BNSSG CCG Governing Body Meeting

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BNSSG CCG Governing Body Meeting Date: Tuesday 5 th February 2019 Time: 1.30pm Location: The Royal Hotel, 1 South Parade, Weston-super-Mare BS23 1JP Agenda number: 8.

Purpose To present the Bristol, North Somerset and South Gloucestershire CCG Month 9 report on Financial Performance including the year to date and forecast outturn position, the key financial

1 BNSSG CCG Governing Body Meeting Date: Tuesday 5 th February 2019 Time: 1.30pm Location: The Royal Hotel, 1 South Parade, Weston-super-Mare BS23 1JP Agenda number: 8.2 Report title: BNSSG CCG Finance Report Month 9 Report Author: R Moors & Nick Tippet Report Sponsor: S Truelove 1. Purpose To present the Bristol, North Somerset and South Gloucestershire CCG Month 9 report on Financial Performance including the year to date and forecast outturn position, the key financial performance indicators and risks and mitigations. 2. Recommendations The Governing Body is asked to: note the financial position, the key risks, issues and mitigations reported at Month Executive Summary The CCG has agreed a financial plan with NHS England that will deliver an in-year deficit of 10m. Delivery of this plan will enable the CCG to access 10m of Commissioner Sustainability Funds which would allow a balanced financial position to be reported for financial year. 4. Financial resource implications This paper presents the financial position of the Bristol, North Somerset and South Gloucestershire CCG. The CCG has a statutory duty to achieve breakeven or better.

2 Governing Body February Legal implications Section 223H of the Health and Social Care Act 2012 sets out the duty for CCGs to break even on their commissioning budget for both revenue and capital. BNSSG is required not to exceed the cash limit set by NHS England, which restricts the amount of cash drawings that the CCG can make in the financial year. The CCG must also comply with relevant accounting standards 6. Risk implications As set out in the report the CCG must ensure it delivers its financial targets. At Month 9 the CCG is reporting net risk of 3.2m. This position reflects the current assessment of financial performance and will be regularly reviewed and updated. 7. Implications for health inequalities No health inequalities issues arise as a result of this report 8. Implications for equalities (Black and Other Minority Ethnic/Disability/Age Issues) There is no impact upon people with protected characteristics. 9. Implications for Public Involvement The financial position of the CCG is subject to regular reporting and review by the Strategic Finance Committee and Governing Body. In addition, the CCG has regular meetings with NHSE to review performance throughout the year. Page 2 of 2

3 Finance Report December 2018

4 Report on financial performance for December 2018

5 Contents 1. Executive Summary 1.1 Headlines 1.2 Financial Duties 1.3 Trends 2. Finance and Contract Management 2.1 Allocation 2.2 Financial Position as at month end 2.3 Acute Commissioning/Acute Contracts 2.4 Non Acute Commissioning 2.5 Primary Care Commissioning 2.6 Efficiency Savings 2.7 Financial Risk 3. Financial Control 3.1 Statement of Financial Position 3.2 Cash Limit Drawdown 3.3 Better Payment Code 3

6 1.1 Headlines The CCG is forecasting delivery of the financial plan for the year as at Month 9 (December 2018) however the CCG is reporting a net (unmitigated) risk of 3.3m against the plan, primarily from additional medicines costs of No Cheaper Stock Obtainable (NCSO) applications. Consistent with NHSE advice this financial cost pressure has been reported in the risks and mitigations position during the year. The CCG, after discussion with NHSE, has secured additional non-recurrent funding of 2.3m to partially mitigate this pressure. Acute spend increased in November. The overall position reported at month 9 is a year to date overspend of ( 15.4m) a deterioration in the year to date variance of 3.0m from month 8. The primary drivers of this deterioration are increased activity pressures at NBT ( 0.7m) and UHB ( 0.9m). The impact of unachieved QIPP savings has impacted the position by 1.2 m in month 9. The audit commissioned following the activity query notice at NBT has now been completed. The verbal feedback confirmed that the increase seen from July onwards is due to electronic recording on Lorenzo of activity that had previously been recorded in paper records within the ED observation area. The final written report will be with us by the end of January and we are in discussions with the Trust on the wider implications that the report has highlighted. The 28.5m savings forecast is unchanged from the previous month 8 position however there have been increases and decreases to certain projects delivery, but the resulting impact means no net change. Key pressures from acute hospital activity have meant deteriorations in delivery of planned care projects but there have been improvements in the delivery of certain medicines optimisation and mental health projects. 4

7 1.2 Financial Duties Financial Duties Target Plan Maintain expenditure within the revenue resource limit Maintain expenditure within the allocated cash limit Outturn is better 10m deficit to than or equal to plan access 10m CSF Cash drawdown is less than or equal to MCD CCG will manage within Cash Limit Forecast Variance RAG Explanation The CCG has an agreed financial plan with NHSE that requires a maximum of 10m deficit in year before commissioner sustainability funding. Now amber due to adverse movement on Acute activity. Cash drawings are in line with plan at month 9. The CCG has a cash flow forecast that is consistent with the income and expenditure plan. Maintain capital expenditure within the delegated limit Expenditure less than or equal to plan CCG will manage within Capital resource limit The CCG expects a Capital allocation of 0.35m in and has plans to fully utilise these funds in year Ensure running costs are within the running cost resource limit Expenditure less than or equal to plan CCG will contain spend within Running Costs Allocation The financial budget for running costs is within the allocation. Ensure compliance with the better payment practice code Greater than or equal to 95% by number & value CCG will achieve payment target throughout year Current performance is above the target for both value and number of invoices paid and performance has improved in month. 5

8 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Attendances Attendances Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Episodes Episodes 1.3 Activity trends - contract data at month 8 Unplanned Elective 10,000 10,500 9,500 9,000 8,500 8,000 7, actual plan actual 10,000 9,500 9,000 8,500 8,000 7, actual plan actual 7,000 7,000 Outpatients A&E 85,000 25,000 80,000 24,000 75,000 70,000 65, actual plan actual 23,000 22,000 21, actual plan actual 60,000 20,000 55,000 19,000 6

9 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Spend ('000) Spend ('000) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Spend ('000) Spend ('000) 1.3 Finance trends contract data at month 8 20,000 Unplanned 12,000 Elective 19,000 18, actual 11,500 11,000 10, actual 17, plan 10, plan 16,000 15, actual 9,500 9,000 8, actual 14,000 8,000 9,500 Outpatients 3,400 A&E 9,000 3,300 8,500 8,000 7, actual plan actual 3,200 3,100 3, actual plan actual 7,000 2,900 6,500 2,800 6,000 2,700 7

10 2.1 Financial Allocation Baseline Adjustments in month 9 Total Revised Allocation at System support UEC Diabetes Mental Health adjustments allocation 30-Nov-18 funding Transformation Transformation Winter pressures Other month 9 31-Dec Acute Contracts 680, ,994 Mental Health 131, ,063 Continuing Care 69, ,621 Community Services 136, ,430 Primary Care 154, ,366 Medicines Optimisation 128, ,137 Other Programmes 17,534 2, ,619 20,153 Deficit -6, ,500 Total Commissioning Budget 1,312,415 2, ,849 1,315,264 Running Costs 20, ,944 Total Allocation ,333,359 2, ,849 1,336,208 The month 9 allocation adjustments resulted in an increase of 2.849m to the CCG baseline funding. Funding from NHSE of 2.3m, non-recurrent, has been received to support the Primary Care and Prescribing pressures within the system. Other allocations transacted at month 9 include: 0.161m for Urgent and Emergency care transformation and length of stay 0.098m further funding for Diabetes transformation 0.075m in respect of Mental Health winter pressures 0.065m for CCG Wi-fi maintenance 0.058m in relation to the medicines optimisation in care homes programme All allocation adjustments transacted in December are on a non-recurrent basis. 8

11 2.2 Financial Position as at December 31 December Month 9 Year to date Annual Forecast See Budget Expenditure Variance Budget Expenditure Variance section Area of spend '000 '000 '000 '000 '000 '000 Acute 513, ,452 (15,395) 681, ,764 (21,117) 2.4 Mental Health 101, , , ,543 (372) 2.5 Community Health 103, ,397 (1,260) 137, ,907 (2,172) 2.5 Continuing Care 52,124 52,682 (558) 69,470 70,183 (713) 2.5 Medicines optimisation 94,670 97,180 (2,510) 126, ,689 3, Primary care 25,959 26,660 (701) 34,586 35,694 (1,108) 2.6 Primary Care Delegated Commissioning 91,068 91,099 (31) 121, ,424 (0) 2.6 Other Programme Services 14,558-5,542 20,100 18,940-3,378 22, Running Costs 14,230 14,277 (47) 18,870 18,882 (12) BNSSG CCG Total 1,009,957 1,009,957 (0) 1,342,708 1,342,708 0 Revenue Resource Limit (RRL) -1,005,957-1,005,957-1,336,208-1,336,208 In Year Financial performance 4,000 4,000 (0) 6,500 6,500 0 Key actions: An independent audit has been carried out NBT following the Activity Query Notice relating to the significant increase in non-elective short stay admissions. The findings of the audit were reported on the 18 th January 2019 and support the CCG s position that the activity is a Counting & Coding change by the Trust. AQP process will be strengthened by the start of Q4 to ensure a check of referrals prior to onward treatment. The CCG had proposed a resolution for the termination of pregnancy services issue which has not been agreed with UHB. The matter has now been escalated for resolution by the Chief Executives on the 14 th February

12 2.3 Acute Commissioning provider analysis Month 9 - Reported Year to Date Budget Actuals Variance North Bristol NHS Trust 214, ,377 (4,196) University Hospitals Bristol NHS Foundation Trust 178, ,375 (3,232) Weston Area NHS Health Trust 49,249 48,074 1,175 South Western Ambulance NHS Foundation Trust 23,901 23, Other NHS Trusts* 10,391 10,871 (480) AQP Contracts 21,815 24,440 (2,625) NHS Non Contract Activity (NCA) 8,866 8, Other Acute Expenditure 6,511 13,064 (6,553) Total Acute services 513, ,452 (15,395) The acute position at month 9 is based on the service level activity monitoring reported by the Trusts for November (month 8). This means the December element of this year to date position is an estimate. The overall position reported at month 9 is a year to date overspend of ( 15.4m) a deterioration in the year to date variance of 3.0m from month 8. The primary drivers of this deterioration are increased activity pressures at NBT ( 0.7m) and UHB ( 0.9m). The impact of unachieved QIPP savings has impacted the position by 1.2 m in month 9. Independent sector and AQP contracts are 2.6m (12.0%) above plan which is a small improvement on the position as at M8 ( 2.7m 14.3%). 10

13 2.3 Acute Commissioning point of delivery performance for Month 8 Point of Delivery Activity Costs Month 8 Year To Date Plan Actual Variance Plan Actual Variance No. No. No. % % Non Elective 68,887 73,690 (4,803) 7.0% 135, ,012 (4,774) 3.5% Elective 74,489 74,999 (510) 0.7% 84,957 85,519 (563) 0.7% Outpatients 1st 147, ,551 (8,386) 5.7% 25,054 25,637 (583) 2.3% Outpatients Follow ups 340, ,997 3, % 25,470 26,319 (850) 3.3% Outpatient Procedure 83,359 92,604 (9,245) 11.1% 12,265 13,654 (1,389) 11.3% A&E 178, ,850 (5,670) 3.2% 25,140 25,714 (573) 2.3% Critical Care 9,557 10,477 (920) 9.6% 10,992 12,129 (1,137) 10.3% Maternity 19,225 20,055 (830) 4.3% 28,079 28,665 (585) 2.1% Drugs and Devices ,503 22, % CQUINS ,309 8, % Other and adjustments* ,226 54,814 (6,588) 13.7% Total 428, ,629 (15,395) 3.6% * Includes adjustments in the reported position arising from validation of reported activity and known data quality issues 11

14 2.4 Non Acute Commissioning Year to Date Budget Actuals Variance Mental Health and Learning Disabiities 101, , Community Services 103, ,397 (1,260) Continuing Healthcare (CHC) 52,124 52,682 (558) Other Programmes 4,444 4, Reserves 10,115-9,803 19,918 Non Acute Total 270, ,292 18,682 There are overspends in Mental Health as a result of IAPT activity pressures and Mental Health Placement commitments with further adverse variances due to unachieved planned savings. These are offset by some underspends across other programme areas. The main driver behind the community services overspend is the impact of the investment in Community services home first model, reducing the need for rehabilitation provision in Weston General Hospital ( 875K year to date). This is partly off-set by the reduction in rehab being charged by WGH, as reflected in the year to date Acute spend. Slippage in implementing some community QIPP schemes represent a 531K under-delivery against planned savings at the end of December. The 0.5% contingency reserve has been released to support the position which equates to 5.0m year to date. The CCG has also benefited from the final 2017/18 North Bristol NHS Trust position which is approximately 2.2m lower than had been anticipated at the end of the financial year. There are a number of other balance sheet flexibilities relating to the previous financial year which are offsetting in year overspends in other areas. 12

15 2.5 Primary Care Commissioning Year to Date Budget Actuals Variance Medicines Optimisation 94,670 97,180 (2,510) GP Contracts 91,068 91,099 (31) Out of Hours and NHS 111 Contract 10,013 10,952 (939) Improved Access 5,720 5, PMS Review 4,778 4,778 (0) Local Enhanced Services 3,565 3, Other Primary Care 1,883 1,985 (102) Primary Care Total 211, ,938 (3,241) The year to date overspend on Medicines Optimisation is associated with no cheaper stock obtainable (NCSO) costs. This means a temporary price concession is applied, normally due to shortages in generic drug supply, and pharmacy contractors are reimbursed at this higher price, rather than the Drug Tariff listed price. Additionally drugs are coming off NCSO status at a higher price. GP contracts are reporting a 31k YTD overspend. This pressure is caused by locum cover payments to practices. This pressure is being offset by the reserve budget held with the delegated commissioning budgets. Costs for the NHS 111 service will exceed budget in because of additional contract expenditure agreed non-recurrently, ahead of the integrated Urgent Care service which has been procured to start from April Improved Access is currently contracted for through OneCare, and includes claw-back of funding for under delivery against the additional 45 minutes/ 000 population target. Quarter 1 performance averaged 93% delivery, and Quarter 2 performance averaged 90% delivery, resulting in a year to date underspend of 233K. Based on actual activity levels, the Enhanced Services are producing a 108k YTD underspend. 90k of this is in relation to a decrease in Anti-Coagulation activity as a result of patients being switched from the Warfarin drug that requires the monitoring. The majority of the 102k YTD adverse variance against Other Primary Care is attributed to the ongoing 111 reprocurement posts. 13

16 2.6 Savings December Month 9 Year to date Risk assessed forecast Trend from Target Achievement Variance Target Achievement Variance Prev month Control Centre '000 '000 '000 '000 '000 '000 % Planned, Ref Mgt, Cancer, Diagnostics 4,904 3,194 (1,710) 7,671 3,859 (3,812) (14%) Urgent and Community Care 4,202 2,557 (1,645) 7,230 4,081 (3,149) 0% Mental Health 2,743 2,445 (298) 5,443 4,365 (1,078) 15% Primary Care % Meds Optimisation 7,356 7,019 (337) 9,169 8,720 (449) 43% CHC and EOL (57) 1, (40) 0% Other Enabling and Back Office 4,428 4,270 (158) 6,000 6, % BNSSG total savings plan 24,716 20,518 (4,198) 37,038 28,561 (8,477) 1% Key actions: Year to date delivery is 83% of plan. 52 of the total 59 projects are reporting savings year to date ranging from 5k to 5m. A core 13 projects are delivering 15.6m of the year to date saving. The 28.5m forecast is unchanged from the previous month 8 position however there have been increases and decreases to certain projects delivery, but the resulting impact means no net change. Key pressures from acute hospital activity have meant deteriorations in delivery of planned care projects but there have been improvements in the delivery of certain medicines optimisation and mental health projects. Control Centres continue to explore areas to support the in-year position. As well as focusing on in-year delivery, plans are also in development for next year (2019/20). The plans are being discussed within the BNSSG system as part of the shared planning processes for 2019/20. 14

17 2.7 Financial Risk Risk Description Transforming care programme for LD risk as no confirmation of funding to meet our estimate of the costs of providing care in the community No Cheaper Stock Obtainable risk is that drugs are becoming available again but at a higher price than previously Risk Value m % Likelihood Adj Risk Value m % % Short stay challenge at NBT Termination of pregnancy contract changes % Total Risks Mitigations Anticipated TCP funding % Assume NBT short stay challenge successful Anticipated improvement in prescribing Cat M position Prior year position better than expected Net risk

18 3.1 Statement of financial position Total non current assets Total current assets Total non current liabilities Total current liabilities Total net assets/liabilities Total taxpayers equity Opening balance Movement Balance at 31/12/18 '000 '000 ' ,778 7,951 18, ,638-8,711-90,349-70, ,414-70, ,414 The aggregate Statement of Financial Position (SoFP) is summarised in the table above. Overall the CCG has negative Taxpayers Equity (its creditors are bigger than its debtors) but the CCG s going concern status is reviewed by the Finance Committee and confirmed by auditors. 16

19 m 3.2 Cash Limit Draw Down Plan Actual Forecast Key points: Cash drawings at 31st December are 75% of the cash limit and are in line with the cash flow forecast Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Reconciliation of cash to I&E position '000 Maximum cash draw down (MCD) 1,009,122 Movement in capital 75 Movement in cash -9,867 Movement in receivables 1,916 Movement in payables 8,711 I&E position 1,009,957 17

20 3.3 Better Payment Code % 98.00% 96.00% 94.00% 92.00% 90.00% Better Payment Performance against target - Year to Date NHS - No. NHS Non - NHS No. Non-NHS Type In Month Payment performance (December 2018) Number '000 Interest to suppliers due to a breach NHS Total bills paid in month ,312 0 Total bills paid within target ,312 0 % bills paid within target % % Non-NHS Total bills paid in month 1,991 42,390 0 Total bills paid within target 1,961 42,283 0 % bills paid within target 98.49% 99.75% Type Year to date Payment performance (Apr - Dec 2018) Number '000 Interest to suppliers due to a breach NHS Total bills paid in year 4, ,196 0 Total bills paid within target 4, ,541 0 % bills paid within target 99.20% 99.53% Non-NHS Total bills paid in year 18, ,722 0 Total bills paid within target 18, ,527 0 % bills paid within target 97.69% 97.94%

MERTON CLINICAL COMMISSIONING GROUP GOVERNING BODY

MERTON CLINICAL COMMISSIONING GROUP GOVERNING BODY Date of Meeting: 30 th November 2017 Agenda No: 9.2 Attachment: 11 Title of Document: Finance Report Month 7 Report Author: Robert Kirton Purpose of Report: