Agenda Item 8.3 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Report of: Mrs Julia Bridgewater, Chief Operating Officer Paper prepar...
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Agenda Item 8.3


Mrs Julia Bridgewater, Chief Operating Officer

Paper prepared by:

Dr Martin Rutter, Clinical Lead, Diabetes Dr Neil Hanley, Clinical Lead, Endocrinology In conjunction with the Specialist Medicine Divisional Team

Date of paper:

11th January 2016


Diabetes and Endocrinology Strategic Outline Case to support a new care model reducing the variations and improving outcomes for our patients, across Manchester and beyond.  Support

Purpose of Report:  Approval

This service development and case for improved estates infrastructure is aligned to the Trust Strategic aims as follows:Consideration of Risk against Key Priorities:

1. Delivering safe, harm-free care focusing on evidence based pathways, supervision and clinical leadership 2. Exceeding all key NHS commissioned standards and deliverables, including access and quality outcomes 3. Delivering personalised, responsive and compassionate care in partnership with patients and families in appropriate environments safeguarding the most vulnerable 4. Development and implementation of Place Based Care models of delivery and integration of Adult Social Care services The Board of Directors to approve:





The proposed strategic direction of travel for the development of a new clinical model of care for diabetes and endocrinology in conjunction with GM CCG. The re-provision of the joint diabetes and endocrinology centre on the Central site as per the recommended option, subject to securing charitable funding for the project.

Name: Tel:

Mrs Dereth Baker, Divisional Director, Specialist Medicine Division 0161 71 65146

Agenda Item 8.3


Purpose/Context Following the Strategic Outline Case supported at Trust Management Board in January 2015, an ensuing Full Business Case, was first partly approved, at Trust Management Board in July 2015 subject to caveats, the latter of which were answered in a revised paper formally approved at Trust Management Board in December 2015. Due to the strategic importance and the value of the capital within the case, the purpose of this paper is to seek the support and approval of the Board of Directors for the following:-


The proposed strategic direction of travel for the development of a new clinical model of care for diabetes and endocrinology in conjunction with CM CCG.

The need for an appropriately scaled facility to replace the existing unsuitable Manchester Diabetes Centre (MDC) facility on the CMFT central site campus. This would be the secondary and tertiary care ‘hub’ in the proposed ‘hub & spoke’ clinical model for Central Manchester.

Background 2.1

National Picture

Diabetes Diabetes is a global health epidemic and right now there are 3.4 million people in England living with the condition (7% of UK adults), and a further 549,000 people in the UK have diabetes but are either unaware, or have no confirmed diagnosis. On average, approximately 16% of all hospital beds in the UK are occupied by people with diabetes - on the CMFT MRI site 25% of all in-patients have diabetes. 80% of current NHS spending is related to managing potentially avoidable complications. Every person with diabetes should receive a programme of nationally recommended checks each year based on nine key care processes including blood glucose, cholesterol & kidney function checks and retinal screening. A significant proportion of patients are not undergoing these checks either in part, or in some cases, at all, so their diabetes is not being properly monitored or controlled. Central Manchester’s vision for improving the care of patients with diabetes is being driven locally through the Living Longer Living Better (LLLB) Programme for patients with Long Term Conditions. It aims to:    

Provide services as close as possible to where people with diabetes live Integrate all services Ensure the workforce is fit for purpose and able to deliver the model via multidisciplinary working Provide services that support patient self-management

Endocrinology There are currently three designated specialist centres for Endocrinology in Greater Manchester - CMFT, The Christie and Salford Royal Hospital. Specialist Commissioner CQUIN exercises are underway to feed into commissioner decisions on where the future of specialist 2

Agenda Item 8.3 endocrine services will be commissioned from, with a view to reducing the number of providers of these specialist services. 2.2

Central Manchester

Central Manchester CCG is currently leading on a new strategic direction for the management of Central Manchester patients with diabetes via the development of a new ‘care model’ between the CCG and ourselves as the Acute Trust. Development of the care model is underpinned by the vision and its aims as described above, and also by a ‘shared care’ philosophy between the CCG and CMFT and agreement for services to be delivered via a hub (CMFT) and spoke (community) based arrangement. From June 2014 and into 2015, workshops and other discussions developed proposals to reshape the care model for diabetes, more specifically for those patients with type 2 diabetes, took place between representatives of Central Clinical Commissioning Group (CCCG), Primary Care Manchester (PCM) and Central Manchester Hospitals Trust (CMFT). Papers were put forward by CMFT to the Manchester Clinical Integrated Care Board and by PCM to the Central Provider Partnership (CPP) meeting on July 18th with the recommendation that a diabetes provider working group was established under the CPP to look at developing new models of care. The CPP identified Type 2 Diabetes as a population group for priority development on the principle that well controlled type 2 diabetes, with the right knowledge, skills and expertise in the community, can and should be managed predominantly outside of the acute hospital setting. A provider working group was established to take forward the development of the model in collaboration with Central CCG. A number of workshops have been held to progress this work, at the first of which in March 2015, CMFT tabled a proposal for the care model in response to the new model of care specification which was produced from the workshops, which is currently in development by the provider working group. The new care model is illustrated below:-


Agenda Item 8.3 As part of this model the CMFT hub will be:  An appropriately scaled, combined Diabetes and Endocrinology Centre as the secondary and tertiary hub, with a critical mass of expertise and experience to ensure optimal patient care, clinical outcomes and patient experience. Defining the group of patients who are currently managed by the hospital, whose care will shift to general practice, is a key aspect of this programme of work, and will inform the facilities and capacity required in both primary and secondary care. Whilst the exact level of activity that will transfer, and as such that which will continue to take place in the hub, is a plan estimate at this time, given the nature and purpose of the hub itself, it will need to accommodate a base from which to operate and provide appropriate services for both inpatients with diabetes and for outpatients who require high levels of diabetes care and those who require multidisciplinary input such as: -

Type I diabetes patients using insulin pumps or with poor control of sugar levels Patients with multiple conditions and complications requiring multidisciplinary input Patients with complications requiring diabetes foot care Patients with nephropathy and receiving dialysis Patients with diabetes who have pancreas, islet or kidney transplants Pregnant woman with diabetes

 Facilitate new inpatient models of care to be developed based on pro-active patient identification and disease management, and thereby prevent avoidable problems and conditions.  The spoke sites will mirror the ‘Living Longer Living Better’ plans for patients with Long Term Conditions, aligned with the Place Based Care Programmes, delivering care close to patients’ homes through selected sites at the geographical four quadrants.  There will be a comprehensive education and training programme, led by the CMFT Hub, for primary care so that knowledge, skills and experience gained through this programme will be transferred to primary care, improving capability and reducing the number of referrals to the centre and increasing those to the community spoke services. This work will be facilitated by a team of Community Diabetes Specialist Nurses as shown in the figure.  There will be structured education programmes, led by the CMFT Hub, delivered in both primary and secondary care settings, for patient self-management to improve patient capability for self-management of diabetes as highlighted in the Central Manchester Commissioning Group’s 2020 vision for diabetes. In the developing landscape of Devolution for Greater Manchester, early ambitions for service improvement and development in diabetes will be sought as one of the priorities and significant gains made in getting the model for diabetes care right. Establishing a central, advanced hub from which such work could be coordinated and led, in conjunction with the university, local authorities and other providers would be a major step advantage for CMFT and the wider conurbation in supporting such a work programme. There would be no comparable facility in Greater Manchester for these specialties.


Agenda Item 8.3 2.3

CMFT – Diabetes Hub

The current state of the Manchester Diabetes Centre (MDC) accommodation and facilities is poor. The service and its resources have significantly outgrown the facility resulting in difficulties and inefficiencies in the provision of care The patient clinical and waiting areas are small and inadequate. The cramped facilities do not facilitate effective organisation nor, therefore, effective management, which in turn does not allow an operationally efficient service to be delivered. The Department of Endocrinology sits within the Directorate of Specialist Medicine and is accommodated in a variety of locations across the central island MRI site. Outpatient referrals have increased over the last three years but the existing outpatient capacity, which is provided from the main MRI hospital site, is restricted. Clinical demand has increased and waiting lists have grown as a result. The current day case/inpatient ward model for inpatient endocrine testing results in a service that is inefficient and requires improvement. Diabetes and Endocrinology conditions often occur in the same patient, it is a single specialty and yet the MDC and the Endocrinology department are currently located in entirely separate buildings. There is an overlap in the knowledge required and approach taken to diagnose and treat patients with these conditions. But, at CMFT, with the two departments not being colocated, there is not the level of overlap there should be which results in less than optimum care and significant service inefficiencies. The existing facilities are not only inadequate for the current services, but they are also unable to provide for service improvement, reconfiguration or for potential expansion required to meet increased clinical demand and/or research opportunities. The service is recognised both nationally and internationally and has opportunities to expand its existing portfolio of services. But it can no longer ‘make do’ if it is to keep up with current developments and if the Trust, and its reputation, are to keep up with the leading, nationally recognised top organisations.


Options for Change & Preferred Option A number of options were identified and considered for replacing the existing unsuitable Manchester Diabetes Centre facility with a new, appropriately-scaled facility for both diabetes and endocrinology on the central site to act as the secondary and tertiary-care base. 1. 2. 3. 4. 5. 6.

Do nothing Refurbish existing MDC facility New Build Re-provide the facilities in the Peter Mount Building (previously Edale House) minimum’ refurbishment Re-provide the facilities in the Peter Mount Building ‘do optimum’ refurbishment Fit-out alternative available space (e.g. lease [part of] Octagon House)

Each option was appraised against the following criteria:    

Clinical Quality and Patient Safety Patient Experience Strategy Efficiency R&D and Education 5


Agenda Item 8.3

From the option appraisal, the preferred option was found to be Option 4, to re-provide the facilities in the Peter Mount Building (previously Edale House) ‘do minimum’ refurbishment. The benefits of this option are that this:Clinical Quality & Patient Safety          

Maintains and improves the delivery of high-quality, safe clinical services Provides a suitable base as the central hub for the new CM Hub & Spoke care model Meets legislative health & safety requirements Provides the required physical capacity to manage the current and future outpatient demand and thereby reduce waiting times for outpatient appointments and delays in ongoing care management in the acute setting Provides a suitable facility from which to deliver national patient education programmes in diabetes to improve patient self-management and glucose control and in endocrinology for the self-care of complex conditions Provides a suitable facility from which to deliver national staff education programmes for primary and secondary care professionals to improve primary care management of diabetes Provides a suitable and safe facility for Endocrinology testing Provide an appropriate critical site from which clinical teams can deliver inpatient services to patients with diabetes and endocrine conditions, and to support the wide range of other clinical services at CMFT Provides a suitable platform from which to develop a new, pro-active ‘preventative’ model of inpatient care for patients with diabetes and endocrine conditions. Co-locates the single specialty of diabetes and endocrinology to ensure the necessary clinical and management overlap

Patient Experience  

Facilitates patients being seen appropriately in either a community or hospital setting Creates an acute hospital environment that is suitable to meet the needs of this group of patients

Strategic    

Facilitates the reconfiguration and development of the CM diabetes care model Enhances our marketable reputation for excellent clinical services, provided in a bespoke and modern clinical environment, including the ability to be Manchester’s specialist commissioning in Endocrinology Provides a platform from which to respond to opportunities for development, growth and self-funding income generation schemes Enables clinical teams to attract and host international events and visiting doctors drawn by our reputation for highly specialised experience and excellence

Efficiency   

Reduces unnecessary and inappropriate outpatient appointments in secondary care Creates improved efficiencies in the use of staff and resources with the co-location of diabetes with endocrinology Frees up prime clinical capacity in the hospital for use by other clinical services 6

Agenda Item 8.3 R&D and Education    

Provides a suitable facility to maintain the current R&D portfolio and facilitate R&D expansion Provides a suitable world class facility to ensure continued involvement and support from the University of Manchester Increases opportunities for local and national teaching for NHS professionals and academics Provides the cohesive education and training that cements our leading place in the NW Deanery and retains our cohort of Deanery-funded trainees.

The capital costs of this option are estimated to be circa £2.1m including VAT, with associated annual revenue costs of circa £300K. The CMFT Charitable Funds Committee (CFC) at its meeting on 9th November 2015 considered a case of support for funding for the relocation of the Manchester Diabetes and Endocrinology Department to the Peter Mount Building and it was reported that this was seen as a priority request for the Charity. The CFC supported the request and agreed that there would be a review of charitable investment funds that were unrestricted to see what contribution could be made. This was in addition to a review of available funds in the Specialist Medicine General Purposes Fund (£187k) and any other identifiable funds that could be deemed relevant for the project. A fundraising campaign would be launched in 2016 to seek donations from corporate and individual donors who may wish to support the project.


Conclusion The diabetes service has outgrown the current, old and poor facilities, and a replacement facility is now required, if high quality services and clinical development are to be provided and supported, ideally as a combined Diabetes and Endocrinology Centre. The re-provision of a joint MDC and Endocrinology department via the preferred option is the most cost effective, and will bring huge and wide-ranging benefits, including the promotion of patient self-management and disease prevention as part of the LLLB and Placed Based Care programmes. The Commissioners agree and support any financial implications for them regarding clinical activity of the model. Commissioners are driving the reconfiguration of Diabetes Services across Manchester as part of LLLB and, therefore, themselves driving the concept and nature of the hub and spoke model, with CMFT as the hub. In recognition that there is significant pressure on the Trust Capital Programme and the Division’s revenue budget, the following has been undertaken:    

Development of income generating schemes to cover the revenue costs of the new build. Continued review as the scheme develops aiming to keep within or reduce the capital cost of £2.1m. Developing a range of ideas and schemes to identify additional charitable funds to add to those available now, including the exploration of the possibility of generating a significant part of the funding through an appeal with the Appeals Office. Continue to look at service transformation and flow to achieve best clinical care in the most efficient way. 7

Agenda Item 8.3


Recommendations The Board of Directors to approve: 

The proposed strategic direction of travel for the development of a new clinical model of care for diabetes and endocrinology in conjunction with GM CCG.

The re-provision of the joint diabetes and endocrinology centre on the Central site as per the recommended option, subject to securing charitable funding for the project.


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