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3 Value for money: Viable trusts and sites 9.13.6 Impact of the Changes – site viability The financial impact of the changes to sites has been assessed by considering the key drivers to costs. These changes are summarised in Figure 9.83. Figure 9.83: Drivers of change in Income and Expenditure due to reconfiguration options Pay cost changes Fixed cost changes Other effects Components Consolidation savings Meet service standards through consolidation Net change due to local hospitals Operating costs and ▪ depreciation on new assets ▪ Avoid backlog maintenance Flows out of NWL – loss of contribution margin Income change due to MFF differences Notes ▪ Efficiency gains through consolidating clinical services and reducing duplication ▪ Modelled as a net reduction in clinical and non-clinical pay cost for when services are consolidated onto a single site ▪ Moving from 9 to 5 Major acute sites and consolidating teams allows for full consultant cover to be provided with current staffing levels, which would otherwise require an increase in the numbers across the current sites. This is reflected in conservative assumption for consolidation savings ▪ Net reduction in fixed costs when current sites are replaced by Local Hospital. These are assumed to have lower costs due to reduced footprint and removal of support services and equipment that would be required on an acute site Additional premises and other fixed costs (e.g. depreciation) for the increased capacity at those Major Hospital sites that increase under the reconfiguration option Note that this excludes the costs associated with new Local Hospitals and increased asset values from covering backlog maintenance, as these effects are included in the two other fixed cost drivers ▪ Excludes impact of capital linked to Imperial College reprovision ▪ Avoid backlog maintenance on sites that become new Local Hospitals as these are assumed to be major refurbishments or new builds, with the fixed costs included in the relevant fixed cost driver ▪ Flows out of sector for activity that is currently provided by NWL hospitals leading to loss of contribution margin on the activity for the NWL Trusts ▪ Note that this is a driver of the I&E metrics for the NWL Trusts, but is neutral from a system point of view and so is excluded from the NPV evaluation (the fixed cost implications of the flows out of sector are included in the NPV) ▪ Differences in MFF for the Trusts leading to increase/decrease in MFF payments in the sector ▪ Note that from a commissioner perspective this is assumed to be accounted for through MFF in the commissioner allocations Using this methodology the surplus or deficit for each site that would occur under each option has been assessed and compared with the „do nothing‟. The outcome is summarised in Figure 9.84. 9d. Decision making analysis stage 6 and stage 7 398
Figure 9.84: Summary of net surplus at site level in 2017/18 16 £m Surplus (>1%) Borderline (within More than £1m Income (I), Cost (C) and Net Surplus / Deficit (S/D) by site under each option £1m of 1% surplus) below 1% surplus) Do nothing Option A Option B Option C Site I C S/D I C S/D I C S/D I C S/D St Mary’s 326 320 6 427 415 12 404 395 9 425 412 13 Hammersmith 327 325 2 361 353 7 329 322 7 359 352 7 Charing Cross 245 231 14 17 16 1 350 334 16 17 16 1 Chelsea & Westminster 332 323 8 417 390 27 47 44 3 420 395 26 West Middlesex 122 130 -8 180 178 2 164 163 1 41 56 -16 Ealing 110 111 -1 15 15 0 15 15 0 171 163 8 Central Middlesex 65 76 -10 31 41 -11 37 48 -11 26 37 -11 Northwick Park & St. Mark’s 247 255 -8 294 293 1 294 293 1 271 273 -2 Hillingdon 1 135 140 -4 156 155 1 156 155 1 141 142 -1 NWL Total 2 1,910 1,910 0 1,897 1,856 42 1,795 1,769 26 1,871 1,846 25 Options A and C evaluation results are as per pre-consultation. Option B evaluation has reduced. This results in the evaluation for site viability as shown in Figure 9.85. Figure 9.85: Evaluation of site viability 17 A B C £m Options Major hospitals ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ West Middlesex St Mary‟s Chelsea & Westminster Northwick Park & St. Mark‟s Hillingdon West Middlesex St Mary‟s Charing Cross Northwick Park & St. Mark‟s Hillingdon Ealing St Mary‟s Chelsea & Westminster Northwick Park & St. Mark‟s Hillingdon Do nothing Gap to get all sites to VFM 1% net surplus, £m # Sites below 1% net surplus 3 evaluation 2 14 15 35 39 2 3 4 5 ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Central Mid Northwick Park West Middlesex Central Mid Northwick Park West Middlesex Central Mid Northwick Park Hillingdon West Middlesex Ealing Central Middlesex Northwick Park Hillingdon (+) (--) (--) # Trusts below 1% net surplus based on current organisations 3 (not used for evaluation) 1 2 3 4 ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ NWL Hospitals NWL Hospitals West Middlesex NWL Hospitals West Middlesex Hillingdon West Middlesex Ealing North West London Hospitals Hillingdon 16 Source: Trusts, Reconfiguration modelling 1. Hillingdon hospital site only – does not include Mt Vernon 2. Difference in total income in Options A, B and C compared to do nothing scenario due to additional effect of (i) activity flowing out of sector, (ii) differences in MFF for each Trust and {iii} income going to UCC providers. 17 Source: Reconfiguration modelling 1. Forecast surpluses in 2017/18 after all reconfiguration changes have taken place and transition costs and income loss occurred in previous years. 2. >£30m subsidy or >=3 sites requiring subsidy (- -); £20m-£30m and 1% (++) 3. Only sites and Trusts with forecast deficits of £1m+ less than 1% are counted, due to margin of error. The assessment against 1% net surplus has been used as the minimum requirement, however for on-going viability as a Foundation Trust, hospitals would require higher surpluses 9d. Decision making analysis stage 6 and stage 7 399
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North West London Shaping a healthi
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Table of contents Volume 1 Foreword
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Foreword Dr Mark Spencer The Clinic
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6. Consultation, feedback and how w
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13. Equalities implications This ch
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1. Executive Summary Introduction t
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The overall programme timeline is b
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The process was used before consult
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• Delivery of multi-disciplinary
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Stage 1 - Case for Change Our work
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For Quality of care, clinicians hav
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1 2 3 4 5 A 6 B 7 C 8 Quality of Ca
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Assuring the proposals Throughout t
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Programme implementation arrangemen
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5. To agree that Hammersmith Hospit
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DMBC Chapter 2 - Introduction to th
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2. Introduction to the NHS in NW Lo
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Figure 2.3: Clinical Commissioning
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West Middlesex University Hospital
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major hospital, elective centre and
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DMBC Chapter 3 - Introduction to th
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3. Introduction to the Shaping a he
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3.3 Programme governance The Joint
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The JCPCT is advised by a Programme
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Consultation - during this phase, t
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Ensure consistency of communication
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Stakeholder Group Political Individ
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o o o o o Rationale for options dev
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The implications of the options in
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DMBC Chapter 4 -The Case for Change
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4. The Case for Change This chapter
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Stroke Services: The provision of s
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We need to do more to support patie
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In NW London, however, the NHS is s
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Figure 4.6: Emergency general surgi
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attack or stroke to designated cent
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Figure 4.9: Evaluation of primary c
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Inequalities would continue and pro
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DMBC Chapter 5 - Process for identi
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5. Process for identifying a recomm
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Figure 5.1: Basis of decision of wh
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We confirmed this decision, and the
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5.5 A detailed description of the s
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Correct care setting to deliver hig
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Figure 5.11: Ratings used in evalua
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DMBC Chapter 6 - Consultation, feed
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6. Consultation, feedback and how w
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6.2.1 Key findings from the consult
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times (particularly for patients tr
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Westminster City Council, Adult Ser
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Analysed and considered consultatio
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6.3 Our responses to feedback This
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Feedback received Stakeholders who
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6.3.3 Theme 3: Clinical vision and
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6.3.5 Theme 5: Proposals for local
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DMBC Chapter 7 - Clinical vision, s
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7a. Clinical, vision, standards and
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Local clinicians agreed that in ord
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▪ Expectant mothers should have t
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# Standard care services (111). As
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Figure 7.8: Development of the acut
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# Standard Adapted from source depa
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Figure 7.11: Shaping a healthier fu
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No. Standard Adapted from source Su
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No. Standard Adapted from source se
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# Standard All emergency department
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# Standard All non-urgent - within
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Figure 7.18: Shaping a healthier fu
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# Standard Adapted from source shou
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# Standard Adapted from source Comm
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The final standards are more demand
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Figure 7.26: Proposed services to b
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Each CCG is taking steps to help pr
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in major hospitals) and equipment t
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tangible differences for patients
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Referral A&E Illustrative patient j
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Illustrative patient journey matern
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Illustrative patient journey in mat
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Illustrative patient journey planne
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GP-led care Illustrative patient jo
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7.8.1 Scope of the CIG’s work The
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Theme Clinical outcomes Staff attit
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Further stakeholder engagement is n
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Figure 7.31 E&UC CIG Responses to N
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NCAT recommendation CIG response Se
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Conditions suitable for UCC Clinica
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Exclusion criterion Mental health A
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Diagnostics 7.14.3 Streaming, regis
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Biochemistry Microbiology Radiology
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The Provider must deliver appropria
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Figure 7.41: E&UC CIG recommended k
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will be able to establish a service
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The UCC provider will be responsibl
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Key differences Governance As with
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should be provided with appropriate
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Process map 1: Assessing UCC patien
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Process map 3: UCC to ED transfer p
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make an appointment with their own
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7.19 ED workforce A programme-wide
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The purpose of this section is to s
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Figure 7.45 Consultation results on
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Figure 7.46: Specific Responses the
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NCAT recommendation Original Progra
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7.25.1 London Health Programmes cli
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Future capacity in centralised serv
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3. There would be an additional "st
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in NWL will have a choice of delive
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Support for the proposal is higher
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Figure 7.49: Specific feedback the
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Sub-Theme Organisation Support Conc
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Sub-Theme Organisation Support Conc
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7.36.1 National Clinical Advisory T
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NCAT recommendation Further engagem
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edistributed nationwide. We envisag
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6. The Maternity CIG have considere
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DMBC Chapter 8A-E - Out of hospital
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Out of hospital improvements This c
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8.2. Settings of out of hospital ca
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practical solution for the site, wh
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Brent Health Partnerships Overview
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Consultation theme Standards for ca
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Consultation theme Integration Inve
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8.5.3. Workforce Following feedback
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Delivering this workforce shift wil
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Measure type Domain Potential measu
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8b. Primary care development 8.6. S
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consultation they could have receiv
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8.10. Next steps We are developing
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Figure 8.11: Hub/health centre requ
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some cases, these will be offered o
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Process for development of local ho
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The result is an emerging picture o
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Across NW London, these sites will
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need redeveloping or rebuilding to
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8d. Urgent care centres When indivi
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Figure 8.22: NW London urgent care
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Conditions suitable for UCC Clinica
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Key differences Governance As with
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processes of the CCG and as such th
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around the table accelerates the un
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Improved empowerment - specifically
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Figure 8.28: Realising our integrat
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Figure 8.29: Summary of CCG commiss
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DMBC Chapter 9 - Decision making an
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9a. Decision making analysis stages
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“The Brent Health Partnerships Ov
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Royal College of Midwives “The RC
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clinicians wanted to take this into
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9.6.3 Feedback received about the s
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Confirm the service models reflect
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Figure 9.9: The seven hurdle criter
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surgeons in NW London, but we would
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We confirmed this decision with the
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Appropriate staffing is integral to
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The proposals are supported by Depa
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NW London to deliver high quality c
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1. Support predicting where activit
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Figure 9.15: Example travel time ma
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The analysis shown in Figure 9.18,
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Figure 9.18: Impact on private car
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33% support 10% opposed 57% of peop
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Figure 9.21: Watershed map for blue
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etained as a major hospital, becaus
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9.7.29 The implications of this fee
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Figure 9.25: Potential activity flo
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Figure 9.27: Changes in travel time
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Figure 9.29: Changes in travel time
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Figure 9.31: Possible choices betwe
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Either Charing Cross or Chelsea & W
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Figure 9.33: Option A, excluding ca
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Figure 9.36: Option C responses, in
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Richmond Upon Thames LINk Royal Bor
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Southall Black Sisters “The closu
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Figure 9.38: Ranking of evaluation
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Figure 9.42: Evaluation criteria as
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anked third according to the mean s
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9.9.5 The analysis of the five eval
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Figure 9.45: Quality Dashboard data
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Response to feedback about the eval
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Page 389 and 390: 3 Value for money 9.9.26 The purpos
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Page 393 and 394: This analysis was agreed prior to c
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Page 397 and 398: Response to feedback about implemen
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Page 401 and 402: 5 Research and Education: Disruptio
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Page 405 and 406: 9.9.48 The outcome of the disruptio
Page 407 and 408: Greg Hands, MP for Chelsea & Fulham
Page 409 and 410: comprises more than 22 million cita
Page 411 and 412: Quality/Impact score Figure 9.65 Re
Page 413 and 414: 9. Decision making analysis - stage
Page 415 and 416: There were six distinct parts of th
Page 417 and 418: Figure 9.69: 5 year gross savings,
Page 419 and 420: Figure 9.73: Commissioners intend t
Page 421 and 422: Figure 9.75: Beds bridge: 2012/13 t
Page 423 and 424: The key modelling assumptions appli
Page 425 and 426: Figure 9.79: DMBC NHS net capital e
Page 427: Figure 9.81: Approach to estimating
Page 431 and 432: Figure 9.86: Evaluation of total su
Page 433 and 434: 9.13.9 Impact of the changes: Updat
Page 435 and 436: Figure 9.89: Effect of the expanded
Page 437 and 438: Correct care setting to deliver hig
Page 439 and 440: Sensitivity tests g) Tariff efficie
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Page 443 and 444: Figure 9.94: Change in expanded NPV
Page 445 and 446: The sensitivity analysis supports t
Page 447 and 448: DMBC Chapter 10 - The recommendatio
Page 449 and 450: 10. The proposed future configurati
Page 451 and 452: The changes to the scoring before a
Page 453 and 454: 10.3. Why this is the recommendatio
Page 455 and 456: In the rest of this section, the se
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