NHS Southwark Clinnical Commissioning Group. Budgetary Framework for

Transcription

1 NHS Southwark Clinnical Commissioning Group Budgetary Framework for Introduction The CCG is entering its fourth year, and faces a tough financial scenario for and future years. The CCG anticipates closing its accounts for , having achieved its 1.9% surplus target, equivalent to c. 7.5M. The NHS England Board meeting received a paper from Paul Baumann, national NHSE Chief Fiancial Officer (CFO), setting out the funding for onwards, under the Five year forward view proposals, as headlined in the autumn statement recently. Allocations were issued on 8 January The NHSE Board took the decision to further significantly change the funding formula weightings for deprivation and age, giving a great change in CCG positions compared to their previous target spend levels. For Southwark this has taken the CCG to a position of some 2.8% above the closing target for This is much higher than 2 years ago, when under the previous formula the CCG was seen to be funded below capitation target level. The publication of the Five Year Forward View and associated planning guidance from the Head of the NHS, has given a set of further priority areas in which to provide assurance that the CCG is investing for The first draft operating plan returns were submitted on 8 February, then in full on 2 March, and a final version in early April. Guidance was issued in late December The guidance sets out nine must dos for each health system. These are attached at Appendix 1. Funding Available Funds have been made available, to cover the full five year period, this will include firm allocations for the first three years, and indicative figures for the last two years. The five year total funding is announced as being over 8.4bn in real terms, ie. above inflation in real terms. It should be noted that inflation is estimated at less than 1-2% per annum. This is weighted more heavily towards year 1 ( ), and year 5. This includes the creation of a transformation fund, which in year 1, , is geared towards 1

2 returning all Trusts in England to in year financial balance, giving them more time to implement long term sustainable recovery plans. There is an emphasis on system wide leadership, and thus the requirement to produce a local economy Sustainability and Transformation Plan covering the five years, as well as a one year operating plan. The draft version of this plan is due in March for some sections, and in June as atotal plan. This will then beput through an assurance process by NHS England, and to ensure alignment with trust plans. Applications of Funds for : General Uplift in CCG allocations- The NHSE board approved a quicker movement towards capitation targets, and to having no CCG at less than 5% under target. This means that the distribution of funds is more skewed than in the past where there was a minimum uplift to all CCG s of nearly 2%. The average increase for will be 3.4%. In London four CCG s have received the new national minimum uplift of 1.39% for These are in West and Central North London. The overall formula has been revised, with a heavier weighting for elderly, and for sparsity of provision, and slightly less for deprivation. This will benefit some CCGs eg. Bromley, but make little change to Southwark overall. Inner city areas will reduce as a proportion of total national funding as a result. CCGs are also being encouraged to drawdown their surplus, where it is above the 1% minimum, over the next three years, to give extra non recurrent funding for pump priming of investment, and meeting non recurrent pressures. Locally this means that Southwark, will apply to draw down c. 3m, at a rate of 1m per annum for each of these three years. This will still leave an accumulated surplus of 4.3m, just over the 1% threshold. We will see three place based allocations for Southwark, a programme budget for commissioning activity, an indicative budget for specialised commissioning, and a co-commissioning budget for primary care medical services. This commits 3.8Bn of the overall uplift in the first year , this percentage uplift reduces in years 2-4, and then rises again in year 5, which is Sustainability and Transformation fund The Department of Health (DH) is setting up a sustainability fund of c 2.1bn, of which 1.8bn will be targeted at failing trusts who can demonstrate their plans to return to recurrent balance, but who need assistance to get there. Currently nearly all 2

3 local Trusts are in deficit, with King s being in the most severe position, and approximately half of all trusts in England have a deficit. This replaces the funding which was previously available via the DH to Trusts. There will be a clear process with NHS Improvement to access these funds. Winter pressures- The policy adopted in remains, in that circa 2m per CCG is built into recurrent baselines, and any further spend in this is to come from our allocation. Specialised commissioning- very few additional services are delegated to CCGs, primarily just bariatric surgery, and some outpatient areas. Funding for specialised services will grow by 8% in , and then by 4-5% in each subsequent year. This reflects the pressures from new approved drug treatments. Primary Care Budgets NHS England have undertaken work using the Carr Hill national primary care funding formula, to arrive at the target budgets for each region, and then down to CCG level for This will be needed to support primary care co-commissioning in and beyond. The Carr Hill formula usually calculates a target that includes GP, Dental, Pharmacy and Optical as one single budget. Additional work has been done to split this between GP services, and the three other categories, as delegated co-commissioning is only currently for GP services. Southwark s baseline budget for GP services is under discussion with NHSE London colleagues who are analysing current spend by practice. There are significant pressures on that funding, which we are discussing through our co-commissioning structures. This primary care medical budget would only be our CCG responsibility if we agreed to take full level 3 delegated responsibility. At present we plan to continue with level 2 in 16-17, with level 3 at a later date. We are currently undertaking a PMS review with NHSE colleagues. This will redefine what is expected from GP contractors, with a focus on population health improvements, but is not intended to reduce spend in this key area of service delivery. This uses GP registered list size, as does the programme budget allocation. Lists grew by 1.7% in the 6 months to September Mental Health- There is an expectation that CCGs will continue to show parity of esteem in that they will grow their investment in mental health, in line with their overall allocation increases of 2-3% per annum. This includes two new access 3

4 standards for IAPT and Psychosis. Our local work on tendering for IAPT, CAMHS joint LA/CCG plan investment, and other investments should put Southwark in a good place to achieve these targets. Other Areas- There will be a bidding process for the Primary Care Transformation Fund capital and revenue funds. This includes digital projects, and also including funding for GP premises improvement schemes. These are due to be submitted in late April, and we are working with practices on these bids. It is still expected that legacy continuing healthcare claims will be met by CCG s, but the latest assessment shows that this requirement will reduce from 250m in , to 100m in , then zero. This is met from non recurrent reserves at the start of the year. We have been asked to set aside a sum of 0.15% for the next year s programme for the Healthy London Partnership as part of these national plans. This is also set aside in our reserves at the start of the year. 2. Opening Southwark CCG Resources Southwark and Lewisham are the only SEL boroughs to be over target in SEL, based on the national formula. Therefore, while Southwark has received 3.05% growth money, some other CCGs have received more to bring them up towards target funding level. Table 1 Opening Resources Recurrent Allocation 375, ,667 NHSE transformation 2,000 funds Surplus drawdown 1,000 Programme resources 382, ,667 Running Costs allocation 6,572 6,457 Total Resources , ,124 Target surplus for the 6,477 6,477 year This is built up from our recurrent baseline, consolidation of non recurrent items from mainly due to the permanent transfer of Public Health funding to the Local Authority, which has been an in year adjustment until now, plus a 3.05% uplift of 4

5 11,647k. In addition we are use part of the uplift to increase the Better Care Fund from NHSE, by circa 1% or just over 200k. 3. Opening Budget Envelopes and Financial Targets for At this stage appropriate budget negotiating envelopes have been drawn up locally, including input from our CSU acute contracting team, to enable the meetings with NHS Trusts to go ahead. Despite the changes, the three largest contracts for Southwark remain Guy s and St.Thomas, King s, and SLAM, which between them account for over 60% of our resources.we are working with approximate contract values at this time, and aiming to sign contracts by the national late March deadline. There have been further changes to the acute Payments by Results tariff, and for this year the net tariff has increased by 1.1% releasing resource to commissioners, this is a combination of inflation of 3.1%, including the national increase in National Insurance, and changes in NHS Pensions, and net of 2.0% efficiency savings. NHS Improvement has set Foundation Trusts a target of at least 2.0% efficiency saving, and in reality cost pressures mean that Trusts will require savings beyond this level. The CCG has a role in assuring the Trusts internal CIP programmes do not detriment patient quality and safety of care. These are currently being reviewed. All our trusts in SE London currently are running inyear deficits in Mental health Payment by Results, based on cluster of service tariffs for mental health will be further shadowed in When implemented this will initially cover only a quarter of the SLAM contract services. In the coming year we will be developing these contract currencies with SLAM and monitoring them on a shadow basis alongside existing contract currencies. In order to achieve a balanced budget position, including making a continued 1.6% surplus, the CCG currently needs a net QIPP programme of c. 8m in total. This figure may still need to increase depending on the outcome of contract negotiations, and on the final level of reserves we deem necessary, and can afford to manage in year risk. This is discussed later in this paper. Table 2 Opening Budget Envelopes Acute services 209, ,145 Mental Health services 53,663 55,313 Community services, primary care and 34,185 35,786 5

6 transformation Primary care prescribing 32,485 34,063 Continuing care and Free nursing care 15,650 17,115 Better Care Fund 20,478 20,682 Corporate costs and property costs 5,838 6,193 Total Budget envelopes 372, ,297 Reserves and Contingencies 10,331 8,370 Total Programme Budget excluding 382, ,667 running costs, net of QIPP savings Negotiations are being held regularly with all major trusts and offers have been received from the trusts. The CCGs have made a contract offer to mental health trusts, and are evaluating the offers received from Guy s and St Thomas NHS Foundation Trust and King s College Hospital NHS Foundation Trust. In addition the CCG has an important role in signing off the internal Cost Improvement Programmes (CIPs), for the trusts, and the commissioner led QIPP programmes as well, to ensure quality of services is not compromised by the changes made to stay within available rsources. As we have a lead commissioner role for King s, we will undertake this for the whole of London CCGs, and also be part of a joint four CCG lead commissioner group for SLAM. Lambeth CCG will lead this work with Guy s and St.Thomas. We are working closely with King s, NHSE, and the NHS Improvement, to take forward the recovery plan for King s. Nationally we will be reporting on progress to the NHSE regularly, and must reach agreement on all NHS contracts by late March at the latest. The model contract for NHS providers has been updated by the DH. In addition there will be local clauses on quality and performance issues. A number of services being redesigned will be subject to procurement processes in year, these will be procured with expert external advisors input, patient representative input, and technical advice. This includes the IAPT service, which was tendered this year, and a lead provider arrangement was awarded to SLAM, effective from April A number of smaller services are also being considered, as their current contract and pilot arrangements come to a natural end. These figures exclude the running costs budget which was 6,572k in It is understood that this figure will be a flat cash allowance for the full five year period. 6

7 This is also based upon ONS population, which has fallen by 7,000 in the last year in Southwark to 292,000. Thus our target spend has been reduced to 6,457k for This represents a cost pressure of 120k per annum, to stay within target. 4. Investment in The CCG continues implementing its Primary and Community Care strategy this year, and has undertaken some reprocurement of services. It is also finalising plans to invest more in mental health services, and the Five Year Forward View requires CCGs to demonstrate that they are investing an amount equivalent to the growth in their allocation, 3% for us, to ensure these services are not eroded in real terms. This can be shown in our work on IAPT and early intervention in psychosis, and in redesign of Adult Mental Health services, and investment in Children s camhs services.-these total over 2m, exceeding this requirement. For the coming year we will continue to invest in improving the quality of community and primary care services, and achieve safety and quality improvements in all our contracts. We have had two Urgent Access 8-8 centres in operation for the past year. These are dealing with patients referred from other practices in their patch, and ensuring people get seen the same day, rather than using other parts of the health system. These are an investment of over 2.5M recurrently. We are seeking to take forward at pace, the development of our local care networks with providers and joint commissioners of services, to realise the vision we have through the Our Healthier South East London programme. These services are managed by our two local GP federations, which all GP practices are members of. Through this we expect to achieve increased quality and consistency of care for all Southwark residents. We intend to invest further in their development in the future. We are also seeking to support practices in their proposals to look at mergers, and in evaluating their future plans. The Dulwich development programme has had various NHSE approvals in the past year, and work is now progressing on the full design of the Health Centre. Also the remainder of the site has been sold for a new secondary school. The business case will be completed by early Other potential developments that support delivery of the primary care strategy are well progressed, as part of council regeneration projects, including the Aylesbury estate. 7

8 The CCG s investment plans are summarised at the end of this paper. These have been categorised into firm commitments that have started, those committed to- but not yet underway, and those schemes where investment is still optional.. In total we are aiming to invest to deal with cost pressures- such as outturn on contracts, and pick up of non recurrent funding. These are appended to this paper. We are also investing in new and improved services in acute, community and primary care health services, new schemes in the Better Care Fund, in winter resilience, and in mental health and disabilities, and safeguarding. These will be reassessed as the contracts are agreed and the overall position becomes firm. 5. Better Care Fund Southwark s Better Care fund plans are currently being updated for The plans total c. 20,682k revenue monies, and another 1.48M capital, the capital flows direct to Councils. The fund will be reported through an existing joint governance structure up to the Health and Wellbeing Board on a quarterly basis. The creation of the fund, has taken in previous payments by NHSE, and the CCG, some new funding from NHSE, and has required the CCG to fund a further 6M from its baseline allocation monies in , to reach the required level. This includes support for the new Social Care Act, to support social work and associated services. A programme of schemes is in place including support to 7 day working in primary, community, and social care, mental health investment, and supporting social workers and elderly care. This is in addition to other jointly managed services, or those which the CCG commissions on behalf of the Council under a S.75 agreement. This will also be assured by NHS England. 6. QIPP Programme for The CCG has determined that it will need a net QIPP saving programme of circa 7M in the year, comprising both new schemes, and the full year effect of some mental health schemes from This is after risk rating by the SMT, and after investment to achieve these savings, and means that the gross programme, is significantly larger.the programme has been derived through examining areas where we feel confident that the CCG can 8

9 achieve savings, and is linked to our service redesign programme. Table 3 below summarises the main areas where risk rated QIPP savings are planned. This programme will need to increase if the outcome of contract negotiations is unfavourable with some Trusts and other providers. Table 3 Net QIPP programme Acute services 5,500 5,100 Community services and primary care Mental health /client groups 1,706 1,200 Corporate services Continuing Care 0 0 Prescribing Total QIPP programme- net 7,982 6,934 Our track record is in delivering the full programme totalling 8m, programme totalling 15.5M, and in delivering programmes between 11m to 20M in the previous three years. Therefore with tight governance, we believe this programme is deliverable in The allocation increase in is lower, so we may well need to plan very early for an increase level of savings in m, potentially exceeding 10m. 7. Reserves and Risk Mitigation The CCG has had significant cost pressures to deal with in the past few years, most significantly the growth in acute activity. The current envelopes include an assumption of funds being set aside for acute growth, for outturn, unwinding non recurrent funding, and demographic growth, and meeting Referral to Treatment targets (RTT). These areas are much more under control now, although there are still concerns about maintaining performance and of delivering suatained quality. Mental Health and client group contracts are overperforming,with an increase particularly in the use of acute MH beds particularly external placements, - costing circa 280k in Significant service change which started in , will continue to be implemented, and to deliver the QIPP savings. 9

10 Prescribing has delivered significant savings to date, and is expected to continue in , but at a lower level, as a result of national price changes. Thus, the CCG needs to maintain a significant level of contingency and earmarked reserves. At this stage of negotiations, some of these may need to be utilised to reach better contract agreements that reduce our in year risk exposure. The outcome of this will not be known until March, when all contracts are agreed, or whether we will need to find further QIPP to mitigate these calls on reserves. All CCGs have again been instructed through nationally agreed Business Rules, to keep aside 1% of budget as an uncommitted reserve to meet non recurrent pressures in year. In SELwe expect to use part of this to fund the CHC risk pool, and HLP programme circa 1m, together. This will be subject to DH approval from now on. In addition we are require to set aside a ½% contingency fund, and funds to meet in year activity pressures. All reserves will require IGP committee approval for their release into contracts, through monthly finance reports. Boards signed off a new SEL collaborative agreement last year, and the SEL risk reserve has thus been reduced to ¼% per CCG. We are also required to create an additional 0.15% Transformation fund for local or London wide projects, again from the Five year Forward View and local commitments. Table 4 Overall planned level of reserves for (as at February 2016) final opening reserves proposed reserves % of allocation Set aside for Non recurrent pressures, inc 3,964 4, Provisions Set aside for Healthy London Partnership Other reserves and risk pools General contingency ½ % 1,981 2, Continuing Care Retrospective Risk Pool 700k reduced to c.300k in Inc. in 1% NR above Inc. in 1% NR above General risk reserve Collaborative SEL risk pool ½% then ¼% 1,982 1, MFF effect of Kings / PRU merging 1,800 0 Total 10,332 8,370 10

11 Risk management arrangements across the CCGs in SEL were agreed formally, as part of our Authorisation process and have been reviewed again with the NHSE London Director of Finance recently. These give a framework for robust support between organisations to ensure that all six can reach their financial targets for the year. Any funding made available can be repayable or not, depending on the agreed package to aid recovery. We have been advised that there will be the last year of a national risk pooling in operation around continuing care retrospective claims in , to fund the cash flow needed by NHSE to make payments. This risk pool will entail a contribution from each CCG, with Southwark required to pool c. 0.3M of resources from its non recurrent reserves. This is a reduction on the 0.7M we contributed last year, as the formula used reflects usage of the fund. It should be noted that the reserves started at 10.3M, but we expect to end the year with c. 0.5M available, after various calls on reserves, and budget adjustments agreed with NHSE, SEL Risk share, and Trusts. Almost all of this was committed to offset cost pressures, including contract overperformance, and deliver the planned surplus. 8. Governance around Budgets and QIPP Programme Delivery All budget papers are considered by the Integrated Governance and Performance committee (IGP), and then recommended to the CCG Governing Body (CCG GB). Service redesign and procurement proposals are put forward to the Commissioning Strategy Committee(CSC), and in some cases proposals arise through our Programme Boards, and are then recommended to the CCG GB. Clinical Board members are involved in all committees, and as Governing Body voting members. They have protfolios of expertise and lead on particular services and contracts. They are involved with officers, in negotiating and agreeing key contract terms and conditions. Key issues are raised and debated at the SMT meetings as well, which holds managers to account. The QIPP programme forms an important part of our Integrated Performance report, challenged by all Board members, and the IGP committee, and its sub groups examine schemes in detail to ensure they are delivered, or mitigations put in place. Finally, the NHSCB holds regular assurance reviews with the CCG at which our contract performance, and management, and the QIPP programme are challenged and reviewed. 11

12 These measures taken together give a robust process for the management of budgets and QIPP, and agreement on the utilisation of reserves in year. There are comprehensive reports from the CSU acute team, and from our client groups team on contract performance each month. These are supplemented by the overview in the Integrated performance Report and Finance Report as well. 9. Forward Look to onwards We need to maintain our record of delivery of improving services, and delivering QIPP savings, to enable transformation and integration to take place, through revised models of Neighbourhood working in Local Care Networks. The Five Year Forward View and planning guidance states the expectation that CCG s will maintain at least a 1% annual surplus each year. The current 1.9% surplus is carried forward from year to year under Treasury rules.this is subject to the current rules remaining in place. We expect to reduce this to 1% through drawdown over the next three years, in line with latest NHSE guidance. We will receive smaller increases to our allocation, from of around 2.5% p.a., for three years, because we will be above target spend levels, and the pressures are expected to remain high, with possible increases in inflation, meaning that as commissioners there will be reduced benefit from tariff changes year to year. The CCG therefore is predicting a total QIPP of over 35M for the next five years to The SEL strategy work will be taken further in the next year, culminating in business case from trusts and commissioners, and public consultation, where appropriate, as part of improving the health outcomes of all people in SE London. Taken together, these issues represent an increased level of risk to achieve targets in 16-17, and it is possible that the level of QIPP required, over the five years, will increase as a consequence. If the outcome of contract negotiations is favourable, this will not be required in 16-17, subject to the effect of other in year pressures. We are operating on a tighter level of reserves, as are most CCG s, and therefore there is some increase in risk, which will be mitigated by the contract arrangements we agree shortly. 12

13 10. Recommendations 1. The Council of Members is asked to approve the Budgetary Framework for The CCG are asked to delegate authority for contract negotiations, to the Chief Officer, Chief Financial Officer, and Chair of the Intergrated Governance and Perfomance Committee (IG&P), to allow these to be concluded by the deadline. They will take account of the advice from clinical members of the committee who are engaged in the negotiations. 3. To note that updates will be made to the IG&P committee, and a final budget paper will be presented to the CCG Governing Body in May. 4. To note that the Governing Body will be kept appraised of developments in national policy on use of reserves and allocation isues by the CO and CFO. Malcolm Hines Chief Financial Officer, Southwark CCG 2 March 2016 Attachments: Five Year Forward View top 9 Must Do priorities for the CCG List of Cost pressures for List of Proposed Investments for

14 Appendix 1 - extract from NHS Planning Guidance issued 17 December 2015 National must dos for 2016/17 Whilst developing long-term plans for 2020/21, the NHS has a clear set of plans and priorities for 2016/17 that reflect the Mandate to the NHS and the next steps on Forward View implementation. Some of the important jobs for 2016/17 involve partial roll-out rather than full national coverage. Our ambition is that by March 2017, 25 per cent of the population will have access to acute hospital services that comply with four priority clinical standards on every day of the week, and 20 per cent of the population will have enhanced access to primary care. There are three distinct challenges under the banner of seven day services: (i) reducing excess deaths by increasing the level of consultant cover and diagnostic services available in hospitals at weekends. During 16/17, a quarter of the country must be offering four of the ten standards, rising to half of the country by 2018 and complete coverage by 2020; (ii) improving access to out of hours care by achieving better integration and redesign of 111, minor injuries units, urgent care centres and GP out of hours services to enhance the patient offer and flows into hospital; and (iii) improving access to primary care at weekends and evenings where patients need it by increasing the capacity and resilience of primary care over the next few years. Where relevant, local systems need to reflect this in their 2016/17 Operational Plans, and all areas will need to set out their ambitions for seven day services as part of their STPs. The nine must dos for 2016/17 for every local system: 1. Develop a high quality and agreed STP, and subsequently achieve what you determine are your most locally critical milestones for accelerating progress in 2016/17 towards achieving the triple aim as set out in the Forward View. 2. Return the system to aggregate financial balance. This includes secondary care providers delivering efficiency savings through actively engaging with the Lord Carter provider productivity work programme and complying with the maximum total agency spend and hourly rates set out by NHS Improvement. CCGs will additionally be 14

15 expected to deliver savings by tackling unwarranted variation in demand through implementing the Right Care programme in every locality. 3. Develop and implement a local plan to address the sustainability and quality of general practice, including workforce and workload issues. We expect the development of new care models will feature prominently within STPs. 4. Get back on track with access standards for A&E and ambulance waits, ensuring more than 95 per cent of patients wait no more than four hours in A&E, and that all ambulance trusts respond to 75 per cent of Category A calls within eight minutes; including through making progress in implementing the urgent and emergency care review and associated ambulance standard pilots. 5. Improvement against and maintenance of the NHS Constitution standards that more than 92 percent of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment, including offering patient choice. 6. Deliver the NHS Constitution 62 day cancer waiting standard, including by securing adequate diagnostic capacity; continue to deliver the constitutional two week and 31 day cancer standards and make progress in improving one-year survival rates by delivering a year-on-year improvement in the proportion of cancers diagnosed at stage one and stage two; and reducing the proportion of cancers diagnosed following an emergency admission. 7. Achieve and maintain the two new mental health access standards: more than 50 per cent of people experiencing a first episode of psychosis will commence treatment with a NICE approved care package within two weeks of referral; 75 per cent of people with common mental health conditions referred to the Improved Access to Psychological Therapies (IAPT) programme will be treated within six weeks of referral, with 95 per cent treated within 18 weeks. Continue to meet a dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia. 8. Deliver actions set out in local plans to transform care for people with learning disabilities, including implementing enhanced community provision, reducing inpatient capacity, and rolling out care and treatment reviews in line with published policy. 9. Develop and implement an affordable plan to make improvements in quality particularly for organisations in special measures. In addition, providers are required to participate in the annual publication of avoidable mortality rates by individual trusts. 15

16 Cost Pressures Budget Area 000 Total 000 Acute and Community 15/16 Acute Outturn (net of acute reserves applied) 8,010 LAS SEL 111 site 100 relocation ICES - growth 100 Eating disorders devolved from NHSEfunded 170 BCF spend up to national minimum rqd. for Fye of Adult Safeguarding Lead Nurse 26 8,636 Mental Health and Client Groups SLAM outturn Additional caseload from Council review YPD cost pressure / growth 1,500 1,050 RHN Price increase 200 GP Support to Nursing Homes Community and residential pressures Children s caseload growth Primary Care (pye) ,684 GMS/ PMS equalisation Other cost presssures Local Care Record - GSTT

17 ongoing costs 130 Total Cost Pressures 12,820 All cost pressures are built into contract negotiation envelopes at present. All contracts for NHS providers to be agreed by end of March

18 Proposed Investments Budget Area 000 Total 000 Category A/B/C ACUTE SERVICES Acute investments including ED redesign and transformation projects 5,276 A Neuro Rehab level 2B- 20 new beds across SEL 600 COMMUNITY SERVICES 2 Beds at Pulross centre- Int care beds 290 Home enteral nutrition growth 70 5,876 C C C Tier 2-3 weight C management 140 Complex cancer B referral pilot 100 Minor eye service 75 C Children s continence C nurse FYE 26 Children s specialist dietician nurse 43 C MENTAL HEALTH AMH Transformation - Home treatment, Clozapine initiation,map Enhanced Treatment with SUN and Optima, Pychosis Community teams (year 2) 1028 Transforming care for LD clients- national issue SH24 sexual health prescribing on line rollout A 35 B A 18

19 Primary care dementia pilot Solidarity in crisis service 65 C 40 A Big White Wall service 36 A IAPT mobilisation of new service -NR 120 A Early intervention in psychosis Additional PICUP activity 130 A 65 A CAMHS plan nationally funded Primary Care and Local Care Networks Developing Federations and LCN s Population Health fellows expansion 3 to 6 Corporate and other budgets CCG structure changes transformation posts and consultancy 689 A 2, B/C B/C 250 Total Investments 10,130 Category A = this investment is already agreed and underway. Category B= this is committed, but has not yet started. 19

20 Category C= This investment is proposed, but is not yet fully committed or approved. 20