Integrated End of Life Services
Business Case
Mark Eaton
January 2016
INTEGRATED END OF LIFE SERVICES
BUSINESS CASE
25 February 2016
FULL BUSINESS CASE (FBC)
NOTE 1: This template should be used for all business cases that exceed £250k for the total lifetime
investment including any recurrent spend that arises from it or where the programme is <£250k but has a
duration longer than 24 months.
NOTE 2: Proposals submitted without measurable KPIs and the appropriate spend and activity profile
information will be rejected. It is not sufficient to detail the expected money requested from the CCG and
fail to provide measurable and tangible KPIs.
NOTE 3: Funding is not approved until you have submitted a fully completed document and the CCG
sends you back the document with the DECISION SUMMARY section fully completed following approval
by the appropriate CCG Committee. It is important that you comply with the funding criteria and progress
reporting notes within the DECISION SUMMARY. Failing to comply may lead to payments being stopped or
refused and further lack of compliance may lead to the programme being terminated.
NOTE 4: Projects that do not start within 3 months of the date stated in the DECISION SUMMARY will be
deemed to have terminated and you will be required to request the funding again.
NOTE 5: Funding will only be paid on submission of the appropriate evidence of the delivery of the agreed
KPIs and evidence of the programme spend occurring to the expected spend profile.
NOTE 6: Variations to the agreed business case will need to be provided in writing by the CCG before any
changes are accepted.
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1.0
Background information
In 2012 Hillingdon CCG, along with partners participating in the Hillingdon End of Life Forum which includes
representatives from the London Borough of Hillingdon (LBH), produced an End of Life Strategy covering the period
to 31st March 2016. The CCG along with partners is producing a new three year strategy covering the period from 1 st
April 2017 to 31st March 2020 to replace the previous strategy and has been undertaking work in preparation for the
new strategy throughout 2015/16. Part of this work has involved mapping existing services across health and social
care as well as services that are available to self-funders and the third/voluntary and charitable sector.
The mapping work identified that the main services delivered to support End of Life Care can be broken into the
following areas:
1.
2.
3.
4.
5.
Hospital Services & Beds
Community Nursing (and Therapy) Services & Community Beds
Primary Care Services delivered mainly by GPs
Non-Hospital/Community Based Beds (including Hospices and Care Homes)
Voluntary, Charitable and/or Third Sector Supporting Services
This Business Case is concerned with the elements of End of Life Care (EoLC) that are commissioned by Hillingdon
CCG that are not related to either of the following:
 Nursing/Therapy Services delivered as part of the CCG’s main Community Contract delivered by CNWL
 Hospital based services delivered by THH or any other acute provider
For this Business Case the services covered are the:
1.
2.
3.
4.
Hillingdon Night Sitting Service (HNSS)
Hillingdon Bereavement Service (HBS)
Hillingdon Lymphoedema Service (HLS)
Hayes Cottage Enhanced Support Beds
The CCG’s new End of Life Strategy (2016-2020) will be aligned to the National End of Life Ambitions and the
services that the CCG commissions may change based on the new End of Life Strategy (2017-2020).
1.1
Project Team
PROPOSED CRO Dr Kuldhir Johal
PROPOSED SRO Jason Nash
FINANCE LEAD
QUALITY LEAD
PPE LEAD
CCG CLINICAL
CHAMPION
CCG MANAGEMENT
CHAMPION
OTHERS
1.2
Chris Perera
Claire Lamb
Diana Garanito
N/a
N/a
N/a
Project Approval Milestones
OD SEMINAR October 2015
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PMO
QSCR COMMITTEE
F&Q COMMITTEE
PPIE COMMITTEE
GOVERNING BODY
PROCUREMENT PANEL
OTHER APPROVALS
2.0
January 2016
February 2016
February 2016
February 2016
March 2016
N/a
N/a
Purpose
The CCG currently commissions a mix of services which have lacked clear definition and KPIs and which have been
dissipated across a range of small sized contracts. This Business Case is concerned with consolidating these into two
contracts, realigning KPIs and making proposed changes to the finances associated with the contracts.
3.0
Objectives
The objectives of this work are as follows:
1.
2.
3.
4.
5.
To reduce unplanned attendances for patients approaching the End of Life.
To ensure that funding is appropriately provided to services to enable them to achieve the objective above.
To consolidate the current mix of contracts into two contracts.
To improve the service definition and key performance indicators (KPIs) associated with the contracts.
To prepare the CCG for the longer term solution that will be put in place from March 2017 onwards.
4.0
Options Appraisal
Your analysis must consider at least three options which must include a Do Nothing option and at least two other
viable options.
4.1
Option 1: No Change (Mandatory)
The Do Nothing option in this case consists of allowing the current services (which are operating without defined
KPIs and with a Contract Tender Waiver) to lapse and to not continue the services.
The net effect of eliminating these services would be as follows:
Service Area
Hayes Cottage
Beds
Hillingdon Night
Sitting Service
Description
The 10 beds at Hayes Cottage currently cost
the CCG £392,604 per year. Assuming 80%
means that they support 2,920 patient bed
days as a minimum.
During 15/16 this service will provide support
to around 130 patients for a total of some
1,200 nights for a total cost of £157,987 from
Harlington Hospice and £15k from Marie
Curie (who are no longer providing support).
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Net Financial Impact of Termination
At £250/bed day in an acute setting this
would cost the CCG £730,000, a net increase
of £337,396.
Extrapolating from the Midhurst Model we
can predict that we would incur an additional
300 hospital -based bed days (300 x £250 =
£75,000) and approximately 26 unplanned
admissions (26 x £1700 = £44,200). Therefore
stopping this service would see a net financial
gain to the CCG of ~£53,787k but at the
Hillingdon
Bereavement
Service
Hillingdon
Lymphoedema
Service
expense of a significantly worse experience
for patients and carers.
Currently this service only covers the South
This service is concerned with patient, family
of the Borough at a total cost of £14,003 for
and carer experience. Whilst ceasing this
15/16.
service would have a net financial gain of
£14,003 it would immeasurably affect the
lives of the patients, families and carers
affected.
Currently this has an RTT of around 2.5
It is reasonable to expect that the costs
months and costs £42,010 per year. The
incurred would be transferred elsewhere in
service reduces the pain and suffering of
the health economy (through GPs, hospital
post-operative breast cancer patients.
admissions and pain medication) and
therefore it would be cost neutral to the CCG
of terminating this service.
Gross Financial Impact of ‘Do Nothing’ £877,207
Costs of Existing Services £621,604
Net Financial Impact of ‘Do Nothing’ Increase in CCG costs of £255,603
Therefore the ‘Do Nothing’ option would increase the CCG’s costs by ~£255k.
Given the above, Option 1 is not recommended.
4.2
Option 2: Continue Existing Services without Change
The second option the CCG could consider is to continue the services as they stand without changes to the
specification or the amounts paid.
The cost of existing services would therefore remain £578,617 for 16/17 (the same as 15/16 without adjustment).
The risks and issues that would arise through this arrangement would be as follows:
1. It is likely that Hayes Cottage would terminate their contract with the CCG as it is uneconomic to them to
continue given the increase in staffing costs associated with the minimum wage changes. At present the CCG
does not have any other option with regard to these Enhanced Beds especially given the complex package of
support that surrounds each bed provided by a mix of specialists from CNWL and THH.
2. We would continue to operate fragmented services spread across four contracts with poor definition of the
service and no key performance indicators.
3. We would be at risk of the Harlington Hospice Night-Sitting Service continuing to be used for inappropriate
patients and/or extended periods of support that are inappropriate. We are also at risk of Harlington Hospice
refusing to provide care to eligible patients where activity exceeds the limits set currently.
4. The Bereavement Service would continue to not be available to people located in the North of the Borough.
Whilst the savings associated with Option 2 compared to Option 1 would realize savings of £255k for the CCG, given
the above risks Option 2 is not recommended.
4.3
Option 3: Continue Existing Services with Changes
The third option the CCG could consider is to continue with the existing services and service providers but to
introduce changes to the specifications and funding to reduce the risks and issues that arise via Option 2 from
materializing.
The changes proposed are summarised as:
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1. Continue the contracts with Harlington Hospice and Hayes Cottage on a Tender Waiver for 2016/17 to allow
time for the finalization of the new End of Life Strategy and to allow time to prepare for a procurement.
2. Consolidate the three Harlington Hospice services (Night-sitting, Bereavement and Lymphoedema) into one
service specification and contract with improved service definition and KPIs.
3. Refresh the Hayes Cottage service specification and improve the service definition and KPIs.
4. Realign activity and costs for each service as shown in the table below:
Service Area
Hayes Cottage
Beds
Hillingdon Night
Sitting Service
Proposed Service Changes
 Support improvements in service
definition for GP Provided services to
assist Hayes Cottage to manage costs.
 Introduce Night-Sitting Support to reduce
unplanned admissions.
 Increase costs to accommodate the
staffing cost increases experienced by
Hayes Cottage.



Change to a core contract of 780 nights
at £187.50 per night with a marginal rate
of £150/night for anything in excess up to
275 nights.
Provide HH with the ability to reject
clients where appropriate and also to
better define their service offer and cap
activity at 28 nights.
Introduce 100 nights of support to Hayes
Cottage at £150/night to reduce patients
who need to be admitted to hospital.
Financial Impact
Increase annual costs from £392,604 to
£415,992 (5.9%) as per the breakdown in
Appendix 1.
Total for 16/17: £415,992
Maximum Increase from 15/16: £23,388
NOTE: Subject to approval to proceed it is
proposed that the CCG negotiate with Hayes
Cottage to reduce the proposed increase. It is
felt that £410k would be the upper limit in
reality.
 £146,250 (Core Contract)
 £41,250 (Cap on Marginal Rate)
 £15,000 (New Hayes Cottage Support)
Total for 16/17: £202,500
Maximum Increase from 15/16: £29,513
The savings associated with this service
would then be:
 300 x Bed Days for existing service
@£250/day = £75,000
 26 x NEL Admission @ £1700 = £44,200
 20 x NEL Admission from Hayes Cottage
@£1700 = £34,000
Total Savings for 16/17: £153,200
Hillingdon
Bereavement
Service
Hillingdon
Lymphoedema
Service



Expand service to cover the North of
Hillingdon and increase activity from 650
sessions in 15/16 to 1,300 sessions in
16/17.
Current service has average time from
referral to treatment of 2.5 months
which means that patients are in pain
and have swelling for an extended time
period and may therefore utilise other
services.
Proposal to reduce RTT to maximum of 2
months with average of 1 month.
Page 6 of 13
Net QIPP Gain (of Loss): -£49,500 but with
improved outcomes/experience for
patients/carers.
Increase in funding from £14,003 to £26,000
for 16/17.
Total for 16/17: £26,000
Maximum Increase from 15/16: £11,997
This service is not concerned with QIPP.
Increase in funding from £42,010 to £50,000
for 16/17.
Total for 16/17: £50,000
Maximum Increase from 15/16: £7,990
This service is not concerned with QIPP.
The total proposed costs under Option 3 would therefore be £694,492. This is an increase of £72,888 compared to
Option 2. Comparing Option 3 with Option 2 and 1 has been summarised below:
Option 2
Option 3
Services without Changes
Services with Changes
Gross Costs
£621,604
£694,492
Gross Savings v Option 1
£877,207
£877,207 + £34,000(Hayes Cottage)
= £911,207
Net Savings v Option 1
£255,603
£216,715
Option 2 therefore generates a greater net saving compared to Option 1 but with significantly increased risk
associated with Hayes Cottage and the perpetuation of poorly defined services with no KPIs.
Option 3 represents an increase in cost of £72,888 to the CCG over Option 2 but protects the CCG from risks
associated with Hayes Cottage, improves the equality of access associated with the services covered, improves the
scope, definition and measurability of the service and lastly, but most importantly, improves the service quality and
experience for patients, carers and families.
In reality, as Option 1 is not viable and there is therefore no Net QIPP Associated with either Option 2 or 3.
Given all of the points above, Option 3 is the preferred option.
4.4
Option 4: Procurement of New Services
A final option for the CCG to consider is to procure the services.
As the CCG is finalizing a new End of Life Strategy covering the period from 2017-2020 and following the mapping
exercise undertaken it is proposed to hold off on procurement until the following have occurred:
1. The strategy has been agreed and published.
2. It is clear what services will be needed that arise from the mapping and other work required to produce the
strategy.
3. The current services have been better defined and tangible KPIs put in place.
The CCG will not be in a position to answer points 1 and 2 until the middle of 2016 whilst the 3rd point will be
addressed via the adoption of Option 3.
As such, it is proposed that a procurement be undertaken for 2017/18 of the services starting in October 2016 and
that the existing services are extended under a Contract Tender Waiver for 2016/17 to allow time for the CCG to
prepare for the procurement.
4.5
Preferred Option
The preferred option for 2016/17 is Option 3.
The preferred option for 2017/18 is Option 4.
4.7
Implementing The Preferred Option
The implementation of the preferred option for 2016/17 (Option 3) will consist of the following steps:
1. Agree the new service specification for all services with the providers and also with the CCG’s QSCR Committee
in February 2016.
2. Agree the finance package and tender waiver with the CCG’s F&Q Committee in February 2016.
Page 7 of 13
3. Agree the service changes, finances and tender waiver with the CCG’s GB in March 2016.
4. Agree a contract with Harlington Hospice and another with Hayes Cottage in March 2016.
5. Commence services and performance monitoring from April 2016 onwards.
IMPORTANT NOTE: If the preferred option involves procurement then the Conflict
of Interest policy will need to be reviewed and appropriate actions taken
5.0
Benefits
Describe the tangible benefits arising from the option selected. This must include measureable targets and impact. It
is not acceptable simply to state “Unknown”, leave blank or enter “TBD” in this section.
Area
Measureable Impact
Description
£, Activity and/or % Change from Baseline
Quality
1.
2.
3.
4.
Safety
Performance
Hayes Cottage
Night Sitting
Bereavement
Lymphoedema
KPIs introduced for
all services
QIPP
1. Night Sitting
(Hayes
Cottage)
Activity Change
1. Night Sitting
2. Bereavement
1. Night sitting support provided
and risk of service withdrawal
removed
2. Support to Hayes Cottage for
Night Sitting
3. Expansion to cover whole of
Hillingdon population and
increase access
4. Reduction in lead time from
referral to treatment from 2.5
months to 2 months (with target
of 1 month)
KPIs in place as per specifications
1. 100 Nights of support to Hayes
Cottage to avoid 20 NEL
Admissions therefore £15k of
cost to realize £34k of saving
(Net £19k QIPP)
1. Capped at 1,075 Nights (down
from 1081 in 14/15 but
increasing number of Pts
supported) plus 100 Nights in
support of Hayes Cottage
2. Increased from 650 to 1300
Sessions and coverage now
extends across Hillingdon
When will impact be
realised?
All to be realized during
16/17.
All to be managed via
contract during 16/17
1. During 16/17 as and
when activity occurs
to support Hayes
Cottage.
Other
6.0
Finance
AREA
DESCRIPTION
Hayes Cottage
Night Sitting
10 Palliative/Enhanced EoL Beds
1075 Nights (plus 100 for Hayes Cottage)
Page 8 of 13
AMOUNTS (£k)
NON-RECURRENT
RECURRENT
£415,992
£202,500
-
Bereavement
Lymphoedema
7.0
7.1
1300 Sessions to cover all of Hillingdon
Reduction in RTT lead time from 2.5 months
to maximum of 2 months
TOTAL
£694,492
Risks (things that may happen)
Hayes Cottage switch to
commercial/paying patients
leading to withdrawal of
service
Harlington Hospice refuse
clients support for Night
Sitting increasing stress on
families and admissions
7.3
£50,000
Risks, Issues and Dependencies
Risks
7.2
£26,000
Mitigating Actions
Agree Option 3 with a
Tender Waiver for 16/17
and Procure for 17/18
Agree Option 3 with a
Tender Waiver for 16/17
and Procure for 17/18
Issues (things that need to be controlled)
Issue
Likelihood
(1-5)
Impact
(1-5)
Total
(Max 25)
4
4
16
4
2
8
Mitigating Actions
Dependencies (things that this project is dependent upon)
Dependency
Impact on Project
Page 9 of 13
Owner
8.0
Governance & Evaluation
When will the programme start if approved? April 2016
Who will manage this programme? Jason Nash
Which CCG Committee will oversee this? Finance & QIPP Committee
How frequently will updates be provided? Quarterly
End of Life Forum
Which other Committees will oversee this?
PMO
When will the evaluation be done? Quarterly
What other Governance is required? None
9.0
Schedules
Detail the 12 month impact/performance against Quality, Activity, Spend and Savings in the tables below
that you would expect to be realised through this programme once your preferred option is approved by
the appropriate CCG committee.
9.1
Quality & KPI Schedule
QUALITY & KPI
SCHEDULE
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Month 9
Month 10
Month 11
Month 12
TOTAL IMPACT
Measure 1
State Baseline
Measure 2
State Baseline
Measure 3
State Baseline
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Measure 4
State Baseline
Measure 5
State Baseline
9.2
Contract Activity Schedule
CONTRACT ACTIVITY
SCHEDULE
Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sep 16
Oct 16
Nov 16
Dec 16
Jan 16
Feb 16
Mar 16
TOTAL IMPACT
9.3
Hayes Cottage
10 Beds
10 Beds
10 Beds
10 Beds
10 Beds
10 Beds
10 Beds
10 Beds
10 Beds
10 Beds
10 Beds
10 Beds
10 Beds
10 Beds
Night Sitting
Service
1081 in 14/15
98
98
98
98
98
98
98
98
98
98
98
97
1,175
Bereavement
Service
650 in 14/15
108
108
108
108
108
108
108
108
108
108
108
112
1,300
Lymphoedema
Service
TBD
Expenditure & Savings Schedule
EXPENDITURE &
SAVINGS SCHEDULE
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Month 9
Month 10
Month 11
Month 12
YEAR 1 IMPACT
Year 2
Year 3
Year 4
Year 5
TOTAL IMPACT
SPEND PROFILE
Total Spend
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£694,492
N/a
QIPP SAVINGS
Total Savings
£0
£0
£0
£0
£0
£0
£0
£0
£0
£0
£0
£0
£0
N/a
Page 11 of 13
NET FINANCIAL POSITION
Net (Spend – Savings)
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£57,874.33
£694,492
N/a
DECISION SUMMARY (INTERNAL CCG USE ONLY)
Identify whether the proposal is approved or rejected and list the next
DECISION
steps and any further approvals that may be required.
DECISION MADE BY Detail the name of the Committee that made the decision to proceed.
DATE OF DECISION Detail the date the decision was made.
Name of the Project Lead from HCCG who will be the point of contact for
PROJECT LEAD
this programme.
FUNDING
Amount of funding awarded.
AWARDED
SOURCE OF
Where the funding is being sourced from.
FUNDING
FUNDING CRITERIA Any notes or criteria that the funding is dependent upon (such as the
OR NOTES provision of information, reporting etc)
PROGRESS &
Details of how the progress and performance of the scheme will be
PERFORMANCE
reported and the frequency.
REPORTING
ADDED TO
Confirm that the details above have been added to the PMO Action Log.
TRACKER
Page 12 of 13
Appendix 1 – Hayes Cottage ‘Open Book’ Costs
Page 13 of 13