The proposed merger of Ealing Hospital NHS Trust and The ...

The proposed merger of Ealing Hospital NHS Trust and The North West London Hospitals NHS Trust

Full Business Case

Version 15: 20th June 2014

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Table of Contents Table of Contents ................................................................................................ i

List of Tables ...................................................................................................... v

List of Figures .................................................................................................. vii

Abbreviations .................................................................................................. viii

0. Executive Summary ................................................................................... 1

Background ........................................................................................................ 1 0.1

The case for change ........................................................................................... 1 0.2

London North West Healthcare – What will day 1 feel like? ................................ 2 0.3

London North West Healthcare - What will be different for patients? .................. 3 0.4

Conclusion ......................................................................................................... 3 0.5

1. Introduction................................................................................................. 4

Background to the FINAL business case ............................................................ 4 1.1

Strategic context ................................................................................................. 4 1.2

Purpose of the Full business case ...................................................................... 6 1.3

Note on SaHF and organisational change .......................................................... 7 1.4

Current situation ................................................................................................. 7 1.5

Chapter summaries ............................................................................................ 8 1.6

Summary of appendices and supporting documents ........................................ 16 1.7

Mapping of the Business Case to TDA Assurance Framework ......................... 18 1.8

Conclusion ....................................................................................................... 18 1.9

Appendices and supporting documents ............................................................ 18 1.10

2. Profile of the Trusts .................................................................................. 19

Overview of the organisations .......................................................................... 19 2.1

SWOT analyses ............................................................................................... 21 2.2

Ealing Hospital NHS Trust ................................................................................ 22 2.3

The North West London Hospitals NHS Trust ................................................... 24 2.4

Services provided ............................................................................................. 26 2.5

Current performance ........................................................................................ 28 2.6

Care Quality Commission inspections .............................................................. 35 2.7

Conclusion ....................................................................................................... 35 2.8


3. Commissioning strategy in North West London ................................... 37

Overview .......................................................................................................... 37 3.1

Local commissioners ........................................................................................ 40 3.2

Demography – Latest trends ............................................................................ 40 3.3

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CCG Profiles .................................................................................................... 41 3.4

NHS North West London and Shaping a Healthier Future ................................ 45 3.5

Results of the IRP............................................................................................. 47 3.6

Links with overall commissioning strategy ........................................................ 48 3.7

CCG out-of-hospital strategies.......................................................................... 49 3.8

CCGs’ vision for out-of-hospital care ................................................................ 50 3.9

Enablers and success factors ........................................................................... 52 3.10

Decommissioning and Procurement ................................................................. 52 3.11

Implications for the acute services .................................................................... 52 3.12

What this means for the future healthcare landscape? ..................................... 53 3.13

Conclusion ....................................................................................................... 54 3.14


4. Why merge EHT-ICO and NWLHT? ......................................................... 55

Introduction....................................................................................................... 55 4.1

Why change is needed ..................................................................................... 58 4.2

Common Lessons from other mergers .............................................................. 60 4.3

Conclusion ....................................................................................................... 60 4.4


5. Clinical and patient benefits of the merger ............................................ 61

Introduction....................................................................................................... 61 5.1

Benefits from acute and community integration – a model for service delivery . 63 5.2

Benefits from merged acute hospital-based services ........................................ 71 5.3

Benefits of the merger for training and education ............................................. 82 5.4

Benefits of the merger for research and innovation........................................... 85 5.5

Conclusion ....................................................................................................... 88 5.6


6. Aims, vision and values of the new organisation .................................. 89

Introduction....................................................................................................... 89 6.1

Vision, aims and objectives .............................................................................. 89 6.2

Values and objectives ....................................................................................... 92 6.3

Development of clinical strategy ....................................................................... 93 6.4

Progressing Clinical Integration ........................................................................ 94 6.5

Conclusion ....................................................................................................... 99 6.6


7. The new organisation’s structure and governance arrangements .... 100

Background .................................................................................................... 100 7.1

The Board and structure of the new organisation ........................................... 101 7.2

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Leadership roles and responsibilities .............................................................. 103 7.3

Board sub-committee reporting structure ........................................................ 107 7.4

Clinical operational structure of the new organisation ..................................... 109 7.5

Corporate quality governance ......................................................................... 114 7.6

Divisional quality governance ......................................................................... 116 7.7

Risk Management Arrangements ................................................................... 120 7.8

Conclusion ..................................................................................................... 121 7.9

Appendices and supporting documents .......................................................... 121 7.10

8. Financial evaluation / LTFM ................................................................... 122

Background and context ................................................................................. 123 8.1

Calculating financial viability ........................................................................... 124 8.2

Historical financial performance of the current Trusts ..................................... 125 8.3

North-west London health economy – financial position ................................. 126 8.4

Merger case modelling and scenarios overview ............................................. 128 8.5

Merger base case financial assessment ......................................................... 130 8.6

cost improvement savings and programme management office ..................... 139 8.7

Forecast savings targets................................................................................. 144 8.8

Non-merger case financial assessment .......................................................... 146 8.9

Financial benefits of merging the Trusts ......................................................... 149 8.10

Funded merger base case .............................................................................. 150 8.11

Downside case ............................................................................................... 153 8.12

Conclusion ..................................................................................................... 155 8.13


9. Engagement and involvement of stakeholders ................................... 157

Introduction and context ................................................................................. 157 9.1

Previous communication and engagement activities ....................................... 158 9.2

Overview of communication and engagement activities .................................. 159 9.3

Refreshing our stakeholder engagement ........................................................ 163 9.4

Communication and engagement with other stakeholders .............................. 164 9.5

Communication and engagement plan for the business case and FBC .......... 166 9.6

Additional key areas of communications and engagement activity .................. 166 9.7

Future communication and engagement ......................................................... 167 9.8


10. Integration and implementation plan .................................................... 169

Introduction..................................................................................................... 169 10.1

Programme governance arrangements and structure ..................................... 169 10.2

The programme management office ............................................................... 170 10.3

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Risk and issue management .......................................................................... 170 10.4

Transaction timeline and assurance ............................................................... 171 10.5

Iterative development of the implementation plans ......................................... 171 10.6

Progress to date and high-level steps to a fully integrated Trust ..................... 172 10.7


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List of Tables Table 1 List of abbreviations .................................................................................... viii

Table 2 Total benefits over five years, comparison of the do minimum and base case (source: Chapter eight)............................................................................. 14

Table 3 Summary of appendices and supporting documents referenced in the FBC ................................................................................................................. 16

Table 4 Supporting materials not referenced in the FBC .......................................... 17

Table 5 NHS Trusts providing care in North West London ....................................... 19

Table 6 Market share percentage based on new patient referrals Apr 2010–Mar 2013 (source: CHKS) ........................................................................................ 20

Table 7 Activity at EHT-ICO (2013/14) ..................................................................... 23

Table 8 Activity at NPH including St Mark’s Hospital (2013/14) ............................... 24

Table 9 Activity at CMH (2013/14) ........................................................................... 24

Table 10 Performance summary for EHT-ICO and NWLHT (as at March 2014) ...... 28

Table 11 Performance indicators (source: NHS Better Care, Better Value Indicators) ................................................................................................................. 33

Table 12 Options appraisal evaluation criteria ......................................................... 57

Table 13 Framework for integrated service delivery ................................................. 64

Table 14 Case study of admission avoidance .......................................................... 69

Table 15 Case Study of MSK care in a community setting ....................................... 69

Table 16 Case study of home therapy...................................................................... 70

Table 17 Benefits of merger for acute and specialist care ........................................ 72

Table 18 Summary of services under specialised commissioning arrangements (source: Trust 2014/15 baseline figures) .................................................. 76

Table 19 Benefits of merger to facilitate joint working .............................................. 80

Table 20 Benefits of merger for elective care ........................................................... 81

Table 21 Educational and development aims ........................................................... 82

Table 22 Research achievements at NWLHT .......................................................... 86

Table 23 Research achievements at EHT-ICO ........................................................ 87

Table 24 Members of the Imperial AHSN ................................................................. 88

Table 25 Summary of enabling issues ..................................................................... 90

Table 26 Values and behaviours (March 2014 joint Board workshop) ..................... 92

Table 27 Clinical strategy and scenario planning themes ........................................ 93

Table 28 Outputs from clinical integration workshops .............................................. 95

Table 29 Summary of Board sub-committee functions ........................................... 107

Table 30 Integrated medicine division structure ..................................................... 111

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Table 31 Community services division structure .................................................... 112

Table 32 Surgical services division structure ......................................................... 113

Table 33 Women and children’s division structure ................................................. 113

Table 34 CSS division structure ............................................................................. 114

Table 35 Corporate objectives for 2014/15 ............................................................ 120

Table 36 Historical financial performance – EHT-ICO ............................................ 125

Table 37 Historical financial performance – NWLHT .............................................. 126

Table 38 Merger Base Case 2013/14 to 2018/19 ................................................... 129

Table 39 Non-Merger Case .................................................................................... 129

Table 40 Downside Case 2013/14 to 2018/19 ....................................................... 130

Table 41 Summary base case financial position .................................................... 131

Table 42 SaHF impact 2013/14 to 2018/19 ............................................................ 135

Table 43 Reconfiguration impact on EHT ............................................................... 136

Table 44 Recent historical CIP performance at EHT-ICO ...................................... 140

Table 45 Recent historical CIP performance at NWLHT ........................................ 141

Table 46 CIP programme 2014/15 ......................................................................... 142

Table 47 CIP programme 2015/16 ......................................................................... 143

Table 48 Forecast savings ..................................................................................... 144

Table 49 Merger-related savings ............................................................................ 145

Table 50 Summary non-merger case financial position.......................................... 147

Table 51 Total benefits over five years, comparison of the do minimum and base case........................................................................................................ 150

Table 52 Summary funded merger base case financial position ............................ 151

Table 53 Non-recurrent implementation costs ........................................................ 152

Table 54 Causes of required funding ..................................................................... 153

Table 55 Downside case risks ................................................................................ 154

Table 56 Downside mitigations .............................................................................. 155

Table 57 Summary of issues raised by stakeholders and the Trusts’ response to these ...................................................................................................... 161

Table 58 Workstream priority deliverables ............................................................. 172

Table 59 Handover preparation summary .............................................................. 173

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List of Figures Figure 1 NHS affordability gap between forecast funding levels and rise in demand

for healthcare (source: London – A Call to Action) ..................................... 5

Figure 2 Borough boundaries and healthcare facilities............................................. 20

Figure 3 SWOT analysis of Ealing Hospital NHS Trust ............................................ 21

Figure 4 SWOT analysis of The North West London Hospitals NHS Trust .............. 22

Figure 5 Breakdown of staff by groups at EHT-ICO as at 31 March 2014................ 23

Figure 6 Breakdown of EHT-ICO income 2013/14 ................................................... 24

Figure 7 Breakdown of staff by groups at NWLHT as at 31 March 2014 .................. 25

Figure 8 NWLHT Income 2013/14 (source: NWLHT Finance Team) ....................... 25

Figure 9 Comparison of GLA population projections with 2011 census ................... 41

Figure 10 Hospital models described in the SaHF consultation (source: SaHF DMBC) ..................................................................................................... 45

Figure 11 Relative deprivation in Brent, Ealing and Harrow (source: DH 2010 Borough Health Profiles) .......................................................................... 49

Figure 12 Activity shifting OOH – a possible approach for Ealing (source: Ealing CCG) ........................................................................................................ 51

Figure 13 Summary of executive leadership structure ........................................... 102

Figure 14 Summary of operational ‘five divisional’ structure .................................. 102

Figure 15 Board sub-committee structure .............................................................. 107

Figure 16 Schematic divisional quality governance arrangements ......................... 118

Figure 17 Modelling approach and scenarios: expenditure plan 2013/14 to 2018/19 ............................................................................................................... 128

Figure 18 Income Plan 2013/14 to 2018/19 ........................................................... 133

Figure 19 Expenditure Plan 2014/15 to 2019/20 .................................................... 134

Figure 20 Profile of capital requirements ................................................................ 138

Figure 21 Capital funding profile ............................................................................ 139

Figure 22 Non-Merger Assumptions Impact ........................................... 149

Figure 23 Schematic transaction and integration/implementation programme governance arrangements ..................................................................... 170

Figure 24 Transaction timeline to merger on 1 October 2014 ................................ 171

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Abbreviations Table 1 List of abbreviations

Initial Description

A&E Accident and Emergency

AAU Acute Assessment Unit

ACS Ambulatory Care Sensitive

AHP Allied Health Professional

CCG Clinical Commissioning Group

CCP Cooperation and Competition Panel

CEO Chief Executive Officer

CFO Chief Financial Officer

CIP Cost Improvement [Savings] Plan

CMH Central Middlesex Hospital

CN Chief Nurse

COO Chief Operating Officer

COPD Chronic Obstructive Pulmonary Disease

CQC Care Quality Commission

CSS Clinical Support Services

CT Computerised Tomography scan

CTB Challenged Trusts Board

Day 1 The date on which the new Trust is established

Day 100 One hundred days post-merger

DGH District General Hospital

DH Department of Health

DMBC Decision-Making Business Case

EBITDA Earnings Before Interest, Taxes, Depreciation and Amortisation

EHT Ealing Hospital NHS Trust

EHT-ICO Ealing Hospital NHS Trust with its associated Integrated Care Organisation

ENT Ear Nose and Throat

FBC Full Business Case

FT Foundation Trust

GP General Practitioner

GUM Genito-Urinary Medicine

HCAI Healthcare Acquired Infection

HEE Health Education England

HES Hospital Episode Statistics

HfL Healthcare for London

HR Human resources

HWB Health and Wellbeing Board

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Initial Description

I&E Income and expenditure

ICH Imperial College Healthcare NHS Trust

ICO Integrated Care Organisation

ICT Information And Communication Technology

IFRS International Financial Reporting Standards

IM&T Information Management and Technology

In prep. Document in preparation

IRP Independent Reconfiguration Panel [on SaHF]

IT Information technology

JCPCT Joint Committee of Primary Care Trusts [re. SaHF]

JETM Joint Executive Team Meeting [of EHT-ICO and NWLHT]

K Thousand

KPIs Key Performance Indicators

LA Local Authority

LAT Local Area Team [of NHS England]

LETB Local Education and Training Board

LINk Local Involvement Network

LTFM Long Term Financial Model

m Million

MAU Medical Assessment Unit

MD Medical Director

MRC Medical Research Council

MRI Magnetic Resonance Imaging Scan

N Engl J Med The New England Journal of Medicine

NCEPOD National Confidential Enquiry into Patient Outcome and Death

NED Non-Executive Directors

NHS National Health Service

NHSL NHS London

NICE National Institute of Health and Clinical Excellence

NIHR National Institute of Health Research

NPH Northwick Park Hospital

NWL North West London

NWLHT North West London Hospitals NHS Trust

OBC Outline Business Case

OD Organisational Development

OMFS Oral and Maxillofacial Surgery

OOH Out-of-Hospital

Opex Operating Expenses

PACS Picture Archiving and Communications System

PAS Patient Administration System

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Initial Description

PAU Paediatric Assessment Unit

PbR Payment by Results

PCBC Pre-Consultation Business Case

PCT Primary Care Trust

PDC Public Dividend Capital

PFI Private Finance Initiative

PIDs Project Initiation Documents

PMIIP Post-Merger Integration and Implementation Plan

PMO Project Management Office

QIPP Quality, Innovation, Productivity and Prevention

QOF Quality Outcomes Framework

QP Qualified Person

R&D Research and Development

RCP The Royal College of Physicians

RCS The Royal College of Surgeons

RIS Radiology Information System

RRU Regional Rehabilitation Unit

RTT Referral to Treatment Time [waiting time standard]

SaHF Shaping a Healthier Future

SD Standard deviation

SHA Strategic Health Authority

SLA Service Level Agreement

SOC Strategic Outline Case

SoS Secretary of State for Health

SPA Single Point of Access

SRO Senior Responsible Officer

STARRS Short Term Assessment, Rehabilitation and Re-ablement Service

SWOT Strengths, Weaknesses, Opportunities and Threats [analysis]

TDA NHS Trust Development Authority

TIA Transient Ischaemic Attack

TULRCA Trade Unions and Labour Relations Act, 1992

TUPE Transfer of Undertakings Regulations, 2006

UCC Urgent Care Centre

UCLH University College London Hospital

WTE Whole Time Equivalent

YTD Year-to-Date

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0. Executive Summary

BACKGROUND 0.1

Ealing acute hospital (Ealing Hospital NHS Trust, EHT) merged with Brent, Harrow and Ealing community services in 2012, making it a large integrated care organisation EHT–ICO), providing seamless care to the local population both within the hospital and outside, whether in the community or in patients’ homes.

The creation of the ICO enabled the Trust to make efficiency savings just as the acute element of the Trust began to be financially challenged. EHT–ICO was achieving well against National performance targets and quality standards, but it was relatively small as a competitor to larger London Trusts, affecting its market share, ability to invest in particular staff groups and achieve increased quality standards.

Northwick Park Hospital (NPH) and Central Middlesex Hospital (CMH) merged in 1999 to form the North West London Hospitals NHS Trust (NWLHT). CMH as the smaller acute site with lower activity levels could not meet the quality standards required of it, similarly to EHT. As a result, emergency surgery, paediatric inpatient care and Trauma services were removed from the CMH site and the accident and emergency (A&E) and emergency medicine services are planned to close in September 2014.

NWLHT has an underlying deficit resulting from the under-occupancy of the CMH and increased year-on-year patient demand for emergency services at NPH. NWLHT has not consistently achieved the A&E waiting time standard, and patients have been waiting longer for elective procedures during the last year.

In 2012 the commissioners of health services in North West London (NWL) consulted on the strategy ‘Shaping a Healthier Future’ (SaHF) in response to demographic projections for NWL, the resultant forecast funding gap for healthcare services in NWL, and to address the national policy framework.

The proposed merger of NWLHT and EHT–ICO sets a direction for the new Trust’s services that will support the implementation of SaHF and ensure that acute services can deliver expected quality and waiting time standards; and that community services are developed to increasingly support people at home avoiding hospital admission and enabling earlier discharge when this does occur. As a result, the new organisation will be financially viable, with improved utilisation of CMH and delivery of services at the right time, in the right setting, by the right people.

Without merger both NWLHT and EHT–ICO will continue to struggle to meet performance standards, and EHT–ICO will not be able to meet the quality standards set by commissioners and expected by the public. The financial deficit position of each Trust will continue to decline, creating an uncertain future for healthcare services in NWL.

THE CASE FOR CHANGE 0.2

The business case describes the clinical and financial benefits in detail. In summary these might be described as:

1. Consultant delivered care 7 days a week in acute care

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2. Out of hospital care provided by the same organisation who would provide any hospital care needed, with swift access to acute specialist opinion and patient records

3. Care provided locally through local hospitals and community facilities, supported by borough-based community teams

4. A large population of patients enabling clinical staff to enhance their specialist skills by dealing with patients with specific medical conditions more frequently

5. Financial stability as the benefits outlined above are attained by one organisation securing economies of scale

The merger enables the new Trust to absorb the financial impact of activity and income losses arising as a result of SaHF to achieve break-even without the need for external support from year three (2016/17) and a surplus of £12.2m in year five (2019/20). If EHT–ICO and NWLHT do not merge the projected total deficit in 2017/18 is £46.6m.

The difference between the £12.2m surplus in 2017/18 generated through the merger of the Trusts, and the non-merger scenario of a £46.6m deficit, represents a potential total loss of not merging of £58.8m. This demonstrates the value for money case for the merger.

Overall merging EHT-ICO and NWLHT will result in a saving to the health economy in NWL of £164m over the next 5 years.

LONDON NORTH WEST HEALTHCARE – WHAT WILL DAY 1 FEEL 0.3LIKE?

The Trust will have a new name: London North West Healthcare, and will be Stronger Together; it will be time for a new start.

There will be a new Trust Board with a single Chair and Chief Executive; one team of Executive Directors will be responsible for the delivery of services and care on all Trust sites and in the community. There will be clear leadership to provide excellent clinical care in the right setting by being: compassionate, responsive, and innovative.

Clinically-led divisions working across the local hospital sites will provide a single direction to each clinical service, whilst local managers and local clinical leads will still be in place to support business as usual during the transition. For example, Major Incident policies, on day 1, on each site would remain the same but there would be a single accountable officer for emergency planning and a single on call director running gold control, with each site maintaining silver control.

Clinical services across the sites will not immediately change as a result of the merger, but the new organisation will need to be mindful of changes occurring in tandem or around the time of merger, such as the closure of CMH A&E and emergency medicine or the possible decommissioning of cardiology services from EHT-ICO.

All sites will be managed as a resource for the patients and carers rather than as a resource for the organisation, this will support key targets such as waiting times in A&E and waits for operations. Capacity will be used flexibly across the sites and community services, removing the boundaries of the organisations and purely

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focusing on the needs of the patient and the wider patient population, providing mutual support by default and without request or transaction.

A single intranet site providing support to our staff will be in place which will link to the separate sites as a number of clinical guidelines will remain unchanged as well as policies which are not key to merger.

LONDON NORTH WEST HEALTHCARE - WHAT WILL BE DIFFERENT 0.4FOR PATIENTS?

Patients will have access to a senior decision maker 7 days a week, they won’t feel forgotten at weekends waiting for their treatment to be progressed, they will feel supported both in the acute hospital, in community settings and at home, cared for seamlessly by one organisation. There will be no information sharing issues or governance issues as their care will be delivered by one Trust.

Patients with long term conditions will be supported to keep well with planned interventions to prevent crisis, and on the occasion when crisis occurs they will have a care plan which all professionals can access so that their acute admission is minimised.

Patients entering the system for unscheduled care will have an acute episode of care in the appropriate acute hospital and once stable and recovering will be transferred to a bed closer to their home providing a quieter less acute environment to complete their treatment and rehabilitation.

CONCLUSION 0.5

The merger will enable London North West Healthcare to support and deliver the strategic direction set by national policy and detailed for North West London in SaHF.

It will ensure that healthcare across the boroughs of Ealing, Brent and Harrow has a clinically and financially sustainable future, enabling investment in the delivery of the most effective healthcare for its patient population, whether in a hospital bed, in the community or at home

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1. Introduction

BACKGROUND TO THE FINAL BUSINESS CASE 1.1

An initial version of the merger Business Case was submitted to the NHS Trust Development Authority (TDA) in November 2013. Feedback was received in December 2013 and following a workshop with TDA colleagues in January 2014. A revised draft of the Business Case was submitted in April 2014 and subsequently further feedback received from the TDA in May and June 2014 have been incorporated into this Full Business Case (FBC) submitted on 20 June for consideration as part of the Gateway 3 sign-off by the TDA.

The main revisions to the FBC are in chapter two (operational performance) and chapter five (clinical benefits). The FBC offers more clarity and detail as to the short to medium term benefits of the merger in helping to resolve both Trusts’ current operational challenges, and in detailing the opportunity the merger provides to a new organisation to ensure that quality standards as described by the Royal Colleges and NHS Commissioning requirements can be met.

Other revisions have been made to reflect the ongoing development of the clinical strategy for the new integrated organisation (chapter six), and its structure at Board and divisional levels (chapter seven). Chapter eight (financial case) has been revised following Board discussion of the three capital business cases in progress as part of SaHF, and the most recent negotiations around support for NWLHTs CMH site.

The case more strongly describes the operational and clinical improvements that would result from merging EHT-ICO and NWLHT, and the advantage of working as a large locality-based integrated care organisation.

The joint executive team has signed-off all revisions to the case, and a detailed reconciliation is attached as Appendix 1-1 to demonstrate how the Trusts have responded to feedback from the TDA within the FBC.

STRATEGIC CONTEXT 1.2

This FBC brings together key evidence supporting the view held for several years that only a merger can achieve the improvements in the quality and safety of care that the organisations aspire to provide as part of the NHS.

Chapter summary

This chapter provides an overview of the Business Case. It includes:

an overview of the work done previously to prepare the case for merger;

a brief context to the chapter;

a summary of each of the chapters; and

reference to the appendices, supporting documents and TDA assurance framework.

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Figure 1 NHS affordability gap between forecast funding levels and rise in demand for healthcare (source: London – A Call to Action)

In 2013, NHS England called for an open and honest debate about the future shape of the NHS in order to meet rising demand, introduce new technology and meet patient expectations in the context of flat funding.1 Building on the national call to action, the NHS in London published a document calling for a debate on the specific problems facing the capital.2 Without change, the funding gap across the NHS is predicted to reach £30bn nationally and £4bn in London by 2020/21 (Figure 1).

The drivers for change across the NHS and in NWL in particular continue to grow and include:

Demographic change – with increases to the total population and particularly older people and those with long term conditions;

Changing technologies, therapies and integrated pathways of care;

Exponential increases in medical knowledge which drives sub-specialisation to deliver teams with the requisite knowledge and skill set;

Medical cost inflation in excess of general inflation;

Increasing expectations from patients, the wider public and their representatives;

1 The NHS belongs to the people: a call to action, NHS England, July 2013 2 London – A Call to Action, NHS England, October 2013

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National policy changes, e.g. to bring care closer to home;

Recruitment – providing the highest quality of services around the clock 24 hours a day, seven days a week throughout the year, when numbers of specialty medical trainees are reducing,3 requires greater numbers of consultant staff and more flexible workforce solutions;

Higher clinical standards being required by commissioners and regulators;

Historic under-investment in primary and community care in NW London, and commensurate over-reliance on the acute sector. These are addressed in the pan-NW London strategy SaHF and in local commissioners’ Out-of-Hospital strategies; and

Constrained resources for the foreseeable future, and the prospect of transfers of NHS funds to social care from 2015/16.

PURPOSE OF THE FULL BUSINESS CASE 1.3

The FBC is part of the formal approvals process overseen by the TDA culminating in Secretary of State for Health (SoS) authorisation for the merger of EHT-ICO and NWLHT to create a new organisation, to be known as London North West Healthcare NHS Trust.4 It will be considered alongside other supporting evidence and the recommendations of independent clinical, financial and legal due diligence.

A number of major changes have been made since the original September 2012 FBC, in particular:

acknowledging the implications of the Shaping a Healthier Future (SaHF) public consultation and demonstrating alignment with this strategic review;

accommodating changes to the NHS following the implementation of reforms under the Health and Social Care Act, 2012; and

responding to the recommendations of the due and careful enquiry carried out in 2012 concerning the need for improved financial robustness.

The FBC sets the current context for EHT-ICO and NWLHT and makes the case for a merger creating a large integrated care organisation with the vision:

To provide excellent clinical care in the right setting by being: Compassionate; Responsive; and Innovative.

Patient, staff and organisational benefits are described throughout the FBC and in detail in chapters four and five, accompanied by a detailed explanation in chapter eight of the financial impact of merger in the context of the changes arising from SaHF over the next five years. The FBC provides a quantitative analysis of the financial impact of not merging the two organisations to provide a de minimis benchmark against which to assess financial sustainability.

The Boards believe that this business case will persuade all key stakeholders that EHT-ICO and NWLHT really will be ‘Stronger Together’, and its patients safer and more secure, as part of one Trust. On the other hand continuing with the ‘status quo’

3 Signalled in the Department of Health mandate with Health Education England, 2013 4 Delivering High Quality Care for Patients: The Accountability Framework for NHS Trust Boards, TDA

(April 2013)

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will severely constrain either Trust’s ability to respond to the implementation of SaHF Strategy and will undermine progress towards financial sustainability - resulting in limited scope to contain aggregate annual deficits of around £40m beyond 2014/15.

NOTE ON SAHF AND ORGANISATIONAL CHANGE 1.4

The FBC takes account of the anticipated future commissioning plans based on SaHF as they would affect both Trusts, but does not make the case for service reconfiguration within the Trust or across NWL outside of what has already been consulted on as part of SaHF programme led by local Clinical Commissioning Groups (CCGs).

As described in chapter three, SaHF proposals were approved by the Joint Committee of PCTs in February 2013 but were delayed because of a challenge from Ealing Council. This challenge was resolved in October 2013 when the SoS accepted the recommendations of the Independent Reconfiguration Panel Report. Ealing Council has also twice been refused permission for a Judicial Review. This decision allowed the SaHF programme to commence planning for implementation.

The merger proposal described in this FBC is entirely separate from, but consistent with SaHF and commissioner out-of-hospital strategies. The case argues that a single merged organisation would facilitate implementation of these strategies more effectively than two independent Trusts.

Commissioners (and specifically CCGs) rightly want to assess the services that they buy to ensure that they meet the standards that would be expected of a modern health service. In particular, care for rarer conditions that require expert treatment in fewer, more specialised centres and care for common conditions provided as locally as possible – ideally in or close to patients’ own homes. In response, the two Trusts have developed a shared service vision to meet these challenges in a context of flat financing for the foreseeable future.

CURRENT SITUATION 1.5

The current uncertainty about organisational futures is corrosive for both Trusts. It deters good people from coming to the Trusts if there is a certain alternative, and it encourages the good people at both organisations to leave.

Since the original September 2012 FBC, the situation at EHT-ICO has deteriorated sharply following the loss of 5% of its turnover over the course of 2012/13 as a result of reduced patient activity (primarily in its maternity service). This is for two reasons:

The disproportionate impact of reduction in contract values with commissioners on top of a small elective workload and the absence of high-value specialist elective services to subsidise emergency services; and

The very public debate about SaHF has led many local people and even their GPs to believe, incorrectly, that the hospital is closing imminently. As a result referrals are falling and it is becoming harder to recruit quality staff in sufficient numbers.

EHT-ICO has reacted to this by placing itself in ‘turnaround’. Over the same period NWLHT continued to run significant operating losses driven by the inherent structural

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deficit associated with the CMH site and sustained increases in demand for emergency services.

With consolidation the new organisation will be able to recruit and retain high calibre staff as the critical mass and case mix of patients grows at NPH, and the future of EHT-ICO and CMH is clearly articulated and developed.

CHAPTER SUMMARIES 1.6

Based on NHS guidance, the structure of this business case begins with summaries of the two organisations (chapter two) and their wider context (chapter three). These summaries provide the basis for understanding the rationale for the Trust Boards’ decisions in 2011 to press ahead with plans for a combined organisation (chapter four). Chapter five presents the benefits that will arise as a result of merger and includes specific examples that have emerged from early collaboration between clinicians from both Trusts.

Having identified the need for outward structural change, the organisations worked together during 2013 to articulate the vision, values and behaviours that will enable the new joint Trust to succeed (chapter six).

Ensuring a safe transition to the new Trust and maintaining high quality services relies on effective leadership, operational and quality governance arrangements (chapter seven), a financially viable organisation (chapter eight), good communication and meaningful engagement with partners (chapter nine), and robust implementation and change management (chapter one0).

1.6.1 Chapter two – Profile of the Trusts

EHT-ICO and NWLHT are two of the seven acute Trusts serving the 1.9m residents of NWL. Both Trusts are committed to delivering high-quality care to patients, and share a common vision for improvement. There is also a significant clinical overlap in the services currently provided by EHT-ICO and NWLHT. Both Trusts have well established clinical networks (e.g. for vascular and maxillo-facial services), as well as with other local Trusts: notably, Imperial Healthcare NHS Trust (ICH) which, for example, provides renal dialysis and neurology services for both Trusts.

Following its establishment in April 2011, EHT-ICO comprises a single acute hospital site with more than 350 acute beds. It also provides community services (160 beds) and had a total budget for 2013/14 of £m. During 2013/14, EHT-ICO moved from a position of financial stability over the past nine years (as described in chapter two) to developing a significant underlying deficit of £8.9m although the Trust delivered a small surplus after non-recurrent in year support.

NWLHT is based on two acute sites: Northwick Park Hospital (which includes St Mark’s Hospital) and the Central Middlesex Hospital sites, with a total of more than 800 beds and a budget of £m in 2013/14.

There is considerable overlap in the services offered by EHT-ICO and NWLHT and both are important providers of services to the boroughs of Brent, Ealing and Harrow, but neither is dominant. This was recognised by the Co-operation and Competition Panel, which concluded that a merger was unlikely to result in a material reduction in choice and completion.

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Over recent years NWLHT has not been able to achieve recurrent financial balance previously applied to the former NHS London Challenged Trusts Board (CTB) for release of funding to pay off its historic loan.5 For the period to 2018/19, the Trust is forecast (chapter eight) to continue delivering a deficit in each year.

Both Trusts have had a good track record of delivering operational targets. However, NWLHT and NPH in particular have struggled to deliver consistent performance against the four-hour wait standard and both Trusts have had challenges with the 18-week wait target.

EHT-ICO and NWLHT have also performed poorly in recent patient surveys. This has informed the joint work on values and behaviours being done as part of the merger.

1.6.2 Chapter three – Commissioning strategy in North West London

Healthcare is commissioned from both Trusts by CCGs which came into being and assumed most of the former PCT responsibilities from 1 April 2013. The Trusts’ specialist services are commissioned by NHS England. There is a CCG for each of the three local boroughs of Brent, Ealing and Harrow.6 All three boroughs share wide variations in current levels of deprivation, health needs and health outcomes.

In addition, the boroughs face common future public health challenges. These include: population growth, changing demographics and an increasing prevalence of Long Term Conditions (LTCs), many of which are lifestyle-related diseases. Local health priorities include a greater focus on preventing disease: boosting access and delivering care in the community; increasing the consistency and quality of care; improving clinical outcomes and enhancing the patient experience.

In the light of these challenges, the local NHS and other stakeholders recognise the need for change in the way services are currently organised and delivered. There is broad agreement among both providers and commissioners that scarce resources are best deployed by delivering care in the community wherever possible and clinically appropriate

Improving patient care will require close joint working across primary, community and acute services, mental health and social services. It will also require greater levels of integrated care in pathways across providers and consolidation of specialist services onto fewer sites. Local commissioners have each compiled their plans in out-of-hospital (OOH) strategies.

NHS NWL consulted widely on options to address their case for change throughout 2012. In February 2013, a Joint Committee of PCTs approved the Decision Making Business Case (DMBC) which recommended changes to the provide landscape. Under the SaHF proposals CMH, Ealing Hospital (EH) and NPH would all become local hospitals for the communities they serve. In addition, NPH would become one of five major acute hospitals in the sector and CMH would develop as an elective centre. Implementation is planned to take up to six years.

5 As of March 2011 6 Brent CCG and Harrow CCG share management support with Hillingdon CCG in the ‘BHH’

commissioning consortium, Ealing CCG has a similar arrangement with the Inner NW London Commissioning Consortium (having previously been allied to BHH).

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The SoS accepted the recommendations of the Independent Reconfiguration Panel (IRP) at the end of October 2013. This included the recommendation that Ealing Hospital A&E should not close for a number of years and that ENT and NWLHT should continue to collaborate clinically in the interim7.

The case for change remains strong. This chapter argues that implementation of the key features of SaHF and commissioner OOH strategies would be best facilitated by the creation of a single Trust rather than two competing organisations.

1.6.3 Chapter four - The case for merger

As a result of NHS NWLs commissioning intentions (described in chapter three), the two Trusts will need to deliver increasingly rigorous quality standards in the acute setting, whilst finance is reinvested into providing care closer to home.

Smaller hospitals will find it increasingly difficult to fulfil commissioning standards and quality requirements, as they will lack the critical mass and case mix to ensure acute specialists can retain their skills. EHT–ICO will find this particularly challenging. Larger organisations – through economies of scale – are better able to reduce their managerial and ‘back office’ functions, thereby reducing the cost base of the organisation.

NWLHT, with NPH operating as a major acute site, has a larger critical mass and so has less immediate concerns about clinical sustainability. For NWLHT, additional benefits and resilience would be provided through larger teams and joint working with EHT-ICO. This is particularly important for emergency care where constrained flexibility of inpatient capacity coupled with year-on-year increases in demand can reduce the quality of patient experience.

The Boards of both Trusts agree that, despite the tough local environment, the proposed merger will create a healthcare organisation with sufficient critical mass, resources and ambition to deliver the following vision:

‘To provide excellent clinical care in the right setting by being compassionate, responsive and innovative.’

1.6.4 Chapter five – Clinical benefits of the merger

The Trusts are committed to aligning themselves with the commissioning strategy for NW London encapsulated in SaHF and the related Out-of-Hospital strategies of local commissioners that were widely consulted upon in 2012/13 and endorsed by the SoS after a review by the IRP in October 2013.

This chapter explains how clinical quality improvements can be achieved in the short term, without significant service reconfiguration through merging EHT-ICO and NWLHT, and describes how the newly merged organisation will deliver the Commissioning quality standards. The chapter also uses case study examples to illustrate the potential benefits of merger from the patient journey perspective.

The merged organisation’s belief in developing borough based services through community services and partnership working, supporting the local hospitals created by SaHF are also described.

7 IRP Report on SaHF, presented to SoS, September 2013, Section 5.7.5

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As stand-alone organisations EHT-ICO lacks the scale and, as shown in chapter eight, both EHT-ICO and NWLHT lack the financial stability to support fully the implementation of SaHF ambitions. Without merger, the ability of EHT-ICO and NWLHT to support commissioners’ ambitions would be limited.

Implementing the strategic reconfiguration of healthcare provision across NWL envisaged by SaHF safely will require a high degree of co-ordination. Co-ordinating implementation with a single organisation will greatly reduce the clinical and financial risks associated with the major changes to patient flows that accompany the proposed:

transformation to a local hospital on the Ealing site;

consolidating emergency, maternity and specialist services onto the major acute centre at NWLHTs NPH site; and

reconfiguration of CMH.

The merged Trust will over the period of SaHF implementation modelled within this BC deliver substantial clinical innovation, efficiencies and synergies to maintain financial stability during a period where the merged Trust income reduces by over £42.3m due to SaHF service changes. The merged Trust is also better placed to absorb the short-term workforce, cost and income impacts of these changes.

The proposed merger gives significantly greater clinical, operational and financial capacity to respond to these stresses. Sustaining long-term resilience is a central tenet of the TDA guidance on strategic planning8 and is a feature of the new Trust borne out in the BC.

Recognising this, both organisations have over the past 18 months begun tactically integrating elements of their executive leadership9, corporate functions10 and aligning clinical functions11. .

Given the strong link between delivering high-quality training and clinical care and staff satisfaction, the new organisation is committed to improving teaching and training. Both Trusts have a strong track record of teaching and training medical and non-medical staff and this will be further developed as part of the new Trust. The new Trust plans to maintain a robust approach to research, development and innovation based on current good practice within existing Trusts.12 Linking these activities to the new Academic Health Sciences Network for NWL gives further leverage to build clinical capability and to keep patient care at the cutting edge.

8 Toward High Quality Sustainable Services: Planning guidance for NHS Trust Boards for 2013/14,

NHSTDA December 2012 9 At the time of writing the Trusts have a single chief executive officer, director of nursing, director of

estates and facilities and director of IM&T operating across both organisations 10 Specifically within estates and facilities and information management and technology (IM&T)

directorates, and in the strategic procurement function 11 Practical examples of collaboration across clinical services ranges from the provision of elements

of the urology service by NWLHT to EHT-ICO under a service level agreement (SLA) to various arrangements for the sharing of clinical staff to support rotas, joint appointments and the standardisation of policies and operating procedures.

12 NWLHT currently holds second pole position in the North West sector for Comprehensive Local Research Network (CLRN) income and EHT-ICO has a large scale observational study relating to cardiovascular disease in its portfolio that accrues well against CLRN targets.

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1.6.5 Chapter six – Clinical vision for the new organisation

Since 2013, closer working of the two Boards and the on-going integration planning have been used to reflect regularly on factors impacting on the vision, including: the current position of both Trusts, drivers of change and the enablers of successful transformation.

Extensive engagement with staff and partners has informed a simple and compelling vision statement for London North West Healthcare NHS Trust below:

To provide excellent clinical care in the right setting by being: compassionate; responsive; and innovative.

The Boards recognise that achieving the vision will involve a long-term transformation of the current Trusts. A set of values and what these will mean for the new organisation have been developed. The clinical strategy is being developed with reference to the future state of the three hospital sites and the community services.

Ultimately, the transformation aims to position the new Trust to demonstrate clearly that it can provide high quality care for patients well into the future, as a large integrated care organisation and training provider in northwest London.

The chapter concludes by describing the organisational development work to facilitate clinical integration for individual service lines and to align these with the local commissioning intentions.

1.6.6 Chapter seven – The new organisation’s structure & governance arrangements

The clinical divisions will form the driving force of the merged organisation, with responsibility for continuous improvement in the quality of patient services in line with best practice and reflective of the new organisation’s vision and values.

The new Trust Board will maintain an appropriate balance of skills and experience to ensure that it is fit for purpose as both an NHS Trust and ultimately a Foundation Trust (FT).

Six Trust Board sub-committees will each take responsibility for a particular area, address any problems, report back to the Board and provide assurance that steps are being taken to maintain the highest standards:

Strategy Organisational Development Communications and Human Resources Committee;

Finance Investment and Estates Committee;

Audit Governance and Risk Committee;

Clinical Performance and Patient Experience Committee;

Charitable Funds Committee; and

Remunerations and Senior Appointments Committee.

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The Chief Executive, executive directors13 and non-board directors will be responsible for the operational management of the Trust.

The Trust will adapt the structure to include a Council of Governors as it moves towards FT status.

Clinical leadership and involvement is pivotal to the merger’s success as improved patient care and efficiency can only be realised by engaging clinical staff. The new organisation will therefore be arranged into the following five clinical divisions, each led by a senior clinician as Divisional Group Director:

medicine;

surgical services;

women and children’s services;

community services; and

clinical support services.

The community services divisional management structure will be based around the three boroughs (Brent, Ealing and Harrow) and will include local GP representation on its management board.

In preparation for merging, and in recognition that information flows are key to safe patient care and good management, joint work has extended to supporting systems. A joint patient administration system and integration engine was implemented across the Trusts in February 2014. Further integration is scheduled with joint systems to be in place for A&E, bed management, order communications and results reporting by end of September 2014. Procurement for a joint radiology system (RIS-PACS) is also now at the final stages of contract negotiation with the preferred bidder, with the joint system planned to be in place during Q4 2014/15. A joint Information Management and Technology (IM&T) CQUIN group has also been established with commissioning leads for Brent, Ealing and Harrow CCGs, overseeing deployment of interoperability projects to extend information sharing and electronic communications with GPs.

1.6.7 Chapter eight – Financial evaluation

Improving clinical quality for the population of the North West of London, in line with SaHF, is the driver for the proposed merger: both Trust Boards believe the merger will deliver significant clinical benefits for patients. To ensure clinical benefits are sustained the Trust will need to be financially viable, and the merger will provide financial benefits to enable this.

This chapter demonstrates the financial case for merger.

NWLHT has been financially challenged for several years and is forecasting a deficit of £21.5m in 2014/15. Whereas EHT-ICO has historically broken even, a combination of factors have led to a rapid deterioration of its financial position resulting in a forecast deficit of £13.6m in 2014/15.

13 The executive members of the Trust Board will comprise the Chief Executive, Chief Finance

Officer, Medical Director and Chief Nurse and Chief Operating Officer.

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The conclusions of the analysis presented in chapter eight are stark as summarised in Table 2. Importantly, merger enables the new Trust to absorb the financial impact of activity and income losses arising as a result of SaHF to achieve break-even without the need for external input from year three and a surplus of £12.2 in year five (2019/20).

Merger-related cost-savings resulting from the integration of management structures and support services, and the ability to increase the scale over which cost-savings projects are delivered, underpin the ability to reverse the trend of increasing financial weakness. Without merger the aggregate deficit of the stand-alone Trusts is predicted to grow to reach £34.5m in 2019/20.

Table 2 Total benefits over five years, comparison of the do minimum and base case (source: Chapter eight)

On the basis of the modelling carried out for the FBC, and taking account of the impact of SaHF, the cash benefit to the NWL health economy is £164m over the five year period. This clearly demonstrates value for money against the funding support package of £123.6m that will be required:

o Fund short term deficits of £54.2m, fund repayments of loans and leases (£38.6m) which includes DH loan payback at NWLHT (£14.3m), PFI and Ealing local hospital commercial loan principal repayments,

o Fund the one-off implementation costs of merger (£12.8m).

o Fund two year Ealing Local Hospital reconfiguration transitional costs (£18m) subject to Final Business Case for Ealing local hospital

This is in addition to the £56.5m of funding requirement included in the model over the next five years to support the CMH structural deficit (i.e. £11.3m per annum for 3 years agreed with Commissioners. For years 4 and 5 the model has assumed the same support as the revised service model expected to ameliorate the deficit is at this stage unknown and not capable of being modelled. This is the subject of a separate business case being led by Commissioners). The forecast deficit position in the ‘do nothing’ case would not reduce the deficit within five years, with the prospect of this increasing by over £46m a year thereafter. Leaving NWL with a potentially insoluble legacy and intensifying funding pressure on the health economy.

The merger presents a real opportunity to address the clinical critical mass issues faced by Ealing-ICO and the financial challenges at both Trusts. The financial case demonstrates that the Trusts will be ‘Stronger Together’ and provides a platform for the merged organisation to achieve a sustainable business plan that will allow it to progress to preparing for FT application.

Non-Merger Case

2014-15 2015-16 2016-17 2017-18 2018-19 2019-20

£m Outturn Forecast Forecast Forecast Forecast Forecast

Merger Surplus/(Deficit) normalised(35.1) (19.1) 0.2 0.6 6.8 12.2

Non-Merger Surplus/(Deficit) (35.1) (30.4) (27.1) (37.0) (34.5) (34.4)

Net I&E benefit 0.0 11.3 27.3 37.6 41.3 46.6

Merger Cash (22.5) (48.2) (47.5) (51.4) (58.9) (30.4)

Non-Merger Cash (22.5) (59.4) (86.1) (127.5) (176.4) (194.5)

Net Cash Benefit 0.0 11.3 38.5 76.1 117.5 164.1

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1.6.8 Chapter nine – Engagement & involvement of stakeholders

Given the importance of developing a FBC that has contributions from, and the support of, local stakeholders, communication and engagement was identified as a priority early in the original merger process.

This chapter provides an overview of communication and engagement activities regarding the proposed merger of Ealing Hospital NHS Trust and The North West London Hospitals NHS Trust.

Both Trusts have actively engaged with stakeholders for more than two years and have continued to update them regularly, as well as their staff.

Following the remobilisation of the programme in January 2013, the communication and engagement programme has been refreshed to take into account changes in the merger process, SaHF and plans for a joint clinical strategy. Issues raised by stakeholders since the initial consultation exercise have continued to be taken on board and included in the evolving programme and business case as these have evolved.

The chapter covers two key phases:

Phase One covers the period January 2011 to December 2012 when the Trusts embarked on an engagement programme with a range of stakeholders about the business case and the proposals to merge; and

Phase Two describes what the Trusts are doing to refresh their engagement with stakeholders in light of the remobilisation of the merger programme in 2013, as well as the next steps for communication and engagement as the Trusts begin to prepare for Day 1 and beyond.

The key themes that emerged consistently from Phase One included:

Transport links and access in general;

Concerns about potential impact of the merger on local services;

Ability to achieve savings targets;

Investment in community services;

Support for staff during the change process; and

Is bigger really better?

Although the merger itself will not directly lead to major service change, for many stakeholders these two issues were seen as the same. These themes are addressed in chapter nine.

1.6.9 Chapter ten – Integration and implementation plan

As described in previous chapters, the new organisation will be patient-focused, clinically-led and financially robust.

This will require transformational change enabling it to: provide the highest quality of care; adhere to patient safety standards; support effective governance processes; remain committed to staff; be responsive to the needs of commissioners; provide transparent communication with stakeholders; and demonstrate strong clinical leadership.

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These objectives must be delivered within specified time frames, through a phased implementation plan with minimal service disruption and risk to patients. In addition, particular care is needed to ensure that the transition on ‘Day 1’ is safe for patients and staff, with appropriate plans in place to ensure a seamless handover takes place.

A robust programme management and risk management approach to integration delivery and benefits realisation has therefore been established and is outlined in this final chapter.

SUMMARY OF APPENDICES AND SUPPORTING DOCUMENTS 1.7

Appendices are used within the BC to provide additional detailed information that is summarised within the body of the main text. Where they have been used, Appendices are listed at the end of the relevant chapter.

In addition to the BC, the TDA assurance process requires the submission of a number of additional Supporting Documents. Any Supporting Document that is referred to in the main body of the text will also be listed at the end of the relevant chapter. Table 3 provides a summary of all supplementary materials referred to within the FBC, with their relevant appendix/supporting document reference.

It should be noted that some of the supplementary materials will only be completed during Gateway 4 and are therefore either not available or only available in draft form for Gateway 3 assurance.

Table 4 lists the remaining supplementary materials that will be available for Gateway 4.

Table 3 Summary of appendices and supporting documents referenced in the FBC

Reference [Chapter] Title

Appendix 1-1 Mapping of business case amendments to TDA feedback

Appendix 3-1 Detailed demographic information

Appendix 3-2 Key elements of the case for change upon which SaHF is founded

Appendix 4-1 Details of the options appraisal

Appendix 5-1 Examples of patient benefits and patient stories

Appendix 7-1 Board sub-committee summary details

Appendix 8-1 Changes in activity flows assumed to result from SaHF

Appendix 8-2 Assumptions

Appendix 8-3 Summary of the financial impact of the main assumptions

Appendix 8-4 Summary income and expenditure (merger base case)

Appendix 8-5 Full balance sheet (merger base case)

Appendix 8-6 Summary income and expenditure (non-merger case)

Appendix 8-7 Full balance sheet (non-merger case)

Appendix 8-8 Workforce Mitigations

Appendix 9-1 Formal responses received from stakeholders

Appendix 9-2 Terms of Reference for the Stakeholder Reference Group

Appendix 9-3 CCG and NHS England letters of support in principle

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Reference [Chapter] Title

(September 2013)

Appendix 9-4 Integration communications plan for the transition period

Appendix 10-1 Terms of reference for transaction programme governance structure

Appendix 10-2 Programme risk and issue register as of time of submission

Appendix 10-3 High-level Day 1/Day 100 plan

Supporting Document 2-1 Estates vision and strategy

Supporting Document 2-2 Letter to NHS England concerning Challenged Trust Board funds

Supporting Document 4-1 Strategic Outline Case

Supporting Document 5-1 Communications and engagement plan

Supporting Document 5-2 Organisational development strategy

Supporting Document 5-3 Estates strategy

Supporting Document 5-4 IM&T strategy

Supporting Document 6-1 Joint strategy development overview presentation (August 13)

Supporting Document 7-1 Draft ToR for new Trust Board and sub-committees

Supporting Document 7-2 Clinical due diligence

Supporting Document 7-3 Financial due diligence

Supporting Document 7-4 Legal due diligence

Supporting Document 10-1 Implementation plan

Supporting Document 10-2 Benefits realisation plan

Table 4 Supporting materials not referenced in the FBC

Financial evaluation

Long Term Financial Model

PIDs - CIP 14/15 and 15/16

Merger Synergies Themes

Communication and engagement

Summary of communications and engagement activities since Sep 2012

CCG and NHS England letters of support

Approvals process

Competition and Cooperation Panel submission and recommendation

OBC

Heads of Terms

Transactions Agreement

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Due diligence reports and action plans

CDD action plan

DTZ Community Property Evaluation

Equality Impact Assessment

Equality Assessment and Action Plan Final

FDD action plan

LDD action plan

Enabling strategies

Equality and Diversity Strategy

Patient and Public Involvement Strategy

Patient Experience Strategy

Quality Governance Strategy

Appendices and Supporting Documentation are available on request.

MAPPING OF THE BUSINESS CASE TO TDA ASSURANCE 1.8FRAMEWORK

The location of evidence in the business case and appendices against each component of the TDA Assurance Framework requirement for Gateway 3 is set out in Appendix 1-1.

CONCLUSION 1.9

This business case has assessed the implications of commissioners’ future plans and the requirements of national, regional and Royal College guidance (see chapters three and four). These requirements are expected to result in less demand (and ultimately income) for acute services with greater investment in out-of- hospital care. This, coupled with the clinical drivers of increased medical sub-specialisation and need for greater critical mass, means that the two Trusts would struggle to be clinically and financially sustainable if they remained independent (see chapters four and eight).

A merger of the two Trusts will provide tangible benefits for patients; staff, commissioners and the local population (see chapters four, five and six). It will create a combined Trust which is both an integrated community and a large acute provider, able to develop more effective clinical care for patients both in hospital and the community.

Meanwhile, the merged Trust will have the scale and critical mass needed to provide the highest quality specialist services on both a local and regional basis. By 2016/17, it will also be well on the way to achieving the financial strength required to begin the FT application process (chapter eight).

APPENDICES AND SUPPORTING DOCUMENTS 1.10

Appendix 1-1 Mapping of business case amendments to TDA feedback

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2. Profile of the Trusts

OVERVIEW OF THE ORGANISATIONS 2.1

Ealing Hospital NHS Trust and its associated Integrated Care Organisation (EHT-ICO) and NWLHT both operate in the catchment that was defined formerly by the NHS North West London (NHS NWL) cluster of CCGs.14 The eight CCGs in NWL are responsible for the health needs of a population of approximately 1.9 million who are served by seven acute trusts, two mental health trusts, four community health providers and approximately 1,300 general practitioners based in 420 practices. As summarised in Table 5below.

Table 5 NHS Trusts providing care in North West London

Acute Trusts The North West London Hospitals NHS Trust

Ealing Hospital NHS Trust

West Middlesex University Hospital NHS Trust

Imperial College Healthcare NHS Trust

The Hillingdon Hospital NHS FT

Chelsea and Westminster Hospital NHS FT

Royal Brompton & Harefield NHS FT

Mental Health Trusts West London Mental Health NHS Trust

Central and North West London NHS FT

Community Health Providers

Ealing Integrated Care Organisation

Hillingdon Community Trust15

Hounslow and Richmond Community Healthcare NHS Trust

Central London Community Healthcare NHS Trust16

Figure 2 shows the location of EHT-ICO and NWLHT sites in the context of the local area.

14 NHS North West London was a partnership or 'cluster' of eight CCGs that has subsequently split

into two groupings: CWHHE Collaborative (including Ealing CCG) and BHH Federation (including Brent CCG and Harrow CCG).

15 Formally joined Central and North West London NHS FT (CNWL) in February 2011 16 Includes inner North West London boroughs as well as Barnet

Chapter summary

This chapter provides a summary analysis of both Trusts, including their service portfolios and financial and operational performance.

The chapter also examines key current issues facing the Trusts, including NWLHTs current efforts to deliver the four-hour wait target and the challenges both Trusts face in delivering the referral-to-treatment (RTT) target across all specialties. Finally, the chapter considers both Trusts’ good clinical outcomes and recent improvements in patient experience surveys.

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Figure 2 Borough boundaries and healthcare facilities

EHT-ICO and NWLHT primarily serve the boroughs of Brent, Ealing and Harrow. Most of the care they provide is commissioned by CCGs in NHS North West London. As illustrated in Table 6, in 2012/13, 38% of new outpatient referrals from Ealing GPs were sent to Ealing Hospital.

In Brent and Harrow, NWLHT enjoyed market share of 53% and 59% respectively.

Table 6 Market share percentage based on new patient referrals Apr 2010–Mar 2013 (source: CHKS)

These market share figures are relatively low given that the three acute hospitals are the sole acute providers in each borough. This is particularly the case in Ealing where, for example, 28% of patients are referred out of borough to ICH.

Low market share is, in part, a reflection of the level of choice and opportunity in NWL for patients who can choose a relatively wide range of hospitals. For example, St Mary’s Hospital (part of ICH) is less than six miles from east Ealing and south

Trust

Referrals Percentage Referrals Percentage Referrals Percentage

The North West London Hospitals NHS Trust 27,576 59.15% 38,639 53.48% 6,561 8.81%

Ealing Hospital NHS Trust 28,650 38.46%

Imperial College Healthcare NHS Trust 1,836 3.94% 16,612 22.99% 20,976 28.16%

The Hillingdon Hospital NHS FT 2,795 5.99% 4,896 6.57%

Barnet & Chase Farm Hospitals NHS Trust 1,915 4.11% 1,572 2.18%

University College London Hospitals NHS FT 2,139 2.96% 778 1.04%

Royal Free London NHS FT 3,381 4.68%

Moorfields Eye Hospital NHS FT 2,755 5.91% 2,229 3.09% 3,617 4.86%

Chelsea & Westminster Hospital NHS FT 2,388 3.21%

West Hertfordshire NHS Trust 1,508 3.23%

Central & North West London NHS FT 2,598 5.57% 2,327 3.22%

West Middlesex University Hospital NHS Trust 3,490 4.68%

BMI 1,151 2.47% 1,003 1.39%

Other 4,490 4,348 6.02% 3,143

Total 46,624 72,250 74,499

Harrow CCG Brent CCG Ealing CCG

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Brent and easily accessible by public transport. The merger of the two Trusts is therefore not likely to undermine this level of choice and opportunity. A position that was confirmed by the recommendation of the CCP Cooperation and Competition Panel (CCP) in June 2012 following their review of the merger proposal:

‘The merger of Ealing Trust and North West London Trust is unlikely to give rise to a material cost for patients and taxpayers because there will remain sufficient patient choice and competition. We concluded therefore that the merger is consistent with Principle 10 of the Principles and Rules.’17

SWOT ANALYSES 2.2

SWOT analyses of the respective Trusts are summarised in Figure 3 and Figure 4 below.

Strengths

Good clinical outcomes

Largest provider of community and integrated pathways across three large boroughs

Wide range of career pathways for staff

Weaknesses

Loss of core DGH services under SaHF

Lack of clarity about future model for EHT-ICO

Financial fragility due to activity and income losses

Reputation for poor patient experience

Opportunities

Outside upper quartile on most productivity indicators

CCGs investing significantly in out-of-hospital and community, which remain a key focus for EHT-ICO

Extending reach of R&D

More efficient use of community estate

Threats

Re-procurement and decommissioning of services by CCGs

Ability to compete with private sector for community contracts

Consequences of Ealing CCG moving from BHH to CNWL CWHHG CCG Collaborative

Figure 3 SWOT analysis of Ealing Hospital NHS Trust

17 Merger of Ealing Hospital NHS Trust with North-West London Hospitals NHS Trust, CCP, 13 June

2012. http://www.monitor.gov.uk/regulating-health-care-providers-commissioners/cooperation-and-competition/archive-co-operation-and--13

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Strengths

Growing emergency demand

Good clinical outcomes

NPH a fixed point under SaHF

St Mark’s ‘jewel in the crown’

One of the largest cancer units in London

NPH growing market share in Harrow

Weaknesses

Ability of NPH to be an acute hub as long as it cannot meet emergency demand

Poor reputation for financial management

Inconsistent performance against elective and emergency targets

Fabric of NPH and restrictive covenants [on estate]

Perception of complacency

CMH – impact of underutilisation, PFI unitary charge, uncertain future

Reputation for poor patient experience

Lack of plastics support for specialist services

Opportunities

Outside of upper quartile across a wide range of performance measures

Extension of well-regarded franchises, e.g. Moorfields, RNOH etc.

Income potential of centralising elective surgery at CMH

Designation of head & neck as one of London’s four cancer centres

New pathways to establish regional centres, e.g. ENT

Extension of St Mark’s brand, e.g. centre for HIPEC and cytoreductive surgery for peritoneal cancers

extended reach of R&D

Threats

Harrow CCG in financial recovery

Re-procurement and decommissioning of services by CCGs

More ‘agile’ and ‘innovative’ competitors

De-designation of head and neck service

Figure 4 SWOT analysis of The North West London Hospitals NHS Trust

The issues facing both Trusts are described in more detail in the remainder of this chapter and also in chapter four which lays out the case for merger.

EALING HOSPITAL NHS TRUST 2.3

Ealing Hospital currently operates as a mid-sized district general hospital (DGH). Acute services are located on a single site in Ealing. The site is shared with the West London Mental Health NHS Trust, though none of the individual buildings or ownership of the buildings are shared. The facilities were constructed in the late 1970s and opened in 1979.

On 1 April 2011, EHT incorporated the community provider organisations of Ealing Brent and Harrow PCTs to form EHT-ICO, an integrated care organisation. Community services operate from more than 30 separate locations including:

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Willesden hospital in Brent, Denham intermediate care unit in Harrow and Clayponds hospital and Meadow House hospice in Ealing.

EHT-ICO own or lease 12 of the premises and they are listed in the Estates Strategy (Supporting Document 2-1). The remaining properties transferred to NHS Property Services in April 2013. EHT-ICO’s acute site has more than 350 beds while its community services division has almost 160. Meadow House Hospice, jointly owned by EHT-ICO and NHS Property Services, is also located on the EHT-ICO site.

Activity at EHT-ICO’s acute site in 2013/14 is summarised in Figure 6.

Table 7 Activity at EHT-ICO (2013/14)

DC EL NEL OP AE

Maternity 2,443 6,258 40,466

Medicine 4,914 223 14,065 100,815

Paediatrics 221 152 2,157 5,281

Surgery 5,483 1,683 3,748 55,188

Total 10,618 2,058 22,412 167,542 40,466

EHT-ICO acute and community services employs a workforce of 3,154 whole-time equivalent (WTE) staff, with a breakdown shown in Figure 5 below.

Figure 5 Breakdown of staff by groups at EHT-ICO as at 31 March 2014

Community services were incorporated into the Trust from 1 April 2011 when the Trust became EHT-ICO, resulting in £96m of additional income. EHT-ICO received income of £250m in 2013/14 and ended the year with a £17k surplus, but only with non-recurrent support. The underlying deficit for the year was £8.9m.

For the current financial year, EHT-ICO is forecasting a deficit of £13.6m as a result of decreasing activity and consequent income, as well as finding it increasingly difficult to deliver savings as a relatively small DGH when minimum service and quality standards must be maintained. Modelling suggests that by 2018/19, EHT-ICO will continue to deliver a year-on-year deficit. EHT-ICO’s overall income breakdown is summarised in Figure 6 and further detail is available in chapter eight.

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Figure 6 Breakdown of EHT-ICO income 2013/14

THE NORTH WEST LONDON HOSPITALS NHS TRUST 2.4

NWLHT operates at the NPH and CMH sites and has a total of around 800 beds. CMH is a modern facility completed in March 2007 and operated under a Private Finance Initiative (PFI) by Bouygues (UK). The NPH site is older, having opened in 1970, and is where the St Mark’s Hospital is co-located. NPH is the major acute hospital for outer NWL and provides a range of specialist services as well as running a very busy emergency service.

NWLHTs activity figures are summarised by site in Table 8 and Table 9 below.

Table 8 Activity at NPH including St Mark’s Hospital (2013/14)

DC EL NEL OP AE

Maternity 619 493 12,386 45,291

Medicine 22,828 1,059 20,889 112,117 86,041

Paediatrics 2,708 322 11,554 13,259

Surgery 4,408 5,267 8,177 107,972

Total 30,563 7,141 53,006 278,639 86,041

Table 9 Activity at CMH (2013/14)

DC EL NEL OP AE

Maternity 1,154 390 1 11,786

Medicine 3,175 263 6,755 47,065 14,400

Paediatrics 1,181 70 15 7,309

Surgery 8,174 2,351 110 47,950

Total 13,684 3,074 6,881 114,110 14,400

NWLHT employs 4,607 FTEs across a number of staff groups that can be seen in Figure 7.

25

Figure 7 Breakdown of staff by groups at NWLHT as at 31 March 2014

NWLHT income in 2013/14 was £418 million and the main sources of this income are shown in Figure 8.

NWLHT achieved in-year break even in one of the last five years, but only with the support of non-recurrent benefits. When the results are adjusted for this non-recurrent support, results show a normalised deficit position for each year.

In the current year NWLHT is forecasting a deficit of £21.5m in line with its operating plan. Modelling suggests (chapter eight) that, by 2018/19, the Trust will continue to deliver a deficit in each year as a result of not being able to fully realise the benefits of an integrated care organisation or merger synergies.

Figure 8 NWLHT Income 2013/14 (source: NWLHT Finance Team)

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SERVICES PROVIDED 2.5

2.5.1 Areas of overlap and collaboration between NWLHT and EHT-ICO

Both EHT-ICO and NWLHT provide a full range of general acute and emergency hospital services. As a result there is significant clinical overlap in the services provided, with the majority of specialties provided across both Trusts.

To avoid duplication and ensure patients have the best outcomes, both Trusts have deployed the following formal hub and spoke clinical agreements:

Oral and maxillofacial surgery (NWLHT provides the hub service)

Vascular (NWLHT provides the hub service)

Interventional radiology (NWLHT provides the hub service)

Urology cancer (NWLHT provides the hub service)

Breast (NWLHT provides the hub service)

Microbiology department with joint on call rota

Both Trusts also jointly provide a number of community services and have agreed the following SLAs in the last 18 months:

Northwick Park and Hillingdon urgent care centres (UCCs) – EHT-ICO is the main contractor while NWLHT and a private partner18 are the subcontractors

Brent Short Term Assessment, Rehabilitation and Re-ablement Service (STARRS) - NWLHT is the main contractor for this intermediate care service and EHT-ICO is the subcontractor. The service has been commissioned by both Brent and Harrow CCGs

2.5.2 Specialist services

In addition to the general services described above, NWLHT provides the following specialist services:

Head and neck surgery

Stroke Care – including a hyper-acute stroke unit

Clinical genetics

Vascular surgery

Regional Rehabilitation Unit (RRU)

Specialist sickle cell and thalassaemia (both adult and children)

Specialist colorectal and intestinal medicine (provided by St Mark’s)

EHT-ICO alone could not easily begin providing these services because either the services do not meet new commissioner standards for designation (e.g. stroke and vascular) or the services are subject to separate specialist arrangements (e.g.

18 Greenbrook Healthcare

27

paediatric sickle cell and thalassaemia, clinical genetics, Intestinal Failure Unit and the RRU service).

2.5.3 Community services

EHT-ICO is the main provider of adult community services for the boroughs of Brent, Ealing and Harrow. Most of these services are provided at a borough level to ensure that they support the health needs of their local populations.

Services include district nursing, health visiting, long-term conditions management, urgent and intermediate care services. Following the creation of the ICO, the Trust has been working to provide some services on a tri-borough basis, as well as progressively integrating acute and community services in the borough of Ealing.

Recent work is also being undertaken to develop and implement new service models in response to the commissioning intentions, including new intermediate care services in Ealing and the new Urgent Care Centre model at Hillingdon Hospital.

2.5.4 Collaborations with other Trusts

NWLHT and EHT-ICO co-operate with a number of other local NHS Trusts to provide specific services, primarily with ICH. Examples of clinical collaborations include:

NWLHT and EHT-ICO have agreed joint pathways with ICH for haemato-oncology, endocrine surgery, nephrology and OMFS trauma

ICH provides Ear, Nose and Throat services at Ealing Hospital. There are also some shared consultant posts in cardiology, neurology, dermatology and rheumatology

ICH provides consultant-led specialist neurology care (elective and non-elective) at EHT-ICO and CMH respectively

University College London Hospitals NHS FT provides consultant-led specialist neurology care at NPH

ICH runs satellite dialysis units at NPH, CMH and EHT-ICO

ICH is the designated cancer centre for NWL and provides oncology support at EHT-ICO – as well as chemotherapy, radiotherapy and specialist cancer surgery for EHT-ICO patients

NWLHT links to Mount Vernon (Hillingdon Hospital NHS FT) as well as ICH for chemotherapy and radiotherapy care

The Hillingdon Hospital NHS FT provides the clinical haematology service to EHT-ICO

Interventional cardiology at EHT-ICO is supported through a formal agreement with the Royal Brompton and Harefield NHS FT

Moorfields Eye Hospital NHS FT provides ophthalmology services at EHT-ICO and NPH

Great Ormond Street Hospital NHS FT provides specialist paediatrics outpatients clinics at EHT

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CURRENT PERFORMANCE 2.6

2.6.1 Operational and clinical delivery

Current performance against the clinical indicators is generally good. Both Trusts are proud of their low mortality and healthcare acquired infections (HCAI) rates and there were no breaches of the mixed sex accommodation target at NWLHT in 2013/14. Both Trust have previously performed well against national cancer targets, however, due to the rising demand in both elective work generally and two-week cancer wait referrals specifically, the resilience of both sites is being tested.

There have been sporadic monthly failures at EHT and failure of the 62 day cancer target for the past 2 quarters and 31 day (surgery) for the past 2 months. Both Trusts have a remedial action plan in place to address this, but overarching capacity to manage all the elective work is challenging individually.

The referral to treatment time (RTT) standard of 18 weeks for admitted patients challenged both EHT-ICO and NWLHT in 2013/14 and work to fully understand the current demand and capacity, as well as waiting list management practice, was undertaken with the national Intensive Support Team (IST) and recovery plans have or are in the process of being agreed with Commissioners and the TDA agreed for 2014/15.

NWLHT and the NPH site in particular have struggled to deliver consistent performance against the type one A & E four-hour wait standard, and the broader all types standard for A&E. EHT-ICO also periodically dips below target for A & E type one. During Q4 of 2013/14 and Q1 of 2014/15 the A&E targets became increasingly hard to maintain / achieve as increased demand continued to be experienced at both sites.

The latest performance indicators are summarised in Table 9 below.

Table 10 Performance summary19 for EHT-ICO and NWLHT (as at March 2014)

A&E performance EHT NWLHT

All type (YTD) 97.3% 93.99%

MRSA cases (YTD) 1 2

C. Difficile (YTD) 13 20

Healthcare Acquired Infections (HACAI)

EHT NWLHT

MRSA cases (YTD) 1 2

C. Difficile (YTD) 15 21

Waiting times EHT NWLHT

<18 wks (YTD) Admitted 89.5% 76.13%

<18 wks (YTD) Non admitted 97.8% 96.29%

Cancelled operations not rebooked within 28 days

Target EHT NWLHT

19 EHT-ICO and NWLHT Trust Board reports for March 2014. Includes February 2014 performance

YTD.

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Cancer Target EHT NWLHT

2 week wait for suspected cancer 93% 94.7% 95.55%

2 week wait for breast symptoms other than suspected cancer

93% 95.2% 97.18%

31 day diagnosis to treatment for first definitive treatments

96% 98.7% 96.90%

31 day diagnosis to treatment for subsequent treatment (drugs)

98% 100% 98.97%

31 day diagnosis to treatment for subsequent treatment (surgery)

98% 100% 95.65%

62 day referral to treatment for all cancers 85% 87.9% 86.42%

62 day referral to treatment from screening 90% 84.6% 97.30%

Summary Hospital-level Mortality Indicator (SHMI) EHT NWLHT

82.9 60.0

Mixed sex breaches Target EHT NWLHT

0 7 0

2.6.2 Emergency care at NWLHT

Northwick Park Hospital has developed from a local district hospital into a major hospital in emergency and elective care, providing most major acute specialities on site.

The number of patients visiting the emergency department has increased by at least 10% per annum for the last three years. Despite investment from commissioners over the years, the Trust continues to struggle to meet the increasing demand, with an expectation of a further 4% growth in 2014/15. The lack of physical bed capacity has led to long delays in finding appropriate beds for some patients. Patients wait for a bed in cubicles in the Emergency Department (ED), which reduces the available space in ED to assess other patients and receive patients from ambulances. Capacity in medical bed availability needs to be increased within the Trust to provide an effective and timely pathway for patients from within the ED into a bed on a ward.

This a significant negative impact on the experience of the patients in the department, research also describes the effects of being treated in an overcrowded Emergency Department and the affect that this has upon individual outcomes20.

The ED at NPH is being reprovided through a £23m capital investment with a completion date of October 2014. This will significantly improve the layout, clinical adjacencies and effectiveness of the department and improve experience for patients in terms of privacy and dignity as all rooms are single rooms with an increase in the number of spaces that are equipped for resuscitation and high acuity patients.

20 Forero R, Hillman K, McCarthy S, Fatovich D, Joseph A, Richardson DW: Access block and ED overcrowding. Emerg Med Australas 2010, 22:119-135

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Capita has recently (May 201421) completed demand and capacity modelling work commissioned by NHS Brent and Harrow CCGs for NWLHT. This concluded that the Trust would need an additional 22 medical beds over summer 2014 and a further 30 beds to meet demand in winter.

EHT has one inpatient ward closed on the acute site, which would release 22 beds to a merged Trust working across a flexible bed base under one bed management structure and system for healthcare delivery (as for example ICHT as a multi-site Trust use). Other capacity may be utilised to support patient flow with commissioner agreement, in Clayponds and Denham.

With commissioner agreement for the SOC at CMH (the end state for CMH is described at chapter six) and the imminent closure of CMH A&E (see below) a further 20 beds will imminently be accessible by NPH as step-down beds following the current successful model of fractured neck of femur patients. This group of patients are transferred post-operatively from NPH; the focus on rehabilitation and reduced internal transfers for these patients has reduced length of stay by 3 days.

Capita found that overall acute length of stay performance at NPH is amongst the best in peer group. The opportunities to reduce length of stay further, supports delivering more in day capacity rather than reducing the number of overall required beds. The opportunities are based around further increasing ambulatory care and the operation of the surgical assessment unit. The Trust’s rates of Ambulatory Care have increased since 2012/13 and by end of 2013/14 were in line with the national upper quartile on which tariff incentives are based22.

NWLHT has taken a range of action to support the demand on its emergency pathway, further improvements could be achieved if the flow of emergency patients were improved and a broader bed base was available and actively managed under a single structure, reducing outliers and thus transfers of patients which are by their nature inefficient.

The Trust action has included investment in extra resources in emergency care

staffing.23 As a result, senior decision makers are working clinically in A&E and paediatric A&E overnight to reduce waiting times and ensure optimal care for patients.

Increased staff resource has enabled the implementation of a revised emergency pathway to maximise the impact of the new beds and new ways of working on the Trust’s Acute Assessment Unit (AAU). Services have also been strengthened through the use of discharge packages of care for patients, with support from a specialist nurse including the roll out of the electronic white board which has moved the average time of discharge from 3pm to 12pm. These improvements helped to support the Trust’s performance through winter 2013/14.

With the continued increase in demand more needs to be done before winter 2014/15, and the additional capacity available at EHT, within community facilities or services and CMH contribute to potential opportunities for improvement in A&E performance. However, the Capita analysis suggests NWLHT needs a further increase in bed capacity to provide stability and sustainability. The Trust has plans to

21 Capita Demand and Capacity at NPH commissioned by NHS Brent & Harrow CCGs May 2014 22 Capita Demand and Capacity at NPH commissioned by NHS Brent & Harrow CCGs May 2014 23 45 additional beds were opened and additional staff recruited to support the Emergency floor.

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deliver this, with a current plan to open two new modular wards (circa 48 beds) in March 2015 and is working with the TDA to agree a process for signing off the business case for this investment to ensure delivery of this capacity at the earliest opportunity.

A net additional 66 beds from current levels would move the Trust to delivery of 95.2% against the national target, but not lower overall occupancy. As a joint organisation where beds over and above the modular build could be accessed, circa 20 at CMH post A&E closure and 20 from Ealing, this will reduce occupancy and allow resilience in the pathway. The clinical risks described in an overcrowded ED would be mitigated and patient experience would be improved by receiving care in a timely manner. Patient would not be waiting excessive times on trollies for the right bed to be available and care would be able to be provided in a setting appropriate to their clinical need.

As well as a physical capacity the new organisation would manage services both in and out-of-hospital by integrating these services, through re-designed patient pathways and collaborative partnerships to accelerate movement to community services, with pro-active care planning and interventions as part of the Whole System Integrated Care pilot. This will avoid A&E attendances and unscheduled care supporting the out-of-hospital strategy. London North West Healthcare will play a major role in supporting delivery of a paradigm shift in care for all three of the local boroughs and our patients.

As well as increasing capacity, improving the availability (speed of response) of senior clinicians from specialities other than the ED at point of admission will improve patient experience and reduce waits for assessment and admission. The merged Trust will be able to ensure this responsiveness to emergency patients by freeing senior decision makers from other clinical duties when they are on-call for the ED. The merger enables this as a result of changes to clinical rotas through increased consultant numbers and increased volume of emergency work. (chapter five details these plans further).

CMH is being developed as a centre for excellent elective care and a number of emergency services24 have been centralised on the NPH site. In March 2011, a new GP-led urgent care centre was opened on a 24/7 basis. The service, provided by Care UK, has been very effective: treating 87% of children and 68% of adults who attend CMH as emergencies.

As the first step in delivering the changes required from SaHF at CMH, the A&E closure is planned for the 10th September 2014. A Project Board within the Trust was established in February 2014 to manage the process, which has membership from NWLHT, Brent CCG, SaHF programme team and Health Watch Brent and provides assurance to the Board of NWLHT and its commissioners.

This dovetails with the CMH NEL Board which has additional representatives from all of the providers, including Imperial and the Royal Free and NHS England, which looks at the broader assurance in the system. A detailed project plan has been presented to the Trust Board and a detailed paper for formal approval of closure will be presented in June 2014, following this there will be detailed assurance processes with both NHS England and the NTDA and Brent and Harrow CCG’s.

24 Including acute paediatrics and emergency surgery and gynaecology

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2.6.3 Elective care at NWLHT

The 18 week RTT standard at NWLHT has been breached for a number of specialties over the last year. A situation that will persist across the worst-affected specialties as the Trust moves towards reducing the backlog, which currently sits at approximately 600 patients. A recovery plan has been agreed with the NHS IMAS Intensive Support Team (IST) and commissioners.

Ensuring that the RTT standard is consistently met will be substantially helped by the merger; capital works to increase theatre capacity and transformation projects aimed at improving theatre utilisation at NWLHT. All of which will increase theatre capacity and productivity. The refurbishment of a theatre at EHT provides a further addition to overall capacity.

In addition, the critical mass of surgical colleagues will be improved, to enable three session days to be achievable in more specialities. Currently trauma and orthopaedics (T&O) are the only speciality doing this in a planned consistent way, where they are moving rapidly to delivery of 18 weeks in this speciality. In T&O EHT-ICO is struggling with delivery and this will be resolved by the wider organisation avoiding the need for costly locum consultants.

A recent independent review of demand and capacity by Capita demonstrated that to deliver and maintain sustainable waiting lists NPH needs one additional theatre and 8–15 additional elective beds despite over £14m having been invested recently in building four new operating theatres at NPH (including a new interventional imaging suite for vascular surgery).

Currently, EHT has an underutilised theatre. A fully merged organisation would allow joint rotas to allow formerly NWLHT-based surgical capacity to be redeployed swiftly to ensure full utilisation of available EHT theatre slots. This, coupled with the development of the modular-built extension of NPH theatres referred to above, would provide a unique opportunity enabling elective capacity to be released from the constraints of emergency patient demand.

2.6.4 Elective Care at EHT

In 2013/14 EHT-ICO experienced pressures in managing demand and meeting the 18 week RTT consistently across all specialties. The Trust has been working with Commissioners, the TDA and the IST to implement remedial actions. As a result of treating more patients waiting over 18 weeks between January and March 2014 the Trust only narrowly missed achieving the 90% standard for the year for admitted pathways.

With aligned joint management, flexible surgical capacity and an improved planning function the merged Trust will be in a stronger position to manage and deliver its 18 week RTT pathways.

2.6.5 Urology at EHT-ICO

There are two consultant urologists at EHT-ICO and five at NWLHT. Following recommendations from the NWL cancer network, EHT’s urology cancer service was decommissioned in 2011 after struggling to remain fully compliant with national standards.

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EHT-ICO has also found it difficult to sustain a viable on-call rota for urology and plans are in place to integrate fully this service with NWLHT to provide the critical mass required to satisfy:

Cancer commissioning standards; and

A joint on-call service (pending review of the non-elective pathway by Ealing OSC in December 2013).

Merging the urology department with NWLHT can provide a robust service with sufficient critical mass to manage EHTs patients across all sites. Aided by the collaborative environment that the merger preparations have created, the Trusts are now well on their way to integrating their urology departments and are recruiting a third substantive consultant to make eight in total.

2.6.6 Productivity opportunities

Although the NHS Institute for Innovation and Improvement is no longer operational, it’s ‘Better Care’, ‘Better Value’ indicators remain a useful tool for assessing an organisation’s relative productivity. Performance for quarter 4, 2012/13 is summarised in Table 11, from which it is clear that both EHT-ICO and NWLHT remain outside of upper quartile of acute trusts for most indicators.25

Table 11 Performance indicators (source: NHS Better Care, Better Value Indicators)

Indicator Trust Performance National Rank

Reducing length of stay EHT 14.12%26 120

NWLHT 13.2% 66

Managing first to follow outpatients27 EHT 1.91 39

NWLHT 2.21 88

Emergency readmissions EHT 6.58% 142

NWLHT 8.51% 162

Outpatient DNA rate EHT 12.48% 153

NWLHT 13.72% 161

Pre procedure non elective bed days EHT 2.06 125

NWLHT 1.54 40

Day case rate EHT 77.95% 104

NWLHT 70.36% 141

Pre procedure elective bed days EHT 0.27 120

NWLHT 0.24 104

Sickness absence EHT 3.95%28 120

NWLHT 3.02% 13

This is a strong indication that there are still good opportunities to release savings through realistic productivity improvements; for example, by improving relationships with primary care and community teams. By integrating care with the community and making the best use of partnerships with general practice and its community

25 Based on the 168 acute trusts in England (www.productivity.nhs.uk) 26 Bed day saving 27 First to follow up ratio 28 Full-time equivalent days lost to sickness absence as a percentage

34

workforce, the merged Trust should be able to make significant gains against a number of the metrics.

Early discharge into the community helps to reduce length of stay, a principle supported by teams working closely with acute staff based in teams like STARRS and ICE.

By agreeing pathways of care with GP commissioners for patients with chronic conditions, the new organisation will enable more patients to be followed up in the community – thus reducing new to follow-up ratios. There are good examples of this already happening, for example in the treatment of diabetes treatment at the new facility at Grand Union Village in Northolt, Ealing.

Chapter six describes in more detail how the clinical vision for the new Trust will deliver clinical benefits based on these opportunities.

2.6.7 Patient experience at both Trusts

Previous Department of Health (DH) performance reports have indicated that both Trusts have been outliers for overall patient experience. NWLHT also performed poorly in the recent cancer experience survey.29

On a positive note, NWLHT scores well on the NHS Friends and Family Test. Since the scheme began, the number of completed questionnaires has increased steadily and more than 70% of patients say they would be extremely likely to recommend NWLHT to their friends and family if they needed hospital care30.

Despite the inconsistent feedback from patients, both Trusts remain committed to improving the quality of care and the experience for local patients and want to be among the highest performing healthcare organisations in London. This is important for a number of reasons:

Staff want to deliver a high-quality service for their patients;

Patients deserve and expect the best quality and experience of care;

When offered choice, patients are likely to choose the hospital with the best reputation; and

There are an increasing number of financial incentives e.g. CQUIN payments, for providers who have good patient experience indicators.31

As described in chapter four, both Trusts believe that the merger provides an opportunity to form a larger, more efficient NHS Trust that is better placed to deliver excellent care to the populations it serves.

29 NWLHT was ranked ninth worst in the country - a slight improvement on the previous year (2012). 30 The test was introduced in April 2013 in line with national recommendations and was initially aimed

at all adult hospital inpatients and A&E attendees. The test has now been extended to maternity services and surveys women’s views at four key touch points in their pregnancy. Patients are asked if they would recommend us if their friends or family needed hospital treatment. They are given six answers to choose from ranging from ‘extremely likely’ to ‘extremely unlikely’ to ‘don’t know’.

31 See Commissioning for Quality and Innovation guidance (www.england.nhs.uk)

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CARE QUALITY COMMISSION INSPECTIONS 2.7

2.7.1 CQC/Chief Inspector of Hospitals visit to NWLHT

On 17 February 2014 the Care Quality Commission (CQC) indicated that North West London Hospitals would be visited by the Chief Inspector of Hospitals (CIH) in May 2014 as part of the April to June 2014 wave of inspections.

During April and May substantial evidence was submitted to the CQC in response to their data requests and were analysed in advance of the visits to the trusts services that took place in the 3rd week of May. The informal feedback to date is that staff were found to be caring to patients and open and transparent with the inspectors. There were no immediate patient safety concerns raised.

The CQC assessment is based upon what the review teams observe in terms of the Trust delivering on essential standards of quality and safety that respect the dignity and protect the rights of patients. This will be based on outcomes and people’s views and experiences as well as the information collected by inspections and interviews with staff, visits to eight key areas of the Trust and an open listening event.

Results of the CQC/CIH visit are expected to be available in late July-early August 2014.

2.7.2 CQC inspection to EHT-ICO

EHT-ICO received a draft report from the CQC following recent inspections in January and February 2014. The Trust met four of the standards inspected and the CQC identified three areas of concern each of which was judged by the CQC to have a minor impact on patients as follows:

Care and welfare of people who use services

Safeguarding people who use services from abuse

Complaints

The Trust is working to implement improvements to its services to meet these three standards and has submitted appropriate action plans to the CQC.

CONCLUSION 2.8

In summary, both NWLHT and EHT-ICO are committed to delivering high-quality care to patients, and share a common vision for improvement. There is a significant clinical overlap in the services currently provided by both Trusts and they have well-established clinical networks between themselves, but also with other local Trusts, notably ICH.

NWLHT has struggled to deliver recurrent financial balance since it was formed in 1999 and previously applied to the CTB for the release of funding to pay off its historic debt (Supporting Document 2-2). These financial challenges, despite having some potential to improve, will continue as commissioners focus on disinvestment in acute care and investing more in out-of-hospital care pathways.

EHT-ICO will find it harder to maintain service standards and quality as activity levels drop and the Trust becomes increasingly financially challenged.

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Both Trusts perform well against the clinical indicators especially mortality and HCAI rates. Results from recent patient surveys, notably the NHS Friends and Family Test show improvements but the four-hour wait standard for A&E remains a challenge for both Trusts as does the 18-week RTT target for NWLHT.


Supporting Document 2-1 Estates vision and strategy

Supporting Document 2-2 Letter to NHS England concerning Challenged Trust Board funds

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3. Commissioning strategy in North West London

Chapter Summary

This chapter describes the structural changes to the commissioning landscape under the Health and Social Care Act, 2012 and key public health issues affecting Ealing, Brent and Harrow. These issues include demographic change, health inequalities and increasing demand linked to both ageing and the prevalence of people with two or more long-term conditions.32

It subsequently describes the local clinical commissioning priorities and strategies across NWL plan that seek to address these issues within constrained resources. In particular, it describes the out-of-hospital strategies for each local CCG

The pivotal strategy for changing healthcare is the Shaping a Healthier Future (SaHF) programme which underwent extensive consultation in 2012 and is now in its implementation stage.

The reconfiguration is one of the largest in England and has been subject to formal challenge although (at the time of writing) has been supported overall by the Secretary of State who has accepted the findings of the Independent Reconfiguration Panel.33 These include recommendations that the A&E at Central Middlesex should close as planned, but that there is a need to sustain EHT-ICOs A&E services safely over a prolonged period (up to five years) while capacity in out-of-hospital services and at other acute hospitals is developed34,35

This chapter concludes with an assessment of the local out-of-hospital strategies emerging from local CCGs and the implications for local hospitals and the wider healthcare landscape.

OVERVIEW 3.1

3.1.1 Structural Changes to the Commissioning Landscape

Since the original proposals to merge the two Trusts surfaced in 2011, the commissioning landscape has changed across the NHS, including NW London. With the passage of the Health & Social Care Act 2012, Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs) were abolished.

The successor organisations had been operating in shadow form in 2012/13 to aid continuity. Most of the functions of PCTs were transferred to clinically-led CCGs, except public health which transferred to local authorities.

Local authorities are charged with setting a local health and wellbeing strategy and lead on Health & Wellbeing Boards (HWBs). CCGs are accountable to NHS

32 Conditions which have lasted for more than one year and are likely to continue 33 Advice on SaHF proposals for changes to NHS services in North West London, IRP, submitted to

Secretary of State on 13 September 2013 34 Ibid 35 DH Press Release 30 October 2013

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England.36 NHS England remains responsible for commissioning designated specialist service provided by the Trusts, as well as primary care and some smaller service areas. It undertakes its functions through a number of Local Area Teams (LATs).

The NHS has also changed the balance between local CCGs and specialist commissioning for NWLHT with CCG commissioned services representing about 70% of Trust income from 2013/14, compared with about 90% in previous years.

The commissioning of Education and Training has passed from University-led deaneries accountable to the SHA to employer-led Local Education and Training Boards (LETBs) accountable to a new body, Health Education England (HEE). The LETB for both Trusts is HEE London. This change will have workforce implications for all Trusts.

3.1.2 Commissioning Strategies

Across NW London the key commissioning strategy has become SaHF, which is linked to the Commissioning Strategy Plans and out-of-hospital (OOH) strategies of local commissioners (originally PCTs and now CCGs) for each Borough. The likely impact of SaHF is described in more detail in section 3.5.

The proposals to merge EHT-ICO and NWLHT should be assessed within the context of these commissioning strategies and the factors that drive them, which include:

Demographic factors and changes to the population served – the populations of all three boroughs are growing faster than the England average and there are big increases in the proportion of older people

Epidemiology37 and changes in patterns of disease – in recent years there have been big rises in the number of older patients and those with complex needs

Changes in clinical practice – including those based on National Institute for Clinical Excellence (NICE) recommendations allied to increasing specialisation to achieve better outcomes

Quality standards – set by commissioners and professional bodies such as Royal Colleges

Drive for specialist centres – to create larger clinical teams and critical mass, for example to support consultant-led care ‘24/7’

National policy guidance and a strategic shift in favour of out-of-hospital care, as set out in SaHF and linked OOH strategies for each CCG (see below)

Changes in workforce requirements – including education and training – smaller teams can struggle to staff rotas fully

36 Referred to as the NHS Commissioning Board in the Health & Social Care Act, 2012 37 Epidemiology is the branch of medicine that deals with the study of the causes, distribution, and

control of disease in populations

39

Financial challenges – £1bn potential gap in NWL, which represents a more than 20% reduction in hospital income

As an underlying principle, NWL commissioners have stated that:

‘Where possible, care should be integrated between primary and secondary care, with involvement from social care, to ensure seamless patient care.’

3.1.3 National Policy Framework

Commissioning strategies will always seek to enhance patient welfare. The Government’s Outcomes Framework published in 2011 sets out five domains for both commissioners and hospital providers to consider in framing their plans:38

prevention of avoidable deaths;

enhancing quality of life for people with LTCs;

improving recovery from illness and/or injury;

patient satisfaction; and

patient safety.

The framework has been used in subsequent guidance from the Department of Health to NHS England39 and NHS England’s Planning Guidance for commissioners.40 In addition to improving patient outcomes, NHS England guidance specifically emphasises the following:

NHS services available seven days a week and greater choice;

more transparency;

more patient participation and better customer service;

better data and more informed commissioning; and

higher standards and safer care.

More recently, NHS England called for an open and honest debate about the future shape of the NHS in order to meet rising demand, introduce new technology and meet patient expectations in the context of ‘flat’ funding. Informing this exercise was a forecast that without change in the way services are delivered, the funding gap across the NHS in England of £30bn by 2020/21.41

More recently, and building on the national Call to Action, a document has been published calling for a debate on the specific problems of the NHS in London.42 This document notes that the average catchment of a London hospital is significantly less than elsewhere in the country and concludes that:

38 Department of Health, Outcomes Framework, 2011 39 The Mandate for the NHS Commissioning Board, Department of Health November 2012

http://mandate.dh.gov.uk/ 40 Everyone counts: Planning for Patients 2013/14; NHS England, December 2012

http://www.england.nhs.uk/everyonecounts/ 41 The NHS belongs to the people: a call to action, NHS England, July 2013 42 London – A Call to Action, NHS England, October 2013

40

‘the way hospitals (in London) are organised is unsustainable and does not support the provision of high-quality care’

In addition, the quality focus of the NHS has become even more rigorous with the CQC introducing a new inspection regime – influenced by the failings at Mid Staffordshire NHS FT that have been highlighted by the Francis Report.43 The new regime focuses on the following five areas:

safety;

effectiveness;

caring attitudes;

responsiveness, including waiting times; and

leadership.

This business case argues that achievement of these national policy goals is much more likely to be achieved (or achievable) within a single organisation with a sustainable future. The corollary being that it will be very much harder, if not impossible to achieve, in a context of ongoing organisational uncertainty with services of sub-optimal scale.

These themes recur throughout this chapter as well as in the commissioning strategies, which are set out below.

LOCAL COMMISSIONERS 3.2

Commissioning in NWL is organised around population needs in the individual boroughs. CCGs’ functions are slightly different from PCTs whose geographical names and local commitments they have retained.

Increasingly, commissioning decisions are also being co-ordinated across the NHS in NWL. To make best use of available resources, NWL CCGs have decided to cluster into two groups:

BHH CCG Collaborative including Brent, Harrow and Hillingdon CCGs; and

CWHHE CCG Collaborative including Central London, West London, Hammersmith and Fulham, Hounslow and Ealing CCGs.44

A single Commissioning Support Unit (CSU) for NWL has also been set up. Details of Ealing, Brent and Harrow – the three boroughs primarily served by NWLHT and EHT-ICO – are set out below.

DEMOGRAPHY – LATEST TRENDS 3.3

In May 2013, the Office for National Statistics refreshed the 2011 census figures to take account of other sources of population data, like usage of local services. This exercise revealed that the actual populations of Brent, Ealing and Harrow are significantly larger than the previous projections for that year. Brent’s was 8.03%

43 Department of Health Press Release 30 October 2013

https://www.gov.uk/government/news/changes-to-healthcare-services-in-north-west-london 44 Ealing CCG moved from the BEHH Federation to the CWHH Collaboration on 1 December 2013.

https://www.gov.uk/government/news/changes-to-healthcare-services-in-north-west-london

41

higher (the highest increase in London) – equivalent to 23,204 more people. The equivalent increases for Ealing and Harrow are +2.76% (9,110 people) and Harrow +4.67% (10,730) respectively as illustrated in Figure 9.

Both Trusts are experiencing the pressure of so many additional residents looking to them for services. Detailed demographic information is included in Appendix 3-1.

Figure 9 Comparison of GLA population projections with 2011 census

CCG PROFILES 3.4

3.4.1 Ealing

NHS Ealing CCG is responsible for healthcare provision for a resident population of 339,000 people, some 40% of whom are from black or minority ethnic (BME) communities. Ealing’s population is growing and dependency is increasing .45 Ealing’s population is projected to increase by a further 16,000 by 2016.46

Long-term effects of population change on the health and well-being of Ealing residents include a rising birth rate which is creating demand for maternity and paediatric services, and an ageing population which will cause a higher prevalence of common diseases of old age. The health needs of the very young and the very old are greater than for other age groups, and consume disproportionately more resources. It is projected that the percentage increase in both these age groups in Ealing (and Brent and Harrow) will be greater than for the population as a whole over the next 10 years.

Although Ealing has overall high average levels of good health and prosperity, this masks significant inequalities in health for sections of the community. Some wards or neighbourhoods are among the most deprived in England. While life expectancy and

45 The relative proportion of non-working age to working age residents, at both ends of the age range 46 Greater London Authority, November 2011

42

infant mortality rates are better than the England average, the frequency of early deaths from heart disease and stroke is worse than the average. There are profound inequalities in life expectancy, which is six years greater in the least deprived areas than in the most deprived.

Over the last decade, all-cause and early cancer-related death rates have improved to above the England average. However, whilst death rates from heart disease and stroke have improved they remain worse than the England average. Notably, there is a high prevalence of diabetes and obesity rates are above the England average – though encouragingly the proportion of children engaging in regular exercise is better than average.

NHS Ealing’s strategic plan prioritises heart disease, stroke, diabetes, dementia, alcohol-related disease and maternity provision.

NHS Ealing has some priorities in common with the rest of NWL, such as reducing variation in life expectancy, improving patient’s perception of their services, improving care of patients with LTCs and improving primary care. Improving the capacity in primary care will facilitate the transfer of services to community settings and closer to where patients live. As part of their OOH strategy, they have begun putting certain planned care services out to tender.47 To develop commissioning and facilitate implementation of pathways of care in Ealing, the 79 practices in the Borough will join one of six GP networks.48

‘Networks of GP practices will work with other health and social care providers to deliver co-ordinated services to the local community, improving care planning and local services and information and

communication standards.’49

A number of non-hospital sites are being considered for local health centres from which some services which are currently hospital-based will be provided.

3.4.2 Brent

NHS Brent CCG provides services for a resident population of 312,000 people, half of whom are from BME groups. As mentioned above, Brent has the biggest population increase in London at 8% above previous projections. It is predicted that the borough’s population will grow by a further 26,000 by 2016.50 As in Ealing, increases peak among the most reliant groups on healthcare – the very young and the very old (Appendix 3-1).

While on average Brent’s residents suffer high levels of deprivation, especially in the south of the Borough, overall health shows a mixed picture. Inequalities in health outcomes are marked: male life expectancy is eight years greater in the least deprived wards than the most deprived wards, with large numbers of potentially

47 Ealing out-of-hospital Strategy at

http://www.healthiernorthwestlondon.nhs.uk/sites/default/files/documents/PCBC%20-%20Vol%2011%20-%20App%20D3%20-%20v1.1.pdf

48 Acton; Ealing North 1; Ealing North 2; Central Ealing; North Southall; South Southall. One of the Networks in Borough-wide

49 SaHF Consultation Document, updated August2012, page 36 50 Greater London Authority estimate November 2011

43

preventable deaths resulting from heart disease and cancer.51 Rates of infectious diseases such as tuberculosis are among the highest in the country.

Over the last decade early death rates from heart disease and stroke, as well as all-cause death rates, have fallen and remain below the England average. However, emergency admissions, including those for coronary heart disease and stroke are rising, in contrast to other parts of the capital where they are falling.52 Obesity rates are higher than the England average and the proportion of children engaging in regular physical activity is worse than average. Smoking rates during pregnancy are also higher than the England average.

The Brent Local Area Agreement Plan prioritises the tackling of childhood obesity, smoking, mortality from circulatory disease and achieving independence for the elderly.

Brent shares NWLs priority areas: reducing variation in life expectancy, improving patients’ perception of their services, improving care of patients with long-term conditions and improving primary care. Brent also wishes to move services from hospital to community settings, wherever possible, and is tendering most planned care for Brent residents through a process of ‘competitive dialogue’ as part of its OOH Strategy.53

To develop commissioning and facilitate implementation of pathways of care in Brent, the 69 practices in the Borough will join one of five GP networks.54 As with Ealing, the networks will work with health and social care providers to provide co-ordinated care and foster the exchange of information. Two sites away from acute hospitals have been identified where certain hospital services can be provided in more accessible locations.

3.4.3 Harrow

NHS Harrow CCG provides services to a resident population of 240,000, more than half of whom are from BME groups. Harrow’s population is set to rise by a further 9,000 by 2016.

The over-50s population in Harrow is higher than the London average and set to grow, but the percentage increase is projected to be lower than in neighbouring boroughs (Appendix 3-1).

The health of Harrow’s population is relatively good overall and the average life expectancy for both men and women is better than the England average. Death rates from smoking, cancer, heart disease and stroke are all lower than average. Rates of diabetes, high blood pressure and infectious diseases such as tuberculosis are higher than average, however.

51 Harlesden ward in Brent has the lowest male life expectancy in North West London at 71.3 years,

17 years less than the ward with the highest life expectancy in NW London. 52 SaHF Factsheet Brent, July 2012 53 Brent out-of-hospital Strategy at

http://www.healthiernorthwestlondon.nhs.uk/sites/default/files/documents/PCBC-Vol09-AppD1-v1.1.pdf

54 Kilburn; Kingsbury; Wembley and Willesden, plus Harness which is Harlesden-based but Borough-wide

44

As with Ealing and Brent, health inequalities in Harrow are marked with male life expectancy being six years greater in the least deprived wards than the most deprived wards. The proportion of children living in poverty is higher than the England average and physical activity levels among children are worse than average. While the proportion of low birth weight babies is higher than average, teenage pregnancy rates are lower.

Local priorities in Harrow include diabetes, vascular disease, the promotion of healthy lifestyles and reduction in emergency admissions.

Like Ealing and Brent, Harrow shares some of NWLs key priorities, notably reducing variation in life expectancy, improving patients’ perception of their services, improving care of patients with long term conditions and improving primary care.

Harrow also seeks to transfer services into the community where possible and is running extended pilots with its existing providers on a specialty-by-specialty basis as part of its out-of-hospital strategy.55

To develop commissioning and facilitate implementation of co-ordinated pathways of care in Harrow, the 36 practices in the Borough will join one of six GP networks, five of which are locality based and one Harrow-wide. In addition two locations have been identified for local health centres which could absorb hospital-based services. A business case is also expected for a third site in the east of the borough the exact location of which is to be confirmed.

3.4.4 Specialist commissioners

In 2012/13, non-local commissioners accounted for 12% of NWLHTs contracts by out-turn value. Over the course of 2013/14 this increased to 31% as a result of the Health & Social Care Act reforms.

As a consequence, Brent CCG, Harrow CCG and Ealing CCG contract values with NWLHT in 2013/14 have declined to 27%, 25% and 6% of the total, respectively, from 34%, 32% and 8%, respectively, in 2012/13. All other CCGs now account for 11% compared with 14% by value at 2012/13 out-turn.

NHS England is now NWLHTs third biggest commissioner at 24%, (behind Brent CCG and Harrow CCG) compared to 10% in 2012/13. This is made up of specialist commissioning through the London Specialised Commissioning Group (LSCG), which accounts for 19% (8% in 2013) and a further 5% for specialist dental services (commissioned through the Local Area Team) and screening (commissioned through Public Health England).

This underlying shift in commissioned activity was underpinned by a validation exercise performed by NHS England in August 2013. NWLHT continues to liaise with NHS England in helping it to determine accredited services and consolidate its specialist commissioning case-mix. NWLHT expects this process to continue as NHS England streamlines its commissioned portfolio both across England and within London.

55 Harrow out-of-hospital Strategy at

http://www.healthiernorthwestlondon.nhs.uk/sites/default/files/documents/PCBC-Vol13-AppD5-v1.1.pdf

45

Other SLAs and non-commissioned activity now account for 4% (2% in 2013). To a large extent this predominantly reflects the shift in some commissioning responsibilities to local borough councils.

NHS NORTH WEST LONDON AND SHAPING A HEALTHIER FUTURE 3.5

Following extensive local consultation the commissioning strategy across NWL is encapsulated in SaHF. The key elements of the Case for Change upon which SaHF is founded are set out in Appendix 3-2. The DMBC was taken to a Joint Committee of PCTs (JCPCT) on 19 February 2013 and the preferred option approved.

This was subsequently referred by Ealing Council’s Overview and Scrutiny Committee (OSC) to the SoS, prompting an IRP. Ealing Council also sought permission for a Judicial Review (JR) and then an oral re-hearing when it was refused in August 2013. The re-hearing failed on 9 October 2013 and the SoSs decision on the IRPs recommendations was published on 30 October 2013.

Faced with the pressures to centralise specialist services and localise routine care within a sustainable cost envelope, SaHF proposed a different model of hospital provision from the DGH. Figure 10 illustrates the types of hospital proposed in the original SaHF DMBC, together with the essential and optional services contained within each.

Figure 10 Hospital models described in the SaHF consultation (source: SaHF DMBC)

The DMBC recommended that the nine A&E Departments in NWL be reduced to five and that only major Hospitals would have a full A&E operating 24/7. It proposed

46

NPH as one of the five.56 This proposal was endorsed by the IRP and accepted by the SoS.

Conversely, CMH and Ealing Hospital were proposed as local hospitals for Brent and Ealing respectively. The DMBC also recommended that CMH become an elective hospital for the NWL sector. Northwick Park would remain as a major hospital.

NHS NWL has established dedicated work-streams to fully consider the implications of the SaHF changes and there are work-streams for each of the Trust sites. These are currently producing business cases to support the proposed capital investment identified in SaHF to facilitate the proposed service changes.

Investment is vital to underpin these strategic changes, including: £48m new build to create capacity for the emergency care pathway at NPH; £19m at EHT to develop an ambulatory care centre;57 outpatients, diagnostics and an elderly rehabilitation unit. In addition, £9m has been earmarked in the capital programme for improving theatre capacity and utilisation at the relatively modern CMH. These capital investments are reflected in the long-term financial model (LTFM) in chapter eight.

3.5.1 Future of the Ealing Hospital site

The local hospital model is being further developed in the light of the SaHF recommendations and local hospital models elsewhere.58 Specific proposals for Ealing Hospital are being worked up (led by Ealing CCG but involving the EHT-ICO) to consider the following components (some of which with the local hospital definition in Figure 11):

outpatients;

acute beds (including step up and step down beds);

a possible Early Pregnancy Unit at Ealing (linked to a major acute obstetric unit);

imaging facilities (including MRI and CT);

endoscopic services (meeting Joint Advisory Group on endoscopy accreditations);

renal dialysis;

chemotherapy; and

physiotherapy.

An outline business case (OBC) for the future of the Ealing Hospital site was presented to the Ealing CCG and EHT-ICO Boards in March 2014. The affordability

56 The other preferred major acute hospitals in the sector are The Hillingdon Hospital, Chelsea &

Westminster; St Mary’s and the West Middlesex Hospitals. The Hammersmith would become a Specialist hospital.

57 The £19m is consistent with the SaHF programme although the SoS press release (30 October 2013) made reference to £80m investment. The higher capital figure has not been included until such time as the business case for a local hospital at Ealing has been completed.

58 Such as the South East Midlands Healthier Together project

47

of the current proposal remains an issue that will need to be resolved before the OBC can be approved and progress made to prepare the FBC for this project.59

3.5.2 Future of the Northwick Park Hospital site

NWP is confirmed in SaHF as a major acute hospital with increasing referral of patients. Recognising the hospital is already operating above optimum capacity, SaHF identified £48m of capital investment for the site to accommodate the rise in patient numbers. A business case has been developed to address these issues and will be considered by the SaHF programme Board.

3.5.3 Future of Central Middlesex Hospital site

A NWL sector group is currently reviewing the future potential of the CMH site as even under the SaHF proposals the site would be significantly under-used. Given that the site is a modern PFI and good quality estate, the review is looking at which combination of services could potentially be located there – releasing savings from other sites or avoiding other costly capital expenditure.

Chaired by Brent CCG, the group has external professional support and the review process has confirmed the underlying deficit in 2013/14 as £10.8m – a loss directly attributed to poor utilisation of the site. This ‘structural’ loss is projected to increase to £15.6m by 2018/19.

A SOC setting out a recommended option for the site was agreed by partners in the CMH project in February 2014. This would see the implementation of a ‘bundle’ of services at CMH including an elective centre, clinical genetics, mental health inpatients and a Brent Hub+ with rehabilitation beds, outpatients, primary care and a wheelchair service. The preferred option also involves backfilling Willesden Hospital with other services to compensate for activity losses on that site as services transfer to the Brent Hub+ at CMH.

The OBC for CMH is being developed with ongoing engagement, but for now the LTFM (chapter eight) assumes there will be funding support to the merged Trust of £11.3m until the wider health community in North West London agrees and implements revised service arrangements on the CMH site.

RESULTS OF THE IRP 3.6

It is also clear from the SoSs recent announcement that Ealing is likely to have an A&E for at least another five years.60 However, ambulance-borne emergencies will be taken to one of the five major acute hospitals in NWL.

Implementation of SaHF is proposed over a six-year period because of the scale of change involved. Investment in CCG OOH services is also needed to transfer appropriate services from acute settings. CCG plans for increasing OOH care are discussed later in this chapter.

The SoS accepted the IRP recommendations on proposals for Central Middlesex as a local hospital and elective hospital. Changes at CMH A&E would be made ‘after the winter’.61

59 Ealing CCG, Ealing Hospital: Design Guide for the proposed future hospital (19 March 2014) 60 DH Press Release 30 October 2013

48

Regarding Ealing Hospital, the IRP advised that further work is required on the proposed changes at Ealing and Charing Cross hospitals. As such, the Health Secretary has stated that the A&E departments at Ealing (and Charing Cross) will remain open, albeit with changes to the services. He also announced new, custom-built hospitals at Ealing (and Charing Cross) costing £80 million each and designed to deliver the specific services most needed in those communities.

Significantly, the IRP linked the future of Ealing’s A&E Department to NWLHT:

‘As well as a lack of clarity about what the local hospitals at Ealing (and Charing Cross) will ultimately provide, the Panel found significant uncertainty about achieving a safe transition for A&E services serving local populations. Whilst it is clear that neither hospital will be a major hospital, there is a need to sustain their A&E services safely over a prolonged period (anticipated to be up to five years) while capacity in out-of-hospital services and at other acute hospitals is developed. This will require continued close clinical collaboration […] between North West London Hospitals NHS Trust and Ealing Hospital NHS Trust for

Ealing.’62

NWLHT and EHT-ICO Trust Boards believe this close clinical collaboration can be best secured within a single organisation. The scale of the change makes organisational uncertainty is inevitable. However, the IRP considered the risks posed by continuing an unsustainable pattern of services in NWL were greater. NWLHT and EHT-ICO share this view and this business case argues that a single new Trust will be more resilient to face these pressures than two organisations with understandably narrower sectional interests tempted to resist change in order to survive.

LINKS WITH OVERALL COMMISSIONING STRATEGY 3.7

It is notable that high levels of cultural diversity and immigration lead to specific challenges common across all three Boroughs – high levels of infectious diseases, higher rates of illiteracy and language difficulties – which can make it hard for people to access services.63

61 Ibid. 62 Independent Reconfiguration Panel Report of SaHF, September 13 2013, section 5.7.5 63 SaHF, NHS NWL Case for Change, January 2012. Latest version at

http://www.healthiernorthwestlondon.nhs.uk/sites/default/files/documents/SaHF%20Consultation%20Document.UpdatedAugust2012_0.pdf

49

Figure 11 Relative deprivation in Brent, Ealing and Harrow (source: DH 2010 Borough Health Profiles)

The case for change also emphasises the correlation between deprivation and poor health. There are wide variations in levels of deprivation, health needs and health outcomes across the three boroughs, as indicated in Figure 11.

CCG OUT-OF-HOSPITAL STRATEGIES 3.8

As described above, all CCGs in NWL have OOH strategies inherited from the former PCTs but still current. SaHF highlighted that 10% more NHS resource is spent on acute hospital care in NW London than the England average.

On the other hand, primary and community care is comparatively under-resourced. SaHF had three-year (2012-15) OOH strategies for each CCG in NWL to redress this balance. While themes are consistent, the various CCGs express them slightly differently, using patient stories to illustrate their points. Acute trusts need to understand and respond constructively to this challenge.

The main challenges identified in the OOH strategies, with minor local variations, are:

Changing health needs due to people living longer and the rise in chronic and lifestyle-related disease – ramping up demand on social and community care.

Current models of care are unaffordable to meet this demand. Better outcomes at lower cost require more planned care, provided earlier, out-of hospital.

Transformation of primary, social and community care is required as current variations in quality and access are unacceptable.

Ealing CCGs OOH strategy also recognises increasing demand due to new treatments and states that to meet this demand within the resources

Relative deprivation in Brent, Ealing

and Harrow

100

90

80

70

60

50

40

30

20

10

0

HarrowEalingBrentLondonEngland

5 – mostdeprivedquintile

4321 – leastdeprivedquintile

SOURCE: 2010 Borough Health Profiles, Department of Health

Residents

%

Bre

nt

Ealin

gH

arr

ow

Deprivation by ward

50

available, greater emphasis needs to be put on prevention, early intervention and care at home, thereby reducing pressure on hospitals

While CCGs in each of the four outer boroughs (Brent, Ealing, Harrow and Hillingdon) have developed locally tailored approaches, the CCGs have concluded that the scale of change required in community care is significant and requires re-thinking the OOH delivery model across four dimensions:

Pathways: what changes are required by pathway, e.g. unscheduled care, planned care, long-term conditions?

Delivery model: what activity should be delivered where?

Infrastructure and resources: what facilities and resources are required and where? What skills does the workforce need?

Enablers: what changes need to be made across the system to ensure success, e.g. information, education and training, estates, incentives, behaviours?

Each of the CCGs articulates its overall vision for out-of-hospital care differently (the Brent vision is described below). Notably, each CCGs vision starts with the premise that good out-of-hospital care begins with high-quality primary care and that better-networked commissioning and provision will be key.

‘We will achieve our vision by improving patient care in five areas…

1) Easy access to high-quality, responsive primary care to make out-of-hospital care first point of call for people

2) Clearly understood planned care pathways that ensure out-of-hospital care is not delivered in a hospital setting

3) Rapid response to urgent needs so that fewer patients need to access hospital emergency care

4) With the patient at the centre, providers (social and health) working together to proactively manage LTCs, the elderly and end of life care out-of-hospital

5) Appropriate time in hospital when admitted, with early supported discharge into well organised community care’

For each of these areas, commissioners specify what the priority means in practice. It is vital that both acute Trusts understand these goals and work collaboratively with the emerging CCGs to deliver more effective healthcare within the resources available.

CCGS’ VISION FOR OUT-OF-HOSPITAL CARE 3.9

3.9.1 Pathways

Four pathways have consistently emerged across the boroughs as priorities for change:

Planned care

Unscheduled care

51

Long-term conditions

Mental Health

Details of required changes are being developed. While they vary by pathway and by CCG, the elements that resonate across all include:

Patient-centred processes

Improved access

Single point of access

Same day access to GP/primary care

24-hour home-based response

Better early diagnosis and intervention, rapid integrated response, including social community services

Implementation of effective and efficient intermediate care service out of hours

Better integration of all pathways with mental health services

Avoidance of duplication

Better value for money

3.9.2 Delivery model

Although there is much further detailed work to be done on the detail, elements of ways in which different activities might be offered in some boroughs have begun to emerge such as the example for Ealing shown in Figure 12.

Figure 12 Activity shifting OOH – a possible approach for Ealing (source: Ealing CCG) | 3

What activity shifting out of hospital should happen where?

Community

hospital

Hub (e.g.,

health centre) GP practice Home

Planned care

Unscheduled

care

Long term

conditions

Mental Health

Complex procedure (low

ASA elective surgery)

MRI

Plain radiography

Ultrasound

Close walk in centre

Active diversion to practice

Telehealth

Emergency assessments

Minor surgery

SOURCE: Ealing workshop

52

ENABLERS AND SUCCESS FACTORS 3.10

The CCGs have also begun to develop an early perspective on what enablers need to be in place to support the outlines of the strategy described above. These fall into five categories:

1. Accountability and joint decision making;

2. Clinical leadership and culture development;

3. Information sharing;

4. Aligned incentives; and

5. Patient and carer partnerships.

DECOMMISSIONING AND PROCUREMENT 3.11

To realise these OOH strategies, CCGs have started to decommission services in acute hospitals including EHT-ICO and NWLHT, starting with planned care. Using a variety of procurement methodologies CCGs have been putting services out to tender with the aim of seeking high-quality provision, delivered more locally and at lower cost than the current acute model.

In Brent the first wave procurement (for cardiology and ophthalmology) has resulted in non-local providers being chosen as preferred bidders. The next wave as part of the 2014/15 contracting process includes the procurement of gynaecology and musculoskeletal (MSK) (including non- trauma orthopaedics and rheumatology).

Harrow CCG will also be putting planned care out to tender and has signalled its intention to decommission a range of services in 2014/15. This is coupled with the introduction of new planned care pathways in MSK, ophthalmology, gynaecology, cardiology, dermatology, diabetes, respiratory and urology; and procurement under the Any Qualified Provider (AQP) mechanism.

Ealing CCG has indicated that it will be looking for lower than PbR tariff for certain services and the introduction of ’year of care’ pathway tariffs. Re-procured services for 2014/15 are expected to included dermatology, cardiology and gynaecology.

On the other hand, the Trusts have started to bid to provide services outside the local area and recently EHT-ICO in partnership with Greenbrook Healthcare succeeded in a bid to provide an enhanced Urgent Care Centre at the Hillingdon Hospital. The Trusts are enhancing their capacity to respond to tenders in the future.

IMPLICATIONS FOR THE ACUTE SERVICES 3.12

The Trusts need to respond to increasing waves of procurement exercises. Traditionally, neither Trust has invested in the necessary skills and competences to compete effectively in an increasingly commercial environment. A merged and stable organisation would be in a much better position to respond to these challenges and opportunities not hitherto viewed as core business.

These opportunities would include provision of high-quality specialised local services for which patients currently have to attend central London hospitals. This would be consistent with Care Closer to Home and should result in a saving for local commissioners. On the other hand, there is a real prospect of commissioner disinvestment rendering the existing acute Trusts unstable.

53

This is already happening at the EHT-ICO where a combination of the impact of SaHF-influenced referral patterns and commissioner disinvestment has resulted in a Trust surplus transforming into a projected deficit. As mentioned elsewhere, the continuance of the ‘status quo’ will prevent implementation of the SaHF strategy and undermine progress towards financial sustainability – resulting in a forecasted 2018/2019 aggregated deficit of £41.8M for the two non-merged Trusts (chapter eight).

Given the rapid deterioration in financial sustainability and the potential for diminishing clinical sustainability currently being experienced, both Trusts are convinced there is a pressing need to accelerate the merger so that it can be initiated in 2014/2015.

The financial consequences of both SaHF and commissioning intentions are discussed in detail in chapter eight.

Since October 2013, CCGs have been refreshing their SaHF plans and commissioning intentions for 2014/15 onwards to align these with the SoSs response to the recommendations in the IRP report and development of business cases to support implementation of the new models of care.64

WHAT THIS MEANS FOR THE FUTURE HEALTHCARE LANDSCAPE? 3.13

Presently, many people go to hospital for services that could be better provided out-of-hospital. For example, some people with long-standing back hip or knee pain are referred to hospital when professionals know they will get better results from seeing a physiotherapist who can advise on exercises rather than an operation.

Other people visit hospital because they struggle to get an appointment with their GP at a time to suit them. This is not good healthcare and a waste of scarce resources. It would be far better to ensure that they can see their GP, or another GP who can provide high-quality primary care at a time and place more convenient for the patient.

Meanwhile, too many older people end up in hospital and then running the risk of contracting a hospital-acquired infection or getting confused in an unfamiliar environment. This often results in them being unable to return home. A better model of healthcare would be one in which people are cared for in a high-quality, consistent, integrated way in the most appropriate location.

The commissioners’ future vision is for a system which is outcomes focused and therefore less dependent on hospital-based care. Under this system people can get access to regular and urgent medical advice from their GP practice or a community-based urgent care centre. Specialist advice and diagnostic tests can be obtained outside of hospital and care for older people and people with long-term-conditions can be organised around their day-to-day needs.

Nevertheless, hospitals will still be an important component of the healthcare landscape – providing modern state of the art facilities in which highly experienced and specialist staff can provide excellent care, working as part of highly-trained teams, with access to leading-edge technology. That is what hospitals are for – other

64 Independent Reconfiguration Panel Report of SaHF, September 13 2013; SoSs response October

30 2013

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centres are better able to provide for the healthcare needs of the overwhelming majority of the population.

The need for innovation and transformation is clear: commissioner Quality, Innovation, Productivity and Prevention (QIPP) schemes have seen an exponential increase in disinvestment from acute hospitals even before decommissioning exercises. The pace of change is accelerating and this is creating instability. A single Trust will give sufficient critical mass to ensure resilience during the change process and offer opportunities to develop innovative cost-effective patient-centred models of care in line with overarching commissioning frameworks.

CONCLUSION 3.14

Given the implementation of SaHF and the wider changes to commissioning, which will substantially alter the services commissioned and delivered to patients; it is essential that the Trusts respond by:

Creating sufficient critical mass to develop thriving hospital-based clinical services alongside the move of certain services to community and primary care settings, closer to where people live;

Supporting the implementation of reconfigured NHS services across North West London as outlined in SaHF and engaging in the co-design of new services through the whole systems projects; and

Creating a sustainable organisation that is fit for future purpose.

These requirements are discussed in greater detail in the next chapter.


Appendix 3-1 Detailed demographic information

Appendix 3-2 Key elements of the case for change upon which SaHF is founded

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4. Why merge EHT-ICO and NWLHT?

INTRODUCTION 4.1

Over three years, EHT-ICO and NWLHT have collaborated to develop the clinical and business case for merger. Successive submissions from the original SOC of 2011 and OBC in 2011 to the two Full Business Case versions prepared in 2012 have refined and strengthened the case for change. However, the two main reasons why merger remains the best and preferred option for the future of both organisations have not changed:

It creates sufficient critical mass to develop thriving hospital-based clinical services simultaneously to moving selected services to community and primary care settings, closer to where people live; and

It creates a sustainable organisation fit for future purpose; the risks of not merging and the clinical and patient disbenefits are tangible and measurable.

Developments since 2013 demonstrate an even more pressing need to accelerate the merger in light of:

The rapid deterioration in clinical sustainability and financial outcomes currently being experienced (particularly at EHT-ICO); and

The confirmation of the recommendations of SaHF by the SoS.

Both Boards accept that the previous version of the FBC did not make a strong enough case.65 Critical issues have been addressed in this revised business case in respect of the financial robustness and benefits of merger (chapter eight) and the need for greater alignment with the SaHF strategy (chapters three and five).

The case for change based on critical mass and sustainability has been strengthened by demonstrating how merger will facilitate the reconfiguration of acute and other services across NWL necessary for the implementation of SaHF.

The potential for integrated services across acute and community services will leave the new Trust ideally placed to support the move of care from hospital to community-based services. The benefits derived from these changes are described in greater detail in chapter five.

There have been a number of important changes at Board level with the appointment of a new Chief Executive (across both Trusts) and a new Chair at NWLHT. The new

65 Submitted in September 2012

Chapter summary

This chapter explains why a merger between NWLHT and EHT-ICO is the right response to the challenges identified in chapter three. The chapter:

Reviews the merger case to date (including a look back of the SOC and OBC processes); and

Summarises why change is needed.

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Board members have commissioned a review of the original clinical strategy which is discussed in chapter six.

4.1.1 Review of work to date (including SOC and OBC submissions)

Before concluding that the merger was the right solution, both Trusts examined a number of options as part of the Strategic Outline Case (SOC) and OBC stages.

This process began in 2011 when the original SOC (Supporting Document 4-1) stated:

‘What are we trying to do?

Our aim is to develop a high-quality healthcare system for the people of North West London that combines the best in cutting-edge specialist care with convenient access to local services.

We believe we can achieve greater benefits for patients by merging Ealing Hospital NHS Trust and the North West London Hospitals NHS Trust into one organisation that will offer everything from highly specialised care (e.g., colorectal services at St Mark’s Hospital) to community nursing care at home.’

Working with doctors, nurses and other clinicians, both Trusts identified a need to change the way care is delivered in Harrow, Brent and Ealing if both organisations were to continue providing high-quality local services. The case for change was based on four main elements:

1. The obligation to local communities – a ‘promise to patients’ to deliver safe, high-quality care locally. Both Trusts believe this promise would be impossible to deliver consistently if they remained as separate organisations.

2. Increasing the scale of both Trusts’ respective teams would enable the organisations to deliver the promise to patients. This would be achieved by organising services around larger, more senior and more specialised clinical teams, with access to the latest equipment to support best and innovative practice.

3. At the same time (as detailed in chapter three), commissioners were developing clinical commissioning strategies with significant local stakeholder input and consultation. They concluded that high-quality care requires a shift of NHS resources from hospitals towards primary and preventative care. This shift of resources forces Trusts like EHT-ICO and NWLHT to re-model the provision of hospital services that risk becoming too small to be safe and improve their productivity. It also means neither Trust can substantially increase the size of individual hospitals.

4. Both Boards recognised the challenges they faced and believed that a solution could be found through a merger. They believed that the move from competing to merging clinical teams would improve clinical outcomes, reduce spend on support and management costs, and reduce waste and duplication.

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4.1.2 Original SOC Option Appraisal

An option appraisal was conducted to determine the best way for both Trusts to deliver the highest quality care in an increasingly challenging environment (Appendix 4-1). Eight options were assessed by a panel of key stakeholders against the two main criteria and three additional criteria as summarised in Table 12:66

Table 12 Options appraisal evaluation criteria

Main Criteria Additional Criteria

1. Acute clinical viability; and

2. Integrated Care potential

3. Geographical proximity

4. Strategic Fit; and

5. ‘Do-ability’

The subsequent OBC for the merger noted that the stakeholder panel agreed that the most favourable option was a merger between EHT-ICO and NWLHT.67 The panel’s strong view was that the merger would allow the Trusts to capture the benefits of increased scale most effectively and deliver the highest quality of care to local people, as a result of being an integrated Trust providing acute and community services. This would also enable savings from the merger and result in a net improvement in the merged Trusts’ financial position.68

‘The potential non-financial / clinical benefits of Option eight – EHT-ICO, NWLHT & community services – had been assessed as offering 30% more potential benefit than the 2nd placed option and more than

50% more benefit potential than the 3rd placed option.’69

As described in chapter two, EHT-ICO formally acquired the Community services for Brent, Ealing and Harrow in April 2011. This partially addressed the integrated care potential within Ealing, but not to the same degree in Brent and Harrow where the main local acute provider is NWLHT. The merger between EHT-ICO and the ICO was unable to fully address the acute clinical viability criterion for EHT-ICO.

The SOC envisaged merger by April 2012 which in hindsight was over-ambitious. Since the last iteration of the FBC the drivers for change continue to grow and accelerate making the case more complex, but ultimately more compelling.70

Ultimately, the last version of the FBC submitted in September 2012 was not formally considered for approval for the following reasons highlighted by the due and careful enquiry:

The range and scale of financial challenge (underlying deficit NWLHT);

The scale of future cost improvement savings plans (CIPs);

Potential for further reduction in income losses facing the merged Trust; and

66 This process was undertaken between November 2010 and January 2011, with the NWL Cluster,

local PCT, Trust and SHA representatives comprising a panel to review the options with the support of an independent, expert consultancy

67 Approved in December 2011 68 Stronger Together – Outline Business Case, October 2011 69 Ibid, page 73 70 Stronger Together Full Business Case, September 2012

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The fact that the FBC had not fully modelled the impact of SaHF which may result in further lost income or increased costs during periods of significant service and organisational change

The Trusts recognise the challenges and the risks of merger, but both possess experience of previous mergers where there are some lessons to be learned.71 Nor do the Trusts believe the benefits for patients, staff and others will accrue merely as a result of merging the organisational forms. Long-term transformational change is needed to achieve that. However, merger will create conditions for:

Service sustainability, integration and improvement within shrinking resources, as set out in the rest of the chapter;

Ending management distraction with merger issues, so they can focus on providing excellent innovative healthcare in all the new Trust’s service areas;

Recruitment, retention and motivation of high calibre staff in an organisation with a stable and viable future; and

The vision, drive and commitment to tackle existing performance challenges and deliver the highest standard of patient care in an innovative, flexible, stable and caring organisation.

The SOC, OBC and previous FBC iterations also drew attention to the risks of not merging which are discussed throughout this document and analysed in chapter eight. These risks remain, especially with the implementation of SaHF and commissioner disinvestment in the acute sector. Maintaining the status quo is not a safe or viable option, especially for EHT-ICO.

WHY CHANGE IS NEEDED 4.2

The Trusts are committed to improving the quality of care and experience for local patients and have set the goal of becoming among the highest-performing healthcare organisations nationally. To deliver this goal, the new Trust must respond quickly to the challenges of modern healthcare in the context of changing healthcare needs, the financial environment and commissioning intentions described in chapter three.

The Trusts recognise that the increasing complexity of medical care, together with changes in the medical workforce, constitute a strong driver towards the consolidation of acute services into larger, more specialised groupings. As discussed previously, these groupings will be required to deliver a full range of emergency and elective healthcare for patients that meet the high expectations of quality and patient experience demanded by commissioners and patients. As the ‘London Call to Action’ points out, small trusts will find it increasingly difficult to meet these expectations and face a real prospect of services being decommissioned.

Commissioners’ clinical plans and NHS NWL’s case for change have been developed with significant local stakeholder engagement and input, and have already concluded that high-quality care requires a shift of NHS resources from hospitals towards primary and preventative care. Such a shift of resources requires

71 NPH and CMH in 1999 and EHT-ICO and the ICO in 2011

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NHS Trusts to remodel the provision of hospital services and work much more effectively with community and primary care services.

Both Trusts believe that, through merging and forming a new NHS Trust, they will be much better placed to meet these challenges. Without merger there is a real prospect of deteriorating clinical and financial performance as commissioning intentions are put into effect.

The merged organisation will be of sufficient clinical scale to meet quality standards and ideally placed to deliver integrated acute and community care. Merger will create a more efficient organisation, offering better value for money to taxpayers

4.2.1 Financial constraints limiting growth

CCG commissioning intentions across NWL, described in chapter three, mean that over the next five years NWLHT and EHT-ICO will need to continue to deliver high-quality services within funding restraints.

A key consequence of these plans is that – despite population shifts – the generating of income alone will not enable the Trusts’ three hospitals to meet clinical quality standards through increased scales. Furthermore, even after substantial savings included in current plans, without a merger both Trusts will face huge challenges to maintain current levels of service provision and quality.

The clear implication for both Trusts is that any strategy that seeks to achieve long-term financial sustainability through growth is simply untenable.

4.2.2 Size of existing Trusts and impact of critical mass

As described in chapter three, smaller hospitals will find it ever more difficult to fulfil the principles outlined in the Trust ‘Promise to Patients’ and other quality requirements. EHT-ICO, in particular, lacks critical mass when compared to other Trusts in key acute specialties and NWLHT faces similar future challenges in areas such as A&E where the Trust has struggled to recruit sufficient doctors.

Furthermore, in an era which the NHS wants to concentrate as much resource as possible in direct patient care, larger organisations through economies of scale have more capacity to reduce their managerial and ‘back office’ overheads.

While NWLHT and EHT-ICO are larger than average in A&E activity (and NWLHT is larger than average in paediatrics and maternity) – for many specialties both Trusts are smaller than the nationwide average for FTs.

The Board and clinicians at EHT-ICO recognise that the promise of high-quality care will be increasingly difficult to deliver. In many cases, teams are currently too small to support delivery of this level of care, and for some conditions EHT-ICO lacks the necessary access to emergency diagnostic or therapeutic techniques. Unless these factors can be addressed, there is a high risk that commissioners would be unable to support some acute services on the EHT-ICO site.

For a sustainable future as a standalone organisation EHT-ICO would need to boost the number of key staff – particularly consultants – and develop more 24/7 availability for some specialised tests and therapies. The financial challenge facing the NWL sector means that this level of additional funding is simply not going to be available.

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As described previously, commissioners are making a clear commitment to invest in primary and community services with a commensurate reduction in the acute sector. Even if finances were available, critical mass for EHT-ICO could only be realised through a substantial rise in the volume of work performed at Ealing hospital.

If the volume did not increase, then efficiency would deteriorate and some specialised teams would lack sufficient work to reach the minimum requirement to maintain their skills and meet commissioning standards. The financial environment and commissioning intentions make this scenario untenable.

NWLHT, with NPH operating as a major acute site, has a larger critical mass and so has fewer immediate concerns about clinical sustainability. Even so, additional benefits and resilience would be provided through larger teams and joint working. This is particularly important in A&E, where the Trust performs poorly due to staffing shortages.

COMMON LESSONS FROM OTHER MERGERS 4.3

EHT-ICO and NWLHT have previous experience of organisational merger: EHT merged with the ICO covering the boroughs of Brent, Ealing and Harrow; Northwick Park Hospital merged first with St Mark’s Hospital in 1994 and then absorbing CMH in 1999.

Both Trusts understand that merger processes are extremely complex and challenging. However, the two Trusts are not relying solely on these experiences to guide future planning. In its Approach to Transactions document, NHS London produced guidance based on experience gained from other mergers in the capital. Development and support assistance from the system continues to be provided under the TDA Assurance Framework and through the TDA London transaction team. Ensuring that lessons are learned from NWLHT and EHT’s own experiences as well as those of others, is discussed in more detail in chapter one0.

CONCLUSION 4.4

The NWL commissioning intentions, the financial context of the wider NHS and the need to continually improve services pose a severe challenge to the future of EHT-ICO and The NWLHT.

Both Boards have a clear vision for the merged trust as a vibrant, high-performing organisation with excellent clinical outcomes, performance and patient and staff satisfaction.

This chapter has described the clinical drivers for change and the advantages of a merged organisation. Both Trusts believe that through merger and realisation of the associated benefits, there will be a tangible and sustained improvement in the quality of care for patients. Crucially, the new organisation will be integrated with community services and become clinically more efficient and effective, thereby reducing cost, as well as improving outcomes.

The clinical models and benefits are described in more detail in chapter five.


Appendix 4-1 Details of the options appraisal

Supporting Document 4-1 Strategic Outline Case

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5. Clinical and patient benefits of the merger

Chapter Summary

This chapter summarises the clinical and patient benefits that arise as a result of the merger. It also highlights benefits to staff and commissioners.

The merger will bring direct benefits to patients with improved clinical outcomes, better patient experience, more equitable access to specialist care and improved access to care closer to home. The merger will help to secure achievement of the performance standards expected of all NHS trusts.

Progressing integrated care between hospital and community services is central to the delivery of improved patient care.

The Trusts have also committed support to improving training and education and research and innovation.

INTRODUCTION 5.1

The Full Business Case focuses on three key arguments for merger:

The need for critical mass to develop thriving hospital-based clinical services, while facilitating the move of certain services to community and primary care settings;

The need to reconfigure acute and other services across North West London, as outlined in SaHF; and

The need for a sustainable organisation fit for future purpose

The FBC recognises that continued uncertainty is corrosive. It creates anxiety in patients and staff and distracts management from providing high-quality healthcare. In his review of 14 hospitals with unexpectedly high death rates, Sir Bruce Keogh remarked:

‘A number of the trusts have been undergoing mergers, restructures or applications for FT status and many have needed to make significant cost savings. These issues may have diverted management time and attention from focusing on quality. This was a key factor raised in the

inquiry into problems at Mid Staffordshire NHS FT.’72

Both Boards recognise this risk and are keen to mitigate it.

Chapter four has set out the case for merger. This chapter looks in more detail at what a merger will mean for patients, commissioners and staff and provides examples of tangible benefits which will result from the merger. Chapter six goes on to describe the clinical vision of the new Trust after merger.

In brief, direct clinical and patient benefits will derive from a number of key features:

72 Sir Bruce Keogh Report, NHS England, July 2013 http://www.nhs.uk/NHSEngland/bruce-keogh-

review/Documents/outcomes/keogh-review-final-report.pdf, section 5.4

http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf

http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf

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Improved clinical outcomes and reduced harm from delivering services across a larger population base with a greater critical mass;73

Improved access to the right specialised teams/equipment when required;

Increased delivery of patient care close to where patients live or in their own home. This is important as patients groups have expressed concerns that merger might make services harder to access;

Integrated care able to provide a rapid response to avoid the need for admission to hospital and reduced length of stay when admitted to hospital; and

Improved disease prevention and health promotion by working more closely in partnership with primary care, social care and public health.

In terms of the National Outcomes Framework domains,74 the merger will therefore facilitate:

Reduction in premature mortality;

Improved quality of life for patients with LTCs;

Enhanced recovery from illness or injury;

An improved patient experience; and

Better patient safety.

Don Berwick in the letter to NHS leaders accompanying his recent report on patient safety calls for a culture of learning.75 He proposes four guiding principles that should inform what we/NHS staff think, say, and do:

‘Place the quality and safety of patient care above all other aims for the NHS. (This, by the way, is your safest and best route to lower cost.);

Engage, empower, and hear patients and carers throughout the entire system, and at all times;

Foster wholeheartedly the growth and development of all staff, especially with regard to their ability and opportunity to improve the processes within which they work;

Insist upon, and model in your own work, thorough and unequivocal transparency, in the service of accountability, trust, and the growth of knowledge.’

A merger between EHT-ICO and NWLHT would facilitate a step change in the acute and community teams’ ability to develop, transform and improve services to achieve these four principles. The clinical and operational benefits for change are highlighted below.

73 The London Call to Action (NHS England October 2013) cites that 400 lives a year have been

saved as a result of the concentration of expertise in eight Hyper Acute Stroke Units, one of which is at NPH; and more lives saved as a result of creating designated trauma centres

74 The NHS Outcomes Framework 2013/14, Department of Health, November 2012 75https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226708/berwick_lette

r_to_Govt.pdf Don Berwick, Department of Health, August 2013

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226708/berwick_letter_to_Govt.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226708/berwick_letter_to_Govt.pdf

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BENEFITS FROM ACUTE AND COMMUNITY INTEGRATION – A MODEL 5.2FOR SERVICE DELIVERY

Chapter four has already described how part of the clinical strategy for the new Trust is to provide amounts of care in the community or patient’s own homes. This is consistent with the Government’s emphasis on integrating health and social care,76 and the local CCGs OOH strategy.

More recently, the Government has signalled the importance of making the best use of resources across health and social care, and is establishing an Integration Transformation Fund of £3.8bn. As part of this process, NWL has been selected as one of only 14 areas nationally to pioneer new plans to improve local provision of health and social care services.

Providing care centred on patients within the community, as proposed through the Whole Systems Integrated Care Pilots across NWL has been consistently supported by service users at engagement events. Both EHT-ICO and NWLHT are already partners within these pilots in Brent, Harrow and Ealing.

The North West London Integrated Care Programme is consistent with both Boards’ vision of creating a large integrated care organisation supporting three boroughs and 850,000 people. This means local people will benefit in the following ways:

closer working between all parts of the health and social care system underpinned by transformation in communication between different organisations and professional groups;

more say over their care and when, where and how they receive it;

a greater variety of more convenient ways of accessing advice and care from different care providers;

access to a clear plan, developed with them, to get the best treatment delivered how and when they want it; and

support to navigate through a much more accessible care system.

The integrated approach will support schemes to:

avoid unnecessary attendances and admissions through A&E;

facilitate seven-day working; and

develop tailored services for particular client groups77.

The clinical managerial structure of the new Trust (described in chapter seven) is designed to promote close working across the acute and community interface. Services based wholly in the community will retain their locality focus and work closely with local primary and social care to keep patients as healthy as possible and reduce the need for more costly hospital care.

Most importantly we recognise that success in community integrated care will not come through continuing ‘business as usual’. Community services, along with aspects of traditional acute care, will need to move to a new paradigm of patient

76 www.gov.uk/government/news/people-will-see-health-and-social-care-fully-joined-up-by-2018. DH

Press Release 14 May 2013 77 Lord Howe, Minister for Health (Lords) speech to Westminster Health Forum 15 October 2013

http://www.gov.uk/government/news/people-will-see-health-and-social-care-fully-joined-up-by-2018

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focussed partnership working if we are to realise these benefits for the whole health economy.

The Trusts are committed to work with the CCGs and other partners on this journey to transform the way care is delivered to patients across the Boroughs that the merged organisation will serve. As mentioned earlier the Boards of the existing Trusts support the Whole Systems Integrated Care pilots and community services have already begun to reorganise to facilitate this – for example Ealing District Nursing service is being refocused into teams linking with the Ealing locality GP groupings. Furthermore, it has been agreed to undertake a review of community services jointly with the respective CCGs the outcome of which will be available in Autumn 2014 and will help inform detailed planning to maximise service delivery in and close to patient’s homes.

This is vital as patient groups and local GPs have voiced concerns about local access and responsiveness of both the acute and community services. The new Trust will engage in a programme of pathway redesign in partnership with commissioners, GPs and other local services to streamline the delivery of care and remove blocks from the system.

When integrating with community services, EHT-ICO developed a framework for service delivery, based on collaborative discussions (Table 13). This approach will be built on in the new Trust:

Table 13 Framework for integrated service delivery

Inclusion of appropriate GP and Primary Care expertise in local service development, delivery and management

Development of community services focused around GP and primary care teams

Continued focus on borough level management of core services, with smaller, specialist services managed on a cross-borough basis

Further development of integrated care pathways across care settings – both at borough and across borough levels

Vertical integration between acute and community services in building on collaborative relationships

Operational resilience and efficiencies in provision of community services

Each of the three boroughs has a history of close links between local acute providers, community services, mental health providers, primary care and social services, particularly when managing patients with complex needs. The new Trust will build on this foundation and provide a range of clinical services with a focus on community and locality-based care.

5.2.1 Transforming community services

A key focus for the merged organisation will be to work collaboratively with CCGs, mental health and social care partners to develop new ways of working that support maintaining patients’ health in the community and avoiding hospital admissions. The merged Trust plans a number of actions to address this aim and to facilitate partnership working including:

the development Borough Partnership Boards;

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the creation of a division of community services with a direct line to the Board through the Chief Operating Officer, to ensure that the community element of clinical services enjoy the same Board-level presence as acute services in the new governance arrangements of the merged organisation (described in chapter seven); and

Building on the regular dialogue with local GP CCGs that NLWHT and EHT-ICO have already established, to ensure that the new organisation continues to work closely with CCGs to achieve shared goals.

The Trust Boards recognise that GP involvement in the planning, governance and delivery of community-based care needs to be strengthened and are committed to ensuring that the new Trust will involve GPs more.

Transformation of community-based services has potential to improve the quality and experience of care for patients served by the new Trust. Working closely with GPs, a process of care pathway redesign will move care out of the acute part of the organisation and bring it much nearer to patient’s homes.

This will improve efficiency and provide better value for money for commissioners and the taxpayer. Certain services will retain a hospital focus when safe delivery in the community is not possible or feasible, but the team that treat the patient will be the same: improving continuity of care and ensuring care is delivered in line with SaHF.

The STARRS programme run by NWLHT was mentioned as a model of good practice in this context. The London Call to Action similarly praises the Integrated Care Pilot (ICP) developed in Inner NWL and the new Trust would be keen to adopt best practice from outside the new Trust as well as within it (see section 5.2.3).

Targeted for greatest transformation will be the interface between the GP surgery and the acute hospital. Community services will be elevated from a poorly coordinated, under-resourced function to a pivotal force in the organisation of health and social care. Joining those already working in the community into a coherent system of locality leadership will streamline the delivery of scheduled and unscheduled care, as well as improving the patient experience.

Primary care will play a key role in the identification of patients in high-risk groups who would benefit from enhanced community services. This proactive approach will foster independence and wellbeing and stem the flow of unnecessary hospital admissions.

Examples of patient benefits and patient stories to illustrate these themes are provided in Appendix 5-1.

5.2.2 Delivering the Change

Delivering these changes is far easier within a merged organisation that has a unified set of overriding aims and objectives. However, a range of activities will be needed to formulate pathway requirements, agree new operating systems and consult GPs, patients and staff about how and where care will be provided. Key elements in the delivery phase will consist of:

A multi-disciplinary team (MDT) to work up the benefits of service-line community integration and produce a business case and project plan for

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commissioners to consider. A programme management office has been established to support this work.

A communications and engagement plan to set out the ways in which the Trust will consult and engage with multiple stakeholders (Supporting Document 5-1).

Organisational development and human resources strategies to manage change and support affected staff (Supporting Document 5-2). The organisational development strategy also identifies the need for a comprehensive training programme, as well as initiatives and interventions to ensure the right staff and skills are in place.

Estates strategy to develop a merged structure. A single structure is already in place and a Joint Director has been in post since 2012, while the first draft of a 5-10 year plan is due in March 2014. Contracts are being reviewed as they come for renewal and are being jointly procured between the two Trusts. Ealing Hospital has recently taken on 11 extra properties that have been transferred from the PCT. The new Trust will work with the local CCGs and other partners to develop the best estates configuration to support the out-of-hospital strategy and SaHF. For example, Acton Health Centre, which is an Ealing ICO property, will need to be developed as one of Ealing CCGs three community hub sites delivering enhanced primary care and integrated secondary care services. Through a coordinated estates strategy the new Trust can gain additional benefits of improving patient flow through and out-of hospital as well as the potential to manage assets more efficiently by disposing of estate that is not fit for purpose (Supporting Document 5-3).

IM&T strategy to harmonise information and communication systems across the two trusts (Supporting Document 5-4). Early systems integration includes:

o implementation of a joint patient administration system and integration engine was implemented in February 2014;

o further scheduled integration with joint systems to be in place for accident and emergency, bed management, order communications and results reporting by end September 2014; and

o procurement for a joint radiology system (RIS-PACS) that is also now at the final stages of contract negotiation with the preferred bidder, with the joint system planned to be in place during Q4 2014/15.

A Joint IM&T Strategy Board is in place and oversees all key investment decisions, currently reporting up to the respective Trust’s Finance and Investment Committees. Common IM&T policies are also now in place across the two Trusts, along with a joint Information Governance Steering Group. The IM&T team have recently completed a ‘day in the life of’ exercise to promote clinical engagement and establish priority requirements for the IM&T programme.

The Trusts recognise that seamless and timely exchange of relevant clinical information between all health and social care providers will be a key enabler

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to achieve high quality, efficient and safe integrated care pathways. This has enormous benefits for patients and staff. There will be a strong commitment from the new Trust to make clinical IT system ‘intra-operability’ a key priority for the IM&T team. Steps are already being taken by the IM&T team, through the current procurement process, with CCG engagement, to make this a reality.

5.2.3 Benefits from integrated care planning

An integrated model of service delivery offers the potential to deliver better healthcare for people in their own homes and community settings. The principle for care planning is simple. Many patients with chronic long-term-conditions – such as diabetes or heart disease – will have complications leading to acute admission and stays in hospital.

These events are distressing for patients and costly to healthcare services. By focusing in more detail on these individuals with a care-planning approach, patients become more involved in their own care, their health is improved and there is less need for acute services.

A wide range of patients may also need to access community services for short periods of time following an acute event. Current variability of service provision and organisation across the three boroughs can increase delay and waste in the system. By working as a comprehensive integrated service, the waste can be eliminated leading to faster more efficient care.

There are already good examples of work between the acute and community sectors in delivering care planning – most notably between NHS Brent and services based at CMH. Outreach community services, for example in respiratory medicine, are more developed at CMH than EHT-ICO. By bringing acute specialties into single departments, the new Trust will be able to share best practice across the organisation: reducing length of stay and avoiding unnecessary admissions.

As well as looking at good practice within the existing Trusts, the new Trust will explore models of good practice elsewhere. For example, the North West London Integrated Care Programme which builds on the ICP adopted in inner and outer North West London. The ICP was described as a model of good practice in ‘London – A Call to Action’ and has provided an exemplar of how to facilitate joint working across organisational boundaries to deliver more efficient, high-quality integrated care.78

In this model, GPs have reviewed their practice lists to identify patients in specific disease groups who are at high risk of needing acute/emergency intervention by health or social care. The patients are then discussed in formal multi-disciplinary meetings with all relevant healthcare personnel, including: primary care, social services, community services, mental health and acute hospital specialists. An individual care plan is devised for that patient and communicated through a shared IT system to all relevant healthcare teams. The patient is fully involved in this process and also has a copy of their care plan.

78 A pioneering integrated care pilot in north west London has produced 37,000 individual care plans

to improve the coordination of care for people over 75 years of age, and adults living with diabetes. Sixty nine percent of patients felt they had increased involvement in decisions about their care. London - A Call to Action, NHS England, October 2013, p12

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NWLHT and EHT-ICO are already committed to supporting this integrated care model for a range of long-term conditions and have been working closely with partners in the NHS and social care over the past 18 months. The new Trust will continue this commitment and look to apply the model to other LTCs. Acute and specialist teams in the Trusts have a wide range of expertise to support primary, community and social services in managing patients out-of-hospital and so are ideally placed to work in partnership with primary care to deliver this and other similar initiatives.

High-priority areas of integrated care for LTCs will be the subject of pathway work within the first year of establishment of the new Trust. Benefits to patients and commissioners – in terms of improved outcomes, reduced admissions, improved communication and reduced cost – will be in place in the second year of running and beyond. Appendix 5-1 provides further detail on key pathways and expected benefits.

The merger will create a healthcare provider that can respond to the needs of a large diverse population and capture the full benefits of integration, so that over time patients and their families, commissioners and staff will benefit from:

improved patient satisfaction;

reduced hospital admissions and expenditure on emergency admissions;

reduced length of stay in hospital and getting people home more quickly;

more flexible services built around the individual;

reduced duplication of service provision;

integrated and collaborative working;

enhanced skill sets and greater development opportunities for staff;

improved data intelligence, patient profiling and early intervention;

clearer management of patient safety and risk;

improved ability to meet commissioners expectations and adapt to change;

provision of care closer to home;

quicker, better access to services; and

services based on patient need and convenience.

Effective integration will have a positive impact on the performance of the merged Trust in a number of ways. Delivering care faster, more efficiently and closer to home is clearly linked to improved patient satisfaction levels. Moreover, effective integration satisfies commissioners’ demands by allowing work to be shifted from the acute to the community sector. This shift will reduce pressure on acute and elective targets, boosting the prospect of sustained high performance in these areas. Finally, efficient integration will bring financial benefits to the whole health economy and make healthcare more sustainable within NWL.

5.2.4 Case studies illustrating benefits from integrated care

Integrating care provides opportunities to improve performance and make better use of financial resource, but most importantly it makes a big difference to the way in

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which care is provided to the patient. Below are some examples of the type of cases experienced within the NHS and how the care that the new Trust would provide could be improved within a merged organisation.

Table 14 Case study of admission avoidance

Rajesh is a 79-year-old grandfather living in Harlesden. He has diabetes but this is reasonably well managed through self-care. He is mobile, but does not get out much these days. Earlier today Rajesh started to feel light-headed and his right leg felt a bit tight, he put this down to needing some food and returned home to eat. After lunch Rajesh felt a little more light-headed and his leg was now visibly swollen. Rajesh called his daughter who was concerned and wanted to call an ambulance for him. Rajesh insisted he call his GP instead, they have a great deal of trust and his GP knew all about his diabetes.

As things stand

Rajesh’s GP was not able to do a home visit straight away so he advised him to attend the A&E department as his daughter was available to drop him off.

A&E is very busy and Rajesh has to wait three and a half hours to be seen. Rajesh is assessed in the A&E department and has an x-ray on his leg and some blood tests. Rajesh needs some medication for a blood clot on his leg and as he lives alone he is admitted to hospital to ensure the injections he needs resolve the problem.

Rajesh does not like being in hospital and has a sleepless night. He feels drained of energy and his general condition worsens. The hospital staff take good care of Rajesh, but he spends four days in hospital.

Rajesh is discharged home and a community nurse visits him for the next two weeks to check on his progress. Fifteen different people were involved in Rajesh’s care during his stay in hospital.

In the merged organisation

Rajesh’s GP discusses his health and contacts an integrated community rapid response team so that they can assess him within his home within two hours.

Two specialist community nurses arrived within the hour to examine Rajesh. The nurses take some blood and organise for an x-ray at a local community hospital. Rajesh has an x-ray and a cup of tea and returns home. The x-ray system communicates the records electronically to the hospital and the experts there confirm a blood clot on the leg.

That evening a specialist community nurse arrives to give Rajesh an injection; he spends the night at home and continues to manage his diabetes. His daughter calls regularly to check up on him.

Rajesh feels better the next day and his leg is less swollen. A district nurse is organised to administer the rest of his injections. The district nurse asks Rajesh about his lifestyle and picks up that he has recently had problems with his continence. This is the reason he has not been out much lately. The district nurse makes a referral to the integrated continence team so that they can support Rajesh with exercises to improve his pelvic floor muscles.

Whilst Rajesh was not fully mobile at home he received support from a carer organised by social services within their re-ablement scheme, whilst only short-term it was there when it was needed most.

Five different people were involved with Rajesh’s care; they were all able to access the same records, so he did not have to repeat any information. Had Rajesh had been admitted to a bed for the night, it would have been to a community based hospital close to his home.

Table 15 Case Study of MSK care in a community setting

Claire has just reached 50 and lives in Wealdstone. While otherwise healthy she is suffering from a painful arm and shoulder. She spends long hours at her computer. Her GP advises more exercise, but as things do not improve, she wants to refer her for an assessment.

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Table 16 Case study of home therapy

Joanna is a 36-year-old single mother of two children aged 10 and 14. She was diagnosed with multiple sclerosis three years ago and has had two previous severe exacerbations. She presents with worsening unsteadiness and several falls. She is well known to her GP, who asks for an urgent admission to hospital for intravenous steroids which have been recommended by the neurosciences centre.

As things stand

Joanna is referred by her GP and seen in the medical admissions unit. She has a detailed history and examination and is reviewed the next morning by the admitting medical consultant.

Joanna is very unsteady and at high risk of falling. She is on her own with two children and the team decides to keep her in hospital. The children are being looked after by a friend and a referral is made to social services. A neurology referral and an MRI brain scan are requested. MRI confirms the diagnosis of MS but adds nothing else to her care. The neurologist recommends high dose intravenous steroids for five days.

Joanna is tearful and upset that she cannot be with her children. She tries to discharge herself but is too unwell to get home. She responds to steroid therapy and also receives daily physiotherapy.

After seven days she is improved enough to be discharged home with a short period of additional social services support and follow up with neurology.

In the merged organisation

Joanna’s GP speaks to the consultant in the medical admissions unit and explains the home situation and that Joanna is desperate to avoid admission. Joanna comes to the Medical Assessment Unit (MAU) for assessment to exclude any other cause of deterioration. She is seen by the medical consultant and has a multi-professional assessment.

Joanna is very unsteady and at high risk of falling. The MAU refer her to the community response team who assess her as suitable to be at home with short term support. MAU also refer her to the home intravenous therapy service.

Joanna goes home nine hours after referral having received her first dose of steroids in the MAU. She is visited daily by a nurse to complete the five days course of steroids.

Joanna is visited by occupational therapy to assess her home environment and receives physiotherapy daily. Hand rails are put up in her bathroom and hallway.

She is given a temporary wheelchair to allow her to get out of the house. She is also given help with personal care and put in touch with a

As things stand: The GP can choose between waiting for a community physiotherapy appointment, or an appointment with a consultant for which the waiting time may be less. By now Claire is very keen to get some help quickly, and the GP chooses the consultant option. At her appointment, the consultant decides to refer Claire to the hospital physiotherapy service. After several journeys to the hospital for treatment, Claire is referred to a rheumatologist who can give a joint injection. She has another visit, and the injection relieves the pain, and she continues with physiotherapy. Gradually things improve, and she no longer finds the pain a problem.

With Integrated Care: The GP refers Claire to a service that is run between community physiotherapists, a GP with specialist training and experience, plus advice and support from hospital consultants. She sees a specialist physiotherapist, who assesses her quickly at a nearby centre, and sees her again several times for treatment. If she needs to see a doctor or a psychologist, there is one in the team, and they all use the same electronic records, so Claire does not need to keep repeating her story. The physiotherapist has trained to give joint injections, saving Claire a visit to hospital. Her therapist can discuss the case with a consultant physiotherapist from Ealing, who runs the service in both boroughs. Claire’s condition gradually improves and the pain is no longer a problem.

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voluntary agency funded support group. Follow up is arranged with neurology by the MAU.

BENEFITS FROM MERGED ACUTE HOSPITAL-BASED SERVICES 5.3

NWL commissioners have stressed that quality standards of acute services should be based on and assessed against strong clinical evidence. There are two critical elements affecting patient outcomes and quality of care that will be improved through merging EHT–ICO and NWLHT.

5.3.1 Care at the right time, in the right place, by the right people

Whilst NWL compares well to the national average in terms of mortality rates, a Pan-London study in 2011established that there is a greater than 10% higher mortality rate in London for emergency admissions at the weekend, compared to weekdays, due to lack of consultant cover and access to diagnostics at weekends.79

Clinical evidence compiled over a number of years highlighted that in emergency care services early involvement of senior medical personnel in assessment and subsequent management of many acutely ill patients improves outcomes.80

A self-reported survey of London Trusts in 2011 demonstrated considerable variation in the availability of senior staff at weekends compared to weekdays. NPH reported that not all emergency general surgery admissions were reviewed by a consultant within 12 hours; and at Ealing Hospital consultants were not freed from other duties when providing emergency cover.

The NHS recognises that it cannot continue as a five-day routine service and there is a strong challenge, backed up by National Quality standards to all Trusts to increase the provision of 24/7 high quality care delivered by staff of appropriate seniority and training. The challenge of delivering this across a large number of hospitals in the same geographic area is one of the key drivers for SaHF. Commissioners must be assured that the hospitals they commission services from are able to meet the new standards. Ealing Hospital, in particular, will have great difficulty as a standalone organisation in investing in the additional consultants, nurses and therapists to meet the new quality standards.

The combined resources of the merged organisation will allow these issues to be tackled in a planned and effective way during the period of service transition set out in SaHF. The end state will be a first-rate, high-quality, high-volume major Hospital on the Northwick Park site delivering the very best care that the public has a right to expect. There will be sufficient numbers of consultants and other staff in both the immediate acute specialities – such as emergency medicine, acute medicine, acute surgery and obstetrics to meet existing and future quality standards for a consultant delivered service.

79 Aylin, Yunus, Bottle, Majeed, Bell: weekend mortality for emergency admissions. A large

multicenter study, NHS London, LHPA 2011 80 NCEPOD 2007, NCEPOD 2011, RCSE: Standards for unscheduled surgical care 2007, RCP:

Right person, in right setting – first time 2007

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Under a combined set of rotas in the merged trust the number of consultants and volume of emergency activity, particularly surgical, would be significant enough to tackle each of these issues and meet the standards set by the Royal Colleges for emergency care with the introduction of 7 day a week consultant ward rounds at NPH, this would allow the acute site to ensure that the medical take was staffed to three consultants per day robustly covering take and post-take 12 hours a day.

5.3.2 Increasing access to specialised care

As with increasing the availability of senior medical professionals to care for patients out of hours, it has been established that in many areas, better outcomes are associated with the level of specialisation of the medical and other professionals in the teams delivering care.81 For example, specialist surgeons achieve better outcomes for patients than generalist surgeons in 9 out of 10 cases.82

To enable surgeons to both gain and maintain specialist clinical skills a hospital needs a sufficient volume and case-mix of patients. Given the effect of sub-specialisation the Royal College of Surgeons (RCS) estimates that hospitals need a large population catchment area.83 In NWL all the A&Es are below the average national catchment area, with the exception of NPH, and all fall short of the RCS’ preferred scale.

Merging EHT–ICO and NWLHT and basing emergency surgery at NPH, will increase the catchment area of the major hospital at the NPH site, increasing the exposure of clinical teams to the diversity of case-mix and volume of cases needed to maintain specialist skills.

An example of the changes can be demonstrated in laparoscopic care.84 Laparoscopic (or key-hole) surgery is associated with shorter recovery times and can improve patient outcomes, yet at EHT-ICO only a third of surgeons providing emergency care can perform laparoscopic surgery. At NPH 83% of surgeons performing emergency surgery can perform laparoscopic surgery.

Table 17 Benefits of merger for acute and specialist care

Benefit Example

Consultant-delivered (rather than consultant-supervised) care will be achievable

Consultant-led care for the acute medicine and emergency surgery pathways

Better patient access to key diagnostic and therapeutic interventions and more efficient use of specialist expensive equipment

Diagnostic and therapeutic endoscopy, interventional radiology, out of hours MRI scanning etc.

81 Hall B, Hsiao E, Majercik S, 82 Chowdhury M, Dagash H, Pierro A …. 83 Royal College of Surgeons: Delivering High Quality Surgery Services 2006 84 NHS London, Adult Emergency Services. Acute medicine and emergency general surgery, 2011,

and Report of the clinical working groups, July 2011

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Benefit Example

Better access to consultants for primary care clinicians for advice on patient care and management

Telephone access to speciality consultants on call

Better opportunities for staff training and development in a larger organisation will allow us to develop a workforce with the right skills in the right place

Larger teams will create capacity to ensure appropriate training can be provided. This will also ensure the merged Trust attracts trainees and maintains training accreditation

Specialist nursing and therapy services available where needed

Bigger teams and consolidation of resources will allow staff to work across hospital and community settings

Greater opportunity to manage patients out-of-hospital through integrated care

Clinical teams have the senior leaders and staff capacity to work with and within primary care and social services to establish revised referral and discharge criteria. The closer relationships built enable colleagues to rely on each other’s assessments and establish effective patient information sharing protocols.

Opportunity to learn from and share best practice across the organisation

Larger teams provide better opportunities to learn lessons from patient feedback, audits and incidents, and make it easier to identify preventative actions.

The merger of EHT-ICO and NWLHT will enable the new Trust to respond to the challenges set out above and in chapter four. Changes at Central Middlesex local hospital and Northwick Park major acute site over recent years demonstrate how some of these challenges can be met by effective joint working between sites and result in improvements for patients. For example:

NWLHT moved emergency surgery from CMH to NPH to provide more consultant input and better dedicated emergency theatre time; and

NWLHT successfully secured the support of local GPs, OSCs and patient groups so that it could move the under-used paediatric assessment unit based at CMH to NPH. The concentration of inpatient services at NPH has enabled specialist doctors to team up on one site and offer 24-hour higher quality care.

Coordinated within one Trust (NWLHT), it was relatively straightforward to introduce these changes. In the same period, EHT-ICO struggled to solve the problem of critical mass for acute surgery through partnership arrangements with a number of other local Trusts. In each case, discussions aimed at creating joint rota arrangements started well with commitment from both parties, but implementation failed due to operational difficulties. The Trust believes such difficulties can be more easily overcome within a single managerial structure.

5.3.3 Examples of clinical benefit to patients of increasing scale in acute and specialist services through merging EHT–ICO and NWLHT

For some key services, either one or both Trusts lack sufficient critical mass to deliver the service in a way that can meet quality standards. Offering seamless

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services across three boroughs, a strong combined organisation will allow targets to be met early on, even without significant reconfiguration.

Examples include:

Vascular surgery – For highly-specialised vascular surgery, NWL has already moved to two acute centres: one of which is based at NPH and takes complex elective and emergency vascular cases from Ealing and Hillingdon Hospitals (the other centre is at St Mary’s Hospital). Ealing had a single consultant vascular surgeon who now works at NPH, as part of the new vascular surgery arrangements, while continuing to see patients at Ealing where they have their diagnostic and follow-up work performed locally.

Emergency general surgery – As previously discussed in chapter four, meeting the quality standards for effective emergency surgery will be challenging for all organisations, but particularly at EHT-ICO. NWLHT has two years’ experience of offering emergency surgery for patients arriving at another site (CMH) who are then transferred to NPH.

NWLHT has recently recruited a team of acute general surgeons and are improving the pathway for acute surgery to ensure sustained high quality, efficient and timely management of patients through the emergency surgery pathway. Ealing has a smaller acute surgery workload and service that requires support to meet new surgical quality standards – for example in relation to access to laparoscopic surgical intervention in emergency cases. In the short- to medium-term following merger, collaborative arrangements and shared rotas will allow the new organisation to meet these standards. However, doing so in a sustainable and efficient manner is, in the longer term, likely to need reorganisation of surgical services across the sites. Under the end state plans for SaHF there will be no acute or elective surgery on the Ealing site. Merger with NWLHT will allow that transition to be phased in a way that is safe for patients and supportive for staff.

Emergency gastroscopy rotas – EHT-ICO does not have enough specialist endoscopists to provide a 24/7 emergency service for patients with major gastrointestinal haemorrhage. This service is available already at NPH and incorporating personnel from EHT-ICO will strengthen the existing on-call rota and in the short-term will improve the service at EHT-ICO, either by stabilising and transferring a patient or by bringing skilled endoscopists to them.

Interventional radiology – This is a challenge for all hospitals as recent guidance rightly recommends that this should be available 24/7 in any centre managing surgical emergencies and some other conditions. NWLHT provides a network solution with consultants from Ealing and Hillingdon joining a 24/7 rota. To ensure all consultants are familiar with the hospital and equipment they all have an elective session at NWLHT too.

Cancer surgery – Improving cancer outcomes guidance recommends that clinical teams (including surgeons, radiologists, oncologists and pathologists) need to manage a sufficient number of patients in line with strict guidelines to get the very best results. Minimum requirements for

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individual cancers have been rising in recent years. This threatens the viability of managing some conditions at both Trusts, but more so in relation to EHT-ICO which saw urological cancer services decommissioned in 2011. As described in chapter three, merging the EHT-ICO urology department with NWLHT has provided a more robust service with sufficient critical mass to manage urological cancer and benign disease effectively across all sites.

To improve the planning and delivery of cancer services the new Trust intends to quickly (within the first six months of merger) move to review and integrate cancer pathways between its three acute sites and partner organisations. There will be a single cancer lead and one cancer strategy to ensure a focus on cancer at a high level in the Trust. Single cancer MDTs will be put in place for each tumour group and there will be active ensure that areas where performance is challenged – for example the provision of acute oncology at Ealing – are addressed.

Cardiology – Cardiovascular disease is a major health problem for residents across NWL, particularly in Ealing, Harrow and Brent. Both existing Trusts have strong cardiology departments with well-established tertiary care links to ICH and the Royal Brompton & Harefield NHS FT. Combining cardiology expertise can only strengthen services further and boost 24/7 access to a first-class local preventative, diagnostic and treatment cardiology service. Just as importantly will be the role of cardiology outreach supporting patients with chronic cardiac disease to prevent admission, working closely with community and primary care-based services.

Paediatrics – Paediatrics is a core service for any general hospital. Paediatricians are required to support A&E, admit and manage paediatric emergencies, diagnose and treat a range of acute and chronic paediatric illnesses and to provide highly specialised care for new-born infants in special care baby units. Increasingly, a general paediatrician cannot be expected to manage all of these responsibilities and, therefore, subspecialisation has occurred – in common with many other areas of medicine.

Infection services - the Trusts have already merged the clinical microbiology service into a single on call rota covering all three hospitals and the community. This has resulted in a much better and sustainable staff rota but is only the first in a planned series of changes. As merger takes place this will be followed by integrating the infection control nursing team – at present neither Trust has an infection control nurse available 24/7 to deal with infection control problems and outbreaks and this capability will part of the merged service.

After merger and service reconfiguration the clinical infectious diseases teams will be of a sufficient size to provide a seven-day dedicated infectious diseases inpatient service, clinical review of patients developing severe infections and support for patients having intravenous antibiotics in community settings or their own home. Outpatient care will continue at the most accessible community or hospital site. Finally only through merger will the HIV service on the three hospital sites achieve the critical mass to meet NHS

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England specialist commissioning standards and be able compete effectively in HIV service procurements which are expected over the next 2-3 years.

Orthopaedic Surgery – the example of fractured neck of femur. Orthopaedic services at NWLHT implemented a hot and cold site approach for patients with fractured neck of femur over the age of 65 in June 2013. Approximately 400 patients are admitted annually through the orthopaedic service with this diagnosis. Having identified the need to free space on the major acute site to manage patient flow and improve patient care, the clinical team has developed a service where the patient are operated on by orthopaedic surgeons on the acute site and then handed over to a dedicated rehabilitation team on the sub -acute site.

The outcomes have been positive from the point of patient safety, efficiency, quality of care and cost effectiveness:

Quality of Care and Efficiency: The number of patients admitted directly to the orthopaedic ward improved to 90%, with 72% going directly from the emergency department to the ward in comparison to 37% in 2012/13. Time to surgery was within the 85% National guideline of patients having surgery within 48 hours, improving from 58% in 2012/13 to 85.7% in 2013/14. Further improvements include 86% of patients being operated on within 36 hours and 70% having surgery within 24 hours of admission. There were no theatre cancellations to the trauma lists during the period of this change and length of stay has reduced.

Patient Safety: The team have reported a significant reduction in 30 day post-surgery mortality rates from 10% (above the National average) to 2.4%.

Cost effectiveness: The team have reported a financial benefit through the receipt of best practice tariff for managing time to surgery within 36 hours showing an improvement in meeting all parameters from 33% to 63%. Length of stay reductions had knock-on benefits as each bed day saved enabled the improvement in patient flow.

5.3.4 Specialised Services Commissioned by NHS England

As with other areas of specialist care described above, the merger of the Trusts will make it easier for services to reach and maintain quality standards through increased scale; whilst for patients the continuity of care offered through one organisation providing care with integrated clinical teams and information systems should improve patient experience. Table 18 summarises the scale of specialised services in EHT and NWLHT.

Table 18 Summary of services under specialised commissioning arrangements (source: Trust 2014/15 baseline figures)

EHT NWLHT

Internal Medicine £2.3m

Cardiac Surgery

Complex Invasive Cardiology

Specialised Respiratory

£9.1m

Cardiac Surgery

Hepatobiliary and Pancreas

Morbid Obesity Surgery

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EHT NWLHT

Specialised Colorectal Services

Specialised Respiratory

Vascular Disease

Cancer and Blood £4.9m

Haemoglobinopathies

Haemophilia and other Bleeding Disorders

HIV

Infectious Diseases

Specialist Cancer

Specialist Immunology and Allergy Services

£8.6m

Haemoglobinopathies

HIV

Infectious Diseases

Specialist Cancer

Trauma n/a £6.9m

Brain Injury Rehabilitation

Specialised Ophthalmology Services

Specialised Orthopaedic Services

Women and Children

£2.3m

Complex Gynaecological Services

Congenital Heart Services

Neonatal Intensive Care

Paediatric Cancer Services

Paediatric Medicine

Paediatric Surgery

£11.8m

Complex Gynaecological Services

Congenital Heart Services

Medical Genetics

Neonatal Intensive Care

Paediatric Cancer Services

Paediatric Medicine

Paediatric Surgery

Specialised Maternity

Other £1.6m £24.5m

Grand Total £9.1m £61.1m

5.3.5 Achieving high levels of operational performance through merging EHT-ICO and NWLHT

Chapter two outlined the current operational performance in both Trusts and highlighted areas in which current performance needs to improve for the Trust to achieve its clinical vision. The details of how performance will be measured and managed are included in chapter seven.

NWLHT is challenged in delivering RTT and A&E performance standards predominantly due to constrained operating and inpatient capacity. Ealing Hospital has previously met the 18 week RTT performance standard but has been challenged in the last quarter of 2013/14 and into 2014/15 and is currently reviewing demand and capacity to meet this target sustainably.

Merger of the organisations and being able to plan and run these services across all sites plus more effective and streamlined working with community staff and the community bedded units will allow the new organisation to move to a position where these two key operational targets are being met sustainably.

The ability to flex capacity across sites at peak times will enhance surge planning and response. This approach works well for NPH, helping to improve A&E waiting

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times during 2013/14, when a partnership to utilise inpatient capacity at Mount Vernon was enacted.

As described in section 5.3.3, a unified bed base under a single patient pathway has been successfully implemented for fractured neck of femur between NPH and CMH. With CMH A&E closing to surgical emergencies in November 2012, fractured hip patients have their operation at NPH and once stable post-operatively at day three, patients are transferred from NPH to CMH for their rehabilitation. Working across sites in this way has resulted in a reduction in average length of stay and improved outcomes for patients.

An immediate benefit from merging EHT-ICO and NWLHT will be the increased capacity available across the Trust. EHT-ICO currently has around 20 beds closed, which could be used more effectively if EHT-ICO and NPH were united under a single bed management system. Draft plans are already in place to begin this ahead of merger.85

The merged organisation’s management of both acute and community services across the boroughs of Ealing, Brent and Harrow will enable care to be delivered to each patient seamlessly from each local hospital into their home.

As well as improving emergency responsiveness, elective flow could be enhanced through streamlining and sharing pathways of care.

Elective RTT and Cancer waiting times will be improved through merger by increasing access to support services such as pathology and radiology, particularly CT and MRI scanning. Additional theatre capacity will become available to the merged Trust in the short term – through use of the one currently under-utilised theatre at Ealing hospital – helping delivery of the 18 week RTT standard and providing essential breathing space to enable the longer term surgical changes through merger and SaHF to progress.

The vision for trauma and orthopaedics demonstrates how service transformation will improve quality, drive up clinical outcomes, reduce complications, improve patient satisfaction, and increase the overall efficiency and resilience of the service. Under these plans most elective orthopaedic work will be separated from emergency trauma and will be managed through dedicated elective lists at CMH. Patients will be pre-optimised for surgery in their locality by local therapy teams, followed by a minimal length of stay episode and prompt return to their locality for aftercare and rehabilitation – in many cases in their own homes.

This model is in place elsewhere, most notably the South West London Elective Orthopaedic Centre, and is proven to deliver higher quality care. Trauma and some higher risk elective care will be centred at NPH alongside co-located dedicated critical care and care of the elderly support to provide the best clinical outcomes. When patients are over the acute episode they will move to rehabilitation for ongoing elderly care in their locality.

Outpatients, diagnostics, minor procedures and therapy will continue in all localities and increasingly in diverse community settings as the OOH strategy is implemented through community-based MSK services. What this will mean for patients is simply receiving the best care, with the best outcome and spending the least amount of time

85 Joint operational capacity planning across sites would be on the basis that EHTs A&E (and thus

inpatient services) remains open for up to five years in line with the SoSs October 2013 statement

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in hospital. What this will deliver for the commissioner is a high-quality cost-effective service. What this will deliver for the merged organisation is a high-quality service that staff can be proud of and that contributes to the sustainability of the delivery of emergency and elective targets.

A hub and spoke model of care operates between CMH and St. Mark’s hospital for endoscopy, with complex services delivered at St. Mark’s and diagnostics at CMH. With increasing demand on endoscopy services following recent bowel screening advances and advertising campaigns, a similar arrangement could work with EHT-ICO, thus improving slot availability and ensuring elective diagnostic capacity could meet growing demand over time.

By merging EHT–ICO with NWLHT the new organisation will be able to offer varied and interesting roles to its staff. This will help the Trust to recruit and retain high calibre staff, improving quality of care, patient experience and reducing reliance of expensive agency staff. For example, EHT–ICO has a high vacancy rate for speech and language therapists (SLT), but at NWLHT SLT recruitment and retention is not problematic because of the interest for professionals of working in the regional head and neck service.

Rotational posts and development and training opportunities could be offered between community and acute services – improving both staff and patient experience.

The merger provides a sound basis for improving and then sustaining performance right across the new Trust, with benefits arising from a range of short and medium-term factors:

The depth, resilience and greater expertise created through merging of clinical teams will make it easier to meet access targets – for example cancer targets, length of time to diagnosis and treatment, such as 18 weeks.

Larger clinical teams provide an opportunity for stronger clinical leadership and clinical involvement in solving performance problems.

The merger will create an environment supporting change in patient pathways and clinical processes. Coupled to which is the ongoing programme of investment into key IT systems to improve communication between all parts of the organisation and primary care. The new Trust will have a unique opportunity to review and redesign many clinical processes and pathways, using IM&T as an enabler. Thus ensuring that these are designed to deliver the best clinical outcomes, improve patient experience and meet operational performance indicators.

The new Trust will have a clear commitment to staff training and to developing a highly skilled and motivated workforce. It will be in a better position to attract staff into hard-to-recruit areas, reducing reliance on bank and agency support; with the further benefit that limiting bank and agency use is proven to improve operational performance and patient experience as well as reducing costs.

The merger will facilitate integration between acute services and the community plus partnership working with primary care and other services. This should lead to a reduction in demand for some acute services – most

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notably emergency admissions – which in turn will make it easier for the new Trust to maintain performance.

Core clinical governance processes are strengthened through the integration of acute and community teams allowing for a greater focus on reducing avoidable harm. For example, a unified infection control service in the new Trust will have the capacity to provide enhanced infection control training and 24/7 support across the new Trust. Medicines management will be improved through focusing more clinical pharmacist time on frontline staff and patients.

A&E performance at the NPH site has been poor so improving this will be a key priority for the new Trust. The A&E facilities at NPH are cramped and not fit for purpose. However, NPH has recently secured £21 million of capital investment (not connected to the planned merger) to build a new larger emergency department which is due to open in autumn 2014.

EHT-ICO provides the urgent care centre on the NPH site and EHT-ICO staff have also gained experience of using new IT systems to help maintain flow through A&E during times of operational pressure. The same IT system is currently being implemented at NPH. In commissioning the new A&E service at NPH, the new Trust will be able to design a clinical space, information system and processes around the needs of the patient, calling on the experience of staff right across the organisation. This will be an exciting opportunity and will aid recruitment of high-quality A&E medical and nursing staff.

Both trusts have been developing ambulatory care and frailty pathways to help relieve some of the pressure on the emergency pathway. Clinical and operational leaders within the two organisations see a much greater potential for doing this in the merged organisation particularly linking with the stronger seven-day working that will develop after the merger.

If the two Trusts remain as separate organisations, they will each have to respond to the drivers for change outlined in this chapter and chapter four. Merger brings significant back office and managerial savings, on a scale in excess of two single Trusts working collaboratively. It will also enable the Trust to address the commissioning challenges and current areas of variable performance in both Trusts.

Although partnership working (rather than full merger) could be considered, the clear view of the Boards was that this would be a poor alternative to full merger. Limiting any arrangements the two organisations would be likely to make being fragmented, complex, costly and less resilient to internal (for example, key staff shortages) or external (for example, service reviews) factors.

The main advantages that both Trusts believe a merger will bring to facilitate joint working and improved performance in general are summarised in Table 19, with further benefits specific to elective care summarised in Table 20.

Table 19 Benefits of merger to facilitate joint working

Benefit Example

Teams working within a single managerial

All members of the team have the same line management who can prioritise and organise resources for the patients benefit

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Benefit Example

structure All members of the team have the same terms and conditions and development opportunities

Clinical leaders can set goals and objectives across the entire team

Greater pool of senior clinical and managerial staff

Easier for key staff to take lead roles in important areas of development, performance and governance i.e. working with GPs to develop new patient pathways to provide more care in the community

Larger teams provide greater potential to deliver care in the best setting such as primary care

More resilience in times of operational pressure, sickness absence etc.

Line managers can prioritise staff availability and skills to provide the best and safest care

Single managerial structure reduces bureaucracy and managerial costs

Fewer managers and flatter managerial structures enable quicker decisions to provide more responsive care. Negotiations on workload, priorities remuneration etc. are made easier as all staff part of the one organisation

Finances are much easier to monitor, control and prioritise

Removal of cross organisational boundaries to staff working flexibly across different setting

Line managers can prioritise and organise the workload of the total care team to meet the needs of the patients without needing to get agreement of other line managers in another organisation.

Table 20 Benefits of merger for elective care

Benefit Example

Greater critical mass allows emergency and elective activities to be separated in key specialities

This is considered best practice in orthopaedic surgery and results in better clinical outcomes, fewer cancelled operations, fewer complications and shorter stays in hospital than when emergency and elective work is mixed.

Greater resource across the new organisation to deal with exceptional demand or temporary loss of capacity in one area

For example, if a key member of staff with specialist skills is off sick or when equipment breaks down.

Greater critical mass allows for more sub-specialist medical, nursing and therapy roles

Larger teams will enable staff to specialise and improve their skills which will also help attract and retain staff.

Greater opportunity to deliver elective care out-of-hospital

Increased provision on community-based clinics and diagnostic procedures in community settings

Community-based teams will enjoy greater support from acute care

Better utilisation of high cost For some specialised diagnostic or therapeutic equipment, the greater critical mass allows the easier purchase and renewal of equipment

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Benefit Example

Greater access to elective care seven days a week

The new Trust will improve its service offering to patients (more availability, fewer cancellations) as well as reviewing its efficiency and productivity (no additional equipment or staff, but more throughput of activity over the full seven days of the week).

BENEFITS OF THE MERGER FOR TRAINING AND EDUCATION 5.4

There is a strong link between staff satisfaction levels and the delivery of high-quality training and high-quality clinical care. A joint vision for the educational and development aims of the new organisation has been created and includes a commitment to excelling in teaching and training across all areas (Table 21).

Table 21 Educational and development aims

Prepare a new generation of world class medical, nursing, midwifery and allied health professional students

Work closely with the leads in the Higher Education Institutes (HEIs) to identify new bespoke education programmes, alongside development of existing programmes and resources

Work closely with our medical school and postgraduate medical training partners to assure high-quality medical training

Assure equitable provision of learning opportunities within the merged organisation

Meet the education and training needs of a diverse and increasingly complex workforce, with new structures, roles and ways of working

Strengthen leadership through integrated learning at all levels

Both Trusts have a respected tradition of teaching and training medical and non-medical staff, although more recently there have been difficulties in maintaining the required teaching standards in all disciplines at NWLHT.

Both Trusts wish to ensure training does not suffer during the transition period when much of the organisational energy is devoted to harmonising clinical teams. The new organisation also needs to exploit the training opportunities that will arise due to the integrated nature of services and the ability to offer novel training experiences.

5.4.1 Medical training

NWLHT and EHT-ICO play an active role in training undergraduate medical students from Imperial College Medical School. The Trusts have reaffirmed their commitment to maintaining medical student activity and, in partnership with Imperial College, developing new teaching opportunities in the new organisation.

NWLHT currently represents the second largest Imperial College Campus. It accommodates some 142 WTE students annually, while EHT-ICO caters for around half that number, so the combined organisation will have a large teaching commitment.

NWLHT is also an examination centre for Imperial College: running year-three OSCEs and some year-six PACE examinations for medicine and surgery. Both

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Trusts have invested in providing basic training in history-taking and examinations, as well as skills and drills – such as venesection and suturing – which some consultants are unable to offer if they are required to increase numbers of patient-facing PAs.

NWLHT employs 12 teaching fellows in obstetrics and gynaecology, paediatrics, critical care module/anaesthetics, infectious diseases, ENT/radiology, cardiology/emergency medicine, haematology, two in general medicine and three in general surgery. NWLHT has a track record of shared posts with Imperial College and a new post in Law & Ethics is in progress.

Imperial College has recently enhanced its pastoral support and educational supervision of students: appointing 16 clinical tutors (eight based at NWHLT and eight at EHT-ICO), each of whom will carry a caseload of 30 students to be seen a minimum of three times a year.

At EHT-ICO, cardiology teaching consistently attains high rankings in trainee feedback. Ealing also functions as a hub for international doctors taking a taught Clinical MD course at the University of Buckingham. In addition, the Ealing Postgraduate Centre publishes an international medical journal (West London Medical Journal), bringing academic rigour to the hospital’s teaching and training environment.

The new organisation will have a single lead and administrative structure for managing medical student rotations, with appropriate facilities at each site. Site-specific facilities will be resourced to provide appropriate facilities dedicated to student use and pastoral support. These will work closely with postgraduate medical facilities to maximise the benefits of shared resources. Additional feedback from students will be gathered during the transition phase to ensure there is no unforeseen impact on course quality and the teaching experience during the merger.

Both Trusts have substantial numbers of doctors in training. Currently, there are approximately 340 commissioned training posts at NWLHT and 150 commissioned training posts at EHT-ICO. The ENT department at NWLHT won the 2011 Elisabeth Paice teaching award for the ‘best secondary care teaching department’. NWLHT and EHT-ICO run popular postgraduate courses and NWLHT has an established simulation faculty.

Medical training posts are vital to the new Trust because as well as receiving training, trainee doctors are closely involved in delivering patient care. Changes in doctors’ duty hours and training requirements have meant that smaller services may struggle to meet all the quality standards for good training. In recent years, both Trusts have had some difficult training inspections and, although issues raised have resulted in some improvement, they believe the merger will make their training programmes more resilient.

For many specialities, training has moved towards a modular approach in which trainees need to gain certain types of experience. This makes it difficult for hospitals with a small critical mass, particularly EHT-ICO, to provide a wide variety of modules.

Consequently, it is difficult to fill all training slots and maintain service continuity. Moreover, this problem is likely to increase due to a planned reduction in trainee numbers in most of the main medical and surgical specialities across London. Hence, organisations that are unable offer a full spectrum of training experience and high trainee satisfaction are likely to lose out.

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A merged organisation will give trainees from all sites greater access to a comprehensive training experience. The joint Trust will serve a population of some 850,000 people, which will provide the same clinical throughput and training potential as many of the teaching hospitals in London.

The proposed merger will allow greater collaboration and flexibility in the delivery of postgraduate medical education – in line with Health Education North West London (HENWL) key educational strategies. It is likely that clinical activity will be reconfigured and rationalised to allow clinical teams to manage appropriate numbers of patients and maintain standards. This will facilitate an environment geared towards excellent postgraduate medical training and greater clinical supervision.

The formation of an Integrated Care Organisation will allow trainees to rotate through innovative community-based modular programmes, which are expected to be the likely basis of future healthcare models. This will allow the Trust to create a critical mass of rotations, thus providing a balance of clinical material to fulfil the requirements of the various specialty schools. Such innovations in medical training are considered favourably when commissioning training posts and rotations.

The new organisation will have a single lead and administrative structure and a combined postgraduate department will build on lessons learned from previous service reconfigurations on the NPH/CMH sites. Appropriate facilities will be maintained at every site where training occurs to facilitate teaching programmes and provide pastoral care for trainees. The merger programme has included involvement from the Regional Postgraduate Trust Liaison Dean and this link will continue during transition, so that training representatives and HENWL are closely consulted during departmental reorganisation and redesign of patient pathways.

5.4.2 Non-medical staff training

The focus on high-quality care puts nurses, midwives and allied health professionals (AHPs) in pole position to improve health outcomes, the quality of care and the experience of patients. Their expertise will be increasingly in demand as the need for skilled care grows. The new Trust must train and develop its support workforce, enhancing skills that are transferable across the organisation

Both Trusts currently support the training of nursing and midwifery students: undertaking adult, paediatric and midwifery programmes from the University of West London and Buckinghamshire New University. Across the various disciplines, pre-registration numbers for the combined organisations constitute between 200 and 250 students per academic year.

The Trusts also provide specialist community practitioner placements for those undertaking district nursing, health visiting and school nursing. The new Trust will maintain and build on these relationships to strengthen nursing and AHP training.

The new Trust’s philosophy will be underpinned by a desire to prepare a new generation of world-class nursing, midwifery and AHP students local higher education institutes such as the University of West London, Buckinghamshire New University and Brunel University. This close partnership with the institutes will allow the co-design, delivery and application of evidence-based education for students across the new Trust.

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The merged organisation will also be ideally placed to develop new practice opportunities between acute and community services. Such work will help build a workforce with the skills and knowledge to support the needs of integrated care.

NWLHT and EHT-ICO receive non-medical education and training (NMET) funding to develop and educate staff. Nurses, midwives and AHPs are sent on training programmes to enhance patient care, develop specialist knowledge and support service provision. This training is usually offered through modules at degree and masters level.

It is vital that new Trust staff are technically competent within a comprehensive academic framework. Ongoing personal development is pivotal to maintaining high standard practice across various disciplines including post-graduate education programmes, work-based learning and multi-professional lead projects. Facilitated by university partners, this emphasis on personal development promotes the sharing of expertise, experience and information. NWLHT has a long history of supporting newly qualified registered nurses and midwives through a preceptorship framework. Preceptorship provides newly-qualified professionals with the best possible start as they embark on their career pathway and will be retained in the new Trust as a reflection of the organisation’s commitment to staff.

Over the last decade, the preceptorship programme has progressed from an enhanced induction period to a work-based learning module supported by the University of West London. Using this model across the new Trust will ensure a proficient nursing workforce – one that is able to deliver high-quality care, willing to challenge unacceptable variations in care standards and willing to enhance skills and knowledge as a commitment to local health service sustainability.

NWLHT are also leading nationally on the training of pharmacists in collaboration with the University College London School of Pharmacy. Objectives include: promoting undergraduate training on the aspects of NHS pharmacy roles; supporting the development of diplomas directed towards supporting pharmacists involved in clinical research; and mentoring pharmacists to undertake their Qualified Person (QP) exams, resolving a national resource issue.86

BENEFITS OF THE MERGER FOR RESEARCH AND INNOVATION 5.5

Research and innovation is crucial for the NHS as a whole, but also brings considerable benefits to NHS trusts, their staff and patients. The new Trust has the potential to adopt a robust position in research, development and innovation (R&D). NWLHT currently holds second pole position in the NWL sector for Comprehensive Local Research Network (CLRN) income, mainly as a result of its interventional studies. Presently, EHT-ICO has a large-scale observational study relating to cardiovascular disease in its portfolio that accrues well against CLRN targets.

The merger will place the new Trust as a significant presence in terms of supporting research in the NWL sector, with recruitment of more than 5,000 patients allowing the new Trust to compete with ICH on an equal basis. A progressive strategy focused on interventional studies will be pivotal to the new Trust becoming the lead partner in the sector.

86 https://www.ucl.ac.uk/pharmacy/q3p/qp

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The infrastructure to support research varies between the two organisations. At NWLHT, the R&D department has gradually increased in size and now houses 12 R&D nurses, five R&D Pharmacists, an R&D Governance Manager, two R&D administrators, an accountant, a health service research manager (who is leading a patient and public involvement forum) and a data manager, together with an overall Assistant Director of R&D.

All these posts are externally funded through the CLRN, Dementias and Neurodegenerative Diseases Research Network (DeNDRoN) and the North West London Cancer Network. The Trust holds four substantial programme grants and undertakes a large number of commercial studies, such that NWLHTs annual R&D turnover in 2012/13 was £2.7m.

NWLHT has recently expanded the R&D department to form a cohesive research hub. The Trust hosts the North West London CLRN and has been recognised by the Collaborative for Leadership in Applied Health Research and Care (CLAHRC) as its partner to lead on outer North West London developments. With a focus of using research to impact on patient care, the R&D hub includes offices for patient advocacy and a GP research network – with Imperial Innovations attending once a week on site to lend help and support regarding intellectual property.

Supported by a CLRN grant, NWLHT also hosts the new national initiative for R&D pharmacist training. Infrastructure at EHT-ICO is much smaller with a R&D clinical lead, part-time research and governance managers (also working at NWLHT), an administrator, three WTE research nurses and pharmacy support.

There is a history of collaboration with commercial research partners, particularly at NWLHT. For example, Parexel performed phase one clinical trials at NPH. Furthermore, the Haematology Unit has received a National Institute for Health Research (NIHR) ‘Green Shoots Award’ linked to working on commercial studies and the Trust is also a partner with two Commercial Research Organisations (CROs).

Properly managed commercial research partnerships offer great value to the new Trust by helping to support and develop a culture of research, as well as providing a revenue stream.

The new Trust will build on the track record for commercial research partnerships (with Paraxel for example) and develop existing plans for a clinical trials unit to support researchers in partnership with its clinical colleagues.

Recruitment to clinical trials is vital to translating research developments into clinical practice, which in turn is valued by patients and staff. Both Trusts are justifiably proud of the contribution research has made to clinical excellence. Table 22 and Table 23 summarise recent achievements at both organisations.

Table 22 Research achievements at NWLHT

A recently published CT colonography standards paper allows standardisation of practice, patient care and patient implementation in CT colonography

CMH-based work on sickle cell disease has led to psychological interventions including cognitive behavioural therapy. The Trust is the principal site and houses the principal investigator for a multi-centre national study looking at more effective pain relief in sickle cell crises

The GUM department has pioneered electronic patient records and was the first in the country to go paperless. On average patients are now treated 11 days

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sooner, generating a potential public health impact and a reduction in clinical complications

The Regional Rehabilitation Unit undertakes research that will be pivotal to the implementation of the National Service Framework for long-term neurological conditions. In particular the unit is demonstrating the cost efficiency of rehabilitation for high dependent patients who offset the additional cost of longer lengths of stay in rehabilitation through large savings in the cost of continuing care

The microbiology department has contributed automated screening for acid fast bacilli to reduce costly consultant time requirements and improve detection rates

The Ehlers-Danlos syndrome diagnostic service is based at the Kennedy Galton Centre and the haemato-oncology unit has produced international guidelines on kyphoplasty and management of spine disease in patients with multiple myeloma

The Trust houses one of only three breast cancer menopause services in the country and is pioneering clinical pathways and drug formulary management in these cases

Table 23 Research achievements at EHT-ICO

The cardiology department – in partnership with Imperial College – has a very large research programme known as LOLIPOP, which examines the causes of premature heart disease in the local population. This programme has led to 15 publications in Nature or Nature genetics in the past five years

The vascular surgery department has pioneered foam sclerotherapy and other techniques for the treatment of varicose veins. This is a more cost-effective and easier treatment for patients than standard surgical techniques

One of the EHT obstetricians has developed a new device for performing assisted delivery for women in labour which can be applied in the developing world without the need for complex equipment

The potential for expansion is vast and the merger with Ealing provides a platform for expanding links with the Primary Care Networking terms of translational research and innovation and new models of healthcare.

Both Trusts are involved in translational research through the CLAHRC hosted at Chelsea and Westminster NHS FT. As a merged organisation, the new Trust will be in a good position to build on these collaborations, as well as working with the Health Improvement Education Cluster (HIEC) and the Local Education and Training Board (LETB). The new Trust will also have a strong platform for links with primary care and community-facing research.

Through the merger, the current Trusts believe they can build on the existing strengths of the R&D infrastructure to galvanise and incentivise research activity in the new organisation. This will benefit patient care and outcomes, benefit the NHS, build staff satisfaction and have a positive impact on the financial position.

5.5.1 Imperial Academic Health Science Network

EHT-ICO and NWLHT are founder members of the Imperial Academic Health Sciences Network (AHSN). The AHSN currently brings together a number of NW London healthcare providers, with Imperial College as an academic partner, to pursue higher quality care for patients in the local area (Table 24).

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Table 24 Members of the Imperial AHSN

Partner organisation

Central London Community Healthcare NHS Trust

Central and North West London NHS FT

Chelsea and Westminster Hospital NHS FT

Ealing Hospital NHS Trust

The Hillingdon Hospitals NHS FT

Hounslow and Richmond Community Healthcare NHS Trust

Imperial College Healthcare NHS Trust

Imperial College London

The North West London Hospitals NHS Trust

Royal Brompton and Harefield NHS FT

West London Mental Health Trust

West Middlesex University Hospital NHS Trust

This new partnership in North West London aims to improve the health and care of the local population of 1.9m people.

CONCLUSION 5.6

The merger of NWLHT and EHT-ICO enables a swifter and more sustainable model of care, with direct patient benefit from clinical teams delivering 24/7 access to senior and specialist expertise and the opportunity to more effectively integrate acute and community services, utilising a larger and more flexible bed base to absorb surge pressures effectively. This approach will improve clinical outcomes, patient experience, operational performance and financial stability.


Appendix 5-1 Examples of patient benefits and patient stories


Supporting Document 5-2 Organisational development strategy

Supporting Document 5-3 Estates strategy

Supporting Document 5-4 IM&T strategy

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6. Aims, vision and values of the new organisation

Chapter summary

This Chapter sets out the aims, objectives and values for the merged Trust, and describes the development of clinical integration and clinical strategy to support their delivery, including:

how local clinicians have led the design of a compelling vision for the merged organisation;

the strengths, weaknesses, opportunities and threats that have shaped the strategy, vision and values of the new organisation; and

the alignment between the clinical vision and local commissioning intentions.

The chapter also discusses the recent strategic review completed earlier in 2014 and lists the strategic enablers that need to be in place to achieve the new vision.

INTRODUCTION 6.1

Previous chapters in the FBC have detailed the context within which EHT-ICO and NWLHT are merging: the implementation of SaHF, the challenges for both Trusts in meeting quality and performance standards sustainably, and the clinical case for change that emerges from these.

To ensure that the benefits of creating a new Trust can be fully realised, the joint Board has determined a set of aims, values and objectives, supported by a process for clinical integration and strategy development.

VISION, AIMS AND OBJECTIVES 6.2

From early in the merger process, clinical and senior operational leaders from across both Trusts have worked closely together, for example:

In 2012 the following changes at Board level were made for both Trusts:

o the appointment of one CEO across both Trusts;

o a new Chair at EHT-ICO and NWLHT; and

o new NED appointments in preparation for the establishment of the new merged entity.87

In 2013 the Trusts launched a joint clinical strategy development and integration planning work-stream as part of the merger programme.

From early 2014, when weekly joint executive team meetings (replacing individual Trust executive meetings) and joint Board workshops began to share and discuss strategic priorities as part of the ongoing work to align the organisations in advance of the merger date.

87 Who have subsequently been appointed to vacant NED positions at both Trusts

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Two facilitated workshops were held in June and July 2013 to review the clinical strategies of EHT-ICO and NWLHT and build on these to create a vision for the new Trust that:

reflected the implementation of SaHF;

took account of the views of new Trust Board members; and

would inform the revised BC for merger.

The simple and compelling vision statement that emerged from this process was:

To provide excellent clinical care in the right setting by being:

o Compassionate;

o Responsive; and

o Innovative.

A subsequent, larger joint clinical strategy workshop in October 2013 identified a series of ‘enabling issues’ that the new organisation would need to address to successfully achieve this vision. These are summarised in Table 25 below.

Table 25 Summary of enabling issues

Enabling issue Rationale What does the new organisation need to believe and/or accept?

Providing care across a large catchment area

A provider of acute and elective care 850,000 people across Brent, Harrow, Ealing and NWL, plus tertiary referrals as part of SaHF strategy and system design

Hospital-based care will become increasingly acute and complex. The Trust will treat more elderly and more acutely unwell patients.

SaHF implementation over 10-year timeframe, requiring a pan health economy approach

Increased elderly and complex emergency demand requiring a seamless multi-organisational approach

Without a controlled emergency pathway, other acute operations are destabilised and compromised.

Top class organisational capability and capacity

Excellent clinical leadership supported by strong management

London-leading clinical education/training

Focused clinical research

Clinical capacity and capability must be identified, nurtured and developed

Clinical education, training and research assures a leading role in the local health community

Clinical Quality Consistently high levels of clinical quality assured by:

24/7/365 patient-centric ‘whole system’ organisational culture

Delivering care across multiple sites / clinical treatment settings

Clinical capacity and capability must be focused across sites and delivered 24/7/365 as clinically appropriate

Delivery of high-quality patient experience is dependent on compassionate service delivery at every level

Improved service lines and functional estate

Provider estate comprises: major acute hub (at NPH); selected specialist tertiary service lines (St Mark’s, head

The proposed acute configuration in north west London post-SaHF must be clearly and efficiently

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Enabling issue Rationale What does the new organisation need to believe and/or accept?

and neck, vascular, RRU, clinical genetics); two community focused local hospital feeder units (Ealing/CMH); and substantial community delivery estate (~50 sites)

organised

Specialist services lines (e.g. St Marks and head and neck) must be nurtured to aspire to meet the highest quality regional, national and international quality standards

Integrated risk-based service planning and delivery

Integrated risk-based service planning and delivery, using IT based systems communicating with other providers to assure treatment of patients in the correct setting (whether primary, community or acute)

Supporting the needs of a large catchment population requires advanced, cross-site information systems and practices and an underpinning IT strategy: effectively using data to improve quality and provide seamless communication throughout the new organisation, and with partners in health and social care

Acute hospitals must increasingly support the management of patients using OOH systems and capabilities, e.g. Harrow and Brent STARRS and Ealing ICE

Financial sustainability

Financial sustainability is achieved through leading clinical performance, effectiveness and patient focus

Clinical leaders must create and drive the development and delivery of the Trusts’ clinical strategy in a way that is financially sustainable

Financial sustainability follows strategy implementation – it does not drive it

The Trusts held a joint Board workshop on 13 March 2014 at which four strategic aims were agreed that built on and were consistent with the framework provided by the rationale for merger (described in chapter four), the merger benefits (described in chapter five) and the enabling issues (identified as part of the 2013 clinical strategy exercise).

These strategic aims have been identified as the basis for setting organisational objectives that are being cascaded throughout EHT-ICO and NWLHT in 2014/15; and a baseline against which service delivery will be measured in the merger year. They are:

1. Critical mass – To create a merged organisation that has sufficient critical mass to deliver high quality services consistently.

2. Strategic fit with SaHF – To be able to respond effectively and safely to the commissioning strategy for NW London whilst providing high quality integrated care.

3. Sustainability – Integrating clinical services across the area to improve patient flows and ensure the way services are delivered (including the estate) is sustainable in the long term and responsive to patients’ needs.

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4. Financial stability – To deliver recurrent surpluses without the need for external support.

VALUES AND OBJECTIVES 6.3

A workshop in March 2014 with members of both EHT Board and NWLHT Board discussed a joint approach to business planning and priority setting for 2014/15; the planned year of merger of the two Trusts, resulting in agreement of the merged Trust’s values and objectives.

6.3.1 Values

Board members agreed six values for the new Trust:

Improvement;

Safety;

Care;

Individual;

Responsibility; and

Respect.

For each value, a set of behaviours was discussed and identified to illustrate how the organisations (now and in future) would expect staff to demonstrate these in their working lives, as described in Table 26 below.

Table 26 Values and behaviours (March 2014 joint Board workshop)

Value Definition Behaviours

Improvement To continuously improve our services and create a positive learning environment.

Setting ourselves high standards to achieve

Celebrating when we do well and learning from our mistakes

Looking for new and innovative ways of working

Safety To do everything we can to make our services safe.

Ensuring we have the right staff, with the right skills caring for each patient.

Constantly monitor standards of care and respond quickly if there are concerns

Care To show compassion and support for our patients

Listening to patients’ needs and concerns

To ensure our care is evidence based and follows best practice

Individual To provide care that addresses individual needs of our patients, their families and our staff.

Involving patients in decisions about their care

Communicating effectively with healthcare partners to ensure good continuity of care

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Value Definition Behaviours

Responsibility To take responsibility for our actions.

Responding positively to feedback

Striving to get it right first time

Respect To treat others as we would expect to be treated.

To be open and honest about our performance

It was agreed the workshop served as a useful forum to set out initial views, however further work was required to develop these with our staff and patients of both organisations. The communications department are working with the human resources and organisational development (HR&OD) workstream to develop a communications strategy that supports the introduction of the 6 values and expected behaviours by the Trusts in advance of merger (we will be working with staff and patient groups to refine these for the merged Trust). HR is also linking the values with its work on the cultural audit being led by Workforce merger workstream.

DEVELOPMENT OF CLINICAL STRATEGY 6.4

The clinical strategy will be developed at service level as part of the integration process for the new Trust. The overall aims for the Trust are set out above and the Board will ensure that the clinical strategy aligns to these.

As preparation for merger and as part of ensuring performance standards are met, the Board has discussed the implications for each of the three acute sites of delivering SaHF and addressing performance issues. The key clinical themes that have been used to frame this debate are outlined in Table 27. This includes a summary description of an ‘end state’ for the Ealing Hospital site that reflects the implementation of SaHF and commissioner preferences, alongside clinical safety considerations.

Table 27 Clinical strategy and scenario planning themes

Key clinical theme Attributes

NPH Major Acute Site

All acute services

Full support services

24/7 365 clinical cover at sub-speciality level

Hub to spoke services

Large critical care services

CMH Large Elective 5/7 Day Services

ASA grading appropriate surgery

Rehabilitation (3 day post-acute) services including care of the elderly

24/7 surgical/medical/care of the elderly cover

Outpatients/planned care

Full diagnostics

Day care and endoscopy

Stand-alone urgent care centre

EHT (transition) Immediately post-merger

Need to deliver all current services – challenge on 7 day working standards

Opportunities for joint rotas/working to improve quality and efficiency

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Key clinical theme Attributes

Transition to SaHF end state

Cease on-site maternity ahead of ED closure

Move of in-patient paediatrics

Impact on other services – anaesthetics, ED, gynaecology, rest of paediatrics, training rotations

EHT ‘end state’ Local Hospital Model

Approx. 100 beds – include rehabilitation (3 day post-acute) services mainly care of the elderly (50% beds nurse-led model)

24/7 medical cover – CMH testing model

Frailty unit linking with IP beds to deliver range of CoE services

Urgent care stand-alone service – CMH testing model

Outpatients/ planned care – ‘one-stop shops’

Full diagnostics – including CT/MRI

Continued delivery and expansion of community services

Primary care hub and enhanced social care

Day care and endoscopy

Ambulatory medicine

Community services

Response to Ealing CCG Community Service Review

Development of networks of care to support local hospital model

Progression of frail elderly clinical integration workstream

Development of estates configuration to support OOH strategy.

Models of care to be developed further

Services will operate planned care across three sites – market capture

Elective surgery ASA levels to be determined at each site

UCC services supported by A&E at NPH

Capacity at NPH for acute care (50% from CMH; 1% from Hammersmith; 1% from Ealing)

Capacity of on-take teams – move to triple take for medicine and double take for surgery.

Critical care beds required across the sector – bed in the right place?

Supporting priorities

Bed management

Emergency Planning

Capacity planning across 3 sites for the benefit of patients (18 weeks and A&E performance)

Ensure that services are moved where it makes sense clinically rather than where the capacity is

Diagnostics/endoscopy/day care

IM&T support to paperless services

PROGRESSING CLINICAL INTEGRATION 6.5

In parallel, a number of other larger specialties have engaged in strategic planning and, in some cases, moved on to begin preparing business cases for change:

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the St Mark’s team at NPH created a proposal for future development of this specialist centre, which was reviewed by the NWLHT Board in July 2013;88

five-year plans for head and neck services at NPH were completed in November 2013;89 and

joint work is underway to set out the strategic direction for research and training across EHT-ICO and NWLHT.

The intention is for the emerging specialty models to coalesce into an overarching clinical strategy that will be implemented in parallel with the key enabling strategies for estates, IM&T and HR, and the associated programme of capital investment.

This is expected to be an iterative process that, ultimately, will be subsumed into the business as usual of the new Trust’s strategic and business planning cycle. In this way the organisation will be able to ‘future proof’ its plans as greater clarity emerges concerning the pace, scale and timing of changes to the NWL healthcare environment as SaHF is implemented. Specifically, the new Trust will need to monitor the ongoing development of the three SaHF business cases most directly relevant to the new Trust (although none is expected to reach FBC stage until 2015 at the earliest), namely:

The capital business case for the development of NPH to accommodate expansion of maternity and emergency pathway capacity (at OBC stage);

The capital business case for the transformation of the Ealing hospital site to a local hospital model (at OBC stage); and

The development of a business case following the recent completion of a SOC for the future service configuration on the CMH site.

As part of the organisational development work to prepare for merging EHT-ICO and NWLHT, a Clinical Integration Programme was set up with six work-streams with representatives from both Trusts looking at opportunities for closer collaboration. The Programme has been supported by Ashridge Consulting and by executive leadership of each workstream. Table 28 below summarises this work.

Table 28 Outputs from clinical integration workshops

Clinical work-streams

Proposed merged service Expected patient and staff benefits

Children & Young people

A three hub OOH model for Brent, Ealing and Harrow, providing community paediatric care, primary care, social care and UCC support.

Each hub has a geographical focus and builds on existing borough working arrangements with local authorities and CCGs.

The hubs ‘mesh’ like cogs in an

Retention of highly specialised services able to be delivered out-of-hospital.

Care at home or closer to home for children and their families – in some cases enabling uninterrupted school attendance.

Sharing of specialities for high

88 St Mark’s Hospital provides local, regional and supra regional services focused on diseases of the

lower gastro-intestinal tract 89 Northwick Park now hosts the largest oral and maxilla facial service in NW London, with a hub and

spoke model extending to eight other hospitals

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engine but can also spin independently of each other depending on the service offered.

Northwick Park will offer a centralised inpatient resource – available to all three hubs as and when required.

Services that might be enabled by this model include: a children’s community nursing team, paediatric audiology and paediatric TB.

risk children and local support for those with complex needs.

Enhanced staff recruitment and retention: ‘hub meshing’ overcomes problem of service in one hub being too small to attract high calibre staff.

Sharing of best practice on safeguarding across three boroughs.

Improved teaching rota for middle grades.

Maternity & Gynaecology

Increasing proportion of antenatal and post natal care to be delivered in community settings – often in centres where women are likely to be accessing other health or social care services (for example, children’s centres).

All obstetric-led deliveries provided at NWP – a service reinforced through the freeing up of consultancy time. This will be achieved by transferring consultant PAs from Ealing to NWP and (over the medium to longer term) developing nurse-led gynaecology services.

NWP capacity for handling high-risk births could also be expanded through the launch of a ‘birthing centre’ at the Ealing site.

Although still very much at proposal stage, such a centre would offer low risk women the option of a midwife-led delivery – and would enable the merged Trust to become a combined centre handling around 8,000 deliveries per annum.

Expansion of peri-mental health services on the Ealing site in conjunction with West London Mental Health Trust. As demand for these services is currently outstripping supply.

Care closer to home and family.

Greater choice for women.

Strengthened maternal and foetal medicine.

Comprehensive local service for mothers and babies across Brent, Ealing and Harrow – cutting out the need for long and tiring journeys to central London.

Improved consultant presence on labour wards at NWP – potentially an extra 168 consultant hours.

Higher calibre of staff attracted by larger combined centre.

More and better public health interventions in local communities through closer collaboration between midwives and other health and other health and social care partners in community settings.

Better, more comprehensive service for mothers experiencing mental health issues.

Emergency Care

An Ealing consultant and all NWLHT consultants are already working cross-site. Once the CMH emergency department is closed, cross-site working for all consultants will be

Vision of ‘providing care that patients want in the right place… by the right team’ will drive better patient experience.

Better clinical outcomes as

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implemented.

Agreement to align teaching of junior doctors and clinical governance. This will happen when CMH emergency department closes and consultant rotas at NWL are revised.

Capital investment in NWL will lead to larger department populated with more substantive consultants.

Seamless care between hospital and community and rapid access to Intermediate and Social Care housing to keep patients out-of-hospital.

Use of Symphony IT system to forge stronger links between NWP and Ealing.

Investigation of opportunities to transfer surgical ‘semi-emergency’ patients to alternative sites to maximise on operating capacity and speed of access to treatment for patients

Harmonisation of ambulatory care models to provide parity and expansion of pathways supported

emergency department becomes more attractive to high calibre staff – reducing reliance on locum consultants.

24/7 emergency care.

Quicker and more effective flow of patients from the ED to admitting specialities.

Rollout of best acute medicine practice rolled out from NWL to Ealing.

Faster access to emergency surgery

Secondary care treatment for more conditions under ambulatory care model allow patient to minimise time spent in hospital

Care of the Elderly

Similar to the ‘children and young people’ service, a hub/locality approach will offer services wrapped around patients and delivered as close to home as possible.

A series of ‘whole systems’ initiatives and working groups have been established in each CCG to consider care to this vulnerable age group.

Although broad agreement has been reached, there are multiple stakeholders involved in the provision of care for elderly people, so the new Trust will need to dedicate time and resource to finalise and implement the model.

Harmonising approach to integrated care bids across 3 boroughs; increasing consistency of care, and maximising use of resources

Care closer to home and family via an integrated assessment and care service with easy access to specialist opinion

Reduction in unnecessary hospital stays

An anticipated 5-7 days length of stay for elderly people who are admitted to hospital, with preparations for discharge beginning at admission stage.

Greater opportunities to rotate staff.

Joined-up services across multiple agencies providing improved, more integrated care.

Greater consistency of care regardless of home borough

Vascular & Diabetes

Based on the ‘hub and spoke’ model, the proposed service hub is a Foot Attack Centre at NWP offering a dedicated treatment area and seven-

Access to intravenous antibiotics in community settings at an early treatment

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day staffing.

‘Spoke’ services will be provided at CMH, Hillingdon and Ealing, in turn linked to podiatry services in these localities.

The restructured service will tackle high variations in access to care across the three boroughs – driven by the knowledge that 80% of lower amputations are preventable.

Underpinning the model is the principle that late interventions have a financial impact as well as a human cost – the average cost of patient care locally is £10,000 and the average length of hospital stay is two weeks.

Outpatient treatment hub/remote wound management clinic transferrable to other specialities increasing value for money, providing innovative opportunities and meeting commissioning intensions for care closer to home

stage.

Reduced morbidity levels and amputations.

Reduced patient stay when hospitalisation and/or surgery are unavoidable.

Timely access to care and better quality of life during and post-treatment.

Lower amputation rates and equitable levels of care across socio-economic groups in the three boroughs.

Patient treatment savings which can be re-invested into other care settings.

Expert care closer to home

Specialist intervention earlier leading to improved outcomes

Orthopaedics Inpatient services centralised onto two sites (instead of three): a trauma Centre (NWP) and an elective surgical site (CMH).

Outpatients meanwhile will be based in multiple settings, aligned to Musculoskeletal services.

Implementation will be complex as it requires the alignment of space (theatre and beds), supporting services and infrastructure (anaesthetics, HDU and IT) and consultant role planning.

Economy of scale provides an opportunity to provide an innovative elective surgical hub on one site within current resource bracket

Enhanced clinical outcomes

Improved waiting times

Freed up theatre and bed space.

Ability to provide out of hours imaging to improve patient experience

Streamlined inpatient elective care

This approach has brought significant benefits for organisational development and cultural change. Supporting the key strategic objective of strengthening our clinically led services, this process has provided clinical specialities with a supportive environment in which to form strong working relationships across the current organisation. Understanding current strengths and weaknesses in their respective services has allowed groups to develop and refine clinical strategies taking the best from each service and to strengthen weakness that may exist.

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The cultural development brought about by this process solidly centring on being ‘stronger together’ has been significant. There has been a high level of buy in from staff, stakeholders and trust Executives. The original six specialities are now working to translate their visions into reality, though most participants articulate this would accelerate once authorisation to merge has been approved.

The next phase of this exercise is to roll out the programme and tool kit to all specialty-based clinical teams to further develop the Trust’s clinical strategy. Given the uncertainty that the impending merger generated amongst some staff and services, we recognise how essential it is to support engagement of staff in the design of future clinical services. We will therefore continue to use this process to provide a supportive environment for groups to develop their vision of clinical excellence and support translation into reality. It is anticipated that some services will have progressed to planning and preparing for early integration changes by this time or earlier once approval to merge is granted

CONCLUSION 6.6

The joint Board believe the values and enablers outlined in this chapter will support the new Trust to meet its aims and live its values in the development of its clinical strategy and improving performance standards and outcomes and experience for patients.


Supporting Document 6-1 Joint strategy development overview presentation (August 13)

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7. The new organisation’s structure and governance arrangements

BACKGROUND 7.1

While the previous chapters set out what the two existing trusts want to achieve, and why, this chapter describes how the new organisation will ensure fitness for purpose in achieving its stated objectives.

Over the last three years the two Trusts have become convinced of the compelling case for merger and have sought to co-ordinate activities wherever it has been sensible to do so. Evidence of this includes:

Reviewing the principles of a ‘Board in common’ and establishing common sub-committee’s and a Joint Executive Team Meeting;

Joint Board away sessions;

A number of joint Executive appointments where appropriate, including recruitment of a shared Chief Executive;

Shared business planning sessions;

Joint bids in response to commissioner procurement exercises; and

Clinical integration work-streams with representation from both existing Trusts

The following sections set out how the new trust would be structured, and the governance arrangements it would put in place to ensure the delivery of high-quality, affordable healthcare provided in the right settings.

In line with the recommendations set out in the Francis,90 Keogh91 and Berwick92 reports of 2013, arrangements in the new trust are designed to assure quality from ward to Board.

90 The final report of the Mid Staffordshire NHS FT Public Inquiry, Chaired by Robert Francis, QC,

published on Wednesday 6 February 2013 http://www.midstaffspublicinquiry.com/report 91 Review into the quality of care and treatment provided by 14 hospital trusts in England: overview

report Professor Sir Bruce Keogh KBE, NHS England, July 2013 http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf

Chapter summary

This chapter describes:

the proposed Board and sub-committee structure including details of non-executive and executive director arrangements;

the proposed divisional management structure to ensure strong and visible clinical leadership of the Trust;

the risk management arrangements for the merged Trust; and

the performance reporting arrangements for the new organisation.

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The new Trust entity will be a large-scale care delivery organisation providing both acute and community care services to the residents of Brent, Ealing and Harrow. It will be much better placed to implement SaHF and other key commissioner strategies than its predecessor organisations. The Trust will be both clinically and financially sustainable and well placed to apply for and be granted FT status in the future. Its proposed governance arrangements have been designed to facilitate that transition.

THE BOARD AND STRUCTURE OF THE NEW ORGANISATION 7.2

7.2.1 Overview

The Trust Board of the merged organisation will be held accountable by the TDA on behalf of the SoS for the following responsibilities:

Putting in place effective arrangements for the purpose of monitoring and continually improving the quality of healthcare it provides to patients

Setting the strategic direction of the Trust within the overall policies and priorities of the Government and the NHS, defining the Trust’s annual and longer term objectives and agreeing plans to achieve them

Overseeing the delivery of planned results by monitoring performance against objectives and ensuring corrective action is taken where necessary

Providing effective financial stewardship through value for money, financial control and financial planning and strategy

Ensuring that high standards of corporate governance and personal behaviour are maintained in the conduct of Trust business to appoint, appraise and remunerate senior executives

Ensuring there is effective dialogue with the community about the Trust’s plans and performance and so the new organisation can be responsive to local needs

The proposed corporate and divisional leadership structure of the Trust will be accountable to the Board are illustrated below. Figure 13 illustrates the senior executive structure and Figure 14 the divisional management responsibilities under the chief operating officer.

92 Berwick review into patient safety: ‘A Promise to Learn, a Commitment to Act’, Department of

Health, August 2013 www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf

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Figure 13 Summary of executive leadership structure

Figure 14 Summary of operational ‘five divisional’ structure

Structures are aligned to Monitor’s Quality Governance Framework and aim to embed arrangements and processes able to provide the new Trust Board with robust evidence that the organisation is improving patient safety, care, experience and outcomes.93

The Trust committee’s structure is described below.

7.2.2 Board sub-committees

Board sub-committees will each be chaired by a Non-Executive Director and will monitor quality performance within their areas of responsibility. By applying critical analysis of data and data quality, each sub-committee will provide robust quality information to the Trust Board.94 The sub-committees are responsible for ensuring the Trust Board is fully apprised of any potential or actual risks pertinent to the committees’ remit. The sub-committees will be as follows:

Audit, Governance and Risk Committee;

93 Quality Governance: How does a board know that its organisation is working effectively to improve

patient care?, Monitor, April 2013 94 supported by the Trust’s Data Quality Strategy

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Clinical Performance and Patient Experience Committee;

Finance, Investment and Estates Committee;

Remuneration and Senior Appointments Committee;

Strategy, Organisational Development, Communications and Human Resources Committee; and

Charitable Funds Committee.

Broad details of the proposed remit of each committee are given in Appendix 7-1.

LEADERSHIP ROLES AND RESPONSIBILITIES 7.3

Brief summaries of the non-executive roles and of the five voting executive members of the Trust Board are set out below. The voting executive Board members will be:

The Chief Executive Officer;

The Medical Director;

The Chief Nurse;

The Chief Operating Officer; and

The Chief Financial Officer.

The following non-voting executive directors, who will be directly accountable to the Chief Executive Officer, are members of the executive team and will be expected to attend meetings of the Board and relevant sub-committees

Director of Human Resources and Organisational Development;

Director of Commercial Development;

Chief Information Officer; and

Director of Estates and Facilities

In addition there will be a Trust Secretary, which is a key post related to high-quality clinical and non-clinical governance.

7.3.1 Non-Executive Directors

The Non-Executive members of the Board will comprise:

the Board Chairman;

five non-executive directors (NEDs); and

a University of London representative.

The role of NEDs is to bring a range of varied perspectives and experiences to strategy development and decision-making. They will also ensure that effective management arrangements and a proficient management team are in place, and have the role of holding the executive to account for performance. The Chairman's role is to lead the Board of Directors; ensuring it effectively governs the Trust.

Operational responsibility is delegated to the Trust executive.

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7.3.2 Chief Executive Officer

The Chief Executive Officer (CEO) will be appointed by the Board. He or she will be accountable to the Chairman and the Board for:

ensuring safe and effective governance processes and systems are in place;

setting the Board’s strategic governance vision and direction;

establishing and upholding the organisation’s overall governance framework;

enabling the development and continuation of a patient safety culture to flourish

scrutinising performance to safeguard the delivery of high-quality services; and

securing the annual agreement of Trust Quality Accounts.

7.3.3 Medical Director

The Medical Director (MD) will work in partnership with the Chief Nurse to support the development and implementation of a robust quality governance framework. This framework will encompass all the Trust’s business and inform medical/clinical risk relating to all aspects of Trust activity, strategy and efficiency plans – thus providing medical leadership to improvements in treatment productivity/efficiency. The MD will be the Trust executive lead for patient safety and will oversee medical staff processes for appraisal, revalidation, professional performance, conduct and disciplinary issues.

The MD will execute the executive role for medicines management lead, act as the new Trust’s Caldicott guardian (role may be delegated but under line management of MD) and be the accountable officer for Infection Prevention and Control.

In collaboration with the NEDs and members of the Governance team, the MD will be responsible for setting medical standards, assessing levels of clinical effectiveness and reviewing risk and incidents relating to medical interventions, treatment or medical staff.

As executive lead for Research and Development, Medical Staff Teaching and Training, the MD will also have line management responsibility for the Director of R&D and medical leads for post-graduate medical training and undergraduate medical education.

The MD will be expected to give the Board expert advice and work closely with the Audit, Governance and Risk Committee and the Clinical Performance and Patient Experience Committee.

7.3.4 Chief Nurse

Accountable for delivering the Quality Governance agenda in collaboration with the Medical Director, the Chief Nurse (CN) will provide executive leadership for Patient Safety and Quality at Trust Board level.

Advising on nursing/clinical risk relating to any aspect of Trust operational, strategic and QIPP plans, the CN will provide nursing leadership to improvements in

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nursing/AHP productivity and efficiency. He/she will oversee processes for nursing and AHP performance, conduct and disciplinary issues.

The CN will be the officer accountable for the development and delivery of the patient experience strategy. His/her management portfolio will specifically include: safeguarding adults, safeguarding children, patient relations, patient advice and liaison service (PALS), the clinical governance team and the wider quality agenda. The CN is also the executive lead for nurse and AHP education and, in partnership with the MD, supervises the Trust research programmes.

He/she will be expected to give the Board expert advice and work closely with the Audit, Governance and Risk Committee and the Clinical Performance and Patient Experience Committee.

7.3.5 Chief Operating Officer

The Chief Operating Officer (COO) has line management responsibility for the Director of Operations who in turns manages the Divisional Clinical Directors, Divisional Heads of Nursing and Divisional General Managers, and the Director of Community Services who manages the community Borough services, and will represent the Trust at partnership forums. As illustrated in Figure 14.

A key aspect of the role is to ensure the operational effectiveness of divisional resources: delivering safe high-quality services that meet contractual, national quality and performance standards. For example, clinical outcomes, access standards, activity volumes, employment of staff (volume and capability) and the deployment of staff to deliver seven-day working. He/she will be expected to advise the Board and its sub-committees on any of these issues

7.3.6 Chief Financial Officer

The Chief Financial Officer (CFO) will have overall executive responsibility for the organisation’s financial management, control and financial strategy – ensuring all statutory targets and duties are met. The CFO will provide intelligent, informed and credible financial advice at Board level.

As an Executive Director, the CFO will have a corporate responsibility for the management and development of the Trust: influencing strategy and delivering key objectives and targets. As well as ensuring professional leadership of the finance, procurement, information and contracting functions of the Trust, the CFO will act as executive lead for the design and delivery of annual Cost Improvement Programmes. He/she will also be responsible for the financial programme management and control of major capital projects.

The CFO will be expected to advise the Board and work closely with the following sub-committees: the Audit, Governance and Risk Committee; the Finance, Investment and Estates Committee; and the Charitable Funds Committee.

7.3.7 Director of Estates and Facilities

The Director of Estates and Facilities will have overall executive responsibility for all aspects of the new Trust’s estates and facilities. For example, the Trust estates strategy and the delivery of capital schemes, including those associated with SaHF implementation.

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He/she will give expert advice to the Board on estates and facilities matters and work closely with regulatory bodies such as: the Finance Investment and Estates Committee, and Audit Governance and Risk sub-committees on health and safety and healthcare environment and amenities issues. The post-holder will also be the Trust’s point of contact for liaison with the Health & Safety Executive

7.3.8 Chief Information Officer

This role will have overall executive responsibility for all matters relating to IM&T – including information governance and the development of a comprehensive information strategy. It is increasingly evident that delivering high-quality, integrated and innovative healthcare will depend on the proficient harnessing of appropriate technologies.

He/she will be expected to give the Board and its sub-committees expert advice – in particular, the Information Governance sub-committee of the Audit, Governance and Risk Committee and the Finance, Investments and Estates Committee (for IM&T strategy).

7.3.9 Director of Commercial Development

The Director of Commercial Development will have overall executive responsibility for developing the Trust’s strategic and business planning processes. He/she will be the lead director for responding to commissioners’ intentions (including implementation of SaHF). He/she will lead the business development unit working with clinical services to review opportunities to develop services and respond to commissioning intentions which are consistent with the Trust’s clinical strategy.

The post-holder will also be the executive director responsible for communications and the development of relationships with a range of external partners, and will advise the Board on related matters; liaising closely with the Strategy, Organisational Development, Communications and Human Resources Committee.

7.3.10 Director of Human Resources and Organisational Development

As the NHS undergoes unprecedented change and funding limitations, Trust employees will also face change to the ways they work, and where and when they work. The move of services out-of-hospital may well be to other providers, requiring delicate negotiation on HR issues.

The Director of HR&OD will be expected to develop the new Trust’s workforce strategy; advise the Board on workforce issues, including training, and be the lead contact with the relevant Local Education and Training Board (LETB): Health Education North West London.

The post-holder will also work closely with the Remuneration and Senior Appointments Committee and the Strategy, Organisational Development, Communications and Human Resources Committee.

7.3.11 Trust Board Secretary

The Trust Board Secretary will be responsible for establishing and maintaining high standards of corporate governance in the Trust, including the functioning of the

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Board and its sub-committees. He/she will also coordinate and maintain the Trust’s Board Assurance Framework and the corporate risk register.

BOARD SUB-COMMITTEE REPORTING STRUCTURE 7.4

Designed to provide clear accountability for all aspects of the merged Trust’s operations from ward to Board-level, the proposed reporting structure shown in Figure 16 is in keeping with those structures described by NHS FTs.

There will be six subcommittees of the Trust Board, each designed to take responsibility for a particular area, address any problems and report back to the Board. The structure is intended to clearly define executive and management responsibilities and support Monitor’s Quality Governance framework parameters.95

Figure 15 Board sub-committee structure

The functions of the six proposed Trust Board sub-committees illustrated in Figure 15 are summarised in Table 29and Appendix 7-1.

Table 29 Summary of Board sub-committee functions

Committee Function

Remuneration and Senior Appointments Committee

Agrees the remuneration and terms of service of the Executive Directors, and also forms part of the panel to appoint Executive Directors.

Charitable Funds Committee

Responsible for developing and monitoring arrangements for the stewardship, control and management of the Trust’s charitable funds.

Audit, Governance and Risk Committee

Responsible for critically reviewing the processes for governance, assurance and risk management on which the Board places reliance. These include the Trust’s risk, financial and performance management systems, which are underpinned by the Assurance framework. Its sub-committees are: Health and Safety; Healthcare Environment; and Amenities and Information Governance.


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Committee Function

Clinical Performance and Patient Experience Committee

Provides strategic direction on all matters relating to clinical quality: promoting safety and excellence in patient care and ensuring effective and efficient use of resources through evidence-based clinical practice and continual improvement and innovation in delivery of clinical services. Its sub-committees are: Safeguarding Children and Adults; Infection Control; Clinical Audit and Effectiveness; Medicines Management and Safety; Human Tissue; Blood Transfusion; Research Governance; Resuscitation; and Patient Experience.

Finance, Investment & Estates Committee

Responsible for providing objective scrutiny of the Trust’s financial plans, investment policy and major investment decisions (including capital expenditure). The committee will also review financial performance and identify the key issues and risks requiring discussion or decision by the Trust Board. Its sub-committees /areas of focus are: Cost Improvement Programme (CIP); Capital Expenditure Programme; Business Continuity Board; Clinical Strategy; IM Strategy; Training Strategy; Medical Devices; and Estates projects.

Strategy, Organisational Development & Communications Committee

Responsible for providing key strategic direction on all matters relating to merger and organisational development. Its sub committees /areas of focus are: Merger Transactions (post-merger Transformation) Board, Clinical Strategic Development Group; Learning, Education and Development forum; Equality and Diversity committee; and Joint Staff Forum.

It is expected that these sub committees will meet four to six times each year, dependent on agendas. There will be one exception: The Remuneration and Senior Appointments Committee will meet annually as a minimum.

7.4.1 Integration Board

Chapter ten describes the current merger programme governance arrangements. These will continue to evolve as Day 1 is approached and as ‘pathfinder’ services move from integration planning to implementation. Figure 23 outlines the programme governance arrangements which are in line with the TDA Accountability

Framework.96 Terms of Reference (ToR) for all of the boards, committees and work-streams can be found in Supporting Document 7-1.

Both existing Boards delegated authority to the Merger Transaction Board to govern and support the merger programme, which was stood down following the establishment of the TDA Transaction Board in November 2013. As a result the Trusts have agreed the Merger Transaction Board will cease and be replaced by the establishment of an Integration Board from June 2014 that will support the transition to the new organisation and lead the required service changes in response to SaHF.

It is also proposed that the Integration Board will include the Chairman, Non-Executives representation and executive representation.

96 Delivering High Quality Care for Patients: The Accountability Framework for NHS Trust Boards,

TDA April 2013.

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7.4.2 Lessons learned

Both organisations will benefit from existing merger experience within EHT-ICO, which was itself created from the incorporation of the former community provider organisations of Ealing, Brent and Harrow PCTs in 2011. Preparations for handover on Day 1 are taking account of lessons learned from the EHT-ICO transaction.

The Board have worked with South London Healthcare to identify lessons learned from major service reconfiguration across sites, and will, as a result, undertake a series of scenario planning / testing workshops with clinical teams as part of the clinical strategy and site development work. Areas of focus for handover planning and scenario testing include:

Patient safety scenarios

o Handover and transfer between sites for clinical need

o Safeguarding issues

On-site medical emergency with off-site cover (with scenarios run for medicine/surgery/obstetrics/paediatrics/community)

Emergency response to a major incident

Cancer patient pathways including MDT decisions

Infection control and flexible use of capacity

Treat/transfer/divert scenarios in times of extreme pressure

Shortages of key staff

7.4.3 Foundation Trust status

The governance structures outlined will be adapted as the new Trust applies for FT status and will ultimately include a Council of Governors, providing a formal link between the organisation’s staff, public and patient membership, and the Board.

The proposed governance and assurance framework for the merged organisation is based on effective quality governance parameters described within Monitor’s Quality Governance framework.97

CLINICAL OPERATIONAL STRUCTURE OF THE NEW ORGANISATION 7.5

7.5.1 Divisional structure of the new organisation

The structure will provide a robust governance, risk and assurance framework with good communication and accountability to the Board.

The new organisation will be arranged in the following five clinical divisions:

Integrated medicine division

Surgical services division


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Women and children’s services division

Clinical support services division; and

Community services division.

Alongside the five clinical divisions, and reporting to the Director of Operations, will be teams responsible for performance and site management (including emergency planning).

7.5.2 Leadership of the clinical divisions

Divisional Clinical Directors (CDs) will be responsible for all aspects of their division’s performance alongside the divisional general manager (DGM) and divisional Head of Nursing (HoN). This ‘triumvirate’ will form the core of the divisional leadership team, as well as senior representation from additional professional groups – such as nursing, therapies, AHPs or medical staff –to meet the needs of the individual division.

CDs will be accountable to the director of operations, along with DGMs and HoNs, and through the director of operations to the COO and the Board.

To ensure that CDs have the necessary time to proactively and effectively lead their division, there will be a required minimum sessional commitment for each CD role. Current management structures mean lead clinicians have a variable dedicated time provision in their job plans. In the new Trust, dedicated time and clear lines of accountability will help to ensure real clinical engagement in delivering the Trust’s priorities of achieving the performance standards for RTT and emergency care and driving improvements in outcomes, standards and efficiency.

The senior clinician (Divisional Clinical Director) leading each division will have agreed protected time in their job plan. In most cases this will mean at least four sessions per week devoted to their divisional leadership role. The selection process for CDs will flow from the appointment of the Trust Board executive team.

Depending on the needs of the division, the Divisional Clinical Director may be a senior consultant or any other suitable senior healthcare professional (for example, a nurse or AHP). It is expected that the Divisions of Integrated Medicine and Community Services will include appropriate senior GP and/or professional clinical leadership with expertise in primary care and social care in their management structures.

A range of professional support will be offered from HR, finance, operations and information management. The amount of time provided by each core team member may vary, depending on the overall size of the clinical division, but will enable the Divisional Clinical Director to fulfil the role. Development of the right skills is critical for the core leadership team and clinical leaders and this need is covered in more detail in the OD strategy.

The divisional leadership team will provide clinical, professional and managerial leadership to the individual service lines within their divisional groups, as well as ensuring the division provides safe, effective and efficient care.

The Divisional Clinical Director is responsible to the Director of Operations for all aspects of clinical, operational and financial performance. The post-holder will work with other divisional directors and associated leads to ensure cohesion across the

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merged organisation. He/she may also take on Trust-wide responsibility for key projects or cross-cutting areas of care. Professional accountability remains with the respective CN/MD as appropriate.

The divisions will have clinical leads for individual service lines and core functions –such as governance, training and education – as determined by the divisional core management team.

The divisions will be responsible for the clinical, operational and financial performance of all services under their management. They will adopt the vision, values and clinical strategy of the new organisation set out in chapter six. Most importantly, they will be a powerhouse for converting the high-level vision and strategy into palpable change in frontline services.

Each clinical division will be expected to rapidly move to integrating speciality teams across existing organisational areas within a single operational and governance framework – this will be essential to foster the culture of the new organisation and prevent a ‘silo’ mentality from developing.

7.5.3 Engagement with commissioners and patients

Each Division is expected to build relationships with patient groups and key partners. Commissioners and healthcare partners will interact with the new Trust in a number of ways. Across all clinical divisions, CCGs will be involved in developing service specifications and in the governance assurance process. Any significant areas of service reconfiguration or patient pathway redesign will have an implementation group – including invited membership from CCGs and relevant partner organisations such as: social services, mental health, patient groups and the voluntary sector.

Patients and service-users will be involved regularly in service evaluation and service design. This will include close liaison with local Healthwatch organisations and speciality patient groups as the new Trust develops during its first year of operation.

Feedback from patient groups, complaints and satisfaction surveys will form part of the agenda for divisional group meetings. CCGs and other commissioners will regularly be invited to interact with each division via quality forums and other meetings. CCGs may wish to consider specific leads to work with the divisions to help foster authentic partnership working at a local level.

7.5.4 Individual clinical service divisions

The integrated medicine division will incorporate most of the medical specialities within the existing Trusts.

Table 30 Integrated medicine division structure

Integrated Medicine Division

Acute medicine and emergency medicine (includes traditional A&E)

Urgent care (if run by the ICO) and liaison with independent UCC

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Integrated Medicine Division

Specialist medicine

Cardiology

Care of elderly

Clinical haematology

Dermatology

Diabetes and endocrinology

Genitourinary medicine and HIV

Infectious diseases

Neurology (including acute stroke)

Renal medicine

Respiratory medicine

Rheumatology

Palliative care

The integrated medicine division will work closely with commissioners, primary care, social care, public health, the community services division and other partners to avoid unnecessary hospital admissions, raise access to services closer to home and minimise hospital stay.

Table 31 Community services division structure

Community Services Division

Podiatry

Health Visitors

Family Planning

Children’s Services

Diabetes (Ealing)

Continence (Harrow)

Stop Smoking

Management of community bedded facilities

Rehabilitation and elderly care beds in the Denham Unit in Harrow, Willesden Centre for Health and Care in Brent, and Clayponds Hospital in Ealing

Meadow House Hospice in Ealing, St Luke’s Hospice serving Harrow and Brent

Complete integration of all hospital and community services does not make sense for those areas in which most care is delivered in the community and patients are unlikely to need hospital services at any stage of treatment. This division will have a strong locality/borough focus: working very closely with general practice, social care and other community organisations.

The division will be organised into three locality-based groupings, based on the existing CCG/borough structures. This will allow effective management of resources across the division, while retaining locality-based clinical teams and building on local relationships and integration with acute services. To maximise the potential for integration and partnership, the division will invite specific membership from each of the local CCGs and borough-based social services.

Some specialised services which span hospital/community care – for example heart failure, diabetes and home intravenous therapy services – will be integrated around patient pathways. Depending on the needs of the patient, the management of these teams may rest within integrated medicine or locality based services. The key principle will be ensuring that teams are managed in one division under a single clinical-operational structure that facilitates rather than hinders work across hospital and community boundaries.

The surgical services division includes the majority of teams involved in undertaking procedures on patients. This includes emergency and planned surgical activity. The emergency surgical services will work closely with acute and emergency medicine on pathways of care for acute admissions. Due to its complex nature, much

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of the division’s work will take place within existing hospital sites. However, there will be opportunities to move some patient assessments and follow-ups closer to home.

NWLHT incorporates St Mark’s Hospital, which has an international reputation for clinical excellence and provides tertiary care services in all aspects of bowel disease and intestinal health. For this reason, the medical and surgical specialities associated with bowel disease will all be managed within this division

Table 32 Surgical services division structure

Surgical Services Division

Emergency surgery – working closely with emergency medicine

Breast surgery

Head and neck including ENT and maxillofacial surgery

Ophthalmology

Urology

Vascular surgery

St Mark’s Hospital

Specialised upper and lower gastrointestinal surgery

Gastroenterology

Cancer services

Also contained in the division is the overview of cancer services. The care of patients with cancer is complex and all of the divisions may be involved in aspects of the patient’s diagnostic and treatment pathway. It is essential therefore that the overall coordination of cancer care is managed in one division to ensure that cancer standards are consistently met in the new Trust.

Bringing together all Trust staff involved in the care of women and children into one division for women and children has great potential to improve joint working and integration across the hospital and community in a similar fashion to that described for Integrated Medicine.

Table 33 Women and children’s division structure

Women and Children’s Division

Maternity care

Including community midwifery and hospital-based services

Gynaecology

Reproductive medicine (family planning)

Paediatrics

Including community paediatrics

Children’s therapies

Health visiting

School nursing

Clinical support services (CSS) describes the key departments that interact with other divisions to make efficient and safe care a reality.

The division encompasses laboratory and diagnostic services, as well as services such as therapies which deliver direct patient care across large parts of the new

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Trust. Therefore, the CSS Division will work closely with the other divisions and play an integral role in patient pathway development and redesign.

Table 34 CSS division structure

Clinical Support Services Division

Critical care and anaesthetics

Laboratory services

Histopathology

Microbiology

Chemical pathology and laboratory haematology

Pharmacy

Radiology

Therapies – when not community based or specifically for children

Physiotherapy

Occupational therapy

Dietetics

Speech and language therapy

CORPORATE QUALITY GOVERNANCE 7.6

7.6.1 Information governance

Given the existing performance challenges described in chapter two, it will be critical that:

the new clinical divisions have access to enhanced information systems to support local service planning and performance management; and

the new Trust Board is able to readily scrutinise performance against corporate objectives, with a unified view across the new organisation.

All levels of management will rely upon high-quality performance information as an essential enabler for clinical integration, workforce change and process innovation. The implementation plan for IM&T includes migration to unified clinical and business systems, which will underpin a comprehensive performance reporting system and a single information management structure. In supporting clinicians and senior management colleagues, the plan includes deployment of dynamic dashboard performance reporting tools, enabling them to access real-time information and analysis at levels of detail appropriate to their roles.

Given issues experienced by NWLHT in maintaining and meeting the 18-week RTT performance standards, a ‘root and branch’ review was undertaken of the whole system of RTT data capture, validation, reporting and monitoring, with external input from the NHS Intensive Support Team. This was then supplemented by a broader external maturity assessment (carried out by KPMG) that reviewed both Trusts’ information reporting and data quality provision, including specific audit of A&E, Cancer and RTT key performance indicators.

The outputs from these reviews are incorporated into the joint IM&T strategic plan, with commitment to ensure the highest quality of information and performance

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reporting is available to Clinical Directors and the Board of the new Trust. This incorporates a proactive and prominent data quality assurance framework, along with adoption of automated data processing and dashboard solutions to ensure ‘single version of the truth’ reporting. As a specific example, a joint RTT reporting suite is scheduled for full deployment by September 2014; this will include dashboard reporting, forecasting tools and an algorithm-based validation engine to highlight data quality queries for operational leads to re-check prior to the reporting of key performance indicators.

Operational performance will be reviewed by the Clinical Performance and Patient Experience Committee and Executive Committee. In addition, there will be a systematic quarterly performance review of each Division with the full Executive team. This will ensure there is clear accountability and responsibility for operational performance and provide designated support and advice for tackling systemic issues outside the direct control of an individual Division.

7.6.2 Key working Relationships

The CN and MD will meet monthly with the Head of Governance to discuss Safety, Quality and Patient Experience issues arising from various Trust committees, meetings, other trust escalation avenues or concerns expressed by staff.

They will also hold a monthly meeting with the Chief Operating Officer; thereby ensuring alignment with, and support for the clinical and operational agenda to deliver a responsive high-quality service for patients. The CN and MD will need assurance that any Trust or commissioner savings proposals do not constitute a risk to patient safety.

The Head of Governance – who will report to the Board through the CN and the Clinical Performance and Patient Experience Committee – will be responsible for the effective management of the Clinical/Quality Governance Department and for key responsibilities in line with this role.

At a corporate level, the Corporate Governance team will maintain Trust-wide databases encompassing quality governance key performance targets monitored by regulatory bodies.

As required, the Corporate Governance team will provide Trust-wide trending reports to the Clinical Performance and Patient Experience Committee. These will encompass clinical and non-clinical incidents, Serious Incidents (SIs), NICE & Quality Standards compliance, NCEPOD compliance, complaints, clinical and non-clinical claims and the mandatory clinical audit programme.

Proactively identifying and managing risk, the team will provide timely information and engage Divisions on a range of topics to support and challenge reports, safety dashboards etc. This will involve populating divisional risk registers and clinical score cards – thus aiding compliance with the CQCs fundamental development standards: Safety, Effectiveness, Caring, Responsiveness and Leadership domains.98

The corporate governance team will maintain the Trust’s corporate risk register and a Trust-wide log of SIs. This log facilitates the meeting of SI reporting targets and

98 Care Quality Commission, Business Plan 2013/14, Priority 2 Changing the way we inspect NHS

hospitals and mental health trust

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monitors the progress of SI action plans, in conjunction with the Divisional Clinical Directors.

The Clinical Governance facilitators based within Divisions will be managed by the core governance team. The governance team itself will ensure the SI panel and complaints investigation process is consistent across all Divisions. The Corporate Governance Department will maintain an inquest log to support compliance with the statutory requirements of the Coroner’s Inquests, which came into effect in 2013.99

The corporate governance team will be responsible for Clinical/Quality Governance training across the Trust. In supporting an open safety culture in which staff can raise concerns, the Head of Governance will establish open governance surgeries. To support shared learning and continuous quality improvement across the Trust, a quarterly ‘Safety and Quality Forum’ will be facilitated by the corporate governance department.

DIVISIONAL QUALITY GOVERNANCE 7.7

The new organisation will be centred on the needs of patients and will step beyond traditional divisions between specialist, acute and community care. To deliver the clinical vision described in chapter six, the new organisation needs to be doing more than simply responding to likely financial or organisational challenges. The new Trust has to focus on delivering high-quality care to a diverse local population in an accessible and effective manner; using the merger to stimulate the creation of new and innovative services.

As described previously, the clinical divisions will form the driving force of the merged organisation, with responsibility for continuous improvement in the quality of patient services in line with best practice and the new organisation’s vision and values.

As illustrated in Figure 14, it is proposed to rationalise the current 11 divisions across both Trusts into five in the new Trust. This is intended to:

promote integration of services across acute and community settings within divisions and thus facilitate the move of services out-of-hospital wherever safe and sensible to do so;

future-proof the divisions by giving them management flexibility;

avoid duplication; and

secure better value for scarce resources.

7.7.1 Divisional and service level governance framework

Each division will form a divisional management board chaired by a Divisional Clinical Director with a core membership of the Divisional HoN and DGM. Depending on the services provided by the division, the management team may also include a senior AHP.

This core group will be supported by designated leads for both workforce and finance. Each division will be required to mirror a defined Trust clinical governance

99 Coroners' inquests - Commons Library Standard Note Published 03 July 2013

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structure, as well as identify governance support roles (e.g. clinical audit lead) with the clinical specialities to support a full ‘ward to Board’ assurance for the organisation.

Additional divisional board membership and attendance will be depend on the nature and size of individual clinical services within the divisional group, but may typically include general managers, clinical leads, AHPs and matrons from the individual clinical services. Any member of staff attending will have defined responsibilities and objectives for safety and quality improvement within their role.

Through the Director of Operations, the divisional board members will be responsible to the COO for all aspects of clinical, operational and financial performance. The board members will collaborate to discharge the divisional safety and quality agenda: liaising closely with the divisional governance facilitator and the corporate governance department.

The corporate governance department will provide timely information and ensure the division remains compliant with the CQCs five fundamental development standards.

The Divisional Clinical Director, or nominated deputy, will represent the division at various Trust committees including the Trust Board sub-committees as required. These would tend to be the Audit, Governance & Risk Committee and/or the Clinical Performance and Patient Experience Committee, depending on the subject under scrutiny.

To support shared learning and continuous quality improvement across the Trust, a quarterly ‘safety and quality forum’ with membership from every division will be facilitated by the corporate governance department.

Each divisional board will develop a supporting governance sub-group structure that mirrors the Trust structure and takes responsibility for delivery under categories aligned to the parameters of Monitor’s Quality Governance Framework.100

Each Division will be expected to include within its governance the following core elements:

Divisional Governance meetings convened monthly;

An overarching review system which will scrutinise and challenge specialities within its sphere of responsibility., This will be facilitated by the use of clinical dashboard scorecards, risk registers and Trust-agreed standing items for governance meetings;

A divisional risk register which will contain higher level risks associated with all its specialities as outlined in the Trust Risk Management Strategy document;

Speciality level risk registers will be maintained as described in the Trust Risk Management Strategy document;

The appointment of dedicated individuals responsible for governance in each speciality and work closely with the Divisional Governance Facilitator and Corporate Governance Department;

100 Quality Governance: How does a board know that its organisation is working effectively to improve patient care?, Monitor, April 2013

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The submission of divisional risk register and divisional quality and patient experience dashboards to the Quarterly Performance Review;

The preparation of exception reports and action plans for risks RAG101 rated red to be presented to the Clinical Performance and Patient Experience committee by the relevant divisional team

The minutes of each Quarterly Performance Review meeting will be submitted to the Clinical Performance and Patient Experience Committee (CP&PEC)

In line with the proposed duty of candour,102 staff within the Division or across Divisions may additionally be asked to present on any specific risks or concerns the CP&PEC deems warrants further exploration (in addition to which divisional leads can attend the committee to raise concerns or specific risk issues directly)

Figure 16 Schematic divisional quality governance arrangements

Figure 16 above illustrates divisional quality governance arrangements in terms of the overall strategy, structures, requisite capabilities and measurements needed to effectively monitor performance.

Divisions will agree their governance agenda with the CN and the corporate governance department. Each division will have areas of specific focus but all will

101 Red, amber or green 102 Robert Francis QCs report on Mid Staffs makes a set of recommendations concerning openness,

transparency and candour, which is a central theme of his report (cited above)

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have a pre-agreed range of governance standards and targets set by the Trust; for example:

1. The Trust Clinical Audit programme which identifies Divisional mandatory audits e.g. Quality & National Account audits; these are assigned to relevant division(s). The division will also be expected to agree a local audit programme;

2. Compliance with NICE guidelines; exception reports on higher than expected peri-operative deaths(CEPOD gap analysis), if appropriate;

3. Progress reports on the achievement of the Trust CQUIN programme targets (if appropriate);

4. Mortality and Morbidity meeting, including unexpected deaths, weekend mortality rates (if appropriate);

5. Reports on the incidence of avoidable infections and incidents, such as C. Difficile, MRSA, MSSA, E. coli incidents and sepsis incidents;

6. CQC compliance – organisational and service specific;

7. The patient experience: complaints, PALS feedback and compliments; themes and trends; new and closed, action plan monitoring;

8. Reports on the CQC Caring domain including: results of patient surveys,; ongoing audits and surveys; progress reports on implementing action plans; feedback from patient groups; environmental issues raised by patients and families etc.;

9. A report on Incidents (Clinical and Non-Clinical) encompassing: a SI tracker (for incidents graded major and moderate); monitoring of action plans identifying any consistent themes and trends; incident closure rate performance; and any events involving the exercise of the staff duty of candour;

10. Risk assessments including: mandatory Health and Safety assessments; monitoring of action plans, if appropriate; and any other risk assessments;

11. Claims: identifying any Clinical and Non Clinical litigation trends, including learning points, to avoid future risk exposure;

12. Coroners’ inquests outcomes and Prevent Future Deaths (PFD)

reports;103

13. Approval mechanism for local policies and protocols based on merged Trust agreed policy/protocol/guidelines documents;

14. Workforce metrics that may have a governance impact;

15. CQC responsiveness domain metrics (if appropriate);

16. Divisional risk registers populated by Speciality Risk Registers and other areas of areas of risk;

17. Mandatory training compliance; and

103 PFDs have replaced Rule 43 letters in recent legislative changes introduced by the Ministry of

Justice, July 2013

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18. Patient Reported Outcome Measures (PROMS) and Safety Thermometer data, if applicable.

7.7.2 Speciality-level governance arrangements

Governance meetings will be convened monthly. They will be chaired by the Clinical lead using an agreed template that reflects the particular speciality governance responsibilities, but also includes Trust pre-agreed core standing items, such as an incident and complaints review.

Each speciality will maintain a local risk register. Governance leads from each speciality will present their risk profile and risk register at divisional governance meetings. Any new serious risks must be escalated immediately to the divisional senior management team.

Membership of the speciality will include appropriate representatives from departmental/ward groups/forums and will include a cross-section of the varied staff groups pertinent to the speciality. Each meeting will discuss risks and/or concerns escalated from the ward or department. Feedback should also be provided from divisional governance meetings to complete the communications loop.

7.7.3 Ward/department-level governance arrangements

Governance meetings will also be convened monthly. Chaired by the matron, ward sister/charge nurse/senior AHP and following a template that reflects the particular ward/ department governance responsibilities and Trust pre-agreed core standing items such as incident and complaints review. The chair is responsible for presenting the ward/department risk profile at speciality meetings, while feedback should also be provided from speciality meetings.

RISK MANAGEMENT ARRANGEMENTS 7.8

By Day 1 of the merged organisation, the Trust Board must have installed robust processes to identify risk and ensure the safe and effective operation of the new organisation, particularly in a time of transition and change.

The new Trust will be helped in advance of merger by the three due diligence exercises undertake as part of the merger process, namely, clinical due diligence (Supporting Document 7-2), financial due diligence (Supporting Document 7-3) and legal due diligence (Supporting Document 7-4). These will help to ensure that systems have been reviewed and that risks have been identified and mitigations planned to manage these if they arise.

A common set of five corporate objectives for 2014/15 has been agreed by EHT-ICO and NWLHT Boards which will continue as the merged organisation’s objectives (Table 35).

Table 35 Corporate objectives for 2014/15

Objective Executive Lead(s)

Improving our focus on safety and quality COO/MD

Improving patient experience, satisfaction and engagement CN

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Objective Executive Lead(s)

Creating a sustainable workforce that is lead and engaged in developing and improving services

Director of HR&OD

Plan for our future CEO

Ensure financial stability CFO

These overall objectives are supported by detailed sub-objectives that have executive ownership and were agreed by each Trust Board in May 2014. In support of delivery of the objectives a revised Board Assurance Framework (BAF) is in process of development and will be presented and agreed at the Boards in July 2014.

An overarching corporate risk register will be maintained to include a comprehensive and up-to-date set of risks and provide robust evidence of risk management in the evaluation of progress with risk reduction and mitigation measures.

Each Division will maintain a local risk register. Any risks that score 15 and above (i.e. a risk which cannot be managed locally) must be escalated by the divisional clinical director for review for consideration of inclusion on the Trust corporate risk register. Divisional risk registers will be presented to the Executive Directors at the quarterly performance review.

CONCLUSION 7.9

This chapter has identified the proposed Board and sub-committee structure and governance arrangements – including details of executive and non-executive director arrangements that will conform to best practice. It then describes the proposed divisional management structure to ensure strong and visible clinical leadership across the Trust. To support the delivery of the Trust’s vision, revised performance reporting systems and accountability arrangements are described for the new organisation.


Appendix 7-1 Board sub-committee summary details

Supporting Document 7-1 Draft ToR for new Trust Board and sub-committees

Supporting Document 7-2 Clinical due diligence

Supporting Document 7-3 Financial due diligence

Supporting Document 7-4 Legal due diligence

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8. Financial evaluation / LTFM

BACKGROUND AND CONTEXT 8.1

In the OBC (dated 26 October 2011), the financial case outlined the financial benefits that a merger between the Trusts would deliver. An FBC was then produced in

Chapter summary

This chapter describes the development of the long-term financial model (LTFM) and how the modelling used captures the historical performance of the independent Trusts, assesses their forecasted financial performance and analyses the planned financial benefits following the merger of the two organisations.

The chapter clearly demonstrates that without change neither Trust is sustainable over the longer term, with each incurring ever increasing deficits. With Ealing, these deficits will be driven by the fact that it is the smallest acute provider in London and cannot continue to deliver the savings required to maintain financial sustainability and safe services.

This picture is in keeping with modelling undertaken by commissioners in respect to SaHF. This modelling confirms that NWLHT cannot deliver financial sustainability, while specific work with local commissioners has further demonstrated the financial burden placed on the Trust through the Central Middlesex site.

The merger will create an organisation which has the critical mass to support clinical sustainability and which will deliver financial surpluses from year two onwards, without the need for further financial support. In short, while merger presents challenges in itself, it is the best option for this local health economy.

This rationale for change is backed up by the analysis in section 8.9 which shows how the deficits of each trust would increase if the merger were not to progress as planned. In particular, the finances of Ealing would deteriorate even further as the activity flows from Ealing forecast in SaHF occur ahead of plan.

To achieve this sustainable state, the new Trust would require PDC cash support of £64.1m in 2014/15, £21m in 2015/16 and potentially a further £38.5m ( (£24.3m PDC, 18.0m income) over 2017/18 to 2019/20 to support the planned new Ealing local hospital. These amounts are made up as follows:

Offset short-term trading deficits in 2014/15, 2015/16 while merger benefits are realised (£54.2m);

Fund repayments of loans and leases (£38.6m) which includes DH loan payback at NWLHT (£14.3m), PFI and Ealing local hospital commercial loan principal repayments;

Fund the one-off implementation costs of merger (£12.8m).

Fund two year Ealing Local Hospital reconfiguration transitional costs (£18m).

This is in addition to the £33.9m of agreed funding from Commissioners included in the model over the next three years to support the CMH structural deficit. The funding requirement is based on the CMH deficit assessment undertaken by the SaHF CMH work-stream and independently assessed by BDO financial consultants after modelling the latest SaHF service plans for the CMH site.

To demonstrate continued financial viability and sustainability of the merged Trust, should the forecast plans and assumptions not occur as expected, the modelling in this chapter assesses the impact of a range of ‘downside’ risks. These identify potential reductions of income or increased costs and in response describe a number of potential actions (mitigations) that have been developed to ensure the Trust will continue to deliver the required financial performance.

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September 2012 which refined the financial case. Since the original FBC was completed, a number of factors led to the reworking of the financial model that underpins this Final Business Case. These factors include:

Revised income assumptions for future years based upon the latest contracts and commissioning intentions;

Modelling of latest assumptions from SaHF relating to the business cases for capital development for Ealing Local Hospital and the Northwick Park site;

Reflection of financial support of £11.3m for CMH site for 3 years, pending the outcome of the business case for the CMH led by Commissioners,

Changes to forecast modelling assumptions i.e. as a result of continued pay restraint in public services. Other changes, such as the way commissioners plan to reinvest savings from reduced acute hospital activity, have been made to the LTFM; and

Revisions to CIP and merger savings arising from detailed review of the plans and external support to strengthen deliverability.

In addition, the LTFM has been revised to take account of updated financial information and assumptions, such as the 2013/14 out-turn positions, the current Trusts 2014/15 operating plans, capital investment priorities and recommendations from the financial due diligence undertaken by KPMG accountants in December 2013 on the November 2013 version of the BC.

An independent analysis of the financial deficit of NWLHT confirmed that a significant factor in its underlying deficit can be attributed to the fixed PFI costs and under-utilisation of the Central Middlesex site. The LTFM assumes that this deficit of £11.3m will be met through transitional funding other than PbR from NWL commissioners, over the next three years. Currently a revised service solution is being finalised through a NWL health sector review leading the development of a business case (following the SOC produced in January 2014) for the potential utilisation of the CMH site which is expected to be implemented from year 4 and ameliorate the deficit.

CALCULATING FINANCIAL VIABILITY 8.2

In producing the FBC, it is important to understand and demonstrate the respective forecast financial performance of both the existing individual Trusts and the new Trust once merged. The merged organisation will achieve a surplus and financial sustainability from 2017/18. Although the financial challenge will be significant, it will be less than that faced by the Trusts over the same period if they were to remain as independent Trusts.

It is this value for money test that the FBC demonstrates. It also provides evidence that at the end of the five-year period, the merged organisation will be in a position to deliver recurrent, normalised surpluses even after delivering significant service change including Ealing local hospital and will be well placed to consider how it will achieve FT status.

Currently, neither Board believe that their independent Trust has a clear route to achieving FT status and conversations with NHS England and the TDA confirm that there are no other sustainable options available at the present time.

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HISTORICAL FINANCIAL PERFORMANCE OF THE CURRENT TRUSTS 8.3

The FBC analysed the historical financial performance of both Trusts. The latest historical performance for the five years to 2013/14 is shown in Table 36 and Table 37 below.

Table 36 Historical financial performance – EHT-ICO

EHT Historical Financial Position

2011-12 2012-13 2013-14

£m Actual Actual Actual

NHS Clinical Income 212.5 206.3 214.9

Other Income 19.0 26.2 24.1

Non Recurrent Income 1.5 1.6 9.4

Total Income 232.9 234.1 248.4

Pay costs (160.3) (163.5) (173.1)

Non Pay costs (63.7) (63.8) (67.7)

Total Operating Expenses (224.0) (227.3) (240.9)

EBITDA 8.9 6.8 7.5

Non-Operating Expenses (6.6) (6.7) (7.5)

Reported Surplus/(Deficit) 2.3 0.1 0.0

Normalised Surplus/(Deficit) 2.3 0.1 0.0

Reported Cumulative surplus/(deficit) 2.3 0.1 0.0

Normalised Surplus/(Deficit)% of income 1.0% 0.0% 0.0%

Net Cash Inflow/(Outflow) 0.0 (1.0) 0.2

Cash and Cash Equivalents 6.2 5.3 5.0

Fixed Assets 91.8 94.3 127.1

Long Term Liabilities (3.9) (3.9) (3.9)

Public Dividend Capital 50.8 51.1 53.3

Retained Earnings/(Accumulated Losses) 11.7 11.8 28.4

Brent, Harrow and Ealing community services were combined with EHT-ICO in 2011/12 and this resulted in turnover increasing.

EHT-ICO has met its financial targets over the past three years. It delivered a surplus of £2.2m in 2011/12, its first year as an Integrated Care Organisation, as described in Chapter two, and broke even in 2012/13 and 2013/14 (which was after receipt of £7m of non-recurrent income support).

However, the underlying deficit in 2012/13 was £2m and in 2013/14 this rose to £8.9m. Furthermore, largely due to the small size of its acute services, EHT-ICO will face increasing challenges in maintaining financial stability as a result of the following (described in more detail in Chapters three to five):

Demands to meet increasing quality standards;

Commissioner-stated strategies to commission from specialist centres with a larger critical mass of specialist staff; and

The transfer of further resources out of acute hospital care into community service.

The table below demonstrates the historical financial performance of NWLHT.

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Table 37 Historical financial performance – NWLHT

NWLHT Historical Financial Position

2011-12 2012-13 2013-14

£m Actual Actual Actual

NHS Clinical Income 307.2 313.4 343.6

Other Income 57.5 66.9 61.4

Non Recurrent Income 21.0 0.0 13.1

Total Income 385.7 380.2 418.0

Pay costs (235.7) (240.5) (254.3)

Non Pay costs (129.8) (140.4) (167.4)

Total Operating Expenses (365.6) (380.9) (421.8)

EBITDA 20.2 (0.7) (3.7)

Non-Operating Expenses (37.0) (50.5) (24.9)

Reported Surplus/(Deficit) (16.8) (51.0) (28.7)

Normalised Surplus/(Deficit) (9.5) (21.5) (23.6)

Reported Cumulative surplus/(deficit) (16.8) (51.0) (28.7)

Normalised Surplus/(Deficit)% of income -2.5% -5.7% -5.6%

Cash and Cash Equivalents 1.4 1.5 1.6

Fixed Assets 279.0 256.9 272.8

Long Term Liabilities (65.1) (64.7) (62.8)

Public Dividend Capital 192.1 225.0 265.2

Retained Earnings/(Accumulated Losses) (60.4) (111.4) (140.3)

NWLHT achieved in-year breakeven in one of the last five years but only with the support of non-recurrent benefits. When the results are adjusted for this non-recurrent support, the Trust delivered a normalised deficit position for each year, including a normalised deficit in excess of £21.5m in 2012/13 and £24m in 2013/14.

The combined operating plans for the two Trusts in 2014/15 forecast a deficit of £35.1m (£21.5m NWLHT and £13.6m EHT) which includes transitional costs from service change, impact of CMH A&E closure, EHT maternity service funding and non-recurrent CMH support. This demonstrates that the challenge has continued to grow and will only get worse in future without merger.

NORTH-WEST LONDON HEALTH ECONOMY – FINANCIAL POSITION 8.4

As discussed in Chapter three, the outcome of the decision making phase of SaHF has concluded. The implementation phase has only recently commenced. Therefore, this section describes financial information on commissioning intentions as contained in the DMBC.

8.4.1 Acute

The modelling shows that commissioners plan to deliver £93.8m of QIPP savings from Ealing and NWLHT in the five years to 2019/20. This is equal to 21% of income at each site. This QIPP will be partly offset by demand growth forecast at 12% at EHT-ICO and 11% at NWLHT.

The modelling for the DMBC only went as far as 2017/18. From this point, SaHF assumed EHT-ICO would stop providing acute services and the main site would be demolished. A local hospital would then be built adjacent to the existing site. The

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business case for Ealing local hospital has been prepared by consultancy firm PwC and the outcome has been included in the LTFM model for merger with additional cost sensitivities included as assessed by the Trust including the impact of commercial loan financing.

The DMBC also made it clear that further work was required to consider the optimum use of the Central Middlesex site. The independent assessment of the financial position of this site has materially confirmed the findings of the DMBC that – after all possible productivity savings have been made, the existing plans for the site result in a £15.3m structural deficit by 2017/18 (due to underutilisation of a PFI site).

These findings led to further work, undertaken jointly by the commissioners, TDA and the Trust, to assess possible options of how this site could be utilised more effectively. The strategic outline case setting out the options with each clinical and financial evaluation has now been produced and will be refined further as part of the development of the FBC for the site led by Commissioners.

The DMBC forecasts that Northwick Park and St Mark’s will gain additional activity and generate additional contributions as a result of transfers from both the Ealing site and the Charing Cross site. However, to have the capacity to service this additional activity, capital investment is required.

An OBC to plan for this increased capacity has been produced and was considered at the NWLHT Board in March 2014 and has a planned capital investment of £72.9m to address the underlying capacity issues (£23m) and impact of SaHF service changes (£50m). This case has been submitted to the SaHF programme board and TDA for further consideration. The additional capital and revenue consequences are included in this business case.

8.4.2 Community

The QIPP savings forecast by commissioners are predicated on a successful out of hospital strategy being implemented. This implementation will involve a total of up to £91m being invested in out-of-hospital care over five years within the Boroughs of Brent, Ealing and Harrow. These assumptions are currently being updated during the implementation phase, with assumptions being refined regarding the reinvestment that will be made in out-of-hospital services from savings made from commissioner QIPP.

8.4.3 Impact of SaHF

Given the time that has elapsed since the production of the original DMBC and uncertainty regarding the implementation phase of SaHF, as well as the need for a number of Business Cases to be drafted and approved, there is uncertainty regarding the precise timing and impact of SaHF. Therefore the Trusts have worked with commissioners to agree an updated set of assumptions and timings for the implementation of SaHF (Appendix 8-1).

These assumptions were used in modelling the merger case and were presented and agreed at the Transaction board on 14 November 2013. Since then work on a refreshed SaHF business case has progressed. There were further changes made to the Trust’s SaHF modelling in order to align it with the commissioner plans which were discussed and noted at the February 2014 SaHF Finance Directors Steering

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Group. It is the outcome of this process that is modelled in the LTFM and updated to reflect the latest version of the Ealing local hospital including a reduction of retained elective activity within the Trust as a result of the development of the Ealing local hospital.

MERGER CASE MODELLING AND SCENARIOS OVERVIEW 8.5

The merger case assessment modelling is complex with many underlying assumptions and forecasts to reflect the ever-changing environment. A number of scenarios have been modelled to fully assess the impact of the merger case and sector reconfiguration (SaHF), as well as evaluate the risks and the impact non-merger would have on the future state of individual Trusts.

The modelling includes the following scenarios:

1. The merger base case. This shows the most likely outcome of the merger business case, including prudent assumptions regarding price, volumes, demand management and SaHF.

2. Non-merger business case. This case assesses the most likely impact on the future financial position of the combined organisations if the merger did not go ahead. It takes into account already apparent downwards activity trends at EHT-ICO.

3. Downside merger case includes the potential risks faced by the merged Trust and proposed mitigations.

Figure 17 below demonstrates the approach taken:

Figure 17 Modelling approach and scenarios: expenditure plan 2013/14 to 2018/19

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8.5.1 Financial Summary of Scenarios

Merger Base case projected normalised surplus of £12.2m by year 5 with a small surplus of £0.2m by year 2. There are £19m of merger savings included, £11.3m of CMH support and SaHF service change impact on the financial plan.

Table 38 Merger Base Case 2013/14 to 2018/19

Merger Base Case

2014-15 2015-16 2016-17 2017-18 2018-19 2019-20


NWLHT Surplus/(Deficit) (42.9) (21.4) (16.1) (12.7) (9.8) (6.0)

EHT Surplus/(Deficit) (13.6) (11.5) (6.6) (8.1) (29.1) 8.5

Aggregated I&E (56.5) (32.9) (22.7) (20.9) (38.9) 2.5

Merger Savings 4.0 15.3 19.0 19.0 19.0 19.0

Inflation/Other (4.0) (0.1) 1.8 1.7 2.5 3.1

SaHF impact (2.3) (1.4) 2.0 0.8 (5.8) (6.4)

Base Case Surplus/(Deficit) (58.9) (19.1) 0.2 0.6 (23.2) 18.2

Normalised Base Case Surplus/(Deficit)

(35.1) (19.1) 0.2 0.6 6.8 12.2

Non-Merger case is based on a realistic assessment of potential adverse factors if the merger does not happen, with the rest of the assumptions remaining the same as the merger base case.

The difference between the £12.2m surplus in 2019/20 generated through the merger of the Trusts, and the non-merger scenario of a £34.4m deficit, represents a potential total loss of not merging of £46.6m. This demonstrates the value for money case for the merger.

Overall it will result in the saving to the health economy in NWL of £164m over the 5 year period.

Table 39 Non-Merger Case

Non-Merger Case

2014-15 2015-16 2016-17 2017-18 2018-19 2019-20


Normalised Base Case Surplus/(Deficit)

(35.1) (19.1) 0.2 0.6 6.8 12.2

Non-Merger assessment impact (11.3) (27.3) (37.6) (41.3) (46.6)

Non-Merger Case Surplus/(Deficit)

(35.1) (30.4) (27.1) (37.0) (34.5) (34.4)

Merger Benefit 11.3 27.3 37.6 41.3 46.6

Downside case includes £54.7m of identified risks which reduce the base case surplus of £12.2m to a deficit of £42.5m by year 2019/20. Overall risks are equivalent of 7% of total revenue and include volume and price risks. Potential mitigations of £52.3m have been identified, to offset these and maintain the operating performance.

129

Table 40 Downside Case 2013/14 to 2018/19

Downside Case

2014-15 2015-16 2016-17 2017-18 2018-19 2019-20


Normalised Base Case Surplus/(Deficit) (35.1) (19.1) 0.2 0.6 6.8 12.2

Downside Risks 0.0 (7.1) (16.4) (30.2) (44.6) (54.7)

Unmitigated Surplus/(Deficit) (35.1) (26.2) (16.2) (29.6) (37.8) (42.5)

Mitigations 0.0 10.7 19.7 30.3 44.6 52.3

Downside Case Surplus/(Deficit) (35.1) (15.5) 3.5 0.7 6.8 9.8

MERGER BASE CASE FINANCIAL ASSESSMENT 8.6

The scale of challenge faced by both organisations, and articulated in financial terms in this section, reinforces the need for change. The proposed merger will give the merged Trust access to financial savings not available to the standalone organisations. By 2019/20, these savings will result in an organisation that is financially stable in the long-term and capable of delivering surpluses without the need for further transitional support.

This revised FBC has clearly built on the previous versions and much of the narrative remains and is consistent with what was said previously: that the organisations will be ‘Stronger Together’, i.e. better placed to respond to increasing patient demand and expectations, increases in quality standards and specialisation, as well as the planned service changes as a result of SaHF.

The merged Trust will be a large-scale Integrated Care Organisation with acute and community services coterminous with its three local authorities. This places it in a unique position to respond to the drive for more streamlined patient pathways with greater emphasis on local service provision at home and in the community, as well as access to the highest quality acute and specialist in-patient services.

8.6.1 Finance plan overview

The base case modelling builds on the 2014/15 annual operating plans. The current year deficit of each Trust within the model is (£58.9m), consisting of (£45.3m) deficit in NWLHT and (£13.6m) in EHT-ICO. NWLHT deficit includes £12.8m of merger costs and £11m of asset impairment cost. The table below summarises the financial position under the base case.

130

Table 41 Summary base case financial position

The main points of the plan above:

• I&E bottom line is forecast to improve from current combined normalised deficit of £35.1m to a £12.2m normalised surplus;

• The improvement in bottom line is achieved due to merger savings and minimisation of decreasing activity and productivity improvement that can be achieved by merging both trusts;

• This merger base case is unfunded, therefore does not include any merger related funding. This is reflected in the negative cash position of £30.4m;

• Fixed assets are increasing considerably (c£120m) due to investment in Ealing local hospital, NPH site and IT;

• Long-term liabilities have increased by £75m due to £114m loan financing of Ealing local hospital offset by DH loan repayment;

• I&E reserve reduces by £23.3m; and

• PDC increasing by £49.6m due to capital expenditure and funding to support repayment of the existing loan at NWLHT of £14.3m.

Merger Financial Overview

2014-15 2015-16 2016-17 2017-18 2018-19 2019-20


NHS Clinical Income 556.4 540.8 545.1 553.1 514.4 518.7

Other Income 75.3 81.0 79.7 79.9 64.6 64.9

Non Recurrent Income 22.4 7.1 11.4 11.4 20.4 20.4

Total Income 654.1 628.9 636.1 644.4 599.4 604.0

Pay costs (431.9) (411.5) (401.4) (400.1) (360.0) (358.3)

Non Pay costs (237.7) (205.3) (201.4) (202.1) (190.0) (184.7)

Total Operating Expenses (669.6) (616.8) (602.7) (602.2) (550.0) (543.0)

EBITDA (15.5) 12.1 33.4 42.2 49.5 60.9

Non Operating Expenses (43.5) (31.2) (33.3) (41.5) (72.7) (42.7)

Surplus/(Deficit) (58.9) (19.1) 0.2 0.6 (23.2) 18.2

Normalised Surplus/(Deficit) (35.1) (19.1) 0.2 0.6 6.8 12.2

Normalised Surplus/(Deficit)% of income-5.4% -3% 0% 0% 1% 2%

CIPs Forecast (in year) 19.1 32.1 28.9 27.3 25.7 25.7

CIPs as % of operating costs 2.9% 5.0% 4.5% 4.3% 4.0% 4.0%

Merger Savings (cum.) 4.0 15.3 19.0 19.0 19.0 19.0

Net Cash Inflow/(Outflow) (29.1) (25.7) 0.7 (3.8) (7.5) 28.5

Cash and Cash Equivalents (22.5) (48.2) (47.5) (51.4) (58.9) (30.4)

Fixed Assets 419.5 436.6 522.6 594.4 563.7 544.3

Long Term Liabilities (64.4) (62.2) (115.9) (169.0) (161.7) (154.3)

Public Dividend Capital 382.3 396.8 420.0 431.9 431.9 431.9

Retained Earnings/(Acc. Losses) (170.7) (189.8) (189.7) (189.0) (212.2) (194.0)

131

8.6.2 Assumptions

A finance working group was established to develop and agree the assumptions underpinning the LTFM. The membership included members of the Programme Management Office for merger, the Director of Finance for each Trust, as well as senior finance representatives from the TDA, local commissioners and NHS England.

Regular meetings of this group agreed assumptions as the LTFM was constructed for the November 2013 submission. These have now been modified further as a result of the FDD findings and further reconciliation of activity profiles to align with SaHF.

The assumptions included in the business case are prudent, reflecting planned pricing, CIP, commissioner demand management, activity growth and related marginal cost and sector reconfiguration due to SaHF impact.

The detailed set of assumptions is shown in Appendix 8-2.

8.6.3 Income

The Trust forecasts that overall income will decrease by £50.4m and NHS clinical income will decrease by £35m. Main income drivers are explained below and shown in Figure 18.

Annual non recurrent income of £11.3m related to CMH funding;

Activity growth income gain (£94.4m) is more or less offset by losses from commission QIPP/demand management (£93.8m);

The Trust is planning to bid for out-of-hospital work has modelled that the Trust will successfully win 70% of A&E, OP and NEL activity losses, but at a reduced tariff. Re-provision income of £32.5m was built into the EHT-ICO income plan;

The impact of SaHF service changes is £55.2m income loss by year 4;

Other income growth relates to price inflation and drug inflation on reimbursable drugs and service developments related to St Mark’s and vascular specialties; and

Winter pressures of £4.2m relate to this year’s funding and are therefore treated as non-recurrent loss in 2015/16.

132

Figure 18 Income Plan 2013/14 to 2018/19

8.6.4 Expenditure

It is forecast that overall expenditure will decrease by £127.2m over the next five years to 2019/20. Main cost drivers are explained below and shown in Figure 19.

Pay and non-pay inflation is forecast to cost £71.6m over next five years. Pay drift will cost £22.6m;

Included is a further £5m of pay cost pressures, £2.8m of pension costs and £2m additional cost related to London Care Quality improvement programme;

Additional activity changes, including re-provision, will cost the Trust an additional £17.3m in marginal cost expenditure to provide the services;

Implementing Ealing local hospital and other SaHF schemes will enable Trust to reduce its costs by £63.7m;

Following TDA guidance, £3.2m non-recurrent contingency each year has been included. Non-recurrent costs of £22.8m relate to merger, RTT and Ealing hospital transitional costs;

The large capital investment programme will result in an £10.1m increase in capital charges;

CIP savings of £139.6m and the merger savings of £19m offset expenditure increases.

654.1

604.0

10.0 15.6 93.8

26.4

55.2 7.0 1.8

4.3

94.4 32.5 4.5

500.0

550.0

600.0

650.0

700.0

750.0

800.0

£m

Income Plan 14/15 to 19/20

133

Figure 19 Expenditure Plan 2014/15 to 2019/20

8.6.5 Shaping a Healthier Future Impact

The financial assumptions that underpinned the SaHF options appraisal, as documented in the DMBC, are currently being revisited as part of the implementation phase of SaHF. As this work is not complete, the Trust has, used the assumptions (demand management and changes in activity flows between providers) underpinning DMBC as the starting point for forecasting acute activity. These DMBC assumptions have then been revised as described below.

The starting point for acute activity assumptions is the 2014/15 budget, including over performance at NWLHT. The activity flows modelled as a result of the implementation of SaHF are largely the same as those outlined in the DMBC and are captured in the diagram in Appendix 8-1. The DMBC assumed that the Local Hospital (forecasted to replace the current Acute Hospital at Ealing) will provide only limited, mainly outpatient, services.

A Business Case for the Local Hospital has been drafted and EHT-ICO and commissioners are now of the view that the local hospital model will provide a greater range of services than envisaged in the DMBC, i.e. more diagnostics, elderly beds and rehabilitation. This business case has been reflected in the modelling and is consistent with the emerging OBC for Ealing local hospital.

The financial impact of SaHF on acute services is detailed in the table below:

713.0

585.8

4.5 63.7 139.6

19.0 0.9

2.6

33.8 37.8

22.6 7.8 2.0 17.3

0.0

400.0

450.0

500.0

550.0

600.0

650.0

700.0

750.0

800.0

850.0

900.0

£m

Costs Plan 14/15 to 19/20

134

Table 42 SaHF impact 2013/14 to 2018/19

SaHF impact

2014-15 2015-16 2016-17 2017-18 2018-19 2019-20

£m Forecast Forecast Forecast Forecast Forecast Forecast

CMH income (9.5) (16.3) (16.3) (16.3) (16.3) (16.3)

NPH income 7.1 14.0 14.0 14.0 31.9 31.9

EHT income (0.8) (8.4) (8.4) (8.4) (83.6) (83.6)

Total income (3.2) (10.7) (10.7) (10.7) (68.0) (68.0)

CMH costs 4.8 8.2 11.6 11.6 11.6 11.6

NPH costs (4.2) (7.1) (7.1) (7.1) (17.1) (17.1)

EHT costs 0.4 8.2 8.2 7.0 67.7 67.0

Total costs 0.9 9.3 12.7 11.5 62.3 61.6

CMH net contribution (4.7) (8.1) (4.7) (4.7) (4.7) (4.6)

NPH net contribution 2.8 6.9 6.9 6.9 14.8 14.8

EHT net contribution (0.4) (0.2) (0.2) (1.4) (15.9) (16.6)

Total net contribution (2.3) (1.4) 2.0 0.8 (5.8) (6.4)

Capital Charges (3.0) (4.0) (5.0) (5.0) (5.0)

Additional Capex 23.4 14.6 80.2 68.9 23.4 0.0


Activity movement to NPH from Ealing site is higher than the original SaHF DMBC, but in line with the latest OBC for Ealing local hospital;

There is an overall £68m reduction in income, mainly due to major service closures at EHT-ICO and c72% leakage to other providers;

CMH closure of A&E and Non Elective activity in year 0;

EHT-ICO maternity service closes in year 1 and local hospital implemented in year 4;

Overall contribution is projected to be negative £11.5m plus £4.2m in capital charges; and

Planned capital investment is £187m is partially offset by £18m from land sale receipts in year 5.

8.6.6 Reconfiguration impact on Ealing Hospital Trust

In business cases modelling the trusts have included the latest plans for Ealing Hospital reconfiguration. The main strands to this are:

Maternity birth related service closure from year 1 based on the latest commissioner intentions; and

Ealing local hospital implementation in 2018/19. The modelling is based on the business case drafted by PwC consultancy adjusted for the changes related to funding sources and increased costs based on the trusts assessment.

The impact of these changes is shown in the table below.

135

Table 43 Reconfiguration impact on EHT

The table above shows an incremental impact of maternity service closure and local hospital development on the merged trust.

Maternity Services

Included in the maternity service closure plans above are only birth and SCBU element of maternity pathway excluding anti and postnatal care and community midwifery. Incremental impact of the closure on the merged trust is loss of £0.2m.

There is a risk that paediatric service will not be sustainable following this. However, as currently there are no commissioner plans for this service the impact has been we have modelled the impact in the downside case.

Ealing Local Hospital

Modelling includes a new build solution which requires £114m investment financed by commercial loan calculated.

136

In contrast to PwC modelling, the trusts have prudently assumed that a new build will be financed by commercial loan financing rather than PDC funding. The impact is £6m interest cost and loan principal repayment is included in the model.

In addition to the above, included is a requirement for transitional costs, and of which funding will be sought from commissioners once the validity and scale of which will has been determined by the FBC for Ealing local hospital in due course.

Following review of the PwC cost model the Trusts have assessed that there is a risk of shortfall of up to £3m which has been added in the LTFM model.

The recurrent impact is a deficit of £12.7m, adjusted for non-recurrent transitional costs and funding.

8.6.7 Activity re-provision

The QIPP savings (demand management plans) forecast by commissioners within SaHF are predicated on a successful out-of-hospital strategy being implemented. This implementation will involve a total of up to £91m (as per the SaHF DMBC proposal) being invested in out-of-hospital care over five years within the boroughs of Brent, Ealing and Harrow.

Commissioners cannot provide detail about the nature of this investment and cannot forecast which providers will benefit from this investment. However, the fact that the merged organisation will provide community services integrated with hospital-based care across the three Boroughs of Brent, Ealing and Harrow suggest it will be well placed to benefit from the investment.

This coupled with the strong track record of Ealing in winning bids for services (as evidenced by two successful bids for Urgent Care Centres and pulmonary rehabilitation services) means that £32.4m of forecast investment will come to the merged organisation.

8.6.8 Capital expenditure and funding

The new Trust will develop its capital programme based on the needs of the new organisation rather than the plans of the existing Trusts. This results in a requirement of £307m of capital requirement over the next five years, as illustrated in Figure 20.

137

Figure 20 Profile of capital requirements

The bulk of capital spend relates to Ealing local hospital development involving a new build hospital at a cost of £114m and a further £73m investment in the NPH site to manage existing demand and create additional capacity to accommodate activity flows from EHT and CMH.

A key priority for capital investments will be IT infrastructure to support the merger and continued development of the community service provision. Some £12.5m of IT expenditure is assumed funded from within the Trusts own internally generated capital programme, with a further £20m relating to additional IT bids, which it is assumed will be funded by PDC. Sources of funding for the capital programme are illustrated in Figure 21.

16.8 8.5

17.2 21.0 18.4 18.4

7.0 9.0

4.0 - - -

57.0 57.0

23.4

14.6

23.2 11.9

- -

-

5.0

10.0

15.0

20.0

25.0

-10.0

10.0

30.0

50.0

70.0

90.0

110.0

14-15 15-16 16-17 17-18 18-19 19-20

De

pre

ciat

ion

Capital Programme £m

NPH SaHF Ealing Local Hospital IT bids

Capex programme Depreciation

138

Figure 21 Capital funding profile

Depreciation will be used in full to fund the capital programme, with additional PDC funding required of £90.7m and £114m commercial loan financing for Ealing local hospital.

COST IMPROVEMENT SAVINGS AND PROGRAMME MANAGEMENT 8.7OFFICE

The proposed merger of the two separate Trusts means that the saving schemes currently being identified will be inherited by the new Trust for delivery. The Trusts previously agreed a Programme Management Office (PMO) approach, combined across the two organisations, represents the best opportunity for delivery of the schemes in an integrated, managed and co-ordinated way. The role of the PMO is to provide industry standard programme management support to managers and clinicians in both organisations: ensuring they understand and document the steps required for each CIP to deliver benefits and holding them accountable for delivery to plan (value and timescale).

Since the combined CIP PMO was established in early April 2012, significant progress has made in bolstering the PMO function to support QIPP development and delivery. The new PMO took the best of the existing processes within the Trusts and has strengthened its systems and processes. The team has 5 WTE in post, including an experienced Head of PMO who has held a number of Director of Finance roles at NHS Trusts. The team also includes experienced project managers and operational managers who have previously held senior positions in the NHS.

Governance structures have been approved and significant progress has been made by the PMO in improving the ownership and robustness of the savings plans. Structures and procedures have been introduced to ensure proficient scheme delivery and financial management and these continue to be modified – in part to achieve further alignment in the governance processes between the two Trusts. For example, Ealing have recently established a Finance and Investment Committee that will align its governance arrangements with NWL’s and wider common practice within NHS FTs.

16.6 15.0 16.2 18.0 18.4 18.4

30.6 17.1

28.2 14.8

- -

57.0

57.0

-

20.0

40.0

60.0

80.0

100.0

120.0

14-15 15-16 16-17 17-18 18-19 19-20

Funding Sources £m

Commercial Loan PDC Funding Depreciation

139

During 2013/14 Ealing introduced an internal Turnaround Director tasked with delivering the Trust’s existing 13/14 programme, identifying further opportunities for savings and drive identification, and implementation of the 2014/15 and 2015/16 CIP programme.

The Turnaround Director works closely with the PMO and part of the team work full-time on the Ealing site to help drive turnaround. The Trust believes this additional investment will further improve the record of CIP delivery.

The recent historical performance of the two Trusts in meeting savings targets is provided in Table 44 and Table 45 below.

Table 44 Recent historical CIP performance at EHT-ICO

2011/12 actual

2012/13 actual

2013/14 Actual

In year recurrent savings £13.5m £11.0m £5.9m

In year non recurrent savings - £0.4m £4.2m

Income generation - £0.2m

Total £13.5m £10.3m

Full Year impact of recurrent savings

£13.5m £13.6m £10.0m

Table 44 shows that EHT-ICO has had a strong history of achieving significant savings. As noted previously, achievement of further savings will be more challenging as the Trust lacks the size to make significant savings in the acute setting.

The Trust continues to explore how it can make further changes within its community services; for example: through tri-borough arrangements, acute/community integration and review of management structures. It also believes that sizeable savings can be made from rationalising the current community estate footprint, and from procurement savings. However, the savings from these last two areas will be bigger if the organisations were to merge.

The Trust’s target for 2014/15 is 3.0%, plus the requirement to make good the recurrent shortfall on 2013/14 schemes. The Trust has allocated targets on a matrix basis with each Directorate allocated a 3.5% target. A series of workshops was held involving clinical, operational and Executive staff. The workshops identified thematic schemes that the Trust believes will enable the Directorates to achieve their targets. Directorates will be accountable for delivering 3.5% and they will be expected to use the thematic schemes to meet this target.

Despite the challenges in the current year, the Trust has made good progress in identifying the schemes reflected in [] and has produced detailed PIDs to support all schemes with a value of greater than £50k.

140

Table 45 Recent historical CIP performance at NWLHT

2011/12 actual

2012/13 actual

2013/14 Actual

In year recurrent savings £16.3m £15.1m £8.0m

In year non recurrent savings £1.7m

Income generation £1.7m £9.4m

Total £18.0m £16.8m £17.4m

Full Year impact of recurrent savings

£16.4m £16.8m £17.4m

Although NWLHT has delivered the CIP requirement, Table 45 shows that this has been achieved through significant one-off means i.e. in 2012/13 revaluation of the estate made a significant contribution to the recurrent saving and historically the Trust has found delivery of savings from across the Trusts services challenging.

However, it also shows that the change in governance processes (as previously described) resulted in increased savings being delivered in 2013/14. This recent track record, combined with significant progress in identifying the 2014/15 schemes, provides assurance that future targets can be delivered.

NWLHT has approached the identification of savings in a similar manner to EHT-ICO. Again, the process has involved clinicians, operational management and the Executive and the schemes for 2014/15 are detailed in Table 46 and merged Trust schemes for 2015/16 are detailed in Table 47.

Before schemes can be included within the CIP they must have a completed QIA signed-off by the Director of Nursing and the Medical Director. The QIA includes an assessment of the impact of the scheme from the patient’s perspective and a risk scoring matrix which triggers mitigation planning and for which scores over nine results in monthly MD and CN review as the scheme progresses to ensure quality is not adversely impacted.

PIDs have been produced for the larger savings schemes identified. Each theme has a summary PID, with greater detail in PIDs for individual projects within schemes. Each scheme has a QIA form. There is in place a monthly CIP Cabinet chaired by the CEO with executives presenting progress and mitigations for slippage where necessary. This is designed to ensure that any ‘blockages’ to delivery can be tackled swiftly. Divisional meetings are also held monthly so that CDs and DGMs can work through any issues specific to delivery in their area.

Across both organisations there are robust monthly monitoring meeting that hold individual Directors to account for delivery.

141

2014/15 and 2015/16 CIP Programme Summary

Table 46 CIP programme 2014/15

2014/15 2014/15 PID Description NWL EHT

£m £m

Workforce Related

Nurse Workforce Initiatives

This PID covers QIPP initiatives which are productivity improvements for nursing staff

1.8 1.1

Medical Workforce Initiatives

This PID coves Medical workforce cost reductions arising from job planning, review of rotas, medical locum costs

1.6 0.4

Admin & Clerical Workforce Initiatives

This PID covers Admin & clerical clinical workforce cost and headcount reductions arising from changing working practices

0.4 0.3

Corporate and Back Office

Corporate Business as usual

This PID covers Corporate cost improvements arising from reviewing costs, reducing headcount, using technology

0.9 2.9

Information Management and Technology

This PID covers Cost improvements arising from the investment in improved Information systems and processes

0.1 0.1

Reconfiguration Initiatives

Reconfiguration at Central Middlesex Hospital

This PID covers the SAHF provisions for the future of the CMH site, in particular, the closure of the emergency department in 2014/15

0.3 -

Acute to community/ patient pathways

This PID covers the pathway changes to community, in particular the extension to the STARRs team provision to patients in Brent & Harrow

0.2 -

Community Management Structures

This PID covers the changes to Community Management structures

0.1

Clinical Productivity Initiatives

Length of Stay efficiency improvements

This PID covers proposed Length of Stay improvements at Ealing Hospital which release capacity reduces cost.

- 1.4

Theatres productivity

This PID covers the improved Theatre productivity by improving and list planning - the anticipated savings arising from reducing additional theatre sessions.

0.2 0.3

Referral to Treatment

This PID covers the net contribution of income offset by the increased cost arising from increasing capacity for treating patients with the 18 week timescale.

1.6 -

Pathology productivity

This PID covers a Productivity achieved by improving laboratory productivity

0.4 -

Estates and Procurement Initiatives

- -

Estates Business as usual

This PID Estates and facilities cost improvements arising from supplier contracts and site utilisation

0.9 1.0

Procurement Business as usual

This PID relates to the procurement department achieving better purchasing of goods and services to secure savings.

0.6 1.3

Procurement related

This PID covers the savings arising from the procurement related to initiatives of better purchasing of drugs and

0.3 -

142

2014/15 2014/15 PID Description NWL EHT

Information technology systems

Income Related Initiatives

- -

Service Developments

This PID (there are 8 PIDs) cover various minor service development / improvement opportunities arising from operational teams at Northwest London Hospitals

1.3 -

Coding and Best Practice Tariff

This PID covers the initiatives which improve the depth and quality of Clinical Coding, but also where services are adhering to Best Practice Tariff requirements (by changing clinical processes and pathways)

0.4 0.2

Other income This PID covers Estates related and research related income opportunities which are not associated with CCGs as an income source

0.4 0.3

Sub Total 2014/15 PIDs

11.5 9.5

Table 47 CIP programme 2015/16

PID Description Total

Admin & Clerical Initiatives

The rationalisation of the clinical Admin and Clerical ("A&C") workforce across all sites following the merger. The schemes seek to make savings by role re-design and the introduction of new technology.

1.8

AHP Workforce Initiatives

There is an opportunity to realise savings through bringing together both EHT and NWL AHP resources and reducing headcount. This would mean forming new structures across all AHP disciplines (excluding Pharmacy) to deliver more efficient services in the newly merged organisation.

2.1

Diabetes Initiatives

This PID focusses on efficiency improvements arising from changing the pathway of care from acute to community in diabetes and savings in process of being confirmed.

0.0

Efficiency Improvement Initiatives

This PID focusses on efficiency improvements arising from benchmarking of weighted average length of stay and outpatient utilisation and DNA rates 7.0

Estates Initiatives

This PID focusses on Estates cost saving re-developments, based on the Estates Strategy submitted for Board approval, although detail of individual schemes still in development.

0.0

HR Initiatives

There is an opportunity, given the merger of the two Trusts, to review the current salary sacrifice arrangements and widen and harmonise employee benefits, as well as look to increase employee take-up. Whilst the intention to harmonise the salary sacrifice arrangements for the Trust’s employees is planned post the merger, there is a lot the Trust could do beforehand to gauge employee interest and send a positive message to employees, especially given the concerns employee’s will have with the forthcoming change.

1.2

Maternity & Gynaecology Initiatives

This PID focusses on the cost savings initiatives which arise from the reconfiguration of maternity and gynaecology at Ealing and North West London reconfiguration

2.7

Medical Workforce Initiatives

This PID focusses on the cost improvement medical workforce initiatives which arise from the integration of the Trusts; reduction in consultant PA's, the use of SAS doctors.

4.1

143

PID Description Total

Nurse Workforce Initiatives

This PID focusses on the cost improvement nursing workforce initiative which arises from the integration of the Trusts and stronger focus on recruitment and deployment of nursing staff.

6.7

Procurement Initiatives

This PID focuses on the cost improvement procurement initiatives which arise from a larger integrated organisation.

2.5

28.9

Further work to close the gap for 2015/16 will take place in from October 2014 as the new Trust leadership and management structure is implemented and by confirmation of the estates and diabetes opportunities.

FORECAST SAVINGS TARGETS 8.8

The table below show the savings targets over the five years of the plan.

Table 48 Forecast savings

CIP programme

2014-15 2015-16 2016-17 2017-18 2018-19 2019-20

% of operating costs Outturn Forecast Forecast Forecast Forecast Forecast

CIP programme 3.00% 4.50% 4.25% 4.00% 4.00% 4.00%

Additional IT investment related target 0.50% 0.25% 0.25%

Merger Savings 0.8% 2.3% 0.7%

Total Savings 3.80% 7.26% 5.24% 4.25% 4.00% 4.00%

CIP Savings

2014-15 2015-16 2016-17 2017-18 2018-19 2019-20


CIP programme 19.1 28.9 27.4 25.8 25.7 25.7

Additional IT investment related target 3.2 1.5 1.5 0.0 0.0

Merger Savings 4.0 11.3 3.7 0.0 0.0 0.0

Total Savings 23.1 43.4 32.6 27.3 25.7 25.7

Pay CIP

2015-16 2016-17 2017-18 2018-19 2019-20

£m/WTE Total Forecast Forecast Forecast Forecast Forecast

Pay CIP related to headcount reduction

47.7 8.6 7.7 10.9 10.3 10.3

Pay CIP related to unit cost reduction

45.4 12.8 11.6 7.3 6.8 6.8

Merger savings 19.0 15.3 3.7 0.0 0.0 0.0

Total Pay Savings 112.1 36.7 23.0 18.2 17.1 17.1

Reduction in WTE due to savings (1,104) (318) (179) (211) (198) (198)

WTE reduction as % of existing -13% -4% -2% -2% -2% -2%

144

The IT-related target recognises that the merged Trust will need sizeable investment and this will have a revenue consequence that requires funding. The table above shows that the most challenging year will be 2015/16 when the Trust will be required to deliver a total of 4.5% CIPs, 0.5% of IT savings and 2.3% merger savings.

The governance processes introduced by the Trusts and supported by the Joint CIP PMO mean that the Trust has confirmed the schemes and developed PIDs for the major scheme in 2015/16. The Trusts have made significant progress in confirming the £19m forecast merger savings as presented in Table 49.

Table 49 Merger-related savings

Synergy Savings Scheme - £000’s

2014/15

2015/16

2016/17

Corporate Integration:

Governance

Corporate

Operations

Estates

Finance

Human Resources

Information Technology

Trust Board

Academic

Directors

68

19

800

704

1100

837

312

160

Nil

Nil

167

39

5019

1104

1550

1036

656

Nil

300

200

181

300

162

Sub Total

4000

10071

643

Clinical Integration:

Bed Management

Digital Care Records

A&E Systems

E-prescribing

Materials Management

Procurement Framework

Medical Directorate

Nursing Directorate

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

175

200

54

nil

Nil

800

Nil

Nil

175

200

53

566

300

900

330

600

Sub Total

4000

1229

3124

Total 4000 11300 3767

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The Trust has made particular progress in targeting the delivery of savings within corporate functions and operational management. These will be the first schemes to be implemented, allowing more time to implement savings from medical, nursing and therapies, which are all assumed to be implemented from 2015/16.

Corporate savings: Each corporate function lead was tasked with determining the best structure to deliver their corporate service following merger. These structures have been built from the bottom-up and subsequently sense-checked; for example, through peer review and benchmarking with other Trusts. Moving to a single Board will also bring savings.

Operational management: the Chief Operating Officer at NWLHT will lead the development of a structure that will enable the merged organisation to deliver strong clinical leadership and governance. The resulting structure, reviewed by senior operational staff within each Trust, has also resulted in savings as result of a streamlined Divisional structure.

Medical and nursing: the Trust has estimated that significant savings will be achieved through medical and nursing staffing (better recruitment, review of rosters, skill mix, management of absence etc.). Work is ongoing to support benchmarking with more granular analysis.

Procurement/Non pay: a number of opportunities have been identified within non-pay. For example, within finance, more than £100k per annum will be saved by having single External Audit, Internal Audit and Local Counter Fraud Services.

NON-MERGER CASE FINANCIAL ASSESSMENT 8.9

Critical to the merger Business Case is the demonstration of the VFM case in comparison to the Trusts remaining as standalone organisations.

A ‘Non-Merger scenario’ has been modelled to determine the value that will be produced through merger.

8.9.1 Non-merger case financial overview

The non-merger case modelling builds on 2014/15 budget. The current year normalised deficit of each Trust within the model is (£35.1m), consisting of (£21.5m) deficit in NWLHT and (£13.6m) in EHT-ICO. The table below summarises the financial position under the non-merger case.

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Table 50 Summary non-merger case financial position


I&E bottom line is forecast to remain at a similar level from current combined normalised deficit of £35.1m to £34.5m deficit;

Non improvement in bottom line is due to reducing activity levels at EHT-ICO, difficulties achieving CIP targets and additional cost pressures;

This case is unfunded, therefore does not include any trading related funding. This is reflected in negative cash position of £193.6m;

Fixed assets are increasing considerably by £124.8m due to investment in SaHF and IT. PDC funding is assumed for £90.7m of capital expenditure;

Long-term liabilities have increased by £75m due to £114m loan financing of Ealing local hospital offset by DH loan repayment;

I&E reserve reduces by £187.4m; and

PDC increasing by £49.6m due to 14/15 capital expenditure and funding to support repayment of the existing loan at NWLHT of £14.3m.

Non-Merger Financial Overview

2014-15 2015-16 2016-17 2017-18 2018-19 2019-20



Other Income 75.3 81.0 79.7 79.9 64.6 64.9


Total Income 654.1 619.5 619.2 622.0 574.6 576.8

Pay costs (431.9) (415.0) (413.1) (416.2) (376.3) (376.6)

Non Pay costs (237.7) (203.6) (199.8) (201.2) (190.1) (186.0)


EBITDA (15.5) 0.8 6.2 4.6 8.1 14.2


Surplus/(Deficit) (58.9) (30.4) (27.1) (36.9) (64.5) (28.5)

Normalised Surplus/(Deficit) (35.1) (30.4) (27.1) (36.9) (34.5) (34.5)

Normalised Surplus/(Deficit)% of income-5.4% -5% -4% -6% -6% -6%




Net Cash Inflow/(Outflow) (29.1) (36.5) (26.3) (41.6) (48.6) (18.0)

Cash and Cash Equivalents (22.5) (59.0) (85.4) (127.0) (175.6) (193.6)

Fixed Assets 419.5 436.6 522.6 594.4 563.7 544.3



Retained Earnings/(Acc. Losses)(170.7) (201.1) (228.2) (265.1) (329.6) (358.1)

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8.9.2 Non-merger assumptions

In this ‘non-merger scenario’ the following assumptions have been made regarding the two stand-alone Trusts:

Income will be less than a merged organisation because activity within some sub-specialties at Ealing is likely to decrease and it has been forecast Ealing will have no growth and lose 3% market share in the first year, then 2% each subsequent year until year 4 when local hospital is implemented.

This income loss is offset by marginal cost savings. However, the marginal cost has been assumed at 40%, compared to an assumption that marginal costs are 57% in the merged organisation. This difference is the result of Ealing, as a stand-alone Trust, already operating below an optimum scale and thus unable to flex costs with activity.

Although the impact of SaHF will be similar, the ability to re-provide activity will fall by 50% as both Trusts will not be able to benefit from the care pathways enabled by the Integrated Care Organisation.

Annual QIPP savings will be lower at the two Trusts due to lost opportunities for economy of scale savings. Savings at NWL will be 0.5% less per annum and at Ealing 1% less per annum.

The £19m of merger savings will not occur in full, although it is accepted that some savings (£2.8m) will be possible ahead of formal merger through closer working relationships.

Pay costs at Ealing are likely to increase (1% assumed) as recruitment and retention become harder as the acute site is scheduled to be demolished without a plan for transition. This will increase agency and interim staff costs further.

8.9.3 Non-merger assumptions impact

The Non Merger forecast joint deficit is £34.5m by year 5. The overall impact of differences in assumptions applied in the non-merger base case as compared to merger base case adds up to £46.6m, for the reasons below:

Activity losses and reversal of activity growth related to EHT-ICO would result in £9.1m loss of income with associated saving of costs of just £3.6m. Within the model, a lower 40% marginal cost rate is applied to reflect the reducing activity scale that in turn reflects the need to maintain safe clinical support services. Community services are not affected;

Shortfall in CIP delivery at both sites would result in a £17.3m impact;

Only £2.8m of merger saving could be achieved via back office joint work, resulting in a £16.2m opportunity loss;

EHT-ICO would incur additional cost pressures of £1.6m (and potentially could be significantly higher) as a result of higher staff turnover and agency premiums, but only until local hospital is implemented;

Reduction in ability to re-provide lost activity would result in a net £7.7m loss in contribution.

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Figure 22 Non-Merger Assumptions Impact

FINANCIAL BENEFITS OF MERGING THE TRUSTS 8.10

As described above, the financial forecasts for the existing Trusts and the clinical sustainability issues for EHT-ICO clearly demonstrate the case for change. The proposed merger of NWLHT with EHT-ICO provides the opportunity to address the key issues: financial viability for NWLHT and clinical critical mass and financial sustainability for EHT-ICO. The merger is a genuine opportunity to address these issues collectively and become ‘Stronger Together’.

The merger will offer the new Trust financial opportunities denied to EHT-ICO and NWLHT (as separate Trusts) by facilitating:

Reduced administration and management costs within corporate functions and operational management

Savings within medical pay by organising rotas across three sites and rationalising service provision in response to SaHF

Reduced higher band nursing costs, particularly in non-ward based staff and within corporate managerial and governance roles

Rationalisation of the estate footprint, particularly in relation to those elements of the estate used to provide community services

Delivery of recurring CIPs through increased critical mass to deliver savings; for example, having the combined purchasing ability to get more for less, and bringing medical and other workforce numbers in line with peers

Clinical pathways that drive savings through vertical integration of services

Reduced leakage of clinical activity to other providers via integrated pathways that cut across community and acute provision and are closely aligned with primary health care.

Section 8.9 described the forecast financial position of the two Trusts if merger did not occur. This showed that the forecast deficit in 2019/20 would be £34.4m

12.2

-34.5 -9.1 -17.3

-16.2

-7.7

3.6

(40.0)

(30.0)

(20.0)

(10.0)

0.0

10.0

20.0

£m

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compared to normalised £12.2m surplus under the merger base case in section 8.6. The total benefits over the planned period are demonstrated in Table 51 below:

Table 51 Total benefits over five years, comparison of the do minimum and base case

Table 51 above shows that the cash benefit of the merger case over the five years is £164.1m, clearly demonstrating value for money. Importantly, the merged organisation is forecast to deliver a surplus from year 2, compared to the deficits forecast under the non-merger case.

FUNDED MERGER BASE CASE 8.11

The preceding sections detailed the merger’s impact on the long-term financial model of the new Trust and showed how this results in a financially sustainable organisation by the end of the five year period.

However, the early years will be extremely challenging as the new organisation seeks to realise the merger synergies successfully, while maintaining clinical quality and safety along with organisational control. Financial support will be required to:

Fund short-term trading deficits in 2014/15, 2015/16 while merger benefits are realised (£54.2m);

Fund repayments of loans and leases (£38.6m) which includes DH loan payback at NWLHT (£14.3m), PFI and Ealing local hospital commercial loan principal repayments;

Fund the one-off implementation costs of merger (£12.8m); and

Fund two year Ealing Local Hospital reconfiguration transitional costs (£18m) subject to Final Business Case for Ealing local hospital.

This is in addition to the £56.5m of funding requirement included in the model over the next five years to support the CMH structural deficit (i.e. £11.3m per annum for 3 years agreed with Commissioners, for years 4 and 5 the model has assumed the same as the revised service model expected to ameliorate the deficit is at this stage unknown and not capable of being modelled).

8.11.1 Funded merger base case overview

Table 52 below summarises the financial position under the funded merger base case:

Non-Merger Case

2014-15 2015-16 2016-17 2017-18 2018-19 2019-20


Merger Surplus/(Deficit) normalised(35.1) (19.1) 0.2 0.6 6.8 12.2

Non-Merger Surplus/(Deficit) (35.1) (30.4) (27.1) (37.0) (34.5) (34.4)

Net I&E benefit 0.0 11.3 27.3 37.6 41.3 46.6

Merger Cash (22.5) (48.2) (47.5) (51.4) (58.9) (30.4)

Non-Merger Cash (22.5) (59.4) (86.1) (127.5) (176.4) (194.5)

Net Cash Benefit 0.0 11.3 38.5 76.1 117.5 164.1

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Table 52 Summary funded merger base case financial position


I&E bottom line is forecast to improve from current combined normalised deficit of £35.1m to £12.2m normalised surplus;

The improvement in bottom line is achieved due to merger savings and minimisation of decreasing activity and productivity improvements that can be achieved by merging both trusts;

This case includes merger related funding as detailed in this section. This is reflected in positive cash position of £58.2m.

Fixed assets are increasing considerably (c£120m) due to investment in local hospital, NPH site and IT. PDC funding is assumed for £90.7m of capital expenditure;

Long-term liabilities have increased by £75m due to £114m loan financing of Ealing local hospital offset by DH loan repayment; and

PDC increasing by £109.1m due to merger funding and capital expenditure.

8.11.2 Implementation costs to deliver the merger

As is the case for any merger, there will be short-term, one-off implementation costs which will generate a need for interim financial support. This section sets out the one-off financial support required and the reasons why it is needed.

Funded Base Case Financial Overview

2014-15 2015-16 2016-17 2017-18 2018-19 2019-20



Other Income 75.3 81.0 79.7 79.9 64.6 64.9


Total Income 654.1 628.9 636.1 644.4 599.4 604.0

Pay costs (431.9) (411.5) (401.4) (400.1) (360.0) (358.3)

Non Pay costs (237.7) (205.3) (201.4) (202.1) (190.0) (184.7)


EBITDA (15.5) 12.1 33.4 42.2 49.5 60.9


Surplus/(Deficit) (58.9) (19.1) 0.2 0.6 (23.2) 18.2

Normalised Surplus/(Deficit) (35.1) (19.1) 0.2 0.6 6.8 12.2

Surplus/(Deficit)% of income -5.4% -3% 0% 0% 1% 2%




Cash and Cash Equivalents 6.5 1.8 2.5 5.1 13.6 58.2

Fixed Assets 419.5 436.6 522.6 594.4 563.7 544.3



Retained Earnings/(Acc. Losses) (170.7) (189.8) (189.7) (189.0) (212.2) (194.0)

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As demonstrated in Table 53, implementation costs will increase the financial challenge faced by the merged Trust through to 2015/16. These costs include restructuring costs and project implementation and delivery costs essential to the successful integration of the new Trust.

In assessing these costs, it has been assumed that staff will be redeployed wherever possible – thus minimising any potential redundancies. All implementation costs are non-recurrent and have been developed by each of the work-streams established to support the merger process. Each work-stream has a Board-level lead, joint Trust membership and professional programme support i.e. Finance/HR. Work-streams have been focusing on what is required to deliver the merger and have developed detailed implementation plans with required actions, resources and timescales.

Table 53 Non-recurrent implementation costs

These plans have been reviewed by the Merger Programme Operating Board and were reviewed and scrutinised as part of the Financial Due Diligence process undertaken by KPMG; the independent firm of accountants commissioned to review the financial aspects of this BC and review the robustness, integrity and resource requirements of the implementation plans.

The impact of the implementation costs and recurrent savings on the organisations is shown below and demonstrates that the costs of merger are recovered during 2016/17 and by the end of 2019/20 there is an overall net benefit of £71.2m.

Table 48 Impact of merger savings

Cash Impact of merger costs and savings

2014-15 2015-16 2016-17 2017-18 2018-19 2019-20


Merger Costs (24.1) (24.1) (24.1) (24.1) (24.1) (24.1)

Merger Savings 4.0 19.3 38.3 57.3 76.3 95.3

Net Impact (20.1) (4.8) 14.2 33.2 52.2 71.2

8.11.3 Trading deficits and loan repayments

In its first year, the new Trust will need to focus on integration of management structures while maintaining safety, quality and control, as described in Chapter six. Significant support is required in 2014/15 and 2015/16 for the in-year trading deficits. However, the non-merger scenario highlights that two standalone Trusts will deliver large deficits over the five-year period and would be likely to require much higher levels of financial support over this period.

Merger Implementation Costs

2013-14 2014-15 Total

£m Outturn Outturn

Transaction Costs (3.3) (0.5) (3.8)

Integration Costs (6.1) (6.0) (12.2)

OD Costs (1.9) (1.8) (3.7)

Redundancy (4.5) (4.5)

Net Impact (11.3) (12.8) (24.2)

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Achieving the in-year trading surplus at the end of the five-year period by becoming ‘Stronger Together’ will allow the focus to shift from constant striving for above- average cost reductions to standard savings requirements thus increasing the Trust’s ability to deliver the highest quality of service to patients.

As can be seen from the Balance Sheet modelling, the Trust will have negative cash balances of £30.4m by the end of the five-year period. The Trust will require additional loan and lease principle repayment financing of £26.3m over next five years.

8.11.4 Amount of financial support required

The factors contributing to the new Trust’s funding needs are shown in Table 54.

Table 54 Causes of required funding

In addition to above there is included in income, is CMH funding support of £11.3m which has been agreed with commissioners for 3 years.

Once all sources of funding are agreed and secured within the Transaction Agreement, receipt of the funding provides the new Trust with a sustainable future.

DOWNSIDE CASE 8.12

In preparing this base case for merger, an analysis has been undertaken of potential risks, as well as actions the new Trust could take to compensate for these risks.

8.12.1 Downside risks

The key risks have been identified as:

Acknowledging cost inflation of tariff deflation could be higher than projected in the base case. The assumption is additional 0.5% pa;

Potential further commissioner demand management schemes could affect the base case;

Potential shortfall in ability to re-provide activity lost due to demand management;

The possibility that the CIP programme could slip or be under-delivered. The assumption is 15% pa;

An extra £25m of capital investment might be needed, resulting in higher capital charges;

Merger Funding Requirement

2014-15 2015-16 2016-17 2017-18 2018-19 2019-20

£m Outturn Forecast Forecast Forecast Forecast Forecast Total

Short term trading deficits (47.9) (19.1) (67.0)

Repayment of Loans and Leases (1.9) (1.9) (6.5) (7.0) (7.1) (24.3)

Ealing local hospital transitional funding (9.0) (9.0) (18.0)

DH loan repayment (14.3) (14.3)

Total Merger Funding (64.1) (21.0) 0.0 (6.5) (16.0) (16.1) (123.6)

Adj for non cash items - CTB payback 14.3 14.3

Total cash funding (49.8) (21.0) 0.0 (6.5) (16.0) (16.1) (109.3)

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The potential shortfall in CMH funding; and

Additional emergency pathway cost and lower EHT activity movement to NPH.

The downside financial risks have been identified, as set out in Table 55. An assessment of risk is used to test the robustness of the new Trust’s plans. However, even if the risks materialised, there may be other influencing factors that mean the new Trust would take alternative actions than those specified below. In addition, some or all of these actions would require detailed discussions with commissioners and staff.

The downside scenario reflects reduced levels of commissioner income and incorporates the combined potential impacts of national tariff changes. Also included are local factors such as increased commissioner QIPP and reduced activity and service growth levels, as well as potential slippage on the delivery of CIP schemes.

Table 55 Downside case risks

8.12.2 Downside mitigations

The Trusts have applied prudent financial assumptions to support the case for merger. These include modelling the impact of mitigating actions the Trust could take should one or more of the risks identified in the downside scenario occur. These mitigations are described below and summarised in Table 56.

The majority of mitigations relate to changes in pay rates and conditions. These include schemes like changes in sickness pay, enhancements, annual leave entitlement, incremental pay increase gateway enforcement and a few others. Some of these schemes are relatively difficult to implement and require sector wide collaboration and require time, therefore they are included in our mitigations plan and not the base case and in the later periods of the plan. A full list of pay schemes with estimated savings and basis of assumptions is shown in Appendix 8-8.

Estates scheme mitigations include estimates of closing or selling surplus estate like Clayponds. It also includes the potential impact of accelerated depreciation of the

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main EHT site which was not included in the base case (estimated value of estate £60m).

Table 56 Downside mitigations

CONCLUSION 8.13

The previous sections of this chapter have demonstrated the compelling financial case for merger. From year 2, the new Trust will be able to deliver recurrent surpluses. This surplus position of £12.2m compares with the forecast £34.5m deficits delivered in year 5 if the Trusts do not merge.

However, it is also evident that a £124.1m support package (£34.3m related to additional cost of Ealing local hospital in years 3, 4 and 5) will be required to cover short-term deficits of £54.2m, repayment of loans and leases of £26.3m, transitional Ealing local hospital support of £18m and loan repayment for NWLHT debt of £14.3m. This level of support package is justified on the basis that it delivers a positive rate of return on the costs of merger and integration. This £124.1m required support is in addition to five-year CMH income funding of £56.4m within the base case.

The above sections highlight a clear benefit of the merger case compared to a non-merger case. The modelling demonstrates that the negative cash position of the non-merger case is forecasted to be £193.6m. It also shows that if merger does not go

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ahead, the projected cash liquidity shortfall will be £164.1m higher than in the event of the merger, creating an additional funding pressure on the NHS health economy.

As part of the clinical and business challenge to ensure financial sustainability, the new Trust will need to deliver:

Merger and associated savings;

Business as usual savings; and

Respond to SaHF commissioning changes.

These are demanding requirements and ones that can only be met through a merger of NWL and EHT-ICO. By 2019/20 the new Trust will be financially viable and resilient, in a position to implement commissioner’s service re-configuration plans, and able to justify the case for the level of interim financial support required.

The merger presents a real opportunity to address the clinical critical mass issues faced by Ealing-ICO and the financial challenges at both Trusts. The financial case demonstrates that the Trusts will be ‘Stronger Together’ and provides a platform for the merged organisation to achieve FT status.


Appendix 8-1 Changes in activity flows assumed to result from SaHF

Appendix 8-2 Assumptions

Appendix 8-3 Summary of the financial impact of the main assumptions

Appendix 8-4 Summary income and expenditure (merger base case)

Appendix 8-5 Full balance sheet (merger base case)

Appendix 8-6 Summary income and expenditure (non-merger case)

Appendix 8-7 Full balance sheet (non-merger case)

Appendix 8-8 Workforce Mitigations

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9. Engagement and involvement of stakeholders

INTRODUCTION AND CONTEXT 9.1

This chapter describes the communication and activities undertaken since the establishment of the Organisational Futures Programme Board (OFPB) in April 2011 and subsequently the setting up of the Transaction Board in July 2013.

Communication and engagement was identified as a key priority early in the merger programme process and a decision was made to identify a dedicated communication lead working across EHT-ICO and NWLHT.

Chapter summary

This chapter provides an overview of communication and engagement activities regarding the proposed merger of EHT-ICO and NWLHT.

The Trusts have actively engaged with stakeholders for more than three years about the merger of their organisations.

In September 2012, when the FBC was deferred by NHS London, the pace of some communication and engagement activities slowed down. However, the Trusts did continue to update stakeholders and staff regularly via their regular communications channels and dedicated merger website.

Following the remobilisation of the programme in January 2013, the communication and engagement programme has been refreshed to take into account changes in: the merger process; the new timeline; the revised content of the business case; alignment with SaHF and plans for integration; and the development of a joint clinical strategy.

However, it is important that previous engagement is captured here and the issues raised during this time continue to be included and taken on board as the programme moves forward.

This chapter therefore covers two key phases:

Phase 1 - covers the period January 2011 to December 2012 when the Trusts embarked on an engagement programme with a range of stakeholders about the business case and the proposals to merge. It includes a summary of the key themes raised by stakeholders during this time and the Trusts’ responses to these. Formal responses received from stakeholders during this period are included in Appendix 9-1.

Phase 2 - describes what the Trusts are doing to refresh their engagement with stakeholders in light of the remobilisation of the merger programme in 2013 and the revised business plan; how they are working with the local Healthwatch organisations (which replaced LINks in April 2013); and next steps for communication and engagement as the Trusts begin to prepare for day one and beyond.

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A Communication and Engagement work-stream was established in December 2011. Membership has changed over time, but it has continued to include communication and HR professionals from both Trusts. It has also included membership from the former NHS NWL (commissioners) now CCGs, as well as advice from Brent, Ealing and Harrow LINks (now HealthWatch) and informal learning from the Barts Health NHS Trust merger programme.

The Trusts took early advice from NHS London and legal representatives regarding statutory duties on consultation regarding merger. This advice was that, under Section 25 of the NHS Act 2006 (National Health Service - Consultation on Establishment and Dissolutions - Regulations 2010), both Trusts were required to consult with their Local Involvement Networks (LINks) in relation to their proposed dissolutions. In addition, both Trusts recognised the importance of, and made a commitment to, engaging with a broader group of local stakeholders.

A communications and engagement strategy for the programme was developed as part of the OBC and included identifying key stakeholders and a programme of activity to ensure that they were kept informed and were given an opportunity to express their views. This is described below.

In September 2012, the Full Business Case was deferred by NHS London as a result of the scale of the financial challenge and the need to align the business case with the SaHF programme. This pause was also reflected in the pace of communications and engagement with stakeholders which slowed down at this time.

However, the Trusts continued to provide regular written updates to the local Overview Scrutiny Committees, updates at public meeting such as annual general meetings, and continued to use existing mechanisms to communicate with staff such as regular newsletters, joint staff side meetings, open forums for staff and the dedicated merger website.

PREVIOUS COMMUNICATION AND ENGAGEMENT ACTIVITIES 9.2

This section summarises the communication and engagement activities undertaken since the establishment of the merger programme up until December 2012.

It is important that the activity is captured so that views can be recognised and to demonstrate that there has been an ongoing dialogue with key stakeholders and the community about the merger.

A communications and engagement strategy for the programme was developed as part of the OBC and included identifying key stakeholders and a programme of activity to ensure that they were kept informed and given an opportunity to express their views.

An overview of the communication and engagement activities for the period between April 2011 and September 2012 is outlined below.

It includes: consultation with LINks; engagement with Brent, Ealing and Harrow Overview and Scrutiny Committees; responses and views from stakeholders from more than 60 events and meetings and including letters and emails; the key issues raised by stakeholders and the Trusts response; communication and engagement with staff; and the benefits of merging and subsequently becoming a FT.

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Overall, a number of stakeholders expressed support or recognised the case for change and the clinical benefits. However, they also wanted assurances on a number of issues. The original formal letters of response and support can be found in Appendix 9-1.

Main themes and issues were:

Transport and access: Links between hospitals and community sites and whether patients would have to travel further for treatment.

Impact on services: Whether services would relocate or close.

Impact on and support for staff during period of change.

Finances: Whether the merged Trust can resolve the financial challenges facing the current organisations.

Community services and out-of-hospital care: Stakeholders wanted assurance that the right support and resources would be in place to ensure that services would be developed in the community.

Whether a larger organisation is better for patients and consideration of other organisational forms: Stakeholders expressed concern that a big organisation would not be able to respond to local needs and wanted to know which other organisational options had been explored before it was agreed that there should be a merger between EHT-ICO and NWLHT.

Table 57 shows the key issues raised by stakeholders, as part of the engagement process, and the Trusts’ responses to these. While these were issues raised some time ago as part of a previous business case, it is likely they will still remain prominent areas of concern for local people and stakeholders. They will be discussed further as part of our engagement going forward.

OVERVIEW OF COMMUNICATION AND ENGAGEMENT ACTIVITIES 9.3

A summary OBC document was published online and in hardcopy in November 2011. The booklet, ‘Stronger Together: the proposed merger of Ealing Hospital NHS Trust and The North West London Hospitals NHS Trust’ set out why merger was being considered and the benefits for patients and staff. The document invited comments and views via a dedicated email address or by contacting Local Involvement Networks (LINks). A new booklet giving an update of the merger timetable and plans and describing the benefits to patients from merging was published in May 2014.

The booklet was made available to download on the Trust websites, as well as LINk and NHS North West London websites. It was offered in large print, audio, Braille and a variety of different languages on request. A poster was published and put up around the Trusts’ sites to encourage people to pick up a copy of the document. More than 12,000 copies have been circulated and recipients included:

all GP practices in Brent, Ealing and Harrow, CCGs and NHS Brent and Harrow and NHS Ealing, Hillingdon and Hounslow;

MPs and assembly members;

voluntary organisations, community groups and LINks across Ealing, Brent and Harrow, as well as libraries and religious organisations;

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local authorities including mayors, chief executives, councillors, and chair and members of Brent, Ealing and Harrow OSCs (Overview and Scrutiny Committees);

NHS organisations, including PCTs (now Clinical Commissioning Groups -CCGs), in NWL; and

staff across EHT-ICO and NWLHT.

A dedicated section on each of the Trusts’ websites was published, giving people access to documents related to the merger and the latest news. A microsite was launched at the beginning of February 2012, bringing together all relevant information about the merger into one place. The website continues to be regularly updated.

Senior staff from the Trusts and the merger programme team regularly attended meetings and events with stakeholders including staff, OSCs, CCGs, LINks, MPs, GP commissioners and voluntary organisations, including West London Citizens.

Three borough deliberative events for stakeholders were held in May and June 2011. A final report was published on websites and shared with commissioners and Clinical Working Groups. Feedback from the events was used in the development of the non-financial evaluation of scenarios in the OBC. Recommendations and an action plan were agreed by the Programme Board.

The three local LINk organisations held events in December 2011 to seek the views of the public and their members on the proposed merger. Harrow LINk had also held an event on 27 June 2011.

A range of events have been held for staff and information was cascaded through the regular communication channels within each Trust. These included intranet, staff bulletins, screensavers, noticeboards, open events and information stands.

Voluntary organisations across Brent, Harrow and Ealing received copies of the summary booklet. The Medical Director of The North West London Hospitals gave a presentation at two local voluntary organisation meetings (Community Voice and Hatch End Residents Association) which included information about the merger. In addition, West London Citizens organised a number of major public events, attended each time by more than 300 members of the community in Ealing, to discuss the merger and the commissioners’ process for consultation on SaHF.

A range of clinical engagement events were held. As part of the development of the OBC, five clinical working group meetings were held with clinicians across the two Trusts and GPs in April and May 2011. In September 2011, an event led by Medical Directors reviewed opportunities for collaboration across the two Trusts and considered whether some could start before the merger. In January 2012, more than 60 staff attended an event that was facilitated by The Kings Fund. The aim of the event was to support the development of effective clinical teams in the new merged organisation, with a focus on integrated care.

Clinical Commissioning Group chairs were invited to join and are represented on the Organisational Futures Programme Board (now Transaction Board). All GP practices and commissioners in Brent, Ealing and Harrow received a copy of the summary booklet and covering letter. Information about the merger was also provided through the NWLHT GP e-newsletter which is distributed to GP practices across Brent, Harrow and Ealing.

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Table 57 Summary of issues raised by stakeholders and the Trusts’ response to these

Issues raised Our response

Transport and access: This included poor links between hospital and community sites and whether patients would have to travel further for their treatment. Concerns were raised about how relatives would visit their loved ones in hospital if they had to travel longer distances.

While a merger in itself will not result in significant changes to services, the Trusts recognise that transport is one of the main concerns for local people and a key issue at public and staff events. It was a key issue raised during the SaHF consultation.

Some stakeholders recognised that, for life-threatening conditions, it was more important to get to the right specialist, even if it takes a little longer. However, many people were concerned that, for other more routine treatments or health checks, they might have to travel further distances, which could be difficult for older people or people with disabilities. Stakeholders also highlighted poor public transport links between hospitals and community sites.

Public consultation on SaHF across North West London has analysed transport and access issues as part of the consultation. A Travel Advisory Group was established to support this piece of work.

The Trust is committed to providing its own internal transport service for staff and patients to ensure easy access to services between sites.

Impact on services: This included whether services will relocate or close as a result of merger. In the event of services moving, how Northwick Park Hospital would be able to cope with additional patients.

Many of the issues raised by stakeholders were about the impact the merger would have on services and whether services would close or move to another hospital or site. There were particular concerns about A&E services.

Previous business cases and this one make the case for organisational merger and not significant changes to services. However, as part of the development of the business case, the Trusts have to take into account what services may look like in the future. Therefore the business case is aligned to the proposals set out in Shaping a Healthier Future which have now been consulted on and approved by the SoS for Health.

The BC describes clinical benefits from an organisational merger without the need to make significant changes to services and this is described in more detail in chapter five.

In terms of Northwick Park Hospital’s ability to cope with any additional patients as a result of merger, NWLHT is implementing a number of measures to improve capacity as a result of recent increases in demand for emergency services and the development of more specialist services, such as stroke.

For example, the Trust has transferred the majority of routine elective services to Central Middlesex to free up capacity at Northwick Park Hospital.

A new 24/7 urgent care centre at Northwick Park Hospital has been opened. The Trust is also building new £21m A&E and new £14m theatres which are due to open in 2014.

A further £48m of capital monies has been earmarked for the implementation of SaHF. The money will be invested in a new larger ITU (Intensive Therapy Unit?), larger theatre recovery

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capacity and a new acute admissions unit.

Impact on and support for staff during period of change: Stakeholders wanted more information about the impact of the merger on staff, whether the merger would result in redundancies, what support was being offered for staff and how the Trusts would continue to retain their staff.

There has been a programme of engagement and communication with staff to ensure they were given opportunities to express their views or find out more about the proposed merger through a number of channels.

The Trusts have established a joint staff-side forum to engage with staff-side representatives from both organisations, and as a means of seeking their input into the various support strategies, policies and initiatives which will be required in the run up to the merger and beyond.

It is vital that this programme of activity and opportunities for two-way feedback is continued beyond Day 1 of the new organisation, and this is reflected in the emerging Organisational Development and Communications and Engagement Strategies which support the Full Business Case. Both of these strategies build on the programme of engagement to date and best practice from within both organisations.

The Trusts recognise that any period of change can be unsettling for staff, particularly those in leadership roles and corporate functions, who undertake work relating to the preparation and implementation of these changes.

To ensure that key staff are retained, we will continue to ensure that information is made available to staff in a clear, timely and transparent manner and that staff know the timetable and key dates within this information.

When such staff leave prior to changes taking place, we will explore whether roles can be covered through acting up, secondments or cross-cover to maximise the development opportunities available to staff while ensuring business continuity.

One of the key priorities for the joint staff-side committee is agreeing a Change Management Policy (based on the principles contained in the Pan London Framework) which will provide the basis to ensure that all change following the merger is handled consistently and is seen to be fair.

Principal objectives will be minimising the number of compulsory redundancies and associated costs through a combination of staff turnover, good establishment control mechanisms and robust redeployment which recognises the grade and transferable skills and transferable knowledge of many of our staff.

When redundancies are required, we will ensure that staff are provided with appropriate practical support, such as career advice, preparing a CV and interview skills training.

Finances: Whether the merged Trust can resolve the financial challenges facing the current organisations?

The BC includes detailed financial modelling for the next five years that will demonstrate how the new Trust will be financially sustainable in the longer term. It will also demonstrate that the financial position of the merged Trust is significantly better than that for either of the individual Trusts if

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they were not to merge.

Community services and out-of-hospital care: Stakeholders wanted assurance that the right support and resources would be in place to ensure that services would be developed in the community. Staff wanted assurances that community services would be strongly represented within the new organisation and that there would be true integration.

As part of discussions with commissioners, there is a commitment to ensure appropriate re-investment of a proportion of resources that would traditionally be spent on hospital care into the development of community services. Clinicians from the Trusts are involved in developing an Out-of-Hospital strategy with GP commissioners as part of the SaHF consultation.

Community services staff wanted reassurances that they would not be seen as ‘poor relations’ to acute/hospital care. Initial proposals for clinical structures in the new organisation are being developed and there is universal support for ensuring that community services are well represented.

Whether a larger organisation is better for patients and consideration of other organisational forms: Stakeholders expressed concern that a big organisation would not be able to respond to local needs and wanted to know which other organisational options had been explored before it was agreed that there should be a merger between EHT-ICO and NWLHT.

Some stakeholders wanted assurance about a larger organisation continuing to meet differing local health needs. In developing structures for the new organisation, community teams would continue to remain borough-based and work with the three local authorities in Brent, Ealing and Harrow. This would be balanced with the other benefits a larger organisation could bring, such as the creation of larger clinical teams and more specialist care, efficiency savings through back office functions and reducing duplication.

With our NHS partners, we undertook an appraisal of eight distinct potential future organisational configurations in the autumn of 2010. This was reported to both Trust Boards in January 2011 and is available from merger website http://www.NWLHT.nhs.uk/stronger-together/why-merge/background.cfm and was also an appendix to the OBC.

The different organisational combinations were assessed against an agreed set of financial and non-financial criteria, such as implications for patient care and feasibility of implementation.

The panel agreed that the most favourable option was a merger between EHT-ICO (including community services) and NWLHT. The panel’s strong view was that the merger of these two would allow the Trusts to capture the benefits of increased scale most effectively and deliver the highest quality of care to local people, as a result of being an integrated Trust providing hospital and community services.

REFRESHING OUR STAKEHOLDER ENGAGEMENT 9.4

Stakeholders’ involvement in the merger and integration process remains a priority. Following the decision in early 2013 to proceed with the merger transaction, the pace of communication and engagement activities has gained momentum. The Trusts have also embarked on a programme of developing a joint clinical strategy, joint working and early integration of specific services where it makes sense to do so. This is a key focus for engagement going forward.

http://www.nwlh.nhs.uk/stronger-together/why-merge/background.cfm

http://www.nwlh.nhs.uk/stronger-together/why-merge/background.cfm

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The Trusts developed a framework for engagement and communications that aligns with communication and engagement programmes to support the implementation of SaHF proposals.

Although the fundamental reasons for the merger have not changed, future communications will aim to explain what is different. For example, the new timeline and process, alignment with SaHF, clinical integration and the new financial model.

The Trusts will continue to use existing mechanisms established to support the merger programme such as the regular ‘Stronger Together’ newsletter and dedicated website and merger email address.

9.4.1 HealthWatch and Stakeholder Reference Group

In July 2013, the Trusts formed a Stakeholder Reference Group (SRG) to ensure continued user/public involvement in the merger programme. It meets monthly and membership includes the chairs of HealthWatch Brent, HealthWatch Harrow and HealthWatch Ealing. The SRG has two key roles:

the first is to keep HealthWatch updated on the merger programme and give them early sight of documents to ensure the patient view/user involvement is incorporated; and

the second is an advisory role to help revive engagement and ensure best practice.

In particular, the group will be looking at how we bring stakeholders into the clinical integration work to support integration and the development of a joint clinical strategy.

Members will also act as a link to other voluntary and community organisations. ToR are attached in Appendix 9-2.

The SRG meets on a monthly basis and agreed that early engagement is essential if stakeholders are to have any real impact on the clinical integration process.

As a result, a toolkit is being developed by the communication and engagement work-stream to ensure that teams in the process of integrating are aware of their engagement responsibilities, the importance of involving patients in service design, and the support available if they need it.

Extra communications and engagement support has been resourced and a communications manager dedicated to integration is now in post. A key part of this person’s work will be to support the development of a communication strategy for the integration programme.

COMMUNICATION AND ENGAGEMENT WITH OTHER 9.5STAKEHOLDERS

9.5.1 Trust staff

Throughout the merger programme, staff have been updated on progress via a range of existing and new mechanisms across both the Trusts.

In September 2013, the Trusts re-launched the ‘Stronger Together’ newsletter for stakeholders: re-stating their commitment to the merger; updating on the new

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process and timeline; communicating plans for integration and the joint clinical strategy; and outlining work with the newly set up SRG.

The newsletter was designed largely for staff but was also sent to key stakeholders including: Overview and Scrutiny Committees; MPs; CCGs; Harrow, Brent and Ealing HealthWatch; and those on the merger programme mailing who have attended previous public meetings or asked to be informed of developments.

Chapter six describes some of the recent engagement that has taken place, specifically with clinical staff regarding the development of a joint clinical strategy and opportunities for early integration and joint working. All clinical services will need to develop an integration plan for implementation within the first year of merger.

Following the remobilisation of the programme in early 2013, senior clinical leaders from both organisations have continued to be involved in both the business case development and overseeing the clinical integration agenda. A series of strategic workshops have also been held with key staff.

All staff were then updated on clinical integration workshops via Team Talk (a core briefing for managers cascaded to staff at NWLHT), and the Chief Executive’s Friday message at EHT-ICO, as well as open forums held at each Trust. These update mechanisms will continue as the integration process develops.

9.5.2 Joint Staff Side

A Joint Staff Side Committee was established early in the merger programme and continues to meet regularly. Communication is a standing item on the agenda and, where possible, written communication is shared with the committee in advance of it being issued to all staff. Every effort is made to ensure messages to staff across both organisations are issued at the same time.

9.5.3 Overview and Scrutiny Committees (OSCs)

The Trusts have continued to provide regular updates about the merger to the three Health OSCs in the form of reports or through senior managers attending meetings. As mentioned above, the Committees have received a copy of the re-launched ‘Stronger Together’ newsletter.

9.5.4 Clinical Commissioning Groups

The three local CCGs are members of the Transaction Board and regular meetings have taken place with them to discuss the merger programme. In September 2013, the CCGs formalised their support in principle for the merger in a joint letter of support (see Appendix 9-3). Further meetings are planned with the CCG’s to discuss the FBC and to formalise their support.

9.5.5 Public

A Communication and Engagement Plan is being developed with the SRG to ensure that broader engagement is refreshed following the publication of the business case. However, the public still have access to the dedicated merger website and are invited to email comments via the dedicated merger email address.

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COMMUNICATION AND ENGAGEMENT PLAN FOR THE BUSINESS 9.6CASE AND FBC

The Trusts continue to provide regular updates on key milestones to stakeholders, such as approvals from TDA and DH. A Stakeholder Reference Group has been launched and a micro-site about the merger created. Newsletters and letters continue to be published updating staff and the public about progress toward merger.

The statutory consultation requirements that are part of the final merger approval process will be met by the TDA and Trusts issuing joint letters to Healthwatch and staff representatives. These will advise partners of the Secretary of State’s intention to seek Parliamentary approval for orders to dissolve the existing Trusts, create a new Trust and transfer of assets into the new Trust.

Consultation letters were approved by the Trust Boards in June and the six-week consultation period concludes in early August and prior to the Secretary of State’s approval process. This provides opportunities to meet with partners to clarify any questions that may arise during the consultation period.

ADDITIONAL KEY AREAS OF COMMUNICATIONS AND ENGAGEMENT 9.7ACTIVITY

9.7.1 Clinical integration and developing a joint clinical strategy

The two Trusts have already embarked on a programme of reviewing clinical integration, joint working opportunities pre-merger and the development of a joint clinical strategy across key specialties ahead of the merger (see chapter six).

After the Board gave the go ahead to set up six clinical teams across both organisations, a series of workshops for clinicians and managers were held in May, July and October 2013 to explore the potential and benefits of early integration

Facilitated by the toolkit mentioned in section 9.4.1, communication and engagement strategies will be developed to ensure appropriate and timely stakeholder engagement for each of these teams.

The clinical integration programme is ongoing and team’s progress will be communicated to staff and stakeholders through regular updates in the ‘Stronger Together’ newsletter, on the intranet and on the dedicated merger website, as well as at public and staff events.

9.7.2 Day 1 and beyond

A communication and engagement strategy for the new organisation is being developed and this – alongside Human Resources, Organisational Development, and patient and public involvement strategies – will set out ways in which the new organisation will continue to engage with its local communities, partners and staff (see Supporting Document 5-1).

9.7.3 Visual branding and the development of a new website and intranet

Visual branding and a name for the new organisation – London North West Healthcare NHS Trust – were agreed by the shadow executive of the two Trusts in the last year. Visual concepts have been agreed and the design for the intranet and

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website has been signed off. Both Trusts will have a new shared website and intranet carrying the brand identity for Day 1. The sites have been built and some content migration has started to take place.

9.7.4 Integrated Communications Plan

To cover the transition period from SoS approval to Day 1 of the organisation, the communication and engagement work-stream will be involved in developing an integrated communications plan with other work-streams. Encompassing communication, engagement, cultural change and change management, the plan will ensure that key communication mechanisms are in place for Day 1 – including joint newsletters and intranet for staff (Appendix 9-4).

FUTURE COMMUNICATION AND ENGAGEMENT 9.8

It is important that the new organisation continues to listen and respond to feedback from its staff, local community and partners as Day 1 approaches, but also well beyond that milestone.

As part of the merger programme, eight work-streams have been established and, in line with their design principles, they are considering all the required stakeholder engagement when developing and agreeing their implementation plans.

A communication and engagement strategy for the new organisation is being developed and this – alongside HR/OD and Patient and Public Involvement strategies – will set out ways in which the new organisation will continue to engage with stakeholders (see Appendix 9-5) and achieve its key vision and goals.

It is important to emphasise that communication is the responsibility of the whole organisation and everyone who works for it. However, for the above strategies to be successfully delivered there needs to be an appropriate level of resource and expertise within the new Trust. The communication teams of both Trusts are small but have met to discuss the future role of the communications and engagement function, its vision and future structures.

The vision includes developing a communications and engagement function which:

moves from being reactive to proactive, and from informing to engaging;

is closely aligned and integrated with key areas such as: organisational development, patient experience and involvement, and business planning and development; and

achieves excellence in communications and engagement through best practice.

When the FBC is approved, the merger programme will have ongoing dedicated resource to ensure that communication and engagement activities can continue to be implemented, building on the work to date.

Crucially, there will be a focus on building internal and external support for the new organisation and ensuring stakeholder engagement in developing its values and vision to provide the highest quality of care to its communities.

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Appendix 9-1 Formal responses received from stakeholders

Appendix 9-2 Terms of Reference for the Stakeholder Reference Group

Appendix 9-3 CCG and NHS England letters of support in principle (September 2013)

Appendix 9-4 Integration communications plan for the transition period


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10. Integration and implementation plan

INTRODUCTION 10.1

The EHT-ICO and NWLHT Merger Programme was established to develop the business case and full business case for the merger, and to provide structure, support and governance arrangements for the development and implementation of integration plans for all corporate and clinical services across both Trusts. This work has been ongoing since the approval of the OBC in November 2011 and is supported by an in-house Programme Management Office (PMO).

PROGRAMME GOVERNANCE ARRANGEMENTS AND STRUCTURE 10.2

Figure 23 outlines the programme governance arrangements which are in line with The TDA Accountability Framework.104 ToR for all of the boards, committees and workstreams can be found in Appendix 10-1.The programme is divided into subject matter-specific workstreams, each owned by a Board director and supported by a dedicated team of project and subject matter specialists.

Each workstream is responsible for designing its own future state (processes, technology and infrastructure, information needs and organisational structure), their integration and implementation plans and for supporting all other workstreams in delivery as subject matter experts. These plans have then been reviewed, challenged and refined at the Merger Programme Operating Board (MPOB). The MPOB operated until April 2014 when it was agreed that the newly formed Joint Executive Team Meeting (JETM) would provide a better oversight to the programme.

The programme also consists of a joint QIPP workstream that supports both Trusts and all other workstreams by advising on improvement targets and providing

104 Delivering High Quality Care for Patients: The Accountability Framework for NHS Trust Boards,

trust Development Authority April 2013.

Chapter Summary

This chapter outlines the programme’s approach to integration planning and implementation, including:

the programme governance arrangements and structure;

the PMO;

risk and issue management;

the high-level timeline and assurance;

iterative development of the implementation plans;

progress to date and high-level timeline for fully integrated trust; and

the benefits realisation framework.

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expertise on cost saving opportunities and initiatives.

Figure 23 Schematic transaction and integration/implementation programme governance arrangements

THE PROGRAMME MANAGEMENT OFFICE 10.3

The programme is coordinated centrally through a formal in-house PMO that reports directly to the programme’s Senior Responsible Officer (SRO). The role of the PMO is to give assurance and support to the planning and delivery of the programme.

By centrally coordinating the overall programme plan, the PMO is able to provide the JETM, Transaction Board and Trust Boards with appropriate assurance that the implementation plan covers every area of the two Trusts. Central oversight also ensures that there are no gaps in delivery and critical work-stream interdependencies are identified, understood and planned for.

In addition, the PMO supports a rigorous tracking and reporting framework to provide delivery assurance to the Board and give early sight of any potential risks and issues to delivery.

Workstream leads complete a monthly dashboard report that is pre-populated by the PMO with milestones and activities from the programme plan for that reporting period. A member of the PMO then works through the report with the lead to provide ‘check and challenge’ and to flush out any potential risks and issues. The workstream reports are then combined into a programme report that is reviewed at the Workstream Leads meeting, escalated as necessary to the JETM and reported to the Transaction and Trust Boards.

RISK AND ISSUE MANAGEMENT 10.4

The programme has a central risk and issue register and a risk review is held monthly with the workstreams to identify new risks and issues, as well as track mitigation progress on existing ones.

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Each risk is assigned a responsible owner to give senior oversight, as well as an actionee who is tasked with the mitigation activity. Risks are rated on a five-point scale for both impact and likelihood.

Risks beyond the tolerance of the workstream lead, or those affecting other workstreams or the overall critical path, are escalated to the Workstream Leads, JETM or Transactions Board as appropriate.

The full programme risk and issue register (as it stood at time of submission) can be found in Appendix 10-2.

TRANSACTION TIMELINE AND ASSURANCE 10.5

The summary transaction timeline agreed with the TDA shown in Figure 24 is included as part of the implementation plan (Supporting Document 10-1). This details the key milestones including: the three due diligence exercises (clinical, legal and financial); the process to the funding agreement; and the Secretary of State approval of the disestablishment/establishment/transfer orders.

Figure 24 Transaction timeline to merger on 1 October 2014

ITERATIVE DEVELOPMENT OF THE IMPLEMENTATION PLANS 10.6

The PMO has been supporting the planning process by providing an overarching planning framework, supplying planning expertise to the workstreams and by overseeing the iterative drafting and redrafting of plans. Throughout this process, the PMO ensures that dependencies between plans are identified and highlighted.

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The PMO provides ongoing ‘check and challenge’ and carries out a quality control function at each iteration of the plan; for example, testing the feasibility of planning assumptions against the overall timeline, resource requirements, dependencies, constraints, assumptions and risks.

Initially, the workstreams were given a set of high priority deliverables (Table 58) that were subject to peer review either at the MPOB or at the workstream leads meetings.

Table 58 Workstream priority deliverables

Priority deliverable Peer review forum

Organisation Current State MPOB

Organisational Future State MPOB

Cross Workstream Dependencies (to include future IM &T and Estate’s needs, HR and Communications support to planning and implementation)

Workstream Leads

Day 1/Day 100 Deliverables Workstream Leads

This information was then used to create initial draft work-stream plans that were checked by the PMO to identify further dependencies, synergies and resource implications. The plans have since been in a state of continuous development with PMO support and MPOB review.

PROGRESS TO DATE AND HIGH-LEVEL STEPS TO A FULLY 10.7INTEGRATED TRUST

The programme has taken a staged and cautious approach to planning and implementing change. It was agreed at the outset that the corporate workstreams would push forward with integration ahead of clinical ones, thus creating stable support functions and reduce risk for subsequent clinical change.

10.7.1 Pre-merger planning and implementation

Following the re-launch of the programme in January 2014, the corporate workstreams were encouraged to pursue early integration and bring forward changes that were not merger-date dependent. All corporate workstreams have commenced implementation activities and are at varying stages in terms of fulfilling their plans. However, it is expected that a high percentage of integration will be complete by Day 1 and all corporate plans will be complete by end of this financial year.

Pre-merger clinical work has focused on engagement and prioritisation. A series of clinical engagement workshops involving clinicians from each Trust has been completed, and an exercise to engage senior member of both Trusts in creating a prioritised list of clinical services for integration has been completed. These exercises have laid a foundation for actual integration which will be managed through the Operations Workstream post-merger.

The Operations Workstream is implementing joint planning and scheduling arrangements that will go live from Day 1.

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Appendix 10-3 gives a high-level pictorial view of the workstreams’ Day 1 and Day 100 plans.

10.7.2 Implementing future states

Plans to implement future states are taking a top-down phased approach. Executive director (‘Tier 0’) appointments will be in place before the merger with ‘Tier 1’ (senior staff reporting directly to executive directors) and ‘Tier 2’ appointments (typically heads of significant functions) to follow around the merger date.

10.7.3 Handover planning

In preparation for a safe transition to the new organisation for patients and staff on Day 1, the Trusts have established a programme of handover preparations around critical areas as outlined in Table 59.

Table 59 Handover preparation summary

Critical Area Rationale Approach

Anticipated change

Not expecting any significant service change on Day 1.

Bespoke project plans and leadership for known service changes to service, e.g. CMH A+E or EHT maternity

Changes to corporate functions /systems will be clearly articulated, project managed and tested in advance of Day 1 i.e. PAS reporting and payroll, bank accounts etc.

Constant review and update of existing corporate integration plans

On-going development and refinement of service change plans with relevant staff and stakeholder groups

Roles and responsibilities

Maintain clarity on lines of decision-making and escalation responsibility, regardless of whether BAU arrangements are changing immediately post-merger

Although chains of command may be well-known, it is likely for there to be some uncertainty post-merger

Individual work stream development of future structures, reporting lines and d1 delivery plans

HR/OD work-stream oversight of all plans supported by communication and engagement even where no change envisaged

Unexpected events

Reminding staff of the processes, arrangements and business continuity plans that are already in place to manage potentially serious circumstances, to avoid any unnecessary delays in response

Communication of all relevant policies, processes and escalation arrangements

Operational Intranet for Day 1

develop list of scenarios with joint executive, work-stream directors, operational directors and undertake scenario-testing events

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Critical Area Rationale Approach

Business critical resources and processes

Reminding staff of the processes and arrangements that are already in place to manage business as usual, to avoid unnecessary post-merger dip in performance or quality of care

Ensuring there are readily available answers to ‘who, what, where’ questions concerning critical people, equipment, facilities etc. across the sites and services

Focus on current operational challenges and recovery plans

review and respond to due diligence recommendations

Continue to drive post Day 1 planned service improvements

Trust wide staff communication and engagement

Organisational memory

To reduce the potential loss of vital information, including knowledge of where information is held, by identifying where information is and the key individuals

prepare handover notes containing key information

IT database archiving solution

The new Trust’s intranet and external website will play a vital and central role in ensuring that important information is available and can be readily consulted. Although the amount of change on Day 1 is deliberately being kept to a minimum, detailed handover materials are being prepared for those services, processes and escalation arrangements that are changing. These materials will inform members of staff and, where appropriate, patients about what will be different and what to do in certain specific situations.

In support of a seamless handover, a series of scenarios testing key business processes will be rolled out in August 2014 so that lessons learned from these practice sessions can be incorporated into handover plans and information materials during September, i.e. ahead of Day 1. Following Day 1, as the clinical services work towards integration, further scenarios may be identified.

10.7.4 Post-merger integration

The corporate workstreams will complete their integration by early 2015.

The Operations Workstream will begin to work through clinical integration activities following Day 1. The integration process is expected to take about two years to complete and will be approached using phases where small cohorts of service areas will integrate at any one time, thus maintaining a controlled and reduced risk approach to change.

10.7.5 Benefits realisation

In line with most large-scale change, it will take several years for the benefits to be fully realised. Although it is anticipated that financial benefits will be realised from Day 1– in line with future state implementation and predictions in the LTFM – the clinical benefits are expected to take shape in the two years post-merger and henceforward the Trust will expect full realisation.

Chapter five identifies the range of service benefits the merger will bring, which include providing vitally important support and immediate action to tackle the existing operational challenges at both Trusts discussed extensively in chapter two.

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The accompanying benefits realisation plan (Supporting Document 10-2) sets out in more detail how, post-merger, the Board and leadership of the new Trust will assure themselves that the clinical synergies and service and organisational improvements that should flow from the merger are being delivered.

In this, the Board and other critical partners will be supported by a dedicated PMO, governance and reporting arrangements. Close and constant monitoring of progress being made in implementing the integration and transformation plan, will go hand-in-band with tracking of the quality of patient care, outcomes and experience as the ultimate benchmarks against which the successful progress of the merger will be judged.


Appendix 10-1 Terms of reference for transaction programme governance structure

Appendix 10-2 Programme risk and issue register as of time of submission

Appendix 10-3 High-level Day 1/Day 100 plan

Supporting Document 10-1 Implementation plan

Supporting Document 10-2 Benefits realisation plan

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