Financial Overview of the BHR CCGs · Financial Overview of the BHR CCGs Barking and Dagenham Health Scrutiny Committee 22 October 2019 Sharon Morrow, Director of Transformation and

Financial Overview of the BHR

CCGs

Barking and Dagenham Health Scrutiny Committee

22 October 2019

Sharon Morrow, Director of Transformation and Delivery – Unplanned Care

Mark Eaton, System Director of Recovery for Barking and Dagenham,

Havering and Redbridge

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Appendix 1

Presentation overview

• CCG Spend Breakdown

• Overview of the 19/20 Financial Position

• NHS Financial Position to 23/24

• Financial Benchmarking for the BHR CCGs

• Closing the Excess Spend Gap

• System Efficiencies with >£1m Net Benefit

• Mental Health Parity of Esteem

• Prevention Investments by the NHS

CCG Spend Breakdown

(B&D CCG)

NHS Barking & Dagenham CCG

Annual

Budget

£’000

ACUTE

In Sector Acute Trusts

Barking Havering And Redbridge Hospitals NHS Trust 100,339

Barts Health NHS Trust 25,436

Homerton University Hospital NHS Foundation Trust 2,269

Total In Sector Acute Trusts 128,043

Total Out of Area Acute Trusts 12,537

Total Other Acute 25,488

TOTAL ACUTE 166,069

Total Mental Health 34,124

Total Community Health 34,882

Total Continuing Care 17,187

Total Other Non Acute 16,056

TOTAL NON ACUTE 102,250

TOTAL PRIMARY CARE 30,433

TOTAL PRIMARY CARE CO-COMMISSIONING 32,416

TOTAL RUNNING COSTS 4,605

GRAND TOTAL 335,773

VARIANCE

RESOURCE LIMIT 334,193

HISTORIC SURPLUS/(DEFICIT) (5,480)

PLANNED SURPLUS/(DEFICIT) 3,900

• This table provides a

summary of the budgetary

spend for NHS B&D CCG.

• Approximate % Breakdowns

are:

o 50% on Acute Care

o 10% on Mental Health

o 10% on Community Care

o 5% on Continuing Care

o 19% on Primary Care

o 5% on ‘Other’

o 1% on Running Costs

CCG Spend Breakdown

(BHR CCGs)

NHS BHR CCGs

Annual

Budget

£’000

ACUTE

In Sector Acute Trusts

Barking Havering And Redbridge Hospitals NHS Trust 365,183

Barts Health NHS Trust 114,529

Homerton University Hospital NHS Foundation Trust 9,123

Total In Sector Acute Trusts 488,834

Total Out of Area Acute Trusts 55,393

Total Other Acute 91,731

TOTAL ACUTE 635,958

Total Mental Health 103,649

Total Community Health 96,047

Total Continuing Care 59,756

Total Other Non Acute 51,737

TOTAL NON ACUTE 311,189

TOTAL PRIMARY CARE 119,900

TOTAL PRIMARY CARE CO-COMMISSIONING 108,463

TOTAL RUNNING COSTS 16,962

GRAND TOTAL 1,192,472

VARIANCE

RESOURCE LIMIT 1,182,623

HISTORIC SURPLUS/(DEFICIT) (20,749)

PLANNED SURPLUS/(DEFICIT) 10,900

• This table provides a

summary of the budgetary

spend for the three NHS

BHR CCGs.

• The approximate

breakdowns are as shown on

the previous slide.

• At the end of 19/20 the

CCGs will have a residual

deficit of £9.8m. This is

expected to be cleared by

the end of 21/22.

Overview of the 19/20 Financial Position

• The Control Total set for the BHR CCGs for 19/20 is a surplus of £10.9m broken

down as follows:

o NHS Barking & Dagenham CCG - £3.9m surplus.

o NHS Havering CCG - £3m surplus.

o NHS Redbridge CCG - £4m surplus.

• As at Month 5 the BHR CCGs are forecasting that they will achieve their control

total for 19/20.

• There is residual risk that the CCGs have mitigated to ensure this position is

delivered including:

o The £10.9m surplus was added to the Control Total in April 2019 (after

contracts were signed) and has been mitigated non-recurrently.

o There is ~£6m of risk associated with the delivery of Commissioner QIPPs

(Efficiency Schemes) that have been mitigated.

o There is additional system risk associated with BHRUT that the partners

have agreed will be mitigated by the BHR CCGs for 19/20.

NHS Financial Position to 23/24

• This table shows the

allocation growth for

NHS B&D CCG out

to 23/24 and the

underpinning analysis

provided by NHS

England around

expected population

growth.

• Allocation growth for

NHS B&D CCG is

above the London

Average.

Programme Baseline 2018/19 2019-20 2020-21 2021-22 2022-23 2023-24

Allocation £k 282,610 302,504 317,713 332,696 346,683 359,761

Growth 19,894 15,209 14,983 13,987 13,078

Total Growth % 7.04% 5.03% 4.72% 4.20% 3.77%

Population Growth 3,858 3,640 3,481 3,251 3,048

Population Growth % 1.72% 1.60% 1.50% 1.38% 1.28%

Growth net Population growth % 5.32% 3.43% 3.21% 2.82% 2.49%

Opening DfT 4.19% 5.13% 5.73% 6.49% 6.92%

Closing DfT 5.00% 5.64% 6.07% 6.31% 4.00%

Primary Care Co-Commissioning 2018/19 2019-20 2020-21 2021-22 2022-23 2023-24

Allocation £k 30,564 32,416 34,099 36,207 37,902 39,622

Growth 1,852 1,683 2,108 1,695 1,720

Total Growth % 6.06% 5.19% 6.18% 4.68% 4.54%




Opening DfT 8.07% 6.76% 7.68% 7.65% 7.51%

Closing DfT 6.9% 6.76% 6.70% 6.71% 6.65% 6.51%

Running Costs 2018/19 2019-20 2020-21 2021-22 2022-23 2023-24

Allocation £k 4,602 4,605 4,061

Reduction 3 -544

Total Reduction % 0.07% -11.81%

Total 2018/19 2019-20 2020-21 2021-22 2022-23 2023-24

Allocation £k 317,776 339,525 355,873 368,903 384,585 399,383

Growth 21,749 16,348 17,091 15,682 14,798

Total Growth % 6.84% 4.81% 4.80% 4.25% 3.85%




Population 2018/19 2019-20 2020-21 2021-22 2022-23 2023-24

Estimated registered population 224,032 227,890 231,530 235,011 238,262 241,310


Population growth % 1.72% 1.60% 1.50% 1.38% 1.28%

NHS Financial Position to 23/24

• This table shows the

allocation growth for

the BHR CCGs to

23/24.

• Allocation growth for

BHR CCGs is, on

average, above the

London Average.

Programme Baseline 2018/19 2019-20 2020-21 2021-22 2022-23 2023-24

Allocation £k 1,009,916 1,076,870 1,127,530 1,178,1231,226,852 1,273,425

Growth 66,954 50,660 50,593 48,729 46,573

Total Growth % 6.63% 4.70% 4.49% 4.14% 3.80%




Opening DfT

Closing DfT

Primary Care Co-

Commissioning 2018/19 2019-20 2020-21 2021-22 2022-23 2023-24

Allocation £k 103,598 108,463 113,900 120,676 126,161 131,782

Growth 4,865 5,437 6,776 5,485 5,621

Total Growth % 4.70% 5.01% 5.95% 4.55% 4.46%




Opening DfT

Closing DfT

Running Costs 2018/19 2019-20 2020-21 2021-22 2022-23 2023-24

Allocation £k 16,955 16,962 14,960

Growth 7 -2,002

Total 2018/19 2019-20 2020-21 2021-22 2022-23 2023-24

Allocation £k 1,130,469 1,202,295 1,256,390 1,298,7991,353,013 1,405,207

Growth 71,826 54,095 57,369 54,214 52,194

Total Growth % 6.35% 4.50% 4.57% 4.17% 3.86%




Population 2018/19 2019-20 2020-21 2021-22 2022-23 2023-24

Estimated registered population 822,785 833,908 844,627 854,953 864,767 874,045


Population growth % 1.35% 1.29% 1.22% 1.15% 1.07%

Financial Benchmarking for the BHR CCGs

• Benchmarking is undertaken both against Demographic Peers

(via the NHS RightCare Programme) and Geographic Peers

(via Local NHS Data). The Geographic Peers consist of the 17

Boroughs of North Central, North East and South East London.

• Against both benchmarking methods the BHR CCGs

overspend in secondary care. Compared to our Geographic

Peers this grew to a maximum of more than £100m/Year in

18/19. Through the work already undertaken this appears to

have dropped in 19/20 to an excess of ~£90m/Year.

• The financial benchmarking on the following slides highlights

why the areas of focus for transformation have been chosen.


• Approximately £30m/Year of the £90m/Year excess is associated with non-

elective activity associated mostly with Older People and people of all ages with

Long Term Conditions as shown in the table below.

• The Older People Transformation Board is focused on helping keep people

healthier for longer, supporting those people at End of Life and reducing the

onset of Frailty and the risk of Falls.

• The Long Term Conditions (LTCs) Transformation Board is focused on both

working on Primary Prevention with Public Health but also focusing on

Secondary Prevention and reducing the number of unplanned care episodes

arising for people with LTCs.

NHS B&D CCG NHS Havering CCG NHS Redbridge CCG BHR CCGs

Reduction Required Reduction Required Reduction Required Reduction Required

Specialty POD Activity TotalCost Activity TotalCost Activity TotalCost Activity TotalCost

Trauma & Orthopaedics NON-ELECTIVE 8 £73,137 242 £1,682,780 4 £248,046 254 £2,001,780

General Surgery NON-ELECTIVE 541 £1,065,817 891 £2,270,064 211 £679,093 1,643 £4,014,373

Geriatric MedicineNON-ELECTIVE

694 £1,724,863 2,669 £8,240,975 1,198 £3,647,292 4,558 £13,605,344

Gastroenterology NON-ELECTIVE 145 £658,553 276 £1,338,452 187 £832,576 607 £2,828,624

Urology NON-ELECTIVE 265 £255,785 487 £644,293 342 £385,929 1,094 £1,285,926

Respiratory Medicine NON-ELECTIVE 154 £602,308 327 £1,308,274 61 £232,765 543 £2,144,735

Nephrology NON-ELECTIVE 254 £489,849 338 £1,048,620 115 £116,923 706 £1,652,746

Endocrinology NON-ELECTIVE 89 £439,563 83 £436,456 146 £635,689 318 £1,513,492

Stroke Medicine NON-ELECTIVE 6 £329,725 82 £923,801 26 £564,773 114 £1,816,589


• Approximately £15m/Year of the £90m/Year excess is associated with excess

Outpatient Activity, much of this associated with patients who are discharged at

the first appointment, have not yet been discharged after finishing their episode

of care, were put into the wrong clinic or required diagnostics before a face to

face appointment. This excess of activity is constraining the ability to achieve

access targets.

• The Planned Care Transformation Board is focused on reducing inappropriate

Outpatient Activity by increasing investment in Out of Hospital support and

services and working with Acute Providers to improve (and streamline) their

Outpatient Services. NHS B&D CCG NHS Havering CCG NHS Redbridge CCG BHR CCGs



Trauma & Orthopaedics

OPFA 1,317 £229,791 3,905 £662,150 3,266 £578,517 8,490 £1,470,877

OPFU 3,011 £219,997 11,302 £820,002 6,553 £505,909 20,871 £1,546,393

OPPROC 1,322 £298,994 2,639 £565,994 1,579 £340,099 5,541 £1,206,223

General Surgery

OPFA 1,851 £391,054 3,086 £610,363 1,909 £402,508 6,845 £1,403,852

OPFU 2,371 £211,980 5,337 £460,208 2,975 £305,175 10,677 £976,986

OPPROC 651 £138,417 1,290 £302,266 832 £176,096 2,773 £617,112

Gynaecology OPFA 4,704 £832,163 4,991 £882,451 3,923 £696,502 13,622 £2,411,669

OphthalmologyOPFA 355 £132,065 111 £93,166 1,050 £282,168 1,521 £508,192

OPFU 1,112 £59,073 6,879 £404,602 3,672 £255,265 11,665 £718,949

CardiologyOPFA 2,883 £174,204 8,578 £735,210 624 £0 12,082 £900,415

OPPROC 723 £120,880 2,961 £517,041 1,695 £266,613 5,382 £904,730

Urology OPPROC 246 £54,285 2,094 £553,004 869 £261,066 3,206 £867,674

Rheumatology OPFU 1,274 £129,893 4,129 £440,982 2,265 £275,336 7,667 £846,423


• Approximately £27m/Year of the £90m/Year excess is associated with excess

spend on Elective Activity. Much of this is associated with care delivered in high

cost settings because of the excess activity in Outpatients preventing people

having timely access to NHS hospitals whilst some relates to services that

should have been provided either as an Outpatient Procedure or in the

community.

• The Planned Care Transformation Board is focused on reshaping how and

where care is delivered including ensuring that the services are provided Closer

to Home and that access rates are improved.

NHS B&D CCG NHS Havering CCG NHS Redbridge CCG BHR CCGs



Trauma & OrthopaedicsELECTIVE

549 £932,566 2,057 £6,285,669 1,435 £3,351,748 4,044£10,572,93

3

General Surgery ELECTIVE 377 £641,938 1,093 £1,855,797 464 £689,444 1,933 £3,184,332

Gastroenterology ELECTIVE 678 £307,249 3,355 £1,615,174 1,906 £915,965 5,940 £2,839,902

Ophthalmology ELECTIVE 4 £0 1,051 £914,380 813 £730,364 1,869 £1,640,794

Cardiology ELECTIVE 0 £0 205 £331,676 240 £374,167 388 £538,883

Urology ELECTIVE 97 £7,497 736 £721,674 364 £385,685 1,199 £1,114,701

ENT ELECTIVE 437 £463,582 618 £720,003 450 £562,984 1,507 £1,747,313

Interventional Radiology ELECTIVE 1,250 £942,293 2,080 £1,528,205 1,229 £998,310 4,557 £3,468,524

Neurosurgery ELECTIVE 142 £346,600 194 £615,570 228 £341,053 565 £1,303,771

Pain Management ELECTIVE 326 £229,521 832 £658,738 456 £339,419 1,614 £1,227,914

Closing the Excess Spend Gap

• The table below shows the expected trajectory for the BHR CCGs to close the

£90m/Year excess spend by 22/23 and to achieve a position of being better

than average by 23/24.

• The financial recovery will be driven by the Transformational Programmes

described earlier and is realised through improved outcomes for our population

and changing the settings of care where clinically appropriate.

FRP Acute Spend Reduction Assumptions 19-20 (£m) 20-21 (£m) 21-22 (£m) 22-23 (£m) 23-24 (£m)

FRP Elective Reductions - -20.9 -16.2 -9.4 -10.4

FRP Non-Elective Reductions - -13.0 -11.4 -9.5 -7.6

Total FRP Acute Spend Reductions - -33.9 -27.7 -19.0 -18.0

FRP Reprovision Assumptions (£) by Provider 19-20 (£m) 20-21 (£m) 21-22 (£m) 22-23 (£m) 23-24 (£m)

BHRUT (BHR CCGs Income) - 4.2 3.5 2.4 2.3

Barts - 0.8 0.7 0.5 0.5

NELFT (Community Services) - 3.4 2.8 1.9 1.8

Primary Care - 6.8 5.5 3.8 3.6

Other - 1.7 1.4 0.9 0.9

Total - 16.9 13.8 9.5 9.0

Net Acute Income Changes 19-20 (£m) 20-21 (£m) 21-22 (£m) 22-23 (£m) 23-24 (£m)

BHRUT (BHR CCGs) - -9.4 -11.8 -10.9 -11.0

Barts - -3.2 -3.5 -2.4 -1.7

Other Providers - -16.2 -8.2 -2.9 -2.1

Other Provider Investments - 11.8 9.7 6.6 6.3

System Net Position - -16.9 -13.8 -9.5 -8.5

System Efficiencies with >£1m Net Benefit

• The Shared Efficiency Programmes for 19/20 with a net benefit of >£1m (after

reprovision costs) are shown below.

• These schemes contribute to closing the excess spend gap in secondary care.

SCHEME

19/20 and

20/21 Total

Net Value

NHS Barking and

Dagenham CCG

NHS Havering CCG NHS Redbridge CCG

£k 19/20 (£k) 20/21 (£k) 19/20 (£k) 20/21 (£k) 19/20 (£k) 20/21 (£k)

MSK Out of Hospital Model 3,588 580 360 953 535 555 605

Minor Surgery 2,400 - 605 - 964 - 831

Long Term Conditions MDT 2,228 45 520 82 833 69 679

Outpatient Transformation for

20-212,100 - 530 - 844 - 727

Long Term Conditions (LTC)

(LIS)1,773 154 325 230 487 185 391

Improving Referrals Together

(IRT)1,752 520 - 695 - 537 -

Enhanced Care Home

Support Programme1,200 - 328 - 501 - 370

15,041 1,299 2,669 1,960 4,164 1,346 3,603

Mental Health Parity of Esteem

• The CCGs are required to hit the Mental Health investment standard in 19/20.

• The agreed 19/20 investment for Barking and Dagenham CCG is shown in the

table below.

19/20

Investment

£000's

Impact of planning guidance / tariff uplifts 992.6

IAPT 777.3

Perinatal 149.1

Home Treatment Team 55.0

CYPMH 276.6

MH Placements 0.0

Physical Health checks for SMI 78

Acute and inpatient services 190.3

Health Based Place of Safety 0

Transformation funding into MH 0Long term plan priorities - IAPT, Perinatal, acute and

inpatient services 0

Grand Total 2,519.0

Prevention Investment

• There are three levels of Prevention:

o Primary Prevention – targets individuals who may be at risk of developing a

medical condition to prevent the onset of disease and subsequent ill-health.

o Secondary Prevention – targets individuals who have developed asymptomatic

disease and institutes a treatment regime to prevent the onset of complications.

o Tertiary Prevention – targets individuals with a known disease with the goal of

limiting or preventing further complications. A large % of the spend of the NHS is

focused on Tertiary Prevention and it has proven impossible to disaggregate the

spend specifically focused on tertiary prevention from the treatment of conditions,

exacerbations and other complications associated with disease management.

• Investing in Prevention at all three levels reduces downstream costs for both

Health and Care organisations and is therefore a key focus of the BHR

Transformation Boards and a specific area of focus for the NHS System

Financial Recovery Plan.

• The following two slides describe how the CCGs meet their commitments to

support the Primary and Secondary Prevention Agenda.

Prevention Investment (Primary Prevention)

• Historically Primary Prevention has focused on wide-scale public

health actions such as tackling obesity, preventing cancers, etc.

• The NHS has historically invested in working with people who are

identified at being at risk of developing disease such as people who

are pre-diabetic, pre-hypertensive, etc. and also working with Local

Authorities to enact Health Checks.

• Currently the NHS are seeking to invest in closing the prevalence

gaps around hypertension and promoting effective cancer screening

(including through Faecal Immuno Testing).

• The NHS will continue to expand the scope of its work in Primary

Prevention primarily through the work of the Long Term Conditions

Board at which Public Health is represented.

Prevention Investment (Secondary Prevention)

• The CCGs invest in a range of Secondary Prevention through a range of Local

Improvement Schemes (LISs) (Diabetes, Atrial Fibrillation and Frailty) and also

through medication with the main spend on medication aligned to secondary

prevention detailed below.

Values

Commissioner / Provider BNF Section

Sum of

Items

Sum of Actual

Cost

BARKING & DAGENHAM CCG Anticoagulants And Protamine 45056 £929,153.60

Beta-Adrenoceptor Blocking Drugs 107437 £129,186.94

Bronchodilators 103408 £923,378.91

Corticosteroids (Respiratory) 59725 £1,478,471.48

Drugs Used In Diabetes 262923 £4,380,146.14

Hypertension and Heart Failure 241215 £518,228.55

Lipid-Regulating Drugs 265056 £400,173.62

BARKING & DAGENHAM CCG Total 1084820 £8,758,739.23

HAVERING CCG Anticoagulants And Protamine 62317 £2,446,944.07


Bronchodilators 127492 £1,304,987.28





HAVERING CCG Total 1326376 £12,625,025.68

REDBRIDGE CCG Anticoagulants And Protamine 41440 £1,730,921.37


Bronchodilators 95820 £733,915.69





REDBRIDGE CCG Total 1256087 £12,377,161.07

Grand Total 3667283 £33,760,925.98

Any questions?

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Financial Overview of the BHR CCGs · Financial Overview of the BHR CCGs Barking and Dagenham Health Scrutiny Committee 22 October 2019 Sharon Morrow, Director of Transformation and