This is an HTML version of an attachment to the Freedom of Information request 'Information following merger of royal and Aintree hospital'.



Foreword 
People in Liverpool experience amongst the highest 
We will do this in partnership with:
levels of poor health outcomes and health inequalities, 
both within the city, and compared to the rest of the 
•  The University of Liverpool and the City Council, 
country1.  Modern medicine has changed; increasing 
as we develop the Knowledge Quarter; over a £1 
specialisation has improved care and outcomes but 
billion development plan, including expansion of 
this means that care for an individual patient is often 
the Liverpool School of Tropical Medicine, the 
multi-disciplinary and needs to be delivered by several 
Accelerator and the Royal College of Physicians 
specialist teams working together. 
Northern Centre of Excellence
The configuration of hospital services across Liverpool 
•  The CCGs, as we implement Healthy Liverpool, 
is highly fragmented with multiple providers, meaning 
the strategy for ‘single service, city wide delivery’ 
that care is also fragmented and variable. This 
of hospital healthcare to improve health 
prevents care being provided in a multi-disciplinary 
outcomes
joined up way, resulting in the sub-optimal outcomes 
and inequalities experienced by the North Mersey 
•  Other hospitals and partners in Cheshire and 
population. The fragmented hospital landscape also 
Merseyside, as we provide coordinated specialist 
increases cost and inefficiencies, due to duplication 
care for the region and beyond
and overlaps in services. 
We will deliver:
Care is compromised, expense is increased, 
• Improved, joined up and patient centred 
efficiency is reduced, and delays result
healthcare – centralised where necessary, local 
where possible
Meanwhile, there is a huge academic opportunity 
that is being missed. A united and coordinated major 
•  Better access for patients to aim to consistently 
university hospital working together with the University 
deliver key standards of care, such as: 18 week 
of Liverpool would have a much greater opportunity to 
waiting times for planned surgery; making sure 
fulfil research potential for the benefit of our patients. 
cancer patients are seen and treated as quickly 
as possible, and ensuring 95% of patients are 
Liverpool has a clinically driven plan to address the 
in A&E for less than four hours before being 
issues around delivering our services. Three years 
treated or discharged
ago over 200 senior doctors from Aintree University 
Hospital NHS Foundation Trust (AUHFT) and the Royal 
•  Increased clinical trial recruitment and increased 
Liverpool and Broadgreen University Hospitals NHS 
research which benefits patients 
Trust (RLBUHT), the two largest hospitals in the city, 
with a combined turnover in excess of £850 million, 
•  Improved productivity and more cost effective 
made the clinical case for the merger of the two 
healthcare 
organisations. Since then, this clinically led vision to 
deliver better quality and more cost effective care, 
•  A sustainable city-wide healthcare service
has been developed with Clinical Commissioning 
Groups (CCGs), the University of Liverpool, the two 
Trust Boards and our other partners.  
 1Healthy Liverpool: The Blueprint. Liverpool Clinical Commissioning Group.  November 2015.
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We will deliver ‘quick wins’ with large 
improvements in care and efficiency in:

•  Orthopaedics (bones)
•  Emergency general surgery
•  Hepato-biliary (digestive) surgery
•  Oesophago-gastric (gullet and stomach) surgery
•  Caring for people who have had severe strokes.
Bill Griffiths
Neil Goodwin
Chair, RLBUHT
Chair, AUHFT
We will build on the new estate within the city:
•  The new Royal Liverpool University Hospital 
(RLUH) (£400 million)
•  The new Clatterbridge Cancer Centre on the 
RLUH site (£120 million)
•  Investment in the Knowledge Quarter (over £1 
billion).
Dr Peter Williams
Programme Director
We will attract:
•  Significantly increased research investment
•  Staff to work in our hospitals, because of our plans 
to create an environment in which healthcare 
professionals can thrive while providing the best 
possible care for our patients.
Aidan Kehoe
Steve Warburton
CEO, RLBUHT
CEO, AUHFT
We will do this because:
•  It is the right thing to do for our city that has 
some of the worst health outcomes in the UK
•  Neither hospital can achieve these goals alone
The proposed merger of AUHFT and RLBUHT has 
widespread support from consultants, the Trust 
Angie Smithson
Boards, the CCGs, the University of Liverpool, the 
Integration Director
City Councils and NHS Cheshire and Merseyside.
 
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Contents of Executive Summary
  
   
 
 
Page
1.  Introduction and strategic context 
5
2.  Patient benefits 
6
3. Finances 
8
4. Workforce 
8
5.  Proposed organisation 
8
6.  Next steps 
9
7.  Public and staff engagement  
9
8. Risks 
9
9. Conclusion 
9
4

1. Introduction and strategic context
and RLBUHT were unable to meet the four hour 
emergency care standard, which states that patients 
The outline business case (OBC) sets out the case for 
should be discharged or have started treatment within 
the merger between Aintree University Hospital NHS 
four hours of arrival, or the 18 week GP referral to 
Foundation Trust (AUHFT) and the Royal Liverpool 
treatment standard for planned care in 2016/17.
and Broadgreen University Hospitals NHS Trust 
(RLBUHT), which aims to improve health outcomes 
Both organisations have experienced a decline in 
for North Mersey patients through the delivery of 
their financial positions, with significant recurrent 
sustainable acute health services. 
structural deficits at the start of 2017/18. For AUHFT 
this is £14.6 million and for RLBUHT, £24.9 million. 
The vision for clinical services, as identified in the 
Neither organisation can bridge the gap through 
Healthy Liverpool Blueprint, is one of a single service, 
their internal Quality, Efficiency and Productivity 
city wide delivery in a number of key areas. These 
programmes, which aim to improve the efficiency 
include urgent and emergency care, cardiology, stroke 
of our hospitals and reduce unnecessary costs.
and haemato-oncology. The vision brings together 
health and academia to improve patient care and 
Meanwhile, there is a huge academic opportunity  
outcomes and to maximise research and development 
being missed. Neither AUHFT nor RLBUHT fulfils its 
capability, attracting and retaining staff.
research potential to both develop new treatments 
and technology for the future population and to 
The OBC sets out the strategic context and service 
attract and retain people to work in the city.
realignment, which aims to improve outcomes for the 
North Mersey population. This will be to the benefit 
RLBUHT and AUHFT, together with Liverpool Women’s 
of the local economy, bringing together health and 
Hospital NHS Foundation Trust (LWHFT) have joined 
academia to improve patient care and outcomes.
forces to buy a £35 million Electronic Patient Record 
(EPR) system, which will support changes in how 
Liverpool is an area of high social deprivation 
care is delivered. RLBUHT is also one of 16 Global 
and health inequalities, with 45% of Liverpool 
Digital Exemplar acute trusts, but there is more to be 
neighbourhoods being in the most deprived 10 per 
done. This is at a time when, over the last five years, 
cent of neighbourhoods nationally on the Index 
Liverpool has received significant investment including 
of Multiple Deprivation 20152. 30% of people in 
the development of a £1 billion Knowledge Quarter, 
Liverpool are living with one or more long term 
attracting science, technology, education and health 
condition3. Almost 26,000 older people have a long-
innovators into the city, including the Royal College 
term illness that limits their day to day activities, 
of Physicians and Liverpool International College, 
with life expectancy across Liverpool remaining 
hosting over 45,000 students. 
below the national average for men and women. 
This presents increasing challenges to the delivery of 
When viewed in the national context of improving 
healthcare in North Mersey as the population lives 
clinical and financial sustainability for a changing 
and survives illness longer.
population and in addressing clinical variation it is 
clear that the presence of two competing university 
Liverpool has multiple specialist providers of care in 
hospitals is not helping the transformational process 
the city, which is unusual.
that is required at this time. When viewed in the 
context of excellence in research and development, 
Currently, AUHFT and RLBUHT duplicate over 20 
digital technology and in education and training, the 
clinical services on two sites just four miles apart, 
lack of a single university hospital trust is impairing the 
which is unsustainable and expensive, particularly at 
ability of Liverpool to fulfil its potential in these areas.
nights and weekends.
The options for delivering the transformation required 
The fragmented configuration of hospital services 
was evaluated in the Strategic Outline Case by senior 
means that patient care is also fragmented and 
clinical staff in 2016, which ranked consolidation 
variable. This in turn prevents care being provided by a 
(merger) as a new single Trust significantly ahead of 
range of different professionals in a coordinated way 
the other options. The appraisal found that, although 
resulting in the poorer outcomes and inequalities.
some benefits could be delivered through collaboration 
short of merger, it would not create the organisational 
In common with other acute Trusts, both AUHFT 
alignment needed to deliver the Healthy Liverpool 
hospital-based care agenda as a whole. 
2The English Indices of Deprivation 2015. Department for Communities and Local Government. 2015.
3Evidence for Supported Self Care at Scale. Liverpool Clinical Commissioning Group. 2016.
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2. Patient benefits 
The consolidation of services to improve outcomes 
and access for patients will include (subject to 
The Patient Benefits Case provides examples from 
public consultation) reconfiguration of trauma and 
ten clinical areas: trauma and orthopaedics, general 
orthopaedics, ENT, urology, clinical haematology 
surgery including emergency surgery, upper GI 
and nephrology in the first year with general 
surgery, hepatobiliary and pancreatic Surgery and 
surgery, stroke services, dermatology and other 
colorectal surgery;  nephrology; Ear, Nose and 
service changes in years two to five
Throat (ENT); cardiology; acute frailty and elderly 
care; stroke services; radiology; rheumatology and 
The Digital Liverpool Strategy at RLBUHT will be 
haematology of new models of service delivery, 
adopted across the merged Trust, with this strategy 
which would be provided by a merged organisation 
being aligned to regional digital plans. RLBUHT 
and achieved through four recurrent themes: 
has achieved paper-free medical records, with 
i)  Service delivery via a shared  
some systems being cited as outstanding by the 
 workforce
Care Quality Commission. The shared learning and 
resource in a merged organisation would enable the 
ii)  Service delivery via best practice 
roll out of these systems more rapidly.
 
pathways with single infrastructure
Competing for research grants and contracts at scale 
iii)  Service delivery by a single 
as a merged organisation represents a commercial 
 
integrated team
advantage for the city of Liverpool. High quality 
iv)  Creating a service of scale.
biomedical research today can only be delivered 
from organisations able to access a comprehensive 
These models will provide better patient outcomes 
range of patients and that possess appropriate 
and patient experience, improved workforce 
technology and high level research expertise. Over 
sustainability and increase operational performance. 
recent years the Government has restructured its 
Importantly, improved outcomes include a reduction 
funding of medical research and development, 
in mortality.
effectively concentrating medical research and the 
development of new treatments in a few academic 
Examples of service redesign to deliver 
centres. The merged organisation would be in a 
improvements are set out in the OBC in the 
stronger position than the current stand-alone 
following eight areas:
Trusts in this field.
•  Improving mortality and morbidity
A single organisation will provide more flexibility for 
deploying junior medical staff to ensure exceptional 
• Improving efficiencies in services through 
training, whilst simultaneously delivering excellent 
reducing duplication
patient care. The placement of medical trainees 
by Health Education England is increasingly linked 
• Providing equality of access for the combined 
to the quality of medical education and training. 
population
Excellent training will ensure that the numbers of 
trainees are maintained or increased and delivers 
• Improving integration with primary care and 
the consultants of the future.
community services
 
• Improving patient care by significantly 
increasing access to research funding and 
clinical trials
• Improving patient care by delivering leading 
edge education and development to attract 
and retain staff
• Improving patient care by maximising the 
benefits of digital technology and innovation
• Improving patient care by maximising the use 
of the hospital estate.
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3. Finances
This will be achieved through the development of 
a workforce and leadership strategy to support the 
The Trusts are committed to improving services for 
design, structure and culture of a single organisation 
patients and within this, achieving the most efficient 
based on delivering patient centred, sustainable 
use of resources to improve their financial position. A 
healthcare.
key outcome of the merger would be the delivery of an 
improved financial position and substantially reduce 
There will be benefits across staff groups. The biggest 
the aggregated deficit of the two organisations, 
impact will be on developing clinically and financially 
which would exist for the standalone entities. 
sustainable rotas across the merged organisations 
medical and multi professional workforce.
The new organisational form will unlock benefits that 
would not be released at the same scale under the 
current organisational structures. Over the last few 
The key areas of workforce efficiencies are:
years increased collaboration across clinical specialties 
has delivered positive results in improving the quality 
• Reduced reliance on agency staff, medical 
of care and patient outcomes, however the scale and 
and nursing through improved recruitment 
pace of the change has not generated any significant 
and retention
savings so far. Greater service collaboration through a 
merger is essential to deliver single city wide services 
•  Standardisation of clinical pathways, reducing 
to avoid duplication and save money. 
duplication, removing variation and reducing 
length stay (LOS)
These synergies cover the broad themes of:
•  Reduction of premium rate payment (such as 
•  Clinical service reconfiguration - delivering both 
waiting list initiative)
quality and financial/efficiency benefits through 
consolidation and reconfiguration of services 
•  Consolidation of medical rotas for consultants 
across all sites, creating a more joined up and 
and other medical staff
efficient service model by standardising practices 
 
and removing variation of costs
•  Enhancement of the multi-disciplinary workforce
•  Corporate and management pay savings – reducing 
• Reviewing the skills required to ensure we can 
the cost base by more effective management 
provide the best possible care for our patients
systems, and avoiding duplication of costs
•  Corporate service synergies - combining corporate 
5. Proposed organisation 
service functions (HR, Finance, Procurement, 
IM&T), centralising processes and removing 
The two organisations would undertake a merger 
duplication.
to consolidate the two separate trusts into one 
enlarged organisation. This will involve the 
•  Increased research and development income 
preparation of a new constitution and preparation 
of a legally binding Heads of Terms and Transaction 
•  Additional savings from reconfiguration of the 
Agreement. The collaboration will be approached 
combined estate.
as a merger between two equal partners, effectively 
forming a new organisation as a result. The Trusts 
are committed to pursuing a partnership of equals 
4. Workforce
between the two organisations.
There is no doubt that the change proposed will be 
In accordance with NHS Improvement guidance, an 
one of the most significant changes experienced by 
Interim Board should be in place at, or soon after, 
the majority of staff across the existing organisations. 
the submission of the Full Business Case (FBC). 
Careful planning and an effective management 
That Board will be required to meet with NHS 
programme will be very important in making sure 
Improvement (NHSI) for a Board to Board meeting 
that staff are supported during these changes. The 
following Competition and Markets Authority 
ambition is to develop a culture for the merged 
(CMA) approval. The process for appointing to the 
organisation built on shared values and behaviours, 
Interim Board will aim to start in early 2018, with 
to help integrate and motivate teams to deliver high 
a view to the process being completed by summer 
quality healthcare for the people of North Mersey. 
2018. 
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A new organisational and operating structure will 
The key risks associated with mobilisation are related 
be developed as part of the FBC through a wide 
to having the commitment of senior leaders and 
engagement process to aim to ensure delivery of 
organisational capacity to deliver the programme. 
quality, safety, financial and performance standards 
Mitigating actions include the development and 
for all services in the new organisation. It is 
implementation of an organisational development  
proposed that the principle of clinical leadership will 
programme to support  large scale change and 
be maintained. The new operational arrangements 
the development of an effective  programme 
will seek to maximise the integration of both clinical 
management office  to provide support to clinical and 
and shared services across the new organisation.
operational staff for their input into development of 
the Patient Benefit Case, Full Business Case and the 
post transaction implementation plan.
6. Next steps
The next phase of planning for the transaction 
9. Conclusion
programme includes the production of the Patient 
Benefits Case and the FBC. It is proposed that an 
The OBC has developed the patient benefits identified 
application is made to the CMA for a stage one 
by the proposed merger of the two Trusts.  The new 
review, which is the shorter process possible. AUHFT 
organisation will minimise variations in the quality 
and RLBUHT aim to achieve an authorisation date 
of services, which arise from the current duplication 
for the newly merged organisation on 1 April 2019.
across AUHFT and RLBUHT, to deliver high quality and 
efficient emergency and planned care.
This depends on the regulatory approval process 
both by NHSI and the CMA, so could change. AUHFT 
The vision for healthcare is part of a greater vision 
and RLBUHT are both committed to progressing as 
for the city based upon the Knowledge Quarter, an 
quickly as possible, so that patients benefit quickly. 
innovation and business area with £1 billion worth 
of developments underway and another £1 billion 
planned. The developments will attract clinicians, 
7. Public and staff engagement
scientists and entrepreneurs to the city, generate 
wealth and increase employment opportunities. 
A staff and public engagement programme will be 
Liverpool and its surrounding areas has great need 
undertaken through the development of the Patient 
for this investment as it has been shown that the 
Benefits Case and the Full Business Case to ensure 
health of a population is strongly associated with the 
that we can consider the viewpoints of a wide range 
wealth of that population.
of people in shaping our new hospital trust.
The OBC also demonstrates an improved financial 
position for the merged organisation, compared to 
8. Risks
the standalone positions, recognising that in the 
current NHS climate the merged organisation will 
The risks and mitigations associated with not 
not achieve financial balance. However, few NHS 
proceeding with a merger, proceeding with a 
organisations across the UK are in financial balance, 
merger and the risks to delivery of the programme to 
and establishing a merged Trust will make it easier 
achieve merger have been identified and addressed. 
to address duplication and inefficiencies.
The key risks associated with not proceeding with 
There are significant risks associated with not 
a merger include the inability to materially improve 
proceeding with a merger, which are similar for 
service quality, patient experience, research potential 
both organisations. These risks have an impact on 
or clinical and financial sustainability, adversely 
the long term clinical and financial sustainability and 
impacting on population health, including mortality. 
ongoing viability of the Trusts, adversely impacting 
Mitigating actions include ensuring sufficient accurate 
on population health, including mortality and health 
detail is provided to outline the benefits of a merger, 
inequalities. 
including clinical and financial benefits. The key risk 
of proceeding with a merger relate to failure to 
The proposed merger is key to delivering the benefits 
deliver on key operational performance standards 
outlined as neither Trust can individually deliver them 
during the work to creating and establishing 
alone. The merger will remove the organisational 
the new organisation. Mitigating actions should 
barriers to service improvement which will benefit 
ensure governance arrangements for the merged 
healthcare for people living across North Mersey 
organisation are flexible and responsive. 
and beyond. 
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