Evidence submitted by Mendip Primary Care
Trust (ISTC 54)
1. INTRODUCTION
1.1 This paper has been prepared for the
Health Select Committee and sets out the development and establishment
of the Shepton Mallet Treatment Centre.
2. BACKGROUND
2.1 As outlined in the Department of Health
prospectus "Growing Capacity", issued in December 2002,
the National Health Service (NHS) needs to increase its available
capacity in order to meet the reduction in waiting times planned
for 2005 and beyond to 2008. By December 2005, no patient will
have waited more than eighteen weeks for an initial outpatient
appointment and no longer than six months for the inpatient treatment
they may need. By December 2008, the maximum wait should be 18
weeks. Meeting and maintaining these demanding targets requires
a permanent increase in capacity.
2.2 The Government and the NHS have sought
a real step change in productivity by seeking to engage the independent
sector in this initiative. Commissioning Primary Care Trusts expected
dynamic and innovate solutions to provide an environment for patients
that is conducive to the provision of first class clinical care.
The Independent Sector Treatment Centre programme represented
a unique opportunity for the NHS and independent sector to work
in partnership.
2.3 The core objective of the Independent
Sector Treatment Centre in Dorset and Somerset was to procure
a service that would:
provide clinical services and not
simply capital solutions;
deliver activity in 2005 at the latest;
provide genuine additionality of
staff;
provide patient choice;
contribute to the long term development
of partnerships between the independent sector and the NHS; and
deliver high clinical standards and
value for money.
2.4. The Shepton Mallet Treatment Centre is
one of ten local schemes and has been delivered within a central
framework set by a national template for the Project Agreement.
2.5 The defining characteristics of the vision
for the Shepton Mallet Treatment Centre are that it:
exemplifies best practice and forward
thinking in the design and delivery of the services provided,
with services that are streamlined and modern, using defined patient
care pathways;
delivers high volumes of activity
in a pre-defined range of routine treatments and or diagnostics,
adding significantly to the capacity of the Dorset and Somerset
Health Community to treat its patients;
delivers scheduled care that is not
affected by demand for, or provision of, unscheduled care;
has services that are planned and
booked, with an emphasis on patient choice and convenience together
with organisational ability to deliver;
provides a high quality patient experience;
and
creates a positive environment that
enhances the working lives of staff.
2.6 To achieve this vision, it was recognised
that the project would require new and innovative ways of working
and need to harness world-class healthcare practices to achieve
the best possible outcomes for patients and the best value for
the NHS.
2.7 The decision to procure an independent sector
Treatment Centre as opposed to a traditional NHS development was
that it offered:
rapid access to a major step change
in capacity in specialties that had long term waiting times issues
such as orthopaedics;
contestability with local NHS organisations
as it would be a catalyst to improve performance further across
Dorset and Somerset. It was envisaged that both NHS Trusts and
existing independent sector providers would need to change to
meet this challenge; and
an opportunity for innovation and
new ways of working.
3. DEVELOPMENT
OF THE
SHEPTON MALLET
TREATMENT CENTRE
3.1. The development of the Shepton Mallet
Treatment Centre has been driven through a close collaboration
between the Dorset and Somerset Strategic Health Authority and
the following five Primary Care Trusts:
Mendip Primary Care Trust.
South Somerset Primary Care Trust.
Somerset Coast Primary Care Trust.
Taunton Deane Primary Care Trust.
North Dorset Primary Care Trust.
3.2 In response to the request from the
Department of Health for interest in the Independent Sector Treatment
Centre programme the Dorset and Somerset Health Community submitted
a proposal for a stand alone purpose built Independent Sector
Treatment Centre to serve a population of 609,000.
3.3 The population of the five Primary Care
Trusts is served by the following NHS Trusts:
Taunton and Somerset NHS Trust.
East Somerset NHS Trust.
Weston Area Health NHS Trust.
Royal United Hospital Bath NHS Trust.
3.4 The above providers were struggling
to deliver the national and local waiting time targets and Primary
Care Trusts were already commissioning additional capacity through
the local independent sector. The rurality of the population and
focus on a small number of local NHS Trusts was felt to limit
patient choice and reduce the leverage of the commissioners to
modernise services. The Independent Sector Treatment Centre programme
was recognised as an opportunity to eradicate waiting times for
key specialties and act as a catalyst for modernisation and innovation.
3.5 A strong project team was established
to lead the selection of preferred bidders including Primary Care
Trust Chief Executives, a Director of Finance, local general practitioners
and representatives of the Dorset and Somerset Strategic Health
Authority.
3.6 Following an extensive evaluation process
involving both the local sponsors and the commercial team at the
Department of Health, the Shepton Mallet Treatment Centre was
awarded to ORI International specialty hospital developers in
2003. ORI International had formed a partnership with the following
two organisations:
WS Atkins plc to lead the building
of the new hospital;
New York Presbyterian to provide
technical and clinical expertise.
3.7 The partnership was awarded the contract
on the basis that:
it could demonstrate value for money;
through the involvement of WS Atkins
plc the partnership had expertise in delivering building projects
such as the proposed Shepton Mallet Treatment Centre within very
short timescales;
through the involvement of New York
Presbyterian the partnership had experts with world renowned clinical
expertise and evidence of the ability to deliver high quality
patient care.
3.8 Both the sponsoring Primary Care Trusts
and ORI International were committed to introducing new ways of
working to increase the capacity of the proposed facility and
improve clinical outcomes.
4. BUILDING PROGRAMME
4.1 The site at Shepton Mallet, selected
for the Independent Sector Treatment Centre, was chosen because
it was within a 30 mile radius of the key population centres of
Taunton, Yeovil, Bristol, Weston-super-Mare and Salisbury offering
potentially large populations for high volume procedures.
4.2 There was an extensive consultation
programme involving local councils, public forums and local residents
meetings throughout the construction to address any concerns.

4.3 The building was a new build, modern,
purpose designed healthcare facility intended to provide on-site
diagnostics and surgical treatments for over 11,800 patients a
year. By using an innovative modular construction process the
centre took only 42 weeks to build and was handed over for the
final phase of mobilisation in the middle of July 2005.
4.4 Shepton Mallet Treatment Centre provides:
four operating theatres;
MRI scanner and diagnostic services;
on site sterilisation facilities;
and
22 doctors and 52 trained nurses
(recruited mainly from Europe).
5. MOBILISATION
5.1 The sponsoring Primary Care Trusts nominated
Mendip Primary Care Trust as the lead commissioner for the project.
Mr Robin Smith, Chief Executive, was appointed as Chairman of
a Project Implementation Board with membership drawn from key
stakeholders in the health community, including social services
and general practitioners.
5.2 A mobilisation programme was developed
covering key areas, such as:
clinical care pathways and quality
assurance;
performance management;
information and information technology;
and
media and communications.
5.3 A Project Director was appointed to
lead the project and manage the programme in accordance with identified
key milestones. The Project Director was supported by a nominated
local general practitioner to act as GP liaison for the project
and managers and clinical leads drawn from the health community.
5.4 As planned, the facility opened on
15 July 2005 with a planned ramp up programme of work to allow
the clinical teams to gain confidence in the new building and
in the equipment and to respond to any early problems. Outpatients
commenced on 15 July 2005, day cases commenced on 18 August 2005
and inpatients commenced on 18 September 2005. Between the dates
of 15 July to 31 December 2005 the Shepton Mallet Treatment Centre
has seen 4,521 outpatients and treated 2,742 patients.
5.5 The maximum waiting times for the Shepton
Mallet Treatment Centre from referral to treatment is fourteen
weeks and already ahead of the national 18 week waiting time target
that has to be achieved by 2008. 60% of patients are treated in
less than 9 weeks from referral by their GP to treatment. The
population of Dorset and Somerset have for a number of years experienced
some of the shortest waiting times in the country and these waiting
times at the Shepton Mallet Treatment Centre are below even that
level.
5.6 Patient satisfaction is very high, with
97% of patients rating the treatment they have received as
excellent or very good.
5.7 Early clinical outcome data is showing
clear evidence of excellence in clinical practice when compared
to NHS outcome data.
6. THE PROJECT
AGREEMENT
6.1 The Shepton Mallet Treatment Centre
has been established within a central framework of the Project
Agreement. The Commercial Directorate of the Department of Health
developed a national framework for commissioning the Independent
Sector Treatment Centre programme, including a template for the
Project Agreement.
6.2 The contract negotiations for the Shepton
Mallett Treatment Centre were led by a Dorset and Somerset Strategic
Health Authority appointed Project Team led by Mendip Primary
Care Trust. At the point of commercial and legal close, the programme
was handed over to the five sponsoring Primary Care Trusts. However,
this continued to be led by Mendip Primary Care Trust.
6.3 The approach was linked to the following
key policy agendas:
Financial and Capital Planning.
Delivery of Local Delivery Plans
and associated targets.
6.4 The Commercial Directorate within the
National Implementation Team at the Department of Health provided
additional skills and expertise to ensure the successful negotiation
of the contract, particularly in respect of the commercial evaluation
of property, hard facilities management and financial modelling.
However, the National Implementation Team lacked the detailed
knowledge of local NHS operational management and how this independent
provider would integrate with the local NHS. Through the life
of the project there was a need to get the balance right between
national and local requirements in areas such as designing care
pathways, mobilisation plans and establishing the Information
Management and Technology infrastructure. This was caused some
tensions at the time but was overcome by close working between
the National Implementation Team and the local Project Implementation
Board and addressing issues on a one by one basis.
6.5 The Project Agreement is complex and
different to agreements used in the NHS between Primary Care Trusts
and NHS Trusts. As a result, there needs to be more contract and
performance management than for a similar value NHS Trust Agreement.
6.6 The payment mechanisms are on a cost
and volume 95% to 100% contract and Payment by Results is not
applied.
7. THE REFERRAL
PROCESS
7.1 The contract with the Shepton Mallet
Treatment Centre is for a range of HRGs from the three surgical
specialties of orthopaedics, general surgery and ophthalmology
as well as endoscopy procedures.
7.2 Each specialty has a sub set of procedures
that the Shepton Mallet Treatment Centre is able to treat. Within
each specialty, each HRG code is broken down into specific operation
procedure codes that can be undertaken at the Shepton Mallet Treatment
Centre.
7.3 The Shepton Mallet Treatment Centre
treats patients who are stable ASA3 or below. Potential high risk
patients or those with complex medical history, are not considered
suitable.
7.4 All referrals to the Shepton Mallet
Treatment Centre are made through a Forward Order Book, which
transmits the referral information daily to the Shepton Mallet
Treatment Centre. This Forward Order Book is maintained by the
Contract Management Team based at the Somerset Referral Management
Centre in Bridgwater, Somerset.
7.5 There are four ways of making a referral
to the Shepton Mallet Treatment Centre. These are as follows:
direct referral from a general practitioner
through the Somerset Referral Management Centre;
clarification of a general practitioner
referral through the Somerset Referral Management Centre, of a
suitable referral that has been made to another hospital;
direct referral from an orthopaedic
interface clinic; and
waiting list transfer from another
hospital.
7.6 The overall volume of referrals by type
for the period November 2005 to January 2006 were:
|
Referrals | November 2005
| December 2005 |
January 2006 |
|
Direct GP referrals | 33%
| 43% | 43%
|
GP referrals after clarification | 40%
| 30% | 29%
|
Interface Clinics | 6%
| 8% | 6%
|
Waiting List transfers | 21%
| 19% | 21%
|
|
7.6 Once a referral has been made to the Shepton Mallet
Treatment Centre, the Centre has the opportunity to accept or
return the referral. The return rate for the first six months
has run at 15% of all referred patients.
8. KEY ISSUES
AND CHALLENGES
8.1 The establishment of the Shepton Mallet Treatment
Centre has been a complex and challenging project involving close
partnership between the local health community and the independent
sector provider. The project continues to grow from strength to
strength, but it is recognised that there remain some challenges
to overcome if the full vision is to be delivered.
Cultural Change and Innovation
8.2 The opening of the Shepton Mallet Treatment Centre
has represented a significant cultural change across Somerset
and North Dorset for both general practitioners and NHS Trusts.
8.3 For general practitioners the Shepton Mallet Treatment
Centre represents an opportunity to offer patients an alternative
treatment location with shorter waiting times. Marketing and maintaining
referral levels remains an ongoing issue. It is envisaged that
Choose and Book will help highlight this as a choice option for
patients.
8.4 For NHS Trusts the Shepton Mallet Treatment Centre
represents both an opportunity and a threat. NHS Trusts have already
improved their waiting times to compete directly and others are
starting to differentiate. An example is ophthalmology where an
NHS Trust is concentrating on complex eye surgery and reducing
the number of routine cataracts. This service re-design has considerable
further potential which is to be addressed by Primary Care Trusts
through Local Delivery Plans.
8.5 There has been some isolated examples of resistance
to the Shepton Mallet Treatment Centre from both general practitioners
and hospital clinicians. These have been appropriately dealt with
by local management.
8.6 The introduction of the Shepton Mallet Treatment
Centre has seen changes in the behaviours of other independent
sector providers. The biggest change has been a reduction in the
price charged for and a desire to agree contracts rather than
charging for ad hoc referrals on a case by case basis.
8.7 The Shepton Mallet Treatment Centre has introduced
a number of innovative practices around their procedures and clinical
treatment. It is hoped that where suitable these will be adopted
by local NHS organisations. However, it is too early at present
to evaluate this.
Additionality
8.8 The stipulation of the Project Agreement that the
Shepton Mallet Treatment Centre is not allowed to recruit professional
staff who have worked for the NHS in the past six months is intended
to ensure that the Independent Sector Treatment Centre programme
delivers genuine additional capacity to the NHS.
8.9 Additionality was a successful strategy for the establishment
of the Shepton Mallet Treatment Centre. As the local NHS is developing
and responding to the Shepton Mallet Treatment Centre it is hampering
integration. There are now examples whereby local NHS Staff wish
to work their uncommitted hours in the Shepton Mallet Treatment
Centre but cannot under the terms of the Project Agreement.
8.10 The development of new services and reduction of
local clinical resistance would be improved by a review of the
current additionality rules.
9. FUTURE INDEPENDENT
SECTOR PROGRAMMES
9.1 The lessons learnt from this programme have proved
invaluable for future independent sector procurement programmes.
One of the biggest challenges remains ensuring that all available
capacity is used and that this matches demand. Flexibility in
service provision and the contractual terms are essential for
this to be achieved.
9.2 As waiting times fall across Dorset and Somerset,
one of the key attractions of the Shepton Mallet Treatment Centre
will be eroded. In four to five years, all organisations in Dorset
and Somerset will be operating on a far more competitive basis.
The establishment of Practice Based Commissioning, Patient Choice
and NHS Foundation Trusts will have an impact on the longer term
success of the project.
10. CONCLUSION
10.1 The Shepton Mallet Treatment Centre has already
proved it can deliver high quality clinical outcomes, excellence
in patient care, and fast treatment to the population of Dorset
and Somerset. The project overall has successfully delivered a
fully functioning, fully staffed modern facility on time and on
budget, within a timescale that would prove difficult for the
traditional delivery methods of the NHS to have achieved. In addition
to expanding choice and reducing waiting times for patients the
establishment of the Shepton Mallet Treatment Centre has had a
beneficial wider impact on the whole of the local health community.
Mendip Primary Care Trust
21 March 2006
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