111/OOH IMPLEMENTATION SOC submission and OBC Approval process. January 2016

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1 111/OOH IMPLEMENTATION SOC submission and OBC Approval process January 2016 PURPOSE To provide EASC with an update on the Strategic Outline Case (SOC) submission to Welsh Government, which aims to develop the technical infrastructure to support an all Wales system providing health advice and urgent care through a free-to-call number and multichannel web access. The main purpose of the SOC was to fully establish the need for capital investment, to appraise the main options for service delivery and to provide a preferred way forward for further evaluation at Outline Business Case (OBC) stage. The preferred options will need to replace the current CAS (WAST) and Adastra (GPOOH) IT systems in 2017 /18. The Emergency Ambulance Services Committee is asked to: Approve Endorse Discuss Note INTRODUCTION In December 2015, following discussions at the 111 Implementation Board and subsequent comments from a number of colleagues, a Strategic Outline Case (SOC) was submitted to Welsh Government. It detailed the options for a proposed capital investment of circa 9m+ to develop and deliver the technical infrastructure required to support an all Wales system providing health advice and urgent care through a free-to-call telephone service and multichannel web access. NHS colleagues have been involved from WAST, LHBs and NWIS. This system will form an integral part of the unscheduled care system in Wales, supporting prudent health care by directing patients to the most appropriate service for their needs Strategic Outline Case (SOC) update Page 1 of 11 Emergency Ambulance Services Committee

2 and offering a genuine alternative to attendance at Emergency Departments and face-toface GP out-of-hours (GP OOH) services where clinically appropriate. The 111 service will ultimately be the mechanism for patients to access urgent out of hospital services and has a key role to play in simplifying how patients navigate a complex and often confusing unscheduled and primary care system on a 24 hour, 7 day a week basis. The free to use telephony and online service will join together the current contact services within NHS Direct Wales (NHSDW) together with the GP OOH call handling and nurse triage services across Wales. This SOC has been produced in accordance with the current 5-Case guidelines as described within Welsh Health Circular (2006) 001. As such it focused at this early stage on building on strategic Case for Change, on preparing and appraising the long list of options within the economic case and on recommending a preferred way forward, together with indicative costs, for further analysis within the Outline Business Case (OBC). The main benefits to stakeholders, patients and staff will be to: Simplify the navigation of the urgent care system so patients can be assessed by the right service, at the right time. Have access to information to enable them to care for themselves by having timely access to information and signposting to the right service. Be able to have access to health information, advice and clinical assessment through a variety of channels (e.g. website, mobile devices). Reduce duplication for callers by sharing data so they are not required to repeatedly provide the same information to access the right service, Know which service to contact and will be empowered to choose well. Patients will be able to consent and have information on their individual care needs shared with relevant clinicians to facilitate the delivery of high quality care and avoid unnecessary duplication. Enable more efficient and sustainable service delivery by supporting different ways of working (e.g. virtual call queues to make the best use of staff time), Be able to receive treatment in their own home /community setting on a consistent basis, where appropriate, and avoid unnecessary transportation by ambulance to ED Support prudent health care delivery across urgent and unscheduled care. Commercial Case It is anticipated that commercial procurement in support of the shortlisted options would be restricted to the replacement of the existing IT infrastructure within NHSDW (CAS) and GP Strategic Outline Case (SOC) update Page 2 of 11 Emergency Ambulance Services Committee

3 OOH (ADASTRA). The 111 service roll out would facilitate the cessation of existing contracts with private sector providers, as these lapse, and repatriation of service back into NHS Wales. Procurement approach The project team has previously noted a desire to submit the OBC swiftly, with the original plan to complete this by the end of January. This was largely driven by the need to progress with the procurement for the full IT solution, and the fact that the CAS legacy system must be replaced in Discussions at the Joint Implementation and Governance Group (JIGG) and with Welsh Government colleagues have supported the adoption of a parallel process, with the start of procurement not being delayed until the OBC has been approved. This will ensure that the approvals and due diligence process is not unnecessarily rushed, and allows the team to fully reflect on and build in comments from a variety of sources into the OBC submission. Additionally, recognising that the key area of development needed for the OBC will be in relation to the likely costs of the new system, suppliers are more likely to provide a suitable level of detail when directly involved in the procurement process. Note: Subject to further analysis at OBC stage, we would envisage procuring the new IT system via an OJEU procurement utilising the Competitive Dialogue procedure. Minimum timescales for the OJEU procurement process is 12 months from FBC sign-off stage however we will also require circa 3-6 months to build and incorporate the system within NHS Wales and a minimum 3 months period for training and education of staff. Required products and services The required products and services required to support the proposed way forward are: a single patient management system incorporating a patient record and workflow queue management, decision support tools for use by clinical and non-clinical staff to support call prioritisation and clinical assessment, interoperability mechanisms with a range of clinical and service systems to support effective clinical decision making and service direction (including secure transfer of data in and out of the 111 IT system), directory of services to enable direction or referral to appropriate services based upon presenting need, time and geographical location for use by health care professionals and (via restricted view) members of the public to support self-care and effective navigation, Appropriate and effective data security and access measures, An appropriate IT service support infrastructure to ensure robust and effective service delivery on a 24 hour basis. Strategic Outline Case (SOC) update Page 3 of 11 Emergency Ambulance Services Committee

4 Critical Next Steps: EASC colleagues are more that welcome to see the more detailed SOC which is already at a greater level of detail than might otherwise be expected for a high level strategic document. This level of detail will however be used as the basis for the OBC with increased focus on the financial case and benefits metrics. Following discussions with Welsh Government (15 th January 2016), there are now a series of critical next steps that we need to undertake: 1. Obtain collective 111 Board and Chief Executive sign-off for the SOC submission. It is proposed that this be discussed at EASC and subject to approval in principle, the Chair /Ambulance Commissioner can jointly sign a letter of support. 2. Continued development of a draft IT specification of requirements to complete by the end of January Continue to refine the financial case for the OBC with support from the finance and Information /IT colleagues. The revenue impact needs careful scrutiny in particular. 4. Instigate the Gateway Review process. No Gateway reviews could be undertaken prior to the submission of the SOC however following discussion with Welsh Government, it is planned that a combined Gate 0 (strategic fit) and Gate 1 (business justification) will take place prior to submission of the OBC. This next stage will be concluded by the early March Welsh Government Panel meeting to specifically review the options appraisal process and benefits measures and metrics of success (end of January 2016) 6. Formal Investment Board presentation and review (following Gateway) on the 23 rd March The 111 Board has previously discussed that, due to the time restrictions linked to the legacy system, the procurement processes will have to commence and run alongside the business case submission process and the pathfinder. This was discussed in principle with Welsh Government and broad agreement reached that was a logical way to proceed but should be formally outlined in writing to Welsh Government following Board and EASC approval. RECOMMENDATIONS EASC are asked to: Note the progress made to date in progressing business case submission, and Endorse the plan to run business case approval as a parallel process to IT procurement. Richard Bowen Project Director, 111 Strategic Outline Case (SOC) update Page 4 of 11 Emergency Ambulance Services Committee

5 APPENDIX 1 EXECUTIVE SUMMARY Introduction This SOC seeks approval to invest an estimated circa 9m+ in the development and delivery of the technical infrastructure to support an all Wales service providing health advice and urgent care through a free-to-call telephone service and multi-channel web access. This service will form an integral part of the unscheduled care system in Wales, supporting prudent health care by directing patients to the most appropriate service for their needs and offering a genuine alternative to attendance at Emergency Departments and face-to-face GP out-of-hours (GP OOH) services where clinically appropriate. The 111 service will ultimately be the mechanism for patients to access urgent out of hospital services and has a key role to play in simplifying how patients navigate a complex and often confusing unscheduled and primary care system on a 24 hour, 7 day a week basis. The free to use telephony and online service will join together the current contact services within NHS Direct Wales (NHSDW) together with the GP OOH call handling and nurse triage services across Wales. Strategic Case The strategic context In February 2014 the Unscheduled Care Improvement Programme produced its vision for how unplanned care needs should be met in Wales. Included in The Way Ahead for Unscheduled Care in Wales were key objectives for NHS Wales such as the need to provide rapid, reliable advice when it is needed; to support for self care; to provide easy access to urgent care across Wales; and enhanced information systems and care networks that cross organisations. A key component in The Way Ahead is for the unscheduled care system in Wales to implement a free, 24 hour telephony service to meet out-of-hours, urgent, primary care needs, (in this context, primary care comprises primary medical, dental, community and mental health). These developments align with 2011 Welsh Labour Manifesto commitment to build on the success of NHS Direct, and offer a single number for accessing out-of-hours health care in Wales, linked in to the local out-of-hours services and numerous other strategic plans, as detailed in section 3.2. The case for change The unscheduled care system in Wales is complex and difficult to navigate for patients, carers and often for health professionals themselves. There is recognition across NHS Wales that the both the urgent /acute elements of the Unscheduled Care system namely 999 ambulances (WAST), Emergency Departments (ED) and GP out-of-ours (GPOOHs) remain under significant pressure which is often compounded by attendances whose needs could be more effectively met by other services or by direct advice or signposting. Outside the hours of Monday to Friday (8am to 6.30pm), urgent primary care services are provided or commissioned by Local Health Boards and each has different service models in place. The GPOOH services operate independently of each other but all provide telephone assessment with signposting to other clinical services and/or face to face appointments or home visits when required. Strategic Outline Case (SOC) update Page 5 of 11 Emergency Ambulance Services Committee

6 NHS Direct Wales (NHSDW) provides a 24 hour service offering health information /advice and signposting to clinical and a range of other services as required. There is no direct link between NHSDW and GP OOHs and some duplication of activity exists. Both services have different service and quality standards, including the prioritisation categories for clinical assessment and appointment. Neither NHSDW nor GP OOH standards reflect those of inhours primary care services or operate align in a strategic manner with other parts of the unscheduled care system. All services face significant pressures in recruiting and retaining appropriate clinically trained staff. There are opportunities within the workforce redesign of the pathfinder to allow for greater flexibility of roles and multi-disciplinary working effectively countered by the operation of an all Wales virtual call queue to make best use of clinical resources. The IT infrastructure in place for both services does not support the transfer or sharing of data, leading to duplication and delays in callers accessing the right service for their needs. Specifically within NHS Direct Wales the IT infrastructure (CAS) is an obsolete product that must be replaced by Within GP out-of-hours services, there are separate contractual arrangements in place with commercial providers and they all utilise different instances /versions of a single IT system (Adastra). There is variance in the sustainability of server infrastructure, meaning that NHS Wales has not been able to take advantage of combined purchasing power to deliver a cost effective and robust infrastructure for GP OOH IT systems. On the basis of this high level analysis, there is huge potential and scope for the scheme and a unique opportunity to transform and reshape our unscheduled and urgent care services so that patients receive the right treatment, in the right place, first time. By implementing a free to access 24 hour, clinically led service, which provides a single access point for NHSDW and GP OOH along with a range of other alternatives, it will support patients to effectively navigate unscheduled care in accordance with their needs. The service would be supported by a common IT and call management system which integrates with a range of other NHS systems to share relevant data for the purposes of improved clinical decision making and reduced duplication. This connected IT infrastructure is a fundamental tool for delivery of the service model, and is the focus of investment for this SOC along prudent healthcare principles. Scope The options considered within this Strategic Outline Case focus on the provision of an IT infrastructure that is fit for purpose to enable the delivery of the new 111 service model, comprising a call management/patient record system and decision support tools with associated clinical content. This includes interfaces with a range of IT systems across NHS Wales, including a Directory of Services and the facilitation of multi-channel access to the 111 service. This document does not consider the capital or revenue requirements associated with the delivery of the service itself (i.e. staff, premises, etc), or the requirements for a telephony platform to deliver calls to the 111 service. Other associated ICT costs do not form part of this document and will be explored within the OBC based on further discussions with suppliers. Strategic Outline Case (SOC) update Page 6 of 11 Emergency Ambulance Services Committee

7 Economic Case The long list The following possibilities were considered using the options framework: Scope: 1. Maintaining separate systems for NHSDW (replacement needed 2017) and each GP OOH service (x7) 2. Connecting the existing NHSDW (replacement needed 2017) and each GP OOH service (x7) system 3. Procurement of a single integrated IT system throughout the 111 and GP OOH service (interoperability critical) 4. Procurement of a single integrated IT system linking 111, GP OOH and in-hours GP services 5. Procurement of a single integrated IT system linking 111, GP OOH, in hours GP services and other public services, (e.g. Social Care) Technical/Contracting Options: 1. Solution run from NWIS data centre on behalf of NHS Wales 2. Solution provided as a managed service by a single commercial supplier 3. Solution provided as a managed service by multiple commercial suppliers Service Delivery Options: 1. NHS Wales development of system utilising (where appropriate) current NHS Wales systems and components 2. Purchase a single commercial solution to replace the current NHSDW and GP OOH systems Implementation Options: 1. Phased implementation as per pathfinder timescales and LHB baseline assessments 2. Big Bang All Wales solution The preferred way forward On the basis of the above analysis, the preferred and recommended way forward (to be confirmed at OBC stage) is to procure a single integrated IT system for the 111 and GP OOH service, from a single commercial supplier, delivered as a managed service and implemented on a geographical /Health Board phased basis. The main benefits to stakeholders, patients and staff will be to: Simplify the navigation of the urgent care system so patients can be assessed by the right service, at the right time. Be able to receive treatment in their own home /community setting on a consistent basis, where appropriate, and avoid unnecessary transportation by ambulance to ED Have access to information to enable them to care for themselves by having timely access to information and signposting to the right service. Strategic Outline Case (SOC) update Page 7 of 11 Emergency Ambulance Services Committee

8 Be able to have access to health information, advice and clinical assessment through a variety of channels (e.g. website, mobile devices). Reduce duplication for callers by sharing data so they are not required to repeatedly provide the same information to access the right service, Know which service to contact and will be empowered to choose well. Patients will be able to consent and have information on their individual care needs shared with relevant clinicians to facilitate the delivery of high quality care and avoid unnecessary duplication. Enable more efficient and sustainable service delivery by supporting different ways of working (e.g. virtual call queues to make the best use of staff time), Support prudent health care delivery across urgent and unscheduled care. The short list On the basis that the proposed way forward is agreed, we recommend the following options for further, more detailed evaluation within the Outline Business Case (OBC): Option 1 Procure a single IT system for NHSDW/GP OOH from a commercial supplier, providing this using NHS Wales national infrastructure and rolling out on a phased basis. Option 2 Procure a single IT system for NHSDW/GP OOH from a commercial supplier, providing this as a managed service and rolling out on a phased basis. Option 3 Procure a replacement NHSDW IT system from a commercial supplier and connect this to the existing (x7) GP OOH IT systems, providing this using NHS Wales national infrastructure and rolling out on a phased basis. (Do Minimum) Option 4 Procure a replacement NHSDW IT system from a commercial supplier and connect this to the existing (x7) GP OOH IT systems, providing this as a managed service and rolling out on a phased basis. (Do Minimum) Option 5 - Procure a single IT system for NHSDW/GP OOH and in hours GP practice from a commercial supplier, providing this using NHS Wales national infrastructure and rolling out on a phased basis. Option 6 - Procure a single IT system for NHSDW/GP OOH and in hours GP practice from a commercial supplier, providing this as a managed service and rolling out on a phased basis. Consequently, the proposed option will be identified and recommended for approval within the OBC. Commercial Case It is anticipated that commercial procurement in support of the shortlisted options would be restricted to the replacement of the existing IT infrastructure within NHSDW and GP OOH. Strategic Outline Case (SOC) update Page 8 of 11 Emergency Ambulance Services Committee

9 The 111 service roll out would facilitate the cessation of existing contracts with private sector providers, as these lapse, and repatriation of service back into NHS Wales. Procurement strategy Subject to further analysis at OBC stage, we would envisage procuring the new IT system via an OJEU procurement utilising the Competitive Dialogue procedure. Required products and services The required products and services required to support the proposed way forward are: a single patient management system incorporating a patient record and workflow queue management, decision support tools for use by clinical and non-clinical staff to support call prioritisation and clinical assessment, directory of services to enable direction or referral to appropriate services based upon presenting need, time and geographical location for use by health care professionals and (via restricted view) members of the public to support self care and effective navigation, interoperability mechanisms with a range of clinical and service systems to support effective clinical decision making and service direction (including secure transfer of data in and out of the 111 IT system), Appropriate and effective data security and access measures, An appropriate IT service support infrastructure to ensure robust and effective service delivery on a 24 hour basis. Potential for risk transfer and potential payment mechanisms The main risks associated with the technical infrastructure procurement relate to the limited time available to replace the existing obsolete NHSDW IT system. This is being countered by commencement of a robust pre-procurement process and further risks will be considered as part of the OBC. Financial Case Summary of financial appraisal All the costs at this stage are high-level estimates and should be used for indicative purposes only. Detailed discussions with suppliers will need to be carried out (should the SOC be approved) at the next (OBC) stage. It should be noted that, as the proposed solution will replace existing IT systems within NHSDW and GP OOH services, based on the estimated costs below, the revenue implications must be largely cost neutral for NHS Wales. T Strategic Outline Case (SOC) update Page 9 of 11 Emergency Ambulance Services Committee

10 he costs shown are indicative direct costs only and illustrate a potential range of costs for comparison purposes based on initial discussions with multiple suppliers. Details Option 1: Desirable Scope NHS Wales Infrastructure Commercial Purchase Phased Implementation Option 2: Desirable Scope Managed Service Commercial Purchase Phased Implementation Option 3: Minimum Scope NHS Wales Infrastructure Commercial Purchase Phased Implementation Option 4: Minimum Scope Managed Service Commercial Purchase Phased Implementation Option 5: Optional Plus Scope NHS Wales Infrastructure Commercial Purchase Phased Implementation Option 6: Optional Plus Scope Managed Service Commercial Purchase Phased Implementation Capital Total Revenue (years 1-6) Total 9,065,000 8,839,500 17,904,500 8,645,000 8,839,500 17,484,500 5,365,000 5,509,500 10,874,500 4,945,000 5,509,500 10,454,500 14,430,000 14,349,000 28,779,000 13,590,000 14,349,000 27,939,000 It is anticipated that the capital costs will be funded from the Welsh Government while the annual costs (revenue) will need to be funded by the Health Boards and WAST. A formula to reflect activity utilisation or population share will need to be agreed with Health Boards in order for them to agree the appropriate share of the costs. Strategic Outline Case (SOC) update Page 10 of 11 Emergency Ambulance Services Committee

11 In summary, option 4 is the lowest cost option, based on estimated indicative costs; this combines a minimum scope product delivered by managed service arrangement. It has been assumed that the costs associated with delivery of the optional plus variants are likely to be significantly higher than a solution focussed primarily on the 111 service. However this does not take into account the ongoing and detailed discussions still required with suppliers to fully explore the context of their submissions and what the definitive costs are likely to entail. Further, the estimated costs relate to direct costs for the system only and do not consider the potential financial implications of increased efficiencies linked to the differing configurations of the 111 IT system. At this stage, it cannot be assumed that the lowest cost option will offer most value for money so the above figures present an upper and lower estimated range and will need to be subjected to sensitivity analysis at OBC stage. Management Case Over the last 9 months we have undertaken a considerable amount of stakeholder support and engagement to develop the Welsh approach for 111; adapted the principles against which the model should be developed and how ultimately we developed and adapted the clinical model to that which we have today. We are now in a position where we have a very good level of support and consensus to across NHS Wales and amongst a number of clinical and professional groups. Importantly, we have the support of NHS Wales Leaders and direct support from a number of patient groups. Project management arrangements In order to meet the formal project management requirements, the Chief Executive of Aneurin Bevan University Health Board is the Senior Responsible Officer (SRO) and chairs the 111 Project Implementation Board. The SRO has formally appointed a Project Director, supported by a Project Team and the organisational structure is outlined in Section 8.2. Copies of the terms of reference and a list of Board members are attached at appendix 2. The project is an integral part of the wider Unscheduled Care Transformation Board agenda which is chaired by Dr Andrew Goodall. It also supports the Ambulance Commissioner programme regarding the delivery of steps 1 and 2 of the Quality and Delivery Framework for Emergency Ambulance Services (EASC). Gateway reviews arrangements No Gateway reviews have yet been undertaken however following discussion with Welsh Government colleagues, it is planned that a combined Gate 0 (strategic fit) and Gate 1 (business justification) will take place prior to submission of the OBC. Recommendation We recommend approval of this Strategic Outline Case, thereby enabling the project to progress to the next stage; continued planning of all Wales roll out post-pathfinder. Approval of this SOC will support the generation of an OBC for a new IT system to facilitate the effective delivery of the 111 service in the medium term, replacing the multiple existing GP OOH system contracts and the obsolete NHSDW IT system which will cease in Strategic Outline Case (SOC) update Page 11 of 11 Emergency Ambulance Services Committee