H&FCCG Primary Care Budgets Update

Transcription

1 H&FCCG Primary Care Budgets Update Introduction These budgets are the result of work between NHSE NWL Finance team and the CCGs; the NWL Finance team produced an initial draft budget which has been adjusted following discussions with CCGs. The budgets presented here are an aggregation of budgets which are set at, and will be monitored at, practice level (with funds for some services/reserves held at CCG level).. Allocations Financial Allocations for 2016/17 to 2020/21 were published by NHSE for core CCG services, Primary Medical Services, and Specialised Services in January The Primary Medical Services allocations for the CWHHE for 2017/18 are as published, except for West CCG where there has been a recurrent reduction of 198K to reflect an initial mis-allocation of funding around Walk in Centres. The allocations for H&F from 2017/18 to 2020/21 are as follows: This indicates a 10% growth in 2017/18, and smaller uplifts in future years. Although the PCMS budgets will form part of the CCGs core allocation, the expectation is that this will be spent on Primary Care services and development. Expenditure NHS Business Rules The Primary Medical Services allocation is subject to the NHS Business Rules, which require A contingency of at least 0.5% of Allocation; A 0.5% non-recurrent Resilience Fund reserve, which must not be committed A further 0.5% of allocation committed only non-recurrently And a 1% surplus will apply from 2018/19. Core contracts The majority of Primary Medical Services expenditure is linked to GMS/PMS/APMS contracts for core and essential services (across CWHHE about 70%-75% total expenditure GMS 40%, PMS 20%, APMS 10%). The GMS Global Sum is determined nationally, and the changes to the GMS Global Sum which set the inyear uplifts for PMS and APMS contract. All three contract types flex with practice populations (to some extent). In combination national settlement and a population driven contract determine the majority of any budget apportionment. This year key elements of the National Settlement are: GMS global sum increase by 5.9% from to per weighted head of population; in addition there is a London Supplement of 2.18 based on a simple patient count. The GMS uplift includes 1% uplift for pay and prices, a 1.4% increase for general expanses. These and the other components, and there applicability to PMS and APMS contracts are shown in the attached table: 1 of 5

2 Table 3 Contract type: GMS PMS APMS /weighted /weighted /weighted Component of uplift patient patient patient MPIG reinvestment Seniority reinvestment Elements of the deal ES reinvestment Inflation uplift balance/roundings Total the Minimum Income Guarantee funding provided to some GMS contracts in 2004 is being dispersed into the Global Sum; it is a redistribution of existing GMS funding so does not apply to PMS or APMS practices 2 - some of the seniority funding within existing GMS/APMS arrangement is being redistributed into core contract funding 3 - this is to cover additional pensions administration levy costs, workforce survey administration, overseas visitors cost recovery, non-recurrent additional patient records workload and other increased business expenses 4 - this is to reflect that Avoiding Unplanned Admissions direct enhanced service (DES) ( ceases on 31 March Overall impact of a 1% increase in the pay element of the Global Sum and 1.07% for general expanses Note: will be a further increase from April 2017 to reinvest seniority payments into core funding. This will see an increase in GMS global sum based on weighted patient share once the quantum of funding being reinvested is identified. This settlement reflects the policy of moving funding into the Global Sum from particular/transactional expenditure items. In addition to these changes the national settlement Increased funding per QOF point to with the total number of QOF points unchanged at 559; Increased the Out of Hours deduction for opted out practice to 4.20 per weighted head; Agreed additional funding for o Care Quality Commission inspection fees to be reimbursed in full to practices o Reimbursement of Indemnify Fees at per weighted head ( based on 1 December 2016 list size) Risk around Out of Hours deductions Practices can Opt Out of providing out of hours services, with the CCG commissioning a replacement service. This is paid for from the CCGs core allocation. A deduction is made to the core contract payment where this is the case. This deduction reduces the overall charge to the Primary Medical Services budgets. The CCG is sensitive to the correct identification of the Opted Out/Opted In status of the practice (for the reduction in contract payments; impact on the CCG commissioned Out of Hours provider) and contemporary confirmation may not be readily available. Premises costs risk: This is an area where the CCG has a risk in understanding its costs and liabilities; this results from the changes to responsibility and focus this subject has received since PCT disaggregation. The CCG is governed by the Premises Cost Directions 2013 which, amongst other things, provided for the reimbursement of premises costs to practices. 2 of 5

3 NHS Property Services is a key provider of premises to GP practices and in the draft budget where 2017/18 values have been notified these have been used; similarly with Community Health Partnerships (LIFT). Both NHS PS and CHP have been increasing their costs over the last couple of years to reflect more market driven rents. For the most part funding to cover these increased costs is within CCGs. But there is a likelihood that CCGs will receive a Non-Recurrent funding adjustment for the increase in premises costs falling within the delegated budget; at the time of drafting the timing and value of adjustments is not known. Another area of risk is around non NHS PS/CHP rent reviews. These are not necessarily up to date. NHSE as part of the delegation framework has agreed to cover once known - the costs accruing up to 1 April the increase rents after that date will fall to be met out of CCG delegated budgets. The liability which may flow to the CCG as a result of back-dated rent reviews is not known; and to provide funds for these on-going/recurrent costs a reserve in each CCG s budget has been set. This is based on the assumption that rents are reviewed on a three year cycle, all are in arrears (except for NHSPS and CHP properties) and rents will rise in line with RPI. Rates reimbursements also present a risk. The impact of the Business Rates revaluation is not known for all practices. o Budgets have been set using a variety of sources: the value of reimbursement claims from practices for 2017/18 rates; values notified by NHS PS; Information provided by a consulting firm engaged by NHSE to look at rates. o (These sources are not always consistent and additional work is required to confirm what the correct value is). Work undertaken by the consulting firm has shown that (where changes are known for more than 10% of the CCGs practices) rates bill are rising by between 13% and 25%, and this has been used to provide a reserve to meet the costs where practice figure are not known: the CCG specific uplift has been applied to the higher or last year s budget or claim. The size of these reserves reflect the high degree of uncertainty around the amount the CCG will need to reimburse for rent and rates, and the lack of agreement between the sundry source available for instance for 3 practices there is c 100K difference between the practice claim and the figures from the consulting firm, many have smaller differences while only a few agree. These values will be kept under review as work being undertaken by the NWL Estates managers progresses. H&F CCG is commissioning a desk top review with the District Valuer to give more certainty on the impact of the rent review. The CCG will maintain a level of reserves to mitigate the increase. Budget Methodology The draft budgets are based upon a draft provided by NWL primary care finance team, and adjusted after discussion with CCGs. The main areas of change have been: Out of Hours deductions - the value of the OOH deductions have been calibrated in line with an updated CCG/NHSE assessment of which practices are Opted Out; QOF QOF values in budgets have been based upon 2016/17 outturn figure Premises inclusion of a an allowance for the impact of rent reviews Seniority based on the values in the Statement of Financial Entitlement, and an expectation of incremental movement up the remuneration scale, the fall in costs has been reduced to 11% rather than 25% APMS contract budgets adjusted to reflect this year s APMS procurements The detailed budgets are attached Appendix A: Budget elements to be finalised: QOF whether the Out of Hospital and other work with practices will lead to higher achievement/recorded prevalence. 3 of 5

4 Population changes the movement in the normalised weighted population will determine the amount of money paid for core contract services, and it difficult to predict. Each 0.1% movement in weighted population has an financial impact of c 25K NWL Financial Strategy CCG Chairs agreed that the Primary Care elements of CCG financial positions should be included within the NWL financial strategy; the details of how the risk share will operate at year end are yet to be confirmed Rent review and budgets To be finalised once a desk top review by the District Valuer has been carried out to inform the level of premises budgets for 2017/18. Potential Mitigations The draft budgets contain allowance for a number of uncertainties and risks which may not crystallise, or only at a lower rate than allowed for. Should these uncertainties mature at a lower level than budgets the funds released will be available to offset pressure or fund additional investment. Most of the benefits would be non-recurrent. The major areas where mitigation may occur are: Table 6 HF CCG '000 Population growth at 50% of budget level 26 No increase in QOF delivery/prevalence 9 Contingency not used % NR resave not used 136 Rent reserve - only 50% utilised 113 Once for London costs met from other sources Personal Medical Services review The Personal Medical Services contract values are within the overall Primary Medical Services Allocations. The approach to transition and commissioning intentions does not alter funding received by the CCG, and any revised contracts values need to be met from within the existing CCG funding. But some of the 2017/18 contract values used in the draft budgets may contain anomalies A process is underway with NHSE NWL finance and the NEL CSU (who are providing support for the PMS review) to assure the 2017/18 values and reconcile them to 2016/17 values. This work is proceeding at pace and its result should be known by month end. On current information it is not thought that there will be and adverse movements to the provisional contract values. Next Steps: There are a number of issues which will need to be reviewed and updated over the year: H&F CCG is commissioning a desk top review with the District Valuer to give more certainty on the impact of the rent review. The CCG will maintain a level of reserves to mitigate the increase. Once this is done, the increased rent will be funded from reserves and revised budgets will be reported back through Primary Care committee, and recommended to Governing body for approval. There will be a CWHHE Joint Finance Working Group on 27 th July to review the Primary Care budgets and agree budget principles and possible mitigations where there are pressures. 4 of 5

5 Element How budget is constructed NHS Hammersmith And Fulham CCG Contract Type GMS PMS APMS All CCG Total Core contracts All three contracts are driven primarily by weighted ( and raw) practice populations, and nationally set uplifts. 14,380,722 1,957,018 2,077, ,414,864 Out of Hours deductions Practice which have Opted Out of the provision of Out of Hours services have their contract values abated in line with nationally prescribed figures per weighted population per raw population. This adjustment effectively reduces the charge against the PMS Allocation; the cost of Out of Hours provision for Opted Out practices is met from within the core CCG allocation - 697,362-74,068-74, ,898 MPIG Population Change The Minimum Practice Income Guarantee was introduced at the time of the newgms contract. It is being phased out in equal instalments over seven year; this is year four This is to provide for changes to population. ONS projections of population growth by CCG ( between 0.4% and 1.5%) are applied to opening contract values to provide a reserve to cover changes over the coming year 245, ,302 41,050 5,649 6, ,707 Population Change This is to bring the Population Change values into a single CCG wide reserve. - 41,050-5,649-6,008 52,707 0 Out of Hours reserve This is ring fenced while deductions are confirmed 580, ,740 Total Core Contract Price 13,928,662 1,882,950 2,002,656 52,707 18,447,715 QOF QOF figures are based on 2017/18 outturn, with a CCG reserve of 1% is provided to accommodate changes in QOF achievement/prevalence for the 2017/18 year ,681 17,681 QOF 70% of the target QOF figure is paid monthly 1,032, ,889 94, ,237,692 QOF 30% of the target QOF figure will be paid once the outturn figures for 2017/18 are known. The actual payment will be made in June next financial year but needs to be a charge to 2017/18 442,299 47,524 40, ,439 Total QOF 1,474, , ,388 17,681 1,785,812 Enhanced Services - Minor SuThis is based on forecast outturn for 2016/17 69,948 15, ,883 Enhanced Services -UnplanneThis Enhanced Service has been decommissioned and the funds added to the Global Sum Enhanced Services - ExtendedThis is based on forecast outturn for 2016/17 332,280 36,467 36, ,865 Enhanced Services -Learning This is based on forecast outturn for 2016/17 and reflects the increase in price per health Check 21,231 3, ,437 Enhance Services - Violent PaThis is based on forecast outturn for 2016/17 45, ,000 Total Enhanced Services 468,458 55,608 36, ,186 Premises - see commentary inhs PS -Rent 169, , ,618 Premises - see commentary inhs PS -Business Rates ,242 17,090 46,332 Premises - see commentary inhs PS -Water Charges Premises - see commentary inhs PS -Clinical Waste Premises - see commentary ichp -Rent 159, , ,175 Premises - see commentary ichp -Business Rates 26, ,888 36,875 66,374 Premises - see commentary ichp -Water Charges 1, ,870 Premises - see commentary ichp -Clinical Waste Premises - see commentary iprivate -Notional Rent 1,123, , ,464,755 Premises - see commentary iprivate -Actual Rent 689, , ,661 Premises - see commentary iprivate -other health centres Premises - see commentary iprivate -Business Rates 127, , ,463 Premises - see commentary iprivate -Water Charges 14, ,290 Premises - see commentary iprivate -Clinical Waste 73,376 5,613 4, ,354 Premises - see commentary iprivate -Trade Refuse Premises - see commentary iprivate - DV etc. costs 4,920 1, ,307 Premises - see commentary in main text Premises - see commentary isub total Premises 2,391, , , ,466 3,897,867 Premises - see commentary iadditional costs - 2% ,024 2,024 Premises - see commentary itotal Premises 2,391, , , ,489 3,899,891 Seniority Payments are paid to individual GPs. The suggested budget is based on forecast outturn for 2016/17 adjusted for the changes to rates set out in the Statement of Financial Entitlement. Seniority payments will be phased out by the end of 2020/21 with the funds reinvested in the Global Sum 278,586 24, ,086 Other CCG administered costthis is to cover a miscellany of items - sick leave, parental leave, and congestion charges 57,944 34, ,153 Indemnity Payments A new item in 2017/18 within the national settlement - practices will receive a payment of per head base on their raw population in December ,612 8,609 8, ,153 CCG Registration Fees Another new items for 2017/18 - Practices are entitled to be reimbursed for their CGC registration fees, which are determined by practice population/number of sites 115,102 5,918 12, ,917 Total CCG administered costs 535,244 73,235 21, ,309 Personally administered drugthis the "handling charge" for drugs administered within the practice. The drugs themselves are a charge to the Prescribing budget 78, ,230 Personally administered drugs 78, ,230 Occupational Health Occupational Health costs 6, ,360 Once for London There are a number of costs ( APMS procurement, clinical waste management undertaken across London the costs of which CCGs will need to make a contribution); ,000 75,000 added to this is 25K per CCG to cover additional costs from PCSE ( Capita) for mail shots and special exercises Contingency The NHS Business Rules require CCGs to hold a minimum of 0.5% contingency; this is the PMS element of that , ,225 1% NR Reserve NHS Business Rules also require CCGs to allow for NR of at least 1%; half of which needs to be uncommitted at the start of the year , ,450 Total expenditure 18,883,041 2,518,452 2,407,393 1,502,553 25,892,178 5 of 5