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Finance Report

Month 3 2012-13

Ealing CCG Finance and Performance

Committee

QIPP

Progress Update

30th August 2013

Kathryn Magson, Chief Operating Officer, Ealing CCG

Peter Buckman, Deputy Chief Finance Officer, Ealing CCG

Charles Wheatcroft, QIPP Programme Director, Ealing CCG

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• Month 2 initial deliverability assessments highlighted a shortfall in savings

achievement of £6.5m.

• Formal month 3 and month 4 assessment of the deliverability of Ealing QIPP

schemes showed improved forecast to a shortfall of £2.9m

• The CCG continues to strengthen the rigor around its QIPP governance

process. In particular the weekly PMO meeting in August have taken a

milestone by milestone approach to test whether the QIPP are on track, or at

risk.

• Overall, the CCG is maintaining the month 4 forecast of £2.9m.

• Risks remain as:

−Identifying schemes and resources to close the remaining £2.9M.

−Project Manager Capacity, though now being addressed through

recruitment.

−QIPP specific risks in ICE, Prescribing, CVD, Pulmonary Rehab and

Paediatrics

−Constraints in the expansion of capacity in primary care and in the

development of GP networks

−Further engagement with member practices to promote delivery of existing

schemes

QIPP: Position summary

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QIPP current performance (M4)

The current reported QIPP forecast reflected in the month 4 financial returns and

reviewed by Finance and Performance Committee

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Remedial actions taken in previous month to

improve QIPP performance against target

• Planned a complete reorganisation of the CDM team complete with matrix

programme management. This has been announced and implemented.

See slides 5 & 6.

• Recruited a new CDM for Mental Health and have commenced

recruitment for a new CDM for End of Life Care, Diabetes and Falls.

• Commenced recruitment of three Network Relationship Managers to help

build capacity in the networks and help the networks to deliver.

• Completed the first iteration of the QIPP output based report which

measures actual attainment against the QIPP objectives based on SUS

data. Commenced work on the practice level version of this report.

• Continued the regular weekly PMO meeting, and conducted Executive

“deep dives” in Mental Health.

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Imperative One:

Supporting Network Development

Supporting the development of networks across Ealing Borough.

Supporting the implementation of CCG out of Hospital strategy

Bringing the CCG QIPP programme to life in a language that makes sense for practices.

Visibility amongst our member practices and building stronger relationships.

CDM TEAM DEVELOPMENT

Imperative Two: Programme Management

QIPP Programme Director to be appointed (interim appointment) until March 2014

New Initial appraisal and business case preparation

Managing the delivery of QIPP and CCG projects and delivery of CCG Plans and assurance responsibilities

Track the CCG performance of QIPP and monitoring progress.

Project planning and reporting

Manage the programme management office (PMO) and interface with the Federation PMO team

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Ealing CCG

A Matrix Management Organisation Date 15th August 2013

COO

Programme Director

Business Mgr (8c)

Business Office Mgr (5)

Information Analyst (CSU)

Execs Business Office

Mgr

Des. Nurse – Safeguarding

Children

Deputy COO

Localities Mgr

CDM Women & Child (8b)

CDM Planned Care (8b)

CDM Urgent Care (8b)

CDM Mental Health (8b)

CDM Diabetes, Falls, EOL (8b)

Network Relationship

Mgr (7)

Network Relationship

Mgr (7)

Network Relationship

Mgr (7)

Head of Medicines

Management

RFS Team

Med Mgmt team

Integrated Commissioner

– Adults

Integrated Commissioner

- Children

Office Admin (4)

Office Admin (4)

Office Admin (4)

Receptionist (3)

Programme

Office

Deputy CFO

Head of Continuing

Care

Mgr PPE

Ldr External Comms

Secondee: ICP Secondee:

RFS

GP Network 1 GP Network 2 GP Network 3 GP Network 4 GP Network 7 GP Network 6 GP Network 5

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QIPP Schemes by Stages of Development

PROJECT LIFECYCLE ANALYSIS STATUS Bubble sizes gives forecast QIPP saving, other than schemes in 'Idea' and 'Appraisal' stages

EOLC Pathway

Paeds Community Nursing, £0.3m

Active Case Mgmt - Nursing Homes, £1.0m

Paediatric Phlebotomy, £0.1m

Remote follow up of Secondary Patients

Closure of 12 Jubilee ward beds in WLMHT , £0.2m

Prescribing, £3.3m

Productive CommunityServices

Gastro

Productive Community Services, £0.7m

Gynaecology, £0.1m

Continuing Care - Mental Health

Shifting Settings of Care - Mental Health, £0.8m

Community Ophthalmology

Paediatric Oral Health

CVD Anticaogualtion, £0.2m

Dermatology Pathway Redesign

MSK Pathway Redesign

Diagnostics - Radiology and Pathology, £0.1m

MSK Pathway Redesign, £0.5m

Pulmonary Rehab, £0.4m

Cardiology redesign

Ealing Falls Service

ICP: IntegratedCare Programme, £0.1m

Urgent and Unscheduled Care Pathway

Intermediate Care Service(ICE), £0.8m

Mental Health -Continuing Care, £0.5m

NCA Validations, £0.1m

Referral Facilitation Service, £0.1m

Continuing care, £0.9m

0

100

200

300

400

500

600

700

800

900

1000

1100

1200

1300

1400

1500

1600

1700

1800

1900

2000

Idea Appraisal & Develpmt Design Delivery Live Benefits

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QIPP: Schemes; YTD & Forecast Delivery

Scheme Name Target

M4+

forecast

saving

M4+

Mitigations

M4+

Variances

(+/-)

Commentary

Intermediate Care Service (ICE) £2,876 -£639 -£1,920 £317

The performance managemeent of EHT ICO to improve the levels of referrals into ICE (and thus avoided admissions) is in progress. The trust have

put forward a trajectory which offer a major improvement through the year. Referrals in june increased to 176 from 143 &142 in April and May.

Saving is based on one admission avoided for every 3 ICE referrals.

Productive Community Services £1,125 -£736 £0 £389 The contract negotiations with EHT ICP over the productive community services has been concluded in August.

Closure of Jubilee beds £0 -£201 £0 -£201 Agreed as part of WLMHT contract discussions

Shifting Settings of Care (Mental

Health)£1,000 -£799 £0 £201

The plans to move the stable patients into primary care are progressing, with the first group of approx 180 by October.

GP Service for Nursing Homes £1,505 -£991 -£394 £120Additional mitigation identified due to lower provision costs as a result of delayed implementation. The registration of nursing home residents in

progressing.

Referral Facilitation Service (RFS) £279 £0 £0 £279

The SUS analysis to estimate the actual saving from RFS has been concluded, and presented to Execs. The scheme is estimated to be saving

approximately £1m per year. The next development is to enforce an agreement in the EHT contract that the Trust not accept direct referrals, but

divert them to RFS.

Paediatric Community Nursing £1,347 -£345 £0 £1,002CCG and EHT clinicians have determined that the Non-elective admissions avoidance element (£92k) cannot be safely delivered. The CCG is now

working on a mityigation and alternative, which inncluded the non funding of £100k pa for specialist community nursing.

Paediatric Phlebotomy ( part of

paedtirc community QIPP)£0 -£95 £0 -£95

On track

Pulmonary rehabilitation £389 -£396 £0 -£7 PR service is up and running, and being promoted to GPs. Analysis of GPs who are not referring has been done, and they are now being targetted.

Anticoagulation Schemes £309 -£184 £0 £125Working with EHT to ensure that number of agreed discharges from EHT to community crystallise, with little scope to increase this. CCG working

GPs to encourage moving patients into primary care - a combination of Acute "push" and primary care "pull".

MSK Pathway £1,771 -£469 -£386 £916Only half year effect now likely due to delays start from April/May to October; some mitigation of reduced reproving costs. Waiting list initiative being

run prior to scheme start and this is on track. Expected that service will commence in October as per plan.

Diabetes £494 -£668 £0 -£174 Augmentation of existing scheme.

Prescribing £3,269 -£3,269 £0 £0A suite of prescribing reports will be delivered in September which will enable detail by drug, by practice and other complex analysis. This is a key

deliverable, and will give the medecines management team a capability to target savings they have not had before.

ICP £138 -£138 £0 £0 Progressing. There is evidence that savings are greater than presently forecast. Data over more months is needed to corroborate

Redesign of EOLC Pathway £574 £0 £0 £574Scheme needs redesign - new pathways required e.g. heart failure, COPD, Requires strong ICO & GP engagement. A new EOL CDM is being

recruited.

Diagnostics – radiology and

pathlology£204 -£100 £0 £104

The QIPP is focussed on negotiating rebates against the TDL contract. To date a rabate of £67k have been achieved, and a futher £65k is presently

being targetted. There is further opportunity for rebates applicable to later in 2013-14.

NCA Validations £75 -£75 £0 £0 Achievement of NCA saving depends upon the CSU addressing major delivery problems. These have been escalated.

Continuing Care £900 -£900 £0 £0 The work necessary to achieve these saving is in place.

Prescribing Stretch £0 -£50 -£50the CCG has decided not to fund additional staff in the medecines management team, but instead is focussed on the focused targetting sttatgety

enable by the new reporting system.

Mental Health CC £0 -£500 -£500 The work necessary to achieve these saving is in place

Gynaecology £0 -£100 -£100The Gynae scheme business case has been approved by the CCG. The QIPP is due to be implemented from September, when the RFS will start

triaging the target patient group.

Total £16,255 -£10,005 -£3,350 £2,900

New schemes shaded orange

Initial schemes shaded grey £2,900

Schemes - line by line analysis (£ 000s)

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Interpretation of first QIPP Report

QIPP Scheme Performance M1-3

Intermediate care service There is a strong reduction (500 spells) in NEL admissions across all

providers. EHT is flat reflecting the slow take up of the QIPP.

Paediatric Community Nursing Oupatients: Is on track to exceed the target reduction on 196 first OP

attendances

Inpatients: Despite the difficulties in agreeing clinical criteria, there is a

reduction and is on track to exceed target.

Ward attenders. Of the target of 993 avoidances, 234 have thus far been

reduced

Pulmonary Rehab Service Report still in development.

CVD Pathway Development Activity in anti-coagulation is not reducing. A major cause for concern

Diabetes Pathway Development Report still in development.

• In August, the CCG has delivered the first full report on actual QIPP

performance, based from the most recent available SUS data.

• The report requires additional development and the information is in its infancy,

but is now giving the CCG the first direct data driven view of actual QIPP

performance for the QIPP schemes that are both in progress and measurable

using SUS data.

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QIPP: Schemes in development

The CCG is actively developing new schemes with potential in 2013-14. Four

schemes presently in full development,

Scheme Name

Savings target (£

000s) - Less

Favourable

Savings target (£

000s) - Expected

value

Savings target (£

000s) - More

Favourable

SLT OwnerCOMMENTS ON SCHEME : Goals and objectives,

development and timelines, risks and issues.

Prescribing Stretch £0 £50 £100 Beryl BevanStretch target which could produce £200k saving from a £100k

investment.

Cardiology (Heart Failure) £0 £0 £30 Michelle Elston

This is the first thread of the reshaping of cardiology services to

be developed; the possibility of implementing it later in the year

with a confederation of existing providers is being explored.

Mental Health – CC funding £250 £500 £1,000 Nicky Bradley A patient cohort has been identified that should be funded by LA.

Gynaecology £50 £100 £150The scheme aims to make greater use of RFS and diverting more

activity into primary care.

Total £300 £650 £1,280

QIPP: Schemes in evaluation with forecast savings beyond 13/14

Scheme NameCOMMENTS ON SCHEME : Goals and objectives, development and timelines, risks and

issues.

Target date for

assessment of

potential savings

Cardiology (Community)

Identifying cohorts of patients who could be safely and more conveneintly be treated in a communtiy

setting. Progress: case for change and options for procurement to be reviewed by Execs on 2nd

October.

2nd October

Urgent / Unscheduled Care

(frail & elderly)

With a focus on the elerly, frail patient what more could be done to provide alternative services,

diverting activity from secondary care. Progress: Opportunity assessments to be reviewed by Execs

on 18th September

18th September

Falls prevention An ICP Innovation Fund scheme this should be launched in 2nd half of 2013/14. 30 September 2013

Imperial Open Access Contract Review the value and validity of continuing this scheme 31 October 2013

Remote follow up of secondary

patients

Scheme has been assessed, and decision taken not to persue for 2012-13Complete.

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Action Date Owner RAG

Action across all QIPP schemes

Review at Finance & Performance Committee each month, and weekly at

QIPP Programme meetings. Focused on structured management of risks,

issues and progress to milestones

Any requirements for any senior leadership and exec support are being

identified.

Ongoing

F&P: Monthly

QIPP: Weekly

F&P: Kathryn Magson

QIPP: Sue Pascoe & Peter

Buckman

Development of QIPP KPIs and performance measures:

a. Output (outcome) measures: Measurement of activity an cost as per

the QIPP Targets.

b. Input measures: Measurement of specific service changes that the

QIPP implementation is aiming to deliver.

c. Clinical quality measures

Completed.

Input Measures – in progress

Quality measures – 31st October

Peter Buckman

Sue Pascoe

Executive Deep dive reviews on existing schemes by COO (monthly)

Completed: Mental Health, Paediatrics, Diabetes, CVD, MSK

August: ICE, RFS, Mental Health

September: Cardiology, Urgent Care

Ongoing: Others, and 2nd round reviews

Kathryn Magson

Creation of a new Role of Programme Director, and implementation of a

cross functional matric structure with all QIPP delivery reporting to Prog Dir.

Completed Kathryn Magson

Actions across all existing schemes:

Identification of additional resources to help support enhanced delivery, and

reorganization of CDM team: e.g. Continuing Care, Mental Health, Urgent

Care and ICE.

Interim staff by 30th September Relevant CDM, with Sue Pascoe

and Michelle Elston

Improvement to delivery management processes, including recruitment. Recruitment: By 30th September

Process: Stepped improvements through Q2

and Q3

Sue Pascoe

Provider performance management e.g. ICE, CVD Anti Coag, Diabetes. Ongoing via regular provider meetings by

QIPP scheme.

Kathryn Magson

Provider (specifically EHT ICO) manager to manager meetings Ditto CDMs

Address engagement barriers with secondary care providers. In progress CDMs with Kathryn Magson

Actions across all new and augmented schemes:

Conduct workshops to develop the full 2014/15 QIPP plan Workshop 11th September Sue Pascoe

Complete opportunity assessment and complete business cases Dates as per slide CDMs for each QIPP schemes

QIPP: On-going actions Update

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QIPP: Risks

Through the PMO process and the executive reviews, in the past month, the

CCG has identified several material risks.

The risks all have mitigation plans which are already in progress.

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QIPP: Update on QIPP quality indicators development

The CCG has an established basis for tracking the clinical quality impacts of the

QIPP schemes:

Clinical Working Groups agree specialty pathways and quality/outcome

objectives.

Formal Quality Impact Assessments.

The driving force for QIPP schemes are the dual goals of better patient care and

safety, and better patient experience.

CCG Federation Quality Leads review quality markers for QIPP programme.

CDMs regularly monitor quality metrics

Quality metrics are built into provider agreements where applicable.

Formal governance is in place:

Reviews at Executive and Innovation Committees

Quality, Safety & Clinical Risk Committee quality problem areas by exception.

Governing Body review quality performance of QIPP programme via CSU

reports.

Consolidated Reporting:

Currently focussed on setting up full reporting of finance and activity reporting of

both “output” (outcome) and “input” measures for QIPP.

Once these are established (in August), the focus will progress to establishing

consolidated reporting associated quality metrics for each QIPP scheme. Target

date for this reporting is by end of September.

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Appendixes

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QIPP: Main reasons for the adverse YTD and forecast outturn

• Ealing CCG has four schemes in particular that have lead to the adverse variance:

Intermediate Care Service (ICE) –The service is having a more limited impact that was envisaged

in the original business case and is reflected in the contract variation with Ealing Hospital. The value

reflects activity assumptions agreed with the clinical; these suggest that only 1/3 of patients

processed by ICE are “avoided admissions”. This is reflected in the QIPP figures, along with the

value of the penalty payable under the contract.

Paediatric Community Schemes –This QIPP covers sub schemes paediatric phlebotomy, and

specialist community nursing, In light of the increasing paediatric demand, and the current quality

issues faced in this service, it has been agreed at CCG Executives that £1m of the schemes

currently identified will not be pursued for now.

MSK Schemes– This scheme was due to start early in the new financial year but this was delayed

due to contract discussions, the delays in recruitment of staff by EHT ICO, and the need to clear the

existing waiting list. October is now scheduled for implementation. The impact of the delay is

mitigated by the reduced re-provisioning costs. This scheme should also see a reduction in the

number of MRIs carried out by InHealth.

Redesign EOLC Pathway– The EOL QIPP budget was based on a detailed opportunity

assessment. However the timing and pace at which a complex and sensitive pathway could be

changed were too fast. It is recognised that there are opportunities to develop new clinical pathways

which improve the quality of care for patients at the end of their lives. The ECCG Exec has laid a

vision for how this QIPP can be formulated and taken forward. The next stage is to re-assess the

real opportunity and design a deliverable QIPP scheme.

Other Smaller Schemes- Five other schemes are contributing towards the adverse forecast.

Appendix 1

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