy. All referrals will undergo an initial administrative and clinical triage to ensure patients are directed for the right care first time. Referrals to the community MSK service will not go through any separate local arrangements for referral management. Following

16

NICE, 2009. Rheumatoid Arthritis: The management of rheumatoid arthritis in adults; https://www.nice.org.uk/guidance/cg79

6

assessment, the clinically-led service will diagnose and treat all MSK conditions and pathologies in a community setting local to patients, keeping them out of an acute setting wherever possible and appropriate (see Appendix 1 for full service Specification).

2.5. It is proposed that through an integrated care pathway, service user experience, need and

demand will be met by:

Improving access to the most appropriate clinician through a single point of referral and central booking system, which aims to receive 100% of GP and ‘Other’ referrals (with named exclusions);

Triage (administrative and clinical) from a standardised minimum data set referral form;

Offering extended hours and ease of access;

Delivering care out of either a number of community hubs or a ‘hub and spoke’ model across the boroughs;

Timely and easy access to face to face patient centred assessment and treatment which is based on identified need and risk;

An integrated care pathway across clinical disciplines and health settings, provided in partnership with other services, which improve navigation and communication for the service user and referrer;

High quality assessment, treatment, advice and education based on clinical need;

Promoting quality of life and independence in relation to health and all forms of disability;

Implementation of health outcome and service user related outcome Key Performance Indicators (“KPIs”) across the different specialities;

Customising services to meet the needs of individual service users; and

Optimising staff wellbeing to provide the best possible environment for service user

7

care.

2.6. It is also proposed that through integrating a seamless care pathway, the quality of the services delivered will be improved, efficiencies will be achieved, and unnecessary hospital appointments reduced. These will be quantified and monitored through contract reporting metrics and indicators. The service aims to:

Enhance the management of patients within primary and community care, and actively manage the demand for secondary care services ensuring patients have quicker access to appropriate treatment in the appropriate setting.

Ensure that there is no delay towards the achievement of the 18 week maximum waiting time from GP referral to definitive treatment;

Utilise the CWHHE developed and agreed clinical pathway guidance and support the further development of clinical guidance as required. This will be used as clinical reference when triaging referrals and providing advice to primary care clinicians on the management of patients with MSK conditions.

Provide care for patients with long term MSK conditions in the community, reducing demand on other services including referrals into secondary care.

Deliver service user and referrer education, information and advice to support both patients and GPs, and to up-skill GPs, promoting confidence to manage a higher number of patients within primary care,

Ensure that the most appropriate community based treatment is offered based on clinical need, but where secondary care intervention is required; the surgical conversion rates are comparable with national best practice.

Ensure better signposting and cross referral to relevant services. 2.7. The clinically-led community MSK service shall deliver integrated;

Single point of triage (administrative and clinical),

Assessment (direct and non-direct),

Onward referral and direct listing, as appropriate, to secondary care (orthopaedics/ rheumatology/ pain) in accordance with patient choice,

Direct access to diagnostics including standard x-ray views, musculoskeletal ultrasound, musculoskeletal MRI (without contrast), open MRI where PPwT has been met, routine screening blood tests (e.g. for inflammation, infection or underlying disease), routine pathology (e.g. for microscopy and culture of joint aspirates), nerve conduction studies, CT and DEXA scanning. Providers will be able to utilise existing CCG arrangements for the provision of diagnostics if required,

Disease management and treatment including; o MSK physiotherapy (exercise, mobilisation, manipulation, splinting, taping,

electrotherapy and education informed and supported by research evidence, hydrotherapy where available)

o Joint injection therapy, o Acupuncture, o Pain management, o Provision of appliances / orthotics o Fitting service (including holding a supply) for splints, o Possible inclusion of other evidence based / NICE approved physical therapies, for

example Osteopath and Chiropractor Services

Service user support, advice and education,

Referrer support, training and advice in the management of MSK conditions in primary care.

2.8. Triage turnaround time is within 1 working day from referral acknowledgement for each

triage point (administrative triage and clinical triage). Booking is to take place following administrative triage for routine physical therapy appointments, and following clinical triage for all other appointments. Service users will be given adequate notice and choice of

8

appointment. For urgent (non-cancer) referrals, and referrals to the interface service, the patient’s first appointment should take place within 2 weeks. For routine physical therapy referrals, the patient should be offered an appointment within 4 weeks.

2.9. There is evidence that the number of referrals into the Community MSK services are increasing, with an increase in the number of related Acute FAOP and FUOP appointments.7

2.10. The proposal is to procure the Community MSK service for a contract period of 3 years (with

an option to extend for a further 2 years), utilising a single stage procurement. Permission is also sought to publish the PQQ and ITT in August 2015, award the contract in November 2015 and for the service to commence on 1st April 2016 for H&F and Ealing CCGs. H&F and Ealing CCGs will be required to serve a 6 month decommissioning notice to their incumbent provider, following approval from their respective Governing Bodies to continue to procurement.

SECTION 3: Economic Case

This section must be completed in conjunction with the CCG Head of Finance.

Some projects will have benefits that are not cash releasing but are never-the-less an important consideration in the decision to make an

investment.

In this section list and, as far as possible, quantity all of the non-cash releasing benefits for the options that you have considered. The

option that has the greatest economic benefit should be strongly considered to be the preferred option, although other factors can be

taken into consideration in the next section. Detailed calculations should be shown as an appendix to this document.

3.1 The financial benefits of providing a Community MSK service are expected as follows;

i. More efficient and targeted use of clinical resources (achieved through specialist triage of referrals and multidisciplinary working);

ii. Reduction in the number of secondary care outpatient attendances (due to assessment and management in the community or earlier discharge from secondary care to the community service);

iii. Reduction in the number of referrals or investigative/diagnostic procedures to secondary care as a result of activity delivered in the community, up-skilling of GPs in primary care and early intervention through timely access;

iv. Reduction in the number of inappropriate referrals or referrals without documented preliminary investigations received by secondary care;

v. Patients receiving the right care first time through clinical triage of referrals; vi. Reduction in the number of interventions needed allowing patients to receive more

coordinated MSK care through a multidisciplinary approach, bringing together orthopaedics, pain management and rheumatology;

vii. Better value for money (VFM) achieved, in line with CWHHE’s Quality, Innovation, Productivity and Prevention (QIPP) agenda.

3.2 The qualitative benefits of providing a Community MSK service include;

i. Earlier diagnosis and interventions in primary care and a greater focus on prevention and self-care through care planning;

9

ii. Development of local care pathways and referral processes (including self-referral to physiotherapy) within the community service;

iii. Education, information and advice provided to support and up-skill GPs, promoting confidence to manage a higher number of patients within primary care before onward referral, or under shared care arrangements;

iv. More patients will be diagnosed and treated within the community in convenient and accessible locations with a reduction in the number of referrals or investigative/ diagnostic procedures to secondary care;

v. Efficient and targeted use of clinical resources; vi. A greater focus on joint care planning with patients and support for patients to care for

their conditions more effectively; vii. Shared Decision Making between patients and clinicians on treatment options will allow

more patient centred care; viii. Avoidance of unnecessary delays or waits for secondary care appointments; ix. Better signposting and cross referral to relevant services; x. Provides access and onward referral to specialist MSK and related services where

necessary.

3.3 There is evidence that the numbers of referrals into the Community MSK service are increasing, with a simultaneous increase in the number of Acute Outpatient First (FAOP) and Outpatient Follow-up (FUOP) appointments17. Directing all referrals to the SPA triage service is likely to increase the proportion of referrals to be appropriately directed to the Community service and away from the acute providers.

3.4 The Community MSK services in H&F saw a combined 11,175 first and 22,183 follow up

attendances (including physiotherapy) in 2014/15 reported by their MSK community services delivered by Ealing ICO18 at a total cost of £2,014,612.

3.5 The Acute MSK related services for H&F saw 4178 first, 9298 follow up attendances and delivered 461 procedures, from GP referrals in 2014/15, at a total cost of £1,177,625.

3.6 Savings to H&F CCG are calculated as £1,143,196 over a three year contract. These expected savings have been calculated by using patient flow pathways through the new community MSK service, and costing them using standard NHS assumptions. Full costs of the new service are detailed in section 6 and appendix 2.

3.7 The financial benefit of providing the Community MSK service, when combined with the

qualitative factors detailed in 3.2 supported by the comprehensive re-design of service model and structure provide strong support to allow the Community service to be procured as per the preferred option in Section 4.

17

Source: Data analyst from each CWHHE CCG 18

Source: Data analyst from H&F CCG

10

SECTION 4: Options Appraisal

In this section please describe the options that are available for achieving the desired outcome. This should include: a summary of the

economic assessment of the various options (as above), details on how the options were evaluated, why they were discounted and the

process by which the selection process was followed. This should include factors such as financial; legal or reputational risk criteria that

impacted these decisions.

It must evidence that alternative approaches were considered, evaluated and dismissed for sound reasons.

The options appraisal should include the formal evaluation of “doing nothing”.

Service Options: There are broadly four service options, the emerging preferred one of which is Option 3. Option 1 and Option 3 have been costed. Option 1: Business as usual / “Do nothing” This option will result in continued fragmented MSK services across CWHHE and their associated variable success in delivery and quality. There is no formal mandate to adhere to the CWHHE MSK Review recommendations or to procure a redesigned Community MSK service. However, the ‘do nothing’ option would not be in keeping with the strategic direction of the CWHHE collaborative and the national strategic direction set out in the MSK framework, and may not deliver the potential patient benefits from accessible care closer to home, reduced waiting times and other qualitative factors (as detailed in Section 3). There will be failure to deliver QIPP financial efficiencies projected from 2017/18 and all activity will retain its status quo. There may also be a reputational risk associated with withdrawing from a collaborative redesign project. The ‘do nothing’ option may be a disadvantage to patients who will continue to experience wide fluctuations in scope and quality of service according to their postcode. For some this may include increased waiting times for secondary care and having to travel potentially longer distances for their diagnosis and treatment. Central London CCG must procure MSK services as the original contract term for current community MSK services has expired and a contract extension is in place. Option 1 is not recommended. Option 2: Do minimum: Vary the existing community MSK service contract with each current provider across CWHHE Under this option, the approach would be to vary the existing Community MSK service contract with the existing provider for each CWHHE CCG. It is felt that this option may be challenged on the grounds that some contracts may have already been extended or varied on previous occasions. The current provider may also be reluctant to agree the contract variations. Progression to procure a new service signals a positive message to service users (both GP referrers and patients) that the CCG deems the CWHHE service re-design to be worthwhile and will provide high quality care. Changes to existing community contracts may not deliver the desired transfer of activity form acute services to the community. A material revision to current contracts, with changes in contract values and the inclusion of pain and rheumatology specialties, could be challenged by new providers wishing to deliver the services under the grounds of not following an open competitive process. Option 2 is not recommended.

Option 3: Procure a new Community MSK service for CWHHE CCGs – this is the preferred option Under this option, a new community MSK service would be commissioned for H&F CCG with a start date of May 2016 using a single stage open procurement process. An open procurement would allow a fair process to attract innovative methods of service delivery, value for money and evaluation of proposals from Bidders against an agreed service specification. Procuring services collaboratively with Ealing CCG (with separate contracts/ lots for each CCG) would allow the benefits of economies of scale. A single stage open procurement would allow a streamlined

11

procurement process, as compared to a two-staged procurement or dialogue process, to be implemented within the required timescales for CCGs. A joint service specification, which meets local needs and strategic objectives, has been developed through extensive engagement with specialists and patient members at a Collaborative level, as well as additional engagement with clinicians and patients at a local CCG level. CL CCG has already gone out to tender as their current community MSK service ends in September 2015 and the new service will aim to start in October 2015. H&F and Ealing CCGs will follow subsequent to a 6 month decommissioning notice which will be issued in July 2015 and a proposed new service start date of May 2016. This procurement will be in keeping with the strategic direction of the CWHHE CCGs, takes account of each CCG’s position in their current community contract, and will deliver the potential patient benefits from accessible care closer to home, reduced waiting times and other qualitative factors (as detailed in Section 3). There will be delivery of QIPP financial savings projected for 5 years of contract. Cost savings currently associated with reduced Acute FAOP and FUOP will be realised (as detailed in Section 6). There is also likely to be a positive message to service users as a result of the service redesign project, further incentivising H&F CCG GPs to refer 100% of their MSK referrals into the SPA triage. Option 3 is the recommended approach to commissioning a Community MSK Service collaboratively for Ealing CCG and Hammersmith and Fulham CCG. Option 4: Procure a new Community MSK service individually for each CWHHE CCG when each contract reaches its end date Under this option, a community MSK service would be commissioned for each CWHHE CCG from the end date of their current MSK provider contract. This procurement will remain in keeping with the strategic direction of the CWHHE CCGs and will deliver patient benefits and other qualitative factors, however it is unlikely to realise the full effect of economies of scale that would be expected from a collaborative procurement. It would also mean that service provision across the collaborative would remain varied for a potentially considerable length of time. This approach has been undertaken by West London and Hounslow CCG as directed by their Executives. The CWHHE Chairs meeting on the 27/01/15 were in favour of a combined procurement for Central London CCG, Ealing CCG and Hammersmith and Fulham CCG, subsequent to which CL CCG needed to go out to procurement sooner to ensure no gap in service provision for CL residents. Option 4 is not recommended for Ealing CCG or Hammersmith and Fulham CCG.

SECTION 5: Commercial Considerations

Outline all of the commercial considerations in taking forward this project. This should include as a minimum:

Procurement route

TUPE implications

Premises

Contracting mechanisms (including proposed payment mechanism)

Length of contract

Exit strategy

Legal implications

5.1 Procurement route Following engagement with the CWHHE procurement support service supplier, NHS Shared Business Services (SBS), the preferred procurement route is a single stage open tender procedure under Part B of the Public Contract Regulations. A single stage procurement is

12

achieved by running the Pre-Qualification Questionnaire (PQQ) and Invitation to Tender (ITT) concurrently, thereby condensing the procurement process into a shorter time period. Information on selection criteria (including financial standing requirements), supported by the detailed service specification, will enable providers to make informed decisions on their eligibility and whether or not to bid for services, which will support an element of ‘self-selection’. This is considered to be the most cost effective and timely option for the commissioners and potential providers. To support the process, a market engagement event will be held prior to publication of the procurement advert to allow the commissioner to inform potential bidders of the service requirements and the process to commission the services. The market event will also allow potential bidders the opportunity to discuss the requirements to ensure a common understanding as well as test potential delivery aspects.

5.2 Existing contractual obligations and notice period required

Each of the five CCGs have separately commissioned community MSK services currently. If Option 3 is agreed and a procurement is followed, notice will need to be served to the current incumbents as per the obligations of standard NHS contracts. If issued prior to the end of September 2015, a standard de-commissioning notice is 6 months. Following agreement of the business case at F&P and Governing Body, a de-commissioning notice can be issued in July 2015, giving the current providers a longer notice period and more time to comply with obligations of an exit strategy, for example providing relevant and comprehensive TUPE information. As the CCGs could potentially move further activity from acute providers into the community, there is a contractual obligation which requires CCGs to give a minimum of six months’ counting and coding notice. The provider can choose to waive this notice clause, but is thought unlikely to do so. The contracting support team will be notified that notice is likely to be required, pending sign off from each CCG’s relevant approval board.

5.3 Contracting and payment options:

An NHS Standard Contract is proposed for a three year period, with an option to extend for an additional 4th and 5th year, subject to the quality standards being achieved. The exit strategy will be in keeping with standard NHS Contract terms. For the benefit of this business case, financial forecasting has been projected over a three year contractual term. The Service will be commissioned under a single procurement under separate Lots for individual CCG to allow commissioners greater flexibility over contract management and service changes. It is proposed that the procurement will seek bidder responses for two lots: Table 2: Contract ‘Lots’

Lot 1. NHS Ealing CCG

Lot 2. NHS Hammersmith and Fulham CCG

5.4 TUPE implications

Subject to Governing Body approval for the proposed procurement to proceed, if a new provider is selected as the Preferred Bidder and awarded the contract, it is likely that staff currently providing the services may be eligible for transfer under the Transfer of Undertaking (Protection of Employment) Regulations 2006 ("TUPE Regulations") when the new service provision commences.

TUPE workforce data will be requested from existing providers for inclusion in the Invitation to Tender. The lead CCG Procurement Team (H&F CCG) and HR departments will be providing advice on this matter prior to procurement commencing.

13

Legal advice may be required. Anonymous information provided by the incumbent provider(s) shall be communicated to Bidders during the procurement in order to assist Bidders in developing their Bid(s).

5.5 Premises

Premises may be mandated by each CCG utilising existing space in current premises in multiple sites across H&F and Ealing to ensure equity of access for patients. The running of these sites will be considered when costing the contract. The provider will be responsible for ensuring each location where services are to be provided meets with Care Quality Commission (CQC) regulations. This process can take between 6 to 12 weeks from the date a contract is awarded. The provider will also be responsible for the lease of the premises and for facilities management of the building, plus cleaning and maintenance. Indicative costs will be provided in the procurement documentation.

5.6 Contract Options

These options were initially presented by Finnamores Management Consultancy in April 2014. The options were discussed at this time by the MSK steering group (clinical and commissioner leads for the 5 CCGs plus patient representatives); prior to the service re-design work that was taken forward by the CCGs. At this time, the steering group did not feel that a lead provider would be the most beneficial option. It was felt that the market in NWL was not ready for one accountable provider across both community and secondary care as the health economy is much more complex than other areas that have taken this approach, with a number of large acute providers. This decision then shaped the service re-design work that took place, and meant that the clinical pathways, service specification and KPIs developed were not geared to encompass secondary care. The contract options have since been presented to H&F Ops group, who endorsed option 5.

1. Implement service specific interventions. This approach would target specific areas that

needed improvement but would not lead to whole system change. This was not supported by the group, who wanted the work to have a wider impact.

2. Commission individual best practice pathways. This approach would involve embedding the CWHHE developed specification and clinical pathways with existing providers. This approach is fully detailed above as Option 2 in the options appraisal and is not recommended for H&F. Hounslow and West London CCGs chose to follow this route subsequent to the service re-design due to their existing contractual arrangements.

3. Commission a transformation partner. This option would rely on a partner working with providers across the system to implement best practice pathways. It was felt by the group that this would hand over managerial responsibility only and would still require a strong commitment to change from all providers.

4. Commission a prime / lead provider. This procurement route leads to one provider being responsible for the whole patient pathway and programme budget (including secondary care services), see figure 1 below. It was decided by the steering group at the time that this was not advisable for MSK services, as the health landscape in NWL is very complex with a number of acute providers, some of which could be de-stabilised if not part of the successful bid. Since April 2014 when the contract options were initially discussed, WL, Hounslow and CL CCGs are no longer part of this potential procurement for varying reasons. This means that some economies of scale have been lost, and there would be significant challenges in providers winning a bid and accepting responsibility for the entire patient pathway for only one or two of the five NWL CCGs.

5. Commission a prime / lead provider for community integrated services. This option varies

14

from 4 above, as the preferred bidder would have responsibility for community services only, not secondary care; see figure 2 below.

Figure 1

Figure 2 5.7 Payment mechanisms

There are three broad payment options that have been considered appropriate for further consideration below. This business case is recommending that Option B, a Hybrid contract (part block and part activity) is adopted as it most closely supports the intended service outcomes with an optimum balance of risk between provider and commissioner. The options that have been considered are:

15

Option A – Block contract A block contract would provide a pre-determined financial envelope within which the service must be delivered by the provider. A proportion of the contract can be attributed to performance / quality payments, structured to incentive the desired outcomes for care delivery. A block approach has a number of advantages: 6 Providers must use resources within the services to best effect so that the service

delivery can be managed within a fixed resource. This would encourage delivery of services more efficiently and innovatively (e.g. telephone follow ups, online advice, using a multi-disciplinary approach to care);

7 An increased demand risk transfers from the commissioner, as the provider has a fixed budget within which services must be delivered;

8 Having a finite financial envelope would incentivise the provider to work more closely with primary care, and operate a high-quality advice service for GPs, to help manage conditions in primary care;

9 Current community MSK services for Ealing CCG is funded through block arrangements and this element may be simpler to determine; and

10 A fixed budget would support management of risks of ‘internally generated demand’ that could occur in a cross speciality MSK service (i.e. patients requiring a combination of physiotherapy, pain management and rheumatology).

However, there are a number of challenges that would need to be managed with a block contract approach, including:

Determining the level at which to set the contract value (for example this could be the total current spend for in-scope MSK community and outpatient services, less QIPP savings (e.g. 10%). This option funds a pre-agreed level of activity based on historical performance and predicted future need. Typically a 10% over/under activity threshold may be set. This would mean that any underperformance up to 10% is not paid for and any over performance up to 10% is not paid for. Agreement would have to be reached on funding flows for in-scope activity delivered in acute settings; and

Ensuring that the provider is required to report activity data and quality/performance data with suitable ‘levers’ for contract management. This option presents a risk to the commissioner of underperformance.

Option B – Hybrid contract This option will fund a pre-agreed level of activity under a block arrangement, with additional activity (within the scope of activity being commissioned) paid under local tariff arrangements. The block element of the contract would include the current community provision which is being decommissioned plus a lower expected level of activity that is being transferred from acute services to the community. This arrangement would continue to allow the provider assurance over revenue to allow innovation and the most effective resource utilisation for care provision. In addition to the element of the contract transferring from current community provision, the first year’s activity and contract level for activity transferring from acute services would be set at a percentage of normal expected volume as it is anticipated that it would take time for activity to ramp up over the first few months. This contract value will also be subject to a performance based element and KPIs which will include meeting waiting times and patient satisfaction to ensure continuing quality of service provision. This approach may provide an appropriate balance of risk between provider and commissioner and incentivise the agreed performance and behaviours. It is anticipated that providers would be given the anticipated number of referrals into the service and the upper affordability limit. With this information they would be expected to provide a local tariff and activity plan as part of their bid. Further details on this approach will be developed in conjunction with contract and finance leads, ahead of procurement commencement.

16

Option C – PbR/Tariff With this option, the CCG would invite Bids for a Local Tariff price. The provider would receive a payment for first appointments, follow-up appointments and procedures. An indicative activity volume would be provided to Bidders through the procurement process to allow pricing of Bids. There would be no minimum or maximum guarantee of payment or activity. The CCGs would propose an expected activity level for budget setting and capping. There is no minimum income guarantee for the provider. Payments on activity will be capped at 10% over the annual expected levels. It is proposed a deviation of 5% below or above annual expected activity levels will trigger an alert and a meeting will be convened with the provider to address any underperformance issues or agree increased activity. This will also include any financial penalties for failing to meet KPIs. A contract with a 5% performance based element can be adopted which includes meeting waiting time KPIs. Prior to the contract commencing, the incremental extra cost of any over activity would be agreed as a marginal rate. The tariff price/contract cap will be re-assessed at the end of year 1 (anticipating activity will go up over the first 12 months).

5.8 Proposed Tender Rate

The tender value would stipulate an affordability threshold with a clear expectation that bids are to be no greater than this level. This threshold has been developed with support from finance through a robust ‘bottom-up’ model that uses patient pathways to determine a fully inclusive indicative cost for the service. The three pathways used have been designed with support from managers and consultants working within the specialties of orthopaedics, pain and rheumatology. This gives assurance to the CCG and to providers that the budget for the service is realistic and the costs achievable. The full details of the patient pathways developed will not be published to the market, they have been used to indicate a cost only, bidders will be able to cost their own service delivery models, allowing for innovative approaches. Bids received above the affordability threshold will not be considered.

5.9 Length of contract

An NHS Standard Contract is proposed for a three year period (with the option to extend for a further 2 years) subject to the quality standards being achieved. The exit strategy will be in keeping with standard NHS Contract terms. For the benefit of this business case, financial forecasting has been projected over a 3 year contractual term.

5.10 Exit strategy

Each CCG has an existing Community MSK service. As part of the bid process for the new community MSK service contract, potential providers will be required to submit a detailed mobilisation plan that will be evaluated as part of their bid. The new Community MSK service agreement will be subject to the terms and conditions of a standard NHS Contract with the appropriate agreed notice period from either Provider or Commissioner.

5.11 Legal implications

The standard NHS Contract will be legally binding and close adherence to the procurement process will ensure that any contract awarded will not be subject to successful challenge.

17

5.12 IT

The provider will be expected to ensure the appropriate IT systems are in place and fully interoperable with SystmOne and absorb these costs in full in their bid. As an indicative guide, the CCG has obtained a quotation from The Phoenix Partnership (TPP) dated 26th March 2014 to the value of £61,277 for a 200 user license. The providers will be asked to include costs for SystmOne in their bids using the above price as a guide. The new community MSK service will require continuity of patient record (electronic and paper), between GP, community service and hospital service.

SECTION 6: Financial Case

This section must be completed by the CCG Head of Finance.

Outline and summarises the financial impact of the project.

For a service redesign programme set out what the current cost of the service is. Using standard activity growth assumptions forecast

what the service will cost over the next three years.

Set out how the recurrent service cost will change as a result of the project, stating the recurrent cost of the new service, the recurrent

cost any residual elements of the old service and any recurrent savings. Underpin all financial assumptions with activity flows.

Present a three year financial model which includes the non-recurrent set up costs to demonstrate financial viability of the overall

investment plan.

For an invest to save project present, if possible, a three year financial model which includes the non-recurrent set up costs to

demonstrate financial viability of the overall investment plan. Clearly demonstrate where the investment will deliver cash-releasing

savings.

For all types of project or investment:

1) Provide a sensitivity analysis and payback calculation.

2) Split out capital investment and include the revenue implication of this in the recurrent cost.

3) Include detailed financial costings and workings in an appendix to this document.

This section sets out the finance and activity projections for a 3 year period from May 2016 for H&F CCG and details the possible savings and investments required to commission the redesigned Community MSK service.

6.1 The 2014/15 combined full year cost for GP referred, acute provider MSK related (T&O, Rheumatology and Pain management) first and follow up attendances plus procedures for H&F CCG was £1,177,625 and total activity was 9107 attendances. The 2014/15 spend on community MSK services in H&F was £2,014,612 and total activity was 33,550. This brings the total 2014/15 spend on MSK services in H&F to £3,192,237.

6.2 It should be noted that Finnamore data19 suggests that 50% of acute provider first appointments are not GP referrals. The latest data is suggestive of an average of 46% when taking into account MSK Pain management, Rheumatology and T&O. For the purpose of this business case, all cost

19

Finnamores consultant data 2013 – see Appendix 3

18

projections have been based on GP referrals only so as not to inflate potential savings. Contract negotiations with current Acute providers will be an additional measure to support activity shifts from acute care to the community, particularly with respect to Consultant to consultant referrals. This issue will also form a specific question during the procurement process that bidders will be expected to provide a robust strategic management response. It is also expected that triaging a large proportion of referrals to the community service will reduce the opportunity for consultant to consultant referrals in the acute services.

6.3 Current community services will be decommissioned and their current community activity will transfer to the new provider.

6.4 In order to calculate a realistic, bottom up cost for providing the new service, patient flow pathways were developed in collaboration with relevant acute consultants for the specialties included in the service; pain management, orthopaedics and rheumatology.

6.5 T&O activity shifts– the service specification brings together a multi-disciplinary skill mix for orthopaedics diagnosis and treatment including ESPs, GPwSIs and consultants which should enable the service the service to see and treat a substantial proportion of orthopaedic activity. A clinical audit of T&O outpatient notes supports the assumptions made in the patient pathway developed. Rheumatology activity shifts– through clinical engagement and feedback in the CWHHE collaborative service re-design and at a CCG level, a large majority of Rheumatology referrals could be seen and treated in the community. There are only a small number of rheumatology conditions that are excluded from the scope of community MSK services. MSK Pain activity shifts – evidence suggests that 30% of Pain referrals are non MSK pain therefore this percentage (30%) has been automatically removed from the data. The evidence base has been taken from the National MSK Pain audit20 and in accordance with Health Improvement Scotland’s - Clinical Guidelines for management of chronic pain21 which denotes that the majority of patients presenting with pain can be managed in a non-acute healthcare setting. The service specification only expects patients with complex needs to be transferred to secondary care, which includes where there are high opioid demands or where intervention is required by a specialist pain team. OPPROC – the percentage transfer for OPPROC has been estimated through clinical analysis of current outpatient activity.

6.6 Indicative Costs and Savings of the new Community MSK Service

The full year effect total projected costs, savings and activity from providing the new community MSK service and transferring secondary care activity are illustrated in the Tables below for H&F CCG. The projected costs assume the current community activity continues, the recurrent CCG funding for existing community services continues and the additional activity is based on the new patient pathways (detailed above and annex 2). A profit allowance of 5% has been included to give an upper affordability limit to the CCG which the savings are based on. The rationale for this is that the finance model was developed using basic NHS assumptions without innovative practices that will be available to the successful bidder. Section 7 details the adjusted position taking into account a service mobilisation and ramp up period assuming 50% transfer of acute activity over the initial 6 month period.

6.7 The H&F CCG indicative costs of the ‘Do Nothing’ option total £10,697,409.

20

Early management of persistent non-specific low back pain - NICE guidelines [CG88] Published date: May 2009 21

Sign 136, Management of Chronic Pain, A national clinical guideline December 2013

(http://www.sign.ac.uk/pdf/SIGN136.pdf

19

Table 3 : H&F CCG Indicative costs of the ‘Do Nothing’ Option

Note: Forecasted activity includes an assumption of demographic and non-demographic growth detailed below;

2015/16 2016/17 2017/18 2018/19

Non-demographic growth 0.74% 0.74% 0.74% 0.74%

Demographic growth 3.00% 3.00% 3.00% 3.00%

Tariff deflator -1.10% 0.40% 0.60% 0.70%

The H&F CCG indicative costs of the new Community MSK service (Option 3) total £6,977,953 over a 3 year contract, giving a combined total spend on community and acute MSK services of £9,554,213 releasing a saving of £1,143,196. Table 4 : H&F CCG Indicative costs and savings of the new Community MSK service

6.8 Activity in the new service will increase over the three year term as more patients are seen in the

community setting. The activity projections for the do nothing option and within the new service are shown in tables 6 and 7 below. Please note that the activity shown in the acute is on total patient attendances (so includes first and follow up appointments), whereas the activity in the community is the total number of referrals made to the service;

20

Table 6: H&F CCG Activity in the ‘Do nothing’ option;

Table 7: H&F CCG Activity in the new Community MSK Service option;

SECTION 7: Funding source

Outline all sources of funding for the project including non-recurrent, recurrent and capital.

Consider the application route for sources of funding that are outside CCG allocations, for example, capital requirements.

7.1. The upper assumed cost of the new Community MSK Service for H&F CCG is £6,977,953. This

gives the upper affordability limit for the tender process to the CCG, and has been calculated using a robust financial model which includes a profit allowance for the provider of 5%.

7.2. The projected funding for the service is comprised of existing recurrent service funding over three years at £6,571,623, with the remainder of the funding required to be released from acute contracts.

21

16/17 17/18 18/19

3 Year Total

RELEASED FROM ACUTE 311,121 605,611 632,794 1,549,525

RELEASED FROM

COMMUNITY 1,974,291 2,248,210 2,349,122 6,571,623

TOTAL AVAILABLE 2,285,412 2,853,821 2,981,916 8,121,148

PATHWAY 1,944,171 2,304,908 2,405,549 6,654,628

PATHWAY WITH 5% PROFIT 2,038,244 2,417,017 2,522,691 6,977,953

SAVING 247,168 436,803 459,225 1,143,196

7.3. This service aims to save H&F CCG £1,143,196 over three years, with the majority of the savings to be realised in the second and third years of the service once more activity is released from the acute contracts.

SECTION 8: Overall Plans for Implementation and timescales

This section builds on the resources and cost of delivery section included in the project mandate.

Outline the resources and timescales required to deliver all phases of the project. Consider procurement cost, legal costs, project

management time, the completion of capital bids, stakeholder engagement, equipment and overheads. These costs should also be

included in the non-recurrent costs in the financial case.

Also consider the cost of slippage in delivery of the project and the inclusion of a contingency.

8.1. An advert signalling an intention to procure new community MSK services, together with a

Memorandum of Information, will be published on Contracts Finder and EU Supply Portal in July 2015. Potential Bidders will be invited to a Market Engagement Event to take place in August 2015. A service specification has been drafted (with local CCG appendices for specific local requirements) and a Procurement Timetable agreed. (See Appendix 4, Procurement timetable).

8.2. The next stage of the procurement is to issue a Pre-Qualification Questionnaire (PQQ) and

an Invitation to Tender (ITT) to the market. Following evaluation of Bids, contracts will be awarded by individual CCGs (subject to Governing Body approval). The procurement timetable is presented below:

Activity Ealing CCG H&F CCG

Governing Body Business Case approval 1st July 2015 14th July 2015

Notice to current providers July 2015

Invite to Market Event and invite EOI July 2015

Publication of MOI and draft specification July 2015

Publication advert and tender documentation 7th August 2015

Bid response deadline (7 weeks) 28th September 2015

Evaluation and internal approval process 29th September – 13th October 2015

Preferred Bidder Approval by Governing Body 4th November 2015 10th November 2015

Bidder notification 11th November 2015

Mobilisation December 2015 – April 2016

Service Commencement 1st May 2016

22

8.3. Once notice on the existing providers has been served following GB approval in July 2015,

there is a risk that if the timetable slips there could be a gap in service for patients. There is a relatively long mobilisation period of 5 months built into the plan to minimise this risk.

SECTION 9: Risks

Build on the key risks identified in the project plan to provide an initial risk register to be used at the commencement of the project. This

will become the live risk register and will form a separate document. Include a detailed list of risks, scores and mitigations in the appendix

of this document.

Description of risk

Likelihood Consequence Score Mitigating Actions

Delay or slippage in project timetable

2 3 6 Project PID completed and detailed procurement timeframe developed which is consistently monitored

Lack of market capacity or interest

1 4 4 Early market engagement, publication of MOI that is linked with commissioning intentions

Challenge from a bidder that is deselected

1 3 3 Clear evaluation criteria of bids, transparency of procurement rules. Close working with procurement advisors to ensure fair and transparent procurement process.

Poor responses from bidders at PQQ and ITT stage

1 3 3 Early market engagement, publication of clear and thorough service specification, with realistic expectations

Bidder responses exceed financial allocation for the project

3 3 9 Effective cost analysis work completed as part of business case, sound financial model and criteria

Incumbent providers indicate high volume of TUPE transfer staff that have financial implication on Bid Price

3 3 9 Early engagement with HR to identify staff that could fall under TUPE, due diligence followed post contract award

Potential absence of contract lead to support throughout and finalise contract with successful bidder

2 2 4 Early identification of risk, negotiation of on-going contract support throughout the procurement

23

22

Hammersmith and Fulham CCG MSK Self-Referral Literature Review, 2014

Conflict of Interest declared by any member of the procurement steering group once procurement has commenced

1 2 2 A definition is provided to each steering group member concerning conflict of interest. Signed COI declarations and confidentiality agreements from all members of the steering group are received pre-procurement

Delay to implementation and potential gap in service delivery

3 4 12 Evaluation of bidder mobilisation plans as part of procurement process, clear timeframes for new incumbent to implement.

Activity procured in community does not result in desired reduction of activity in Acute hospital provision.

2 4 8 Service specification defines a high quality service with better access than hospital provision. A single point of access will support transfer of new appointments to the community. The procurement process will seek solutions to the transfer of ‘on-going’ care to the community.

Risk of unmet demand activity results in a community service that requires additional investment

2 3 6 Potential unmet demand will vary across the CCGs. For example, Ealing CCG JSNA (2014) estimates 31% of the local population are suffering long term back pain and 10% have pain due to lower limb osteoarthritis. Since many of these patients are persistent uses of primary care and physiotherapy strict referral guidelines and inclusion criteria for community MSK services will be mandatory to access the service. In addition activity levels should be closely monitored on a monthly basis and contract management action taken as appropriate. A further mechanism to cap over performance of self-referral can be to utilise the suggested rate of 50 referrals per thousand registered patients22.

24

SECTION 10: Stakeholder Engagement

Include here a summary of the stakeholder engagement plan, highlighting particular interdependencies. This should be a summary of the

communication plan to support project delivery.

The MSK review project was undertaken by an engaged and committed group of CWHHE CCG commissioners and lead clinicians, GPs, acute and community service operational managers and clinicians, public health (for the initial stages) and two patient representatives. This review took place over a total period of 11 months during 2013/14. The new MSK service resource pack, including service specification, core model pathway and clinical pathways, have been presented and approved by the CWHHE CCG’s Quality and Safety Committees (or equivalent). The MSK procurement steering group for this project will have representation from various stakeholder areas including CWHHE commissioners (project lead, support manager, all CCG stakeholders), contracting, HR, IT, Estates, Clinicians (an out of area consultant and an out of area GP) and patient representation. This group will meet regularly and will be responsible for signing off any CCG specific addendums to the service specification and tender documentation, and will undertake a desktop equalities impact analysis of the service. Full public consultation was considered but not seen as necessary as the service is a continuation of one that is already running and the service re-design has had patient user involvement. Interdependencies following service commencement include;

RMS (where applicable)

GPs

Consultants in secondary care

CWHHE CCGs

Diagnostic services

Acute Settings – Chelsea & Westminster NHS Foundation Trust, Imperial College Healthcare Trust, West Middlesex University Hospital, Ealing Hospital Trust, Northwick Park, Kingston Hospital, Ashford and St Peters

Tissue Viability Service

Practice Nurses

Bio-mechanical podiatry

Dietetics

Health Improvement Teams

Central West London Mental Health Service

Community Occupational Therapy Services

Local Authority

Community Health Services Community Rehabilitation

Further engagement with patients will take place ahead of concluding the procurement of services. Market management A separate bidders’ information event is planned for August 2015. The aim of the bidders’ will be to gauge the level of interest, clarify the commissioning intentions and procurement timeline and respond to appropriate queries ahead of the procurement process. This event will be supported by Procurement Team (SBS).

25

SECTION 11: Recommendation

Include here an outline of the key decisions that the reviewer (s) of this business case are required to make.

It is recommended that following review of this business case, and taking into consideration the successful review of the CWHHE community MSK services and approval of the Finance and Performance Committee to proceed to procurement for the service, that the request to procure the Community MSK Service for H&F CCG, with an estimated contract value of £6,977,953 is approved over the term of three years. The PQQ and ITT will be published in August 2015 and a further paper brought to the Board to approve contract award in November 2015 for service commencement from 1st May 2016. The Finance & Performance Committee and the Governing Body will also be asked to endorse the MSK resource pack and approve the request to commence a procurement process in August 2015, noting the estimated service cost of £6,977,953.

26

APPENDICES

Appendix 1: Service Specification

Included as separate document

Appendix 2: Full costing model

Included as separate document

Appendix 3: Finnamore Data (Feb 2014)

Page 1

Framework for scaling the opportunity – CWHHE

Numerator: Procedures

Denominator: 1st Appt. Referrals

Conversion Rate =

25 to

50%

3,327 £531k £128k £403k £403K

25 to

25-50%

1,101 £182k £43k £139k)

25-50%

to 65%

1,860 £246k £71k £175k £175k

Conversion Rate:All referrals

GP referrals

Other referrals

Referral Rate:

(1st appt with discharge:

Referral Rate:

OP joint injections:

MRI instead of diag. arthroscopy:

Target Activity

change

Gross

Value

Reprov’n Net Opp. For

14/15

80 to

90%

615 £85k £39k £46k £46k

90% 145 £211k £37k £174k £174k

By managing referrals more consistently

the goal is to refer to the acute only those

patients most likely to require acute level

procedures. The rest are managed in

primary care and the community.

65 to

75%

25,605 £4288k £1022k £3266k

Total net opportunity: £798k

33 to

39%

11,318 £1895k £450k £1444kCurrent + 10%:

Appendix 4: Draft Procurement Timetable

Included as separate document