Finance Report, end of November 2015 (month eight)

Agenda item: 8.1a Subject: Presented by: Submitted to: Finance Report, end of November 2015 (month eight) Steve Ham, Chief Finance Officer Governing Body Date: 13 January 2015 Purpose of paper: For information and discussion Executive Summary: This report highlights the NHS South Norfolk Clinical Commissioning Group (CCG) financial position at the end of month eight, 2014/15. The CCG financial plan for 2014/15 reflects a requirement to deliver a 1% surplus ( 2.495m) in line with NHS England s planning framework. The year-to-date position as at month eight is a deficit of (0.354)m, 1.992m below plan. The financial underperformance is largely due to additional acute cost pressures, elective and nonelective activity, as well as increased costs of High Cost drugs and ambulance conveyances. Additional costs pressures exist in Continuing Healthcare, Prescribing and the costs arising from the Integrated Community Equipment Store (ICES). In total the CCG has 11m of recurrent cost pressures, of which 5m has been mitigated in year by planned contingency and uncommitted reserves. Of the balance, 0.5m has been mitigated by brought forward accruals and provision, resulting in a cost pressure of 5.5m. The CCG is putting in place recovery plans, to deliver the 1% surplus, as required by NHS England. Recommendation to Governing Body: The Governing Body is requested to: - Note the month eight reported year-to-date deficit and forecast end of year position; - Note the risks to delivery of the planned surplus of 2.495m for 2014/15; - Recommend further actions and priorities that could be undertaken to mitigate the risk of not achieving the planned financial surplus. 1

Key Risks Clinical: Finance and Performance: Impact Assessment (environmental and equalities): Reputation: Legal: Resource Required: Reference document(s): Programme budgets may need to be revised if funds unavailable. Delivery of financial balance is a statutory duty for the CCG; Not achieving the planned surplus will increase the 2015/15 QIPP requirement. N/A Reputational risk if the CCG fails to meet its 14/15 financial targets. N/A N/A Documents referred to in report GOVERNANCE Process/Committee approval with date(s) (as appropriate) N/A 2

1. Summary of 2014/15 Financial Performance 1.1 NHS South Norfolk Clinical Commissioning Group (CCG) is reporting a 354k deficit for the eight month period to 30 November 2014, 1,992k below plan of 1,638k. A detailed analysis of variances is shown in Appendix one, with a summary shown below. Month eight Financial Position Description Budget for year '000 Budget '000 Position for month 8 Actuals '000 Variance '000 Forecast Outturn '000 Allocation (251,017) (167,045) (167,045) - (251,017) Acute 127,969 84,700 89,062 4,363 130,715 Community Health Service 27,399 18,269 18,575 305 27,700 Continuing Care 18,613 12,804 12,838 34 19,563 Mental Health 20,339 13,559 13,896 336 20,806 Primary care 42,135 28,173 27,975 (198) 42,292 Other 2,861 1,989 1,976 (13) 2,773 Running Costs 5,610 3,746 3,078 (669) 4,674 Reserves 3,596 2,165 - (2,165) - CCG Total 2,495 1,638 (354) (1,992) 2,495 Note: (Negative) variance = underspend / Positive variance = overspend NHS England rules do not allow for CCGs to make unauthorised changes to their forecast outturn surplus and, instead, require risks to delivery to be reported prior to the commencement of a Finance Recovery Plan process, which is intended to recover the reported shortfall in delivery. 1.2 Changes to Allocation The CCG s funding allocation has been amended since the beginning of the year as follows: Type Rec/ NonRec Revenue Revenue Resource Resource Programme Admin 000 000 Description Month of transaction Non-Recurrent 241,426 Initial CCG Programme Allocation Mth01 Recurrent 5,610 Initial CCG Running Cost Allocation Mth01 Recurrent 2,348 Brought Forward surplus/(deficit) Mth01 Non-Recurrent 576 GPIT Allocation (Core) Mth03 Recurrent (33) Trsf Acute Military Budget to NHS England (re Swanton Morley) Mth04 Non-Recurrent 12 1415 Referal To Treatment Funding Mth05 Non-Recurrent 87 GPIT Transitional Allocation (Core) Mth05 Recurrent (178) 2014-15 CEOV and non-rechargeable services allocation adjustment Mth06 Recurrent (119) Intra-Norfolk CCGs Baseline Adjustment Mth06 Non-Recurrent (24) Intra-Norfolk CCGs Baseline Adjustment Mth06 Non-Recurrent 1,312 Winter resilience Funding Mth07 245,407 5,610 3

The surplus from 2013/14 has been allocated on a non-recurrent basis but the CCG does not have authority to spend this surplus in-year. There have been no changes to the allocation in month 8, which was unchanged by NHS England to allow for calculation of revised 2015/16 allocations. 1.3 Acute Expenditure 1.3.1 Norfolk and Norwich University Hospital Foundation Trust (NNUHFT) NNUHFT is overspent by 2,724 at month eight (calculated by extrapolating month seven actuals per contract monitoring). This is largely due to the contract not including anticipated 14/15 growth, net of the impact of QIPP schemes, plus additional activity beyond that anticipated by the CCG. The commentary below looks at the actual contract monitoring data for month seven. See Appendices two and four. A&E A&E is 102k overspent. This is due to activity, which has increased by 4.9% from 13/14. All areas of treatment are over plan, but with major and category two treatment increasing at a faster rate, 9.8% and 13% respectively. When compared to 13/14, self-referrals and those conveyed by ambulances remain the main pressure experiencing 9.5% increase and 7% increase, respectively. This is offset by a reduction in GP A&E referrals, down by 9.2%. Those being admitted from A&E has increased by 5.9%, with the conversion rate remaining constant, suggesting that the admission activity growth of 4.9% on 2013/14 is explained by more people accessing A&E. A&E continues to overperform consistently each month, which has had an impact on the percentage of patients seen within four hours, with no months since May meeting the 95% target. Non Elective Overall, Non-Electives is 408k overspent. Activity is over plan by 6%, equating to 625 admissions. This is offset by the marginal rate and readmissions credits, resulting in a 2.4% overspend. Short stay emergencies are experiencing the fastest growth, but with long stays causing the largest cost pressure ( 578k). The admission area with the largest growth is GP admissions, which are up 8%; 216 admissions equating to an extra 451k. Elective Overall elective activity is 363k overspent. Daycase procedures contribute 320k of this overspend (offset by Lucentis credit of 250k), while elective procedures are within plan and down 5.4% on 13/14. This increase is as result of a large activity growth, equating to 1314 additional procedures on 13/14; 1205 over plan (317 relate to Lucentis). Elective Gastroenterology is the area with the largest overspend, 224k above plan, with endoscopies driving the increase. Outpatients Overall outpatient activity is 339k overspent. This is across all areas of outpatients, with follow up attendances contributing 168k and outpatient procedures contributing 79k. This can be partially explained by the additional funding and focus to reduce waiting lists. Cost & Volume Overall Cost & Volume is 289k overspent. Critical Care contributes largely to this, being 140k above plan, an additional 110 days. 4

West Suffolk Hospital Foundation Trust (WSHFT) WSHFT has a year-to-date overspend of 225k at month eight (calculated by extrapolating month seven actuals per contract monitoring); see appendix three. The main areas of overspend include critical care ( 134k), Outpatient procedures ( 157k) and Electives ( 182k). Within Electives, ordinary admissions are 45 procedures over plan, equating to 172k; 106k of this is within trauma & orthopaedics. Non Elective admissions are 11% over plan, but taking into account a reduction in excess bed days (30.5%), marginal rate and readmission credits, Non Electives is 59k underspent. A&E has seen a swing from minor to major complexities, with minor reducing by 174 attendances on 13/14 and category 2 increasing by 171 attendances. This case mix change has driven a 23k increase in cost. 1.3 Community Health Services Included within Community Health Services is an overspend on the Integrated Commissioning Equipment Store (ICES) of 403k. In 2013/14, the CCG benefitted from a risk share arrangement with Norfolk County Council (NCC). In 2014/15 the CCG costs now reflect actual activity, which has risen significantly over the last two years largely due to demand for pressure-relieving beds and mattresses. Costs appear to have stabilised in the last three months. The CCG is working with other Norfolk CCGs and NCC to reduce this expenditure by reviewing the controls over how equipment is ordered and by employing a clinical advisor to advise on the equipment to be included within the provider s catalogue. The CCG has incurred additional 221k (stated after risk share) for the Neurological Rehabilitation which has been offset by reduced Intermediate Care costs. 1.4 Continuing Health Care (CHC) Continuing Healthcare is overspent by 34k at month 8, month 7 overspend was 445k, the reduction in overspend is due to the one off release of 2013/14 CHC provision of 395k. Within the prior month, the CHC backlog conversion rate estimate reduced from 55% to 45%, although the number of referrals for a CHC assessment have increased significantly, many from adult social services who have cleared a backlog of social care assessments in the first half of the year. As well as a reduced conversion ratio, the CCG is experiencing a reduction in average price due to the increased referrals largely for Physical Disability, packages of care for which tend to be lower cost than for, say, Learning Disabilities. Staff shortages in the North and East London CSU CHC team have resulted in an increase in the backlog number of South Norfolk CCG referrals requiring an eligibility decision and this backlog represents a significant risk to estimating the 2014/15 expenditure. 1.5 Mental Health Month eight shows a net overspend of 336k across a number of contracts. There are overspends on Child and Adolescent Mental Health and Learning Difficulties, 170k and 116k respectively, relating to the costs of individual packages. The CSU have been reviewing these packages of care to ensure adequate accruals and Forecast Outturns are included for 1415. Other mental health expenditure is largely contracted via a block contract, which means that there is little, or no, variation in price. 5

1.6 Primary Care Primary care overall is 198k underspent in month eight. Local Enhanced Services is showing an underspent of 766k due to the later than anticipated implementation of schemes focussing on the care of over 75s by Primary and Community care. Prescribing costs of 24,009k are 582k overspent largely due to a 121k shortfall in QIPP delivery, together with an increase in Cat M funded drugs. In part this increase relates to the seasonal uptake in flu vaccine and it is not anticipated that this level of overspend will continue to the end of the year. 1.7 Risk Share Norfolk CCGs have agreed to share the financial cost of neurological rehabilitation and critical care. As at month 8, the CCG has received a credit of 675k from the other three Norfolk CCGs. 1.8 Running Costs The 669k underspend on running costs is largely due to slippage on pay costs as the CCG recruits to its full establishment. There is also an underspend on the CSU SLA, largely due to the delayed implementation of the new DSCRO arrangements to deal with patient identifiable data. A new contract with North and East London CSU (NELCSU) is to be agreed with effect from 1 October 2014, which will contribute to the CCG s requirement to reduce its running cost expenditure from 2015/16 as the split between programme and running costs is agreed. 1.9 Reserves At the end of month eight 2014/15, the CCG has 3,596K of budgeted reserves, which have been used to support the CCG s bottom-line. In addition the planned contingency of 1,247k is also mitigating recurrent cost pressures. The CCG has no uncommitted reserves, funding commitments for unspent system resilience and marginal rate credit schemes have been allocated to the appropriate programme budget line. 2. Underlying Surplus The CCG s underlying surplus is the forecast surplus adjusted for known non-recurrent costs and income, as well as for the full year effect of QIPP schemes implemented in year. The CCG s forecast underlying surplus, at the end of month 8, is 2m (0.82% of programme allocation). This assumes that the risks to delivery of the planned surplus do not materialise or are mitigated. This figure highlights the importance of delivery of the remaining QIPP target and of acute and CHC activity pressures being mitigated before the end of 2014/15. 3. 2014/15 QIPP (Quality Innovation Productivity and Prevention) The CCG s Financial Plan for 2014/15 anticipates delivery of 9,518k of QIPP savings, including 820k of recurrent savings from 13/14 QIPP schemes. The current development of QIPP schemes is highlighted in Appendix five. The value of unidentified QIPP required to meet the annual target, forecast at the end of month eight, was 2,781k a small improvement on the 2,996k identified at month seven (Appendix 5). The CCG s focus has now turned to the preparation and delivery of a financial recovery plan, the schemes in which will largely have a non-recurrent impact. The forecast outturn from the existing QIPP schemes will now be monitored and reviewed in line with the year-to-date delivery. The QIPP scheme with most risk, to achieving the forecast outturn, is the CCG s prescribing incentive scheme and this will be monitored closely. 6

At the end of month seven the CCG is reporting QIPP achievement of 4,293k against a YTD plan of 5,349k. 4. Risks and Mitigations There are some significant financial risks faced by the CCG. The table below shows the key risks in 2014/15 and the available mitigations. NHS England s procedures regarding the authorisation of any change to the Forecast Outturn, require CCGs to first quantify the net risk. From month 7 to month 8 the recognised risks reduced from 6.81m to 6.01m ( 5.51m net of the estimated incremental cost of preparing and delivering the financial recovery plan). The reduction was due to a revised assessment of the Forecast Outturn ( 0.9m), undertaken with the support of North and East London CSU, together with the impact of the CHC provision reversal ( 0.4m) following a revision to the calculation of refunds due to patients who have self-funded healthcare whilst waiting for CHC eligibility to be confirmed and packages of care put in place. Whilst the CCG s gross risks total 6.0m, it anticipates delivering an additional 4.12m as part of the Financial Recovery Plan process resulting in a net risk of 1.9m, which if crystallised and unmitigated would result in the CCG delivering a surplus of 0.6m. Risks & Opportunities Risks CCGs Potential Risk Value Mth07 Full Risk Value m Probability of risk being realised % Potential Risk Value m Acute SLAs 2.55 2.00 76.40% 1.53 Acute and Ambulance overperformance (including High Cost Drugs) Community SLAs 0.05 0.20 25.00% 0.05 Community Equipment costs Continuing Care SLAs 0.50 0.73 70.00% 0.51 QIPP Under-Delivery 3.32 3.88 85.52% 3.32 Running Costs 0.00 0.50 100.00% 0.50 Consultancy and capacity to implement FRP Other Risks 0.10 1.40 7.14% 0.10 TOTAL RISKS 6.81 8.71 6.01 Mitigations Uncommitted Funds (Excl 2% Headroom) Expected Mitigation Value Mth07 Full Mitigation Value m Please enter the probability of success of mitigating action Probability of success Expected of Mitigation Commentary mitigating Value action m % Investments Uncommitted 0.02 0.07 30.00% 0.02 Slippage on Uncommitted Over75s monies (Breckland) Uncommitted Funds Sub-Total 0.02 0.07 0.02 Actions to Implement Further QIPP Extensions 3.32 3.30 100.00% 3.30 Financial Recovery Interventions (no contingency) Non-Recurrent Measures 0.00 0.80 100.00% 0.80 Balance sheet flexibilities and provision valuation Mitigations relying on potential funding 0.00 0.00 0.00 Actions to Implement Sub-Total 3.32 4.10 4.10 TOTAL MITIGATION 3.34 4.17 4.12 NET RISK / HEADROOM (3.46) (1.89) Commentary Impact of increased referrals to CHC Unidentified QIPP at mth 7 + identified risks re Non-Recurrent savings and Prescribing Savings NHS Property Service costs arising from NHS Organisation exiting estate due to no leases plus risk of overspend on system resilience. 7

5. Balance Sheet Statement of financial position as at 30 November 2014 NHS SOUTH NORFOLK CCG STATEMENT OF FINANCIAL POSITION AS AT 30 NOVEMBER 2014 Position as at 30/11/14 Position as at 31/10/14 Position as at 31/03/14 Description '000 '000 '000 Comments Total non-current assets Trade and Other Receivables 3,785 3,291 2,602 Cash and Cash Equivalents 2,467 4,615 1,752 Cash increasing in year Total current assets 6,252 7,906 4,354 Trade and Other Payables (24,027) (23,281) (17,492) Provisions for liabilities and charges (688) (1,083) (1,140) CHC provision balance Total current liabilities (24,715) (24,364) (18,632) Non-current assets plus/less net current assets/liabilities (18,463) (16,458) (14,278) Non-current liabilities (846) (846) (846) Norfolk & Suffolk R&D (over 1 year) Total assets employed (19,309) (17,304) (15,124) FINANCED BY TAXPAYERS EQUITY General fund (19,309) (17,304) (15,124) Negative as liabilities exceed assets Total taxpayers equity (19,309) (17,304) (15,124) Current assets are largely unchanged from the previous month but are higher than those reported at 31 st March 2014 due to higher cash balances being held in anticipation of settling trade and other payables which have increased during the year as there are a number of invoices submitted by providers, particularly Norfolk County Council, that are being queried. Often the value of the query is a small percentage of the value of the invoice. CCGs are expected to hold minimal cash balances at each month end and the CCG is working with North and East London CSU to settle unpaid invoices and reduce its cash holding, as can be seen above. NHS England has recently introduced a concept of notional penalties for holding excess cash balances and for recording variances to the weekly cash usage. Additionally, CCGs are required to manage their cash so that balances of no more than 1.25% of the monthly drawdown, equating to approximately 200k, are held at each month end. If the penalties were to be applied they would be expected to total no more than a few hundred pounds. The CCG also holds approximately 1.6m of cash on behalf of third parties funding the activities of the Norfolk and Suffolk Primary and Community Care Research Office. Approval to funds has been given by NHS England to hold these funds in addition to the 1.25% cash balance. 8

6. Better Payment Practice Code The table below shows how NHS South Norfolk CCG is performing against the Better Payment Practice Code for April to November. Measures of compliance Apr 14 - Nov 14 Apr 14 - Nov 14 Non-NHS Payables Number 000 Total Non-NHS trade invoices paid in the year 5,331 29,230 Total Non-NHS trade invoices paid within target 4,993 28,762 Percentage of Non-NHS trade invoices paid within target 93.66% 98.40% Apr 14 - Nov 14 Apr 14 - Nov 14 NHS Payables Number 000 Total NHS trade invoices paid in the year 1,655 115,147 Total NHS trade invoices paid within target 1,603 115,019 Percentage of NHS trade invoices paid within target 96.86% 99.89% The CCG is meeting its requirement to pay eligible invoices within 30 days. 7. 2015/16 Planning Details In December 2013 the NHS England Board agreed two year Allocations for 2014/15 and 2015/16 (indicative only), with the funding formula being adjusted to reflect unmet need and inequalities. The Autumn Statement on 3 December 2014 confirmed 1.98bn of additional funding for the NHS in England. Of this funding 1.5bn is to cover funding pressures on front-line services. 1.1bn of additional funding has been added to the CCG Allocations, including 350m of Seasonal Resilience funding. CCG s with an allocation below the target level of funding have received proportionately more of the additional funding. South Norfolk CCG has received an additional 4.678m of programme funding, including 1.312m of winter resilience funding. With this additional funding the CCG s allocation for 2015/16 is 3.7% higher than in 2014/15, of which 0.5% represents winter resilience funding. This additional funding will be required to meet additional cost pressures arising as a result of updated business rules for 2015/16 but will, in part, be available to mitigate the CCG s recurrent cost pressures. 8. Conclusion NHS England has requested the completion of a Financial Recovery Plan, returning the CCG s forecast outturn to deliver the planned 1% surplus of 2.495m. The development of the CCG s Plan was due to be discussed with NHS England on 8 th January 2015. The CCG has engaged Deloitte LLP to assist in the development of the Plan. Steve Ham Chief Finance Officer 13 January 2015 9

NHS South Norfolk CCG - Month 8 Financial Report Appendix 1 10

NNUHFT - Contract Monitoring Appendix 2 Activity Finance 000's NNUHFT Contract Monitoring Variance Variance YTD: April - October Plan Actual Variance Plan Actual Variance % % National Traiff Payment System 43,005 44,217 1,212 2.8% A&E 18,499 19,427 928 5.0% 1,882 1,985 102 5.4% Elective 16,035 17,214 1,179 7.4% 13,365 13,728 363 2.7% Daycase 13,647 14,825 1,178 8.6% 7,285 7,785 500 6.9% Elective Ordinary 2,389 2,389 0 0.0% 6,081 5,943 (137) (2.3%) Non-Elective 10,390 11,015 625 6.0% 16,992 17,400 408 2.4% Emergency 8,945 9,508 563 6.3% 16,897 17,818 921 5.5% Other Non-Electives 1,445 1,507 62 4.3% 2,455 2,553 97 4.0% Credits & Readmissions (2,361) (2,971) (610) 25.8% Outpatient 103,121 105,316 2,195 2.1% 10,766 11,104 339 3.1% Attendances 81,566 84,411 2,845 3.5% 7,938 8,212 275 3.5% Procedures 16,417 16,391 (26) (0.2%) 2,708 2,787 79 2.9% Telephone 5,138 4,514 (624) (12.1%) 120 105 (15) (12.1%) Other Charges 8,872 9,216 344 3.9% Cost & Volume 39,949 40,873 924 2.3% 5,856 6,146 289 4.9% Critical Care 869 979 110 12.6% 889 1,029 140 15.8% Maternity pathway 2,373 2,347 (26) (1.1%) 1,968 1,957 (10) (0.5%) Outpatient Radiology 9,787 10,244 457 4.7% 1,031 1,058 27 2.6% Direct Access Radiology 18,793 18,439 (354) (1.9%) 941 939 (1) (0.2%) Other 8,126 8,864 738 9.1% 1,027 1,162 134 13.1% Block 418 418 - - CQUIN 1,265 1,303 38 3.0% Other 1,332 1,349 17 1.3% Month 7 Contract Monitoring Total 51,877 53,434 1,557 3.0% Month 8 CCG Adjustments 5,787 6,954 1,167 20.2% Month 8 plan / accrual 7,200 7,461 261 3.6% YTD RTT Credit 0 (533) (533) Non contract charges - Overseas visitors 95 95 - - Maternity pathways prepayments 0 (69) (69) YTD QIPP budget (1,508) 0 1,508 (100.0%) Financial Position Reported at Month 8 57,664 60,388 2,724 4.7% Note: positive variance = overspend / (negative) variance = underspend 11

WSHFT - Contract Monitoring Appendix 3 WSHFT Contract Monitoring YTD: April - October Plan Actual Variance Variance % Plan Actual Variance Variance % National Traiff Payment System 6,146 6,376 230 3.7% A&E 3,797 3,816 19 0.5% 386 410 24 6.3% Elective 1,244 1,324 80 6.5% 1,503 1,686 182 12.1% Daycase 1,049 1,084 35 3.3% 919 917 (2) (0.2%) Elective Ordinary 195 240 45 23.3% 584 769 184 31.6% Non-Elective 1,627 1,790 163 10.0% 2,839 2,780 (59) (2.1%) Emergency 1,332 1,479 147 11.0% 2,527 2,855 328 13.0% Other Non-Electives 294 311 17 5.6% 520 522 2 0.5% Credits & Readmissions (208) (597) (390) 187.6% Outpatient 13,455 13,088 (367) (2.7%) 1,418 1,500 82 5.8% Attendances 3,073 3,121 48 1.6% 958 886 (72) (7.5%) Procedures 3,102 3,527 425 13.7% 438 595 157 35.8% Telephone 1,162 903 (259) (22.3%) 22 19 (3) (13.3%) Other Charges 1,328 1,478 150 11.3% Cost & Volume 1,382 1,445 63 4.6% 825 916 91 11.0% Critical Care 103 236 133 129.8% Maternity pathway 424 394 (30) (7.2%) Outpatient Radiology 143 131 (12) (8.2%) Direct Access Radiology 554 729 175 31.7% 33 42 9 26.3% Other 828 716 (112) (13.6%) 122 113 (9) (7.5%) Block 30 30 - - CQUIN 181 181 - - Other 292 351 59 20.2% Month 7 Contract Monitoring Total 7,474 7,854 380 5.1% Excluded Drugs Reduction (219) (297) (77) 35.3% Month 7 Contract Monitoring Total (excluding drugs) 7,255 7,557 302 4.2% Month 8 CCG Adjustments 1,015 938 (77) (7.6%) Month 8 plan / accrual 1,015 1,078 63 6.2% Maternity pathways prepayments 0 (140) (140) Other adjustments 0 (0) (0) Financial Position Reported at Month 8 8,270 8,495 225 2.7% Note: positive variance = overspend / (negative) variance = underspend Activity Finance 000's Activity Trends - Specialty Groups Appendix 4a NNUHFT & WSHFT Specialty Groups Activity Finance 000's Finance Trend YTD: April - October 13/14 14/15 Variance Variance % 13/14 14/15 Variance Variance % (most recent 12 months) Accident & Emergency Attendances 22,294 23,408 1,114 5.0% 2,291 2,405 114 5.0% A&E 22,294 23,408 1,114 5.0% 2,291 2,405 114 5.0% Elective Admissions 17,460 18,721 1,261 7.2% 15,369 15,730 361 2.4% Surgical 7,503 7,869 366 4.9% 10,083 9,755 (329) (3.3%) Medical 6,990 7,593 603 8.6% 4,803 5,297 494 10.3% Radiology 2,922 3,185 263 9.0% 422 564 142 33.7% Other Childrens 45 74 29 64.4% 61 115 54 88.8% Non-Elective Admissions 12,098 12,660 562 4.6% 22,545 23,490 945 4.2% Medical 8,922 8,948 26 0.3% 16,023 16,175 153 1.0% Surgical 2,914 3,435 521 17.9% 5,924 6,671 747 12.6% Radiology 237 264 27 11.4% 551 622 72 13.0% Other Childrens 25 12 (13) (52.0%) 48 18 (30) (63.0%) Outpatient Attendances & Procedures 106,334 118,552 12,218 11.5% 11,658 12,557 899 7.7% Medical 46,918 49,964 3,046 6.5% 5,603 5,987 384 6.9% Surgical 55,116 55,338 222 0.4% 5,689 5,737 48 0.8% Pathology 2,936 2,510 (426) (14.5%) 258 201 (56) (21.8%) Therapies 20 7,768 7,748 38740.0% 3 378 376 14671.7% Other Childrens 1,216 1,269 53 4.4% 90 94 3 3.7% Radiology 33 1,605 1,572 4763.6% 3 147 144 4791.2% Grand Total 158,186 173,341 15,155 9.6% 51,863 54,183 2,320 4.5% Note: due to yearly coding changes variances may appear large within specialty 12

Activity Trends - Specialities with spend greater than 100K Appendix 4b NNUHFT & WSHFT Specialties over 100k YTD YTD: April - October Activity Finance 000's 13/14 14/15 Variance Variance % 13/14 14/15 Variance Variance % Accident & Emergency Attendances 22,294 23,408 1,114 5.0% 2,291 2,405 114 5.0% A&E 22,294 23,408 1,114 5.0% 2,291 2,405 114 5.0% Elective Admissions 17,460 18,721 1,261 7.2% 15,369 15,730 361 2.4% TRAUMA & ORTHOPAEDICS 1,068 972 (96) (9.0%) 3,386 3,048 (338) (10.0%) GENERAL SURGERY 1,218 1,219 1 0.1% 2,301 2,289 (12) (0.5%) OPHTHALMOLOGY 2,449 2,843 394 16.1% 1,496 1,639 143 9.6% GASTROENTEROLOGY 2,777 3,084 307 11.1% 1,436 1,596 159 11.1% UROLOGY 1,007 1,168 161 16.0% 1,016 1,136 120 11.9% GYNAECOLOGY 865 642 (223) (25.8%) 1,021 930 (90) (8.8%) CARDIOLOGY 387 453 66 17.1% 722 864 143 19.8% PLASTIC SURGERY 620 647 27 4.4% 801 680 (122) (15.2%) ENT 518 501 (17) (3.3%) 616 573 (43) (7.0%) CLINICAL ONCOLOGY (previously RADIOTHERAPY) 2,910 3,162 252 8.7% 412 536 124 30.0% DERMATOLOGY 584 703 119 20.4% 372 447 75 20.1% RHEUMATOLOGY 511 644 133 26.0% 354 455 102 28.7% CLINICAL HAEMATOLOGY 1,034 1,234 200 19.3% 326 397 71 21.8% PAIN MANAGEMENT 454 436 (18) (4.0%) 317 286 (32) (10.0%) RESPIRATORY MEDICINE 167 159 (8) (4.8%) 158 170 12 7.6% NEUROLOGY 231 209 (22) (9.5%) 132 122 (10) (7.8%) Non-Elective Admissions 12,098 12,660 562 4.6% 22,545 23,490 945 4.2% GERIATRIC MEDICINE 1,977 1,951 (26) (1.3%) 5,208 5,238 30 0.6% GENERAL SURGERY 1,156 1,329 173 15.0% 2,262 2,599 336 14.9% TRAUMA & ORTHOPAEDICS 722 736 14 1.9% 2,377 2,321 (56) (2.4%) OBSTETRICS 1,014 1,054 40 3.9% 1,878 2,000 122 6.5% GENERAL MEDICINE 1,469 1,479 10 0.7% 1,478 1,438 (40) (2.7%) RESPIRATORY MEDICINE 594 605 11 1.9% 1,409 1,411 1 0.1% GASTROENTEROLOGY 429 403 (26) (6.1%) 1,118 1,029 (90) (8.0%) CARDIOLOGY 492 359 (133) (27.0%) 1,012 808 (205) (20.2%) PAEDIATRICS 1,006 1,042 36 3.6% 785 795 11 1.4% UROLOGY 432 526 94 21.8% 539 734 195 36.1% CLINICAL ONCOLOGY (previously RADIOTHERAPY) 237 264 27 11.4% 551 622 72 13.0% NEPHROLOGY 201 255 54 26.9% 565 689 125 22.1% MIDWIFE EPISODE 418 371 (47) (11.2%) 672 610 (62) (9.2%) ENDOCRINOLOGY 240 289 49 20.4% 459 694 235 51.1% NEUROLOGY 256 237 (19) (7.4%) 394 337 (56) (14.3%) PLASTIC SURGERY 160 274 114 71.3% 242 453 211 87.2% GYNAECOLOGY 365 375 10 2.7% 297 298 1 0.3% NEONATOLOGY 254 306 52 20.5% 251 277 27 10.6% CLINICAL HAEMATOLOGY 98 97 (1) (1.0%) 215 223 8 3.9% ENT 134 227 93 69.4% 150 262 111 74.1% CRITICAL CARE MEDICINE 47 61 14 29.8% 173 200 27 15.7% PAEDIATRIC SURGERY 221 182 (39) (17.6%) 220 162 (58) (26.4%) ACCIDENT & EMERGENCY 55 142 87 158.2% 60 105 45 74.5% Outpatient Attendances & Procedures 106,334 118,552 12,218 11.5% 11,658 12,557 899 7.7% OPHTHALMOLOGY 18,427 17,543 (884) (4.8%) 1,718 1,563 (155) (9.0%) UROLOGY 6,314 6,763 449 7.1% 1,025 1,142 117 11.4% TRAUMA & ORTHOPAEDICS 10,797 11,018 221 2.0% 981 1,031 51 5.2% GENERAL SURGERY 8,796 8,682 (114) (1.3%) 820 811 (9) (1.1%) CARDIOLOGY 5,553 5,982 429 7.7% 656 651 (5) (0.8%) DERMATOLOGY 6,742 7,431 689 10.2% 597 695 97 16.3% GYNAECOLOGY 4,255 5,155 900 21.2% 547 662 115 21.0% ENT 5,146 5,546 400 7.8% 534 569 35 6.6% DIABETIC MEDICINE 4,345 4,522 177 4.1% 442 438 (4) (0.8%) CLINICAL HAEMATOLOGY 3,950 3,792 (158) (4.0%) 443 439 (4) (0.9%) RHEUMATOLOGY 3,418 3,411 (7) (0.2%) 435 422 (13) (3.0%) NEUROLOGY 2,011 2,376 365 18.2% 341 396 55 16.1% RESPIRATORY MEDICINE 3,370 3,448 78 2.3% 352 357 5 1.5% GASTROENTEROLOGY 2,944 2,762 (182) (6.2%) 345 343 (3) (0.7%) PLASTIC SURGERY 2,950 3,049 99 3.4% 289 296 6 2.2% AUDIOLOGY 2,936 2,477 (459) (15.6%) 258 199 (59) (22.8%) PAEDIATRICS 1,303 1,417 114 8.7% 206 220 15 7.1% PAIN MANAGEMENT 1,786 1,852 66 3.7% 208 211 2 1.2% NEPHROLOGY 1,380 1,406 26 1.9% 190 196 5 2.8% GERIATRIC MEDICINE 840 875 35 4.2% 186 191 5 2.9% PALLIATIVE MEDICINE 951 1,160 209 22.0% 161 190 29 17.9% CLINICAL NEUROPHYSIOLOGY 674 660 (14) (2.1%) 137 132 (6) (4.1%) ENDOCRINOLOGY 1,015 1,182 167 16.5% 123 141 19 15.1% HEPATOLOGY 833 1,143 310 37.2% 101 139 37 37.0% PHYSIOTHERAPY 0 3,787 3,787 0 163 163 DIAGNOSTIC IMAGING 31 1,580 1,549 4996.8% 3 143 140 4908.4% OCCUPATIONAL THERAPY 0 2,580 2,580 0 122 122 Grand Total 158,186 173,341 15,155 9.6% 51,863 54,183 2,320 4.5% Note: due to yearly coding changes variances may appear large within specialty Finance Trend (most recent 12 months) 13

NHS South Norfolk CCG 2014/15 QIPP Appendix 5 Transactional / Transformational SERVICE Project Process RAG Savings RAG YTD Plan YTD Actuals FY Plan FOT QIPP Risk Adjusted FOT Transactional Acute services Pathology Re-procurement A R 413 213 619 319 319 Return on Primary Care Investment >75s A R 191-574 50 - AMD and Other Eye Conditions G R 367 287 550 430 430 Falls A R 320 117 480 175 165 Contract Levers and Compliance A R 233 122 350 182 182 Lower Limb A G 163 163 245 245 245 Clinical Academic Reserve (NR) G G 60 60 181 181 181 Other QIPP Plans < 100K A G 55 22 159 239 39 Other QIPP Plans < 100K A R 202 43 505 64 64 Other QIPP Plans < 100K G A 7 6 10 9 9 Other QIPP Plans < 100K G G 99 204 149 341 273 Other QIPP Plans < 100K R R 120-207 - - WSH A R 95-142 - - Long Term Conditions Review R G 42 115 125 172 172 Upper Limb A G 77 77 116 116 116 Data Challenges R G - 197-296 257 Community Health Services Contract Negotiation G G 223 223 334 334 334 Patient Transport G G 54 54 163 163 163 Intermediate Care Beds A G 83 83 150 150 150 Other QIPP Plans < 100K G G 47 47 71 71 71 Continuing Care Services Continuing Health Care A R 417 112 750 250 250 Continuing Health Care (13/14 - FYE) G G 377 377 565 565 565 Mental Health Services Contract Negotiation G G 173 173 260 260 260 Other QIPP Plans < 100K G G 18 18 27 27 27 Primary Care services Prescribing for Quality and Safety A A 833 786 1,250 1,179 1,179 Prescribing for Quality and Safety (13/14 - FYE) G G 142 142 213 213 213 Running Costs Running Costs (NR) G G 61 628 92 668 536 Transformational Acute services Reablement G R - - 180 - - End of Life G R - - 100 - - Other QIPP Plans < 100K A R - 24 95 36 36 Unidentified Unidentified Unidentified QIPP G 476-856 2,781 - Grand Total 5,349 4,293 9,518 9,518 6,238 Mitigation: Deferred Primary Care Investment > 75s 670 862 862 Unidentified QIPP after Mitigation: 1,920 7,100 14