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Outline Business Case


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									                                                Hillingdon PCT:

                                                Proposal to Procure
                                                Commissioning Services

Project number
Prepared by      Yi-Mien Koh


Date             11 January 2007

Executive Summary

Four options are explored – Do nothing, Specialised Services, Build and Outsourcing, to
improve PCT commissioning to bring the PCT back into financial balance. The conclusion is
that outsourcing the majority of the PCT commissioning functions gives the greatest benefit
and the greatest probability of success.

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Strategic Case

Strategic Context
     1. Hillingdon PCT has failed as an organisation and significant changes are required to turn it
        around. At the December Board it was agreed to endorse development of case to test options
        for the future of commissioning. Key stakeholders have also endorsed this approach.

Why Change
     2. Hillingdon PCT commissioning is currently weak and not fit for purpose. For example acute
        providers will continue to over perform by £9.8 million in 06/07, and to add to the historic debt.
        Weaknesses include poor relationships, lack of information and evidence, poor contract

     3. Hillingdon PCT commissioning has to be highly effective within the new NHS environment of
        Payment by Results, Practice based commissioning and choice, to ensure the best possible
        health outcomes, best health care and value for money. The new approach has to ensure
        effective demand management.

     4. Hillingdon PCT commissioning has to be different, as there will be a key role in developing
        markets, and contracting from the independent and other sectors

Key Stakeholders
     5. A number of key stakeholders have been identified as having an interest in the proposal.
        They are:

          Key Partners
              Practice Based Commissioning Consortia

          Department of Health
              Commissioning
              Commercial Directorate

          Regulators (Scrutiny)
              National – Healthcare Commission
              Local – SHA, Overview and Scrutiny Committees

               Inter-personal
               Inter-organisational
               Media

          Local players (expectations)
              Staff
              Politicians
              Trades unions
              Pressure groups
              Interest groups
              Clinicians
              Patients
              Public

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               Other local organisations
                   Other NHS trusts
                   Independent sector providers
                   Primary care providers (GPs)
                   Voluntary sector
                   Other public organisations, e.g. councils

   The breadth of stakeholders will require an effective and well managed communications plan to be

   Identified Options Case

   Assessment criteria

        6. The overarching goals for the PCT can be summarised as maximising the health gain and
           achieving more for the pound spent. In order to support the assessment of the options
           available to the PCT these goals were further expanded. The expanded goals and some
           supporting questions to help define the goal are shown below:

       Goal           Key Supporting Questions

Cost efficiency       •Will this support reduction in cost of managing the delivery of healthcare? (management costs lower)
(internal)            •Does this demonstrate ‘value for money’ ?
                      •Can the outsource provider do this more efficiently than the PCT?

Financial             •Does this permit greater financial control in healthcare?
Re-engineering        •Does this free up investment funds and promote greater investment freedom?

Innovation            • Does this facilitate the delivery of healthcare services at a lower cost per head of population?
                      • Will outsourcing this function encourage adoption of innovative approaches to the delivery of healthcare
                        and health that will:
                           –Reduce overall healthcare costs? (e.g. care pathway redesign, innovative purchasing practice)
                           –Improve patient outcomes?

Productivity          •Can the outsourcer deliver more productivity than the PCT?
                      •Will this permit a broader scope of activities to be delivered with current resources?
                      •Will this free up time for employees to focus on core organisational competencies?

Transfer of           •Will this reduce quantity or cap the risk to the PCT in delivering healthcare services in Hillingdon?
Risk (share)          •Are you ensuring that significant new risks are being managed?

Better Services/      Will outsourcing: fill in gaps in activities, not currently undertaken by the PCT?
Improve Quality       To provide access to specialist skills and capabilities? Build stronger skills and capabilities internally?

Better                Will outsourcing: Free up time for employees to focus on core organisational competencies? Provide access
Management            to better skills management and the tools to support better overall management for staff internally?


        7. Four options were evaluated against the goals developed to identify the preferred approach in
           meeting the overall objectives.

   Page 3 of 14                                                                                                              21/04/2010
Do Nothing
   8. The initial option of doing nothing met none of the proposed goals and is not an acceptable
       action given the current financial situation of the PCT.

Build Internal Capability
    9. This option has the potential to deliver some of the desired goals but it was recognised this
        would require a comprehensive development programme across the PCT over a period of
        time. Typical development tasks will need to address all areas of capability (people,
        technology and policy and process) across the PCT.

     10. It is considered that building these capabilities internally through this style of programme
         would present a high risk option due to the failure to achieve similar outcomes in previous
         years within the financial and funding constraints placed on the PCT by the NHS.

Develop synergies with other organisations
   11. This approach typically looks for economies of scale to deliver savings and is therefore initially
       focussed around the support functions of the PCT and is therefore unlikely to meet the
       overarching objectives. Options in this space include the Human Resources and Finance
       Shared Business Services and the Commissioning Support Service currently proposed for
       London. The nature of these options present Hillingdon with a number of problems which
       makes these options less attractive to Hillingdon:

                  Reliance on other organisations for the pace of change
                  Reliance on other organisations to support and drive economies of scale and
                  Tendency to result in a “one size fits all” outcome
                  Economies of scale are unlikely to realise size of savings required

     12. Although supportive in delivering Hillingdon’s turn around and Fitness for Purpose objectives,
         these options are unlikely to address the fundamental over-spend in healthcare currently seen
         today and have therefore been discounted as viable options in their own right. But they do
         provide a useful lever that may allow additional savings to be realised through the out-
         sourcing option, as they provide benchmark costs for elements of the services to be out-
         sourced enabling harder negotiations to be undertaken.

   13. The out-sourcing of the Commissioning activities to a specialist supplier looks to deliver
       desired outcomes quicker by buying in the skills and expertise. Out-sourcing also permits a
       longer term approach to investing in the PCT infrastructure (people and systems) to be
       adopted, overcoming the drawbacks of developing the capability internally within the NHS.

Preferred Option
     14. The senior management team believe a degree of out-sourcing is the most preferred option
         for Hillingdon to meet the stated objectives and wish to explore the options open to them
         under the Department of Health Commissioning Service Framework procurement. This needs
         to be explored further through an Outline Business Case (OBC).

The Commissioning Services Framework (“CSF”)

     15. The CSF contains four functional commissioning categories, based on a set of core business
         processes for PCTs (see Figure 1):

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              Assessment and planning
              Contracting and procurement
              Performance management, settlement and review
              Patient and public engagement

     16. A PCT could choose to outsource one or more of these functional categories as a “macro”
         contract, parts of a macro (known as “micro”), or all four macros (known as an “end to end”
         contract). Cutting across all of these commissioning categories is data collection and analysis.

     17. Initially, Hillingdon PCT wanted to explore out-sourcing the two (middle) macro categories of
         “contracting and procurement”, and “performance management, settlement and review”.
         Recent discussions have highlighted a number of key dependencies that would indicate the
         ability to deliver greater benefits by including some Assessment and Planning activities within
         the scope of the out-sourcing.

     18. Under the Commissioning Services Framework there are a number of out-sourcing options for
         consideration, i.e. Micro, Selected Macros, All Macros.


     19. The feasibility of out-sourcing at the micro level (single elements of the CSF framework) was
         considered at the project workshop on the 19 December and it was agreed that the scope of
         micro out-sourcing would not enable the PCT to meet it’s stated objectives. This was because
         out-sourcing at this level would potentially result in a fragmented organisation with no single
         accountability for measurable out-comes.

Macro Options

     20. Two Macro options were considered at the workshop:

          Vertical Macros - Out-sourcing the management of a service segment. For example, the
          management of Acute Unplanned Services across Assessment and Planning, Contracting and
          Procurement, Performance Management and Public and Patient Engagement.

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                                                                          Vertical Macro
                                                                                                    Service Segments

                                                                                                                        "First Contact"
                                                                                          Mental Health

                                                                                                                        Primary Care
                                                                                          and Learning
                                                           Acute Health

                                                                           Acute Health

                                                                                                          Social Care










                                                            AH-U            AH-P             MH            SC               PC             CS          SS           AS
                  Health Needs Assessment              1
                  Reviewing Service Provision          2
                  Deciding Priorities                  3
        ent &
                  Designing Services                   4
                  Shaping the Structure of Supply      5
                  Managing Demand                      6
     Contracti    Primary Care Services                7
       ng &       Extended Primary Care Services       8
     Procurem     Secondary Care Services              9
     Performa     PbR Transactions                    10
        nce       Budget and Activity Management      11
     Managem      Performance Management              12
        ent,      PBc Operating Management            13
     Settlemen    Patient Feedback and GP Inteligence 14
                  PCT Prospectus                      15
      Patient &
                  Referralsand advice on choices      16
                  Patient-Initiated Petitions         17
                  Engagement Strategies               18
                  Communications Strategies           19

          Horizontal Macros - Out-sourcing a function across all service segments. For example,
          assessing and planning the health needs of the population across all service segments.

                                                                          Horizontal Macro
                                                                                                    Service Segments

                                                                                                                        "First Contact"
                                                                                          Mental Health

                                                                                                                        Primary Care
                                                                                          and Learning
                                                           Acute Health

                                                                           Acute Health

                                                                                                          Social Care











                                                            AH-U            AH-P             MH            SC               PC             CS          SS           AS
                  Health Needs Assessment              1
                  Reviewing Service Provision          2
                  Deciding Priorities                  3
        ent &
                  Designing Services                   4
                  Shaping the Structure of Supply      5
                  Managing Demand                      6
      Contracti   Primary Care Services                7
        ng &      Extended Primary Care Services       8
      Procurem    Secondary Care Services              9
      Performa    PbR Transactions                    10
         nce      Budget and Activity Management      11
      Managem     Performance Management              12
         ent,     PBc Operating Management            13
      Settleme    Patient Feedback and GP Inteligence 14
                  PCT Prospectus                      15
      Patient &
                  Referralsand advice on choices      16
                  Patient-Initiated Petitions         17
                  Engagement Strategies               18
                  Communications Strategies           19

     21. Vertical macros were eliminated as an option as it was felt that whilst they could provide a
         step change in the skills and productivity of a service, it would be difficult to hold a functional
         activity responsible for delivering specific outcomes, as is necessary to deliver on the
         objectives of the PCT.

     22. Individual horizontal macros were more attractive, (excluding Patient and Public Involvement)
         as an option, however this was unlikely to enable the out-source supplier to have the ability to
         deliver the scale of financial savings required.

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All macros
    23. Out-sourcing all service segments through all macros, gave the greatest opportunity to make
        savings and hold the out-source supplier accountable for outcomes.

     24. This proposals document will explore future management arrangements for the
         commissioning functions for the PCT. These functions are defined in the Commissioning
         Services Framework as:
              Assessment & Planning
              Contracting & Procurement
              Performance Management, Settlement & Reviews

     25. From a service perspective this will include all eight service areas as defined in the
         Commissioning Services Framework:
             Unplanned Acute Health services
             Planned Acute Health services
             Mental Health and Learning Disabilities services
             Social Care services
             Primary Care “First Contact” Services
             Community Services
             Specialist Services (where the PCT has a lead role in commissioning these services)
             Ambulance Services

     26. For the purpose of clarity the above scope includes responsibility for services jointly
         commissioned with Local Authorities.       This would include managing any risk share
         agreements. The scope of the work will also include consideration of:
              FHS Services
              Data Processing

     27. The review of out-sourcing options will not cover:
               Patient & Public Engagement (PPE) (being reviewed separately)
               Future arrangements for finance, HR, Estates and Provider Services
               Creation of an Intelligent Board
         All three areas are being considered as part of separate work streams.

     28. The roles, activities and responsibilities currently undertaken by commissioning to delivery
         £258 m of health care services across Hillingdon would potentially be scoped to move to the
         out-source supplier. This will be worked through in detail in the Outline Business Case (OBC).
         PBC has been introduced to increase efficiency and drive through innovative delivery of
         services. Suppliers would have to work closely with PBC as PBCs will make decisions as to
         the design and delivery of services which suppliers will be required to contract and procure on
         their behalf. The PBC Chair is a member of the Project Team to enable this.

High level Risk analysis

     29. There is an element of risk in any out-sourcing activity. As the scope of the out-sourcing grows
         and the perceived PCT control over day to day commissioning activities reduces, the
         perception of increased risk will grow. This is generally true, but as the scope of out-sourcing
         increases the opportunity for the out-source supplier to deliver greater profit also increases
         and the out-source supplier can be held more accountable for healthcare outcomes. The
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          attractiveness and accountability will allow the PCT to reduce risk commercially through the
          structure of the contract.

     30. Higher potential returns for the supplier and the increased accountability for performance will
         allow the PCT to reduce risks through the supplier taking on board greater commercial risk for
         their performance, particularly if the contract term is sufficiently long to make the possibility of
         realising profit over a number of years greater. If the scope of the out-sourcing is too small,
         the potential gains for the out-source supplier will be insufficient for them to accept outcome
         oriented commercial risk and the out-sourcing is likely to be less successful.

     31. Therefore, the scope of activities out-sourced needs to be sufficiently broad to offer potential
         profit whilst ensuring the accountability for the desired health outcomes can be transferred to
         the out-source supplier.

       32. The table below summarises some of the risks facing the PCT in out-sourcing Commissioning
           and recommended mitigating actions:

Risk                                           Mitigating Action

Supplier set-up costs exceed potential         It is envisaged that most suppliers will be considering this as a
gains of contract with Hillingdon              market entry step that will need some set-up investment from
                                               themselves. Therefore it is not expected that the suppliers will pass
                                               on all set-up costs to the PCT.

                                               A mechanism for understanding the set-up costs within the contract
                                               and their repayment during the life of the contract will need to be
Delivery of financial balance for the          It is currently assumed financial balance will be achieved in 2008/9.
PCT takes longer than currently                The definition of financial surplus/balance/deficit will need to be
planned                                        clearly defined and mechanisms put in place to give visibility of
                                               surpluses and the mechanism for sharing these surpluses between
                                               the supplier, the PCT and key stakeholders.

                                               Conversely, the out-source supplier may not have the same
                                               confidence in the speed with which financial balance is achieved
                                               and will look for some degree of under-writing of deficits in the early
                                               years of the contract.

                                               General under-writing principles will need to be agreed with NHS
                                               London and the Department of Health.
Requirement to repay historic debt             This presents the biggest risk to the successful out-sourcing of the
make the contract unattractive to out-         Commissioning activities, as the need to repay this deficit will
source supplier                                prevent the savings generated through out-sourcing being re-
                                               invested in the health economy. This may further impact the scale of
                                               the savings that are realised and make the contract unattractive to
                                               potential suppliers.

                                               A mechanism for understanding the outstanding historic deficit costs
                                               within the contract and their repayment during the life of the contract
                                               will need to be agreed. Alternatively the write-off of the historic
                                               deficit may be agreed with a profit share mechanism put in place

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Risk                                         Mitigating Action

                                             that reflects the level of write-off between the PCT and the supplier.
North West London Acute services             There is currently a project underway to set out the strategy for the
strategy                                     delivery of acute services across the North West Sector of NHS
                                             London. The proposed strategy will need to be regularly reviewed to
                                             ensure that the recommendations being made do not adversely
                                             impact the ability of the supplier in delivering financial and quality
Business Continuity and HR                   Any out-sourcing activity will inevitably raise concerns within staff
                                             over their personal futures, potentially adversely affecting the
                                             performance of these staff in their roles and raising staff turn-over.

                                             A well managed communications programme will be required to
                                             keep staff informed of progress and key messages at the
                                             appropriate times in the programme.

                                             In addition, a well thought through HR strategy will need to be put in
                                             place to manage any potential staff turn-over issues, ensure a
                                             smooth transition of any workforce to the supplier and develop the
                                             appropriate PCT organisation left behind.
Adverse Public Reaction                      This may take the form of concerns over the quality or continued
                                             delivery of healthcare services across the PCT.

                                             Again a well managed communications programme that recognises
                                             key stakeholder groups within the community and keeps them
                                             appropriately informed will be essential to ensure the acceptance to
                                             the out-sourcing of commissioning by the local community.
Concern over clinical standards              The out-source supplier will still be held accountable in meeting the
                                             standards set for PCTs in the commissioning of health care
                                             services. A key role for the “Intelligent Board” and remaining PCT
                                             staff will be to ensure clinical standards remain and stakeholders
                                             will need to be comforted that the PCT has the appropriate
                                             procedures and skills to ensure clinical quality.
Fail to define clear responsibilities for    A detailed specification developed as part of the Outline Business
IMT and data                                 Case (OBC)
Expected benefits from the out-              A robust and open mechanism will need to be implemented to
sourcing are not realised                    enable the PCT and Supplier to ascertain the degree to which the
                                             expected benefits from the out-sourcing activity are being realised.
                                             This will require that the benefits of out-sourcing be identified early
                                             and the contract “position” regularly reviewed against these
                                             expectations by both PCT and the supplier.

                                             A key mitigating action will be to ensure the PCT has the
                                             appropriate skills and infrastructure to manage the out-sourcing

     33. Risks will be regularly reviewed during the project cycle and appropriate actions taken to
         ensure the probability of them becoming issues is minimised. As new Risks emerge these will
         be managed through the Project Office and responded to appropriately.

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Attractiveness of Contracts to the Supply Market

     34. There are a number of factors which will attract potential outsourcers to tender for
         commissioning functions at Hillingdon PCT. These are:

               Financial Reward
               Platform for expansion into outsourcing contracts for other PCTs, the NHS and the public
               Geographical expansion
               Develop relationships within Hillingdon, other PCTs, the NHS and the public sector
               Risk management for the supplier
               Staff development fro the supplier
               Staff redeployment for the supplier

     35. Potential out-source suppliers would not be interested in small scale, short duration
         outsourcing contracts. The potential financial gain would be offset by the considerable setup,
         training and administration costs. Organisations will also not be attracted to high risk
         functions that provide low levels of return. Interest will only be generated by lucrative
         contracts offering opportunity and reduced financial risk in their duration.

Financial Case

High level affordability analysis
     36. The current budget for managing and delivering healthcare across the PCT is £258m for the
         delivery of healthcare services and a further £10m in PCT management costs. The
         affordability of an out-sourcing contract is dependent on potential out-source suppliers
         considering it feasible to deliver the desired level of healthcare across the Hillingdon
         geography within this financial envelope set by the Department of Health and meet their
         internal ROI requirements. Funding will continue to be set by the Department of Health based
         on a sum of money per head of Unified Weighted Population (UWP). At this time there is no
         reason to think this approach to funding will change.

     37. There are a number of challenges that will need to be resolved to provide greater clarity
         around the financial management of the contract:
          Handling of historic deficit of £54m
          Impact of estimated 2006/7 £11m overspend
          Profit share of future surpluses

Handling of historic deficit

     38. The historic deficit of the PCT is potentially the biggest barrier to the successful out-sourcing
         of the commissioning activities and appropriate actions need to be agreed with the
         Department of Health and NHS London to overcome this barrier. If this deficit is to be repaid, it
         will place a significant financial burden on the contract, with much of the profits realised from

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          the out-sourcing activity being used to eliminate the historic debt, rather than being reinvested
          to improve future healthcare services.

Estimated 2006/7 overspend

     39. The PCT is currently forecasting a deficit at the end of this fiscal year of £11m, with turn-
         around plans in place aimed at delivering in-year fiscal balance or surplus in 2007/8. The
         confidence a potential out-source supplier has in the ability of these plans to deliver financial
         balance in this timescale will have a significant impact on their willingness to take on the PCT
         activities for the agreed 2007/8 budget. Therefore an appropriate contingency plan for
         managing and funding any remaining deficit in the early years of the contract should be
         developed and agreed with NHS London.

Profit share of surpluses

     40. This is an area that will need significant focus over the coming months to ensure the
         mechanisms for balancing the quality and timing of healthcare provided meets national and
         local requirements whilst driving down healthcare costs. Profits in the early years are likely to
         be small due to the set-up costs for the out-source supplier and the potential need to pay back
         the historic deficit.

     41. The share of any surplus should also be seen to be fair and equitable meeting the ROI needs
         of the out-source supplier but also seeing appropriate funds being made available for re-
         investment in the local health economy.

     42. As the scope of the out-sourcing becomes clearer, the market will need to be tested to ensure
         the contract is still attractive to potential out-source suppliers.

Project Management

Project Management Arrangements

     43. The Commercial Directorate (CD) have a commissioning pathway that drives the desired
         project planning for the out-sourcing. There is an action plan in the outsourcing timetable with
         number of key milestones with delivery of a full business case (FBC) in June 2007. The
         importance of this project to the success of the Commissioning Services Framework currently
         being tendered, will probably require that this project will be given “Gateway Project” status
         requiring that greater external scrutiny of the process undertaken will be incurred.

     44. Yi Mien Koh (Deputy Hillingdon CE) will be the Project Director for the Project. Yi Mien Koh
         will be accountable to the PCT Board for the successful delivery of the project. A dedicated
         project team will be established to implement the outsourcing project and will be headed by
         the Project Director. Within the PCT, the Project Board will oversee the delivery of the project.
         The Board will meet fortnightly. The project board is appointed to provide overall direction and
         management of the project. The project board provides strategic alignment and oversight, has
         responsibility and authority for the project, and is accountable for the project's success. The
         project board serves as the champion of the project to the outside world and is responsible for
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          any publicity or other dissemination of information about the project. The new Project Director
          and Board, will fully develop the governance policies and procedures of the outsourcing
          project. Membership of the Project Board includes a Non Executive Director, Director of
          Finance, Director of Commissioning, the Chair of the PBC Consortia, the Chair of Community
          Voice. The Project Board is accountable to a Programme Board that includes the PCT Chair
          and Chief Executive. The Programme Board manages all work streams for future PCT

Hillingdon PCT Outsourcing Programme structure

                                             Programme Board

                                                Project Board

                                                Project Team

     45. The successful management of stakeholder relations will be a key priority for the project. The
         Project Director will have overall responsibility for this but with there will be a project team
         communications lead to take the day to day responsibility. The project management approach
         will be based on PRINCE2 principles, as is required for a public sector project of this scale
         and profile.

Managing Transition

     46. Transition refers to the movement from the current as-is footprint to the future state
         outsourcing model. It will encompass a number of key project management tools including
         change management, communications, risk and issues management and progress tracking.

     47. The transition phase is one of the most important elements of an outsourcing programme and
         is often citied as one of the main reasons for failure. The phase will be planned in detail and
         executed in accordance with the plan within pre-determined timeframes. The appropriate PCT
         and 3 party resources will have clearly defined roles and be able to commit time and effort to
         transition planning and execution.

High Level Transition Approach
     48. The following diagram shows the transition approach that will be adopted at Hillingdon PCT. It
         includes the planning, execution, monitoring, control and close phases of the transition.

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                                             Plan                          Execute, Monitor and Control                     Close
                             Definition of a consistent planning              Mobilise an empowered                  Facilitate effective
                             approach across all delivery teams               central Transition Office              transition to BAU

                               Transition                                                 Communications                  Programme
                                               Programme                                   & knowledge
                                Planning                                      Monitor                                     review and
                                               Mobilisation                                management
                               & Design                                      Changes                                        closure
 Transition Approach

                                                                   Monitor and
                        • Define approach and                      track critical
                          vision including                                                                                        • Finalise
                                              • Mobilise Transition milestones                                                      documentation,
                          management             office                                                                             lessons learned
                          processes            • Implement agreed                                     Track                         and transfer to
                                                 programme                                         dependencies                     business-as-usual
                        • Define roles /
                          responsibilities and   management              Analyze
                                                 processes               Portfolio       Report &
                          governance forums                              risks &                                      • Proactively
                        • Exit and contingency • Mobilise                issues                                         identify and track
                          planning               governance forums                     programme                        critical
                                              • Deliver programme                       performance                     dependencies
                                                orientation / kick- • Co-ordinate
                                                off workshop(s)       resolution of cross   • Consistent reporting templates
                                                                      programme risks,        completed and reviewed by
                                                                      issues &                Transition Office

At the heart of the transition management process is proactive mitigation of “people” aspects of the
change – a large number of staff will be changing employers and roles, and transition is dependent
on successful integration

Transition Phase Deliverables
                       49. Key deliverables for the transition phase include:
                              Workforce Strategy Plan – HR Lead will be appointed to implement HR strategy
                              Capability Transfer Strategy and Plan
                              Transition Communications Plan (part of the wider communications plan)

Outsourcing timetable

                       Activity Plan

                                                Jan      March        May         June         July         Aug         Sept        Oct

          Hardware Design
            Outline Case

                Outline Business
                  Case (OBC)

                        Full Business
                         Case (FBC)

                       Prepare Tender

              Signed Contract


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Resource Requirements for Outsourcing

     50. A team of up to 11 WTE will be required for the life of the project. This will include a full time
         Project Manager, Administration, Human Resources, Communications, Information Architect,
         Financial/Commercial and specification development. The estimated costs are £500,000 for
         the project support excluding secondments from the Commercial Directorate, SHA and PCT.

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