INITIAL BUDGETS AND PERFORMANCE PLANS 2011/12 PCT BOARD 13 TH APRIL 2011 Jonathan Wise, Director of Finance & Performance
Contents Introduction/Context – NHS Brent journey – 11/12 planning process Part 1 - 2011/12 Budgets/Finance Plan (Slides 6 - 53): – Medium Term Financial Strategy – Key Financial Assumptions – Budget Setting Process – Budget summary – Main Budget Changes • Acute • Non-acute • Primary Care • CSP Investments • Running Costs • Estates – QIPP Summary and Plan – Budget sign-off and in-year management – Risks and Contingency – Planning for 2012/13 onwards Part 2 – 2011/12 Performance Plans (Slides 54 - 67) : – Overview – health context – Performance Targets – 11/12 plans Part 3 – GP Delegation (Slides 68 - 84) 2
National and NW London context National context • The national Operating Framework for 2011/12 was published in Dec 2010 and sets out the national framework for maintaining and improving quality and outcomes, together with the finance and business rules. • “The most significant challenge we face in 2011/12 is to maintain a grip on current performance and QIPP delivery, whilst simultaneously preparing and beginning to put in place the future system” (Sir David Nicholson, December 2010) NW London context • In December 2010, NW London finalised its four year Strategic Commissioning and QIPP (Quality, Innovation, Productivity and Prevention) Plan to 2014/15, including – Case for change – Use of benchmarking and case studies to set priorities – Development of models of care aligned to the settings in which they could be delivered – Review of the impact of the proposals on provider clinical and financial viability – Development of high level implementation plans • NW London issued its specific Commissioning Intentions for 2011/12 in January 2011 3
Brent context WCC Assessment GP Commissioning • Strategy – Amber (Green for PCT strategy plan) • GPCE established. Clinical Directors funded as per agreed Business Case • Finance - Green • Pathfinder application approved • Board – Green Performance Health Outcomes th • Some significant improvements in 10/11 • Brent is ranked 11 in London for male all th • However Brent remains poor on a number of key areas age all cause mortality rates and 12 for female. • CVD mortality rates place Brent 18 th and cancer mortality rates ranked 14 th. 4
11/12 Planning Process Contract negotiations Nov - Mar 11 CSP Jan 10 10/11 Operating Plan Apr 10 Workshop Reviews with GP commissioners Jul - Oct 10 Joint development of 11/12 QIPP Nov - Mar 11 Budget setting process Nov– Mar 11 5
Part 1 – 2011/12 BUDGETS/ FINANCE PLANS 6
National context • Spending review settlement in October 2010 covering 11/12 – 14/15 – overall NHS spending to increase by 0. 4% in real terms over the course of the Spending Review period • Allocations to PCTs for 11/12 (not beyond) confirmed in December 2010 • Key points: – Average increase in 11/12 allocations to PCTs = 3% • Brent = 2. 6% – Of this, element is to be transferred to local authorities to support social care via a section 256 agreement • Net growth after this = Brent 2% (minimum level) – 2% of all PCTs resources will be held by SHAs, with PCTs being required to submit business cases to access the funding that demonstrate the non-recurrent nature of the proposed expenditure – PCT debt that has arisen pre 11/12 to be repaid by 2013/14 – Any debts/overspends in 11/12 -12/13 become the responsibility of GP consortia – Revised weighted capitation formula published – now shows Brent 15% over target 7
NW London context • Cluster (NW London) financial strategy agreed by Cluster Board 9 March 2011 • 4% QIPP (excluding running costs) target at sub-Cluster level • Financial support provided/received in 09/10 to be repaid in 2011/12 – 2012/13 (£ 5. 3 m owed by NHS Harrow to NHS Brent) • 2011/12 NW London Challenged Trust Board contributions/utilisation: – Brent contribution – 1% (provided in 10/11) plus £ 2. 8 m in 11/12 – Harrow utilisation - £ 20 m support • Use of 2% non-recurrent resource – Harrow £ 5. 3 m assumed in initial plan – Balance to be agreed by NHS London /Sector in-year • Contribution from PCTs to London fund to support GP Pathfinder – £ 3. 2 m contribution from Brent and Harrow – £ 2 per head to be returned (est. £ 700 k Brent, £ 450 k Harrow) 8
Medium Term Financial Strategy • Strategic plan (Jan 10) - set out a five year programme to deliver our vision of making a significant improvement to the health and wellbeing of the people of Brent • The Medium Term Financial Strategy (MTFS) embedded in the Strategic Plan set out the plan to maintain a sustainable financial position over the period to 2013/14. • The key points were: – do nothing scenario based on historic activity growth rates – £ 60 m efficiency and disinvestment programme over 4 years – strong underlying position means we could aim to deliver this is 11/12 onwards but given the scale and complexity, plan to start delivery in 2010/11 – sustainable plan under all scenarios – non-recurrent investment to support implementation – downside allocation assumed for 11/12 onwards • We refreshed the MTFS projections as part of the CSP review/development of the QIPP in Summer/Autumn 2010 and confirmed that the MTFS projections remained valid 9
Key Financial Assumptions 2011/12 The financial plan: • Is consistent with 2011/12 Operating Framework and NHS London guidance, including the impact of : -Tariff changes for 2011/12 -11/12 allocations • • • Is consistent with NHS NWL financial strategy (JCPCT paper Feb 2011) Includes an assessment of the outcome on acute and other contract negotiations where these have not yet been concluded Excludes BCS as a provider as a result of transfer to ICO Incorporates QIPP plans and Performance Improvement plans Reflects an outturn based approach to budget setting, including acute contracts Includes a financial risk assessment, risk mitigation plans and an in-year sub-Cluster contingency plan 10
2011/12 Budgets Budget Setting Process • The budget setting process has been conducted in accordance with good practice criteria (generated from a combination of Audit Commission recommendations and local additions): –There has been an agreed budget preparation approach and timetable –The impact of prior year over/underspendings has been reflected in 2011/12 budgets –Operational and financial responsibilities are aligned –Budgets are linked to workforce and activity plans –Budgets are reconciled to the PCT’s cash plan for 2011/12 –Budgets are based on realistic assumptions for inflation and other cost pressures –Budgets include the full year effect of 2010/11 changes –Savings plans have been risk assessed –Investment plans will be subject to Business Case approval as appropriate –Budgets will be appropriately profiled across the financial year –Budgets will be supported by a rigorous sign-off and in-year management regime 11
2011/12 Budgets Overview • Initial budgets totalling £ 539. 9 m are summarised in the next slide • 2011/12 forecast allocation is £ 551. 0 m resulting in planned surplus of £ 11. 1 m (2%). 12
2011/12 Budget Summary £m Acute 286. 8 Non-acute 78. 6 Primary Care 136. 9 CSP Investments 14. 1 Corporate 12. 1 Estates 6. 4 Contingency 5. 0 TOTAL 539. 9 • Detailed budgets and budget holders on schedule attached 13
Main Budget Changes – Acute Contracts (1) • Baseline based on 2010/11 outturn adjusted for: – % population growth – Tariff changes – see slide 15 – Demand Management (Urgent Care Centre, STARRs, End of Life, Case Management) – see slide 16 – Sector Commissioning Intentions – see slide 17 – CQUIN continues at 1. 5% – see slide 20 – Out of Sector contracts not finalised (risk assessment included in budget together with in-year risks) 14
Main Budget Changes – Acute Contracts (2) Tariff changes 11/12 – national • Standard national contracts for acute and mental health now incorporating PCT provider arm services • Bespoke contract for the care homes sector now available • National tariff reduction of 1. 5% (2. 5% inflation less 4% efficiency) • Emergency readmissions within 30 days of discharge following an elective admission not to be charged. All other readmissions within 30 days subject to locally agreed thresholds • Some expansion in scope of tariff for 11/12, including changes to specialised services top ups and HRG 4 for A&E • Marginal rate for emergency admissions above baseline maintained • CQUIN to remain at 1. 5% (also extended to care homes) 15
Main Budget Changes – Acute Contracts (3) Demand Management • Total = £ 6. 4 m 16
Main Budget Changes – Acute Contracts (4) Sector Commissioning Intentions • Planned Procedures with a Threshold (PPw. T) – In 2010/11 there has been a process to implement systems to better manage requests for and the contracting of PPw. Ts. Following work by the NW London Clinical Reference Group an extended list has been determined for inclusion in 2011/12 contracts. – The relevant HRGs have been removed from Trust baselines in their entirety. Unless one of the listed procedures has been explicitly approved using the specified process of approval it will not be funded. • Outpatient ratios – Outpatient first to follow up ratios have been revised and applied consistently to providers from April 1 st 2011 to achieve progressive improvement by all providers • Day Case/Outpatient ratios – In addition to monitoring day case rates, the Sector is extending this to include procedures undertaken in outpatients leading to achievement of Best Practice ratios for the proportion of procedures carried out in an outpatient setting as opposed to a day case. This recognises that some procedures do need to be undertaken as a day case and incentivises the provision of care in less acute clinical settings where clinically appropriate. 17
Main Budget Changes – Acute Contracts (5) Sector Commissioning Intentions • Emergency readmissions – The national guidance on this is clear and is spelt out in a letter from David Flory of the 18 th February 2011 “there is no discretion about the use to which the savings from not paying for some emergency readmission, accruing within PCTs, should be put. SHAs will be asked to monitor the progress of PCTs in identifying and using this money to develop services to support patients in the 30 day period following discharge. This responsibility will pass, along with the funding, to the acute sector from 1 April 2012…” – Given the need to develop new services to tackle 30 day admissions and the time this will take a phased approach to this issue in NWL has been taken. The precise phasing is subject to agreement but the key impact is the overall in year potential loss of income to acute Trusts. In NWL this is set at 25% of the calculated readmissions value. – Funds will only be paid to Trusts on the basis that both commissioners and Trusts are developing joint plans to create new services aimed at improving services to support patients in the 30 day period post discharge. In the first quarter 100% of one quarter of the total annual calculated figure will be paid to Trusts subject to agreement by 1 st July of the joint plan. Over the full year it is expected that Trusts will receive 75% of the annual calculated funding with 25% invested in out of hospital services. These percentages may be varied in year subject to both parties agreement but have been used in setting contract for 2011/12 • Quality metrics and consequence of breaches– within NWL the quality metrics included in acute contracts have been reviewed and financial consequences of breached of some metrics established. See next slide 18
Main Budget Changes – Acute Contracts – Quality metrics and consequence of breaches(6) Quality metric Penalty NSE 1 -% patients seen within 18 weeks across all specialty groups for admitted and non-admitted th pathways and direct access audiology treatment and incomplete pathways 95 centile £ 10 k per month per specialty missed NEW – waiting for diagnostic test Non payment per patient + £ 500 penalty per patient NEW – Choice of named consultant led team £ 20 k per month for missing trajectory N 38 C – LAS arrival to patient handover more than 60 mins Non-payment + £ 1000 penalty per patient NSE 19 – in hospital maternal death from post-partum haemorrhage after elective caesarean section Non-payment + £ 20 k penalty per patient NSE 8&9 - % patients with suspected cancer, detected through national screening prog/hospital specialists who wait more than 62 days for referral for treatment £ 10 k per month for missing target NSE 11 – maximum waiting time of one month from diagnosis to treatment for all cancers £ 10 k per month for missing target NSE 4&10 – Two-week maximum wait from urgent GP referral to first OP appointment for all urgent suspected £ 10 k Per month for missing target NEWL 29 – Providers should achieve new cancer waits performance and data completeness (radiotherapy) £ 10 k per month for missing target NEWL 24 – Cancer services: all providers of A&E services should have automatic alert systems for known oncology patients £ 20 k per month for missing trajectory NEWL 38 – use of e-prescribing for patients under chemotherapy treatment £ 20 k per month for missing trajectory NEWL 39 – referral to transfer time for all ACS patients £ 500 fine per day in excess of required wait time Children P 54 – Safeguarding children (demonstrating compliance) £ 20 k per month for not demonstrating compliance N 1 – MRSA Bacteraernia Non-payment + £ 20 k per patient above target NEVER EVENTS Non-payment + £ 20 k penalty per patient P 52 – Medicines Management – proportion of low cost prescribing for: Statins and ACE inhibitors £ 20 k per month for missing trajectory NEW – no mixed sex accommodation £ 500 penalty per patient • Note: also a number of quality metrics for which no consequence of breach 19
CQUIN – ACUTE CONTRACTS 11/12 • CQUIN payments have been divided into two areas: – National incentive schemes – Regional /Local incentive schemes • National incentive scheme – These remain unchanged from 2010/11 and are: – VTE risk assessment on admission to hospital – Composite indicator on responsiveness to personal needs • London/Local incentive scheme for NWLH – Falls: the total number of falls within NWLHT will be reduced by 25% and the number of those falls resulting in harm to the patient will be reduced by 50% – End of Life Care: the care of end of life patients referred to the specialist palliative care team will be improved through the local implementation of the Department of Health End Of Life Care Strategy’s quality standards. A locally developed and agreed improvement trajectory will be established. – COPD Discharge Care Bundle (chronic obstructive pulmonary disease) 75% of patients who are admitted with an acute exacerbation of their COPD will be discharged with a completed discharge care bundle in the required format – Patients seen by a consultant within 12 hours of admission: 75% of patients admitted in an emergency, ether via A&E or directly from the community will be assessed by a consultant within 12 hours. 20
Main Budget Changes – Other Acute Specialised Commissioning • Other Acute - Applying tariff deflator of 1. 5% to Walk-In Centres, Non Contracted Activity and Sexual Health - reduction of £ 0. 1 m - Termination of the Clinicenta contract - reduction of £ 1. 7 m • Specialist Commissioning - Net cost pressures due to increases in activity of £ 1. 3 m of which the increase in NICU is £ 1. 1 m 21
Main Budget Changes – non-acute • Mental Health - Specialist commissioning cost pressure (£ 0. 6 m) - Transfer of Learning Disability Community Team and Substance Misuse Project from BCS to CNWL (£ 1. 2 m) - Application of tariff deflator - reduction of £ 0. 5 m - Other contract reductions - reduction of £ 0. 3 m - Planned savings on CNWL contract - Learning Disability community teams – reduction of £ 0. 3 m - Rehabilitation bed reduction – reduction of £ 0. 85 m - Rationalisation of Teams – reduction of £ 0. 5 m - Contract rebasing between PCTs – reduction of £ 0. 6 m • Continuing Care - Application of tariff deflator - reduction of £ 0. 4 m - Decommissioning of Continuing Care Beds with CNWL – reduction of £ 169 k - Savings with other providers due to repatriation and the transfer of Adults into the Older Adults service – reduction of £ 0. 8 m • Other - Social Care Allocation to Local Authority (£ 3. 4 m) - Savings on Women & Children small contracts - reduction of £ 0. 1 m • 2% efficiency on all contracts (£ 0. 1 m) Drug & Alcohol Action Team - Increase in national Pooled Treatment funding (£ 0. 7 m) 22
CQUIN - CNWL Regional: 40% allocation of CQUIN payment Indicator Description Weighting – 0. 6% overall 1 a-d To improve physical health and medicines reconciliation for patients 15% with mental health problems 2 a-d Understanding and improving patient reported measures of care 15% 3 a Promoting recovery based care 10% Local: 60% allocation of CQUIN payment Indicator Description Weighting – 0. 9% overall 4 a-c Increasing the routine use of outcome metrics (Ho. NOS) at key points in care pathways to include CAMHS patients 20% 5 a-b Improve the response for individuals in crisis 20% 6 Locally reported Patient Experience / CQC Survey 20% 23
Main Budget Changes – Primary care • Medical budget has an uplift of 0. 5% (£ 0. 22 m) • Pharmacy contract budget remains the same as 2010/11 with 2% uplift to Pharmacy Global Sum element only (£ 0. 1 m) • • Prescribing uplift 5% (£ 1. 9 m) QIPP Savings – Prescribing (£ 0. 9 m) – GMS (£ 0. 8 m) 24
Main Budget Changes – ICO and Community Services • Contract with BCS adjusted to reflect service transfers, commissioning intentions for 11/12 and QIPP savings for 11/12. • Service transfers from BCS – Brent Rehabilitation Service (£ 1. 1 m) to NWLH as part of STARRS service – Peel Road transfer (£ 0. 85 m) to Local Authority – Community team for Learning Disabilities (£ 0. 77 m) to CNWL – Substance Misuse Project – (£ 0. 47 m) to CNWL • QIPP savings – £ 0. 9 m – subject to in-year review 25
CQUIN – BCS (ICO) • To follow 26
Main Budget Changes – CSP Investments Smoking Cessation Health Checks Immunisation Breastfeeding STARRS Case Management Chlamydia End of Life Care UCC at CMH Performance investment increase in performance fund from £ 2. 28 to £ 3. 00 Kilburn MSK extension for 6 months Re-provision for additional QIPP cost of staff working notice during April - June Balance of in-year investments Total Status Agreed 10/11 Subject to BC Agreed 10/11 Subject to BC Agreed 10/11 Subject to BC Recurrent £'000 1, 001 520 242 124 4, 031 259 477 254 1, 714 8, 622 Non. Recurrent £'000 1, 000 250 150 300 175 3, 620 5, 495 27
Main Budget Changes – Corporate/Running costs (1) • National Operating Framework 2011/12 – Running cost = any cost incurred that is not a direct payment for the provision of healthcare or healthcare related services – By 2014/15 the overall running costs of the new NHS structure, compared to the running costs of the current NHS structure, will decrease by one third – Expectation that GP Consortia will spend between £ 25 - £ 35 per head on running costs by 2014/15 • Brent and Harrow staffing structures designed to fit within above indicative envelope – approximately £ 30/head • In budgeting for 11/12, assumed split of costs for corporate functions calculated at 62% (Brent) and 38% (Harrow) • Figures (see next slide) exclude additional non-recurrent support from Sector for QIPP delivery 28
Main Budget Changes – Corporate/Running costs (2) 29
Main Budget Changes – Corporate/Running costs (3) Corporate costs savings BRENT HARROW London inc CSL Sector PCT Total £ 000's 10/11 1, 053 1, 197 13, 556 15, 806 Change (359) 483 (3, 846) (3, 722) 11/12 694 1, 680 9, 710 12, 084 % change (34%) 40% (28%) (24%) Running costs savings London inc CSL Sector PCT Total £ 000's 706 761 7, 631 9, 098 (272) 269 (1, 907) (1, 910) 434 1, 030 5, 724 7, 188 (39%) 35% (25%) (21%) (excludes primary care, FHS and public health, includes estates) BRENT London inc CSL Sector PCT Total £ 000's 10/11 1, 053 1, 197 11, 293 13, 543 Change (359) 62 (3, 872) (4, 169) 11/12 694 1, 259 7, 421 9, 374 % change (34%) 5% (34%) (31%) HARROW London inc CSL Sector PCT Total £ 000's 706 761 6, 299 7, 766 (272) 11 (1, 977) (2, 238) 434 772 4, 322 5, 528 (39%) 1% (31%) (29%) 30
Main Budget Changes - Estates • • • Budget transfer of Estate responsibilities from BCS, including 31 staff FYE of Chalkhill & Hillside incorporated Loss of income from NWLH at Willesden (£ 0. 4 m) Creation of revenue maintenance budget (£ 0. 3 m) Inflation - £ 0. 3 m Savings - £ 0. 1 m 31
QIPP summary • • • Detailed QIPP plans set out on next slides QIPP plan prepared prior to contract finalisation and are therefore subject to initial contract agreement and then delivery Summary of Brent and Harrow’s position below: Brent Harrow £m % 10/11 plan actual % delivery 11. 7 8. 3 71% 2. 2 1. 5 - 18 12 67% 5. 5 3. 6 - 11/12 plan 13. 9 2. 6 12 3. 6 • Note: above excludes additional in-year savings – un-quantified for Brent, £ 2 m for Harrow • Cluster wide risk assessment applied pre-contract finalisation. Post contract finalisation, QIPP plans have a higher risk profile Green: 90% > Detailed plans in place with clearly defined financial savings trajectory > Evidence of implementation or preparatory activity > Low level of risk or barriers to implementation Amber: 60% > Scheme defined with evidence of plans and approach to implementation > Little progress achieved or savings > Medium level of risk or barriers to implementation Red: 30% > Proposed scheme identified, but little or no evidence of financial target, commencement date or implementation plans > High risk due to implementation costs or stakeholder buy in 32
QIPP Plans (1) 33
QIPP Plans (2) 34
QIPP monthly delivery expectations 35
QIPP Savings by category and provider Provider impacts: • Acute – • Community – • Mental health – • Primary care – • Other - £ 5. 8 m £ 1. 1 m £ 3. 3 m £ 1. 7 m £ 2. 0 m £ 13. 9 m 36
QIPP Savings by category and risk assessment Risked: • 100% • 90% • 60% • 30% £ 6. 5 m £ 5. 3 m £ 2. 0 m £ 0. 1 m £ 13. 9 m 37
Capital • In 2011/12 PCT’s no longer have delegated responsibility for capital projects. All new capital projects must be approved by the SHA; • Initial capital resource limit (CRL) of £ 375 k has been granted for fire and health and safety works. 38
2011/12 Budgets Sign-off and in-year management The 11/12 budgets sign-off and in-year management process will be consistent across Brent and Harrow as follows: Date – SBS implemented across Brent and Harrow 1/4 – Financial risk management plan agreed by Board (see slides 40– 47) 14/4 – Governance and reporting structure agreed by Board (see slide 48) 14/4 – Budgetary responsibilities will be documented and signed off by all budget holders 30/4 – New financial management support arrangements to Boroughs/ GPs in place 30/4 – Budget holder refresher training provided (including finance guide for managers) 31/5 – A development programme for finance managers will be in place 30/6 39
In-year Financial Risk assessment Risk Impact Likelihood Total RAG Mitigations 5 x 5 1. In-year acute overperformance 4 4 16 See slides 47 -42 2. Demand management - QIPP 4 4 16 See slides 43 -44 3. Other QIPP delivery 4 4 16 See slide 45 4. In-year cost pressures 4 4 16 See slide 46 5. Further in-year savings 4 4 16 See slide 47 40
Risk area: In- year acute over-performance – in Sector Risk 1. 2. 3. 4. Planned Procedures with a Threshold - anticipated reductions do not materialise Outpatient ratios – discharge of patients results in clinical risks and/ or additional costs in primary care Internal factors such as improved counting and costing and shift of elective work not undertaken in final weeks of 2010/11 drive unplanned over activity External factors e. g. winter pressures drive unplanned demand Current risk Rating (5 x 5) Actions SRO 4 x 4 • Structured project management • Clinical engagement with local GP work shops and primary/secondary care workshops • Contract monitoring in – year GS 4 x 4 • Detailed dialogue between primary and secondary care clinicians under auspices of Clinical Quality Group • Management of transfers of follow up patients by GP consortia GS 4 x 5 • Careful monitoring of median elective waits by ACV • Careful monitoring, enquiry and enactment of subsequent activity management plans for any unexplained shift of activity indicating counting and coding changes GS 4 x 3 • Early dialogue with providers on flexibility of elective planning within eighteen week scope • Secure winter planning processes in place GS Controls and assurance sources (e. g. systems in place and how we gain evidence on effectiveness of systems) ACV contract monitoring and application of contractual levers and claims management combined with active budgetary management by clinical commissioners – claims yield, queries raised and resolved 41
Risk area: In- year acute over-performance – out of Sector Risk 1. 2. Out of Sector contracts – over performance results from poor claims management and challenges and inability to negotiate commissioning intentions with lead commissioners Out of Sector - over performance results from absence of local demand management plans Current risk Rating (5 x 5) 5 x 4 Actions • Claims management and challenges rationalised and aligned with lead commissioners • Structured baseline setting established for 2011/12 • Exchange of intentions with other sectors backed up by dialogue • Dedicated OOS team at ACV • Demand management schemes designed, scoped and risk assessed • Clinical commissioners actively engaged through improved reporting and follow up action on OOS performance SRO GS JO Controls and assurance sources (e. g. systems in place and how we gain evidence on effectiveness of systems) Improved reporting of OOS activity with specific action plans – utilisation of reporting and action plan milestones and outcomes 42
Risk area: Demand management – QIPP (1) Risk 1. 2. 3. CMH UCC outsourcing – Over performance reduces opportunity to realise savings. End of Life – revised community pathways do not reduce acute admissions. Case Management – revised treatment in the community does not reduce non-elective admissions. Current risk Rating (5 x 5) 4 x 4 Actions • Monitor activity for triggers of over-performance and ensure ‘send away’ stream is operating effectively. • Plan local workshops with GPs and nursing homes to gain buy-in for new way of working, ensure referral mechanisms for new pathway are known and publicised. • Set clear KPIs for service improvement and monitor referral patterns. Action to improve performance. • Frequent review of case managed patient workload for admission profile changes; monitor use of risk stratification tool. • Monitoring of admissions at a practice level and interventions to support improvement in individual/practice level disease management as required. SRO JO JO JO Controls and assurance sources (e. g. systems in place and how we gain evidence on effectiveness of systems) • CRO and SRO project ownership. Milestone plans, activity and finance monitored through frequent project reporting to project team & PMO, supported by information and finance team. 43
Risk area: Demand management – QIPP (2) Risk 4. STARRs – revised pathways do not reduce non-elective admissions & A&E attendances. Current risk Rating (5 x 5) 5 x 4 Actions • Monitor referrals to service at GP level and compare to NEL admissions. • Reinforce use of the SPA service to GPs to ensure consistent referrals. • Monitor STARRS team regarding emphasis on admission avoidance vs discharge. SRO JO Controls and assurance sources (e. g. systems in place and how we gain evidence on effectiveness of systems) • CRO and SRO project ownership. Milestone plans, activity and finance monitored through frequent project reporting to project team & PMO, supported by information and finance team 44
Risk area: Other QIPP delivery Risk 1. 2. 3. 4. Prescribing – GP prescribing does not operate within budget. ICO efficiencies not realised to release savings. Mental Health efficiencies not realised. Primary Care list validation – number of ‘ghost’ patients not at expected level. Current risk Rating (5 x 5) 5 x 4 4 x 4 Actions SRO • Individual budgets allocated by practice (devolved to GP commissioners). • Monitoring of usage at practice level and early support provided to understand improvement areas. JO • Willesden beds function and staffing levels evaluated. • Service reviews undertaken to release savings. • Assess individual patients. • Provide alternative service where appropriate. • Ensure correct process for evaluating patients has been followed. JO JO JO Controls and assurance sources (e. g. systems in place and how we gain evidence on effectiveness of systems) • CRO and SRO project ownership. Milestone plans, activity and finance monitored through frequent project reporting to project team & PMO, supported by information and finance team. 45
Risk area: In-year cost pressures Risk 1. Acute over-performance 2. Specialist commissioning 3. Prescribing 4. Continuing care 5. External events e. g. flu, national initiatives Current risk Rating (5 x 5) 4 x 4 4 x 3 Actions • See earlier slides • Review monthly update from LSCG • see earlier slides • strong budgetary control processes • awareness of environmental changes SRO GS/JO JO JO Controls and assurance sources (e. g. systems in place and how we gain evidence on effectiveness of systems) • Strong monthly budgetary control focus 46
Risk area: Further in-year savings Risk 1. 2. 3. 4. Planned care – revised pathways can not be commissioned at lower cost than acute tariff. Planned care – referral management does not reduce activity. Collaborative services with LBB do not offer efficiency savings expected. ‘bottom-up’ consortia savings not realised. Current risk Rating (5 x 5) 4 x 4 Actions • Model expected cost. • Test market prior to full tender process. • Monitor referrals at practice level. • Act to understand high referring practices and monitor outcomes (including peer challenge). • Create clear business case and specification • Clear budget allocation (and responsibilities). • Monitor usage of services. • Each consortia to develop plans, peer challenge at GPCE. • Lead CRO in each consortia. SRO JO JO Controls and assurance sources (e. g. systems in place and how we gain evidence on effectiveness of systems) • CRO and SRO project ownership. Milestone plans, activity and finance monitored through frequent project reporting to project team & PMO, supported by information and finance team. 47
In year financial management Governance and reporting structure Board GP Commissioning Executive Review monthly financial position of budgets (indicative and devolved) including GP consortia performance Finance Quality & Performance Committee Audit Committee Reviews overall financial position focussing on key variance, risks and medium term planning Reviews overall financial management system of internal control and Board Assurance Framework Receives: • Mthly Finance & Activity report • Mthly QIPP/Performance dashboard • Qtly MTFS update Receives: • Internal & external audit reports • Qtly Finance reports in annual – account format • Board Assurance Framework In addition to the above : QIPP Performance monitored by Project Boards – Mthly Finance reports to all practices 48
QIPP Monitoring Process GP Commissioning Executive QIPP performance dashboard Cluster PMO Summary of actual vs planned Project boards Clinical RO Senior RO Project Highlight report Sub-Cluster PMO (Strategy & QIPP) Milestone plans Risk log Financial tracking Activity tracking • • Each project has a highlight report which contains the key project management elements to deliver a successful project. The highlight reports are used within the project boards to update on progress. The highlight reports are collated on a fortnightly basis and summarised into a QIPP performance dashboard. The dashboard is reported to our GP Commissioning Executive and to the cluster programme management office. 49
Contingency plans • Brent has surplus plan, low QIPP but significant risks to delivery • Harrow has break-even plan, high QIPP including additional in-year savings plan, with potential £ 5 m gap • To enable plan sign off by the PCT Board, Sector and NHS London, Brent has identified non-recurrent £ 5 m in-year contingency, sourced from: – 0. 5% contingency reserve (£ 2. 7 m) – CNWL rebasing (£ 0. 4 m) – Emergency readmissions benefit (£ 0. 5 m) – Non-elective thresholds (£ 1. 4 m) • This will be held by Brent and only released in-year (none, part or all) subject to: – – Brent able to achieve its control total Peer review of Harrow to provide assurance that all measures being taken Harrow delivery of 11/12 QIPP and additional in-year savings plan Harrow has developed plans for 12/13 to enable repayment • As part of reaching this agreement, the Cluster will be asked to: – prioritise Brent’s use of non-recurrent funding to enable continuation of local GP incentive scheme at £ 3 and support Brent’s plans for referral management and pathway development – help find a solution to Kingsbury and Kilburn premises issues – confirm no financial support will be required for NWLH – support the accelerated development of GP Commissioning in Brent including the release of the £ 2 per head to support GP Commissioning development locally – confirm that Brent’s surplus in 11/12 will be carried forward to 12/13 50
Underlying financial position and Financial outlook for 12/13 onwards (1) The financial forecast for 2012/13 - 2014/15 has been developed for Best, Mid and Worst case scenarios reflecting the following assumptions : - • Resource Limit : - » Best case - continues at 2011/12 levels - 2% per annum » Mid and Worst cases - 0% growth after 2011/12 reflecting Brent’s capitation position • Net Tariff Deflator: - » Best case -1% per annum from 2012/13 » Mid and Worst cases - 0. 5% on acute services only from 2012/13 • Cost increases from demographic and other pressures: » All scenarios - 4% per annum • Achievement of 2011/12 Savings (QIPP) Programme: » Best and Mid cases assume 100% achievement » Worst case assumes 50% achievement • All financial scenarios have been developed on a PCT ‘do nothing’ basis i. e. no further savings after 2011/12 51
Underlying financial position and Financial outlook for 12/13 onwards (2) 52
Identification of other QIPP opportunities and planning for 12/13 Data of current service use across QIPP buckets Benchmarked opportunity in key areas Borough managers evaluation of current services Joint GP commissioner and Borough Manager use information to formulate opportunities Size of opportunity scoped & project overview completed GP Commissioning Executive agree initiative Continuous review process over next 3 months. Final sign off, end June. 53
Part 2 – Performance plans 2011/12 54
Health Context • • The life expectancy of men living in the least deprived parts of the borough is over 8 years higher than for men living in the most deprived parts. The difference is over two years for women Over the past 10 years the rates of deaths from all causes has fallen however the rate of early deaths from stroke and heart disease remains worse than the England average The proportion of children living in poverty is worse than the England average One in four people in Brent smoke causing approximately 290 deaths per year Almost 20% of Brent’s Adult population are estimated to be obese. Approximately 2/3 rds of Brent's population are estimated as not eating the recommended amount of fruit and vegetables per week. Over half of our population is not taking part in any form of physical exercise High and increasing prevalence of diabetes, HIV and TB Ø Brent is ranked 11 th in London for male all age all cause mortality rates and 12 th for female. Ø CVD mortality rates place Brent 18 th and cancer mortality rates ranked 14 th. 55
Performance Targets 2010/11 – 2011/12 • Overall framework – CQC overall measurement dropped but focus on improved performance maintained – 10/11 Operating Framework revised in June 2010 – 11/12 Operating Framework published in December 2010 § Suite of Headline measures and supporting measures to measure Quality (safety, effectiveness and patient experience) • The NHS Outcomes Framework for 11/12 was published in Dec 2010 – a number of indicators have moved from the Operating Framework into the Outcomes framework. For 2011/12 no targets are set and, for many of the indicators, reliable information is not yet available 56
Brent 10/11 Plan – overall approach • Brent’s performance transformation programme centred around four elements: Top team alignment; Performance culture; Performance transformation building blocks and Releasing the potential of primary care Top Team Alignment • Bi-weekly performance EMT meetings to update and identify risks and issues to delivery – regular escalation and analysis by EMT to ensure mitigating actions can be implemented quickly Performance transformation building blocks • Focus on development of high quality delivery plans • Extensive programmes to support key targets, supported by NR funding • Robust social marketing plan to support delivery Performance culture • Dedicated Performance Delivery team to support leads • Weekly dashboards created • Data utilised to inform decisions Releasing the potential of primary care • Performance Bond introduced for GP Access and Patient Experience, Immunisations, Smoking and Maternity to support improved performance in Primary Care • Engagement between clinical leads and commissioning leads on performance 57
Brent 10/11 Plan – mid year review • A mid year review was undertaken to enable the PCT to review progress against the performance management approach taken in 2010/11. • A stock take of where the PCT was in terms of addressing the issues highlighted, was essential in understanding if/where more needed to be done to support delivery in the 2 nd half of 10/11 onwards. • Overall the responses were very positive in all key areas with Performance Culture and Performance Transformation Building Blocks being the strongest categories with (73%) and (72%) respectively of respondents agreeing these were in place or nearly in place. • Performance Delivery and Releasing the Potential of Primary Care were the areas identified as needing further work although it was evident that improvements in these areas had also been made. • A number of actions to take forward were developed and have been encompassed in 11/12 planning 58
Performance delivery 10/11 • • • The achievement is based on the current months performance (although this may relate to a previous month due to the availability of data) Where a table indicates progress, the progress relates to the most recent published data where available or monthly or weekly leading measures for each indicator. The tables do not forecast the end of year performance National Priority Indicators 09/10 December January February Achieving 7 9 8 8 Under - Achieving 5 8 10 11 Failing 11 6 5 4 • Note Access to Primary Care has been removed from the National Priorities for 2010/11 following the revision to the 2010/11 operating framework National Commitments 09/10 December January February Achieving 9 8 8 8 Under - Achieving 1 2 2 2 Failed 0 0 • Ambulance response times (Cat B in 19 minutes) and Early Intervention psychosis are underachieving 59
• absolute movement – unable to specify date as not all are 09/10 comparatives 2009/10 & 2010/11 National Priorities (excl. 3 cancer mortality rates) 09/10 fail underachieve Smoking quitters Movement within band 10/11 score as at Feb 11 Ranking* +/- Not available n/a underachieve 16 +4 fail achieve 20 +10 Breastfeeding fail underachieve 14 -1 Drugs misuse fail underachieve Not yet available n/a Maternity fail 18 +9 Staff satisfaction underachieve Not yet available n/a Dental access underachieve 29 -1 Chlamydia screening achieve underachieve 7 +11 C. diff. achieve 21 -8 achieve underachieve 15 (admitted) 17 (non-admitted) -7 +1 Cancer waits - 2 weeks achieve 8 +7 Cancer waits - 62 days achieve 1 +12 Cancer waits - 31 days achieve 2 +5 Stroke care fail achieve 3 +24 Teenage conceptions fail 17 -5 Childhood obesity achieve 6 +20 Breast screening fail underachieve 21 +10 achieve - - underachieve 27 (25 -49 yrs) 17 (50 -64 yrs) 0 0 Patient experience Immunisation 18 weeks CAMHS Cervical screening *against 31 London PCTs. Ranking based on latest available data – Q 3 where available compared to Q 4 09/10 60
Approach to 11/12 Plans Top Team Alignment • GPCE identified areas for key focus (Smoking, Immunisations, GP Access and Patient Experience, Cervical and Breast Screening) • Performance as a standing agenda item at GPCE Performance transformation building blocks • Working with performance leads to develop robust plans for delivery of 11/12 targets with focus on risks and issues to performance • Programmes to support key targets, supported by NR funding (TBC) • Robust social marketing plan to support delivery (TBC) Performance culture • Fortnightly dashboards for key areas of focus • Public Health now leading on most indicators (lesser impact on capacity following restructure) Releasing the potential of primary care • Performance Bond for GP Commissioners incorporated in overall ‘use of resources and outcomes’ incentive scheme • Clinical Director leads identified for each area with input into 11/12 planning 61
11/12 Plans SRO Target SB Immunisations - % uptake of immunisations 11/12 Target Age 1 DTa. P_IPV_Hib 95% Age 2 PCVbooster 92% Hib_Men. Cbooster 92% MMR 90% Age 5 DTa. P_IPVbooster 85% MMR 90% Movement from FOT + 0. 5% + 4. 7% + 4. 1% +3. 5% Cervical Screening - % of women with an expected date of delivery screening test result within 14 days of the test being taken SB Breast screening – Uptake 50 -74 yrs & percentage of women aged 47 -49 &71 -73 invited for screening • Monitor & support practices to operate effective call/recall process • Development of practice immunisation action plans • Explore facilitation of a dedicated Imms team to reach out to DNAs • Explore implementation of evening and weekend clinics and home visits +8. 8% +20. 3% HPV 90% SB Key Actions/Activities +10% Coverage 25 -49 yrs 67% +5% Coverage 50 -64 yrs 80% +9% Results received within 14 days 100% +6% Uptake 50 -74 yrs 60% +6% Percentage of women invited (new measure) awaiting target n/a • Telephone follow up of DNA’s and reinvite previous DNAs • Targeted social marketing for hard to reach groups • Implement Cervical Screening action plan to promote screening and increase access & choice • Targeted telephone follow up of DNAs • Targeted social marketing for hear dot reach groups • Systematic liaison with GP practices – training, data management, reminder flags, screening list validation 62
11/12 Plans SRO Target SB 11/12 Target Bowel screening - Percentage of adult Movement from FOT Key Actions/Activities • Roll out of pilot to test feasibility of telephone follow up of DNAs • Targeted social marketing plan population aged 70 -74 23% invited for bowel cancer screening - Uptake of 60 -69 yr 42% olds SB +1% 2400 +40 • GP Scheme to increase activity from 36% to 40% • Improve access to BSSS core clinics • Health check programme – imbed referral pathways & support clients & providers Prev: 72. 7% Cov: 95. 2% Prev: +2. 5% Cov: +1. 9% • BFI stage 2 – audit and clinical practice for health visiting staff • Launch of Baby Friendly Initiative (pending agreement) • Peer Support workers continuing working in community and acute settings 90% +20% • Ensure GPs use choose and book to ensure referrals are received by providers in a timely manner • Continue social marketing to improve awareness among late presenting communities • Audit of late bookers by NWLH to inform further actions to improve access Smoking Quitters - number +3% of 4 week quitters SB Breastfeeding - prevalence of breastfeeding at 6 -8 weeks JO Early Access to Maternity - % of women who have seen a midwife or a maternity healthcare professional, by 12 weeks and 6 days 63
11/12 Plans SRO Target JO Dental - Number 11/12 Target 174, 370 Movement from FOT Key Actions/Activities +9942 (tbc) • Publicise dental messages to public • Focus on call/recall levels • Re-attendance rates of contractors to make sure they are not higher than London averages of patients receiving NHS primary dental services within a 24 month period JO Patient Experience GP access (linked to appointments) (Questions and domain groupings not yet confirmed by DH) • Follow up from ACE programme – focus on practices that have not made changes • Plans in development as part of proposed GP incentive scheme SB Health Checks 1) Invited: 90% of eligible population 2) Received: 50% of eligible population receive check • Roll out health checks across whole Borough • Scheduled programme of GP support visits by PH team • Facilitation of GP cluster delivery plans - 1) the percentage of people eligible for the NHS Health Check programme who have been offered an NHS Health Check 2) the percentage of people eligible for the programme who have received a NHS Health Check (40% uptake achieved in 10 pilot practices in 10/11) 64
11/12 Plans • The Director of Acute Commissioning will be the responsible officer for the monitoring and performance of acute targets: Cancer waits Stroke Care Emergency readmissions PROMs scores Low value procedures VTE risk assessment • Referral to treatment waits (median wait measures) A&E quality indicators In addition, the Sector will be responsible for the monitoring and performance of: Ambulance quality indicators 65
11/12 Plans • The Director of Public Health will also be the responsible officer for the monitoring and performance of health outcomes HCAI (C. dif and MRSA) • Childhood obesity Diabetic retinopathy The Borough Director will also be the responsible officer for the monitoring and performance of the following: % deaths at home LTCs – people feeling independent and in control of their condition Mental Health – IAPT, Early Intervention in Psychosis, CPA, Crisis Resolution Safeguarding Carers breaks Community services LTC – emergency readmissions 66
Risks and mitigations Risk Impact Likelihood Total RAG Mitigations 5 x 5 1 Lack of capacity 4 2 3 Specific and significant challenge in primary care - Majority of red indicators have a link back to the GP workforce Various sub-issues within targets - Each target/indicator has a number of issues. 4 4 4 16 16 Majority of targets held by a single SRO however lesser impact on capacity following restructure in Public Health than elsewhere in the PCT Cervical screening, access, patient satisfaction, smoking cessation, immunisations etc. have a heavy reliance upon GPs for delivery List inflation is potentially increasing the actual targets of a number of indicators 4 4 16 Ongoing monitoring and escalation of issues 4 5 Potential silo’d working - Teams working on similar initiatives rather than combining efforts under one initiative 4 3 12 Unable to maintain improvements in performance culture/top team alignment 4 4 16 3 cross-target initiatives identified : • List cleanse • Data collection from GPs • Social/ behavioural marketing • Monthly dashboards for key areas of focus • Performance a standing agenda item on the CCB 67
Part 4 – GP Delegation Contents 1. 2. 3. 4. 5. 6. 7. 8. 9. Background – NWL context Budget setting options: Indicative vs. Delegated budgets Fair shares methodology Fair shares pace of change comparison Acute risk pool arrangements Prescribing budget setting Budget allocation 11/12 Incentive scheme Reporting 68
Background – NWL context (1) NWL principles • Consortia will have assumed delegation for all services by 31 st March 2012 • Consortia progressively achieve delegation for increasing range of services based on ability to demonstrate performance management capability • This a learning process for both Consortia and Transition management • Maintaining a strong grip on performance and finance this year • Commissioning support funding given to Consortia will supplement existing management resource • The Cluster ACV and Borough based teams are fixed points • The Cluster CEO will remain the Accountable Officer and consortia are bound by PCT governance and financial rules 69
Background – NWL context (2) • Grouped services into 3 bundles Complexity of service matrix Clinical Service vision Financial risk Performance risk Bundles Low – services that GPs can influence directly through patient consultations Medium – majority of services High – services where each individual GP has least control and in influencing 70
Background – NWL context (3) Bundles Low High Prescribing Community health Community mental health services/IAPT Community Paediatrics Direct access diagnostics Outpatients (GP referrals only) Sexual health Critical care Specialist mental health Continuing care Non Pb. R drugs and devices (unless there is an SLA cap) Medium Acute Paediatrics Elective care Urgent Care – A&E / UCC Urgent care – inpatients Maternity End of Life Care Non GP-referred outpatients Intermediate Care Re-ablement Voluntary Sector CAMHS Inpatient mental health Physical disability Pathways spanning multiple providers eg. care of elderly Services provided by GPs in primary / community care settings (low risk but high governance requirement to managing conflicts of interest) Services provided by non NHS providers 71 71
Background – NWL context (4) Four phases for taking on delegation 1. Now – 30 th June – Any low complexity service + some medium 2. 1 st July – 30 th Sept – Any medium complexity service – Requires 3 months evidence of good performance management system in place 3. 1 st Oct – 31 st Dec – Any high complexity service 4. 1 st Jan – 31 st Mar – No new services delegated – Preparation for full delegation from 1 st April 2012 72
Background – NWL context (5) Assurance process – five steps 1. Description of the basic governance arrangements required for delegation of any commissioned service 2. Completion of a planning and assurance template for the commissioned services consortia wish to take responsibility for 3. A presentation by the consortia and relevant borough/sub cluster team to NHS NW London Cluster Chief Executive 4. Approval of the Cluster decision by NHS London 5. Signing of a Cluster- Pathfinder agreement for the services delegated. 73
Background – NWL context (6) Key lines of enquiry for Consortia governance • Constitution which sets out the clinical leadership structure • How the GP practices work in partnership, and with the relevant sub cluster / borough management team and sub cluster board • Mechanisms in place to deliver engagement with patients and LAs • How GPs in the Consortia will be involved in the decision making process. • How conflicts of interest that may arise will be managed • How the Consortia will set and agree budgets between practices • How the Consortia will share financial risk and manage over/under spends 74
Background – NWL context (7) Key lines of enquiry for each delegated services • Indicative timescale for the delegation • Value of all the budgets being delegated. • Vision for each of the services taking delegated responsibility for • Clinical and financial outcomes are wishing to achieve this financial year • What elements of the borough QIPP programme are covered by these services and what plans are in place to deliver these QIPP initiatives • What are the critical clinical, financial and operational risks? • Performance management approach for the services - what information will you use and where will the Consortia obtain it from? • What management / commissioning support will you require to manage these delegated services and who will provide it? 75
Budget setting options: Indicative vs. Delegated budgets ØIndicative Budgets • Formal budget holder status remains with PCT – budgetary performance reported to GPCE/GPs ØDelegated Budgets • GPCE (Chair? ) to have formal budget holder status, accountable to CEO with responsibilities as per SFI’s. • Clinical Directors have delegated budget holder status, accountable to (GPCE chair? ) • It is proposed that as much as possible is reported as an indicative budget with delegated budgets to be agreed in line with Sector guidance as stated in the “NWL Delegation of responsibilities to GP Consortia”. 76
Fair shares methodology (1) • It is recommended by DH that PCTs calculate practice indicative budgets using “fair shares” and that they move towards fair shares; • The DH have developed a ‘Person Based Resource Allocation formula’ (PBRA) which is embedded in the toolkit published for PCTs for the purpose of allocating budgets to GP practices; • In developing the model the Nuffield Institute looked at using a number of markers as predictors of health use. They concluded that the use of morbidity markers based on 152 ICD 10 groups gave the most robust predictions, and that QOF based disease practice disease prevalence rates were no substitute for these markers 1. • Fair shares are calculated using DH 2011/12 Test Toolkit, making use of GP list size demographics information (e. g. age/Sex) weighted percentages, the percentages included are: Brent Element Acute Share Maternity Share MH Share Prescribing Share Inequalities Share Total Weighting 57. 7% 5. 6% 17. 2% 9. 3% 10. 2% 100. 0% • 1 Developing a person-based resource allocation formula for allocations to general practices in England The Nuffield Trust 77
Fair shares methodology (2) • There a number of options as to the calculation of the pace of change movement to fair shares target. » Setting a standard maximum movement +/- to fair shares target applied to all practices e. g. options could be 2% or 3% maximum change or 100% move to capitation; » Setting a differential pace of change movement depending on the distance from fair shares target and the maximum number of years to move to target e. g. all practices to move to targets by 2013. • In fair shares calculations we specifically exclude: » The acute risk pool spends from the outturn and fair shares calculation in order that the calculations are not distorted; » Unallocated budget for activity that cannot be specifically apportioned to Practices would also be excluded from both the outturn and fair shares calculation to enable practice shares to be accurately calculated; » GP Access Centre due to the nature of its population growth. • The fair shares target will be calculated including prescribing. 78
Fair shares pace of change comparison Pace of change adjustment at locality level under recommended option Gain +, Lose ( ) Localities Harness Kilburn Kingsbury Wembley Willesden Total Fairshares movement Adjustment to 50% of @ 100% capitation movement in 11/12 £'000 8 (4) 194 (97) (230) 115 46 (23) (18) 9 0 0 Combined 10/11 Acute Net movement in Pb. R and Prescribing Change over 11/12 FOT 10/11 FOT £'000 % 4 38, 934 0. 01% 97 38, 089 0. 25% (115) 33, 733 (0. 34)% 23 29, 421 0. 08% (9) 24, 025 (0. 04)% 0 164, 202 1) Locality figures are based upon 10/11 Forecast figures and they include Acute Pb. R and prescribing values. 2) This calculation excludes GP Access Centre, spend unattributable to the practices and spend assigned to risk pool. 3) The PBC management leads recommendation is based on the twin aims of moving all practice budgets to within the fair shares threshold by April 2013 but meant that the budgets are deliverable for those practices who are losing. 4) The recommendation to use the DH fair-shares toolkit for acute Pb. R and prescribing spend and to move to capitation over 2 years is due to be considered by the GPCE on 13 th April. 79
Acute risk pool arrangements • The national guidance suggests that practices contribute 3 -5%of their indicative budget to a risk pool; • The currently agreed criteria for the risk pool, that is used for spells costing more than £ 10 k; • Any under/overspend on the acute risk pool at the end of the year is allocated to practices pro-rata to initial contributions. 80
Prescribing budget setting (1) 10/11 Prescribing budget Forecast out-turn @ Jan 11 (1. 3% o/s budget allocation) 36, 739, 272 £ 37, 208, 421 Add 10/11 Cost pressures @ 5% £ 1, 860, 421 Less 11/12 QIPP savings target (1, 023, 363) 11/12 prescribing budget allocation % Increase on 10/11 budgets £ 38, 045, 479 3. 56% 81
Prescribing budget setting (2) • No validated national/local satisfactory formula to take into account all influences on GP prescribing costs at a practice level; • National recommendation = prescribing budgets should not be based on or relied upon either on total capitation or total historic budgets, but should be set on a mix of weighted capitation methodology, historic budget patterns and local judgement; • For 11/12, the management leads recommend that: – a policy is set for the next two years – To include prescribing in the DH fair-shares toolkit – An adjustment is made to reflect the impact of nursing home registration – that in 11/12, the budget setting policy would be to apply the uplift and savings consistently across all practices – that from 12/13, a lower uplift / higher savings targets would be applied to those practices that had not kept within the 11/12 prescribing budget 82
Incentive scheme • Unified Incentive schemes for 11/12 following on : A. Improved Clinical Outcomes - Performance priorities B. Delivery of QIPP C. Effective use of resources - Achieving financial balance on indicative budgets - Measured at locality level • Total recurrent budget £ 2. 28 (reduced as per Clinical Commissioning business case), proposed to be increased non recurrently to £ 3 83
Reporting Proposed Reporting framework (in development) 1) Finance slide pack (Monthly) Overview of financial position, covering information and analysis of practice over spends/under spends. 2) Summary Variance report Practice level (Monthly) Covers the cost and activity variances at practice level & by different budget headings. 3) Practice level reports (Monthly) Reports at practice level containing detailed information by provider, point of delivery and specialty. 4) Backing Data (Monthly) We are planning to implement a web based reporting tool that will provide drill down to patient level data. Also, backing data at patient/practice level for these areas will be available to practices: • In Health • Walk in Centre; 1) Non Contracted Activity; 2) Direct Access; 3) A&E. 5) Benchmarking pack (Quarterly) Activity and financial benchmarks and trends for each practice compared with others 84
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