The strategic case

The COVID-19 pandemic has highlighted the need for healthcare services to adapt to changing population needs and healthcare pressures and priorities. Maximizing opportunities for admission avoidance and early supported discharge for patients and improving patient flow to ensure those with the greatest care needs can access the right services at the right time has never been more important. As the NHS works to recover from the pandemic, inpatient resources need to be optimally and efficiently deployed for acute care and safe and cost-effective alternatives to hospitalisation should be expanded with creation of capacity for both acute, elective and cancer care.

As well as being one of the commonest reasons for hospital admission, infections may complicate hospital treatments and surgical interventions. In the 2016 national point prevalence survey of antimicrobial use in English hospitals it was estimated that 37% of inpatients received an antimicrobial and 60% were via the parenteral route. As healthcare advances and the complex needs population grows, patients receiving intravenous (IV) antimicrobial therapy in hospital are likely to increase. Reviewing IV therapy, optimising timing of IV to oral switch and considering the need for Outpatient Parenteral Antimicrobial Therapy (OPAT) are established recommendation at the 48-72 hour stage in the NHS England antimicrobial stewardship guidance “Start Smart then Focus”.

OPAT services are provided by multidisciplinary clinical teams with infection management expertise who enable patients with a wide range of infections requiring intravenous therapy to be managed safely and cost-effectively in a non-inpatient setting. Infections managed via OPAT range from skin and soft tissue infections like cellulitis to complex urinary tract infections through to chronic respiratory, cardiovascular, orthopaedic, and other complex post-surgical infections.

Clinical activity data relating to OPAT are not routinely captured across the NHS in England. The British Society for Antimicrobial Chemotherapy (BSAC) developed a national outcomes registry in 2015, which for 5 years collected data from up to 57 affiliated OPAT services across the UK. Although data were incomplete (not all services contributed data for the entire 5-year period), a total of 27,841 patients received treatment via OPAT (either through admission avoidance or early supported discharge) and a total of 442,280 inpatient days were avoided. On average, therefore, 16 inpatient days were avoided per patient.

It is estimated that more than 56,000 patients per year could benefit from OPAT services across the NHS in England with up to one million inpatient days avoided and care delivered at substantially lower cost compared to the traditional inpatient care model (see Economic case below).

Providing safe and effective alternatives to hospitalisation via OPAT has several patient benefits, including care closer to home, improved satisfaction with care and reduced hospital associated risks (including risk of hospital associated infection and deconditioning). Provision of an OPAT service may also support a more rapid return to normal activities including work or school as well as a reduction in transport costs and associated emissions, for friends and family. This is particularly relevant in rural counties where round trips may be over 50 miles.

As with other initiatives that provide care closer to home/reduce inpatient stay and bed occupancy there are clear organisational benefits, including improvement in inpatient capacity for both scheduled and unscheduled care and enhanced patient flow, which supports greater operational resilience.

Multidisciplinary OPAT services are ideally configured to support the best evidence-based clinical practice, including optimising cost-effective infection management, and maximising antimicrobial stewardship opportunities. As such, optimally functioning OPAT services as well as delivering intravenous therapy will also ensure appropriate IV to oral switch and monitoring of complex oral therapies which are associated with lower treatment costs and avoid potential problems related to indwelling vascular devices. Although OPAT services are distinct from the commissioned virtual ward development in the NHS in England, there are clear opportunities for OPAT teams to work synergistically within the wider commissioned virtual ward environment, supporting infection management and antimicrobial stewardship. In addition, the virtual ward infrastructure may support OPAT services to enable enhanced monitoring of specific patient groups, including the frail elderly and those with enhanced needs in whom traditional OPAT models will be less well suited [7]. As with the virtual ward development and hospital@home services, OPAT aligns closely to NHS strategy to decentralise care, provide care closer to home and move towards more integrated community-based provision of care.

Importantly, OPAT development across the UK is supported by the BSAC OPAT initiative, which has developed a suite of resources to support best practice including the OPAT good practice recommendations which provide a framework for service governance and delivery. Education and training in OPAT are supported by BSAC, who have developed an e-learning programme suitable for all members of the OPAT team as well as a service directory and peer support network. BSAC is also committed to organising regional workshops and an annual learning event/ conference that supports OPAT education and networking across the UK.

Antimicrobial stewardship is a key component of OPAT, and this supports the UK’s 20-year vision for controlling antimicrobial resistance and 5-year national action plan. Key stewardship goals include ensuring the most effective and shortest appropriate therapy and promotion of earlier IV to oral switch. Infection specialist led multidisciplinary OPAT services are ideally suited to ensure focus on these goals, from expert vetting/assessment of referrals through patient centred treatment and care planning to expert monitoring and follow up. Although much of the published literature around OPAT focuses entirely on outpatient IV therapy, clinical practice has evolved and, in the UK, OPAT services now support both IV and complex oral antimicrobial therapies which require close outpatient monitoring including facility to switch between oral and IV therapies during longer community-based treatment courses. In one well developed OPAT service in NHS Greater Glasgow and Clyde approximately 1,300 referrals were received in 2022. Of these, 30% were vetted to an alternative non-OPAT strategy (including discharge without need for specialist follow up), 30% were switched to oral therapy (with close follow- up including subsequent switch to IV therapy in a proportion) and 30% continued and completed with IV therapy (RA Seaton, unpublished data).

Although there is a growing emphasis on earlier IV to oral switch in therapy, the focus of OPAT services remains safe and cost-effective delivery of IV antimicrobials in the community. To this end Lord Carter’s 2020 review of NHS Pharmacy aseptic services in England emphasised the importance of additional efforts to support the development of national initiatives to provide ready to use infusible antimicrobial medicines for use in the patient’s home specifically to support OPAT services in efforts to avoid unnecessary hospital admissions. The review also recommended that the NHS in England should incentivise contracts for OPAT to provide care closer to home.

The economic case

For suitable selected patients, OPAT care provides outcomes at least equivalent to inpatient care and at between 20% and 50% (depending on the condition treated and model of OPAT care) of the cost of traditional inpatient care.

The infection specialist led nature of the service ensures expert directed care is given to all patients and that the principles of antimicrobial stewardship (and limiting unnecessary antibiotic therapy in particular) are integral to patient management. Infection specialist led care also allows deployment of best evidenced, cost-effective management strategies for patients otherwise requiring inpatient management.

Patient-centered OPAT services offer significant additional benefits, including greater patient satisfaction, reduced risk of hospital-associated deconditioning, healthcare-associated infections (HCAIs), venous thromboembolism and psychological morbidity, with additional healthcare, societal and cost benefits that are less easy to quantify. Not developing and implementing an OPAT service is a failure of opportunity to maximise inpatient resources or enable patient flow and a failure to deliver patient centred care closer to home.

Several complementary and adaptable OPAT delivery models are necessary to maximise the reach of the service and to ensure equity and cost-effectiveness for the population. Most established OPAT services will offer a few different delivery options based on patient needs, infection type, preferred antibiotic and whether admission avoidance or supported (early) discharge is the goal. These models are detailed later.

OPAT services can be developed incrementally as skills and experience develop and as local needs are assessed through service planning and clinician engagement. Proportionate development of service models and distribution of patient groups is considered further and costed in the “Financial case” below.

It is strongly recommended that the structure of the OPAT service team is multidisciplinary with specialist nurses, infection specialist (infectious diseases or clinical microbiology) doctors and specialist pharmacists forming the core team. Roles, functions, and governance processes are detailed within the BSAC good practice recommendations. Adherence to these recommendations is fundamental to ensuring that any associated clinical risk is minimised and patient outcomes are optimised. An OPAT service is typically specialist nurse led day to day with seamless communication with medical and pharmacy team members. In addition to the core clinical team, an OPAT service should also be supported by administrative staff and healthcare support workers with some models also utilising community nursing support.

Although patients will be managed as outpatients, an OPAT service will typically be co-located with acute services reflecting the need for proximity to acute care or medical review and investigations as required given the acute nature of community referrals and potential complexity of hospital referrals.

Some patient groups, including the frail elderly and those who are housebound with complex needs, may benefit from OPAT supported by community-based nursing teams and potentially NHS England’s virtual ward or hospital@home infrastructure and workforce. It is important that infection management within the virtual ward environment falls under the same antimicrobial stewardship framework as in hospitals and OPAT services.

Key performance indicators for OPAT length of inpatient days avoided and outcome as per the BSAC good practice recommendations and as recently adapted by the Scottish Antimicrobial Prescribing Group. Other key metrics include adverse events monitoring including vascular device related infection, bacteraemia, C. difficile and venous thromboembolism.

Estimating economic benefits of OPAT for the NHS

The economic benefit of OPAT is the avoidance of inpatient (overnight) stays and the associated care and hotel costs. Currently routine clinical activity is not systematically captured across NHS OPAT services in England and so there are no accurate estimates of total patients accessing OPAT and inpatient bed days avoided. Based on a systematic 1-year prospective survey of OPAT activity across NHS Scotland (population 5.52 million) in 2022, OPAT was delivered to 3,058 patients (55.4 per 100,000 population) and a total of 85,624 inpatient bed days were avoided (mean 28 days of OPAT care). There was wide geographic variation in delivery of OPAT in Scotland between no service provisions and up to 84 patients per 100,000 population in one large Scottish health board. Based on an estimate of unmet OPAT need in the 2 largest Scottish health boards it has been estimated that upwards of 100 patients per 100,000 population would benefit from access to OPAT services (RA Seaton, unpublished data).

Given the commonality in clinical presentations across the UK it may be assumed that the same proportion of patients per 100,000 population will benefit from access to OPAT services across the NHS in England. As an example, for an Integrated Care System (ICS) with a population of 1 million it could be estimated that 1,000 patients per year could benefit from OPAT services with an estimated saving of between 16,000 and 28,000 inpatient bed days. Based on a population of around 56 million, and extrapolating from the 2022 Scottish data, an estimated 56,000 patients (100 per 100,000 population) would benefit from OPAT per year across NHS in England.

The BSAC OPAT National Outcomes Registry System (NORS) captured OPAT activity across 57 services (the majority from the NHS in England) for a total of 27,841 patient episodes with a mean treatment duration of 16 days [5]. Using the NORS data and Scottish estimates for potential OPAT activity it is estimated that upwards of one million inpatient bed days may be avoided annually if OPAT services were developed fully across the NHS in England.

In NHS Scotland around 34% of patients accessing OPAT services avoid admission thereby maximizing inpatient bed days avoided for that patient group (RA Seaton, unpublished data). The percentage avoiding admission to the NHS in England is currently not quantified.

The financial case

A bespoke OPAT health economic model has been developed by the Scottish Health Technology Group based on the top six OPAT conditions identified through the BSAC OPAT NORS. This model is applicable to all UK health systems and includes an estimate for NHS staffing time per patient episode (medical, nursing and pharmacy) and including multidisciplinary team meetings, typical OPAT antimicrobials used, consumables and transportation costs.

6 different key OPAT delivery models recognised to be prevalent (and evidence based) in the UK and throughout the NORS participating services were separately costed. These were as follows:

• daily attendance at an OPAT clinic for an intravenous infusion and monitoring
• self-administration of intravenous antibiotic at home following training by OPAT team
• self-administration of a continuous infusion via an elastomeric device at home, following training by the OPAT team
• specialist nurse intravenous antibiotic administration at home
• single intravenous dose of long-acting intravenous antibiotic for cellulitis
• administration of complex oral therapy with weekly clinic monitoring for bone and joint and diabetic foot infections

The cost of a typical NHS OPAT episode was calculated based on the NORS mean observed duration of therapy for each of the 6 OPAT conditions with a separate costing for each of the 6 service models as applicable for the condition treated. The calculated cost (for each condition and associated delivery models) was then compared with published NHS inpatient bed day cost estimates (see table below).

Table 1. Base case results – intravenous infusions

SSTI, skin and soft tissue infections; UTI, urinary tract infections; CIVI, continuous intravenous infusion

In view of the evidence-based change in OPAT clinical practice for management of orthopaedic or bone and joint infections and diabetic foot infections further calculations were performed to estimate costs for incremental use of supervised complex oral therapy within OPAT (see Table 2 below and [16]). This model was associated with further reduction in healthcare costs to between 13% and 26% of inpatient costs depending on the proportion of oral versus intravenous antibiotic therapy used.

Table 2. Base case results – oral antimicrobials for orthopaedic and diabetic foot infections

OPAT, outpatient parenteral antimicrobial therapies; IV, intravenous

The relative cost to deliver OPAT care therefore ranged between 22% and 56% of inpatient costs depending on the condition treated and the model of OPAT deployed. The costliest OPAT model was a daily visit from an OPAT nurse at home and the least costly was the patient attending daily for intravenous therapy.

The above calculations give estimates of costs per condition treated per patient for each NHS OPAT treatment model used. To estimate total OPAT service delivery costs using a combination of all 6 conditions managed via a variety of OPAT models a cost calculator has been developed by the Scottish Health Technology Group OPAT Cost Calculator). In addition to the published calculations this model has incorporated confidence intervals for the duration of therapy used. Although the cost model does not include the full range of less frequent infections treated in OPAT (notably infective endocarditis, vascular graft, ENT, maxillofacial, transplant medicine and central nervous system infections have not been included) these can be reasonably assumed to be managed at between 22% and 56% of inpatient costs based on the model of OPAT care deployed with potential avoided costs calculable based on equivalent hospital lengths of stay. It is also important to note that as the evidence base for infection management and antimicrobial stewardship evolves infection specialist led OPAT services will be well placed to implement the latest evidence into practice including use of complex oral therapy and long-acting antimicrobials in a broader range of OPAT indications.

While OPAT offers a cost-effective alternative to hospitalisation for a wide range of infections at a fraction of the cost of inpatient care, it is important to acknowledge that this does not generate cost savings per se. The additional value of OPAT from a health service delivery perspective is in the creation of inpatient capacity allowing more efficient and appropriate use of the available inpatient resource both for unscheduled and planned care, including cancer care and elective surgery. Safely reducing emergency department and acute admission unit footfall and improving patient flow through early supported discharge are both better for seamless healthcare delivery and better patient-centred care and support COVID-19 recovery.

Notably OPAT services also serve as an exemplar for other admission avoidance and supported discharge services for other clinical specialties. While the published cost model for OPAT has itemised the cost of individual care per OPAT patient, it is important to design service configuration based on the expected patient population size. Based on expert consensus and observed service configuration across the UK a comprehensive OPAT service serving an NHS England Integrated Care System of a population of up to 1 million requires a minimum of ten specialist OPAT nurses including at least one Agenda for Change Band 7 nurse lead. Additional specialist nurses are required for larger population sizes (one additional nurse per 100,000 population). Mixed grading of nurses (including advanced practitioners) and healthcare support workers for supporting clinic tasks can be considered depending on local needs. For a population of one million it is recommended that the OPAT service should also include one whole time equivalent Band 8A antimicrobial pharmacist and one whole time equivalent medical infection specialist (infectious diseases physician or clinical microbiologist). In addition, it is recommended that OPAT should be supported by clerical administration staff. The level of support is dependent on the service size and physical co-location of the OPAT service as support staff (administration and healthcare support workers) may potentially be shared with other admission avoidance or ambulatory care clinical services. Administrative support and deployment of healthcare support workers will provide significant benefits to the core team, allowing diversion of non-specialist tasks away from the specialty team, so improving efficiency and cost utility.

The management case

OPAT should function within the BSAC good practice framework and should closely align with the local antimicrobial stewardship programme. Local stewardship programmes provide assurance on antimicrobial use. The OPAT clinicians should work within established clinical governance structures and reporting processes should be in place as with any other clinical service. Contingency plans for staff shortages and logistical complications (including factors delaying or preventing patient attendance) should be anticipated. OPAT services should be subject to continued quality improvement programmes to ensure good clinical practice, to maximise impact on early discharge or admission avoidance and expand equity of service delivery. BSAC is currently developing a national OPAT service accreditation scheme based on the published good practice recommendations. Local and national OPAT service connections and peer support can be made via the BSAC OPAT clinical network.

Key OPAT metrics that should be measured are:

1. number of patients referred and OPAT vetting outcomes
2. number of patients entering and discharged from the service
3. duration of time in the service (virtual OPAT bed days)
4. outcome measures, which should be captured via the established BSAC OPAT outcomes:
5. treatment aim achieved (uncomplicated or complicated)
6. treatment aim not achieved
7. death
8. adverse events including vascular device related complications, bacteraemia, C. difficile and venous thromboembolism

Supporting documentation comprising stakeholder analysis, SWOT analyses and a list of questions to consider is included below.

Understanding the context for the business case

Before starting to think about the design of an OPAT service it is important to understand the local healthcare landscape, involve relevant stakeholders and discuss potential patient populations. Having these conversations early will help understand the drivers, barriers, or challenges before formally developing the business case application. Executive support for the application should be identified in each of the provider(s) and the ICB, and one of these should act as the senior responsible officer for the project.

This document is designed to aid navigating those initial thoughts and questions around OPAT business case planning. The document provides a range of experience and ideas from teams that have been successful in setting up OPAT services in the hope that the process may be facilitated for others.

The business case template that accompanies this document will give reference to sections in this document that may wish to be considered. The business case template gives direction and includes background and rationale for OPAT together with an interactive cost calculator model developed by a partnership between BSAC and Health Improvement Scotland based on the BSAC OPAT NORS published data. The business case template shows the potential value of a service, but it cannot describe the local model that is chosen nor the local healthcare dynamic/ partnerships that exist.

To support service development and improvement BSAC has set up an OPAT directory of services, which provides a list of key contacts of individuals managing successful OPAT services. Organisations that are setting up new OPAT services may wish to contact these individuals to explore in detail the differences between the models of care.  This will help to determine the best model for local adaptation.

Remember the key objective of an OPAT service is to manage patients safely and effectively with infections as outpatients, ensuring that their treatment is optimised, appropriately delivered, and supervised and that risks are minimised.

OPAT should operate within existing antimicrobial stewardship guidelines, and it is suggested that OPAT services review the BSAC OPAT good practice recommendations.

Overview of contents

Stakeholder analysis

Summarises the key individuals and services within organisations that will be involved in OPAT. These will need to be contacted during the planning stage and, where relevant, included in the business case.

SWOT (strength/ weakness/ opportunities/ threats) analysis

Provides detail on the service models and describes a range of variations to the models in providing OPAT. 9 models of care are presented, together with a summary of their strengths and weaknesses.

Organisations that wish to set up OPAT services can consider which of these service models is best suited to the local healthcare setting and use the risk scoring tool within the business case to justify the chosen model of care.

Checklist for consideration in preparing a business plan for new OPAT services

• benefits of a business plan
• importance of showing innovation
• the role of the team
• the importance of a shared vision
• content of the OPAT plan
• improvement over existing services
• areas expected to improve (in addition to efficiency)
• minimising rejection
• focus on the details

Stakeholder analysis

To develop a successful business case and populate it with accurate information requires the input of several individuals or departments within an organisation and often external stakeholders. It is unlikely that the lead person driving the business case will have the information readily available to them and therefore it is important to consider what information is required and who it can be accessed from. Although many people may be involved in the data gathering phase, only 1 or 2 people should write the business case to ensure a consistent style throughout.

The following key elements are required for an OPAT programme:

Staffing

• infection medical specialist(s) – infectious disease or microbiology
• OPAT nurse specialist(s)
• antimicrobial pharmacist(s)

See “Financial Case” above in relation to estimated whole time equivalents for each of these specialists.

• specialty consultant support (for example, orthopaedic, diabetic foot specialist)
  • to improve engagement and to support or advocate for the service
  • vascular access
  • support for training and advice on vascular devices or health
• administrative support
  • will be required as service grows and will enable specialist nurses to focus on patient care
• healthcare support worker(s)
  • important as service develops to support day to day clinic tasks including phlebotomy, physiological measurements and intravenous access

Service governance

• written policies, procedures and risk assessment
  • written jointly among the multidisciplinary team
• patient education and information
• rapid and effective communication between team members and patients
• standard operating procedures for out-of- hours advice and support for patients
• reporting requirements and accountability frameworks, for example antimicrobial stewardship group or similar
• outcome monitoring and audit

The table below indicates the type of information required to develop an OPAT business case and which departments or stakeholders are likely to have it. It is not an exhaustive list but is intended to highlight the many different types of information required and the variety of places this can be found. Many organisations will use a template that they require all business cases to utilise, so it is important to make sure you check and present your business case in the correct format.

The table also highlights the information required to develop details of the business case. Some information may be appended to the business case as supporting information rather than included in the business case document itself. A business case should flow in its structure and any information that breaks up the flow of a document should be appended rather than included in the main body of the text.

The business case will also include an implementation plan for the delivery of the proposed service model based on the information provided, for example staff availability and timeframes required for recruiting, time taken to find and refurbish clinic space.

Some of the departments that generated the information for the business case will be part of a working group charged with the implementation of OPAT and be given specific work streams which will be coordinated by the Project Manager or OPAT lead. The individuals forming the working group will vary depending on which service model is proposed and the scope of input required from their specific area.

Information to consider for OPAT service development

SWOT analysis of OPAT services

OPAT can be principally delivered in 4 ways that are not mutually exclusive:

• delivery of intravenous therapy in the patient’s home by the patient or a relative who has been trained in line care and drug delivery
• delivery of intravenous therapy in the patient’s home by a healthcare professional
• delivery of intravenous therapy in a clinic
• delivery of intravenous therapy in an intermediate care setting

Each service has its advantages and disadvantages and there is not one model that suits all patients or healthcare settings. Most OPAT services have started on a small scale targeting a particular patient population and using one of the above models. The services have then expanded over time to incorporate other patient groups and other delivery options so that the service offers the maximum amount of choice and ensures that efficiency and inpatient bed day savings are optimised.

SWOT analysis matrices (and scoring matrix) have been developed for the following models of service delivery options:

Administration of intravenous antibiotics to patients in hospital (that is, standard inpatient care)

A patient is assessed as requiring intravenous antibiotics by a suitable specialist and a treatment regimen designed. The patient remains in hospital for delivery of treatment regimen and is discharged home when cured or suitable for switching to an oral regimen.

SWOT Analysis

Self-administration of intravenous antibiotics (patient or carer administration of intravenous antibiotics)

A patient is assessed as suitable for OPAT by a specialist and a treatment regimen is designed. The patient or a designated carer is taught to administer intravenous antibiotics either as an inpatient or via a hospital-based OPAT clinic and when assessed as competent is discharged home to self-administer therapy. There is weekly clinical review in either infection clinic or specialty clinic.

This model can be included as an option alongside a service where administration is predominantly by visiting nurses in patients’ homes or alongside a model prioritising an infusion centre.

Visiting district nurse (administration of intravenous antibiotics by district nurse to patient at home)

A patient is assessed as suitable for OPAT in hospital by a suitable specialist and a treatment regimen designed. The patient is referred to district nursing services for delivery of treatment regimen and discharged home. There is periodic clinical review in either infection clinic or specialty clinic. Rapid response services based in the community may be involved.

This model can be adapted to delivery in the intermediate care setting.

Visiting OPAT nurse (administration of intravenous antibiotics to patient at home by attending OPAT nurse)

A patient is referred to an OPAT service, assessed as suitable for OPAT by a specialist and a treatment regimen designed. The patient is discharged home and a hospital-based OPAT nurse visits the patient on a frequent basis to administer intravenous antibiotics.

Model can be adapted to delivery in the intermediate care setting.

Visiting private nurse (administration of intravenous antibiotics to patient at home by attending OPAT nurse employed by a private company which specialises in delivering healthcare in the home setting)

A patient is assessed as suitable for OPAT by a specialist and a treatment regimen is designed. The patient is referred to a private company OPAT service to administer intravenous antibiotics at home and discharged.

Scope of private company involvement may vary according to local needs. This model can be included as an option for out-of-area patients alongside a service where administration is predominantly by visiting district nurse or OPAT nurse.

Infusion centre – hospital OPAT clinic (administration of intravenous antibiotics to patient attending OPAT clinic)

A patient is referred to an OPAT service, assessed as suitable for OPAT by an infection specialist and a treatment regimen is designed. The patient is discharged home and attends a hospital-based OPAT clinic on a frequent basis to receive intravenous antibiotics.

Infusion centre – hospital ambulatory care clinic (administration of intravenous antibiotics to patient attending ambulatory care clinic)

A patient is referred to a medical or A&E ambulatory service, assessed as suitable for OPAT by a generalist, potentially also with specialist input and a treatment regimen designed. The patient is discharged home and attends a hospital-based ambulatory clinic on a frequent basis to receive intravenous antibiotics.

Infusion centre – discipline-specific (administration of intravenous antibiotics to patient attending discipline-specific hospital clinic)

A patient within a specialist discipline (for example, oncology, orthopaedics, diabetes) is assessed as suitable for OPAT by a non-infection specialist usually with infection specialist input and a treatment regimen designed. The patient is discharged home and attends the specialist ward or clinic on a frequent basis to receive intravenous antibiotics or self-administers antibiotics in addition to other drugs.

Skilled Nursing Facility – community-based unscheduled care clinic (administration of intravenous antibiotics to patient attending an intermediate care clinic)

A patient is referred by GP or discharged home from an acute hospital to attend a community-based ambulatory service, such as a nurse-led walk-in treatment centre, or a community hospital.

Patients are assessed as suitable for OPAT by a specialist nurse and a treatment regimen. Implemented either following a patient group direction for GP-referred patients with specific conditions (for example, cellulitis or multidrug resistant urinary tract infection) or based on a hospital discharge plan. The patient attends the community-based ambulatory clinic on a frequent basis to receive intravenous antibiotics. For patients referred from an acute hospital there is periodic clinical review in either an infection clinic or specialty clinic.

SWOT risk scoring            

The process of risk scoring will allow for the measuring and comparison of each service model under consideration. The risk scoring matrix works as follows:

1. A list of benefits that could apply to all options (between 5 and 8 in number) should be identified. NOTE: Accepting that total benefit will be 100/100 (or 100%), each benefit should be weighted to reflect its overall importance (for example, where there are 5 benefits, one of which is patient choice, you may consider patient choice to comprise 25% of the entire benefit, in which case it would score 25).
2. Score each of the shortlisted options against the weighted benefit criteria. Scoring should be on a scale of 0-10 where:

0 = does not meet benefit criteria at all and

10 = meets the benefit criteria extremely well or could not be bettered.

3. The weighting factor and benefit score are multiplied to give the weighted score.

Download an editable copy of the SWOT risk scoring template. 

Benefits of a business plan

• can you explain the benefits of completing the process of producing a business plan for OPAT?
• can you outline the aims and goals of your OPAT project?
• can you describe the OPAT project’s aims and objectives? Have you included a description of the current problem and proposed solution that OPAT will provide?
• have you described the setting where OPAT services will be delivered?
• have you explained the expected benefits or outcomes plus outline assumptions made about cost savings that are expected from the introduction of OPAT services?

Importance of showing innovation

• have you positioned the OPAT proposal as both innovative and feasible?
• have you included all relevant OPAT literature?
• have you provided examples of the effectiveness of OPAT implementation elsewhere as evidence to show it can be done successfully in your organisation?

Checklist for consideration in preparing a business plan for new OPAT services

The role of the team

• can you explain the role of the OPAT team in preparing the plan?
• can you show that teams are integral to success and how the work of the team and the role of the team leader are key in dynamic environments?
• does your plan recognise that within the NHS business strategies are evolving?
• have you positioned OPAT as a new solution that is needed that delivers what customers are seeking?
• have you shown that you recognise the need within the modern NHS to work efficiently, considering value for money and in more collaborative and integrated ways?

The importance of a shared vision

• does your plan for OPAT fit within the vision of your organisation and the Integrated Care System (the direction in which your trust is going)?
• do your plans demonstrate that your OPAT aims will connect with the organisation’s vision?
• do your OPAT leaders and team members align and engage resources and stakeholders effectively?
• have you demonstrated that you are effective in encouraging the OPAT team to leverage their collective expertise?
• have you demonstrated that your team can maintain focus and drive needed to meet the team’s goals?
• is everyone open to give and receive feedback both inside and outside the team and with stakeholders?

Content of the OPAT plan

• does your OPAT plan clearly describe?
• where OPAT will be delivered (products, departments or specialties)?
• how OPAT will be effectively implemented (means to implement)?
• how OPAT will be judged as superior to existing methods of care?
• how fast the service can be implemented and what should be the logical order of events?
• how money will be saved by implementing OPAT?

Does your plan include the following?

• a project title. Have you included the name of your healthcare organisation or the site where your service is or will be located (primary care, secondary, tertiary or all three)?
• have you included the name of the project leader, i.e. the primary contact? This person needs in- depth knowledge of the project proposal and must be available throughout the life of the project. This may be you or the project leader.
• have you described the qualifications of the project leader and the people who make up the team?
• the project leader is often responsible for planning, delivering and reporting on progress with OPAT. It may help to describe the project leader’s current role in the hospital.
• describe each other member of the project team – explain their current role in the organisation and their planned role within the OPAT project team. It may also help to explain why they were each brought together to join the team for this project and the special knowledge and skills that each brings.

Role of stakeholders

• have you demonstrated the importance of identifying stakeholders?
• have you described how stakeholders can play small or large roles in shaping the OPAT service, funding the project or influencing others to contribute time and resources?
• have you shown that although stakeholders may play no role at all in implementation, they may be recognised opinion leaders or have a strong interest in the outcomes?
• have you shown that stakeholders can help in identifying all potential stakeholders’ early involvement builds lasting solutions?
• have you recognised the benefits of ensuring that stakeholders fully understand the complexities of the challenge?
• have you demonstrated how stakeholders themselves can offer other approaches to the problem?
• have you demonstrated how the patient experience will be captured?
• have you identified who has overall responsibility for delivering the plan (senior responsible officer)?

Improvement over existing services

Potential money-releasing opportunities

Have you explained how your OPAT service may be capable of increased efficiencies by:

• reducing low acuity clinical activity that could safely be managed in the community, allowing inpatient resources to be better prioritised for unwell and unstable patients?
• reducing complications and eliminating defects in care, for example will you be able to reduce complication rates and longer lengths of stay and greater spend on medicines and readmissions?
• improving infection management with the input of an infection specialist where possible (infectious diseases or microbiology)?
• gaining greater value from previously under-used resources, for example enabling patients, carers and communities manage and improve their own health; empowering members of the healthcare team; removing potential barriers that may block the full value of the team?

Areas expected to improve (in addition to efficiency)

Have you explained how your OPAT service may be capable of improving:

• the safety of patient care?
• the effectiveness of care offered?
• a more patient centred caring?
• timeliness (available 24/7 and at the time of need)?
• equity of services for all potential patients (and how this will be monitored and evaluated)?

Minimising rejection

• what measures have you taken to minimise the rejection or delay in approval of the OPAT plan?
• have you clearly described the expected impact of OPAT as an innovative service?
• where appropriate, have you provided robust modelling of the real (not potential) cash savings that can be delivered within the 12 months?
• have you included clear assumptions about where the savings will come from, for example staffing, equipment, as measured against any implementation costs?
• have you explained where future savings will be accrued and then redeployed?
• have you provided whatever evidence is available that OPAT will not only lead to savings, but will also improve or maintain other aspects of the quality of care provided?
• have you emphasised the likely impact on the numbers of patients benefiting through the pilot phase (if a pilot is planned) and the longer-term potential scale of the impact if OPAT was successfully spread?

Focus on details

• have you explained in detail the methods planned to be used to assess the impact of OPAT?
• have you explained why experts chosen were chosen?
• have you provided evidence of the team’s high level of technical expertise to measure and evaluate progress achieved with OPAT?
• have you provided examples of measurement work carried out by members of the team who will be responsible for evaluating OPAT?
• have you provided clear examples of overall and day to-day activities responsibility that will be assigned to individuals for managing the OPAT project?
• have you demonstrated examples of how the Team Leader will lead on implementing the new OPAT service?
• have you explained the level of commitment already obtained from senior management or clinical champions within the hospital? Described individual team members’ work plans covering their key activities and quarterly milestones.
• have you provided recent examples of a successful clinical quality improvement project led by the team leader or implemented by the team?
• have you described anticipated risks that may arise and the detailed plans to manage these risks?

Have you itemised costs of all major activities:

• projected the anticipated set up costs for OPAT in your location and included details on:
• dedicated time to lead and undertake the project?
• clinical involvement, as appropriate (for example, reimbursement of travel, costs, locum, backfill, focus, groups, survey design)?
• supply of technical skills (for example, statistical support, data collection, quality improvement skills, evaluation)?
• travel costs?
• have you explained how you arrived at the costs and how these represent good value for money?
• have you provided evidence that you have explored and researched your costs in detail?

Publication reference: PRN01192_ii