Hounslow CCG Finance and Activity Performance Report Month ... · not being delivered fully. This...

11-Nov-14

Hounslow CCG Finance and Activity Performance Report Month 06 (September 2014)

Acronym Full Provider NameASP Ashford And St Peter's Hospitals NHS Foundation TrustBLT Barts Health NHS TrustBMIH BMI HeadquartersC&W Chelsea And Westminster Hospital NHS Foundation TrustCLCH Central London Community Healthcare NHS TrustCNWL Central And North West London MH NHS Foundation TrustEHT Ealing Hospital NHS TrustESH Epsom And St Helier University Hospitals NHS TrustGOSH Great Ormond Street Hospital For Children NHS Foundation TrustGSTT Guys And St Thomas NHS Foundation TrustHRCH Hounslow And Richmond Community Healthcare NHS TrustHUH Homerton University Hospital NHS Foundation TrustHWP Heatherwood And Wexham Park Hosps NHS Foundation TrustICHT Imperial College Healthcare NHS TrustIHGL InHealth Group LimitedKCH Kings College Hospital NHS Foundation TrustKHT Kingston Hospital NHS TrustMEH Moorefield's Eye Hospital NHS Foundation TrustNWLHT North West London Hospitals NHS TrustRBH Royal Brompton And Harefield NHS Foundation TrustRFT Royal Free London NHS Foundation TrustRMH The Royal Marsden Hospital NHS Foundation TrustRNOH Royal National Orthopaedic Hospital NHS TrustRSC Royal Surrey County NHS Foundation TrustSGT St George's Healthcare NHS TrustSLAM South London And Maudsley NHS Foundation TrustSWL&StG South West London And St George's Mental Health NHS TrustTHH The Hillingdon Hospital NHS Foundation TrustUCLH University College London NHS Foundation TrustWHH The Whittington Hospital NHS TrustWLMH West London Mental Health NHS TrustWMUH West Middlesex University Hospital NHS Trust

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The following acronyms of providers are used throughout this pack.Key message

Contract Acronyms

Executive summary 3 Surplus/deficit including Running Costs 10CCG Finance dashboard 4 Break-down of Programme (comm.) spend 11Risks and opportunities 5 Investments & Reserves 12Underlying Position 6 Break-down of Running Cost spend 13

Key Issues and Actions relating to the Financial position

7&8 QIPP 14

Capital Creditor payments and cash 15


Appendices Overall financial position

Contents

Overall financial position

Contracts performance Overall financial position Executive summary

Executive summary 3CCG Finance dashboard 4Risk and Opportunities 5Underlying Position 6Key issues and Actions relating to the financial position - West Middlesex 7Key issues and Actions relating to the financial position - Imperial 8

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Contents

Overall financial position Contracts performance

Appendix Executive summary


Status

Whilst the forecast remains on track there are a number of financial pressures to note :

Contract Performance Amber

QIPP Green

Investments & Reserves Green


Green

Green

The forecast for the year is for a full year achievement of 102.8% of plan, value £9.106m. This position includes the value of fixed price acute contracts, which deliver QIPP regardless of underlying activity. However the recurrent position requires the delivery of significant activity reductions, particularly in non elective services, which to date are not being delivered fully. This activity driven recurrent slippage against QIPP plan is forecast as £0.813m and this will have an impact on the affordability of 2015/16 financial plans

At month 6 the CCG has met it's year to date target surplus of £2.088m and is forecasting delivery of the planned full year surplus of £4.176m.

Acute services are £1.053m overspent at month 6, with a forecast full year overspend of £1.935m; this has been mitigated by contingency funds.

Continuing care pressures have worsened, particularly the Physical Disability and Adult placements which are forecast to overspend by £1.119m. This forecast is based on the Caretrack patient database information. As a high cost low volume service any change in activity can have a significant financial impact : this risk is captured on slide 5, Risks and Opportunities.

3

There are £4.350m of risks identified including £2m relating to C&W and WMUH merger and £0.8m for additional acute FOT, the CCG has identified £4.323m opportunities to mitigate these risks.

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Acute contracts are forecast to overspend by £1.879m an increase of £0.067m from last month. The most significant forecast overspends are : Ashford St Peters £0.719m. North West London Hospitals £0.413m,, Guys St Thomas £0.271m, St Georges £0.248m & Bart's £0.227m. A break-even position is reported for the fixed price contracts at West Middlesex & Imperial College, however the underlying activity data suggests ytd overspends of £1.158m and £0.563m respectively - although there are on going data quality issues at both providers.

The CCG budget included a total of £9.887m for reserves and investments. The F&P Committee has approved investments totalling £7.422m and of the remaining £2.465m c£0.6m may be required to cover forecast overspends. £1.865m has been earmarked to either pump prime the 2015/16 BCF programme or support the year-end Collaborative risk share if required.

Risks and Opportunities

Executive summary

On planTake noteAction required

Indicator ActualRating this month

Financial position in month £350k £307k (0.2%) variance as a % of in-month RRL allocation

Financial position year to date £2,088k £2,088k 0.0% variance as a % of year-to-date RRL allocation

Financial position forecast outturn £4,176k £4,176k 0.0% variance as a % of forecast annual RRL allocation

Running costs forecast outturn Break even Break even 0.0% variance from planned position

QIPP year to date £4,391k £4,391k 0.0% variance from plan

QIPP forecast outturn £8,860k £9,106k 2.8% variance from plan

Risks and opportunities Net risk (£276k) (6.6%) (net risk) / opportunity outside reported position (against outturn budget)

Creditors - Better Payment Practice Code 95.0% 92.3% (2.8%) of invoice value paid in 30 days

Capital forecast outturn 1,620k 1,620k 0.0% forecast variance from allocation

Cash £133,755k £139,716k 4.5% year to date variance from cash limit.

Financial position in month - This is to due increased run rates in Acute SLA.

Risks & Opportunities - the CCG has a net risk of £276k at month 6

Creditors - Better Payment Practice Code - This is improving as work with SBS budget holders continues to ensure invoices are paid within terms

Source: Financial ledger

4

Key

Target

NoteFor RAG rating definitions please see appendix 2.1


CCG Finance Dashboard

Key message

Amount

£000s Percentage Value Percentage Value Percentage Value

C&W and WMUH merger (2,000) 90% (1,800) 100% (2,000) 100% (2,000) Possible transaction / merger costs of C&W and WMUH

Acute over performance (800) 50% (400) 0% 0 100% (800) Acute over performance over FOT @ month 6

Continuing Care placements (500) 50% (250) 0% 0 100% (500) Cost of placements if patients numbers increase furtherNCA - Bucks NHS trust

(450) 50% (225) 0% 0 100% (450)

The CCG has received charges for delayed discharge for specialist spinal patients. It is a grey area of PBR guidance which requires clarifying to determine whether the CCG is the responsible commissioner.

UCC income (400) 50% (200) 0% 0 100% (400)

Risk our invoices will not be paid due to absent PID backing from BI

GP IT primary care(200) 50% (100) 0% 0 100% (200)

2014/15 Funding allocation reduced by NHSE after budget had been set

Total (4,350) (2,975) (2,000) (4,350)

Amount

Opportunities£000s Percentage Value Percentage Value Percentage Value

Investment slippage2,000 100% 2,000 100% 2,000 0% 0

Value of investment slippage required to cover risks

13/14 settlement provisions800 50% 400 100% 800 0% 0

Mainly due to agreeing 13/14 acute actual outturn at a lower level.

14/15 slippage on imperial bond800 0% 0 100% 800 0% 0

Non payment of performance Bond as payment criteria not delivered by Trust

Learning Disabilities300 50% 150 100% 300 0% 0

14/15 budget includes increased Winterbourne review costs that have not/unlikely to crystallise.

Running cost 250 0% 0 100% 250 0% 0

Current underspend that may not be required to cover costs of transition.

Contingency125 100% 125 100% 125 100% 125

Utilisation of contingency

Property Services / CHP 48 50% 24 100% 48 0% 0 As per notification by NHS Property on 14/15 costs.

Total 4,323 2,699 4,323 125

Net (Risks) & Opportunities (27) (276) 2,323 (4,225)

The gross risks facing the CCG at month 6 amount to £4.350m, likely case £2.975m: these are nearly fully mitigated by £4,323m, likely case £2.699m resulting in a net risk of £276k.


Risks

Likely Case Best Case Worst Case

Comments

Likely Case Best Case Worst Case

Comments

Risks and Opportunities

Key message

Recurrent Non recurrent

Total

293,513 13,718 307,231

294,854 8,201 303,055

Surplus/(Deficit) -1,341 5,517 4,176

Total Total

-1,341 -0.4%

-396 -0.1%

Improvement / (worsening) -945

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Expenditure

Underlying Position

Forecast

Planned (per Op Plan 20th June)

£'000 %

At M6 the underlying position has deteriorated by £0.945m to £1.341m from the planned position of £0.396m adverse. This is mainly due to the extra recurrent costs of the revised Out of Hospital contract costs.

FOT at month 6

Revenue

£'000 £'000 £'000

Underlying Position

West Middlesex 14/15 contract

Block contract £86.4m An agreed WMUH 14/15 Finance and Activity Schedule to support the SLA to date has not been produced. Therefore it remains difficult to accurately verify the underlying performance and QIPP scheme delivery. The M5 WMUH summary [page 18] shows an underlying overperformance of £1.158m at month 5. This is a £344k on NEL, £293k on Outpatients, £415k on day cases and elective, and £170k on A&E. This overperformance, if continued to the year-end will impact on the affordability of 2015/16 plans.

Sibghat Ullah n/a

Ashford & St Peter's 14/15 contract

Activity/cost (PBR) based

£12.01m The total value for ASP is agreed at £12.01m for Hounslow CCG. The YTD overspend is £386k, this is mainly in non elective services £166k critical care £67k and drugs £62k and out patient procedures £67k

Sibghat Ullah n/a

Source: Financial ledger, CSU analysis

TimelineBriefing Key driversFinancial impact YTD Action Owner

Actions for CSU


Key issues and actions in Financial Position Key issues and actions in Financial Position Key issues and actions in Financial Position Key issues and actions in Financial Position Key issues and actions in Financial Position Key issues and actions in Financial Position

Key lines of enquiry

Issue

Month 5 Performance- The underlying ICHT position at Month 5 is an overperformance of £563k

The main areas of ytd over performance are; Critical Care (£441k) and NEL (£317k)

Details of the number of adjustments made to the Trust's reported position are:

1. Maternity charges have been increased by (£61k) to reflect estimate of missing Antenatal/Postnatal data.

2. Additional credit due for readmissions of £16k for patients first seen at another provider.

3. Other mitigations relating to penalties for national breaches; LAS, MRSA and 18 weeks/RTT and also automated claims, PPwT, and diagnostic breaches which amount to £85k. In line with the contract variation proposed by CCG Associates at the Associates meeting, in mid August fines/penalties above the plan value of £38k (excl. CQUINs) will be reinvested back into the trust.

4. CQUINS adjustment to reduce YTD charges by £55k to acknowledge that the Trust did not sign the contract until May. The Trust has the opportunity to earn back month 1 CQUINs, through the delivery of specified actions linked to the closure of H&F A&E.

5. Finally a ‘ force back’ adjustment of (£24k) to ensure the YTD charges match the agreed IG.

£0 (Mitigated variance)

Continual monitoring of adverse/favourable variances.

next update October 2014

Helen Poole

Information Data Issues- Following the Implementation of Cerner in April 14, there has been significant data issues affecting the accuracy and completeness of information in M1–M4.

The significant data issues affecting the accuracy and completeness of information are:

1. Point of delivery classification; Patients are incorrectly coded as NEL when their activity is EL- likely impact being costs are overstated. Day cases charged as regular day attenders- likely impact being costs are understated. Day case and Elective switches- likely impact being nil.

2. Critical Care has not been fully recorded (this is due to a separate, simultaneous system roll-out across the trust) - Impact unknown.

3. The majority of A&E attendances have been recorded as the lowest HRG -minimal cost impact, the CSU dispute the majority being incorrectly classified.

4. Maternity pathway under recording by approximately 2 weeks - impact estimated and this has been accrued in the year to date position.

5. Outpatient under-recording, particularly on outpatient procedures - Impact being costs are understated, as additional charges due for the incremental cost between a first and follow up attendance and the procedure cost.

Information breach notice issued to the Trust 30th July. The Trust has recovery plans for all areas and for assurance that patient care has not been compromised as a result of the data issues. The Associates agreed for the Trust to resolve all data issues by (Feb 15), however the Trust to provide a detailed recommended action plan.

next update October 2014

Helen Poole


Owner

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Commentary

Action Date

Key issues and actions - acute contracting - ICHT

Surplus/deficit including running costs 10

Break-down of Programme (commissioning) spend 11

Investments & Reserves 12Break-down of Running Cost Spend 13

QIPP 14Capital Creditor payments and cash 15

9 high quality support to commissioners to improve health and wellbeing

Contents

Executive summary Overall financial position Contracts performance Appendix

Contents

Executive summary Overall financial position Contracts performance Appendix

Key message

Forecast

CCG Budget Group

Budget Actual Variance Budget Actual Variance Budget Forecast Variance Variance

month 5 £k

Allocation Resource Limit 26,708 26,708 0 147,313 147,313 0 307,231 307,231 0 0 -

Acute Services 15,195 15,563 (368) 82,286 83,339 (1,053) 171,583 173,518 (1,935) (1,813) (122) Community services 1,919 1,999 (80) 15,254 15,302 (48) 30,508 30,558 (50) 100 (150)

Mental health 2,484 2,512 (28) 14,913 14,808 105 29,826 29,852 (26) 0 (26)

Prescribing 2,572 2,544 28 15,431 15,339 92 30,863 30,829 34 34 0

Continuing Care 749 795 (46) 4,497 4,979 (482) 8,994 10,113 (1,119) (1,001) (118)

Primary Care Service 1,487 1,316 171 4,455 4,329 126 10,089 9,860 229 (133) 362

Other (includes NHS property, CSU and local CCG programme staff, CHC provision, NHS 111, Safeguarding, Patient transport & interpreting)

1,249 1,253 (4) 4,168 4,230 (62) 7,305 7,296 9 (11) 20

Contingency 185 0 185 1,112 0 1,112 2,225 126 2,099 2,225 (126)

Reserves 0 0 0 0 0 0 5,060 4,301 759 599 160

Running Costs Corporate costs 518 419 99 3,109 2,899 210 6,602 6,602 0 0 0

Total Expenditure 26,358 26,401 (43) 145,225 145,225 0 303,055 303,055 0 0 0

Surplus/(Deficit) 350 307 (43) 2,088 2,088 0 4,176 4,176 0 0 0


The CCG is meeting its YTD surplus target of £2.088m and is on target to deliver the full year surplus of £4.176m with the support of its contingency. The main forecast variances against plan are : Acute services FOT £1,935k, this has worsened by £122k from last month, the movement by trust is shown on slide 17. The key in cluster SLAs that are contributing to the FOT overspend are NWLH £0.413m and C&W £0.174m. Out of cluster trusts over performance forecast contribute to nearly 76% (i.e. £1.421m) of overall forecast overspend, including Ashford Hospital £0.719m. The volume of Continuing Care patients is above plan and a year-end cost pressure of £1.119m is forecast and an additional risk of £0.25m has been flagged in the risks and opportunities for further patient costs. The adverse change in FOT under community services relates to Wheelchair services this is due to clearing of backlog repairs and maintenance of equipment. The favourable change in FOT under primary care is mainly due to realignment of ICP budget lines, this service was previously hosted by CLCH however from Q1 the budget has been devolved to CCGs. At month 6 £0.759m of slippage against investments is supporting the delivery of the £4.167m surplus.

In-month (£k) Year to date (£k) Full year (£k)

Expenditure on Programme Areas (Commissioned services)

Change in FOT

Variance £k

Surplus/Deficit including Running Costs

Key message

Commissioning Spend Breakdown

Budget Actual Variance Budget Actual Variance Budget Forecast Variance

Acute NHS SLA Services (incl. CQUIN & Ambulance) 13,552 13,844 (292) 77,434 78,501 (1,067) 157,992 159,871 (1,879) (1,812) (67)

Other Acute Activity Services 1,643 1,719 (76) 4,852 4,838 14 13,591 13,647 (56) (1) (55)

Acute sub total 15,195 15,563 (368) 82,286 83,339 (1,053) 171,583 173,518 (1,935) (1,813) (122)Continuing Care 749 795 (46) 4,497 4,979 (482) 8,994 10,113 (1,119) (1,001) (118)Community Services 1,919 1,999 (80) 15,254 15,302 (48) 30,508 30,558 (50) 100 (150)

Mental Health Services 2,484 2,512 (28) 14,913 14,808 105 29,826 29,852 (26) 0 (26)

Prescribing 2,572 2,544 28 15,431 15,339 92 30,863 30,829 34 34 0

Primary Care Service 1,487 1,316 171 4,455 4,329 126 10,089 9,860 229 (133) 362

Other Non Acute Services (includes CHC provision, NHS 111, Safeguarding, Patient transport & interpreting) 835 823 12 1,682 1,695 (13) 2,332 2,323 9 (11) 20

Non acute sub total 10,046 9,989 57 56,232 56,452 (220) 112,612 113,535 (923) (1,011) 88

Commissioning Contingency 185 0 185 1,112 0 1,112 2,225 126 2,099 2,225 (126)Programme Staffing (CSU and local team) 129 142 (13) 774 807 (33) 1,548 1,548 0 0 0

NHS Property 285 288 (3) 1,712 1,728 (16) 3,425 3,425 0 0 0

Reserves 0 0 0 0 0 0 5,060 4,301 759 599 160Planned Surplus 0 0 0 0 0 0 0

Reserves and other sub total 599 430 169 3,598 2,535 1,063 12,258 9,400 2,858 2,824 34TOTAL Commissioning spend 25,840 25,982 (142) 142,116 142,326 (210) 296,453 296,453 0 0 0



The CCG has overspent on its year to date programme allocation, this is mainly to do with changes in run rates. The main adverse year to date variances against plan are Acute SLA services £1,067k, this has worsened by £292k in month. The key SLAs that are contributing to the year to date overspend includes - Ashford Hospital £0.463m; NWLH £0.213m; Guys & St Thomas £0.135m, St Georges £0.124m, Bart's £0.114m and C&W £0.087m. Continuing care year to date is overspent by £482k, this includes increased activity and cost of care packages. Mental health £105k underspend year to date relates to an increased element within the 14/15 budget to account for potential learning difficulty patients transferring back for NHSE specialist commissioning. Primary care has inpmorved in month due to realignment of ICP budget lines, this service was previously hosted by CLCH however from Q1 the budget has been devolved to CCGs.

In-month (£k) Year to date (£k) Full year (£k) Forecast variance

month 5 £'000

Commissioned services

Change in FOT

Variance £k

Break-down of Programme (commissioning) spend

Key message

12

Of the total reserves and investment funds of £9.887m, £4.827m has now been placed in specific service budgets and £5.060m remains in reserves of which £2.465m is unallocated. Of the unallocated funds it is estimated that £0.600m will be required to support the year-end position and £1.865m is forecast to be available to either contribute to the Collaborative year-end risk pool or help pump prime the joint LBH /NHS Better care fund schemes for 2015/16

Investments & Reserves

Key message

Commissioning Spend Breakdown

Budget Actual Variance Budget Actual Variance Budget Forecast Variance

Resource Limit 518 419 99 3,109 2,899 210 6,602 6,602 0

Pay Costs 153 149 4 919 732 187 1,868 1,868 0

CSU Costs 275 284 (9) 1,648 1,640 8 3,296 3,296 0

Other Non Pay Costs 90 (14) 104 542 527 15 1,438 1,438 0

TOTAL RC spend 518 419 99 3,109 2,899 210 6,602 6,602 0



Running costs

13

The CCG is underspent on it's running cost allowance by £210k at month 6. Corporate costs are under spent mainly due to vacancies that have been budgeted for the new CCG structure. The Forecast outturn is as per plan as it is uncertain how CSU transition costs will impact on the budget in year and potentially use any underspend.

In-month (£k) Year to date (£k) Full year (£k)

Further detail

Allocation

Break-down of Running Cost spend Break-down of Running Cost spend

Key message

Key initiatives (Net QIPP)

Initiative Plan Actual Var Plan Forecast Var Further detail

£'000 £'000 £'000 £'000 £'000 £'000

Community 375 375 0 749 870 121 Includes HRCH contract efficiency & ICRS, this has been received through 13/14 contract negotiations.

Contract Efficiencies 2,193 2,193 0 4,385 4,385 0 Includes acute SLA efficiencies, this includes contract caps in place for

14/15.

Direct Access 50 50 0 116 141 25This includes direct access pathology cost and volume reduction through demand management tools (i.e. maximise utilisation of Order Comms), this scheme is over achieving.

Locality based Delivery 692 692 0 1,383 1,383 0

Shown as achieved due to block agreement, these schemes aims to reduce the number of admissions through the identification of high risk patients - it should be noted that activity reductions are not being achieved in this scheme and without the blocks being in place these schemes are forecast to under achieve by approx. £805k.

Mental Health 325 325 0 700 697 (3)Shifting setting of care - review of high cost of out of area continuing care by repatriation of mental health patients to lower cost local provision, this scheme is on target.

NHS 111 0 0 0 0 103 103 This is the saving achieved on renegotiating year 2 of the NHS 111 contract.

Planned Care 57 57 0 114 114 0Shown as achieved due to block agreement, includes impact of RFS - it should be noted that this is scheme without the block being in place is forecast to over achieve by £64k.

Prescribing 300 300 0 600 600 0

Prescribing has been shown as break-even although the first Q1 PPA shows an forecast underspend of £647k. The data was reviewed at practice level and highlighted some abnormalities thus it has been confirmed by the medicines management lead to show breakeven on drugs until more meaningful and accurate forecast data issued.

Unscheduled care 400 400 0 813 813 0

Shown as achieved due to block agreement, includes community Heart Failure service and UCC scheme - it should be noted that activity reductions are not being achieved in these schemes and without the blocks being in place these schemes are forecast to under achieve by approx £460k

Total 4,391 4,391 0 8,860 9,106 246

Source: PMO QIPP report


QIPP position year to date & FOT is showing an over achievement of 2.8%. For 14/15 the CCG has a number of block contracts with its main acute providers which means in financial terms its delivering its 14/15 QIPP target however it should be noted that a large proportion of these savings are non-recurrent except where underlying activity is reduced in line; any non-delivery of planned activity reductions will create a cost pressure for 2015/16. Activity data to date indicates a recurrent pressure of £0.813m mainly relating to the locality schemes.

Year to date Full year

14

Quality, Improvement, Productivity Plan (QIPP) Quality, Improvement, Productivity Plan (QIPP)

Key message

InvoiceCount

InvoiceCount

(Passed)

% Passed BPPCAmount

InvoiceAmount(Passed)

% AmountPassed

NHS 1,853 1,640 88.5% 110,512 102,055 92.3%Non NHS 4,420 4,151 93.9% 13,255 12,406 93.6%Total 6,273 5,791 92.3% 123,767 114,461 92.5%

Maximum Cash Drawdown (MCD) : 302,486k* Drawn Down to Date: £139,716k

Forecast Draw Down at Month 6: £133,755k Drawn down over plan: £5,961k

Source: CSU analysis


Capital• NHSE has confirmed the Capital allocation of £1,620k for 14/15, which is made up of £1,300k for

Heston Health Centre, £212k for Chiswick Health Centre, £108k for Heart of Hounslow. They are all subject to the business case process.

Creditor payments

•

The CCG has not met the Better Payment Practice Code (BPPC) target. This is mainly due to issues around validation of Non Contracted Activities. We are currently working with budget holders to ensure that invoices are coded and that outstanding queries are dealt with promptly in order that invoices are paid within payment terms.

Cash

•

The CCG overdrew on its cash forecast as it was anticipating settlineg prior year balances including WMUH 13/14 over performance. This remains un resolved but progress is being made to agreeing the final outturn. *The proposed current Maximum Cash Drawn (MCD) limit has now been set for 2014/15 by NHS England. The CCG will have an opportunity at yearend to request a change to the MCD so that it supports it's final cash requirements and ensures the CCG meets it's 14/15 cash limit.

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