February 2013

Croydon 2012/13 Financial Position and Recovery Plan Month 10 YTD Performance

0

Attachment C1, Appendix 15

Index 1. Financial Position Summary 2. Mitigations 3. QIPP Recovery Performance 4. 5 Year Projection (pre-QIPP) 5. Allocations/Population 6. Governance

1

1. Executive Summary

• The key risks/variances facing the PCT at Month 10 continue to be:

• Acute over-performance (CHS, ESH/Kings/GST/SLH)

• QIPP: unidentified projects and reducing capacity from activity shifts

• Contractual/performance issues on UCC and community services

• Primary Care/Specialist Commissioning

• The PCT is forecasting a breakeven position based on Month 10, following

the release of funds from the SWL Risk Sharing Arrangement (£9.0m) and

additional resource limit released for continuing care restitution payments

(£2.6m) and Croydon share of transition costs.

• Recognising that a year-end agreement has not been reached with

Croydon Healthcare Services (CHS) this risk range on the position is +/-

£1m.

2

1.1 Financial Outturn – M9 Forecast

3

Financial

Performance

Target/ Indicator

Measure Target Forecast Status Performance

Trend

Statutory Break Even Duties

Revenue Resource

Limit (RRL) Stay within RRL

£614.7m

(incl £9.0m

from risk

share)

£614.7m

Red

(underlying

performance)

Capital Resource

Limit Stay within CRL £2,0m £2,0m Green

Cash Resource

Limit

Stay within Cash

Limit

£614.2m

(incl from

£9.0m risk

share)

£614.2m

Red

(underlying

performance)

Administration Duties

Better Practice

Payment Policy

Payment of valid

invoices within 30

days.

90%

Non NHS

87% to 80%

NHS 82% to

96%

Amber

Other Significant Financial Targets

QIPP

Delivery of

Programme

Savings

£25.0m £20.6m Red

Running Costs Stay within running

cost envelope. £12.0m £12.0m Green

1.2 Financial Performance

By Receiver Organisation

4 *Note the the CCG position reflects the benefit of the SWL risk share arrangement (£9.0m in

forecast outturn). The underlying adverse forecast outturn for the CCG is £5.5m.

M10 Forecast Outturn Variance

by Receiver Organisation

£2.0m

(£3.1m)

£0.0m

£3.5m

(£4.2m)

£0.0m£1.1m £0.8m

(£6.0m)

(£4.0m)

(£2.0m)

£0.0m

£2.0m

£4.0m

CCG NCB LA PCT

De

fici

t /

Su

rplu

s

Year to Date

Forecast Outturn

1.3 Financial Performance

CCG: ACUTE

5

1.4 Financial Performance

CCG: Out of Hospital Services

6

CCG: Out of Hospital Care

M10 Financial Performance

(£3.0m)

(£2.0m)

(£1.0m)

£0.0m

£1.0m

£2.0m

£3.0m

£4.0m

Comm

unity

SLA

Continuing

Care

APMS

Presc

ribing

LES/

Inte

rmed

iate

MH/L

D

Corpora

te

Unmet

QIP

P

Ad

vers

e /

Fav

ou

rab

le V

aria

nce

Year to Date

Forecast Outturn

1.5 Financial Performance

NCB: Primary Care / Specialist

The forecast outturn on specialist services does not reflect “2nd take” services. Currently there is a

£1.5m adverse variance on these services (renal and mental health) which is currently reported

under CCG acute/mental health. The PCT is working closely with the London Specialist

Commissioning Group and providers to disaggregate.

National Commissioning Board Services

M10 Financial Performance

(£2.5m)

(£2.0m)

(£1.5m)

(£1.0m)

(£0.5m)

£0.0m

£0.5m

Specialist

Acute

GMS/PMS APMS Dental Pharmacy Ophthalmic Other

Adv

erse

/ F

avou

rabl

e V

aria

nce

Year to Date

Forecast Outturn

7

1.6 YTD Financial Performance

By GP Network (1 month in arrears)

The CCG has established 6 GP Networks across Croydon. This is based on the original

configuration of GP networks. There is now agreement to migrate rapidly to geographic based

networks. Future data will be presented on that basis. Whilst no network is in balance, there are

individual practices in a surplus position. 8

1.7 YTD + FOT QIPP Performance Graph

9

1.8 RAG Rating of QIPP Schemes

The Patient Navigation Service (£0.4m QIPP) has won the HSJ Efficiency in Commissioning

Support Services Award for 2012 and was shortlisted as a finalist for the prestigious HSJ Awards

2012 for Secondary Care Service Redesign (with Croydon Health Services NHS Trust) 10

PMO RAG

Rating

Number of

Projects

Annual Plan

(£000)

Forecast

Saving

(£000)

Variance

(£000)

Green 20 13,608 18,420 4,812

Amber 6 2,564 1,777 (787)

Red 17 6,324 388 (5,936)

Unidentified 2,504 - (2,504)

Total (M9) 43 25,000 20,585 (4,415)

Total (M8) 43 25,000 20,161 (4,839)

2. Mitigating Actions

• Capacity

• Addressing Acute Overperformance

• Closing QIPP Gap

• Other Actions

11

• All CCG Directors appointed as of 1 September 2012

• Lay members, nurse and secondary care clinician have

all been appointed from December 2012

• Deputy Director of Strategy appointed and starting end of

February 2013.

• Review of time commitment from clinical leaders and

development of practice engagement scheme.

• Shadow running SL CSU services (finance, informatics

etc)

2.1 Actions - Capacity

12

2.2 Actions – Acute Overperformance

13

Trust (M10 FOT) POD Action

All / General Planned Care • Rollout of CReSS referral management system by March 2013, especially

northern practices (1 Oct 2012) re Kings/GST

• Waiting List validation on a 8 weekly basis by GPs

• QIPP includes a number of project to provide alternative settings of care to

reduce activity in acute.

All / General Non Elective

Care

• Manage benefit of NHS 111 implemented in 11/12 – lower OOH

• Implementing UCC new model of care at CUH from April 2012

• Progress transfer of satellite UCC services to GP provision

• Joint programme with borough to invest reablement funds to reduce

admissions and readmissions

• QIPP scheme on long term conditions, EOLC and COPD Hot Clinic CUH

• Development of Long Terms Conditions strategy to avoid inappropriate

admissions, incl risk stratification across all practices in 2012/13

CUH

(£5.2m Adv)

Non elective

Maternity

High Cost Drugs

• Above: ACU validating appropriateness of short stay

• ACU reviewing ratio of non-deliveries/deliveries

• CCG Prescribing team validating against SWL policy

• Borough Team seeking to conclude year-end agreement in February

ESH(£2.0m Adv) Non elective

SWLEOC

• Year end agreement

• Referral management via CReSS system.

St George’s (£1.0m) Critical Care • Year end agreement

King’s Healthcare

(£2.5m Adv)

Maternity

OP Proc

• Roll out of CReSS to northern practices to manage referrals

• Closer working with Lambeth Commissioners through SL CSU structure

Guy’s and St Thomas

( £1.9m Adv)

Non elective

Critical care

• See above on non elective care

• Year end agreement

2.3 Actions – Year End Agreement

14

Trust Action

Croydon Health

Services

• Identified gap of £3.5m (KPIs, ECIs, Community

Overperformance, seasonality)

• EWTD agreed (40% settled)

• PCT has offered 50/50 ie £1.7m to close the gap

• Trust is YTD deficit and not in a position to negotiate.

• Discussions/letters on-going/ meetings planned.

• Seeking arbitration process to resolve.

St George’s • Wandsworth CCG leading

• Year end agreement reached – in process of being confirmed in

writing.

Epsom & St Helier • Sutton CCG leading

• Year end deal agreed (not EOC), in process of being confirmed in

writing

South London

Health

• Cap agreed in the contract. No risk

Guy’s & St Thomas

• Lead commissioner has reached year end agreement.

South London &

The Maudsley

• Negotiations being concluded in February – low risk

2.4 Actions – QIPP Gap

15

• QIPP Governance Arrangements in place.

• Maximise impact of existing schemes during 2012/13.

• Long Term Conditions (incl Risk Stratification) and

Urgent care are key opportunities to be pursued for Q4.

• Review of local, London and national QIPP case studies.

• Completed local benchmarking and opportunities review.

• Croydon facilitating SL QIPP Leads forum and

participation in NHS Benchmarking Network (longer

term).

• GP Engagement

- 6 x GP networks – agreed to move to geographic basis

- eQuIPPed newsletter to practices on QIPP Actions

- Finance Team attending GP Networks to present practice

level financial performance (see 1.8)

2.5 Actions – Clinical Leadership

16

• £25m recovery target (net after investment)

• £22.5m Net Savings Plans Agreed (90%)

• Risks on Forecast outturn:

• Non-delivery on agreed schemes (£1.9m)

• Non-delivery to be identified (£2.5m)

3. Recovery/QIPP Performance

17

• Based on 9 months actual data

• Achieved net savings of £14.6m against plan of £17.3m (84%)

• Key areas of adverse performance:

• Primary Care

• Shift of Care: Intermediate Services / Demand Management

• Mental Health Efficiency

• LTC and GP Support for Care Homes initiatives

• Direct Access Diagnostics

• Key areas of favourable performance:

• Continuing Care: Mental Health, Children and LD

• Prescribing

• Corporate/Public Health

• Community Efficiency

• Acute KPIs/underperformance in outpatient activity

3.1 Year to date performance

18

3.2 2012/13 Programme Overview

QIPP Category

2011/12

Outturn

2012/13 Planned Net Savings

Confirmed Work in

Progress Total

Mental Health 1,465 3,083 3,083

Acute Sector 1,977 9,978 9,978

Primary Care 1,294 824 824

Community Support Services - 1,416 1,416

Activity Shifts - 1,147 1,147

Long Term Conditions 480 2,158 2,758

Urgent Care 2,365 104 404

Planned Care 3,547 1,407 1,407

End of Life 350 877 877

Staying Healthy - 325 325

Back office 2,965 177 277

Staffing - 240 240

Prescribing 2,325 800 800

Total 16,769 22,536 0 23,536

Unidentified 2,464

Target savings for 2012/13 22,536 0 25,000

RED HIGHLIGHT: Delivering shifts of activity, but not seeing underperformance on acute

SLAs

19

3.3 Top Ten QIPP Schemes

Project £’000 PMO

Rating Status Description

Acute KPI/CQUINs – CUH 8,145 G New Savings from agreed contract levers with CUH

Mental Health Efficiency 2,030 R New Reduction in acute MH contract value, activity

reductions and shifts into primary care

CCHS (Community) Efficiency 1,416 G New Reduction in agreed value of CCHS contract

COPD Community Service 874 R Exp. COPD ‘hot clinic’ to avoid emergency

admissions, doors opened in March

Prescribing Efficiency 800 G New Reduction in GP prescribing spend. Limited

data YTD.

LSCG Efficiencies 778 G New Principally reduced pricing for SCG services

Acute KPI/CQUINs – Other Trusts 746 G New Savings from agreed contract levers with other

Acute Providers

Mental Health National Efficiency 735 G New National efficiency adjustment

Urology Service Redesign 600 G New Savings agreed with CUH through service

redesign

Intermediate Ophthalmology Pathway 575 R FYE Community triage service established to reduce

activity flow into Secondary Care

Total (67% of total target) 16,699

20

3.4 Key Programme Risks - Update

Risk Mitigation

1 Lack of support from clinical commissioners to the relevant aspects of the programme.

• CCG sign up to QIPP and recovery plan.

• Responsibility for aspects of the plan taken on by clinical commissioners.

• Continued engagement through GP open meetings, Clinical Leadership Group and GP Networks.

• Continued involvement of CCG leaders in decision making and key meetings

2 Lack of buy in from acute clinicians and management to support the required service developments.

• Establishing dedicated strategic group with CUH.

3 Loss of organisational memory due to the transition process.

• All QIPP schemes will have a detailed delivery plan held centrally by the PMO

• Expectation that a number of staff will be retained in the new structures

4 Lack of resources to deliver the programme as a result of the reduction in headcount.

• Where possible schemes are being stretched rather than new schemes introduced

• May require additional resource if not possible to manage with existing structure

5 Failure of specific QIPP plans. • Continuation of QIPP Operational Board to tackle problem schemes

• Continuation of existing PMO structure

• Development of further QIPP schemes to allow for shortfalls on existing schemes

6 Unforeseen cost pressures in other areas such as continuing care and forensic mental health

• The development of specific plans to protect against over spends in areas that are likely to give rise to cost pressures.

21

4. Programme Governance

• The governance structure has been revised to include tighter oversight and

monitoring arrangements. The tactical and operational focus on delivery of the

recovery programme and management of programme risks has been

enhanced. The arrangements also anticipate CCG governance requirements.

• GPs are involved through all levels of the recovery programme, including

leadership of the integration agenda, oversight of the recovery programme,

unblocking specific operational issues and support to individual projects.

• Each project has a a project manager, GP sponsor, SMT sponsor and finance

lead. This matrix working is integral to ensuring delivery

22

4.1 Programme Governance (Transition)

Governance structure has been

designed along the lines used for

NHS Sutton & Merton with a separate

Challenge Trust Board formed to

oversee the recovery process and to

inform Finance Committee and the

Joint Boards.

A second structure has been agreed

from 1 April 2013 when CCG is

authorised.

SWL Joint Finance

Committee

Croydon Challenged

Trust Board

SWL PCTs Joint

Boards

QIPP Op’s Board

(weekly)

Acute Task Group

(monthly in QOB)

Croydon CCG

Board

Croydon CCG Management Team

(Incl dedicated Recovery Agenda)

Strategic

Transformation Board

23

4.2 Programme Governance (CCG 1/4/13)

A second structure has been agreed

to operate from 1 April 2013 when

CCG is authorised.

Inevitably there will be an equivalent

body to the current Challenged Trust

Board arrangement that would

between the CCG Governing Body

and NHS Commissioning Board.

QIPP Op’s

Board(weekly)

Acute Task Group

(monthly in QOB)

NHS Commissioning

Board

Croydon CCG Management Team

(Incl dedicated Recovery Agenda)

Strategic

Transformation Board

Croydon CCG

Governing Body

Integrated

Governance Committee

Finance Committee

Members

24

4.3 Programme Management

• Director of Commissioning in place

to lead Commissioning Team

• Chief Finance Officer in post

• Dedicated PMO/recovery team to

lead and oversee delivery.

Recruiting third member of team.

Accountable Officer (Designate)

Borough Managing Director

Chief Finance Officer

(Finance and Recovery)

Commissioning Managers

(QIPP leads)

Programme Office Support

Head of Programme Office

Programme Office Support

Data analyst (to be appointed by CSU)

Director of Commissioning

25