Business Case
For
Local Enhanced Service
For the
Provision of
Enhanced Gynaecology Care
In
Welwyn Hatfield Locality

Introduction

The proposed Local Enhanced Service for the provision of Enhanced Gynaecology care in the Welwyn Hatfield Locality includes:-

•	Removal of cervical polyps
•	Assessment for the fitting of and the changing of vaginal ring pessaries.
•	Insertion of HRT implants
•	Care of women with polycystic ovarian syndrome (excluding) infertility care).

Evidence Based Clinical Effectiveness.

The proposed service would follow the same guidelines as are used in secondary care at present.

The effectiveness of this service will be equal to that offered in secondary care.  The service will follow the recognised   professional guidelines from NICE, the RCOG or other required professional bodies.

Strategic Fit with National and Local Priorities

     Local and nation priorities include:-

•	The treatment of patients closer to home
•	For patients referrals to secondary care an eighteen week time limit from referral to treatment.
•	A shift of care from secondary to primary care where appropriate.

The enhanced service will:-

•	Provide more services in primary care thus treating patients closer to home.
•	Reduce the number of secondary care referrals enabling patients to be treated more quickly in primary care and help secondary care to meet their 18 week target.
•	Facilitate the process of moving services into primary care from secondary care.

Governance Arrangements.

•	General

As general Practitioners will be treating registered patients within their own GMS/PMS practice the same governance arrangements will apply.

•	Accreditation

Doctors/Registered Nurses and other practice staff who have previously provided services similar to this Enhanced Service and who satisfy at appraisal and revalidation that they have relevant continuing medical/nursing experience, training and competence as is  necessary to enable them to contract for the Enhanced Service, shall be deemed qualified to do so.
It is the practices responsibility to ensure all staff attend an            appropriate course or provide evidence of equivalent experience or qualification.

Thereafter evidence of continuing professional development by accessing gynaecology educational sessions will be required.

•	Untoward Events

It is a condition of this LES that practitioners will give notification to the PCT Clinical Governance Lead, within 72 hours of the information becoming known to him / her, of all emergency admissions or deaths of any patients covered under this LES related to any of the care given or procedures done.

This is in addition to the practitioner’s statutory obligations.

Monitoring Arrangements.

Practices will need to record the following information to the Locality Commissioning Board on a quarterly basis:-

Service Review

•	Patient identifier
•	Date of Procedure / episode of care
•	Number of patients referred to secondary care
•	Procedure / Episode of Care carried out using the appropriate READ Code set out in the LES

Clinical Audit

An annual clinical audit of the patients registered as having had enhanced gynaecology care will be carried out and the following details will be required:

•	Number of patients seen
•	Reason for referral and treatment required for each patient
•	Outcome of each appointment (ie treatment complete/follow-up appointment scheduled/referred into secondary care)
•	Outcome of an annual patient satisfaction survey

Contribution to National and Local Targets.

 The local enhanced service will contribute to these targets by

•	Reducing the need for referral to secondary care, thereby facilitating the secondary to primary care shift.
•	Reducing the pressures on secondary care facilitating the attainment of the 18 week target wait for other treatments in gynaecology.

Assessment of Potential Discrimination on all Population Groups.

This service is committed to equal opportunities and will not discriminate unlawfully within the meaning of any law, relating to discrimination (whether relating to race, gender, disability, religion or otherwise) in performance of the service and shall take all reasonable steps to ensure observance of this.

Patient / Public Support.

This local enhanced service has been discussed by both the Welwyn Hatfield Locality Board and the Executive Board. The lay representatives on both these committees fully support this proposal.

Stakeholder Support from all Organisations Involved.
  
All eight practices in Welwyn Hatfield who are also represented on the Locality Board support this proposal.
Both the Welwyn Hatfield Locality Board and the Executive Board support this proposal.

Justification / Evidence that Resources  can be released through   the Substitution of Care.

•	The Local Enhanced Service will be financed from the Welwyn Hatfield Local Enhanced Service budget which is currently £80,000.00 under spent.
•	The reduction in referrals to secondary care will mean that secondary care budget savings will be made through this substitution of care.
•	The estimated savings from the secondary care budget following a survey of the local practices is as follows:

Within Welwyn Hatfield Locality Population

Clinical
Problem	Estimated Numbers	Out Patient Tariff	If provided in 2 care	
Cervical Polyps
	56	138 (x56)	£7728	
Fitting of Ring Pessaries	18	138 (x18)	£2784	
Changing of Ring Pessaries	50	76 (x50)	£3800	
Care of Polycystic ovaries. 
New patients	15	13 (x15)	£2040	
Care of Polycystic Ovaries. 
Follow up	60	76 (x60)	£4560	
	
						Total Cost		    £20,912

Affordability within Current Care and Projected Indicative    Budgets

total estimated costs for this service from the Enhanced Services budget for all eight practices 
	
Cervical Polypectomy	56x£60	£3360
	
Fitting of Ring Pessary	18x£60	£1080
	
Changing of Ring Pessary	50x£60	£3000
	
Care of Polycystic ovaries, new patients	15x£120	£1800	
Care of Polycystic Ovaries follow up	60x£60	£3600	

 					Total			             £12,840

For all eight practices there will be a cap on the amount that can be claimed for this enhanced service dependent on their population.

Bridge Cottage		(   15509	)	=			£1847
Peartree			(   22332	)	=			£2660
Garden City		(     8870	)	=			£1056
Hall Grove			(   16422	)	=			£1956
Burvill House		(     8399	)	=			£1000
Lister House		(   11999	)	=			£1429
Potterells			(   15007	)	=			£1787
Wrafton House		(     9254	)	=			£1102

Total	Locality Population as at 1.1.2008 (107,792)           £12,840

If practices do not exceed their total financial budget a cap will not be enforced for each type of activity.

Assessment of the Impact on Current Service Provider

Outpatient activity for E & N Herts	 Gynaecology Service for 12 months
1.04.06 – 31.03.07		
Proposed Local Enhanced Service	
New Referrals	Follow up appointments		New patients	Fellow ups	

1708	
2471		
90

(patients appropriate to be seen in primary care	
116

(patients appropriate to be seen in primary care	

As illustrated above this enhanced service will have a minimal impact on our current service provider the East and North Herts NHS Trust

Value for Money

As illustrated in the previous section this proposed enhanced service will provide value for money as it is offering a cost effective service provided in the community.

Benefits for Patients

The proposed enhanced service is providing the following benefits to patients:

•	Care closer to home
•	Care through their own practice which they are familiar with
•	Care equal to clinical quality provided by the acute trust.
•	Faster care for new referrals compared to secondary care

Proposed Procurement Route
 
The Service Level Agreement will be between East and North Hertfordshire Primary Care Trust (“The Commissioner”) and the GP Practice (“the Provider”)

Practices wishing to participate in this LES will notify the Welwyn Hatfield Locality Board in writing.  Once agreed, the LES contract will be for one year and may be renewable following annual review.

Risk Assessment and Controls

All the care / procedures in this enhanced service are of low risk to the patient.
All the care / procedures will be provided under the governance arrangement already outlined in this business case and in the enhanced service.
There will be a financial cap to this service to ensure that the budget allocated is not overspent.

Timescales for Implementation

It is proposed to introduce this service on 1st April 2008.

Proposals for the Care of Freed Up resources

Any freed up resources will go into the Welwyn Hatfield Locality’s overall savings for the financial year.  The use of these savings will be decided by the locality Board in line with PCT procedure.