NHS Hammersmith & Fulham CCG QIPP Performance Report M12 ... · Unique Ref Project Name POD Gross Plan Gross Actual Gross Variance Gross Variance (%) Gross Plan Gross Actual Gross

1

NHS Hammersmith & Fulham CCG QIPP Performance Report

M12: April-14

Contents

Section 1: Executive Summary

• Financial summary

• Programme summary

Section 2: M12 Finance and Activity

• Financial Summary

• Activity Summary

Section 3: Progress Reports

Part A: Unscheduled Care

• Care Planning and co-ordination

• Excess bed days reduction

Part B: Planned Care

• Dermatology

• Gynaecology

• MSK

• Respiratory adult

• Diabetic medicine

• Peer review of GP referrals

Section 4: Project Confidence Report

Section 5: Key Programme Risks

Appendices

2

The year end forecast shifted adversely by c.2% in M12 due to shifts in prescribing and NEL schemes

Financial summary

• YTD and forecast position: delivered savings of £8,921k against a plan of £10,549k (£1,628k / 15.4% under performance)

• The year end forecast has deteriorated from last month by £240k (the biggest shifts were on prescribing of £140k and £88k on NEL scheme)

• SUS data used for reporting year to date position: M01 to M10 (freeze), M11 (flexed), M12 (forecast)

3

QIPP Year to Date Delivery

YTD Plan £’000

YTD Actual £’000

Variance £’000

Variance %

RAG

10,549 8,921 -1,628 -15.4% A / G

QIPP Full Year Forecast

Full Year Plan £’000

Forecast Net Savings to Year End

£’000

Forecast Variance to Year

End £’000

Forecast Variance to

Year End %

RAG

10,549 8,921 -1,628 -15.4% A / G

Key successes:

• 100% of practices are now on SystmOne. 31% of patients will have a summary care record by end of March 2014. By the 1st April, CLCH will have migrated their Adult Community Health Services to record on SystmOne

• Interim model of Geriatrician support for VW/CIS team agreed with increased level of consultant support for the OPRAC clinic

• MH nurse recruited into CIS with a drug and alcohol background who will be able to support the VW team

• Social worker commencing in April-14

• H&F are within the top 6 London boroughs for use of CMC

• Clinical guidelines are being set up (involving primary, community and secondary care) and clinician educational course is being developed for approval by the group

• Single point of triage to be implemented for Respiratory service initially in shadow form for 2 months from 1st May-14

• Capacity modelling to date for MSK shows that we will achieve a reduction of waiting times to 4 weeks by June-14

4

Part A: Unscheduled care

1. Care Planning and co-ordination: The NEL SUS data has been highly variable in 13/14 with a range of savings achieved from £0 - £180k with no clear direction behind the trend. We have therefore based our M12 forecast on a three-point estimate in order to take into account the potential benefit of delivering the most optimistic scenario (full M12 plan including additional impact from virtual ward) and mitigate the risk of actually achieving the most pessimistic scenario (no year on year savings in M12)

2. Excess bed days: Savings delivered month on month have been highly variable. The In-reach activity went down in Feb-14 due to the fact that the member of staff who was providing this role at Hammersmith Hospital has been signed off on 6 weeks sickness & the CIS have been unable to recruit a locum to cover them. Jan-14 and Feb-14 activity has been affected as a result of a few patients discharged after a long stay

Part B: Planned care

1. Dermatology : This scheme is delivering above the planned level of savings and we expect the year end forecast to be in trend. Given the success, we are looking at how to expand this service with additional clinics next year and support from a second GPwSI. Meeting took place on 6th Feb-14 with CLCH and GP providers to discuss service provision and the specification for 14/15

2. Gynaecology: The single point of triage introduced in May-13 has proven effective and additional clinics put on appear to have been effective in further reducing acute gynaecology activity. A decision has been made to procure this service in 14/15 and the current contract has been extended until 31.12.14. The service will be procured for 3 years

3. MSK: Waiting list catch up clinics began on 6th Jan-14. Physio waiting times have reduced to 9 weeks and 10 weeks for CATS. CATS will show a greater impact in April/May due to difficulties in recruiting ESPs (2wte start in April and 1wte to be trained and starts in May). Capacity modelling to date shows a reduction to 4 weeks waiting by June-14

4. Respiratory: Strategic meetings took place with Acute and Community providers to develop and agree service developments for 14/15. A single point of triage will be implemented, initially in a shadow form for 2 months from May-14. Agreement has been reached to discuss with Imperial and ChelWest to bring existing Acute Sleep service into the Community service. The Sleep consultant will also audit all referrals for 2 months detailing current pathway and outcomes

5. Diabetes: We do not forecast any impact on activity flows until 14/15. As a result of the clinical service review, diabetes leads have been identified in all practices. Collaborative Strategy meetings are taking place. A working group is to be set up to detail the clinical guidelines and patient structured education

6. Peer review: As anticipated, no savings were seen as a result of this scheme this month and none are anticipated for the rest of the year

7. Part C: Prescribing

The year end forecast in the financial ledger has improved significantly this month, now reporting £44k overspend. The QIPP forecast this month has been revised in line with ledger instead of using the Jan-14 ePACT report that forecasts an underspend of £54k

The year end forecast has been revised reflecting an adverse movement in prescribing and NEL

Contents












• Dermatology

• Gynaecology

• MSK




Section 4: Project Confidence Report (for schemes not requiring progress reports)


Appendices

5

Financial Summary

6 (Negative) value or variance reflects under achievement Positive value or variance reflects over performance

Year to date (M12)- Financial Summary Full Year Forecast (Net)

Unique Ref Project Name POD Gross Plan

(£000)

Gross Actual (£000)

Gross Variance

(£000)

Repro Plan

(£000)

Repro Actual (£000)

Repro Variance

(£000)

Net Plan (£000)

Net Actual (£000)

Net Variance

(£000)

Net Variance

(%)

Net Plan (£000)

Net Actual (£000)

Net Variance

(£000)

Net Variance

(%)

HFCCG01a Care Planning and Co-ordination

NEL 2,592 984 -1,608 1,044 405 -639 1,552 579 -973 -62.7% 1,552 579 -973 -62.7%

HFCCG01d Excess Bed Days Reduction XD BDs 132 108 -24 0 0 0 131 108 -22 -16.7% 131 108 -23 -17.6%

HFCCG03 Musculoskeletal Services OPFA / OPFU

338 13 -324 0 0 0 338 13 -325 -96.3% 338 13 -325 -96.3%

HFCCG04 Respiratory Adult OPFA / OPFU

86 12 -75 0 0 0 86 12 -75 -86.4% 86 12 -75 -86.6%

HFCCG05 Diabetic Medicine OPFA / OPFU

53 0 -53 0 0 0 53 0 -53 -100.0% 53 0 -53 -100.0%

HFCCG06 Dermatology OPFA / OPFU

49 88 40 0 0 0 49 88 38 77.2% 49 87 38 77.4%

HFCCG07 Gynaecology OPFA / OPFU

101 79 -22 0 0 0 101 79 -22 -21.6% 101 79 -22 -21.5%

HFCCG08 Peer Review of GP Referrals OPFA / OPFU

169 18 -150 0 0 0 169 18 -151 -89.7% 169 18 -151 -89.3%

HFCCG09 Children Services (Maternity Service Improvement)

688 688 0 0 0 0 688 688 0 0.0% 688 688 0 0.0%

HFCCG10a Current MH Proposals- WLMHT

1,008 1,008 0 216 216 0 788 788 0 0.0% 788 788 0 0.0%

HFCCG10b Current MH Proposals- NHS specialists & Independent sector providers

294 294 0 0 0 0 294 294 0 0.0% 294 294 0 0.0%

HFCCG10c Current MH Proposals- CNWL

100 100 0 0 0 0 100 100 0 0.0% 100 100 0 0.0%

HFCCG11 Community Services (CLCH Contract)

1,500 1,500 0 0 0 0 1,500 1,500 0 0.0% 1,500 1,500 0 0.0%

HFCCG13 Prescribing 900 860 -40 0 0 0 900 856 -44 -4.9% 900 856 -45 -4.9%

HFCCG14 Acute Contracts 3,800 2,850 -950 0 0 0 3,800 2,850 -950 -25.0% 3,800 2,850 -950 -25.0%

Additional Contract Benefits 0 950 950 0 950 950 950 950

Total 11,809 9,554 -2,255 1,260 621 -639 10,549 8,921 -1,628 -15.4% 10,549 8,921 -1,628 -15.4%

7

Activity Summary

(Negative) value or variance reflects under achievement Positive value or variance reflects over performance

Year to date (M12)- Activity Analysis Full Year Forecast (Net) Unique Ref Project Name POD Gross Plan Gross

Actual Gross

Variance Gross

Variance (%)

Gross Plan Gross Actual

Gross Variance

Gross Variance (%)

HFCCG01a Care Planning and Co-ordination NEL 1,188 336 -852 -72% 1,188 394 -794 -66.9%

HFCCG01d Excess Bed Days Reduction XD BDs 528 420 -108 -20% 527 420 -107 -20.3%

HFCCG03 Musculoskeletal Services OPFA / OPFU 2,563 28 -2,535 -99% 2,563 28 -2,535 -98.9%

HFCCG04 Respiratory Adult OPFA / OPFU 539 114 -425 -79% 539 114 -425 -78.8%

HFCCG05 Diabetic Medicine OPFA / OPFU 337 0 -337 -100% 337 0 -337 -100.0%

HFCCG06 Dermatology OPFA / OPFU 458 792 334 73% 458 861 403 87.9%

HFCCG07 Gynaecology OPFA / OPFU 887 538 -349 -39% 887 561 -326 -36.7%

HFCCG08 Peer Review of GP Referrals OPFA / OPFU 1,214 121 -1,093 -90% 1,214 121 -1,093 -90.0%

Total 7,714 2,349 -5,365 -70% 7,713 2,499 -5,214 -67.6%

Contents












• Dermatology

• Gynaecology

• MSK






Appendices

8

9

Unscheduled Care: Care Planning & Co-ordination Summary

PROGRESS PLAN

Project code HFCCG01a Date form updated 09.04.14

Project name Care Planning and Coordination CCG project lead Rob Sainsbury Reason remedial plan triggered (E.g.. Finance, quality, severe delay, high risk, other difficulty)

QIPP performance under 80% of plan

Condition on which remedial plan will be closed (E.g.. Back on plan, agreed by Board)

QIPP performance over 80% of plan

1. Financial position

Year to date Full year forecast

Month Plan

£'000s Actual £'000s Variance £'000s Variance% RAG

Rating Plan £'000s Forecast £'000s

Variance £'000s Variance %

RAG Rating

M12 1,552 579 -973 -62.7% RED 1,552 579 -973 -62.7% RED

2. Cause of variance from plan (Rationale for current delivery) Issues identified as causing variance from plan

1 It is difficult to quantify the impact on the NEL admissions for patients who have had care plans completed. This is because we are not able to identify the patients involved (due to IG restrictions). The targeted cohort who should receive care plans has not been revised since April-13 because the Combined Predictive Modelling Tool is not updated

2 Clinical system migration to SystmOne has caused some issues with consistent access to care planning templates. This has affected the no of care plan completed during the year but we expect care planning activity to increase significantly in Q4

3 The behavioural shift involved in moving from a re-active to a preventative approach is taking time to embed and awareness of usage of services such as the CIS has taken time to spread

4 Performance impacted by delay in the roll out of GP model supporting VW. CIS, H&SCCs and matrons are in post

Rationale for current forecast

We have revised our forecast this month to deliver a net savings of £579k compared to £666k forecasted last month (adverse movement of £88k). This reflects the delay we have experienced in the roll out of the GP model and we are looking at alternatives with Networks and Acute partners (for e.g.; interim model of geriatrician support for the VW/CIS team has been agreed). The revised forecast takes into account assessment of the current Virtual Ward model in operation. Going forward, we need to increase engagement with Network GPs so that they are beginning to identify patients suitable for Virtual Ward and increase consultant input into the VW model. M12 forecast is based on a 3-point estimate approach in order to take account the potential benefit of delivering the most optimistic scenario

10

Care planning & co-ordination finance and activity trends

Note: Planning for 14/15 is on-going and estimates could change

-£50

£0

£50

£100

£150

£200

M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12QIP

P P

lan

Vs

Act

ual

(£

00

0)

QIPP Plan Vs Actual (£000 savings)

Net QIPP Plan

Net Actual & Forecast

500

550

600

650

700

750

1 2 2 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3

12-13 Actuals (baseline) 13-14 Plan Net of QIPP 14-15 Q1

No

n-e

lect

ive

adm

issi

on

s

Non- Elective activity trend: actual and forecast

12-13 Actual

13-14 Net of Planned QIPP Requirement

13-14 Actual

Forecast

11

Care Planning & co-ordination reprovision activity

Rapid Response Service

Rapid Response is one element of the Community Independence Service (CIS). The CIS provides admission avoidance and early supported discharge for patients and integrated intermediate care support for up to 6 weeks

Rapid Response Activity relates to community based referrals to the Community Independence Service requiring a 2 hour response in order to prevent a hospital admission and/or care home placement

0

20

40

60

80

100

120

140

160

180

Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Total Rapid Response referrals per month

Rapid Response

In Reach

Total

010203040506070

Month

Number Of Rapid Response Referrals By Source Per Month Social work team

Self refer

Reablement

Other

London Ambulance

Informal carers

GP

Falls team

District Nurse

Care Home

A&E

12

PROGRESS PLAN

Project code HFCCG01d Date form updated 09.04.14 Project name Excess bed days reduction CCG project lead Rob Sainsbury 1. Financial position

Year to date Full year forecast

Month Plan

£'000s Actual £'000s Variance £'000s Variance%

RAG Rating

Plan £'000s

Forecast £'000s


RAG Rating

M12 131 108 -23 -17.6% AMBER / GREEN 131 108 -23 -17.6%

AMBER / GREEN

2. Cause of variance from plan (Rationale for current delivery) Drivers of current performance

1 Savings delivered month on month based on SUS data are highly variable

2 In-reach services which operates as part of the Community Independence service has seen an increase in the no of referrals and is proving effective to discharge patients from hospital. In Feb-14, there was a drop in activity as member of staff who was providing the role at Hammersmith Hospital has been signed off on a 6 weeks sickness

3 Jan-14 and Feb-14 also saw few patients discharged after a long stay (beyond the trim point)


Savings delivered month on month are highly variable and taking into account the delivery in recent months, we revised our forecast delivery down from £131k to £108k in M11 and we have maintained this forecast this month. High activity in Jan-14 and Feb-14 is a result of few patients discharged after a long stay

Unscheduled Care: Excess Bed Days Summary

13

Excess bed days finance and activity trends

-£15

£5

£25

£45

£65

1 2 3 4 5 6 7 8 9 10 11 12

QIP

P P

lan

Vs

Act

ual

(£

00

0)


Net Target


100

150

200

250

300

350

400

450

500

550

600

650

1 2 2 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

12-13 Actuals (baseline) 13-14 Plan Net of QIPP

Exce

ss B

ed D

ays

Act

ivit

y

Excess bed days activity trend

12-13 Actual


13-14 Actual

Forecast

14

In Reach

The In-reach activity went down in Feb-14 due to the fact that the member of staff who was providing this role at Hammersmith Hospital has been signed off on 6 weeks sickness & the CIS have been unable to recruit a locum to cover them. Agreement has been reached to cover this function across the team and locums are recruited that will then back fill this support

Excess bed days reprovision activity

0

50

100

150

200


Total In Reach referrals per month

Rapid Response

In Reach

Total

0

20

40

60

80

100

120


Number Of In Reach Referrals By Source Per Month

St Mary's Hospital

Hammersmith Hospital

Chelsea Westminster Hospital

Charing Cross Hospital

15

PROGRESS PLAN

Project code HFCCG06 Date form updated 09.04.14

Project name Dermatology CCG project lead Julie Scrivens

1. Financial position Year to date Full year forecast

Month Plan


RAG Rating

Plan £'000s

Forecast £'000s


RAG Rating

M12 49 87 38 77.4% GREEN 49 87 38 77.4% GREEN

2. Cause of variance from plan (Rationale for current delivery) Drivers of current delivery

1 GPs have a high level of confidence in this service. It is provided by a single, very experienced GPwSI who is known to the networks and attends the Acute MDT meeting

2 The Service is also very popular with patients as it is provided in several locations which are close to home and accessible to patients (Lilliville Surgery and Canberra Health Centre; Minor Surgery operates from Parsons Green Health Centre)


The forecast is based on the current trend and assumes that over-delivery will continue at its current rate to year end. A meeting has taken place with CLCH and GP providers to discuss the service and understand the specification for 14/15. The service specification is being re-visited and a proposal to enhance the clinical sessions is being considered

Planned care: Dermatology Summary

16

Dermatology finance and activity trends

£0

£2

£4

£6

£8

£10

£12

£14

£16

1 2 3 4 5 6 7 8 9 10 11 12

QIP

P P

lan

Vs

Act

ual

(£

00

0)


Net Target


200

300

400

500

600

700

800

1 2 3 4 5 6 7 8 9 10 11 12 1 2 2 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

11-12 Actual 12-13 Actuals (baseline) 13-14 Plan Net of QIPP

Ou

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(Fir

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Fo

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-up

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Dermatology acute OP activity trend: actual and forecast

11-12 Actual

12-13 Actual


13-14 Actual

Forecast

17

PROGESS PLAN

Project code HFCCG07 Date form updated 09.04.14 Project name Gynaecology CCG project lead Julie Scrivens & Michelle

Davidson Reason remedial plan triggered (E.g.. Finance, quality, severe delay, high risk, other difficulty)





Month Plan


RAG Rating

Plan £'000s

Forecast £'000s


RAG Rating

M12 101 79 -22 -21.5% AMBER 101 79 -22 -21.5% AMBER

2. Cause of variance from plan (Rationale for current delivery) Drivers of current performance

1 Single point of triage for all GP referrals has been in place since May-13. This has ensured patient care is directed to the correct service, first time around and in the most timely manner, taking into account patient choice for acute provision

2 Telephone advice and information is also available to support GPs


Based on savings delivered in the last 3 months, we have revised our forecast this month to deliver net savings of £79k compared to £88k in m11. Current contract has been extended to 31.12.14 to allow for full procurement to take place with plans to develop the service specification to include acute consultant input

Planned care: Gynaecology Summary

18

Gynaecology finance and activity trends

£0

£2

£4

£6

£8

£10

£12

£14

£16

£18

1 2 3 4 5 6 7 8 9 10 11 12

QIP

P P

lan

Vs

Act

ual

(£

00

0) QIPP Plan Vs Actual (£000 savings)

Net Target


200

250

300

350

400

450

500

550

600

650

1 2 3 4 5 6 7 8 9 10 11 12 1 2 2 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

11-12 Actual 12-13 Actuals (baseline) 13-14 Plan Net of QIPP

Ou

tpat

ien

t A

tten

dan

ces

(Fir

st &

Fo

llow

-up

)

Gynaecology actue OP activity trend: actual and forecast

11-12 Actual

12-13 Actual


13-14 Actual

Forecast

19

PROGRESS PLAN

Project code HFCCG03 Date form updated 09.04.14 Project name MSK CCG project lead Julie Scrivens Reason remedial plan triggered (E.g.. Finance, quality, severe delay, high risk, other difficulty)





Month Plan £'000s Actual £'000s Variance £'000s Variance% RAG



RAG Rating

M12 338 13 -325 -96.3% RED 338 13 -325 -96.3% RED 2. Cause of variance from plan (Ratio10e for current delivery) Issues identified as causing variance from plan

1 Initial lack of awareness of the Community service on offer has resulted in low levels of referrals from GPs 2 There has been slow re-direction of GP referrals - analysis has demonstrated that a group of practices in Network 2 continued to refer to

Charing Cross Acute Hospital 3 Staffing issues with the Community service- lack of specialist staff in T&O increased the waiting times. Activity has also been impacted with

vacancies existed over the winter months and maternity leave 4 Waiting times- community waits need reducing. The reported waiting times are 9 weeks for Physio, 13 weeks for CATs and 2 week for Pain

management. Waiting times rose in October/November as a result of increased referrals- historically this happens each year. Waiting times rose again due to clinics closed over the Christmas period but wait list initiative clinics began in January-14

5 Impact of waiting list clinics which started in Jan-14 is assumed to be slower than anticipated due to difficulty in ESP staff recruitment for CATs service and a delay in GP confidence returning until the waiting times have reduced to acceptable level


We have maintained the m11 forecast this month to deliver no further savings in m12. CCG / provider meeting have taken place to discuss the current service and clear actions have been agreed (waiting time lists, reinstallation of patient booking line, DNA reduction, GP education and support peer review). Waiting times need to return to an acceptable level to and 3wte ESPs starting in the CATs service from April/May 2014 will help

Planned care: MSK Summary

20

MSK finance and activity trends

£0

£5

£10

£15

£20

£25

£30

M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12

QIP

P P

lan

Vs

Act

ual

(£

00


Net QIPP Plan


0

100

200

300

400

500

600

700

800

900

1000

1 2 3 4 5 6 7 8 9 10 11 12 1 2 2 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

11-12 Actual 12-13 Actual (baseline) 13-14 Plan Net of QIPP

Ou

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(Fir

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Fo

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-up

)

MSK acute OP activity trend: actual and forecast

11-12 Actual

12-13 Actual


13-14 Actual

Forecast

21

PROGRESS PLAN

Project code HFCCG04 Date form updated 09.04.14 Project name Respiratory Adult CCG project lead Julie Scrivens Reason remedial plan triggered (E.g.. Finance, quality, severe delay, high risk, other difficulty)

QIPP performance under 80% of plan Condition on which remedial plan will be closed (E.g.. Back on plan, agreed by Board)



Month Plan

£'000s Actual £'000s

Variance £'000s Variance%

RAG Rating

Plan £'000s

Forecast £'000s


RAG Rating

M12 86 12 -75 -86.6% RED 86 12 -75 -86.6% RED 2. Cause of variance from plan (Rationale for current delivery) Issues identified as causing variance from plan

1 Service delivery has been affected following departure of a long standing and well respected Consultant (Irem Patel) in January 2013 . Locum cover was sought and a new consultant (Vince Mac) started on 16th September

2 Performance has been affected as GPs view the current service only suitable for COPD conditions and not a true alternative to the hospital service. Greater clarity is required in regards to what conditions can be treated by both nursing specialist and consultant. GP education programme to be undertaken by the service


We have revised our forecast this month to deliver savings of £12k, an adverse movement of £8k on previous forecast. New consultant is attending network meeting to offer peer review of referrals and education & training. Consultant has also made effort to review all community follow up patients and discharged where appropriate, back to GP with a management plan. Discussions have started with Community and Acute providers to develop and agree service development for 14/15 including implementing single point of triage

Planned care: Respiratory Summary

22

Respiratory finance and activity trends

Note:. Planning for 14/15 is in progress and estimates may change

£0

£1

£2

£3

£4

£5

£6

£7

£8

M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12

QIP

P P

lan

Vs

Act

ual

(£

00


Net Target


-20

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9 101112 1 2 2 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 1 2 3

11-12 Actual 12-13 Actual (baseline) 13-14 Plan Net of QIPP 14-15Q1

Ou

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dan

ces

(Fi

rst

&

Follo

w-u

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Respiratory medicine acute OP activity trend: actual and forecast

11-12 Actual

12-13 Actual


13-14 Actual

Forecast

23

PROGRESS PLAN

Project code HFCCG05 Date form updated 09.04.14 Project name Diabetic medicine CCG project lead Julie Scrivens Reason remedial plan triggered (E.g.. Finance, quality, severe delay, high risk, other difficulty)





Month Plan


RAG Rating

Plan £'000s

Forecast £'000s


RAG Rating

M12 53 0 -48 -100.0% RED 53 0 -53 -100.0% RED 2. Cause of variance from plan (Rationale for current delivery) Issues identified as causing variance from plan

1 Staffing issues- Specialist diabetic nurse vacancy due to retirement and then long term sickness of temporary staff has resulted in increased waiting times

2 Low profile of the Community service offered resulting in low referrals


Based on issues identified to-date and discussions with GP lead, it's unlikely that any actions to address the issues will delivery savings this year. Hence, the year end forecast is maintained to deliver £0 savings. However, we do expect to see a significant impact next year of rolling out a new service model, with significant focus on patient education, use of practice leads and leverage of the single clinical system which will then be in place. Third Collaborative CWHHE Diabetes Strategy meeting will take place on 24

th April .

Several meetings are due to take place regarding Patient structured education (conversation maps) and are trying to secure a meeting with current provider CLCH to scope future works

Planned care: Diabetic medicine Summary

24

Diabetic medicine finance and activity trends

Note: Planning for 14/15 is in progress and estimates may change

£0

£1

£1

£2

£2

£3

£3

£4

£4

£5

£5

M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12

QIP

P P

lan

Vs

Act

ual

(£

00


Net Target


0

20

40

60

80

100

120

140

1 2 3 4 5 6 7 8 9 101112 1 2 2 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 1 2 3

11-12 Actual 12-13 Actuals (baseline) 13-14 Plan Net of QIPP 14-15Q1

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Diabetic medicine acute OP activity trend: actual and forecast

11-12 Actual

12-13 Actual


13-14 Actual

Forecast

25

PROGRESS PLAN

Project code HFCCG08 Date form updated 09.04.14 Project name GP Peer review CCG project lead Sophie Ruiz Reason remedial plan triggered (E.g.. Finance, quality, severe delay, high risk, other difficulty)

QIPP performance under 80% of plan Condition on which remedial plan will be closed (E.g.. Back on plan, agreed by Board)



Month Plan £'000s Actual £'000s Variance £'000s Variance% RAG



RAG Rating

M12 169 18 -151 -89.3% RED 169 18 -151 -89.3% RED

If non-financial trigger of remedial plan, include descriptor of current position here: 2. Cause of variance from plan (Rationale for current delivery) Issues identified as causing variance from plan

1 Data analysis has shown that the biggest area of increase in spend from 12-13 to 13-14 is attributed to Vascular Surgery and Gastroenterology. Further work has been done investigating Vascular Surgery activity and follow-up with Trust is underway

2 We have had a discussion with a member of the CCG who has identified waiting list and availability of the leg ulcer community clinic issues


Detailed analysis done has identified significant differences in what is measured in the network plan (30 specialties and OPFA activity only) and in the QIPP scheme (10 specialties & OPFA and FU activity). The specialities reporting an increase in cost in the QIPP scheme are also reporting an increase in the network plan. Network plan in its entirety is reporting a reduction in expenditure (9 specialities reporting an increase and 21 specialties showing reduction). However, the reductions are seen mostly in the low volume specialties (including a number of paediatric specialties) which we have assumed to be a result of changes in Specialised Commissioning. We have maintained our forecast to deliver £0 savings in m12

Planned care: GP Peer review

26

Peer review (10 top OP specialties) finance and activity trends

£0

£2

£4

£6

£8

£10

£12

£14

£16

£18

£20

M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12

QIP

P P

lan

Vs

Act

ual

(£

00

0)


Net Target


1200

1400

1600

1800

2000

2200

2400

1 2 2 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

12-13 Actuals (baseline) 13-14 Plan Net of QIPP

Ou

tpat

ien

t A

tten

dan

ces

(Fir

st &

Fo

llow

-up

)

10 top acute OP activity trend (excluding those with community services): actual and forecast

12-13 Actual


13-14 Actual

Forecast

Contents












• Dermatology

• Gynaecology

• MSK






Appendices

27

28

Ref Scheme Title Delivery Delivery Rationale Outcome Outcome Rationale Unscheduled Care Schemes HFCCG01d Excess Bed Days Reduction

(contractual lever) Green The impact of reduction in LOS and XS bed days will result in

increased activity for our Community Independence service and our core Community services such as District Nursing

Green Over delivering to-date and forecast to exceed the planned level of savings

Other Scheme HFCCG02 Children Services (Maternity Serv

Improvement) Green Non-recurrent funding agreement has been terminated and

contract agreed with the provider Green The required reduction of £688k

has been agreed in contract with the provider

Mental Health HFCCG10 Current MH proposals- WLMHT (3

work streams: efficiency, IP to Community, Community to Primary Care)

Green Contract negotiations have concluded with WLMHT and review of provider CIP and QIPP has taken place

Green Contract negotiations have delivered the required QIPP of £788k

HFCCG10 Current MH proposals- NHS Specialists & Independent Sector providers (out of area placements)

Green There is a continual process of gatekeeper the referrals made out of area and reviewing out of area placements and step down to less intensive care. This approach is adopted through a mutli-disciplinary panel

Green Monthly monitoring is through review of out of area placement budgets

HFCCG10 CNWL MH Trust SLA (efficiency) Green Contract negotiations have completed with CNWL Green Contract negotiations have delivered efficiencies savings of £100k as planned

Community Services HFCCG11 CLCH Contract (including 2012/13

efficiency) Green Contract negotiations have completed with CLCH Green Contract negotiations have

delivered the required QIPP of £1,500k

Prescribing HFCCG13 Prescribing opportunities Green Savings will be delivered through drugs switching, reduce medicine

related harm, primary care rebates, reduce medicine wastage. Medicine management team will visit each practice and Eclipse and ePAC will inform a view of the best few opportunities for each individual practice

Green Current performance is based on variance reported in the financial ledger of £44k overspend by year end

Confidence for programmes without remedial plans remains high- done

Contents












• Dermatology

• Gynaecology

• MSK






Appendices

29

30

Ref Title Description of Issue L I R Actions Required

1 Acute contract over-performance

Acute budgets report over performance year to date. Need to understand the reasons at provider

3 2 6 CSU to provide performance reports on timely basis and CCG to raise any concerns with the Customer Accounts Director and Lead CCG Commissioner Need regular updates on provider issues (e.g.: waiting times by specialty, capacity issues)

2 Year 3 Network Plan Failure to deliver the requirements of the Year 3 Network plan will have direct impact on the achievement of QIPP savings (planned and unscheduled)

3 4 12 All practices have signed up to the Network plan. Practice performance review is done on a monthly basis via the GP Portal and Q4 performance will be reviewed in Q1 of 14-15

3 Small contracts management

Need effective contract management and to deal with operational and contractual issues quickly

3 4 12 CCG has not received the level of support for management of contracts this year due to staff changes in CSU. CCG still requires on-going contract management of small contracts this year and in 14-15

4 Inability to change referral behaviour in required timeframe

Referral behaviour of some practices may not change when new services or pathways are put in place. (Note: It is high risk on a number of programmes but its overall potential impact on QIPP is low)

3 2 6 Awareness of Community services available is raised through network meetings and communication with practices. We are also bringing in specialists where relevant to raise awareness including involvement of consultants

5 Prescribing expenditure Difference in forecast expenditure in financial ledger (indicated over spend) and ePACT (indicated under spend)

3 2 6 QIPP forecast has been revised this month in-line with revised ledger forecast of £44k overspend. This is different to £54k underspend forecasted in the Jan-14 ePACT report. Given the lag in ePACT reporting, we have reported QIPP based on ledger position

6 Care Plans SystmOne rollout has affected the level of care planning activity, which may have affected our NEL admissions

3 3 9 Care planning was affected during Q2 following SystmOne migration and availability of a SystmOne care planning template. This has been resolved and care planning should increase in Q4 given on-going work that practices are doing to meet QOF requirements. Compared to Q2 there was 10% (700 care plans) increase in care plan activity in Q3

7 Specialised Commissioning Uncertainty around coding and charging of Specialised commissioning activity

4 2 8 On-going monitoring of this situation

Note: the risks identified and assessed above are related to the delivery of overall QIPP programme of £10.5m

Overall programme risks at this stage in the year are mainly yellow or amber

Appendix 1: Data Sources

31

Ref Title POD Provider(s) Data Source HFCCG01a Care Planning and Co-ordination NEL Imperial & ChelWest

predominantly BIU (SUS)

HFCCG01d Excess Bed Days Reduction XS BD Imperial & ChelWest predominantly

BIU (SUS)

HFCCG03 Musculoskeletal Services OPFA/OPFU Imperial & ChelWest predominantly

BIU (SUS)

HFCCG04 Respiratory Adult OPFA/OPFU Imperial & ChelWest predominantly

BIU (SUS)

HFCCG05 Diabetic Medicine OPFA/OPFU Imperial & ChelWest predominantly

BIU (SUS)

HFCCG06 Dermatology OPFA/OPFU Imperial & ChelWest predominantly

BIU (SUS)

HFCCG07 Gynaecology OPFA/OPFU Imperial & ChelWest predominantly

BIU (SUS)

HFCCG08 Peer Review of GP Referrals OPFA/OPFU Imperial & ChelWest predominantly

BIU (SUS)


- Imperial Ledger

HFCCG10a Current MH Proposals- WLMHT - WLMHT Ledger


- NHS Specialist & Independent Sector providers

Ledger

HFCCG10c Current MH Proposals- CNWL - CNWL Ledger

HFCCG11 Community Services (CLCH Contract) - CLCH Ledger

HFCCG13 Prescribing - - Ledger HFCCG14 Acute Contracts - Imperial & ChelWest

predominantly Ledger

32

Appendix 2: Activity Re-provision Impact

Ref Title POD Provider(s) Activity Reduction Activity Reprovision

Description Data Source Description Data Source 13/14 Impact

HFCCG01a Care Planning and Co-ordination

NEL Imperial & ChelWest predominantly

Improved case management and care co-ordination will reduce NEL activity for patients identified as high / non-high risk. Better utilisation of admission avoidance schemes and better management of non-complex patients with Ambulatory Care Sensitive conditions should avoid NEL admission. Strengthen MH care planning and improved adherence for patients with LT conditions and MH co-morbidities will improve outcomes and avoid preventable hospital admissions

BIU (SUS) Admission avoidance schemes will result in activity reductions in acute settings and we anticipate an increase in Community services contacts particularly Community Nursing

BIU (from CLCH) 394

HFCCG01d Excess Bed Days Reduction XS BD Imperial & ChelWest predominantly

Reduction in NEL activity will impact on associated XS bed days. Assume care planning and the engagement of Community Independence team will deliver LOS reduction resulting in XS BDs

BIU (SUS) The impact of reductions in LOS and XS Bed days will result in increased activity for our Community Independence Service and our core Community Services such as District Nursing

BIU 420

HFCCG03 Musculoskeletal Services OPFA/OPFU Imperial & ChelWest predominantly

Reduction in Acute activity with increase in referrals to Community service

BIU (SUS) No of attendances in Community service BIU (Community activity)

28

HFCCG04 Respiratory Adult OPFA/OPFU Imperial & ChelWest predominantly



114

HFCCG05 Diabetic Medicine OPFA/OPFU Imperial & ChelWest predominantly



0

HFCCG06 Dermatology OPFA/OPFU Imperial & ChelWest predominantly



861

HFCCG07 Gynaecology OPFA/OPFU Imperial & ChelWest predominantly



561

HFCCG08 Peer Review of GP Referrals

OPFA/OPFU Imperial & ChelWest predominantly

Seek significant reductions In avoidable referrals to acute setting (i.e. refer patient to the right place) by peer review of GP referrals

BIU (SUS) No of attendances in Community service (as those deemed appropriate for primary care will have £0 impact)

BIU (Community activity)

30


- Imperial Expenditure reduction- contractual agreement Ledger N/A N/A -

HFCCG10a Current MH Proposals- WLMHT

- WLMHT Expenditure reduction- contractual agreement Ledger N/A N/A -


- NHS Specialist & Independent Sector

providers

Expenditure reduction- contractual agreement Ledger N/A N/A -

HFCCG10c Current MH Proposals- CNWL

- CNWL Expenditure reduction- contractual agreement Ledger N/A N/A -

HFCCG11 Community Services (CLCH Contract)

- CLCH Expenditure reduction- contractual agreement Ledger N/A N/A -

HFCCG13 Prescribing - - Expenditure reduction Ledger N/A N/A -

HFCCG14 Acute Contracts - Imperial & ChelWest predominantly

Contractual agreement Ledger N/A N/A -

Documents

NHS Hammersmith & Fulham CCG QIPP Performance Report M12 ... · Unique Ref Project Name POD Gross Plan Gross Actual Gross Variance Gross Variance (%) Gross Plan Gross Actual Gross