www.pwc.co.uk
A Model of Integrated Health
and Social Care
Bedford Health and
Care Economy
Strictly Private
and Confidential
June 2016
Contents
Introduction
3
The case for system wide change
6
Background
8
Health changes being considered
13
Introducing integrated care
15
How an integrated care organisation could work in Bedford
18
Clinical sustainability
31
System wide financial sustainability
35
Summary and next steps
41
Glossary
45
Appendices
48
Bedford Health and Care Economy
PwC  2
Introduction
PwC  3
Introduction
Key points:
•
•
•
•
The report builds upon the
Bedfordshire and Milton Keynes
Healthcare Review (BMKHR)
demonstrating the potential
demand reduction impact of the
integration of social care with a
similar hospital/community health
specification to the Integrated Acute
and Community Services (IACS)
option.
This report is complementary to the
BMKHR, designed to act as a
catalyst and support increasing its
scope and sustainability (by
including social care).
The report proposes that system
wide integration of health and
social care promotes the best use of
resources across the economy.
Efficiencies from the model of care
have been identified based on
assumptions specific to Bedford,
these would need to be tested across
the wider health and social care
economy footprint.
Bedford Health and Care Economy
Across England health and social
commissioners are planning integration
to deliver benefits for the local
populations they serve. This is being
driven through Sustainability and
Transformation Plans (STP), supported
by specific implementation funding and
the ‘Better Care Fund’ resource. There is
an acceptance across the system that the
‘do nothing’ situation is not sustainable.
Areas of the country are progressing at
different rates with different levels of
ambition ranging from small pilot
schemes in specific pathways (such as
falls prevention) to more ambitious full
integration of health and social care
provision/budgets creating new
integrated care organisations.
In our work to support local
partnerships to plan integration in areas
like Tameside and Greater Manchester,
PwC has identified that integration can
achieve significant system wide benefits
that are more sustainable than current
arrangements.
In Bedford stakeholders understand
that the time for small pilot schemes has
expired and more fundamental change
is needed to build a sustainable system.
In order to provide a catalyst for
integration, the Local Authority (LA) has
commissioned this piece of work that
will identify the probable benefits of
integration to the ‘system’ and find out if
the Bedford area health and social care
economy can benefit in the same way
Tameside did.
The intention of the project (reported in
this document) is not to challenge the
BMKHR, but to complement and
support it, by highlighting potential
benefits of the IACS specification if
delivered through an integrated care
organisation that included social care. It
focuses on the health and social care
economy in the area surrounding
Bedford Hospital, building a model that
allows the comparison of the current
system, the three options highlighted by
the BMKHR (2b, 4 and IACS) and a fully
integrated model of health and social
care designed to complement the IACS
option by widening its scope to improve
sustainability.
If by examining the Bedford part of the
wider health and social care system to
understand and model the impact of the
future operating models and
organisational design it demonstrates
that integration could deliver significant
benefits (equal to or greater than other
options being proposed), it is suggested
to then widen the scope of the model to
cover a wider footprint including Central
Bedfordshire Council, Milton Keynes
Hospital and Milton Keynes Council.
PwC  4
Introduction
The purpose of the document
PwC have been commissioned by
Bedford Borough Council (BBC), a key
partner in the STP process, to
investigate and model the impact that a
fully integrated model of health and
social provision in Bedford could have as
part of the IACS option in the BMKHR.
All three options being considered as
part of the BMKHR would take several
years to implement requiring significant
capital outlay combined with
organisational and system change. As
these options focus only on health, an
opportunity to achieve system wide
sustainability may be being missed.
The council is concerned that by the
time any finding of the BMKHR is
implemented, another significant part of
the wider system could be
unsustainable, social care. The council
is also concerned that an unsustainable
social care system would then
undermine any positive changes in the
health care system.
At a time when populations and needs
will rise quicker than resources
available, a model that is designed to
reduce demand will have the greatest
chance of sustainability. Unless artificial
Bedford Health and Care Economy
organisational barriers are removed
from the system, the best case scenario
will be a better reactive system, stopping
short of a prevention-based system.
The purpose of this document is not to
challenge, delay or derail the BMKHR,
but to act as a catalyst to accelerate the
implementation and ambition of the
review to consider the whole system,
including social care.
By modelling the impact (positive or
negative) of integration for the system
as a whole it will help the BMKHR have
the information to make an informed
choice for the healthcare element of the
system. This includes how a modern
district general hospital could be
specified as part of an integrated system,
a potential integrated delivery model (an
integrated care organisation) and
examples of changes to the customer
experience and journey.
The task this paper sets out to achieve is
to identify any system wide net benefits
(financial and clinical) that could be
identified in the Bedford system that
could improve the sustainability of the
economy as a whole. The model uses
forecast activity levels, the impact of
prevention and benefits that could be
achieved removing some of the current
organisational boundaries across health
and social care. Any assumptions in the
model are based on national and
international research, with sources
clearly referenced in the appendices.
Once the findings of the modelling work
are complete they will be available to
feed into the BMKHR. Suggestions for
the optimal model for integration locally
will be made to deliver the most
sustainable system able to manage the
challenges of a growing population and
need, without the same level of growth
in funding.
This report is to be considered as a
preliminary exploration of the possible
feasibility of an integrated care
approach, not as a completed plan. If the
stakeholders in the Bedford area and in
the footprint of the local STP agree to
consider a solution as suggested in this
report, more detailed work would be
required to confirm and verify the
assumptions and suggestions in this
report in order for a final decision to be
taken.
PwC  5
The case for system wide change
PwC  6
The case for system wide change
System wide change is needed to
enable sustainability
PwC support the conclusion that change
is needed in the Bedford and Milton
Keynes health system to achieve
clinically and financially sustainability.
At the moment, the hospital trusts are
financially challenged, Bedfordshire
Clinical Commissioning Group (BCCG)
has previously experienced significant
overspends (but has received a more
favourable financial settlement for
2016/17 onwards) and BBC is facing a
social care funding deficit of £21m by
the year 2021. This status quo will not
meet the needs of local people and will
not support a sustainable health and
social care system.
The BMKHR has done a great deal of
detailed work to identify a solution to
the challenges faced by the hospitals and
CCGs. The review sets out a case for
change which is compelling:
•
•
Bedford Health and Care Economy
Insufficient sub-acute care in
Bedford borough.
Financial deficits across the
Bedfordshire and the Milton Keynes
Health Economy limiting investment
in new technologies or preventative
services. The 2014 report forecast
that the two CCGs needed to save
£50m-£70m (the new settlement
reduces this) and the two acute
hospitals faced a combined deficit of
£47m.
•
By 2021 local populations are
expected to grow by 45,000 in
Bedfordshire (Bedford Borough
Council and Central Bedfordshire)
and by 39,000 in Milton Keynes.
•
An additional 50,000 will develop
long term conditions and need
support and care to live well with
their condition.
•
Some concentration of specialist
services is required to provide the
critical mass to effectively use
expensive equipment and very
specialised professionals.
PwC confirm the assumption that the
current system is unsustainable,
however we propose that any solution
that does not look system wide could be
unsustainable in the medium term as
funding deficits in social care grow that
in turn could impact on discharge
(increasing length of stay) and miss the
chance to intervene early and reduce
demand.
Changing hospital specifications and the
organisational delivery of acute and/or
hospital based services will form part of
a solution to clinical and financial
sustainability issues, but only part.
There is acceptance across Bedford
Hospital Trust and Bedford Borough
Council that some changes to the
services that the hospital provides are
necessary as part of system wide
solution.
This report explores the potential
system wide benefits for a new,
integrated and sustainable health and
social care system in Bedford
complementing and improving the
sustainability of the IACS specification.
This enables an informed discussion to
take place on the benefits of an
integrated system as an enhancement to
the health options identified to date in
the BMKHR.
PwC  7
Background
Sustainability challenges across the Bedford Health
and Social Care system
PwC  8
Background – Key partners in the system
Bedford Hospital NHS Trust
2015/16 was one of the busiest years
Bedford Hospital Trust has ever
encountered. Emergency admissions
were up by over 4.4%, referrals into the
hospital for outpatients grew by 7.4% on
the previous year and A&E attendances
increased by 3.3%. In February 2016 the
hospital saw its busiest day ever in A&E
with 246 patients attending on just one
day. Despite rising demand and the
pressures on the A&E and acute medical
services, the Trust has consistently been
one of the best performing organisations
in the NHS for the 4hr A&E wait target,
for the most part in the top 20 of Trusts
and successfully achieved the target for
the full year.
The Trust’s financial situation has
continued to be challenging and it
reported a year end deficit position of
£18m, slightly better than 2014/15’s
outturn of £19.8m deficit. The pressure
on the Trust’s finances are mirrored
nationally and reflect common themes Figure 1: NHS and private acute providers for Bedfordshire and Milton Keynes CCGs
increased emergency demand, the cost of
temporary staffing to meet demand and
maintain quality, Payment by Results
business rules and penalties. A smaller
deficit is forecast for 2016/17,
demonstrating a positive direction of
travel.
Bedford Health and Care Economy
PwC  9
Background – Key partners in the system
Bedfordshire Clinical
Commissioning Group
Bedfordshire Clinical Commissioning
Group (BCCG) is responsible for
planning, organising and buying NHSfunded healthcare for the 425,000
people who live in Central Bedfordshire
and Bedford.
During 2014/15 they had a budget of
£462m to spend on local health services
including hospital care, community
health and mental health services.
Figure 2: The CCG has experienced
significant financial challenges in
recent years and forms part of one
of the most financially challenged
health ‘patches’ in England. No
agreement on repayment of
historical debt has been agreed to
date (this stood at £45m at the end
of 2014/15).
In 2015/16 BCCG expect to achieve a
deficit of around £20m (an area that
covers both Bedford Borough Council
and Central Bedfordshire Council).
The CCG’s position is improving, new
permanent leadership is in place and the
latest funding announcement confirms
an above inflation rise in baseline
funding in 2016/17 and beyond.
Clinical performance in many areas has
been good.
Bedford Health and Care Economy
PwC  10
Background – Key partners in the system
Since becoming a unitary authority
Bedford has been at the forefront of
recent progress in delivering care
services to individuals. A progressive
investment in extra care housing; the
retention of a strong quality assurance
framework; close working with
providers; retention of a range of
preventative services; provision of a
range of in-house and other providers
combined with good information and
advice; and, safeguarding and care
assessment services has meant that
customer satisfaction rates have
remained good despite austerity. The
service has also managed budgets
prudently and has a good relationship
with the community and voluntary
sector. The service is, however, facing
real challenges as a result of the
following:
•
•
The over 65 and 85 populations are
rising in number, some now have
highly complex packages and most
are living longer.
The Borough was formerly home to a
number of institutions which were
closed in the early 90s and as a result
has a profile of need which is
different to the average unitary.
•
•
A number of Learning Disability (LD)
clients of working/older age have
exceeded original life expectations
and many now have highly complex
care needs met through either
homecare and/or supported living.
In the previous year there has been
an increase in client number of
approximately 8% (October 2014 to
October 2015) and the average size of
a package has been growing.
ONS projects that the Borough’s
population will rise to approximately
174,700 in 2021, an increase of 7%
between 2014 and 2021.
However, the older population is
forecast to increase at a much higher
rate, with the 65+ population rising by
16% between 2014 and 2021. The 85+
population is forecast to increase by an
even higher level of 32%.
Longer term, the Borough's
population is projected to reach
199,000 by 2037. This would represent
a 21% increase between 2014 and 2037.
Again, however, older age groups are
projected to rise by much greater levels,
with those aged 65+ increasing by 67%,
and those aged 85+ by 156% (from 3,910
in 2014 to 10,010 in 2037).
Demographic shifts in Bedford
5%
200,000
Population
Bedford Borough Council – Social
Care
150,000
2%
15%
3%
16%
18%
83%
81%
77%
2014
2021
2037
100,000
50,000
Under 65
Bedford Health and Care Economy
65-84
85+
PwC  11
Background – Key partners in the system
Other partners in the Health and Social Care system
SEPT
Community nursing, therapy and other communitybased services are provided in Bedford Borough and
Central Bedfordshire by South Essex Partnership Trust
(SEPT),
GP surgeries
Within Milton Keynes, there are 165 GPs working from
28 practices on 28 sites. In Bedford Borough, there are
106 GPs working from 26 general practices, with 154 GPs
and 29 general practices in Central Bedfordshire.
Practices vary significantly in size, from single-handed
doctor practices to practices with a dozen doctors
working from that site.
ELFT
From 1 April 2015 East London NHS Foundation Trust
(ELFT) will be providing mental health and associated
services for Bedford Borough.
GPs
BCCG
BCCG
The CCG are the key commissioner of health services in
the area and vitally important in the process of
integration.
Citizens of
Bedford
3rd sector
ELFT
Eastamb
The East of England Ambulance Service are a key
stakeholder, as patterns of patient transport would
change in an integrated model, with fewer emergency
transfers but more planned transfers.
Bedford Health and Care Economy
SEPT
Bedford
Hospital
NHS
Trust
Bedford Hospital NHS Trust
The hospital plays a key role in the health and social care
economy of the area.
Eastamb
3rd Sector
The Voluntary Sector plays an important role in
prevention and early intervention and needs to be
included in both design and consultation of any system
wide solution.
BBC and
CBC
Bedford Borough Council and Central Bedfordshire Council
Central Bedfordshire Council are a significant partner because some of their
population use Bedford Hospital for some important health pathways
PwC  12
Health changes being considered
PwC  13
Health changes being considered
Bedford and Milton Keynes
Healthcare Review
2B, 4 Model and IACS options
Prior to the requirement for health and social care provision to integrate by 2020 (publishing plans by 2017) a review of health
provision across Bedford and Milton Keynes commenced. Both Bedford Hospital Trust and Milton Keynes Hospital Trust have
experienced financial deficits understandably leading to the conclusion that doing nothing was unsustainable and not an option. This
review led to the development of three options known as 2B, 4 and IACS options.
The three currently focus on health, rather than take into account the whole health and social care economy. They look at the system
through a ‘health lens’ and do not focus on benefits (and/or costs) associated with integration of health and social care provision. This
report aims to encourage the widening of the lens, supporting BMKHR to a sustainable solution.
Both areas have a growing population so any solution that misses the opportunity to invest in prevention and reducing demand is likely
to need more capacity in the medium to longer term. The models do not consider additional costs of supporting discharge of patients
from a hospital located outside their area, creating more pressure on already stretched social work teams.
2b
•
•
*A fourth option is emerging in
BMKHR discussions and is
referred to as ‘Test Model 2’. This
is understood to be a similar
concept to IACS but without
obstetric services and
emergency services at night.
Bedford Health and Care Economy
IACS
4
•
Increased activity and services
provided at Bedford Hospital
Trust (also known as a Major
Emergency Centre) and
decreased activity at Milton
Keynes Hospital Trust.
Likely to incur high capital costs,
as Bedford Hospital needs
expansion and remodelling.
If option 2b were introduced
without integration, reducing
social care funding and rising
demand could erode any financial
benefits, exacerbating delayed
transfers of care back into the
community.
•
•
•
Increased activity at Milton
Keynes Hospital Trust and
decreased activity and services
provided at Bedford Hospital
Trust (also known as an
Integrated Care Centre).
Likely to incur high capital costs,
as Milton Keynes hospital needs
expansion and remodelling.
If option 4 were introduced
without integration of social care,
reducing social care funding and
rising demand could erode any
financial benefits, exacerbating
delayed transfers of care back
into the community.
•
•
•
•
Integrated Acute and Community
Services.
Integrated primary, community
and acute care networked with
other hospitals to provide some
hyper-acute and fragile services
(also known as Modern DGH).
Likely to have the lowest capital
costs.
Appears to be the most
compatible with integration with
social care.
PwC  14
Introducing Integrated Care
PwC  15
Introducing Integrated Care
Integrated Care is a key part of
the Sustainability and
Transformation Plan (STP).
Key points:
•
•
•
This report is complementary to the STP
and BMKHR, designed to act as a
catalyst for the IACS specification whilst
increasing its scope and sustainability
(by including social care).
The report proposes that system wide
integration of health and social care
allows better use of resources across the
economy and shifts the focus to
prevention rather than reaction.
The report assumes that any new
system driven by the STP will have to
reduce demand by design, or be
unsustainable (as populations/need will
rise quicker than available budgets).
Bedford Health and Care Economy
The first high level iteration of the
Sustainability and Transformation Plan
(STP) for the Bedfordshire, Milton
Keynes and Luton footprint reflects both
the need and a desire for the integration
of health and social care.
All areas of England are working to
achieve integration of health and social
care by 2020 and it constitutes an
important part of most STP plans.
The STP sets out the following
ambitions:
•
To promote prevention and
early intervention in out of
hospital settings, enabled through
self-awareness, self-help and
personalisation;
•
Closer working of primary,
community and social care,
including investment in out-ofhospital services and infrastructure;
•
Finalise and implement the Health
Care Review to deliver a
sustainable and affordable
secondary care platform across
BLMK, taking into account
strengthened capacity and
capability in primary and
community and social care
services and of new national
requirements around the
organisation of emergency care;
•
Develop cost-effective and clinically
sustainable delivery model(s)
of primary, community and
social care across the STP
footprint, with a view to intervening
earlier and in a less intensive way,
based on the principle of care close
to the home, but calibrated with,
and underpinned by, secondary
physical and mental health.
This report complements the direction
of travel identified in the STP and can
support the high level intentions to get
to a practical level of detail more quickly
than would otherwise be the case. The
development of an integrated provider
organisation to deliver both health and
social care can support the intention for
greater early intervention and
prevention and give the best chance of
achieving clinical and financial system
wide sustainability. It is felt that the
IACS specification (part of the BMKHR)
has the potential to conclude the
BMKHR and support the STP to achieve
meaningful and sustainable integration
delivering system wide benefits.
The STP highlights decisions that
need to be made:
1) There needs to be a coherent and
rational outcome to the BMKHR,
but in a way that is ‘future-proofed’
and therefore, takes account of
parallel developments in
prevention, emergency and urgent
care and in primary, community and
social care.
2) All STP Partners need to buy into a
model that will see investment flow
away from hospitals and into
prevention, into community
engagement and self-care and into
primary, community and social
services and infrastructure. STP
Partners need to enact the new
models within their services, and,
where necessary, redesign their own
services so they are properly
calibrated with the new models.
STP leaders share a responsibility
for messaging, adopting and
promoting new models emerging
from the STP with their all relevant
stakeholders.
This report provides a potential
solution on both decisions.
PwC  16
Patient flows
How could things look different from an individual’s point of view if integrated care
could be established in Bedford?
The existing arrangements to support
people are complex and co-ordination of
care can rely on ad hoc communication
between staff rather than on a robust
system and processes.
In the existing system she will have a disease-focused COPD review and a disease
focused diabetes review. She will also have a social worker seeing her to access her
needs for social care. If Mary becomes unwell and is in need of enhanced care she
will go to hospital where the only access they have to her past medical history is a
summary of her medical records.
There are unaligned incentives which
create discontinuity of care and make it
difficult for care professionals to ‘do the
right thing’ on system wide
benefits/cost.
Multi-disciplinary teams (MDT)
operating under one organisational
construct will provide joined up care that
is focused on delivering a better
patient/person journey through the
system.
Care co-ordination is a key function of
the MDTs. People fulfilling this role will
develop relationships and work closely
with a range of professional groups to
ensure patients receive joined up care
from across health and social care, not
just within a MDT.
Bedford Health and Care Economy
Mary is an 89 year old lady with
COPD and diabetes who needs
help living independently with
her husband.
In an integrated system, she will have a person-centred review within her practice,
where all her health and social care needs are addressed. She may be invited to
attend an expert patient course and her husband to an expert care course where
they would learn about all the local initiatives to keep healthy, engaged and how
they can self-refer to exercise, diet advice, physiotherapy etc. and learn about safe
management of medication.
Twice a year their situation would be discussed at a multidisciplinary team by a
joint social worker, GP and community nurse team and consideration will be given
to an upgrade in the levels of care they receive. At one of these reviews, Mary and
her husband would be present. They will also be invited to access the medical
records and they could choose to share this with other relatives as they chose.
Should either Mary or her husband become unwell they will have been provided
with a care plan which describes who to contact and when, and also a named key
worker. There will be rapid access to an improved enhanced urgent care service in
the community, and should she need hospital admission her key worker would be
able to offer help to support the staff in the hospital caring for her.
PwC  17
How an Integrated Care organisation could
work in Bedford
An organisational structure that can deliver
integration
PwC  18
Introduction to the model of care we are proposing for Bedford
3
4
2
5
1
Key points:
•
The patient centred model of care
combines the currently disparate
services into an integrated model of
providing the health and social care
for the population of Bedford.
•
Having examined the options in the
BMKHR we feel that the IACS model
could have its scope increased to
become an Integrated Care
Organisation (ICO) also covering
social care.
•
The model utilises multidisciplinary teams (MDTs) made up
of health and social care
professionals based in a number of
different localities in the areas.
Bedford Health and Care Economy
In order to test the concept that
integration of health and social care can
bring benefits (both clinically in terms of
improved outcomes and financially
through demand reduction and meeting
needs earlier at a lower costs) this report
examines one part of the system in
detail. For the purpose of building the
model the areas in scope is the Bedford
Borough Council area and the
catchment area for Bedford Hospital
Trust commissioned by Bedford Clinical
Commissioning Group.
It is accepted that by focusing on one
specific area (of a wider health and
social care economy) the model
simplifies a complex network of current
patient flows, clinical pathways and
organisational boundaries with three
acute hospitals dispersed across the
footprint (and others near by).
The model of care we are proposing has
been designed with the person / patient
being at the centre and aims to deliver
better patient outcomes for the
population of Bedford within an
affordable financial envelope.
PwC  19
Key elements of the high level model of care proposed for Bedford
3
4
2
The key elements of the model of care
•
The model is proposed to work around 5 key elements of the model of care – as patients and citizens experience and
interact with them.
•
The table below describes some of the features of the 5 key elements of the model of care.
5
1
Key element
Key points:
•
In the model the structuring of the
services into the key elements is
designed to allow professionals to
engage in how they could best work
together.
•
The new model includes a potential
new governance structure for the
partners in Bedford.
•
Specific efficiencies from the model
of care have been identified based
on assumptions specific to Bedford.
•
GPs can align to the MDTs to
improve effectiveness of prevention
and proactive care.
Bedford Health and Care Economy
&
1 Preventative
proactive care
2 Urgent
integrated care
3 Planned care
4 Obstetrics
5 Hospital
specification
Features of this element of the model of care
Benefits
• Currently, responsibility for the proactive and preventative care is diffused, and most care
provided is reactive (responding to crisis or urgent need, rather than managing a condition to
obviate or minimise crises or urgent need).
• In the new model, fully integrated Multi Disciplinary Care Teams (MDTs) will have clear and
unequivocal responsibility for the long term outcomes of the populations they serve. These
multi-disciplinary teams will proactively engage with patients with long term conditions, to
help them manage their conditions in their own homes.
• Proactively managed health for atrisk parts of the population.
• Earlier interventions reducing
downstream crises and costs.
• Enhances the role of GPs
• All of the urgent care resources will be managed as a single operational Urgent and
• Simplified services – reducing
Emergency Care Service team (UECS). This will include A&E, out of hours primary care and
complexity and duplication in
the aspects of community healthcare, mental healthcare and social care that need to be able to
expensive 24/7 services.
respond to a crisis.
• Unnecessary hospital stays avoided.
• Response will be co-ordinated and increasingly in people’s own homes.
• The UECS acts as a single point of access and can mobilise all relevant assets across the health
and care system. There is clear accountability between the MDTs and the UECS.
• Alignment of community and hospital services, as well as appropriate referral management,
through single management and capitated budgets.
• Networked provision with access to greater specialist expertise and critical mass.
• Access to improved networked
services.
• More defined and efficient portfolio.
• Maintain the obstetrics function in Bedford Hospital based on a forecast of around 3,200
births per year.
• Local services protected.
• Choice for parents.
In the model of care every resource, including the hospital, is brought together around the
elements of care above. We consider the following factors:
1.
Key services have significant fixed and stepped costs (such as the need to have 24/7
consultant cover, estates and diagnostic services); and
2. Critical mass is required to deliver services safely and affordably.
3. Bedford Hospital has an elective surgical centre with an A&E (as part of the UECS),
maternity services and a slight reduction in medical beds (as needs are met in the
community).
• Efficient use of healthcare assets.
• Local hospital services.
PwC  20
Benefits of the model of care
3
4
2
Benefits for the population
5
1
We believe that there are a number of
benefits within this model of care,
including:
•
Less fragmented care, with fewer
handovers and greater continuity
whether in hospital, at home or in
the community.
The model of care is compatible
with the STP and the requirement to
integrate accepted when receiving
the Better Care Fund.
•
Services structured to be able to
look after people with multiple
physical and mental health, and
social care needs.
The organisation will have a clear
sustainable model for the future and
will improve the ability to retain and
attract staff.
System benefit
•
A far greater focus on preventing ill
health, and proactively keeping
people as healthy and well as
possible.
Since November 2014, the Trust has
been using 399 acute beds, and on
average 20 community beds are
accessed by the hospital.
•
A provider structured and
incentivised to promote and protect
their long term health and social
outcomes.
Over the period, the model is forecasting
a 'do nothing' need for 47 additional
inpatient beds, 7 additional day case
beds.
•
Key points:
•
•
This model of care is not a “soft”
aspiration or intention – it
represents a radical restructuring
of how all of the resources and
assets in the system are deployed.
It is designed as a catalyst for the
BMKHR to help support the need for
health care reform and achieve
sustainability system wide.
•
Benefits for the Trust
•
Bedford Health and Care Economy
prioritise resources and ultimately
be best placed to accept population
demand risk.
The Trust would have control over a
sufficiently broad range of resources
to be able to plan end-to-end care,
use of system resources – will deliver a
range of benefits.
The impact of the changes (net of the
demand increase) is a 81 bed reduction
in inpatient beds and 4 bed reduction in
day case beds. This bed reduction
represents approximately a quarter of
the financial savings associated with the
integrated model of care.
The model of care – through better
preventative and proactive care, a more
efficient and joined up approach to
dealing with crises, a networked
approach to planned care and effective
PwC  21
Model of care
Preventative and proactive care
3
2
4
Model
of care
•
Currently, responsibility for the proactive and preventative
care is diffused amongst a range of different organisations
between BBC, the CCG, the Trust and other care providers.
•
The overwhelming majority of care provided, including
primary care, is reactive – responding to crisis or urgent
need, rather than managing a condition to obviate or
minimise crises or urgent need, and the services provided
are complex, duplicated and unevenly distributed.
5
1
Key points:
•
•
•
Potential MDT areas
The current model of preventative and proactive care
The MDTs draw in both core
primary care and resources such as
diagnostics and consultant skills
that are currently focused on
Bedford Hospital.
The system could support a number of
Multidisciplinary care Teams (MDTs)
•
Clinical accountability will reside
with either the GP or consultant.
Bringing all providers together
under one structure will tighten
clinical accountability.
It is possible that the MDT model
may also apply to Central
Bedfordshire Council, but
investigation would be needed to
determine how this might work.
Bedford Health and Care Economy
•
The MDTs will be responsible for:
-
Identifying people who would most benefit from
preventative and proactive care (risk stratification);
-
Using multi-disciplinary teams to develop care plans,
share these across the system and maintain them so
they reflect current status;
-
Assigning care co-ordinators;
-
Social care.
•
With primary care at the very centre, these teams will
•
empower citizens and patients to better manage their own
care and remove the boundaries between services and care
professionals.
Geographically, potential localities are highlighted above.
The localities have differing populations with different
needs. Consistency and simplicity in MDT structures are
also key – so MDTs will have the same operating model –
however, the level of resourcing in different specialist roles
will vary in response to different population needs.
The MDTs will draw together all of the care resources that
support preventative and proactive care – including
primary care, community nurses, drug and alcohol teams,
mental health practitioners and others – into single
operational units across each MDT area. These MDTs could
align to GP clusters.
PwC  22
Model of care
Preventative and proactive care
3
2
4
Model
of care
•
5
1
•
MDTs will have clear and unequivocal
responsibility for the long term outcomes of the
defined populations they serve. In order to achieve
this they will have:
-
Control over all of the health and care
resources so they can be directly deployed, coordinated and focused on those who would
most benefit; and
-
Shared risk and incentives across every
constituent part of the MDT.
Our modelling indicates that the MDTs will be
staffed by slightly more staff than currently work
in the community:
-
New locality management roles;
-
New care coordinator roles; and
-
A restructured and retained workforce based
in localities and focused around
multidisciplinary ways of working.
Bedford Health and Care Economy
PwC  23
Model of care
Urgent integrated care
3
2
4
Model
of care
The current model of urgent care provision
•
5
1
The new UECS
•
Key points:
•
In the event that there is an
unplanned decline in a person’s
health it will be managed by a
single Bedford Urgent and
Emergency Care Service (UECS).
•
The UECS will have unequivocal
responsibility for looking after local
people who are in social crisis, or
who are acutely unwell.
•
The UECS acts as a single point of
access and can mobilise all relevant
assets and resources across the
health and care system to help get
the patient well and back in the
lowest cost and most appropriate
care setting as quickly as possible.
•
There is clear accountability
between the MDTs and the UECS.
Bedford Health and Care Economy
Various different services are run separately, with A&E,
out of hours primary care and other key elements of
urgent care response run by different organisations.
•
The proposed Urgent and Emergency Care Service
(UECS) will draw together all of the resources that need
to be able to respond to urgent needs under a single
operational management – including A&E, urgent
primary care as well as some key mental health, social
care and other support that needs to be deployed rapidly.
These services are noted in the diagram opposite.
The UECS will have unequivocal responsibility for looking
after local people who experience a crisis (whether
medical or social). They will look after people from the
moment they report their difficulties, until they have
undergone diagnosis, treatment, support and
rehabilitation in order to be able to live independently or
with the help of the MDT.
Accessing
the UECS
3rd sector
PwC  24
Model of care
Urgent integrated care
3
2
4
Model
of care
Accessing the UECS
•
5
1
•
Key points:
•
The IACS model of care retains an
A&E as part of the UECS.
•
The retention of local A&E services
– in addition to being no more
expensive than sending A&E
activity out of area – provides key
resources and expertise to support
urgent care response throughout
the community as an integrated
part of the UECS. It also smooths
discharge routes as well as avoiding
additional travel for patients.
•
It is proposed Key urgent care
services that require scale to be
effective and efficient – such as
emergency surgery and very
complex medical patients – could be
centralised at larger A&Es outside
of Bedford (such as Luton and
Dunstable)
Bedford Health and Care Economy
Access into the UECS could be
through different routes as shown in
the diagram on the previously page.
Specific details of how 111 and 999
would need to link in with the UECS
will build on existing local plans and
include:
-
-
•
team. Access is as shown in the
diagram on the previous page
although some patients may directly
access the MDT (i.e. 999 / 111 to
MDT rather than UECS if most
appropriate).
•
Work would be needed with
Eastamb to identify
“alternatives to transport”; and
We propose community
response teams led by
Bedfordshire Fire and Rescue
Service respond to low-priority
calls from to falls in the home,
where they can help people to
stay in their own homes rather
than going to hospital. They
could also attend calls from
Bedfordshire Police involving
low level mental health crises.
Mental health crises are dealt with
in the UECS through a range of
services including the access and
crisis team, the home intervention
teams and the home treatment
The UECS would be staffed by a
smaller WTE (in comparison to the
current establishment of WTE). This
includes:
-
Urgent care system / triage;
-
Urgent Assessment Response
Team; and
•
Delivery of intermediate care.
This model currently only considers
the geographical area of Bedford
Borough Council, it would be logical
to consider the UECS also covering
part or all of Central Bedfordshire
Council to reflect patient flows.
Urgent care within Bedford
Hospital
•
Unlike the MDTs, the high cost and
variable demand mean that a single
service UECS model will be available
for all of Bedford.
•
Wherever possible, the UECS will
respond to urgent needs in
community settings.
•
Within the Bedford Hospital site, all
physical urgent care services (A&E,
EAU etc.) will be co-located in the
Urgent Care System.
•
There will be no emergency general
surgery on site at Bedford hospital.
As such, emergency surgery cases
will be diverted elsewhere, e.g. Luton
& Dunstable.
Flow of patients into and out of
hospital
•
The model will support the effective
flow of patients through the health
and social care system.
•
With access to alternative care
options within direct control,
individuals are only admitted to
hospital when absolutely required.
•
The discharge team as part of the
UECS would take an integrated team
approach to supporting discharge
from bed based care back to the
person’s home.
PwC  25
Model of care
Urgent integrated care
3
2
4
Model
of care
5
Components of the integrated Urgent Care Service within Bedford Hospital as part of IACS
A combined A&E and GP-led urgent care centre – with a single front door and working as a single team to provide
resilience and flexibility – working under the same operational management as other urgent care resources
UECS
1
“Urgent Care System
Primary Care Led – Urgent Care Centre /
Minor Injuries Unit
Staffing: GPs, Nurses, AE Middle Grades
MDT
UECS out of
hospital /
community
based rapid
response
Integrated
Hospital
front end
with
Triage Nurse /
Doctor
assess all
ambulatory
patients
Medical Admissions / Assessment Unit
AE Majors Staffing: Medics
A&E Majors
Staffing: AE Drs working with Medics
UECS MDT
Hospital Admission –
Acute or Intermediate
UECS MDT
Paediatric Injuries / Medical Illness
Staffing: AE Drs and Paediatricians
Bedford Health and Care Economy
PwC  26
Model of care
Planned and maternity care
4
3
2
Model
of care
5
1
Planned care
Proposal for planned care
Obstetrics
There is building evidence of the need
for scale in planned care, including:
The portfolio of planned care surgery
recommended in the model of care is
based on the conclusions of the IACS
model that Bedford Hospital Trust have
developed to improve clinical and
financial sustainability:
The Trust currently provides an
obstetrician-led maternity service at
Bedford Hospital, with approximately
3000-3200 births per year, and with
complex births being transferred to
other hospitals.
•
Day case surgery for simple cases for
the population of Bedford Borough
Council and surrounding localities;
•
Elective surgery that requires
inpatient stays (e.g. joint
replacements) where overnight
cover can be provided by medical
staff, rather than requiring
dedicated overnight surgical
support; and
The Trust will continue to provide
obstetrics-led maternity services, in
accordance with the best practices
identified in the Cumberlege Review
providing a local choice for local
parents.
•
Key points:
•
Retention of some services needs
more detailed monitoring
contingent upon agreement of
•
networking with other providers
(although many such agreements
are already in place and operating).
•
•
Bedford Health and Care Economy
The Royal College of Surgeons
recent analysis showed centres
which undertake higher numbers of
complex and emergency surgery,
have better mortality and morbidity
rates improving quality of care for
patients;
The Dalton Review suggested
networked models of care between
high performing larger
organisations and smaller
organisations to improve quality of
care; and
The BMKHR review includes
options that suggested a networked
model of care for surgical services
with central hubs for complex
surgery.
Bedford Hospital has developed a
proposal called IACS (or Modern
District General Hospital) that
includes the new hospital
specification.
•
Paediatrics
Paediatrics will remain as it currently is
at Bedford Hospital.
Day case surgery for patients from
outside of BBC as part of the
BMKHR of hospital portfolios
pending commissioning decisions
such that providers can share access
to assets and infrastructure.
PwC  27
Model of care
Hospital specification
3
2
4
Model
of care
Description of Bedford Hospital
•
5
1
Key points:
•
•
•
Under the proposed model of care,
more local services are retained at
Bedford Hospital than under the
option 4.
•
The benefits of integrated care rely
upon having sufficient expertise
focused on the local population and
working closely alongside local GPs
and other community-based care
professionals.
•
The financial benefit of moving
activity elsewhere is marginal or
negative if local stranded costs and
the cost of providing that care
elsewhere are included.
•
In the integrated model Bedford
Hospital will be used as a core
inpatient medical unit with focus on
acute medicine, non-interventional
cardiology, respiratory,
gastroenterology and geriatrics with
associated required specialties.
Acute surgical services including;
general surgery, gynaecology and
orthopaedic trauma will be
networked with other local services.
The following services would no
longer be provided on site at
Bedford Hospital: breast surgery,
vascular surgery, plastic surgery,
stroke medicine, as suggested in
IACS. There would also be no
emergency general surgery.
This portfolio of services is clinically
sustainable, and optimises the
balance between localism and scale.
Combined
acute
medicine
and A&E
assessment
Required for a
safe inpatient
medical unit
Bedford will
continue with fully
functioning
paediatric
services
Key
functions
of Bedford
Hospital
Required for a safe
inpatient medical
unit
Networked
surgical services
providing access
to surgeons on
site
Elective noncomplex day
surgeries, surgical
procedures with
inpatient stays
Bedford will
continue with a
fully functioning
obstetrics unit
Key functions of Bedford Hospital
The diagram to the right shows the key
functions that will be provided at
Bedford Hospital.
Bedford Health and Care Economy
PwC  28
Model care
Hospital specification
3
2
4
Model
of care
•
5
1
•
High acuity inpatient medical
services will form the core function
of the hospital.
•
Surgical services consist of elective
non-complex day case and surgical
procedures that require inpatient
stays where overnight cover can be
provided by medical staff.
Key points:
•
•
In percentage terms, the largest
decrease in activity comes from
non-elective and emergency
admissions.
This is due to emergency cases being
prevented altogether or having
•
their need met in the community, as
well as emergency General Surgery
•
no longer taking place at Bedford
Hospital.
•
Bedford Health and Care Economy
The hospital will be an asset to the
community, with MDTs, UECS both
benefitting from access to local
specialist expertise and diagnostic
capabilities from Bedford Hospital.
Core elements of the Hospital Specification
The table below shows how activity will change at Bedford Hospital as a result of the
integration of health and social care. Demand reduces because of the preventative
effect of an early intervention model.
Proportionally, the greatest decrease in activity will be from emergency admissions,
as more cases which would have become emergency admissions are dealt with in
the community, or else prevented altogether. The greatest reduction in cost will
come from non-elective activity, as the integrated care model suggests the removal
of a large proportion of high cost non-elective activity.
FY21 Activity
FY21 Cost
Do Nothing
Integrated
care
Percentage
Decrease
Do Nothing
Integrated
care
Percentage
decrease
Obstetrics-led maternity services
will continue at similar levels
Elective
(PoDs: EL &
DC)
25,680
21,614
16%
£30.9 m
£26.1 m
15%
Paediatric services continue to be
delivered in an integrated fashion.
Non-elective
(PoDs: NES
& NEL)
43,508
36,153
17%
£64.4 m
£50.7 m
21%
Emergency
(PoDs: EM)
73,408
57,992
21%
£11.3 m
£9.6 m
15%
Outpatients
(PoDs: NCL,
CL and
OPROC)
274,279
239,082
13%
£38.5 m
£35.5 m
8%
Direct Access
(PoDs: DA)
1,970,200
1,970,200
0%
£9.0 m
£9.0 m
0%
Other
(All other PoDs)
158,170
153,659
3%
£19.5 m
£19.2 m
1%
Critical care and diagnostic services
are required for a safe functioning
inpatient medical unit.
PwC  29
Model of care
Provider considerations
Key points:
•
•
Provider scope and shape
In our view in order for the model of •
care to truly integrate services it
requires single operational
management, shared incentives and
long term accountability for health
•
outcomes. This is most simply
delivered through a single provider
where possible.
A long term capitated contract
would be an appropriate type of
contract for the ICO.
•
The model of care describes how the
resources in Bedford will be
optimised by working as integrated
functions.
Currently these resources are held
within multiple different
organisations. PwC proposes a single
provider form with the scope laid
out in the diagram below.
The rationale follows these 3
criteria:
-
Bedford Health and Care Economy
Simplicity: minimising the need
for complex alliance contracting
or sub-contracting where
possible;
-
Single operational management:
a single provider with
operational management of staff
etc. can ensure services are fully
integrated and deployed in the
most effective way overall.
-
Ability to implement: this form
and scope recognises that it is
easier to implement the changes
as one organisation but
implementing some options –
such as employing GPs directly
– is more difficult.
The diagram below sets out our recommendations for the scope and shape of the
integrated care provider.
Services provided outside the ICO after integration
Services provided by the ICO after integration
Mental health
• Secure
• Mental health
wards
Primary care
• Community
mental health
teams
Acute services • Remaining
acute services
• Acute services
moving outside of at Bedford
the Trust under
the new model
Community
Services
• All services
The
ICO
New services/
initiatives
• MDTs
• UECS
Social care
• Adult social care • Children’s
safeguarding
• Children’s social
care
PwC  30
Clinical sustainability
We have made assumptions that clinical sustainability of the
model of care is sound. The hospital specification in the model
is based on the IACS model agreed with local clinicians as both
sustainable and better than the current model.
The proposed service changes should improve clinical
sustainability, though further work would be needed to
confirm this as the proposals move forward.
PwC  31
Clinical sustainability
Key points:
•
The BHT view is that the model of care
is clinically sustainable.
•
The proposed model of care is designed
to improve almost all dimensions of
clinical sustainability.
•
An ICO should reduce demand and have
the best outcomes regarding travel time
(overall).
Clinical sustainability
•
Bedford Hospital’s clinical team has
assessed the clinical sustainability of
the model of care that underpins the
IACS model. As the model at the
core of this option is based on the
specification proposed in IACS and
this was developed and agreed by
local clinicians, this paper assumes
that the model is clinically
sustainable and fit for purpose.
Approach
The Bedford Hospital Trust followed a
detailed process to determine the
hospital and community health
specification as part of the IACS option.
Clinical sustainability was the major
consideration under-pinning the entire
process of designing the new model of
care. Indeed, many specific features of
the model of care have been shaped
through iterations driven mainly by
considerations of clinical sustainability
via Bedford Hospital Staff. Their
assessment focused on clinical
sustainability of the new model of care
Bedford Health and Care Economy
and the changes it would bring to
clinical services. PwC have not reviewed
this process, assuming for the purposes
of the model that it was a robust and
safe process. We are informed this
involved Care Design workshops and
other sessions;
•
Discussions with a range of local
clinicians, the Trust’s Medical
Director and Nursing Director and
other Clinicians in the Trust;
•
Reference to relevant national
guidance such as from the Royal
Colleges;
•
Reference to the regional Clinical
Senate who will review
implementation plans for clinical
services;
PwC  32
Clinical sustainability
Key points:
•
The BHT view is that the model of care
is clinically sustainable.
•
The proposed model of care is designed
to improve almost all dimensions of
clinical sustainability.
•
An ICO should reduce demand and have
the best outcomes regarding travel time
(overall).
Assessment and conclusion
Although further work would be needed
before implementation, we have
concluded that the model of care is
clinically sustainable. In reaching our
conclusion, we note:
•
Safety, outcomes and patient
experience (Quality) will
continue to improved;
•
Workforce challenges would
reduce by networking hospital
clinical teams with other providers
to ensure adequate activity levels
across provider sites for maintaining
clinical skills, for training purposes,
and to maintain on-call rotas; and
•
Clinical governance will be
improved by bringing currently
diverse and fragmented provider
teams under one integrated
governance arrangement.
It is important that implementation
work streams continue to assess the
clinical impact of all proposed changes
during the implementation process.
Bedford Health and Care Economy
Risks to manage post
implementation
We have noted the key risks to manage
post implementation;
•
Travel times for the majority
should be minimised in a fully
integrated IACS model. Some less
regular activities could be adversely
impacted when patients for
emergency surgery or elective
inpatient procedures need to be
treated at other hospitals. Some
patients may arrive directly at the
Trust’s A&E and require transfer.
After surgery, patients may be
repatriated back to the Trust if
further post-operative hospital care
is required, leading to another
transfer. Additionally, while
inpatient at another provider, it
would be less convenient for visitors
to reach those patients.
•
By reducing demand and treating
more people in the community
(including in peoples own homes),
the IACS model integrated with
social care (ICO) would provide the
greatest benefits regarding travel
time.
PwC  33
IACS/ICO Clinical sustainability
Key points:
•
Clinical sustainability is designed to
improve significantly in the new model
of care.
Improvements
Safety
Outcomes
Patient
experience
Workforce
Clinical
governance
Bedford Health and Care Economy
•
The entire model of care is designed with safety concerns at the centre during the
design phase.
•
Some sub-scale services (e.g. emergency surgery) are diverted to larger providers,
or networked (e.g. elective surgery).
•
Integration of care across care settings improves communications and care
monitoring.
•
The ICO reduces risk of inappropriate discharge and bounce backs into hospital.
•
Consolidating surgical activity in larger units (also when networked) improves
outcomes.
•
Integrated care model with early expert clinician input early in care pathways
leads to better outcomes.
•
More services will be provided closer to home, which is a key driver of better
patient experience.
•
Care professionals act as one integrated team providing one cohesive service.
•
The ICO reduces risk of inappropriate discharge and bounce backs into hospital.
•
Networked services ensure sufficient activity to maintain skills, achieve better
training and sustain on-call rotas.
•
“One team” approach has been shown to lead to greater staff satisfaction, which
should help with local recruitment and retention.
•
New model of care does not require material numbers of additional staff.
•
Bringing governance from multiple separate teams together into one governance
arrangement. This reduces risk of governance boundaries with gaps and conflicts.
Challenges and risks
•
Diverting surgical
emergencies to other
providers adds travel time.
However a recent analysis by
the CCG has found that travel
times for emergency surgery
are acceptable.
•
N/A
•
Diversion of emergency and
inpatient elective surgery to
other providers makes access
less convenient for patients
and their visitors.
•
Many members of current
staff would require additional
support and retraining to new
roles and ways of working.
•
New governance
arrangements have to be
designed and implemented.
PwC  34
System wide financial sustainability
In this section we have considered the financial
sustainability of the Bedford health and care system. To
achieve this, we have looked at the system’s financial
challenge, the benefits of the model of care and the forecast
position across the whole economy.
PwC  35
Summary of financial sustainability assessment
We have modelled the financial impact
of the model of care with the Trust as
the provider.
Key points:
•
There is a system deficit before the
benefit of model of care in FY21 of
c£15.7m (CIPs 2%).
•
The financial benefit of the integrated
model of care is c£8.6m (base case).
•
The integrated model thus potentially
delivers better financial outcomes than
the proposed 2b and 4 models, although
caution must be exercised in
interpreting these figures as the 2b and
4 models were not built according to the
same methodology, and do not consider
social care (forecasting a deficit of
£20.6m by 2021).
Bedford Health and Care Economy
Financial sustainability
assessment
Financial modelling
PwC has modelled the activity and
financial impact of the new model of
care. This includes:
•
Reductions in inpatient demand
from proactive and preventative
care;
•
Changes to Bedford Hospital’s
specification after integration.
We have performed a financial
modelling exercise, to estimate the
financial impact of 2 scenarios:
1. The ‘do nothing’ scenario is used
as a comparison against integrated
care. This scenario maintains the
current structure of delivering
health and social care across
Bedford, taking into account
planned CIPs and QIPPs. It is
forecast up to FY21.
2. Integrated care scenario reflects
the impact on activity levels and the
cost of provision from the new
model of care described elsewhere in
this document.
The table below describes some of the
features of the financial analysis. Further
details on these are provided on the
following pages.
Financial analysis
Summary of findings
1
The affordability challenge if
the system does nothing
• We have modelled a ‘do nothing’ scenario, which maintains the status quo of separate organisations
delivering care, along with ‘normal’ efficiencies.
• This results in a forecast deficit of c£15.7m in FY21.
2
What is the impact of the
model of care?
• We have modelled the financial impact of the model of care across the health and care system.
• The benefit of the model of care reduces the system wide deficit by c£8.6m.
• The c£15.7m deficit in the do nothing scenario in FY21 improves, leaving a system deficit of c£7.1m.
3
The integrated solution thus
• The deficit of c£7.1m is a better outcome than that calculated by the 2b and 4 models, which predict a
delivers better financial
deficit for the hospital part of the economy of £8.8m and £11.0m respectively.
outcomes that the proposed 2b • Furthermore, the 2b and 4 models do not include social care, which would further increase this deficit.
and 4 models
• Caution must be exercised when making these comparisons, as the 2b and 4 models were not created
using the same methodology as PwC’s integrated care model.
PwC  36
The affordability challenge in the do nothing scenario
The affordability gap is based on the
assumptions and plans from the Trust,
CCG and BBC.
Approach to financial modelling
and the financial impact of the
model of care
Key points:
Our financial analysis has taken
forward the work undertaken by the
CCG, Trust and Bedford Borough
Council:
•
•
The ‘do nothing’ system has a
financial deficit driven largely by
rising demand, cost inflation and
the underfunding of social care
costs.
•
The combined system deficit in 5
years is c£15.7m, after ‘normal’
efficiencies of 2% CIPs pa.
Bedford Health and Care Economy
We have applied financial
planning and demand
assumptions to update the deficit
for the whole system, split by
organisation;
•
We have built an activity and
finance model, to show the cost of
providing existing services and
the impact of the model of care
and linked this with income,
demand and other assumptions;
•
Our approach is organisation
agnostic when we consider how
the cost of provision changes with
the impact of the model of care
(changing demand, acute
configuration, MDTs etc.)
1
The affordability gap in a do nothing scenario
In FY16, the system experienced a c£12.5m deficit. The key drivers from the current
deficit to the forecast deficit in 5 years are shown in the diagram below and include:
•
Income to the system from large funding increases in the Bedfordshire CCG
allocation, and a small income from other CCGs;
•
Non-demographic demand growth and cost inflation; and
•
A large net deficit for Adult Social Care.
•
The contribution of BCCG to the system in FY21 is adjusted to acknowledge that
Bedford only represents 37% of the population which the CCG serves.
PwC  37
What is the impact of the model of care?
We have modelled the financial impact
of the model of care with the Trust as
the provider.
Key points:
This drives a system wide deficit in FY21
of c£7.1m, which is an improvement of
c£8.6m.
2
The model of care improves the
sustainability within the health
and social care system in Bedford
The graph shows our estimate of the 5
year deficit within the health and social
care economy of a c£15.7m. It also shows
the benefit of integrated care in Bedford,
which reduces the deficit by c£8.6m, to a
deficit of c£7.1m.
The benefits of the model of care are
phased in over time. For the first two
years, it is expected that no benefits will
have been realised, as the
implementation of an integrated care
organisation takes time. Therefore, the
first financial benefits of the integration
are seen in FY18.
Bedford Health and Care Economy
PwC  38
Financial summary
Key points:
•
A base and stretch case have been
modelled for the integrated care
organisation. In the base case, the lower
bound of activity and length of stay
reduction research findings is used,
whereas in the stretch case the upper
bound is used.
•
With CIPs at 2% pa, the system outturn
in FY21 is c£8.6m better than the do
nothing scenario in the base case, and
£9.9m better in the stretch case.
•
With CIPs at 3% pa, the system outturn
in FY21 is c£7.2m better than the do
nothing scenario in the base case, and
£8.3m better in the stretch case.
•
In both cases, the integrated care
organisation represents a better
financial outcome than either the do
nothing scenario, Option 2b, or Option
4, especially once social care costs have
been taken into account.
† Trust income only.
‡ Any BCCG surplus or deficit applies to both Bedford and Central Beds. Bedford’s population is 37% of the total population in the area. Only Bedford’s
population is considered for the integrated system.
* In the Do Nothing scenario, the figures are for the Hospital Trust only. In the Integrated scenarios the figures are for the new Integrated Care Organisation
(ICO). Adult Social Care expenditure is expected to form part of the expenditure for the ICO.
** Indicative, because these options exclude social care costs and the calculation methodology is different. In reality, these deficits are likely to be c£20m
larger due to the social care deficit. In Option 4, there is a further increase in the deficit of £1.2m due to the Market Forces Factor, making the overall deficit in
Option 4 c£12.2m.
Bedford Health and Care Economy
PwC  39
Drivers of the cost improvements
Key points:
•
The model is based on international
research into the activity reduction
a hospital may experience when
health and social care are
integrated under a single provider.
•
The new hospital specification in an
integrated model is based on
Bedford Hospital’s IACS model.
•
The modelling assumptions are
given in detail in the appendices.
International research evidence
for activity reduction due to
integrated models of care
Monitor commissioned a review,
Improvement Opportunities in the NHS:
Quantification and Evidence Collection
(2013), of the major opportunities there
might be for improving the NHS over the
next ten years, focusing on how to
achieve better quality care at lower cost.
Part of the review presented evidence for
opportunities to reduce emergency
admissions for specific conditions, nonelective activity and A&E attendances.
The integrated model of care presented
in this report uses this evidence from
Monitor’s report to predict a
reduction for these activity areas
when moving to an integrated
model which includes social care.
New hospital specification based
on Bedford’s IACS model
The second key driver of cost
improvements in an integrated model is
the closure of some specialties at
Bedford, as modelled by the IACS model.
In IACS, it is suggested that some
specialties and PoDs will be closed, or
the care will be delivered in a different
format.
The integrated model of care presented
in this report uses the same hospital
specification as IACS wherever
possible; in addition it includes the
removal of emergency general
surgery.
See the appendix for details of the
percentage decreases in each activity
area.
Bedford Health and Care Economy
PwC  40
Summary and next steps
PwC  41
Summary
Summary
This report highlights the benefits of
integration across health and social care,
and the contribution integration can
deliver towards the goal of sustainability
for the health and social care system, in
both clinical and financial terms. The
only way stop the flow of avoidable
admissions into an acute environment is
to change activity, organisation and
incentives in the community. The same
theory applies for hospital discharge, the
best way to reduce pressure is to
improve community resilience and stop
any inappropriate admissions before
they happen.
The report is designed to complement
the BMKHR (focusing on the health
aspects of the economy) and should feed
into the detailed STPs due to be
submitted for the wider health footprint.
It is fair to state that any conclusion of
the BMKHR needs to consider the
system wide impact and needs to factor
in a social care system that is currently
very challenged and is forecast to
become unsustainable.
Bedford Health and Care Economy
The model demonstrates that the
Bedford Health and Social Care economy
has the greatest sustainability by
choosing the specification of the IACS
specification (but with emergency
surgery removed) in the BMKHR review
combined with the integration of health
and social care delivery via an integrated
care organisation. We recognise that any
model is a simplified version of reality
and will be open to scrutiny, but this is
equally the case for all the options in the
BMKHR (especially if they don’t
consider social care).
It is accepted that this report covers one
area of a complex wider footprint of
acute providers and patient flows,
however the potential benefits of
integration are sufficiently significant in
this scenario that they warrant further
investigation in the other localities,
including Central Bedfordshire and
Milton Keynes (even if the delivery
vehicle, in this case an ICO, may need to
differ).
The solution for health provision is in
the fortunate position of having more
than one potential solution (when
looking only at health). When the scope
is a system wide solution for
sustainability there is only one option
emerging with the potential to be
successful, the hospital specification of
IACS (without emergency surgery)
combined with the integration of health
and social care delivery in an ICO. Any
other options risk being undermined by
a collapsing social care system suffering
from reducing budgets, workforce issues
and rising demand.
PwC  42
Next steps
Next Steps
This report is designed to complement
the BMKHR and feed into the next
iterations of the STP for the
Bedfordshire, Milton Keynes and Luton
footprint. The model demonstrates that
there would be benefits from an
integrated model in Bedford.
£24.9m and MKCCG benefiting
from a rising income over the next 4
years. With these similarities to
Bedford, it might be worth carrying
out a similar exercise to model the
benefits of integration ‘system wide’
for the Milton Keynes health and
social care economy and potential
delivery models;
The following options are appropriate:
•
Bedford Health and Care Economy
Using the findings of this report in
the decision-making process of the
BMKHR, in particular the focus on
system wide impact and integration
benefits;
•
Use the findings of the report to
help develop the detail in the STP
for the area;
•
The Milton Keynes health and social
care economy shares many
characteristics with Bedford,
including, a rapidly rising
population, a council forecasting
pressures in adult social care of (the
Milton Keynes Council MTFS
predicts £8.4m by 2019), the Milton
Keynes University hospital
returning a deficit in 2014/15 of
•
Share the findings of the report with
NHS England and NHS
Improvement;
•
Periodically refresh the model as
baselines adjust (this project
coincides with reviews of the 2b, 4
and IACS). This will help ensure a
fair comparison between potential
options (whether system wide or
health only);
•
Consider developing joint
commissioning teams between
Bedfordshire CCG and Bedford
Borough Council;
•
Consider/calculate the capital cost
benefits of integration compared to
option 2b and 4.
PwC  43
Assumptions and modelling decisions
This report has made the
following assumptions and
decision concerning the model
Capital costs
Workforce/Recruitment
Data Quality
Capital costs have not been considered
in the report. It is assumed that options
2b and 4 would incur the highest capital
costs by developing a Major Emergency
Centre. It is assumed that the IACS
model would have the lowest capital cost
of the 3 options in the BMKHR.
Although no capital benefit has been
assumed in the model, it is assumed that
integration has some potential to free up
current estate owned by the Council or
Hospital Trust, though this isn’t
quantified at this stage.
It is assumed that an integrated care
organisation will be a more attractive
option to potential employees than the
current social care system. Recruitment
in the Bedford area is likely to remain an
issue, but strengthening the community
based resources is anticipated have a
neutral or beneficial impact (in a market
that is severely challenged currently).
It is assumed that data provided by
Bedford Hospital, Bedfordshire CCG
and Bedford Borough Council is
accurate and the most recent version
available. It is accepted that as the
financial year progress new versions of
baseline with different assumptions will
be available. The data in this report can
be refreshed as this occurs.
Implementation Costs
The report assumes that any new system
driven by the STP will have to reduce
demand by design, or be unsustainable
(as populations/need will rise quicker
than available budgets).
Lowest travel times
Travel times are currently being
refreshed as part of the BMKHR. They
are not specifically considered in this
report. It is assumed that by reducing
demand and treating more people at
home (via the ICO teams in MDTs and
the UECS) that the best travel times
would be achieved by the IACS model
combined with integration delivered by
an ICO.
Bedford Health and Care Economy
There will be implementation costs to
move from the current organisation
structure and delivery models to an
IACS model. No specific number has
been identified in the report as it is
assumed that these would cost the same
or less than implementing any of the
other options being considered in the
BMKHR.
PwC  44
Glossary
PwC  45
Glossary of key terms
Term
Definition
BBC
Bedford Borough Council
BCCG
Bedfordshire Clinical Commissioning Group
BHT
Bedford Hospital Trust
BMKHR
Bedfordshire and Milton Keynes Healthcare Review, a review of options for the delivery of health care services.
Cost and activity model
The model for the service specification and the hospital specification that shows the cost and activity in the health economy. This includes the
operational assumptions that convert the service specification and hospital configuration into assumptions that can be modelled.
Delivery vehicle
The organisation responsible for delivering the new model of care.
Eastamb
East of England Ambulance Service
Health and social care economy
All spend on health care and social care in a defined area.
Hospital Specification or
configuration
The part of the model of care and service specification that covers the proposed configuration of services at BHT.
IC
Integrated care.
ICO / integrated care
organisation
The organisation responsible for delivering all health and social care provision under the new model.
MDT / Multi Disciplinary Team
A team composed of members from different healthcare professions with specialised skills and expertise working collaboratively to make
treatment recommendations that facilitate quality patient care, and keep people well and out of hospital.
Bedford Health and Care Economy
PwC  46
Glossary of key terms
Term
Definition
Model of care
The way the health economy works, that spans health and social care and covers what is to be provided within an ICO and the services outside
an ICO.
PoD
Point of Delivery
Service specification
What is being delivered, where and by whom. This describes the model of care.
SPOA
Single Point of Access.
the Trust
Bedford Hospital NHS Trust.
UECS / Urgent and Emergency
Care Service
Multi disciplinary team responsible for dealing with urgent care patient needs under a single operational management structure.
Bedford Health and Care Economy
PwC  47
Appendices
PwC  48
Assumptions
Assumption
FY16
FY17
FY18
FY19
FY20
FY21
Demand growth (demo. and non-demo.)
1
2
3
4
5
Acute demand growth, non-demographic growth
Cost inflation
NHS TDA Economic Assumptions 16/17 - 20/21
Local additional inflation uplift
Acute inflation uplift
NHS guidance
Tariff efficiency factor
NHS TDA Economic Assumptions 16/17 - 20/21
Even demographic growth, set at 1.2% p.a, and even non-demographic growth
set at 1% p.a., applied at unique specialty / PoD-level
BCCG Medium Term Financial Plan 16/17
3.10%
2.30%
2.00%
2.00%
2.90%
0%
0%
0%
0%
0%
0%
0.0%
0.5%
0.5%
0.5%
0.5%
0.5%
-4.0%
-2.0%
-2.0%
-2.0%
-2.0%
-2.0%
Latest available published inflation guidance.
£628.7 m
Data includes Bedford and Central
Bedfordshire. The integrated system only
considers income applicable to Bedford. Any
surplus is apportioned 37% to Bedford
according to population proportion.
£493.1 m
£539.9 m
£559.3 m
£578.0 m
£597.9 m
BCCG expenditure
7
BCCG Medium Term Financial Plan 16/17
9
Bedford Borough Council (BBC)
Adult social care cost growth
BBC Finance advice
BBC Finance advice
Bedford Health and Care Economy
No uplift applied in Bedford LTFM.
£493.1 m
£539.9 m
£559.3 m
£578.0 m
£597.9 m
£628.7 m
£43.5 m
£43.5 m
£43.1 m
£42.6 m
£43.7 m
£43.7 m
Budget in FY16 was c. £43,521k. Assumed to
change in line with total BBC core spending
power.
8%
8%
8%
8%
8%
8%
£43.5 m
£46.3 m
£51.2 m
£55.5 m
£59.7 m
£64.3 m
Adult social care expenditure
10
Latest available published inflation guidance.
Data includes Bedford and Central
Bedfordshire. The integrated system only
considers expenditure applicable to Bedford.
Any deficit is apportioned 37% to Bedford
according to population proportion.
Adult social care income budget
8
Demographic growth taken from Bedford
Hospital Long Term Financial Model (LTFM).
Non-demographic growth taken from NHS
England Five Year Forward View (May 2016)
2.60%
Bedford CCG (BCCG) income allocation
6
Rationale
Costs increase annually by growth percentage,
less the income for additional packages, plus
the National Living Wage impact.
PwC  49
Assumptions
Assumption
11
Social care funding gap
Income - expenditure
FY16
FY17
FY18
FY19
FY20
FY21
£0 m
-£2.7 m
-£8.1 m
-£12.8 m
-£16.0 m
-£20.6 m
£16.4 m
£17.3 m
£18.1 m
£18.9 m
£19.6 m
Rationale
BHT income from BCCG
12
£113.4 m
From BHT LTFM for 2015/16
13
BHT income from CCGs other than BCCG
£25.0 m
From BHT LTFM for 2015/16
14
BHT income from other sources
From BHT LTFM for 2015/16
£15.5 m
Direct, indirect & overhead cost split
15
Bedford Hospital Trust SLR data
CIPs
16
Delivered through productivity/ efficiency
Specific % applied for each unique specialty and PoD combination
2% (or 3% in an alternative case) in each year, applied year-on-year for Figures are compounded year-on-year.
each unique specialty/PoD combination
Applies to all scenarios except ‘Do Nothing’.
QIPP - baseline
17
In line with BCCG plan
QIPP - annual
18
In-year annual efficiencies
Bedford Health and Care Economy
Proportions applied to reference costs to determine
variability in unit costs.
Allows realistic cost impacts of activity changes to be
estimated.
£16.2 m
£15.6 m
£16.2 m
£16.7 m
£17.3 m
£18.2 m
3% in each year, applied in each year for each unique specialty/PoD
combination
Future QIPP targets are dependent on delivery of service
reconfiguration. To include them would mean doublecounting benefits.
Taken from BCCG plan for FY16-17. Extrapolated for
FY18-21.
Figures are applied in the year, not compounded.
Applies to all scenarios except ‘Do Nothing’.
PwC  50
Assumptions
Assumption
FY16
FY17
FY18
FY19
FY20
FY21
Reduction in A&E attendance
19
… as a result of preventative measures, and
redirection of activity (principally to GPs)
21% (base case) or 36% (stretch case) for all specialties
Rationale
Evidence base suggests a range of benefits
between 21% and 36%.
Reduction in Non-Elective Admissions
20
… resulting from ability of A&E clinicians to admit to
full spectrum of integrated care packages (i.e. admit
to acute or send home not the only choices)
Evidence range (0-26%) varies based on case mix.
Total of 8% (base case) or 11% (stretch case) distributed across specialties Bedford case mix profile based on activity levels by
diagnosis code.
Reduction in length of stay
21
… from removal of organisational boundaries
allowing faster transfers
Average of 12% reduction distributed across specialties
Data obtained from Better Care Better Values. A
mean of 12% suggested as opportunity to bring BH
up to NHS upper quartile. Ranges from 0-21%.
Average of 11% reduction distributed across specialties
Data obtained from Better Care Better Values. A
mean of 11% suggested as opportunity to bring BH
up to NHS upper quartile. Ranges from 0-81%.
Reduction in outpatient demand
22
… from closer working between GPs and specialist
clinicians
Reduction in elective/Day case demand
23
… from closer working between GPs and specialist
clinicians
Phased integration
24
Integrated model of care is phased in over the full
period
Limited IC evidence available. Range based on
Commissioning for Value, upper quartile
Total of 7% (base case) or 13% (stretch case) distributed across specialties
benchmark with 10 similar CCGs. Ranges from 022%.
Changes to integrated model are phased between FY16 and FY21, with 0%
for all specialties in FY16-17, and 100% for all specialties in FY20-21.
Exact phasing differs between specialties for FY18-19.
Specialties not maintained in an integrated
model of care
25
Integrated Acute & Community Services (IACS)
model
Bedford Health and Care Economy
Breast Surgery, Vascular Surgery, Plastic Surgery, Stroke Medicine, nonelective General Surgery
Some of these specialties do not have all PoDs
removed in the integrated system as suggested in
the IACS model. For simplicity they have been
considered to be fully removed – the material
difference is negligible.
PwC  51
The timetable for the BMKHR
Bedford Health and Care Economy
PwC  52
More Detail on Options 2b and 4
(options being considered in the BMKHR)
Bedford Health and Care Economy
PwC  53
www.pwc.co.uk
This publication has been prepared for general guidance on matters of interest only, and does
not constitute professional advice. You should not act upon the information contained in this
publication without obtaining specific professional advice. No representation or warranty
(express or implied) is given as to the accuracy or completeness of the information contained in
this publication, and, to the extent permitted by law, PricewaterhouseCoopers LLP, its
members, employees and agents do not accept or assume any liability, responsibility or duty of
care for any consequences of you or anyone else acting, or refraining to act, in reliance on the
information contained in this publication or for any decision based on it.
© 2016 PricewaterhouseCoopers LLP. All rights reserved. In this document, “PwC” refers to
PricewaterhouseCoopers LLP which is a member firm of PricewaterhouseCoopers International
Limited, each member firm of which is a separate legal entity.
160513-140639-LD-UK