Financial Impact and Risks This paper presents the year to date financial position of North Somerset CCG.

Transcription

1 Governing Body Agenda Item: 9 Date of Meeting: 4 July 2017 Author: Michael Vaughton, Chief Financial Officer Clinical Lead: Mary Backhouse, Clinical Chair CCG Director/Manager: Michael Vaughton, Chief Financial Officer Integrated Performance Report Month /18 Recommendations The Governing Body is asked to: Discuss the Clinical Commissioning Group s latest performance delivery as at May 2017 for, Finance and Performance standards. Review mitigating actions for those areas of exception. Background Everyone Counts: Planning for Patients 2014/15 to 2018/19 sets out NHS ambitions to achieve high quality care for all over the next five years and provides planning guidance to support delivery. The CCG will be judged on delivery of the commitment to patients set out in the NHS Constitution the quality of outcomes set out in the NHS Outcomes Framework and the management of expenditure within budget. Purpose To report on the performance of the CCG against the plans for Overview This report provides an overview North Somerset CCG performance on NHS Constitutional rights, financial delivery including performance against key commissioning contracts and risks. Mitigating actions to support delivery are described for the main areas of poor performance and/or substantial risk. Financial Impact and Risks This paper presents the year to date financial position of North Somerset CCG. Legal Impact There are no legal implications anticipated in relation to this report. Risk Implications, Assessment & Mitigation The reported overall performance position of the CCG has been assessed for risks and includes the expected impact of relevant mitigating actions. Consultation, Involvement and Engagement This report is updated monthly and presented at Governing Body. The clinical Commissioning Leadership Group also reviews the Quality and Performance reports. If you require this document in an alternative format please telephone Gov Body 03/11/2015 Item 9 Page 1 of 2 Version 1

2 Governing Body Equality Impact No health inequalities issues arise as a result of this report, and there is no impact upon people with protected characteristics. Evidence and Research Not applicable Appendices Appendix 1 Performance Report Appendix 2 Finance Report Appendix 3 NSCCG Publication of CCG Accounts (Letter) Appendix 4 NSCCG Auditors Report Appendix 5 NSCCG Auditor Statement on the Consolidation Schedules If you require this document in an alternative format please telephone Gov Body 03/11/2015 Item 9 Page 2 of 2 Version 1

3 Item 9, Appendix 1 Governing Body, 4 July 2017 Performance Performance Month /18 April 2017 Creating the Healthiest Community Together 1

4 Executive Summary Challenges Referral to Treatment (RTT) incomplete 52ww target missed by NBT and UHB in April. RTT Incomplete pathway standard not achieved by NBT or UHB in April. Diagnostic 6 week standard not achieved by NBT or UHB in April. Overall 2ww cancer standard not achieved by NBT or WAHT in March (validated April data not currently available). Overall 62 day cancer standard failed by WAHT and UHB in March. A&E 4 hour standard continues to be failed by all 3 trusts in April. Zero standard for Mixed Sex Accommodation breaches failed at UHB in April. 28 day rebooking breaches at UHB each month since October Ambulance handovers continue to fail the zero standard at all 3 trusts in April. Creating the Healthiest Community Together 2

5 Executive Summary Achievements RTT incomplete 52ww target achieved by WAHT since December RTT Incomplete standard continues to be achieved by WAHT in April. Diagnostic 6 week standard achieved by WAHT since October Overall 2 week wait cancer standard achieved by UHB since October All 31 day cancer standards achieved by NBT and UHB in March. All 31 day cancer standards (except 31 day surgery) achieved by WAHT in March. Both 62 day cancer standards continue to be achieved by NBT. Ambulance Category 1 Response rate achieved by NS CCG since January Zero Mixed Sex Accommodation breaches at WAHT and NBT in April. Zero 28 day rebooking beaches at WAHT since November Zero urgent operations cancelled for a second time at all 3 trusts. Zero >12 hour trolley waits at all 3 trusts in April. Creating the Healthiest Community Together 3

6 Constitution Dashboard - exceptions Referral to Treatment Times Org Indicator Target Red Threshold May-16 Jun-16 Q1 2016/17 Jul-16 Aug-16 Sep-16 Q2 2016/17 Oct-16 Nov-16 Dec-16 Q3 2016/17 Jan-17 Feb-17 Mar-17 Q4 2016/17 Apr /18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value UHB RTT: Admitted 52ww NBT RTT: Admitted 52ww NSCCG RTT: Admitted 52ww UHB RTT: Non-Admitted 52ww NBT RTT: Non-Admitted 52ww NSCCG RTT: Non-Admitted 52ww UHB RTT: Incomplete Pathways 52ww NBT RTT: Incomplete Pathways 52ww NSCCG RTT: Incomplete Pathways 52ww DoT RTT Incomplete 52 week waits Issue WAHT: There were no 52 week waiters on an incomplete pathway in April. UHB: Increased to 5 in April. One was due to clinical complexity but the majority of breaches were due to patient choice resulting from changes to the Access Policy and Paediatric theatre capacity (staffing). NBT: Reduced to 43 in April: Ortho-Spinal and Orthopaedic (27); Neurosurgery (6); Epilepsy (10). The Trust continues to meet the trajectory for Neurosurgery at the end of April. Whilst the Epilepsy trajectory has not been met in April, the service remains on track to clear all >52 week waiters by the end of Quarter 3 of 2017/18. The Trust has also reported in-month breaches for Orthopaedic and Spinal patients. The 27 breaches were due to patient choice and root cause analyses have been completed for these patients. Current Status Commissioners are assured that all long waiting patients on RTT pathways are actively reviewed in line with a standard operating procedure designed to identify any risk of harm and expedite treatment of patients if required. UHB: Commissioners have expressed concern around the number of week waits at UHB which has risen due to capacity pressures in Women s and Children s. The Trust is working to reduce non-admitted backlog to mitigate the risk of conversion to admitted pathways. An additional Medway/System C function is being tested to mitigate the risk of incorrectly listing patients and an RTT trainer has now been appointed. Long waiting patients are monitored to ensure those waiting over 18 weeks are validated according to the SOP and patients at risk of breaching 52 weeks closely monitored. NBT: RAPs and recovery trajectories are in place for all 52 week waiters Neurosurgery and Epilepsy by Q3 2017/18. This report focuses on Red and worsening amber performance. Full performance detail can be found in the Appendices that accompany this report. Creating the Healthiest Community Together 4

7 Constitution Dashboard - exceptions Diagnostic Test Waiting Times Org Indicator Target Red Threshold May-16 Jun-16 Q1 2016/17 Jul-16 Aug-16 Sep-16 Q2 2016/17 Oct-16 Nov-16 Dec-16 Q3 2016/17 Jan-17 Feb-17 Mar-17 Q4 2016/17 Apr /18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value UHB Diagnostic 6ww 99.00% 94.99% 98.55% 96.25% 96.25% 96.09% 95.51% 96.88% 96.88% 98.88% 99.05% 98.27% 98.27% 98.48% 98.78% 98.65% 98.65% 98.63% 98.63% NBT Diagnostic 6ww 99.00% 94.99% 98.54% 98.91% 98.91% 98.86% 96.35% 93.99% 93.99% 96.39% 94.57% 86.01% 86.01% 88.40% 92.43% 99.19% 99.19% 98.26% 98.26% NSCCG Diagnostic 6ww 99.00% 94.99% 98.81% 98.10% 98.10% 98.10% 96.31% 96.62% 96.62% 98.62% 97.71% 95.21% 95.21% 95.95% 97.45% 99.04% 99.04% 98.57% 98.57% DoT Diagnostic 6 week waits Issue UHB: Performance worsened slightly in April and the Trust failed to achieve the agreed trajectory and the national target. The number of patients waiting over 6 weeks for a Sleep Studies test continued to reduce in April. There has been a doubling of demand for Cardiac CT scans due to implementation of recent NICE guidelines. These high levels of demand cannot be met in the short-term, and ad hoc sessions are being set up pending a review of ongoing capacity requirements. NBT: Performance worsened slightly In April and the Trust marginally underperformed against the standard. The majority of breaches were for Non-obstetric Ultrasounds (101), which were 64 breaches above threshold for that test type. These breaches combined with the underperformance in other test types brought the overall Trust position below standard. Current Status UHB: A medium term capacity plan has been established. Additional capacity is also being established to replace capacity lost in the stress echo service in April and early May, and to keep pace with heightened demand. Adult endoscopy is being outsourced to Prime Endoscopy and 2 consultant physicians are being recruited. Recover of the standard is expected by September NBT: The trust has advised that the endoscopy surveillance backlog has now been cleared and outsourcing is being used to maintain capacity where necessary. The non-obstetric ultrasound issue is minor and in hand. Recovery of the standard is not know. This report focuses on Red and worsening amber performance. Full performance detail can be found in the Appendices that accompany this report. Creating the Healthiest Community Together 5

8 Constitution Dashboard - exceptions Cancer Waits - 2 Week Wait Org Indicator Target Red Threshold May-16 Jun-16 Q1 2016/17 Jul-16 Aug-16 Sep-16 Q2 2016/17 Oct-16 Nov-16 Dec-16 Q3 2016/17 Jan-17 Feb-17 Mar-17 Q4 2016/ /17 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value WAHT Cancer 2ww - All 93.00% 87.99% 95.51% 94.77% 95.64% 92.62% 94.94% 94.56% 94.05% 88.48% 97.79% 96.02% 93.94% 87.56% 85.19% 76.27% 82.82% 91.50% NBT Cancer 2ww - All 93.00% 87.99% 94.03% 93.00% 93.80% 92.17% 86.94% 90.97% 89.87% 92.41% 89.83% 91.55% 91.25% 93.69% 94.21% 92.97% 93.56% 92.13% NSCCG Cancer 2ww - All 93.00% 87.99% 93.24% 93.66% 93.86% 93.02% 91.99% 90.89% 92.05% 89.98% 93.55% 94.75% 92.66% 91.43% 90.23% 85.62% 88.99% 91.89% WAHT Cancer 2ww - Breast symptoms 93.00% 87.99% 95.45% 96.30% 93.75% 80.00% 92.86% 83.33% 84.88% 90.48% 87.10% 93.94% 90.57% 82.76% 94.12% 84.38% 87.37% 89.13% NSCCG Cancer 2ww - Breast symptoms 93.00% 87.99% 96.77% 94.87% 93.86% 85.00% 94.74% 83.33% 88.12% 95.56% 85.29% 92.50% 91.60% 87.88% 94.44% 87.50% 89.91% 90.99% DoT 2 week wait - all Issue April validated cancer data is not available. Cancer exceptions relate to March performance. WAHT: Performance worsened again in March, with 112 breaches out of 472 patients treated, failing to achieve the standard for the month, Quarter 4 and the year 2016/17. Failure was due to capacity issues in the colorectal and breast service. Current Status WAHT: Performance is monitored at the monthly ICQPMB meetings. Additional capacity was sourced in March and April to ensure every patient waiting over 14 days was seen. Referrals were also clinically reviewed to ensure no patients were coming to harm. An increase in referrals in March also impacted on performance. 2 week wait breast symptoms WAHT: Performance worsened in March with 5 breaches out of 32 patients treated failing to achieve the standard for the month, Quarter 4 and the year 2016/17. Failure was due to capacity issues in the colorectal and breast service. Performance can fluctuate month by month due to the small numbers of patients involved. WAHT: See above. This report focuses on Red and worsening amber performance. Full performance detail can be found in the Appendices that accompany this report. Creating the Healthiest Community Together 6

9 Constitution Dashboard exceptions Cancer Waits - 31 Days Org Indicator Target May-16 Jun-16 Q1 2016/17 Jul-16 Aug-16 Sep-16 Q2 2016/17 Oct-16 Nov-16 Dec-16 Q3 2016/17 Jan-17 Feb-17 Mar-17 Q4 2016/ /17 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value WAHT Cancer 31 day - surgery 94.00% 88.99% % % % 85.71% % % 91.67% % % % % % % 66.67% 94.44% 96.77% NSCCG Cancer 31 day - surgery 94.00% 88.99% % % 96.74% 89.66% % 97.06% 95.51% % % % % % 88.00% 88.00% 92.11% 96.11% Cancer Waits - 62 Days Org Indicator Target Red Threshold Red Threshold May-16 Jun-16 Q1 2016/17 Jul-16 Aug-16 Sep-16 Q2 2016/17 Oct-16 Nov-16 Dec-16 Q3 2016/17 Jan-17 Feb-17 Mar-17 Q4 2016/ /17 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value UHB Cancer 62 day - NHS Screening 90.00% 84.99% 35.29% 85.71% 47.22% 66.67% 55.56% 44.44% 55.56% % 83.33% % 94.29% 57.14% % 83.33% 77.78% 68.94% DoT DoT 31 day wait - Surgery 62 day wait NHS Screening Referral Issue April validated cancer data is not available. Cancer exceptions relate to March performance. WAHT: Performance worsened in March, with 1 breach out of 3 patients treated, failing the standard for the month. UHB: Performance worsened in March, with 1 breach out of 6 patients treated. This was due to patient choice. The standard was failed for the month, Quarter 4 and the year 2016/17. Performance is liable to large fluctuations in month due to the small numbers of patients involved. Current Status WAHT: Performance can fluctuate greatly due to the very low number of patients being treated. The standard was achieved for Quarter 4 and the year 2016/17. Performance is monitored at the monthly ICQPMB meetings. UHB: An improvement plan continues to be implemented to minimise avoidable delays. Performance is monitored through the UHB Access Performance Group. The reasons for breaches and the small volumes are the biggest challenges against achievement of this standard at population level. This report focuses on Red and worsening amber performance. Full performance detail can be found in the Appendices that accompany this report. Creating the Healthiest Community Together 7

10 Constitution Dashboard exceptions A&E Waits 4hr Performance Org Indicator Target Red Threshold May-16 Jun-16 Q1 2016/17 Jul-16 Aug-16 Sep-16 Q2 2016/17 Oct-16 Nov-16 Dec-16 Q3 2016/17 Jan-17 Feb-17 Mar-17 Q4 2016/17 Apr /18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value WAHT A&E 4hr Waits 95.00% 93.99% 89.34% 88.11% 84.85% 84.57% 82.57% 74.62% 80.74% 71.18% 68.47% 66.85% 68.90% 63.69% 69.39% 77.65% 70.44% 82.56% 82.56% UHB A&E 4hr Waits 95.00% 93.99% 91.66% 88.99% 89.32% 89.33% 90.01% 87.33% 88.89% 82.94% 78.45% 79.64% 80.35% 80.37% 80.73% 83.25% 81.53% 82.31% 82.31% NBT A&E 4hr Waits 95.00% 93.99% 76.16% 82.18% 78.47% 79.42% 78.76% 83.71% 80.62% 76.57% 80.72% 77.95% 78.34% 75.31% 81.69% 88.31% 81.95% 86.23% 86.23% DoT A&E 4hr waiting time Issue WAHT: Performance improved again in April and achieved the monthly STP trajectory. UHB: Performance worsened in April and was slightly worse than the monthly STP trajectory. Whilst emergency admissions via the BRI ED are 1.2% up on the same period last year, total emergency admissions into the BRI are down by 2.3%. The number of 14 day stays is significantly above last year s levels, with bed occupancy remaining un-seasonally high as a result. The reduction in outlier bed-days, combined with lower patient acuity, should help to reduce length of stay. But the time taken to access the right bed may continue to lengthen waits in the ED. NBT: Performance worsened in April by 2.13% compared to March. There was an increase in breaches compared to March, from 615 to The largest increase was in ED attributable breaches. Although there has been a significant increase in non-bed breach reasons, which would imply that this is driven by internal ED issues, the analysis also shows a drop in admitted performance. ED workforce issues have meant that they have not had the resilience to prevent a similar fall in the non-admitted performance which they were previously maintaining. Current Status BNSSG system performance is monitored at the Urgent Care Delivery Board, which coordinates system wide actions. 2017/18 STP trajectories for both WAHT and UHB predict a return to the 95% standard at the end of March WAHT: A revised RAP is being implemented with a new STP trajectory for 2017/18. Performance is monitored through the Hospital Flow Working Group. UHB: STP actions are being monitored at the Access and Performance Group meetings. A revised plan, following the NHSI Critical Friend visit, will include an estimate of breach savings for each action. Current actions include initiatives to improve prediction and management of demand, management of flow, improving communications, admission avoidance and improving discharges. An action is in place to improve the experience for frequent ED attendees. May s trajectory of 83.5% is not forecast to be met. NBT: A plan is being put in place to support and maintain ED staffing requirements 24/7. This report focuses on Red and worsening amber performance. Full performance detail can be found in the Appendices that accompany this report. Creating the Healthiest Community Together 8

11 Constitution Dashboard exceptions Ambulance Category 1 Response Org Indicator Target Red Threshold May-16 Jun-16 Q1 2016/17 Jul-16 Aug-16 Sep-16 Q2 2016/17 Oct-16 Nov-16 Dec-16 Q3 2016/17 Jan-17 Feb-17 Mar-17 Q4 2016/17 Apr /18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value SWASFT Ambulance - Category 1 Response 75.00% 69.99% N/A N/A N/A N/A N/A N/A N/A 66.56% 72.85% 69.70% 70.76% 71.16% 73.96% 76.64% 73.85% 71.25% 71.25% DoT Ambulance - Category 1 Response Issue SWASFT: Following a new code set trial, a new Category 1 response measure was introduced on the 25th October 2016, replacing the Red 1 response measure. Measures pre and post this date are not comparable. The Ambulance Response Programme (ARP) continues and, following achievement in March, performance worsened in April against the 75% standard to 71.25% Current Status SWASFT: The trust have initiated a rota review which it is envisioned will help to improve performance. The North sector has already gone live and the South will be going live soon. The Trust report on delays at their IQPMG. These are also being discussed at the Quality Sub-Group workshop session where a Deep Dive will be presented. At this stage, due to Purdah, the future progress of the ARP has not been published. BNSSG has achieved delivery of the target for Category 1 performance for ARP. This report focuses on Red and worsening amber performance. Full performance detail can be found in the Appendices that accompany this report. Creating the Healthiest Community Together 9

12 Constitution Support Measures exceptions Mixed Sex Accommodation Breaches Org Indicator Target Red Threshold May-16 Jun-16 Q1 2016/17 Jul-16 Aug-16 Sep-16 Q2 2016/17 Oct-16 Nov-16 Dec-16 Q3 2016/17 Jan-17 Feb-17 Mar-17 Q4 2016/17 Apr /18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value UHB Eliminating MSA Breaches DoT Eliminating Mixed Sex Accommodation Issue UHB: 11 breaches were reported by the Trust in April.. Reasons for the breaches were reviewed at the UHB Access Performance Group on the 25th May. Current Status Commissioners monitor breaches through the monthly ICQPMB and sub group meetings. This report focuses on Red and worsening amber performance. Full performance detail can be found in the Appendices that accompany this report. Creating the Healthiest Community Together 10

13 Constitution Support Measures exceptions Cancelled Operations Org Indicator Target Red Threshold May-16 Jun-16 Q1 2016/17 Jul-16 Aug-16 Sep-16 Q2 2016/17 Oct-16 Nov-16 Dec-16 Q3 2016/17 Jan-17 Feb-17 Mar-17 Q4 2016/17 Apr /18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value UHB Operations not rebooked in 28 days DoT Cancelled operations not rebooked within 28 days Issue UHB: 4 breaches in April. Emergency pressures continues to be the predominant cause of cancellations in March, with ward and critical care bed availability, and emergency patients needing to be prioritised, making-up 58% of all cancellations. However, there were more potentially avoidable causes of cancellations in April than seen in previous months. Current Status UHB: An action plan to reduce elective cancellations continues to be implemented and a Contract Performance Notice / RAP for 28 days remains in place for which penalties are applied. Recovery is not expected in 2017/18. Performance continues to be monitored at the monthly ICQPMG and Access Performance Groups. This report focuses on Red and worsening amber performance. Full performance detail can be found in the Appendices that accompany this report. Creating the Healthiest Community Together 11

14 Constitution Support Measures exceptions Ambulance Patient Handovers Org Indicator Target Red Threshold May-16 Jun-16 Q1 2016/17 Jul-16 Aug-16 Sep-16 Q2 2016/17 Oct-16 Nov-16 Dec-16 Q3 2016/17 Jan-17 Feb-17 Mar-17 Q4 2016/17 Apr /18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value WAHT Ambulance Handovers >30min <1hour UHB Ambulance Handovers >30min <1hour NBT Ambulance Handovers >30min <1hour WAHT Ambulance Handovers >1hour UHB Ambulance Handovers >1hour NBT Ambulance Handovers >1hour DoT Ambulance Handovers >30 minutes <1 hour Ambulance Handovers >1 hour Issue Recovery is linked to the successful implementation of urgent care plans that focus on patient flow and 4hr performance. WAHT: Performance worsened for the >30 minute standard, from 9 to 33 breaches, and worsened for the >1 hour standard, from 3 to 7 breaches in April. UHB: Performance worsened against the >30 minute standard, from 67 to 103 breaches, but improved against the >1 hour standard, from 11 to 8 breaches, in April. NBT: Performance improved against the >30 minute standard, from 30 to 25 breaches but worsened against the >1 hour standard, from zero to 2 breaches in April. As above. Current Status WAHT: Discussed at the monthly ICQPMB. A recovery date is not known. The CCG is liaising with WAHT and SWASFT to fully align the reporting of the number of ambulance handover delays. The Trust has appointed a new lead and is currently in the process of validating 2016/17 data. UHB: Performance is monitored against an improvement trajectory and is discussed at the monthly ICQPM. SCWCSU is liaising with UHB and SWASFT to fully align reporting of the number of ambulance handover delays. NBT: A RAP and improvement trajectory is in place. As above. This report focuses on Red and worsening amber performance. Full performance detail can be found in the Appendices that accompany this report. Creating the Healthiest Community Together 12

15 Constitution Support Measures - exceptions Planned Care Org Indicator Target Red Threshold May-16 Jun-16 Q1 2016/17 Jul-16 Aug-16 Sep-16 Q2 2016/17 Oct-16 Nov-16 Dec-16 Q3 2016/17 Jan-17 Feb-17 Mar-17 Q4 2016/17 Apr /18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value NBT RTT: Incomplete 18 Weeks 92.00% 86.99% 86.37% 86.54% 86.54% 85.52% 86.37% 86.33% 86.33% 87.26% 87.17% 86.29% 86.29% 86.19% 86.39% 87.64% 87.64% 87.59% 87.59% DoT RTT: Incomplete Pathways 18 Weeks Issue NBT: Although performance worsened slightly in April to 87.59%, the RTT trajectory and backlog trajectory were both achieved. Musculo-skeletal (MSK) and Gynaecology at a specialty level both achieved their recovery trajectories for the first time in a number of months. Current Status The Referral to Treatment Programme Board continues to work with Providers to deliver 18 weeks RTT standard for patients of BNSSG. There are four project areas within the wider RTT programme of work: Demand Management, Choice, Capacity and Provider Best Practice. Commissioners also continue to promote the use of appropriate alternative providers, at point of referral, through the local choice support centre. NBT: Remedial action plans are in place to monitor progress across a number of specialties who are not meeting the constitutional standards. Key focus areas include operational management/training, further capacity and demand modelling and an improvement of business intelligence reporting This report focuses on Red and worsening amber performance. Full performance detail can be found in the Appendices that accompany this report. Creating the Healthiest Community Together 13

16 Constitution Support Measures - exceptions High Risk TIA Org Indicator Target Red Threshold May-16 Jun-16 Q1 2016/17 Jul-16 Aug-16 Sep-16 Q2 2016/17 Oct-16 Nov-16 Dec-16 Q3 2016/17 Jan-17 Feb-17 Mar-17 Q4 2016/17 Apr /18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value UHB High risk TIA patients treated in 24hrs 60.00% 53.99% 68.80% 61.50% 63.40% 76.50% 71.40% 80.00% 76.50% 60.00% 65.20% 81.80% 68.20% 51.70% 72.20% 61.50% 60.00% 56.30% 56.30% DoT High risk TIA patients assessed and treated within 24 hours Issue UHB: Very small numbers impact greatly on performance. A breakdown of breach reasons has been requested. Current Status UHB: A review is undertaken for all breaches. The standard is monitored at the Quality sub-group meeting. This report focuses on Red and worsening amber performance. Full performance detail can be found in the Appendices that accompany this report. Creating the Healthiest Community Together 14

17 Item 9, Appendix 2 Governing Body, 4 July 2017 Finance Finance Month Creating the Healthiest Community Together 1

18 Contents 1. Cover Sheet 2. Contents 3. Summary 4. Income and Expenditure (1) 5. Income and Expenditure (2) 6. Resources 7. Reserves 8. Underlying Position 9. Risk and Mitigations 10. Cash 11. Statement of financial Position 12. Better Payment Performance Creating the Healthiest Community Together 2

19 Summary The 2017/18 financial position for the North Somerset CCG is being managed within the aggregated BNNSG CCG position in order to achieve the overall BNSSG CCG control total required by NHS England. BNSSG CCGs revised operational plans were submitted to NHSE at the end of March 2017 which reduced the combined in year deficit to 25.1m. These plans fell short of the NHSE requirement to reduce the overall in year deficit for BNSSG CCGs to 8.0m in 2017/18 and revised plans to achieve the 8.0m control total were submitted on 12 June. These plans increased the BNSSG CCGs savings requirement to 83m. Once NHSE have confirmed approval of the BNSSG CCGs plan submission a budget paper providing the full detail will be presented to Governing Bodies. In addition a consolidated BNSSG CCGs financial position will be reported at month 3. The turnaround processes put in place at the end of 2016/17 have identified potential savings schemes of 83m across BNSSG CCGs. The financial position at month 2 as reported here and to NHSE measures performance against the plan as submitted in March and does not reflect the additional savings target included in the June submission. Data to inform the financial position is limited in the first 2 months (prescribing reports are 2 months behind and acute contract performance 1 month behind) and variances from budget as an indicator of future performance should be treated with caution at month 2. Budgets will be revised for month 3 following the response of NHSE to the recently submitted financial plan. Creating the Healthiest Community Together 3

20 Income and Expenditure (1) Line No Creating the Healthiest Community Together Budget ( 000s) Year to Date Actual ( 000s) Variance 000s Budget ( 000s) Forecast Actual ( 000s) Variance 000s 1 Independent Sector Treatment Centres ,744 4, Individual Patient Treatment Approvals (1) NHS Non Contract Activity (NCAS) ,340 2, North Bristol NHS Trust 5,784 5, ,648 33, University Hospitals Bristol NHS Foundation Trust 6,843 6, ,114 40, Weston Area Health NHS Trust 10,847 10, ,092 62, Royal United Hospital Bath NHS Foundation Trust Taunton and Somerset NHSFT South Western Ambulance Service NHS Foundation Trust 1,201 1, ,205 7, Patient Transport services ,395 1, AQP services Other Acute expenditure (1) ACUTE 26,623 26, , , Better Care Fund previous section 256 funding ,321 5, (CCG)Community Health Services 4,082 4, ,492 24, Children's Community Services ,032 1, Joint working between Health and Social Care ( communiy BCF Other Community Services (4) 2,000 2, Safeguarding COMMUNITY 5,577 5,577 (0) 33,142 33, Continuing Healthcare Adult 1,843 1,828 (14) 10,577 10, Continuing Healthcare Children ,520 1, NHS Funded Nursing Care ,850 5, End of Life (0) CONTINUING CARE/END OF LIFE 3,208 3,193 (15) 18,707 18, Central Drugs (0) Home Oxygen Service (0) Medicines Management Other Prescribing (2) Primary Care Prescribing 5,305 5, ,832 31, Prescribing Incentive schemes MEDICINES MANAGEMENT 5,701 5, ,208 34,

21 Income and Expenditure (2) Line No Budget ( 000s) Year to Date Actual ( 000s) Variance 000s Budget ( 000s) Forecast Actual ( 000s) Variance 000s 33 Primary Care LES (2) 1,680 1, Primary Care Other (5) Service Out of Hours ,200 2, GP Support Unit PRIMARY CARE (7) 4,972 4, Avon and Wiltshire Mental Health Partnership NHS Trust 2,569 2, ,412 15, Improving Access to Psychological Therapies ,504 1, Other Mental Health and Learning Disability Services 1,676 1, ,694 9, MENTAL HEALTH 4,495 4, ,609 26, % Contingency reserve ,393 1, % System Reserve ,383 1, % CCG NR Reserve ,383 1, CCG Reserves ,109 3, RESERVES ,268 7, Community Services Re-Procurement Estates Management Recharges GPIT Connecting Care Procurement Public Health England Research and Development Other Support costs SUPPORT COSTS ,210 1, CCG Running Costs (8) 4,402 4, RUNNING COSTS (8) 4,402 4, TOTAL EXPENDITURE V BUDGET 48,387 48, , , Planned In Year Deficit (1,120) 0 1,120 (6,720) 0 6, Application of Planned Deficit on Balance Sheet (4,210) 0 4,210 (25,262) 0 25, TOTAL EXPENDITURE V ALLOCATION 43,056 48,387 5, , ,269 31,982 Creating the Healthiest Community Together 5

22 Resources Recurrent Non Recurrent Total 000s 000s 000s 2016/17 Programme Allocation 270, , /17 Running Cost Allocation 4,689-4,689 Programme Growth 5,895-5,846 HRG4+ Allocation (1,682) (1,682) Specialist Commissioning Transfers (972) (972) Running Cost Allocation Adjustment (49) - (49) Debt Repayment - (25,262) (25,262) Allocation M2 278,549 (25,262) 253,287 Creating the Healthiest Community Together 6

23 Reserves Budget YTD Actual YTD Variance Budget Forecast Forecast YTD Variance 0.5% System Risk Reserve ,383 1, % CCG Reserve -Non Recurrent Use ,383 1, % CCG Contingency ,393 1,393 0 CCG Reserves 0 0 CAMHS Slippage Dementia Slippage Cost of Savings BNSSG Savings 2016/17 trf to reserves ,365 2, Total ,268 7,268 0 Note: 0.5% System Risk Contingency must be held unused until M12 and can only be released with NHSE authorisation. Creating the Healthiest Community Together 7

24 Underlying Financial Position 000s In year Allocation 253,287 Add Back Non Recurrent Debt Repayment 25,262 Recurrent Allocation 278,549 Total Forecast Expenditure 285,269 Less Non Recurrent Spend 1% reserve (2,766) Primary Care 3 per head (325) Non recurrent savings 325 Total Recurrent Expenditure 282,503 Underlying Recurrent Deficit 3,954 Creating the Healthiest Community Together 8

25 Risks and mitigations Risks CCGs Potential Risk Value Mth01 Full Risk Value m Probability of risk being realised % Potential Risk Value m Proportio n of Total % Acute SLAs % % QIPP Under-Delivery % % TOTAL RISKS % Mitigations Uncommitted Funds (Excl 1% Headroom) Expected Mitigation Value Mth01 Full Mitigation Value m Probability of success of mitigating action % Expected Mitigation Value m Proportio n of Total % Contingency Held % % Contract Reserves % % Investments Uncommitted % Uncommitted Funds Sub-Total % Actions to Implement Further QIPP Extensions % Non-Recurrent Measures % Delay/ Reduce Investment Plans % Other Mitigations % Mitigations relying on potential funding % Actions to Implement Sub-Total % TOTAL MITIGATION % NET RISK / HEADROOM 0.00 (11.92) (3.47) BEST CASE IMPACT WORST CASE IMPACT 0.00 (11.92) (3.47) Forecast Outturn Underspend/Deficit 0.00 (6.72) RISK ADJUSTED CONTROL TOTAL 0.00 (10.19) Risk Adjusted Control Total Without Potential Funding 0.00 (10.19) Mitigations relying on potential funding From National From Regional Geographies From CCGs Potential Allocations Creating the Healthiest Community Together 9

26 April May June July August September October November December January February March Cash m Proportion of Cash Limit utilised cumulative - Month 2 Cash drawings at Month 2 represent 19.2% of annual cash limit compared with 16.7% based on 12 month straight line drawings Cash Drawings Cash LImit Reconciliation of Cash to I&E Position 000s Cash drawn at 31 May 49,925 Collaboratives adjustment (92) Cash Balance at 31 May (2,934) Cash Utilised 46,899 Opening balance (15,912) Receivables as per M2 Balance Sheet (3,543) Payables as per M2 Balance Sheet 20,943 I&E Position M2 48,387 Creating the Healthiest Community Together 10

27 Statement of financial position Balance at 1 April 2017 Movement Year to Date Balance as at 31 May s 000s 000s Non Current Assets Current Assets: Cash & Cash Equivalents 159 2,775 2,934 Current Trade And Other Receivables 3,887 (343) 3,543 Total Current Assets 4,046 2,432 6,477 Current Liabilities : Trade and other Payables (19,957) (985) (20,943) Total Current Liabilities (19,957) (985) (20,943) Current Assets and Liabilities (15,912) 1,446 (14,465) Non Current Provisions For Liabilities & Charges Total Net Assets/(Liabilities) (15,912) 1,446 (14,465) Taxpayers Equity: I&E Reserve - General Fund (15,912) 1,446 (14,465) Total Taxpayers Equity (15,912) 1,446 (14,465) Creating the Healthiest Community Together 11

28 Better Payment Code Payment Performance M2 99% 100% Year to Date Payment Performance M2 Non NHS No Non NHS NHS No NHS The Better Payment Code requires the CCG to pay 95% of non-nhs trade creditors within 30 days of receipt of goods or a valid invoice. The current year to date performance meets the target standing at 99.7% of Non NHS invoices paid by value and 99.5% by volume. Non NHS No Non NHS NHS No NHS 99% 100% Creating the Healthiest Community Together 12

29 Michael Vaughton Chief Financial Officer North Somerset CCG Castlewood Tickenham Road Clevedon BS21 6FW 26 May 2017 Gr ant Thornton UK LLP Har twell House Vic tor ia Srteet Br istol BS1 6FT T +44 (0) Dear Michael North Somerset CCG : Auditor's reports on the financial statements We are pleased to be able to advise you that the audit of the CCG's accounts for the year ending 31 March 2017 has been completed. An unqualified opinion on the accounts and the audit certificate were issued on 26 May On the same date we also issued an qualified, except for conclusion on the Council s arrangements for securing value for money as required by the Audit Commission s Code of Practice Please accept my thanks to everybody at the CCG for your help and support during this year's audit. I have set out below further details regarding the finalisation and publication of the financial statements. Auditor's reports on the financial statements We have noted your wish to publish and distribute the financial statements in electronic format. In accordance with International Standards of Auditing 720 Section A, as issued by the Financial Reporting Council, we are required to: review the process by which the financial statements to be published electronically are derived from the financial information contained in the manually signed accounts; check that the proposed electronic version is identical in content to the manually signed accounts; and check that the conversion of the manually signed accounts into an electronic format has not distorted the overall presentation of the financial information, for example, by highlighting certain information so as to give it greater prominence. However: the examination of the controls over the electronic publication of audited financial statements is beyond the scope of the audit of the financial statements and the auditor cannot be held responsible for changes made to audited information after the initial publication of the financial statements and auditor's report; where you wish to publish or distribute the financial statements electronically, you are responsible for ensuring that the publication accurately presents the financial statements Chartered Accountants Member firm within Grant Thornton International Ltd Grant Thornton UK LLP is a limited liability partnership registered in England and Wales: No.OC Registered office: Grant Thornton House, Melton Street, Euston Square, London NW1 2EP A list of members is available from our registered office. Grant Thornton UK LLP is authorised and regulated by the Financial Conduct Authority.

30 and auditor's report on those financial statements. This responsibility also applies to the presentation of any financial information published in respect of prior periods; and the audit report on the financial statements should not be reproduced or referred to electronically without our written consent. Please ensure that: you only publish the financial statements accompanied by the auditor's report on those statements; you only publish the financial statements accompanied by the "other information" provided to us before we issued our audit report and specifically referred to in our audit report; and you do not publish the financial statements accompanied by any other information not provided to us prior to issuing our audit report. Additionally, please ensure that whilst the published report is dated, you do not reproduce the signature of the auditor in any electronic format for any purpose. Please feel free to contact me if you like clarification on any point. Yours sincerely Peter Barber Peter Barber For Grant Thornton UK LLP 2

31 INDEPENDENT AUDITOR S REPORT TO THE MEMBERS OF THE GOVERNING BODY OF NHS NORTH SOMERSET CLINICAL COMMISSIONING GROUP We have audited the financial statements of NHS North Somerset Clinical Commissioning Group (the CCG ) for the year ended 31 March 2017 under the Local Audit and Accountability Act 2014 (the "Act"). The financial statements comprise the Statement of Comprehensive Net Expenditure, the Statement of Financial Position, the Statement of Changes in Taxpayers Equity, the Statement of Cash Flows and the related notes. The financial reporting framework that has been applied in their preparation is applicable law and International Financial Reporting Standards (IFRSs) as adopted by the European Union, as interpreted and adapted by the Department of Health Group Accounting Manual 2016/17 (the 2016/17 GAM ) and the requirements of the Health and Social Care Act We have also audited the information in the Accountability Report that is subject to audit, being: the single total figure of remuneration for each director on page 86; CETV disclosures for each director on page 90; the analysis of staff numbers and costs on page 97; and the table of fair pay (pay multiples) disclosures on page 95. This report is made solely to the members of the Governing Body of NHS North Somerset CCG, as a body, in accordance with Part 5 of the Act and as set out in paragraph 43 of the Statement of Responsibilities of Auditors and Audited Bodies published by Public Sector Audit Appointments Limited. Our audit work has been undertaken so that we might state to the members of the Governing Body of the CCG those matters we are required to state to them in an auditor's report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the CCG and the members of the Governing Body of the CCG, as a body, for our audit work, for this report, or for the opinions we have formed. Respective responsibilities of the Accountable Officer and auditor As explained more fully in the Statement of Accountable Officer s Responsibilities, the Accountable Officer is responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view and is also responsible for ensuring the regularity of expenditure and income. Our responsibility is to audit and express an opinion on the financial statements in accordance with applicable law, the Code of Audit Practice published by the National Audit Office on behalf of the Comptroller and Auditor General (the Code of Audit Practice ) and International Standards on Auditing (UK and Ireland). Those standards require us to comply with the Auditing Practices Board s Ethical Standards for Auditors. We are also responsible for giving an opinion on the regularity of expenditure and income in accordance with the Code of Audit Practice as required by the Act. As explained in the Governance Statement the Accountable Officer is responsible for the arrangements to secure economy, efficiency and effectiveness in the use of the CCG's resources. We are required under Section 21 (1)(c) of the Act to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and to report by exception where we are not satisfied. We are not required to consider, nor have we considered, whether all aspects of the CCG's arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively.

32 Scope of the audit of the financial statements An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of: whether the accounting policies are appropriate to the CCG s circumstances and have been consistently applied and adequately disclosed; the reasonableness of significant accounting estimates made by the Accountable Officer; and the overall presentation of the financial statements. In addition, we read all the financial and non-financial information in the Performance Report and the Accountability Report to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report. In addition, we are required to obtain evidence sufficient to give reasonable assurance that the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them. Scope of the review of arrangements for securing economy, efficiency and effectiveness in the use of resources We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criteria issued by the Comptroller and Auditor General in November 2016, as to whether the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined these criteria as that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the CCG put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2017, and to report by exception where we are not satisfied. We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary. Opinion on financial statements In our opinion: the financial statements give a true and fair view of the financial position of NHS North Somerset CCG as at 31 March 2017 and of its expenditure and income for the year then ended; and the financial statements have been prepared properly in accordance with IFRSs as adopted by the European Union, as interpreted and adapted by the Department of Health Group Accounting Manual 2016/17 and the requirements of the Health and Social Care Act Basis for Qualified Opinion on regularity The CCG reported a cumulative deficit of 25.3 million in its financial statements for the year ending 31 March 2017, thereby breaching its duty under the National Health Service Act 2006, as amended by paragraph 223l of section 27 of the Health and Social Care Act 2012, to break even on its commissioning budget.

33 Qualified Opinion on regularity In our opinion, except for the effects of the matter described in the Basis for qualified opinion on regularity paragraph, in all material respects the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions in the financial statements conform to the authorities which govern them. Opinion on other matters In our opinion: the parts of the Accountability Report to be audited have been properly prepared in accordance with IFRSs as adopted by the European Union, as interpreted and adapted by the Department of Health Group Accounting Manual 2016/17 and the requirements of the Health and Social Care Act 2012; and the other information published together with the audited financial statements in the Performance Report and the Accountability Report for the financial year for which the financial statements are prepared is consistent with the audited financial statements. Matters on which we are required to report by exception We are required to report if we refer a matter to the Secretary of State under Section 30 of the local Audit and Accountability Act 2014 because we have reason to believe that the CCG, or an officer of the CCG, is about to make, or has made, a decision involving unlawful expenditure, or is about to take, or has taken, unlawful action likely to cause a loss or deficiency. On 13 March 2017 we referred a matter to the Secretary of State under Section 30 of the Local Audit and Accountability Act 2014 in relation to NHS North Somerset Clinical Commissioning Group s planned breach of its revenue resource limit for the year ending 31 March We report to you if we are not satisfied that NHS North Somerset CCG has put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources Basis for qualified Value for Money conclusion The CCG reported a cumulative deficit of 25.3 million in its financial statements for the year ending 31 March 2017 and in September 2016 was placed into financial special measures by NHS England. The CCG has not yet succeeded in addressing the underlying deficit in its budget and is forecasting an in year deficit position of 6.7 million for the year ended 31 March This issue is evidence of weaknesses in proper arrangements for planning finances effectively to support the sustainable delivery of strategic priorities and maintain statutory functions. Qualified value for money conclusion On the basis of our work, having regard to the guidance issued by the C&AG in November 2015, except for the effect of the matters described in the basis for qualified conclusion paragraph, we are satisfied that, in all significant respects NHS North Somerset CCG has put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2017.