Harrow CCG Month 5 QIPP PMO Report

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Harrow CCG Agenda Item 15 Title of Meeting : Governing Body Date of meeting: 30 th September 2014 Paper No Attachment 15a O Harrow CCG Month 5 QIPP PMO Report Purpose of the report To provide a

1 Harrow CCG Agenda Item 15 Title of Meeting : Governing Body Date of meeting: 30 th September 2014 Paper No Attachment 15a O Harrow CCG Month 5 QIPP PMO Report Purpose of the report To provide a report on the management and performance of the Harrow QIPP Programme. Executive Summary (to include outcome benefits) The M5 QIPP FOT forecast is based on M3 SUS data and is of a shortfall at year end of 1,171k an improvement of 424k on the M4 FOT. The improvement in the forecast since M4 is largely the result of Harrow s QIPP Rectification Plans, details of which are provided in the slides that follow. These plans were discussed with NHSE at the CCG s September Assurance meeting. Decision required: The Board / Committee is asked to: Note the contents of the report. Corporate Objectives and Board Assurance Framework: Objective 3: Manage resources effectively. Equality and Diversity considerations and implications from which an Impact Assessment might be made: n/a Resource implications: (Confirmation that any resource implications have been agreed with Finance) Risks Attached to this initiative (Reference to Corporate Risk Register as appropriate n/a Patient & Public Engagement Input to and/or Impact of this initiative n/a Safeguarding Implications: n/a Communications Strategy: (How will this initiative be disseminated) n/a

2 Clinical Director: Name: Dr Amol Kelshiker Job title: Chair Contact: Name: Javina Sehgal Job title: Chief Operating Officer

3 This image cannot currently be displayed. Harrow Month CCG 11 QIPP PMO Report Finance Report Month Month /15 QIPP Report Harrow CCG Javina Sehgal, Chief Operating Officer, Harrow CCG 1

4 QIPP: Month 5 Position Summary The following slides identify M5 FOT, adverse variances and remedial actions The M5 QIPP FOT forecast is based on M3 SUS data and is of a shortfall at year end of 1,171k an improvement of 424k on the M4 FOT. The improvement in the forecast since M4 is largely the result of Harrow s QIPP Rectification Plans, details of which are provided in the slides that follow. These plans were discussed with NHSE at the CCG s September Assurance meeting. Harrow s QIPP Rectification Plan Since the year end under delivery of 1,595k forecast in month 4 Harrow CCG has reviewed its QIPP programme to identify additional savings. The resulting Rectification Plan has contributed to a reduction in the underdelivery forecast at month 5 of 424k to 1,171k. The following slides describe the components of the resulting recovery plan. The additional schemes described in the plan, which are expected to deliver 160k of saving in 15/16 have not yet been added to the schedule of QIPP schemes or included in the forecast. 2

5 QIPP: Month 5 Position Summary The following schemes are the main areas of forecast variance against plan at M5. Scheme 14/15 Plan M5 YTD Variance M4 FOT variance M5 FOT variance Comments Urgent Care Centre / A&E Demand Management Increased proportion of activity realising additional saving through price difference with A&E. Expand Ambulatory Emergency Care Revised analysis for M5 actuals (M6 forecsat) to measure impact of pathways rather than all ambulatory conditions. Improve A&E Flow Negotiation of local price to be completed. Referral Management Significant increase in referral rates in Q1 subject to further analysis. Remedial planning underway. End of Life Care Pathway month project slippage will affect benefits realisation. Acute Direct Access - Physiotherapy Woodland Hall Recharge Further analysis has identified incorrect charging by NWLHT and revision to metric. Plan to review 1:1 observation practices expected to realise 200k savings from total of approximately 1m. Repatriation of Learning Disabilities Clients (PEP) Scheme underdelivering but expected to recover to plan by year end. FYE of 13/15 savings to be included in actuals from M6. Continuing Care Reviews Invest to save proposalincluded in recovery plan; to be confirmed w/c 22/9. Community Budget Growth Contract management process to manage ICO failure to plan required activity. CSU Acute Contract Metrics Data on 3 of 5 measures indicates savings in range of k. 3

6 Workstream Scheme Name 14/15 Plan M5 QIPP Forecast M5 YTD Variance M5 Forecast Out-turn Variance Comments Unscheduled Rapid Response & Home Care (STARRS) /ACS Scheme ramp up on track and expected to deliver. Unscheduled Expand Ambulatory Emergency Care High level of activity in unscheduled care at NWLH undermining planned savings. Unscheduled Improve A&E Flow Negotiation of local price for 0-4 hour admissions based on independent audit begins w/c 22/9 (agreement to be backdated to 1st ). Unscheduled Improve Acute Flow Scheme overperforming in first quarter. Unscheduled NHS Scheme overperforming in first quarter. Unscheduled Urgent Care Centre / A&E Demand Management Increaseed proportion of activity realising additional saving through price difference with A&E. Planned Outpatient Pathways Collaborative approach to delivery of Opthalmology and Gynaecology pathways on track. Planned Referral management -1, Some recovery expected through peer group review process and targeting of high referring practices. Planned EOLC pathway, including CMC roll-out Scheme slippage of 3 months. Planned Acute Direct Access - Physiotherapy Price reduction agreed in contract delivering savings.referral rates to be addressed through referral management process. Planned Respiratory pathway, including Pulmonary Rehab No net savings planned. Mental Health Redesign of Roxbourne Complex & Annex Mental Health Implementation of Mental Health panel (PEP) Mental Health Repatriation of Learning Disability clients (formerly PEP) Mental Health Enhanced Primary Mental Health Care Scheme delivery on track. Mental Health Shared Care prescribing protocols Scheme delivered. Mental Health Voiceability Scheme delivered. Commissioners ensuring effective use of capacity to accommodate patients to avoid high cost placements. Scheme delivering ahead of schedule. Scheme forecast to deliver planned savings. FYE of 13/15 savings to be included in actuals from M6. Scheme underdelivering but expected to recover to plan by year end. FYE of 13/15 savings to be included in actuals from M6. Mental Health BEH contract review Contract not yet agreed. Forecasting contract will include QIPP anticipated. Continuing Care Woodland Hall recharge Plan to review 1:1 observation practices expected to realise 200k savings from total of approximately 1m. Continuing Care Continuing Care reviews Invest to save proposalincluded in recovery plan; to be confirmed w/c 22/9. Continuing Care Review of Section 28A patients Discussions underway with LA. Continuing Care Shared Lives Discussions underway with LA. Continuing Care Non Eligible Continuing Care - FYE of 13/14 cases Scheme delivered. Medicines Mgmt Medicines Management Scheme on track. Integrated Care Integration of primary, acute, social and community care Scheme on track to deliver forecasted savings. Community Community budget growth (Supplies) Contract management process to manage ICO failure to plan required activity. Children's Integrated Pathway for Complex Children (Tri-partite) Scheme delivered. Other CSU Acute Metrics Data on 3 of 5 measures indicates savings in range of k. Total -7,490-1,203-1,171 4

7 Harrow CCG s 15/16 QIPP Rectification Plans The Rectification Plan has two parts: Additional schemes expected to realise 159.5k of additional savings in 14/15 (see slide 6). These schemes are part of the 300k attributed to new QIPP in the recovery plan. Values for other new schemes included in the recovery plan, e.g. joint schemes with LBH, will be added once agreed. The CCG expects to deliver new QIPP schemes to the value of 300k. Remedial actions on existing schemes estimated to recover 590k of the under delivery forecast in month 4 (see slide 7). The combined impact of these measures is 749.5k. The identification of further opportunities for savings is an ongoing part of the CCG s QIPP delivery programme. 5

8 Harrow CCG s 15/16 QIPP Rectification Plans Additional QIPP Schemes in 15/16 The following additional schemes are expected to realise 159.5k of additional savings in 14/15; Additional Schemes Start Date Estimated 14/15 Savings BNP October 18 Faecal Calprotectin October 78 Anti-coagulation Therapy Monitoring January 27.5 Maternity Acuity Project - 36 Pathway and activity figures agreed, currently discussion about reduction in the tariff, service can be launched asap. Pathway and activity figures agreed, currently discussion about reduction in the tariff, service can be launched asap. Pathway, activity agreed by PCG, awaiting Procurement Panel sign off on the costs- conservating estimate of savings based on earlier estimates, may change after Procurement Panel's opinion B&H CCGs and NWLHT have agreed to undertake a maternity audit using PbR principles and guidelines. Currently NWLHT are some 15% away from national predicted average and it is envisaged that this audit will reflect a lower acuity than currently being paid for in contract. Target reflects a small proportion of the c2,100 Harrow deliveries a year at NPH. Opportunity to review acuity has arisen due to new maternity tariff. New scheme from Q3 risk rated at 75%. Total

9 Harrow CCG s 15/16 QIPP Rectification Plans Remedial actions to reduce under deliver on existing schemes The impact of the following measures is estimated as a 590k improvement on the underdelivery forecast in month 4. Remedial Actions to reduce M4 forecast under delivery on existing schemes Existing Scheme M4 Year-end Forecast Variance Year-end forecast variance postremedial action Additional saving at 14/15 year-end Expand Ambulatory Care -145 TBC TBC Urgent Care Centre Remedial Actions Data now available allowing the application of contractual rules on duplication of appointments and other inappropriate coding of HRGs. Current (M4) forecast underestimates saving. Metric revised to rectify underestimate. NOTE: BG assessment of M1-4 = 58.72k Acute Direct Access Physiotherapy Current (M4) forecast underestimates saving due to incorrect charging by NWLH. CSU Acute Metrics CSU advises a forecast saving in the range of k. Continuing Care Review Woodland Hall Total 590 Initial scheme delayed due to need to review and reconfigure BHH service. Invest to save scheme proposal to be completed w/c 22nd September. Scheme to review and reduce use of 1:1 observation in Woodland Hall. 7

10 QIPP under-delivery: Issues, Risks and Actions QIPP scheme Expand Ambulatory Emergency Care: Forecast underdelivery of 145k. Improve A&E Flow: Forecast underdelivery of 66k. Remedial Actions Remedial Action: Revised analysis for M5 to measure impact of pathways rather than all ambulatory conditions. Provider procuring Echo equipment to allow implementation of 3 cardiac pathways. Remedial Action: Negotiation of local price scheduled for week commencing 22/9.. Referral Management: Forecast underdelivery of 586k against the 14/15 plan of 1.027m. End of Life Care: Forecast underdelivery of 180k. Acute Direct Access Physiotherapy: Forecast underdelivery of 30k. Woodland Hall Recharge: Forecast delivery according to plan. Remedial Action: Further analysis of referral patterns underway. Significant further reduction required to meet plan. Remedial plan to be confirmed. Support to target high referral rates in specific areas rather than across the CCG. Remedial Action: Project under review. Identify 1% of practice patients in last year of life and use ICP MDGs to facilitate care planning. Link to existing care Home Support Team project. Remedial Action: Review of metric calculation.for M4 data and contract charging has reduced forecast underdelivery by 140k.. Remedial Action: Plan to review 1:1 observation practices expected to realise 200k savings from total of approximately 1m.. 8

11 QIPP scheme QIPP under-delivery: Issues, Risks and Actions Continuing Care Reviews: Forecast underdelivery of 178k. Pressure on continuing care from increased inpatient capacity, including escalation beds, to meet winter pressures will increase demand for continuing care packages. Limited staff resources to undertake targeted assessment of patients. Integrated Care Programme: Forecast underdelivery of 30k. Remedial Actions Remedial Action: Initial scheme delayed due to need to review and reconfigure BHH service. Invest to save scheme proposal to be completed w/c 22nd September. Remedial Action: Increased support to GP practices in the development of care plans. 6 Care Navigators recruited to support practices. Multi-agency database of frequent user, social services and community nursing data to be available in M5. Community Budget Growth (Supplies): Forecast underdelivery of 122k. Risks The budget for continence supplies is held by the CCG but the District Nurse assessments required to reduce the use of those supplies is provided by the ICO. Remedial Action: CSU to advise on contractual mechanisms in response to ICO s failure to deliver action plan for District Nursing as agreed.

12 Harrow 14/15 QIPP Schemes 14/15 QIPP Scheme 14/15 Plan Savings assumption Commences Progress Update & Next Steps Plan Total -7,489 Unscheduled Care STARRS -777 Reduce NEL admissions and A&E attendances. ramp-up with full effect by August. For 2014/14 no reconciliation has been completed with SUS due to IG issues. Based on STARRS internal KPI s metrics, discounted at rate derived from 13/14 validation, the scheme is on track. Expand Ambulatory Emergency Care additional pathways targeting short stay admissions and A&E attends. ramp-up with full effect by June. Data from the provider has not previously allowed the commissioner to identify those patients seen in the AECU. It has been confirmed by the provider that data should be flagged to identify activity in Fletcher Ward (AEC). Revised analysis for M5 actuals (M6 forecsat) to measure impact of pathways rather than all ambulatory conditions. Contract process monitoring deployment against risk share agreement which contains sanctions for under delivery. Revised analysis for M4 to measure impact of pathways rather than all ambulatory conditions. Improve A&E Flow hour local price at 75% tariff and prevention of short stay admissions in adults and paeds. Tariff reduction. Revised pathway agreed to impact on short-stay admissions June. Audit completed, negotiation of local tariff to commence 22/09. Proposal to trust was for local price for all 0-4 hour 75% short-stay tariff. Contractual agreement to clinical audit followed by negotiation of pricing for 0-4 hour admissions. Audit complete. Negotiation to commence 22/9. 10

13 Harrow 14/15 QIPP Schemes 14/15 QIPP Scheme 14/15 Plan Savings assumption Commences Progress Update & Next Steps Unscheduled Care -1,574k Improve Acute Flow -203 Reduction in EBDs through joint pathway improvement project.. M4 actuals on track. The NEL Bed Flows work stream from the JI will look to make recommendations in this area for the remedial action plan. Review of community beds completed in August Output from this project will contribute to a reduction in the number of Delayed Transfer of Care (DTOCS) patients. NHS Plan reviewed and agreed to be relatively modest. Opportunity to review the DoS to steer appropriate activity. Urgent Care Centre / A&E Demand Management -42 Prevention of 68 A&E attends per month. Prevention of A&E attends through increased use of UCC and redirection. On track. Increase in NPH site unscheduled attendances resulting in overperformance M1-4 of 33k. A recent audit carried out by the UCC the provider has identified that there are on average an additional 15/20 patients a day that are going into A&E via the streaming nurse and the London Ambulance Service that could be seen within the UCC. An action plan to address this has been developed to enhance the skill of the ENP teams. It is anticipated that the new LAS co-ordinator role will assist with directing the crews to the most appropriate place for the patients attending NPH 11

14 Harrow 14/15 QIPP Schemes 14/15 QIPP Scheme 14/15 Plan Savings assumption Commences Progress Update & Next Steps Planned care -2,622k Community Pathways -803 Community pathway at 75% of cost of outpatient tariff. Phasing staggered: July 14 to Jan 15. Opthalmology and gyneacology collaborative negotiations are ongoing but have yet to be concluded. Procurement approaches to remaining pathways to be confirmed. Main risks are delay in commencement of new pathways, scope of reduced prices and achieving planned price reductions; Phasing of schemes in original plan has been pushed back resulting in a revised gross plan of 3,212k, reprovision of 2,409k and savings of 803k. Referral Management % reduction in referrals measured through 1 st outpatient attendances. Delay in confirmation of LIS has affected performance. No savings in M1-4. Further analysis of referral rates to be undertaken by the CSS and discussed in peer groups. Main risk is that Harrow has low referral rates benchmarked to London CCGs. Further reductions will require continued support to target high referral rates in specific areas rather than across the CCG. Community pathways for outpatient specialties will assist primary care to support patients in the community and provide GPs with specialist advice as an alternative to referral. EoLC Pathway -537 Reduction of 207 unscheduled admissions. Identify 1% of practice patients in last year of life and use ICP MDGs to facilitate care planning. Link to existing care Home Support Team project. July 3 month delay in implementation of project. Project under review. 12

15 Harrow 14/15 QIPP Schemes 14/15 QIPP Scheme 14/15 Plan Savings assumption Commences Progress Update & Next Steps Acute Direct Access Physiotherapy -255 Local price at community tariff plus 10% reduction in referrals from primary care. Local price equivalent to community tariff accepted by NWLH. Audit of referrals indicates that a 10% reduction in physiotherapy referrals is easily achievable. Remedial planning underway. Scheme metric reporting 12k underperformance to M4. Further examination of data required. Mental Health -1,093 Redesign of Roxbourne Complex -400 Ensure appropriate level of care for patients in revised inpatient and community rehab pathways Q1 3 patients transferred, transfer dates for 4 more agreed. Scheme will exceed plan. SW/SM assessing potential for 5 bed supported living unit as additional source of savings. Implementation of Mental Health Panel Saving delivered. Repatriation of Learning Disability Clients (PEP) Commissioners requesting remedial plans from CNWL. Existing scheme to ensure efficient use of placements. Existing scheme to ensure efficient use of placements. Ongoing Ongoing Reporting overachievement in year to date. FYE of 13/14 cases not yet included in reporting. Forecast to achieve plan. Scheme underperforming in M1-4, excluding FYE of 13/14 cases. 13

16 14/15 QIPP Scheme 14/15 Plan Savings assumption Commences Progress Update & Next Steps Enhanced Primary Mental Health Care -58 Shifting settings of Care McKinsey modelling of savings. Patients to be transferred identified. LIS confirmed. An additional 215k reprovision cost has been included in this scheme to fund a 50:50 risk share with the provider. Shared Care Prescribing Protocols Harrow 14/15 QIPP Schemes TBC -25 Reduce CCG prescribing costs. TBC Requires contractual agreement from CNWL. Additional 30k risk mitigation included to reduce exposure to 25k. Scheme implementation managed by the Harrow MH Transformation Board Delivered. Mental Health Growth / Voiceability -30 Retention of some growth funding. BEH Contract Review -30 Contract review process. Scheme delivered. BEH contractual agreement required. 14

17 14/15 QIPP Scheme 14/15 Plan Savings assumption Commences Progress Update & Next Steps Continuing Care -848 Harrow 14/15 QIPP Schemes Woodland Hall Recharge -200 Initial plan to charge commercial rates for capacity not required for Harrow patients. Revised to focus on reducing 1:1 observation costs. CC workstream has agreed to focus on savings on 1:1 observation costs. Significant additional income dependent on vacancies arising among B&H patients. SW to arrange a review of patients needs. Continuing Care reviews -278 : Potential for invest to save proposal. FYE of disputed continuing care cases (13/14) Review of Section 28a patient funding status Priority review of cases with highest potential savings as a result of reassessment of need. FYE of cases settled through 13/14 QIPP scheme Discontinue 28a funding of patients without proof of status. Delayed due to insufficient capacity in continuing care team. TBC Invest to save proposalincluded in recovery plan; to be confirmed w/c 22/9. Delivered. Discussions underway with LBH. LB Harrow have agreed to confirm criteria for 28a patients. Those patients that do not meet the criteria will be reviewed with responsibility for funding apportioned according to existing agreements. Shared Lives -37 Recovery of adult fostering costs. Discussions underway with LBH. 15

18 14/15 QIPP Scheme 14/15 Plan Savings assumption Commences Progress Update & Next Steps Medicines Mgt -698 Harrow 14/15 QIPP Schemes Medicines Management -698 Budget based on 13/14 out-turn plus 5% uplift. Plan requires 50% of uplift (2.5% 13/14 outturn) to be saved. Includes 155k invest to save budget. M3 data indicates target met. Integrated Care -253 Integration of primary, acute, social and com care -253 Reduction in: A&E attendances NEL and EL admissions Outpatients Increased support to GP practices in the development of care plans. 6 Care Navigators recruited to support practices. Multi-agency database of frequent user, social services and community nursing data to be available in M5. 16

19 14/15 QIPP Scheme 14/15 Plan Savings assumption Commences Progress Update & Next Steps Community -135 Community Budget Growth (Supplies) -135 Reduction in expenditure on continence supplies. ICO have failed to provide plan for completion of DN assessments. CSU advising on contractual measures. CSU to pursue contractual sanctions following repeated failure of ICO to provide plan for completion of DN assessments required to reduce wastage in use of continence supplies. Childrens Services -83 Harrow 14/15 QIPP Schemes Integrated Pathway for Complex Children (Childrens Tri-partite) -83 Tri-partite panel to ensure eligibility criteria s applied in continuing care. Scheme delivered. Other -183 CSU Acute Contract Metrics -183 Acute contract metrics proposed following McKinsey analysis. Data on 3 of 5 measures indicates savings in range of k. 17

2017/18 Financial Plan and Budgets. John Ingham, Chief Finance Officer, NHS Norwich CCG. Discussion and Approval

Agenda Item: 13 NHS Norwich CCG Governing Body Tuesday 28 th March 2017 Subject: Presented By: 2017/18 Financial Plan and Budgets John Ingham, Chief Finance Officer, NHS Norwich CCG Submitted To: NHS Norwich