Brent CCG INITIAL BUDGETS AND FINANCIAL PLAN 2017/18 & 2018/19. Governing Body Meeting 12 th April Neil Ferrelly Chief Finance Officer BHH CCGs

Transcription

1 This image cannot currently be displayed. Brent CCG INITIAL BUDGETS AND FINANCIAL PLAN 2017/18 & 2018/19 Governing Body Meeting 12 th April 2017 Neil Ferrelly Chief Finance Officer BHH CCGs

2 Contents Executive summary and recommendations Context and background National context NHSE guidance Allocations PbR changes Local context 17/18 financial planning update NWL financial strategy Key assumptions - Contract Status/outcome (incl. tariff) - Primary Care Co-commissioning 18/19 financial planning overview Part 1: 2017/18 Programme Budgets Budget setting process, methodology and assumptions Main budget assumptions Budget overview and summary, including underlying position Budget analysis Part 2: 2017/18 QIPP, Investments and other analyses QIPP Investments Better Care Fund Activity projections Risk assessment BHH In-year risk reserve Part 3: Running cost budgets Part 4: Practice budget setting Part 5: Cash and balance sheet Part 6: Next steps 2

3 Executive Summary (1) This document sets out the initial budgets and financial plan for 2017/18 and an indicative plan for 2018/19 for Brent CCG, in the context of the strategic and financial circumstances in which the CCG is operating. 1. Brent CCG is forecasting a 16/17 outturn surplus of 13.5m (M11) (see point 11 below) and has a closing underlying recurrent surplus position of 1.3m. In January 2016 NHSE confirmed that Brent CCG was assessed as over its target allocation by 1.6%. It received an increase in allocation in 17/18 of 2.00%. 2. The 17/18 financial plan is to deliver a surplus of 13.5m, and whilst the plan is consistent with NHSE Business Rules, with the exception of its normalised (recurrent) 17/18 position which is in deficit (see page 5), 17/18 plans are subject to final agreement with NHSE. 3. In line with STP planning the CCG had assumed 4.8m drawdown in 17/18 and was planning on a 8.7m surplus. The drawdown has not been granted because the STP as a whole has not met its financial control total. This has caused a financial planning gap, the majority of which has been accommodated through additional QIPP and a reducing the planned contribution to the NWL strategy to 1%, however 0.7m remains and is shown as unidentified QIPP. 4. The CCG s underlying position moves from 1.3m surplus in 16/17 to a closing position of 1.5m deficit in 17/ Key assumptions and features of the 17/18 plan are: a) The main in-sector contracts have been agreed, however where some out of sector contracts are not agreed, these values have been estimated and therefore initial budgets will be reset to match contract agreements, once agreed. b) Net QIPP plans total 14.8m, equivalent to 3.6% of recurrent programme baseline, of which 1.1m is FYE of 16/17 schemes, 13.4m is recurrent net new schemes and 0.3m net non-recurrent schemes. This compares with 16/17 forecast delivery of 9.3m (2.2%). c) Acute QIPP values included in in-sector contracts were restricted to STP planning values. Where the current QIPP programme exceeds STP planning values for in-sector providers, these QIPPs are not embedded in contract baselines. The net value of the acute QIPPs not embedded in in-sector contract baselines is 4.8m. 3

4 Executive Summary (2) d) The main risks in the 17/18 plan are: Making progress on the 4.8m acute QIPP plans not embedded in in-sector contracts The Brent share of the 7m LNWHT income recovery target (approximately 2.2m) which is not included in the LNWHT contract baseline. Continuing Care costs do not continue to increase at the rate experienced in 15/16 and 16/17. Any additional in-year Mental Health investments are matched by QIPP Overall, the risk assessment shows that mitigations required above the 0.5% contingency are at least 3.4m (slide 60) these have not yet been identified Any further requirement to increase QIPP/ / reduce expenditure in order to resolve outstanding financial issues in the STP. e) The 17/18 financial plans reflect activity forecast increases in all PODs ranging from 0.5% in first outpatients to 2.9% in non-elective admissions /19 financial plan will be subject to further work once the 17/18 plan has been assured by NHSE. Hence 18/19 figures included in this paper should be treated as indicative. 7. Proposed initial running costs budgets are within the 17/18 running cost allocation. 8. Practice Budgets The plans and principles governing budget setting for GP Practice budgets are set out in slides Cash & Balance Sheet - Assumptions regarding balance sheets and Cash flow forecasts are set out in slide Next Steps are set out in slide The 16/17 outturn position is due to improve by 5.1m at M12 16/17 as the CCG (in line with others across the country) has been directed by NHSE to release a non-recurrent reserve held to offset deficits in the Trust sector. This is expected to increase the carry forward from 16/17 and also the 17/18 bottom-line surplus by 5.1m (as no drawdown is expected). 4

5 17/18 Plan : Consistency with NHSE business rules The 17/18 Financial plan is consistent with NHSE business rules except for the underlying recurrent (normalised) position. 1% non- recurrent headroom Yes (planned non-recurrent contribution to NWL financial strategy is 1%) Contingency Included at 0.5% 1% surplus 3.3% surplus Normalised position 1.5m deficit Running costs Budgets within allowance Surplus Drawdown rules Brent did not receive drawdown Mental Health Investment Standard 0.5% Uncommitted Reserve The increase in mental health spend investment consistent with the overall CCG uplift A 0.5% non-recurrent uncommitted reserve is included in the plan 5

6 Recommendations The Governing Body is asked to: 1. Agree the initial programme budgets as summarised on slide 26, based on the key assumptions set out on slides Note the current assumptions regarding the NWL financial strategy on slide Note the financial risk assessment and mitigations on slide Agree the continuation in 17/18 of a BHH in-year risk share, as per slide Agree the approach to practice budget setting on slides Agree the next steps outlined on slide 77. 6

7 Context and Background 7

8 NHS England planning guidance (1) The NHS Operational Planning and Contracting Guidance set out how it will support Sustainability and Transformation Plans (STPs) become the route map for how the local NHS and its partners implement the Five Year Forward View to drive improvements in health and care; restore and maintain financial balance; and deliver core access and quality standards. the requirement for two year contracts agreed by 23rd December 2016 and supported this with a two-year tariff, CQUIN and CCG quality premium schemes. STP financial control totals with the flexibility for STP partners to adjust organisational control totals (both for providers and for CCGs) within an STP footprint, provided the overall system control total is not breached. That the financial focus for is on efficiency as the level of growth is significantly less than has previously been available to the NHS and therefore that the expectation that the national transformation and efficiency programmes Right Care, Continuing Healthcare, New Models of Care, Urgent and Emergency Care, Self Care and Prevention, Getting It Right First Time and the Carter productivity programme led by the NHS Improvement are incorporated into STP planning. 8

9 NHS England planning guidance (2) The 2017/18 and 2018/19 must dos are summarised in the table below. Must Do Including 1. STP Implement agreed STP milestones, so that you are on track for full achievement by 2020/21. Achieve agreed trajectories against the STP core metrics set for Finance Deliver individual CCG and NHS provider organisational control totals, and achieve local system financial control totals. At national level, the provider sector needs to be in financial balance in each of 2017/18 and 2018/19. At national level the CCG sector needs to be in financial balance in each of 2017/18 and 2018/ Primary Care Ensure the sustainability of general practice in your area by implementing the General Practice Forward View, including the plans for Practice Transformational Support, and the ten high impact changes. 4. Urgent and Deliver the four hour A&E standard, and standards for ambulance Emergency response times including through implementing the five elements of the Care A&E Improvement Plan. 5. Referral to treatment and elective care Deliver the NHS Constitution standard that more than 92% of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment (RTT). Deliver patient choice of first outpatient appointment, and achieve 100% of use of e-referrals by no later than April 2018 in line with the 2017/18 CQUIN and payment changes from October Cancer Working through Cancer Alliances and the National Cancer Vanguard, implement the cancer taskforce report. 7. Mental Health Deliver in full the implementation plan for the Mental Health Five Year Forward View for all ages 8. People with Learning Disabilities 9. Improving quality in organisations Deliver Transforming Care Partnership plans with local government partners, enhancing community provision for people with learning disabilities and/or autism. All organisations should implement plans to improve quality of care, particularly for organisations in special measures. 9

10 NHS England planning guidance (3) The CQUIN will remain at 2.5% of annual contract value as follows: 1.5% linked to delivery of nationally identified indicators 0.5% available subject to full provider engagement and commitment to the STP process 0.5% payable at the beginning of 17/18 if a provider delivers its control total in 2016/17 (if not the CCG holds it in reserve). Quality Premium NHSE has stream-lined the indicator set. It has: Retained indicators on Cancer Stage of Diagnosis and Patient Experience of Accessing their GP Evolved the existing Anti-Microbial Resistance measure into a measure on Bloodstream infections Retained a locally selected indicator towards delivering the aims of the Right-Care programme and introduced two new indicators. One to be selected from a Mental Health menu and one focused on delivery of Continuing Healthcare. 10

11 Allocations (1) NHS England has published CCG allocations for the next 3 years with indicative allocations for the following 2 years in January Allocations for Primary Care Medical and Specialised Services at a CCG level have also been published. Brent CCG has received 6.507m (1.6%) more than the CCG Target Allocation in 2017/18, by 2020/21 this will reduce to 4.335m above target (1.1%). Brent CCG Primary Medical & Specialised allocations are both below their respective target allocations and as a consequence the overall Total Place allocation is 2.129m below the Total Place target allocation in 2017/18. Primary Medical allocation growth in 2017/18 reduces the Primary Medical distance from target in 2017/18, reducing the 16/ gap to m. 2015/ / / / / /21 Population projection 369, , , , , ,680 Population Growth 0.94% 0.86% 0.87% 0.80% 0.78% Resource Allocation m CCG Allocation Primary Medical Specialised Total Place Target Allocation m CCG Allocation Primary Medical Specialised Total Place Distance from Target m 2016/ / / / /21 CCG Allocation Primary Medical Specialised Total Place

12 Allocations (2) Recurrent allocations are not being re-opened for 2017/18 and 2018/19, however there are two significant nonrecurrent allocations being made in order to maintain commissioner purchasing power in respect of The modelled impact of the changes to prices in the 2017/18 and 2018/19 National Tariff for the move to HRGV4+ complemented by an updated system of top-up payments in order to better reflect different levels of complexity and current clinical practice; and, Funding transfers between CCGs and Specialised commissioning following work to implement improved and universally consistent identifications rules (IRs). These adjustments will be made non-recurrently for 2017/18 and 2018/19, and then formally taken into account when recurrent allocations are revisited for 2019/20 and beyond. Each Lead CCG had a role in jointly validating with NHSE IR adjustments for their providers (e.g. Brent CCG with LNWHT). Allocation and current planning assumptions for IR changes are shown in the table below. HRGv4+ IR RRL Funding 2,485 (2,147) Less transfer to Hillingdon CCG (400) Net funding 2,085 (2,147) SLA adjustments Imperial 791 (2,427) Hillingdon Hospital 52 3 London North West Hospitals 660 (763) Royal Brompton and Harefield (89) 54 Chelsea And Westminster (13) 141 Barts and the Royal London (52) (311) Guys & St.Thomas 84 Kings Healthcare 7 Moorfields Eye Hospital (155) UCL Hospitals 226 The Royal Free Total 1,886 (2,798) Reserve The balance of 0.7m is kept in reserve pending in-year monitoring of UCLH contract as this reserve has been caused predominantly due to a difference between 0.9m expected and actual 0.2m contract baseline adjustments due to IR changes in this contract. The allocation Brent CCG has received for HRGV4+ has exceeded planning assumption within 17/18 baselines. This is not the case in all CCGs, notably Hillingdon CCG. The BHH in-year risk share has been invoked to transfer 0.4m of Brent s gain to offset Hillingdon s loss. 0.2m remains in reserve for this item. 12

13 2017/18 and 2018/19 National Payments System The tariff uplift of 2.1% will be net of a 2% efficiency requirement each year, resulting in a 0.1% net uplift each year. The cost uplifts include revised projections for pay drift, the costs of the apprenticeship levy and pass through drugs and exclude HRG-specific uplifts included in the tariff prices for CNST. In order to incentivise reduced follow-ups, outpatient the percentage of followup costs bundled into first attendances has been increased in adult surgical specialities and medical specialities. There is no change for Oncology, haematology and paediatric specialties and where Best Practice Tariffs apply. 13

14 17/18 Planning update Regular monthly reports to the Finance Committee have been made on the 17/18 financial planning progress. The most material cost pressures have arisen due to the finalisation of 17/18 contracts and pressures on other budgets. These have been offset in the main by increases in the QIPP programme, reductions in the contribution to the NWL Financial Strategy, and improvements in the recurrent 16/17 position and other flexibilities. The most recent issue was caused by the decision not to award drawdown of the carry forward surplus due to financial pressures in the STP which created a 4.8m gap. This has now been covered as shown in the table below, with 0.7m QIPP unidentified. Reduction in NWL Financial Strategy contribution Increased QIPP see NWL Financial Recovery plan (slide 15) m Other net improvements 0.2 Remaining unidentified QIPP 0.7 Total mitigations 4.8 Due to financial pressures across the NWL sector a financial recovery plan to identify new QIPP opportunities has been set up. This has contributed to an increased QIPP programme in Brent and is show in the following slide. 14

15 NWL Financial Recovery Plan The NWL additional Financial Recovery Actions aims to look for other areas of saving that CCGs have not considered Reduce operating costs (staffing and NWLFS budget) New opportunities looking at the work of other STPs Non-recurrent fixes The schemes identified prior to the submission of operating plans had a full year gross value of m, adjusting for part year and risk of delivery the value was reduced to m The BHH % share of these actions was 5.723m. CHC values were not included as there are existing QIPP savings in BHH plans that may overlap. Hillingdon & Harrow have incorporated these values to increase identified QIPP. Brent has incorporated 1.8m of the 2.2m opportunity into its QIPP programme (balance of 0.4m duplicates plans in existing QIPP programme) BHH Financial Recovery Brent Hillingdon Harrow BHH NWL Financial Recovery Actions: Out of Sector Contracts - claims & challenge Choosing Wisely CHC and other placements 0 Prescribing Waste ,739 Biosimilars PPWT Urgent Care and LAS Demand Management Addressing Variation in existing schemes Operating Cost reduction Challenging RTT assumptions ,243 2,246 1,911 1,566 5,723 15

16 Local context NWL Financial Strategy The North West London (NWL) Financial Strategy is proposed to continue in 17/18, with detailed budgets proposed for Governing Body agreement, and the impacts (assuming agreement) are included in CCG 17/18 financial plans. It should be noted that all aspects of the NWL financial strategy are also subject to NHS England agreement as part of their review and sign-off of 17/18 Operating Plans for all CCGs, and as part of this, ensuring adherence to statutory and other requirements on CCGs. The business rationale for a NWL-wide financial strategy is: - SaHF is a NWL-wide programme and the probability of successful implementation would be significantly enhanced by a NWL-wide financial strategy. - Individual CCGs are in radically different financial positions with surpluses/deficits which are predominantly the result of inherited PCT positions, and surpluses/deficits correlate with under/over funding positions. - If the wide disparity in CCG financial positions is not addressed through a NWL-wide financial strategy, SaHF implementation as a whole could be compromised. - A NWL-wide financial strategy provides resilience to all CCGs in the light of potential future funding changes, and also in facing provider issues together. The financial strategy comprises two component parts: 1) Pooling of CCG and NHSE non-recurrent headroom to support non-recurrent costs. 2) Continuation of SaHF Out-of-Hospital investment fund to support investment in primary care and community services The planned contributions in 17/18 from Brent CCG are as follows: Non-recurrent contribution 4.2m (1.0%) ( 6.5m (1.6%) in 16/17). This value of contribution is a planning assumption but has yet to be signed off by the NWL CCG Governing Bodies. 16

17 Contract Status/Outcome The vast majority of contracts for 17/18 have been agreed. Where contracts have not been agreed the opening budgets therefore reflect our best assessment of the likely agreed 17/18 contract baseline values. Due to budget pressures no in-year risk reserve has been set aside in opening budgets to cover in-year over-performance. Indeed 4.8m of acute QIPP sits outside of acute SLAs forming a contract underperformance target and a further 0.7m is unidentified. This represents a much higher level of planning risk currently in the 17/18 budget setting than has been the case in recent years. 17

18 Primary Care Co-commissioning NHS Brent CCG is currently in a (level 2) Co-Commissioning arrangement, jointly commissioning Primary Care with NHS England (NHSE). Between October 16 February 17, member practices explored the option of a move to full delegation of Primary Care (General Practice) commissioning. Member practices were asked to vote on the CCG assuming full responsibility for the Primary Care Medical Allocation (financial allocation) and for commissioning of services from 1st April There was insufficient support for the proposal to be approved under the terms of the Brent Constitution therefore finances relating to delegation will not be included in the 17/18 financial plan. The financial transactions for core services will continue to go through the NHSE ledger and the primary medical allocation for Brent remains with NHSE. The CCG will continue to commission enhanced and out of hospital services from practices locally and make its own investments in primary care. The CCG also received 0.8m funding to support implementation of the GP Forward View. Investment was received to support extended access (8-8 over 7 days), online consultations, training of Care Navigators and medical assistants and to support practice resilience and provider development. The CCG continues to invest this money in 17/18, alongside 50% of the 3 per head CCGs have been asked to ring-fence to support Practice Transformation. The latter represents 0.6m per year planned to be spent in 17/18 and 18/19. This will support practice development and resilience and on-going development of the GP Networks and their Federation. 18

19 18/19 Plan Overview For the 18/19 financial plan the following key assumptions have been made 6.9m drawdown will be made available to move the bottom line surplus down from 13.5m to 6.6m There is a QIPP programme of 12.5m The underlying position will be recovered All other NHSE business rules will be achieved The 18/19 financial plan will be subject to further work once the 17/18 plan has been assured by NHSE. Hence 2018/19 budgets values are indicative and are subject to change. 19

20 Part /18 Programme Budgets 20

21 Approach to budget setting process for 17/18 The budget setting process for 17/18 has been designed to follow good practice: Clear distinction between recurrent and non-recurrent income and expenditure. the impact of outturn and full year effects from 16/17 reflected in baseline. budgets reconciled to activity plans. budgets reconciled to cash plan. budgets based on realistic assumptions for inflation, demographic growth, etc. QIPP embedded in individual budget lines and contracts (no balancing items)* Risk assessment of QIPP. budgets appropriately profiled across the financial year. budgets supported by a clear sign off and in year management regime. in year contingency established to cover known and unknown risks. budgets reconciled to agreed contracts and contracts agreed by 1 April. CCG budgets devolved to practices (where applicable) using CCG agreed methodology, including risk sharing arrangements. *As described above, in 17/18 there are acute QIPP plans that were not able to be included in agreed contract baselines. In addition, there is Mental Health QIPP currently not included in contract baseline. 21

22 Triangulation of budgets, contracts and QIPP A critical aspect of the process has been to ensure that budgets, contracts and QIPP plans have been kept in alignment. Budget setting Integrated Financial Plan Provider contracts QIPP plans 22

23 Budget setting key assumptions (1) Overall planning assumptions: Planning assumption NHSE guidance Local interpretation Demographic growth Non-demographic growth Price inflation prescribing Price inflation health care Mental Health Parity of Esteem Local determination using age profiled population projections Local determination based on historic analysis and evidence Local determination expected to be in a range of 4% to 7% per annum increase Local determination expected to be in a range of 2% to 5% per annum increase 0.9% as per population growth assumption 3.0% acute, 0.1% mental health, 8% continuing care, 1.5% community, 2.8% primary care 6.8% (above 16/17 PPA M9 forecast outturn) 2.1% Acute providers, 2.1% Mental Health & Community, 5% continuing care, 3.5% primary care Level of commitments increased in Total commitments increased by line with allocation 2.00% National Tariff Published tariff Assessment of tariff impact including impact of HRGv4+ 23

24 Budget setting key assumptions (2) Other key assumptions: Nil in year acute contract reserve QIPP delivery of 14.8m (including 4.8m acute QIPP not embedded in SLAs and a further 0.7m unidentified) - see slides Quality premium no assumption of funding or spend has been included in 17/18 plans NWL financial strategy see slide 16 Allocation as per NHSE see slide 25 London Health Commission contribution 0.11% of baseline 0.4m slide 25 No draw down of 16/17 surplus in 17/18 24

25 2017/18 Allocation summary YOY increase % 2017/18 Allocation YOY increase % 2018/19 Allocation Recurrent Initial Programme allocation 406, ,714 17/18 uplift 2.00% 8,145 18/19 uplift 2.08% 8,637 Recurrent programme allocation 414, ,351 Running costs 7,066 7,078 Total Notified Allocation 421, ,429 Non Recurrent Allocations RAB - Return of Prior Year's Surplus 13,498 13,500 Winter resilience: London Ambulance Service NHS Trust Hosted funding 3,408 3,408 Charge Exempt Overseas Visitors - LNWHT Hosted funding Charge Exempt Overseas Visitors- contribution to England fund (350) (350) NWL Financial Strategy contribution (4,218) (6,456) London Healthcare Commission Strategy (healthy London Partnership (464) (464) Harrow repayments 6,900 1,500 Hillingdon repayments - 5,050 Transfer of HRG4 reserve to Hillingdon - BHH risk share (400) IR Changes (2,147) (2,181) HRG4 changes 2,485 2,525 Brent Council - Health related income 3,500 1,500 GPFV - Online consultations GPFV - Training Care navigators and medical assistants GPFV - Access Funding Total Non Recurrent Allocation 23,726 19,579 Total Allocation 445, ,008 25

26 2017/18 Initial Budget Summary Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s Acute 259, ,243 Mental Health 39,112 39,657 Continuing Care 17,839 19,059 Community 50,879 51,720 Includes BCF Social Care funding and Out of Hospital schemes Reprovision 4,384 9,082 QIPP Reprovision GP Prescribing 38,714 39,896 Primary Care 2,538 2,651 Corporate & Estates 8,746 7,831 Contingency 2,074 2, % contingency as per NHSE Business rules 0.5% uncommitted reserve 2,074 2,117 As per NHSE Business Rules Unidentified QIPP (700) - Running Costs 7,066 7,078 Matches Running cost allocations Total 432, ,451 Allocation 445, ,008 Surplus / (Deficit) 13,500 6,557 26

27 Overall Bridge 16/17 17/18 Underlying Position The table below shows the bridge between 16/17 and 17/18 and compares it to the STP planning assumptions. SaHF 5 Year Model Budget Model Difference Commentary Recurrent Forecast Exit Run Rate (underlying Position) (+) 7,167 1,281 (5,886) Increase in recurrent allocation 8,156 8,157 1 Deterioration based on 16/17 M8 reported position due mainly to acute and Continuing Care pressures Net Tariff Inflation (4,168) (2,518) 1,651 Net 0.19% inflation rather than 0.5% assumed previously Activity Growth (Demog) (3,563) (3,652) (89) Activity Growth (Non-Demog) (11,022) (10,623) 399 Other Recurrent Cost Pressures (69) (4,572) (4,502) QIPP Gross Saving 15,278 12,958 (2,320) QIPP in SLAs/budgets QIPP Investment (3,341) (4,410) (1,069) QIPP outside of SLAs 4,799 4,799 Investment (Recurrent) (3,443) (840) 2,603 Mental Health 5YFV investments Contingency (2,074) (2,074) NHSE now classifying contingency commitment as recurrent Sub total - 17/18 Recurrent 4,994 (1,493) (6,488) Non-Recurrent Prior year c/f 13,500 13,500 0 Harrow repayments 1,500 6,900 5,400 Hillingdon repayments 2,500 - (2,500) JIF funding 3,500 3,500 NWL Strategy Contribution (8,131) (4,218) 3,913 Assumed reduction from 2% to 1% Contingency (2,109) 2,109 contingency moved to recurrent London Healthcare Commission contribution (622) (464) 158 Overseas Vistitors (350) (350) National contribution Other NR Cost Pressures (+) (2,886) (548) 2,338 Includes 0.4m N/R QIPP re-provision Primary Care resilience 3 per head over 2 years - (560) (560) New commitment in Operating Plan, assumed 50% in 17/18 and 50% in 18/19 Project posts - (994) (994) Net Non-Recurrent QIPP % uncommitted reserve - (2,074) (2,074) New commitment in Operating Plan Sub -total 2017/18 Non-Recurrent 3,752 14,993 11,241 Total /18 Plan 8,746 13,500 4,754 27

28 Overall Bridge 17/18-18/19 Underlying Position The table below shows the bridge between 17/18 and 18/19 and compares it to the STP planning assumptions. SaHF 5 Year Model Budget Model Difference Commentary Recurrent Forecast Exit Run Rate (underlying Position) (+) 4,994 (1,493) (6,488) Position carried forward from 17/18 Increase in recurrent allocation 8,650 8,649 (1) Net Tariff Inflation (4,359) (2,621) 1,738 Net 0.19% inflation rather than 0.5% assumed previously Activity Growth (Demog) (3,655) (3,756) (100) Activity Growth (Non-Demog) (9,364) (8,835) 529 Other Recurrent Cost Pressures (145) (2,478) (2,333) QIPP Gross Saving 15,575 17,639 2,064 QIPP Investment (3,408) (5,188) (1,781) QIPP outside of SLAs Investment (Recurrent) (979) (1,868) (889) Mental Health 5YFV investments Contingency (43) (43) In addition to amount in 17/18 Sub total /19 Recurrent 7,309 6 (7,303) Non-Recurrent Prior year c/f 8,747 13,500 4,753 Increased carry forward from 17/18 Harrow repayments 1,500 1,500 - Hillingdon repayments 2,550 5,050 2,500 JIF Funding 1,500 1,500 NWL Strategy Contribution (8,131) (6,456) 1,675 Assumed reduction from 2% to 1.5% Contingency (2,152) 2,152 contingency moved to recurrent London Healthcare Commission contribution (635) (464) 171 Overseas Vistitors (350) (350) Other NR Cost Pressures (+) (2,631) (4,353) (1,722) Primary Care resilience 3 per head over 2 years - (560) (560) Project posts - (700) (700) 0.5% uncommitted reserve - (2,117) (2,117) Sub -total 2018/19 Non-Recurrent (752) 6,550 7,302 Total /19 Plan 6,557 6,556 (1) 28

29 2017/18 Initial Budget Summary ( 000s) Acute (bridge to 17/18) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s Forecast Outturn 269, ,281 Non-recurrent adjustment to allocation (17,568) (4,094) Mainly pass through payments to LNWHT and LAS Non-Recurrent Adjustment 2,053 - Non-recurrent contract risk share benefits - LNWHT and Imperial FYE of QIPP (414) - Other Full Year Effects 1,883 - Initial Recurrent Baseline Total 255, ,187 Net Tariff Deflation / Inflation Activity Growth (Demog/Non Demog) 9,915 8, % demo growth and 3% non-demo growth Other Recurrent Cost Pressures 2,519 2,554 RTT, critical care expansion at LNWHT etc QIPP Gross Saving (13,333) (12,632) includes QIPP outside of SLAs QIPP Investment Opening Budgets Recurrent 255, ,438 Application of NR Allocation / Pass through funds 4,108 4,108 LAS 3.4m, Charge Exempt NCAs 0.7m Non-recurrent cost pressure 48 4,353 Impact of HRG 4 changes 2,085 2,525 Impact of identification rule (IR) changes (2,147) (2,181) Relates to net changes of commissioning responsibility to Specialist commissioning TOTAL 259, ,243 29

30 2017/18 Initial Budget Summary ( 000s) Acute (17/18 summary) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s In Sector Main NHS SLAs 184, ,701 Includes LNWH and Imperial Out of Sector Main NHS SLAs 39,935 40,842 Includes Royal Free, Moorfields, OCLH and other out of destor SLAs Commercial Sector Providers 9,525 9,906 Includes Pathology services, In-Health and BMI Acute In Year Risk Reserve (3,913) (1,187) QIPP sitting outside of SLAs 4.4m net of Reserve relating to IR rules 0.7m and HRGV4+ 0.2m Sub Total - Acute SLAs 230, ,261 Ambulance and other NHS SLAs 12,335 12,642 London Ambulance includes hosted funding High Cost Drugs, Cost per Case and NCA's 4,082 4,218 Other Acute Services 12,749 13,122 Includes Walk in Centres, UCC and Wembley GP Access Centre TOTAL 259, ,243 30

31 2017/18 Initial Budget Summary ( 000s) Mental Health (bridge to 17/18) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s Forecast Outturn 38,733 39,112 Non-recurrent adjustment to allocation (656) - CNWL transformation fund, CYP funding Non-Recurrent Adjustment 63 (498) FYE of QIPP (166) - Other Full Year Effects 65 - Initial Recurrent Baseline Total 38,039 38,614 Net Tariff Deflation / Inflation Activity Growth (Demog/Non Demog) Other Recurrent Cost Pressures Add back of CNWL QIPP not delivered in 16/17 QIPP Gross Saving (1,227) (1,258) 0.9m of this QIPP is not included in CNWL SLA (balances investments also outside of CNWL SLA) QIPP Investment Also not inlcuded in CNWL SLA Recurrent Investment 810 1,868 Forward View investments - 0.1m included in CNWL, balance outside of SLA Opening Budgets Recurrent 38,614 39,657 Non-recurrent cost pressure Re-instating CNWL transformation fund TOTAL 39,112 39,657 The test of Mental Health Parity of Esteem is that Mental Health spend is keeping pace with the general uplift that CCGs received. 2016/ /18 increase '000 '000 % Core MH spend 38,733 39, % Mental health in Acute 2,497 2, % Mental health in Continuing Care 7,101 7, % Mental health in Primary Care Prescribing 2,159 2, % Overall Mental Health Spend 50,490 51, % The Mental Health bridge below shows that the increase on mental health spend from 16/17 outturn to 17/18 plan is 1.0%. However when taking into account planned mental health spend included in Acute (3%), Continuing Care (6.7%) and Prescribing (4%), which has higher increases than in the core spend the overall increase matches the 2% allocation increase to the CCG. 31

32 2017/18 Initial Budget Summary ( 000s) Mental Health (17/18 summary) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s Main NHS SLAs 36,823 35,620 Mainly CNWL NHSF Trust CAMHS Learning Difficulties Mental Health Cost per Case Mental Health Other 756 2,489 Includes investments and QIPP not in SLAs TOTAL 39,112 39,657 32

33 2017/18 Initial Budget Summary ( 000s) Continuing Care (bridge to 17/18) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s Forecast Outturn 16,732 17,839 FYE of QIPP (567) - Initial Recurrent Baseline Total 16,165 17,839 Net Tariff Deflation / Inflation Activity Growth (Demog/Non Demog) 1,439 1,588 Other Recurrent Cost Pressures QIPP Gross Saving (828) (1,260) TOTAL 17,839 19,059 Increase over 16/17 outturn 1,107 1,220 % increase 6.6% 6.8% The continuing Care budget has faced significant pressure over the 15/16 and 16/17 going up by 8.4% and 20% respectively (16/ % excluding FNC national rates uplift). The budgeting approach for 17/18 has been to take the current 17/18 CHC Care-track commitments and ensure there is a 5% uplift net of QIPP. As 17/18 CHC Care-track commitments are higher than in 16/17 the net increase above 16/17 is 6.6%. 33

34 2017/18 Initial Budget Summary ( 000s) Continuing Care (17/18 summary) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s Continuing Care Adults 12,689 13,192 Funded Nursing Care 3,787 4,313 Continuing Care Children 1,364 1,553 TOTAL 17,839 19,059 34

35 2017/18 Initial Budget Summary ( 000s) Community (bridge to 17/18) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s Forecast Outturn 50,076 50,879 Non-recurrent adjustment to allocation (405) - Quality Premium, Latent TB fundng Non-Recurrent Adjustment (638) - Joint delivery fund with LBB, Wheelchairs waiting list offset by re-instating elderly 5 per head investment Other Full Year Effects Full year effects of mid-year starts of Wheelchair and Referral management (BROS) contracts Initial Recurrent Baseline Total 49,744 50,879 Net Tariff Deflation / Inflation Activity Growth (Demog/Non Demog) 1,135 1, % growth Other Recurrent Cost Pressures 182 (44) QIPP Gross Saving (428) (387) QIPP Investment TOTAL 50,879 51,720 35

36 2017/18 Initial Budget Summary ( 000s) Community (17/18 summary) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s Main NHS SLAs 25,482 26,119 Includes Ealing ICO Other Community SLA's 11,905 12,062 Includes Winter Pressures, ICP, Brent Equipment and Palliative Care BCF Funding 7,174 7,310 Pass through funding plus Care Act contribution Out of Hospital Services 6,319 6,230 Includes Referral Management, Extended Hours- HUBs, Commissioning incentive and Elderly 5 per head investment TOTAL 50,879 51,720 36

37 2017/18 Initial Budget Summary ( 000s) Primary Care (bridge to 17/18) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s Forecast Outturn 1,377 2,538 Non-Recurrent Adjustment (301) (1,374) 16/17 GP access and resilience spend Initial Recurrent Baseline Total 1,076 1,164 Net Tariff Deflation / Inflation Activity Growth (Demog/Non Demog) Opening Budgets Recurrent 1,164 1,244 Non Recurrent Investments 1,374 1,407 Access, online and training investments plus 3 per head transformation investment TOTAL 2,538 2,651 37

38 2017/18 Initial Budget Summary ( 000s) Primary Care (17/18 summary) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s Local Incentive Schemes 1,134 1,212 Includes Phlebotomy, Cardiology, Diabetes, Carers, Zoladex Other Primary Care Services 1,404 1,439 Includes Transformation Support and Funding to improve access to GP services TOTAL 2,538 2,651 38

39 2017/18 Initial Budget Summary ( 000s) Prescribing (bridge to 17/18) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s Forecast Outturn 37,952 38,714 Net Tariff Deflation / Inflation 1,328 1,355 Activity Growth (Demog/Non Demog) 1,233 1,239 QIPP Gross Saving (1,800) (1,412) TOTAL 38,714 39,896 Tariff uplift / Growth 2,562 Initial QIPP (1,045) Net Uplift before NWL schemes 1,517 % uplift before NWL schemes 4.0% NWL recovery plan schemes Choosing Wisely (221) Prescribing Waste (534) Net uplift after NWL schemes 762 % net uplift after NWL schemes 2.0% A net uplift of 4% was planned. When further schemes from the NWL recovery plan programme where required to meet the CCG s planning gap the net uplift has reduced to 2.0%. However this still compares favourably to the 1.4% reduction between 15/16 and 16/17. 39

40 2017/18 Initial Budget Summary ( 000s) Prescribing (17/18 summary) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s GP Prescribing 37,079 38,152 Central Drugs Cost 1,103 1,177 Other Prescribing Includes Oxygen and Medicines Management non-pay costs TOTAL 38,714 39,896 40

41 2017/18 Initial Budget Summary ( 000s) Estates & Corporate (bridge to 17/18) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s Forecast Outturn 8,490 8,746 Non-recurrent adjustment to allocation (812) - Relates to Market rent costs funded non-recurrently in 16/17 Non-Recurrent Adjustment (56) (994) Other Full Year Effects 63 - Initial Recurrent Baseline Total 7,684 7,752 Activity Growth (Demog/Non Demog) Other Recurrent Cost Pressures Mainly expected cost pressure relating NHS Property charges QIPP Gross Saving (605) (690) Mostly planned savings on Estates QIPP Investment 63 - Opening Budgets Recurrent 7,752 7,131 Non-recurrent cost pressure Project management including procurement support TOTAL 8,746 7,831 41

42 2017/18 Initial Budget Summary ( 000s) Estates & Corporate (17/18 summary) Budgets Opening Opening Budgets Budgets Comments on 17/ / /19 '000s '000s Corporate - Non Running Cost pay 3,764 3,798 Safeguarding pay, Other Programme Support Costs, Medicines Management pay costs and Clinical Leads NHS Property Services 2,385 1,887 Corporate - Other 1,669 1,211 Includes CHP estates, SaHF Transformation, Interpreting Sercices and Organisatonal Development costs GP IT TOTAL 8,746 7,831 42

43 Part /18 QIPP, investments, activity analysis and risk assessment 43

44 QIPP 2017/18 Summary This report provides an update of Brent CCG s 2017/18 QIPP plan following contract negotiations with our local providers and progress to date in agreeing QIPP targets that are forecast to total 14.79m in the next financial year. Schemes have a % deliverability risk rating applied to identify a post-risk QIPP position of 9.98m. A scheme-by-scheme breakdown can be found in the following slides. A summary of contracting round developments include: Gross QIPP total included in in-sector contracts reflect STP planning assumptions. These were included in 17/18 contracts agreed Dec 16. The task between Jan-March 17 is to agree the details of the QIPP plans to the value agreed in the contract. Greatest progress with this has been achieved with LNWHT. Further progress needs to be achieved with Imperial. This approach has created further QIPP opportunities outside of in-sector contracts where QIPP plans identified greater opportunities than QIPP totals included in the contract. There is a net 4.8m outside of in-sector SLAs. Mental Health QIPP is included in the programme however no new QIPP has been agreed in the CNWL SLA. There is a planning expectation that this can still be negotiated during the financial year. In addition, due to planning pressures and lack of drawdown there remains 0.7m of unidentified QIPP. POD Gross Savings Reprovision Net QIPP Risk Adjusted QIPP Acute (13,340) (13,340) (9,341) CHC (1,395) (1,395) (1,141) Community (370) (370) (334) Estates and Corporate (605) (605) (303) Mental health (1,393) (1,393) (915) Other (461) 5,274 4,813 3,377 Prescribing (1,800) (1,800) (1,318) Unidentified (700) (700) Total (20,068) 5,274 (14,794) (9,975) 44

45 QIPP 2017/18 Acute: Planned Care Key Scheme fully assured Scheme not yet fully assured Scheme with high risks & issues Scheme RAG Service Description Key Risk & Issues Provider Status Gross (,000) Reprov Net (,000) % Risk Post Risk Anti-coagulation therapy Reduction in follow up by transferring stable patients to Primary Care. No major risks/issues. LNWHT: Agreed RFH : Agreed ICHT : TBC (127) 55 (72) 90% (65) BMI Reductions 10% reduction in volume of activity referred to BMI through application of BROS scheme, based on better triage of referrals No major risks/issues. BMI: Contract Efficiency (327) - (327) 80% (262) BNP Test Avoid further unnecessary echo's over 2 years by making greater use of BNP testing to rule out heart failure with symptomatic patients (e.g. breathlessness) No major risks/issues. ICHT: TBC LNWHT - Agreed (61) 5 (56) 90% (50) DMARD Reduction in follow up by transferring stable patients to Primary Care. Increase in stable patients accepted by General Practice required. LNWHT: Agreed RFH : Agreed ICHT : TBC (156) 47 (109) 90% (98) ENT Balance Introduction of dizziness and vertigo one stop shop, reducing need for follow-up appointments and multiple referrals within ENT The Trust may be unable to recruit AVP resources to be able to run this service. LNWHT: Agreed (P) RFH : Agreed ICHT : TBC (91) 64 (27) 70% (19) Endoscopy FC tests Reduction in secondary care activity by performing FC tests in Primary Care. No major risks/issues. LNWHT: Agreed (38) 2 (36) 90% (32) Gastroenterology IBD Nurses Set up of IBD nurse led model in the community, employed by the trust as a bespoke investment.. The Trust will also roll out the Adacolumn device, which reduces the need for biologics. No major risks/issues. LNWHT: Agreed (113) 65 (48) 80% (38) Sub-Total Planned Care (913) 238 (675) (564) 45

46 QIPP 2017/18 Acute: Planned Care Scheme RAG Service Description Key Risk & Issues Provider Status Key Scheme fully assured Scheme not yet fully assured Scheme with high risks & issues Gross (,000) Reprov Net (,000) % Risk Post Risk Gynaecology Expansion of community gynaecology service to whole of Brent at community tariff, seeing a wider range of conditions and with access to appropriate diagnostics. Scoping of model still to be confirmed. Trust do not agree to scheme. LNWHT:Agreed (P) RFH : Agreed ICHT : TBC (127) 55 (72) 70% (65) Hernia Repair Set up walk in service for hernia repair in community under local anaesthetic, reducing number of hernia repairs undertaken in acute setting Trust do not agree to scheme. LNWHT: Agreed (P) RFH : Agreed ICHT : TBC (232) 178 (54) 70% (38) Ophthalmology LTC Transfer of long-term condition patients from LNWHT to BMI ophthalmology contract No major risks/issues. LNWHT: Agreed (P) (93) - (93) 70% (65) Ophthalmology Cataracts Negotiate improved tariff on cataract procedures Trust do not agree to scheme LNWHT: Agreed (P) RFH : Agreed ICHT : TBC (166) - (166) 70% (116) BROS Reduction in unnecessary first, follow-ups and outpatient procedures as a result of consultant and GPwSI led triage service for all Brent referrals and C2C referrals C2C element of scheme does not progress as expected. Practices do not fully utilise benefits of the scheme LNWHT: Agreed RFH : Agreed ICHT : TBC (2,928) 848 (2,080 70% (1456) Respiratory Right Care Improve quality and staff training in primary care and community and put in place surveillance systems and detection systems for early intervention in complications, reducing unscheduled admissions for COPD and asthma Scheme to achieve programme milestones with minimal delay & confirm activity assumptions. LNWHT: Agreed (P) RFH : Agreed ICHT : TBC (157) 55 (102) 80% (82) Right Care Diabetes Reduce variation in Hba1c and other key diabetes indicators through education and management of diabetes in primary care Scheme to achieve programme milestones with minimal delay & confirm activity assumptions. LNWHT: Agreed (P) RFH : Agreed ICHT : TBC (120) 44 (76) 80% (61) Right Care MSK improvement to physiotherapy services, introduction of shared decision aids, introduction of new T&O pathways and community pain pathways Scheme to achieve programme milestones with minimal delay & confirm activity assumptions. LNWHT: Agreed (P) RFH : Agreed ICHT : TBC (298) 104 (194) 80% (155) 46 Total Planned Care (5,137) 1,651 (3,486) - (2,569)

47 QIPP 2017/18 Acute: Unplanned Care Key Scheme fully assured Scheme not yet fully assured Scheme with high risks & issues Scheme RAG Service Description Key Risk & Issues Provider Status Gross (,000) Reprov Net (,000) % Risk Post Risk LNWHT: Agreed Whole Systems Integration Reduction in NEL activity by case managing complex patients in the community. Scoping of New clinical model to be confirmed RFH: ICHT: Agreed TBC (1,849) 956 (893) 70% (625) STARRS Rapid Response NEL avoidance via rapid response service. New specification & target specific patient cohorts. Scoping of New clinical model to be confirmed LNWHT: Agreed RFH: Agreed ICHT: TBC (2,018) 1,172 (846) 70% (592) STARRS Rehab & Reablement NEL avoidance & readmissions. To sustain people in the community following discharge from hospital.. No major risks/issues. LNWHT:Agreed (P) RFH : Agreed ICHT : TBC (557) ) 70% (390) Nursing Homes - GP Network Contracts NEL avoidance by commissioning GP networks to provide care to nursing home patients. No major risks/issues. LNWHT: Agreed (83) - (83) 70% (58) Community Falls & Bone Health Service Reduction in NEL falls & fractures via comprehensive community service. Service to launch with minimal delays LNWHT: Agreed (P) RFH : Agreed ICHT : TBC (572) 370 (202) 70% (141) Improving Fragility Pathways To ensure patients visiting ED have an appropriate pathway and access to service to minimise Length of stay. Scoping of service model still to be confirmed LNWHT: Agreed (P) (688) - (688) 70% (482) Sub-total (5,767) 2,498 (2,712) - (2,288) 47

48 QIPP 2017/18 Acute: Acute: Unplanned Care Key Scheme fully assured Scheme not yet fully assured Scheme with high risks & issues Scheme RAG Service Description Key Risk & Issues Provider Status Gross (,000) Reprov. Net (,000) % Risk Post Risk Community Respiratory Service Reduction in NEL activity via redesigned community service and specification. No major risks/issues LNWHT Agreed (P) RFH: Agreed ICHT: TBC (268) % 26 Atrial Fibrillation Reduction in follow ups by case finding patients who have undiagnosed atrial fibrillation. No major risks/issues LNWHT Agreed RFH: Agreed ICHT: TBC (58) 54 (4) 70% (3) End of Life Redesign Reduction in NEL admissions by piloting single point of access for EOL patients and their carers. This requires agreement and collaboration with Harrow CCG & S&T LNWHT Agreed (P) RFH: Agreed ICHT: TBC (515) 226 (290) 70% (203) Deliver the 7 day services standards MH- IAPT & LTC MH -Adults with SMI To ensure people are only in an acute bed for as long as their condition requires, through focussing on delivering clinical standards in acute hospitals relating to 7 day services. improve quality of life and reduce the overall cost of care by integrating IAPT services in the treatment following a shortstay for hypertension, particularly in the context of stroke, diabetes, and COPD improve quality of life and reduce the overall cost of care by integrating services for people with Serious and Long term MH, in coordinated community and primary care, with urgent crisis support, that reduces further need for NEL AND A&E admissions. Scoping of service model still to be confirmed TBC (72) - (72) 70% (50) Scoping of service model still to be confirmed TBC (466) % (217) Scoping of service model still to be confirmed TBC (49) 17 70% (22) Total Unplanned Care (7,195) 3,251 (3,944) - (2758) 48

49 QIPP 2017/18 Acute: other Key Scheme fully assured Scheme not yet fully assured Scheme with high risks & issues Scheme RAG Service Description Key Risk & Issues Provider Status Gross (,000) Reprov. Net (,000) % Risk Post Risk Use of Biosimilars Urgent Care LAS Demand Management Funds continue to be spent on high cost drugs (e.g. Etanercept, Infliximab, Rituximab, Adalimumab) when lower cost, effective, biosimilars could be used Interventions to manage predicted growth in LAS journeys. Work links with NHSE IUC programme (particularly with the NHS111 winter pilot) Scheme not fully developed TBC (392) - (392) 505 (196) Scheme not fully developed TBC (121) - (121) 50% (61) Challenging RTT Challenge to contracted RTT volumes Scheme not fully developed TBC (298) - (298) 50% (149) Out of Sector claims PPWT Controls and challenges around out of sector acute activity require improvement to deliver best value Better medicines management through PPwT process Scheme not fully developed TBC (144) - (144) 50% (72) Scheme not fully developed TBC (53) - (53) 50% (27) Sub-total (1,008) (1,008) (505) 49

50 QIPP 2017/18 Continuing Healthcare Services Key Scheme fully assured Scheme not yet fully assured Scheme with high risks & issues Scheme RAG Service Description Key Risk & Issues Provider Status Gross (,000) Reprov. Net (,000) % Risk Post Risk Mental Health Repatriation 16/17 FYE (PEP) Placement efficiency programmes for MH & LD cases to match to appropriate settings of care No major risks/issues CNWL: Agreed (500) - (500) 80% (400) Mental Health Repatriation 17/18 (PEP) Placement efficiency programmes for MH & LD cases to match to appropriate settings No major risks/issues CNWL: Agreed (650) - (650) 80% (520) CHC High Cost Packages To achieve better value for money through rigorous contract negotiations with providers No major risks/issues TBC (178) 13 (165) 90% (149) Continuing Healthcare (Elderly PEP) FYE Placement efficiency programmes for continuing healthcare patients No major risks/issues NHSE: TBC (67) - (67) 90% (60) Sub-total (1,395) 13 (1,382) - (1,129) Community Services Scheme RA G Service Description Key Risk & Issues Provider Status Gross (,000) Reprove Net (,000) % Risk Post Risk Community Care Respite Grant Decommission carers grant. No major risks/issues NHSE: TBC (300) 150 (150) 95% (143) End of Life Redesign Contract efficiency through procurement No major risks/issues NHSE: TBC (70) - (700) 70% (49) Sub-total (370) 150 (220) - (192) 50

51 QIPP 2016/17 Mental Health Key Scheme fully assured Scheme not yet fully assured Scheme with high risks & issues Scheme RAG Service Description Key Risk & Issues Provider Status Gross (,000) Reprov. Net (,000) % Risk Post Risk Memory Clinic Placement efficiency programmes for MH & LD cases to match to appropriate settings of care No major risks/issues CNWL: As per 1718 contract. (166) 0 ( % (158) Host Family Peer support Host Families Peer Support is a scheme that finds suitable foster families for vulnerable mental health service users (adults). No major risks/issues TBC ( (850 70% 960) SSOC & Section 117 The purpose is for secondary care mental health patients to be discharged into primary care with closer links to an enhanced primary mental health service staffed by specialists. Trust to agree as part of in year contract negotiations CNWL: TBC (273) - (273) 70% (191) Oats Reduction- Borders Activity This scheme will work to reduce the use of 'out of area treatments' (i.e. long-stay hospital admissions, community and nursing homes) for people with mental health needs. BEHMT Trust does not work with the CCG to move patients to local CNWL settings BEHMHT: TBC (175) - (175) 70% (123) Oats Reduction Rehab Service will ensure care closer to home and maximise the use of geographically local beds Trust to agree as part of in year contract negotiations CNWL: TBC (158) - (158) 70% (111) Homelessness Assist homeless inpatients find appropriate supported accommodation in Brent (linked to the NAIL project), or find beneficial reconnections outside Brent. Reduce delayed discharges (and associated occupied bed days) due to accommodation issues. Trust to agree as part of in year contract negotiations CNWL: TBC (510) 133 (377) 70% 9189) Sub-total (1,393) 159 (1,234) (830) 51

52 QIPP 2017/18 Primary Care Key Scheme fully assured Scheme not yet fully assured Scheme with high risks & issues Scheme RAG Service Description Key Risk & Issues Provider Status Gross (,000) Reprov. Net (,000) % Risk Post Risk GP Prescribing Prescribing plan to identify savings and audit areas to improve prescribing practices No major risks/issues TBC (1,045) 50 (995) 90% (896) Prescribing Choosing Wisely More efficient control process and non-core prescribing items that should be offered only on an exceptional basis (e.g. Emollients/Shampoos, Eye Treatments, Laxatives, Gluten Free foods) Scheme high risk, not fully developed. TBC (221) - (221) 50% (111) Prescribing Waste Tighter control around community pharmacy repeat prescribing of unnecessary items Scheme high risk, not fully developed. TBC (534) - (534) 50% (267) GP WIC Procurement Contract efficiency No major risks/issues TBC (161) - (161) 90% (145) CMH UCC- Care UK Contract efficiency No major risks/issues TBC (300) - (300) 90% (270) Other Work-streams Sub-total (2,261) 50 (2,211) (1,688) Scheme RAG Service Description Key Risk & Issues Provider Status Gross (,000) Reprove Net (,000) % Risk Post Risk Estates Efficiency achieved via reduced Estates costs Scheme High risk with several issues. NHS Property: TBC (605 - (605) 50% (303 Sub-total (605) - (605) (303) 52

53 QIPP Agreement NHSE have asked us to classify QIPP plans into the following four buckets reflecting agreements with providers 1) fully worked up PID and agree by providers 2) fully worked up PID shared with providers and yet to be agreed 3) opportunity identified only & PID in development 4) unidentified. Our analysis on acute schemes is as follows reflecting greater progress made with LNWHT. QIPP Development Acute Providers Total Gross Savings ( 17-18) Total Investment Net QIPP Identified (17-18) Post Risk % QIPP Status Fully worked up and agreed with providers (7,207) 0 (7,207) (5,190) 56% London Northwest Healthcare NHS Trust (4,200) 0 (4,200) (3,003) 58% Imperial College Healthcare NHS Trust (1,973) 0 (1,973) (1,422) 27% Royal Free London NHS FT (707) 0 (707) (503) 10% Other (327) 0 (327) (262) 5% Fully worked up and shared with providers, yet to be agreed (4,538) 0 (4,538) (3,237) 35% London Northwest Healthcare NHS Trust (3,426) 0 (3,426) (2,455) 76% Imperial College Healthcare NHS Trust (450) 0 (450) (315) 10% Other (662) 0 (662) (467) 14% Opportunity identified only and PID in development (1,595) 0 (1,595) (915) 10% London Northwest Healthcare NHS Trust (381) 0 (381) (267) 29% Imperial College Healthcare NHS Trust (192) 0 (192) (135) 15% Royal Free London NHS FT (87) 0 (87) (44) 5% Other (935) 0 (935) (470) 51% Grand Total (13,340) 0 (13,340) (9,340) Across the whole programme our analysis is as follows QIPP Summary QIPP Development Status Total Gross Savings 1718 Total Investment Net QIPP Post Risk % Fully worked up and agreed with providers (9,927) (239) (9,688) (7,394) 74% Fully worked up and shared with providers, yet to be agreed (5,905) (4,861) (1,044) (804) 8% Opportunity identified only and PID in development (3,535) (173) (3,362) (1,778) 18% Unidentified (700) 0 (700) 0 (20,068) (5,274) (14,794) (9,975) 100% 53

54 QIPP monthly delivery expectations QIPP savings are phased slightly towards the last six months Finance (61%) Activity (54%). 54