Download Option 2: Introduce a Mohs service

NHS Trust Name
Business Case Template
Mohs Micrographic Surgery for
NHS Foundation Trust
(Specialist Services)
Version 1
June 2013
NHS Trust Name
Contents
1.
EXECUTIVE SUMMARY:
3
2.
BACKGROUND INFORMATION
4
3.
CURRENT POSITION
5
4.
PROPOSED SERVICE DEVELOPMENT
6
5.
MARKET ASSESSMENT:
7
6.
OPTION APPRAISAL:
7
7.
BENEFITS APPRAISAL:
8
8.
PERFORMANCE ACTIVITY:
9
9.
FINANCIAL ANALYSIS:
9
10. CRITICAL ASSUMPTIONS AND RISK ASSESSMENT:
10
11. IMPLEMENTATION TIMELINE:
11
12. LEADERSHIP AND WORKFORCE:
11
13. EXIT STRATEGY:
12
14. CONCLUSIONS:
12
15. REFERENCES:
12
16. APPENDICES
12
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NHS Trust Name
Note: Use the local business case proforma ensures all the areas your Trust considers
important are included.
Top Tips
1. Executive Summary:
A short summary of the entire business case; It should be succinct and convey vital
information about the proposal/project.
This section should include a summary of:
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Organisational scope
The proposition and the benefits of supporting it
Cost benefits
How it will be made affordable
Major risks
Organisational Scope:
The Trust objectives state that it should deliver a ‘Gold Standard’ of healthcare to meet NHS
Outcomes Frameworks.
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The proposition and the benefits of supporting the proposal: NICE supports Mohs
surgery as a treatment for specific Basel Call Carcinomas (BCC), reducing recurrence
rates for patients with skin cancer. As a tertiary Hospital for xxxx (add local area)
and a recommended provider of a Mohs service by the xxxx Cancer Network, it is
important to ensure patients have equitable access to care and can be treated
locally. Setting up this service also meets the requirements for NHS England
specialised services for Dermatology.
Cost benefits: for specific types of BCC and difficult tumours like SCC and DFSP the
value of Mohs may be of use. Mohs increases patient satisfaction and at the same
time reduces Trust costs from unnecessary repeated procedures. Furthermore, it
will allow the Trust to keep the surgery in house without referring and paying for
external hospital management, cutting down additional referrals across patient
pathways.
How will it be made affordable: the start up costs average at around £50,000; the
trust should recover this money within 2 years based on 126 Mohs cases per year.
Contingency needs to be made for tariff reduction and should be agreed with
commissioners as part of defining a business case.
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NHS Trust Name
2. Background Information
This should be a clear introduction to the business case describing the setting background
and context. It should clearly state the purpose of the business case. Explain the objectives,
requirements and problems addressed by the proposal. Objectives should be clear and
measureable where possible.
The highly specialized service of Mohs micrographic surgery is used to treat contiguouslygrowing primary or recurrent skin cancers, particularly basal cell carcinomas. There is
substantial evidence for its use in the surgical treatment of primary skin sarcoma,
particularly dermatofibrosarcoma, and some evidence for its use in the treatment of highrisk squamous cell carcinoma. The principal of Mohs surgery is that the cancer is mapped as
it is removed. The main benefit is a high degree of confidence that surgical excision of
clinically unapparent disease is complete. A secondary yet important benefit is that the
technique minimises the amount of normal tissue that is removed at surgery.
At each stage 100 percent of the surgical margin is tested, and this continues until it is clear.
This ensures cure rates of 98-99% for previously untreated skin cancers.
Mohs may also have a place in confirming complete excision of rare skin cancers, whose
biological behavior is not well characterized. Under these circumstances it is combined with
a wide local excision to minimize risk of inadequate treatment of any local metastases. Each
Network SSMDT for skin cancer will see a small number of such cancers each year, and this
approach provides a rational care pathway in a very data-poor area.
In most cases, Mohs surgery is an outpatient procedure that uses a local anesthesia and is
completed in one visit. Patients not only receive consultation and surgery at the clinic, but
doctors and surgeons from other departments also may be brought in to assist in a patient’s
pre- or post-surgery needs. Interdepartmental collaboration with Radiation Oncology,
Dermatology, Plastic Surgery and Head and Neck Surgery helps complete the full circle of
care.
NICE Improving Outcomes Guidance for skin tumours published in February 2006
recommended Mohs surgery for large high risk BCCs of the face and should be available in
each Cancer Network; (add name here) Cancer Network is therefore keen to develop this
service. It is also expected that the Peer Review process will reflect the need for a Mohs
service within the Network to meet patient demand. It is important that the Trust as a
tertiary hospital is able to provide specialised services such as Mohs for local and regional
patients in order to meet NHS England commissioning objectives.
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NHS Trust Name
3. Current Position
This section should describe existing services and their current deficiencies i.e. staff or
equipment shortages. Demographic profiles, patient activity and unmet need should be
included.
SWOT analysis looks at the Strengths, Weaknesses, Opportunities and Threats that your
business faces. SWOT analysis provides information that is helpful in matching resources
and capabilities to the competitive environment in which you operate. It can be helpful in
strategy planning or business review.
Explain current arrangements for Mohs service provision, for example:
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‘As there is no service currently available within the Network, patients have in the
past been referred to a service in xxxx. However, demand on this service has been
so great that referrals are now being refused, further increasing pressure for the
development of a local service’.
Include skin cancer data for the Trusts patients and regional estimates for patients who
would be suitable for the service.
Include prevalence statistics for increasing incidences of skin cancer against a local
population demographic profile considering age, occupation and ethnicity.
Include Cancer Network support and feedback for the development of the service, for
example:
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‘The Network discussed the need for Mohs treatment for the region and recognised
that there is both the aspiration and facilities to deliver this service in the
Dermatology Department at (add trusts name) Hospital. The Trust is fully engaged
and is supportive of this development’.
Explain the surgical staffing arrangements and deficiencies in the Trust and local areas;
reference discussions and agreements to work together where relevant, for example;
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‘It should also be recognised that the Trust already has the services of a maxillofacial
surgeon and oculoplastic surgeon available to support this service with good links to
plastic surgery at (add other local hospitals and services, where these exist). Informal
discussions with consultant plastic surgeons from local and nearby trusts confirm
they would support this service’.
Or
‘The Trust will need to recruit an additional Mohs surgeon into post to provide the
service; as training in Mohs occurs post CCT consideration will also be given to
developing the dermatological surgeon consultant currently employed by the Trust.’
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NHS Trust Name
4. Proposed Service Development
Outline the drivers for change and situate your proposal within the context of both local and
National strategies in order to promote service development. Use all appropriate guidelines
(see reference in the back of this template).
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Identify where the service will be provided
Identifying staffing
Establish what the proposal will deliver i.e. community services
Explain skin cancer service provision, for example:
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‘For a population of approximately xxxx million (i.e. that served by xxxx Cancer
Network) it would be expected that (add number range) cases each week would be
referred for treatment. As there has been no local service provision to date and a
true level of demand has been difficult to assess, xxxx Network have undertaken an
audit to assess patients eligible for Mohs surgery. The results of the audit show an
anticipated (add number) patients per week, though it is felt this could be an
underestimate’.
There is constant pressure on the Dermatology Department to meet two week
cancer waiting time targets and not infrequently additional lists are required. The
workload already exceeds the capacity of the (add number of) existing
dermatologists and intermediate services in the community have not had a
noticeable effect on the department to date.
Explain staffing, for example:
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‘While any additional post would help with achieving cancer targets it is not designed
to alleviate the general pressure in the department. The treatment of these patients
is very time-consuming and it is unlikely one surgeon would be able to meet
demand; however, this will need a more accurate assessment once the post is
established.’
Include support staff required for the Mohs services existing or addition as required, for
example;
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‘In addition to the consultant post, it is proposed to appoint a Skin Cancer Clinical
Nurse Specialist which would improve skin cancer services considerably. This post
would play a key role in identifying psychological as well as physical needs and
provide counselling and advice. Links with Oncology services would be strengthened
and involvement in the Specialist MDT meetings would enhance the quality of care
for patients. The Network is supportive of this post and it is also necessary to ensure
Peer Review requirements are met.’
‘The Network also recommends the support of a Clinical Psychologist and has
suggested one session per week to provide a service to patients with facial
problems’.
‘There is also considerable input required from a Biomedical Scientist to support the
preparation of frozen sections for slide review under the microscope. Whilst a
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NHS Trust Name
Consultant Histopathologist is not required to be involved in the reporting of the
frozen sections, some cases have to be submitted for a second opinion or for quality
control’.
Include acquisitions required for specialist equipment and sites where the service will be
provided, for example:
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‘A microscope with video link and a cryostat machine will be require, in addition to
the usual capital costs associated with new appointments (computer, furniture, etc)’.
5. Market Assessment:
This section needs to show an understanding of the market place environment and the
services place within it.
It should include all analytical data including; needs assessments, market analysis and
performance targets.
Outline how patients, the public and other community stakeholders have been involved and
have informed and influenced the range of options.
Include the following information and consultations undertaken:
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Outline how the trust is able to meet the commissioning requirements for NHS
England specialised services.
Provide information on Mohs service provision in your regional areas and
neighbouring cancer networks
Include patient consultation exercises with your skin cancer patients and feedback
on options for cancer treatments.
Consider setting up a patient panel of service users identified as suitable candidates
for Mohs to be involved in setting up of the service. Include this action in your
business case.
6. Option Appraisal:
This will not always be required and should be used if you are weighting up the pros and
cons of undertaking a project, along with the implications of not undertaking that project.
This section will include the long and short lists.
Option 1: Do nothing
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‘The xxxx Cancer Network are committed to this service being provided in order to
comply with NICE Improving Outcomes Guidance. If we do not progress with an
appointment for this post, the Network will need to look to an alternative Trust to
provide this service. The hospital and the Cancer Network would probably fail peer
review.
Option 2: Introduce a Mohs service
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NHS Trust Name
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This will result in higher cancer cure rates, reduction in recurrence (and subsequent
treatments), increased patient satisfaction, better healthcare outcomes and a quality
reputable service on a cost effective basis.
‘The post already has the support of the Cancer Network and there is a commitment
to developing this service within the Dermatology Department. As a Trust we are
well placed to provide the service, already having further surgical support in terms of
maxillofacial surgery and oculoplastic surgery.’
This is the preferred option and has the support of local patients and consultants.
7. Benefits Appraisal:
Provide a list of benefits that the proposal is intended to deliver. This should support the
areas covered already in the business case, identifying the relative importance of each of
the benefit.
Include a list which covers the following areas:
 Highlights the functional relationships between departments
 Accessibility to the service by patients
 Acceptability of service by patients, staff, public, commissioners, Cancer Network etc
 Able to deliver strategic objectives of the Trust
Examples of benefits include:
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A more focused approach to skin cancer services improving the critical mass of the
department and sub-specialisation
Ability to identify and target spending to this priority area
More effective delivery of health services and greater patient/carer satisfaction with
high success rates for treatment
Effective utilisation of funds and greater value for money
Creation of a patient centered approach and information sharing
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NHS Trust Name
8. Performance Activity:
Demonstrate an understanding of how the service will be monitored in terms of
performance against targets in relation to the service level activity; include:
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Demographics of the population to demonstrate demand.
Demonstrate the capacity to meet demand and to incorporate unmet need.
Detail the systems in place to collected and report patient activity.
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We looked at the number of patients that were being referred for Mohs and this
formed the basis for a business plan.
The number equated to around xxxxx
Anticipating increased demand for Mohs once the service started and neighbouring
trusts, we estimate at least 100 cases to start with for Mohs service first year.
Unmet demand, what contingencies are in place to deal with increased referrals
from GPs who identify patients with reoccurring BCC as suitable for Mohs surgery.
How will surgical activity be captured for charging purposes and reporting to the
CCG.
How will reduction in recurrence rates for treated patients be audited?
What service standard and outcomes will be used for the service?
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9. Financial Analysis:
This section should be completed in conjunction with the finance and other relevant
departments.
Ensure data on activity is accurate and as up to date as possible (service managers or
information teams in the Trust will be able to support you) include activity figures for
service – e.g. new and follow up numbers, numbers of surgical patients, cancer patients and
any other detailed data on the case mix (see our service review template).
Ensure any planned savings are realistic and achievable within the specified timetable.
Savings do not need to be financial but greater efficiency and increased throughput can
impact on meeting targets and increasing income.
This section should clearly identify the cost benefit of the proposal and should include
graphs or tables to highlight the case.
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Ensure all financial consequences of the proposal are identified and accurate.
Demonstrate affordability and value for money.
Demonstrate costs (savings where appropriate) over a 12 month period.
Show costs relevant to tariffs outlined in the services specification.
Define any non-financial benefits if significant.
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Financial Analysis
Income (£93,100)
o
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o
o
Based on 100 cases per year
Average cost for 1 case + £750 (+MFF)
Total for 1 case = £931
Income for 100 cases ( 2 sessions) = £93,100
Year 1 Expenditure (£
k)
o Consultant Mohs surgeon (2 sessions per week) = £k
o Nurse = £k
o Mohs technician = £k
Non-pay: (approximately £
o
o
o
o
o
o
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o
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k)
Theatre/Procedure room cost
Linear stainer
Fume cupboard
Cryoblock
Chucks for cryostat
Hot plate
Consumables
Microscope
Total Year 1 deficit = income – year 1 expenditure
10. Critical Assumptions and Risk Assessment:
Document any assumptions made in the proposal which may affect the proposal i.e.
dependencies that affect timeline.
Document any risks to the proposal and their likely impact. Risks should be:
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Identified
Qualified
Manageable
Explain the risks associated with providing the service and how these will be managed, for
example:
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‘The main risk could be seen as sufficient referrals not being received to maintain
financial viability. Given the support from the xxxx Network and the audit work
already undertaken, this is thought to be unlikely’.
‘There is a risk that demand will very quickly exceed capacity creating problems with
waiting times and this will need to be closely monitored’.
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NHS Trust Name
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‘Although this post would ease some pressure in the Department regarding access
for two week cancer patients, it will also generate further work and realistically the
Department will remain under pressure with demand exceeding capacity’.
‘Without a dedicated Skin Cancer Nurse Specialist the Department are likely to fail
Peer Review.’
‘A suitable space for providing the Mohs services needs to be identified and costs for
the site identified (including Health and Safety etc)’
11. Implementation Timeline:
This should detail all the major implementation issues in detail including major milestones
and dependencies. It should also include any procurement or staffing arrangements that
may affect the timeline.
Include a time table with implementation details and milestones for setting up the service,
for example;
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‘A job description is being compiled for submission to the Royal College of Physicians
for approval prior to advertising’. Six months has been allocated to achieve this
milestone including recruitment and acquisition of equipment for the department.
12. Leadership and Workforce:
This section should include the workforce planning requirements how these will be met for
the immediate and longer term.
This section should include the following areas:
 The structure for the service and how it links into the existing staff structures.
 What can and cannot be controlled e.g. recruitment and what you cannot control
 How will Mohs service provision affect the current and future demand of the Trusts
skin cancer service and LSMDT/SSMDT? What will be the future staffing needs –
succession planning.
 How many staff are needed now and how many will be needed in the future,
recruitment and training issues.
 Identify how the success of the workforce will be ensured and the factors that may
influence this plan in the future.
 ‘A qualified Consultant is needed in the field that provides service direction, staff
clinical overview and quality monitoring’
 ‘Workforce: The service needs specialist nursing, pathology technician staff and
relevant administrative support; all need to be trained adequately to carry out
duties.’
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NHS Trust Name
13. Exit Strategy:
Detail staff, premises and other assets which will be affected if the current service should be
decommissioned. This should include the management of staff under TUPE and rental
agreements for premises and equipment.
Include:
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Possibility of appointing fixed term staff and to rent equipment for a trial period in
order to assess service uptake.
At the end of the period if the service uptake is poor equipment can be returned and
staff can be redeployed to other services.
14. Conclusions:
Summarise the proposal and highlight the key points of your proposal.
It is recommended that we appoint a Consultant Mohs Surgeon with supporting staff to
enable the development of Mohs surgery in the Trust for the (add local area) catchment
area.
15. References:
Include all the relevant documents used in the proposal.
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BAD staffing and facilities guidance 2011
BAD staffing and facilities for surgery units 2012
BAD/BSDS Mohs service standards 2011
NICE Improving Outcomes Guidance for skin tumours published in February 2006
NHS England Specialised Commissioning service specification.
http://www.england.nhs.uk/ourwork/d-com/spec-serv/consult/
BAD Patient Information Leaflet Mohs micrographic surgery 2013
16. Appendices
Finally, add any appendices that are relevant and will support the plan such as detailed
calculations, figures, reference material and other back up data that may only appear in
summary in the main body of the business case. In the same way detailed assumptions and
risk may also be placed here.
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