IMPORTANT NOTE: This text version of the consultation document does not contain maps and tables that are an integral part of the full document. Some symbols and punctuation are not properly reproduced in this text version. The Local Health Partnerships NHS Trust A proposal to establish a new NHS Trust and to transfer to that Trust staff, property, rights and liabilities of: _ Allington NHS Trust _ East Suffolk Local Health Services NHS Trust _ Mid Anglia Community Health NHS Trust which existing Trusts would dissolve A public consultation by the Anglia & Oxford Regional Office of the NHS Executive for the Secretary of State for Health, and being conducted on their behalf by Suffolk Health Authority JULY 1998 Contents Page 1 Introduction 2 2 The Consultation Process 3 3 Present NHS Trusts and their services 5 4 The new NHS: Modern _ Dependable 11 5 The Suffolk NHS Review 14 6 The Local Health Partnerships NHS Trust 27 7 Benefits for patients 30 8 Management arrangements 33 9 The new Trust and its staff 38 10 Financial outlook 41 11 Conclusions 48 1 Introduction 1.1 Over the past eighteen months Suffolk Health Authority and the six NHS Trusts serving the people of Suffolk have been reviewing their organisational arrangements to consider what is the best, long term, structure within which health services should be delivered. A Steering Group was established to carry out the review, consisting of the chairmen and chief executives of the seven organisations. Finnamore Management Consultants were commissioned to undertake analysis and consultation on a number of options for service configuration. These were considered by the Steering Group, which made the unanimous recommendation that the best way forward was to create a single NHS Trust to deliver community services, mental health services and services for people with learning disabilities. This would involve the dissolution of Allington NHS Trust, East Suffolk Local Health Services NHS Trust and Mid Anglia Community Health NHS Trust and the transfer of their staff, property, rights and liabilities to a new Trust, The Local Health Partnerships NHS Trust, which would become responsible for managing their services pursuant to sections 5(1)(a) and 5(1)(b) of the NHS and Community Care Act 1990. The new Trust would not manage mental health services in the Waveney area. These are provided by the Norfolk Mental Health Care NHS Trust. The new Trust would enable over _1.4m of savings per annum to be made from management costs and offer the opportunity to improve both the quality and the range of services provided within the community. Additionally, recognising the financial pressures which health services locally are continuing to face, the release of these savings would in part be required to help sustain present services. At the same time, the merged Trust would ensure that mental health and learning disability services within the county could continue to be strong and well-managed should community services subsequently transfer to the management of Primary Care Trusts. This proposal, therefore, reflects the direction set by the recent White Paper _ The new NHS: Modern _ Dependable. This document is the basis for formal public consultation with local Community Health Councils (CHCs) on the proposal to create a new Trust through the merger of Allington, East Suffolk Local Health Services and Mid Anglia Community Health NHS Trusts. Subject to the approval of the Secretary of State for Health, who will take into account the responses made to the consultation document when coming to his decision on this proposal, it is hoped that this merger would become effective from 1 April 1999. 2 The Consultation Process 2.1 The Anglia & Oxford Regional Office for the Secretary of State for Health has statutory responsibility for conducting the public consultation process and has asked Suffolk Health Authority to manage this process locally. There will be a three month period of public consultation. The Anglia & Oxford Regional Office of the NHS Executive will then report on the outcome of the consultation. Responses will be collated and forwarded to the Secretary of State, who will decide whether and, if so, when the proposed new organisational arrangements would go ahead. This document is being circulated widely within the area served by the three Trusts and copies will be available from local CHCs and for inspection at GP practices, libraries, Citizens Advice Bureaux, offices of local authorities and on the world-wide web at the following address: http://www.allington-nhs.demon.co.uk The CHCs and all interested parties are invited to comment on the proposals set out in this consultation document. Responses must be made in writing and be sent to: Ionne Hammond Suffolk Health Authority PO Box 55 Foxhall Road Ipswich IP3 8NN All written responses will be acknowledged in writing, and if requested you will be notified of the Secretary of State_s decision when this has been announced. Members of the public may also wish to comment via their local CHC. Their addresses are: East Suffolk CHC Great Yarmouth and Waveney CHC West Suffolk CHC Ivry Lodge The Old Court Building 77 Whiting Street Ivry Street 5 Police Station Road Bury St Edmunds Ipswich IP1 3QW Lowestoft NR32 1NY Suffolk IP33 1NX Tel: (01473) 226820 Tel: (01502) 500635 Tel: (01284) 761390 2.2 Public Meetings A number of public meetings have been arranged at which senior officials of the Regional Office, Health Authority and Trusts will explain the proposals and their implications and answer questions from members of the public. Every effort will be made to ensure that all those who wish to contribute to this consultation are able to do so. A hearing loop will be available at all the public meetings and all venues will have access for people with disabilities. Assistance with any special needs (for example access to taped documents) or support in responding to the document can be obtained from Ionne Hammond (see page 3). All meetings will be advertised in advance and the local media will be asked to assist in publicising them. Arrangements for the meetings are being handled by Suffolk Health Authority and any questions about them (or requests for additional meetings) should also be made to Ionne Hammond. 2.3 Further information Additional information, including further copies of this document, are available from Ionne Hammond. The Annual Reports and Summary Business Plans of the three Trusts give more details about the services offered by them, their performance and plans for the future. Copies are available on request from: Tony Ranzetta David Long Antek Lejk Chief Executive Chief Executive Chief Executive Allington NHS Trust East Suffolk Local Mid Anglia Community Health Services NHS Trust Health NHS Trust Trust Headquarters (south) PO Box 247 Child Health Centre Allington House Sampson House Hospital Road Woodbridge Road Foxhall Road Bury St Edmunds Ipswich IP4 4ER Ipswich IP3 8BL Suffolk IP33 3ND Tel: (01473) 275204 Tel: (01473) 276583 Tel: (01284) 775055 Trust Headquarters (north) Lowestoft and North Suffolk Hospital Tennyson Road Lowestoft NR32 1PT Tel: (01502) 587311 3 The Present NHS Trusts and their services 3.1 Allington NHS Trust Allington NHS Trust currently has a turnover of £32m, employs over 1700 staff and manages land, buildings and equipment valued at £16m. Allington was formerly the East Suffolk Community and Mental Handicap Unit, providing care in the community to children, adults, older people, the terminally ill, the physically disabled and people with learning disabilities. In 1992 Allington became an NHS Trust (taking its name from its clinic at Allington House in Ipswich). Allington provides services within the home, school, GP practices, community-based clinics, local hospitals and the workplace. Its services include community hospitals, children's and school health services, primary care services, services for people with a learning disability, social care services and specialist therapeutic services such as speech therapy, physiotherapy, occupational therapy, chiropody and dentistry. At present, Allington provides community care to a population of 650,000 people in Suffolk, Essex and Norfolk and does so from over 100 locations across the three counties. As a consequence of the large geographical area covered by the Trust, considerable responsibility has always been placed with its local management teams. In east Suffolk, Allington's main clinics are located in Ipswich, Stowmarket, Felixstowe, Saxmundham, Hadleigh and Woodbridge. The population served by Allington in east Suffolk is in excess of 320,000 people and the area covered is over 900 square miles. From 1 September 1997 the Trust has provided all community and children_s services for people living in the Waveney area of Suffolk; learning disability, continence and wheelchair services for people in Waveney and Great Yarmouth; and taken on the management of the three community hospitals in south Waveney. The population served is in excess of 210,000 people and the area covered is just over 800 square miles. In 1996 the Trust went into partnership with the North East Essex Mental Health NHS Trust to create Braintree Health which provides community and mental health services to a population of 50,000 people in and around Braintree in Essex. From 1 April 1997 the Trust has provided some community services (district nursing, health visiting, physiotherapy and phlebotomy) to practices in Mundesley, North Walsham, Stalham and Hemsby in Norfolk. The population represented by these practices is in excess of 40,000 people and the area covered is over 100 square miles. Location of Allington NHS Trust's Facilities in east Suffolk, east Norfolk and Essex A key aspect of the Trust is its commitment to patient care and to developing high quality services. Allington_s mission is to provide the highest quality health and social care as near as possible to people's homes, schools or places of work. In recent years, the Trust has invested considerable time and funding in training, clinical audit and research. It has initiated many developments of national significance, especially in the fields of community nursing and care for people with learning disabilities. Since 1995, Allington has invested over £1.5m in new clinics and new clinical equipment. The Trust has saved over _250,000 in management costs to fund additional consultant posts in paediatrics, psychiatry, family planning, palliative care and occupational health. Other savings have enabled the Trust appoint additional speech therapy, district nursing and psychology staff. 3.2 East Suffolk Local Health Services NHS Trust East Suffolk Local Health Services NHS Trust has a turnover of £26m, employs over 1000 staff and manages land, buildings and equipment valued at £23m. The Trust provides comprehensive mental health and care of the elderly services for 320,000 people in east Suffolk, within the home, local community, general practice, community hospitals in Felixstowe, Aldeburgh and Eye, day hospitals (including Stow Lodge in Stowmarket) and nursing homes (including St Edmund_s in Ipswich). The Trust also includes inpatient services for the mentally ill at St Clement_s Hospital in Ipswich. Location of East Suffolk Local Health Services NHS Trust's Facilities in east Suffolk Adult mental health services The Trust has developed integrated mental health services, designed to focus on discrete communities (Sectors) during the last few years. This has placed the Trust at the leading edge of service development in the country. Services, ranging from those delivered to a person in their own home, in GP surgeries and as an inpatient, are available to people living within a Sector. Each Sector has been created by grouping GP practices into areas serving a population of about 45,000 people, with services focusing specifically on local communities. The range of services provided includes: 24 hour assessment and emergency home visits, a comprehensive outpatient service, liaison with the Ipswich Hospital inpatient and A&E service, community psychiatric nurse links into primary care teams, day facilities, depression groups and carer support. The Trust provides every client with an individual package of care combining active treatment and supportive counselling. Child, Adolescent and Family Consultation Services (CAFCS) The Trust provides care for children and young people up to the age of 18 with emotional disorders (including school refusal and anxiety), behavioural disorders (including hyperactivity and aggression), psychosomatic problems (such as recurrent abdominal pain and soiling), behavioural problems in pre-school children, children suffering psychological consequences from traumatic experiences, child and adolescent self-harm, psychosis in adolescence, eating disorders and anorexia, behavioural difficulties in children with autism, and the breakdown of relationships between parent and child. Care of the Elderly The Trust provides a number of services for the elderly mentally ill, including outpatient clinics, home assessments, day hospitals, inpatient services and community support from community psychiatric nurses, occupational therapists and physiotherapists. The Trust also provides elderly day care, rehabilitation and respite care from its community hospitals in Felixstowe, Eye and Aldeburgh, and from St Edmund_s Nursing Home, and its day hospitals at Stow Lodge Centre (Stowmarket), Minsmere House (Ipswich) and Whitwell House (Melton). Whether an elderly person is cared for in their own home or in hospital, they each have a personal care plan identifying the support they will receive. 3.3 Mid Anglia Community Health NHS Trust Mid Anglia Community Health NHS Trust has a turnover of £25m, employs over 1000 staff and manages land, buildings and equipment valued at _19m. It provides community, mental health and learning disability services to a population of about 230,000 people. Centred in west Suffolk around Bury St Edmunds, the Trust's services extend to the Thetford area of Norfolk, to Cambridgeshire around Newmarket, to Essex around Haverhill and Sudbury and into central Suffolk around Stowmarket. The Trust is the only one in Suffolk to have combined mental health, learning disabilities and community services. This has enabled close working between specialist and primary care services which has resulted in continuity across the whole spectrum of care. This is a benefit that would transfer into the new Trust. It commissioned and built the new Newmarket Community Hospital, which opened in 1996. It is the centre of community health services for local people and works closely with the West Suffolk Hospital in Bury St Edmunds and Addenbrooke_s Hospital in Cambridge. The Trust is also working in partnership with Addenbrooke's Radiology Department to develop further high quality, consultant-led, radiology services in the community. The Trust is currently proposing to relocate its inpatient adult mental health services to purpose-built premises, under a privately financed scheme. This will support the five multi-agency teams, that provide 24 hour services. The Trust has also secured significant investment from the Mental Health Challenge Fund to develop rehabilitation mental health services. In recent years, the Trust has secured new contracts from Suffolk Health Authority, East Norfolk Health Authority and local GP fundholders to extend its mental health services (for instance around Thetford), and is working in partnership with local GPs, as part of a total fundholding pilot project, to provide all mental health services in Haverhill. In 1997, the Trust secured a contract to provide health visiting to residents of both Cambridgeshire and Suffolk around Newmarket. It has also implemented changes in the children_s service to focus on a strong health promotion programme in schools and the creation of a paediatric nursing team to support children with complex needs. This development has established the shape and direction of child health surveillance for the rest of the county. Location of Mid Anglia Community Health NHS Trust's Facilities in west Suffolk and Norfolk The table below and overleaf lists the services provided by all three Trusts: Services Allington East Suffolk Mid Anglia Local Health Community Services Health Community Services Aids to daily living 3 3 Child health 3 3 Chiropody 3 3 Continence services 3 3 Community cardiac support 3 Community hospitals 3 3 3 Community psychiatry 3 3 3 Counselling 3 3 Day centres and day hospitals 3 3 3 Dentistry 3 3 District nursing 3 3 Drug advisory service 3 3 Eating disorders therapy 3 Elderly rehabilitation 3 3 3 Family planning 3 3 Family therapy 3 GP beds 3 3 3 Health visiting 3 3 Home care service 3 Macmillan and Marie Curie 3 3 Neurological counselling 3 3 Occupational health 3 Community services (cont) Occupational therapy 3 3 3 Phlebotomy 3 3 Physiotherapy 3 3 3 Podiatry 3 Portage 3 3 Psychology 3 3 3 Psychosexual counselling 3 3 3 School nursing 3 3 Services for adults with a physical disability 3 3 Services for children with a physical disability 3 3 Speech and language therapy 3 3 Stoma care nursing 3 Welfare foods 3 3 Wheelchair services 3 3 Specialist children_s services* Adoption and fostering 3 3 Audiology 3 3 Child development centres 3 3 Child protection 3 3 Communication aids 3 Consultant paediatricians 3 3 Services for children in special schools 3 3 Statementing for children with special educational needs 3 3 Adult mental health services* Inpatient 3 3 Community teams 3 3 Continuing care 3 3 Day hospitals 3 3 Forensic psychiatry 3 Hostel support 3 Intensive care unit 3 Specialist rehabilitation 3 3 Old age psychiatry* Inpatient 3 3 Community teams 3 3 Occupational therapy 3 3 Shared residential care 3 3 Child and adolescent mental health* Community-focused teams 3 3 Learning disability services* Community teams 3 3 Day services 3 3 Respite care 3 3 Community care 3 3 Residential care 3 3 Assessment and treatment 3 3 * These services all operate in multi-disciplinary teams typically comprising psychiatry, community paediatrics, psychology, nursing, occupational therapy, physiotherapy and speech and language therapy staff. 4 The new NHS _ Modern Dependable 4.1 Introduction The White Paper: The new NHS: Modern _ Dependable was published in December 1997 and marks a turning point for the NHS. It replaces the internal market with integrated care and begins a process of major organisational change within the NHS which will see local doctors and nurses determining the shape of health services in the future. Six important principles guide the changes within the White Paper: _ To renew the NHS as a genuinely national service. _ To make the delivery of health care against these new national standards a matter of local responsibility. _ To get the NHS to work in partnership. _ To improve efficiency so that every pound in the NHS is spent to maximise the care for patients. _ To shift the focus on to quality of care so that excellence is guaranteed to all patients. _ To rebuild public confidence in the NHS. These underpin the proposal to merge the three community Trusts in Suffolk. 4.2 Driving quality in the new NHS The White Paper sets out a number of areas for action in order to improve the quality of health services, including: At National Level The establishment of national standards of service and guidelines, and the establishment of a new Commission for Health Improvement to tackle specifically any areas or organisations which are not meeting these standards. At Local Level Teams of local GPs and community nurses will work together as part of Primary Care Groups to shape services for patients and to provide a local drive for quality. Clinical governance will become a new statutory duty for NHS Trusts. The new Trust would assist in the development of Primary Care Groups and also provide the opportunity to share examples of best practice, thus driving upwards the standard of care for mental health, learning disability and community services. 4.3 New roles and responsibilities The new NHS will have new roles and responsibilities for health authorities and NHS Trusts. Primary Care Groups will be developed across the country and these will have the potential to become Primary Care Trusts, managing community hospitals and community services. Health Authorities will be leaner bodies with stronger powers to improve the health of their residents and oversee the effectiveness of the NHS locally. Over time, they will relinquish direct commissioning responsibility to Primary Care Groups. Working with local authorities, NHS Trusts and Primary Care Groups, they will take the lead in drawing up Health Improvement Programmes which will provide the framework within which all local NHS bodies will operate. Primary Care Groups comprising all GPs in an area together with community nurses will take responsibility for commissioning services for the local community. Primary Care Groups will evolve through four stages of development with the potential to become Primary Care Trusts. Typically, Primary Care Groups will serve populations of 100,000 people but this will vary depending on local circumstances. The cost of management arrangements for Primary Care Groups will be capped within the overall management cost target for health authorities. Primary Care Groups will be accountable to health authorities for commissioning care. NHS Trusts will have devolved responsibility for providing health care services and be a party to the local Health Improvement Programme. They will agree long term service agreements with Primary Care Groups and have new statutory duties of partnership and quality. NHS Trusts will also be more accountable to the public and will publish details of their performance and the development and involvement of their staff. 4.4 Delivering _The new NHS_ in Suffolk It is envisaged that the new Trust (The Local Health Partnerships NHS Trust) would build on the relationships that have already been established with general practice and local authorities within the community to develop locally managed community teams. These could typically serve populations of 50-100,000 people. Singly or jointly they would form the nucleus of community services which would be commissioned by Primary Care Groups and could become part of the emerging Primary Care Trusts in the county. The proposed new Trust would wish to develop robust support functions which would assist the development of the Primary Care Trusts. It could continue to provide corporate services such as personnel, estates and audit which would be uneconomical if established and duplicated locally. The new Trust would also be large enough to afford to transfer community services to the Primary Care Trusts without this affecting the clinical and financial viability of mental health, learning disability and specialist community services. If the present configuration were to continue, it would be a significant barrier to the development of Primary Care Trusts. Potentially all three community Trusts and their services would become non-viable, following the transfer of community hospitals and community services. This proposed merger is in line with the White Paper and the new responsibilities and duties it outlines. In particular, the Suffolk NHS Review (see Section 5) foresaw the potential development of Primary Care Trusts and the benefits of establishing a single community Trust in Suffolk. Community services within the new Trust, if and when established, would be managed within three geographically-based directorates. These in turn would be divided into locally based health networks, described as Health Partnerships, and from which the new Trust would derive its name. The timescale and process for the development of Local Health Partnerships and the establishment of Primary Care Trusts within the county, would be linked. It is also envisaged that Primary Care Groups would commission community services from one or two Local Health Partnerships and then take on management responsibility for some them should they become Primary Care Trusts. At that stage, the new Trust would reduce from being an organisation with a turnover in excess of £80m to one with a turnover in the region of £60m. 5 The Suffolk NHS Review 5.1 Introduction In 1996, the chairmen and chief executives of Suffolk Health Authority and the six NHS Trusts predominantly serving Suffolk agreed to undertake a review of the organisation of health services within the county. Important in this context was recognition of the financial pressures facing the NHS in Suffolk and the need to leave no stone unturned in responding to these pressures. This, together with new policy imperatives, for example on a primary care led NHS, formed the background to the joint review. In its first stage, the chief executives identified the key drivers of change relevant to the future organisation of services. These included social and demographic changes, advances in medical technology, higher public expectations and pressures to contain public spending. Specifically, the review noted that GPs and primary care teams were likely to take on more responsibility for patient care. This in turn was linked with increased integration between primary care and community services and a move to day surgery and declining lengths of stay in hospital. In parallel, it was recognised that the NHS would have to work more closely with local authorities, both to address the public health agenda and to ensure seamless care for, among other groups, children, the elderly, people with learning disabilities and mental illness. It was easy to conclude that change was necessary. It was more difficult to agree on what should replace the existing structure of services. Three main options were identified and investigated to determine the consequences on patients and staff, and the possible financial savings. This led into a second stage of the review, which examined a total of seven options. Independently of the Review Suffolk Health Authority and East Norfolk Health Authority decided in September 1996 to transfer all patient services formerly provided by the Anglian Harbours NHS Trust to new providers. Mental health services transferred to the Norfolk Mental Health Care NHS Trust on the 1 April 1997, and the remaining services transferred to the James Paget Healthcare, Norwich Community Health Partnership and Allington NHS Trusts on the 1 September 1997. Suffolk Health Authority wished to allow the new providers sufficient time and opportunity to manage and develop the services in the Waveney area, without prompting any additional disruption. Consequently the options considered during the Review assumed that the services which transferred during 1997 should remain with their present Trusts. Thus, for example, mental health services in the Waveney area would not become part of any proposed new Trust on its establishment. 5.2 The Review The Review was conducted in four stages between August 1996 and December 1997, namely: Stage One: Setting the strategic context Stage Two: Reviewing the options Stage Three: Detailed consideration of the preferred option Stage Four: The new NHS: Modern _ Dependable. Each of these stages and the key findings are described below: STAGE ONE: Setting the strategic context August 1996 to November 1996 This was undertaken by the Chief Executives of Suffolk Health and the six NHS Trusts in Suffolk, and facilitated by Professor Chris Ham. The terms of reference (in outline) were: l to identify the principal implications on current patterns of local health care of emerging local and national strategies; l to recommend options which could be tested in order to identify the most effective structure of NHS Trusts to ensure the fair and effective delivery of health care; l to develop a Project Plan for the systematic review of options, the identification of and consultation on a preferred option. At the end of this stage of the Review, Professor Ham prepared a report called _Review of Health Services Provision within Suffolk_ which was adopted by all parties involved as the strategic context for a more detailed options appraisal. The key findings within this report were: The need for change Changes in the nature and composition of society, advances in medical technology and practice, increased public expectations, pressures on public expenditure, and the inherent unfairness and inconsistency in the provision of health care within the county were all seen as important drivers for change. The present configuration of Trusts is seen as failing in several regards: it is inconsistent and not easily understood by the public; even where collaboration exists, it is impractical to switch resources between Trusts in order to address inequities in the provision of health care; services are provided in different ways and to different standards across the county; management costs are comparatively high; a number of the Trusts are small compared to national averages making them vulnerable to pressures on services. Options to be tested Three options were identified which would enable a number of different Trust configurations to be tested. In essence, the original three options allowed the benefits of secondary care and community combinations to be tested against combining community services, and also allowed options involving the combination of mental health and community services to be compared with those options that kept these services separate. These were: l A county-wide community Trust, county-wide mental health Trust and 3 secondary care Trusts. l A county-wide combined community and mental health Trust and 3 secondary care Trusts. l A county-wide mental health Trust and 3 combined secondary care and community Trusts. The criteria to be used for evaluation The ten criteria were identified to be used in stage two, namely: integration of care, benefits to patients, contestability, the clinical effectiveness of services, acceptability to stakeholders, robustness, fairness, cost effectiveness, delivery of health service priorities, and practicality. This stage concluded with a recommendation that an independent appraisal be commissioned to test the options against these criteria. STAGE TWO: Reviewing the options December 1996 to May 1997 The terms of reference for this stage were to test each of the identified options against the evaluative criteria (above) and to identify the potential for financial savings. This was facilitated by Finnamore Management Consultants and resulted in a clear recommendation that a combined mental health, learning disability and community NHS Trust should be established and that the three secondary care Trusts should be retained. This stage of the review was conducted in two parts: an initial review of the three options identified within the strategic context (see above), and then a more detailed review of six options plus the present configuration. Suffolk NHS Review: The Options Option 1 1 county-wide mental health Trust 5 Trusts 1 county-wide community Trust 3 secondary care Trusts Option 2 1 county-wide community and mental health Trust 4 Trusts 3 secondary care Trusts Option 3 1 county-wide mental health Trust 4 Trusts 3 combined secondary care and community Trusts Option 4 1 combined community and mental health Trust in the west 5 Trusts 1 combined community and mental health Trust in the east 3 secondary care Trusts Option 5 1 combined community, mental health and secondary care Trust in the west 4 Trusts 1 combined community and mental health Trust in the east 1 secondary care Trust based on Ipswich Hospital 1 secondary care Trust based on James Paget Healthcare Option 6 1 combined community, mental health and secondary care Trust in the west 3 Trusts 1 combined community, mental health and secondary care Trust in the east 1 secondary care Trust based on James Paget Healthcare Option 7 Present configuration 6 Trusts Finnamore Management Consultants were commissioned to examine the options and to involve key stakeholders. The latter involved 10 workshops across the county, including representatives of the public, CHCs, local authorities, GPs, and clinicians and managers from Suffolk Health Authority and the six NHS Trusts. In all, over 200 people took part. Each option was assessed against a range of factors, specifically: _ Activity analysis which examined current activity, demographic trends, access rates for catchment populations, existing overlap and integration of services, and professional coverage. _ A financial appraisal of possible service configurations in order to generate estimates of the potential savings from each option. _ An appraisal of the potential benefits to patients of each option. The key findings are summarised below: The case for change The future for health services in Suffolk will see the development of defined models for primary and secondary care with community services becoming part of: primary care teams (general community services and some community hospitals); secondary care (some specialist community services and community hospitals); or county-wide specialist services (mental health and learning disabilities). The strategy for both mental health and learning disability services is to develop a single structure of secondary care, rehabilitation, community, primary and day care. Suffolk Health Authority faces a difficult financial future. The long term viability of the county_s Trusts has been called into question in view of their relatively small size. It is judged that the present structure is not sufficiently strong or adaptable to meet the longer term health care needs of the county. It is concluded that Option 2 would provide the greatest opportunity for developing the Health Authority_s strategies for mental health, learning disability, primary and community services. Activity analysis An analysis of patient flows shows that there are clear east-west-Waveney catchment populations for all services. Patient flows reflect the current configuration of services and (despite apparent disparities in access) there has been little movement between Trusts. This indicates that services should be provided in such a way that they reflect the three catchment populations, but that to achieve fair access to community services a county-wide structure may be required. The greatest requirement for co-ordination of care lies between secondary care and community services _ in particular community hospitals _ but this is in the absence of any data regarding the links between primary and community care. Based on the above analysis of activity, it is considered that Options 3 and 6 would provide the best opportunities for integrating health care, and also best reflect the east-west-Waveney catchment populations. Option 2 would best enable the integration of community and mental health services and provide the opportunity to address the disparities in provision in different parts of the county. Benefits for patients and services All of the options for change provide the opportunity to deliver better services for patients. Options 2, 3 and 6 would offer the greatest opportunity either through improving access to services (Option 2) or through the better co-ordination of services (Options 3 and 6). In general, however, discussion regarding the patient and service benefits of each option focused on which model of service would best reflect the nationally and locally emerging strategies for the provision of primary and secondary care. A consensus was reached regarding Option 2. Financial savings Savings in the range of £0.6m to £2.3m per annum were identified. However, at this stage, it was recognised that the figures were for comparative purposes between the options and potentially under-stated. Likewise, transitional costs were potentially under-stated at between £1.4m and £3.3m. The greatest savings were envisaged from Option 6 (£2.3m), with Options 3 and 5 achieving approximately _1.5m savings and Option 2 achieving £1m per annum. All four of these options would result in payback periods of less than two years. The savings identified at this stage of the Review from each option were as follows: Option No. of Components Savings Trusts _m 1 5 1 county-wide mental health Trust 0.6 1 county-wide community Trust 3 secondary care Trusts 2 4 1 county-wide community and mental health Trust 1.0 3 secondary care Trusts 3 4 1 county-wide mental health Trust 1.5 3 combined secondary care and community Trusts 4 5 1 combined community and mental health Trust in west 0.7 1 combined community and mental health Trust in east 3 secondary care Trusts 5 4 1 combined community, mental health and secondary care Trust in west 1.5 1 combined community and mental health Trust in east 1 secondary care Trust based on Ipswich Hospital 1 secondary care Trust based on James Paget Healthcare 6 3 1 combined community, mental health and secondary care Trust in west 2.3 1 combined community, mental health and secondary care Trust in east 1 secondary care Trust based on James Paget Healthcare Next steps The recommended next steps were to determine the future model for primary, community and secondary care services, taking into account any policy shifts following a General Election and then to assign services around the configuration in Option 2. STAGE THREE Detailed consideration of the preferred option (Option 2) May 1997 to August 1997 This involved a detailed analysis of Option 2 to determine: l those services which should be assigned to each of the four proposed Trusts; l the actual and verifiable savings and transitional costs; l specific improvements in patient services that would result from its implementation. Assigning services to the new Trusts The following services were identified where a case could be made for them either to be managed by a community Trust or for them to transfer to the local secondary care Trust: Specialist children_s services to include children with special needs, child development centres, school health, school doctors, community paediatric nurses, paediatric physiotherapy and speech therapy; to exclude child protection. Professions allied to medicine to include dietetics, physiotherapy, radiography, speech therapy, occupational therapy (in each case excluding those services associated with mental health and learning disability or secondary care services). Specialist practitioner services to include community midwifery and all outreach nursing services eg stoma, continence, palliative and diabetic nursing; to include audiology and family planning services. Rehabilitation and elderly medicine services to include all specialist and general medical and nursing staff, including bed provision. Clinical support services to include orthoptics, orthotics, technical audiology. In each case, the possible options for configuring the above services were considered against the following objectives: _ to ensure that services were broadly consistent and common throughout Suffolk; _ to enable the delivery of a primary care led service in Suffolk; _ to maximise clinical synergy; _ to enhance the potential to expand existing services of excellence; _ to meet the requirement to be better able to manage future demand for services. The majority of the services listed above are provided within the community and their main service links are with the primary care team. In many cases, the support for these is provided by one or other of the community Trusts, and the transfer of these services to a secondary care Trust would result in the un-picking of managerial and support services down to the level of secretarial and data input staff (many of whom are shared between services). Equally, consideration was given to all children_s and elderly services transferring to the new county-wide Trust. This option was also rejected as it would cut across existing links between specialties within each of the hospitals and impact on existing support structures shared. In the absence of clinical evidence to support the assignment of a service to one or other Trust, it was recommended by the clinical staff that the service configuration should remain as it is at present ie those services currently managed by Allington, East Suffolk Local Health Services or Mid Anglia Community Health should transfer to a single, new community and mental health Trust. The outcome of this analysis was a clear recommendation to Suffolk Health and the six Trusts in August 1997 that Option 2 should be considered as a merger of the existing services managed by the Allington, East Suffolk Local Health Services and Mid Anglia Community Health NHS Trusts. The savings and transitional costs associated with Option 2 The existing management costs and organisational structures of the three merging Trusts was compared post by post with the proposed management structure outlined in the consultation document. In addition, non pay budgets were assessed and savings that would be achieved by eliminating unnecessary duplication were identified. The detailed analysis can not be made public until any new Trust determines its management structure and initiates consultation with those staff, who may be affected by the change in management arrangements. This document summarises the information on both the savings that can be achieved and the associated termination costs. The result of this analysis was to identify £1.4m savings against current budgets, with transitional costs of _2.1m. In order to achieve this level of savings, it is envisaged that the new Trust would require fewer managerial and administrative staff. There are likely to be redundancies as a consequence of the merger. However, only 300 out of 3800 jobs are expected to be affected by the proposed change, and the majority of those whose jobs would change are anticipated to continue to be employed by the new Trust, but with new responsibilities. Specific improvements in patient care and patient services This consultation document lists (in Section 7) a number of specific benefits for patients and also general benefits from the merger which it is envisaged would allow further benefits for patient services. In the case of the specific benefits, these are service proposals which either: (a) have already been implemented by one Trust and the Health Authority cannot afford to set up a duplicate service within another Trust; or, (b) where the different components of a service lie in each of the existing Trusts, and only by bringing the three Trusts together can a new service be established. Implementation of these developments would be dependent on two key features, namely: (a) where it is dependent on a reinvestment of savings, these would not have been committed to address cost pressures in existing services which have a higher priority; (b) where it is dependent on pulling inappropriate funding back from out of county that the new regime for funding extra contractual referrals would allow this to happen. STAGE FOUR The new NHS: Modern _ Dependable December 1997 The Government's White Paper has further influenced the thinking of Suffolk Health Authority regarding the options for Trust reconfiguration, and in particular which option will best equip health services for the changes ahead. The new NHS: Modern _ Dependable makes some explicit statements regarding the future configuration of Trusts, community services, mental health services and (to a lesser degree) learning disability services. The following points are made: _ community services should not merge with secondary care services as the link with primary care services is more important for patient care; _ specialist services in the community, especially mental health and learning disability services, are provided better under the co-ordination of a specialist community Trust; _ community services and community hospitals may be managed in the future by Primary Care Trusts; _ the government_s aim is to integrate health and social care policies. Options 3, 5 and 6 would run counter to the direction set within the White Paper, whilst Option 4 would not be sustainable on the introduction of Primary Care Trusts. The proposed new Trust and the White Paper The proposed new Trust would be able to develop support functions which would assist the development of the Primary Care Trusts and could continue to offer those corporate functions which would be too expensive if established and duplicated locally. The new Trust would also be large enough to afford to transfer community services to the Primary Care Trusts without this affecting the clinical and financial viability of mental health, learning disability and specialist community services. As mentioned earlier, if the present configuration were to continue, it would be a significant barrier to the development of Primary Care Trusts with the potential that all three community Trusts and their services would become non-viable, following the transfer of community hospitals and community services. This proposed merger is in line with the new responsibilities and duties outlined in The new NHS: Modern _ Dependable. In particular, the Suffolk NHS Review foresaw the potential development of Primary Care Trusts (described during the review as Primary Health Care Agencies). The prime responsibility of the new Trust would be to organise community services so that they could be effectively transferred to the management of Primary Care Trusts without adversely impacting on the development of mental health and learning disability services. Community services within the new Trust would be managed within three geographically-based directorates, reflecting the analysis of patient flows identified in Stage Two. These in turn would be divided into locally based health networks. Of the options considered, only 1, 2 and 6 would be sustainable on the implementation of the White Paper, and the latter option (by combining secondary care and community services and establishing mental health services within a Trust that does not specialise in mental health services) runs contrary to the structure envisaged in The new NHS: Modern _ Dependable. Option 1 is the configuration that is closest to the structure envisaged within The new NHS: Modern _ Dependable, however, it has been discounted on a number of grounds, not least because it will generate the least savings whilst causing considerable disruption to community, learning disability and mental health services. The new NHS: Modern _ Dependable is discussed in more detail in Section 4. The proposed Trust, based around Option 2, would have the advantages of being flexible enough to meet the proposed changes in the way in which community services are configured, whilst delivering over _1.4m savings per annum. It would also enable the better co-ordination of community and mental health services, and provide the Health Authority with the opportunity to address apparent differences in access to and the provision of community services. 5.3 Selecting the preferred option The proposal to merge is the preferred option of Suffolk Health Authority and the county_s six Trusts, for the following reasons: _ it would allow the establishment of Primary Care Trusts without destabilising the mental health, learning disability and specialist community services within the existing community Trusts; _ there would be significant opportunities to extend the range and quality of specialist mental health and learning disability services; _ it would be the least disruptive, allowing secondary care services to concentrate on the important national priorities of emergency care, cancer services and waiting times and lists; _ the services that would transfer to the proposed new Trust are easy to define; _ specific patient and service benefits would follow the merger. These would be more difficult or more costly to achieve within the present configuration; _ there is a requirement in the future to review access to community services across the county (within the context of Suffolk's Health Improvement Programme) to ensure that access is fair; _ there are specific and general service benefits from integrating mental health and community services; _ financial savings of _1.4m have been identified following a detailed assessment of existing pay and non-pay budgets. At the same time, the other options considered would also deliver some of the above benefits or have other advantages which would not be delivered by the proposed merger. All of the options considered represent an improvement on the present configuration but there is no single option which represents the ideal solution. Throughout the Review, the evidence has supported a requirement for three secondary care Trusts within the county. It recommends not only the establishment of a county-wide community and mental health Trust, but also confirmation of the continued Trust status and longer term viability of the three existing secondary care Trusts. Option 1: County-wide community, county-wide mental health and 3 secondary care Trusts (5 Trusts in total) This option would see the creation of two new NHS Trusts: one to provide community services across the county and the other to provide mental health services in east and west Suffolk (mental health services in Waveney remain with the Norfolk Mental Health NHS Trust). Allington, East Suffolk Local Health Services and Mid Anglia Community Health NHS Trusts would need to dissolve and their services be transferred to one or other of the new Trusts. It is closest to the shape of services envisaged within the Government's White Paper: The new NHS: Modern _ Dependable. However, it would achieve the least savings, would cause considerable disruption as the services of three Trusts are split, and would provide no opportunity for co-ordinating care between mental health and community services. This option would also see the separation and disruption of the learning disability and community services which have recently transferred from Anglian Harbours NHS Trust. Option 2: County-wide combined community and mental health Trust and 3 secondary care Trusts (4 Trusts in total) This would involve the merger of the Allington, East Suffolk Local Health Services and Mid Anglia Community Health NHS Trusts and is the preferred option. It is seen as the most likely to ensure the development of Primary Care Trusts, whilst ensuring that mental health, learning disability and specialist community services are not destabilised. The option would allow the integration of community and mental health services where appropriate and would achieve a reasonable amount of savings with the least disruption to services. Other options would achieve larger savings (but with higher transitional costs and causing greater disruption to patient care services). Other options would also enable the greater integration of secondary care and community services. Option 2 would provide the opportunity for the greatest continuity of both care and management for community services, in advance of any transfer to Primary Care Trusts. In the light of the White Paper, this option was considered to be preferable to those which saw secondary care and community services combine, and those options which did not reflect the emerging county-wide strategies for health and social care. This option would promote collaboration between Suffolk County Council and the NHS and create an organisation that would be better placed to deliver the joint strategies agreed between the Health Authority and Suffolk Social Services. This would be the case for services such as mental health and learning disability, which would become stronger as part of a single Trust. This option would also provide the opportunity to address apparent inequities in access to community services. The variances in access may be due to differences in activity reporting and capture (which the county-wide Trust would be able to resolve) or to an unfair distribution of resources across the county (which would be addressed more easily within a county-wide Trust). Option 3: County-wide mental health Trust and 3 combined secondary care and community Trusts (4 Trusts in total) This would result in the dissolution of six NHS Trusts in Suffolk and the creation of four new Trusts: one county-wide Trust providing learning disability services across the whole county and mental health services across all of Suffolk except Waveney; and three combined secondary care and community Trusts based in the west, east and north of the county. It would achieve the second highest level of savings. However, the disruption to emergency and secondary care services was considered to be a disadvantage. This option would provide the greatest opportunity for integration of care between secondary care and community services, whilst allowing the development of the county-wide strategy for mental health services. Option 3 would not provide the opportunity to address the apparent disparity in provision of community services within the county, and would see further disruption to the three secondary care Trusts as community services transfer to Primary Care Trusts. As with the other options which combine secondary care and community services, this option would not be in line with the structure of health services envisaged within the White Paper. It would provide many benefits both to patient care and in achieving financial savings. It is not proposed as it would result in community services transferring to new management within secondary care Trusts in 1999 and then potentially being transferred to Primary Care Trusts from 2001 onwards. On the creation of Primary Care Trusts, and the transfer of community services to them, Options 2 and 3 would look very similar. Preference is given to Option 2 because it protects both secondary care and community services from the potential disruption mentioned above. Option 4: Combined community and mental health Trust in west Suffolk, combined community and mental health Trust in east Suffolk and 3 secondary care Trusts (5 Trusts in total) This in practice would result in the merger of Allington and East Suffolk Local Health Services NHS Trusts. The advantages are: this would be relatively less disruptive than many of the other options, with lower transitional costs; and would reflect the east-west split within Suffolk. However, the establishment of Primary Care Trusts could result in this new Trust and the Mid Anglia Community Health NHS Trust becoming unstable and potentially being forced into merger at some later date. This option would be likely to become either Option 2 or 5 (see below) as a consequence. It would also result in comparatively small financial savings and no opportunity to address the apparent disparities in the provision of community and mental health services across the county. Option 5: Combined community, mental health and secondary care Trust in west Suffolk, combined community and mental health Trust in east Suffolk and 2 secondary care Trusts: Ipswich Hospital and James Paget Healthcare (4 Trusts in total) This would see two mergers: between Allington and East Suffolk Local Health Services NHS Trusts; and between Mid Anglia Community Health and West Suffolk Hospitals NHS Trusts. The advantages are that it would achieve large financial savings and reflect the split in the county between east and west. It would also cause less disruption than many of the other options (involving only four of the six Trusts in reconfiguration) and consequently have lower transitional costs. The disadvantages are that the existing organisational barriers to the development of county-wide specialist services and implementation of Suffolk's strategies for mental health and learning disability services would continue to exist. It would also result in two different models of provision within the county for mental health services and by combining secondary care and community services in the west, would be moving in a different direction from that set in the White Paper: The new NHS: Modern _ Dependable. In addition, the proposed new Trust in the west of the county would be established with a number of small departments (with the problems this brings over recruitment and clinical viability) only to see the Trust go through a period of gradual de-merger as community services transfer to Primary Care Trusts. Option 6: Combined community, mental health and secondary care Trust in west Suffolk, combined community, mental health and secondary care Trust in east Suffolk and a secondary care Trust: James Paget Healthcare (3 Trusts in total) This option would create two total health care systems around the geographical areas formerly covered by East Suffolk and West Suffolk Health Authorities. It would present considerable benefits in terms of the integration of care between community and secondary services, whilst achieving the greatest level of savings. It would also allow for the integration of community and mental health services in east and west Suffolk. Each of the Trusts would be large enough to remain viable on the transfer of community services to Primary Care Trusts. The key disadvantages with this option are: it would provide no opportunity to address the apparent disparities in access to and the provision of community services within the county; it potentially would be a barrier to the implementation of the county_s mental health strategy; and as an option it would fit least well with the direction set by the White Paper. It would also result in considerable disruption of services in the short term and in the reconfiguration of five of the six NHS Trusts in the county. Option 7: The present configuration of Trusts (6 Trusts in total) This option remains the least attractive as it does nothing to address the existing differences in the way in which community and mental health services are provided across the county; achieves no financial savings, and leaves community, mental health and learning disability services poorly placed to manage the transfer of community services to Primary Care Trusts. 5.4 Summary of findings On service and financial benefit grounds, the chairmen and chief executives proposed that four Trusts should be established from 1 April 1999. The preferred configuration is to keep the current secondary care Trusts, each serving a distinct part of Suffolk, and to establish a single Trust responsible for community services, mental health and learning disability services (Option 2). The latter would need to be formed by merging the three existing community Trusts. The three options which include combined secondary care and community NHS Trusts were seen to have considerable benefits: for providing comprehensive and integrated packages of care; for using community hospitals to address pressures on emergency care; and for transferring services between secondary and community care settings. However, preference was given to Option 2 because: (a) a strong relationship exists between community and primary care services; (b) the three secondary care Trusts all have important strategic relationships with secondary care units outside the county eg. Addenbrooke_s, Norfolk and Norwich and Colchester General Hospitals. The review found to date that there were no especially strong links between the three secondary care Trusts within the county, whereas the reverse was the case for community services; (c) Suffolk Health Authority was seeking through its strategies for mental health and learning disability services (in particular) to set a county-wide direction for community-focused services. The White Paper: The new NHS: Modern _ Dependable envisages the future links between community and primary care services and specifically discourages secondary care and community combinations, reinforcing the findings of the Suffolk NHS Review. Options 1 and 4 were rejected because they gave rise to too many Trusts and did not achieve sufficient financial and service benefits to offset the disruption and costs associated with merger. The main rationale for a single community Trust is the opportunity to strengthen mental health services across the county and to integrate community and primary care services more effectively. Also, this option would promote collaboration between local authorities and the NHS and create an organisation that would be better placed to deliver the joint strategies agreed between the Health Authority and Suffolk Social Services. The creation of a single Trust would also allow for a move away from historic patterns of service delivery to one where resources could be targeted more effectively to reflect the identified needs of populations, and hence to address health inequalities and demographic trends. At the same time, where clinical services need to develop differently in each of the communities served by the new Trust, this would be assisted by the establishment of Local Health Partnerships. The Review's financial analysis suggested that recurrent savings of £1.4m would be achieved from the changes after a payback period of less than two years. The proposed new Trust would also enable the eventual establishment of Primary Care Trusts (managing community hospitals and community services) without such a change having an impact on the viability of mental health, learning disability and specialist community services. 6 The Local Health Partnerships NHS Trust 6.1 Size, services and area covered The proposed Trust would provide community, mental health and learning disability services to a population of 850,000 people within Suffolk, parts of Cambridgeshire, Norfolk and Essex. It is proposed that the new Trust would manage all of the services currently provided by the three merging NHS Trusts. It would have a turnover in excess of £80m and employ over 3800 staff. The Trust would also be responsible for managing the following facilities: St Clement's Hospital (Ipswich), psychiatric units on the West Suffolk Hospital site (Bury St Edmunds), residential care facilities for people with a learning disability in Ipswich, Kedington and Lowestoft, nine community hospitals, day centres, community clinics, health centres and residential homes. Population Served Services Provided West Suffolk Mental health, learning disability, community hospital services at Newmarket, general community services, community paediatrics, school health East Suffolk Mental health, learning disability services, community hospital services at Aldeburgh, Eye and Felixstowe, general community services, community paediatrics, school health South Waveney, Suffolk Learning disability, community hospital services at Beccles, Halesworth and Southwold, general community services, community paediatrics, school health services Lowestoft, Suffolk Learning disability, general community services, community paediatrics, school health Thetford, Norfolk Mental health, learning disability, community hospital services at Thetford, general community services, community paediatrics, school health Great Yarmouth, Norfolk Learning disability Norfolk Coastal Villages General community services Braintree, Essex Braintree Health and Day Centre, general community services 6.2 Priorities and vision for the new Trust Delivering the aims of the National Health Service It is envisaged that the new Trust would be established to deliver the aims of the National Health Service as laid down in National Guidelines and the White Paper: The new NHS: Modern _ Dependable, specifically to provide: _ A focus on improving the public's health, a key aspect of which is tackling health inequalities. _ A commitment to fairness in health services, reducing significant local avoidable health variations. _ The opportunity to develop the quality of services, through effectiveness of treatment, enhancement of skills, involvement of carers, and continuity of delivery, accountability and good organisation. _ The opportunity to promote partnerships and co-operation both within the NHS and with other organisations in the health and social care system. _ The means by which public confidence in health services can be rebuilt, through more open management, consistency and services reflecting the needs of local people. Managing the immediate pressures on health services The Trust would need to manage a number of pressures on the health service including to be able to: _ provide prompt and effective responses to emergencies including avoiding admissions by the provision of appropriate community services, ensuring no funded bed is unavailable at peak times because of foreseeable staff shortages and reducing discharge delays. _ maintain waiting time standards including the effective organisation of appointments and clinic times and avoiding unnecessary cancellations of clinics. _ ensure financial stability including minimising management and administrative costs, increasing clinical effectiveness and establishing appropriate monitoring and reporting systems. A new role for the Trust The new Trust would seek to develop services which: _ offer a leading role for primary care, in the provision of health care that is responsive to patients_ needs and addresses local health inequalities. _ provide comprehensive mental health care for people of all ages. _ deliver improvements in clinical and cost effectiveness. _ build on the relationships and joint arrangements which already exist with the secondary care Trusts in the county. _ offer a greater voice and influence for users. The immediate priorities These can be summarised as follows: _ To improve equality and fairness in access to services and their distribution across Suffolk. _ To develop a comprehensive mental health care service for people of all ages. _ To provide an innovative response to the rising demand for emergency care in Suffolk. _ To assist in the continued development of primary care services. _ To be a financially stable organisation. _ To be a good employer. _ To achieve savings which will be reinvested in the priorities for service development (A to F below). _ To reduce management costs and generate savings to meet the pressures on all health services in Suffolk. Priorities for service development The following would be the priorities for health service development within the new Trust. Changes would be implemented in line with the Health Improvement Programmes in Suffolk, Essex and Norfolk, and subject to the availability of resources. A. The implementation of the key Benefits for Patients as set out in Section 7. B. The development of mental health services, especially the development of a single infrastructure for psychiatric services with a focus on: providing community services in partnership with other agencies; and the creation of intensive support networks. C. The development of supportive living arrangements for people with a learning disability, in conjunction with specialist support teams. D. The development of primary care, especially primary care teams, primary care networks, local access to specialists through the use of technology, social care, consulting pharmacists, emergency and intensive support teams. E. The development of general community services in partnership with Primary Care Groups to provide comprehensive packages of care for those requiring family planning, dental care, foot care and access to community-based therapeutic and diagnostic services. Reducing unnecessary hospitalisation and elective admissions, in particular looking at alternative therapies, pre-admission screening, hydration and nutrition, day services and day surgery (including podiatry) and early discharge packages. F. The development of a county-wide strategy for children's services. This would encompass the creation of a network of child development centres. The Trust would work with secondary care Trusts and other agencies to develop integrated packages of care for children, supported by single child records. 7 Benefits for patients 7.1 Introduction The proposed new Trust would have the organisational benefit of being an employer of staff with many and varied clinical skills. Taking advantage of the increased scale of the new Trust would provide the opportunity to achieve the following: - the development and implementation of joint county-wide Suffolk Health Authority and Suffolk Social Services strategies. - the development of a comprehensive range of integrated services across the county. - management arrangements which would be able to reflect those of local authority services and voluntary groups. - a reduction in duplication, overlap and tensions over the distribution of resources inherent in present arrangements. - the opportunity to improve quality of care to the highest standards, through sharing best practice and investment in clinical audit and research. 7.2 Specific benefits The new Trust would be able to deliver a number of tangible improvements in patient care. In the first years of operation, its performance would be capable of being monitored on the achievement of these changes through its monthly Board meetings in public, and its annual reports and annual meetings. The rest of this section shows some of the benefits which could follow the proposed merger, subject to the need to meet the growing pressures on current health services in the county first. A. Intensive support team for people with learning disabilities >From December 1997, there has been an intensive support team operating in the east of the county. The new Trust would extend this to the rest of Suffolk. This would provide a county-wide service and would be funded by reducing Suffolk Health Authority's investment on similar services outside the county. B. Respite care for people with learning disabilities There is a continuing call on respite care both to ease the burden on carers and provide further treatment and support. A community focused service would be provided to reduce the need for inpatient care. C. Admission and assessment services for people with learning disabilities The Trust merger would make it possible to expand the admission and the assessment service to benefit everyone across the county. D. Additional consultant psychiatrists for adults with mental health problems The new Trust would set a target to improve the ratio of consultant psychiatrists to 1:40,000 people in east and west Suffolk. At present, some of the consultants in Suffolk are expected to provide services for up to 80,000 people resulting in variations across the county in waiting times and differences in prioritisation and standards of clinical practice. E. New specialist teams for adults with mental health problems At present, in excess of _500,000 is spent between caring for people with challenging behaviour and on Forensic Psychiatry. People receiving care out of the county could more appropriately be supported within Suffolk if services were in place. A new specialist team would be developed to support these individuals. This team would be able to build on the expertise and facilities that are already in place across the three existing NHS Trusts. In addition, county-wide specialist Forensic Services would be developed. F. Specialist community mental health support for primary care teams The new Trust would improve the services to children and adolescents who experience a range of mental health problems. Health visitors working with the primary care teams would be trained in this field by specialists within the child and adolescent mental health services. This would ensure care would be delivered as locally as possible. The health visitors would be supported by the existing specialist services and/or other health visitors, community nurses and practice nurses who had received advanced training. G. Improved access to aids and equipment for people in their homes The new Trust would establish a county-wide equipment store for people of all ages, providing a wheelchair service and aids to daily living equipment. This would provide improved value through better purchasing and ensure an equitable service for people wherever they live within the county. H. Rapid response teams for those requiring urgent care in the community Pilot schemes began in December 1997 to study the impact of the provision of community-based rapid response teams. Concentrating on the needs of older people, in particular, their purpose is to reduce inappropriate emergency admissions. The pilot schemes were funded from Winter Pressures monies, granted non-recurrently up to March 1998. Building on the success of the pilots, the new Trust would seek to develop these services to support all communities in Suffolk. 7.3 the opportunities for further improvement It is envisaged that a single community, mental health and learning disability Trust would provide both stability and room for innovation, and would offer the following additional benefits to patients: - clear and equitable access to services for all patients across Suffolk. - a flexible organisation with the capacity to be better able to absorb and deal with peaks and troughs in demand, whether in a specific locality or dealing with winter pressures. - the opportunity to deal with inequality in resource allocation across the new Trust by supporting and developing existing best practice in the three existing Trusts. - the scope to support innovation, evaluate it and develop new practice, confident that it has been robustly demonstrated to be effective in local conditions. - reduced duplication of services, which would provide greater clarity of responsibility for care, improve access for referrers, and release resources which could be reinvested in improving services. - an authoritative and powerful voice for service users, carers, voluntary groups and local communities in discussion with other local agencies, and nationally. - improved information systems which would reduce duplication and confusion in clinical information, improve the speed and accuracy of communication between services and localities and offer enhanced opportunities to use new technology, especially in the delivery of clinical services. 8 Management arrangements 8.1 Responding to the needs of different communities It is proposed that the new Trust would provide patient care to the whole of Suffolk, and also to people living in Essex, Norfolk and Cambridgeshire. Suffolk, itself, divides into discrete populations, with different mixes of elderly, the unemployed, the poor, with urban and rural communities. The existing Trusts have established managerial and service links with their local communities, are recognised as part of them, and have designed services to reflect their needs. It is envisaged that the new Trust would be run across distinct geographical principles, with the most senior directors and local managers being given responsibility to determine with local people, the service needs for their communities. Three community services directorates, covering east, west and north Suffolk would work in partnership with Suffolk Health Authority and the proposed Primary Care Groups to develop a Health Improvement Programme which tailors services to meet these needs. The three directors would be charged with meeting and engaging CHCs, local people, town and parish, district and county councils as well as other local organisations to ensure that the new Trust would be responsive to its communities. The role of the Board would be to discuss competing priorities for investment, to establish common standards of care to which all of those served by the Trust would be entitled, and to oversee the establishment of county-wide services where they exist only in one area but are required across the whole of Suffolk. All three NHS Trusts are already accustomed to managing services across a large geographical area by moving away from centralised management and locating managers alongside clinical services. The Trusts have been active in the use of telecommunication and information technology. Examples of this include the video links between Ipswich and Lowestoft, and the electronic mail links that already exist within each of the Trusts and between East Suffolk Local Health Services NHS Trust and Allington NHS Trust. All three Trusts also have the same philosophy towards mobile and visible senior management, and have developed and encouraged managers to spend the majority of their time with staff and the public, rather than at their desks. 8.2 The involvement of clinicians A key reason for merging the three Trusts is to remove the organisational barriers that interfere with clinical performance. It is proposed that the new Trust would continue the tradition of senior and service managers coming from a clinical background that exists in all three of the present NHS Trusts. They have active professional advisory networks and these would continue. With the exception of specialist support functions such as finance, personnel, information and estates, the majority of managers within the corporate planning arm of the new Trust would also be from a clinical background. Responsibility for the clinical performance of the Trust on a day-to-day basis would sit with the chief executive, who in turn would delegate this responsibility to the medical director and three community services directors, covering west Suffolk, Cambridge and Thetford; east Suffolk and Essex; and north Suffolk and the east coast of Norfolk, respectively (see below). The new Trust would be managed through both functional and geographical networks, with those services which eventually might form part of Primary Care Trusts, being established within locally managed teams (the Local Health Partnerships from which the Trust would derive its name) whilst specialist services (including mental health and learning disability) would be managed either within larger geographical groupings or county-wide. For those services which would not eventually form part of Primary Care Trusts, medical involvement is essential and lead doctors will be appointed, reporting to the new Trust's Board through one of the executive directors. The Trust would also establish GP adviser posts for each of its community services directorates to ensure appropriate liaison between the Local Health Partnerships (as they develop within the Trust) and the Primary Care Groups, which ultimately may become responsible for managing community hospitals and community services. The medical and nursing directors of all three NHS Trusts have been involved in developing the proposal to merge and fully support it. All staff have been invited to express their views and have been involved throughout the process of evaluating the options and determining the preferred option for change. 8.3 Community Services Directorate (west Suffolk) The west Suffolk directorate would be responsible for Local Health Partnerships, centred around Bury St Edmunds, Newmarket, Sudbury, Haverhill and Thetford. This directorate would be responsible for the mental health, community services, community hospitals, learning disability and children_s services provided by the Mid Anglia Community Health NHS Trust. The directorate as a whole would have a senior management team, chaired by a director, supported by finance, personnel and estates advice, and be involved in regular meetings with the public. This team would work in partnership with the local Primary Care Groups, CHC, councils, divisions of local county Social Services and Education, and the voluntary sector in reviewing and evaluating the delivery of services. The team would also produce Business Plans for Board approval and be required to report publicly on performance as part of the Trust_s Annual Report and Annual Meeting. The west Suffolk directorate would serve a population of 280,000 people, predominantly within Suffolk, have a turnover in the region of _24m and employ approximately 900 staff. 8.4 Community Services Directorate (east Suffolk) The east Suffolk directorate would be responsible for the mental health services provided by the East Suffolk Local Health Services NHS Trust. It will also manage those community services, community hospitals, learning disability and children_s services located within the area covered by the Southern division of Suffolk Social Services and Education, with the addition of services in Braintree, Essex. The directorate would be responsible for Local Health Partnerships, centred around Ipswich, the Brett and Stour Valleys and Stowmarket, Felixstowe and Braintree. The directorate's senior management team would function in the same way as the west Suffolk directorate (see 8.3). It would cover a population of 330,000 people, have a turnover in the region of £35m and employ approximately 1600 staff. 8.5 Community Services Directorate (north Suffolk) The north Suffolk directorate would manage community services, community hospitals, learning disability and children_s services in those areas covered by the Northern Division of Suffolk Social Services and Education, together with these services provided for people living in Great Yarmouth and the Norfolk coastal villages. This directorate would not manage any mental health services. In the Great Yarmouth and Waveney area these are provided by the Norfolk Mental Health Care NHS Trust. Mental health services for people living in east Suffolk would be managed by the new Trust_s east Suffolk directorate (see Section 8.4). The directorate would be responsible for Local Health Partnerships, centred around Woodbridge, Eye and Saxmundham, Waveney and Norfolk coastal villages. The senior management team would function along the same lines as the other community services directorates. The directorate would cover a population of 240,000 people, have a turnover in the region of £20m and employ approximately 600 staff. 8.6 The Board It is proposed that the Board of the new Trust would commence with six non-executive directors (including a non-executive chairman and five non-executive directors drawn from all parts of the county) and six directors (all with executive responsibilities, one of whom would be an associate director). The Board as a whole would be responsible for determining and ensuring the delivery of the Vision, Values, Priorities and Responsibilities of the new Trust (including Clinical and Corporate Governance), agreeing the Trust_s Business Plan and developing the Strategic Direction for each of the Trust_s services. It is envisaged that individual directors would have lead responsibility for the development of mental health, learning disability, community, and children's services. Three of the directors would also have operational responsibility for all clinical services within the three community services directorates. The new Trust would hold Board meetings in public, moving this venue to allow all of the communities it would serve to have easy access. 8.7 Corporate functions The Board would be supported by a corporate planning arm comprising planning and information, research and development, clinical effectiveness and corporate affairs departments. Planning and Information This department would bring together the information departments of the three Trusts and also incorporate a dedicated planning function, providing the Board with access to in-house project management skills, contingency management and scenario planning. Research and Development (R&D) Investment in R&D projects across the three Trusts is just over _50,000 per annum. The new Trust would be the largest community trust in the Anglia & Oxford Region and might wish to develop a dedicated R&D function, in order to attract research funding into Suffolk. At the same time it would ensure that service developments were at the leading edge of best clinical practice. Clinical Effectiveness It is envisaged that the new Trust would amalgamate the existing Clinical Effectiveness programmes and Clinical Governance arrangements. There is currently some duplication of Audit projects (not least regarding leg ulcer treatment and child surveillance). The new Trust would wish to run a consolidated programme of Audit projects, releasing resources to support those currently awaiting approval. In particular, the Clinical Effectiveness department would be responsible for monitoring and evaluating the delivery of the patient benefits listed in Section 7. Corporate Affairs This department would include health & safety and fire safety staff, mental health administration, legal support, the Board secretariat and public relations support. 8.8 Headquarters In the months between the proposed merger first being suggested and this formal public consultation, there has been considerable speculation concerning the location of the headquarters of the new Trust. As a consequence, this document takes the unusual step of describing the proposed future headquarters_ location. This is an issue which ultimately would be left to the Shadow Board of a new Trust to determine. None of the three NHS Trusts proposing to merge currently has a dedicated headquarters - all three have located _headquarters functions_ alongside clinical services. The new Trust is proposing to do the same. The use of video links and electronic networks would allow senior managers to keep in constant communication. Some functions, such as information technology, may benefit from being in a central location. If so, it is envisaged that it would be determined on the basis of a fully costed and independent options appraisal and be the subject of further consultation. Most services, however, and especially those in direct contact with patients, the public, other agencies and organisations, would be set in local communities and receive senior management support from the three community services directorate teams. 9 The new Trust and its staff 9.1 The process of change It is recognised that the process of change in bringing together the Trusts would be very demanding. The new Trust would, therefore, meet this challenge by consolidating and strengthening existing resources to ensure the development and implementation of the new human resource strategies necessary to support the change process. The Trust would also be able to benefit in the future from a strengthened human resource function, through economies of scale and the sharing of proven practice within each of the existing Trusts. Over 3800 staff would be involved in the merger. Existing clinical services would not be affected by the process of merger. There would be extensive discussions with staff and their representatives throughout the period of change. Every effort would be made to minimise uncertainty through effective vacancy management and in collaboration with other health service employers in Suffolk. The new Trust would be able to benefit from the recent experience of transferring 1700 staff at the Anglian Harbours NHS Trust to new employers. 9.2 Staff currently employed by the NHS Trusts Indicative staff numbers in whole time equivalents (WTE) (excluding Bank staff) likely to be involved in the merger are: STAFF NUMBERS by Trust @ 1 June 1998 Allington East Suffolk Mid Anglia TOTAL Local Health Community Services Health No WTE No WTE No WTE No WTE Medical and dental 77 24.59 83 35.81 49 37.63 209 98.03 Nursing 1070 708.63 611 522.59 567 474.43 2248 1705.65 Professional and technical/PAMS 222 135.77 145 108.91 145 85.75 512 330.43 Other (including managers, admin & clerical, ancillary and maintenance) 341 234.58 220 183.79 296 213.74 857 632.11 TOTAL 1710 1103.57 1059 851.10 1057 811.53 3826 2766.22 9.3 Employment policies Appropriate policies and procedures are essential to the Trust_s achievement of its core purpose through effective management and development of staff. Policies must be sufficiently sensitive and flexible to accommodate issues such as: demographic changes, developments in technology, changes in culture and a changing national agenda. Each of the three trusts has a range of well established policies formulated in consultation with recognised trade unions. This could be built upon by the new Trust. All staff employed by the merging Trusts at the time of transfer would move to the new Trust on their existing terms and conditions in accordance with current legislative requirements. The new Trust would need to make over _1.4m savings (as outlined in Section 10) and would require less managerial and administrative staff. There would be redundancies as a consequence of the merger, but all staff will have their existing entitlements to protection, redundancy and early retirement. Prior to 1 April 1999, the personnel departments of the three existing Trusts would examine the opportunities for harmonisation of policies. Consultation would take place with staff on any redundancies and on changes in policies and procedures where differences would interfere with the new Trust's ability to co-ordinate the delivery of patient care. 9.4 Employee relations Each of the existing Trusts already enjoys good management/staff relations founded on well established local negotiation and consultative arrangements. It is envisaged that these would be merged to provide the new Trust with joint arrangements for discussion, consultation and, where appropriate, negotiation between staff representatives and managers. All trade unions currently recognised by the merging Trusts would be formally recognised by the new Trust. Staff side organisations recognised by the existing NHS Trusts Allington East Suffolk Mid Anglia Trust LHS Trust CH Trust AEEU Amalgamated Engineering and Electrical Union 3 BDA British Dental Association 3 3 BMA British Medical Association 3 3 3 CSP Chartered Society of Physiotherapists 3 3 3 MSF/CPHVA Manufacturing, Science and Finance/ Community Practitioners and Health Visitors Association 3 3 RCN Royal College of Nursing 3 3 3 SCP Society of Chiropodists and Podiatrists 3 3 TGWU Transport and General Workers Union 3 UCATT Union of Construction, Allied Trades and Technicians 3 UNISON (including British Association of Occupational Therapists) 3 3 3 9.5 Training and development Experienced, knowledgeable, skilled, well trained and highly motivated staff are essential to the delivery of effective health services. By combining the resources of the three existing Trusts, the new Trust would be able to increase the effectiveness of its use of training resources, avoiding duplication and ensuring the sharing of best clinical and managerial practice. Training and development would be a key element of the culture of the new Trust, founded on a single appraisal system which would help in identifying and addressing the training needs of individuals in relation to its business and development plans. Within the new Trust there would be increased development and career opportunities for all staff. Being a much larger Trust, with stronger links to educational bodies, it would also be able to provide more varied training, helping recruitment and retention. In addition to providing excellent training for its own staff, the new Trust could also lead in the provision of primary care training thus strengthening its close working relationship with primary care teams. 10 Financial Outlook 10.1 Financial position of the three NHS Trusts Allington NHS Trust In 1996/97, Allington achieved all of its financial duties, having declared an end of year income and expenditure surplus of £124,000. Allington's provisional results show a small surplus of £11,000 in the financial year 1997/98 following excellent financial performances in 1995/96 and 1996/97. The forecast income and expenditure position for 1998/99 is break even. Allington NHS Trust: Financial Position 1995/96 1996/97 1997/98 1998/99 _000s _000s _000s _000s actual actual provisional forecast Income Operating income 18781 19725 28387 32713 Expenditure Operating expenses (18321) (19243) (27864) (31767) Surplus before interest 462 485 523 946 Interest and dividends (278) (360) (512) (946) Surplus/(deficit) 184 124 11 0 East Suffolk Local Health Services NHS Trust Since the Trust came into operation in 1993, it has performed well against its financial targets. In the years 1993 to 1996, the Trust achieved all of its financial duties. In 1996/97 the Trust recorded an income and expenditure deficit of £521,000. These were calculated after making a provision for early retirement costs of _560,000 in that year. Adjusting for this provision, the Trust made a surplus of _39,000, which is the result that reflects the true financial performance of the Trust for that year. The Trust's provisional results for 1997/98 show a surplus of £26,000 at the year end. In 1998/99 the Trust faces significant cost pressures based on current activity and commitments continuing throughout the year. The Trust has made efficiency savings of some £4m since its inception, so the scope to achieve more is limited. However, the Trust has developed a plan to address the recurrent problem for 1998/99 and its successful record of addressing cost pressures suggests that this is achievable. Suffolk Health Authority has consulted on possible changes to the way rehabilitation services are provided, which could result in the closure of the Bartlet Hospital in Felixstowe with the resulting costs of change which are excluded from the analysis below. East Suffolk Local Health Services NHS Trust: Financial Position Income Operating income 24932 25485 25987 26754 Expenditure Operating expenses (23523) (24876) (24684) (25462) Surplus before interest 1409 609 1303 1292 Loss on disposal assets (85) Interest and dividends (1141) (1130) (1192) (1292) Surplus/(deficit) 268 (521) 26 0 Mid Anglia Community Health NHS Trust 1996/97 saw the Trust not only achieve a £400,000 savings programme, but also bring the it into recurrent balance for 1997/98 and beyond. After adjustments for early retirement (£252,000) and PFI costs (£46,000) the Trust achieved a surplus of £24,000 in 1996/97, which reflects the true performance of the Trust for that year. The Trust is also on target to break even and achieve all of its financial targets in 1997/98. Mid Anglia Community Health NHS Trust: Financial Position Income Operating income 26234 27029 25265 26528 Expenditure Operating expenses (25472) (26082) (24045) (25334) Surplus before interest 762 947 1220 1194 Interest and dividends (881) (1221) (1220) (1166) Surplus/(deficit) (119) (274) 0 28 10.2 Financial forecasts of the proposed NHS Trust Income profile The income the three NHS Trusts receive by service and community served in a full year is as follows: Service Community served Income in 1998/99 (forecast) _m Mental health West Suffolk (including Thetford) 7.7 East Suffolk 17.7 Care of the elderly West Suffolk (including Thetford) 0.8 Community hospitals West Suffolk (including Thetford) 2.7 East Suffolk 8.4 South Waveney 4.4 General community services West Suffolk (including Thetford) 8.0 East Suffolk 11.1 North Suffolk 2.6 Norfolk Coastal 0.5 Braintree 1.1 Children_s services West Suffolk (including Thetford) 1.6 East Suffolk 1.8 North Suffolk 0.8 Learning disability services West Suffolk (including Thetford) 4.1 East Suffolk 4.9 Great Yarmouth and Waveney 2.8 Other income 5.0 TOTAL INCOME 86.0 The proposed new Trust is forecast to receive the income and provide the services to the same communities as each of the existing NHS Trusts. Future income levels would depend upon how the projected _1.4m savings are used. Savings proposals The proposed new Trust is forecast to achieve £1.4m savings as a consequence of merger. These recurring savings would assist in helping to maintain existing clinical services of the three Trusts, make a contribution to the financial pressures on all health services within the county and for some to be re-invested to fund specific service developments. Area of Savings Full year effect once implemented _000s Reduction from three Trust Boards to one 370 Corporate functions (revised management structure, personnel, finance, information, contracts and estates) 770 Rationalisation of non-pay budgets 270 Total 1410 A small element of the savings (approximately _200,000) will be achieved in advance of the merger as part of the Service and Financial Frameworks (SAFFS) for 1998/99. This leaves a further _1.2m savings which will be released following the merger. The full year effect of the savings will not be achieved until after April 2000 and it is estimated that only half the full year savings (£700,000) will be available in the first year 1999/2000, because of the time involved in implementing the new management structure once a decision is announced. Cumulative savings 1998/99 1999/2000 2000/01 2001/02 _000s _000s _000s _000s 200 700 1410 1410 Costs of change The following are the forecast non-recurrent costs associated with the proposed merger. The total costs associated with the merger would be £2.09m to achieve £1.4m savings (or a payback period of less than two years). The estimate of Board and other corporate staff termination costs (including redundancy payments, capitalised pensions and outplacement counselling) is £1.710m. The costs associated with winding up the three existing Trusts is estimated at £150,000. The costs associated with establishing and running the shadow Trust Board and other start-up costs (eg. legal fees and project management fees) is estimated at £230,000. In summary, the costs of change totalling _2.09m will be incurred in accordance with the following schedule: 1998/99 1999/2000 Total _000s _000s _000s Termination costs 1000 710 1710 Wind-up costs 150 150 Start-up/Double running costs 100 130 230 Total 1100 990 2090 The funding for these costs would need to be agreed between the Regional Office, Suffolk Health Authority and the Trusts involved. Income and Expenditure forecast for the new Trust The overall Income and Expenditure forecast is shown in the Table opposite and incorporates the above savings and growth plan assumptions. The figures for the financial years 1998/99 and 1999/2000 show the costs that would be associated with dissolving and merging three NHS Trusts and introducing the revised Management Structure, outlined in Section 8. Growth plans and assumptions Suffolk Health Authority received the minimum level of growth funding for 1998/99. As a consequence of changes in the formula by which the NHS is funded (a formula which allocates funding by head of population but weighted for needs, deprivation and local labour market forces), the Authority is currently over-funded compared with others in the country. Both the Health Authority and the Trusts in Suffolk are assuming, therefore, that the county will receive either no growth or the minimum level for the next five years. Cost pressures and service developments will need to be funded from existing resources and expenditure on all services will remain under constant examination. Income and Expenditure Forecast (based on assumed costs at April 1998) No change Merger Creation 1998/99 1998/99 1999/00 2000/01 of Primary _000s _000s _000s _000s Care Trusts Forecast Forecast Forecast Forecast _000s 3 Trusts New Trust New Trust New Trust Forecast** Income Patient care 80955 80955 80955 80955 55600 Other 5040 5040 5040 5040 4400 Totals 85995 85995 85995 85995 60000 Expenditure Pay (57359) (57359) (56994) (56419) (39600) Non pay (22275) (22275) (22140) (22005) (15900) Depreciation (2729) (2729) (2729) (2729) (2000) Total (82363) (82363) (81863) (81153) (57500) Interest and Dividends* (3404) (3404) (3404) (3404) (2500) Costs of merger 0 (1100) (990) 0 0 Savings already released (200) (200) (200) (200) SURPLUS/ (DEFICIT) 28 (1072) (462) 1238 0 Additional savings to be released *** (500) (1210) * These are the payments made to HM Treasury to service the Government debt associated with the use of land, buildings and equipment for NHS purposes. NHS Trusts have no shareholders. ** This column is an estimate of the financial impact on the new Trust of the creation of possible Primary Care Trusts within Suffolk. For the financial analysis above it has been assumed that Primary Care Trusts would manage all the community hospitals, district nursing and health visiting services. *** The additional savings shown above are net of the £200,000 savings already achieved in advance of the proposed merger. Financial duties for the new NHS Trust Break even The proposed new Trust is forecast to break even from the year 2000 onwards. In its first year the Trust would make a deficit due to the costs of dissolution and merger of three NHS Trusts. The forecast of break even from 2000 onwards is based on a number of assumptions concerning income and the achievement of savings plans. Value for money The Audit Commission undertakes an annual analysis of the comparative costs of services provided by individual NHS Trusts. This has consistently shown that the three community NHS Trusts in Suffolk already offer good value for money. Anglia & Oxford Regional Office_s own analysis of comparative expenditure on community services highlights that the cost of community care is lower in Suffolk than the average for the rest of the region and that the number of patients seen is higher than average. It is envisaged that the new Trust would build on the outstanding track records of the three existing NHS Trusts in the delivery of effective and efficient health care within the community and, by delivering cost savings through merger, would ensure that health services in Suffolk offer even greater value for money. Achieve management cost targets When the proposed new NHS Trust has achieved the anticipated management saving of over £1m, its management cost percentage would be 4.4% (based on December 1997 definition). 10.3 Capital plans The estates profile of the new Trust It is envisaged that the new Trust would manage psychiatric services at St Clement_s Hospital, Ipswich and the West Suffolk Hospital, Bury St Edmunds; community hospitals in Newmarket, Thetford, Eye, Aldeburgh, Felixstowe, Beccles, Southwold and Halesworth; learning disability residential services in Kedington, Ipswich, Lowestoft and ten group homes in east Suffolk; health centres, health clinics, day centres, and day surgical units in over 100 locations across three counties. The total value of the land, buildings and equipment owned and managed by the new Trust would be £58m. Planned major capital developments beyond April 1999 (including PFI projects in progress) There are no major capital developments (over £250,000) planned after 1 April 1999. Based on the present capital allocation for the existing Trusts, the new Trust would receive an estimated allocation of _1.5m for 1999/00 and would have the power to approve at Board level (subject to express support from Suffolk Health Authority) schemes of up to £1m in value. One of the first priorities for the new Trust Board prior to 1 April 1999 would be to consolidate the capital programmes and plans of the three Trusts, given the different positions each has reached regarding backlog maintenance, fire and health and safety requirements, investment in clinical equipment and IT. The existing NHS Trusts have the following PFI projects in progress and it is envisaged that responsibility for these schemes would transfer to the new Trust, including any liabilities to third parties relating to them. The East Suffolk Local Health Services NHS Trust is working with Suffolk Health Authority on two capital schemes: _ the re-provision before March 1999 of the 20 place ESMI Day Hospital, currently located on the former St. Audry's Hospital site in Melton, into two new-build facilities in Kesgrave and Saxmundham, each offering 12 places; _ the re-provision of adult mental health long stay accommodation comprising some 50 beds on the St. Clement's Hospital site in Ipswich, with the first phase of 16 beds being progressed during 1998/99. Mid Anglia Community Health NHS Trust is currently going through the PFI process to replace the inpatient adult mental health ward in the West Suffolk Hospital in Bury St Edmunds. It is envisaged that consultation on this change will begin in late 1998. The Allington, East Suffolk Local Health Services and Mid Anglia Community Health NHS Trusts were established for the purpose specified in Section 5(1)(a) of the National Health Service and Community Care Act 1990. Briefly summarised, this section enables Trusts to manage former Health Authority sites assigned to Trust ownership on establishment. Trusts have come to regard establishment for the Section 5(1)(a) purpose alone as restricting their ability to respond to changing patterns of health care delivery, including the ability to benefit from PFI schemes. It is proposed that the new Trust should instead be established for the purposes specified in Sections 5(1)(a) and 5(1)(b) of the 1990 Act, namely _to provide and manage hospitals or other establishments as facilities in the area served by the Trust that being Cambridgeshire, Essex, Norfolk and Suffolk_. 11 Conclusions The proposal to merge the Allington, East Suffolk Local Health Services and Mid Anglia Community Health NHS Trusts represents the preferred option for the three merging Trusts, Suffolk Health, the West Suffolk Hospitals, Ipswich Hospital and James Paget Healthcare NHS Trusts for the following reasons: _ the proposed merger would allow the establishment of Primary Care Trusts without destabilising the mental health, learning disability and specialist community services within the existing community Trusts; _ there are significant opportunities to extend the range and quality of specialist mental health and learning disability services in a larger Trust; _ the proposed merger is the least disruptive, allowing secondary care services to concentrate on the important national priorities of emergency care, cancer services and waiting times; _ the services to transfer to the new Trust are easy to define; _ specific patient and service benefits would follow the merger. These would be more difficult or more costly to achieve within the present configuration; _ financial savings of £1.4m have been identified following a detailed assessment of existing pay and non-pay budgets; _ there is a requirement in the future to review access to community services across the county (within the context of Suffolk_s Health Improvement Programme) to ensure that it is fair; _ there are specific and general service benefits from integrating mental health and community services. This proposal to merge follows a detailed review of health services within Suffolk. It is prompted by a genuine desire by those involved to secure the maximum available resource for patient care and to deliver health care in the most efficient, effective and equitable manner possible. The proposed merger of Allington, East Suffolk Local Health Services and Mid Anglia Community Health NHS Trusts would bring together three organisations with excellent records of financial performance, similar services and service directions and each serving parts of the county of Suffolk. This merger would create a new Trust _ The Local Health Partnerships NHS Trust _ and in so doing create the opportunity to: _ develop the new roles and responsibilities for the NHS laid out in the White Paper: The new NHS: Modern _ Dependable; _ secure the long term future of mental health and learning disability services following the development of Primary Care Trusts; _ deliver specific and measurable benefits for patients; _ improve the quality of community care by sharing examples of best practice across the county; _ achieve over _1.4m savings which would be re-invested to help meet the cost pressures on health services in Suffolk. It is envisaged that the proposed new Trust would be managed through both functional and geographical networks, with those services which eventually may form part of Primary Care Trusts being established within locally managed teams (the Local Health Partnerships from which the Trust would derive its name), whilst specialist services (including mental health and learning disability services) would be managed either within larger geographical groupings or county-wide.