meeting (held in public) - Bexley CCG body... · 62 day standard target was achieved in August at 85.7% against a target of 85% Estimated diagnosis rates for people with dementia

DATE: 24 November 2016

Title

Integrated Quality, Safety and Performance Report

This paper is for Information

Recommended action for the Governing Body

That the Governing Body: Note

1. Integrated Quality, Safety and Performance Report

Potential areas for Conflicts of interest

None.

Executive summary

The integrated report includes appendices with associated information. The key issues identified in this report are: Areas where performance is below target are RTT and Diagnostics 62 day cancer standard target was achieved 85.7% Improving Access to Psychological Therapies (IAPT), proportion of patients moving to recovery is maintaining the target of 50% Estimated diagnosis rates for people with dementia achieved the target for August Breast cancer 2 week wait referrals exceeded the target at 97.9% Healthcare Acquired Infection rates have improved Child and adult safeguarding continue to be a priority Quality alerts are now routinely used and provide intelligence and feedback to aid commissioning and quality improvement for Bexley patient services

How does this Patients: Improve the health and wellbeing of people in Bexley in

ENCLOSURE: N(i) Agenda Item: 150/16

Governing Body meeting (held in public)

paper support the CCGs objectives?

partnership with our key stakeholders.

People: Empower our staff to make NHS Bexley CCG the most successful CCG in (south) London.

Pounds: Delivering on all of our statutory duties and become an effective, efficient and economical organisation.

Process: Commission safe, sustainable and equitable services in line with the operating framework and which improves outcomes and patient experience.

What are the Organisational implications

Key risks

N/A

Equality

No Equality and Diversity issues identified.

Financial

N/A

Data

N/A

Legal issues

N/A

NHS constitution

Paper supports the NHS constitution.

Engagement

Audit trail

Comms plan None

Author: Ina Herridge Sue Higgins

Clinical lead: Dr Sonia Khanna-Deshmukh Frognal Locality Representative

Executive sponsor: Anne Douse Director of Governance, Performance and Business Services (Interim)

Date 14 November 2016

CONTENTS

Item Page no.

Key Issues – Summary Page 2

Patient Stories 3

Engagement Activity 4

CCG Outcomes Data 6

CQUINS 7

Quality Premium 11

Safeguarding Children 13

Safeguarding Adults 14

Continuing Healthcare (CHC) 15

Medicines Management 16

Infection prevention & control 17

CQC news 18

Serious Incidents 19

Quality Alerts 19

Provider Highlight Reports 20

KEY ISSUES – SUMMARY PAGE RTT – all indicators for the CCG are reported below target for August

Diagnostics 6 weeks+ is slightly below the target of 99% at 98.9% for August

Breast Cancer symptoms urgent referral 2 week wait achieved 97.9% against a target of 93% for August

62 day standard target was achieved in August at 85.7% against a target of 85%

Estimated diagnosis rates for people with dementia achieved the target of 67.5% at 66.4% for Q1

All 31 day cancer targets were met in August with subsequent surgery and subsequent drug treatment both achieving 100% against a target

of 98% 62 day screening missed the target of 90% at 66.7% for August

Improving Access to Psychological Therapies (IAPT), proportion of patients moving to recovery – maintained performance at 50.7% against

a target of 50% for Q1 Healthcare Acquired Infections – the CCG has not had any MRSA cases declared in Q2 and are currently below trajectory for C-diff with 17

cases C.diff against NHS England a trajectory of 27 YTD.

PATIENT STORIES Dispensing error – Queen Elizabeth Hospital Patient X was experiencing difficulty in obtaining medication prescribed following a consultation at Queen Elizabeth Hospital (QEH) Enquiries established the Consultant had requested the patients GP to continue the prescription. However, the GP was unable to assist as the medication requested is a controlled/ licensed drug. The GP subsequently contacted the Consultant to clarify the situation and explain that he was unable to help. Consequently, the Consultant made arrangements for a prescription to be dispensed via the hospital pharmacy. The pharmacy then dispensed just one month supply of medication – although the course of treatment was over a three month period. Following referral to the Patient Experience Team action was taken to liaise with our Medicines Management Team and the Lead Pharmacist at QEH, this quickly established that a dispensing error had occurred. Consequently, swift action was taken to ensure Patient X was able to receive her medication along with an apology for any distress caused as a result of the delay. Mystery Shopper – Acorns Unit at Queen Mary’s Hospital One of our mystery shopper members recently shared feedback following a visit to the new Acorns Unit at Queen Mary’s Hospital. Staff on the reception desk were welcoming, as always. We waited a few minutes for our appointment but this was not a problem as it is such an exciting environment with lots of things to do. The Doctor was pleasant and friendly and offered good clear advice on the options available (and gave us plenty of time for questions). The report specifically mentioned Donna & Becky (Receptionists) They never fail to make my child feel at ease and X looks forward to seeing them. Details of the positive feedback has been shared with the unit along with positive feedback lapel badges for the staff highlighted in the report

Patient gave consent for experience to be shared

PATIENT EXPERIENCE & ENGAGEMENT ACTIVITY

During Quarter 2 2016 the following insights and headlines have been recorded

King’s College Hospital NHS Trust

NHS Choices – 11 positive comments noted across PRUH & Orpington sites, 4 for Trauma & Orthopaedics at Orpington Hospital

3 informal complaints – poor clinical treatment (Renal surgery), appointment delays (Neurosurgery) & (Ophthalmology)

Quality alerts – 15 recorded. 5 delay treatment, 4 insufficient/poor discharge & 4 no discharge arrangements/poor communication

Mystery shopper – (45) 25 positive (MSK) & 14 (Ophthalmology) clinical treatment. 19 negative, 8 (MSK) 5 (Ophthalmology) – appointment delays, cancellations, administration etc.

Lewisham & Greenwich NHS Trust

1 formal complaint (multiagency) regarding ward 17 & community District Nursing–issues relate to standards of care (pressure sores), discharge planning

3 informal complaints. Discharge arrangements (Ward 19) & prescribing (Gynaecology) QEH; appointment delays (ENT) UHL

NHS Choices – 16 positive comments, 6 (A&E) UHL. 13 negative comments noted. 6 (Obstetric services) UHL, 4 (A&E) QEH, all relate to quality of clinical treatment

1 MP enquiry re discharge arrangements (Oncology)

Quality alerts – 34 recorded. 12 insufficient/poor discharge, 6 delay in receipt of diagnostics, 5 poor clinical treatment & 4 delay in treatment

Mystery shopper – (34) 17 positive – 4 (Urology) & 3 (Phlebotomy) positive clinical treatment. 17 negative - common themes, attitude of staff and discharge arrangements

Hurley Group

The CCG were copied into 5 complaints regarding UCC at QMH. All concerns highlight concerns regarding attitude of staff and quality of care and treatment/ delays

NHS Choices - highlights concerns regarding UCC at Erith Hospital site in relation to access; patient arrived at 9pm and was turned away.

Mystery shopper – (37) 33 positive clinical treatment. 4 negative - attitude of staff and quality of care and treatment

Formal complaints 3 Correspondence 24 General enquiry 48 Informal concerns

20

MP Enquiries 3 Mystery Shopper 212 NHS Choices 67 Total 377

Oxleas NHS Foundation Trust

2 informal complaints regarding the administration (Continence advisory service) & funding (Mental health rehabilitation)

NHS Choices – I negative comment, attitude of staff at Green Parks House

Mystery shopper – (8) 4 positive clinical treatment. 4 negative. 2 of which were poor administration (Continence Advisory Service) & (Podiatry)

Quality alert – 6 recorded, 3 delay in treatment and 2 poor clinical care Guy’s Hospital

2 informal complaints regarding appointment delays (Cardiology) & clinical treatment (Urology)

Mystery shopper – (6) 3 positive clinical treatment. 3 negative of which 2 appointment delays (Cardiology) & 1 patients privacy (Urology)

Quality alert – 4 recorded. 2 delay in treatment, 1 poor clinical treatment & 1 poor communication Darent Valley Hospital

1 informal complaint (Community maternity services), specifically relates to poor communication following miscarriage

NHS Choices – 15 positive comments 4 (A&E) 2 negative reports noted, one regarding Accident & Emergency waiting times, the other relates to surgery cancelled on day (lack of beds)

Mystery Shopper – (15) 10 negative comments. 3 (Radiology) Access, clinical treatment & administration. 3 (Urology) Waiting time & communication

Quality alerts – 7 recorded. 3 Insufficient/poor discharge (Gynaecology/Obstetrics) 2 medication issues/error (A&E) NHS Bexley CCG

One formal complaint regarding CCG arrangements to commission interpreter services – specifically linked to Accessible Information Standard

1 informal complaint regarding a refusal to refer (Dermatology)

Mystery Shopper – 3 compliments noted regarding CCG mystery shopper initiative Engagement activities included

2 meetings of Bexley Patient Council 4 visits to PPGs

Attendance at Erith Fun Day community event Mystery shopper AGM and awards

CCG OUTCOMES DATA

Health Outcomes Framework / Every one Counts Target Jun Jul Aug Breaches 12M

Trend

Safe environment and protecting from avoidable harm

MRSA 0 0 0 0 0 (YTD) ▼

C. difficile - Incidence of HCAI YTD 4 4 4 1 0 (YTD) ►

RTT

RTT admitted 90% 76.0% 73.9% 70.5% 358 ▼

RTT non-admitted 95% 90.4% 89.4% 90.1% 392 ▼

RTT incomplete 92% 90.5% 89.8% 89.2% 2073 ▼

RTT 52+ week waiters 0 6 7 10 10 ▲

RTT Admitted Backlog

803 806 866 ▲

Diagnostics Diagnostics - 6 weeks + 99% 97.1% 98.8% 98.9% 27 ►

Cancer - 2 weeks 2 week wait 93% 92.8% 94.2% 91.0% 72 ►

Breast symptoms 2 week wait 93% 89.8% 83.3% 97.9% 1 ►

Cancer - 31 days

31 day first definitive treatment 96% 98.7% 98.5% 98.8% 1 ▲

31 day subsequent treatment surgery 94% 95.2% 100.0% 100.0% 0 ►

31 day subsequent treatment drug 98% 89.7% 100.0% 100.0% 0 ►

31 day subsequent treatment radiotherapy 94% 97.2% 100.0% 94.3% 2 ►

Cancer - 62 days

62 day standard 85% 74.0% 69.0% 85.7% 8 ►

62 day screening 90% 100.0% 100.0% 66.7% 1 ►

62 day upgrade

100.0% 100.0% 66.7% 2 ►

Mental Health & Learning Disabilities

IAPT - Patient numbers as % population with depression etc. 1.1% 1.25% 1.20% 1.38% ►

IAPT - Proportion in recovery 50% 51.6% 50% 50.7% 75 ►

Estimated diagnosis rate for people with dementia 67.5% 66.3% 66.6% 67.8% 926 ▲

Transforming care – Bexley patients meeting the criteria 2 3 2

CQUINS - Lewisham & Greenwich Trust

CQUIN Indicator Q1 Q2 Q3 Q4

National Indicator 1 -Health & Wellbeing

1 a) Health & Wellbeing- Introduction of health and wellbeing initiatives: introducing a set of employer let schemes for staff around physical activity, MSK and Mental health.

1 b) Healthier Food – healthy foods for NHS staff, visitors and patients.

1c )Improving update of flu vaccination

National Indicator 2 - Timely identification and treatment for sepsis

2 a) Timely Identification of Sepsis Emergency Department. (2 part indicators)

2 b) Timely Identification of Sepsis Inpatient (2 part indicators)

National Indicator 4 – Antimicrobial Resistance and Antimicrobial Stewardship

4 a) Reduction in antibiotic consumption per 1,000 admissions

4 b) Empiric review of antibiotic prescriptions

Local Indicator 5 - Frailty

5 a) Frailty pathway impact on outcomes for > 75 emergency admissions The Frailty Pathway includes a number of sub-components: 1. Frailty Assessment Service; 2. Consultant led Short- Stay beds on Ward 2; 3. ED department and UCC (Front End) 4. Core Care of the Elderly wards;

5 b) Frailty Assessment and impact on outcomes for > 75 emergency admissions

CQUIN Indicator Q1 Q2 Q3 Q4 5 c) Frailty Short Stay

Delivery of a unit for patients over the age of 75 who have an estimated length of stay of 3 days or less. Unit to have dedicated Consultant Geriatrician input, covered by two Consultant Geriatricians doing daily MDT ward rounds. The aim of the service will be to move patients who currently have a longer length of stay to a shorter length of stay due to this early Geriatrician and MDT input. This is not an assessment area and all patients on the unit will be those who require admission

5 d) Frailty Integrated Management plans

Develop individual management plans for frail elderly patients with long term conditions for safe and early discharge of non-complex patients, in line with best practice and in collaboration with all community services

5 e) Training program - front end

Development and roll out of a comprehensive training programme on frailty including its identification and management, done in two stages, initially front end assessment staff, then ward based staff. The development of the training and reporting back on progress will be done through the frailty working group. Multi-disciplinary staff groups are trained so the Frailty pathway is integrated and effective.

5 f) Training Programme – Inpatients

Development and roll out of a comprehensive training programme on frailty including its identification and management, done in two stages, initially front end assessment staff, then ward based staff. The development of the training and reporting back on progress will be done through the frailty working group.

Covers all Care of the Elderly wards and other clinical areas where the 75+ are admitted (excluding surgical HRGs); estimated 200 multi-disciplinary staff will be trained in 1 year.

CQUINS – Oxleas NHS Foundation Trust

Oxleas Community Contract CQUIN 2016/17

Local CQUIN Indicator Q1 Q2 Q3 Q4

Local Indicator 1

Identify and support for adult and young carers across Bexley and avoiding crisis

To ensure timely and responsive support for adult and young carers in the community to meet their needs and prevent a breakdown in the caring relationship. To ensure early identification and referral to social services.

Local Indicator 3

Health Promotion and Prevention – Making every contact count

Provider nominated lead and development of organisational culture to deliver health promotion and prevention

Development and roll out of a health promotion and prevention strategy

Oxleas Mental Health Community Contract CQUIN 2016/17

National CQUIN Indicator Q1 Q2 Q3 Q4

National Indicator 1 - Health and wellbeing

1a) Health & Well Being- Introduction of health and wellbeing initiatives: introducing a set of employer let schemes for staff around physical activity, MSK and Mental health.

N/A – reported at Q2. Contract variation applied.

1b) Healthier Food – healthy foods for NHS staff, visitors and patients.


1c )Improving update of flu vaccination


National Indicator 3 - Improving physical healthcare to reduce

3 a) Cardio Metabolic assessment and treatment for patients with psychoses

National CQUIN Indicator Q1 Q2 Q3 Q4 premature mortality in people with severe mental illness (PSMI)

3b) Communication with General Practitioners

CQUINS – Dartford & Gravesham Trust

National CQUIN Indicator Q1 Q2 Q3 Q4

National Indicator 1 -Health & Wellbeing

1 a) Health & Wellbeing- Introduction of health and wellbeing initiatives: introducing a set of employer let schemes for staff around physical activity, MSK and Mental health.

1 b) Healthier Food – healthy foods for NHS staff, visitors and patients.

1c )Improving update of flu vaccination .

National Indicator 2 - Timely identification and treatment for sepsis

2 a) Timely Identification of Sepsis Emergency Department. (2 part indicators) Partially achieved

2 b) Timely Identification of Sepsis Inpatient (2 part indicators) Not

achieved

National indicator 4 – Antimicrobial Resistance and Antimicrobial Stewardship

4 a) Reduction in antibiotic consumption per 1,000 admissions

4 b) Empiric review of antibiotic prescriptions

QUALITY PREMIUM

2015/16 measures Latest actual Target Period value R/G

1 Reducing potential years of lives lost through causes considered amenable to healthcare (10%).

DSR 1785.00 2012 DSR 2008.3 2014

1.2% reduction

2012 -15 10% 2014- Not achived.

2 Urgent and Emergency

Care (30%)

Avoidable emergency admissions (30%). Either a) a reduction, or a zero per cent change, in the annualised trended change in the Indirectly Standardised Rate of emergency admissions for these conditions over the 4 years 2012/13 to 2015/16 ; or b) the Indirectly Standardised Rate of admissions in 2015/16 at less than 1,000 per 100,000 population

The CCG achieved reduction in all four areas of this indicator.

2015-2016 30% Achieved

3 Mental Health

15% each

Increase in the proportion of adults in contact with secondary mental health services who are in paid employment

48%

2015/2016 15% Achieved

Improvement in the health related quality of life for people with a long term mental health condition

2.5% improvement

2015/2016 15% Achieved

4

Improving antibiotic

prescribing in primary

and secondary care (10%)

Reduction in the number of antibiotics prescribed in primary care (5%) antibacterial items per STAR PU

1.204 1.150 2015/2016 5% Not achieved

Reduction in the proportion of broad spectrum antibiotics prescribed in primary care (3%)

11.3% <13.3% 2015/2016 3% Achieved

Secondary care providers validating their total antibiotic prescription data (2%)

2015/2016 2% Awaiting

data(King’s data pending)

5 Local

Priorities 10% each

a) Introduction of a safeguarding measure (10%). Agreed: May 2015. 1st step: Evidence

of process to collect data developed: A workshop on 21st July at the Forum Community

Centre in Greenwich to discuss and agree this. Target by end of Q4:80% of service users of Oxleas (Bexley) adult mental health services are asked whether they live with a child/young person under 18yrs. Oxleas will audit recording in April 2016

Regular data collection in place

2015/2016 10% Achieved

b) Increase in quality reporting (10%). Agreed: May 2015.

1st step: Design new process and start pilot in a 2-3 care homes who are currently

commissioned by Bexley CCG continuing care. Q2 QA System and IT has been set up for Care Home usage and instructions and leaflets prepared. 2 Care Homes were set up. Q3 Invitations are being made to another 8 Care Homes to participate in the online process. Target by end of Q4:10 care homes setup and reporting on QAMS.

Local CCG Visits to 9 care homes and Hospice now registered.

2015/2016 10% Achieved

2016/17 measures Target Period

value R/G

1

National measures

Improving antibiotic prescribing in primary care

Part a) reduction in number of antibiotics prescribed in primary care (worth 50%)

Q1 5% 1.2

Part b) reduction in the proportion of broad spectrum antibiotics prescribed in primary care (worth 50%)

Q1 5% 10.9

2 Cancer diagnosed at early stage:

4% point improvement or achieve greater than 60% of all cancers diagnosed at early stages in calendar year.

Q1 20% Data

pending

3 Increase in the proportion of GP referrals made by –e-referrals 80% and year on year increase in the % or 100% achieved or exceed March 2016 performance by 20%

Q1 20% Data

pending

4 GP patient Survey – overall experience of making a GP appointment 85% or 3% points increase from July 2016 publication.

Q1 20% Data

pending

5 Local

measures

2 - Cancer - Receiving first definitive treatment within two months of urgent referral from GP 85% Q1 10% 75%

36 - Mental Health - Mental Health - Reported numbers of dementia on GP registers as a % of estimated prevalence 67.7% Q1 10% 66.4%

38 - Mental Health - Waiting < 28 days for IAPT: % of referrals (in quarter) waiting <28 days for first treatment 90% Q1 10% 97%

National measures will be reported when available from NHS England

SAFEGUARDING CHILDREN

1. Child protection – Information sharing project (CP-IS)

The Child Protection – Information Sharing (CP-IS) project is a Department of Health sponsored work programme dedicated to delivering a higher level of protection to children who visit NHS unscheduled care settings such as accident and emergency wards and UCC’s. It connects local authorities’ child protection social care IT systems with the healthcare systems of the NHS to enable health practitioners to see the social worker contact details if a child has

A Child Protection Plan

Is Looked After by a local authority

A pregnant woman whose unborn child has a pre-birth Child Protection The project will deliver a national system that will enable NHS organisation in England offering unscheduled care services access to timely information, which would help to inform a clearer assessment of a child’s risk of abuse or neglect. The information will support the clinician in the decision making process and encourage communication with social care. The availability of such a system will not override the assessment of the child’s needs. The CCG has established a steering group with representation from our local EDs, the Hurley group and Greenbrook with LB Bexley’s IT lead. We are working with the London CP -IS project officer with a view to going live early 2017.

2. CQC/Ofsted Local area inspection of Special Educational Needs and Disability Inspectors looked at how well Bexley partners were meeting the requirements of the Children and Families Act 2014. Their report will be available at the end of November. Key issues raised for health economy was the importance of ensuring plans for 19-25yr age group, joint commissioning and transition arrangements. A Designated Medical/Clinical Officer to support the CCG in meeting its statutory responsibilities for children and young people with special educational needs and disability is key requirement and has been agreed by the CCG. 3. Initial Health Assessments for Looked After Children

It is the responsibility of the local authority to ensure health assessments are carried out and that every child has a health plan. Children looked after are required to have a health assessment within 20 working days of coming into care. Children often enter the care system with undiscovered and unresolved health issues. It is therefore not in the best interests of children to delay this medical. Clinicians have given assurance of their clinical capacity to be able to meet this target. Clinicians are reliant of the local authority providing notification that a child has been placed and consent for the medical to take place from the parent or themselves as the corporate parent. In Bexley compliance with this requirement is difficult to meet and to maintain. In July 2016 71% are seen in the timescale. Whilst this is a considerable improvement on previous year, it is not good enough. CQC has highlighted it with Oxleas and expect improvement in 3 months. There continue to be delays in this information being sent. A pathway of escalation to managers when consent is not received within an agreed timescale has been established and a weekly status list is provided to social care teams. Oxleas are about to begin a weekly conference call. The Designated nurse will escalate the issue to the Corporate Parenting group.

SAFEGUARDING ADULTS ACUTE TRUSTS


Prevent training at 62% - 4 WRAP trainers with plans to carry out another train the trainer course for security personnel. Plan in place to reach 80% by 2017/18.

Quarter 2 figures show 45 Deprivation of Liberty Safeguarding referrals against 32 in quarter 1. This number still appears low – work being done by the safeguarding team at Queen Elizabeth Hospital to raise awareness.

114 referrals were made to the Local Authority in quarter 2.

30 Domestic Violence referrals, including 18 for QEH, made in quarter 2 following the implementation of a routine enquiry about Domestic Violence at triage and the appointment of link nurses. Work is being carried out to improve the patient experience of those disclosing domestic violence, an update will be shared with the Quality and Safety Subcommittee in the New Year.

MARAC database established

Training figures for Safeguarding level 2, Domestic violence, Prevent and MCA and DoLS 1% below target.

WRAP training compliance has dropped from 565 in quarter 1 to 39% in quarter 2. Plans are in place to reach target by 2017/18

Safer recruitment training very low at 9.6% against a target of 85%. This is an improvement from quarter 1 whereby the trust was only 2.6% compliant. Significant work has been completed to improve the service to patients with a learning disability. Champion are in place and extensive training taking

place. A hundred hours has been secured from a charitable organisation to produce aides for accessibility.

LD Mortality Review – The Trust has not been selected as a pilot but will be part of a 6 borough collaborative review group.

There are two potential Safeguarding Adult Reviews pending.

KPMG Audit: Positive outcome from the audit there was significant assurance with minor defects. An action plan has been completed. KPMG reviewed policies, referrals database; terms of reference for Assurance meetings and sample DOLS for the audit.

Dartford & Gravesham NHS Trust

Adult safeguarding training will be available via e-learning from January 2017.

Adult Safeguarding and MCA level 2 and 3 – no data available. Training needs analysis is in progress and the Darent Valley Safeguarding lead is working closely with North West Kent CCG safeguarding lead to put a plan in place to reach compliance.

The CCG Safeguarding Adults Lead is taking part in a safeguarding review into the death of a Bexley patient from self-neglect.

20 safeguarding concerns raised in quarter 2 including 3 pressure ulcers. Oxleas NHS Foundation Trust CQC rating of ‘Requires Improvement’ 58 out of 70 categories good or above. – Action plan in place.

MCA workshop being rolled out. Case review taking place to encourage reflective practice and a re- audit is to take place in February 2017.

CONTINUING HEALTHCARE (CHC)

Continuing Healthcare is based on Department of Health documentation and has a national framework (which is currently being revised) National Framework for NHS Continuing Healthcare and NHS- funded Nursing Care November 2012 (Revised) This incorporates: NHS Continuing Healthcare Practice Guidance, NHS Continuing Healthcare frequently asked questions, NHS Continuing Healthcare Refunds Guidance. The Bexley CHC team consists of:

Clinical Manager

Business Manager

Administrators

Nurses

Those patients eligible for CHC include:

Learning disability patients with complex needs

End of life needs

Complex physical needs

Those with behaviours that challenge who often require 1:1 care even in nursing homes

Those not eligible for CHC but with nursing needs over and above what social services / community services can provide

Activity:

In the first 2 quarters of 2016/17 (1April to 30 September 2016, the cumulative activity was 410 patients eligible for NHS CHC and the CHC team arranged/ funded their care at home or in a Care Home.

284 fast track patients (district nurses do some of the personal care / symptom control under the Oxleas contract)

126 non fast track CHC patients

11 joint funded (with social services) patients CHC has a clinical component and the CCG has a responsibility to meet those clinical needs. Whilst meeting those needs is a priority, the CHC team is mindful of budget pressures and keeps this in mind when arranging care packages / placements.

MEDICINES MANAGEMENT

Marlborough Court the reviews carried out are still awaiting discussion with the associated GP Practice. It has been highlighted to the GP concerned, and will be raised as part of the Contract Review Meeting which has been scheduled. Shaftesbury Court had their medication reviews closed by the CCG, due to recommendations not being actioned to date. The CCG has met with the GP and assurance has been given that systems will be in place to manage future reviews. St. Margaret’s medication reviews for have all been completed and actioned. In addition, as part of their medicines administration concerns, the care homes pharmacist has supplied them with protocols for three high-risk medicines, that have been incorporated into their working practice. A meeting with the supplying pharmacy has also been completed to manage the process for monthly medication. The care homes pharmacist worked with the LBB colleagues for this care home. Maples Care Home has also had their reviews completed, with a particular focus on dementia. Lyndhurst Care Home, St. Mary’s and Riverdale Court all have reviews completed and actioned to-date Adelaide Care Home is still being actioned and there are several concerns around medicines waste. Work in progress care homes that have been planned for the next cycle of reviews are Cedar Court, Parkview, Meyer House and Groveland Park. The remaining six care homes are awaiting a plan of review from their associated GP practice. The Anticipatory Guidelines are currently being disseminated for comments and will be submitted to the MMSC. A Repeat Prescription Process is currently being drafted. The Care Pathways Directory is still being compiled as protocols are being collected from all the practices, and the draft version is expected to be completed in Q4 of 2016/17. Medicines Management continues to liaise with the Quality & Safeguarding Lead, and Contracts & Commissioning Team on contracts linked to care homes e.g. dietetics, care home review meetings and any other concerns that are raised.

INFECTION PREVENTION & CONTROL C.Difficile

The CCG remains in a positive position with 17 cases C.diff against a trajectory of 27 for Apr-Sept16; this is a marked improvement on the previous year with 48 cases at this point. If this trend continues the CCG should fall within the C-Diff limit.

MRSA – no cases reported for Bexley patients for Apr-Sept16.

CQC NEWS

In Qtr2 the CQC published 17 reports relating to inspections of NHS funded services within the borough

GPs – 4 practices rated good Nursing & residential homes – 4 rated good and 4 requires improvement

Homecare agencies 2 rated good and 2 requires improvement

Bursted Wood Surgery Bursted Houses Oakdene House Bluebird Care (Bexley)

Dr Ebenezer Timeyin Groveland Park Care Home St Aubyns Nursing Home Carewatch (Bexley)

The Westwood Surgery Maples Care Home Sunrise of Frognal London Borough of Bexley

Dr Thavapalan Chapel Hill Parkview Care Matters UK Limited

Community & Mental Health Services Oxleas NHS Foundation Trust were rated as requires improvement 58 out of 70 categories good or above – Action plan in place. EXCEPTIONS: i) Mental Health Crisis Service – inadequate for safety

Response – Refurbishment of places of safety – Oct 2016 work starting Documentation and management of clinical risks- new standards agreed further training

ii) Mental Health wards for adults of working age – inadequate for safety, responsive well led and overall Response – Ligature Risks – audits completed in all communal areas SI’s – Processes reviewed – additional member of staff in patient safety team. Local risk registers now in place. Care planning – changes to RIO in November Health Seclusion room – Refurbishment starting in December 2016 Lone working operational policy changed.

iii) Adult acute inpatient - Waiting for admissions Response Same sex accommodation - female only ward at Oxleas House. Sleep overs – 12 beds purchased from East London NHS foundation trust. Free bed available on each ward by 3pm every day

IV) Community services for someone with a learning disability – Outstanding for Caring.

Oxleas have identified in the action plan support required from the System which they state can be achieved through parity of esteem funding for 2016 /17 and 2017 /18

Developing a 24 hour crisis and home treatment team Increasing patient capacity in the trust

Facilitating timely discharge Creating a temporary pre- admission lounge

SERIOUS INCIDENTS

Serious incidents reported for Bexley patients in Q2 – three Pressure ulcers, one suboptimal care of deteriorating patient, two Surgical/invasive procedure incidents and one Treatment delay Across all providers there were three never events reported in Q2 they were two Surgical/invasive procedure incidents, one medication incident and one Maternity/Obstetric incident. (No Bexley patients affected)

QUALITY ALERTS

70 Quality Alerts in Quarter 2 2016 Organisation alert is related to: 49% Lewisham & Greenwich NHS Trust 21% King’s 10 % Darent Valley 9% Oxleas 6% GSTT 5 % Other (LAS, Moorfields, Medway, Community Provider)

Source: Quality Alert Management System (QAMS) October 2016

Themes (Top 3): 36% Insufficient information/Poor discharge 24% Delay in treatment 11% Poor Clinical treatment Risk Rating: 44 Amber (response required from provider) 26 Green (majority provider informed for learning, no response required) 0 Alerts unrated – awaiting further information to risk rate 0 Contact not an alert and has been appropriately redirected

PROVIDER HIGHLIGHT REPORT Lewisham & Greenwich Trust

Complaints – The performance in complaints has shown a dip of 8% from June to July regarding the number of complaints being resolved within agreed

timescales. This metric is being monitored closely to ensure that performance continues to increase. Complaints are monitored weekly through a scorecard so that issues that can be identified immediately and resolved and the complaints department is working closely with the divisions where areas for improvement have been identified. The department has also designed a training package and is delivering this to staff groups across the Trust. It is hoped that this will impact on the quality of responses being produced thus reducing the time spent reviewing complaints.

Cancer – The Trust has met the overall 2ww and 31 day cancer targets with the exception of the 62 day target and the inter Trust transfer target, though its performance against the ITT is higher than the trajectory in July, the trust reported that all nurses have or will have level 2 training, other support schemes such as a buddying scheme pilot is being reviewed on the UHL site with a view to rollout to Bexley and Greenwich patients; the Trust has also developed “cloud boxes” which will help parents explain their condition to their children. The provider’s improvement in increasing the reporting of stageable cancers is linked to the quality premium in 16/17. The Trust has provided its initial assessment of actual performance and a trajectory for improvement which will move the Trust from its current 13% to 62% by the end of this financial year. Electronic discharge summaries – Performance remains below the standard that 95% are completed with 24 hours. The weekly performance summaries circulated show that a significant proportion of the shortfall is accounted for by discharge summaries that are completed but not sent. The review of the current iCare discharge process has been completed and proposals to change this will be taken to the IM&T Management Board prior to being introduced. Daily text reminders are being sent to ward matrons of outstanding discharge summaries. Trust policies and procedures will be reviewed and brought into line with these changes once they have been tested and implemented. Caesarean section – The emergency caesarean section rate for both QEH and UHL were red in July. The Trust presented an in-depth review of factors

which are contributing to high c-section and stillbirth rates (higher at Lewisham than QEH). The trend for both is upwards and some of the contributing factors such as older mothers, deprivation and social circumstances were explained in considerable depth, Commissioners requested that the action plans arising from the recent Lewisham CCG stillbirth workshop is brought back to CQRG for assurance and that CQRG continues to actively monitor the actions the Trust is taking to reduce c-section rates. FFT – Both sites continue to implement action plans to improve the response rate towards the local trust standard of 20%. This includes the appointment of new FFT champions, a greater focus on FFT at Directorate meetings and improvements to the process for handing out/returning completed forms. This is expected to improve the response rate from September. The recommend rate continues to be higher than the England and London average of 85% with 95% at UHL and 97% at QEH. Children’s Safeguarding – The Safeguarding lead has re-mapped eligible staff as some job roles have moved up or down levels which may have a different update period, for instance staff who have moved from Level 2 to Level 3 Core or Level 3 Specialist will now require an annual update, rather than every 36 months. In addition, the overall MT compliance rate has dropped by 2% during August, this is largely due to the intake of new F1/F2's whose medical

induction has not been completed/recorded yet - their completion of MT should reflect in September 2016 reports.

Dartford & Gravesham Trust Mixed Sex Accommodation (MSA) Breaches – 167 mixed sex accommodation breaches reported in August. The MSA remedial action plan has been revised and sent to the CCG for agreement. Weekly review of MSA performance conducted with director of nursing, ward sisters and matrons. Robust validation is in place as well as discussions at every site safety meeting. Patient Experience are monitoring patient complaints /concerns reported in line with single sex accommodation HCAI – MRSA Bacteraemia – The Trust reported that there was 1 MRSA bacteraemia case reported in August (not Bexley patient), IPC taskforce in place to drive forward MRSA action plan. Accountability process alongside taskforce frequency to be reviewed by director of nursing alongside the new DIPC when appointed, DIPC interviews have taken place and appointment to be confirmed, Peripheral cannula proforma has been re-designed to facilitate improvement in documentation and cannula assessment. Compliance with MRSA screening has been audited monthly as from June 2016, and hand hygiene compliance data (via SNAP Audits). Mandatory training - The mandatory training rate has dropped by 1% to 82%. Incremental progression policy has been drafted and ratified for implementation. A core component includes completion of required mandatory training Pressure Ulcers (Grade 2, 3 & 4) - Hospital Acquired pressure sores have decreased in Aug-16. C-Section (Elective) - The C-Section rate was at 13% in August. A nine point action plan is in place to reduce the C Section (CS) rate: Multidisciplinary Caesarean Taskforce- targeting work on the section pathways. Daily review of all CS completed within 24 hour period. Review DGT against NICE Caesarean Section Guidance 132. C/Section- Debriefing Proforma. There was 100% agreement for no CS for non-clinical reasons. The decision was taken that every CS to be made at consultant level. There was 100% agreement that uncomplicated elective CS (with 1 previous CS) will be performed at 39 weeks or beyond. Midwife to Birth Ratio – The Trust met the Midwife to Birth ratio 1:36 in August. Appraisals - The appraisal rate has increased to 76% in July to 79% in August. The Trust has communicated widely about focussing appraisals within the first 2 quarters of the financial year, and Director of HR has asked executive directors to address areas of low compliance.

King’s College Hospital

Friends and Family Test (FFT) – PRUH continues to achieve Trust targets for the Inpatient Friends and Family test (IP FFT). 92% of patients recommended DH for in-patient (IP) care in August, which is slightly below the internal target. 96% of patients would recommend PRUH for IP care, which is higher than last year at this time (August 2015 - 93%). The response rate for IP FFT has dropped at DH from 14% in July to 12.3% in August. Similarly, the response rate for IP FFT at the PRUH has decreased from 13.3% in July to 9.3% in August. There has been a slight increase in the percentage of patients recommending A&E via the Friends and Family test (A&E FFT) across both sites in month 5. 85% of patients recommended PRUH for A&E in August compared to 82% in July. 79% of patients would recommend DH for A&E in August compared to 75% in July. Also, the response rate for A&E FFT has improved across both sides (DH 11.8%, PRUH 16.5%) compared to previous month (DH 9.5%, PRUH 14.6%).

Never Events There have not been any Never Events reported in Q2 16/17 at either site.

Falls – There has been decrease in the number of ‘moderate’ falls reported in August with a total of 1 across both sites (1 at the PRUH and 0 at DH) compared to 3 reported in July and 3 last year at this time. The number of ‘major’ falls reported across both sites remains the same as in the previous month with 3 in August (0 at the DH and 3 at the PRUH). Pressure Ulcers – There has been a decrease in the number of all hospital acquired pressure ulcers in month 5 with a total of 18 (grades 2-4) across both sites compared to 30 in July. It is worth noting that this is also less than the previous year at this time (August 2015 - 28 Trust wide). There is a noticeable improvement in the number of all hospital acquired pressure ulcers reported at the DH in August with total of 13 ulcers compared to 22 in July. There were no grade 3 or 4 pressure ulcers in August and no grade 4 ulcers have been reported since beginning of the year on any site. HCAI – A total of 6 C-Difficile cases were reported in August, which is consistent with the target quota of 6 cases for the month. They were 2 cases of C-Difficile reported at DH and 4 at the PRUH in August. Therefore, a total of 19 cases at DH and total of 8 cases at the PRUH have been reported YTD. There have been 2 MRSA cases reported since beginning of the financial year both at DH. No new cases reported in August.

Safeguarding – Levels remain a challenge across both sites, the 80% target for Level 2-5 Adult Safeguarding has not been met since beginning of the financial year with 65.3% compliance at DH and 72.8% compliance at the PRUH in August. Children’s Safeguarding training targets have also not been met in August at the DH with 57.3% compliance for Level 2 and 75.3% compliance for Level 3. The situation is better in terms of safeguarding training for Children’s Level 2 (72.2%) and Level 3 (89.4%) at the PRUH in August.

Caesarean section – continues to be within the target of <27% at the PRUH (25.7%) as well as within the target of <26% at the DH (25.1%) in August. The numbers of women booked after 12 weeks met the target of 90% at the PRUH with 90.5% reported in August. Although, there has been improvement in the numbers of women’s booked from last year (August 2015 -78%) this target remains a challenge at the DH with 84% in August.

Staffing – The Trust is not meeting its internal vacancy rate target (<8%) at either site, with poorer performance at the PRUH (15.4%) compared to DH (11.5%). There has been slight improvement at the PRUH in August (15.4%) compared to July (16.2%). There has been a slight decrease in the statutory and mandatory training rates at the DH from 80% in July to 76% in August, and compared to last year at this time (77%). Similarly, at the PRUH there has been a drop from 84% in July to 78% in August.

Guy’s & St Thomas’ Trust Never events – One never event was reported in August, this related to a retained swab which is under investigation. The Trust continues its work on Never Events and is planning a Never Event workshop organised by the Chief of Surgery and the Royal College of Surgeons at GSTT. FFT – The Trust has met the internal target of >=97% for Inpatient (IP) Friends and Family Test (FFT) but did not meet the target of >=88% for A&E FFT. For IP 97% of patients would recommend the Trust, which is in line with the target and more than previous month (96%). This is also better than this time last year, when 85.5% of patients recommended IP services. In August 86% of patients would recommend the Trust for A&E FFT, which is below the target. The Trust FFT IP and A&E response rate continues to be below internal targets of >=33% and >=18% respectively. A 25% IP response rate was reported in August, which is lower compared to the previous year at the same time (29%). There has been decrease in the A&E response rate from 17% in July to 14% in August. Safeguarding – The Trust continues to perform well against Children’s Safeguarding training targets in month 5. Children Level 2 and Level 3 Safeguarding figures are both above 80%. In August the Trust did not meet the target of 80% of staff trained in Level 2 Safeguarding Adult training with 73.47% compliance. The Trust explained that this is due to a change in the way the data is being reported as it includes staff who has received a three year training update in the denominator. This change is in line with London Multi-Agency Adult Safeguarding Policy and Procedures (April 2016). The Trust is aiming to reach the 80% target by the end of December. Caesarean section rate – The caesarean section rate is slightly lower than target and shows similar level to last year in August at 32.9%. This reflects the case-mix of mothers who deliver at St Thomas’. In order to reduce the overall number of caesarean sections within the Trust we have introduced measures to review the appropriateness of emergency caesarean sections, as well as to reduce the number of repeat caesarean sections. Accident & Emergency (A&E) – August saw a deterioration in performance in waiting time within A&E services. There were two breaches of the >30 minutes ambulance off-load target and no >60 minute delays. St Thomas’ was the 2nd best receiving hospital in London (in terms of 30 minute breaches) in 2015 and continues to be at this level in 2016 despite high ambulance arrivals. This month the trend of increased overall attendances continues with Aug-16 seeing a 6% increase in attendances compared to August 2015. Attendances at ED have increased month on month compared to last year with an average increase of 7% compared to the same period in 2015. Increases in attendances have been seen across all areas of the department and are in-line with national trends. Referral to Treatment (RTT) - The 92% target of patients treated within 18 weeks has not been achieved due to demand on waiting lists and delay in implementing an outsource program for adult ENT. The trust have have experienced a 17% increase in demand from GPs leading to a significant increase in waiting list size. The Trust met the diagnostic target for August with a positive outcome from work within Urology and other areas; however a number of delayed patients in Audiology have been identified that will cause performance problems during Q3.

Oxleas Foundation Trust

There were no incidences of CDI or MRSA recorded in this financial year.

Serious Incidents – there are a number of overdue serious incident reports to be sent to CCG’s. To address this, the monthly Patient Safety report to the Quality Committee will now monitor compliance with the 60 day deadline and implementation of actions.

Duty of Candour - In Aug-16 duty of candour was applied to all applicable cases within 10 working days.

There have been no grade 4 pressure ulcers acquired in Oxleas care since 17/3/14. There is a continued increase in the total number of grade 2 pressure ulcers reported this quarter compared to the previous 2 years which is encouraging as nurses are being open and honest in their reporting.

Clients with a history of self-harm who have been discharged should receive a follow-up within 48 hours. In Aug-16 100% of patients fitting the criteria were followed up within 48 hours.

The dashboard now shows timescales for formal and local complaints separately. Since the Trust started reporting on all complaints received in writing both formally and informally, this has had an impact on complaints investigation timescales. The Trust took a decision to maintain the 30 day target for investigating complaints.

Delayed discharges as a percentage of admitted patients (Mental health). In Aug-16 the overall Trust figure reported against the monitor target of <7.5% was 4.0%. This equates to 568 of 14115 days (Excluding forensic services). Bexley figure has fallen every month since May-16 to 6.8% in Aug-16.

Patients detained under the Mental Health Act, who are provided with information as per Explanation of Rights (s132) was recorded for 95.2% of patients, down from the target of 100% achieved at the start of the financial year.

Consent to treatment was obtained for all (100%) of patients assessed and detained in Aug-16, under the Mental Health Act.

50% of early intervention in psychosis (EIP) referrals seen within 2 weeks. This is a newly requested addition to the dashboard. The target was met in Aug-16 for Greenwich 67% and Bromley 50% but missed in Bexley 0% (1 patient).


Title

Month 6 2016 (September) Finance Report

This paper is for Discussion

Recommended action for the Governing Body

That the Governing Body:

1. DISCUSS & NOTE that the Month 6 (September) financial position and forecast outturn financial position are in line with the plan submitted to NHS England;

2. NOTE the details of the 2016/17 allocations (programme and running costs) received and expenditure to date;

3. NOTE the returns made to NHS England reporting the Month 6 financial position (Appendix 1);

4. DISCUSS & NOTE the key risks identified in achieving the planned position in 2016/17 and the management actions being taken to address and mitigate these risks where possible;

5. NOTE the potential underlying recurrent financial position for 2017/18;

6. NOTE the financial position for month 6 (September) for primary medical services as provided by NHS England;

7. NOTE the month 6 actual performance against the key national finance targets.

Potential areas for Conflicts of interest

GPs will be interested in the Primary Medical Services information which relates to contracts with GP practices.

Executive summary

A surplus of £82k was reported at month 6, in line with the 2016/17 plan position submitted to NHS England. The in-month position necessitated the use of some available reserves to achieve this.

The CCG is forecasting an outturn position of £169k surplus in line with the original plan and in agreement with NHS England, as it is accepted that the CCG is still unable to meet 1% surplus. In order to meet the planned

ENCLOSURE: N(ii) Agenda Item: 150/16


surplus, the CCG is using its contingency plus significant non-recurrent support. The additional costs being seen in 2016/17 affect the CCG’s recurrent position which will need to be resolved by additional QIPP in 2017/18 if the CCG is to achieve a reported breakeven position next year.

There are a number of risks to the financial position. One of the main issues is the acute contract position, which includes potential over-performance on the 2016/17 PbR contracts with Dartford and Gravesham NHS Trust (although there was an improvement in month on this contract) and Guy’s and St Thomas’ NHS Foundation Trust. For King’s NHS Foundation Trust, the CCG has agreed to a block contract deal in order to mitigate the risk for this year, but the underlying position with King’s remains of some concern despite the position improving this month; work is being undertaken by the CCG with CSU colleagues to investigate this further. For Lewisham and Greenwich NHS Trust, there is a block contract in place for some elements of the contract for the first 6 months of the year and there are still on-going discussions regarding the second half of the year; the overall contract value for this trust therefore remains unknown at this point and is dependent on a number of issues being resolved.

In addition to the acute position risks, a number of additional risks for the CCG have also been identified, further details of which are given in the paper. These include prescribing, the prime contractor contract for cardiology and possible additional charges from the Local Authority. The CCG has very limited mitigation against such risks as the 1% transformation fund must be kept uncommitted at this stage in the financial year.

Running costs remain within the budget which has been set £868k lower than the allocation. This is accentuated this year as the levies were taken as an IAT rather than by invoice. A full review of running costs, in line with the agreed pan London guidance, was undertaken in month 3 to correct any errors in the original split. It should be noted that any underspend on running costs can be used on programme costs but an underspend on programme costs cannot be used to fund running costs.

At month 6, forecast outturn QIPP delivery has been assessed at £7.93m (92.9%) of the RAG rated QIPP, a deterioration from month 5 There is currently slippage on the diabetes, acute productivity, CFV falls, prescribing and GP referral schemes which is offset by over-performance on the Ophthalmology, Prime contractor, AQP, Delayed Transfer of Care and Corporate schemes. The overall forecast position is a net under-achievement of £(0.61)m, which results in the CCG being RAG rated Amber by NHS England for QIPP delivery.

Performance against the Better Practice Payment Code (BPPC) has

performed well overall so far this year, with all targets being met in month. The cumulative targets which the CCG is monitored against are also being met. The CCG finance team, in conjunction with CSU colleagues, will continue to remind budget holders of the importance of correctly processing invoices, via SBS, in a timely manner to ensure that all targets continue to be met in future months.

For month 6, the Non ISFE return to NHS England included the same requirements as in previous months, with the additional requirements on the mental health tab; there was still no requirement to report on penalties. The return was completed in line with the national guidance and a copy is included in the appendices to this report.

The Primary medical services results for Bexley to the six months to 30th September are showing an overspend of £11k (0.1%) due to a slight overspend on PMS contract after a non-recurrent benefit from 2015/16 accruals (£106k). Refunds in relation to prior year business rates are expected to contribute towards the QIPP savings target. The forecast year end outturn variance based on month 6 is an overspend of £74k after a non-recurrent benefit on prior year accruals (£212k). Bexley’s weighted population has slightly increased by 0.3% year on year from April 2015 to April 2016. There has been a year to date growth of 0.8% (1,856 weighted population) for the two quarters to 1st July 2016.

How does this paper support the CCGs objectives?

Patients: N/A

People: N/A

Pounds: The CCG is currently meeting all of its statutory duties year to date and is currently forecasting achievement for year end.

Process: The CCG has processes in place to ensure that it commissions high quality services for the residents of Bexley.


Key risks

As detailed in the report, there are a number of risks which may affect the CCG’s ability to achieve breakeven. These have been identified as being primarily acute over-performance, uncertainty around the LGT contract for the second half of the year, impact of negotiations around the prime contractor contract for cardiology and a potential prescribing overspend. There are limited mitigations in place for these items and at this point in the year the risks remain uncertain. NHS England has also stated that the 1% transformation fund must be kept uncommitted and the CCG is therefore unable to use these funds. The risks are constantly monitored and updated.

Equality

N/A

Financial

At this point in the year, the CCG is predicting achievement of the planned surplus of £169k. However, there are a number of risks identified to achieving this position as above. In order to qualify for any quality premium the CCG will be expected to achieve its financial plan.

Data

N/A

Legal issues

N/A

NHS constitution

N/A

Engagement N/A

Audit trail This paper has also been presented at the November Finance Sub-Committee

Comms plan None

Author: Julie Witherall AD Financial Management

Clinical lead: Dr S Deshmukh GP Finance lead

Executive sponsor: Theresa Osborne Chief Financial Officer

Date 28 October 2016

1

Financial Performance Update as at Month 6 (September 2016) 2016/17

1. FINANCIAL KEY INDICATORS 2016/2017

Table 1 below sets out the CCG’s statutory targets, and progress to date, on which it reports to NHS England; and will include in its Annual Accounts and Annual report. Table 1: Key Indicators 2016/17

Target Forecast Outturn

Var

% Var M6

% Var M5

Indicator M6

CCG Statutory Targets:

Achieve control total (Programme)

£169k £169k £0k £0k £0k

=

Achieve Financial Balance – Revenue (Programme)

£0k £0k £0k £0k £0k

=

Remain within Running costs allocation

£5,109k £4,301k £(808)k (15.81)% (15.91)%

Better Payments Practice Code (BPPC) Compliance – by count (number)

95% 98.97% 3.97% 3.95%

Better Payments Practice Code (BPPC) Compliance – by value

95% 99.83% 4.83% 4.86%

KEY: Significantly Below Target (over 3%)

Marginally Below Target (Between 1% and 3%)

On or above target or less than 1% below target

Reduction in Performance from last period

Same performance as last period =

Improvement from last period

2

2. HIGHLIGHTS

A surplus of £82k was reported at month 6, in line with the 2016/17 plan position submitted to NHS England. The in-month position necessitated the use of some available reserves to achieve this.

The CCG is forecasting an outturn position of £169k surplus in line with the original plan and in agreement with NHS England, as it is accepted that the CCG is still unable to meet 1% surplus. In order to meet the planned surplus, the CCG is using its contingency plus significant non-recurrent support. The additional costs being seen in 2016/17 affect the CCG’s recurrent position which will need to be resolved by additional QIPP in 2017/18 if the CCG is to achieve a reported breakeven position next year.

There are a number of risks to the financial position. One of the main issues is the acute contract position, which includes potential over-performance on the 2016/17 PbR contracts with Dartford and Gravesham NHS Trust (although there was an improvement in month on this contract) and Guy’s and St Thomas’ NHS Foundation Trust. For King’s NHS Foundation Trust, the CCG has agreed to a block contract deal in order to mitigate the risk for this year, but the underlying position with King’s remains of some concern despite the position improving this month; work is being undertaken by the CCG with CSU colleagues to investigate this further. For Lewisham and Greenwich NHS Trust, there is a block contract in place for some elements of the contract for the first 6 months of the year and there are still on-going discussions regarding the second half of the year; the overall contract value for this trust therefore remains unknown at this point and is dependent on a number of issues being resolved.

In addition to the acute position risks, a number of additional risks for the CCG have also been identified, further details of which are given in the paper. These include prescribing, the prime contractor contract for cardiology and possible additional charges from the Local Authority. The CCG has very limited mitigation against such risks as the 1% transformation fund must be kept uncommitted at this stage in the financial year.

Running costs remain within the budget which has been set £868k lower than the allocation. This is accentuated this year as the levies were taken as an IAT rather than by invoice. A full review of running costs, in line with the agreed pan London guidance, was undertaken in month 3 to correct any errors in the original split. It should be noted that any underspend on running costs can be used on programme costs but an underspend on programme costs cannot be used to fund running costs.

At month 6, forecast outturn QIPP delivery has been assessed at £7.93m (92.9%) of the RAG rated QIPP, a deterioration from month 5 There is currently slippage on the diabetes, acute productivity, CFV falls, prescribing and GP referral schemes which is offset by over-performance on the Ophthalmology, Prime contractor, AQP, Delayed Transfer of Care and Corporate schemes. The overall forecast position is a net

3

under-achievement of £(0.61)m, which results in the CCG being RAG rated Amber by NHS England for QIPP delivery.

Performance against the Better Practice Payment Code (BPPC) has performed well overall so far this year, with all targets being met in month. The cumulative targets which the CCG is monitored against are also being met. The CCG finance team, in conjunction with CSU colleagues, will continue to remind budget holders of the importance of correctly processing invoices, via SBS, in a timely manner to ensure that all targets continue to be met in future months.

For month 6, the Non ISFE return to NHS England included the same requirements as in previous months, with the additional requirements on the mental health tab; there was still no requirement to report on penalties. The return was completed in line with the national guidance and a copy is included in the appendices to this report.

The Primary medical services results for Bexley to the six months to 30th September are showing an overspend of £11k (0.1%) due to a slight overspend on PMS contract after a non-recurrent benefit from 2015/16 accruals (£106k). Refunds in relation to prior year business rates are expected to contribute towards the QIPP savings target. The forecast year end outturn variance based on month 6 is an overspend of £74k after a non-recurrent benefit on prior year accruals (£212k). Bexley’s weighted population has slightly increased by 0.3% year on year from April 2015 to April 2016. There has been a year to date growth of 0.8% (1,856 weighted population) for the two quarters to 1st July 2016.

4

3. BUDGETS A summary of the 2016/17 budgets showing the approved opening budgets and any movements between month 5 reported position and month 6 are shown in table 2 below. The month 6 budgets equal the expected allocation shown further on in the report allowing for rounding. The resources shown are net of miscellaneous income that the CCG receives for the goods/services it provides to other organisations. The total allocations reflect the resource limit that the CCG receives from NHS England. During the month, the only adjustments made have been to move budgets between codes within cost centres, giving no impact on the bottom line; no new allocations have been received in month 6. Table 2: 2016/17 Budget Summary

Note: Budget changes are only shown where there is a change between directorates.

5

4. CCG ALLOCATIONS / REVENUE RESOURCE LIMIT (RRL)

In month 6, the CCG did not receive any changes to its allocation for 2016/17 which was as expected. The CCG is not aware of any further potential adjustments to the allocation in future months at this stage. The guidance states that allocations should not be anticipated and anticipated items would not be shown in the table below. The final allocation / RRL is the figure that the CCG’s net spend will be measured against when reviewing its achievement of financial balance for the year. The current allocations are shown in table 3 below. Table 3: Month 6 (September) CCG Allocation

Month Description Allocation

Initial Initial Allocations (293,260,000)

Initial Return of 2015/16 Surplus (169,000)

Initial Running Cost Allowance (5,109,000)

Initial Allocations (298,538,000)

Month 1 Allocation (298,538,000)


Month 3 Eating Disorder Service (130,000)

Month 3 Healthy London Partnership 440,000

Month 3 London Levies 150,000



Month 5 GP Development Programme - Reception (20,000)

Safeguarding children named GP (13,000)


Month 6 Allocation (298,111,000) The final programme allocation cannot be used to fund any overspend on running costs. However, any underspend on the running cost allowance may be used to fund the programme costs of the CCG.

6

5. CAPITAL RESOURCE LIMIT (CRL)

Within the 2016/17 financial planning return, a capital plan was submitted in accordance with table 4 below which now forms part of the CCG’s monthly non ISFE return (Appendix 1). Table 4: Planned Capital Expenditure

The CCG submitted Project Initiation Documents (PIDs) to NHS England in support of the bids in the table above. The outcome of these bids has been received and the CCG has been successful in obtaining the £35k requested. The allocation has also now been received and the procurement of the equipment has begun so that it can be deployed asap. At month 6, there has been spend of £15k. In addition to bids for the CCG, a number of bids in respect of Primary Care IT have also been made with PIDs to NHS England. Approval has been given but at a lower value than the bid values.

7

6. 2016/17 MONTH 6 (SEPTEMBER) FINANCIAL POSITION Table 5.1 summarises the financial position, at category of care level, for the CCG at Month 6 (September). The financial position is then also reported at a cost centre level for information. The national ISFE / SBS system has an extremely limited coding hierarchy and the CCG has to work within the nationally set parameters. Additional levels of information can be provided off line if required. Table 5.1: Summary financial position by category of care – September 2016

Table 5.2: Summary financial position by cost centre – September 2016

8

9

10

At the end of month 6 the CCG is reporting a surplus of £82k year to date, which is in line with expectations at this time of the year to meet the predicted full year surplus of £169k in the financial plan submitted to NHS England. This surplus position is based on the 2015/16 final position, as NHS England has agreed that the CCG will not be required to make the expected 1% surplus in 2016/17.

The CCG has achieved a balanced position through significant utilisation of reserves and non- recurrent resources. There is very little headroom now left in reserves should the financial position worsen further, which will put the CCG’s ability to achieve its planned full year surplus of £169k at risk. It has been made clear by NHS England that the 1% non-recurrent reserve held by the CCG cannot be used for non-recurrent spend or to support overspends in other areas this year and this is factored into the outturn. QIPP monitoring continues and the CCG has successfully bridged the QIPP gap which was evident in its initial planning. However, an element of slippage is now being seen on some schemes. Programme project costs incurred in supporting the delivery of QIPP, PCIF and other GP payments and the SE London PMO total £2,487k to date, which is slightly under plan year to date.

11

7. SUMMARY OF MAIN VARIANCES

Mental Health YTD Variance £139k, FOT £0k The Mental Health overspend of £139k at month 6 is due to overperformance on the SLAM SLA of £97k within the adults element. There is also an overspend of £42k in Mental Health NCAs which is due to high cost patient billing from Kent & Medway SCP Trust. The CCG continues to raise invoices to the London Borough of Bexley for joint funded patients under Section 117 requirements. To date all other areas within Mental Health are currently spending to plan which is encouraging at this stage of the financial year. The reason for FOT being breakeven is that any overspend will be the first call on the mental health parity of esteem investment which is available and is currently sitting within the reserves cost centre. Acute YTD Variance £1,736k, FOT £4,500k The acute position continues to be a significant issue this month is £1,736k overspent year to date, with an overall FOT overspend of £4,500k. Within this overspend we are continuing to predict a £1m worsening in FOT for the cardiology prime contractor. Negotiations are ongoing on this issue. It should also be noted that due to the fact that the CCG has a block contract arrangement with King’s, there is also an underlying over-performance position which will need to be reflected in the 2017/18 planning, this is currently additional costs of circa £800k. The underlying LGT position adds a further £100k risk. The NCA position has deteriorated from month 5 and is due to large invoices from providers for high cost episodes. For acute activity passing through the CCG’s main provider trusts, there is an overspend of £1,078k reported YTD, with a forecast outturn overspend of £3,512k for the full year. The year to date variance has improved from month 5. Prudent measures have been included within the acute provider costs to recognise that some risk exists around activity on elective work; for Bexley the forecast outturn on expenditure for electives is on plan indicating that activity is under control although this is not the general picture locally and as such 50% of the underspend on elective work has been accrued in addition to recognising the £140k impact on FOT of the emergency review, local price review and maternity casemix audit at LGT. Challenges and queries are ongoing and outcomes will be reflected in the financial position as they are resolved. Additional information on the performance of the acute providers can be found in the integrated contracts report presented by the Commissioning team.

12

Performance as at month 6 is analysed as follows:

Provider YTD

spend

£k

YTD

variance

to plan

£k

Commentary – main YTD variances to plan FOT £k FOT

variance

£k

Main Providers

Dartford & Gravesham NHS Trust 15,905 53 Outpatients £(205)k, Elective £(65)k, Other £378k. 32,338 (34)

Guys and St Thomas’s NHS Foundation

Trust

9,044 (456) Other £(176)k, Drugs & devices £(110)k, Outpatients £(174)k, Non-Elective £(98)k. 18,391 (1,216)

Kings College NHS Foundation Trust 12,111 (112) Outpatients £(284)k, Critical care £(74)k, Emergency £76k, Maternity £146k, Other £11k. 24,111 (112)

Lewisham & Greenwich NHS Trust 30,784 (563)

Non-elective £(437)k, Other £243k, Direct Access £(186)k, Maternity £(88)k, Elective

£180k, Emergency £69k.

63,050 (2,150)

Subtotal 67,844 (1,078) 137,890 (3,512)

Other Providers

London Ambulance Service 4,121 0 Block contract. 8,243 0

Non Local acute contracts 3,083 38 Barts & The London £(80)k, Queen Victoria Hospital £73k, BMI £42k. 6,053 188

NCA activity 1,572 (170) 2,980 (176)

Subtotal 8,776

(132)

17,276 12

TOTAL 76,620 (1,210) 155,166 (3,500)

13

(+ variance = under budget, - variance = over budget)

14

In addition to the acute activity at providers detailed above, the acute cost centre includes maternity services, planned care and winter pressure costs. These contribute a further £12,864k of expenditure YTD, resulting in a £527k overspend against plan. The FOT includes the £1m full year FOT adjustment in respect of the cardiology contract as discussed above. Primary Care YTD Variance £(45)k - FOT £250k Prescribing costs are informed by data received from the Prescription Pricing Authority (PPA), which is two months in arrears. The latest FOT suggest that there will be no overspend in 2016/17. However, discussions with the AD of Medicines management suggest that this may not be the case and that it is appropriate to report a FOT overspend of £250k as this more realistically reflects the trend emerging from actuals YTD. Given prescribing activity in previous years, there is considerable risk attached to the current underspend position reported via the PPA so this is considered a prudent approach. YTD costs for NHS 111 are £104k under budget based on data received from the service provider via Bromley CCG as host commissioner. This includes the SE London 111 clinical lead costs as well as operating costs for provision of the 111 service, and is principally driven by reduced cost per call rates. Continuing Healthcare (CHC) YTD Variance £444k - FOT £1,000k The CHC staff element continues to be underspent by £(30)k, which is due to staff vacancies and staff reducing hours. Some of the vacant posts have been recruited to therefore we should start to see the underspend gradually reduce. The budget for 16/17 has been calculated based on the 15/16 outturn position plus 5% to take into account the impact of the implementation of the National Living Wage and the impact this has had on providers. Therefore it is expected that CHC spend should remain within budget. There is an overspend of £475k in FNC which is due to significant increased nursing home charges, which could not have been predicted during planning. There is also the addition of a nursing home. The costs will continue throughout the year with an expected FOT of £1m. Community Health YTD Variance £117k - FOT £400k Community Health Services is overspent by £117k at month 6, which is partly due to the community anti-coagulation (£74k) where the provider invoices are greater than the set budget. There is also an overspend on Intermediate care of £29k due to Plaster of Paris cases jointly funded with the LB Bexley and 2 non-accrued invoices for 15/16 which will have to be managed within the current year. Other YTD Variance £(2,368)k - FOT £(6,209)k In order to achieve the financial position, it has been necessary to utilise a large proportion of non-recurrent resources year to date and for forecast outturn.

15

Programme project costs, comprising GP incentive schemes, on-going service redesign work, and local primary care cost innovation and federated working projects, are underspent by £93k YTD; this is due to an underspend to date for the south east London PMO and payroll costs allocated to programme expenditure, offset by a pooled contribution to LBB and front-ended training costs. Corporate YTD Variance £(22)k - FOT £60k Within corporate, finance is contributing most significantly to the underspend, particularly in the areas of professional fees, consultancy and depreciation. This is offset by increased agency staff costs in some other areas but overall results in a £(22)k overspend in total running costs for the CCG YTD. Continuing Care Unassessed Periods of Care Claims For 2016/17, Bexley CCG has been required to contribute £691k to a risk pool to cover the outstanding continuing care claims. It is expected that all claims will be settled during this financial year and hence there will be no need for a risk pool in 2017/18 and beyond, as advised by NHS England. The calculation of the 2016/17 contribution was issued in 2015/16 based on the numbers of successful claims made from the risk pool across the country and was attached to a previous finance report. Updates are provided on a regular basis by the CHC team and the best, worst and most likely cases for the various categories of care are calculated. As knowledge becomes better on the remaining cases, the CCG can more accurately predict the provision. Claims are continuing to be approved for settlement, with £1,313k approved for payment as at 30/09/2016. Any expenditure incurred by the CCG in 2016/17 will be repaid by NHS England from the national risk pool. Latest calculations based on the information available as at 30/09/2016 shows that the most likely impact of the claims received is now £1,131k, which is lower than the provision advised to NHSE at the end of the year. From last year the CHC return was incorporated into the non ISFE return which requires the approval of the Director of Commissioning and is appended to this report (Appendix 1). Excluded from this value is the £1,313k of settled/agreed claims. Others are awaiting payment or calculation at this time. The worst case position remains substantially higher than the provision. In order to arrive at the potential liability figures, percentages have been assigned to the likelihood of the claims coming to fruition. This includes provision for a percentage of the claims going to the ombudsman in case a decision is made against the organisation. The other variable in the calculation is the number of weeks that it is expected would be paid. For many cases this is not known, an average of the number of weeks, where this is known, has therefore been used in these cases. Guidance received prohibits the cost of administration to settle the claims being paid from the provision. For cases which were received for subsequent periods, i.e. for periods of care from 1st April 2012, the CCG included the values as either a provision or contingent liability in the 2015/16

16

year end accounts. The CCG will assess any further claims received on an individual basis and included in the accounts as appropriate. As reported last month, an updated position has been reported at month 5 which predicts a year end provision value of £40k based on the information available at this time. This has now been reflected in the ledger. Personal Health Budgets (PHBs) The CCG is monitoring the numbers of PHBs which are in place as there may be a requirement to reach a target in the future. As at 30/09/2016, Bexley CCG had the following PHBs:

Children’s PHBs – 1

Mental Health PHBs – 1

CHC PHBs – 5

Notional PHBs – 10

This is an increase from last month which shows good progress.

17

8. RUNNING COSTS (CORPORATE) Within the ledger there are a number of cost centres which are mapped as administration, where running costs must be coded. The running costs allocation for 2016/17 is £5,109k with a forecast outturn of £4,301k giving rise to a £808k underspend. In month 3, a further review of the running costs was undertaken to ensure that they have been correctly mapped and are in accordance with the pan London guidance. From this review, a number of changes were made in month 3. No further changes are then expected to be made in year unless circumstances change. In order to arrive at the initial 2016/17 budget and expenditure figures the CCG has ensured the following steps have been taken:

The application of the London running cost guidance, formulated by London CFOs; and agreed with the NHS England London Director of Finance. This guidance gives standard definitions for running costs expenditure to be applied across London. This has resulted in some staff being split coded between running costs and programme costs in consideration of the roles undertaken.

The expenditure on running costs is under constant review and monitoring to ensure that it is kept to a minimum.

An analysis of rental costs has been undertaken to ensure appropriate allocation between programme costs and running costs.

18

9. RISKS

Table 7: Risks as at month 6

Table 7 shows the risks to the CCG at month 6. It shows the likely position, which matches the actual reported position, the best case and worst case (based on the information available if all of the potential risks come to fruition); and how the risks can be mitigated within the current resources available to the CCG. At the time of preparation, the range of forecast outturn was between a £3.9m deficit, should all risks occur, and £1.1m surplus, if

19

the position improves. It is still not possible at this stage in the financial year to be able to assess the likelihood and value of some of the potential risks to the financial position. The largest risk to the CCG’s financial position during the year is the acute activity, although there has been a small improvement in this month; whilst the CCG has a block with King’s and a block for some elements of the contract for the first 6 months with Lewisham and Greenwich (LGT), the CCG has full PbR contracts with Dartford and Gravesham and Guy’s and St Thomas’. There are also a number of items to be worked through with LGT for the second half of the year in order to agree the final contract value. Whilst not a direct impact for 2016/17, there are concerns around the underlying positions at King’s, despite an improvement in the position this month, and LGT, which the CCG is working with the CSU to investigate. Another significant risk is around the prime contractor contract for cardiology which has yet to be finalised and whilst there is £1m factored into the financial position, further risk is identified. Negotiations are ongoing in order to reach an agreed position for this contract before the next report is due. Although the Lewisham and Greenwich element of the contract has now been signed there are ongoing concern regarding over-performance. There is a potential risk around the prescribing expenditure in 2016/17. The CCG has now received an initial view of FOT for 2016/17 from the PPA based on the month 4 position, as reporting is two months behind. This initial view shows a predicted underspend at year end, although less than in previous months. However, following discussions with the AD of Medicines Management, in order to be prudent, a risk of £250k in addition to a reported £250k overspend is being declared. Once a further month’s data has been received, the CCG will be in a better place to assess the risk again. Two of the localities have adopted the delegated prescribing scheme for 2016/17 and it is hoped that this may mitigate any potential overspend. There are some other much smaller risks around neuro rehab and community which are currently being offset by reserves whilst ensuring that the 1% transformation fund remains uncommitted. Some of these risks have been identified as arising from additional costs being requested from the London Borough of Bexley in respect of children in placements and clients with mental health issues in placements. These placements are currently being assessed and reviewed to identify whether they require health funding. The final risks are around an overspend against budget on corporate due to some staffing pressures, although the CCG is still within its running cost allowance, and a risk around CHC for any additional clients coming on stream mid year. All of these risks will be continually reviewed and adjusted, and the impact on the financial position monitored as they crystallise or circumstances become clearer. The most likely case is as shown in the reported forecast outturn income & expenditure position. The non ISFE risk return for month 6 (Appendix 1) has been populated based on the difference between the likely case and the worst case scenarios, with assumptions made around the probability of each event actually occurring.

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10. 2016/17 QIPP / SAVINGS PLANS

QIPP schemes with a total value of £8.5m are required to meet financial planning requirements for 2016/17. This target was initially £6.7m. However, following additional planning information from NHSE stating that the 1% transformational funding could not be committed in planning, the QIPP requirement increased by £1.8m, resulting in an increased unidentified QIPP at the start of the year of £1.5m. However, additional QIPP schemes were identified during late May and early June and this has now been reduced to zero. To ensure robust governance, schemes were also risk assessed, by a multi-disciplinary/agency panel, to produce a RAG rating for each. The panel met on 14th June 2016 and its RAG rating of schemes resulted in a total risk assessed value of £6.9m, £0.1m below the values included in financial planning. The month 6 assessment suggests that QIPP delivery will be £7.93m (92.9%), a reduction from month 5. Schemes are reviewed every month in consideration of the latest intelligence. There is currently slippage on the diabetes, acute productivity, CFV falls, prescribing and GP referral schemes which is partially offset by over-performance on the Ophthalmology, Prime contractor, AQP, Delayed Transfer of Care and Corporate schemes. The overall forecast position is a net under-achievement of £0.61m, which results in the CCG being RAG rated Amber by NHS England for QIPP delivery. Regular meetings are held within the CCG to review and agree project RAG ratings and assess the financial delivery. This includes monthly meetings held with Project Managers that inform the completion of the QIPP implementation and monitoring forms. Those schemes RAG rated red in the monthly assessment are presented to the Finance Sub-committee, in the monthly QIPP report. Star Chamber meetings are also held to help to progress schemes. The CCG continues to work with the CSU to accurately report acute QIPP schemes. QIPP information is provided to NHS England (NHSE) in the Non-ISFE return (Appendix 1). The return is split between transactional and transformational QIPP and by Acute, Mental Health, Community, Continuing Care, Primary Care, Other Programme services and Running costs. The recurrent / non-recurrent split across the categories is also shown. Health economy wide QIPP, in the form of efficiencies built into contracts is also included within the dashboard.

21

Table 8: Summary of 2015/16 QIPP schemes

22

11. FINANCIAL MANAGEMENT

Better Payment Practice Code (BPPC)

Target

One of the CCG’s financial targets is to ensure that at least 95% of NHS and non-NHS trade creditors are paid within 30 days of receipt of the invoice. Performance against this target is regularly reported to the local NHSE performance team, and the annual cumulative figure for the year is published in the Annual Accounts and Annual Report.

Table 9: Better Practice Payment Code (BPPC) performance

NHS NON-NHS TOTAL NHS NON-NHS TOTAL NHS NON-NHS TOTAL NHS NON-NHS TOTAL

Target By Count By Count By Count By Value By Value By Value By Count By Count By Count By Value By Value By Value

% % % % % % % % % % % % %

April 95.00 98.51 98.84 98.74 99.99 99.97 99.99 98.51 98.84 98.74 99.99 99.97 99.99

May 95.00 98.44 98.30 98.33 99.99 99.47 99.93 98.48 98.59 98.56 99.99 99.77 99.96

June 95.00 98.66 98.47 98.53 99.96 98.77 99.72 98.54 98.55 98.55 99.98 99.39 99.88

July 95.00 100.00 99.63 99.71 100.00 99.49 99.92 98.88 98.89 98.89 99.99 99.42 99.89

August 95.00 98.22 99.36 99.15 99.98 98.45 99.74 98.78 99.00 98.95 99.99 99.23 99.86

September 95.00 98.58 99.25 99.05 99.98 97.39 99.66 98.74 99.04 98.97 99.98 98.99 99.83

CUMULATIVE

At month 6, all of the in month and cumulative targets were comfortably being met with fairly small movements in most cases between the 6 months to date. Overall, the CCG’s performance in this area is historically very good and at this point in the year, the CCG is on track to meet the statutory duty for 2016/17. A concern with respect to the target remains that NHS England takes their measurement straight from the ledger without making any technical adjustments, and this is known to be an inaccurate measure of performance. As this is one of the measurable targets for the CCG, it is important to ensure that these targets are continually met. Budget holders are constantly being asked to approve invoices in a timely manner or, if there is a problem, to place the invoice on hold until they have resolved the issue; this ensures that these invoices are removed from the calculation. These measures should help speed up the approval process and maintain the BPPC performance during the year.

23

Cash Management

Cash Limit

The CCG will not be receiving a formal cash limit again in 2016/17. Instead the organisation has been advised of a maximum cash drawdown (MCD) value to work within. At month 6, this has been advised to be £298,242k and is reflected in the cash reporting process (see table 10). The MCD value is expected to be the figure, prior to the topslice for prescribing spend. It is understood that as long as this value is not breached then the CCG will have met its duty in relation to cash. Table 10: Maximum Cash Drawdown

Cash Resource Limit

Cash

Report

July 16

'£000

Cash

Report

Aug 16

'£000

Cash

Report

Sept 16

'£001

CCG cash requirement 297,390 298,277 298,242

Less

Prescription Pricing Authority 31,907 31,993 31,993

CHC Risk Pool 0 691 691

Other Central / BSA payments 156 300 300

Remaining Cash limit 265,327 265,293 265,258

Cash Drawings

Table 11 shows the year to date cash drawings to Month 6 compared to the planned drawings for the same period based on the latest FIMS plan. The cash plan uses the maximum drawdown value, as advised above, (after the estimated adjustments for prescribing spend) as a proxy for the cash limit, and once completed will show that the requirement does not exceed this value. At this point in the year, the CCG has drawn down very slightly more cash than planned (50.1% compared to 50.0%); therefore at this point in the year, no problems regarding cash at the year end are expected.

Table 11: Planned and actual cash drawings

24

The cash balance at the end of month 6 was £103k. Month end cash is now measured against the NHSE guidance stating that it should be 1.25% or less of cash drawn down in the month. This requirement was met in September. The revised guidance on cash management, received from NHSE, includes the requirement to calculate notional charges against differences in the drawdowns and values of payment runs, in order to show how the Department of Health is being charged by the Treasury for poor cashflow forecasting. The CCG receives weekly cash forecasting information which is being used to help the Chief Financial Officer and finance team ensure good cash flow during the month and to reduce the cash balance before month end. The CCG and CSU have also developed a cash protocol, adopted by both parties to ensure that the roles and responsibilities around cash management are clear and well defined. This protocol is now operational and is proving a useful tool in the cash draw down process as it includes personnel from the CCG, ARC team and acute MDT team. Debtors and Income Collection

Table 12: Aged Debtors Position

The level of aged debtors has decreased this month which is encouraging. There are 129 transactions making up the aged debt balance. The highest level of debt remains with LBB and currently stands at £444k, of which £345k is over 60 days old. The CCG is actively engaging with them in trying to clear these dated items and will continue to do so over the next few weeks, although there has been some misallocation of cash identified which has now been corrected. Oxleas owes £388k which is mainly an agreed recharge value which is expected to be settled in full and will be followed up. There are no other high value debtors on the books. There are also no other debts over 60 days old with a large value. The local CCG team are continuing to work with CSU colleagues to try to resolve any outstanding issues and ensure that these items are paid as quickly as possible.

25

Statement of Financial Position (Balance Sheet) The Statement of Financial Position is presented in table 13 in order to comply with good practice reporting. The CCG has a negative Balance Sheet as it has very few fixed assets, cash or debtors, but a high level of creditors at any time. It is unusual for an organisation to have a negative balance sheet, but most CCGs are in this position due to the nature of their business and the inability to hold many fixed assets. The Statement of Financial Position shown in this report is generated by Business Intelligence from the SBS ledger. Table 13: Statement of Financial Position

2015/16 2016/17

ADJ-16 Sep-16

Property, Plant And Equipment 241,661.90 235,128.31

Non-current Assets Total 241,661.90 235,128.31

Current Trade And Other Receivables 1,654,056.68 4,148,292.40

Cash And Cash Equivalents 41,254.62 103,200.07

Current Assets Total 1,695,311.30 4,251,492.47

Current Trade And Other Payables (28,314,040.81) (12,423,787.07)

Current Other Liabilities (424,783.88) (18,440,040.66)

Provisions (86,000.00) (50,000.00)

Current Liabilities Total (28,824,824.69) (30,913,827.73)

Grand Total (26,887,851.49) (26,427,206.95)

2015 2016/17

ADJ-16 Sep-16

General Fund 26,887,851.49 26,427,206.95

Financed by Taxpayers Equity: Total 26,887,851.49 26,427,206.95

Grand Total 26,887,851.49 26,427,206.95

Closing Balance

Closing Balance

26

12. PRIMARY CARE MEDICAL SERVICES FINANCIAL REPORT The expenditure budgets have been set for each CCG based on contractual commitments and to meet all known and anticipated costs. The average growth in London Medical allocations for 2016/17 is 4.78%, but this does not fall evenly across CCGs due to their differing distance from target. Due to the shortfall on the recurrent QIPP target in 2015/16, there is an underlying deficit to make up on Medical Services in 2016/17. Across London this means in aggregate the 2016/17 cost increases are met by the 4.78% growth. An aggregate QIPP of 0.5% has been included in the plan, which is forecast to be delivered from transactional savings managed by NHS England. This will mostly be from the recurrent impact of the rates reductions, reducing premises reimbursement costs. The Primary medical services results for Bexley to the six months to 30th September are showing an overspend of £11k (0.1%) due to a slight overspend on PMS contract after a non-recurrent benefit from 2015/16 accruals (£106k). Refunds in relation to prior year business rates are expected to contribute towards the QIPP savings target. The forecast year end outturn variance based on month 6 is an overspend of £74k after a non-recurrent benefit on prior year accruals (£212k). Bexley’s weighted population has slightly increased by 0.3% year on year from April 2015 to April 2016. There has been a year to date growth of 0.8% (1,856 weighted population) for

the two quarters to 1st July 2016.

27

Table 14: Primary Medical Services Financial Position as at Month 5

28

13. RECOMMENDATIONS

Members are asked to:

DISCUSS & NOTE that the Month 6 (September) financial position and forecast outturn financial positions are in line with the plan submitted to NHS England;

NOTE the details of the 2016/17 allocations (programme and running costs) received and expenditure to date;

NOTE the returns made to NHS England reporting the Month 6 financial position (Appendix 1);

DISCUSS & NOTE the key risks identified in achieving the planned position in 2016/17 and the management actions being taken to address and mitigate these risks where possible;

NOTE the potential underlying position for 2016/17;

NOTE the financial position for month 6 (September) for primary medical services as provided by NHS England;

NOTE the month 6 actual performance against the key national finance targets.

Appendix 1

29

Month 6 Financial Position

CCG codeYear to Date

PlannedYear to Date

Year to Date

VarianceFull Year Planned

Full Year

Forecast Outturn

Full Year

Variance

07N Bexley £'m £'m £'m £'m £'m £'m

Surplus / (Deficit) 0.082 0.082 - 0.169 0.169 -

Month 6 Running Costs

CCG codeYear to Date

PlannedYear to Date

Year to Date

Variance

Full Year

Planned

Full Year

Forecast Outturn

Full Year

Variance

07N Bexley £'m £'m £'m £'m £'m £'m

Running Cost 2 2 (0) 4 4 0

Appendix 1

30

Month 6 Activity

Appendix 1

31

Appendix 1

32

Month 6 Non ISFE Reporting

Non ISFE Reporting M06 M06_CCG_v3

Clinical Commissioning Group

NHS Bexley CCG 07N

Regional Geography

London Q71

Region

London Y56

Month

Sep-16 06

Completed By:

Simon Beard

Email:

[email protected]

Contact Number:

020 8298 6073

Authorised By:

Theresa Osborne

Authoriser's Title:

Chief Financial Officer

Select CCG from drop

down

Please complete all

fields shaded red

Appendix 1

33

CCG NHS Bexley CCG

CCG Code 07N

Month 06

In-year allocation: YTD

16/17 Core Allocation 297.94 148.89

Allocation of prior years surplus for drawdown 0.00 0.00

Total share of NHSE mandate for 2016/17 297.94 148.89

Expenditure:

Forecast Expenditure 297.94 148.89

Forecast under/(over)-spend against in year allocation (0.00) (0.00)

In-year performance:

Performance against 16/17 core allocation (0.00)

Made up of:

Planned use of prior year surpluses (agreed drawdown) 0.00

Other in year under/(over)-spend against resource limit (0.00)

Memorandum: cumulative (historic) surplus/(deficit)

Total share of NHSE mandate for 2016/17 297.94

Return of remaining prior year surplus/(deficit) 0.17

Total allocation plus historic surplus/deficit 298.11

Forecast Surplus / (deficit) against total allocation 0.17

Target additional surplus required to meet business rules 2.81

To f

orm

bas

is o

f h

ead

line

I&E

rep

ort

ing

Mem

ora

nd

um

info

rmat

ion

to

be

incl

ud

ed

as f

oo

t n

ote

s

Appendix 1

34

Month 6 Commentary

Appendix 1

35

Appendix 1

36

Appendix 1

37

Appendix 1

38

Month 6 Underlying position

Appendix 1

39

Month 6 Mental Health

Appendix 1

40

Appendix 1

41

Month 6 CHC

Appendix 1

42

Appendix 2

43

GLOSSARY OF TERMS BCF BETTER CARE FUND BPPC BETTER PAYMENT PRACTICE CODE CAMHS CHILDREN’S AND ADOLESCENTS

MENTAL HEALTH SERVICES CCG CLINICAL COMMISSIONING GROUP CHC CONTINUING HEALTHCARE CIP COST IMPROVEMENT PROGRAMME CRL CAPITAL RESOURCE LIMIT CSU COMMISSIONING SUPPORT UNIT DES DIRECTLY ENHANCED SCHEME DVH DARENT VALLEY HOSPITAL FIMs FINANCIAL INFORMATION MONITORING

RETURNS FOT FORECAST OUTTURN GSTT GUY’S & ST THOMAS’ NHS FOUNDATION

TRUST HRG HEALTH RESOURCE GROUP ISFE INTEGRATED SINGLE FINANCIAL

ENVIRONMENT LA LOCAL AUTHORITY LBB LONDON BOROUGH OF BEXLEY LES LOCAL ENHANCED SCHEME LIS LOCAL INCENTIVE SCHEME LHNT LEWISHAM HOSPITAL NHS TRUST KCH KING’S COLLEGE HOSPITAL NHS

FOUNDATION TRUST KPI KEY PERFORMANCE INDICATOR MDT MULTI DISCIPLINARY TEAM NHSE NHS ENGLAND PMO PROGRAMME MANAGEMENT OFFICE PPA PRESCRIPTION PRICING AUTHORITY QIPP QUALITY, INNOVATION, PRODUCTIVITY

& PREVENTION QOF QUALITY OUTCOME FRAMEWORK RRL REVENUE RESOURCE LIMIT RTT REFER TO TREATMENT SBS SHARED BUSINESS SYSTEMS SLA SERVICE LEVEL AGREEMENT SLHT SOUTH LONDON HEALTHCARE NHS

TRUST UHL UNIVERSITY HOSPITAL LEWISHAM TSA TRUST SPECIAL ADMINISTRATOR YTD YEAR TO DATE


Title

Consolidated Contracts Report Months 5 and 6

This paper is for Discussion

Recommended action for the Finance Sub-Committee

That the Governing Body : Note

1. The performance of the Acute, Community & Mental Health contracts shown in the consolidated contracts report.

Potential areas for conflicts of interest

None known.

Executive summary

Acute Contracts At Month 5 (August) the acute contracts, including other acute services

(non-local Providers and non-contracted activity) are reporting an indicative year-to-date variance of £1,254k against the planned position with a projected forecast outturn over performance of 2% against the full year plan.

The local price review at LGT has been completed and the expected impact for Bexley for 2016/17 is £167k and the total impact over three years (2016-2019) is £670k.

The independent clinical review of the admission criteria and charging at LGT has been completed and there will be a contract variation when the outcome has been finalised. M7-M12 contract activity for emergencies at LGT will revert back to Cost & Volume from a Block contract.

The Maternity case mix audit at LGT to verify on coding practices has been completed and final outcome will be reported in next month’s report.

Community Contracts Oxleas- Agreement has been reached with Oxleas to provide flu vaccinations for all housebound patients, this includes patients that are not on Oxleas District Nursing caseload. The vaccinations programme has commenced and will run from October through to November 2016. Contract Variations have been issued to Oxleas for the Bexley Home First Team Project and the National CQUIN for Staff Health and Wellbeing.

ENCLOSURE: N(iii) Agenda Item: 150/16


MSK Prime Contractor Contract: Pain Service- The contract variation issued to KCH to incorporate the revised local quality indicators and the revised finance schedule has been signed.

Cardiology- Bids are being sought for the Community Cardiology

Services. Discussions have continued with GSTT on the Transition Plan to ensure continuity of service delivery until the 31st March. LGT Cardiology - The Activity and Finance report for month 1 – 4 shows Elective activity is under plan down but Day Cases and Out Patient FUs are significantly over plan. A formal challenge has been raised and the CCG is working with the Trust on a remedial plan. Mental Health

The Integrated Commissioning Team continues to work with the Bexley; Bromley & Greenwich (BBG) commissioner’s to assess the impact of the proposed re-design of MH Rehabilitation services. A meeting was held on 24th October. Proposals are being developed and these will be considered by the each CCG’s Governing Body. The IAPT tendering has concluded and an award recommendation made to the Governing Body. The Invitation to Tender bids for the re-procurement of Independent Mental Health Advocate (IMHA) Services returned by bidders have been evaluated. The interview panel is scheduled to take place in November. LAS LAS continue to experience higher than expected demand and will miss their trajectory for September. Bexley have experienced an 8% increase in Category A transport month 1-5 16/17 - in view of this the CCG will be reviewing all LAS data to establish reasons why this may have occurred.

How does this paper support the CCGs objectives?

Patients:

The NHS Constitution Standards and the CCG commissioning intentions have been translated into the contracts to ensure that the commissioning priorities are addressed and the impact on quality and safety of services is considered.

People: N/A

Pounds:

It is important that the CCG negotiates contracts within overall baselines set. Currently this is the case. However, risks remain that contracts will over-perform against these negotiated baselines.

Process: The CCG’s Operating Plan informs the negotiation of Activity

and Finance plans for the main contracts. The contract negotiations are clinically led to ensure appropriate governance.


Key risks

Financial risks are associated with the over performance, although these are within the forecasts, funding to cover them has had to be found elsewhere within the CCG’s budgets. No clinical risks have been introduced in these reports.

Equality

All new contracts are assessed for equality and diversity.

Financial

The main risk relates to the contracts over performance against the baselines agreed. The year-to-date variances and mitigating actions and assurances are noted in this report.

Data

There are no data issues raised in this paper.

Legal issues There are no legal issues raised in this paper.

NHS constitution

The rights of patients are enshrined within our contracts.

Engagement None

Audit trail Contracts reports are also presented to the Financial Sub- Committee

Comms plan None

Author: James Olweny & Alison Rogers

Clinical lead: Dr V Bhalla Dr N Kanani Dr S Deshmukh

Executive sponsor: Sarah Valentine Director of Commissioning

Date 8 November 2016

1

NHS Bexley CCG Contracts Monitoring Report

November 2016 (v2)

Section No. Description

1

Acute Contracting Report (Month 5)

2

Community Contracting Report Including Procurement Projects (Month 5 and 6)

3

Mental Health Contracting Report (Month 6) Prepared by the Integrated Commissioning Unit (ICU) between BCCG and London Borough of Bexley (LBB)

4

111 Contracting Report (Month 6) – provided by the South East CSU

5

LAS Contracting Report (Month 6) – provided by South East CSU

2

Acute Contracting and Performance Section 1

Main Report - Provided by CSU

1.1 Executive Summary

This section of the report sets out the Month 4 Freeze and the Month 5 Flex position for the Acute contracted activity for Bexley CCG and the contractual actions being taken. At Month 5 (August) the acute contracts, including other acute services (non-local Providers and non-contracted activity) are reporting an indicative year-to-date variance of £1,254k against the planned position with a projected forecast outturn over performance of 2% against the full year plan. This represents an adverse forecast outturn of £3.5m. A key area of over performance across the 4 main providers is Non-Elective activity which accounts for 25% (439k) of the over-performance, predominately driven by activity at LGT (364k). The other main areas driving over performance are Outpatient First (253k), Outpatient Follow-up (238k), Outpatient Procedure (188k), Critical Care (148k), Direct Access (166k), Drugs and Devices (160k) and unbundled diagnostics (118k).This over performance is offset by under performance in Elective (£150k) predominately at LGT (150k), Emergency (265k) and other Expenditure (135k). At specialty level, the over performance is across a multitude of specialties but with notable material variances in general surgery, general medicine, urology (flex- cystoscopy), clinical haematology, non-transient stroke, Stroke, ENT, minor gynaecology procedures, and ophthalmology. Direct Access diagnostics activity remains above plan in both activity and finance for referrals for X-rays and ultrasounds at DGT, and pathology tests at LGT. Further analysis is being done at practice level to understand the clinical reasons for the increased demand for pathology tests. Other points to note in the report are:

The local price review at LGT has been completed and the expected impact for Bexley for 2016/17 is a cost pressure of £167k and the total impact over three years (2016-2019) is £670k.

The independent clinical review of the admission criteria and charging at LGT has

been completed and there will be a contract variation when the outcome has been finalised. M7-M12 contract activity for emergencies at LGT will revert back to Cost and Volume from a Block contract. The revised Ambulatory Care (ACE) tariffs and pathways have been agreed to be implemented from April 2017 and are expected to have a mitigating effect on the emergency spend.

The Maternity case mix audit at LGT to verify on coding practices has been completed

and the final outcome will be reported in December’s report.

PLEASE NOTE THAT THE SCALE USED ON ALL GRAPHS WITHIN THE ACUTE CONTRACTS

REPORT DIFFERS WITH EACH GRAPH

Bexley CCG Integrated Report

A consolidated view of CCG contracting performance

Month 5


A consolidated view of CCG contracting performance

Month 5

Modules Contents

Finance & Activity

4. CCG Overview 13. Dartford & Gravesham 15. Lewisham & Greenwich

17. King’s College Hospital 20. Guy’s & St. Thomas’ 23. Summary of key finance & activity drivers, commissioning / contractual actions

Quality 32. Dartford & Gravesham 34. Lewisham & Greenwich 38. King’s College Hospital 40. Guy’s & St. Thomas’

Please note that is not be possible to align the scaling on the graphs

and that these are different.

Context South East CSU provides Contract Management services on behalf of South London CCGs. This involves a range of activities including supporting the annual negotiation process, monthly and financial, performance and activity monitoring, and the query and claims management process. The purpose of this report is to provide a comprehensive understanding of the CCG’s contracting performance position. The report is modular and is constructed from a number of components. Modules

Finance & Activity

Performance Quality

Full glossary is available on the SLCSU Portal:

http://nww.mdt.southlondoncsu.nhs.uk/integratedreport/glossary

• Finance data primary source is finance adjusted SLaM data.

• Activity data primary source is SUS (Referrals is PIMS).

• Performance data primary source is relevant national websites

(e.g. Unify2, Open Exeter, HPA HCAI database)

• Quality data primary source is Trust Scorecards

Glossary

Contents | Introduction | Glossary

Finance & Activity


Introduction This report sets out the CCG’s Month 4 Freeze position for the acute portfolio of contracts and the underlying Month 5 (flex) position. This report looks across all local providers and external providers, combining contractual, performance and quality issues.

At aggregate level the overall year-to-date contracts spend at Month 5 for Bexley CCG (including finance risk assessed claims) shows an indicative £1,254k overspend against the planned position with a projected forecast outturn position of a 2% overperformance of £3.5m across all contracts. Significant supplementary work is being undertaken by the CSU to understand, and challenge where required, any areas of concern. When challenges are successfully upheld, these will then be reflected within the reported position. In addition note should be made to the fact that this position does not include the underlying position at King’s College Hospital NHS Foundation Trust (KCH) as this is block contract this year. The element that is cost and volume, the Urology activity transfer to Lewisham and Greenwich NHS Trust (LGT) is however, included.

Performance at Dartford and Gravesham NHS Trust (DGT) has consistently been good, with continued achievement of the Referral to Treatment (RTT), Cancer and Diagnostic Thresholds. Elective activity, whilst over planned levels has reduced this month in line with planned activity, supporting delivery of the target. Challenges had been in place and referral source is being reviewed. Across all local providers, however, at CCG level, RTT performance has been non-compliant and elective performance overall, whilst improved, continues to underperform at an aggregate level. LGT elective remains considerably under plan, being the key driver at aggregate underperformance and continues to see issues within key elective specialities. Phased plans are in place to remedy performance and trajectories are being met, supported by outsourcing.

KCH continues to underperform against plan for Elective activity; however, the underperformed position has reduced this month and is forecasted to align to plan by the end of the year within the block arrangement. This will support compliance with the RTT threshold and additional management is now in place to support achievement of the local improvement trajectory to reach compliance by year end.

Across all local providers, a key driver in the portfolio overperformance continues to fall within the Non-Elective (excluding emergency) POD, specifically at LGT. Key drivers within this POD include excess bed day pressures which a proportion have been successfully challenged. Pressure areas also include births and stroke related activity.

Maternity Pathways continue to over perform financially at DGT and LGT with an increase in case-mix complexity. DGT post challenge has concluded to be below benchmarked national average, and a successful challenge at LGT has improved the financial position for Bexley CCG post adjustment to case-mix.

Drugs and Devices are financially over plan. Formal challenges are in place with providers relating to potential Prime Contracting activity that shouldn’t be charged through the acute portfolio.

Direct Access remains over plan both financially and for activity and queries have been raised with DGT and LGT. DGT continues to see a significant increase in GP referred X-rays and Ultrasounds and LGT has seen a significant increase in Pathology tests. A review has been undertaken at LGT to determine any impact of repeat testing at the trust and has concluded that the increase in activity does not result from duplicate testing, with the CSU providing a detailed report showing total test by practice and pathology discipline from 2015 to date as well as an analysis by weighted population to support CCG discussions on why pathology demand has increased.

The Emergency POD position has improved and now under plan. This has been supported by a number of challenges, specifically in emergency excess bed days and incorrectly billed activity at DGT within General Medicine. Note should also be made to the LGT overperformance in this POD at this stage in the year, mitigated by the block arrangement in place until Month 7. The forecasted position reflects that the contract is reverting to cost and volume as there will be an impact of exiting this arrangement.

Outpatient 1st remains over plan and work has been undertaken by the CSU to support the CCG to further understand drivers and referral source - note should be made to the increase in Ophthalmology activity at KCH and continued trend in overperformance.

Outpatient Procedures continue to be over plan, and the position has deteriorated further this month, both financially and for activity; key drivers include an increase in Urology (flexi cystoscopy) and minor Gynaecology procedures and respiratory procedures at DGT. This has been challenged and the review has highlighted an increase in GP referrals, shared with the CCG

Critical Care overperformance has deteriorated further this month, driven by LGT; checks are in place to ensure activity is correctly attributed and outlying activity aligned within the forecasted

plan.

Please see Summary of Contractual Actions (from Page 23 onwards) for further detail around queries and challenges raised with the local providers.

Executive Summary Pages

Finance & Activity


The overall year-to-date contract spend at Month 5 for Bexley CCG shows a £(1,254)k over plan position and an indicative projected forecast outturn 2% over performance of £(3.5)m. Queries and challenges, as set out

on the Summary of Contractual Actions Pages – page 23 onwards, have not been reflected in this position (except the risk assessed automated challenges or confirmed as agreed revisions in the position) Note should

be made to the fact that the forecast is based on four months freeze data and therefore subject to potential variation.

Dartford and Gravesham NHS Trust (DGT): The Contract position YTD spend at Month 5 is £13.3m with a YTD over spend against plan of £(5)k; this is an improvement on last month, driven within the Other POD and

Emergency POD. The Emergency POD improved position is being explored with the trust, in particular the un-commissioned Ambulatory Care (AEC) pathway, as underperformance partially relates to the short stay and

low complexity tariffs. Areas of over performance are mainly within the following PODs: OPFU – £(131)k (mitigated with the KPI efficiency adjustments in Other POD (see below), Maternity Pathway £(73)k (previous

challenge showed that case-mix is below national average) and Elective £(54)k (improved position). The over performances has been partially offset by under spend noted predominantly in Other £276k-adjutements to

plan to reflect contract reductions i.e. readmission rates and KPIs. Further detail is provided on page 13. Note should be made to the fact the trust is challenging application of all financial adjustments, despite being

outside the remit of national Guidance, and this is formally contested at Director level. Challenges are also in place within the Drugs and Devices POD relating to Prime Contracting recording - see Summary of

Contractual Actions (from Page 23 onwards).

Lewisham and Greenwich NHS Trust (LGT): The Contract position YTD spend at Month 5 is £25.7m with an over spend against plan of £(646)k. Over performance is predominantly driven within the Non-Elective

£(364)k, Direct Access £(155)k, Critical Care £(98)k, Outpatient 1st £(74)k, Maternity Pathway (£73k), and Outpatient Procedure £(72)k PODS – see page 16 for the detail. The most significant movement was within

Critical Care, attributable to a high value patient discharged in month (non-recurrent for forecast purposes). Non-elective activity pressures include transfers from the PRUH site for stroke activity and an increase in

births. The CSU and the CCG are reviewing Direct Access and Outpatient 1st increases by GP Practice. Drugs and Devices have deteriorated against plan in month, with challenges are in place relating to potential Prime

Contracting activity - see Summary of Contractual Actions (from Page 23 onwards).

King’s College Hospital NHS Foundation Trust (KCH): The Contract with KCH is a block agreement with a cost and volume element relating to the Urology transfer at the PRUH site. The recurrent overperforming

underlying position has significantly improved this month to £(229)k/ 2.2% over plan. Over performance is driven by: Outpatients (aggregate) £(237)k –predominantly Ophthalmology £(110)k (seen in Outpatient

Follow-up activity too), Unbundled Diagnostics £(82)k, Critical Care £(61)k and Non Elective £(10)k. The underlying position and supplementary narrative relating to Claims and Queries is set out on the Summary of

Contractual Actions (from Page 23 onwards) and Page 19.

Guy’s and St Thomas’s NHS Foundation Trust (GSTT): The Contract position YTD spend at Month 5 is £7.5m with an overspend against plan of £(380)k. The largest overspend YTD areas are within Other £(146)k, Out

Patient Procedure £(98)k, Drugs and Devices £(91)k, and Non-Elective £(82k). The Non Elective position has deteriorated from last month and is seen in Gastroenterology and upper GI specialities. Overperformance is

also seen in the Maternity Pathway POD-following investigation the Quarter 1 closedown position concluded the change seen in antenatal pathways is attributable to national tariff changes. A further challenge remains

open relating to an increase in incurred cost following bankruptcy of a subcontractor for Patient Transport (PTS)-this query has been included within the Quarter one closedown position-note should be made to the fact

the Patient Transport budget is under plan on aggregate - see Summary of Contractual Actions (from Page 23 onwards).

CCG overview | Finance

The key over-performance by Point of Delivery (POD) across the four main local providers are: 1. Elective - The financial underperformance within this POD is driven by LGT £150k (5%). This relates to 172 activities and also at KCH £65k (3%). This is offset in part by the overperformance at DGT, £(54)k (2%), 139 cases. See Executive Summary. Note should be made to the fact this position does not include the underlying overperformance at KCH as this is a block contract and only relates to overperformance in Urology for the planned transfer to LGT . Activity is expected to achieve planned levels for all providers so the position aggregate is expected to align to plan towards the end of the year. 2. Emergency – this POD is under plan across all local providers with an even spread of underperformance. 3. Non Elective – Over performance is predominantly driven by LGT £(364)k (27%), (113 cases) and GSTT £(82)k relating to 3 cases, however, there is also a small overperformance at DGT of £17k. No noted provider shift in activity. 4. A&E – The under performance of £33k is driven by LGT £29k. 5. Out Patient 1

st – Overperformance driven by DGT £(18)k (2%), LGT £(74)k (5%) , KCH (£153)k (24%) and GSTT £9k (2%)

6. Out Patient Follow Up - Overperformance within this POD is seen among three of the main providers, predominantly led by DGT £(131)k, KCH £(89)k, GSTT £(38)k with a small underperformance at LGT of £20k. Note should be made to the financial adjustments reflected in Other. 7. Critical Care - this POD is overperforming; driven by LGT £(98)k (6%), KCH is £(61)k (15%), DGT £(9)k whilst GSTT is underperforming by £20k (4%). 8. Direct Access – The overperformance in this POD is predominantly driven by LGT £(155)k (9%) - this relates to Clinical Business Unit Specialty (pathology testing) and DGT £(13)k (3%) - see Summary of Contractual Actions (from page 23 onwards). 9. Drug and Devices – The overperformance within this POD is driven by GSTT £(91)k, LGT £(65)k, DGT £(34)k with KCH are underperforming by £30k - see Summary of Contractual Actions (from page 23 onwards). 10. Maternity Pathway – The overperformance within this POD is driven by LGT and DGT both £(73)k, GSTT £(22)k, offset by underperformance at KCH £121k - see Summary of Contractual Actions (from page 23 onwards) for LGT and DGT. 11. Unbundled Diagnostics - Overperformance within this POD is driven by KCH £(82)k and LGT £(28)k - see Summary of Contractual Actions (from page 23 onwards) for LGT. 12. Other - Underperformance within this POD is caused by DGT £265k (Contractual KPIs). This is offset by GSTT’s contract alignment £(146)k.

CCG overview | Finance | Main providers (D&G, L&G, KCH, GSTT)

Overall non-local providers are £33k over plan at M5. Areas of notable under and over performance are: In part this is linked to activity that should be charged via the MSK prime provider. Q1 challenge letters have been issued to correct this.

Barts and The London NHS Foundation Trust – (£67k) over performing. Unable to drill down as plans on the SLAM does not match agreed plan

Royal National Orthopaedic has deteriorated to a YTD over performance of (£30k) o This is within mainly within Elective 19k and Drugs and Devices £10k. o Elective is within T&O £12k

Maidstone has deteriorated with a YTD over performance of (£21k) o This is within Elective £18k and Critical Care £10k. o Elective is within General Surgery £30k, this is offset by an improvement within Gynaecological Oncology £14k

St Georges has continued to over perform (£11k)

Maidstone and Tunbridge Well is overspent by £21k o This is within Elective £23k. This is within General Surgery £12k and Gynaecological Oncology £12k.

Queen Victoria is underspent by £61k YTD o This is within Other 22k, Emergency 20k and Elective £19k. o Other is within Not a treatment Function £21k o Emergency is within Plastic Surgery £18k o Elective is within Plastic Surgery £28k. This is offset by a overspend within all other TFCs

Moorfields is underspent by £37k YTD, 88k FOT o This is within Elective £22k and Outpatient 1st £13k. This is all within Ophthalmology

BMI is underspent by £35k YTD – at present the CSU is unable to drill down as plans on the SLAM do not match agreed plan – this is being follow-up with the provider.

CCG overview | Finance | Other contracts

Module | Finance & Activity

External Provider

YTD Budget YTD ActualYTD

Variance

%

Variance

£'000s £'000s £'000s %

London Ambulance NHS Trust £3,434 £3,434 £0 0%

Barts and The London NHS Trust £368 £434 (£67) (18%)

Chelsea and Westminster Hospital NHS Foundation Trust £58 £62 (£5) (8%)

Great Ormond Street Hospital For Children NHS Trust £68 £59 £9 13%

Imperial College Healthcare NHS Trust £72 £61 £11 15%

Maidstone & Tunbridge Wells NHS Trust £103 £124 (£21) (21%)

Medway NHS Foundation Trust £261 £254 £7 3%

Moorfields Eye Hospital NHS Foundation Trust £523 £487 £37 7%

London North West Hospitals NHS Trust £0 £0 £0 0%

Queen Victoria Hospital NHS Foundation Trust £219 £159 £61 28%

Royal Brompton & Harefield NHS Foundation Trust £84 £75 £9 11%

The Royal Marsden NHS Foundation Trust £0 £0 £0 0%

The Royal National Orthopaedic NHSFT £59 £89 (£30) (51%)

St George's Healthcare NHS Foundation Trust £80 £91 (£11) (14%)

University College London Hospitals NHS Foundation Trust £369 £373 (£4) (1%)

Inhealth Ltd £264 £262 £3 1%

BMI Healthcare Collections £74 £38 £35 48%

SUB TOTAL - NON LOCAL CONTRACTS £6,036 £6,003 £33 1%

CCG overview | Activity | Referrals M05

Module | Finance & Activity | Interactive Activity Dashboard Available at: http://nww.mdt.southlondoncsu.nhs.uk/integratedreport/activity

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CCG overview | Activity | Main Providers M05 (D&G, L&G, KCH, GSTT)

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Bexley Commentary | Referrals and Activity Referrals The charts displaying referral activity is based on datasets provided to the CSU directly from the providers on a monthly basis, as individual referrals datasets. To clarify, these charts are not produced from MAR returns although the expectation would be that these two would align to some extent, nor are they derived from SUS First attendances. Therefore this reflects a count of referrals received by the trust each month and, although they are Bexley patients, some of this activity will eventually fall under specialised commissioning and there will be a natural cohort of unattended and/or cancelled activity. This slide is therefore a measure of demand on the service rather than actual activity that will eventually be attributed to CCGs. Dartford & Gravesham Trust: Overall rise of 249 (14%) month-on-month mainly, originating mainly from increases in GP referrals. Appears to be an earlier seasonal change, where we can see a similar rise in October 2015; Lewisham and Greenwich Trust: In line with last month’s findings, regarding unexpected trends for a few specialties, this was formally raised with the provider who has started reviewing these anomalies and has advised that a corrected refreshed dataset will be issued shortly. Although unlikely, there may be other areas affected, but the trust has already confirmed that the spikes observed for M3/4 of 2015/16 are the result of a data processing error which would take current months year-on-year position back to a flat trend line; Kings College Hospital Trust: The process of resubmission by the trust and respective validation continues to progress, therefore this data should not be used until that exercise is completed; Guy’s & St. Thomas Trust: Fall of 9% on last month (equivalent to a reduction of 111 referrals), driven by Cardiology (78 less referrals than in previous months).

SUS Activity trends – Aggregate Main Providers Outpatients: Analysis of the main 4 Providers’ activity by ‘Source of Referral’ shows a rise in follow up attendances by 2647 (31%) on last year and 1404 (14%) on last month, owing mostly to increases in “C2C” referrals. This is mainly due to a reporting fault at GSST whereby the system allocated this activity assigned to CCG rather than specialist skewing the charts for months 2 and 3 which remain incorrect in SUS, with month 4 returning to M1 levels (consistent year on year). This error in allocation has not affected SLAM billing; A&E – Month on month fall of 419 which is equivalent to 9% across all four providers, but this is in line with last year’s trend; Inpatients: Non-Elective –Slight decrease on the previous month by 7% (49); Elective – In line with previous month.

SUS Activity trends – Dartford & Gravesham NHS Trust Outpatients: GP referred: Firsts - Saw a monthly decrease of 5% (84) mainly within Ophthalmology (58), however this was a 29% (346) increase on the same period last year; Follow ups – rose from 1924 to 2078 from last month (8%) with Urology and Gynaecology seeing the greatest variances; C2C referred Firsts & Follow Ups – In line with previous month; A&E – 11% fall (186) MoM, but saw a year-on-year rise of 189 (14%); Inpatients: Emergency - Month-on-month decrease of 17% (84) as a result of fall in Paediatrics (35), A&E (24) and General Medicine (18); Non-Electives – Monthly increase of 10% (24) following a similar trend to previous year; Electives – 9% rise (693 to 753) MoM, where Ophthalmology saw the highest increase by 20. YoY rise of 150 (25%) over a number of specialties.

SUS Activity trends – Lewisham & Greenwich NHS Trust Outpatients: All Sources of Referral – Increases in Firsts caused by rises in GP First referrals, and increases in Follow ups by rises in GP, C2C and Other sources of referral; GP Referred: Firsts – 11% monthly rise (147) with the main increase in Dermatology (86); Follow ups – 10% increase on M4, equivalent to 161 activity, largest rises from Clinical Haematology with 58 and ENT with 48; C2C referred: Follow ups – 4% month on month increase (29); Other referrals: Firsts – 79 fall in activity (18%) mainly in Gynaecology and General Medicine, in line with last year’s trend; Follow ups – A 10% (99) rise on previous month’s figures, this was a result of Cardiology referrals increasing by 110 (32%). This is a notable 52% (376) increase on the previous year with Cardiology increasing by 396; A&E – 9% (204) decrease on last month, 8% (187) decrease on last year; Inpatients: Emergency – Overall MoM rise of 44 (5%), although it appears to be more significant on the chart, this was mainly due to General Medicine rising by 72; Non Electives – 93 decrease (25%) on previous month, main contributor Obstetrics – 50. Fall brought back down to similar levels to last year, with a yearly increase of only 4% (269 to 280); Electives – In line with previous month and year

SUS Activity trends – King’s College Hospital Outpatients: All Sources of Referral – In line with previous month; GP referred: Firsts – represents an 8% fall month-on-month (30 attendances), largest decrease in Dermatology (26); Follow ups – in line with previous month, however an increase of 21% (141) on last year; Other Source of referral: Follow ups – 14% change month on month (fall of 43) via multiple specialties, also a 5% fall year-on-year (14 attendances); A&E - 8% (39) decrease on previous month, a little more significant 12% drop of 57 on last year; Inpatients: Emergency - 27% fall (71) on previous year primarily in Urology; Non Electives - 23% rise (14) on M4, which is also a 16% (15) fall on last year; Electives – Fall from 496 to 462 (7%) month on month.

SUS Activity trends - Guy’s & St. Thomas’ Outpatients: Reporting fault at GSST whereby the system allocated this activity assigned to CCG rather than specialist skewing the charts; A&E – In line with last year monthly but 37 decrease (25%) year-on-year; Inpatients: Emergency - 12% (16) fall from 78 to 69 month on month; Non Electives - small value changes which look more significant on the chart, a MoM increase of 11 activity; Electives – In line with previous month, year-on-year decrease of 32 activity (8%).

CCG overview | Finance | Bridging analysis

Agreed YTD

Dartford & Gravesham NHS Trust £244,742

Lewisham & Greenwich NHS Trust £61,205

All Other Providers £522

Total £306,469

TAP Challenges Raised YTD Agreed YTD Rejected and Closed YTD Open YTD

Dartford & Gravesham NHS Trust

TAP - Other Financial Claims £110,114 £30,575 £39,492 £40,047


TAP - Other Financial Claims £143,943 £0 £0 £143,943

Grand Total £254,057 £30,575 £39,492 £183,990

CCG overview | Finance | Claims

The figures in these tables reflect the Claims issued to your Providers YTD, so they include Raised Claims

up to M4 inclusive. Agreed, and Rejected and Closed claims reflect only the responses (and current CSU

closure status) up to M4 as the deadline for M5 responses is after the production of this report. The

process for quarterly reconciliation is under way with local providers therefore, the figures presented

here on agreed/open claims are in the process of being updated.

Finance colleagues will be able to provide you with an updated report as of M5 reporting of the impact

of these Claims in your underlying and previously reported financial position.

For Drugs related queries, details on Agreed or Rejected Claims can be sought from your Medicines

Management representatives.

For all other accepted claims, further checks are carried out at the Freeze position to ensure either

SLAM or SUS or both instances as the case may be reflect the necessary amendments, when this is not

the case the Providers are issued with further rechallenges but these are obviously not reported here so

as not to incorrectly inflate the figures reported. We can advise the volumes of Freeze challenges issued

to LGT and D&G are not substantial.

Claims classed under Other High Risk Queries (likely no Yield) represent data queries issued to Providers where the CSU cannot at point of issuing these be completely confident that the activity has been correctly coded and/or costed, hence Providers being asked to answer our queries and confirm one way or the other. These are extremely likely not to produce any financial yield.

Module | Finance & Activity

Detail

Trust Raised YTD Agreed YTD

Rejected and

Closed YTD Open YTD

Likely

Yield of

Open YTD

Dartford & Gravesham NHS Trust £563,588 £244,742 £181,560 £137,286

Maternity Pathway £91,076 £25,999 £29,927 £35,150 10%

Automated SUS Attributions (exc. Specialist) £52,108 £43,703 £0 £8,405 10%

Manual Non SUS Attributions (excl. Specialist) £0 £0 £0 £0 10%

Specialist Commissioning Attributions £31,490 £13,475 £0 £18,015 10%

Data Quality Claims with potential financial impact £4,306 £4,306 £0 £0 10%

Other Financial Claims £384,608 £157,259 £151,633 £75,716 10%

Other High Risk Queries (l ikely no yield) £0 £0 £0 £0 10%

Lewisham & Greenwich NHS Trust £370,256 £61,205 £36,108 £272,942




Specialist Commissioning Attributions £0 £0 £0 £0 10%

Data Quality Claims with potential financial impact £30,110 £5,746 £0 £24,364 10%



All Other Providers £123,371 £522 £0 £122,849

Maternity Pathway £0 £0 £0 £0 10%

Automated SUS Attributions (exc. Specialist) £21,665 £0 £0 £21,665 10%


Specialist Commissioning Attributions £61,908 £0 £0 £61,908 10%

Data Quality Claims with potential financial impact £10,122 £0 £0 £10,122 10%

Other Financial Claims £29,676 £522 £0 £29,154 10%


Grand Total £1,057,215 £306,469 £217,668 £533,078




Specialist Commissioning Attributions £93,398 £13,475 £0 £79,923 10%

Data Quality Claims with potential financial impact £44,538 £10,052 £0 £34,486 10%



Dartford & Gravesham NHS Trust | Finance

Dartford and Gravesham NHS Trust (DGT)’s contracted reported spend position at Month 5 is over plan by £(5)k and activity by 979 cases. This is an improved position from last month’s overperformance. The notable

overperforming PODS are in the following areas and the CSU is closely monitoring finance and activity through regular Finance and Information Groups (FIG) and Contract Management Board (CMB) meetings with DGT colleagues –

see Summary of Contractual Actions (from page 23 onwards):

Elective- Elective activity remains over plan by (£54k), This is an improved position from last month and follows contractual challenge. The current overperformance in Month 5 is driven by Urology (56k), Clinical Haematology (27k)

and General Medicine (22k). This is offset by an improvement within Gastroenterology (£46k) and Gynaecology (£28k). The CSU has challenged activity over plan through the monthly FIG with the Trust to better understand this rise

in activity and both the Provider and Commissioner have agreed to collaboratively review referral rates and source to determine next steps. Note should be made that activity has aligned further to plan this month. The outcome of

the review will be addressed at this month’s CMB.

Emergency – this POD remains under plan at £81k at M05, this is driven by A&E £87k and some underspend in short Stay and low complexity case-mix which is being explored through the Ambulatory Care (AEC) review to determine

cost impact and pathway for Bexley CCG patients at the trust - see Summary of Contractual Actions (from page 23 onwards).

A&E – there remains a small level of over performance within this POD by (£13K), with a notable increase in Multiple Trauma, Emergency Medicine and Rehabilitation for activity this month.

Outpatient 1st - remains over plan by (£18K), with overperformance noted General Surgery (£14k). Practice level information has been provided to the CCG for review.

Out Patient Follow up - this POD continues to over perform (£131k), driven by plan adjustments of (£106k) – see Summary of Contractual Actions (from page 23 onwards).

Out Patient Procedure – Overperformance occurs by (£22k), within Urology by (£22k) – HRG – LB72A - Diagnostic Flexible Cystoscopy, 19 years and over – (£17k). See previous challenge-increase GP referrals.

Critical Care – remains over plan by (£9k) but is an improvement from month 4, for Adult Critical Care, 4 Organs Supported: Critical Care Medicine (£68k) and Adult Critical Care, 1 Organ Supported: Critical Care Medicine. This is

partially offset by Adult Critical Care, 3 Organs Supported: Critical Care Medicine C Critical Care, 3 Organs Supported: Critical Care Medicine

Maternity Pathway- this POD remains over plan by (£73k), - this is driven by Obstetrics (£48k) and Gynaecology (£15k). This is being challenged through the monthly FIG with the Trust to better understand this rise in activity.

Benchmarking shows that the case-mix at the trust is under national average levels. The contested value challenged has been closed but the CSU will continue to observe case-mix trend to ensure no further increase-month 5

maintains the same run rate.

Other - Underperformance within this POD is £265k includes £35k for KPI productivity metrics and QIPP (£31K). Note should be made to the challenge in place by the trust to contents all Transformation and Sustainability Plan

financial adjustments outside the remit of national Guidance.

Dartford & Gravesham NHS Trust | Activity M05

The reported contract position in month 5 is showing an overperformance of £(646)k (3%) , and is a deteriorated position from last month.

Elective – this POD continues to under perform by £150k/172 cases, with key underperforming specialties within Gastroenterology £40k, Colorectal Surgery £36, Medical Oncology £34k and Urology £22k. The Trust are now outsourcing to BMI

and are advising they are on track to meet the performance trajectories set, specifically for T&O, ENT and Gynae by Feb/Mar 2017. At the time of drafting all trajectory thresholds have been met. Diagnostic activity remains a risk with associated

performance delivery risk following a pay dispute with radiographers - outsourcing options to BMI and Oaks are being explored with further risk with JAG accreditation and Cancer targets noted.

Emergencies - this POD has continued to underperform in month 5. Activity run rate continues to be under 15/16 levels (and 16/17 plan). During month 4 there has been a significant reduction of excess bed days, an area that has over

performed in previous months, pre CSU challenge. This has been raised with the Trust to ensure that no activity linked to Foxbury and Hospital at Home has been charged.

Non – Elective - this POD remains over plan by £364k/113 spells, the main over spend is within General Medicine (£120k) – HRG (AA22A - Non-Transient Stroke or Cerebrovascular Accident, Nervous System Infections or Encephalopathy with CC

–(£87K), (GB06B - Endoscopic Retrograde Cholangiopancreatography category 2 with length of stay 3 days or more with In – (£28K). Midwife Episode (£120k) – HRG - NZ11B - Normal Delivery without CC – (£68K), (NZ11F - Normal Delivery with

Induction without CC – (£11K), Geriatric Medicine (£43k) – HRG (AA22A - Non-Transient Stroke or Cerebrovascular Accident, Nervous System Infections or Encephalopathy with CC – (£73k), Obstetrics (£25k) – HRG NZ14B - Emergency or Upper

Uterine Caesarean Section without CC: Obstetrics (£25k), Endocrinology (£18k) – HRG (DZ24A - Inhalation Lung Injury or Foreign Body with Major CC – (£25K). Excess bed days for elective & non-elective activity remain over plan and this has been

raised with the Trust, and there is a formal challenge in place – see above.

Out Patient 1st - overperformance continues within this POD (£74k) within General Medicine (£39k) – HRG - WF01B - Non-Admitted Face to Face Attendance – First (£39k), Colorectal Surgery (£20k) – HRG - WF01B - Non-Admitted Face to Face

Attendance - First: Colorectal Surgery (£20k), Respiratory Medicine (£17k) – HRG (WF01B - Non-Admitted Face to Face Attendance – First and Colorectal Surgery (£18k).

Out Patient Procedure – overperformance within this POD is predominantly driven within Dermatology (£72k) – HRG - JC10Z - Specified Skin Examinations and Investigations (£45k), JC14Z - Skin Therapies level 2 (£24k) , and Gynaecology

(£26K).

Critical Care – this POD remains over plan by (£98k) Critical Care Medicine. The CSU undertakes attribution checks on all activity.

Direct Access - Remains over plan (£155k) - specifically within Clinical Business Unit Specialty and is driven by pathology testing – see Summary of Contractual Actions (from page 23 onwards). The issue of duplicate reporting in June was raised with the trust to ensure no double charging, and has concluded. Drugs and Devices - Over plan by (£65k) mainly within Clinical Business Unit Specialty by (£65k) - there are currently challenges in place relating to Prime Contracting activity - see Summary of Contractual Actions (from page 23 onwards).

Maternity Pathway – This POD remains over plan (£73k), this has deteriorated from last month. Mainly within WASH Specialty by (£73k). Note should be made to the challenge is place for case-mix wit the trust-now concluded- see Summary of

Contractual Actions (from page 23 onwards).

Unbundled Diagnostic - Activity remains over plan mainly within Diagnostic Imaging by (£28k).

Lewisham & Greenwich NHS Trust | Finance M05

Trust Proposal

CCG Adjusted

Plan Actual

Variance

movement

CCG Adjusted

Plan Actual

£'000 £'000 £'000 £'000 % £'000 % £'000 %

Elective 2,902 2,902 2,752 150 5% 150 5% 0 3,944 3,772 172 4%

Emergency 9,004 9,004 8,946 58 1% 58 1% 0 4,233 4,213 20 0%

Non-Elective 1,334 1,334 1,698 (364) (27%) (364) (27%) 0 593 706 (113) (19%)

A&E 1,943 1,943 1,914 29 1% 29 1% 0 12,543 11,830 713 6%

Out Patient 1st 1,456 1,456 1,530 (74) (5%) (74) (5%) 0 8,769 9,499 (730) (8%)

Out Patient Follow Up 1,397 1,397 1,377 20 1% 20 1% (0) 15,508 15,555 (47) (0%)

Out Patient Procedure 711 711 783 (72) (10%) (72) (10%) 0 3,473 4,175 (702) (20%)

Critical Care 1,788 1,788 1,886 (98) (6%) (98) (6%) (0) 1,265 1,330 (65) (5%)

Direct Access 1,667 1,667 1,822 (155) (9%) (155) (9%) 0 742,311 810,322 (68,011) (9%)

Drugs & Devices 479 479 543 (65) (13%) (65) (13%) 0 2,327 2,119 208 9%

Maternity Pathway 878 878 951 (73) (8%) (73) (8%) 0 1,386 1,329 57 4%

Unbundled Diagnostics 412 412 440 (28) (7%) (28) (7%) 0 0 0 0 0%

GUM 0 0 0 0 0% 0 0% 0 0 2 (2) 0%

All Other Expenditure 1,036 1,036 1,010 26 2% 26 2% 0 7,143 7,278 (135) (2%)

Total 25,007 25,007 25,653 (646) (3%) (646) (3%) 0 803,494 872,130 (68,636) (9%)

60,900 60,900 63,050 (2,150) (4%) (2,150) (4%) 0

Year to Date - Finance (over) / under Year to Date - Activity (over) / under

Variance to Trust Proposal Variance to CCG Plan Variance

Forecast Outturn - Finance

Lewisham & Greenwich NHS Trust | Activity M05

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Emergency Non-Elective Non-Emergency Elective



A&E (Type 1 only)

KCH | Bexley CCG| Overview Commentary M05

KCH | Bexley CCG| Overview Commentary

Quality

Finance and activity Performance

Quality

Context:For 2016/17 the CCG has agreed a block contract with King’s, with a fixed payment for the year thus providing financial certainty for both the CCG and the Trust. The contract was set based on a forecast assessment of 15/16 outturn plus an additional 3% growth and also upfront adjustments for contractual KPIs. The reinvestment of any 'national performance penalties’ has been agreed as part of the block contract agreement.

Month 5 Finance & Activity Position:The tables and graphs show the year to date service level agreement monitoring (SLAM) position by point of delivery (PoD) for finance and activity to show the underlying contractual position. The finance table then adjusts the position back to breakeven to reflect the block contract arrangement. Whilst block contract agreements added growth there is a strong likelihood of underlying over performance in 2016/17. At M5 trends are continuing to develop but it is still early in the year and these will develop over the coming months.

Bar charts show the percentage variance against the year to date finance and activity plans across all PoDs. Further analyses for four PODs are provided to show the 2016/17 plan, 2016/17 actuals, 15/16 actual outturn on a monthly basis and also a cumulative year to date position.

The M5 SLAM position identifies the following points of interest:

• The recurrent underlying position, prior to the application of financial adjustments, is £229k/2.2% at M5 compared to £449k/5.6% over plan at M4. • The contractual underlying position after the application of financial adjustments is £229k/2.2% over plan. • The Elective POD is no longer over performing and at M5 is £65k under plan compared to £4k/0.2% over plan at M4. The improvement can be seen across a number of specialities including Ophthalmology, Trauma and Orthopaedics and Dermatology, mainly within daycases. There is still £107k over performance within Clinical Haematology, of which £45k is for Acute Myeloid Leukaemia with complications. The Trust have suggested that the increase in clinical Haematology relates to an improvement in the coding of DVT patients, shifting them from Emergency activity to Daycase, although further discussions are underway to fully understand the pathway.• Emergency over performance has improved and is £60k/2.1% at M5 (£65k/2.9% at M4). Improvement seems genuinely activity driven within general admissions rather than an improvement in excess bed days. Stroke and Trauma are the two main areas where improvement has been seen however Hepatobiliary and Pancreatic System Surgery and Mouth Head Neck and Ears Procedures and Disorders are still over performing.• Critical Care is over performing by £61k/15.4% at M5 compared to £80k/25.0% at M4 and £115k/48.3% at M3. Over performance is driven by Adult Critical Care patients requiring 5 organs supported at PRUH where current over performance is £66k YTD against a zero plan and 3 organs supported patients at Denmark Hill (£65k over plan). • Outpatient 1st attendances are over performing by £153k/23.5% at M5 compared to £133k/25.6% at M4. There is £87k of over performance within Ophthalmology for non-admitted face to face attendance at PRUH.• Outpatient Follow Ups are over performing by £89k/10.2%, particularly within General Surgery and Ophthalmology. The general level of over performance within Ophthalmology has been raised with the Trustand a response is outstanding.• Unbundled Diagnostics are over performing at M5 by £82k/45.9%, driven by £222k of overperformance in Diagnostic Imaging. A joint review is underway with KCH to assure the process around counting and attributing unbundled diagnostics. This will form part of an external audit planned shortly.• Other is overperforming at M4 by £83k/9.2%. This is driven by additional payment for the cost and volume element of the contract for Urology (£112k at M5). • Drugs and Devices are over performing by £5k/2.5% at M5. Bespoke Orthopaedic Prosthesis are over performing by £23k/74.8% and Cytokine Modulators are overplan by £44k, this is offset by underperformance in other areas. • The Maternity Pathway is under performing by £121k/14.1%. ChallengesThe CSU is running monthly challenge processes to ensure the integrity of data. For M1-4, challenges have been raised for misattributions and a consolidated Q1 process has been completed. SLAM positions have been

A & E A performance trajectory has been agreed for 16/17, noting this reflects an incremental improvement in performance over the

year but that KCH will not meet the national performance standard in 2016/17. The improvement is supported by an ED Recovery plan covering: Out of hospital actions (focused on admission avoidance; proactive care; access to ambulatory and rapid access specialist services; early supported discharge and enhanced community services); in hospital actions – a 6 point

plan for DH and 7 point plan for PRUH (reviewing and re-designing the urgent care pathway, non-elective end to end transformation programme); and bed capacity (increase and reconfigure bed capacity across PRUH, DH, and Orpington). April

and May performance was ahead of this trajectory, however the trajectory becomes more challenging over the year and the Trust was below trajectory for both June and July. August saw an improvement with the Trust expected to be very close to trajectory at around 88%, however performance dipped again in September to approx. 83%, driven by a drop in performance on

both sites. Integral to the plans is additional bed capacity at Orpington. This is on track for delivery in January.

Cancer 62 dayThe agreed trajectory shows this target being met each month for 16/17, with a trajectory to improve the timeliness of ITT from KCH to GST. The Trust met the target in April and June and met Q1 as a whole. However, July has underperformance at 83.1%

but draft August data show a return to improved performance at 91.1%, which supports the Trust expectation to meet the Trust’s 62 day trajectory in Q2. ITT performance dipped in June and continued improvement remains challenging. The Trust has

an action plan in place to support ITT improvements and expects to be on trajectory in Q3.

RTT

The Trust has submitted an improvement trajectory to get to 88% (trust wide) by March 2017, alongside this the Trust has submitted an over 18 week backlog reduction trajectory. This is reliant on an increased capacity both through internal changes

and outsourcing. Performance in April was behind the RTT trajectory, while May - July were ahead of the trajectory, and August back below. It should be noted however the performance masks the fact that there has been an overall increase in the numbers of waiters. At M5 there were 144, 52 week waiters.

DiagnosticsThe agreed trajectory is for a trust wide performance of 1% from August 2016. However, performance deteriorated in Q1.

Weekly reports show an big improvement in performance across August to 1.84% but it is not to the level required to hit trajectory. Performance issues mostly remain in MRI, with a significant reduction in the numbers of patients waiting in non -obstetric ultrasound. Sustained delivery against this plan is considered high risk.

In overall terms, commissioners remain broadly assured in relation to Quality outcomes at KCH, although commissioners continue to work with the Trust on a number of important issues, including the potential quality impact of the Trust's signif icant

2016/17 Cost Improvement Programme, the high level of 52 week breaching patients, and the continued failure of the Trust to meet a number key access performance targets. These issues are monitored at the CQRG and other forums to ensure no impact on quality.

At the August CQRG, the Trust provided an update on the 2015 national cancer patient experience survey. There was an

improvement in the overall rating of care compared to 2014, and although it is still less than the national average, it does therefore represent an improvement on the previous survey. Trust reps noted disappointment that they are currently ranked last amongst Shelford Group Trusts but are involved in cross-site learning. It was also noted that the positive impact of the

Chartwell refurbishment (PRUH) should be reflected in the next survey. The main agenda item focused on Trust Services for Children and Young People (CYP). The new CYP governance structure was noted with a Children’s Board in place to oversee the

quality of care provided, an important new addition. In terms of patient experience, the Trust noted that they have started to collect feedback direct from children as often the information collected from the parents/ guardians is not always complete in relation to the needs of the child. Inpatient experience is positive and consistent across both Trust sites with FFT performance in

this area is above internal benchmark set.

They were no Never Events reported in month 5 (2 YTD). A total of 6 C-Difficile cases were reported in August, which is consistent with the target quota of 6 cases for the month. There were no cases of MRSA (2 cases reported YTD). The Trust is n ot meeting its internal vacancy rate target (<8%) at either site, with poorer performance at the PRUH (15.4%) compared to DH

(11.5%). There has been a slight increase in the percentage of patients recommending A&E via the Friends and Family test (A&EFFT) across both sites in month 5. 85% of patients recommended PRUH for A&E in August compared to 82% in July. 79% of

patients would recommend DH for A&E in August compared to 75% in July. Also, the response rate for A&E FFT has improved across both sides (DH 11.8%, PRUH 16.5%) compared to previous month (DH 9.5%, PRUH 14.6%).

King’s College Hospital | Activity

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A&E (Type 1 only)

GSTT | Bexley CCG| Overview Commentary M05

GSTT | Bexley CCG| Overview Commentary

Quality

Finance and activity Performance

Quality

Context:For 2016/17 CCGs in South London and Surrey have agreed cost & volume agreements with Guy’s & St Thomas’. Contract offers from GSTT were set based on a forecast assessment of 15/16 outturn plus additional growth to meet the Trust’s assessment of demand increases and also to meet RTT backlog requirements. Many CCGs reduced the levels of activity from that in the Trust’s proposals in

agreeing their cost and volume contracts and this will be driving an element of performance against contract plans.

Month 5 Finance & Activity Position:The tables and graphs show the year to date service level agreement monitoring (SLAM) position by

point of delivery (PoD) for finance and activity to show the underlying contractual position. Whilst

many contract agreements added growth, the overall demand that the Trust is experiencing particularly for elective work, is significant, so there is a s trong likelihood of underlying over

performance in 2016/17. Small contracts will also be particularly prone to month on month fluctuations. For these reasons and the fact that we are at a very early s tages the year the M4 underlying position should be treated with some caution.

Bar charts show the percentage variance against the year to date finance and activity plans across

al l PoDs. Further analyses for four PODs are provided to show the 2016/17 plan, 2016/17 actualsand a lso a cumulative year to date position.

The M5 SLAM pos ition identifies the following points of interest:

• M5 Underlying position is an over performance of £385k/5.4% and moves to an over performance of £380k/5.3% following the application of Contractual Adjustments.

• Over performance in Non Elective £82k/62.6% which is a deterioration compared to M4. The deterioration is notable in both gastroenterology and upper GI specialties .

• Over performance in Maternity Pathway £22k/35.7% is being driven by both deliveries and antenatal pathways. The Q1 closedown process concluded the change seen in antenatal pathways is attributable to the impact of national tariff changes.

• Over performances in Drugs and Devices has improved slightly £91k/18.1% and continues to be seen across a number of specialities, with notable variances against YTD plans for Lane Fox Ventilators and Thoracic Stents.

• Over performance in Other £149k/10.4% is a continuation of performance seen in M4 for Ambulatory Categories covering: Dermatology Mohs Surgery; Oncology MDTs; ACU; and

Amputee Rehab under Best Practice Tariffs.• Out Patient Procedure over performance £98k/43.9% is mainly in follow ups, and across a ll

specialties. This will be reviewed jointly with the Trust in Q2.

• Elective under performance £18k/1% continues from M4, however the Trust remains on plan to increase levels of activity from Q2 onwards.

Challenges:The Q1 closedown process has been concluded with the exception of CQUIN. Adjustments to reflect

Q1 agreed claims are expected to be included in the M5 SLAM freeze position.

A & EThe Trust trajectory for 16/17 showed a return to compliance in May with planned underperformance from September across Q3 and Q4 following necessary rebuild configuration and impact at that point in the year. This trajectory is supported by a comprehensive ED action plan, actions have been split into: Capacity (expansion of majors); ED Trial (maximise UCC, Golden hours, Rat 2 Triage); Escalation; ED Action (attendance survey); Ward Action (Discharge lounge);

IT / Informatics; ACE project (split into 3 work streams to improve efficiency of the Emergency Pathway outside of the Emergency Department 1.Maximise efficiency and increase use of Evan Jones. 2. Admissions Wards and Hot Clinics. 3. Reduce delays to discharge and increase morning discharge). Monthly performance up to August has been below trajectory, with work on-going to reinforce current recovery plan actions and pilot new initiatives. Cancer 62 day

Overall trust-wide performance improvement is linked to reducing late referrals into the Trust from other providers. A system wide recovery trajectory has been agreed with separate trajectories from both LGT and KCH outlining improvement in the number of patients referred to GSTT within 38 days. This will support improved performance in 2016/17 but due to continued late referrals from Southern Region providers, the Trust will not be compliant for the whole of 2016/17. GSTT has committed to meet the target for patients on an internal pathway for all months in

2016/17. In August the Trust met the internal target for the first time this financial year, the Trust expect sustained compliance in Q4. Overall performance (including patients referred in) was ahead of the trajectory for April and May but below for June, July and August.RTTThe agreed 16/17 trajectory for GSTT reflects a planned underperformance in April and May with performance met for

all other months. For Q1 the Trust was ahead of their trajectory, however demand has continued at a rate higher than expected which has put the Trust at 90.5% in August. Work is on-going to explore the scope for outsourcing , Trust-wide referral management and commissioner led demand management schemes. The Trust has informed NHSI of the continued risk to meet the trajectory across the year.Diagnostics

The agreed trajectory shows a return to compliance in June 16/17 with marginal under-performance in Q1. The Trust met the diagnostic target in August for the first time this financial year, however due to on-going issues in some service areas the Trust predicts it will be October before they are able to deliver sustained performance.

In overall terms, commissioners remain broadly assured in relation to Quality outcomes at GSTT, although commissioners continue to work with the Trust on a number of important issues, including the level of Never Events over the last 18 months, the functionality of the Carenotes IT system (community-based IT system), the continuing pressure on key access performance targets and issues around management of patient follow up appointments. All these issues are monitored at the CQRG and other forums to assess any impact on quality.

At the August CQRG the main agenda item focused on Medicines Management within the Trust. Trust reps noted that the CQC report was broadly positive in its review of Trust Medicines Management. The current focus of the MM team is the Carter Report recommendations to drive out unwanted variation in the Medicines Optimisation Pathway. In terms of current challenging issues, Trust reps reflected that whilst the Trust score on the national Side Effects performance

metric is just 55%, this metric is nationally one of the lowest performance KPI measures and that GSTT is broadly in line with other Trusts. Information leaflets are provided to patients indicating side effects, with a list of questions that patients can ask their pharmacists. Commissioners raised patient adherence as a pressing issue that needs primary and secondary care action to address.

Trust reps continued to report a significant increase in the number of GP and tertiary referrals received by the Trust (compared to the same period last year) and noted that all key access targets are under significant pressure as a result, particularly RTT.

In August the Trust met its internal performance target for the Inpatient (IP) Friends and Family Test (FFT) but did quite

meet the performance target for the A&E FFT. The Trust FFT IP and A&E response rate targets were both below the internal threshold set. Children’s Safeguarding training levels were above the threshold (>80%), but adults safeguarding training is below the >80% at 73%. The Trust expects to meet the target by the end of December.

Guy’s & St. Thomas’ | Activity M05

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OP 1st 2015-16 OP 1st 2016-17

OP FU 2015-16 OP FU 2016-17

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OP 1st 2015-16 OP 1st 2016-17

OP FU 2015-16 OP FU 2016-17

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OP FU 2015-16 OP FU 2016-17

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2015-16 2016-17

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2015-16 2016-17

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2015-16 2016-17





A&E (Type 1 only)

Performance issue Commissioning action Contractual action

Lewisham & Greenwich NHS Foundation Trust: Local Price Review Impact of price changes and pace of change

NHSE confirmed phasing of report – 25% FYE impact in 16/17

Review concluded

Draft report circulated to CCGs on impact (14/9/16) Range of areas where further discussions required – four pathway areas

identified which Lw CCG are leading on with the Trust Steering Group to meet pre 30/9/16 to confirm and agree actions Review completed-total impact for Bexley CCG component over three

years is £670K, with the 255 impact for this year:£167K Principle item driving increased cost is Critical Care-small offset within

other areas This item is now closed

Lewisham & Greenwich NHS Foundation Trust: Emergency Pathway Audit Clinical review of admission criteria /appropriate charging

19/9/16 draft report produced and shared for CCG review (meeting 20/9/16)

Report to be finalised and agreed for Steering Group 29/9

Review concluded

Contract Variation to be agreed once finalised outcome Final output from the external review: B&M is now completed. The

remainder of this year, M7-12 Contract will revert to Cost and Volume from a block arrangement for emergencies. The impact of unpicking the block and M7-12 effects of local pricing changes recommend by B&M have been modelled and shared with CCG along with assumptions.

The revised Ambulatory Care (AEC) costs and pathways have been agreed to be implemented from 1st April so there will be no impact on the forecasted position for this year but with the expectation that this has a mitigating effect on emergency spend

This item is now closed

Lewisham & Greenwich NHS Foundation Trust: Maternity Casemix Audit Review of maternity coding to verify accuracy, in response to increase casemix seen in 2015/16

Review concluded An audit was undertaken to verify the accuracy of coding at the trust for the increase in recorded case-mix

Currently findings are under review by Trust and commissioners with report out come to Sept/Oct CMB to advise on actions

A new case-mix has been determined and is subject to annual audit. The revised position is favourable to the CCG.

This item is now closed

Lewisham & Greenwich NHS Foundation Trust: Q1 Close Down

Q1 close down process in hand. A range of issues have been raised and challenged with the trust

Activity has been challenged relating to Prime Contracting Drugs and Devises activity for and this is currently in escalation between the CCG and trust following CSU review

Finance | Summary of key drivers, commissioning and contractual actions


Dartford and Gravesham NHS Trust (DGT) Drugs and Devices Rheumatology-Cytokine Modulators (Prime Contracting):

Drugs and Devices are on plan however the Trust is not supplying the specialty identifier (TFC ) and this is a Contractual requirement. The CSU is unable to

fully identify all drugs and devices potentially funded within the Programme Budget for MSK Prime contracting. Evidence is therefore required to identify

as Homecare where not defined or non-chargeable. Formal challenge set out in July's Challenge Letter to Provider listing drug type and value of contested

payment; Provider response highlights majority of activity with gastroenterology; some activity not advised on and challenge continues to also include

activity for M4. Provider and SCU working to determine interim reporting to provide TFC to avoid subsequent challenges where unknown.

Formally challenged through the escalation process

This is being challenged through the monthly FIG with the Trust to better understand this rise in activity.

Challenge progressed through Quarter one closedown position-trust accept position and conversations progressing re upheld challenge.

Dartford and Gravesham NHS Trust (DGT) Elective Overperformance: Specialties (TFC):

- General Medicine

- Urology

- General Surgery

- Clinical Haematology

- Breast Surgery

- Paediatric Urology

Referral source and rate to be

reviewed

This is being challenged through the monthly FIG with the Trust to better understand this rise in activity. Provider and commissioner have agreed to re-profile the plan phasing to ensure overperformance is aligned to plan by year end. Activity aligning to plan-for review over the next few months and referral rate and source review under way.

Dartford and Gravesham NHS Trust (DGT) Maternity Pathway-Antenatal pathway A query at M2 has been raised with the Trust following an increase in activity showing as disproportionate against aggregate for the intensive Standard

(15%) over plan-the Provider has been asked to justify; outturn for last year compared to the first two months of this year show a 50% increase compared

to an increase of 6% growth for the standard phase and 7% intermediate.

- National Benchmarking (NBM) comparator checks undertaken:

Intensive DGT casemix 10%: NBM 11.4%

Intermediate DGT casemix 31%: NBM 50%

Standard DGT casemix 58%: NBM 38%

Shift to benchmarked levels due to the application of the new complexity factors.

Challenged via FIG-maternity audit undertaken; in-line with benchmarking and audit compliant.

Review now closed

This is being challenged through the monthly FIG with the Trust to better understand this rise in activity. Benchmarking shows casemix under national average. External advise taken to determine if notification required for change in recording. Not required. Contested value closed but CSU to observe casemix trend to ensure no further increase-month 4 maintains same run rate. Month 5 has maintained the same run rate, therefore, this item is closed.


Dartford and Gravesham NHS Trust (DGT) Direct Access; Diagnostic Imaging

There has been a marked increase at M2 in GP referrals for General X-ray Diagnostic Imaging (DI); over plan by

£11k (10%); 339 tests (10%)

and RA23z-Ultrasound Scan less than 20 minutes DI - £5k over plan (8%); 102 tests (8%).

This has been raised with the Trust and there have been no known pathway changes.

To review referral rates/ source Review concluded and closed

This is being challenged through the monthly FIG and Challenge Letter – note made that 99% of referrals are from referral source GP

CCG reviewing GP referrals CSU has provided the CCG with referral source and trends; predominantly GP referrals. This item is now closed

Dartford and Gravesham NHS Trust (DGT) Emergency: General Medicine

Following a detailed HRG review the CSU determined an unexplained charge for EB03H - Heart Failure or Shock

with CC - no plan, no recorded activity in 2015/16

This was challenged with the Provider-determined error with reporting of cardiology HRGs that will be

removed from the SLAM for M3 (no plan, or actuals). FYE successful challenge value (£186k).

Successful challenge upheld and closed

This item is now closed following a CSU review to ensure that no further activity is submitted via the provider in the SLAM invoicing

Dartford and Gravesham NHS Trust (DGT) Outpatient Procedure: Urology and Gynaecology

Following a detailed HRG review the CSU determined an increase in the HRG coding for Urology: LB72A -

Diagnostic Flexible Cystoscopy, 19 years and over and Gynaecology: MA23Z - Lower Genital Tract Minor

Procedures - Category , and as such the Provider has been asked to investigate growth via the Challenge Letter/

FIG discussions.

To review referral rates/ source Review concluded and closed

This is being challenged through the monthly FIG and Challenge Letter. As there remains a steady increase over plan the CSU has progressed this to a query in the Challenge Letter (M3) and asked the trust to explore this issues with the clinical leads and service managers in readiness for FIG discussions with the view to advise on reasons for the increase. Issue explored and referrals GP driven.

CCG to explore GP referrals (nb. activity reduced in M4) Activity has maintained the dame run rate as last month-the CSU has advised the CCG on run

rate and GP referral source. This item is now closed

Dartford and Gravesham NHS Trust (DGT) Ambulatory Care (AEC) and Frailty services

Pathway changes enacted by provider-uncommissioned pathways. Contract lever determines no cost pressure

will be funded and local tariff to be determined post review of activity and pathway.

Collaborative Working Group set up with North Kent CCGs to understand impact and agree local tariff.

Commission pathway post review if applicable.

This is being challenged through the monthly FIG and Challenge Letter. Some activity information provided; CSU undertaking modelling to determine impact and agree local price

Agreement has been made to work collaboratively with Kent CCGs and prioritise agreement of a local price and agree pathways the CCG requires through the 2017/19 contracting round

A review is underway around determining any cost pressure from collective emergency spells for 2016/17 which will be discussed with the CCG and the trust-any cost pressure will not be funded as per the agreed contract terms

Guys’ and St Thomas’s NHS Foundation Trust (GSTT) Drugs and Devices (respiratory) The CSU has queried the significant growth in Lane Fox, a supplier for respiratory equipment; low volumes high

cost, specifically 3402YA - Lane Fox Unit - Purchase of Ventilator;

Review concluded and closed

This is being raised through the monthly FIG and trends in growth will be monitored in three months

M4 activity has reduced-small volumes high cost-attribution checks in progress Attribution checks have been repeated to provide assurance to the CCG No further action, therefore, this item is closed


Guys’ and St Thomas’s NHS Foundation Trust (GSTT) Prime contracting In addition to the automated challenges the CSU is challenging any high cost activity that appears to be prime contracting-note made to orthopaedic activity in elective and Drugs and Devices

Challenge process Support CCG with challenge process; detailed review of the monthly SLAM

Activity has been challenged by the CSI and is being progressed by the CCG to enable completion of the Quarter one closedown

Guys’ and St Thomas’s NHS Foundation Trust (GSTT) Other; Patient Transport The CSU has raised concern around the increase in cost for patient transport – increased costs due to change in provider (cancelled contract) – under investigation

None Trust to advise on progress to secure permanent provider. The outcome will be concluded in the quarter one closedown as concern raised with cost of sub-contractor arrangements. Nb. PTS budget under plan overall.

This item is upheld in the Quarter one closedown conversations

Kings College Hospital NHS Foundation Trust (KCH) Critical Care High value of YTD over performance. Given instability of reported datasets and WiP inclusion in M1, assurance was required that M2 was

accurate. Reporting issues checked and Critical Care supporting data attribution checks completed-activity is clarified

None To observe trends in activity over the next three months

M4 activity significantly reduced-high cost patient attribution under review

The CSU is contesting payment of this high cost patient and the challenge is upheld in the Quarter one closedown conversations

Kings College Hospital NHS Foundation Trust (KCH) Drugs and Devices; Cytokine modulators Cytokine Modulators included in actuals-agreement reached to remove from M3 reporting (already adjusted for in reported position).

Successful challenge-this item is now closed Removed in month 3 Freeze. Small amount noted in M4-not funded-

assurance given no further activity will be present in future months

Activity has been removed from the SLAM invoicing and this item is therefore, now closed

Kings College Hospital NHS Foundation trust (KCH) Elective; Sleep Studies Significant overperformance noted, specifically higher for Bexley CCG. Referral source GP-for further review by CCG.

Review of GP practice referral This review has now concluded and is closed

To observe trends in activity over the next three months

CSU exploring any additional clinics in place post soft intelligence-trend continues

GP referral source provided to CCG This review has now concluded and is

closed

Quality


22

Community Contracting and Performance Section 2

This report provides exception reports on key indicators and contracting issues that have arisen since the last report to the Governing Body in September 2016.

This report has been structured as follows:


2.2 Oxleas Community Contracts

2.3 Prime and Lead Contractor Contracts

2.4 Urgent Care Services and Out of Hours

2.5 AQP contracts

2.6 Other Community Contracts

2.7 Procurements

.

23

2.1 Executive Summary Oxleas Adult Community Service

Oxleas have agreed to provide flu vaccinations for all housebound patients, this includes GP housebound patients as well as those patients already on the District Nursing case load. Vaccinations have commenced and the programme will run through October and November. A contract variation has been issued to Oxleas to support the Bexley Home First Team Project. A contract variation has been issued to Oxleas to add the National 16-17 Health and Wellbeing CQUIN.

MSK Prime Contractor Contract: Pain Service

A contract variation has been agreed by KCH to incorporate the revised local quality indicators and the revised finance schedule.

Cardiology

Community Cardiology Services – bids are being invited from a group of existing

providers to provide services from April 2017. Discussions have continued with GSTT on

the transitional arrangements until then.

The Activity and Finance report submitted by LGT for Cardiology for month 1 – 4 shows

elective activity is down but Day Cases and Out Patient FUs are significantly over

performing. A formal challenge has been raised to understand the causes for the

unexpected pattern of activity and determine the actions required for the remedial plan.

A program of clinical audit will be jointly undertaken.

24

2.2 OXLEAS Community Contracts

2.2.1 Adult Community Health Services Adult Community Services

Oxleas still reporting an over performance in activity against plan at month 5. The CCG are working with the Trust to understand the reasons for the over-performance, how the information is reported and the next steps. The review of the demand and utilisation of the continence products has been completed. A meeting will be conveneved with Oxleas to discuss the outcome of the review. Integrated Care for Older People

There has been a significant rise in referrals from LBB Emergency Duty Office from 12 referrals in August to 31 September. There has been a decrease in the numbers seen in the community and in admission avoidances

The average length of stay on Meadowview has reduced from 29 days to 27 days

Rapid response data and Analysis: Rapid Responses Referrals: The number of referrals received reverted to nearer the previous average in September, but with a significant rise of 158% in referrals from the Emergency Duty Office from LBB which includes out of hours. The reason for this rise is being investigated.

Total number of people seen by Rapid Response (including initial assessments and follow ups: There has been a dip in number of people seen compared to August, which was a 5 week month, but remains higher than July .

Total number of patients seen in the Community (Including initial assessments and follow ups): There has been a 34%

decrease in people seen in the community during this month compared to August but again remains higher than July.

25

Total avoidances of admission (including by CART): There has been a

decrease in numbers reported as admission avoidance. The average admission avoidance per week for August was 79 and for September 60. However the September number is comparable with the same period last year. Avoidances of presentation to Emergency Department (ED): The total number of presentation avoidances to A&E has decreased by 58% compared to the August spike but is in line with the average for the year. Meadowview Continues to work at near capacity, with occupancy at 98% for September. The average length of stay reduced from 29 days to 27.

26

2.3 Prime and Lead Contractor Contracts

2.3.1 MSK Prime Contractor Service with Kings FT (KCH)

KPIs Month 6 August 2016

Local Quality Measures

Indicator Measure

Target April 16%

May 16 %

June 16 %

July 16 %

Aug 16 %

Sept 16 %

Patients seen Total

Average wait (days)

Physiotherapy

Urgent: To be seen within 10 working days

95% 96 98

95 97 94 95 126/133

Routine: To be seen within 20 working days

90% 85 80

91 93 91 91 819/900

T&O


95% 66.7 33.3

30 41.7 0 25 2/8 17.5


90% 71.7 85.7

67.5 36 34.3 59.3 131/221 19.6

Pain Services


95% 0 100

0 0 100


90% 14.3 5.6

48.6 44.6 84.6 100 45/45 11.2

Rheumatology


95% 100 77.8

35.3 88.9 75 88.9 8/9 8.1


90% 90.3 86.5

74.8 78.4 84.6 82.4 70/85 19.5

Trauma & Orthopedics

Urgent patients are continuing to be managed on a case by case basis whilst the Trust addresses capacity issues. Capacity within routine clinics has improved during September following the recruitment of two additional consultants. The access target is expected to be achieved in October.

Pain Service

The Nurse Consultant has started employment during September. The Trust are working towards achievement of targets during October. Rheumatology Following on from the restructure of the service an extra two clinics per month have been added, this will enable the target to be achieved for October.

27

Patient Outcome Reports These remain very positive. Feedback from patients on the MSK programme board is also good. See below:

OHSEL MSK Pathway Group

A further meeting of the MSK pathway group took place on the 21st October 2016.The

aim of the meeting was to discuss the draft standards for the pathway and the

recommendations to achieve the proposed MSK standards. The Group agreed that the

next steps will be to formalize the standards and guidelines. These will then be

presented at the next Committee in Common meeting.

How long after the stated appointment time did your appointment start?

Were you involved as much as you wanted in decisions about your care and treatment?

If you had to wait for your appointment, were you told how long you would have to wait?

How would you rate your experience of booking your appointment/time slot?

28

2.3.2 Cardiology

Contractual and financial matters

Bexley CCG is in the process of seeking bids from a range of existing providers for the the Community Cardiology Service from April 2017. Discussions have continued with GSTT on the Transition Plan which should cover the delivery of the service until the 31st March 2017. LGT Cardiology - The Activity and Finance report submitted by the Trust for month 1 – 4 shows elective activity is down but Day Cases and Out Patient FUs are significantly over performing. A formal challenge has been raised to understand the causes for the unexpected pattern of activity and determine the actions required for the remedial plan. A joint clinical audit will be undertaken. Current Performance

Maximum wait of 4 weeks; target is 85% - Max wait of 4 weeks. Target achieved duw to 33 additional sessions.

100 % of patients requiring Consultant appointment (other than rapid access chest pain) who are seen within 4 weeks – Achieved 80% in September as 7 of the 35 clinics were cancelled at short notice due to Consultnat sickness/ absence.

Analysis of diagnostic test results has shown that 26 times more are being sent for consultant triage in 2016 compared to 2015. GP Direct access Diagnostic result pathway changed to ensure that all results go back to the referring GP this will ensure that only the urgent abnormal results get reviewed by the consultant of the week.

29

Below is an extract from the September 2016 cardiology dashboard

Local Requirements - Reported Locally Month: September 2016

Standard Target Frequency

1. Dates, topics and attendance at clinical educational events

Quarterly Next: tbc Most recent: 02/06/2016

Topics: AF and intro for all 7 pathways

4. Referral outcome – appointment, advice, diagnostics, discharged

Monthly GSTT: manual breakdown shows; 246 consultant referrals, 216 appointment, 20 test and / or advice and 10 rejections.

PML: 279 diagnostic referrals, 249 accepted, 30 rejected.

5. % of referrals received via Choose and Book

100% Monthly 100% However it has been discovered that fax referrals are being made to QEH

6. % of referrals triaged within contractually agreed time standards

100% Monthly 100% daily triage by consultant of the week from mon - fri. Standard is 3 days

7. Number of Choose and Book Advice & guidance request received, time taken to respond and outcome

100% Monthly September - 15 requests, all responded on time

100% within C & B standard (3 days)

8. % of patients receiving diagnostic tests who are seen within 4 weeks

100% Monthly PML report 333 of 385 = 87% within 4 weeks. 38% July 15, 51% Aug, 65% Sep, 72% Oct, 74% Nov, 87% Dec, 62% Jan 16, 62% Feb, 54% March, 54% April, 64% May, 81% June, 96% July, 81% Aug

Max wait of 4 weeks. Target is 85%. There were 33 additional sessions.

9. % of patients requiring Consultant appointment (other than rapid access chest pain) who are seen within 4 weeks

100% Monthly 80% as unfortunately 7 of the 35 clinics were cancelled at short notice. Those requiring separate diagnostics first were all booked within 9 weeks.

Cancelled clinics due to (1) unwell consultant requiring hospital admission and (2) another had a family emergency,

10. % of rapid access chest pain patients who are seen within 2 weeks

100% Monthly 100% (average during September was 6 patients per week)

Within 2 weeks

12. % clinic letters sent within 5 days

>70% Monthly All clinics now use digital transcription.

30

2.3.3 Ophthalmology Kings

31

2.4 Urgent Care Services (UCC) and OOH

2.4.1 Overview – Hurley Group

UCC on both sites continues to overperform. A review is currently being undertaken to analyse the underlying reasons, and the options and action required. We will be working with a number of stakeholders in order to address particular areas of overperformance in order to explore how we might influence and reduce it.

2.4.2 Future Development and Risks

The Contract Performance Notice remains open regarding paediatric cover at UCC . Hurley Group are to provide a plan setting out how they intend to recruit paediatric nurses to provide the service specified in the Contract. The plan will be reviewed by the Quality and Safety Committee. Activity- September

Site Bexley Non-Bexley Total

QMH UCC 2399 2725 5124

Erith UCC 3188 870 4058

QMH OOH 993 84 1077

Paeds QMH UCC

783 871 1654

Paeds Erith UCC

1179 261 1440

Paeds OOH 216 21 237

32

2.5 AQP contracts

2.5 AQP contracts

2.5.3 Anti Coagulation Tier 1

2.5.1 Termination of Pregnancy Services (TOPS)

The aggregate spend from April 2016 to September 2016 across the 3 AQP TOPS providers is £211,646 compared with the same period last year when the spend was £206,522. The annual budget for TOPS is set at £462,359 so we are forecasting expenditure within budget.

The aggregate spend from April 2016 to September 2016 was £148,712. This is a reduction on the expenditure for last year (£255, 155). This is due to no reported activity from LGT. This issue has been raised again with LGT who are seeking to establish clarity on payments due for this financial year we are also in the process of analysing some new SLAM data.

2.5.2 Adult Hearing Loss (Audiology Services)

The aggregate spend for April 2016 to September 2016 is £329,396. 3 NOAC patients were initiated in July 16 and 8 in August 2016 and 15 in September 2016.

The budget has not been updated following the January 2016 Governing Body report and there is a cost pressure. The budget stands at £597,617. There is a forecast overspend at year end is estimated at £61k.

33

2.5.4 Dermatology, Gynecology, Urology and Minor Surgery AQP’s

The chart below shows latest YTD at M6 activity and spend for Communitas Dermatology, Oxleas Gynecology AQP and Dartford AQP activity. As previously reported, LGT Gynaecology AQP activity has gone back into the main contract and they have agreed to provide a proportion of their activity at reduced tariff (70% of National tariff).

AQP activity in Dermatology continues to increase month on month. Minor surgery activity does not reflect the weekly slot report from RMBS.This issue will be queried with the general manager at Dartford & Gravesham Trust . Work is continuing with providers and clinicians to ensure that the appropriate patients are triaged to Community services by improving the quality of referrals from GPs through revised referral forms for each specialty and a revision of the inclusion criteria described with the service specifications, which will in turn support procurement.

2016/17AQP Performance by month

Sept

Provider Speciality POD Activity Value Invoice Activity Value Invoice Activity Value Invoice Activity Value Invoice Activity Value Invoice Activity Value Invoice

Communitas Dermatology Firsts 107 £10,379 £10,379 96 £9,312 £9,312 120 £11,640 £11,640 110 £10,670 £10,670 68 £6,596 £6,596 129 £12,513 £12,513

Follow ups 17 £969 £969 14 £798 £798 20 £1,140 £1,140 29 £1,653 £1,653 26 £1,482 £1,482 46 £2,622 £2,622

OPROC 41 £3,403 £3,403 24 £1,992 £1,992 30 £2,490 £2,490 42 £3,486 £3,486 23 £1,909 £1,909 47 £3,901 £3,901

Total 165 £14,751 £14,751 134 £12,102 £12,102 170 £15,270 £15,270 181 £15,809 £15,809 117 £9,987 £9,987 222 £19,036 £19,036

DGT Minor Surgery Firsts 6 £708 £708 0 0 £0 0 £0 £0 0 £0 £0 0 £0 £0 0 £0 £0

Follow up 0 £0 £0 0 £0 £0 0 £0 £0 0 £0 £0 0 £0 £0 0 £0 £0

Daycase 6 £2,610 £2,826 7 £3,010 £3,010 15 £7,615 £7,615 9 £5,721 £5,721 20 £11,491 £11,491 2 £943 £943

Diagnostics 0 £0 £0 0 £0 £0 0 £0 £0 0 £0 £0 0 £0 £0 0 £0 £0

Total 12 £3,318 £3,534 7 £3,010 £3,010 15 £7,615 £7,615 9 £5,721 £5,721 20 11491 11491 2 £943 £943

DGT Urology Firsts 39 4173 £4,277 38 £4,168 £4,168 25 £2,741 £2,741 21 £2,303 £2,303 14 £1,535 £1,535 34 £3,728 £3,728

Follow up 23 £1,357 £1,391 36 £2,177 £2,177 33 £1,995 £1,995 20 £1,210 £1,210 41 £2,237 £2,237 35 £2,116 £2,116

OPROC 0 £0 £0 0 £0 £0 1 £140 £140 0 £0 £0 0 £0 £0 0 £0 £0

Total 62 £5,530 £5,668 74 £6,345 £6,345 59 £4,876 £4,876 41 £3,513 £3,513 55 £3,772 £3,772 69 £5,844 £5,844

DGT Gynaecology Firsts 3 341.34 £341 12 £1,365 £1,365 0 £0 £0 12 £1,365 £1,365 13 £1,479 £1,479 16 £1,820 £1,820

Follow up 4 £283 £283 11 £778 £778 0 £0 £0 11 £778 £778 6 £424 £424 9 £636 £636

OPROC 0 £0 £0 8 £1,120 £1,120 0 £0 £0 10 £1,120 £1,120 8 £1,120 £1,120 9 £1,260 £1,260

Total 7 £624 £624 31 £3,263 £3,263 0 £0 £0 33 £3,263 £3,263 27 £3,023 £3,023 34 £3,716 £3,716

Oxleas Gynaecology Firsts 38 £4,218 £4,218 36 £3,996 £3,996 35 £3,885 £3,885 21 £2,331 £2,331 40 £4,440 £4,440 32 £3,552 £3,552

Follow ups 6 £414 £414 11 £759 £759 15 £1,035 £1,035 21 £5,271 £5,271 17 £1,173 £1,173 12 £828 £828

OPROC New 18 £4,518 £4,518 18 £4,518 £4,518 25 £6,275 £6,275 10 £690 £690 16 £4,016 £4,016 9 £2,259 £2,259

OPROC F/up 3 £627 £627 1 £209 £209 2 £418 £418 4 £836 £836 14 £2,926 £2,926 4 £836 £836

Total 65 £9,777 £9,777 66 £9,482 £9,482 77 £11,613 £11,613 56 £9,128 £9,128 87 £12,555 £12,555 57 £7,475 £7,475

LGT* Gynaecology Not specified TBC

Total

GRAND TOTAL 311 £34,000 £34,354 312 £34,202 £34,202 321 £39,374 £39,374 320 £37,433 £37,434 306 £40,828 £40,828 384 £37,014 £37,014

Apr May June July Aug

34

2.6 Other Community Contracts 2.6.2 Greenwich and Bexley Community Hospice

A joint review of the Lymphoedema service has commenced. A service protocol is being developed to inform future service provision.

Greenwich & Bexley Hospice Activity Data

Qtr 4 15/16 Qtr 1 16/17 July 16 Aug 16 Sept 16

Total Referrals Inpatient Unit 85 90 38 26 27

Day Care 20 17 13 10 11

Community 150 186 51 56 76

Hospital 118 128 37 37 43

Lymphoedema 11 17 5 5 5

Rehabilitation 59 70 22 24 24

Total 443 508 166 158 186

Inpatient Admissions 57 60 32 17 19

Inpatient Discharges 13 20 7 10 8

Inpatient Deaths 37 44 21 8 9

Average Bed Occupancy 79.8% 74.6 % 80% 86% 80%

Average days Length of Stay 9.2 11 5.8 12.6 13.4

New Outpatient Admissions Community

129 128 57 50 47

Hospital 115 116 29 36 40



Total 290 296 104 114 105

Number of Outpatient Deaths Community

85 98 42 22 36

Hospital 53 56 16 17 15



Total 151 172 65 44 52

Number of OP Discharges Community

15 22 4 10 5

Hospital 56 62 13 21 21



Total 102 130 33 57 43

Total Numbers Attending Day Care 363 377 115 100 111

Number of Day Care Deaths 8 2 0 1

35

2.6.3 GPwSI – Dermatology, Erectile Dysfunction, Vasectomy

GPwSIs are contracted to carry out Tier 1 activity in the community for referrals which would otherwise be seen in the acute setting. September performance for the GPwSI contracts is within budget. Referrals into Dermatology are being triaged to ensure patients are seen in the most appropriate service. Month 6 activity for Dermatology is within expected levels. The levels of activity for Erectile Dysfunction have dropped by approximately 40% following changes in prescribing and the expiry of the patent on Viagra which allowed cheaper generic versions to be available. Vasectomy activity is within expected levels but activity is increasing at the Hospitals. This is mainly due to the number of patients who have needle phobia or wish to be anaesthetized for the procedure. A full review of the GPwSI services for Dermatology, Erectile Dysfunction and Vasectomy has been carried out at M6. The analysis of the data shows that the community services continue to provide value for money and savings on secondary care spend. A separate report has been prepared for FSC.

A cumulative picture of GPWSI activity and spend for the year to date is set out in the

table below.

2.6.4 GP Support to Care Homes: The bids for the Support to Care Homes are currently being evaluated. The new contracts for the GP Support to Care homes LES is due to commence on 1 April 2017. The service specification has been revised to include additional quality indicators. Most of the mid-year Contract Review Meetings have taken place, and the Q2 KPI returns have been submitted and show an improvement in performance compared to last year.

GPWSI - ACTIVITY

Annual Annual ACTIVITY

SPECIALTY PROVIDER Activity Clinics New Follow Up DNA

DERMATOLOGY DR S ILOBI 736 92 8 41 5 5

DERMATOLOGY DR A MALONE 1,104 138 15 89 73 9

DERMATOLOGY DR N PAUL 264 33 3 21 0 1

ERECTILE DYSFUNCTION DR MB ADAGRA 332 55 1 3 0 0

VASECTOMY DR SK GUPTA 88 11 2 6 0 0

VASECTOMY DR S NEHRU 88 11 1 2 0 0

Number

of

Clinics

GPWSI - YEAR TO DATE SUMMARY

Annual Annual CUMULATIVE ACTIVITY

SPECIALTY PROVIDER Budget YTD £ Activity Clinics New Follow Up DNA

Sep-16 DERMATOLOGY DR S ILOBI 34,700 19,600 736 315 92 52 274 41 56

DERMATOLOGY DR A MALONE 34,700 23,100 1,104 529 138 58 398 131 33

DERMATOLOGY DR N PAUL 11,700 1,400 264 28 33 4 28 0 1

ERECTILE DYSFUNCTION DR MB ADAGRA 18,400 1,524 332 17 55 4 17 0 0

VASECTOMY DR SK GUPTA 14,520 7,425 88 45 11 8 45 0 0

VASECTOMY DR S NEHRU 14,520 1,815 88 11 11 4 11 0 0

AnnualYTD

Activity

YTD

Clinics

36

2.7 Current Procurements 2.6.1 The Invitation to Tender for the re-procurement of Improved Access to Psychological Therapies (IAPT) Services is now nearing conclusion. An award recommendation is being made to the Governing Body. 2.7.2 The procurement for Gynaecology Any Qualified Provider (AQP) has now commenced. Bid responses are due back at the end of October, and will be evaluated in early November. 2.7.3 The Tender for the re-procurement of Independent Mental Health Advocate (IMHA) Services is now nearing conclusion. The Invitation to Tender bids have been returned by bidders, have been evaluated, and a date for the interview panel has been set for November. The new contract will be in place for April 2017. 2.7.4 The Tenders have been issued for the re-procurement of circa 20 beds for older people with dementia. It is anticipated that these will be returned in late October, and a date for the interview panel has been set for early November. 2.7.5 The procurement for Minor Surgery Any Qualified Provider (AQP) has now commenced. Bid responses are due back at the end of October, and will be evaluated in early November. 2.7.6 The re-procurement of the Referral Management Service has now reached the Pre-Qualification Questionnaire Evaluation stage. The invitation to Tender should be issued in early November. 2.7.7 The bid documents for the re-procurement of Primary Care Support to Care Homes have now been completed by the bidders, and are currently being evaluated. 2.7.8 The procurement for Urology Any Qualified Provider (AQP) has now commenced. Bid responses are due back at the end of October, and will be evaluated in early November. 2.7.9 The procurement for Neurological support for HIV patients has now commenced. The Pre-Qualification Questionnaires (PQQ) have been issued, and the PQQ responses are due back at the end of October, and will be evaluated in early November. 2.7.10 The procurement for Dermatology Any Qualified Provider (AQP) has now commenced. Bid responses are due back at the end of October, and will be evaluated in early November. 2.7.11 The procurement for Community Dietetics has now commenced. The Pre-Qualification Questionnaires (PQQ) have been issued, and the PQQ responses are due back at the end of October, and will be evaluated in early November.

37

Mental Health Contracting & Performance

Section 3 (Month 6 – September 2016)

Provided by the Integrated Commissioning Unit (ICU) for the CCG & LBB


3.2 Financial Update

3.3 Mental Health Main Contracts

3.4 New Mental Health Access requirements

3.5 Procurements

38

3.1 Executive summary

The Integrated Commissioning Team continue to work with BBG commissioners to assess the impact of the proposed re-design of MH Rehabilitation services. A meeting is planned for October where commissioners will review and clarify the process for the proposal to be considered by respective Governing Bodies / systems within CCG’s. The tender for IAPT is due to be completed in November following evaluation of the submitted bids. An award recommendation will be made to the Governing Body. IMHA and Care Act Advocvacy will follow soon after with all completed by the end of the year.

3.2 Financial Update

3.2.1 All main budgets remain mostly on track.

3.2.2 The Mental Health overspend of £139k at month 6 is due to over performance

on the SLAM SLA of £97k within the adults element. There is also an overspend of £42k in Mental Health NCAs which is due to high cost patient billing from Kent & Medway SCP Trust.

3.2.3 The CCG continues to raise invoices to the London Borough of Bexley for joint funded patients under Section 117 requirements. To date all other areas within Mental Health are currently spending to plan which is encouraging at this stage of the financial year.

3.2.4 The reason for FOT being breakeven is that any overspend will be the first call on the mental health parity of esteem investment which is available and is currently sitting within the reserves cost centre.

3.3 Mental Health Main Contracts

3.3.1 Oxleas MH FT – Adult Mental Health Services The recent CQC inspection of Oxleas has highlighted a range of areas where imrpvoement is required. Commissioners will be working with the Trust to identify areas for improvement and monitoring, with the CCG quality Team the improvements required. The SDIP and DQIP are also being reviewed to ensure that the Trust has either commenced or has detailed plans in place to commence reporting areas agreed upon during this FY.

39

MIND in Bexley – IAPT The access target for 2016/17 is set at 3712 / 15% of the population with a common mental health disorder entering into first treatment. The quarter 1 access target was met with 928 entering into first treatment / 3.75%. First treatment numbers for September 2016 are reported at 306. Full quarter 2 First Treatment numbers are reported at 945 against an expected 928 – 3.82% against the target of 3.75%. This data is uncleansed and may be subject to revision when full quarter 2 data is submitted to HSCIC. The national IAPT recovery target for 2016/17 is set at 50%. The quarter 1 recovery target was achieved with 51% recorded. Recovery for September is reported at 49.6% with quarter 2 reported on target at 50%. As at the mid-year point, recovery is recorded at 50% and on target. 6 and 18 week waiting time targets continue to be met above the required minimum standard. 3.3.2 Mind in Bexley Recovery Services The Recovery College and Employment Hub continues to perform well with no service issues or concerns reported. Available data for quarter 1 records 294 referrals made to the service and overall, 329 clients enged in activities/workshops to support their mental helath recovery. The Employment Hub has discharged 20 clients into paid employment with a further 16 taking up voluntary positions. Quarter 2 data is due to be submitted by the end of October. A further update will be given at this point. Currently, there are no service issues or concerns reported. 3.3.3 MCCH – Chapel Hill

Quarter 1 data shows that across the 18 mental health rehabilitation beds, 100% availability and utilisation levels have been recorded. Crisis and Respite beds have utilised at 81%. Commissioners have presented reports at the LB Bexley Procurement Board, recommending that the option to extend this contract for a further 2 years is taken up. An extension until March 2019 has been agreed. Commissioners are currently negotiating future terms with MCCH. Quarter 2 data is due to be submitted by the end of October. A further update will be

given at this point. Currently, there are no service issues or concerns reported.

40

3.3.4 KMPT Commissioners are working in partnership with DGS who are leading on discussions with KMPT in respect of extending service availability to midnight, 7 days per week. A collaborative commissioning agreement is being produced by DGS. The current service performes well and meets/exceeds required targets of 103 client contacts per quarter, with 185 recorded in Quarter 1. Quarter 2 data is due to be submitted by the end of October. A further update will be

given at this point. Currently, there are no service issues or concerns reported.

3.3.5 Out of Borough Service Provision

The Integrated Commissioning Team continues to work towards appropriate re-allocation of responsible commissioner for some out of Borough placements. This remains a priority for 16/17 and is being supported by the appointment of a residential placement coordinator working 1 one day per week.

CCG Mental Health and Learning Disability Placements (Out of Borough /

Spot Purchase

South London and Maudsley NHS FT Diagnosis /

Primary Presentation

No of Service Users

Notes

Autism 2

Both users under review

every 6 months and alternatives

being sought to repatriate appropriately

when possible

Mental Health 18

All patients appropriately placed and

under review

Learning Disability

2 2 well placed in long term

services

£250,000.00

£300,000.00

£350,000.00

£400,000.00

£450,000.00

£500,000.00

£550,000.00

£600,000.00

£650,000.00

£700,000.00

£750,000.00

Forecast Outturn to Year End

41

3.3.5.1 South London and Maudsley NHS FT (Tertiary MH) At the start of 16/17 month 6, the forecast overspend at year end remains at 48% which is a stabilised position. A continued increase in referrals from primary and secondary care and continued treatment of those already within the SLaM services will continue to add pressure to the budget and despite efforts for effective triage and review of referrals, the majority of referrals are destined for a tertiary level intervention. Contracting meetings will continue to review individual referrals and discharges and continued work with GP referrers will continue to seek safe and acceptable local alternatives. Discussions have commenced with Oxleas NHS FT to look at the potential for local commissioning of some services and updates will be provided in due course. In particular, ADHD is being considered. 3.3.5.2 Spot Purchased Placements (Mental Health) These remain under review with closer scrutiny being given to proposed discharges from MH rehabilitation services. Work continues towards changes in responsible commissioner where this is indicated appropriate.

42

3.4 New Mental Health Access Requirements

The requirements are as below and form part of both monthly activity reporting and key performance / quality indicators for Oxleas NHS FT, MIND in Bexley and providers to which these targets relate.

Service Area Requirement Current performance RAG

IAPT

15% prevalence (3.75% per quarter)

3.75% achieved during Quarter 1

50% recovery rates 51% achieved during Quarter 1

75% of adults to have 1st treatment session within 6 weeks of referral,

97.5% achieved during Quarter 1

A minimum of 95% are to be treated within 18 weeks

99% achieved during Quarter 1

DEMENTIA

Prevalence of 2945 patients diagnosed (67% diagnosis rate required)

Currently 66.3% performance against a national average performance of 66.6%. This is an reduction of 0.3%. An action plan has been developed and is in the process of being implemented to address the consistent minor shortfall

EARLY INTERVENTION IN

PSYCHOSIS

50% of people experiencing a 1st episode of psychosis will receive treatment within 2 weeks

Oxleas are currently delivering this target (currently 55% of patients treated within 2 weeks year to date (as of end of August 2016)

LIAISON PSYCHIATRY IN

ACUTE HOSPITAL SETTINGS (ALL

AGES)

Improved access to liaison psychiatry by 2020 across all groups to reduce admissions, reduce LOS

Bexley CCG is working with Greenwich to deliver a joint approach to this – increased access through additional hours of operation covering all adult age has been agreed in principle deploying non-recurrent funding to pump prime.

43

3.5 Procurements

Mind In Bexley – IAPT and associated services IAPT submissions have been evaluated, and a recommendation is being made to the Governing Body in November. IMHA and Care Act Advocacy submissions for tender (ITT) will be evaluated in October 2016. Updates will be provided on both of the above in due course. The Contract for Chapel Hill (Mental Health Rehabilitation) has been approved by LBB and Governing Body and therefore negotiations of costs will commence with expectation of formal agreement towards the end of November 2016.

44

111 Contracting & Performance (LAS)

Section 4 - Provided by SECSU

4.1 SEL 111 Call Volumes

4.2 Summary of September 2016 Performance

4.3 Impact on Local Urgent and Emergency Care Services

45

4.1. SEL 111 Call Volumes

Since late January 2016 there have been periods of increased activity that have been

volatile and dissimilar to previous years. This became particularly marked in July with

higher than forecast call volumes consistently experienced across weekdays and calls

close to forecast at weekends. In response, LAS uplifted their predicted call volumes by

5% for the remainder of the financial year and adjusted the predicted spread of calls

across the week in line with the emerging trends. The green bars in the graph show

LAS’s revised predicted call volumes, the red bars show their actual call volumes.

August and September saw a slight drop in call volumes, which has had a positive

impact on performance.

4.2 Summary of September 2016 Performance

(Data taken from LAS’s weekly UNIFY2 submissions. This data set is suitable for benchmarking against other providers as this is the same data set used by NHS England to produce their weekly reports.)

46

Key Performance Indicators (Data taken from LAS’s weekly UNIFY2 submissions) All Key Performance Indicators (KPIs)

have been met, with the following exceptions:

Reference Quality and Performance Indicators (KPIs) Target

September 2016

Performance

QR5 Call waiting time (NQR8)

No of calls answered within 60 seconds at the end of the introductory message

≥95% 94.8%

QR6 Life threatening referrals (NQR9)

No of calls referred to London Ambulance Service within 3 minutes which are life threatening

100% Not available from UNIFY2

QR11 Attend Accident & Emergency Department (LQR6)

Percentage of patients advised to attend Accident and Emergency Department

<5% 9.9%

QR12 Warm Transfers (LQR7)

% of calls warm transferred to NHS 111 Nurse Advisor within 30 seconds where required

98% 47.5%

QR13 Time taken for call back (LQR10)

Time taken for call back by NHS 111 Nurse Advisor <10 minutes

100% 60.9%

QR5 Call waiting time LAS narrowly missed this target by 0.02%.

QR6 Life threatening referrals LAS’s monthly performance report includes data for the percentage of calls referred to the ambulance service within 3 minutes where life threatening symptoms are identified. The measure is calculated as the difference between the time the symptoms are identified as life threatening and the time the ambulance is confirmed. Performance for this measure since November 2015 has been between 92.7% (February 2016) and 96.3% (June 2016). LAS have completed an audit to understand where the three minute target is exceeded; what the reasons are; and therefore inform what actions are required. A total of 35 calls in May 2016 breached the three minute target and all 35 calls were included in an audit to understand why there was a delay between the need for an ambulance being established and the Call Handler or Clinical Advisor selecting the send button on the system. Out of the 35 calls audited the following findings were observed:

8 Calls were due to Caller/Patient delay -These were calls taken by Clinical Advisor or Call Handler where the need for an ambulance was established but for a variety of reasons the delay was caller/patient related i.e.; Patient refusing the ambulance

11 Calls were due to Call Handler/Clinical Advisor delay whilst seeking advice regarding outcome. 10 were Call Handlers which may be attributed to lack of confidence. There was one call where a Clinician sought advice for a 22 year old with severe crushing chest pain.

47

12 Calls were due to Clinical Advisor seeking further clarification from caller/patient after establishing the need for an Ambulance.

4 Calls were related to a system failure i.e.; call had to be handed over manually or call cut off from caller.

Next Steps A further audit is currently taking place for calls that breached the three minute target during June and July. On completion of the three month audit the findings will be reviewed with recommendations which may include changes to current operations procedures.

QR11 Attend Accident & Emergency Department, last 13 months (Data taken from LAS’s weekly UNIFY2 submissions)

There has been a slight increase in Emergency Treatment Centre (ED and UCC) referrals

during September 2016.

QR12 Warm Transfers & QR13 Time taken for call back The commissioners have agreed a let for QR12 and QR13, in order to allow LAS to carry out a pilot to prioritise warm transfers and call backs according to clinical need.

Performance against call prioritisation model (Data taken from LAS’s Performance Report, submitted to the SEL 111 Contract Management

Meeting)

The following table sets out LAS’s performance against the call prioritisation model from 1 March 2016 –

31 August 2016.

LAS have generally been performing well against these revised KPIs on call prioritisation. CQI staff are monitoring the call back queue at all times and they pull out priority calls and either allocate them to clinicians or take the calls themselves – the second option is avoided if at all possible. No serious incidents have occurred.

48

Exceptions are reported in weekly breach reports. SEL CCGs’ 111 Clinical Lead has confirmed that he receives these reports and raises any issues on an ad hoc basis with LAS. Average Call Back times by priority show that P2s and P3s are all well within target, while P1s are slightly outside of target.

49

LAS Contracting & Performance

Section 5

5.1 Bexley CCG LAS Performance Dashboard

5.2 CAT A Performance Charts

50

5.1 LAS Performance Dashboard (Pan London) – September 2016 Dashboard

TargetMonthly

Trajectory

Current

Month

Performance

YTD

Trajectory

Current YTD

Performance

75% 71.9% 70.1% 68.3% 69.9%

75% 68.3% 63.2% 64.7% 64.9%

95% 93.0% 92.8% 93.0% 93.7%

50% 75.4% 75.7% 78.7% 81.6%

75% 81.7% 83.0% 84.9% 87.5%

50% 76.0% 77.3% 79.9% 83.2%

75% 86.2% 87.0% 89.1% 91.0%

50% 75.5% 78.2% 77.9% 82.7%

75% 86.3% 87.5% 88.0% 90.6%

50% 55.2% 58.6% 59.8% 63.7%

75% 69.3% 71.3% 73.8% 76.0%

Green 4 Performance (60 minutes)


Cat A Performance (19 minutes)



Green2 Performance (60 minutes)



Performance Dashboard

Red 1 Performance (8 minutes)

Red 2 Performance (8 minutes)


September Performance:

LAS has restated it's REAP level in accordance with revised national definitions and is at REAP 2 (Moderate).

Our tri-partite updates continue with our lead Commissioner, NHSE and the TDA.

• Red 1 (8 minute) monthly performance was 70.1% which is below the national standard of 75% and below the agreed monthly trajectory of

71.9%

• Red 2 (8 minute) monthly performance was 63.2% which is below the national standard of 75% but above the agreed monthly trajectory of

68.3%.

• Category A19 monthly performance (19 minutes) was 92.8% which is below the national standard of 95 % and below the agreed monthly

trajectory of 93.0%

• Hear and Treat figures for September show 10304 incidents resolved.

Priority remains around safety and minimising the impact on quality – managed through a series of internal

governance programmes and external stakeholder engagement. We ask CCGs to continue to raise the profile around wider system pressures, in

particular:

- Reduction of 111 conversions to 999 across London;

- Work with SRGs/ UCBs to understand, review & reduce demand.

Finance:

Please see below overall summary of the outstanding CCG debt as at 17th October 2016.

• CQUIN ADJUSTMENTS: APRIL 2016 TO JUNE 2016-2017 – £1,097.13 (Hounslow CCG)

• CQUIN ADJUSTMENTS: JULY 2016 -2017 - £610.24(Brent & Hounslow CCG)

• Adrenaline Research Trial 2014/2015 - £9,569.00 (10 NEL CCGs) – This amount is being disputed as the correct process for authorising the work

was not being followed.

No: Completion

Date

Open /

Closed

LAS Messages

51

5.2 CAT A PERFORMANCE CHARTS FOR September 16

CCG Category Cat A (R1 & R2) within 8 minutes and category A within 19 minutes Performance

CCG Category Red 1 Performance Chart

CCG Category Red 2 Performance Chart

CCG Category A (R1 &R2) Performance Chart

Cat A

Incidents

within 8

mins

% within

8 minsytd Incidents

within 8

mins

% within

8 minsytd Incidents

within8

mins

% within

8 minsytd

within

19 mins

% within

19 minsytd

NHS Bexley CCG 29 22 75.9% 66.3% 1144 680 59.4% 63.0% 1173 702 59.8% 63.1% 1036 88.3% 92.7%

All CCGs (LAS) 1310 918 70.1% 69.9% 43011 27162 63.2% 64.9% 44321 28080 63.4% 65.0% 41133 92.8% 93.7%

Cat A sub category Red 1 Cat A sub category Red 2 Cat A 8 performance Cat A 19 performance

62.5%

66.7% 67.7% 67.9%

56.3% 56.5% 55.2%

82.9%

74.1%

60.0%

73.7%

0

5

10

15

20

25

30

35

40

45

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Inci

den

ts

R1 Incidents R1 2015-2016 %R1 within 8 mins

Per

form

64.8%

70.1% 66.9% 67.3%

64.2% 65.0% 65.7%

61.4% 64.4%

56.4% 53.9% 55.0%

980

1000

1020

1040

1060

1080

1100

1120

1140

1160

1180

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%


Inci

den

ts

R2 Incidents R2 2015-2016 %R2 within 8 mins

Per

for

64.8%

70.0% 66.9% 67.3%

63.9% 64.8% 65.5% 62.1%

64.7%

56.2% 54.0% 55.5%

1000

1050

1100

1150

1200

1250

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%


Inci

den

ts

Cat A Incidents A8 2015-2016

%Cat A within 8 mins A19 2015-2016

Per

form

52

Calls Resolved by Telephone Advice (LAS)

The following graph shows the number of calls resolved through telephone advice without the further neeed for transport

Activity totals include incidents, Hear & Treat and Surge

0

2000

4000

6000

8000

10000

12000

14000

16000

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Hear & Treat 2016/2017 10084 10950 10039 11404 9987 10304 0 0 0 0 0 0

Hear & Treat 2015/16 13133 13480 13624 13759 12405 12346 12814 12058 12363 12381 12393 12948

81

,85

2

98

,15

6

96

,74

4

10

0,4

82

97

,50

4

95

,39

7

10

1,4

19

10

0,9

83

10

5,4

74

10

4,8

30

98

,48

1

10

6,6

11

88

,53

7

94

,93

3

92

,21

2

95

,36

2

91

,90

8

89

,52

1 1

3,1

33

13

,48

3

13

,62

9

13

,76

0

12

,40

5

12

,34

6

12

,81

4

12

,05

8

12

,36

3

12

,38

1

12

,39

3

12

,94

7

10

,08

4

10

,95

0

10

,03

7

11

,40

3

9,9

88

10

,30

4

60000

80000

100000

120000

140000

160000

180000

Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16

999 calls, activity, responses

Incidents Hear & Treat 999 calls Responses