Business Case - LNWH NHS Trust - London North West Healthcare

Transcription

The proposed merger of
Ealing Hospital NHS Trust and
The North West London Hospitals NHS Trust
Full Business Case
Version 15: 20th June 2014
Table of Contents
Table of Contents ................................................................................................ i
List of Tables ...................................................................................................... v
List of Figures .................................................................................................. vii
Abbreviations .................................................................................................. viii
0.
Executive Summary ................................................................................... 1
0.1 Background ........................................................................................................ 1
0.2 The case for change ........................................................................................... 1
0.3 London North West Healthcare – What will day 1 feel like? ................................ 2
0.4 London North West Healthcare - What will be different for patients? .................. 3
0.5 Conclusion ......................................................................................................... 3
1.
Introduction................................................................................................. 4
1.1 Background to the FINAL business case ............................................................ 4
1.2 Strategic context ................................................................................................. 4
1.3 Purpose of the Full business case ...................................................................... 6
1.4 Note on SaHF and organisational change .......................................................... 7
1.5 Current situation ................................................................................................. 7
1.6 Chapter summaries ............................................................................................ 8
1.7 Summary of appendices and supporting documents ........................................ 16
1.8 Mapping of the Business Case to TDA Assurance Framework ......................... 18
1.9 Conclusion ....................................................................................................... 18
1.10 Appendices and supporting documents ............................................................ 18
2.
Profile of the Trusts.................................................................................. 19
2.1
Overview of the organisations .......................................................................... 19
2.2 SWOT analyses ............................................................................................... 21
2.3 Ealing Hospital NHS Trust ................................................................................ 22
2.4 The North West London Hospitals NHS Trust................................................... 24
2.5 Services provided ............................................................................................. 26
2.6 Current performance ........................................................................................ 28
2.7 Care Quality Commission inspections .............................................................. 35
2.8 Conclusion ....................................................................................................... 35
3.
Commissioning strategy in North West London ................................... 37
3.1 Overview .......................................................................................................... 37
3.2 Local commissioners ........................................................................................ 40
3.3 Demography – Latest trends ............................................................................ 40
i
3.4 CCG Profiles .................................................................................................... 41
3.5 NHS North West London and Shaping a Healthier Future ................................ 45
3.6 Results of the IRP............................................................................................. 47
3.7 Links with overall commissioning strategy ........................................................ 48
3.8 CCG out-of-hospital strategies.......................................................................... 49
3.9 CCGs’ vision for out-of-hospital care ................................................................ 50
3.10 Enablers and success factors ........................................................................... 52
3.11 Decommissioning and Procurement ................................................................. 52
3.12 Implications for the acute services .................................................................... 52
3.13 What this means for the future healthcare landscape? ..................................... 53
3.14 Conclusion ....................................................................................................... 54
4.
Why merge EHT-ICO and NWLHT? ......................................................... 55
4.1 Introduction....................................................................................................... 55
4.2 Why change is needed ..................................................................................... 58
4.3 Common Lessons from other mergers.............................................................. 60
4.4 Conclusion ....................................................................................................... 60
5.
Clinical and patient benefits of the merger ............................................ 61
5.1 Introduction....................................................................................................... 61
5.2 Benefits from acute and community integration – a model for service delivery . 63
5.3 Benefits from merged acute hospital-based services ........................................ 71
5.4 Benefits of the merger for training and education ............................................. 82
5.5 Benefits of the merger for research and innovation........................................... 85
5.6 Conclusion ....................................................................................................... 88
6.
Aims, vision and values of the new organisation .................................. 89
6.1 Introduction....................................................................................................... 89
6.2 Vision, aims and objectives .............................................................................. 89
6.3 Values and objectives ....................................................................................... 92
6.4 Development of clinical strategy ....................................................................... 93
6.5 Progressing Clinical Integration ........................................................................ 94
6.6 Conclusion ....................................................................................................... 99
7.
The new organisation’s structure and governance arrangements .... 100
7.1 Background .................................................................................................... 100
7.2 The Board and structure of the new organisation ........................................... 101
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7.3 Leadership roles and responsibilities .............................................................. 103
7.4 Board sub-committee reporting structure ........................................................ 107
7.5 Clinical operational structure of the new organisation ..................................... 109
7.6 Corporate quality governance ......................................................................... 114
7.7 Divisional quality governance ......................................................................... 116
7.8 Risk Management Arrangements ................................................................... 120
7.9 Conclusion ..................................................................................................... 121
7.10 Appendices and supporting documents .......................................................... 121
8.
Financial evaluation / LTFM ................................................................... 122
8.1 Background and context ................................................................................. 123
8.2 Calculating financial viability ........................................................................... 124
8.3 Historical financial performance of the current Trusts ..................................... 125
8.4 North-west London health economy – financial position ................................. 126
8.5 Merger case modelling and scenarios overview ............................................. 128
8.6 Merger base case financial assessment ......................................................... 130
8.7 cost improvement savings and programme management office ..................... 139
8.8 Forecast savings targets................................................................................. 144
8.9 Non-merger case financial assessment .......................................................... 146
8.10 Financial benefits of merging the Trusts ......................................................... 149
8.11 Funded merger base case .............................................................................. 150
8.12 Downside case ............................................................................................... 153
8.13 Conclusion ..................................................................................................... 155
9.
Engagement and involvement of stakeholders ................................... 157
9.1 Introduction and context ................................................................................. 157
9.2 Previous communication and engagement activities....................................... 158
9.3 Overview of communication and engagement activities .................................. 159
9.4 Refreshing our stakeholder engagement ........................................................ 163
9.5 Communication and engagement with other stakeholders .............................. 164
9.6 Communication and engagement plan for the business case and FBC .......... 166
9.7 Additional key areas of communications and engagement activity .................. 166
9.8 Future communication and engagement ......................................................... 167
10. Integration and implementation plan .................................................... 169
10.1 Introduction..................................................................................................... 169
10.2 Programme governance arrangements and structure ..................................... 169
10.3 The programme management office ............................................................... 170
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10.4 Risk and issue management .......................................................................... 170
10.5 Transaction timeline and assurance ............................................................... 171
10.6 Iterative development of the implementation plans ......................................... 171
10.7 Progress to date and high-level steps to a fully integrated Trust ..................... 172
iv
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
v
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
vi
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
vii
Abbreviations
Table 1 List of abbreviations
Initial
Description
A&E
AAU
Accident and Emergency
ACS
Ambulatory Care Sensitive
AHP
Allied Health Professional
CCG
CCP
Clinical Commissioning Group
CEO
Chief Executive Officer
CFO
CIP
Chief Financial Officer
Cost Improvement [Savings] Plan
CMH
Central Middlesex Hospital
CN
Chief Nurse
COO
COPD
Chief Operating Officer
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
DH
District General Hospital
Department of Health
DMBC
Decision-Making Business Case
EBITDA
Earnings Before Interest, Taxes, Depreciation and Amortisation
EHT
EHT-ICO
Ealing Hospital NHS Trust
Ealing Hospital NHS Trust with its associated Integrated Care
Organisation
ENT
Ear Nose and Throat
FBC
Full Business Case
FT
Foundation Trust
GP
GUM
General Practitioner
HCAI
Healthcare Acquired Infection
HEE
Health Education England
HES
Hospital Episode Statistics
HfL
Healthcare for London
HR
Human resources
HWB
Health and Wellbeing Board
Acute Assessment Unit
Cooperation and Competition Panel
Chronic Obstructive Pulmonary Disease
Genito-Urinary Medicine
viii
Initial
Description
I&E
Income and expenditure
ICH
Imperial College Healthcare NHS Trust
ICO
ICT
Integrated Care Organisation
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
JETM
Joint Committee of Primary Care Trusts [re. SaHF]
Joint Executive Team Meeting [of EHT-ICO and NWLHT]
K
Thousand
KPIs
Key Performance Indicators
LA
LAT
Local Authority
Local Area Team [of NHS England]
LETB
Local Education and Training Board
LINk
Local Involvement Network
LTFM
m
Long Term Financial Model
Million
MAU
Medical Assessment Unit
MD
Medical Director
MRC
MRI
Medical Research Council
Magnetic Resonance Imaging Scan
N Engl J Med
The New England Journal of Medicine
NCEPOD
National Confidential Enquiry into Patient Outcome and Death
NED
NHS
Non-Executive Directors
National Health Service
NHSL
NHS London
NICE
National Institute of Health and Clinical Excellence
NIHR
NPH
National Institute of Health Research
NWL
North West London
NWLHT
North West London Hospitals NHS Trust
OBC
OD
Outline Business Case
OMFS
Oral and Maxillofacial Surgery
OOH
Opex
Out-of-Hospital
PACS
Picture Archiving and Communications System
PAS
Patient Administration System
Information And Communication Technology
Northwick Park Hospital
Organisational Development
Operating Expenses
ix
Initial
Description
PAU
Paediatric Assessment Unit
PbR
Payment by Results
PCBC
PCT
Pre-Consultation Business Case
PDC
Public Dividend Capital
PFI
Private Finance Initiative
PIDs
Project Initiation Documents
PMIIP
PMO
Post-Merger Integration and Implementation Plan
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
RRU
Radiology Information System
Regional Rehabilitation Unit
RTT
Referral to Treatment Time [waiting time standard]
SaHF
Shaping a Healthier Future
SD
SHA
Standard deviation
Strategic Health Authority
SLA
Service Level Agreement
SOC
Strategic Outline Case
SoS
SPA
Secretary of State for Health
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
Year-to-Date
YTD
Primary Care Trust
Project Management Office
x
0. Executive Summary
0.1
BACKGROUND
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.
0.2
THE CASE FOR CHANGE
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
1
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.
0.3
LONDON NORTH WEST HEALTHCARE – WHAT WILL DAY 1 FEEL
LIKE?
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
2
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.
0.4
LONDON NORTH WEST HEALTHCARE - WHAT WILL BE DIFFERENT
FOR 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.
0.5
CONCLUSION
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
3
1. Introduction
Chapter summary
This chapter provides an overview of the Business Case. It includes:
1.1

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.
BACKGROUND TO THE FINAL BUSINESS CASE
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.
1.2
STRATEGIC CONTEXT
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.
4
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 subspecialisation 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
5
1.3

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
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)
6
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.
1.4
NOTE ON SAHF AND ORGANISATIONAL CHANGE
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.
1.5
CURRENT SITUATION
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
7
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.
1.6
CHAPTER SUMMARIES
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.
8
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 18week 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-ofhospital (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).
9
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
10
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.
11
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:
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.
12
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.
13
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)
Non-Merger Case
2014-15
£m
Outturn
Merger Surplus/(Deficit) normalised
(35.1)
Non-Merger Surplus/(Deficit)
(35.1)
Net I&E benefit
0.0
Merger Cash
(22.5)
Non-Merger Cash
(22.5)
Net Cash Benefit
0.0

2015-16
Forecast
(19.1)
(30.4)
11.3
(48.2)
(59.4)
11.3
2016-17 2017-18 2018-19 2019-20
Forecast Forecast Forecast Forecast
0.2
0.6
6.8
12.2
(27.1)
(37.0)
(34.5)
(34.4)
27.3
37.6
41.3
46.6
(47.5)
(51.4)
(58.9)
(30.4)
(86.1)
(127.5) (176.4) (194.5)
38.5
76.1
117.5
164.1
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.
14
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.
15
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.
1.7
SUMMARY OF APPENDICES AND SUPPORTING DOCUMENTS
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
Appendix 3-1
Mapping of business case amendments to TDA feedback
Detailed demographic information
Appendix 3-2
Appendix 4-1
Key elements of the case for change upon which SaHF is
founded
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
Appendix 8-2
Changes in activity flows assumed to result from SaHF
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
Appendix 8-6
Full balance sheet (merger base case)
Summary income and expenditure (non-merger case)
Appendix 8-7
Full balance sheet (non-merger case)
Appendix 8-8
Appendix 9-1
Workforce Mitigations
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
Assumptions
16
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
Appendix 10-3
Programme risk and issue register as of time of submission
Supporting Document 2-1
Estates vision and strategy
Letter to NHS England concerning Challenged Trust Board
funds
Strategic Outline Case
Communications and engagement plan
Organisational development strategy
Estates strategy
IM&T strategy
Joint strategy development overview presentation (August
13)
Draft ToR for new Trust Board and sub-committees
Clinical due diligence
Financial due diligence
Legal due diligence
Implementation plan
Benefits realisation plan
High-level Day 1/Day 100 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
17
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.
1.8
MAPPING OF THE BUSINESS CASE TO TDA ASSURANCE
FRAMEWORK
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.
1.9
CONCLUSION
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-ofhospital 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).
1.10 APPENDICES AND SUPPORTING DOCUMENTS
Appendix 1-1 Mapping of business case amendments to TDA feedback
18
2. Profile of the Trusts
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.
2.1
OVERVIEW OF THE ORGANISATIONS
Ealing Hospital NHS Trust and its associated Integrated Care Organisation (EHTICO) 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
West Middlesex University Hospital 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
19
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)
Trust
The Hillingdon Hospital NHS FT
Barnet & Chase Farm Hospitals NHS Trust
University College London Hospitals NHS FT
Royal Free London NHS FT
Moorfields Eye Hospital NHS FT
Chelsea & Westminster Hospital NHS FT
West Hertfordshire NHS Trust
Central & North West London NHS FT
BMI
Other
Total
Harrow CCG
Brent CCG
Ealing CCG
Referrals Percentage Referrals Percentage Referrals Percentage
27,576
59.15% 38,639
53.48%
6,561
8.81%
28,650
38.46%
1,836
3.94% 16,612
22.99%
20,976
28.16%
2,795
5.99%
4,896
6.57%
1,915
4.11%
1,572
2.18%
2,139
2.96%
778
1.04%
3,381
4.68%
2,755
5.91%
2,229
3.09%
3,617
4.86%
2,388
3.21%
1,508
3.23%
2,598
5.57%
2,327
3.22%
3,490
4.68%
1,151
2.47%
1,003
1.39%
4,490
4,348
6.02%
3,143
46,624
72,250
74,499
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
20
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
2.2
SWOT ANALYSES
SWOT analyses of the respective Trusts are summarised in Figure 3 and Figure 4
below.
Strengths
Weaknesses
 Good clinical outcomes
 Largest provider of community and
integrated pathways across three
large boroughs
 Wide range of career pathways for
staff
 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
Threats
 Outside upper quartile on most
productivity indicators
 CCGs investing significantly in out-ofhospital and community, which remain
a key focus for EHT-ICO
 Extending reach of R&D
 More efficient use of community estate
 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-andcompetition/archive-co-operation-and--13
21
Strengths
Weaknesses
 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
 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
Threats
 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
 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.
2.3
EALING HOSPITAL NHS TRUST
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:
22
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
Maternity
Medicine
Paediatrics
Surgery
Total
4,914
221
5,483
10,618
EL
223
152
1,683
2,058
NEL
2,443
14,065
2,157
3,748
22,412
OP
6,258
100,815
5,281
55,188
167,542
AE
40,466
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.
23
Figure 6 Breakdown of EHT-ICO income 2013/14
2.4
THE NORTH WEST LONDON HOSPITALS NHS TRUST
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)
Maternity
Medicine
Paediatrics
Surgery
Total
DC
619
22,828
2,708
4,408
30,563
EL
493
1,059
322
5,267
7,141
NEL
12,386
20,889
11,554
8,177
53,006
OP
45,291
112,117
13,259
107,972
278,639
NEL
OP
11,786
47,065
7,309
47,950
114,110
AE
86,041
86,041
Table 9 Activity at CMH (2013/14)
Maternity
Medicine
Paediatrics
Surgery
Total
DC
1,154
3,175
1,181
8,174
13,684
EL
390
263
70
2,351
3,074
1
6,755
15
110
6,881
AE
14,400
14,400
NWLHT employs 4,607 FTEs across a number of staff groups that can be seen in
Figure 7.
24
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 nonrecurrent 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)
25
2.5
SERVICES PROVIDED
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
26
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 haematooncology, 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 nonelective) 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 EHTICO and NPH

Great Ormond Street Hospital NHS FT provides specialist paediatrics
outpatients clinics at EHT
27
2.6
CURRENT PERFORMANCE
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
MRSA cases (YTD)
C. Difficile (YTD)
EHT
97.3%
1
13
EHT
1
15
NWLHT
93.99%
2
20
NWLHT
2
21
<18 wks (YTD) Admitted
<18 wks (YTD) Non admitted
EHT
89.5%
97.8%
NWLHT
76.13%
96.29%
All type (YTD)
MRSA cases (YTD)
C. Difficile (YTD)
Healthcare Acquired
Infections (HACAI)
Waiting times
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.
28
Cancer
2 week wait for suspected cancer
2 week wait for breast symptoms other than
suspected cancer
31 day diagnosis to treatment for first
definitive treatments
31 day diagnosis to treatment for
subsequent treatment (drugs)
31 day diagnosis to treatment for
subsequent treatment (surgery)
62 day referral to treatment for all cancers
62 day referral to treatment from screening
Target EHT
93%
94.7%
93%
95.2%
NWLHT
95.55%
97.18%
96%
98.7%
96.90%
98%
100%
98.97%
98%
100%
95.65%
85%
90%
87.9%
84.6%
86.42%
97.30%
EHT
82.9
NWLHT
60.0
Summary Hospital-level Mortality Indicator (SHMI)
Mixed sex breaches
Target EHT
0
7
NWLHT
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
29
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.
30
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
31
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 EHTICO 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.
32
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
Reducing length of stay
EHT
NWLHT
EHT
NWLHT
EHT
NWLHT
EHT
NWLHT
EHT
NWLHT
EHT
NWLHT
EHT
NWLHT
EHT
NWLHT
14.12%26
13.2%
1.91
2.21
6.58%
8.51%
12.48%
13.72%
2.06
1.54
77.95%
70.36%
0.27
0.24
3.95%28
3.02%
Managing first to follow outpatients27
Emergency readmissions
Outpatient DNA rate
Pre procedure non elective bed days
Day case rate
Pre procedure elective bed days
Sickness absence
National
Rank
120
66
39
88
142
162
153
161
125
40
104
141
120
104
120
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
33
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)
34
2.7
CARE QUALITY COMMISSION INSPECTIONS
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.
2.8
CONCLUSION
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 wellestablished 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.
35
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.
2.9
APPENDICES AND SUPPORTING DOCUMENTS
Supporting Document 2-1 Estates vision and strategy
Supporting Document 2-2 Letter to NHS England concerning Challenged Trust Board funds
36
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 outof-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.
3.1
OVERVIEW
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
37
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
38

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
39
‘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.
3.2
LOCAL COMMISSIONERS
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.
3.3
DEMOGRAPHY – LATEST TRENDS
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.
40
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
3.4
CCG PROFILES
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
41
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
42
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 allcause 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 coordinated 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-AppD1v1.1.pdf
54 Kilburn; Kingsbury; Wembley and Willesden, plus Harness which is Harlesden-based but Boroughwide
43
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-AppD5v1.1.pdf
44
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.
3.5
NHS NORTH WEST LONDON AND SHAPING A HEALTHIER FUTURE
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
45
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
46
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.
3.6
RESULTS OF THE IRP
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
47
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, custombuilt 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.
3.7
LINKS WITH OVERALL COMMISSIONING STRATEGY
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%2
0Document.UpdatedAugust2012_0.pdf
48
1 – least
deprived
quintile
Relative deprivation in Brent, Ealing
and Harrow
Deprivation by ward
2
3
4
5 – most
deprived
quintile
Residents
%
Brent
100
90
80
70
Ealing
60
50
40
30
Harrow
20
10
0
England London
Brent
Ealing
Harrow
SOURCE: 2010
Health Profiles,
Department of Health
Figure
11Borough
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.
3.8
CCG OUT-OF-HOSPITAL STRATEGIES
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
49
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 rethinking 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 betternetworked 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-ofhospital 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.
3.9
CCGS’ VISION FOR OUT-OF-HOSPITAL CARE
3.9.1 Pathways
Four pathways have consistently emerged across the boroughs as priorities for
change:

Planned care

Unscheduled care
50

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.
What activity shifting out of hospital should happen where?
Planned care
Unscheduled
care
Community
hospital
Hub (e.g.,
health centre)
Complex procedure (low
ASA elective surgery)
MRI
Plain radiography
Ultrasound
GP practice
Home
Minor surgery
Close walk in centre
Active diversion to practice
Long term
conditions
Telehealth
Mental Health
Emergency assessments
3
Figure
12
Activity
SOURCE:
Ealing
workshop shifting OOH – a possible approach for Ealing (source: Ealing| CCG)
51
3.10 ENABLERS AND SUCCESS FACTORS
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.
3.11 DECOMMISSIONING AND PROCUREMENT
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.
3.12 IMPLICATIONS FOR THE ACUTE SERVICES
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.
52
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
3.13 WHAT THIS MEANS FOR THE FUTURE HEALTHCARE LANDSCAPE?
Presently, many people go to hospital for services that could be better provided outof-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 communitybased 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
53
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.
3.14 CONCLUSION
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
54
4. Why merge EHT-ICO and NWLHT?
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.
4.1
INTRODUCTION
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 communitybased 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
55
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.
56
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
3. Geographical proximity
2. Integrated Care potential
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 – EHTICO, 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
57

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.
4.2
WHY CHANGE IS NEEDED
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
58
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 highquality 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 longterm 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.
59
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.
4.3
COMMON LESSONS FROM OTHER MERGERS
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.
4.4
CONCLUSION
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 EHTICO 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.
4.5
Appendix 4-1 Details of the options appraisal
Supporting Document 4-1 Strategic Outline Case
60
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.
5.1
INTRODUCTION
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
61

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
62
5.2
BENEFITS FROM ACUTE AND COMMUNITY INTEGRATION – A MODEL
FOR 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
63
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;
64

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 EHTICO 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
65
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
66
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
67
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
68
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
In the merged organisation
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.
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.
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.
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.
69
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.
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
In the merged organisation
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’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 multiprofessional assessment.
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.
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
70
voluntary agency funded support group. Follow
up is arranged with neurology by the MAU.
5.3
BENEFITS FROM MERGED ACUTE HOSPITAL-BASED SERVICES
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 PanLondon 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
71
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 subspecialisation 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
Better patient access to key diagnostic
and therapeutic interventions and more
efficient use of specialist expensive
equipment
Consultant-led care for the acute medicine
and emergency surgery pathways
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
72
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
73
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 EHTICO, 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
74
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 EHTICO 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 carebased 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
75
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)
Internal Medicine
EHT
NWLHT
£2.3m
Cardiac Surgery
Complex Invasive Cardiology
Specialised Respiratory
£9.1m
Cardiac Surgery
Hepatobiliary and Pancreas
Morbid Obesity Surgery
76
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
77
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
78
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 EHTICO, 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 mediumterm 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
79
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
80
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.
Single managerial
structure reduces
bureaucracy and
managerial costs
Line managers can prioritise staff availability and skills to
provide the best and safest care
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.
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
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
81
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).
5.4
BENEFITS OF THE MERGER FOR TRAINING AND EDUCATION
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 nonmedical 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
82
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 patientfacing 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. Sitespecific 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.
83
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, preregistration 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.
84
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
5.5
BENEFITS OF THE MERGER FOR RESEARCH AND INNOVATION
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
85
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
86
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).
87
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
The Hillingdon Hospitals NHS FT
Hounslow and Richmond Community Healthcare NHS Trust
Imperial College London
Royal Brompton and Harefield NHS FT
West London Mental Health Trust
This new partnership in North West London aims to improve the health and care of
the local population of 1.9m people.
5.6
CONCLUSION
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.
5.7
Appendix 5-1 Examples of patient benefits and patient stories
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
88
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.
6.1
INTRODUCTION
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.
6.2
VISION, AIMS AND OBJECTIVES
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
89
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:
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
90
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 riskbased 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.
91
4. Financial stability – To deliver recurrent surpluses without the need for
external support.
6.3
VALUES AND OBJECTIVES
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
Improvement
To continuously improve our
services and create a
positive learning
environment.
Behaviours



Safety

To do everything we can to
make our services safe.

Care

To show compassion and
support for our patients

Individual

To provide care that
addresses individual needs
of our patients, their families
and our staff.

92
Setting ourselves high standards to
achieve
Celebrating when we do well and
learning from our mistakes
Looking for new and innovative ways of
working
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
Listening to patients’ needs and
concerns
To ensure our care is evidence based
and follows best practice
Involving patients in decisions about
their care
Communicating effectively with
healthcare partners to ensure good
continuity of care
Value
Definition
Behaviours
Responsibility To take responsibility for our
actions.


Responding positively to feedback
Striving to get it right first time
Respect

To be open and honest about our
performance
To treat others as we would
expect to be treated.
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.
6.4
DEVELOPMENT OF CLINICAL STRATEGY
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
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
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
CMH
EHT (transition)
93
Key clinical theme
EHT ‘end state’
Community
services
Models of care to be
developed further
Supporting
priorities
6.5
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
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
 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.
 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?
 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
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:
94

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 workstreams
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
95
benefits
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.



Maternity &
Gynaecology
Emergency
Care
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.

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

96








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.
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.
Vision of ‘providing care that
patients want in the right
place… by the right team’ will
drive better patient experience.
Better clinical outcomes as
benefits
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
Care of the
Elderly
Vascular &
Diabetes





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

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-

97





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 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
Access to intravenous
antibiotics in community
settings at an early treatment
benefits
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
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












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
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.
98
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
6.6
CONCLUSION
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.
6.7
Supporting Document 6-1 Joint strategy development overview presentation (August 13)
99
7. The new organisation’s structure and
governance arrangements
Chapter summary
This chapter describes:
7.1

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.
BACKGROUND
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-finalreport.pdf
100
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.
7.2
THE BOARD AND STRUCTURE OF THE NEW ORGANISATION
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
101
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
102

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.
7.3
LEADERSHIP ROLES AND RESPONSIBILITIES
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.
103
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
104
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.
105
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
106
Board and its sub-committees. He/she will also coordinate and maintain the Trust’s
Board Assurance Framework and the corporate risk register.
7.4
BOARD SUB-COMMITTEE REPORTING STRUCTURE
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.
107
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 subcommittees 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 (postmerger 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 workstreams 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, NonExecutives representation and executive representation.
96 Delivering High Quality Care for Patients: The Accountability Framework for NHS Trust Boards,
TDA April 2013.
108
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
7.5
CLINICAL OPERATIONAL STRUCTURE OF THE NEW ORGANISATION
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
109

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
110
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
111
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
112
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
113
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
7.6
CORPORATE QUALITY GOVERNANCE
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
114
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 nonclinical 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
115
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.
7.7
DIVISIONAL QUALITY GOVERNANCE
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
116
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
117

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)
118
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
119
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.
7.8
RISK MANAGEMENT ARRANGEMENTS
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
120
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.
7.9
CONCLUSION
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
121
8. Financial evaluation / LTFM
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 workstream 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.
8.1
BACKGROUND AND CONTEXT
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
122
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.
8.2
CALCULATING FINANCIAL VIABILITY
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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8.3
HISTORICAL FINANCIAL PERFORMANCE OF THE CURRENT TRUSTS
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
£m
NHS Clinical Income
Other Income
Non Recurrent Income
Total Income
Pay costs
Non Pay costs
Total Operating Expenses
EBITDA
Non-Operating Expenses
Reported Surplus/(Deficit)
Normalised Surplus/(Deficit)
Reported Cumulative surplus/(deficit)
Normalised Surplus/(Deficit)% of income
Net Cash Inflow/(Outflow)
Cash and Cash Equivalents
Fixed Assets
Long Term Liabilities
Retained Earnings/(Accumulated Losses)
2011-12
Actual
212.5
19.0
1.5
232.9
(160.3)
(63.7)
(224.0)
8.9
(6.6)
2.3
2.3
2.3
1.0%
0.0
6.2
91.8
(3.9)
50.8
11.7
2012-13
Actual
206.3
26.2
1.6
234.1
(163.5)
(63.8)
(227.3)
6.8
(6.7)
0.1
0.1
0.1
0.0%
(1.0)
5.3
94.3
(3.9)
51.1
11.8
2013-14
Actual
214.9
24.1
9.4
248.4
(173.1)
(67.7)
(240.9)
7.5
(7.5)
0.0
0.0
0.0
0.0%
0.2
5.0
127.1
(3.9)
53.3
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.
124
Table 37 Historical financial performance – NWLHT
NWLHT Historical Financial Position
2011-12
Actual
307.2
57.5
21.0
385.7
(235.7)
(129.8)
(365.6)
20.2
(37.0)
(16.8)
(9.5)
(16.8)
-2.5%
1.4
279.0
(65.1)
192.1
(60.4)
£m
NHS Clinical Income
Other Income
Total Income
Pay costs
Non Pay costs
EBITDA
Non-Operating Expenses
Reported Surplus/(Deficit)
Reported Cumulative surplus/(deficit)
Fixed Assets
Retained Earnings/(Accumulated Losses)
2012-13
Actual
313.4
66.9
0.0
380.2
(240.5)
(140.4)
(380.9)
(0.7)
(50.5)
(51.0)
(21.5)
(51.0)
-5.7%
1.5
256.9
(64.7)
225.0
(111.4)
2013-14
Actual
343.6
61.4
13.1
418.0
(254.3)
(167.4)
(421.8)
(3.7)
(24.9)
(28.7)
(23.6)
(28.7)
-5.6%
1.6
272.8
(62.8)
265.2
(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 nonrecurrent 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.
8.4
NORTH-WEST LONDON HEALTH ECONOMY – FINANCIAL POSITION
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
125
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
126
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.
8.5
MERGER CASE MODELLING AND SCENARIOS OVERVIEW
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 nonmerger 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
127
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
£m
NWLHT Surplus/(Deficit)
EHT Surplus/(Deficit)
Aggregated I&E
Merger Savings
Inflation/Other
SaHF impact
Base Case Surplus/(Deficit)
Normalised Base Case
Surplus/(Deficit)
2014-15
Outturn
(42.9)
(13.6)
(56.5)
4.0
(4.0)
(2.3)
(58.9)
(35.1)
2015-16 2016-17 2017-18 2018-19 2019-20
Forecast Forecast Forecast Forecast Forecast
(21.4)
(16.1)
(12.7)
(9.8)
(6.0)
(11.5)
(6.6)
(8.1)
(29.1)
8.5
(32.9)
(22.7)
(20.9)
(38.9)
2.5
15.3
19.0
19.0
19.0
19.0
(0.1)
1.8
1.7
2.5
3.1
(1.4)
2.0
0.8
(5.8)
(6.4)
(19.1)
0.2
0.6
(23.2)
18.2
(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
£m
Normalised Base Case
Surplus/(Deficit)
Non-Merger assessment impact
Non-Merger Case
Surplus/(Deficit)
Merger Benefit
2014-15 2015-16 2016-17 2017-18 2018-19 2019-20
Outturn Forecast Forecast Forecast Forecast Forecast
(35.1)
(35.1)
(19.1)
0.2
0.6
6.8
12.2
(11.3)
(27.3)
(37.6)
(41.3)
(46.6)
(30.4)
(27.1)
(37.0)
(34.5)
(34.4)
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.
128
Table 40 Downside Case 2013/14 to 2018/19
Downside Case
2014-15 2015-16 2016-17 2017-18 2018-19 2019-20
£m
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
8.6
MERGER BASE CASE FINANCIAL ASSESSMENT
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.
129
Table 41 Summary base case financial position
Merger Financial Overview
£m
NHS Clinical Income
Other Income
Total Income
Pay costs
Non Pay costs
EBITDA
Non Operating Expenses
Surplus/(Deficit)
2014-15
Outturn
556.4
75.3
22.4
654.1
(431.9)
(237.7)
(669.6)
(15.5)
(43.5)
(58.9)
(35.1)
-5.4%
2015-16
Forecast
540.8
81.0
7.1
628.9
(411.5)
(205.3)
(616.8)
12.1
(31.2)
(19.1)
(19.1)
-3%
2016-17 2017-18 2018-19 2019-20
545.1
553.1
514.4
518.7
79.7
79.9
64.6
64.9
11.4
11.4
20.4
20.4
636.1
644.4
599.4
604.0
(401.4) (400.1)
(360.0) (358.3)
(201.4) (202.1)
(190.0) (184.7)
(602.7) (602.2)
(550.0) (543.0)
33.4
42.2
49.5
60.9
(33.3)
(41.5)
(72.7)
(42.7)
0.2
0.6
(23.2)
18.2
0.2
0.6
6.8
12.2
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%
4.0
(29.1)
(22.5)
419.5
(64.4)
382.3
(170.7)
15.3
(25.7)
(48.2)
436.6
(62.2)
396.8
(189.8)
19.0
0.7
(47.5)
522.6
(115.9)
420.0
(189.7)
19.0
(3.8)
(51.4)
594.4
(169.0)
431.9
(189.0)
19.0
(7.5)
(58.9)
563.7
(161.7)
431.9
(212.2)
19.0
28.5
(30.4)
544.3
(154.3)
431.9
(194.0)
Merger Savings (cum.)
Fixed Assets
Retained Earnings/(Acc. Losses)
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.
130
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.
131
800.0
Income Plan 14/15 to 19/20
32.5
94.4
750.0
10.0
4.5
15.6
93.8
26.4
700.0
7.0
650.0
£m
1.8
55.2
4.3
654.1
600.0
604.0
550.0
500.0
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.
132
900.0
Costs Plan 14/15 to 19/20
850.0
37.8
800.0
22.6
7.8
2.0
17.3
4.5
63.7
139.6
33.8
750.0
700.0
650.0
£m
19.0
713.0
600.0
550.0
0.9
0.0
2.6
585.8
500.0
450.0
400.0
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:
133
Table 42 SaHF impact 2013/14 to 2018/19
SaHF impact
£m
CMH income
NPH income
EHT income
Total income
CMH costs
NPH costs
EHT costs
Total costs
CMH net contribution
NPH net contribution
EHT net contribution
Total net contribution
Capital Charges
Additional Capex
2014-15 2015-16 2016-17 2017-18 2018-19 2019-20
Forecast Forecast Forecast Forecast Forecast Forecast
(9.5)
(16.3)
(16.3)
(16.3)
(16.3)
(16.3)
7.1
14.0
14.0
14.0
31.9
31.9
(0.8)
(8.4)
(8.4)
(8.4)
(83.6)
(83.6)
(3.2)
(10.7)
(10.7)
(10.7)
(68.0)
(68.0)
4.8
8.2
11.6
11.6
11.6
11.6
(4.2)
(7.1)
(7.1)
(7.1)
(17.1)
(17.1)
0.4
8.2
8.2
7.0
67.7
67.0
0.9
9.3
12.7
11.5
62.3
61.6
(4.7)
(8.1)
(4.7)
(4.7)
(4.7)
(4.6)
2.8
6.9
6.9
6.9
14.8
14.8
(0.4)
(0.2)
(0.2)
(1.4)
(15.9)
(16.6)
(2.3)
(1.4)
2.0
0.8
(5.8)
(6.4)
(3.0)
(4.0)
(5.0)
(5.0)
(5.0)
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.
134
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.
135

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.
136
Capital Programme £m
110.0
25.0
23.2
20.0
11.9
70.0
15.0
50.0
30.0
57.0
57.0
10.0
23.4
7.0
14.6
10.0
16.8
9.0
8.5
-10.0
14-15
15-16
4.0
17.2
21.0
18.4
18.4
16-17
17-18
18-19
19-20
NPH SaHF
Ealing Local Hospital
Capex programme
Depreciation
Depreciation
90.0
5.0
-
IT bids
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.
137
Funding Sources £m
120.0
100.0
80.0
57.0
57.0
60.0
40.0
30.6
20.0
-
17.1
28.2
14.8
16.6
15.0
16.2
18.0
18.4
18.4
14-15
15-16
16-17
17-18
18-19
19-20
Commercial Loan
PDC Funding
Depreciation
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.
8.7
COST IMPROVEMENT SAVINGS AND PROGRAMME MANAGEMENT
OFFICE
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.
138
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 fulltime 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
£13.5m
Total
Full Year impact of recurrent
savings
£13.5m
£0.2m
£10.3m
£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.
139
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
£1.7m
£9.4m
Income generation
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 EHTICO. 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.
140
2014/15 and 2015/16 CIP Programme Summary
Table 46 CIP programme 2014/15
PID
Description
Workforce Related
Nurse Workforce
Initiatives
This PID covers QIPP initiatives which are productivity
improvements for nursing staff
Medical Workforce
Initiatives
Admin & Clerical
Workforce
Initiatives
Corporate and
Back Office
Corporate Business
as usual
Information
Management and
Technology
Reconfiguration
Initiatives
Reconfiguration at
Central Middlesex
Hospital
Acute to
community/
patient pathways
Community
Management
Structures
Clinical
Productivity
Initiatives
Length of Stay
efficiency
improvements
Theatres
productivity
Referral to
Treatment
Pathology
productivity
Estates and
Procurement
Initiatives
Estates Business
as usual
Procurement
Business as usual
Procurement
related
This PID coves Medical workforce cost reductions arising
from job planning, review of rotas, medical locum costs
This PID covers Admin & clerical clinical workforce cost
and headcount reductions arising from changing working
practices
This PID covers Corporate cost improvements arising
from reviewing costs, reducing headcount, using
technology
This PID covers Cost improvements arising from the
investment in improved Information systems and
processes
This PID covers the SAHF provisions for the future of the
CMH site, in particular, the closure of the emergency
department in 2014/15
This PID covers the pathway changes to community, in
particular the extension to the STARRs team provision to
patients in Brent & Harrow
2014/15
NWL
£m
2014/15
EHT
£m
1.8
1.1
1.6
0.4
0.4
0.3
0.9
2.9
0.1
0.1
0.3
-
0.2
-
This PID covers the changes to Community Management
structures
This PID covers proposed Length of Stay improvements
at Ealing Hospital which release capacity reduces cost.
This PID covers the improved Theatre productivity by
improving and list planning - the anticipated savings
arising from reducing additional theatre sessions.
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.
This PID covers a Productivity achieved by improving
laboratory productivity
This PID Estates and facilities cost improvements arising
from supplier contracts and site utilisation
This PID relates to the procurement department achieving
better purchasing of goods and services to secure
savings.
This PID covers the savings arising from the procurement
related to initiatives of better purchasing of drugs and
141
0.1
-
1.4
0.2
0.3
1.6
-
0.4
-
-
-
0.9
1.0
0.6
1.3
0.3
-
PID
Description
Information technology systems
Income Related
Initiatives
Service
Developments
Coding and Best
Practice Tariff
Other income
This PID (there are 8 PIDs) cover various minor service
development / improvement opportunities arising from
operational teams at Northwest London Hospitals
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)
This PID covers Estates related and research related
income opportunities which are not associated with CCGs
as an income source
Sub Total 2014/15
PIDs
2014/15
NWL
2014/15
EHT
-
-
1.3
-
0.4
0.2
0.4
0.3
11.5
9.5
Table 47 CIP programme 2015/16
PID
Description
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.
AHP
Workforce
Initiatives
Diabetes
Initiatives
Efficiency
Improvement
Initiatives
Estates
Initiatives
Total
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.
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.
This PID focusses on efficiency improvements arising from benchmarking
of weighted average length of stay and outpatient utilisation and DNA rates
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.
Maternity &
Gynaecology
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.
This PID focusses on the cost savings initiatives which arise from the
reconfiguration of maternity and gynaecology at Ealing and North West
London reconfiguration
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.
HR
Initiatives
142
1.8
2.1
0.0
7.0
0.0
1.2
2.7
4.1
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.
8.8 FORECAST SAVINGS TARGETS
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
3.00%
4.50%
4.25%
4.00%
4.00%
4.00%
CIP programme
0.50%
0.25%
0.25%
Additional IT investment related target
0.8%
2.3%
0.7%
Merger Savings
3.80%
7.26%
5.24%
4.25%
4.00%
4.00%
Total Savings
CIP Savings
2014-15 2015-16 2016-17 2017-18 2018-19 2019-20
£m
19.1
28.9
27.4
25.8
25.7
25.7
CIP programme
3.2
1.5
1.5
0.0
0.0
Additional IT investment related target
4.0
11.3
3.7
0.0
0.0
0.0
Merger Savings
23.1
43.4
32.6
27.3
25.7
25.7
Total Savings
Pay CIP
£m/WTE
Pay CIP related to headcount
reduction
Pay CIP related to unit cost
reduction
Merger savings
Total Pay Savings
Reduction in WTE due to savings
WTE reduction as % of existing
Total
2015-16 2016-17 2017-18 2018-19 2019-20
47.7
8.6
7.7
10.9
10.3
10.3
45.4
12.8
11.6
7.3
6.8
6.8
19.0
112.1
(1,104)
-13%
15.3
36.7
(318)
-4%
3.7
23.0
(179)
-2%
0.0
18.2
(211)
-2%
0.0
17.1
(198)
-2%
0.0
17.1
(198)
-2%
143
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
Governance
68
167
Corporate
19
39
Operations
800
5019
Estates
704
1104
Finance
1100
1550
Human Resources
837
1036
Information Technology
312
656
Trust Board
160
Nil
Academic
Nil
300
300
Directors
Nil
200
162
Sub Total
4000
10071
643
Bed Management
Nil
175
175
Digital Care Records
Nil
200
200
A&E Systems
Nil
54
53
E-prescribing
Nil
nil
566
Materials Management
Nil
Nil
300
Procurement Framework
Nil
800
900
Medical Directorate
Nil
Nil
330
Nursing Directorate
Nil
Nil
600
Sub Total
4000
1229
3124
Total
4000
11300
3767
Corporate Integration:
181
Clinical Integration:
144
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.
8.9

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 sensechecked; 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
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.
145
Table 50 Summary non-merger case financial position
Non-Merger Financial Overview
£m
NHS Clinical Income
Other Income
Total Income
Pay costs
Non Pay costs
EBITDA
Surplus/(Deficit)
2014-15
Outturn
556.4
75.3
22.4
654.1
(431.9)
(237.7)
(669.6)
(15.5)
(43.5)
(58.9)
(35.1)
-5.4%
2015-16
Forecast
531.4
81.0
7.1
619.5
(415.0)
(203.6)
(618.6)
0.8
(31.2)
(30.4)
(30.4)
-5%
2016-17 2017-18 2018-19 2019-20
528.1
530.7
489.6
491.5
79.7
79.9
64.6
64.9
11.4
11.4
20.4
20.4
619.2
622.0
574.6
576.8
(413.1) (416.2)
(376.3) (376.6)
(199.8) (201.2)
(190.1) (186.0)
(612.9) (617.4)
(566.5) (562.6)
6.2
4.6
8.1
14.2
(33.3)
(41.5)
(72.7)
(42.7)
(27.1)
(36.9)
(64.5)
(28.5)
(27.1)
(36.9)
(34.5)
(34.5)
-4%
-6%
-6%
-6%
19.1
32.1
28.9
27.3
25.7
25.7
2.9%
5.0%
4.5%
4.3%
4.0%
4.0%
4.0
(29.1)
(22.5)
419.5
(78.7)
329.0
15.3
(36.5)
(59.0)
436.6
(62.2)
343.5
19.0
(26.3)
(85.4)
522.6
(115.9)
366.7
19.0
(41.6)
(127.0)
594.4
(169.0)
378.6
19.0
(48.6)
(175.6)
563.7
(161.7)
378.6
19.0
(18.0)
(193.6)
544.3
(154.3)
378.6
(170.7)
(201.1)
(228.2)
(265.1)
(329.6)
(358.1)
Fixed Assets

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;

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.
146
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.
147
20.0
12.2
10.0
-9.1
3.6
-34.5
-17.3
0.0
(10.0)
£m
-16.2
(20.0)
-7.7
(30.0)
(40.0)

Figure 22 Non-Merger Assumptions Impact
8.10 FINANCIAL BENEFITS OF MERGING THE TRUSTS
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
148
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
Non-Merger Case
2014-15
£m
Outturn
Merger Surplus/(Deficit) normalised
(35.1)
Non-Merger Surplus/(Deficit)
(35.1)
Net I&E benefit
0.0
Merger Cash
(22.5)
Non-Merger Cash
(22.5)
Net Cash Benefit
0.0
2015-16
Forecast
(19.1)
(30.4)
11.3
(48.2)
(59.4)
11.3
2016-17 2017-18 2018-19 2019-20
0.2
0.6
6.8
12.2
(27.1)
(37.0)
(34.5)
(34.4)
27.3
37.6
41.3
46.6
(47.5)
(51.4)
(58.9)
(30.4)
(86.1)
(127.5) (176.4) (194.5)
38.5
76.1
117.5
164.1
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.
8.11 FUNDED MERGER BASE CASE
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:
149
Table 52 Summary funded merger base case financial position
Funded Base Case Financial Overview
2014-15
£m
Outturn
NHS Clinical Income
556.4
Other Income
75.3
22.4
Total Income
654.1
Pay costs
(431.9)
Non Pay costs
(237.7)
(669.6)
EBITDA
(15.5)
(43.5)
Surplus/(Deficit)
(58.9)
(35.1)
2015-16
Forecast
540.8
81.0
7.1
628.9
(411.5)
(205.3)
(616.8)
12.1
(31.2)
(19.1)
(19.1)
2016-17 2017-18 2018-19 2019-20
545.1
553.1
514.4
518.7
79.7
79.9
64.6
64.9
11.4
11.4
20.4
20.4
636.1
644.4
599.4
604.0
(401.4)
(400.1)
(360.0)
(358.3)
(201.4)
(202.1)
(190.0)
(184.7)
(602.7) (602.2) (550.0) (543.0)
33.4
42.2
49.5
60.9
(33.3)
(41.5)
(72.7)
(42.7)
0.2
0.6
(23.2)
18.2
0.2
0.6
6.8
12.2
Surplus/(Deficit)% of income
-5.4%
-3%
0%
0%
1%
2%
19.1
32.1
28.9
27.3
25.7
25.7
2.9%
5.0%
4.5%
4.3%
4.0%
4.0%
4.0
6.5
419.5
(64.4)
424.1
(170.7)
15.3
1.8
436.6
(62.2)
459.6
(189.8)
19.0
2.5
522.6
(115.9)
482.8
(189.7)
19.0
5.1
594.4
(169.0)
501.2
(189.0)
19.0
13.6
563.7
(161.7)
517.2
(212.2)
19.0
58.2
544.3
(154.3)
533.2
(194.0)
Fixed Assets

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;

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.
150
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
Merger Implementation Costs
£m
Transaction Costs
Integration Costs
OD Costs
Redundancy
Net Impact
2013-14
Outturn
(3.3)
(6.1)
(1.9)
(11.3)
2014-15
Outturn
(0.5)
(6.0)
(1.8)
(4.5)
(12.8)
Total
(3.8)
(12.2)
(3.7)
(4.5)
(24.2)
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
£m
Outturn
(24.1)
Merger Costs
4.0
Merger Savings
(20.1)
Net Impact
2015-16
Forecast
(24.1)
19.3
(4.8)
2016-17 2017-18 2018-19 2019-20
(24.1)
(24.1)
(24.1)
(24.1)
38.3
57.3
76.3
95.3
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.
151
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 aboveaverage 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
Merger Funding Requirement
£m
Short term trading deficits
Repayment of Loans and Leases
Ealing local hospital transitional funding
DH loan repayment
Total Merger Funding
Adj for non cash items - CTB payback
Total cash funding
2014-15
Outturn
(47.9)
(1.9)
(14.3)
(64.1)
14.3
(49.8)
2015-16 2016-17 2017-18 2018-19 2019-20
(19.1)
(1.9)
(6.5)
(7.0)
(7.1)
(9.0)
(9.0)
(21.0)
0.0
(6.5)
(16.0)
(16.1)
(21.0)
0.0
(6.5)
(16.0)
(16.1)
Total
(67.0)
(24.3)
(18.0)
(14.3)
(123.6)
14.3
(109.3)
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.
8.12 DOWNSIDE CASE
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;
152

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
153
main EHT site which was not included in the base case (estimated value of estate
£60m).
Table 56 Downside mitigations
8.13 CONCLUSION
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 nonmerger case. The modelling demonstrates that the negative cash position of the nonmerger case is forecasted to be £193.6m. It also shows that if merger does not go
154
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
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:
9.1

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.
INTRODUCTION AND CONTEXT
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.
156
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.
9.2
PREVIOUS COMMUNICATION AND ENGAGEMENT ACTIVITIES
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.
157
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.
9.3
OVERVIEW OF COMMUNICATION AND ENGAGEMENT ACTIVITIES
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;
158

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.
159
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
160
Issues raised
Our response
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
161
Issues raised
Our response
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.
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.
9.4
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 Outof-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.
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/whymerge/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
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.
162
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.
9.5
COMMUNICATION AND ENGAGEMENT WITH OTHER
STAKEHOLDERS
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
163
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.
164
9.6
COMMUNICATION AND ENGAGEMENT PLAN FOR THE BUSINESS
CASE 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.
9.7
ADDITIONAL KEY AREAS OF COMMUNICATIONS AND ENGAGEMENT
ACTIVITY
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
165
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).
9.8
FUTURE COMMUNICATION AND ENGAGEMENT
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.
166
9.9
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
Supporting Document 5-1 Communications and engagement plan
167
10. Integration and implementation plan
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.
10.1 INTRODUCTION
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).
10.2 PROGRAMME GOVERNANCE ARRANGEMENTS AND STRUCTURE
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.
168
expertise on cost saving opportunities and initiatives.
Figure 23 Schematic transaction and integration/implementation programme governance
arrangements
10.3 THE PROGRAMME MANAGEMENT OFFICE
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.
10.4 RISK AND ISSUE MANAGEMENT
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.
169
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.
10.5 TRANSACTION TIMELINE AND ASSURANCE
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
10.6 ITERATIVE DEVELOPMENT OF THE IMPLEMENTATION PLANS
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.
170
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.
10.7 PROGRESS TO DATE AND HIGH-LEVEL STEPS TO A FULLY
INTEGRATED 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.
171
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
Maintain clarity on lines of decisionresponsibilities 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
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
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
172
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.
173
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-inband 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
174

Business Case - LNWH NHS Trust - London North West Healthcare

Transcription

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