Select Committee on Health Written Evidence


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:

    —  34 beds;

    —  four operating theatres;

    —  MRI scanner and diagnostic services;

    —  outpatient clinics;

    —  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:

    —  building;

    —  human resources;

    —  clinical care pathways and quality assurance;

    —  performance management;

    —  referral processes;

    —  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:

    —  Capacity Planning.

    —  Financial and Capital Planning.

    —  Delivery of Local Delivery Plans and associated targets.

    —  Patient Choice.

  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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Prepared 25 July 2006