Attachment D1. Month 6 QIPP Report. 1 Background

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Roland Rice
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1 Attachment D1 Month 6 QIPP Report 1 Background 1.1 The South West London (SWL) Quality, Innovation, Productivity and Prevention (QIPP) plans are set in a context of an environment in which complex issues are acting to increase patient demand and expectations, but where cost reduction, reducing unwarranted practice variation and improving efficiency are critical success factors. The proposals within Croydon s QIPP Plan aim to provide a basis on which to implement a range of service improvement opportunities within a changing and challenging environment (ageing demographics, the economic downturn, health inequalities, unhealthy lifestyles, rising demand, rising patient expectations, healthcare cost inflation and technology advances etc). 1.2 NHS Croydon has a net QIPP target to deliver 25m net savings in 2012/13 to assist in the recovery of the organisation to bring it back into financial balance. To date, initiatives have been identified to deliver 22.54m net savings in the year, leaving a gap of 2.46m net savings still to be found (with no adjustment for optimism bias). Work continues between the Croydon Borough Team (CBT) and the Croydon Clinical Commissioning Group (CCG) to identify additional projects that will close this gap. However it is recognised that any new schemes identified at this stage of the year are unlikely to yield significant savings in 2012/13. Therefore, the inyear focus is now on maximising and extending the impact of current schemes and to ensure there is no additional slippage to delivery. 1.3 The projects that form Croydon Borough Team s 2012/13 QIPP Plan were developed as part of the normal business planning cycle and include those with either pre-existing agreed funding or yielding a positive net saving in year. 1.4 This report and the attached Dashboard (Appendix 1) provide an update by the Programme Management Office (PMO) on the performance of Croydon s 2012/13 QIPP Plan as at month 6, September Table 1 below, gives a summary position of projected savings against plan as at month 6. PMO Rating Number of Projects Annual Plan Forecast Saving ( 000) ( 000) Green 20 13,760 16,827 Amber 7 1,698 1,342 Red 16 7,077 3,156 Unidentified 2,464 0 Total 43 25,000 21,325 Table 1 Page 1 of 12

2 2 QIPP Performance Summary at Month Graph 1 below shows Croydon s cumulative net saving position at month 6 (actual) and FOT against both the 25m and 22.5m targets. Graph Graph 2 below shows Croydon s monthly net saving at month 6 (actual) and FOT against both the 25m and 22.5m targets. Graph 2 Page 2 of 12

3 NOTE: The YTD and FOT figures for the LTC and GP Support for Care Homes projects have been reduced to zero due to the lack of monitoring information available. In previous reports, this project was reporting to plan. 2.3 Year to date (YTD), 9,552k net savings have been delivered against a plan of 10,206k, a shortfall of 654k (93.6% achievement). Performance in September 2012 with actual net savings delivered of 1,660k falls short of the planned 1,847k, with an underperformance of 187k. 2.4 The forecast outturn (FOT) net position has decreased by 571k in month 6 from 21,896k to 21,325k. This reduction in forecast is mainly due to underperformance in the following areas: Mental Health Efficiencies ENT Gynaecology: Outpatients Long Term Conditions (LTC) GP Support for Care Homes End of Life 2.5 However, it should be noted that a number of projects have improved their FOT position between month 5 and month 6 reporting, so are offsetting some of the underperformance referred to in section 2.4 above. This improvement in forecast is mainly due to additional efficiencies that have been identified in the following areas: Prescribing Corporate Vacancies Public Health Effective Commissioning Initiative 2.6 This revised forecast represents an underperformance of 3,675k against the plan of 25m, which equates to 85.3% achievement of the target. This underperformance reflects the following: High risk of not delivering the unidentified QIPP saving of 2,464k Under achievement / slippage of savings against identified projects of 1,211k 2.7 It should be noted that the following project is still reporting to plan as at Month 6 due to issues with data analysis and monitoring: Telehealth 3 Performance by QIPP Category PRODUCTIVITY: Mental Health 3,083 2,502 (581) R The Primary Mental Health Care Pathways project is projected to slip due to an issue re: cost of prescribing in current SLAM service, which delayed the progress of the scheme, but has now been resolved. The Project Lead is now developing the LES with the Steering Group and it is planned that the first patients will begin to be managed in primary care from 1 st January Mental Health Efficiencies: YTD referrals into services (Forensic, CAMHS, and Specialist Mental Page 3 of 12

4 Health) are greater than expected. However, the month 6 spend in CAMHS Tier 4 has dropped significantly (from months 1-5 average of 172,898 to 98,548 in month 6). The Commissioning Lead is investigating this variation in spend with the Provider to confirm the accuracy of the reporting. Furthermore, there is slippage in the initiatives to reduce spend in Private Sector and reduce crossboundary spend. Further analysis of spend in Mental Health Continuing Care bed days has resulted with projected net savings of 540k in 2012/13 against the plan of 168k, although this is subject to change in-year, due to the volatility of the activity. PRODUCTIVITY: Acute Sector 9,978 9,753 (225) G The projected savings against the Consultant-to-Consultant and New:Follow-up KPIs at CUH have reduced at month 6, but the savings are being made through the reduction and therefore underspend in outpatient activity (firsts, follow-ups and outpatient procedures). The projected savings against KPIs for Trusts other than CUH has reduced this month by 71k due to the non-delivery of the 30-Day Readmission KPI at Kings College Hospital NHS Foundation Trust and Guy's and St Thomas' NHS Foundation Trust. There has been some slippage against the Direct Access Diagnostics project with GPs being informed about the change of referral pathway at the beginning of Q2. However in the last three months, an increase in spend at CUH can be seen and In-Health have reported a reduction in patient flow. Work is ongoing with CUH to ensure delivery of the unbundled 1 st OP savings. PRODUCTIVITY: Primary Care (640) R Savings are unlikely to materialise in the GP Contracting project. A LES/DES Review is underway where recommendations will be made to consolidate or cease a number of enhanced services currently provided, but savings are unlikely to be made in-year. Underperformance against the saving target for SWL Dental Contracting has been reported at month 6. PRODUCTIVITY: Community Support Services 1,416 1,416 0 G The saving represents an efficiency removed from the Croydon Community Health Services (CCHS) budget at the beginning of 2012/13. Page 4 of 12

5 INTEGRATED CARE: Activity Shifts 1, (632) R An in-depth audit of the month 6 reporting for the Intermediate Services (Dermatology, ENT, Gynaecology: Outpatients, Gynaecology: Hysteroscopies and Ophthalmology) was carried out and resulted in the identification of discrepancies between the invoiced and reported activity. This has resulted in a more accurate, but reduced YTD and FOT position being reported in month 6 when compared to month 5. Patient flow from GP referrals into the Intermediate Services is below expected. A member of the Planned Care Team is visiting GP Practices who are low referrers to the services to determine what the reasons are and if there is anything that can be done to improve their referral rate. The continued roll-out of CReSS throughout the year will improve referral rate to the Intermediate Services. Currently, there are 40 practices live on CReSS, which is above the target of 30 at the end of October. The two new ophthalmology projects in 2012/13 Community Cataracts and Ophthalmology Triage are underperforming YTD and there are concerns that they will not catch up by year-end. The Project Lead is working closely with all stakeholders to improve and streamline the referral pathways and ensure they are adhered to by GPs and Community Optometrists. Those Optometrists and GPs that bypass the triage will be targeted to understand the reasons. Furthermore, an agreement has been made with CUH to divert all referrals back to the triage service if they have not already been triaged before reaching the Trust. There has been further slippage in the recruitment of the TB DOT Outreach Nurse at CUH, which will impact on the savings made in-year by this project. The post was recruited to and the successful candidate was due to start in October, but pulled out at the last minute. CUH are now re-advertising the post and the Project Lead is working with them to fill the vacancy with Bank staff in the interim period. INTEGRATED CARE: Long Term Conditions (LTC) 2,158 1,584 (574) R The list of anti-coagulation postal patients has been received from CUH and the project lead has written to the 100 with stable AF to move them to the community service. The conditions of a further 150 postal patients are being reviewed to determine if the community service can be safely expanded to include more conditions i.e. not just those patients with stable AF. The Project Lead has begun the process to move this service to AQP to ensure there is equitable coverage across Croydon. The LTC initiative was recently discussed at QOB and the following recommendations were made: o The project continues in the interim period (i.e. until the end of 2012/13) and where possible, GPs continue to be encouraged to engage. o For month 6 QIPP reporting, the savings relating to this project be reduced to 0, where previously it had been reporting to plan as we attempt to develop and agree a monitoring Page 5 of 12

6 o methodology (this can be reversed in future reports if a monitoring methodology is agreed). The LES is disbanded in its current form at the end of 2012/13 and is incorporated in the LTC/Transformation LES that is currently in development. Further savings have been identified through the review of the Learning Disabilities Continuing Care process and with the additional dedicated input of a 0.25 wte Continuing Care Nurse, the commissioner is optimistic that this will improve further in-year. An additional savings target of 180k had been put forward against Continuing Care for adults, but due to the review and developments of the LPP Framework for 2013/14, it is unlikely that these savings will be made. INTEGRATED CARE: Urgent Care (54) R The saving in Urgent Care is made through the redesign of the DVT pathway at CUH. An agreement with Virgin Care to pay them 43 to assess patients when they first present has been reached, however there has been some confusion at CUH with the new pathways. The Project Lead is meeting with CUH to discuss, confirm and agree the pathways and ensure the smooth roll-out of the new service. INTEGRATED CARE: Planned Care 1,407 1,316 (91) A The Patient Navigation project is currently projecting full-year savings of 365k against the target of 311k. This is mainly due to the reduction in diagnostic procedures being ordered routinely for patients in the gastroenterology specialty as patients are moved from a 1 year review cycle to 2, 3 or 5 year cycles. The CUH Waiting List Initiative slipped against its original implementation timescales. At the end of October, information relating to 1,794 patients on the elective waiting list at CUH were sent to Croydon GPs. 858 (47.8%) of these patients were reviewed by the GPs and of these, only 29 (3.4%) were cancelled from the Trust s waiting list. The Project Lead is going to review those patients that had their procedures cancelled to understand where to focus for the next review. They will also work with the Clinical Lead to encourage better uptake across the GPs. The Q1 Effective Commissioning Initiative audit was carried out in September The ACU have reported that a saving of 186k is likely for Q1 and a projected saving of 100k for quarters 2, 3 and 4. The Review of the Neuro-Rehab Pathway project has slipped in the recruitment of a Case Manager. It is unlikely to recover the year-end position. A new Project Lead is taking this project forward and is reviewing the option for working with other Boroughs to provide this service across SWL. The direct-listing of patients requiring surgery for hernias is approximately in-line with plan. Take-up by more GP Practices may require reimbursement for them to carry out the pre-op element of the pathway prior to referring the patients for surgery. The Project Lead is currently exploring how this Page 6 of 12

7 needs to be taken forward in 2013/14 i.e. LES/AQP. It is difficult to quantify the number of patients that GPs are carrying out watchful waiting on and a requirement for a quarterly return may be included in the LES. INTEGRATED CARE: End of Life (480) R A revised monitoring methodology has been developed for this project, which includes the review of all deaths in private residential and care homes each month. This is currently showing that since the project began in 2009/10, there has been an increase in the number of deaths recorded in private residential and care homes each year, although the overall number of deaths has remained stable. Just over 50% of GP Practices in Croydon are signed up to providing the Palliative Care LES and this will need to increase to meet the 2012/13 target. INTEGRATED CARE: Staying Healthy (325) R This GP Support for Care Homes project was recently discussed at QOB and the following recommendations were made: o The project continues in the interim period (i.e. until the end of 2012/13) and where possible, GPs continue to be encouraged to engage. o For month 6 QIPP reporting, the savings relating to this project be reduced to 0, where previously it had been reporting to plan as we attempt to develop and agree a monitoring methodology (this can be reversed in future reports if a monitoring methodology is agreed). o The LES is disbanded in its current form at the end of 2012/13 and is incorporated in the LTC/Transformation LES that is currently in development. The GP Support for Care Homes LES does not have wide uptake in Croydon, with only approximately 20 practices signed up currently. There are concerns that the LES is not financially viable for GPs, so as part of the LES/DES review, the funding for this LES is being appraised. RUNNING COSTS: Back Office G Further non-recurring pay-related savings have been identified in addition to the 4.13% efficiency saving in the Public Health Department already reported. Page 7 of 12

8 RUNNING COSTS: Staffing G There was slippage in Q1 of the year to the recruitment of the Children s Complex Care Co-ordinator, creating a part-year saving. Savings of 559k have been identified following a full analysis by the Finance Department of the current vacancies within the Croydon Borough Team. REDUCING DRUG SPEND: Prescribing 800 2,274 1,474 G A number of initiatives and projects have been put in place or are in development and are forecasting a full-year saving of 2,274k against the target of 800k from the Prescribing budget in 2012/13. This includes the recent identification of a number of cost pressures and the forecast underspend of the contingency. 4 QIPP Operational Board (QOB) 4.1 In line with Croydon s turnaround position, since December 2011 the PMO have implemented the QIPP Operational Board (QOB) to support the Croydon Borough Team and Clinical Commissioning Group to achieve a sustainable position of financial balance and value for money, focusing on supporting QIPP and enabling success of delivery. 4.2 The QOB reviews both underperforming FYE projects to assist in improving performance and unblocking any barriers that arise and require Senior Management assistance and the new schemes for 2012/13 to ensure the plans for delivery are robust and implementation runs to plan. The QOB is also looking at options for new/additional projects which will begin to close the gap in 2012/13 and will review all new projects suggested and worked up by both Borough and Cluster. 4.3 All projects are reviewed on a regular basis by QOB with red-rated schemes being recalled 2-4 weekly, amber schemes 4-6 weekly and green schemes 6-8 weekly. The Business Programme for QOB can be seen in Appendix 2. The schedule of projects reviewed by QOB in the last 4 weeks are as follows: Page 8 of 12

9 18 October October November November2012 Acute Review with ACU CAMHS Anti-Coag Service Neuro Rehab Service Redesign Community Pre-Op Continuing Care: DVT Ophthalmology Assessment Children Decommissioning: End of Life ENT Urgent Care Hernias Urgent Care Neuro-Rehab Service Redesign GP Support for Care Homes Waste Avoidance: Patient Navigation Telehealth LTC Urology TB DOT 4.4 The outcomes of these meetings are shown in the Action Log (Appendix 3). 4.5 A number of key risks/themes that have been discussed at QOB are outlined below: One of the main risks to project delivery in the Older Adults Commissioning Team has been Project Lead resource. Numerous vacancies and the use of interim staff has meant there is a continued risk to project continuity and delivery. Furthermore, the Senior Commissioning Manager in the team is due to leave by the end of November. To mitigate this risk, following the appointment of the Director of Commissioning, Stephen Warren, the two Band 7 vacancies within the team were filled (one permanent, one interim) and additional interim Project Leads were brought in to review the Enhanced Services and take forward the Urgent Care Strategy. An interim Deputy Director of Commissioning has also been recruited to take forward the LTC/Transformation agenda. However, due to the many changes within the team, the performance and delivery of the following schemes are at risk of delivery in 2012/13: LTC Telehealth Continuing Care Review of Neuro-Rehab Pathway CUH Waiting List Initiative (now managed within the Planned Care Team) End of Life GP Support for Care Homes Urgent Care A number of schemes that have been developed with Croydon University Hospital have slipped in terms of delivery and/or reporting due to issues with engagement of the Trust. This has affected the progress/reporting of projects including TB DOT, DVT, Direct Access Diagnostics and Anti- Coagulation. It has been noted that although discussions and negotiations of these schemes began way in advance of 1 st April 2012, often the agreements were not made through the formal contracting routes with the ACU. Following a review of QIPP governance, the Acute Task Group is convened monthly to triangulate acute and QIPP issues with local commissioning/qipp leads and the ACU. Page 9 of 12

10 4.5.3 An additional barrier to the delivery of the QIPP Plan is the engagement of GPs in referring to the Intermediate Services (e.g. ENT, Gynaecology, Dermatology, MCATS and CORS) and taking up the Enhanced Services aimed at reducing emergency admissions (e.g. LTC and GP Support for Care Homes). The Planned Care Team market the Intermediate Services to GPs in a number of ways including presentations at the Clinical Leadership Group and GP Networks, bulletins in the equipped newsletter, targeting GP Practices with low referral rates etc. The Older Adults Commissioning Team are working with the GPs and LMC to determine the reasons for poor uptake of the Enhanced Services and to develop alternative models to encourage more GP support of the schemes. 5 Closing the Gap 5.1 It is recognised that any new schemes identified at this stage of the year are unlikely to yield significant savings in 2012/13 to contribute to closing the gap. Therefore, the in-year focus is now on maximising and extending the impact of current schemes and to ensure there is no additional slippage to delivery. 5.2 To enable this, the Croydon Borough Team continues to engage with the local GPs by attending CCG meetings to discuss the QIPP schemes in 2012/13. An exercise was carried out to review which QIPP initiatives each GP practice are engaged with and by what degree this has been shared with the CCG to encourage better uptake of Local Enhanced Services and boost referral rates into the Intermediate Services. 5.3 Earlier in the year, a brainstorming exercise was undertaken with GPs, Croydon Borough and SWL Cluster staff to create a long-list of possible projects/initiatives to take forward in 2012/13/14 to ensure Croydon reaches the QIPP target of 25m net savings. Additional support has been brought in to review and prioritise this list. Initial recommendations are as follows: Potential areas for further work: Review of whole systems referral and clinical pathways for Cardiology Audit of clinical rationale for cardiac revascularisation procedures at CUH RAID (Rapid, Assessment, Interface and Discharge) Services for alcohol being taken forward as a CQUIN in 2012/13 with CUH Review and consolidation of enhanced services Not significant areas of saving, although would improve patient care: Consultant advisory sessions for GPs 5.4 Further areas of opportunity being explored are: Frail elderly and children's integrated care Page 10 of 12

11 Use of alternative care pathways with LAS Ambulatory Emergency Care In particular, for frail elderly and children s integrated care, the Borough Team and CCG are proceeding to develop and implement transformational change in the care pathways for Long Term Conditions. Non-recurring funding has been allocated from 1% Strategic Fund to support this work. The roll out of the risk stratification tool to Croydon Practices has commenced. 12 November 2012 Additional supporting papers are available from Jennifer Farnall QIPP Delivery Manager; Telephone jennifer.farnall@croydonpct.nhs.uk Page 11 of 12

12 01-Dec Dec Dec Dec Jan Jan Jan Jan Feb Feb Feb Feb Mar Mar Mar Mar Apr Apr Apr Apr May May May May Jun Jun Jun Jun Jul Jul Jul Jul Aug Aug Aug Aug Aug Sep Sep Sep Sep Oct Oct Oct Oct Nov Nov Nov Nov Nov Dec Dec Dec Dec Jan Jan Jan Jan Jan Feb Feb Feb Feb Mar Mar Mar Mar-13 APPENDIX 2: QOB 2012/13 Business Programme QOB BUSINESS PLAN ACUTE REVIEW WITH DI CARTER (1hr) Y Y Y Y Y Y Y ECI Process Y Y Y Y Anti -Coag Service Y Y Y Children's Planned Care / CAMHS Y Y Y Y Y Y Y Y Y Y Y Y Y Community Pre-op Assessment Y Y Y Y Y Y Y Continuing Care: Adult Y Y Y Y Y Y Continuing Care: Children Y Y Y Y Y Y COPD Community Service Y Y Y Y Y Y Y Y Decommissioning: Cataracts Y Y Y Y Y Y Y Y Decommissioning: Hernias Y Y Y Y Y Y Y Y Dermatology Y Y Y Y Y DVT Y Y Y Y Y Y End of Life Y Y Y Y Y Y Y Y Y Enhanced Services (LES/DES REVIEW) Y Y Y Y Y ENT Y Y Y Y Y Y GP Support for Care Homes Y Y Y Y Y Y Gynaecology: Outpatients Y Y Y Y Y In-Health / Direct Access Diagnostics Y Y Y Y Y Y Y Y Y LTC Y Y Y Y Y Y Y Y MCATS Y Y Y Y Y Y Y Y Mental Health: Efficiencies Y Y Y Y Y Y Mental Health: Continuing Care Y Y Y Y Y Y Mental Health: Primary Pathways Y Y Y Y Y Y Y Neuro-Rehab Service Redesign Y Y Y Y Y Y Y Y Ophthalmology Y Y Y Y Y Y Y TB DOT Y Y Y Y Y Y Y Telehealth Y Y Y Y Y Y Y Y Y Y Y Urgent Care Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Urology Y Y Y Y Y Y Y Waiting List Initiative Y Y Y Y Y Y Y Waste Avoidance: CReSS Y Y Y Y Y Y Y Waste Avoidance: Pat Nav Y Y Y Y Y Y Y Y Y Page 12 of 12

NHS Wandsworth Finance Report. For the period April 2012 November 2012 & Interim Report up to December 2012

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