Primary Care Commissioning Committee (PCCC) Finance Paper November 2017

Transcription

1 Primary Care Commissioning Committee (PCCC) Finance Paper November CCG Finance Update Shown below is a summary of the financial position to 30 th November 2017 of the areas of Primary Care spend under Primary Care Commissioning Committee (PCCC) s remit: Table 1 Financial Summary: YTD Budget YTD Actual YTD Variance Annual Budget Forecast Outturn Forecast Variance Additional Primary Care funding allocations (see table 3) 41,994-26,993-68,987 63,000 63,000 0 Early Home Visiting Service 257, ,039 1, , ,241 13,287 Locally Commissioned Services (see table 4) 1,353,128 1,191, ,606 2,023,675 2,023,675 0 Primary Care Delegated Commissioning (see tables 5 & 6) 16,166,452 15,764, ,667 24,933,000 24,556, ,995 Transformation fund - 3 / head (see table 3) 60,136 58,565-1,571 90,204 90,204 0 Grand Total 17,879,561 17,246, ,643 27,510,833 27,147, ,708 The relevant sections of the Primary Care budgets are forecast to underspend by 364k (-1.32%). As agreed at the June 2017 PCCC meeting, a summary is provided below of other Primary Care expenditure to 30 th November 2017 for information only. Table 2 Summary of other Primary Care spend: YTD Budget YTD Actual YTD Variance Annual Budget Forecast Outturn Forecast Variance BDUC 1,762,032 1,760,859-1,173 2,643,058 2,659,030 15,972 Central Drugs 427, ,140-22, , ,000-31,225 Home Oxygen 128, ,455 26, , ,008 3,709 Medicines Management Team 381, ,771-64, , , ,953 NHS Care UK 377, ,558-8, , ,342-30,840 Other Primary Care 50,784 48,292-2,492 76,182 73,117-3,066 Prescribing 16,397,604 17,133, ,986 24,602,956 24,792, ,630 Primary Care IT 539, , , , ,633-40,354 Grand Total 20,064,890 20,548, ,957 30,114,031 30,073,904-40,127

2 2.1 Commentary by Exception Summary: There are no material variances to report. As a result, the CCG s primary care budgets within PCCC s remit have been forecast to budget with the exception of Primary Care delegated commissioning and a small overspend on the Earlier Home Visiting Service (EHVS). The underspend on delegated commissioning of 377k is associated with the release of the 1% surplus target and the 0.5% risk reserve headroom within the Primary Care delegated commissioning allocation. It has been agreed with NHS England that these funds can be released as they would not have been available to Primary Care in any case. The overspend of 13k on EHVS has arisen due to recruitment issues around Specialist Paramedics in the Norton / Radstock area. Shifts are instead being covered by GPs which has caused a cost pressure. There has also been an increase in EHVS prescribing costs above the budgeted amount Project funding including additional allocations: A summary is shown below of spend on the additional funding allocations received by the CCG from NHS England as well as an analysis of spend on projects including those funded from the Primary Care Transformation Fund: Table 3: Additional allocation & Transformation Fund spend to 30 th November 2017: Budget 2017/18 Variance Forecast Forecast Budget YTD Actual YTD YTD Outturn Variance EXTRA ALLOCATIONS GP PROGRAMMES GP Forward View Reception & Clerical Training 35,000 23, ,330 35,000 0 GP Resilience Funding 28,000 18, ,706 28,000 0 BEMS+ PCPF Staff Bank refund ,451-13,451 Contribution to Estate Management ,500-13, Total 63,000 41,994-26,993-68,987 63,000 0 Transformation Fund ( 3 per head) In-house Practice Pharmacist 37,500 25,000 25, ,500 0 Evaluating a new Multi-Practice Unit Model 15,000 10,000 10, ,000 0 Pilot for Respiratory Chronic Disease Management 23,565 23,565 23, ,565 0 Dispensing Practices Scheme 14,139 1, ,571 14,139 90,204 60,136 58,565-1, ,204 0 The CCG has, in addition, received ETTF funding for Practice websites and e- consultation software of 91,788 which is included within the GP IT budget but is not in the table above as this a separate budget.

3 2.1.3 Locally Commissioned Services (LCS): Table 4: Locally Commissioned Services (LCS) spend to 30 th November 2017: Budget 2017/18 Variance Forecast Forecast Budget YTD Actual YTD YTD Outturn Variance PMS Review ECG Service 137,889 91,926 84,580-7, ,889 0 Ambulatory Blood Pressure Monitoring(ABPM) and Home Blood Pressure Monitoring (HBPM) 110,267 73,511 71,875-1, ,267 0 Care/Residential Homes (Non Nursing) 99,000 66,000 57,549-8,451 99,000 0 Doppler Service 28,304 18,869 7,431-11,439 28,304 0 Spirometry 63,432 42,288 42,288-63,432 0 Basket LES 2 of low volume procedures 60,000 40,000 40,000-60,000 0 Health Inequalities / Promotion / Population 84,269 56,179 23,881-32,298 84,269 0 EMI Nursing Home 8,899 5,933 5,933-8, , , ,536-61, ,060 0 Winter Pressures 160, ,667 53,333-53, ,000 0 Balance Old Year 16/17 90,854 64,581 92,870 28,289 89,854-1,000 LCS Schemes: Low risk Basal Cell Carcinoma (BCC) service 8,272 5,515 3,677-1,838 8,272 0 Care/Residential Homes (Nursing) 258, , ,058-39, ,987 0 Drug Monitoring Community Enhanced Service 116,195 77,463 70,955-6, ,195 0 Primary Care: Enhanced Diabetes Service 19,858 13,239 9,353-3,885 19,858 0 International Normalised Ratio (INR) Monitoring 387, , ,258-33, ,699 0 Hormone Injections 7,185 4,790 6,573 1,783 7,185 0 Leg Ulcer Management Service 91,381 60,921 58,919-2,002 91,381 0 Secondary Care Initiated Pre & Post-Operative Procedures 142,695 95,130 95, ,695 0 Supporting Primary Care engagement in CCG Clusters (payments to GP practices) 139,489 92, ,858 12, , ,171, , ,676-72,498 1,171, Opthom - Glaucoma & Cataracts 9,000 6,000 1,552-4,448 9,000 0 Clinical Leads , ,060 Travel Booking Services Total 2,023,675 1,353,128 1,191, , ,023,675 0 Year-to date figures are based on the amounts paid for quarters 1 and 2 with an accrual for estimated costs for October and November Now that quarter 2 data has been received, there is a year-to-date underspend of 162k (-11.9%). This is mostly caused due to phasing of the winter pressures budgets which are forecast to breakeven at 160k of spend by year end and an expectation that spend will increase in line with annual budget on other services, especially PMS review services. Page 3 of 9

4 2.1.4 Primary Care Delegated Commissioning: As previously reported, the process of transferring the payment of GP practices PMS contracts from NHS England to the CCG has gone smoothly. Some transitional issues regarding the coding of training and appraisal payments are still to be resolved, but practices continue to be paid on time by NHS England rather than the CCG for these services with recharges being identified and invoiced between the two commissioners. The volume of recharges between the two organisations has decreased in recent months, reflecting that more transactions are now being charged directly to the correct organisation s ledger. NHS England and the CCG representatives are due to meet again during January 2018 to discuss the next stages of handover of finance-related tasks as part of the delegated commissioning arrangements. The current focus is on reviewing the costs against budget lines within the CCG ledger to build an accurate and robust forecast of costs for and the likely reserves position for Primary Care. Following on from the last PCC report, the November PCOG meeting was advised that budget movements from reserves had been processed to cover some of the items where costs were being incurred with no budget assigned and for known changes in costs, e.g. locums and LD assessments. The forecast underspend of 377k is due to the 1% NHS England surplus target of 251k that is given to CCGs on all budgets but not required to be delivered on the Primary Care budget. It can therefore be used to contribute to the overall CCG position as it would not have been available to spend on Primary Care in any case. There is then a further 126k (0.5%) of risk reserve headroom funding. The business rules mandate CCGs to leave this funding uncommitted so again would not be available to Primary Care. NHS England has agreed that this funding can be released against the CCG s overall financial risk. A breakdown of the Primary Care delegated commissioning year-to-date and forecast spend is shown overleaf with a breakdown by budget line. This shows the position reported at the end of November A further table is then provided showing the outcome of the work carried out on the forecast position which will be incorporated into December 2017 reporting. As this is the last finance paper to be presented to PCCC prior to the financial year end, this information has been provided in order to illustrate where risks and opportunities lie in terms of the year end position and for consideration to be given to requests made against Primary Care reserves.

5 Table 5: Primary Care Delegated Commissioning Breakdown: Year-to-date budget Year-to-date actual Year-to-date variance Forecast outturn Please note: GP Occupational Health budgets were transferred back to NHS England during month 6. Forecast variance Description Annual budget Core Contract PMS Contract Value 10,448,508 10,448, ,672,920 15,672,920 0 PMS Baseline Adjustment 47,308 47, ,981 70,981 0 PMS Funding Differential Review 376, , , ,839 0 PMS List Size Adjustments 0 7,655 7, Total Core Contract 10,872,298 10,880,357 8,059 16,308,740 16,308,740 0 DESs Extended Hours DES 256, , , ,972 0 LD Health Checks DES 57,182 57, ,834 85,834 0 Minor Surgery DES 196, ,352-10, , ,333 0 C&M-PMS DES TPP QRISK 0 5,083 5, Out of Area Registrations 0 4,206 4, Total DESs 510, , , ,139 0 Premises Actual / cost rent 84,889 82,204-2, , ,338 0 Notional rent 1,423,043 1,425,799 2,756 2,134,657 2,134,657 0 Business Rates 282, ,322-12, , ,424 0 Water Rates 21,842 22,990 1,148 32,856 32,856 0 Total Premises 1,812,650 1,801,315-11,335 2,719,275 2,719,275 0 Dispensing Dispensing Quality Scheme 39,801 39, ,720 59,720 0 Prescription charges remitted by GPs - 147, ,545-6, , ,801 0 Professional fees - dispensing 716, ,065-8,866 1,075,419 1,075,419 0 Professional fees - prescribing 88,408 55,242-33, , ,694 0 Total Dispensing 697, ,563-48,397 1,047,032 1,047,032 0 QOF QOF Achievement , ,166 0 QOF Aspiration 1,121,563 1,121, ,682,485 1,682,485 0 Total QOF 1,121,563 1,121, ,334,651 2,334,651 0 Other payments Training Expenses 16,955 16, ,557 21,557 0 Other professional fees (e.g. District Valuer) 14,937 14, ,418 22,418 0 Occupational Health Indemnity fees 69,482 69, , ,370 0 Contract- Refuse & Clinical Waste 64,896 55,126-9,770 97,347 97,347 0 Other General Supplies & Services (needles & vacs) 61,576 59,760-1,816 92,368 92,368 0 Appraisal payments 36,442 36, ,707 54,707 0 Doctors Retainer Scheme 31,846 46,511 14,665 47,787 47,787 0 Locums - Adoption / Maternity / Paternity Leave 117, ,137 4, , ,648 0 Locums - Sickness cover 45,717 71,164 25,447 68,289 68,289 0 CQC fees reimbursement 86,136 86, , ,370 0 Seniority 193, ,851 5, , ,077 0 Training costs payment 14,333 14, ,434 25,434 0 Medical Fees - Adoption / Fostering reports ,141 1,141 0 Translation Fees 7,634 7, ,457 11,457 0 Sterile Products 0 1,814 1, Total Other Payments 762, ,498 40,088 1,143,970 1,143,970 0 Reserves Reserves 389, , , , ,995 Total Reserves 389, , , , ,995 Grand Total 16,166,452 15,764, ,667 24,933,000 24,556, ,995 5

6 Primary Care Delegated Commissioning Commentary: The year to date position is a favourable variance of 402k against the year to date budget of 16,166k (2.49% favourable). The main variances at month 7 are:- The TPP QRISK DES is overspending as the CCG are awaiting confirmation of the national funding available to support this. This temporary enhanced service has been introduced to support practices identify patients significantly affected by the TPP QRISK2 code mapping error. Business rates budgets are underspending by 13k due to councils nationally revising charges as GP practices are now assessed on the basis of rebuild cost rather than rental value. Prescribing and Dispending fees are 48k under budget year to date. This can fluctuate on a seasonal basis, so the underspend may not be sustained in future months, especially through the winter. Seniority is 6k overspent year-to-date. Seniority payments are in process of being phased out with the costs reducing each year. The budget was set based on costs less 22% based on the average national reduction expected. It appears the actual reduction in BaNES has been lower than this which has resulted in the overspend. Locum costs are currently 30k over budget year to date despite the budget having been increased from reserves. There have been additional claims this year due to the following rules being applied nationally from 1 st April 2017 as follows: Sickness leave reimbursement - Cover may be provided by external locums or existing GPs already working in the practice but who do not work full time. - An increase in the maximum amount payable from 1, to 1, per week. - Payments will no longer be discretionary. The qualifying criteria for reimbursement will commence when the absence is two or more weeks (as opposed to previous arrangements which is linked to patient numbers and the period of absence). 6

7 - Sickness leave payments will not be made on a pro-rata basis and will be the lower of actual or invoiced costs up to the maximum amounts as set out in the Statement of Financial Entitlements (SFE). Parental leave reimbursement - Parental leave payments will not be made on a pro-rata basis and will be the lower of actual or invoiced costs up to the maximum amounts as set out in the SFE. All other requirements will remain unchanged Revised forecast position As explained above, work has been completed during December to understand trends that are beginning to emerge and the likely forecast position at financial year end. The following are expected to be variances against budget that are now expected. These figures will be validated for inclusion within month 9 financial reporting. Table 6: Revised Delegated Commissioning Forecasts: Description Forecast (under-) / over-spend '000s Notes Retainers 22 Locums 69 Due to change in policy around Locums (see narrative for more details) CQC Fees -11 Actual costs from almost all practices now received. Seniority 9 Reduction in costs has been lower than budget setting asumptions. Rent 3 Rates -19 Review of busiiness rates commissioned by NHSE has generated savings Water 2 Dispensing / Prescribing -75 Forecast based on previous years' trend data for prescribing costs. QOF 44 Assumes maximum achivement by practices List size adjustments 14 Based on payments for quarters 1 to 3 Supplies -8 LD 3 Minor Surgery -16 Lower than expected activity levels Out of Area Registrations 8 Item not budgeted for Clinical Waste -52 Impact of savings from re-procurement exercise Balance to add to contingency held 7 See reserves table Primary Care Reserves Within the Primary Care Delegated Commissioning budget is an element of reserve. Shown overleaf in Table 7, is a summary of the transactions against Primary Care reserves during , alongside a list of known commitments against this reserve shown in Table 8. 7

8 Table 7: Primary Care Reserves transaction listing Narrative Amount General reserve - per NHS England budget setting 595,478 Premises Improvement funding per NHSE budget setting 224,400 Primary Care national risk reserve (0.5%) 125,665 Primary Care Surplus target (1%) 251,330 Roundings on load of primary care budgets - 3 Occupational Health balance for IAT /17 PMS review duplicate to refund to NHSE on month 3 IAT - 188, /18 PMS review trf'd to LCS budget - 188,000 Budget setting corrections - 207,321 Ledger balance at ,193 Whilst a number of the costs have been quantified, based on agreements, quotations etc. (for example, for the St Augustine s costs), there are still a number of items that require quantification. For example, two practices are due a rent review this financial year and it is currently not possible to quantify the cost pressure involved until the valuation and associated negotiations have been concluded. There is also the possibility that costs in other areas within the budget could continue to increase, for example locum cover. NHS England have also advised the CCG to expect indemnity costs to create a further cost pressure. Indemnity is currently budgeted at 104k based on 51.6 pence per patient. It is unclear at the time of writing as to how many insurers will increase indemnity premiums and whether any national funding will be released to help cover the cost pressure. It has been suggested a contingency equivalent to 100% of the budget (i.e. a further 104k) be held to cover this risk. This is in line with the approach being taken by neighbouring CCGs. A contingency reserve is currently being held to cover any further cost pressures in Figures for future financial years are subject to the outcomes of the financial planning and budget setting process. It was agreed at December 2017 s PCOG meeting that the governance process for transactions involving the Primary Care reserve would not be any different from that in place with other CCG budgets. Virements (transfer of budgets) to and from reserves are subject to approval by the Deputy Chief Financial Officer in conjunction with budget holders and appropriate committees. A listing of budget transactions associated with Primary Care reserves will regularly be provided to both PCOG and PCCC. 8

9 Table 8: Primary Care Reserves commitments listing: Narrative (Recurrent) St Augustine's move to Chocolate Quarter in Keynsham 46, , ,511 Premises growth & inflation 4,400 4,400 4,400 Premises improvement - Heart of Bath 0 9, ,000 Premises improvement - Hope House 0 8, ,000 Impact of rent reviews TBC TBC TBC St Augustine's IT costs - 10 PCs, monitors etc. 17, St Augustine's - HSCN connection 13,084 13,084 13,084 Surplus reserve (1%) committed 251, , ,330 Risk reserve (0.5%) committed 125, , ,665 Indemnity cost pressures 104, , ,000 Total Commitment 562, , ,990 Budget available 613, , ,193 Net impact of update to forecasts at month 9 7,000 7,000 7,000 Total resources 620, , ,193 Balance held for contingency and to support resilient Primary Care 58,050-81, ,797 9