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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 Page 2 of 12 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: 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. 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. Page 3 of 12 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. Page 4 of 12 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: ‘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: ‘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; ‘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.’ Page 5 of 12 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). 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: ‘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: ‘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; ‘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 Page 6 of 12 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: ‘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: 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 ‘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 Page 7 of 12 NHS Trust Name 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: 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 Page 8 of 12 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: 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. 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? 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. 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. Page 9 of 12 NHS Trust Name Financial Analysis Income (£93,100) o o 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 o o 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: Identified Qualified Manageable Explain the risks associated with providing the service and how these will be managed, for example: ‘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’. Page 10 of 12 NHS Trust Name ‘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; ‘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.’ Page 11 of 12 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: 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. 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. Page 12 of 12