REPORT TO NHS WARWICKSHIRE BOARD
15th September 2010
Agenda Item: 11.6
Subject: Transfer of Community Services
Business Cases – WCH
Business Cases - PCTM
Presented to the Board by: Rachel Pearce (Director of Compliance)
Author Mark Harris (Head of Compliance and Assurance)
PURPOSE OF THE REPORT:
To present the draft business cases for the transfer of community services from NHSW
to identified alternative providers
In June 2010, the Department of Health published the revised Operating Framework for
the NHS in England 2010/11.
This stated that separating PCT commissioning from the provision of services remained
a priority and must be achieved by April 2011. PCTs have been instructed to continue to
develop and review proposals for the divestment of their directly-provided community
services and in doing so ensure that
- They have been tested with GP commissioners and local authorities
- Final proposals are consistent with the aims of the forthcoming NHS Strategy in
strengthening the delivery of public health services and health services for children
- They consider the implications for choice and competition
- They consider a wide range of options, including the development and early delivery
of Community Foundation Trusts and Social Enterprises, providing employee
leadership and ownership
- There has been effective engagement of staff and their representatives when
- Previous proposals for continued direct provision are reviewed and alternative
options developed which secure separation; and
In furtherance of this directive NHS Warwickshire conducted a robust provider selection
process to identify a preferred destination for its Community Services. This process
settled that the bulk of services currently provided by Warwickshire Community Health
should be transferred to South Warwickshire Foundation Trust. The vertical integration
offered by this solution providing a range of advantages for patients whilst affording best
fit in terms of service delivery and local context. The process for the divestment of
PCTMS practice concluded that George Eliot Hospital was the most suitable location for
To mange this process NHSW has put in place the following programme management
1: Programme Board – containing representatives from NHSW, SWFT and GEH.
Its purpose being to oversee the work required to deliver an effective transfer.
2: An Organisational Form Steering Group to manage various workstreams that are
essential to the delivery of the transfer (eg HR/ICT/Estates/Communications and
A crucial part of the transfer process is the requirement that any preferred solution to be
subject to external scrutiny. The key aspects of this are:
1: The SHA assess the proposals against a series of tests to ensure that the
transfer delivers improvements in the quality and efficiency of service delivery.
2: The Cooperation and Competition Panel (CCP) examines proposals to ensure
they are consistent with the Principles and Rules for Cooperation and
Competition – providing benefit to both patients and taxpayers.
In addition the fact that the preferred destination for WCH is a Foundation Trust requires
SWFT to gain approval from Monitor which regulates the work and activity of such
NHSW has so far received SHA approval for its proposals for the transfer of WCH
services to SWFT. We are awaiting approval of the proposals to transfer PCTMS
practices to George Eliot.
Annexes a (SWFT transfer) and b (PCTMS Transfer) contain a draft business plan
submissions to CCP for their approval. These document set out
- the rationale for change
- background to community healthcare provision in Warwickshire
- the key care pathways of community services
- an outline of the process and rationale for the selection of preferred providers along
with the expected benefits that will accrue.
Given the requirement to have affected the transfer by 31st March 2011 the timetable is
by necessity very challenging. It is intended that the business case for SWFT will be
forwarded to the CCP in the first week in October. It is expected that the proposals we
have put forward will conform to CCP’s fast track procedure which takes 10 days. This
will enable consultation with staff and stakeholders to take place during, October/
November/ December. SWFT are expected to take their case through Monitor process
in December following the completion of due diligence. This will take approximately 8
weeks allowing transfer to be completed in time for the 31st March 2011.
As regards PCTMS transfer, this will form part of an array of services moving to George
Eliot including a number of Public Health services. These will be brought together into a
combined George Eliot business case that will be brought to this Board in October.
Given the complexity of the services and the unusual nature of the PCTMS
arrangements it is expected that the business case for George Eliot will be subject to a
more intense examination by CCP – conforming to their 40 day standard process. It is
expected that this will still enable transfer to be completed by 31st March 2011.
The Trust Board is asked to comment on the draft business cases and delegate
authority to the Chairman and Chief Executive to approve the final documents prior to
their submission to the CCP.
Financial: The business cases for transfer of provider services have
no specific financial impact in themselves. The transfer of
services will however have a significant impact on finances
and financial structure of the Trust. This issue is being
dealt with through the due diligence exercise and via the
work of the Organisation Form Steering Group
HR / Personal: The transfer of staff from NHSW to WCH has very
significant personnel/HR implications. These are a key
area of activity within the work of the Steering Group
Healthcare / National The proposed transfer accords with national policy and the
Policy: nhs operating framework
Primary Care Trust Medical Services
Cooperation and Competition Panel
Author Caroline Capell
Date 31st August 2010
Distribution Laura Mhlanga, Andy Newth, Francis Campbell, Lesli Davies,
Rachel Pearce, Andrew Kennedy, Mark Harris, SHA.
PCTMS CCP Business Case V2.0 Page 1 of 20
1. Introduction & Background ............................................................................................................ 3
1.1 NHS Operating Framework ..................................................................................................... 3
1.2 Warwickshire .......................................................................................................................... 3
1.3 Selection Process .................................................................................................................... 4
1.4 Involved Parties ....................................................................................................................... 4
2. PCTMS Practices .............................................................................................................................. 5
2.1 Staffing .................................................................................................................................... 6
2.1.1 The Chaucers ................................................................................................................... 6
2.1.2 Leicester Road: ................................................................................................................ 6
2.1.3 Satis House: ..................................................................................................................... 7
2.2 Patient List Size ....................................................................................................................... 8
2.3 Budget ..................................................................................................................................... 8
2.4 Review ..................................................................................................................................... 8
3. Hosting ............................................................................................. Error! Bookmark not defined.
3.1 Market Definition .................................................................................................................. 10
3.2 Patients ................................................................................................................................. 10
3.2.1 Impact ........................................................................................................................... 10
3.2.2 Benefits ......................................................................................................................... 11
3.3 Taxpayers’ ............................................................................................................................. 12
3.3.1 Impact ........................................................................................................................... 12
3.3.2 Benefits ......................................................................................................................... 12
3.4 Service Delivery ..................................................................................................................... 12
3.4.1 Current Services ............................................................................................................ 12
3.4.2 Impact ........................................................................................................................... 14
3.4.3 Benefits ......................................................................................................................... 14
4. Timescales ..................................................................................................................................... 18
5. Risks .............................................................................................................................................. 19
6. Appendix .......................................................................................... Error! Bookmark not defined.
6.1 Supporting Documentation ..................................................... Error! Bookmark not defined.
6.1.1 Letter to interested parties .............................................. Error! Bookmark not defined.
PCTMS CCP Business Case V2.0 Page 2 of 20
1. Introduction & Background
1.1 NHS Operating Framework
In June 2010, the Department of Health published the revised Operating Framework for the NHS in
This stated that separating PCT commissioning from the provision of services remains a priority. This
must be achieved by April 2011. PCTs are instructed to continue to develop and review proposals for
the divestment of their directly‐provided community services, but in doing so ensure that:
- They have been tested with GP commissioners and local authorities;
- Final proposals are consistent with the aims of the forthcoming NHS Strategy in
strengthening the delivery of public health services and health services for children;
- They consider the implications for choice and competition;
- They consider a wide range of options, including the development and early delivery of
Community Foundation Trusts and Social Enterprises, providing employee leadership and
- There has been effective engagement of staff and their representatives when considering
- Previous proposals for continued direct provision are reviewed and alternative options
developed which secure separation; and
- Proposals should be capable of being implemented or substantial progress made towards
implementation, by April 2011.
NHS Warwickshire agreed with the SHA proposals for the future organisational form and has plans to
have this implemented by April 2011.
Warwickshire has a rapidly ageing population. The current over 65 population levels are 17.3% (16.2
nationally) Growth figures are not consistent across all age ranges, with the over 50’s growth level
the greatest in England. The number of people over 65 is projected to increase by 20% and those
over 85 to increase by 140%.
This rapid ageing is compounded by high levels of deprivation in the North of Warwickshire. These
factors have lead to many people needing support with long term conditions.
However, funding levels per head of population are low, since the pockets of extreme deprivation
are mixed in with some of the most affluent populations in the country. This low level of funding has
necessitated the extraction of many of the easy efficiencies that better funded PCT’s aim to remove
through this process. The low levels of funding have also lead to the development of an efficient
provider service which meets the needs of a population of circa 550,000 spread over Warwickshire
with a spend of less than 60 million pounds per annum.
The local health economy benefits from strong primary care. So it has developed a diverse range of
products which work between primary care and community health these include, virtual wards,
PCTMS CCP Business Case V2.0 Page 3 of 20
community hospitals and intermediate care that has effective admission prevention referral
criterion. This quality is reflected in a death rate of 0.88% (national average 1%), emergency
admission rate of 86.53 (NA 96) and 21.43% home death rate (NA19%).
The combination of these factors evidences the lack of efficiency options when considered in the
context of the national clinical productivity tools, and allowed NHS Warwickshire to come to the
conclusion that further efficiencies and improved patient benefits could only be extracted from the
system by closer working with acute and Local Authority colleagues.
1.3 Selection Process
All NHS Acute providers, including PBC (Practice Based Commissioning) Consortium were invited to
express an interest to manage both Warwickshire Community Health and PCTMS (Primary Care Trust
Medical Services) Practices. An example of the letters that were sent out to potential organisations
are in Section 6.
Following an Options Appraisal and a robust selection process, George Eliot Hospital NHS Trust was
chosen as the preferred organisation to host the PCTMS Practices.
The transfer of PCTMS Practices to a hosted organisation will meet the requirements identified in
the Operating Framework, and provide a more secure and stable management structure for the
PCTMS Practices. The benefits are highlighted in more detail from section 2 below.
1.4 Involved Parties
The parties involved are:
NHS Warwickshire George Eliot Hospital NHS Trust
Westgate House College Street,
Market Street Nuneaton,
CV34 4DE CV10 7DJ
The PCTMS Practices are:
The Chaucers Leicester Road Practice Satis House
Off School Walk 57 Leicester Road 10 Birmingham Road
Attleborough Bedworth Water Orton
Nuneaton CV12 8AB B46 1TH
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2. PCTMS Practices
NHS Warwickshire has 76 GP Practices covering the majority of patient needs in Warwickshire.
All of these practices have to comply with the Health Service (General Medical Services Contracts)
Each practice provides identical core services, and a mix of additional and local services. The table
below explains the current contracts that are in place and the number of practices contracted.
Contract Description No of Practices
General Medical Services Practices with at least one GP provider 67
(GMS) who provide essential services and
additional services for their own
Personal Medical Services This incorporates core services and 10
(PMS) provides additional funding for identified
needs in the area.
Alternative Provider This is a contractual route through which 1
Medical Services (APMS) the PCT can contract with a wide range of
providers to deliver services tailored to
local needs. The contractor is obliged to
deliver on specific key performance
Primary Care Trust Medical These are practices that provide essential 3
Services (PCTMS) and additional services under the
management of the PCT.
Enhanced Services Enhanced Services are services above and
beyond basic primary care, but also
include some bonus payments for
providing basic primary care to a high
National Enhanced Services These are services that are nationally
Direct Enhanced Services These are services that PCTs are required
Local Enhanced Services These are services that the PCT choose to
commission based on the need of the
NHS Warwickshire has three PCTMS Practices; these were taken over by the Primary Care Trust for
the following reasons:
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2.1.1 The Chaucers
The Chaucers was set up as a purpose built building in 2002/3. Dr Arora acquired the land and built
the premises on agreement with the Director of Primary Care (North Warwickshire PCT) at the time.
The building was over budget and is now in negative equity. The PCT took over the practice from Dr
Arora, who has now retired from practicing, but remains the landlord of the premises.
The practice is currently open 8 – 6.30, five days a week, with a practice list size of 2,500. The
premises have the potential to expand.
The Chaucers has the following staff:
Role Grade Hours
Practice Manager 6 37.5
Practice Nurse 6 30
Administrator 4 21
Administrator 4 30
HCSW 4 25
GP MQ00 5 sessions
GP MQ00 10 sessions
GP MQ00 6 sessions
Receptionist 2 30
Receptionist 2 15
Receptionist 2 10
House Keeper 1 8
2.1.2 Leicester Road:
In 2003 Dr Patel, a GMS contractor at Leicester Road became ill and the PCT had to take over the
practice. All staff was tuped across to the PCT. Dr Patel died, so the PCT continued with the practice,
and leased the premises from Dr Patel’s wife. The practice itself has fallen into disrepair, and it is the
responsibility of the PCT to maintain the standards of the premises.
The practice is currently open 7.30 – 6.30, five days a week, with a practice list size of 2,500.
Leicester Road has the following staff:
Role Grade Hours
Practice Manager 6 18.75
Practice Nurse 6 15
Secretary 3 30
HCSW 3 20
GP MQ00 5 sessions
GP MQ00 10 sessions
GP* KQ00 Suspended
Receptionist 2 16
Receptionist 2 27.87
Receptionist 2 27.87
Receptionist 2 22.5
Receptionist 2 14.19
House Keeper 1 5
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2.1.3 Satis House:
This started as a GMS practice with Dr Street as the Senior partner. In 2001 the PCT took over the
practice and lease the building from Dr Street. All staff were tupe’d over to the PCT, including Dr
Street. The PCT agreed in writing to Dr Street that he has the right to return to GMS at any time.
However the validity of this is in question and would need to be investigated further and legal advice
sought. Dr Street continues to do 8 GP sessions a week on a salaried basis at the practice. The
practice is on the border with Birmingham (Castle Bromwich) and has some Birmingham patients on
their register. The building lends itself to further development. There is currently ten years left on
the lease with Dr Street.
The practice is currently open 8am – 6.30pm, five days a week, with a practice list size of 4,500
Satis House has the following staff:
Role Grade Hours
Practice Manager 6 18.75
Practice Nurse 6 15
Practice Nurse 6 16
Practice Nurse 6 11
Administrator 4 8
Administrator 3 37.5
Secretary 3 25.34
GP MQ00 3 sessions
GP MQ00 6 sessions
GP MQ00 8 sessions
GP MQ00 6 sessions
Receptionist 2 31
Receptionist 2 14
Receptionist 2 27.5
Receptionist 2 21.5
House Keeper 1 10.14
The intention of the transferring of the PCTMS Practices to a Host organisation is that the above staff
and existing premises, with their lease terms, will be transferred across to the Host organisation.
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2.2 Patient List Size
The patient list size for all three practices has remained fairly static over the last three years, as
reflected in the table below.
Practice List Size
January 2010 January 2009 January 2008
The Chaucers 2,492 2,623 2,474
Leicester Road 2,476 2,448 2,459
Satis House 4,189 4,202 4,194
Average ‐ North Warwickshire 6,510 6,744 6,707
Average ‐ Warwickshire 7,215 7,280 7,228
The three PCTMS practices provide core and additional GP services. The budget for each practice
currently stands as follows:
The Chaucers £381,670
Leicester Road £512,212
Satis House £577,389
The totals above include pay and non‐pay.
Prior to the decision to transfer the three PCTMS practices to an alternative organisation, A Value for
Money Review was undertaken for all three PCTMS practices. This review looked at the following
- Costs (including per weighted patient)
- Services and Quality of services delivered.
- Other Practices
On completion of the review, the following options emerged:
- Tender all three practices for patients and premises
- Tender all three practices for patients only
- Close practices and disperse patients to neighbouring practices.
All three options highlighted significant risks, these included:
PCTMS CCP Business Case V2.0 Page 8 of 20
- The cost of making GPs redundant made the project prohibitively expensive
- The employment rights of staff, including GPs, meant that whatever organisation took over,
the staff would have TUPE rights.
- The demand for Primary Care access in the North of the County remains a priority therefore
any of the options above would have created a gap in services as well as upheaval to
patients and staff.
- The timescales were considerable.
NHS Warwickshire Exec Team concluded that the risks for the options identified were too high.
Therefore, it was agreed that the preferred option would be to include the management of the three
PCTMS practices in the Transforming Community Services Programme.
This decision, as highlighted above, ensured that NHS Warwickshire fulfilled the requirements of the
NHS Operating Framework, and ensured minimum impact on patients.
PCTMS CCP Business Case V2.0 Page 9 of 20
The aim of NHS Warwickshire is to transfer the three PCTMS Practices to the George Eliot Hospital
NHS Trust for a period of up to three years.
3.1 Market Definition
In Warwickshire there are 76 GP Practices, each providing identical core services, and a mix of
additional and local services. These practices cover the majority of patient needs in Warwickshire.
The volume of patients in each practice depends on:
• The clinical capacity of the practice (wte of GP / Nursing Staff)
• the ability of the premises to facilitate the delivery of Primary Medical Services
• the need of the population
A need has to be identified in order for a new GP Practice to be commissioned. The PCTMS Practices
are within areas of need, and meet the needs of the patients within the surrounding areas of the
premises. There is little or no competition with other neighbouring practices, as all comply with the
same regulations for patient care.
All GP Contractors have to abide by the National Health Service (General Medical Services Contracts)
Regulations 2004. This means that patients have a choice relating to their practice and GP
preference, unless there are reasonable grounds for refusal. The PCTMS Practices will remain under
these same regulations, regardless of the contract holder. Therefore the market opportunities will
remain the same, and patient choice is safeguarded, and inequalities remain at a minimum.
The next sections demonstrate the impact and benefits this process will deliver for patients and the
As described above, the Patient choice will remain the same; patients can still be registered at any
suitable practices. The services delivered will still remain the same, and the PCTMS practices will still
have to comply with the regulations.
The intention is that the patients that reside on the current practice lists will remain the same, and
that the services that the PCTMS Practice provides, will remain the same. This will be enforced
through an agreement between the PCT and the chosen organisation. Along side this agreement, the
George Eliot Hospital NHS Trust will be obliged to comply with the Health Service (General Medical
Services Contracts) Regulations 2004.
The existing leases and assets that are within the three practices, will be transferred to the George
Eliot Hospital NHS Trust, who will continue the lease.
PCTMS CCP Business Case V2.0 Page 10 of 20
The intention is that all existing staff, including medical and administrative are transferred, therefore
there will be no change in staff, which may have a negative impact on the patients. The intention is
that the services will be run from the existing GP Practices as this is an essential part of the delivery
of the existing services, and within specific boundaries for the patients in the local surroundings. This
will mean that there will be no impact on patients and the service relocating to other locations.
The patients should see no impact on this change, as the intention is that the process will be as
smooth and seamless as possible, to minimise any impact on patients. The transfer of the service
enables this process for patient perception to be as seamless as possible.
As part of the management of the PCTMS, George Eliot Hospital NHS Trust will be able to work
closely with the PCTMS GPs to improve referral pathways. Having direct access to the services that
both Primary and Secondary providers provide will enable the Host organisation to ensure the best
is provided for the patients. This enables a better understanding of the direct relationship between
the referral pathways, and the transfer allows a direct impact on the services delivered.
The relationship will enable earlier intervention for prevalent conditions, thus enabling the potential
reduction in Secondary care at a later date. This can be developed through the direct access to
resources from within both Primary and Secondary Care.
Having integrated pathways will help reduce the need for patients to have to move between primary
care and secondary care by having access to key stakeholders who are responsible for the pathways.
George Eliot Hospital NHS Trust will have the responsibility of both sides of the pathways and
therefore in an ideal position to improve efficiencies.
Should these benefits be realised, this will provide a potential opportunity for other practices, and to
develop processes for improved referrals across Warwickshire.
George Eliot Hospital NHS Trust already has considerable experience in managing a General Practice,
through the successful of the APMS Contract for the Camp Hill GP Led Health Centre, and ensuring
the needs of the patients are paramount. The Key Performance Indicators see 184.108.40.206; ensure that
the needs of the patients are continuously met.
The GP practices, the buildings and assets are already established so will have minimal patient
This will enable the PCT to review the local demands and priorities, with the intention to secure
permanent contracts that meet the needs of the patient.
As the intention is to transfer all of the current staff that work within the PCTMS Practices, to the
George Eliot Hospital NHS Trust, this will ensure that the patients have continuity of staff, in
particular the clinicians.
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Transferring PCTMS Practices in its current existing form ensures that there will be no additional
costs to the tax payer.
The intention is that the payments for the current costs of managing and delivering the services
provided in PCTMS practices will remain the same. The current staffing levels and costs have been
identified in sections 1.1 and 1.3. The intention is that this will remain at the same level for the
As the PCT currently pay for services provided by the PCTMS Practices, as well as the rent on the
premises, and costs allocated per patient. The transfer of the practices to George Eliot Hospital NHS
Trust will have no impact on the finances. They will be taking over the like for like costs of the
service, premises lease and the staffing costs as they stand. This means there will be no additional
unexpected costs for this through like for like transfer.
The transfer will enable cost effective working through shared IT and establishing shared pathways
from providing opportunities to reduce resource duplication in the system and consolidation
management, service delivery and backroom functions. This could be in areas where there are
duplicate records in both areas, and where the service is duplicated in both Primary and Secondary
Care. This could result in savings made in Secondary Care by removing duplication of services within
both, through having access to similar resources, in both manpower and assets.
3.4 Service Delivery
3.4.1 Current Services
The three PCTMS Practices currently provide the following services from their practices:
• Core General Medical Services
• Direct Enhanced Services:
- Childhood Immunisations
- Minor Surgery
- Violent Patients
- Flu Monitoring
- Improved Access
- Choice and Booking
• National Enhanced Services:
- INR Level 1
- Drug Misuse / Shared Care
- Near Patient Testing
- Minor Injury
- Alcohol Misuse
• Local Enhanced Services:
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- Treatment Room
- MMR Immunisations
- Baby Checks
- Nursing Home
- Pneumoccoccal – Children
- DPT Immunisations
3.4.2 Quality Outcomes Framework
Introduced in 2004 as part of the General Medical Services Contract, the Quality and Outcomes
Framework (QOF) is a nationally negotiated, voluntary incentive scheme for GP practices in the UK,
rewarding them for how well they care for patients.
It contains a range of national standards based on the best available research evidence, in domains
of clinical, organisational, additional services and patient experience. There are a maximum of 1,000
points available, with each point achieved worth on average £126.77 (2009/10) for a Practice with
an average list size.
Achievement payments take account of recorded disease prevalence and also the ability to except
patients (exception reporting) from the QOF indicators (against a small number of criteria) without
loss of reward to practices.
The current level of quality for the PCTMS three practices is below the average for Warwickshire.
The graph below represents the latest QOF (Quality Outcomes Framework) points scores compared
to other practices in North Warwickshire.
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Transferring these practices will enable more focus on improving the quality of the services
provided, with the PCT being able to actively manage the actions plans for the improvements with
the George Eliot Hospital NHS Trust, rather than having to manage them alone.
The transfer will also strengthen Governance and Clinical support that will enable improvements and
integrated decision making in ensuring the targets set within the Quality Outcomes Framework are
NHS Warwickshire use their own Primary Care Dashboard to look at the overall performance of the
practice relating to GP referrals, A&E attendances, prescribing and their overall rating compared to
other practices in Warwickshire.
The table below shows the current ranking of the three PCTMS Practices as recorded on the
Practice Ranking out of 75 for all Referrals Ranking out of 75 for A & E
(1st being the highest). attendances – admitted (1st being
The Chaucers 69 75
Leicester Road 64 74
Satis House 66 57
As shown above, the current rating for the three PCTMS Practices is poor. The intention would be for
the George Eliot Hospital NHS Trust to work on improving this rating and the agreement to be
developed would focus on these improvements.
The transferring of the PCTMS Practices should have a significant impact on the service delivery, in
particular the quality of those services delivered. The focus on this as a key area for improvement
will enable the Host organisation to invest their time in making these improvements. Having the
George Eliot Hospital NHS Trust as an Acute provider should enable improvements through the
availability of different expertise and knowledge that will enable improvements in the clinical
delivery of service.
As the Contractor will be the same for both the Primary and Secondary Care services, it will be in the
best interest of the contractor to ensure the service delivered is cost effective.
The emphasis on maintaining quality services will be with the George Eliot Hospital NHS Trust, at the
moment, this resides with the PCT and therefore it is difficult to subjectively monitor the delivery of
Transferring this responsibility to a Host organisation allows the PCT to monitor more subjectively
and hold the organisation to account to make improvements where necessary.
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The transfer will also enable more focus on improving the quality of the services provided, with the
PCT being able to actively manage the actions plans for the improvements with the George Eliot
Hospital NHS Trust, rather than having to manage them alone.
The George Eliot Hospital NHS Trust will be accountable for the delivery of all statutory and local
requirements, including QoF (Quality and Outcomes Framework), Contractual Reviews, Performers
and appraisals, and other related governance. This has been demonstrated by the George Eliot
Hospital NHS Trust in their role as Contract Holders for the Camp Hill GP Led Health Centre.
The Camp Hill GP Led Health Centre EAPC Contract came into place in October 2009 and the practice
still has to perform within the Health Service (General Medical Services Contracts) Regulations 2004.
The agreement includes a set of Key Performance Indicators, and the PCT work with George Eliot
Hospital NHS Trust to ensure the delivery of these KPIs. The KPIs that the Camp Hill GP Led Health
Centre comply with are listed below in section 220.127.116.11
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18.104.22.168 The KPIs that are currently measured are:
GP and PCP availability/appointments 3rd available routine GP and nurse appointment PCAS return
within 24 hours (1 working day)
Patient satisfaction with access Percentage overall patient satisfaction for all 4 Patient Survey
factors as per the national patient survey Results
Diversity Percentage of patients whose notes record their Clinical System
ethnic origin and first language
Prevention and health improvement
Percentage of all registered patients aged 16 or Clinical System
over who have had their alcohol consumption
recorded in the past 12 months
Percentage of patients whose alchohol Clinical System
consumption is more than 16 units/21 units per
week (male/female) have a recording of advice
Alcohol given and type of advice recorded
over 5 years reduction (compared to 3 years
pooled data 2005-7) in age standardised rate of
admissions for alcohol-related conditions to the
Nuneaton and Bedworth rate - equally divided
into 5 years as trajectory (using latest
Cervical Screening Percentage of all eligible patients from the Clinical System
appropriate aged groups whose notes record
that a cervical smear has been performed in the
last three/five years - in line with NHSCSP
Childhood Immunisations PSB uptake for 2 year olds Clinical System
MMR uptake for 5 year olds Clinical System
Breast Feeding In children aged less than 6 months the % of Clinical System
notes that record breast feeding status at 6 - 8
weeks - measured quarterly
percentage of infants less than 6 months old Clinical System
recorded as breastfeeding
Obesity Percentage of registered patients aged 15-75 Clinical System
who have had their height, weight, waist (Registration / BMI
circumference and BMI recorded in the last 12 Guideline)
Percentage of patients with a BMI of over 30 Clinical System
who have been given appropriate (Registration / BMI
signposting/referral and information Guideline)
Percentage of all children (aged 5 and above) Clinical System
who have height and weight recorded on (Registration / BMI
registration and centile calculated Guideline)
The percentage of children with a centile over 80 Clinical System
that are provided with appropriate (Registration / BMI
signposting/referral and information (all Guideline)
Percentage of those adult patients with a BMI of Clinical System
over 30, achieving a reduction in BMI of 10% or
more within 9 months
Following reduction in BMI of 10% or more, Clinical System
maintenance or further reduction of weight over
a 12 month period (within a tolerance of BMI + 1)
The percentage of patients aged 5-15 years with Clinical System?
a recorded Weight centile over 91 are recalled
after 12 months and have a 1% centile drop
Smoking cessation Percentage of all registered patients over 16 Clinical System
years old have their smoking status recorded in
last 15 months
Percentage of smokers with advice given and Clinical System
type of advice recorded
The percentage of patients aged 15-75 who Clinical System
have accepted the smoking cessation program
whose notes record their success at 12 weeks
The percentage of patients aged 15-75 who Clinical System
have accepted the smoking cessation program
whose notes record their success at 12 months
% of pregnant smokers whose age is recorded Clinical System
and whose smoking status is discussed at time
of positive test confirming pregnancy; patients
carbon monoxide levels recorded;
resources/information provided and signposting
PCTMS CCP Business Case V2.0 Page 16 of 20
Prevention and health improvement
Flu The percentage of patients aged 65 and over and those at Clinical System
risk (on a practice disease register) who have had a flu
Pneumococcal The percentage of patients aged 65 and over and/or who are Clinical System
at risk (on the practice disease register) who have had a
Choose and Book Percentage of referrals through choose and book system with Clinical System
Emergency admissions of older people Percentage of emergency admissions (admitted during Clinical System
opening hours) from care homes with explanatory letter from
Percentage of over 75 year patient who have had an annual Clinical System
Accidental injury % of patients aged 75 years and above who have been Clinical System
assessed for falls and referred appropriately and followed up
Teenage pregnancy/sexual health % satisfaction that the service provided is 'user friendly' and Patient Survey
follows the You're Welcome criteria (as a minimum), based on
the results of a patient satisfaction survey to be agreed
between the PCT and provider
Number of registered and non registered people aged 15-24 Clinical system
years accepting chlamydia testing
Maternity care % of pregnant mums with fully optimised ante-natal care Clinical system
recorded in their notes (minimum requirement being advice
on diet, smoking, exercise, drugs, alcohol) and who have
been referred to parentings skills services (if appropriate)
percentage of late (by 10 weeks gestation) presentations of Clinical system
pregnancy for patients
Obesity in pregnancy – % of women to achieve their target ?
weight gain during pregnancy according to thresholds set by
QOF Percentage of maximum score available Clinical system
Currently, the PCT meet with George Eliot Hospital NHS Trust on a monthly basis to monitor the
progress of the contract, and address any contractual and quality issues.
The intention is that the George Eliot Hospital NHS Trust will be subject to an agreement that will
have similar quality outcomes as determined in the contract for the Camp Hill GP Led Health Centre.
This ensures that the PCT remains driven to deliver quality outcomes in General Practice when given
The role of the Operations Manager, who is responsible for the overall management of the three
PCTMS Practices, ensures that the practices meet the legal and local requirements. This role also
ensures that there would be no inappropriate referrals into George Eliot Hospital NHS Trust through
ongoing monitoring and that all referrals are based on patient choice and clinical judgement. This
will also ensure that any potential invested interest is minimised.
The PCT also has a responsibility to manage this with all GP referrals into Acute Hospitals. The PCT is
responsible for taking action if there seems to be any inappropriate referrals from any GP Practice.
The role of the Operations Manager ensures any action plans are acted upon accordingly. These
steps ensure that risks are mitigated.
PCTMS CCP Business Case V2.0 Page 17 of 20
Task Completion Date Status
PCTMS Review Completed April 2010 Completed
This was a review carried out by the PCT
analysing the current and historic status of
the three practices.
Board approval for TCS April 2010 Completed
The principals of the TCS process and the
services to be included were signed off by the
Business Case to PCT Board September 2010 In Progress
The Business Case to transfer three PCTMS
Practices to a Host Organisation will be taken
to the PCT Board for approval to submit the
Business Case to CCP.
Business Case to CCP September 2010 In Progress
The Business Case to transfer three PCTMS
Practices to the George Eliot Hospital NHS
Trust will be submitted to the Cooperation
and Competition Panel for approval to
CCP Approval October 2010 (TBC)* Not Yet Started
To gain approval from the Cooperation and
Due Diligence October 2010 Not Yet Started
The process of Due Diligence will be
Consultation December 2010 Not Yet Started
The PCT will consult with the relevant key (TBC)*
stakeholders in relation to the changes that
Heads of Terms for GEH December 2010 Not Yet Started
The PCT will draft an agreement for the (TBC)*
ongoing management of the three PCTMS
Practices. This will be the agreement that the
George Eliot Hospital NHS Trust will be
required to sign up to.
Shadowing January 2011 (TBC)* Not Yet Started
The GEH will shadow PCTMS Practices
Tupe of Staff April 2011 (TBC)* Not Yet Started
The staff will be tuped across to the George
Eliot Hospital NHS Trust by this date.
Transfer Complete April 2011 (TBC)* Not Yet Started
The transfer will be complete by this date.
* Please note (TBC) is noted due to the dependency on the CCP Approval for the tasks beyond
PCTMS CCP Business Case V2.0 Page 18 of 20
Detailed below are the current risks identified in relation to transferring the three PCTMS Practices
to the George Eliot Hospital NHS Trust. The mitigation statement would be the steps the PCT would
take to ensure that the risks do not materialise into issues.
Description There is the risk that a Hospital managing GP practices can lead to inappropriate
referrals into Secondary Care as they could have a vested interest in referring.
Impact This can lead to a higher volume of inappropriate referrals that could lead to
additional revenue for the George Eliot Hospital NHS Trust.
Mitigation Regular contract reviews and monitoring by the PCT to ensure this does not
happen and corrective action should it occur.
The role of the Operations Manager overseeing all three PCTMS Practices will
help in preventing this risk.
Regularly updated referral data will enable the PCT and George Eliot Hospital NHS
Trust to remain vigilant.
Description The uncertainty around the White Paper and the framework of the consortia.
Impact Potential change of management
Mitigation PCT to monitor the progress of the White Paper and ensure regular
communication with the PBC Consortia to ensure any risks are kept to the
The PCT will ensure the engagement with all GPs and GP Consortia remains, and
that they are communicated with any progress.
The PCT will address any issues / concerns as they arise.
The PCT will ensure that GPs continue to be involved in GP commissioning now
and in the future.
Description There is a risk that the GEH will not accept the terms and conditions of taking over
the PCTMS Practices.
Impact An agreement will have to be in place between the PCT and George Eliot Hospital
NHS Trust with the conditions of taking over the practices.
Mitigation The agreement will be drafted asap so any issues can be addressed prior to final
transfer of services.
The process of Due Diligence will ensure that any issues that are likely to emerge
are addressed very early on in this process.
The Programme Governance Structure in place for the whole process of
Transforming Community Services ensures that issues are responded to as they
PCTMS CCP Business Case V2.0 Page 19 of 20
Description The Cooperation and Competition Panel may not accept the Business Case, or
subject the Business Case to the Forty‐day process.
Impact This may prevent the PCT meeting the deadline of 1st April 2011 for completion of
Mitigation The PCT are submitting early draft reports to the Cooperation and Competition
Panel so to obtain feedback so that a final version can be submitted in adequate
The Programme Governance Structure in place for the whole process of
Transforming Community Services ensures that issues are responded to as they
PCTMS CCP Business Case V2.0 Page 20 of 20
NHS Warwickshire Community Health Services Transfer to
South Warwickshire Foundation trust
Cooperation and Competition Panel
Author Caron Williams
Date 2nd September 2010
WCH to SWFT CCP Business Case V3.0 Page 1 of 18
1. Introduction & Background
This document sets out the background and rationale for the decision by NHS Warwickshire to transfer its
community services division (Warwickshire Community Health) to South Warwickshire Foundation Trust. It
provides an outline of:
• the national policy requirement as set out in the Revised Operating Framework
• the background to community healthcare provision in Warwickshire
• the key care pathways of community services and how they link to the Transforming Community
• an outline of the process and rationale for the selection of an acute provider ‐ South Warwickshire
Foundation Trust ‐ as the preferred destination for the services currently provided by Warwickshire
• the benefits that the preferred solution has for patients, the community and taxpayer
• the timescales involved in the transfer
• Risks involved in the project
• The impact on patient choice and competition.
1.2 The Requirement for Change – The NHS Operating Framework
In June 2010, the Department of Health published the revised Operating Framework for the NHS in England
This stated that separating PCT commissioning from the provision of services remained a priority and must
be achieved by April 2011. PCTs were instructed to develop and review proposals for the divestment of their
directly‐provided community services, ensuring that:
• They have been tested with GP commissioners and local authorities;
• Final proposals are consistent with the aims of the forthcoming NHS Strategy in strengthening the
delivery of public health services and health services for children;
• They consider the implications for choice and competition;
• They consider a wide range of options, including the development and early delivery of Community
Foundation Trusts and Social Enterprises, providing employee leadership and ownership;
• There has been effective engagement of staff and their representatives when considering options;
• Previous proposals for continued direct provision are reviewed and alternative options developed which
secure separation; and
• Proposals should be capable of being implemented or substantial progress made towards
implementation, by April 2011.
This new guidance required NHS Warwickshire’s Board to reconsider its previous decisions on the destination
and future organisational form for NHS Warwickshire’s provider organisation, as these options did not
include the previously identified preference of an Arms Length Provider Organisations (ALPO), or the
retention by the PCT (except in the circumstance of exceptional delivery quality measured against clear Value
WCH to SWFT CCP Business Case V3.0 Page 2 of 18
for Money criterion). To assist the decision making process the SHA offered a small sub‐set of acceptable
• Integration with an acute provider
• Integration with another community provider
• Social enterprise
• Contracting to a Private Provider
• Combination with an LA
The timeline for implementation of this new form is exceptionally challenging. The business transfer of
provider services into the selected option should be substantially completed by April 2011.
The exclusion of an ALPO as an option has therefore required NHS Warwickshire to construct a new efficient,
effective organisational form for Warwickshire Community Health that delivers improved patient outcomes
whilst also creating a contestable market structure within the local health economy. This has involved an
evaluation of; the local market drivers, the providers of local services’, and the needs of the population to
establish the best option for the future. Also due to the challenging timelines, this solution needs to be
sufficiently robust to be implemented in a year.
2. Background to Healthcare in Warwickshire
2.1 The Community of Warwickshire
There are a number of key factors that help shape the provision of and need for health care in Warwickshire:
• The population of Warwickshire is 535,000 (mid year 2009 estimates).
• Warwickshire is a relatively sparsely populated county. Its population is spread across some 763 square
miles (197,509 hectares) providing a population density of 701 people per square mile. This sparsity
helps shape the nature of health service provision in the county and adds to its costs.
• The county has a rapidly ageing population. The over 65 population level is currently 17.3% compared to
16.2% nationally). In terms of future population trends, considerable growth is expected amongst those
aged 65 and over. The rate of growth increases with age, with the eldest group (those aged 85 and over)
projected to increase by over 194% by 2033. This trend is reflected across all the districts and boroughs
• This rapid ageing is compounded by high levels of deprivation in the North of Warwickshire. These
factors mean that many people need support with long term conditions.
• Health service funding levels per head of population are low, since the pockets of extreme deprivation
are mixed in with some of the most affluent populations in the country. This low level of funding has
necessitated the extraction of many of the easy efficiencies that better funded PCT’s removed through
this process. There are few duplications of resource and services have been designed to match the
needs of local populations and as such are not uniform across Warwickshire. Risk sharing contracts with
South Warwickshire Foundation Trust have been developed and the positioning of community services
has led to a non‐elective admission rate of 86.53 where the national average is 96%.
• The low levels of funding has lead to the development of an efficient provider service which meets the
needs of a population with a spend of less than £60 million per annum to meet the needs of both adults
and children in the county.
WCH to SWFT CCP Business Case V3.0 Page 3 of 18
2.2 Warwickshire’s Strategic Vision for Healthcare “Best Health for Everyone”
Warwickshire has developed a commissioning strategy for the next 3 years called Best Health for Everyone.
Through this strategy 36 initiatives have been developed to direct the development of health services to
ensure that they offer the best chance at equity, accessibility and quality for the population of Warwickshire.
Initiatives to support the Transforming Community Health programme form an integral part of the strategy
and those initiatives include work in the following areas:
• Single Point of access ( Warwickshire Health line)
• Community Emergency response ( urgent response intermediate care with extended opening hours)
• Community Hospitals ( development and modernisation of the provision)
• Virtual Wards ( specialist teams for the management of long term conditions)
• Productivity improvements in Practice ( to facilitate the expanded opening hours of community services)
• Integrated Health Teams ( to meet the need of populations close to home)
• End Of Life Care ( to increase the options for patients to die in a place of their own choosing)
Additional work is being undertaken to map these initiatives to the local QIPP programme and improve
alignment of community health provision with acute providers. It is likely that additional work will be
undertaken in the area of admission prevention and early facilitated discharge.
2.3 Overview of local health economy and community services
The local health economy benefits from strong primary care and has developed a diverse range of services
that work between primary care and community health. These include, virtual wards, community hospitals
and intermediate care that has effective admission prevention and referral criterion. This quality is reflected
in a death rate of 0.88% (national average 1%), emergency admission rate of 86.53 (NA 96) and 21.43% home
death rate (NA19%).
The combination of these factors evidences the lack of scope for further efficiencies when considered in the
context of the National Clinical Productivity tools, and allowed NHS Warwickshire to come to the conclusion
that further efficiencies and improved patient benefits could only be extracted from the system by closer
working with acute and Local Authority colleagues.
There are a diverse range of health and social care providers in Warwickshire; a non‐unitary County Council
delivering social care along with 5 district councils responsible for housing and transport. However, the size
and population diversity that is evident in Warwickshire has led to difficulties in developing a cohesive and
co‐ordinated Third Sector response. For example there is no carers centre, and this has left the Local
Authority working intensively to develop the market in this areaThere is a local mental Health Trust (
Coventry and Warwickshire Partnership NHS Trust) and 3 acute hospitals:
• University Hospital Coventry and Warwickshire NHS Trust
• George Eliot Hospital Trust
• South Warwickshire Foundation Trust
University Hospital Coventry and Warwickshire (UHCW) is a tertiary care centre sited in Coventry and is
currently endeavouring to achieve Foundation Trust status. The Trust is subject to severe financial pressures
due to its PFI mortgage requirements and has a history of struggling to meet its Cost Improvement and
Productivity improvement Programmes (CIP and PIP). The focus and value base of the hospital is shaped by
its major trauma, neurological surgery and surgical care provision; it currently has little focus on community
WCH to SWFT CCP Business Case V3.0 Page 4 of 18
services. The Trust’s performance dash board indicates a lack of stability throughout the winter pressure
George Eliot Hospital Trust (GEH) is sited in North Warwickshire. One third of its current capacity is used by
Leicestershire. It has experienced issues of staff recruitment and retention particularly within its Accident
and Emergency Department. GEH has also been subject to extended periods where there have been
paediatric diverts from A&E in place. GEH are familiar with the delivery of community services and currently
deliver primary care solutions from Camp Hill and community therapist solutions for the north of the county.
However, their performance challenges as an Acute Trust and the issues they face around bed flow and
discharge management means that resources in a community setting might be considered as vulnerable to
being drawn into acute to meet the Trust’s needs. Their performance dash‐board indicates a lack of stability
throughout the winter pressure period.
South Warwickshire Foundation Trust is a small Acute Trust focussed on meeting the needs of their local
population in Warwickshire. The Trust which has recently gained Foundation status and is financially stable.
The Trust has previously entered into a risk sharing contract with NHS Warwickshire around emergency non‐
elective admissions which have sharpened their focus on bed flow and supportive works around admission
avoidance. Audits of their front door intake have shown a high degree of appropriateness to admissions for
the elderly given the current shape of the health economy. Their performance dash board indicates the
greatest degree of provider stability in Warwickshire during the winter pressure period.
There are 76 GP Practices currently shaped into 4 Practice Based Commissioning Groups. These groups have
been subject to less stability since the publishing of the white paper ‘Liberating the NHS’. The current PBC
shapes are not of uniform size and have some issues of overlapping geography. The quality of primary care is
generally good in Warwickshire, each providing identical core services, and a mix of additional and local
services. These practices cover the majority of patient needs in Warwickshire.
The volume of patients in each practice depends on:
• the clinical capacity of the practice (wte of GP / Nursing Staff),
• the ability of the premises to facilitate the delivery of Primary Medical Services,
• the needs of the population.
The Coventry and Warwickshire Partnership Trust is currently seeking Foundation Trust status. They have
had historical issues with management instability and have recently managed to secure a new Chief
Executive and senior management team. Their values and speciality is predominantly based around
working age mental health issues and have a high degree of compliance with the NSF for Mental health.
However, their delivery in the areas of organic mental health disease and its cross over with general nursing
issues are not as well supported.
3. Selection of a Preferred Provider
NHS Warwickshire, using the national guidance framework, stakeholder engagement opportunities and input
from Warwickshire Community Health, has considered the options for the future organisational form of its
provider arm. As part of this process all of the above NHS Acute providers, including PBC groups were invited
to express an interest in taking on services provided by Warwickshire Community Health and PCTMS
Practices by 17th February 2010. A range of local health and social care providers responded to this
WCH to SWFT CCP Business Case V3.0 Page 5 of 18
A rigorous process was put in place to identify a preferred provider. This included an intense options
appraisal and robust selection criteria. As part of this process a joint agency panel event was held on 19th
April 2010. The panel contained Executive and Non Executive Directors of NHS Warwickshire, the Assistant
Chief Executive of Warwickshire County Council, the Chief Executive Officer of the PCT, and PBC leads. The
process was observed by staff side officers, Independent Committee Members for Warwickshire Community
Health, the full time officer staff side (RCN) RCN representative and the Managing Director of WCH. The
panel’s decision was a unanimous decision that Warwickshire Community Services should transfer to South
Warwickshire Foundation NHS Trust.
Services transferring from Warwickshire Community Health can be categorised into the following TCS
• Acute Care Close to Home
• Long Term Conditions
• End of Life Care
South Warwickshire Foundation NHS Trust was also selected to temporarily host the Children and Young
People’s Services. Although there are high degrees of integration with the Local Authority provision in this
area, no legal form is in place to support the transfer of children’s services to the Local Authority in year.
Extensive ongoing work with the local authority to ensure inclusion and the best form for children’s services
in the future will run alongside this transfer process.
The transfer of Warwickshire Community Health services to South Warwickshire Foundation NHS Trust will
meet the requirements identified in the Operating Framework. It will also importantly provide:
• a more secure and stable management structure for the delivery of Acute Care Close to Home, Long
Term Conditions, Rehabilitation, End of Life Care services
• a more appropriate base for the temporary hosting of Children Services. It is also crucially compatible
with NHS Warwickshire’s Strategy ‘Best Health for Everyone’.
The benefits of our preferred approach are highlighted in more detail in the subsequent sections of this
4. Structuring Services and the Market
The aim of NHS Warwickshire is to transfer the five Transforming Community Services pathways to South
Warwickshire Foundation NHS Trust for a contract period of three years. South Warwickshire Foundation
NHS Trust will establish a trading arm to support the northern and Rugby based services and draw in
additional Non Executive Directors and Governors to reflect its broader range of activities
During this time Commissioners will have the opportunity to re‐shape the demand, priorities and the
currency for Community Health Services in line with the Transforming Community Services programme and
policy in accordance with Any Willing Provider
The establishment of a trading arm for services outside of South Warwickshire will ensure that future
contract lets for Community Health services in North Warwickshire will not be tied to only one of the acute
settings. Central to this is the development of a functional currency for community health and the
streamlining of the handovers between services and organisations in the Warwickshire health economy.
WCH to SWFT CCP Business Case V3.0 Page 6 of 18
This can be achieved by structuring a 3 year contract to recognise the functions that Warwickshire
Community Health performs, the geographical boundaries of those services and align these against the
needs of the local community and the available “pot of resources” whilst ensuring equality of access to
health and community services for the all people of Warwickshire.
The functional delivery areas of Community Health are:
• Community /Home urgent care
• Community / Home wards
• Community/Home outpatients
• Community / Home rehabilitation
The application of this functional currency to community health services allows them to be more easily
understood in a market that sees them as complex and has traditionally been dominated by acute contract
solutions. It also makes the services more easily understood by GP’s and members of the public, ensuring
that better options are selected for patients and that efficiencies gained by right first time referrals can be
realised. This grouping of services into alternate destinations where care needs can be met also adds to the
choices that patients can make about their care settings.
The creation of a functional currency for community health services aids the development of a distinct and
comparable fiscal currency for services. Traditionally cost models for community health have either been
constructed around marginal cost models on block contracts or based on activity cost models where the
relevance of activities has not been clear to all parties. This has disadvantaged those parties who are not
currently part of the internal health market when they wish to enter the market place. The lack of
transparency on cost, pricing information and activity has helped maintain a lack of market diversity.
A market economy has few of the constraints of a health market. Buyers and sellers move freely into the
market setting and taking prices for goods and services based on supply and demand. There is little need for
regulation and information (symmetry of data,) is freely available, money coming into the system is not fixed,
there is no single seller of services, and anyone can buy them. To achieve the ‘Choice and Competition’
model that Le Grand refers to in ‘The Other Invisible Hand’ (2007) these market entry disadvantages in health
markets must be mitigated. Since health economies cannot reflect these fundamental conditions, they have
developed as ‘quasi’ markets, and they have to be artificially managed. The contact structure that will be
developed with South Warwickshire Foundation Trust will be structured with these needs in mind.
Historically therefore new suppliers into the market are not on an equal footing, and this requires an
increasing number of management tools to create a market economy which has any parity within it. This
view would seem to be supported by the findings of Entwistle and Martin ‘After more than an decade of CCT
internal providers were still winning 57 % of contracts….they won a disproportionately large share of the
highest value contracts…they held onto 71 % of the estimated £2.4 billion that was subject to contracting at
that time’ Entwistle T Martin S (2005) From Competition to Collaboration in Public service delivery: A New
Agenda for Research. This implies that there is sufficient speciality in the market to ensure that when forced
by law down a route of opening up the market to competition that some service providers entering will
always remain at a disadvantage due to the complexities of the current delivery. South Warwickshire
Foundation NHS Trust is willing to share their commercial capability to support NHS Warwickshire in
developing a functional and fiscal currency for community health services and simplify the development of
contestable contracts. The establishment of a trading arm that relate to local needs and priority setting
ensures that both efficiency and choice are maintained for the population on the North of Warwickshire. .
WCH to SWFT CCP Business Case V3.0 Page 7 of 18
In addition there are other benefits from selecting a Foundation Trust to host Warwickshire Community
Health services. The white paper ‘Liberating the NHS’ calls for all future providers of community services to
be Foundation Trusts. This is to support the development of contestability in the market place since
Foundations Trusts have the best available legal NHS framework to ensure the mitigation of the above issues.
Also by working with a Trust that has already achieved this status, total focus can be applied to re‐structuring
Community Health services, rather than supporting a chosen partner to achieve this status.
5. Services and Pathways
5.1 This section describes the services and organisation of Warwickshire Community Health Services that form
part of the proposed transfer. It also sets out the key patient pathways and how they will evolve as a result
of this work.
5.2 Warwickshire Community Health – Services and Budgets
The range of services and budgets that fall within this transfer are set out at appendix 3
5.3 Warwickshire Community Health ‐ Properties and Assets (To be included at appendix 5)
5.4 Service Pathway ‐ Acute Care Close to Home
Acute Care Close to Home will provide specialist nursing support options to permit people to receive as
much care as is possible in their own home or in a community setting away from acute providers. Vertical
integration with an acute provider in this pathway allows NHS Warwickshire to support the local QIPP
programme in the following areas:
• Admission avoidance /Nursing Home /LOS
• Extended Community Team/specialist community LTC team
Vertical integration offers many direct benefits to patient experience and care delivery. The
implementation plan will ensure that we enhance the delivery of secondary care diagnostics and specialist
nursing skills into community services. Even though South Warwickshire Foundation Trust is the selected
provider for Warwickshire Community Health, all Warwickshire’s acute providers are working with NHS
Warwickshire to support this activity. The medical governance structure that is associated with consultant
led delivery significantly enhances the capability and safety of nurse led services. By providing a stronger
governance structure for the care of patients in the community and a rapid escalation planning capability,
more services can be delivered both safely and closer to peoples own homes.
The Local Authority is included in these developments plans. NHS Warwickshire is working with
Warwickshire County Council through Warwickshire Community Health on a Common Assessment
Framework (CAF). This is one of a small number of national demonstrator projects commissioned by the
Department of Health. This is a major initiative to design, pilot and prove solutions for integrated NHS and
local authority personalised care and support model. This programme is fully integrated with the
Transforming Community Services programme. By working to vertical pathways that include social care,
patients will not experience ‘delays’ as they pass through different assessment and care processes of
different agencies. This will result in a better discharge experience for patients and lower the likelihood of
them returning to an acute setting.
These stronger working relationships will in turn aid the development of a single patient record, CAF and
risk stratification pilots, improving information sharing and increase the ability to identify individuals and
personalise their care and support options in a setting of their choosing.
WCH to SWFT CCP Business Case V3.0 Page 8 of 18
Specific examples of this planned for 2010/11 are:
• There is a strong working partnership between community and acute providers with specifications for
integrated pathways of care including Chronic Obstructive Pulminary Disease (COPD), Stroke and End of
Life Care (EoLC) in the development schedules for this year’s contracts.
• Development work around cardiac rehabilitation and support to cardiac patients who have moved from
the curative stage of their disease is under MDT pathway engagement/ specification development.
• Integrated team pilots have been established where both Social Care and Community Health workers
are delivering to the same patient stated / focussed outcomes. This work provides clear evidence of our
capacity to deliver improved quality through partnership. This will be further enhanced through the
integrated organisation form drawing acute workers into this strong patient centred pathway.
• Areas of joint working and shared activity are:
• CAF( health and social care)
• Risk stratification ( primary care and community health)
• Advanced care planning ( acute care and community health)
• Additional resources can be provided to this pathway. This will reduce Length of Stay in acute settings
by combining acute and community resources. Areas of focus would be post operative care, vac therapy
and nursing home settings
5.5 Service Pathway ‐Long Term Conditions
The TCS Pathway associated with Long Term Conditions (LTC) is envisaged to deliver improvements in the
delivery of support around unstable long term conditions to allow more people to receive care close to
home. It requires the linking of primary care, secondary care, and social care with community health
provision to ensure that patients benefit from a wider range of opportunities, can learn to self manage
elements of their own care planning and receive care and support in a setting of their choosing Vertical
integration with an acute provider in this pathway will allow NHS Warwickshire to support the local QIPP
programme in the following areas:
• Admission avoidance /Nursing Home /Length Of Stay
• Extended Community Team/specialist community Long Term Condition team
People who have been diagnosed with an LTC are the most prevalent users of all areas of health and social
care and a co‐ordinated response to meeting their needs from all areas of the health and social care
economy will deliver the best and most cost effective results for people.
They will receive all of the system benefits listed above for acute care close to home but as service users
who are subject to repeated exposure to services for the duration of their treatment programme, they
require additional support options.
NHS Warwickshire is an Innovation Centre in the NHS West Midlands Risk Stratification Programme. The
risk stratification tool is used to identify patients with an LTC who are at most risk of hospitalisation.
Warwickshire Community Health is already using risk profiles successfully to identify these patients. The
vertical integration of services with an acute setting offers an opportunity to remove duplications in the
system and position resources in the most relevant settings to meet the needs of patients.
WCH to SWFT CCP Business Case V3.0 Page 9 of 18
Vertical Integration provides an opportunity to work with acute settings to boost the delivery of these
products by adding medical risk assessments and supportive care plans so that episodes of care that are
currently delivered in an acute setting but involve symptom control or are ‘sub acute’ in nature can be
delivered in the community if that is the choice of the patients. The contributions of acute medicine
specialists and older age medicine specialists to the care plans of these individuals add an assurance to the
delivery of nurse led services.
Therefore community health services such as Virtual Wards and Community Hospital Services will be shaped
to make a significant contribution to supporting the work of the acute provider by bringing the self care and
prevention agenda closer to the specialist secondary care service. While acute medicine specialists will
boost the community provision and self care with their contributions to community care planning.
People who are subject to LTC also cross the most organisational barriers in the execution of their care
plans. The removal of some organisational barriers by adopting this organisational form, offers
opportunities provide a more “seamless service” reducing the impact moving between different
organisational transactional (funding stream) boundaries. The additional benefits of this are:
• A reduction in the number of assessments patients require
• The removal the funding boundaries that add to delays in treatment and increase costs
• Utilisation of the same information and care planning tools
• Delivery of the appropriate skill mix, drawing secondary care decision making closer to home.
5.6 Service Pathway – Rehabilitation
Warwickshire has a rapidly ageing population who are subject to health episodes associated with age and
long term conditions. Older adults who are subject to episodes of ill health benefit from early interventions,
preventing what are initially minor problems escalating into more serious conditions on the rehabilitative
pathway. Currently people who may benefit from rehabilitation struggle to set their own goals for
rehabilitation since the additional benefits they may gain are not always apparent whilst in an acute setting,
and there may be an undue focus on physical functioning. Additionally goals set on the behalf of patients
can be wasteful and not relevant to the life they choose to lead in the community. The failure to achieve
these can lead to people choosing not to return to their own home due to a lack of confidence.
Whilst closer working between community services and acute providers can bring greater access to the
specialist elements of rehabilitation, community services can also offer a greater knowledge of the specific
settings for specialist rehabilitation. Additional provision within this area is currently being developed by
the Local Authority where the social, psychological and lower level physical benefits of rehabilitation are
being explored through the development of re‐ablement services.
This pathway truly benefits from vertical integration across all partners within the health and social care
economy. NHS Warwickshire is working on this pathway in its ‘Cutting the Costs of Frailty’ programme led
by the Medical Director Professor Ian Philp. With strong commissioning input the aim is to allow patients to
set their own goals, to better use the resource in the system and by co‐ordinating the delivery from acute
settings to social care ensure that the local QIPP target around reducing the Length of Stay in acute settings
By removing duplications and conflicting toolsets from this pathway, older adults will receive improved
benefits within the current envelope of resource. However, their improved physical condition will reduce
future costs to the health economy in the areas of urgent care and long term condition management. This
WCH to SWFT CCP Business Case V3.0 Page 10 of 18
is due to the empowerment and expectation management which will be inherent in this type of
5.7 Service Pathway ‐ End of Life Care
Since the NSF for End of Life Care (EoLC) was published in July 2008, NHS Warwickshire has endeavoured to
establish a strategic approach to EoLC that is acceptable in terms of quality, public needs and affordability. A
strategy that incorporates all of the required elements of the NSF has been drawn up and ratified in January
2010.The market situation in Warwickshire is unique and its base starting point in this area is high due to the
• Warwickshire enjoys good quality primary care
• Low non elective admission rates (86.53 when the national average is 96)
• 21.43 % of deaths occur at home (NA 19%).
• A low death rate 0.88% (NA 1% range 0.5‐2.2%)
This leaves NHS Warwickshire with few efficiency options when considered in the context of the national
clinical productivity tools. In short there are few quick wins.
In Warwickshire during 2009 4,765 people died. Of those deaths 1,378 occurred in hospital on a Length of
Stay of less than 14 days. This is the SHA/NAO accepted measure on deaths to target for EoLC admission
avoidance. These deaths cost NHS Warwickshire £3,659,926 in 2009.
However, this cohort of patients was subject to multiple admissions in the last year of their life. These spells
of care are associated with an ageing population who are living with long term conditions and end their life
with complex co‐morbidities but generalist palliative care needs. As a result these conditions might be used
to form indicators of the deterioration that occurs in the last year of life and identify those patients who
would benefit from supportive care plans. In order to maximise benefits to patients and NHS Warwickshire
we would need to establish a planned approach to managing this frailty.
The local health economy has the tools and the foundation to do this, having a diverse service range including
strong primary care, virtual wards, community hospitals and intermediate care. This year’s CQUINs for
community have been established to progress the long term care agenda. If managed effectively the planned
programme of vertical integration with acute settings adds a new efficiency opportunity as well as health
outcome benefits to patients on this pathway.
The evidence base clearly shows that people in Warwickshire would benefit from a continuity of care linking
to the management of LTC’s. This requires the contribution of secondary care chronic disease and older age
medicine specialists at the heart of the delivery. Enhancing the generalist palliative response is more likely to
allow older adults to die in a place of their own choosing rather than in a hospital setting and increase the
current home death rate from 21.43 %.
Vertical integration with contributions from secondary care older age medicine specialists will deliver better
supportive care planning (Liverpool Care Pathway and Community Pathway for Care in the last year of life). It
also offers an opportunity to draw this specialism into the community to support primary care practitioners
improving their advanced care planning skills for older adults and the identification of generalist palliative
5.8 Service Pathway ‐ Children and Young People:
South Warwickshire Foundation Trust have agreed to host services for this TCS pathway while the longer
stream of work associated with a developing a suitable clinical and legal structure for the development of a
children’s trust is undertaken. Please see annex A for a more detailed document on this area.
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6. Impact on Patients
The number of deaths in comparison to the number of births is projected to rise over the next 60 years (Gov
Actuary Department, 2004). Evidence makes clear that people approaching the end of life should have access
to high quality treatment and care. This will support them to live as well as possible until they die and have
the opportunity to be actively involved in decisions about where they wish to live and die to enable them to
die with dignity (see for instance, GMC, 2010; RCGP, 2009; DH, 2008a; DH 2008b; DH 2006). Recent guidance
also makes clear that end of life is not only a matter of priority but core to good practice (GMC, 2010; RCGP,
Evidence suggests that people receive inconsistent and sub‐optimal care, with many people experiencing
unnecessary pain, lack of dignity and respect and die in a place not of their choosing (RCGP, 2009; DH,
2008a). It was recently reported that 65% of people would prefer to die at home if given the choice; yet, two
of three people die in hospital (You Gov, 2008; NAO, 2008). This view is also evident among terminally
patients who report satisfaction with hospice care (Dunlop et al, 1989).The majority of deaths that occur are
due to cancer, organ failure, frailty and dementia (End of Life Programme, 2006).
It is anticipated that vertical integration and the delivery of supportive care plans and a greater volume of
care closer to home will assist in facilitating the choice of patients to die in a place of their own choosing. The
target is to increase home deaths to 27% by the end of year 1 of the integration plan. Further detail on
efficiency benefits is provided in appendix.
7. Impact on Taxpayers’
There will be no additional costs to the tax payer.
The implementation of this plan will ensure that health infra structure will be developed to support the
changing health landscape and available revenues for care.
8. Risks (to be included)
NHS Warwickshire believes that by considering all of these influences whilst making the decisions on
organisational form we have selected an option that meets the needs of our local population and their
stated desired health outcomes.
In considering the choice of provider (SWFT) we scored and assessed each provider against the assurance
framework as outlined in the guidance to PCT’s. NHS Warwickshire believe that we have found a partner
who is prepared to work closely with us and other providers of health care services (including other acute
trusts) to ensure equality of access to services, choice, quality of service, and a risk sharing outlook that will
offer the best health outcomes to our local population while delivering best value and sustainability to the
local health economy.
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The strategy has been designed with the following national and local policies in mind.
• National PolicyOur Health Our Care Our Say: a new direction for community services ( DH 2006)
• Putting People First ( DH, 2007)
• Delivering Care Closer to Home: meeting the challenge ( DH,2008)
• NHS Operating Framework 2007‐2010
• Your Health, Your Way – a guide to long term conditions and self care NHS choices ( 2008)
• Common assessment framework ( DH, 2009)
• National Clinical Productivity Tools
• Transforming Community Services ideal form documentation
• JSNA 2008
• Best Health for Everyone ( NHSW 2009)
• West Midlands SHA local QiPP agenda
• Observatory information on local developing needs
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Efficiency Benefits – more detail.
Locally, during 2009, there were 4944 deaths of which 4,476 deaths were classed as end of life deaths. These
patients resulted in a total of 5,829 emergency admissions at a cost of £16,892,399. Currently, 70% of those patients
at the end of life are being admitted to hospital during the last year of life. The average length of stay (LOS) was 13.4
days. The average cost per person admitted is £3,774. When outpatient attendance and community services are
factored for, the average cost per person for the final year of life equates to £5,191.
Moreover, of the 5,829 emergency admissions, 278 were from nursing home/residential care or their usual place of
care. The average LOS for this group of patients was 92 days. This is significantly higher than the overall LOS of 13.4
and the cost of these admissions amounted to £839,000. This equates to nearly £3000 per patient in acute care
costs for the final few months of life.
The vertical integration strategy has been designed to reduce length of stay and improve choices for care close to
home the implementation of the EoLC strategy offered as an option through vertical integration will save 900K when
we achieve 27% home deaths.
250K has been targeted as a management cost saving with the removal of post duplication and alterations to infra
structure that can be achieved through vertical integration with SWFT.
Community hospital reviews and modernisation of services through the contract period have been prioritised. This
presents the option for the removal of up to 90 beds from the current bed state in Warwickshire. The current
business case for the removal of 20 beds provides a saving in excess of £2 million. The savings from the removal of
the other 70 beds are still to be worked up but should realise similar savings per bed.
These are the only savings that have currently been fully explored. It is anticipated that the expansion of virtual
wards and increase in opening hours on Intermediate care and the enhancement of their urgent care capabilities
with medical decision making from acute trusts will further impact on the bed state and allow future bed reductions
to be planned.
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Staff Groups ‐ Appendix 3
Adults WCC/TCS pathway match
• Community Hospitals –
• Stroke, Acute(closer to home)|LTC
• Rehabilitation, Rehab
• Young Adult, Rehab/LTC
• Community Wards LTC
• Community Matrons LTC
• Continence LTC
• District Nursing LTC
• Intermediate Care Rehab
• Rugby Urgent Care Services(subject to consultation) Acute(closer to home)
• Specialist Palliative Care LTC/EoLC
• Tissue Viability LTC
• PCT MS No Fit
• Heart Failure Nurse LTC
• Diabetes Nurse LTC
• Stoma Nurse Acute(closer to home)
• Phlebotomy (Rugby) No fit
• Virtual Wards Acute(closer to home)
• North (Permanent)
• South (permanent)
• Rugby (pilot)
Children, Young People & Family Services
• Child Development Service CYPF
• Community Children’s Nursing Team CYPF
• Community Contraceptive Services CYPF
• Health Visiting CYPF
• Paediatric Audiology Under Tender
• Portage CYPF
• School Health CYPF
• Community Paediatricians Acute(closer to home)
• Safeguarding Children’s Team CYPF
• Family Nurse Partnership CYPF
Allied Health Professions
• Community Neuro‐Rehabilitation Team Rehab/LTC
• Dietetics Health and Wellbeing
• MUSCAT service N/A
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• Occupational Therapy Rehab‐LTC
• Physiotherapy Rehab/LTC
• Podiatry LTC
• Specialist Falls Team LTC
• Speech & Language Therapy LTC/Rehab
• Wheelchair Service Rehab
• Special Care Dental Service No Fit.
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Budget Appendix 4
Row Labels Sum of HC Sum of Fcst
Acute C2H 130.83 6,025
SWFT 130.83 6,025
Community Wards 57.66 3,071
District Nursing 2.83 112
Intermediate Care 53.54 2,063
MIU 3.93 204
Muskat 3.68 216
Not applicable 0.00 1
Virtual Ward 9.19 358
LTC 324.23 13,830
NHSW 0.00 7
Discharge Liaison 0.00 7
SWFT 324.23 13,823
Chiropody 31.06 1,270
Community Matrons 13.51 602
Continence 7.31 718
Corporate, Facilities & Estates 3.21 813
Dietetics 12.00 485
Discharge Liaison 3.00 26
District Nursing 179.46 7,273
Not applicable 0.00 0
OT 27.27 871
Physio 44.91 1,645
Tissue Viability 2.50 120
Other 51.84 3,267
NHSW 0.00 354
Out Of Hours (Service Ceased) 0.00 354
OTT 51.84 2,913
Dental 29.93 1,565
PMS 21.91 1,348
Rehab 170.94 12,472
UHCW 35.23 2,318
Neuro. Rehab. 32.88 1,680
Rehabilitation/Neuro Rehab 2.35 638
SWFT 135.71 10,154
Community Wards 0.55 352
Corporate, Facilities & Estates 38.84 1,569
District Nursing 2.51 108
ICES 2.60 2,486
Not applicable 0.40 0
OT 2.25 145
Physio 10.96 684
Rehabilitation 68.06 3,697
SALT 3.49 89
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Wheelchair service 6.04 1,024
EOLC 12.22 619
SWFT 12.22 619
Not applicable 0.00 (1)
Paliative Care 12.22 620
Grand Total 690.06 36,213
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