lambeth sw locality practice based commissioning consortium web viewby commissioning the proposed...

Streatham & Clapham Health

Business case Commissioning a Community Based

Ultrasound Service

Prepared by:

Streatham & Clapham Health PBC business case

March 2008


This document sets out the business case for developing a Community Based Ultrasound through practice based commissioning. The Streatham & Clapham Health PBC Consortium proposes to commission this service from 01 October 2008. This business case is presented using the template provided by Lambeth Primary Care Trust (PCT) and starts with background on the Streatham & Clapham Health consortium and its commitments to date.

SECTION A CONSORTIA OVERVIEW 1.0 PRACTICES IN THE CONSORTIUM

Streatham & Clapham Health (PBC) consortium is an organisation of 18 practices in Streatham and Clapham. The practices are working together in a consortium to commission high-quality, local services for around 110,080 registered patients

Table 1 shows the practices in the consortium and their list sizes.

Practice List sizeClapham Family Practice 14,386Dr Ala’s surgery 2,336Dr Santamaria 2,980Dr Gunasuntharam’s surgery 3,778Dr Ramanan’s surgery 2,995Drakewood Road Medical 3,531Edith Cavell Practice 5,550Hetherington Group 10,020Pavillion surgery 6,639Sandmere Road Practice 16,310Streatham Common Group 7,978Streatham High Practice 2,407Streatham Place Surgery 8,311Prentis Road Surgery 6,945Clapham Park Group Practice 12,543The Courtyard Surgery 4,448The Exchange Surgery 2,231Valley Road Surgery 5,692TOTAL 110,080


1.1 The consortium’s three key priorities for 2008/09 are:

To develop Community Based diagnostic service particularly ultrasound

To develop a community based anticoagulation monitoring service

To develop a local base for Out of Hours unplanned care

Other areas that the consortium would like to address are:

Sexual health services including monitoring of CD4 counts in HIV positive patients

Management of long term conditions including COPD, renal diseases and hypertension and diabetes

Management of patients with substance misuse

Urology

Community based ophthalmology

Community based Adult audiology

Ear, Nose and Throat services

Community based dermatology

1.2 Description of consortia support to delivery of 2008/09 key targets, including primary care extended hours access, health promotion and prevention, support to relevant acute sector targets, national and local QOF targets and Standards for Better Health

The practices commit to helping the PCT deliver key 2008/09 key targets. Specifically, the consortium has committed to:

Continuing to supporting practices to improve their QOF scores and to deliver the necessary information for Lambeth PCT’s local QOF targets

Continuing to deliver excellent patient access and participate in the Extended Hours DES. Compared to London as a whole, Lambeth achieved a higher level of satisfaction on the access indicators which include Telephone access, 48 hours access to a GP, advanced bookings.


Continuing use and uptake of Choice and Booking even though the DES incentives have been removed.

Continuing to explore opportunities to support the 18 week and 2 week cancer waiting times targets.

Demonstration of a commitment to health promotion campaigns for “Staying healthy” including full participation in the primary care stop smoking service and support for patients with substance misuse.

Use the predictive model to develop care plans for patients with long term conditions to better manage their conditions and reduce the likelihood of emergency hospital admissions.

Support the development of a Primary Care led Sexual Health service in the Clapham neighbourhood.


1.3 Description of consortia support to overall PCT 5 year Strategy priorities i.e. long term conditions, Birth, Children and Young People, Sexual Health, Mental health, Staying healthy, Planned care, Unplanned Care, End of life care and Development of Primary and Community care infrastructure

The practices support the nine priority areas set out in the PCTs 5 Year strategy. These are:

Long term conditions

Birth, Children and young people

Sexual health

Mental Health

Staying Healthy

Planned care

Unplanned care

End of life care

Development of Primary and Community care infrastructure

Examples to illustrate the consortium’s commitment include:

Long-term conditions - the consortium has agreed a business case to provide a Local Enhanced Service (LES) for post-treatment follow-up for patients with PSA-stable prostate cancer. The scheme aims to provide patients who require routine follow-up blood tests or other investigations following treatment for prostate cancer, the opportunity to have these tests within the primary care setting.

Children and young people - the consortium Board is encouraging practices to attend the GP forum this month which is about team around the child.

Sexual health - the consortium has members on the Lambeth steering committee on sexual health provision and practices in the consortium are biding to provide the GP lead Primary Care Sexual health services in Clapham.

Mental Health – piloting a new model of case management of patients with depression


Planned and unplanned care – through the work done around demand management and now with future access to the predictive tool the consortium has worked to both reduce demand and understand the requirement for unplanned care and along with the community matrons implement case management to avoid unnecessary emergency admissions.

Developing Primary care infrastructure – two consortium practices have moved into new premises at Gracefield Gardens along with PCT and local council staff as the first phase of a potential GP Led health center “hub and spoke” arrangement.


SECTION B

2.0 SERVICE TO BE COMMISSIONED AND RATIONALE

2.1.1 Proposed service

This business case is for a community-based ultrasound service, providing a local diagnostics service for all Lambeth patients. The Streatham & Clapham Health (PBC) consortium proposes to commission this service from 01 October 2008. The service will redesign the care pathway for a group of patients who previously would have been referred to hospital-based diagnostics and either been referred into an outpatient follow up or discharged back to their GP.

This proposal is also in line with current policy on moving diagnostic services closer to the patient as highlighted in lord Darzi’s review and the vision of the polyclinic model of care. The proposal also interfaces and will further enhance the successful MSK service currently commissioned by the consortium. This bid is for service substitution more than new business activity although it may well generate additional activity due to it location.

Through commissioning the Community Based Ultrasound Service (CBUSS), the consortium aims to reduce overall referrals to orthopaedics, rheumatology, endocrinology and general medicine hospital outpatients by 20 per cent.

The forecast annual cost for the CBUSS is £922,500 based on 20,400 scans at its optimum throughput. The forecast potential net savings for commissioning the CBUSS model are £124,118.

The CBUSS will be able to recommend referral into primary care clinicians with specialist interest in orthopedics, rheumatology, endocrinology, gastroenterology and urology and be able under the governance arrangements to access consultant advice.

The service will:

Scan and save the digital images, report recommendations for patients who have been referred for either onward referral or discharge back to the GP for the following:

Abdomen Pelvis Small tissue (e.g. Thyroid, Testicular) Muscoskeletal Breast


USS guided diagnostics Antenatal Service

2.1.2 Current service

Currently, all GP referral are to a hospital based service. The SW locality refers patients to Guy’s and St Thomas’ NHS Foundation Trust, St George’s Healthcare Trust and King’s College Hospital NHS Foundation Trust. In common with the national picture, hospital based services have struggled to keep up with high demand.

Local GPs and national research with patients and clinicians have identified several problems with the current services.

There are significant delays in accessing diagnostic ultrasound. A local based service would be more accessible to all patients and reduce

travel time significantly Only around 50% of patients referred require further outpatient

appointments or go on to require surgery Fewer delays in diagnosis will result in patients being referred to the most

appropriate service and clinician

This business case proposes to commission this CBUSS through practice based commissioning. The service will be commissioned on a cost per scan basis at two levels. Level 1 for a scan lasting less than 15 minutes £45.00 and over 15 minutes at £65.00

Section 2.11 sets out the financial basis for the business case, including forecasts for the number of referrals, onward referrals with costs and anticipated cost savings.

The following section sets out the objectives for commissioning a community based CBUSS and the rationale underpinning these goals.

2.1.3 Aims and rationale for the proposed service

The main aims for the service are to:

Give access to Community Based Ultrasound services for patients

Extend choice of location for patients

Increase the number of patients seen in the community and reduce referrals to hospital based outpatient appointments


Reduce waiting times

Provide a cost-effective Community Based Ultrasound service.

Rationale for the proposed service changes:

There is high demand for Ultrasound services and much of the need is unmet. Orthopaedics and Rheumatology are two of the top 5 overspend areas and the PCT priority areas for reducing referrals in 2007/08.

The total forecast spends for 2007-08 on first outpatient attendances and follow ups to:

Trauma and orthopaedics for the consortium is £704,292 for 2,531 1st OP and 4,086 follow ups ratio 1:1.61

Rheumatology is £268,768 for 534 1st OP and 1,400 follow ups ratio 1:2.62

Endocrinology is 119,618 for 259 1st OP and 656 follow ups ratio1:2.53 Gastroenterology £183,869 for 502 1st OP and 849 follow ups ratio 1:1.69 Urology is £225,052 for 700 1st OP and 1,281 follow ups ratio 1:1.83

Total spend forecast for 2008-09 for the consortium in these specialties is £1,499,599

Even a small change in the number of referrals will result in a significant reduction in spend.

There’s good evidence to show that people can be dealt with effectively and safely in non-hospital settings such as CBUSS.

Such services can ensure that patients are actively managed by skilled staff, rather than being lost in the system or ‘bounced around’ and thus help patients to receive treatment at the appropriate time and in the most appropriate place.

Establishing a CBUSS can improve the conversion rates through rapid access diagnostics By decreasing demand on hospital based services, CBUSS can also reduce waiting times for people who need specialist care, particularly surgery.


2.2 STRATEGIC OBJECTIVES AND OUTCOMES, INCLUDING FIT TO PCT STRATEGY

This section outlines the strategic objectives for the Community Based Ultrasound service (CBUSS) and describes how these will support national and local PCT strategy. 1 Providing care closer to home

A key objective of the proposed service is to offer rapid access to diagnostic ultrasound services and a service in a community setting close to people’s homes. The proposed centers at Gracefield Garden’s and Clapham High Street can be easily accessed by patients from Clapham and Streatham practices as well as from Brixton and Stockwell areas. This would negate the necessity for patients to travel to distant secondary care providers for this type of diagnostic service. This will offer an access driven and locally based service operating at time convenient to patients.

This is in line with the January 2006 White Paper Our Health, Our Care, Our Say. In this, the Government made it clear its strategy was not simply to rely on expanding hospital capacity but to use the extra investment to modernise the way services are delivered in order to expand the choices available to patients. Part of this was a commitment to increase the amount of activity which takes place in primary and community settings with for example, more outpatient and diagnostics appointments taking place in the community rather than in hospital.

This has been echoed more recently by the Lord Darzi report on the future provision of services and the polyclinic model.

The PCT’s 5-year commissioning strategy reflects this national policy and emphasises the need to shift care along the care pathway and to deliver services closer to home.

2 Delivering the 18 week target

By commissioning the CBUSS, the consortium aims to provide rapid access to diagnostics and to reduce current waiting times. This will help to deliver an 18 week patient pathway from GP referral to the start of treatment by the end of 2008, a key objective for the NHS. As illustrated in section 2.1, waiting times for CBUSS should be much shorter than for hospital outpatient services.


The commitment to achieve a 18-week patient pathway includes diagnostic tests. Many people require investigations in order to make or confirm diagnosis and recommend appropriate interventions.

3 Patient Choice

The Government is committed to giving patients a greater choice within the NHS, starting with choice of hospital for patients who require elective care. This proposal support the choice initiative by offering an alternative for patients needing onward referral to diagnostic ultrasound services..

2.3 DETAILS OF CHANGES TO PATIENT PATHWAY

The proposed service changes/redesign the care pathway for people requiring ultrasound investigations and will provide a alternative point of access to diagnostic ultrasound.

The pathway

Patients will initially be assessed by the GP to establish if ultrasound investigation is required and refer as a choice to the community based service

The CBUSS will:

Triage all referrals and return inappropriate referrals to the referring health care professional.

Offer an appointment to patients suitable for ultrasound diagnosis

Provide the diagnostic ultrasound and make recommendations to the referring GP on the most appropriate course of further action if required.

Patients who present to their GP with ‘red flag’ pathology will be referred directly to secondary care. Paediatric patients (under 16 years) will be referred to the Paediatric service.


2.4 DESCRIPTION OF PRACTICE/CLINICAL TEAM INVOLVEMENT (PRIMARY AND SECONDARY CARE) AND HOW CLINICAL INTERFACES WILL WORK

All the consortium GPs are committed to referring their patients to the CBUSS.

GP referrals will be faxed or email to a central point in the CBUSS Referring GPs will be expected to have undertaken an initial assessment The service will make recommendations to the referring GP on the

appropriate follow up supported by a diagnostic report

2.5 DESCRIPTION OF HOW PATIENT VIEWS HAVE BEEN SOUGHT AND WILL CONTINUE TO BE SOUGHT

The tight timescale for this business case has prevented a robust patient involvement exercise. However, there are very good opportunities for on-going involvement of patients in the consortium are commissioning plans for Community Based Ultrasound services.

This project aims to bring together patients and patient groups with clinicians and allied health professionals to:

Monitor local service provision Identify and campaign on local service issues using policy initiatives Provide a forum for service users

The PCT 5-year commissioning strategy sets out patient’s aspirations gathered from a range of patient consultation exercises. Patient’s priorities are: easier access (e.g. faster access to appointments), support for shifting hospital services to community and primary care, better quality care and smarter delivery of care.

The national public consultation exercise, “Our health, Our care, Our say”, carried out by the Department of Health also emphasised the need for high quality services closer to home.

It is planned to issue patient questionnaires in all consortium practices to gauge patients views during April 2008 and the results of the survey will be published in may 2008.

The CBUSS provider will be expected to routinely collect the views of

service providers and share these with the consortium at 3 monthly meetings.


2.6 IMPACT ON CURRENT CONTRACTS/COMMISSIONING ARRANGEMENTS By commissioning the proposed Community Based Ultrasound service (CBUSS) the consortium will significantly reduce referrals into diagnostic services in the three identified providers with the aim of further reducing unnecessary outpatient appointments in the orthopaedic, rheumatology, gastroenterology and urology outpatient appointments to King’s College Hospital NHS Foundation Trust, St George’s Healthcare Trust and Guy’s and St Thomas’ NHS Foundation Trust

This section sets out the current outpatient activity for orthopaedics and rheumatology and the anticipated reduction in GP referrals to the hospital based services. It begins with a summary of the main changes and then provides detail of activity and spend for each practice.

2.6.1 Summary

It is anticipated that consortium GPs will reduce unnecessary referrals direct to orthopaedic outpatients by 253 patients across the year and there will be 407 fewer follow up attendances.

It is anticipated that consortium GPs will reduce unnecessary referrals to rheumatology outpatients by 53 patients across the year and there will be 69 fewer follow up attendances.

It is anticipated that consortium GPs will reduce unnecessary referrals to endocrinology outpatients by 26 patients across the year and there will be 66 fewer follow up attendances.

It is anticipated that consortium GPs will reduce unnecessary referrals to gastroenterology outpatients by 50 patients across the year and there will be 85 fewer follow up attendances.

It is anticipated that consortium GPs will reduce unnecessary referrals to urology outpatients by 70 patients across the year and there will be 128 fewer follow up attendances.

The annual costs of directly referring patients to orthopaedics, rheumatology, endocrinology and urology will be reduced from £1,449,599 (2007/08 forecast spend) to £1,307,124 a saving of £142,475

These figures are based on GPs referring 75 percent of ultrasound patients to the CBUSS instead of hospital based diagnostics


There will be onward referrals to orthopaedics, rheumatology, endocrinology, gastroenterology and urology from the activity of CBUSS service. These are presented in section 2.11 within the costs of the CBUSS.

2.6.2 Impact of the proposals on current provider activity and revenue Impact on activity

Based on GPs directly referring 75 percent of patients to the CBUSS and only 25 percent to hospital diagnostics, the consortium will refer 253 fewer patients directly to orthopaedic outpatients and there will be 407 fewer follow-up attendances across the year.

For rheumatology, the proposals will mean GPs directly refer 53 fewer patients and there will be 69 fewer follow up attendances across the year.

For endocrinology, the proposals will mean GPs directly refer 26 fewer patients and there will be 66 fewer follow up attendances across the year.

For gastroenterology, the proposals will mean GPs directly refer 50 fewer patients and there will be 85 fewer follow up attendances across the year.

For urology, the proposals will mean GPs directly refer 70 fewer patients and there will be 66 fewer follow up attendances across the year.

Impact on spend and revenue

The current payment structure for outpatient appointments and follow-ups is through the national tariff and in most cases the diagnostic costs are included in the tariff so it is difficult, without unbundling of the tariff give a true like for like comparison of the impact of the actual service to the acute providers. The saving that can be identified is through the anticipated reduction in direct referrals.

In 2007/08, the consortium is forecasted to spent £1,449,599 on GP initiated referrals for first outpatient appointments and follow ups in orthopaedics, rheumatology, endocrinology, gastroenterology and urology.

Under the CBUSS model, the consortium intends to directly spend £142,475 less on outpatient orthopaedic, rheumatology, endocrinology, gastroenterology and urology from 01 October 2008 to end of September 2009 when the new service is commissioned.


2.7 DETAILS OF QUALITY AND SERVICE SPECIFICATIONS This section sets out quality and service specifications that the consortium expects the provider of the CBUSS service to meet. It also sets out the process for monitoring and reviewing the performance of the service. These criteria are included in the contractual arrangements and Service Specification that the consortium will agree with providers. The contractual arrangement is closely based on the draft prepared by Lambeth PCT for SPMS services agreements.

2.7.1 Level of service

The Service will undertake scanning and reporting of patients who have been referred by their GP to the Community Based Ultrasound, to determine the nature and status of their condition.

All diagnostic scans will be done in accordance with relevant national protocols or guidelines (where they exist), or accepted national and international practices. A best-practice model will be used at all times to incorporate the latest evidence based strategies that are relevant to Ultrasound services.

The Service will:

The service will provide community based ultrasound diagnostics from two locations, one in Clapham High Street and the other at Gracefield Gardens in Streatham. It is envisaged that the service will provide ultrasonic diagnostics in the following areas:

Abdomen Pelvis Small tissue (e.g. Thyroid, Testicular) Muscoskeletal Breast USS guided diagnostics Antenatal Service

The service will be staffed by a Senior Sonographer who will provide both imaging services, unsupervised and supervised, and interpretation of the digital images to the referring clinician to assist in ongoing patient management. The service can provide a verbal report to its patients if appropriate to relieve any anxiety in having to wait for results.

The service will take electronic referrals via NHSmail with referrals vetted for their appropriateness and, if required, bookings will be made within 2 working days. Feedback to referring clinicians for inappropriate referrals will be logged and monitored.


Results from the digital image will be made available with the report to the referring clinician within 2 working days or sooner if appropriate with decisions for onward referral for an X-ray examination if required to support ultrasound finding will be made via NHSmail.

All encounters will be recorded on the clinical system for audit and research projects and the service is expected to actively participate in audit.

Offer a choice of providers to the patient if they need to be referred for diagnostic ultrasound.

Collect as much clinical information as possible (within the remit of the Service), and present this information in an accurate and concise report with the aim of reducing the demand on further consultations and investigations in secondary care.

Share Community Based Ultrasound best practice with the consortium and the PCT to develop local protocols that facilitate and enhance the patient experience and outcome.

Monitor all inputs to, and outcomes from, the service and report these on a regular basis as detailed below.

The CBUSS will publicise the Service to relevant stakeholders to ensure that potential service users are aware of the provision and of how to gain access to the Service.

2.7.2 Professional qualifications of staff

The clinical staff of the Service will be qualified and registered Health Professionals within the UK for their stated discipline. The clinicians will be recognised as Specialists in Community Based Ultrasound medicine e.g. a Senior Sonographer The clinical staff will have appropriate administrative support in order to effectively and efficiently discharge their duties within the Service. The provider will remain responsible for quality assuring the clinical staff.

2.7.3 Underlying principles

The following health care principles will apply to the Service:

to promote the independence, choice, dignity, privacy, respect and participation of service users;


to acknowledge and respect a service user’s gender, sexual orientation, age, physical or mental health ability, race, religion, culture, social background and lifestyle;

to give service users maximum possible choice of service within the resources available to meet their needs;

to recognise the right of service users to have the optimum possible control over the service they receive and so gain the most benefit from it;

to plan and provide the Service in partnership with all stakeholders to ensure that the Service responds sensitively and flexibly to individual needs;

to ensure that service users’ views are taken into account in the running and development of the Service;

to ensure that the service users’ Community Based Ultrasound well-being is monitored and promoted;

to work in a collaborative and coordinated way with other providers.

2.7.4 Service outcomes

The Provider must aim to contribute to the following outcomes:

that Service Users have access to, and the opportunity to use, all other relevant community health and social care services appropriate to their needs

The service provides ease of access for patients to ultrasonic diagnostics

That Service Users maintain an optimum level of health and general well-being.

2.7.5 Quality Assurance

The Provider shall be monitored on how the Service is being provided in relation to the Service Specification.

The Provider must implement a reliable, internal quality assurance system in relation to standard setting, monitoring, management of the Service and periodic performance review.

As a part of the annual review of the Service, the Provider shall be required to identify and put forward any necessary quality improvements that it proposes to implement and develop during the course of the following year. These improvements will be discussed and, if a cost is involved, agreed by the consortium, prior to an Annual Review.


The Provider shall ensure that all personnel it engages in the Service adhere to the PCT’s Policy on Customer Care by offering: the highest quality of service within the resources available; fairness to all Service Users; and a means of making a complaint.

2.7.6 Service User Feedback

The Provider shall ensure that Service Users are given every opportunity to present their views and ideas about the future of the Service. Service User involvement must play a key part in planning how the Service develops. This shall include the provision for the active involvement of Service Users in evaluating the Service and planning service changes.

The Provider shall ensure that systems for consulting Service Users and Relevant People, and for monitoring Service User satisfaction, are developed and implemented.

2.7.7 Complaints

Service Users must have access to a clearly defined written complaints’ procedure, which must be implemented by the Provider to the satisfaction of the consortium. The procedure must include provision for a written record to be made of all complaints and of any action taken. Details of written records of complaints shall be available to the consortium upon request. A copy of the complaints’ procedure must be given to the Service User on commencement of the Service.

The Provider must ensure that each Service User knows how to use the PCT’s complaints’ procedure and that each Service User is aware that they may use it at any time.

2.7.8 Monitoring arrangements

The Provider shall submit to the consortium at a frequency of every 3 months, a report providing an overview of the Provider’s performance.

The 3 monthly reports shall include details of the Provider’s achievements in relation to the service outcomes and performance targets detailed below:

the number of Service Users who have received the Service during the monitoring period, including their age, gender, ethnicity and registered practice


the volume of the Service provided, including diagnostic testing, and the outcomes (i.e. needed onward referral, discharged back to GP, DNA’s)

the number of new referrals received by age, gender and ethnicity broken down by practice.

Details of how Service Users’ views are collected;

feedback from Service Users, Relevant People Professional Carers and the Consortium

details of all complaints and the action taken by the Provider;

details of Service Users held on a waiting list

Education needs within the referring practices

There will be three-monthly monitoring meetings arranged by the Consortium in conjunction with the Provider and Commissioner. The monitoring meetings will be used to:

monitor and evaluate performance and targets listed above

consider any financial, operational or management issues

review the targets and consider any proposals for amendment

provide feedback on referral trends including appropriateness of referrals

discuss any specific issues


Other forms of monitoring which the consortium could use shall include:

checking relevant written records maintained by the Provider

Announced and unannounced visits to the premises where the services are located.

A nominated representative of the consortium will be responsible for monitoring the Provider’s overall performance in meeting the requirements of the Specification.

A more detailed performance monitoring framework is contained in the Service SPMS contract attached in appendix A.

2.8 EXPLANATION OF HOW PATIENT CONSENT AND CHOICE REQUIREMENTS WILL BE MET

The proposed CBUSS model provides a service within the community that can then offer a choice of secondary providers to patients who need further diagnostic investigation

Providers will be expected to have consent procedures in place and this will be set out in the service specification.


2.9 RISK ASSESSMENT

This section sets out what could happen to affect the success of the proposed service redesign, the effect of this and how risks can be managed.

Risk Effect Managing the risk Lack of effective engagement with the 18 practices in the consortium. GPs in the consortium are committed to PBC, but some are more cautious about engaging in it.

Lower than expected referrals to the CBUSS.

Patients do not receive the most appropriate service or benefit from shorter waiting times.

Lack of cost-effective, evidence based provision in SW locality.

CBUSS provider will continue to visit practices and inform doctors about the service and referral procedures

The Board will set up a process to keep all practices up to date with the activity and costs of the service, the benefits to patients and any savings being made. It will provide advice and support to those practices that are under-referring.

The consortium has set a realistic goal of referring 75% of patients to the CBUSS. The figure is based on local experience

More patients than anticipated require onward referral

Decrease in anticipated savings on referrals

The CBUSS provider will audit regularly the quality of the digital ultrasound image and the recommendations in the clinical reports. The consortium will audit 1st referrals for conversion rates and feedback to the provider as a quality indicator.

CBUSS increases demand due to ease of access and short waits for diagnostics

Waiting times get longer for the service

The consortium will monitor referrals into the service to ensure that any potential problem is addressed early


Risk Effect Managing the risk Patients prefer to be referred to the Hospital for USS

The CBUSS service does not deliver the target numbers of scans and the cost of the service increases

Information packs about the service will inform patients of the service and what it can offer to enable them to make an informed choice of provider.

Management time availability for the consortia to manage the processes and monitor the service

The service is not monitored effectively, anticipated cost savings are not made, patient access not improved with long waits

The Board must decide how it will make the management resource available and ensure protected time for clinicians to support the management arrangements.

The CBUSS does not meet the service specification or meet the governance standards for the service

Patients will not receive either a quality or safe USS service

The consortium representative will meet the provider for review every 3 months. In the case of issues with the governance arrangements remedial notice will be served and if necessary breach and termination of the contractual arrangement.


2.10 RESOURCE REQUIREMENTS (INCLUDING PREMISES, IT, WORKFORCE ETC)

The resources required to provide the service include the leasing of the Ultrasound scanner, digital imagining storage, recruitment of a Sonographer to the proposed CBUSS service. The premises current exist for the servicc to be based in Streatham - Gracefield Gardens and Clapham High Street. The estimated start up costs for the service in year one are expected to be £128,000. Once the service is established it will be a self-funding service.

2.11 FORECAST OF EFFICIENCIES GAINED AND BASIS FOR ASSUMPTIONS

This section presents the costs of the CBUSS model and the potential cost savings that can be achieved through the service redesign.

2.11.1 Summary

The forecast costs for the CBUSS is £922,054 based on 20,400 scans

The continued forecast savings on direct referrals to orthopaedic, rheumatology, endocrinology, gastroenterology and urology outpatients is £142,475.

2.11.2 Calculating the cost savings

It is anticipated that through commissioning the CBUSS, the consortium will reduce GP initiated referrals to orthopaedics, rheumatology, endocrinology, gastroenterology and urology hospital outpatients by around 10 percent:

The cost savings presented below are based on the following assumptions:

GPs refer 75% of Community Based Ultrasound patients to the CBUSS instead of hospital based diagnostic ultrasound

CBUSS recommends referral of only 65% of patients onwards to outpatients

These assumptions are based on local evidence of diagnostic ultrasound converting to outpatient appointment.


The consortium understands that:

70 percent of any freed up resources will be made available to practices. For any freed up resources to be released, practices will need to

underspend across budgets directly in their control in 2008/09 and deliver breakeven on their prescribing budgets before they are underspending and PBC freed up resources are being delivered.

The consortium practices will agree with the PCT which additional objectives will be met from any freed up resources released.

2.12 COMPLIANCE WITH COMMISSIONING GROUND RULES, SFIS, TENDERING PROCEDURES, FORMAL CONSULTATION REQUIREMENTS ETC IF RELEVANT

The proposals within this business case comply with all relevant commissioning ground rules. A full and open competition tendering process is required for the selection of the provider of this service and a formal process will be put in place once the Business plan is signed off.

2.13 KEY MILESTONES

Consultation and analysis of patient questionnaires April – May 2008 The business case will need to be signed off by the PEC early may 2008

Then two options are available to commission the new service:

The tender process and documentation needs to be completed by the end of May 2008 (including PQQ, Service Specification, local information, Response to tender template)

or alternatively go down the “Any willing Provider” route to obviate the need for tendering as described in section 3.35 of the DOH Publication “Practice Based Commissioning: Practical Implementation” (DH 28th November 2006). In this process the Provider will not be guaranteed a level of activity or income. Contracting should however ensure that there is a appropriate ceiling on both activity and income. This method encourages competition within a range of services rather than for them. This is seen as inclusive not exclusive.

For either option advertising for Providers of the service and short-listing for tenders June 2008.


For the “Any willing Provider” route selections of candidate/s measured against an application criteria demonstrating

Clinical governance Financial governance Operational experience and sustainability Organisational stability and accessibility

At this stage under the “Any willing Provider” route a contract will be awarded if the Provider meets the standards required under the criteria and can deliver the service specification.

Final responses to the tender reviewed and assessed and shortlist for interview agreed

Interview of short-listed Providers Award of the contract for an initial 12 months

For both commissioning route performance meetings should be scheduled for December 08, March 09, June09 and September 09 and the evaluation of the new service July/August 2009

Future of the contract to be decided by 31st August 2008 and provider notified of the position.

The consortium will sign a APMS/SPMS contract or a Service Level Agreement (SLA) with the selected provider of the CBUSS for an initial 12 months. At this point, (September 2009) the consortium may after evaluation extend the agreement or consider other providers depending on the outcomes delivered by the current service.

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