Primary Care Commissioning Committee. Approval of Initial 2018/19 Budgets. 22 March 2018

Transcription

1 Primary Care Commissioning Committee Approval of Initial 2018/19 Budgets F 22 March 2018 Author Sponsor Director Purpose of Paper Linda McDermott Finance Manager Julia Newton - Director of Finance The purpose of this paper is to ask PCCC to approve the initial budgets for primary care services for 2018/19 based on the latest information available. Key Issues PCCC has full responsibility for approving the use of the Primary Care Co-commissioned (delegated) budget from NHS England (NHSE) and has responsibility for approving the use of other funding for primary care allocated from within the CCG s main programme allocation. It is the responsibility of the CCG s Governing Body to approve the overall financial plan for the CCG and hence the aggregate level of funding to be made available for primary care within this overall plan. The CCG s Governing Body approved the CCG s overall financial plan for 2018/19 on 1 March This plan seeks to deliver the in year breakeven control total set by NHSE, support delivery of the national must be dones as set out in the planning guidance and make progress on local priorities as identified through the Sheffield Place Based Plan and subsequently agreed Sheffield Accountable Care Partnership (ACP) priorities. This plan requires 16.7m QIPP (efficiency) savings and these have principally been targeted at acute hospital spend, while still requiring some efficiencies in other areas of spend such as GP prescribing and continuing care. In this context it is important to note that the CCG s Governing Body kept the recurrent level of funding for primary care from within the CCG s main allocation in line with 2017/18 forecast out-turn spend and confirmed non recurrent budgets in line with national guidance or previously announced NHSE FYFV funding. NHSE published the national planning guidance and revised CCG allocations / business rules on 2 February There were no additional specific allocations for primary care announced and no specific additional requirements. GMS contract negotiations are ongoing and therefore the outcomes are not yet known and the Doctors and Dentists Remuneration Board (DDRB) is not scheduled to make recommendations until the end of May. Thus the pay pressures for 2018/19 are not yet established. The 1% budget reserve (0.7m) is being held for pressures in excess of previous 1% planning figure because it is not yet clear whether additional national funding will be made available linked to any pay settlement in excess of 1%. Is your report for Approval / Consideration / Noting Approval. 1

2 Recommendations / Action Required by the Primary Care Commissioning Committee The Primary Care Commissioning Committee is asked to: approve the initial budgets for primary care as set out in Appendices 1 and 2 note the additional non recurrent funding expected to be available in 2018/19 as set out in Table 1 and Appendix 3 Governing Body Assurance Framework Which of the CCG s objectives does this paper support? Strategic Objective - To ensure there is a sustainable, affordable healthcare system in Sheffield. It supports management of the CCG s principal risks 3.1, 4.1, 4.2 and 4.3 in the Assurance Framework. Are there any Resource Implications (including Financial, Staffing etc)? Resource implications are discussed in the paper. Have you carried out an Equality Impact Assessment and is it attached? Please attach if completed. Please explain if not, why not There are no specific issues associated with this report. Have you involved patients, carers and the public in the preparation of the report? Not applicable. 2

3 1. Purpose of Paper Approval of Initial 2018/19 Budgets for Primary Care The purpose of this paper is to provide: Primary Care Commissioning Committee 22 March 2018 the opening budgets for 2018/19 for primary care services Appendices 1 and 2 a summary of the main assumptions used to develop the plans a summary of known additional funding for 2018/19 the key issues and risks which require further work and consideration As noted in the cover sheet, PCCC has full responsibility for approving the use of the Primary Care Co-commissioned (delegated) budget from NHSE and has responsibility for approving the use of other funding for primary care services allocated from within the CCG s main programme allocation. It is the responsibility of the CCG s Governing Body to approve the overall financial plan for the CCG and hence the aggregate level of funding to be made available for primary care within this overall plan. The CCG s Governing Body kept the recurrent level of funding for primary care from within the CCG s programme allocation in line with 2017/18 forecast out-turn spend and confirmed non recurrent budgets in line with national guidance or previously announced NHSE FYFV funding. 2. Primary Care Delegated Budget and Compliance with NHSE Business Rules. While revised CCG allocations for 2018/19 were published 2 February 2018 there were no changes made to the Primary Care Delegated Allocations and uplifts announced on 8 January These confirmed cash uplifts for primary care delegated budgets as: Cash Uplifts Sheffield Primary Medical k 1,375 1,469 Sheffield Primary Medical % 1.8% 1.9% National Primary Medical % 3.1% 2.5% The table above confirms that Sheffield CCG receives uplift well below national average growth due to having a historic allocation well above fair shares target and the policy decisions taken by NHSE s board on 17 December It is important to note that GMS contract negotiations are ongoing and the Doctors and Dentists Remuneration Board (DDRB) is not scheduled to make its recommendations until the end of May. Thus the pay pressures for 2018/19 are not yet established and it is not yet clear whether additional national funding will be made available linked to any pay settlement in excess of 1%. Existing allocations were based on a 1% uplift assumption. 3

4 For 2018/19 NHSE changed some of the business rules as follows: CCG Financial Business Rules Value Sheffield CCG has been set an in year breakeven control Breakeven total. As part of this primary care budgets will be expected to deliver a breakeven position ie expenditure to equal budget. CCGs no longer have to set aside 0.5% of their allocation for potential contribution to a national risk reserve; CCGs can choose to spend the 0.5% of allocation which we previously had to demonstrate was only spent non recurrently, recurrently. CCGs should hold a 0.5% uncommitted general contingency at the start of the year to manage their in-year pressures and risks; This rule applies to primary care delegated budgets and is not changed from 2017/18. Potentially 740k release of resources for new investment BUT need to await outcome of DDRB settlement to see if required for inflation pressures 370k reserve required at start of financial year. 3. Initial Budgets for Primary Care Services /19 The proposed opening budgets for 2018/19 are attached at Appendices 1 and 2. Table 1 below summarises the allocations as currently known for 2018/19, together with the anticipated spend. It shows all the non recurrent allocations from within the CCG s programme allocation, together with those currently confirmed as from NHS England as part of the Five Year Forward View work. We expect additional in year allocations in respect of the latter and these will be added into budgets once confirmed and received. 4

5 Table 1 : Summary of Resources 2018/19 Primary Care Additional CCG Additional CCG Delegated Commissioned Commissioned Total Budgets Services Services Total Non- '000 '000 '000 ' /17 Confirmed Allocation Less: Subsequent claw backs by NHSE Add: confirmed cash uplifts /18 uplift /19 uplift Less: Transfers to CCG Commissioned Services = PMS transition released -mainly to fund "over & above" LCS 74,747 74,747 (226) (226) 1,375 1,375 1,469 1,469 (3,425) 3,425 0 CCG commissioned service recurrent budget b/f Primary Care Access funding made recurrent for 18/19 9,185 9,185 3,496 3,496 Non- Funding PCS System-Wide Work Practice Transformational Support (bal of 3 per head) Primary Care at Scale - Networks - 1 per head Primary Care at Scale per head On-Line Consultations ,539 1, Initial Budgets 2018/19 (note 1) 73,940 16,106 2,724 92,770 Use of Proposed Budget 2018/19: Delegated Expenditure Core Contract Premises Directed Enhanced Services QOF Other GP Services Additional CCG-Commissioned Expenditure: Ophthalmology GP Services Pharmacy Other Primary Care Expenditure QIPP PLI Budget Reserves: Non- Reserve - 1% (note 2) General Contingency Reserve 0.5% (note 3) Development Reserve Practice Transformational Support & Primary Care at Scale 50,828 10,139 1,731 7,635 2,498 50,828 10,139 1,731 7,635 2, , , ,670 (24) ,820 (24) ,574 2,574 Total Use of 2018/19 Budgets 73,940 16,106 2,724 92,770 Note 1: Budget is 103k higher than per GB Board Paper as it includes budget for PLIs which forms part of CCG's RCA Note 2: 1% reserve to be held for outcome of DDRB settlement and any other pressures arising from GMS contract negotiations Note 3: at the start of the year, to meet NHSE Business Rules the CCG must provide for a 0.5% contingency on Delegated Budgets 5

6 4. Delegated Primary Care Budgets 2018/19 Initial Budgets are set out at Appendix 1. As noted above, 2018/19 GMS contract negotiations continue and the recommendation of the DDRB is not expected until the end of May Therefore a number of assumptions have been used as advised by NHS England, when setting these draft budgets including: A best estimate of the recurrent commitments as the 2017/18 brought forward position. For QOF this is based on 2016/17 achievement as further work is still required on the likely 2017/18 position 3.4% uplift for core GMS and PMS contracts (which includes 1% DDRB, 1.7% other expenditure and 0.7% demographic growth) 1.4% inflation increase on premises reimbursements 1.0% uplift on everything else The impact of these changes is an additional potential cost of 1,933k. This is in excess of the allocated growth funding of 1,469k and therefore creates a 464k cost pressure. This is as a direct result of receiving a lower allocation uplift (1.9%) than the national average (2.5%) as shown in section 2. In addition there are other estimated recurrent cost pressures from 17/18 including premises and CQC fees, after off-setting anticipated savings in Seniority payments. These cost pressures can be funded by the reduction in PMS budgets of 720k as part of the PMS transition arrangements (last year of a 5 year scheme), leaving a small (66k) residual reserve which is being transferred to CCG primary care commissioned services to support pressures in 2018/19. In 2017/18 CCGs had to hold 0.5% of the delegated budget to contribute to national risk reserves and a further 0.5% for non-recurrent purposes. For 2018/19 this restriction has been lifted and thus 740k is available. The first call on this funding must be if the DDRB settlement for core contract is greater than 1% and the CCG receives no additional funding. CCGs have been told to plan on 1% and that is what the draft budgets are based on. The second call would be any other pressures which may arise from the GMS contract negotiations. As a result of last year s GMS contract negotiations a number of initiatives were announced including reimbursement of CQC fees and an indemnity payment of 51.6p/head which CCGs were expected to fund. It is possible that there may be further new commitments agreed as part of the contract negotiations for 2018/ k will fund approximately 1.5% additional settlement. The potential downside scenario is that if the settlement is more than 2.5% in total and the CCG receives no additional funding then there will be an additional pressure for the CCG to fund. A decision on where this could be funded from will need to be taken by Governing Body or PCCC but some budgets would be ring-fenced e.g. the Transformation Support budget and the 1.50 for primary care at scale as set out in appendix 3 to this paper. The upside scenario is that all or part of the 740k may be available for investment on local primary care priorities, including winter resilience schemes, if the settlement is fully or partly-funded. 6

7 There are a number of other cost pressures that may also need to be managed in year and we would anticipate these been a first call on the 0.5% general contingency reserve. These include: The revenue consequences of any capital developments. A number of schemes have been agreed from the Business As Usual capital funding. The agreement is that there will be no revenue consequences for five years, but future schemes may require a different approach, particularly if they are the more strategic ones as part of the Estates and Technology Transformation Fund The increase in the weekly amount payable for sickness cover may mean that additional budget is required, This is entirely variable expenditure and hard to forecast 5. Budgets for the Additional CCG Commissioned Services 2018/19 Initial Budgets are set out at Appendix 2. The starting point has been the recurrent forecast out-turn spend on each budget. It is important to highlight that the figures shown are the available recurrent budgets for services and not necessarily the amounts included in contracts from 1 April For example, PCCC last month approved that the Engagement LCSs as they currently exist with GP Practices would all end at 30 September 2018 with a decision shortly as to how the budgets will be deployed from 1 October Similarly the budget for Primary Care Sheffield Ltd includes the funding for CASES and Extended Access (hubs) for which contract arrangements are still being finalised for 2018/19 and so the value shown is not necessarily the final contract value. No adjustment for inflation or efficiency savings has been made. Historically the CCG has not applied the nationally agreed net tariff (inflation less efficiency) % reduction to LCS budgets. In 2018/19 the national inflation/efficiency factor is an overall 0.1% increase to budgets (inflation of 2.1% less efficiency requirement of 2%). Given that LCS budgets have not suffered a cumulative funding reduction in recent years as we have exceptionally applied cash stand still, the proposal is to include the minimal 0% increase in 2018/19. Efficiency Savings (QIPP) 24k QIPP has been planned on the Additional CCG Commissioned Services. This is as a result of the expected reconfiguration of Dermatology services which will see more work undertaken in a community setting but is likely to see one of the existing services transfer into the new arrangements resulting in a QIPP. The intention is for a number of new city-wide community services to be commissioned in 2018/19. The business cases currently being prepared assume funding will be made available to support these developments by making savings from acute care. This is as part of the CCG s strategy to improve out of hospital care and achieve greater resilience of services in primary care. Thus budgets for CCG commissioned community services are likely to increase in year and these may be included in the reports to PCCC depending on the provider(s) of the services. Confirmed Non Investment in Primary Care in 2018/19 Appendix 2 shows the budgets which are currently confirmed. 2,742k in total. PCCC has already received (Primary Care at Scale networks - 1 per head) or will be receiving this 7

8 month (Transformation balance of 3 per head over 2 years and 0.50 per head Primary Care at Scale) papers outlining the process for determining and allocating the funding. There is likely to be other FYFV funding announced/issued in year and will therefore be included in budgets in due course. Summary of Investments In response to queries at Governing Body on 1 March 2018 and also at a recent City Wide Locality Group meeting in March, a summary was produced which provides an overview of funding for the current financial year and for 2018/19 as currently known. This may is attached at appendix 3 as supporting information to this paper. Recommendation: The Primary Care Commissioning Committee is asked to: approve the initial budgets for primary care as set out in Appendices 1 and 2 note the additional non recurrent funding expected to be available in 2018/19 as set out in Table 1 and Appendix 3 Julia Newton Director of Finance 6 March

9 Primary Care Commissioned Services (Delegated) Budget Appendix 1 Initial Budgets 18/19 Budget Budget 17/18 Forecast Variance Opening 18/19 Budget Requirement Use of Growth Monies 18/19 Final Year of PMS Transition release of budget Virement (to) LCS 18/19 Proposed 18/19 Budget Core Contract GMS practices 20,479,007 20,479, ,054 Core Contract PMS practices 27,372,551 27,372, , ,545 Core Contract APMS practices 1,663,343 1,663,343 59,394 List Size Reserve Within Core Contract 189, , ,000 Directed Enhanced Services 1,763,214 50,000 1,713,214 17,632 Premises 9,602, ,000 9,890, ,473 Premises Revaluation Reserve 107, ,655 1,507 QOF 7,559,000 7,559,000 75,590 Other GP services Seniority 1,044, , ,628 8,446 Locums 456, ,370 4,564 Occupational Health 45,359 45, CQC Fees 206, , ,241 3,622 Indemnity 298, ,980 2,990 Training 11,000 11, Prescribing & Dispensing Doctors 481, ,142 4,811 Reserves 1% Reserve (which in 17/18 0.5% had to be held for NHSE Risk Reserve) 726, ,000 14, % General Contingency 363, ,000 7,000 RESERVE 0 464, ,545 66,232 Total 72,359, ,000 72,537,000 1,469, ,232 21,159,061 27,566,672 1,722, ,593 1,730,846 10,029, ,162 7,634, , ,934 45, , ,970 11, , , , ,939,768 9

10 Additional CCG Commissioned Expenditure on Primary Care Services Initial Budgets 18/19 Appendix 2 Budget Budget 17/18 Forecast Variance 17/18 or FYE of New Investment Opening Budget for 18/19 Opening NON recurrent Budget for 18/19 Proposed 18/19 Budget Paediatric Referral Refinement 21,900 2,925 24,825 Glaucoma Service 7, ,295 CATS Scheme 10,180 (790) 9,390 PEARS Scheme 250,989 41, ,442 Ophthalmology Services Sub Total 290,944 44, , Hour Blood Pressure Monitoring 196,954 23, ,541 Anticoagulation 904,729 (84,481) 820,248 Care Homes 754, ,667 Care Planning 500,000 (200,000) 300,000 Care Of Homeless 42, ,667 Carpal Tunnel 10,281 (9,001) 1,280 Eating Disorders 37, ,756 D Dimers 2,025 (375) 1,650 Dermatology/Cryotherapy/Cutting 31,875 (4,505) 27,370 Dmards 192,043 23, ,634 Endometrial Biopsy 4,475 8,215 12,690 Hepatitis B 7,405 (395) 7,010 Mirena 29,583 (8,215) 21,368 Colorectal Screening 6,562 1,540 8,102 Pessaries 47,550 (130) 47,420 Latent TB Screening (allocation due) Zoladex 41, ,040 Minor Surgery 21,905 (1,345) 20,560 Existing Dermatology & Respiratory Clinics 65, ,000 PMS Transition:"Over and Above" 2,896, ,896,000 Special Cases 530, ,000 GP Engagement Elective Service Transformation 1,158, ,158,434 GP Engagement Prescribing Quality 289, ,637 GP Engagement Neighbourhood Developments 868, ,834 QIPP proposals (24,000) (24,000) Services Commissioned from GP Practices Sub Total 8,639,046 (274,138) 8,364,908 0 Pharmacy Sub Total 448, ,100 0 GP IT 1,238,936 4,676 1,243,612 Current Budget for contract with Primary Care Sheffield Ltd in 18/19 90,256 4,445,005 4,535, ,000 Out of Hours 20, ,083 GP Training 40, ,000 Interpreting Services 782,595 (18,000) 764,595 Other Primary Care Expenditure Sub Total 2,172,096 4,432,455 6,604, ,000 Primary Care Developments 250, ,000 0 Practice Transformational Support (Bal of 3 per head) 0 0 1,539,000 Networks 1 per head ex NHSE ,000 Primary Care at Scale 0.50 per head partly ex NHSE ,000 On Line Consultation ,000 Reserves Sub Total 250, ,000 2,574,000 24,825 8,295 9, , , , , , ,000 42,667 1,280 37,756 1,650 27, ,634 12,690 7,010 21,368 8,102 47, ,040 20,560 65,000 2,896, ,000 1,158, , ,834 (24,000) 8,364, ,100 1,243,612 4,685,261 21,083 40, ,595 6,754, ,000 1,539, , , ,000 2,824,000 Additional CCG Commissioned Expenditure on Primary Care Services Total 11,800,186 4,202,325 16,002,511 2,724,000 18,726,511 PLIs 103,000 Total Budget 2018/19 18,829,511 10

11 Primary Care: Summary of New and Continued Funding in 2017/18 and 2018/19 Appendix 3 Non A) From CCG Main Allocations 1 Transformation Support (3/head over 2 years) This Funding is RING FENCED Prescribing Quality Incentive Scheme 2017/ /19 When will it be '000 '000 available from? 227 1,539 TBC could be several '000 Different times depending on solutions 01/06/2018. Need to await final 17/18 prescibing costs known mid May Process for Making Available PCCC approved principles in July 2017; Update to PCCC in March 18 re 18/19; Examples of spend to date include on 10 physican associates and training for 60 managers via ILM Practices can earn upto 1 per head if practice (0.50), locality(0.25) and CCG (0.25) underspend, Plus if Locality underspends 50:50 gain share with CCG; Funding available for primary care spend per rules set out in PQIS. Business Case proposal re Prescribing Order Line due to CCG's CCC 6 March which may be a possible use of PQIS funding if Localities/Practices agree. 3 Virtual Ward Pilot B) From NHS England mainly as part of Primary Care FYFV 1 Primary Care at Scale This funding is RING FENCED 2 Primary Care Workforce Development Hub 3 Primary Care at Scale Local Care Network (1/head) This funding is RING FENCED 4 On Line Consultations 5 Training Care Navigators and Practice Staff 6 Resilience Funding 7 Contribution to Winter Resilience 324 TBC TBC TBC 591 TBC Apr 18 In progress Business case to be completed by end of March 18 to determine if city wide roll out appropriate and possible models. Funding source not yet identified New 's including 64k top up from CCG to make to 50p per weighted pop; Expected funding for practices re MDTs. Paper to PCCC in March 18 This is funding to which is SY&BL wide. 175k of funding comes from HEE in 2017/18. Paper to PCCC in January 18; Distrbution linked to completion of Primary Care Neighbourhood development tool. Due to be completed April 18. Funding from NHSE for roll out of this IT solution Funding for 17/18 allocated. 2018/19 TBC Received 200k contribution from NHSE, plus 150k from CCG allocation to continue additional primary care access through the winter. At the moment no budget for 2018/19 as NHSE confirmed no funding. Potentially dependent on DDRB settlement whether any reserves available. TOTAL NEW FUNDING AVAILABLE 1,127 2,832 A) From CCG Main Allocations Locally Commissioned Services Other eg GP IT, Interpreting, PLIs Local Primary Care Development Reserve PCS ltd Extended Access PCS ltd CASES pilots, clinical pharmacists Contribution to Social Prescribing CSWs etc 9,172 2, , ,148 2, ,496 1, There are NO plans to reduce the total funding available This covers the full range of LCSs most of which were the subject of paper to PCCC in public in February 2018 to discuss future arrangements. Development reserve for non recurrent pump priming initiatives etc. For example in being used to support training for practice staff via Microsystem Academy (80k across 2 years) and in 17/18 each Locality received 12.5k to support neighbourhood development in additional to neighbourhood LCS Contract with PCS ltd for hubs pre committed until 31 M 18/19 funding dependent on final agreement re CASES contract. Final recurrent funding for CASES from April 19 will depend on outcome of procurement Contract arrangements via City Council C) Primary Care Co commissioning Delegated Reserve TBC. DDRB settlement expected to be known by end of May. In 2017/18 CCGs had to hold 0.5% of delegated budget to contribute to national risk reserve and a further 0.5% for non recurrent purposes. This was used to fund some of NR costs above. For 2018/19 these restrictions have been lifted. Thus we have 740k available. The first call on this funding MUST be if the DDRB settlement for core contract is greated than 1% and the CCG receives no additional funding. CCGs told to plan on 1% and this is what is in our budgets at the moment. IF CCGs have to self fund an increase above 1% from within existing allocations we will first use this reserve which will fund approx 1.5% additional settlement. DOWNSIDE SCENARIO: If the settlement is more than 2.5% and we get no extra funding we have an additional pressure into CCG. Decision on where this could be funded from will need to be taken by Governing Body or PCCC, but we will ring fence 3 and 1 per head budgets. UPSIDE SCENARIO All or part of 740k may be available for investment in local primary care priorities if settlement fully /partly funded. Total 16,406 17,069 Total 17,533 19,901 11