Primary Care Trust Nhs Business Case

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					                   Peterborough
               Primary Care NHS Trust




   Strategic Service Development Plan for
  Future Service Commissioning and Direct
       Arms Length Service Provision



Compiled in collaboration with key partners and with assistance from




                                                                        Final
                                                               December 2007
                                          Peterborough Primary Care NHS Trust




CONTENTS
Section                                                                                                            Page No
Preface - Glossary of Abbreviations used in the Plan
1.0      Executive summary ............................................................................................................... 1
2.0      Introduction and Background ................................................................................................ 8
3.0      Current Position and Case for Change ............................................................................... 11
4.0      Strategic Context, Vision and Principles for Development .................................................. 23
5.0      Proposed Approach to Matching Services and Resources to the Vision ............................ 31
6.0      Procurement of Services and Supporting Infrastructure ..................................................... 42
7.0      Impact of the Plan on the Health and Well Being of Greater Peterborough........................ 44
8.0      Impact of the Plan on Services Provided Directly by the NHS and Public Sector Partners 45
9.0      Requirements for Other Delivery and Development Partners ............................................. 52
10.0     Stakeholder Support ........................................................................................................... 52
11.0     Financial Appraisal.............................................................................................................. 52
12.0     Implementation Timetable and Project Management.......................................................... 56




Appendices

    1.     Boundary and Population Maps
    2.     Demography & Health Need
    3.     Service Matrices
    4.     Services maps
    5.     Estate Performance
    6.     Provider SSDP
    7.     Workforce – Current Profile and Future Strategy
    8.     Financial Profile
    9.     Present IM&T Infrastructure and Future Strategy
   10.     Internal Change Drivers
   11.     Global Change Drivers
   12.     Option Appraisal & Impact Assessment of Alternative Models of Services
           Commissioned
   13.     Risk Assessment & Management Plan
   14.     Financial Modelling
   15.     Stakeholders with an Interest in the Plan’s Proposals
   16.     Workshop attendees
   17.     A Summary of the Consultation Process
   18.     Integrated Service and Estate Procurement Process & Timetable
   19.     Application of the SSDP to the Future Commissioning of Specific Services




                        Strategic Service Development Plan for Future Service Commissioning
                                        & Direct Arms Length Service Provision
                                                       Contents
                        Peterborough Primary Care NHS Trust




         Glossary of Abbreviations used in the Plan

Abbreviation                      Meaning
ASP                               Anglia Support Partnership
CHD                               Coronary Heart Disease
CPL NHS                           Commissioning a Patient Led NHS
CPMHT                             Cambridgeshire and Peterborough Mental Health
                                  NHS Trust
DCAG                              Departmental Cost Allowance Guides
DDA                               Disability Discrimination Act 1995
DGH                               District general hospital
Diversity                         Population diversity
GPHIP                             Greater Peterborough Health Investment Plan
Green Book                        HM Treasury Guidance on Investment Appraisal
ICT                               Information and communications technology
IM&T                              Information management and technology
LAA                               Local Area Agreement
MDT                               Multi disciplinary team
NPPCT                             North Peterborough Primary Care Trust
OBC                               Outline Business Case
ONS                               Office of National Statistics
P&SFT                             Peterborough & Stamford Hospitals NHS
                                  Foundation Trust
SHA                               East of England Strategic Health Authority
SMR                               Standardised Mortality Ratio
SPPCT                             South Peterborough Primary Care Trust




           Strategic Service Development Plan for Future Service Commissioning
                           & Direct Arms Length Service Provision
                                  Glossary of Abbreviations
                          Peterborough Primary Care NHS Trust




1.0 Executive summary
1.1   This is the SSDP for services commissioned for and provided to people living
      in the area illustrated on the following map.




                 Oundle




1.2   It has been prepared to inform:
      i.   The development of detailed commissioning                 plans       mainly   by
           Peterborough PCT and Peterborough City Council
      ii. The development and approval of business cases for investment in new
          and improved premises to enable the changes of direction for the
          commissioning and delivery of services set out in the plan.

1.3   It is set against a context in which, among other things:
      i.   The values of publicly financed health and social care delivered equally to
           those who need it are to the fore
      ii. Government policy is seeking new and better approaches to the
          commissioning and delivery of services and to the diversification of the
          health and social care market place
      iii. Practitioners are finding new and better processes for organising the
           delivery of health and social care
      iv. The benefits of integrated working are recognised more
      v. Advancing medical and information technology are making it possible to
         do more and better things for service users




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      vi. People are consumers and have and express expectations about the
          health and social they need either to stay well, overcome illness or cope
          with a long term condition or end of life
      vii. Peterborough has a growing and ageing population and has the scope to
           do more to improve the health of a population that is affected by the high
           levels of poverty in the city

1.4   The planning process has allowed the development of the plan to be
      influenced by:
      i.   Robust analysis of objective evidence about Peterborough, its population,
           the services available at present and the performance of primary care
           premises that are used at present
      ii. Analysis of external change drivers particularly those operating through
          the medium of national government policy
      iii. The participation of partners and stakeholders through a variety of ways of
           engaging and consulting with them

1.5   The process has been overseen and managed by a Project Board with
      appropriate membership, including PCT and GP representation. The local
      authority and other local NHS providers have been represented in the
      development process through interactive workshops.            This partnership
      approach will be built on to develop a robust project organisation for delivering
      the proposed changes speedily and cost effectively. A first task for the project
      organisation will be to develop a detailed project delivery and benefits
      realisation plan.

1.6   Involvement of partners and stakeholders in the process of developing the
      plan has been through:
      i.   The project board
      ii. Interactive workshops
      iii. An extensive consultation process

1.7   The benefits of this have been:
      i.   The successful development of an innovative plan which sets out
           principles that blend a variety of stakeholders’ visions into a model that
           should transform services sustaining their fitness for purpose over the
           next ten years across all organisations
      ii. Positive feedback and strong support for the ideas contained in the plan
          and an economy wide commitment to deliver it
      iii. Further strengthening of the partnerships between the PCT and local
           stakeholders

1.8   The plan proposes realistic change to a sustainable whole system of care
      delivery for the area that will deliver modernised, integrated, patient centred
      services, responsive to national objectives and the SHA’s strategic vision. The
      proposed changes are evidenced by local community, health and social care


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         needs assessment and backed by the will to implement an integrated service
         strategy. The specific package of changes proposed has been selected from
         a number of possible alternatives using a weighted criteria option appraisal
         process undertaken with stakeholders in interactive workshops.

1.9      The changes proposed should give Peterborough’s population access to
         effective health and social care efficiently and involve migration to a model of
         service based on sound principles for:
         i.   The commissioning of services including the matching of services to
              identified need, determining the size of catchment populations for services
              commissioned and scoping the range of services that should be available
              in a primary care or community setting
         ii. Organising the workforce delivering services
         iii. Organising provider networks to match commissioning intentions
         iv. Fitting the configuration of the estate that accommodates services to the
             needs of the catchment populations

1.10     The following graphics illustrate the changes proposed.

                          Present day                            Future proposed
                         Historical basis          SSDP          Commissioner
      Need                                                       intentions based on
      identification                                             needs assessment &
      principles                                                 consumer
                                                                 aspirations
                         Access at city,
                                                   LAA
                         locality,                               Varies by service to
                         neighbourhood &                         assure quality, meet
      Population
                         lower levels                            standards & be cost
      sizing
                         Mostly to small local                   effective
      principles
                         populations or            Outline
                         whole city                Business
                                                   Cases
                                                                 Seamless person
                                                                 centred pathways to
      Service            Historical basis with
                                                                 cover prevention,
      scope              many service gaps &
                                                   "Next         screening, support,
      principles         unmet needs
                                                   Steps"        treatment & self care


                        Large number of            SSDP          Contestable provider
                        uncoordinated                            market
                        providers

                                                                 High dependence on
                        Fragmented                               community based
                        contractor network                       services
      Provider
                                                   LAA           Whole system
      organisation
                                                                 contractor network
      principles                                   Outline
                        Coordinated health         Business      Coordinated health &
                        & social care for          Cases
                                                                 social care for all
                        older people
                                                                 needs
                                                   "Next         Supported service
                        Uncoordinated              Steps"
                                                                 users
                        childrens services




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                         Peterborough Primary Care NHS Trust




                          Present day                            Future proposed
                       Indivual                    SSDP           Virtual pathway
                       practitioners are                          based teams
                       main care deliverers



                                                   LAA
                       Some MDT                                   New practitioner
   Workforce
                       development                                roles defined by
   organisation
                                                                  pathway skill needs
   principles
                                                   Outline
                                                   Business
                                                   Cases
                       Traditional roles &                        Unneccessary
                       professional &                             organisational &
                       agency boundaries                          professional
                                                   "Next          boundaries removed
                                                   Steps"



                        Small surgeries &          SSDP           Structured network
                        clinics relying on                        of primary health &
                        DGH for support                           well being centres
                                                                  within each locality

                                                                  Supported by
                                                   LAA
                        Dedicated to single                       locality and central
   Physical
                        service use as                            resource centres
   resource
                        provided by
   configuration
                        premises "owner"
   principles                                      Outline        Flexible in range of
                                                   Business       services provided by
                                                   Cases          multiple agencies
                        Low technology


                                                                  All fully technology
                                                   "Next
                                                                  enabled
                                                   Steps"



1.11   The SSDP makes a clear case for these changes based on the evidence that:
       i.   Peterborough has a needy population with pockets of extremely high
            levels of socio economic deprivation.
       ii. The city is expected to experience unusually high population growth in
           specific district centres due to its status in the Regional Spatial Plan
       iii. There is considerable scope for improving the fit between the present
            models of service commissioning and delivery and the opportunities
            offered by continuous improvement in health and social care delivery
            processes. This change has already begun and has some way to go.
       iv. Factors that restrict the necessary changes include the design of services
           and clinical roles along traditional lines, the imbalance of care between
           different service sectors, the structure of the workforce, access to an
           appropriate IM&T infrastructure and the capacity and performance of the
           estate.
       v. Change is progressing least quickly in terms of improving the estate.
       vi. The point is being reached where the performance of the estate will be the
           most limiting factor. Without investment in a reconfigured estate the
           excellent progress being made towards service modernisation will come to
           a halt.

1.12   The proposed changes should result in:


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       i.   Improved service delivery performance
       ii. Improved response to health and social care need
       iii. Improved response to changes in service demand
       iv. Improved response to the substantial changes that are expected in local
           demography
       v. Improved response to local geography
       vi. Changes in ways of working
       vii. Opportunity to embrace technological change opportunities
       viii. Improved response to changes in the law or government policy
       ix. Improved response to changes in public and service user expectations
       x. Improved response to economic change
       xi. Improved response to partnership opportunities

1.13   The SSDP sets out a case and priorities for facility investment that will match
       facilities to the proposed whole system service model. The investment will
       result in networks of modern, fit for purpose and technologically enabled
       premises. These premises will accommodate generic primary care and
       community based health and social care services in 7 self contained localities
       supported by a network of centrally located facilities providing the most
       specialised services. The development of new facilities in each locality will
       take place in district centres and other growth opportunity areas. This should
       strengthen the links between services and areas of need based on current
       demographics and the expansion proposals set out in the Regional Spatial
       Plan. The process for prioritising between the locations for proposed
       investment has been based on current and changing demography, relative
       service need and the performance of the present facilities in each district
       centre or growth opportunity area.

1.14   The following graphic illustrates the proposals for investment in a facilities
       network to deliver the proposed whole system service model.




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                                                                                                Localities with
                              NORTH EAST LOCALITY                                               Health & Well
                                                                                          1     Being Centre
                               4                                                                developments in
                                                                                                the Plan Peroid
                                                                                                with priorities
                                              8
                                                                    RURAL EAST LOCALITY         Areas where
                                                                                                development
                              5                                                                 may take
                                                  2                                             place at a later
   NORTH WEST LOCALITY                                CENTRAL & EAST LOCALITY
                                                                                                date

                                                                              Resource Centre Network
RURAL WEST LOCALITY                                                           Integrated Care Centre
                                              1                               Well Being Centre
                                                                                         ing
                                                                              Healthy Liv Centre
                                  3
                                                       SOUTH EAST LOCALITY
                                          6
                                                               7




    SOUTH WEST LOCALITY




  1.15      The SSDP has been costed for its impact on the PCT’s revenue. The costing
            of the plan has also been subjected to sensitivity testing. This has
            demonstrated that the plan is financially robust, affordable and deliverable.
            The financial plan has taken into account:

                        i.   Resource development programmes (Workforce, IT and estate)
                       ii.   Set up costs
                      iii.   Transitional costs
                      iv.    Recurrent costs (savings)

  1.16      The financial plan is based on worst case scenario assumptions for access to
            funding over and above its expected revenue allocation and planed growth in
            that allocation. The PCT may have access to funds that would allow for
            capitalised payments to developers thus reducing the burden of additional
            premises occupation revenue costs, e.g. section 106 payments and targeted
            government allocations such as Darzi Report funding. Such opportunities will
            be taken into account in the process for developing outline business cases for
            individual investment projects.

  1.17      The SSDP recognises that its delivery and the achievement of excellent
            services depends on highly skilled and motivated workforces within both
            commissioning and provider organisations who are flexible enough to respond


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       to changes in service needs and empowered to take actions to improve their
       services. It is therefore supported by a workforce strategy, developed in
       parallel, which sets out a framework for achieving this.

1.18   The main text of the SSDP provides evidence that the proposals for change fit
       with other plans being developed within the city’s health and social care
       community, especially its Joint Strategic Needs Assessment, Commissioning
       Strategy, locality commissioning plans and intentions for commissioning
       specific services and plans for remodelling the internal provider arm as an
       arms length organisation. There is also a good fit between the SSDP and the
       GPHIP and the plans of the Cambridgeshire & Peterborough Mental Health
       Partnership NHS Trust.




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                        Peterborough Primary Care NHS Trust




2.0 Introduction & Background
2.1   This is the SSDP for Peterborough City which covers the areas shown on the
      map at paragraph 3.1.

2.2   The Peterborough PCT commissions and provides services to that part of the
      area for which the former Peterborough South and Peterborough North were
      responsible prior to 1st Oct 2006 area within the Peterborough city boundary.
      It continues to have contractual obligations to provide community based
      services to the following areas outside the city:-
      i.   Cambridgeshire

              a. Yaxley (1 GP Practice)

              b. Whittlesey (2 GP Practices – 1 with a branch surgery in
                 Stanground – within the Peterborough city boundary)
      ii. Northamptonshire

              c. Oundle (1 GP Practice)

              d. Wansford (1 GP Practice)

2.3   The development of the plan has been led by Peterborough PCT on behalf of
      other agencies in the area that it works in partnership with. The Peterborough
      PCT has taken this lead role because the SSDP is required to facilitate the
      approval of plans and funding proposals by health agencies at regional level.

2.4   Within the city’s health and well being community, the plan will:
      viii. Inform the development of detailed commissioning plans mainly by
            Peterborough PCT and Peterborough City Council
      ix. Inform and facilitate the development and approval of business cases for
          investment in new and improved premises to enable the changes of
          direction for the commissioning and delivery of services set out in the
          plan.

2.5   The SSDP is a plan for strategic change influenced by a vision for what is
      considered to be the foreseeable future (the next 10 years). It proposes
      changes in the way that the health and well being needs of the Peterborough
      area are met through commissioning intentions and providers’ obligations.
      The proposals for change have been influenced by factors such as:
      i.   The changing population of the area and its changing health and well
           being needs.
      ii. Health and well being professionals’ improved knowledge and changing
          ideas about best practice
      iii. Peoples’ lifestyles and expectations



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      iv. Drives for comprehensiveness, excellence and equity in the way that
          health and well being needs are met
      v. Incentives to improve health and well being outcomes and processes and
         disillusionment with the status quo
      vi. Financial pressures
      vii. The emergence of new organisations, cultures and contracts
      viii. Political views about health and well being
      ix. Expanding technology
      x. The views and potential contributions of the private and voluntary sectors.

2.6   Commissioners and providers will be driven to respond to these influences
      through soft pressures and hard pressures. Soft pressures will include
      improved knowledge, public opinion and professional advice. Hard pressures
      will include commitment to joint plans and strategies of local partnerships,
      government policy, guidelines and targets, nationally negotiated contracts and
      legislation.

2.7   These influences are described in more detail in Section 4 of this plan. The
      more significant influences include:
      i.   The expected growth in Greater Peterborough’s population from its
           present 160,000 to around 225,000 and the expectation that areas of
           Peterborough will continue to experience high levels of deprivation and
           the health and well being issues associated with such high levels of
           poverty.
      ii. Evidence based new ideas that will be developed both globally and locally
          about how best to organise health and well being services cost effectively
          and how to achieve the best health and well being outcomes for
          populations and the individuals within them. These will set increasingly
          high standards for both commissioning and delivery of services.
      iii. A growth in the market of providers of high quality and demonstrably cost
           effective services.
      iv. New technologies will evolve which are expected to enable practitioners to
          change the way they organise the provision of access to services, people
          to live more independent lives and to be more knowledgeable about and
          responsible for their own health and well being.

2.8   This plan responds to this vision by proposing changes to be achieved over a
      ten year period in the ways that:
      i.   The PCT and its partners approach the commissioning of services,
           migrating away from a present position where a traditional range of
           services are provided based predominantly on historical practice. The
           change will take the PCT and its partners to a position where
           comprehensive and integrated services are provided based on an
           objective assessment of health and well being needs and the needs
           articulated by local populations and individuals within them. The changes
           proposed in the plan fit with current local commissioning intentions.


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       ii. The workforce delivering services is organised moving from an
           organisation that is constrained by traditional professional and
           organisational boundaries. The pattern of workforce organisation that
           commissioners will increasingly expect to see would define roles in terms
           of the skill requirements for delivering integrated pathways and place
           emphasis on teams rather than individual practitioners in meeting each
           person’s whole health and well being needs. The changes proposed in
           the plan and plans developed in parallel for the future organisation of the
           internal provider arm are consistent with each other.
       iii. Provider networks are organised by seeking provision from providers
            with whole systems capability that are able to integrate services to both
            meet health needs and impact positively on the social determinants on
            poor health and well being. The provider networks of the future would
            need the capacity to deliver person centred services in the right place
            (which will increasingly be in a person’s own neighbourhood or home)
            avoiding the need to use secondary care services unless this is indicated
            as the best way of meeting disease specific standards cost effectively.
            The changes proposed in the plan and plans developed in parallel for the
            future development of the workforce are consistent with each other.
       iv. The population bases for service commissioning and delivery are
           defined so that services are delivered to areas with populations large
           enough to sustain the cost effective delivery of the widest possible range
           of high quality services. This would need to be done in a flexible way to
           continue to provide local access to services where most needed and to
           maximise the care available to people in their own homes.
       v. Remodel the estate so that it is made up of premises that support these
          changes in service commissioning and delivery and facilitate the use of
          change enabling technology.

2.9    The plan has been developed in the context of the requirement of Primary
       Care Trusts to arms length their internal provider organisations and to work
       with partners to foster contestability (i.e. a local market with a range of
       sustainable providers of high quality and cost effective health and well being
       services). It recognises therefore that the plan needs to be developed from
       the strategic visions of both the local commissioning partners and with a
       shared understanding of how this will affect both public and other sector
       owned provider organisations.

2.10   The plan has been developed through a process that:
       i.   Has been overseen and managed by a Project Steering Group with PCT
            commissioner and provider, GP and local authority membership (see
            Section 12 of the plan)
       ii. Ensures that the development of the plan is based on sound knowledge
           and understanding of the area, its population and the services that they
           receive (see Appendices 1 to 5 and 7 to 9)
       iii. Has reviewed all relevant areas of current national policy, key areas of
            best practice research and regional and local plans to inform an
            understanding of the whole system strategic context for the plan. This


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         ensures the plan’s fit with national regional and local directions (see
         Section 4 and Appendices 10 and 11)
      iv. Used robust methods to test key strategic aspects of current service
          commissioning and delivery models to evidence any proposals for change
          (see Sections 3 and 5 and Appendix 12)
      v. Quantified the performance of present facilities to inform an assessment
         of their fit with proposed service commissioning and delivery models (see
         Section 5 and Appendices 7 and 12)
      vi. Quantified the impact of the plan on the PCT’s current and predicted
          revenue income and budgets to inform an analysis of affordability (see
          Section 10 and Appendices 8 and 14)
      vii. Used recognised risk assessment techniques to predict and quantify risks
           and propose plans for managing them to assure the deliverability of the
           changes proposed in the plan (see Section 5 and Appendix 13)
      viii. Engaged a wide range of stakeholders either directly or indirectly in the
            plan’s proposals (see Section 12 and Appendices 15, 16 and 17)
      ix. Used approaches such as horizon scanning to encourage consideration of
          new strategic opportunities and the search for innovative strategic
          solutions (see Section 3 and Appendices 10 and 11)

3.0 Current Position & Case for Change
3.1   The Area Covered by the Plan

3.2   The area covered by the Plan is shown on the following map.




                     Oundle




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3.3   Peterborough is situated on the River Nene at a point where the boundaries
      of Cambridgeshire, Leicestershire and Rutland, Lincolnshire and
      Northamptonshire meet. It sits within a triangle of roads (the A1, the A47 and
      the A605) and at a point where the main East Coast railway line is met by a
      line incoming from Cambridge to the south east and from the west a line to
      Leicester and Birmingham.

3.4   Geographically the area is flat with few or no natural boundaries. The
      Peterborough City boundary and the Peterborough PCT boundary are now
      coterminous as shown on the map at paragraph 3.1.

3.5   Within the city the main road system is radial. The rivers, railways and roads
      crossing the city act as boundaries to 5 fairly distinct natural localities (shown
      on the following map) which tend to be used for purposes of planning and/ or
      delivering health and well being services.


                                     NORTH EAST LOCALITY




                   NORTH WEST LOCALITY

                                                  CENTRAL & EAST LOCALITY




                                                      SOUTH EAST LOCALITY




                   SOUTH WEST LOCALITY




3.6   Local Demography and Health Need

3.7   At Appendix 2 there is a summary of key population, socio-economic, other
      health and well being indicators and public health statistics for the wards
      within the localities shown on the map above.

3.8   They indicate issues of:
      i.   Variations in population density (north: south split with the South West
           and South East localities being the least densely populated and most
           likely be areas where significant future housing development takes place).



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       ii. Variations in the percentage of populations aged 65 and over, the
           localities with older populations being Central and East and South East.
           At ward level, North Ward in the Central and East locality at its boundary
           with the North East locality has the highest percentage of residents in the
           older age groups.
       iii. Variations in the percentage of populations aged under 5. Ironically
            Central and East has the highest percentage as well as the highest
            percentage of people aged 65 and over. Three of its wards have
            percentages between 7.51 and 10 percent of their populations in this age
            group.
       iv. Variations in population diversity, Central Ward in the Central and East
           Locality having the most diverse population as measured by the
           percentage of the population who are not White British in origin.
       v. Relative poverty in the population generally based on there being:

               a. Around one third of electoral wards with the overall Index of
                  Multiple Deprivation rankings that place them in the most deprived
                  quintile of wards nationally (including one in the most deprived
                  100) and over a half of wards in the 2 most deprived quintiles
                  combined. This leads to a robust assumption that in overall terms
                  at least half of the people living in the City of Peterborough
                  experience high to very high levels of relative poverty.

               b. Anything between one quarter and one half of wards with rankings
                  for all of the specific domains of the Index of Multiple Deprivation
                  (except the Access domain) which place them in the most deprived
                  quintile nationally.

               c. Low levels of car ownership especially in the Central and East
                  locality where all wards have at least 25 per cent of no car
                  households.
       vi. Relative pensioner poverty in selected areas – all wards in the Central
           and East Locality have more than 6 per cent of pensioners claiming
           pension credit.

3.9    Furthermore the population of the city is expected to grow. This growth is
       fuelled by a number of factors the most important ones being:
       i.   Urban development and regeneration initiatives featured in the
            appropriate Regional Spatial Plans and promoted by agencies such as
            East of England Development Agency, East Midlands Development
            Agency, South Lincolnshire Growth Proposals and Opportunity
            Peterborough.
       ii. Inward economic migration.

3.10   The policies in the Regional Spatial Plans affecting the area around
       Peterborough focus regeneration and development investment in and around
       the margins of already developed urban areas. For Peterborough this means
       regeneration within the areas identified as District Centres in the Regional


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       Spatial Plan as broadly indicated using current ward boundaries in the map
       below. Significant housing and retail growth is expected in these areas or
       surrounding areas such as Yaxley (see map at paragraph 3.5). This will be
       matched by development of the transport infrastructure and builds on the
       present urban infrastructure which has a well developed partnership approach
       to integrated transport provision.




                                                   Wards related to Regional
                                                   Spatial Plan District Centres




3.11   A net effect of these developments will be to narrow the population density
       gap between the more densely populated localities in the north and the less
       densely populated localities in the south.

3.12   The strategic health issues raised for the Peterborough area by public health
       statistics are:
       i.   There is a low expectancy of life at birth compared to the whole of
            England – males and females
       ii. The city has the lowest life expectancy in the Office of National Statistics
           “new and growing towns” cluster as a whole
       iii. Circulatory disorders (38%) and cancers (25%) are the largest single
            causes of death in the area
       iv. Death rates from circulatory disorders are higher than the mean rate for
           the whole of England and Wales:

               a. For females aged 55 – 74



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               b. For males aged 50 – 74.
       v. There are electoral ward based variations linked to deprivation in relation
          to:

               a. Self reported health status

               b. Life expectancy

               c. CHD mortality.

3.13   The PCT and its partners already recognise the need for health and well
       being improving strategies in the following domains to tackle these issues:
       i.   Partnership working focused on determinants of health and well being
       ii. Economic development AND regeneration
       iii. Increased income/ benefit uptake
       iv. Informed partnership with communities
       v. A positive start to life for all children
       vi. Reducing active and passive smoking
       vii. Getting people to enjoy healthy exercise
       viii. Promoting healthy eating
       ix. Tackling the health and social harm of alcohol misuse
       x. Developing a high quality whole system service to deliver condition
          specific standard guidance.

3.14   Target Zones for Health Improvement

3.15   Of the 22 electoral wards in the city, 12 demonstrate characteristics of
       extreme socio economic deprivation in relation to at least one indicator.

3.16   Nevertheless none of these is designated as a target zone for health
       improvement.

3.17   The Present Service Model

3.18   A strategic description of the current position requires the use of a service
       model.

3.19   The concept of a service model used throughout this document is that it is a
       description of what is commissioned and done now or can or should be
       commissioned and done in the future to meet health and well being needs in
       terms of certain underlying strategic principles. The descriptions of both
       current and possible alternative models have been expressed in terms of four
       main sets of strategic principles:
       i.   Principles for service commissioning
       ii. Principles for provider organisation


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       iii. Principles for workforce organisation
       iv. Principles for the organisation of supporting physical infrastructures
           (estate and ICT).

3.20   The principles for service commissioning have been informed by considering
       three subsets of principles in the following categories:
       i.   Principles for determining the scope of services
       ii. Principles for matching resources with service need
       iii. Principles for defining populations served.

3.21   The way these principles generally shape the model is illustrated in the
       following diagram.




             Principles for                   Principles for                      Identifying
             organising                       service                             service
             physical                         commissioning                       need
             resources

                             SERVICE MODEL                                        Sizing
                                                                                  populations
            Principles for                     Principles for
                                                                                  served
            workforce                          provider
            organisation                       organisation
                                                                                  Deciding
                                                                                  service
                                                                                  scope

3.22   This way of describing the service model recognises the current dual role of
       the PCT as commissioner and provider of services. It means that the SSDP
       is developed primarily as a plan to achieve evolving commissioner intentions
       whilst also clarifying, at a strategic level, the service and resource implications
       for the internal provider arm.




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3.23   The actual model in place can be described by the following illustration:


                                                      Principles for service
             Principles for                           commissioning
             organising physical
             resources                                                                     Principles for m atching
             Small surgeries & clinics                                                     resources w ith service need
             Low technology                                                                Historical basis for range &
                                                                                           volume




                                                                                           Principles for defining
                                                                                           populations served
                                                                                           Provided at 4 levels
                                                                                           Mostly to small local populations
                                    PRESENT SERVICE MODEL                                  or w hole city




                                                                                          Principles for determ ining
                                                                                          the scope of services
                                                                                          Substantial service gaps &
                                                                                          unmet needs
            Principles for workforce
            organisation                                Principles for provider organisation
            Indivual practitioners                      Large number of providers
            Some MDT development                        Heavy dependence on acute DGH
            Traditional roles                           Fragmented contractor network
            Professional boundaries                     Coordinated health & social care for older people
                                                        Uncordinated childrens services



3.24   Current Services

3.25   The services used by people living in the Peterborough area are provided in
       the main by:
       i.   General medical practices (28 in number) from 34 surgeries
       ii. Other primary care contractors (general dental contractors, optometrists
           and pharmacists – from 71 service bases)
       iii. Peterborough PCT which has contractual obligations to provide
            community based health and social care services to Peterborough city
            and areas outside such as Yaxley
       iv. The Peterborough and Stamford Hospitals NHS Foundation Trust
           (secondary care services)
       v. Cambridgeshire & Peterborough Mental Health Partnership NHS Trust
          (Acute and community based mental health services).

3.26   This section of the plan quantifies the current service provision using the
       following selected broad strategic indicators:
       i.   Number of general medical practices
       ii. Number of general medical practitioner principals
       iii. Number of patients registered with general medical practices
       iv. Mean general medical practice list size



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           v. Residents in a locality per GP principal with main base in locality
           vi. Percentage of patients registered with a general medical practice with a
               list size over 2000
           vii. Percentage of physical capacity available to deliver fully extended primary
                health and social care for present patient numbers at practice level – this
                has been expressed as the current floor space within practices as a
                percentage of the total standard floor space needed based on current
                Department of Health activity space standards applied to practitioner
                numbers.
           viii. Numbers of community health services bases
           ix. Numbers of other primary care contractor service bases
           x. Numbers of residential homes.

3.27       The following table shows the current position in relation to each of these
           indicators for each locality and for the PCT area as a whole.
                                                                             Indicator

                 GP               GP            Patients   Practice    Residents   Percentage   Physical      Community   Other       Residential
NIS Area         Practices        Principals    Registered Mean List   per GP      Patients     capacity as   Health      Primary     Homes
                                                           Size        principal   Registered   percent of    Service     Care
                                                                                   where list   standard      Bases       Contractors
                                                                                   >2k
Central & East               13            46       82820        1800      852        21.50%       45.57%             3           27            2
North East                    3             8       14539        1817     3533        77.20%       34.69%             2            7            0
North West                    3            15       21855        1457     1855         0.00%       56.70%             4           12            2
South East                    0             0           0           0 N/A              0.00%        0.00%             1            3            1
South West                    7            25       35254        1410     1202         0.00%       41.60%             5           12            0
Rural Areas                   2             5        8615        1723     2093         0.00%       28.55%             0            5            1
TOTAL                        28            99      163083        1647 1616.162        17.82%       43.74%            15           66            6


3.28       Resources Deployed in Present Service Delivery (Workforce)

3.29       The following table shows the number of staff in post and vacancies for
           personnel directly employed by the Peterborough PCT and by General
           Medical and Dental Practitioners as at March 2007.




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             Greater Peterborough PCT Staff in Post (SIP) &
                      Vacancies as at March 2007
                      Full Time Equivalents (FTE)
                                                                    Vacancies,
                                                      SIP, FTE
                                                                       FTE

       Staff Group (see notes)                         Mar-07        Mar-07

       Medical & Dental                                      21.9             0.0
         of which - M&D Consultants                           7.0             0.0
         of which - directly employed GPs                     7.3             0.0
       Reg. Nurses & Midwives                              245.9              2.0
         of which Midwives                                    0.0             0.0
       Reg. Scientific, Therapeutic & Technical            158.9              1.0
         of which Allied Health Professions                  64.7             1.0
         of which Healthcare Scientists                       0.0             0.0
       Ambulance Staff                                        0.0             0.0
       Managers & Senior Managers                            48.4             2.0
       Administrative & Estates                            326.8          10.8
       Support Staff                                       364.8              1.0
       Other Staff                                           2.0              0.0
       Total for Organisation                             1168.8          16.8

       General Practitioners                                 88.3             0.0
       Practice Nurses                                       50.7             0.0
       Dentists Employed in Dental Practices                 77.0             0.0

3.30   Resources Deployed in Present Service Delivery (Estate)

3.31   The following table shows the estate for health and social care services in
       Peterborough categorised by function.




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                                                                       Locality
Premises type                    Central & North        North        South      South        Rural
                                 East      East         West         East       West         Areas        Total
Community clinic/ health
                                        3          0            4            1          2            0            10
centre/ dental centre
General Practice Main
                                       13          2            3            0          7            2            27
Surgeries
General Practice Satellite
                                        2          3            0            0          2            2             9
Surgeries
Offices/ Occupational health/
                                        3          1            0            0          0            0             4
Community home

Other contractor premises              27          7            12           3          12           5            66

Residential homes                       2          0            2            1          0            1             6

TOTAL                                  50          13           21           5          23           10           122


3.32     Resources Deployed in Present Service Delivery (ICT)

3.33     At present a hardware infrastructure is required that will support the integrated
         management of information and communications within a business model
         comprising:


         i.   The joint provision of community based well being services for adults
              provided by the PCT internal provider arm through a partnership
              arrangement with Peterborough City Council
         ii. The provision of primary care general medical services by general
             practices
         iii. Community based health services provided by the PCT internal provider
              arm
         iv. Community based well being services for children provided separately by
             the Peterborough PCT Provider Arm and Peterborough City Council.

3.34    The business need for Information and Commendations Technology may
        change shortly if a further partnership arrangement between the PCT and the
        City Council for the joint provision of community based health services for
        children to be provided by the Peterborough City Council goes ahead. The
        proposal is currently out to consultation.

3.35    The present arrangements for ICT involve separate data networks and
        systems for the health and other care providers in the Peterborough area.
        There is a shared system for the Electronic Single Assessment Process
        (ESAP) providing health and well being needs assessment for people aged
        65 and over. There are plans to purchase a similar system to support the
        impending partnership arrangements for children's services. This will support
        the Common Assessment Framework for Children (ECAF).

3.36    Community and primary health care systems are supported by a server
        network managed by Anglia Support Partnership. This supports the different


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       software systems used by the PCT internal provider arm and general
       practices. It also supports ESAP and will support ECAF.

3.37   Current Service Model – Future Benefits Potential

3.38   Through an interactive workshop process, the potential future benefits of
       continuing to base the commissioning model on the current service model
       have been appraised. Appendix 12 details the methodology for this. The
       results are set out in the Appendix and summarised in Section 5 of the plan.

3.39   The conclusion drawn from the appraisal is that the “No Change” option is not
       suitable as a model for commissioning in the future and demonstrates the
       clear need for some change already set out in the plan.

3.40   Assessment of Size and Skill Mix of Present Workforce

3.41   The current workforce is mainly organised along traditional lines with a
       traditional mix of skills. Significant progress has been made in moving
       towards more generic and integrated health and social care roles. Further
       change is needed to achieve fully the benefits that generic and multi skilled/
       professional working can offer in the delivery of person centred care. A
       strategy for enabling this change, that is consistent with this plan, is set out
       Appendix 7.

3.42   Assessment of the Current Estate

3.43   At Appendix 5 there is a detailed assessment of the performance of the
       premises that make up the present estate.

3.44   The GP owned and leased premises and PCT owned and leased premises in
       the present estate have been assessed in terms of the following 7 facets:
       i.   Physical condition (building, mechanical and electrical).
       ii. Fire and health and safety.
       iii. Environmental / energy management.
       iv. Functional suitability & space utilisation.
       v. Quality.
       vi. Asbestos
       vii. DDA compliance.

3.45   Adult social care premises and those used by other independent contractors
       (dentists, optometrists and pharmacists) have not been assessed.

3.46   For each facet the indicator of performance used is the expenditure required
       to return each property assessed to a satisfactory standard, equivalent to
       NHS Estatecode condition B. The summary results of this assessment are
       set out in the following table.




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                                               Indicator - expenditure to improve premises to Estatecode B rating

                 Physical      Fire & Health   Environmental Functional      Quality.       Asbestos        DDA          GIA (costed      TOTAL    Cost per
NIS Area         Condition     & Safety        / energy      suitability &                                  compliance   areas only    EXPENDITURE square metre
                                               management. space                                                         included in
                                                             utilisation                                                 total)

                       £             £               £               £             £             £               £            M2            £            £
Central & East        507944          31550            4100         204750          77450            5779       573170          7439       1404743           189
North East             46719           7960            1250          16300          11750            1259        21740          1554        106978            69
North West            144453          14500           38250          16000           1000            2105        10400          3919        226708            58
South East                 0              0               0              0              0               0            0           103             0             0
South West             35992           1200               0           3500           1200               0         6850          4778         48742            10
Rural Areas                0              0               0              0              0             647            0           799           647             1
Grand Total           735108          55210           43600         240550          91400            9790       612160         18592       1787818            96



3.47       A separate assessment has been undertaken for the buildings used by
           Peterborough and Stamford Hospitals NHS Foundation Trust that is part of
           the case for the redevelopment of the acute hospital facilities in the PCT area
           and the development of a new community hospital.

3.48       The main issues identified by the assessment of the current estate are:
           i.    The need to replace Peterborough District General Hospital and provide a
                 new mental health facility and a new generation community hospital. The
                 latter, known as the Integrated Care Centre, would also incorporate a
                 community resource centre to make good the lack of a facility for providing
                 services at the secondary/primary care interface. The case for these
                 changes has already been made in the Greater Peterborough Health
                 Investment Plan (GPHIP).
           ii. The lack of space for fully extended primary health and social care in
               localities and practice areas.
           iii. The high cost of improving existing facilities to a standard equating to
                Estatecode B. The expenditure required is approaching £2million and
                even if incurred would achieve no improvement in service capacity.
           iv. Significant differences between service localities in terms of premises
               used to accommodate their services.

3.49       Assessment of the Current IT Configuration

3.50       The IT configuration presently in place meets current and anticipated
           business needs but will require investment in networks, hardware and
           systems to meet the needs of a fully modernised and integrated community
           based health and social care system.




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3.51    Summary of the Case for Change
        The area has a needy population with pockets of extremely high levels of
        socio economic deprivation. There is a requirement for a modern whole
        system approach to commissioning and delivering services to meet the needs
        of this population and change its health and well being status for the better.
        This change has already begun but has some way to go. Factors that restrict
        the changes that need to be made include the design of services and clinical
        roles along traditional lines, the imbalance of care between different service
        sectors, the structure of the workforce, access to an appropriate IM&T
        infrastructure and the capacity and performance of the estate. Change is
        progressing least quickly in terms of improving the estate. The point is being
        reached where the performance of the estate will be the most limiting factor.
        Without investment in a reconfigured estate the excellent progress being
        made towards service modernisation will come to a halt.

4.0 Strategic Context, Vision & Principles for
    Development
4.1     The plan is written against a context of pressures for strategic change that
        already influence what is done and being planned for in the Greater
        Peterborough health and social care community. The main influences have
        been taken into account in developing the plan. The main sources of
        knowledge of these influences have been:
        i.   A range of current of supra local government policies and initiatives
        ii. Key local planning documents
        iii. The views of a wide range of local stakeholders who contributed to the
             process through externally facilitated SSDP development workshops.

4.2     Influence of Supra Local Policies and Initiatives

4.3     The SSDP process has sought to achieve fit with recent national government
        documents and publications and central initiatives that are intended to shape
        the way that services for people with health and well being needs develop
        now and in the future. The main influences on the plan from this source are
        set out in the following table.

Policy area/ initiative         What the SSDP must do in response
National Service                Give high priority to services covered by frameworks
Frameworks                      and standards and evidence base to influence the
                                scope and ways of working for services to be
                                commissioned at whole system and individual service
                                levels.




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Policy area/ initiative        What the SSDP must do in response
Regional Spatial Plan          Recognise the role of Peterborough as a key centre
                               for development and change with at least 20,000
                               additional jobs in the period 2001-2021 together with
                               strong housing growth, sustainable transport
                               improvements and provision of social community and
                               green infrastructure.
                               Foster close working with Opportunity Peterborough,
                               the Urban Regeneration Company for the city and
                               cooperation across regional boundaries.
                               Utilise the opportunity created by regeneration and
                               redevelopment in Peterborough for the use of Section
                               106 contributions to fund health and well being
                               facilities improvements.
New General Medical            Enable expansion of primary health care teams to
Services Contract              achieve the levels of access anticipated to the highest
                               quality local services.
Alternative Provider           Facilitate opportunities to commission a wide range of
Medical Services Contract      providers delivering services with similar benefits as
                               those achieved through the nGMS contract route.
New Pharmacy Contract          Create opportunities for the engagement of
                               community pharmacists in the care of patients by
                               primary health care teams.
Our Health, Our Care, Our      Focus on the key priority of helping people to lead a
Say                            healthy, active and independent life.
                               Demonstrate that specialist health and social care is
                               being shifted from out of town sites into the local
                               community.
                               Develop a new generation of community hospitals.
Modernising Adult Social       Accelerate movement towards a culture for
Care – what’s working          commissioning and delivering services that fits with
                               the seven elements of the action and interaction
                               model.
The ‘Quality Strategy for      Develop roles at the interface between providers of
Social Care’ (2000)            health and social care that help deliver the policy’s
                               aspirations to promote independence, strengthen
                               families, improve the life chances of children in need
                               and to be a dynamic positive force in tackling
                               inequality and promoting social inclusion.
National Programme             Use information to give a greater understanding of
Budget project                 where the money for health and social services is
                               being spent and to allocate resource to geographical
                               areas and programme categories of greatest need.
Payment by Results             Use local funding to procure healthcare from provider
                               settings that meet disease based standards safely
                               and cost effectively.
Practice Based                 Engage practices and other frontline primary care
Commissioning                  professionals in the commissioning of health and well
                               being services. Point the way to delivering high quality
                               services for patients in local and convenient settings.



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Policy area/ initiative        What the SSDP must do in response
Social Enterprise              Foster organisations that are run along business
                               lines, but where any profits are reinvested into the
                               community or into service developments and involve
                               patients and staff in designing and delivering services,
                               improving quality and tailoring services to meet
                               patients' needs.
Primary Health and Social      Create excellent physical capacity to enable:
Care Premises Policy               The transfer of care from the acute to the primary
                                   care sector
                                   Healthcare professionals to develop and practice
                                   new skills
                                   Consumerism
                                   Design quality and sustainability
                                   Enhance the patient experience through
                                   improvements to the organisation of care and the
                                   quality of healthcare premises.
Healthcare Environment         Create facilities that enhance patient experience and
Policy                         matter to patients, their visitors, carers and to staff.
Self Care                      Foster a local culture of self care as one of the key
                               building blocks for a person centred health and well
                               being service and as a key component of the local
                               model for supporting people with long term conditions.
SHAPE                          The White Paper, Our health, our care, our say: A
                               new direction for community services (DH 2006)
                               encourages commissioners to use a Department of
                               Health tool that is under development to support
                               service reconfiguration. SHAPE is a web-enabled
                               toolkit that is being designed to support the strategic
                               planning of services and physical assets across a
                               whole health economy.
                               It takes as its starting point the current clinical activity,
                               projections of need and potential demand, and the
                               existing estate or physical capacity. SHAPE will
                               provide a scenario-planning tool to determine
                               optimum service delivery model and to identify
                               investment needs and disinvestment opportunities to
                               support delivery of the model. It will be rolled -out on
                               the DH website from April onward as data for health
                               economies is progressively incorporated. The
                               process for developing this SSDP has used the
                               principles on which SHAPE is being based.

Emergency Care Policy          Free the costly resources of A&E Departments to deal
                               with genuine emergencies and provide a responsive
                               service so that no person spends more than four
                               hours in an A&E Department.




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Policy area/ initiative       What the SSDP must do in response
Integrated Care Policies      Foster change to sustain reductions in the number of
                              patients who are delayed in hospital even though they
                              are fit to be discharged including the development of
                              whole system provider organisations.
Secondary Care Policy         Encourage the development of Treatment Centres
                              (TCs) to offer safe, fast, pre-booked day and short-
                              stay surgery and diagnostic procedures in areas that
                              have traditionally had the longest waiting times.
                              Promote the role of NHS Foundation Trust as being at
                              the cutting edge of the Government's commitment to
                              the decentralisation of public services and the
                              creation of a patient-led NHS.
Primary Care                  Enable the application of The Fairness in Primary
                              Care procurement principles to tackle inequalities in
                              access to primary medical care services and to
                              provide patients with greater access and choice,
                              including flexible opening hours, extended services
                              and easier access to primary medical care services in
                              their local area.
National Standards, Local     Sustain the achievement of the standards set for NHS
Action: Health and Social     organisations and social services authorities.
Care Standards and
Planning Framework
2005/06 - 2007/08
The NHS in England        Foster changes to sustain:
Operating Framework 2007     A maximum wait of 18 weeks from GP referral to
-2008                        start of treatment
                             Reductions in rates of MRSA and other healthcare
                             associated infection
                             Reduction in health inequalities
                             The promotion of health and well being
                             The financial health of organisations
                             commissioning or delivering health or social care
                             A modern IT enabled NHS as set out in Delivering
                             21st Century IT support for the NHS and a national
                             programme for IT (NPfIT)
                             The strengthening of NHS providers through the
                             NHS Foundation Trust programme
                             Increased plurality of provision through the ISTC
                             and extended choice network
                             Commissioning that engages practitioners and
                             gives people more control over their own care.
Small change, big         Foster changes to encourage people to make even
difference campaign       minor changes in their lifestyles, to give them a better
                          chance of living longer, healthier lives.
Choosing Health White     Enable the application of the principles for supporting
Paper                     the public to make healthier and more informed
                          choices in regards to their health.




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4.4   A more detailed statement setting out how these influences will affect
      Peterborough in the future is in Appendix 11.

4.5   During the development of the Plan:
      i.   The Department of Health published “our NHS our future” an interim
           report of a review by Professor the Lord Darzi of Denham on the next
           stages of modernisation in the NHS in England.
      ii. The SHA published the Document “Improving Lives: Saving Lives” setting
          out the Authority’s ideas on the vision it should have and the pledges it
          should make to improve healthcare for people living in its area.

4.6   The ambition behind the Darzi report is to make the NHS world class in every
      aspect so that it prevents ill health, saves lives and improves the quality of
      people’s lives. It sets out a vision of a service that is fair, personalised,
      effective and safe and assesses the extent to which such a vision is being
      realised today based on listening to the experiences of NHS personnel and
      people who use the services of the NHS. It advocates the universal
      achievement of this vision through step change and not incremental
      development, with continuous improvement, ambition, empowerment,
      centrally supported locally driven and evidence based change and
      effectiveness combined with efficiency as the engines that will realise the
      achievement of the vision. Immediate steps are also proposed that will
      impact on health inequalities, the degree of personal choice that people will
      have in terms of primary care and care for long term conditions, the range of
      services available in new and improved facilities, hours of access,
      dissemination of best practice, safety and the planning of change for acute
      services. This SSDP is based on a direction of travel for the modernisation of
      services in Peterborough that anticipates many of these themes.

4.7   “Improving Lives: Saving Lives” sets out a proposal for 11 pledges for patients
      as follows:
      i.   Year on year improvements in patient satisfaction
      ii. Quicker access to services
      iii. Making it easier to see a doctor at a more convenient time
      iv. NHS dentistry available to all who want it
      v. Fewer people suffering or dying from heart disease, cancer or stroke
      vi. Access to the safest healthcare
      vii. Improved lives for people with long term illnesses
      viii. The difference between the life expectancy of the 20 per cent of poorest
            communities and the rest of England halved by 20 per cent
      ix. Number of smokers cut by 140,000
      x. Halt in the rise of and then reduction in numbers of obese children
      xi. Same healthcare available to marginalised groups and looked after
          children as to the rest of the population



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4.8    In developing the principles for and configurations of future services the
       SSDP has been influenced by aims that are consistent with these pledges.

4.9    Synergies with Current Local Planning

4.10   To inform the development of the plan the following main local planning
       documents were reviewed:
       i.   The Future Direction of Community Health and Social Care Services
            directly provided by Peterborough Primary Care Trust – A Consultation
            Document – July 2007
       ii. A Strategy for Older People's Accommodation and Housing Related
           Support Services for Peterborough – 11 June 2007
       iii. Peterborough City Council Department of Adult Social Services Key Roles
       iv. Peterborough PCT Primary Care Estate Strategy – December 2002
       v. Growing the Right Way - Peterborough’s Local Area Agreement - July
          2005
       vi. Action Plan for Accommodation and Housing Related Support Strategy for
           Older People
       vii. Continuing Care - Future Options & Issues: A Discussion Paper
       viii. Business Case for Public Capital Investment in Peterborough Primary
             Care Trust’s Primary Care Physical Facilities Developments 2006 to 2010.

4.11   The documents reviewed suggest a model for future commissioning services
       that will require changes in:
       i.   Response to users’ needs by:

            a. Fostering a “responsibility for own health and well being” culture in the
               Peterborough area
            b. Increasing the influence of commissioners and the general public the
               expression of health and well being needs and the specification of
               services to meet them
            c. Designing and delivering services around individual needs
            d. Delivering responsive services with fast and convenient access
            e. Giving users equitable access to services they need irrespective of the
               personal and social factors that have traditionally disadvantaged them
               (e.g. age, ethnicity, poverty)
            f. Giving all residents of Peterborough access to dental services that
               match their needs
            g. Supporting vulnerable people who want to continue to live in their own
               homes or wherever they choose to be and in making those choices
       ii. The organisation of agencies providing care by:

            a. Procuring all services from arms length providers
            b. Integrating the organisation of health and social care provision
            c. Encouraging agencies to team up and possibly evolve into single
               provider agencies to provide integrated health and social care


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   d. Encouraging organisations to work together to support families in
      giving children the best possible start in life
   e. Encouraging the role that all sectors and agencies can play in the
      maintenance of health and well being
   f. Collocating of providers to give service users access to a wide range
      of services and to enable practitioners to share skills effectively
iii. The roles of practitioners delivering services by:

   a. Enhancing the roles of domiciliary and primary care practitioners
   b. Rebalancing care between that provided by individuals and that
      provided by multi-disciplinary and multi-agency teams
   c. Expanding primary care practitioner roles
   d. Encouraging agencies to make joint appointments

iv. The balance of care provided at different levels and by different agencies
    by:

   a. Rebalancing care between hospitals and the community
   b. Distinguishing organisationally between specialist and general
      services
   c. Placing services as close to peoples’ homes as clinical governance
      and economy of scale principles will allow
   d. Giving users access to one stop community based unplanned care
      services to support the role of A&E services as major trauma service
      providers
v. Service delivery outcomes by:
   a. Delivering services that result in high levels of health, independence
      and well being
   b. Enabling people with the greatest support needs to live independent
      lives
   c. Encouraging people with illness and disability to live fulfilling lives by
      developing effective coping and/or health improving lifestyles
   d. Helping people to stay well by developing health improving lifestyles
   e. Developing specialist community based services to enhance “out of
      hospital” capacity
vi. Community capacity by:

   a. Supporting the development of inclusive social networks to promote
      healthy living and ageing, to support carers and to support bereaved
      people after the death of a loved one
   b. Conferring on service users the status of equal partners in the
      planning and delivery of services
vii. Service capacity by:

   a. Maintaining strong teaching, continuing professional development,
      multi professional learning and research functions
   b. Placing emphasis on prevention and rapid rehabilitation


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            c. Expanding the capacity for the joint assessment of individual service
               users’ needs and providing them with integrated care packages
            d. Facilitating growth in capacity to keep pace with changes in service
               demand balanced across the whole system
            e. Facilitating growth driven by practice based/ locality commissioning.

4.12   Stakeholder views

4.13   Seen through the eyes of local stakeholders there is a need varying in
       intensity to shape services in response to broad categories of drivers such as:
       i.   Local plans
       ii. Improved knowledge
       iii. Peoples’ lifestyles & expectations
       iv. Drive for comprehensiveness
       v. Drive for equity
       vi. Incentives & disillusionment
       vii. Financial pressures
       viii. New organisations, cultures & contracts
       ix. Legislation
       x. New best practice
       xi. Political views, government policies, guidelines & targets
       xii. Expanding technology
       xiii. Contestability and competition and a level playing field for new entrants to
             the market place including the private sector and the third sector.

4.14   All of the change factors identified at the workshops are listed in Appendices
       10 and 11 of this plan as either pressures coming from within the local health
       and well being community or from a variety of global influences that affect
       health and well being strategic planning UK or even world wide.

4.15   In considering this wide range of pressures for change people contributing to
       the SSDP have had a significant opportunity to consider what works well both
       locally and elsewhere and to think innovatively about how services
       commissioners and providers should respond to a world in which contextual
       change is both significant and rapid.

4.16   Influence of Change Drivers on the Peterborough Vision

4.17   The analysis of internal and external influences can be summarised in the
       following diagram that illustrates the “new world” vision that lies behind the
       changes in this plan.




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                             PUBLIC EXPENDITURE       STANDARDS FOR              EVIDENCE BASED       CONSUMER LED
                             EFFICIENCY TARGETS      EVIDENCE BASED               NEW WAYS OF        COMMISSIONING
                                                           OUTCOME                  WORKING

           AGENDA TO REDUCE                           IMPROVEMENT                                             EXPANSION OF
             INEQUALITIES                                                                                          ENABLING

                                                  external influences                                         TECHNOLOGIES

          GROWTH IN
         CONSUMERIST                                                                                                     PETERBOROUGH
                                                             pockets of high
         EXPECTATIONS                                                                                                   REDEVELOPMENT &
                                                               deprivation                                               REGENERATION
                                         traditional make                      scope for health &                         INITIATIVES
      GROWTH OF SOCIAL
                                         up of w orkforce                           ell
                                                                                  w being
         ENTERPRISES                                                                                                      NEW OPPORTUNITIES
                                                                                 improvem  ent
                                                            larger, older &                                                    FOR PROVIDER
                                                            more diversified                                                   CONTRACTING
                                     high num bers of                               phy sical capacity
                                                              population
        PRACTITIONER                  pre school age                               of present facilties
                                         children                                                                       NEW GENERATION OF
       INVOLVEMENT IN
                                                   unequal service     cost of improving                                      COMMUNITY
       COMMISSIONING
                                                     distribution       present facilties                                     HOSPITALS


         PRESSURE FOR
                                                                                                               GROWING SELF CARE
      SPEEDIER RESPONSES
      TO CHANGES IN NEED
                                              INTERNAL INFLUENCES                                                  EXPECTATIONS &
                                                                                                                    OPPORTUNITIES


               DATA TO INFORM                                                                   JOINT WORKING TO
                                        OPPORTUNITIES TO
             CHANGES IN BALANCE                                  DATA TO INFORM             PROMOTE INDEPENDENCE,
                                        MOVE ACTIVITY AND
                   OF CARE                                       IMPROVED MATCH               FAMILY WELL BEING &
                                       RESOURCES BETWEEN
                                                                 BETWEEN NEED &                 SOCIAL INCLUSION
                                          CARE SETTINGS
                                                                      RESOURCE
                                                                     ALLOCATION




4.18       Impact of the Strategic Context on the Case for Change

           The world outside Peterborough is undergoing rapid and significant changes
           that will affect the city’s health and social care services if they are to keep
           pace with those in other parts of the UK. New ideas, technologies and
           opportunities abound. It is part of the vision of Peterborough PCT and its
           partners to be in the vanguard of that change because this will benefit the
           populations they serve. When the force of external drivers is combined with
           the impact of internal drivers they create a need for rapid and significant
           change. If this is not made or delayed Peterborough may fall rapidly behind
           other areas and fail to achieve its vision of ‘Peterborough people living longer,
           healthy, independent and self-determined lives'



5.0 Proposed Approach to Matching Services and
    Resources to the Vision
5.1        Developing the Service Vision and Preferred Commissioning Model

5.2        There is strong consensus in the local health and social care community that
           the appropriate response to the case for change arising from the assessed
           performance of the current commissioning model and the strategic context
           that are driving change is to replace the existing commissioning model with
           the one illustrated in the following diagram.




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                                                       Principles for service
  Principles for organising
                                                       commissioning
  physical resources                                                                      Principles for m atching
  Structured network of technology                                                        resources w ith service need
  enabled primary care centres                                                            Commissioner intentions based
  supported by locality and central                                                       on needs assessment &
  resource centres                                                                        consumer aspirations




                                                                                          Principles for defining
                                                                                          populations served
                                                                                          Varies by service to assure
                                                                                          quality, meet standards & be
                             STRATEGIC GOAL SERVICE                                       cost effective

                              MODEL SSDP OPTION 6
                                                                                          Principles for determ ining
                                                                                          the scope of services
                                                                                          Seamless person centred
                                                                                          pathw ays to cover prevention,
                                                                                          screening, support, treatment &
 Principles for workforce                                                                 self care
 organisation
 Virtual pathway based teams
                                                         Principles for provider organisation
 New practitioner roles defined by
                                                         Contestable provider market
 pathway skill needs
                                                         High dependence on community based services
 Unneccessary organisational &
                                                         Whole system contractor network
 professional boundaries removed
                                                         Coordinated health & social care for all needs
                                                         Supported service users



5.3      This conclusion was reached from consideration of the results of an
         interactive workshop process to define and evaluate a range of
         commissioning model options in the context described in the previous section
         of the plan. The options were evaluated in terms of potential to achieve
         required benefits, sensitivity to future uncertainty and cost.

5.4      The assessment of cost was undertaken by making assumptions about the
         required changes to the configuration of the estate to inform an assessment
         of the amount of space required to be built, altered or refurbished to support
         each option. Department Cost Allowance Guides were used to assess the
         cost of building or altering the space required and on appropriate costs were
         added. Following selection of the preferred commissioning model a range of
         possible estate configuration options were evaluated to determine which
         would most effectively support the proposed commissioning model. The
         process for this and the results of the process are set out from paragraph 5.17
         to paragraph 5.23.

5.5      The process followed option appraisal guidance set out in the NHS Capital
         Investment Manual and the HM Treasury guidance on investment appraisal
         (the Green Book).

5.6      The process is described in detail in Appendix 12.

5.7      The appraisal provided results that inform a selection of a preferred option
         based on the following indicators of potential performance:
         i.         Likely benefits
         ii.        Minimum benefits


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            iii.       Maximum benefits
            iv.        Certainty of weighted benefit scores
            v.         Capital cost
            vi.        Net present cost
            vii.       Likely weighted benefit points per NPC
            viii.      Minimum weighted benefit points per NPC
            ix.        Maximum weighted benefit points per NPC.

5.8         The following table summarises these results.

Indicator                                                                 Distance from best by Option
                                                                  Op. 1     Op. 2    Op. 3   Op. 4       Op. 5   Op. 6




                                                         Change
                                                         No
Likely weighted benefits                                 185%     200%       99%      47%       5%        31%      0%
Minimum weighted benefits                                212%     234%      130%      83%       9%        51%      0%
Maximum weighted benefits                                149%     173%       71%      53%       3%        17%      0%
Certainty of weighted benefit scores                      31%       0%       98%      35%      16%        85%      4%
Capital cost                                               n/a     70%       42%       0%      21%         0%      9%
Net present cost (NPC)                                     n/a     70%       42%       0%      21%         0%      9%
Likely weighted benefit points per NPC                     n/a    154%       99%      43%      15%        25%      0%
Minimum weighted benefit points per NPC                    n/a    166%      121%      83%      24%        51%      0%
Maximum weighted benefit points per NPC                    n/a    136%       80%      53%      20%        17%      0%


Note: The table shows the amount of change required by each commissioning
model option to become the best option for each of the indicators.

LEGEND zzz

              Cell Colour              Denotes
                                       Best option for selected indicator
                                       Second best option for selected indicator
                                       Mid rank options
                                       Second worst option for selected indicator
                                       Worst option for selected indicator

5.9         The considerations for each option that led to the selection of the preferred
            option are as follows:
            i.         “No Change” Option

                    a. This option incurs no additional capital costs. It is likely over time to
                       incur increasing revenue costs to keep up to standard an estate
                       infrastructure that is shown elsewhere in this plan to perform poorly
                       and in achieving ways of meeting increased service requirements in
                       buildings that will become more and more unsuitable for this.




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       b. These have not been calculated as the option appraisal shows that the
          option is capable at best of a level of benefits achievement at least 1.5
          times poorer than the option with the greatest potential.

       c. The appraisal results also show this option as the fourth most
          sensitive to future uncertainty (quantified by the certainty of weighted
          benefit scores indicator) which could make it up to twice as poor as
          the option with the greatest benefits potential.

       d. Taken together, these results show that the “No Change” option is not
          suitable as a model for commissioning in the future and demonstrates
          the clear need for some change already set out in the plan.
ii.       Option 1

       a. It has been assumed that this option would require investment in an
          estate infrastructure similar to the present one and would benefit from
          few economies of scale. As a result its capital and net present costs
          are high (nearly three quarters as much again as the option with the
          lowest costs). Its benefits potential is poor also (between 1.75 and 2.5
          times poorer than that of the most beneficial option). It is consistently
          the poorest of the 7 options appraised in terms of costs and benefits.
          Its sensitivity to future risk is relatively low but this only confirms that it
          is relatively certain to perform poorly.

       b. Current guidance suggests that the primary indicator of preference
          among options is the weighted benefit points per unit of net present
          cost. Option 1 is ranked worst against this indicator.

       c. Taken together, these results show that Option 1 is not suitable as a
          model for commissioning in the future and would almost certainly
          result in significant expenditure to achieve fewer benefits than would
          be achievable by the “No Change” option.
iii.      Option 2

       a. It has been assumed that this option would require investment in a
          decentralised “hub and spoke” estate infrastructure and would benefit
          from few economies of scale. As a result its capital and net present
          costs are high (nearly half as much again as the option with the lowest
          costs). Its benefits potential is poor also (between 3/4 and 1.5 times
          poorer than that of the most beneficial option). It is consistently the
          second poorest of the 7 options appraised in terms of costs and
          benefits. Its sensitivity to future risk is the highest of all options.

       b. Current guidance suggests that the primary indicator of preference
          among options is the weighted benefit points per unit of net present
          cost. Option 2 is ranked second worst against this indicator.

       c. Taken together, these results show that Option 2 is not suitable as a
          model for commissioning in the future and could result in significant



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         expenditure and risk to achieve fewer benefits than would be
         achievable by the “No Change” option.
iv.      Option 3

      a. It has been assumed that this option would require investment in a
         decentralised estate infrastructure collocating a full range of services
         at neighbourhood level and would benefit greatly from economies of
         scale. As a result its capital and net present costs are low (equal as
         the option with the lowest costs). Its benefits potential is moderate
         also (between 1/2 and 3/4 times poorer than that of the most beneficial
         option). Its rank in relation to other options in terms of costs and
         benefits show it to be a moderately successful option with very low
         costs. Its low costs are masked to some extent by having not included
         the sunk cost of the Peterborough and Stamford Hospitals NHS
         Foundation Trust PPP investment in a new community hospital/
         resource centre for the city. It is the third poorest option of all options
         in terms of sensitivity to future risk.

      b. Current guidance suggests that the primary indicator of preference
         among options is the weighted benefit points per unit of net present
         cost. Option 3 is ranked second worst against this indicator.

      c. Taken together, these results show that Option 3 is more suitable as a
         model for commissioning in the future than either the “No Change”
         Option, Option 1 or Option 2 having the potential to achieve a
         moderate level of benefits with low levels of additional expenditure and
         moderate levels of risk. If on these grounds it was to be considered as
         the future model its impact on the financial viability of the
         Peterborough and Stamford Hospitals NHS Foundation Trust PPP
         would have to be examined. The certainty that this would rule it out of
         consideration let alone selection as the basis for the future
         commissioning model is extremely high.
v.       Option 4

      a. It has been assumed that this option would require investment in a
         locality and neighbourhood based estate infrastructure and would
         benefit from economies of scale. As a result its capital and net
         present costs are moderate (the option with the third lowest costs and
         significantly lower than the 2 options with higher costs). Its benefits
         potential is very high (within 3 to 9 percent of the option with the
         highest scores). Its rank in relation to other options in terms of costs
         and benefits show it to be a potentially very successful option with
         moderate costs. Its moderate costs are masked to some extent by
         having not included the sunk cost of the Peterborough and Stamford
         Hospitals NHS Foundation Trust PPP investment in a new community
         hospital/ resource centre for the city. It is the third best option of all
         options in terms of sensitivity to future risk.




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       b. Current guidance suggests that the primary indicator of preference
          among options is the weighted benefit points per unit of net present
          cost. Option 4 is ranked second best against this indicator for likely
          and minimum scores and third best for maximum scores, ignoring the
          impact on costs of changes to the Peterborough and Stamford
          Hospitals NHS Foundation Trust PPP investment proposals.

       c. Taken together, these results show that Option 4 is very suitable as a
          model for commissioning in the future having the potential to achieve a
          very high level of benefits with moderate levels of additional
          expenditure and risk. If on these grounds it was to be considered as
          the future model its impact on the financial viability of the
          Peterborough and Stamford Hospitals NHS Foundation Trust PPP
          would have to be examined. The certainty that this would rule it out of
          selection as the basis for the future commissioning model is extremely
          high unless the commissioning principles and other required features
          of provider organisation embedded within it were deliverable with an
          estate infrastructure that did not require change to the Greater
          Peterborough Health Investment Plan.
vi.       Option 5

       a. It has been assumed that this option would require investment in a city
          centre and locality based estate infrastructure and would benefit
          significantly from economies of scale. As a result its capital and net
          present costs are low (equal as the option with the lowest costs). Its
          benefits potential is moderately high (within 17 to 51 percent of the
          option with the highest scores). Its rank in relation to other options in
          terms of costs and benefits show it to be a potentially very successful
          option with low costs. It is the second worst option of all options in
          terms of sensitivity to future risk.

       b. Current guidance suggests that the primary indicator of preference
          among options is the weighted benefit points per unit of net present
          cost. Option 5 is ranked third best against this indicator for likely and
          minimum scores and second best for maximum scores, ignoring the
          impact on costs of changes to the Peterborough and Stamford
          Hospitals NHS Foundation Trust PPP investment proposals. Its
          ranking for sensitivity to future risk suggests that it is very unlikely to
          achieve its maximum potential benefits.

       c. Taken together, these results show that Option 5, in spite of its low
          costs, is fairly unsuitable as a model for commissioning in the future
          having the potential only to achieve a moderately high level of benefits
          but with extremely high levels of risk.
vii.      Option 6

       a. It has been assumed that this option would require investment in a city
          centre and neighbourhood based estate infrastructure with additional
          services at locality level and would benefit significantly from



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              economies of scale. As a result its capital and net present costs are
              low (ranked second lowest of all options). Its benefits potential is
              extremely high (ranked the option with the highest scores). Its rank in
              relation to other options in terms of costs and benefits show it to be a
              potentially very successful option with low costs. It is the second best
              option of all options in terms of sensitivity to future risk.

          b. Current guidance suggests that the primary indicator of preference
             among options is the weighted benefit points per unit of net present
             cost. Option 6 is ranked best against this indicator.

          c. Taken together, these results show that Option 6 is dominant as a
             model for commissioning in the future having the potential to achieve
             extremely high levels of benefits with relatively low levels of cost and
             risk.

5.10   Conclusion

5.11   The clear conclusion from the results of the appraisal is that Option 6 forms
       the best all round solution as the future commissioning model for the
       Peterborough area. Only one additional factor to consider is the achievability
       of such a scale of change within the period covered by the SSDP. Clearly to
       invest in an estate infrastructure other than the one needed to support Option
       6 would be short sighted. However it is likely that the minimum degree of
       service change desirable within the plan period would equate to Option 4
       which would on an interim basis deliver benefits very close to those
       achievable from Option 6 but with higher risk. As the risks probably arise
       from sustaining this option when a better is available, the plan to move on to
       Option 6 gradually should mitigate these risks. Option 4 can be illustrated as
       follows:




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                                                     Principles for service
   Principles for organising
                                                     commissioning
   physical resources
   Structured network of technology
   enabled resource centres and                                                       Principles for m atching
   local polycentres                                                                  resources w ith service
                                                                                      need
                                                                                      Commissioner intentions based
                                                                                      on needs assessment



                                                                                      Principles for defining
                                                                                      populations served
                              INTERIM SERVICE MODEL                                   Predominantly locality based
                                                                                      w ith outreach to sub
                                  SSDP OPTION 4                                       populations




                                                                                      Principles for determ ining
                                                                                      the scope of services
                                                                                      Tending to comprehensive
                                                                                      range
  Principles for workforce
  organisation
  Lower dependence on indivual                        Principles for provider organisation
  practitioners                                       Contestable provider market
  Significant MDT development                         Increased dependence on community based services
  New practitioner roles                              Whole system contractor network
  Professional boundaries                             Coordinated health & social care for all needs




5.12     The following diagrams illustrate the migration path from the present service
         model through changes enabled by the SSDP and other complementary
         plans (such as LAA, P&SFT OBC) to Option 6 for each set of principles on
         which the models have been based.

5.13     Changes in Commissioning Principles

                                  Historical basis              SSDP                Commissioner
    Need                                                                            intentions based on
    identification                                                                  needs assessment &
    principles                                                                      consumer
                                                                                    aspirations
                                  Access at city,
                                                                LAA
                                  locality,                                         Varies by service to
                                  neighbourhood &                                   assure quality, meet
   Population
                                  lower levels                                      standards & be cost
   sizing
                                  Mostly to small local                             effective
   principles
                                  populations or                Outline
                                  whole city                    Business
                                                                Cases
                                                                                    Seamless person
                                                                                    centred pathways to
   Service                        Historical basis with
                                                                                    cover prevention,
   scope                          many service gaps &
                                                                "Next               screening, support,
   principles                     unmet needs
                                                                Steps"              treatment & self care




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5.14   Changes in Provider Organisation Principles

                       Large number of             SSDP             Contestable provider
                       uncoordinated                                market
                       providers

                                                                    High dependence on
                      Fragmented                                    community based
                      contractor network                            services
   Provider
                                                   LAA              Whole system
   organisation
                                                                    contractor network
   principles                                      Outline
                      Coordinated health           Business         Coordinated health &
                      & social care for            Cases
                                                                    social care for all
                      older people
                                                                    needs
                                                   "Next            Supported service
                       Uncoordinated               Steps"
                                                                    users
                       childrens services



5.15   Changes in Workforce Organisation Principles

                      Indivual                     SSDP             Virtual pathway
                      practitioners are                             based teams
                      main care deliverers



                                                   LAA
                      Some MDT                                      New practitioner
   Workforce
                      development                                   roles defined by
   organisation
                                                                    pathway skill needs
   principles
                                                   Outline
                                                   Business
                                                   Cases
                      Traditional roles &                           Unneccessary
                      professional &                                organisational &
                      agency boundaries                             professional
                                                   "Next            boundaries removed
                                                   Steps"




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5.16   Changes in Physical Resource Organisation Principles

                        Small surgeries &             SSDP             Structured network
                        clinics relying on                             of primary health &
                        DGH for support                                well being centres
                                                                       within each locality

                                                                       Supported by
                                                      LAA
                        Dedicated to single                            locality and central
   Physical
                        service use as                                 resource centres
   resource
                        provided by
   configuration
                        premises "owner"
   principles                                         Outline          Flexible in range of
                                                      Business         services provided by
                                                      Cases            multiple agencies
                        Low technology


                                                                       All fully technology
                                                      "Next
                                                                       enabled
                                                      Steps"


5.17   Configuration of the Supporting Estate

5.18   There are a number of ways of configuring the estate to achieve the service
       principles on which the preferred commissioning option is based. The range
       of possibilities is set out in the following table.

Estate           Possible make up of the estate
Configuration
Option
Option 1         Network of small to medium sized GP surgeries and clinics
Option 2         Network of small to medium sized primary care centres supported by primary care
                 resource centres/ community hospitals.
Option 3         Network of neighbourhood based primary care resource centres
Option 4         Network of small to medium sized primary care centres supported by locality
                 primary care resource centres
Option 5         Network of locality based resource centres supported by local "polycentres" at or
                 below neighbourhood level
Option 6         Network of multi locality based resource centre/ community hospital supported by
                 local "polycentres" at or below locality level
Option 7         Network of multi locality based resource centre/ community hospital supported by
                 a locality based network of local primary health and well being facilities one in each
                 locality developed as a centre for selected specialist services.

5.19   An appraisal has been undertaken to establish the potential of each option to
       achieve a set of decision making criteria that represent the 5 sets of principles
       on which the preferred commissioning model is based. Details of the



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          appraisal are set out in Appendix 12 and a summary of the results is shown in
          the following table.
                                                                            Estate Configuration Option




                                       Weight
Decision making criteria                            1             2               3             4             5             6             7
Fit with principles for provider
organisation
                                           18   1        18   2        36     1        18   2        36   3        54   3        54   4        72
Fit with principles for workforce
organisation
                                           18   1        18   2        36     1        18   4        72   4        72   3        54   4        72
Fit with principles for determining
the scope of services
                                           20   1        20   3        60     2        40   3        60   3        60   2        40   3        60
Fit with principles for matching
resources with service need
                                           30   1        30   3        90     1        30   3        90   2        60   2        60   4       120
Fit with principles for defining
populations served
                                           14   2        28   3        42     2        28   3        42   3        42   2        28   5        70
TOTAL                                   100             114           264             134           300           288           236           394


5.20      Based on this the preferred option is “Option 7 – A network of multi locality
          based resource centre/ new generation community hospital facilities
          supported by a locality based primary health and well being centres with the
          capacity to integrate a wide range of services that can ensure local access to
          a comprehensive primary care and community based service network.
          Wherever future service providers consider this can be done without
          compromising the benefits gained from the current model, these centres
          would encourage different providers to work together in one building, enjoying
          the benefits that this brings. One of these centres in each locality would be
          developed as a centre for selected specialist services to ensure that local
          access to these is secured safely and cost effectively.

5.21      The areas where the PCT and its partners see the need to invest in these
          facilities within each locality are mainly the areas defined as district centres in
          the Regional Spatial Plan (i.e. City Centre, Millfield, Hampton, Werrington,
          Bretton and Orton) see paragraph 3.10. However there are “other opportunity
          areas” in Peterborough which will require investment due to population
          growth, including Stanground, Paston and the 25 or so village communities in
          the Rural West and Rural East localities.

5.22      The following map indicates the areas in which the proposed central and
          locality based facilities should be developed during the period covered by the
          SSDP and potential further developments beyond that.




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                                                                                                     Localities with
                                   NORTH EAST LOCALITY                                               Health & Well
                                                                                             1       Being Centre
                                    4                                                                developments in
                                                                                                     the Plan Peroid
                                                                                                     with priorities
                                                  8                RURAL EAST LOCALITY
                                                                                                     Areas where
                                                                                                     development
                                  5                                                                  may take
                                                      2                                              place at a later
          NORTH WEST LOCALITY                             CENTRAL & EAST LOCALITY
                                                                                                     date

RURAL WEST LOCALITY                                                                Resource Centre Network
                                                                                   Integrated Care Centre
                                                  1                                Well Being Centre
                                                                                              ing
                                                                                   Healthy Liv Centre
                                      3
                                                           SOUTH EAST LOCALITY
                                              6
                                                                   7




           SOUTH WEST LOCALITY




         5.23         The numbers in the graphic above represent proposed priorities, which are
                      based on population expansion, service need and the performance of the
                      present estate.

         5.24         The PCT has already begun to consider how the commissioning of particular
                      services will fit with this model. A summary of the results of this is at
                      Appendix 19.

         6.0 Procurement of Services and Supporting
             Infrastructure
         6.1          The Peterborough Primary Care NHS Trust and its partners expect to achieve
                      progressive migration from the present day commissioning model to the
                      preferred options proposed in this plan through processes of service and
                      facilities procurement and contracting.

         6.2          The choices for how they will progress these two streams of procurement and
                      contracting are made up of variations in:




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       i.   The timing of procurement for service providers relative to the timing for
            facilities procurement.
       ii. The source of funding for the procurement of facilities.

6.3    Based on this structuring of the choices available the following procurement
       and contracting options have been considered.



                                                 Capital Source Options

Service/    Facilities   Timing    Public Capital       PPP/ Third                LIFT
Option                                                    Party
                                                        Developer

Service first: facilities last           1A                  1B                   1C

Facilities first: services last          2A                  2B                   2C

Services & facilities
                                         3A                  3B                   3C
together

6.4    Appendix 17 contains the results of an assessment of these options against
       appropriate weighted criteria and concludes that the simultaneous
       procurement of service providers with third party development partners
       (Option 3b) is the preferred way of contracting to achieve the delivery of the
       proposed changes in commissioning model that underpin the SSDP.

6.5    As part of the Human Resource strategy for achieving the benefits of the plan,
       the PCT will need to develop its own commissioning workforce to have the
       skills required to procure and contract manage all contracts with its providers
       to ensure the plan is achieved.

6.6    In undertaking its procurement processes, the PCT will require all potential
       providers to demonstrate, in their tenders for services details of how they will
       ensure their workforce, estate and technology resources can meet the
       outcomes of the contract that are indicated in this plan. This will include
       evidence of education training and development, any necessary professional
       registration, clinical, and health and safety training and development,
       professional supervision and support for continuing professional development.
       It will also include all legal and statutory employment requirements and best
       practice, including having in place robust process to manage performance
       and practically to deal with professional competency issues.

6.7    It will also either need to employ or procure professionals skilled in the
       specification of standards to be met by physical facilities and to ensure that
       providers with estate development contractual obligations comply with these.
       If it invests capital in PCT owned estate it will need to have access to
       personnel with operational estate management skills to ensure that it



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        complies with its obligations as landlord to its commissioned service providers
        and as owner occupier of any vested estate used for its own functions.

7.0 Impact of the Plan on the Health & Well Being of
    Greater Peterborough
7.1     The plan will help the PCT and its partners to tackle important strategic health
        and well being issues that have been identified in the process of developing
        this plan and other potential issues identified by other local and regional plans
        and national and global policies.

7.2     The goals to that should be achieved to tackle these issues have been
        identified from planning work undertaken prior to or in parallel with the
        preparation of the SSDP (predominantly the Local Area Agreement and the
        Health and Well Being needs assessment).

7.3     The SSDP changes are expected to have a positive impact on these goals as
        indicated in the following table.

Health & well being     LAA       Expected impact of proposed strategic changes in
outcome                 Target    commissioning model
Active & passive        Yes       Potential to increase health promotion activity and
smoking reduced                   smoking cessation programmes. Opportunities to
                                  promote increased responsibility for life style choices
                                  through the engagement of individuals and communities
                                  in making decisions about their own care.
Children given a                  Expansion and integration of children’s services at
good start in life                community level. Integrated and expanded services
                                  focused on family well being.
Determinants of                   Increased opportunities for better health and well being
poor health & well                screening, early detection of health and well being
being better                      issues and early and integrated health and social care
addressed                         interventions.
Disease specific                  Increased opportunity to design services in line with
standard guidance                 guideline principles.
met
Environment & living              The planned changes should enable Peterborough’s
conditions improved               urban redevelopment and regeneration proposals by
                                  matching them with improvements in health and well
                                  being service provision.
Health & social harm    Yes       Changes promote easier access to services and better
of alcohol misuse                 support for communities.
reduced
Healthier               Yes       Engagement of communities and individuals in decisions
Communities built                 affecting their health and well being.
Healthy exercise                  Promotion of increased responsibility for lifestyle
being enjoyed                     choices.
Income/ benefit                   Better access to welfare agencies within communities.
uptake increased



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Health & well being      LAA       Expected impact of proposed strategic changes in
outcome                  Target    commissioning model
Inequalities in health   Yes       The planned changes and Peterborough’s urban
reduced                            redevelopment and regeneration proposals will
                                   complement each other by improving the urban
                                   infrastructure and matching this with improvements in
                                   health and well being service provision.
Informed partnership               Engagement of communities and individuals in decisions
with communities                   affecting their health and well being.
established
Life expectancy          Yes       Create capacity for focused primary and secondary
improved                           prevention services affecting main causes of death.
Limiting long term                 Create capacity for generic and specialist practitioner
conditions better                  teams needed to support people within their own
managed                            communities.
Mental health and        Yes       Create capacity for expanded multidisciplinary and
well-being across                  agency team services at primary care level.
the age range
from school age
upwards improved
Obesity reduced          Yes       Promote healthy eating and increased responsibility for
                                   lifestyle choices.
Older people helped      Yes       Create capacity for the expansion of multidisciplinary
to remain fit                      and agency intermediate care teams.
and healthy and safe
from
accidents for longer
Sexual health            Yes       Easier informal access to fully integrated services.
improved


8.0 Impact of the Plan on the Services Provided
    Directly by the NHS & Public Sector Partners
8.1    Peterborough PCT directly provided services.

8.2    This section of the plan considers its impact on the Peterborough PCT
       provider arm which has contractual obligations to provide community based
       health and social care services to Peterborough city and areas outside such
       as Yaxley.

8.3    The Peterborough PCT and Peterborough City Council are consulting on
       plans for forming a partnership to integrate Children’s services with the City
       Council as the lead provider in the same way that the PCT is currently the
       lead provider in a partnership for older person’s services.

8.4    Assuming this goes ahead the SSDP will affect PCT provider arm’s:
       i.      Organisational concept
       ii.     Service configuration


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       iii.     Levels of activity
       iv.      Workforce organisation
       v.       Estate infrastructure
       vi.      IT infrastructure.

8.5    Organisational Concept

8.6    Peterborough PCT has issued a consultation document called “Next Steps”
       that sets out current thinking on how Peterborough PCT directly provided
       services might be organised in the future.

8.7    The document recognises seven different groups of services provided by the
       PCT provider arm will affect:-
       i.       General services for adults and older people
       ii.      Specialist services for adults and older people
       iii.     Services for adults with learning disabilities
       iv.      Services for children
       v.       Directly managed GP services
       vi.      Dental services
       vii.     Unplanned care services.

8.8    A full list of the services covered by these groups is included in Appendix 3.

8.9    The PCT and its partners have considered a range of options for the type of
       business model that could organise the delivery of each of the seven different
       types of service most effectively.

8.10   The five models considered were:-
       i.       Model 1 – arms length organisation within the PCT
       ii.      Model 2 – community foundation trust
       iii.     Model 3 – integration with another organisation
       iv.      Model 4 – social enterprise
       v.       Model 5 – independent sector.

8.11   The following table shows the results of the matching of the seven service
       groups with these business models.




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LEGEND




8.12   Following public consultation the PCT Board has decided to proceed with the
       strategy of establishing the provider arm as an Arms Length Management
       Organisation (ALMO) with the option of that organisation commencing
       development of an application for Community Foundation Trust status in
       October 2008. The earliest date from which such a Trust would operate if the
       application was successful would be April 2009.

8.13   This direction of travel is consistent with the SSDP, because it contributes to
       the development of a contestable provider market, made up of whole system
       providers offering coordinated health and social care and with the potential to
       respond to increased dependence on community based services. It can also
       support the longer term goal of supporting consumers as organisers of at
       least part of their own care.

8.14   Service configuration

8.15   To obtain the maximum benefit from procuring services within a contestable
       market, the PCT will expect providers to make their own proposals for service
       configuration within the framework of principles set out in the proposed
       commissioning model.




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8.16       The SSDP proposals could suggest a service configuration for the community
           services currently provided by Peterborough PCT made up of:-
           i.    Specialist community based services integrated with other provider
                 specialist services and new generation community hospital services.
           ii. Semi specialist community services integrated with services of similar
               complexity provided by other agencies and with primary contractor
               services at locality level.
           iii. General and visiting community services integrated with general
                services provided by other agencies and local primary care services
                at neighbourhood level within localities.

8.17       Levels of activity

8.18       The following table describes how the changes to the commissioning model
           that underpin the SSDP are expected to impact on the activity levels of
           providers in the market place for health and social care services in
           Peterborough. Quantification of this impact is dependent upon further
           modelling of the factors in the table.
                                                    Expected                                                          Expected Expected
                                                    direction Resultant service                           Activity    direction scale of
Factor      Demand driver      Demand Indicator of change change                   Workstream affected    indicator   of change change
Population                                                    Scope & volume       All PC and community
change      Population size    Total population     Increase growth                services               Contacts    Increase   Very high
Population                     Proportion aged 65             Scope & volume       Specific PC and
change      Population make up & over               Increase growth                community services     Contacts    Increase   Very high
Population                     Proportion aged 4              Scope & volume       Specific PC and
change      Population make up & under              Increase growth                community services     Contacts    Increase   Very high
Population                     Proportion non                 Scope & volume       All PC and community
change      Population make up white british        Increase growth                services               Contacts    Increase   Moderate
Population                     Multiple deprivation           Scope & volume       All PC and community
change      Population make up rank                 Increase growth                services               Contacts    Increase   Moderate
Pathways                       Hospital                       Substitute service   Specific PC and
redesign    Pre admission      admissions           Reduction developed            community services     Contacts    Increase   Low
Pathways                       Hospital IP length             Substitute service   Specific PC and
redesign    Post discharge     of stay              Reduction developed            community services     Contacts    Increase   High
Pathways                       community                      Scope & volume       All PC and community
redesign    Healthy lifestyle  contacts             Increase growth                services               Contacts    Increase   High
Pathways    Chronic condition community                       Scope & volume       Specific PC and
redesign    management         contacts             Increase growth                community services     Contacts    Increase   Low
Pathways                       Hospital A & E first           Substitute service   Specific PC and
redesign    Unscheduled care attenders              Reduction developed            community services     Contacts    Increase   Low
Pathways                       Out patient                    Substitute service   Specific PC and
redesign    Early intervention attendances          Reduction developed            community services     Contacts    Increase   Moderate
Pathways                       Hospital X ray                 Substitute service   Specific PC and
redesign    Early diagnosis    examinations         Reduction developed            community services     Contacts    Increase   Moderate
Pathways                       Phlebotomy                     Scope & volume       Specific PC and
redesign    Early diagnosis    contacts             Reduction growth               community services     Contacts    Increase   High
Pathways                       Hospital IP length             Substitute service
redesign    End of life        of stay              Reduction developed            Residential care       Bed days Increase      Moderate
Service                        community                      Scope & volume       All PC and community
response    Unmet need         contacts             Increase growth                services               Contacts    Increase   Moderate
Service     Quality            community                      Scope & volume       All PC and community
response    improvement        contacts             Increase growth                services               Contacts    Increase   Moderate
                               Life expectancy                Scope & volume       All PC and community
Health need Morbidity          gap                  Increase growth                services               Contacts    Increase   High
                                                              Scope & volume       All PC and community
Health need Mortality          SMR (proxy) gap None           growth               services               Contacts    Increase   Low
                               Prevalance per                 Scope & volume       All PC and community
Health need Prevalence         1000 population      Increase growth                services               Contacts    Increase   Moderate


8.19       Workforce Organisation

8.20       The current PPCT workforce planning process ensures the workforce can
           meet current service requirements and future planned service changes over


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                  the next 3 years. The workforce plan is refreshed annually to reflect known
                  changes in services which require, or have an impact on, changes in the
                  workforce. In order to achieve the SSDP there will need to be a review of the
                  current workforce plan to meet the vision, with milestones.

8.21              Broad indications of the estimated scale of change needed in the size and
                  broad make up of the workforce are given in the following graph.

                                                                                             s
                          Planned growth in the generic workforce profile in line with commis ioning
                                         needs /requirements for the next ten years .


                600                                                                                                 70%


                                                                                                                    60%
                500

                                                                                                                    50%
                400




                                                                                                                          Percentage increas
 Staff number




                                                                                                                    40%
                300
                                                                                                                    30%

                200
                                                                                                                    20%

                100
                                                                                                                    10%


                 0                                                                                                  0%
                      Year 1   Year 2    Year 3   Year 4    Year 5   Year 6   Year 7    Year 8   Year 9   Year 10

                                        Generically trained staff
                                        % Change of ov  erall workforce (based on total 1502 employees)



8.22              The PCT will require all its providers to have a coordinated approach to
                  workforce planning to ensure the changes required to achieve this plan
                  including the transition of services from acute and specialist to primary and
                  community services.

8.23              Over the last few years within the NHS there has been a significant drive to
                  improve service provision and productivity by modernising the workforce.
                  These changes have included enablers such as contract changes for general,
                  support and clinical staff such as “Agenda for Change”, the nGMS contract,
                  the NHS consultant contract and contracts for very senior managers. Whilst
                  these enablers have had some impact, it is recognised that the full benefits of
                  contract / workforce modernisation have not been realised, and that the
                  anticipated benefit of improved productivity has not occurred.

8.24              There is a clear case for productivity measures to be developed and used in
                  primary and community services, and in implementing this plan, the PCT will
                  work with all its providers to introduce such measures.

8.25              To achieve the vision will require significant changes to the current workforce
                  working in primary care and community health and social care. This will
                  require coordinated strategic workforce planning including education training


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           and development of the existing and future workforce, possible changes to
           the educational qualification and therefore changes in the commissioning
            from the training providers, including where necessary the accreditation of
           new professional training programmes. In its function as a commissioner, the
           PCT will ,as part of its commissioning intentions and contract arrangements
           with its providers, ensure and monitor that its providers have in place robust
           Workforce Planning mechanisms including role redesign plans, to meet the
           future service delivery requirements outlined in the SSDP.

8.26       Provider proposals should include evidence of:
           i.   Robust knowledge of their current workforce skills and qualifications.
           ii. Robust planning for known workforce changes, such as retirements of
               key staff, turnover and shortage areas.
           iii. Evidence of Education, Learning and development plans to ensure
                the workforce has the skills required to undertake changed roles to
                meet future services.
           iv. Evidence of strong link to the education bodies to ensure accredited
               education courses in required skills are in place.
           v. Evidence of close working between all providers on a coordinated
              approach to workforce planning.

8.27       Estate infrastructure

8.28       The strategy for adapting the estate infrastructure is set out in section 5.

8.29       The following table, based on this strategy, demonstrates that investment and
           disinvestment in the current estate would lead to considerable improvements
           in estate performance with expenditure to raise GP and PCT premises to
           Estatecode B rating standard almost eliminated and a factor of 10 reduction in
           the expenditure required per square metre of estate in the same service
           categories.
                                                      Indicator - expenditure to improve premises to Estatecode B rating

                       Physical       Fire & Health   Environmental Functional       Quality.        Asbestos        DDA            GIA (costed       TOTAL    Cost per
NIS Area               Condition      & Safety        / energy      suitability &                                    compliance     areas only     EXPENDITURE square metre
                                                      management. space                                                             included in
                                                                    utilisation                                                     total)

                             £              £               £               £              £              £               £              M2             £            £
Grand Total                 735108           55210           43600         240550           91400             9790       612160           18592       1787818            96
Post plan position          237022            6500             100          11500           10300             1143        43440           30759        310005            10
Post plan difference       -498086          -48710          -43500        -229050          -81100          -8647         -568720          12167       -1477813           -86
Percent difference           -67.76         -88.23          -99.77          -95.22          -88.73         -88.33          -92.90          65.44         -82.66      -89.52



8.30       The service capacity shortfall referred to in the table at paragraph 3.31 is
           totally eliminated by bringing the space provided in primary care facilities up
           to the current Department of Health Primary Health and Social Care Guidance
           space standards.

8.31       This indicates the potential of the plan to support future community based
           providers effectively through access to facilities that are fit for purpose, have
           sufficient capacity for access to a broad range of services both locally and
           centrally and have low residual and ongoing costs of fabric maintenance. It


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       should enable community based providers to strengthen local services taking
       unnecessary pressures off acute hospitals.

8.32   IT Infrastructure

8.33   The PCT and commissioned providers will need to work together to support
       these changes by:
       i.   The development of a single health and well being record for the
            whole community
       ii. Making connectivity for net based access to and communication of
           data, voice and images easy and cost effective
       iii. Creating flexibility to adapt to changes in ways of working, particularly
            supporting people who work in their own and/ or service user's homes
            through the development of wireless networks and mobile working
       iv. Migrating towards a single system for general medical practices
       v. Enabling the sharing of information between different provider
          organisations.

8.34   Therefore, the SSDP will need to be supported by an ICT implementation plan
       to work out in detail how the above changes will be achieved and how to
       tackle the issues that flow from shared systems such as personal and
       commercial confidentiality. The implementation plan would also need to be
       costed in detail. The currently anticipated capital cost of achieving the
       strategic changes over the 10 years of the plan is £150,000 or approximately
       £15,000 per annum.

8.35   Peterborough and Stamford Hospitals NHS Foundation Trust Services

8.36   The proposals for change in the SSDP are consistent with those in the GPHIP
       that sets out the case for a £330 million project to build a new acute hospital,
       integrated care centre and a mental health hospital in Peterborough by 2010.

8.37   They are also consistent with the goals shared by Peterborough PCT and
       Peterborough and Stamford Hospitals NHS Foundation Trust to rebalance
       care between the secondary and primary care sector where quality, standards
       and cost effectiveness can be assured and appropriate funding and skills can
       transfer with the activity.

8.38   Cambridgeshire & Peterborough Mental Health Partnership Trust
       Services

8.39   The proposed changes in this plan also fit with the plans of the mental health
       services provider to provide a safe, strong and effective specialist acute
       service located in the centre of Peterborough to support more local services
       working closely with other members of extended primary health care teams
       throughout the area.




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9.0 Requirements for Other Delivery & Development
    Partners
9.1    The changes planned in the SSDP especially the drive to integrate and/ or
       network providers and provide local access to an extended range of service
       will create opportunities for all health and social care providers to work
       together in ways that are not possible now.

9.2    The changes will also stimulate opportunities for private sector providers to
       seek contracts with the PCT as commissioner if they can demonstrate the
       ability to meet standards of quality, safety and efficiency.

10.0 Stakeholder Support
10.1   The Peterborough Primary Care Trust and its partners have taken a
       participative approach to the development of this SSDP.

10.2   Stakeholder analysis was undertaken to determine the range of stakeholders
       affected by the plan and the results of this are set out at Appendix 15.

10.3   Stakeholder participation in the development of the plan was achieved
       through the interactive workshop process described in section 5. Details of
       the stakeholders involved in this process are set out in Appendix 16.

10.4   Formal consultation with stakeholders has been undertaken prior to the
       approval of the plan by the SSDP through the following main processes:
       i.   Written and verbal briefings on the proposed future commissioning
            model and structured questionnaire
       ii. Consultation workshops
       iii. Peterborough Health Fayre - 12 September 2007 (Attended by
            representatives from 90 per cent of GP practices)
       iv. Provider Arm Formal Consultation Document “Next Steps” - 1 August
           to 1 November 2007
       v. Draft SSDP Summary Reports & Presentations - 20 November 2007
          to 31 December 2007

10.5   Appendix 17 details the stakeholders involved in each of these processes.

10.6   Consultation feedback has been positive and supportive of the plan’s
       proposals and has raised no issues of major concern.

11.0 Financial Appraisal
11.1   Revenue Affordability




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11.2   The revenue financial appraisal of the changes in the SSDP is based on an
       updated version of the financial model for the Greater Peterborough Health
       Investment Programme.

11.3   This model takes into account the amount and timing of the following receipts
       that are significant to the determination of available resources over the
       lifetime of the plan:
       i.      Recurring allocation
       ii. Modernisation agency funds borrowed
       iii. Repayment of SHA contributions
       iv. (Contribution to SHA wide recovery).
Note: items in brackets represent cash outflows.

11.4   The model indicates that the recurring allocation at year 0 will be in the order
       of £243m and in the order of £399m in year 10. Cumulative receipts from this
       source will be £3.55bn over the period from year 0 to year 10 and including
       both. On average this equates to £322m per annum. Over the same period
       the PPCT receives net funding of £2.8m from other sources. The model also
       assumes loss of income from neighbouring PCTs for their current payments
       for community health and social care services to practices in their areas
       (Cambridgeshire and Northamptonshire). The base modelling assumes
       growth of 4.50% (i.e. 4.5% less 2.5% inflation which leaves 2.0% real terms
       growth).

11.5   The significant expenditures factored into the model are:
       i.        PPA reduction 2nd instalment
       ii.       Debt repayment to Modernisation Agency
       iii.      Bundles Shortfall
       iv.       Choosing Health White paper 2007/2008 *
       v.        Choosing Health White paper 2006/2007 *
       vi.       Net increased costs for Integrated Care Centre *
       vii.      Revenue transfer to capitalise part of unitary payment*
       viii.     (Occupancy charges to PSHFT/CPMHT)
       ix.       Capital charges on capitalised element
       x.        Additional costs CPMHT
       xi.       Primary Care Investment supporting GHIP *
       xii.      High cost drugs and other new technologies *
       xiii.     18 week wait and other commissioning issues.*
       xiv.      Private sector diagnostics/Other Commissioning Issues *
       xv.       Demographic changes (explicit demographic changes factored in
                 with effect from 2012/2013. In previous years these demographic



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                    changes have been built into the specific lines such as 18 week
                    wait and other commissioning issues) *
         xvi.       Increased contingency
         xvii.      Existing Savings programme
         xviii.     Primary care developments *.
Note:
Items in brackets represent cash inflows.
Items with asterisks are specific areas of PCT planned development and cover
changes proposed in the SSDP

11.6     All of the expenditure incurred by changes arising from the SSDP in the plan
         period is included against the lines listed in the previous paragraph, the main
         ones marked with an asterisk.

11.7     GPHIP expenditure has slipped in the updated model by one year into
         2009/10. This has the impact of the recurring position of the PPCT being out
         of balance for two years i.e. 2009/10 and 2010/11 but in balance for all years
         in the plan period except those two.

11.8     Assuming that "lodgings" are returned from the SHA in full in 2010/11, PPCT
         has non recurring resources to use in some years to demonstrate bottom line
         financial balance or better in all years in the plan period.

11.9     This is illustrated by the following graph.


                 PCT Income and Expenditure for Years Covered by SSDP

        450000
        400000
        350000
        300000
                                                                                                                             Total resources available for
        250000                                                                                                               plan
£'000
        200000                                                                                                               Total expenditure in each plan
                                                                                                                             year
        150000
        100000
        50000
             0
                  2006/7

                           2007/8

                                    2008/9

                                             2009/10

                                                       2010/11

                                                                 2011/12

                                                                           2012/13

                                                                                     2013/14

                                                                                               2014/15

                                                                                                         2015/16

                                                                                                                   2016/17




                                                                 Year



11.10 Sensitivity Testing




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                                            Peterborough Primary Care NHS Trust



11.11 A sensitivity analysis was carried out to assess two scenarios individually and
      then their combined impact as follows:
              i.            Scenario 1. A reduction in resources assumptions of 1% post
                            2007/2008. The assumption does not include movement to
                            capitation target and the reduction leaves 1% real terms growth
                            assuming 2.5% net inflation is funded
              ii.           Scenario 2. PCT Revenue costs related to GPHIP increase by
                            10%
              iii.          Scenario 3. A combination of scenarios 1 and 2.

11.12 A further 2 scenarios with more positive assumptions than those used in the
      base modelling were assessed as follows:
              i.            Scenario 4. Assumes a 1% increase in resources
              ii.           Scenario 5. Assumes a 3% increase in resources.

11.13 The results are presented in the following table.

                                               2006/2007 2007/2008 2008/2009 2009/2010 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017
                                                 £000'S    £000'S    £000'S    £000'S    £000'S    £000'S    £000'S    £000'S    £000'S    £000'S    £000'S

ASSUMPTION 1
original variance in year                                        0     2957       211      2998      3246      3517      3591      3652      3726      4046

If resources growth assumptions were 1% less                           -2140     -2235     -2336     -2441     -2551    -2665     -2786     -2911     -3042

revised in year variance 1% less resource                        0      817      -2024      662       805       966       926       866       815      1004


ASSUMPTION 2
original variance in year                              0         0     2957       211      2998      3246      3517      3591      3652      3726      4046

if GPHIP related costs 10% higher                      0                -213     -1079     -1113     -1147     -1183    -1220     -1258     -1297     -1338

revised in year variance 10% cost increase             0         0     2744       -868     1885      2099      2334      2371      2394      2429      2708


ASSUMPTION 3
original variance in year                              0         0     2957       211      2998      3246      3517      3591      3652      3726      4046

If resources growth assumptions were 1% less                           -2140     -2235     -2336     -2441     -2551    -2665     -2786     -2911     -3042
if GPHIP related costs 10% higher                      0         0      -213     -1079     -1113     -1147     -1183    -1220     -1258     -1297     -1338

revised in year variance impact of
both events                                            0         0      604      -3103      -451      -342      -217      -294      -392      -482      -334




ASSUMPTION 4
original variance in year                              0         0     2957       211      2998      3246      3517      3591      3652      3726      4046

If resources growth assumptions were 1% less                           2140      2235      2336      2441      2551      2665      2786      2911      3042

revised in year variance 1% less resource              0         0     5097      2446      5334      5687      6068      6256      6438      6637      7088


ASSUMPTION 5
original variance in year                              0         0     2957       211      2998      3246      3517      3591      3652      3726      4046

If resources growth assumptions were 3% less                           6421      6705      7007      7323      7652      7996      8357      8732      9125

revised in year variance 10% cost increase             0         0     9378      6916     10005     10569     11169     11587     12009     12458     13171




Note: these calculations are before transfer of practices under CPLNHS and assume
continued use of Peterborough services as currently agreed.
Note: the growing variance is a result of the cumulative effect of the assumptions
year on year.



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                         Peterborough Primary Care NHS Trust



11.14 The projections are most sensitive to a reduction in growth assumptions for
      the allocation. The above assumption 1 is effectively a real terms 1% growth
      with no movement to target. The PCT is already below weighted capitation
      target at the end of 2007/2008 by 3.5% (£5.6m) for NPPCT and 2.3% (£2.5m)
      for SPPCT. With the transfer of practices it is anticipated that SPPCT DFT
      will grow.

11.15 The projected population growths will serve to increase the DFT for the PCT
      allocations if no movement to capitation share is received.

11.16 Each 1% is worth in excess of £2m.

11.17 If funding is lower than projected then the PCT would need to consider
      reviewing the affordability of the assumptions around the Choosing Health
      White paper and growth in contingency fund and other efficiency gains that
      might be required.

11.18 Contributions to Funding

11.19 At this stage in their development the Peterborough Primary Care Trust’s
      plans have been costed on a worst case scenario basis. This takes no
      account of potential available funding over and above its recurrent allocation
      and any growth in that allocation. Such funds might include section 106
      contributions from local regeneration initiatives and funds from NHS central
      initiatives, such as those to fund the implementation of the Darzi report. Such
      contributions may enable the PCT to capitalise payments to developers thus
      reducing the burden of future increased rental and other premises running
      costs on its recurring allocations. The impact of such funds would be best
      assessed as individual investment projects are developed and will be factored
      into financial evaluation of each project at the outline business case stage.

12.0 Implementation Timetable & Project Management
12.1  Throughout the development of the SSDP its production has been managed
      by a Project Steering Group with the membership set out in the following
      table.
Representing               Name                 Post
PCT Board                     Ms Veronica Watson        Finance Director & Project Director

Project Management            Mr Chris Palmer           PCT Project Manager

PCT Provider Arm              Mr Paul Sproat            Assistant Director Corporate
                                                        Services - Provision Services
General Medical Contractors   Dr Sohrab Panjay          GP Principal

                              Dr Vijay Iyer             GP Principal

PCT Commissioning             Mr Derrick Mortimer       Commissioning Manager




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                               Peterborough Primary Care NHS Trust



12.2       Based on current priorities and procurement Option 3B, the expected
           implementation timetable is as follows:
Locality             District Centres &   Investment                     Year
                     Other Investment     priority
                     Opportunity Areas    ranking
                                                       1   2   3   4     5      6   7   8        9    10
Central & East       City                     1
Central & East       Millfield                2
South West           Hampton                  3
North East           Werrington               4
North West           Bretton                  5
South West           Orton                    6
South East           Stanground               7
North East           Paston                   8
Rural East & West    To be determined         9


12.3       The investment priorities in the above reflect the outcome of a prioritisation
           process based on service need and estate performance criteria as outlined in
           section 5 of this plan. The proposed timing of investment into a particular
           area reflects the practicalities of readiness for planning and development
           opportunities.

12.4       The proposed arrangements for the project management                             of       the
           implementation of the SSDP are illustrated by the following diagram.




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                         Peterborough Primary Care NHS Trust




12.5   As indicated by this diagram both the execution and monitoring of the
       implementation of the SSDP will be an integral part of the mainstream work of
       the Peterborough PCT. This will keep the focus on the SSDP as a vehicle for
       sustaining effective partnership working and achieving real change.

12.6   Initially, commissioned providers will be represented in the group by current
       providers namely:
       i.   Anglia Support Partnership
       ii. Cambridgeshire & Peterborough Mental Health Partnership Trust
       iii. East Midlands Ambulance Service NHS Trust
       iv. East of England Ambulance Service NHS Trust
       v. General Dental Services Providers in the Greater Peterborough Area
       vi. General Medical Practices in the Greater Peterborough Area
       vii. Ophthalmic Services Providers in the Greater Peterborough Area
       viii. Peterborough and Stamford Hospitals NHS Foundation Trust
       ix. Peterborough City Council Housing Services
       x. Peterborough City Council Social Care Services
       xi. Peterborough Primary Care NHS Trust Provider Arm
       xii. Pharmacy Services Providers in the Greater Peterborough Area
       xiii. Registered Nursing Home Providers
       xiv. Registered Care Home Providers.

12.7   All positions on the SSDP Steering Group would be executive. Other
       mechanisms would be used for the processes of ongoing wide stakeholder
       engagement, briefing and consultation.

12.8   The following executive roles would be carried out by members of the group:
       i.   Project Director and Group Chair –Director of Finance and Contracts
            Peterborough PCT
       ii. Project Champion – Non Executive Director of Peterborough PCT
       iii. SHA liaison – Senior Manager East of England Strategic Health Authority
       iv. PBC commissioning liaison – Locality commissioning lead
       v. Commissioning Project Manager
       vi. Capital and FM procurement project manager
       vii. Primary Care Liaison – General Practice Nominee (possibly PEC
            representative)
       viii. Contractor Professions Liaison – Dental/ ophthalmic/ pharmacy contractor
             nominee



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       ix. Community services and registered homes liaison – Senior Manager PCT
           provider arm
       x. Local Authority Services Liaison – Director of Adult Social Care
          Peterborough City Council (joint appointment with PCT)
       xi. Mental Health Services Liaison - Cambridgeshire & Peterborough Mental
           Health Partnership Trust
       xii. Secondary Care Services Liaison – Senior Manager Peterborough and
            Stamford Hospitals NHS Foundation Trust
       xiii. Support Services Liaison – Senior Manager Anglia Support Partnership
       xiv. Ambulance Services Liaison – senior manager from one of commissioned
            ambulance services.

12.9   The project managers would be responsible for arranging appropriate
       contribution to the project from support and advisory functions within the
       Partnership Organisations, e.g. Human Resource, IMT, Finance, Public
       Health.

12.10 There has been a thorough interactive assessment of the risks of migrating
      from the present day service model with its associated network of providers,
      organisation of human resources and physical facilities and IMT infrastructure
      to the commissioning and human resource model proposed for Option 4 and
      the physical infrastructure proposed for Option 6 over the 10 years of the
      plan. The methodology for and detailed results of this part of the SSDP
      development process are set out Appendix 13.

12.11 The outcome of the project risk assessment process has been to identify the
      following high priority risks in priority order (risk number 1 being the greatest
      risk) and mitigation strategies for each of them as follows:


Risk   Description of   Proposed mitigation strategy
No     Risk
1      Lack of          Act on ongoing review of "commissioning capability"; review of
       change           organisation 6 months on after the implementation of CPLNHS;
       management       provider reviewing as part of "Next Steps" project; coterminosity
       capacity         with PCC constantly under review and opportunities sought where
                        possible to do things jointly.




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                          Peterborough Primary Care NHS Trust




Risk   Description of     Proposed mitigation strategy
No     Risk
2      Conflict           The PCT will provider strategic workforce planning leadership and
       between            support and will undertake a coordinating role, to ensure its
       proposed           providers have in place robust workforce planning and change
       change and         processes.
       professional
                          Focus in the planning of proposed developments on preventing
       aspirations        disintegration of primary care, giving top priority to continuity of care
                          and personal care also

                          Use of available evidence to demonstrate successes locally and
                          elsewhere of development of new and extended roles. Some risk
                          issues are around roles and responsibilities of PBC which will
                          mature in time. Engaging staff in organisation development activity
                          such as facilitated reviews of current service delivery methods and
                          the development of more cost effective ways of organising patient
                          care and administrative support activities. Implementation of market
                          forces and the contestability of providers will facilitate this change.
                          Movement of new providers into the market is influencing current
                          workforce practices to change. Public influence and individuals
                          taking greater responsibility for health and well being. Using
                          national support for modernisation of medical and clinical workforce
                          and training (national direction of travel). Peterborough PCT has
                          developed a workforce strategy that is set out at Appendix 7 of this
                          plan.
3      Change in          Increase local politicians’ engagement in the health and well being
       political policy   agenda.
       direction          NHS colleagues have been developing awareness and
                          understanding of NHS issues for new Members of Council. DoH
                          policy division met in Peterborough (August 07) and PPCT involved
                          in feedback. Progress politically driven change speedily, e.g.
                          provider split to reduce risk of being affected by any “u turn”.
4      Lack of two        Further development of Communications Strategy and Stakeholder
       way                Co-ordinator role. Replacement of PPI with LINKs (these will be
       engagement         hosted by Local Government, therefore, ensures health and well
       with affected      being agenda is addressed). PCT involved in increasing numbers
                          of consultations, therefore, lessons learnt from each one, means
       communities
                          more effective in future ones. Overview and Scrutiny Committee
                          increasingly used and involved at early stages.
5      Lack of            Movement of new providers into the market - issue of contestability
       quality            (SHA requiring PCT to demonstrate how we are doing this).
       providers in       Effective contracting, including quality and effectiveness measures.
       the market         Market stimulation locally will be occurring (happening in ASC, will
                          increasingly do so in Health with armslengthing of providers). Use
       place
                          national drive for procurement, collaborative hubs and ISTCs.




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                         Peterborough Primary Care NHS Trust




Risk   Description of Proposed mitigation strategy
No     Risk
6      Constraints    Use SSDP to "open more doors" to funding - SHA capital & EADA
       on the         (east of England Development Agency). Joint strategy linking PCT
       flexibility of and PCC enables use of resources across boundaries.
       financial      Development of 106 contributions. Market opportunities with third
                      party developers as providers diversify. Alignment between PCC
       resources
                        asset holdings and promoting public service centres being
                        consistent with PCT strategy for neighbourhoods. Social Enterprise
                        Trusts developing into market (small and larger scale) brings new
                        funding opportunities. Secondary to primary care shift enables tariff
                        to be reused more efficiently.
7      Unable to        Scanning horizons to secure funding from varied and extended
       access           sources not just traditional routes.
       transitional
       funding at the
       right time
8      Inability to     Growing population with untapped potential. Sound PCT strategies
       attract,         for staff development, retention and succession planning. Flexible
       develop and      working arrangements and promotion of work-life balance. Well
       retain           being centre promoting "return to work" schemes. Greater
                        Peterborough - highest importer of workers in EoE.
       personnel
       with right
       skills
9      Conflict         Defining and recognising roles and responsibilities of providers and
       between          commissioners are essential to ensure this conflict is managed.
       proposed         Partnership working re: health and well being for the whole
       change and       population irrespective of which organisation we sit in
                        Develop ability of providers to adapt to proposed commissioning of
       providers'
                        patient centred pathways.
       financial
       interests
10     Constraints      A constraint if we do not have shared agendas, talk to each other
       on the ability   and manage the risks.
       of agencies to
       work in
       partnership
11     Increase in      Need for effective communications and links with public to ensure
       population       diversities are recognised and reflected sensitively in service design
       and diversity    not polarised. Need for partnership approach for planned
                        integration. Review of resources to meet diverse needs and cultural
                        differences (including interpreter services).




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