Formal Bexley Clinical Commissioning Group

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Meeting Formal Bexley Clinical Commissioning Group Agenda Heading For information Enclosure ENCLOSURE G Date of Meeting 28 th June 2012 Title of report Recommendation Executive summary Quality

1 Meeting Formal Bexley Clinical Commissioning Group Agenda Heading For information Enclosure ENCLOSURE G Date of Meeting 28 th June 2012 Title of report Recommendation Executive summary Quality Innovation Productivity Prevention (QIPP) & Programme Management Office Update BCCC members are asked to NOTE the contents of this report and support the delivery of the QIPP agenda within Bexley. BCCC members are asked to ENDORSE recommendations made by the Programme Management Office. This report provides an update on QIPP within the Care Trust for 2011/12 and 2012/13. The current position regarding delivery and ongoing monitoring is also included within this report. Key points to note are as follows: 1. There is a final adverse variance of 2,021k against planned QIPP of 10,203k for 2011/12. However 80.2% of schemes were delivered /13 Schemes submitted as part of the 2012/13 Operating plan (OP) and FIMs plan have a risk assessed total of 7,585k. 3. Of the remaining QIPP schemes to be delivered in 2012/13, monitoring of eight are the responsibility of the BSU. The rest relate to acute schemes and will be monitored by cluster. Organisational implications Financial There is a risk that Bexley Care Trust will not meet the 2011/12 control total or breakeven if QIPP is not achieved. Equality and This is considered in all QIPP schemes. Diversity Risk N/A (governance and/or clinical) Patient impact This is considered in all QIPP schemes. NHS constitution N/A 1

2 Which objective does this paper support? Improve choice and access to integrated health services for Bexley patients Reduce the level of health inequalities across Bexley Improve care for patients with long term conditions & increase the range of services offered within the community Improving the health & wellbeing for people in Bexley Maximizing the opportunities of joint working (APoH, JSNA, Wellness agenda etc) Using our resources in the most efficient & effective manner (organisational & financial) Insert Tick ( ) Report Author Michael Boyce Assistant Director of Finance & Business Date 13th June 2012 Contact Details Michael.boyce@bexley.nhs.uk Executive sponsor Theresa Osborne Chief Financial Officer 2

3 Bexley Care Trust QIPP Update 1. Introduction This paper provides an update on Bexley Care Trust s 2011/12 final position regarding delivery of the Quality, Innovation, Productivity and Prevention (QIPP) Schemes, it also provides an update on 2012/13 schemes following submission of the final Operating plan (OP) & FIMS plan to NHS London in June This paper also provides an update on the Programme Management Office (PMO) that supports this. 2. Final Position 2011/12 QIPP Schemes The summary table 1 on the next page shows the final performance of the 2011/12 QIPP schemes. These schemes were reviewed and discussed at the quarter 4 stocktake meeting held on 29 th May 2012 with NHS South East London cluster. Lessons to be learnt around the implementation and future delivery of QIPP schemes, along with monitoring, were also discussed. Future meetings with cluster are to be arranged to take this work forward. The majority of the shortfall relates to expected savings from specific KPIs and performance metrics in the South London Healthcare acute contract, which through the contract negotiation process, arbitration and subsequent challenge process have not reached the original targets set. Additionally the cancer network savings were delayed until a future year. Prescribing, PEARS and Minor Oral Surgery also under-performed against their QIPP targets. However, for PEARS this is marginal. The prescribing over-performance is reflected in the Prescription Pricing Authority (PPA) reports and reported in the monthly position. The value of over-performance was covered by the prescribing reserve held to mitigate this. LTC Management and Cardiology over-performed against their QIPP targets along with the initial unidentified QIPP gap of 4,572k. This gap was closed at the end of month 6 with the help of GPs re-prioritising investments and scrutinising budgets. The overall delivery of 2011/12 QIPP schemes equated to 80.2% of the total value of schemes which is a significant achievement. 3

4 Table 1 Final performance of 2011/12 QIPP schemes Ref QIPP Project QIPP Category Responsible Team Prime Owner Short Description Risk Assessment May 2011 BXOT 01 Unidentified QIPP BSU BCCC 2.5m identified from AWP and other budgets G A G G 4,572,000 4,891, , ,280 n/a Increased to address 3m deficit repayment Reduction In Short Stay Non-Elective Admissions S Masters / S A TBC A A BXUC 07 From A&E Urgent Care Cluster Cottingham - 1,454, ,954-1,186,452-1,186, April Budget based on 2009/10 outturn rather than A G A A 2010/11 outturn. Overall saving means net BXPL 12 Prescribing in Primary Care Planned Care BSU Clare Fernee Reducing prescribing costs by using generic brands 1,230, , , , October 2011 growth of 2% only in 2011/12 which seems low BXPL 08a Referral management - POLCE SLHT Planned Care Cluster S Masters / S Cottingham Employing evidence-based threshholds (for the 41 procedures outlined by CSL) and decommissioning procedures which have limited clinical effectiveness Q1 Risk Assessment Q2 Risk Assessment Q3 Risk Assessment A A A A Q4 Risk Assessment Year to Date planned Savings (M12) Year to Dawe Actual Savings (M12) Year to Date surplus/ (Shortfall) Year end Forecast Surplus/ (Shortfall) Delegation? 588, , , April 2011 Comment Sector to agree consistent list and to be agreed with providers BXPL 16 LTC Management and Admissions Avoidance Planned Care BSU John Grummitt A number of workstreams to improve the quality and focus of long term conditions management to reduce unnecessary admissions to hospital, shift care from secondary to primary care and improve quality of life. Initiatives include Ambulatory Care Sensitive Conditions (ACS) programme Seting up a community cardiology service and primary care chest pain clinic, provided at a lower cost in a more convenient location with more effective links with general BXPL 18 Pawhway redesign - Cardiology Planned Care BSU Sab Kaur practice This project aims to shift chemotrheraphy services from hospital into the community (at home or in local satelite BXCA 04 Cancer - chemotherapy at home Specialised Services Cluster Sab Kaur services) Development of a minor oral surgery service, transferring the majority of the activity currently carried out in hospital to BXPL 17 Minor oral surgery Planned Care Unconfirmed Emma Wallis - tbc primary care. S Masters / S BXPL01b First to Follow Up Reduction Planned Care Cluster Cottingham Reduced amount from Feb stocktake S Masters / S BXPL 20 Planned procedures not carried out Planned Care Cluster Cottingham Reduction In OP Followups to Top Quartile S Masters / S BXPL 01 Performance Planned Care Cluster Cottingham G G G G G G G G R R R R G A G G A G A A A G A A A G A A 600,000 1,000, , , April 2011 Figure already risk assessed 572, , , , October , , ,618 Not Delegawed 346, , , ,250 Not Delegawed Community provision 267, , , April Community scanning and community service - net of significant investment and agreed as part of contractual negotiations with SLHT and Guys Community provision and repatriation from GSTT to SLHT 199, , April 2011 Subject to contractual agreement 140, , , April BXPL 19 Primary Eyecare Assessment and Referral Service (PEARS) Planned Care BSU David Parkins BXPL08b Referral management - POLCE DVH Planned Care Cluster Reduction in Non-Elective Readmissions on Same BXUC 06 Day as Discharge Urgent Care Cluster S Masters / S Cottingham S Masters / S Cottingham This scheme will deliver a Primary Eyecare Assessment and Referral Service (PEARS) thaw uses the skills of optometrists to prioritise and manage pawients presenting with the majority of minor eye conditions. This enables as many pawients as possible to be seen quickly and in a local primary care setting thus avoiding unnecessary referral to secondary care services. Employing evidence-based threshholds (for the 41 procedures outlined by CSL) and decommissioning procedures which have limited clinical effectiveness 57k removed following SLHT arbitration decision A G A A A G R R N/A N/A R R 54,000 40,929-13,071-13, October , ,000-40, April April Total 10,202,612 8,181,110-2,021,502-2,021,502 4

5 /13 QIPP Schemes The 2012/13 identified QIPP schemes total 8,165k with a risk assessed value of 7,585k. The schemes have been summarised into four broad areas for the purpose of this report, these being Central Acute, Local Acute, Cost Improvement programmes (CIPS) & Local Redesign. The following sections outline each of these areas along with their generic associated risks to delivery. Central Acute The Central Acute QIPP schemes total 1,337k with a risk adjusted value of 759k. A full breakdown of the schemes is shown in table 2 over the page. The schemes are reductions to the 2012/13 baseline contract values and have been removed from acute contracts for 2012/13 as part of the contract negotiation process. The risk to delivery is from over-performance in the areas listed. Therefore activity associated with these schemes needs to be monitored on a monthly basis to ensure that they deliver the required reduction levels with corrective action being taken by the contracting department should there be an increase above the contract levels during the year. 5

Table 2 - Central Acute QIPP Schemes 2012/13 2014/15 Local Acute The Local Acute QIPP schemes total 1,392k with a risk adjusted value of the same amount.

6 Table 2 - Central Acute QIPP Schemes 2012/ /15 Local Acute The Local Acute QIPP schemes total 1,392k with a risk adjusted value of the same amount. All of these schemes relate to South London Healthcare NHS Trust (SLHT). A full breakdown of the schemes is shown in table 3 over the page. The schemes are reductions to the 2012/13 baseline contract value and have been removed from the SLHT contract for 2012/13 as part of the contract negotiation process. However, although green rated because they have been deducted from baseline contract values, the risk to delivery is from nonimplementation of the proposed redesign schemes. It is vital that the schemes are completed to ensure that activity does not flow through SLHT. Failure to implement these schemes will result in higher activity than planned and the cost of the SLA rising towards 6

7 the proposed cap. Implementation of these schemes therefore needs to be closely monitored along with acute activity associated with them on a monthly basis to ensure they deliver the required reduction levels. Corrective action, or the finding of replacement schemes, will need to be carried out by the Business Support Unit if these schemes do not deliver. Table 3 - Local Acute QIPP Schemes 2012/ /15 7

The risk to delivery is from over-spending where there has been a budget reduction.

8 CIPs CIPs total 5,086k with a risk adjusted value of the same amount, as shown in table 4 below. All of these schemes result from a full review of the 2012/13 budgets and investments by the Clinical Cabinet, Business Support Executive team and budget holders. The risk to delivery is from over-spending where there has been a budget reduction. However, in most cases these budgets were not utilised in previous years or processes have been implemented to allow the budget reduction. Expenditure on all budgets is monitored as part of monthly Finance reporting and specific attention will be given to these areas. Corrective action will need to be taken by the Business Support Unit should there be slippage in these areas. Table 4 - CIPS, QIPP Schemes 2012/ /15 8

9 9

10 Local Redesign The Local Redesign QIPP schemes total 350k with a risk adjusted value of the same amount, shown in table 5 below. Other redesign schemes are linked to the SLHT contract and are shown under local acute schemes earlier in the report. This scheme relates to the re-tendering of the Diabetes service. This service is currently being re-specified to ensure that the service provides what is required for tier 2 and 3 services as well as training support. Although rated green in the plan submitted, the actual QIPP value will not be known until this work has been completed. Furthermore, a full year s savings cannot now be achieved in 2012/13. The risk to delivery is therefore from a delay in the tendering process and the delay in procuring a suitable service provider. Progress will be monitored on a monthly basis. Table 5 - Local Redesign QIPP Schemes 2012/ /15 10

11 In order to ensure that the QIPP target is met in 2012/13 additional schemes will be continually sought. Schemes are currently being reviewed to evaluate the projected savings levels that will be realised in the current financial year. In addition to working with GPs, the Local Authority and the Cluster, BSU staff are meeting with Bromley and Greenwich colleagues to explore areas that can be developed across the three boroughs. This approach to working will facilitate the decommissioning of services within the acute sector, especially those included within SLHT negotiations. A summary of the current QIPP schemes identified compared to those in original planning is shown in table 6 below: Table 6: Summary of 2012/13 QIPP schemes Table 7 over the page shows all the above QIPP schemes as reported and submitted as part of the final 2012/13 Operating Plan (OP) and FIMS plan submissions to the Department of Health in early June

12 Table 7 Submitted QIPP schemes Bexley Care Trust QIPP Plan (+) QIPPS 1) QIPPS included in the operating plan should be net after risk adjustment 2) QIPPS should also be net of investments made to generate savings 3) There should be no income generation within QIPPS 4) Only new QIPPS are to be recorded QIPP Level 1 Main Categorie QIPP Level 2 Categories IN MONTH PLAN 2012/13 Full Yr April May June July August September October November December January February March Mental health Productivity Acute Sector 2, Primary care productivity 0 0 Community support services 1, Activity shifts Long Term Conditions Urgent Care Integrated care Planned Care 0 0 End of Life Care 0 Prevention 0 Staying Healthy 0 Procurement Non Clinical Procurement Decommissioning ineffective procedures 0 Demand management Enhanced recovery 0 Referral management Back office 0 Running costs Estates Staffing 0 Clinical support rationalisation 0 Clinical overheads Diagnostics 0 Direct access 0 Reducing drug spend Medicines use 0 Prescribing 1, Unidentified Unidentified 0 0 Total 7, Efficiency built into provider contracts 10, Cost Avoidance savings (non cash releasing) Total savings (To agree with total DH operating plan QIPPs) 18,049 1,499 1,515 1,492 1,508 1,515 1,492 1,515 1,506 1,501 1,515 1,487 1,501 QIPPs allocated to CCG within the total in Row 39 7, IN MONTH PLAN QIPPS 2012/13 Full Yr April May June July August September October November December January February March Recurrent QIPP schemes 7, Non Recurrent QIPP Schemes 0 Total (should agree to ROW 39) 7, Validation OK OK OK OK OK OK OK OK OK OK OK OK >90% 75%-90% <75% GROSS NET 2012/13 Full 2012/13 Full QIPPS Low Risk Medium Risk High Risk Year Plan Year Plan April May June July August September October November December January February March Full Yr Effect 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s Demand Management Schemes 2,875 2,875 2, Decommissioning Schemes 705 1,161 1,866 1, CIP schemes 3,424 3,424 3, Total (should agree to ROW 39) 7,004 1, ,165 7, Validation OK OK OK OK OK OK OK OK OK OK OK OK IN MONTH PLAN 2012/13 Full Yr April May June July August September October November December January February March Workforce QIPPs (000s) IN MONTH PLAN 2012/13 Full Yr April May June July August September October November December January February March Workforce QIPPs (FTEs) Total

13 4. Programme Management Office (PMO) Report A brief summary of the schemes that have been reviewed by the PMO since the last Clinical Cabinet meeting, and their status in the process, is shown in table 8 below. Table 8 - Recommendations made by the Programme Management Office Date of Meeting Agenda Item Detail 19 th April 2012 Comms & Engagement budget review 44k saving in CIPs identified and agreed. 10 th May 2012 Healthcare at Home Drugs budget review 61k saving in CIPs identified and agreed. Budget reductions as follows; 1. Patient Group Directions 30k reduced to 15k 2. Patient Information 34k reduced to 24k 3. Engagement 28k reduced to 23k 4. PALS/Complaints 29k reduced to 15k Budget reductions as follows; 1. Home Healthcare Drugs budget 1,607k reduced to 1,546k. Learning Disability funding for Occupational Therapist post at Oxleas. Not approved. Proposal was not approved as it did not form part of the current strategy and financial position. Implanon budget review 46k saving in CIPs identified and agreed. Dietetics Tendering approved. Budget reductions as follows; 1. Implanon budget 102k reduced to 56k based on review of 11/12 spend + 10% Interim solution agreed using Bromley Healthcare for 6 months at a cost of 65k until tendering completed. Kitemark budget approved for 2012/13 Budget approved for Kitemark at 900k for 2012/13. 7th June 2012 Mckinsey s Opportunities General Surgery Length of Stay An investigation into this opportunity identified that no savings were possible. All schemes were reviewed in line with agreed PMO processes as previously agreed by the BCCC. BCCC members are asked to endorse the PMO decisions. Attached at Appendix 1 is a list of the closed schemes which were discussed and approved at the PMO meeting on 7 th June

14 5. Recommendation BCCC members are asked to: NOTE the contents of this report and support the delivery of the QIPP agenda within Bexley. ENDORSE recommendations made by the Programme Management Office shown in table 8. 14

15 Appendix 1 Closed QIPP schemes PMO ref: Various Name of Proposal Closure of existing schemes now incorporated in new PMO schemes Proposer Fiona Moore Contact details Fiona@baileyandmoore.com Details of the scheme Brief details explaining the rationale for proposed closure of scheme, including steps taken to mitigate against closure. These are schemes, mainly started in 2011/12, which have been incorporated into schemes refreshed and reviewed for 2012/13. There is no financial impact as these have not been taken into account in the QIPP quantum to date. Is this scheme linked to, or included in, another work stream? What impact will closure have on these? PM013 Pathway redesign - Cardiology Now PM013 - Minor oral surgery Cluster scheme - now PM075 - First to Follow Up Reduction Now PM005 PM060 Reduction In OP Followups to Top Quartile Now PM005 PM024 PM029b Performance Primary Eyecare Assessment and Referral Service (PEARS) Treatment Access Policy -DVH - NOW PM042 Treatment Access Policy - SLHT - NOW PM042 Now PM076 - MB to review ophthalmology Combine providers as PM029 PM029 B&M to look at for 13/14 - work with BBG to agree PM028 NEL Admissions Avoidance - NOW PM050 B&M to look at for 13/14 - work with BBG to agree PM063 Externalisation of Diabetes Service CANX - not patient service - see PM069 PM044 GP blood test - INCLUDED AS PM009 Under review to see if any savings PM061 Repeat of PM012d Outline of cost and benefits of the scheme per the QIPP summary Costs detail (Specify whether recurrent or Non- Recurrent) 2012/ / /15 What did you think would be the cost? Savings detail (Specify whether recurrent or Non- 2012/ / /15 Recurrent) What did you think would be the savings? For assessment completed by PMO Is the scheme essential to meet strategic and financial objectives? Should further resources be used to support this scheme or deliver it another way? 15

16 Appendix 1 Closed QIPP schemes PMO ref: Various Name of Proposal Closure of schemes not agreed by PMO Proposer Fiona Moore Contact details Fiona@baileyandmoore.com Details of the scheme Brief details explaining the rationale for proposed closure of scheme, including steps taken to mitigate against closure. These are schemes presented to PMO but not confirmed as suitable for investment or inclusion as QIPP. There is no financial impact as these have not been taken into account in the QIPP quantum to date. Is this scheme linked to, or included in, another work stream? What impact will closure have on these? PM032 TB Not managed via PMO as PH transfers 13/14 PM034 PH - Imms & Vaccs Not managed via PMO as PH transfers 13/14 PM035 PH - Screening Not managed via PMO as PH transfers 13/14 PM036 Stop Smoking Not managed via PMO as PH transfers 13/14 PM038 Obesity Not managed via PMO as PH transfers 13/14 PM039 Sexual Health Not managed via PMO as PH transfers 13/14 PM040 Children & Young People Not managed via PMO as PH transfers 13/14 PM067 Imms & Vaccs PH post Not managed via PMO as PH transfers 13/14 PM068 PH Screening awareness project Not managed via PMO as PH transfers 13/14 PM082 LD OT for Oxleas NOT AGREED BY PMO 10/5/12 Outline of cost and benefits of the scheme per the QIPP summary Costs detail (Specify whether recurrent or Non-Recurrent) 2012/ / /15 What did you think would be the cost? Savings detail (Specify whether recurrent or 2012/ / /15 Non-Recurrent) What did you think would be the savings? For assessment completed by PMO Is the scheme essential to meet strategic and financial objectives? Should further resources be used to support this scheme or deliver it another way? PMO ref: Various Name of Proposal Schemes no longer taken forward Proposer Fiona Moore Contact details Fiona@baileyandmoore.com Details of the scheme Brief details explaining the rationale for proposed closure of scheme, including steps taken to mitigate against closure. 16

17 Appendix 1 Closed QIPP schemes These are schemes which will no longer be taken forward by QIPP lead/pmo, either because they have been reviewed and are not found to be feasible, relate to schemes delivered in 2011/12 or are being taken forward elsewhere. There is no financial impact as these have not been taken into account in the QIPP quantum to date. Is this scheme linked to, or included in, another work stream? What impact will closure have on these? - Unidentified QIPP 11/12 only PM030 Reduction In Short Stay Non-Elective Admissions From A&E Close for 12/13 as ltd by collar and cap - Prescribing in Primary Care 11/12 only PM070 Cancer - chemotherapy at home Cancer Network now taking this fwd PM031 Planned procedures not carried out B&M to look at for 13/14 - work with BBG to agree PM008 MFF Saving Budget adjustment PM018 Orthotics (FYE?) FYE of 11/12 contract reduction PM027 Palliative Care CLOSED - clinical lead taking over. Education for GPs PM033 Gynaecology CLOSED - never started scheme - Bexley is lowest referers in London Outline of cost and benefits of the scheme per the QIPP summary Costs detail (Specify whether recurrent or Non- Recurrent) 2012/ / /15 What did you think would be the cost? Savings detail (Specify whether recurrent or Non- 2012/ / /15 Recurrent) What did you think would be the savings? For assessment completed by PMO Is the scheme essential to meet strategic and financial objectives? Should further resources be used to support this scheme or deliver it another way? 17

NHS North Central London Commissioning Strategy and QIPP Plan 2012/ /15

NHS North Central London Commissioning Strategy and QIPP Plan 2012/13-2014/15 Joint Health Overview and Scrutiny Committee 9 th July 2012 Sylvia Kennedy AD Strategy & Planning www.ncl.nhs.uk Key messages