Financial Recovery Plan

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1 Airedale Wharfedale and Craven Clinical Commissioning Group Financial Recovery Plan 2015/16 onwards Neil Smurthwaite 11/17/2015 0

2 Contents - 1. Executive Summary 2 Page 2. Financial Background and Context 4 3. Savings plan Financial trajectories and scenarios Management and Governance of recovery Summary 30 Appendices 1. Health and Social Care Financial Analysis 2. Financial Controlled Environment 3. Detailed QIPP plan 4. Risk 1

3 1. Executive Summary Airedale Wharfedale and Craven CCG is a small CCG covering a population of circa. 156,000 with an overall allocation of 200m to fund the commissioning of health care provision. The CCG was formed in 2013 from the amalgamation of smaller elements of 2 historical PCTs, Bradford and Airedale and North Yorkshire PCT. The total fund received incorporates an allocation of 3.5m to support the running costs of the CCG. Within the running costs it is recognised that the CCGs management and staffing structure is small and was originally created to be heavily reliant of the resources from the Commissioning Support Units that were created at the same time. The CCG has a diverse population within its geographical boundaries that has a spectrum of complexity including inner city deprivation and areas of remoteness, plus the added complication of two local authorities within its locality. At the end of 14/15 the CCG was selected as a national Pioneer site by NHSE to develop New Models of Care for its population following on from Simon Stevens Five Year Forward View vision. The CCG has developed a Complex Care Model the aim of which is to be implemented at the latter stages of the financial year if not before. A significant impact on the CCGs financial position was the introduction of the Better Care Fund in April 2015 to promote greater integration between Health and Social Care. Over the last 2 years the CCG has relied upon non recurrent reserves to achieve its financial targets which have resulted in reducing the CCGs overall run rate that is monitored by NHS England (NHSE). As part of the financial planning exercise at the end of financial year 14/15, the CCG recognised that 15/16 would continue to be highly challenging and resulted in the CCG submitting a plan to deliver a cash releasing target of 3.9m, in order to achieve financial balance. This value increased at the end of the financial year of 14/15 following the impact of further identified cost pressures to a final target of 4.4m. It was identified that an in-year recovery plan was required following the reported risk-adjusted forecast position at month 4. The CCG recognised within its monthly reporting cycle a high level of risk at not meeting the required NHS England business rules of achieving a 1% surplus. The CCG has since this date continued to work hard to reduce the level of risk within system, and has at October reduced its overall unmitigated risk adjusted position to 0.77m. It is it also striving to ensure that the surplus of 1% is achieved in line with its overarching business rules. This document has been produced to summarise the CCGs financial recovery actions that will underpin the processes to support both the in-year recovery plan for financial year 2015/16 and the medium term recovery plan from financial year 16/17 to 18/19 in line with the overall long term direction for the CCG as a whole. Below demonstrated in table 1 summarises the current reported financial position of the CCG (October) and the level of unmitigated risk it has identified for the remainder of 15/16, this position has been based on a medium case scenario and if realised reduces the surplus to an achievement of only 0.60%. 2

4 Table 1 - Reported Financial Position as at Month 7 Financial Year 15/16 Financial Year 15/16- Month 7 Forecast Year End Position- m Risk Forecast Position - m Total Allocation Expected Costs Level of Risk Surplus Position % Achievement 1% 0.6% As a result of these unmitigated risks the CCG understands the full implications of failing to improve both its in-year position and aims to achieve all the business rules set including achievement of the 1% surplus as well as a continuation to improve its overall long term sustainability. The CCG is fully committed to taking all possible actions to deliver the planned reported position. Through the Pioneer programme the Executive, Council of Members and Governing Body is fully committed to the Five Year Forward view and delivering new models of care for its population but recognise the challenge in achieving this with such financial constraints. As a result of this the CCG has committed within 15/16 that it must embed and develop the following to ensure financial sustainability moving into future financial years - Create a culture in the organisation and wider health system of tighter financial understanding and accountability; Ensure that systems and governance will support and direct this; Improve the CCGs overall run rate; Re Prioritise the transformational and QIPP schemes that will reduce costs, whilst improving patient care. 3

5 2. Background and Financial Context 2.1 Overview Since its formation in 2013 the CCG has faced growing financial pressures, but has been successful in achieving its financial targets and meeting all its financial planning requirements, with minimal QIPP plans in place. It was during the financial year of 14/15 that the CCG started to experience unprecedented growth in the majority of its commissioning areas in comparison to its overall contracted growth as part of 14/15 planning/contracting rounds; the financial impact of this growth was mainly felt within the areas of In-year Growth 14/15 to 15/16 Secondary Care services 3% Medicine Management 4.5% Continuing Health Care 3% During 14/15 its underlying recurrent position deteriorated with the year-end surplus achievement being significantly supported by the use of non-recurrent budgets. During this period, the CCG prudently restricted new investments funded from non-recurrent budgets stipulating that bids could only approved after month 6 to allow assessment of the financial position before investing. As part of the 15/16 planning and contracting rounds the providers expectations on funding were high with an anticipated additional requirement of between 1% to 2% on contracts in addition to the in year growth that had been incorporated within the overall contract quantum (most contracts based on FOT at month 10. This high funding of growth this was in comparison to the overall growth of 1.9% (net impact after Systems resilience money was only 1.4% uplift on general funds) received during the 15/16 national allocation. Whilst in 14/15 these financial risks were mitigated, the ongoing recurrent risk impact of this level of growth seen was built in the 15/16 financial plans submitted to NHSE and as a result in the last reiteration a cash releasing saving of over 3.9m to achieve financial balance. This value later increased to a final QIPP target when budgets were set of 4.4m Below in Fig 1 demonstrates the utilisation of how the CCG committed the uplift and income received leaving the final gap of funds identified. 4

6 Figure 1 15/16 Growth Allocations AWC CCG Utilisation of Growth 2015/ Acute Community Better Care Fund Continuing Care Medicine Management Enhanced Services/GPwSI Urgent Care Reserves Mental Health Voluntary Sector Other Non-Recurrent Projects BCF Allocation Growth (1.4%) Gap 5

7 As part of the overall planning round for FY 15/16 the CCG identified a number of risks within the health care system that had not been built into the overarching plan, these related to Financial Year 15/16 Risk Schedule Planning Round Risks Value Probability Revised Probability Value Narrative Acute SLA 1.3m 100% 1.3m Growth funded at 1%, 3% experienced in 14/15 Mental Health Pressures 0.2m 70% 0.14m Increase pressures in out of area placements Continuing Care 0.25m 30% 0.75m On-going increase in costs primarily in Craven QIPP Under delivery 3.71m 50% 1.85m Potential slippage of QIPP schemes Prescribing 0.7m 50% 0.35m funded budget at 3% - national expectation to grow 4-5% Overall Risk 6.16m 60% 3.72m It was also identified with the plan that the CCG had non-recurrent mitigations of 3.5m to offset these pressures; however as part of the planning round this flagged an overall recurrent risk for the CCG. From April 2015, in addition to the levels of demand having to be funded from non-recurrent resource and contingencies, the system introduced the new funding requirement relating to the Better Care Fund (BCF). This created new pressures within the health economy with the need for CCGs to meet national levels of investment in order to support Social Care and promote integration within both areas. Whilst the CCG rebadged a number of existing schemes and services there has still been a requirement and expectation to maintain/protect social services from 2015 onwards; this additional level of investment will need to be considered as to whether it is sustainable as part of the CCG s long term strategy. However the financial constraints on social care and the pressures on local authority finances and the impact these areas can have on health services are recognised by the CCG. As part of both in-year and long-term planning, the CCG has projected funding and expenditure streams for the next 3 financial years. The basis of this scenario is assuming achievement of its surplus position for 15/16 and is shown in table 2. The risk and implications around failure to achieve this position are discussed as part of this plan. 6

8 To achieve the in-year recovery position the CCG clearly understands that robust decisions need to be made on what areas are targeted to make big ticket savings to support its long-term sustainability. It is imperative the any savings plans that are put in place address the need not only to improve the health needs of its population but delivers efficiency savings. It should be noted at this stage the financial plan is based on a number of assumptions and this plan will be refreshed in line with the spending review released in December 2015, within the plan it incorporates the following assumptions Full achievement of the 2m surplus in 15/16 to carry forward into 16/17; The CCG will achieve its 1% surplus in 16/17 and onwards; Identifies an additional 3.3m saving in 16/17 to achieve its business rules moving into 17/18; 2.5m QIPP built into overall expenditure plan relating to 15/16 schemes (full details within QIPP section); 1m savings from New Models of Care for 16/17 & 17/18 plateauing in 18/19; Investment of 0.9m for 3 years in relation to the invest to save programme of New Models of Care; Uplift of 1.4%; Tariff deflator in place. Table 2 CCG 3 Year Draft Financial Plan Financial Years 16/17 17/18 18/19 Total Allocation 202, , ,110 Expenditure Contingency 1,003 1,017 1,030 Non Recurrent 2,006 2,033 2,033 Surplus 2,006 2,033 2,033 Running Costs 3,354 3,354 3,354 Programme Costs 197, , ,961 Total Cost 205, , ,412 Shortfall - 3, ,698 7

9 The formulated plan demonstrates ongoing financial risks moving into 16/17, with a continuation to achieve cash releasing QIPP target of 3.3m. To support this target the CCG has developed a full 2 year QIPP plan and this is discussed at length with the QIPP section. The CCG is aware of risks around these assumptions based on the projections, and have pulled together a worst case scenario projection and how they will be managed which is discussed within the long term strategy section. It should be noted based on these projections that the CCG will start to improve its financial position from 17/18, returning a surplus position and improving its overall run rate by removing the reliance on non recurrent resources to fund pressures in the system. The table below outlines the projection of the CCG in line with the current run rate to improve its use of non recurrent funds to support recurrent expenditure in line with financial plan put in place. Table 3 - CCG Projected Run Rate 8

10 As a CCG and wider health economy QIPP is high on the agenda with all sectors experiencing financial challenge and to support an overall shared understanding of the risks in the system. As such the CCG s plans have been shared with our main provider and meetings have been timetabled to discuss contracts for 16/17 and address the risks to both organisations. These discussions will include floor/ceiling contracts; risk share agreements and the building of QIPP in overall contracts to mitigate as much risk to the health economy as possible. To note, in-year QIPP achievement to date has realised a saving of 1.0m relating to over forecasting of 14/15 costs, reducing the target required to 3.4m. As previously highlighted the CCG has a small internal staffing structure and is reliant on services being provided from Commissioning Support Units, the impact of the CSUs failure to deliver commissioned services and its impending closure has impacted the CCG significantly. Until this situation is resolved the CCG must recognise that as well as having limited financial resources, the current staffing resource should also be deemed as a limited resource when its makes decisions on which services to commission/transform and what QIPP plans it can realistically undertake. As a result of this the CCG has developed a Decision Tree that supports senior staff to enable to make structured decision and to focus on priorities that take into account both these limited resources. It is key that any decisions that CCG makes around schemes or projects that a full realistic cost benefit analysis of the project is carried out to understand the return of investment of the project and when it will break even if investments are required. The CCG should not only in this period of financial recovery undertake schemes that will generate the greatest savings, but evaluate any investments robustly. Figure 2 CCG Decision Tree Yes Evidence of Impact Yes Assess through limited factor analysis Yes Is the a Net saving? No Do not Proceed IDEA! Does it improve or maintain health outcomes No Yes Do not Proceed Develop Clincial Policy NO Case for clinical policy No Do not Proceed 9

11 Low < 0.2m Level of Savings Realised Medium > 0.2m High > 0.5m Figure 3 Limited Factor Matrix HIGH PRIORITY HIGH PRIORITY MEDIUM PRIORITY High level of savings can be realised with low costs of resource IMMEDIATE High level of savings can be realised with medium costs of resource <1 YEAR Level of resource required means that implementation will occur over a longer period. 2+ YEARS HIGH PRIORITY MEDIUM PRIORITY LOW PRIORITY Medium level of savings can be realised with low costs of resource <1 YEAR Level of savings need analysing against cost of resource to ensure benefit is realised. 1-2 YEARS Level of savings need analysing against cost of resource to ensure benefit is realised. 2+ YEARS LOW PRIORITY DO NOT PURSUE DO NOT PURSUE Low level of savings mean benefit is unlikely to be significant Cost of resource potentially outweighs the benefit Cost of resource outweighs the benefit 1-2 YEARS Low Medium High Level of Resource Required 10

12 2.2 Current Financial Year 15/ Projected Year End Forecast Within the NHSE planning rounds the CCG identified that they would achieve their overall surplus position of 2.018m, and are on target to do so, however recognise that there were potential unmitigated risk in the system of 0.2m based on a medium case projection, these risks were highlighted to both the Executive Board and Governing Body as part of the internal sign off of the 15/16 financial plan. As the year has continued a number of these risks have been realised and the CCG has seen increased growth in a number of areas including Acute, Prescribing and Continuing Health Care spend, plus the added impact of non delivery of expected QIPP targets. Table 4 below demonstrates how areas of spend have deviated from the original plan submitted to NHSE, as at October the CCG has managed these risks internally by the utilisation of non recurrent funds, slippage in contracts and services and by a non recurrent benefit of 14/15 costs. Table 4 Financial Plan vs Current Forecast Spend at October /16 Plan vs Month 7 Forecast Area 15/16 Plan Month 7 Forecast Movement Commentary Resource Limit 201, , Additional Allocations in Year Acute services 116, ,294 2,860 Increased activity across all acute providers compared to plan Mental Health services 15,916 15, Community Health Services 13,677 13, Continuing Care services 10,231 10, In Year growth in CHC Primary Care services 29,274 29, In year growth in Prescribing ( 464k) Other Programme services 9,551 7,818-1,733 BCF Reapportioned over other areas Total - Commissioning services 195, ,958 1,875 Running costs 3,354 3, CHP costs in plan not being charged to CCG in 15/16 Contingency 1, ,008 Used to fund over spends in other areas therefore no foreast in mth 7 Total Application of Funds 199, , Additional Allocations in Year Surplus/(Deficit) 2,018 2,

13 As part of the continued monitoring of risk in the system the CCG has recognised a level of unmitigated risk in the system of 0.77m as at October, it should be noted this is a significant improvement of its position from month 4 where the unmitigated risks totalled 1.6m. The expectation is that this position will improve by the end of the financial year, and the graph demonstrates the movement of unmitigated risk over the year to present. Figure 4 CCG Unmitigated Risk Movement Within month 7 financial reports the CCG recognised a number of financial mitigations within the financial position based on agreement at board around readmission funds and the release of the BCF Performance Fund, this has improved the overall unmitigated risk and to this improved position, the current projected risks and mitigation are included within appendix 4. Table 5 provides a comparable of risks identified as part of the planning cycle to the reported position at month 7. As previously mentioned a number of cost pressures predicted in number of commissioning areas including Acute spend have been realised and included in the overall financial position to date, table 2 of this document shows how the CCG has moved from original plan by area of commissioning spend. The CCG has to date offset these pressures with the non recurrent budgets held. 12

14 Table 5 - Planned Unmitigated Risk vs Current Projected Risk Risk Summary m m m Plan month 7 Movement Acute SLAs Mental Health SLAs Continuing Care SLAs QIPP Under-Delivery Prescribing Running Costs Total Mitigation Unmitigated As the report advises the main risks are around the Acute Sector and a potential overtrade position of a further 0.9m, in addition to the forecast overtrade recognised within the CCGs overall financial position. The main area of risk relates to an estimated Stroke costs and additional pressures in acute spend due to winter pressures. The forecasts the CCG have provided take into account seasonal variation and past trends of spend by each contract however the CCG has seen a significant pressures in expenditure within the Independent Sector and the CCG as part of the contract process is working closely with providers to bring activity back in line with expected plan. Prudently the CCG has recognised these ongoing risks into the reported NHSE position but will reduce as it moves through the financial year and forecasting can be more accurate. Another pressure area for the CCG is the recognised non achievement of the QIPP target, the CCG has recognised within the financial position that QIPP will not be achieved in its entirety, but will need to achieve 1.3m in the event the others areas of risk materialise, which will increase the risk of non achievement of business rules. Therefore the CCGs first priority action is to secure and maintain recurrent financial balance as soon as possible in order that it can stabilise its in year financial position, in year and moving forward in the future. It is vital that the identified QIPP schemes (full details are outlined in section 3) are assessed in line with the CCGs prioritisation matrix to achieve the greatest clinical and financial outcomes. 13

15 As part of the in-year Recovery Plan the following areas have been targeted to address its in-year financial position Readdress the focus of the CCG to ensure that projects are put through a standardised process, which improves the systems in place within the CCG. Ensuring that the focus of the CCGs efforts makes the most impact on spending patterns with the CCG Ensure that all contractual levers are in place and properly applied Identify new areas of savings within the CCG which will support longer term sustainability of the organisation moving forward in line with the CCG impact assessment Commission services for patients that are of only clinical value Ensure the success of the New Models of Care Pilot. The CCG currently has identified a number of QIPP schemes and these are reviewed in section3 of this plan however it is aware that in order to improve its in year position it will require a real focus on Big Ticket programmes. The CCG has reviewed that the following schemes will deliver the best savings in the current financial year In Year Priority QIPP Schemes Areas of Clinical Appropriateness The CCG is currently reviewing a number of areas that have been deemed as being of limited clinical effectiveness for patients and is in the process of developing a policy around a number of clinical areas that whilst may be clinically necessary for some patients, but have no benefit to others. The identified cost of the areas alone in 14/15 cost the CCG 5.9m, the projected cost for 15/16 based on month 4 activities is approx. 6.0m; this cost assumption is based on the general elective costs alone. Upon review of these areas the following costs associated to these areas are forecast below (based on 14/15 activity levels) - First Appointment m Follow up m (based on 1 follow up only) Diagnostics m (based on 30% of 14/15 activity requiring diagnostic support). In total if all activity was stopped this would result in a full year saving impact of 7.007m. The CCG realise that all of this activity cannot be stopped due to clinical need however has identified that should the activity be reduced, the following savings could be achieved. 14

16 Millions Millions Figure 5 Potential Forecast Savings Based on % reduction Project Savings Full Year 10% 20% 30% 50% 70% 100% Reduction in activity as a % Projected Savings from November onwards % 20% 30% 50% 70% 100% Reduction in activity as a % Based on these projected numbers if the CCG reduced activity from November on an average rate of 20%-30% this could release savings between 0.5 to 0.8m Pain management/neurosurgery The CCG currently spent in 14/ m on the provision of all services and activity relating to the treatment of pain management. Based on month 4 activity data the estimated forecast position is expected to reach over 1.3m, this is an overall increase of 38% from last year s activity. The main areas of increased activity appear to be around facet injections and increases of activity in neurosurgery and spinal surgery. The majority of treatment for this condition is under taken in the independent sector and current patients receiving (based on current activity) a 1:3 ratio on first to follow up activity. It should be noted that there are some caveats in these assumptions and require finalising. However the CCG are part of this service review is focusing on the following areas 15

17 Clinical criteria review on how patients access the service Reduction in follow ups of Drugs costs Whilst some savings can be expected to be realised relatively early upon review of this scheme, the full impact is not expected until later in the project life of the scheme and may take 1-2 years to fully implement fully. However, the CCG work will be working with providers to reflect the work undertaken as part of the contracting rounds for 16/17, where greater recurrent savings will be seen. Figure 6 Trajectories of savings for Pain Management 16

18 3. Savings Plan 3.1 Overview The CCG recognised at the start of the year the financial challenge it faced and as part of the overall plan submitted to NHSE recognised a cash releasing QIPP plan of 3.7m, with an investment of 0.903m in New Models of Care to enable the CCG to recognise these savings, however after the plan was submitted a number of cost pressures materialised and increased the overall cash target to the final 4.4m reported with the CCG accounts. Below summarises the original QIPP plan submitted and how it moved to the final reported target - 15/16 Original QIPP Plan QIPP Gross Target 3.71 Prescribing 0.30 Acute Contracts 0.35 New Models of Care 2.20 Enhanced Primary Care 0.61 Continuing Care 0.25 Revised QIPP Target 4.40 Movement from Target 0.69 Post plan Movements YAS Contract 0.40 Out of Area Mental Health 0.09 Impact of Tariff Changes 0.20 Total

19 As part of this revised QIPP target the CCG recognised that the development of a robust and comprehensive savings plan had not been a priority during the first two years of operation and following a number of sessions that included both members of the executive board and the senior management team, ideas were generated; discussed and agreed. Table 6 below gives a brief summary of the schemes agreed as part of the original QIPP work undertaken within the planning rounds and QIPP sessions with board members. The plan looks at the next two financial years as the CCG is aware its long term aim is to work towards developing an Accountable Care Organisation (a full summary can be found in appendix 3 of the supporting documentation). Table 6 QIPP Summary Pain Management Work Stream Description Ref Two main areas targeted - Number of procedures undertaken - including no of injections and follow up per patient 15/16 net Savings 16/17 Savings Opoids Reduce overall spend on Opoid prescribing Rheumotology risk share with trust to reduce overall cost basis Inflixab risk share with trust to reduce overall cost basis Mental Health Service - clincial appropriateness review of clinical appropriateness of referrals of patients to New Models of Care introduction of complex care pilot within the CCG utilising KPPI prescribing Scheme targeting 10 indicators within primary care to support better prescribing within primary Care Prescribing Waste Scheme Review of presribing waste within the CCG Aire Unit Review of Aire Unit - issues around service provision and potential double counting of activity Community Rehab Stroke Part of Neuro Review and stroke MSK/T&O - Patient decision aids Review of service provision - Nationally agreed patient decision units for patients and clinicians to work through. Allows patients to under the consequence of decision around treatment Catheter Mgt within Community Currently 8 patients per week admitted via day case without trial catheter. Quality and charge issues Wheelchairs and therapies High growth area. Service review and potential cap of spend in year Diabetes part of diabeties review - benefits to be seen 16/17 onwards TOPS Scheme to provide terminations within private provider setting Continuing Health Care Establishment of Staff Bank and block arrangements for CHC within Craven Area Tissue Viability Joint formulary for primary and secondary central procurement Minor Injuries Unit Provision of unit to stop patients using A&E, 111 and Ambulance Service Consultant of the Day The value of the service for the CCG in terms of admission versus use of number to contact consultant ED Streaming - Manchester pathway Streaming of patients via the LCD/OOH route Quality improvement in Care Homes Provision of care home pilot in Ilkley - potential to roll out around locality Better Care Fund Initiatives Monitoring of Craven BCF schemes. 1. Craven Care Home QI scheme Procedures of limited clincial Effectiveness Review of services to review the clinical appropriateness Prescribing of Limited Clinical Value Review of Bury model around prescribing of paracetamol, Ibuprofen etc TOTAL QIPP SCHEMES

20 As part of the process of development of these schemes it was agreed the following principles should be adhered to - All schemes would have a clinical and managerial lead to support its development All Schemes would be financially quantified and rag rated in respect to priority All schemes will be monitored and reported via the CCG governance structure to ensure financial accountability at board level. Whilst all the schemes identified fully supported the CCGs commissioning decisions as an organisation it was later recognised that in some cases the agreed schemes had failed to have a full cost benefit evaluation undertaken. Therefore to mitigate this weakness the CCG has recently recruited a project accountant whose role is to work with service and project leads to work in developing robust financial assumptions. The CCG overall has agreed the prioritisation of the schemes to be delivered, the categories are outlined below - In year scheme Mid-short term Long Term transformational schemes In light of the CCGs in year position two of schemes (ref 1 and 23 in Table 3) have been identified low resource and high impact as a return on investment. These big ticket areas will free up resources to enable long term transformation schemes to be developed in the mid to long term period, schemes such as the New of Model of Care, which will incorporate Complex Care and Enhanced Primary Care. It is recognised that further work is required to develop the QIPP schemes to fully quantify the ROI they will deliver, the reality is that some schemes may be discounted or brought forward into 15/16 as they will release more savings and benefits to patients. The QIPP targets for 15/16 are mostly expected to be realised in 16/17 contracting round and as mentioned previously these savings have been built into the planning assumptions for the next 3 years, the schemes relating to 16/17 are expected to deliver the additional 3.3m identified in for the forthcoming year as a minimum, to return the CCG back into a recurrent position. 3.2 Invest to Save As part of the Better Care Fund the CCG has had the opportunity to invest in specific areas of commissioning spend to harmonise services across the district. Within these ring fenced funds the CCG has both developed and enhanced services within Craven patch that have previously been under resourced due to financial pressures within the old North Yorkshire PCT. The work undertaken by commissioning staff highlighted disparages in service provision in comparison to services provided and received by our Airedale and Wharfedale population. 19

21 The CCG has used its experience of previous Bradford & Airedale PCT investments in these under resourced areas that have in the past shown better outcomes to patients but have delivered a real return in investment on areas such as non elective activity. These current investments are currently being monitored and evaluated. However CCG understands the recognition that investments of this nature can take time to mature to realise both financial and efficiency savings and these considerations should be factored into the evaluation in the process. But also they need to be strong commissioners and make the decisions to decommission services that are not delivering the outcomes that are required. Moving forward the CCG is addressing its long term sustainability and is developing radical new services that are expected to deliver only small cash releasing savings in 15/16, which is much less than expected due to delayed start, but are expected to really start to generate savings and better patient outcomes from 16/17 onwards. As previously mentioned the CCG is a Pioneer site and is targeting its mid to long term strategy on the introduction of a new type of care for its population in doing so the CCG has invested 0.9m of its previous overachievement of surplus to carry out this work. This pilot is discussed in detail as part of the CCGs overall Long-Term strategy. 20

22 4. Financial Risk and Long Term Planning 4.1 Financial Risk The culture of the CCG and that of an organisation is to be transparent around all the decisions it makes and issues it may face; this includes being fully open around the financial challenges experienced in 15/16, and ensuring all identified risks are identified; quantified; discussed; challenged and then reported. As an organisation the CCG recognises the NHS landscape is changing and some previous resources are no longer available, within our own local commissioning area we have a number of providers who are all fighting for growth in the same services in order to maintain their own financial stability. The reality is that the CCG no longer has the ability to fund the levels of growth that these providers are striving for. As part of the review of the current makeup of activity being generated by the CCG, it can clearly be seen that while activity is growing, a shift can be seen with the cost of the case-mix in services moving to a more complex/high costing tariff basis which is adding additional costs within the system. As a CCG we are monitoring how this trend is occurring within non-elective areas; this trend can also been seen within other acute specialties, the impact of PBR on the system appears to be causing additional pressures within CCGs and the impact of the new HRG4 is currently being quantified as the impact of this change may have major implications to the CCGs financial position if the allocation does not follow. It should also be noted that factors such as national targets including maintaining 18 week and 4 hr A&E targets really impact the CCGs ability to plan and forecast activity correctly and should not be underestimated by the NHSE. During the 15/16 contract round, the CCG funded growth where it was financially able to, to allow its patients to be seen within these national targets, however what is often not reflected in allocations received is the level of in-year growth that is experienced, which adds to CCGs financial constraints moving forward. The growth allocation utilisation shown in fig 1 clearly demonstrates this shortfall. The CCG understands as part of the its long term strategy that moving to new payment structures, delivery of services and having accountable care organisations working together in an integrated state is the only way the CCG can survive, and the overall plan in table has been developed to take into account what investments and savings it needs to put in place over the forthcoming years to make this vision a reality. 21

23 /16 in year financial risk The CCG has reported centrally in July at 1.6m unmitigated risk position. The CCG as part of its monthly reporting cycle reviews all areas of spend and reviews potential risks to its position based on past trends and horizon scanning. In order that the CCG can fully monitor risks in the system a best, medium and worst case scenario against its reported position is produced monthly. These risks as previously discussed are challenged in line with CCGs governance structure and how they are being mitigated. Appendix 4 of this plan outlines the current risk adjusted position that is being reported to the boards and NHSE /17 onwards As shown in table2 of this recovery plan the CCG has projected its 3 year financial position from 16/17 based on a medium case plan, as advised previously it assumes the following The CCG will achieve a minimum 1.8m QIPP cash releasing targets within all areas but primarily secondary care Allocation of growth will be at 1.4% in line with previous allocations Assumed a national deflator of -1% Assumes reduction in YAS contract of 0.5m due to in year under trade position against 15/16 block Growth areas of 1% in main spend areas, 2% in CHC and 3% in Medicine Management Assumes that contingency, non recurrent and surplus at current business rules No recurrent adjustment for ETO tariff funding Status quo of financial Social Care expectations around BCF. With all plans there are real risks in these assumptions it does not address that growth is high, allocations are not yet confirmed at this level and the tariffs are still in discussion. To address this the CCG has developed a number of what if? scenarios to take account of changes in these assumptions. The below outlines the financial position in the event the following risks materialise - Allocation at 1% Recurrent growth at 2% Acute from 17/18 (16/17 included in forecast outturn) Cost neutral inflator/deflator Non achievement of surplus and impact over 3 years 22

24 Table 7 - Scenario 1 risk adjusted forecast assuming 15/16 surplus achieved Risk Adjusted Position Original Position Variance Financial Years Financial Years Financial Years 16/17 17/18 18/19 16/17 17/18 18/19 16/17 17/18 18/19 Total Allocation 201, , ,738 Total Allocation 202, , ,110 Total Allocation 761 3,547 4,372 Expenditure Expenditure Expenditure Contingency 999 1,009 1,019 Contingency 1,003 1,017 1,030 Contingency Non Recurrent 1,999 2,018 2,018 Non Recurrent 2,006 2,033 2,033 Non Recurrent Surplus 1,999 2,018 2,018 Surplus 2,006 2,033 2,033 Surplus Running Costs 3,354 3,354 3,354 Running Costs 3,354 3,354 3,354 Running Costs Programme Costs 200, , ,436 Programme Costs 197, , ,961 Programme Costs - 2,874-5,793-8,476 Total Cost 208, , ,845 Total Cost 205, , ,412 Total Cost - 2,855-5,755-8,433 Shortfall - 6,918-9,124-11,107 Shortfall - 3, ,698 Shortfall 3,616 9,301 12, Table 8 - Scenario 2 risk adjusted forecast assumes non achievement of 15/16 surplus Risk Adjusted Position Original Position Variance Financial Years Financial Years Financial Years 16/17 17/18 18/19 16/17 17/18 18/19 16/17 17/18 18/19 Total Allocation 199, , ,738 Total Allocation 202, , ,110 Total Allocation 2,779 3,547 4,372 Expenditure Expenditure Expenditure Contingency 999 1,009 1,019 Contingency 1,003 1,017 1,030 Contingency Non Recurrent 1,999 2,018 2,018 Non Recurrent 2,006 2,033 2,033 Non Recurrent Surplus 1,999 2,018 2,018 Surplus 2,006 2,033 2,033 Surplus Running Costs 3,354 3,354 3,354 Running Costs 3,354 3,354 3,354 Running Costs Programme Costs 200, , ,436 Programme Costs 197, , ,961 Programme Costs - 2,874-5,793-8,476 Total Cost 208, , ,845 Total Cost 205, , ,412 Total Cost - 2,855-5,755-8,433 Shortfall - 8,936-9,124-11,107 Shortfall - 3, ,698 Shortfall 5,634 9,301 12,

25 These calculations show the fragility of the financial position of the CCG and how slight deviations to assumptions can impact the financial position. It should be considered that these forecasts are based on a worst case scenario and does not reflect all the long-term plans of the organisation on the 17ongoing QIPP target that will be incorporated into 16/17 contracts and what is expected to be achieved in 16/17. The CCG must identify that there is potential that a small number of these worst case assumptions that may occur which would increase the expected QIPP target from 3.3m to be nearer the worst case position of 8.9m. At this point decisions will have to be made in respect to achieving financial balance, these include Investments stopped Reduction in social care protection Increased QIPP target Acknowledgment that the Business Rules will not be achieved in 16/17 to create stability into future years. 4.2 Long Term Strategy As a CGG and its wider health economy are considerably aware of the escalating costs and growth in system, the CCG has been aware of these pressure areas building for some time and understand action needs to prevent the above scenarios occurring and to mitigate as much risk as possible. The CCG, as demonstrated in appendix 1 of the supporting documentation, is achieving strong clinical results in a wide number of areas, however recognises there are improvements to be made in others. As part of its long-term vision, the CCG is to create an integrated, accountable, and commissioning and care delivery system to realise our shared vision where healthy people live as independently and safely as possible and those who need support are able to access the health and social care and support they need in a timely way. As part of this approach the individual will be at the centre of their care, with a flexible, technology-enabled, workforce integrated around them, encouraging and supporting them to take responsibility for their own health and wellbeing, helping them improve their longer term health ambition and ultimately change their care utilisation. In order to achieve this the CCG and its local partners aim to; Supporting individuals to be active participants by implementing our ambitious self-care and illness prevention plan Placing the individual at the centre with all of their care (triple integration) truly integrated around their individual needs Developing sustainable, system-wide clinical and social care models for urgent and planned care services with more care provided at home/closer to home Coming together into an integrated, accountable, commissioning and care delivery system Creating an integrated digital care record across health and social care enabling patient access so they become more empowered with shared consent to access individual knowledge across the system and inform population and community health planning Investing in the local economy through strengthening local relationships and creating opportunities for the local economy by working with the University of Bradford, SMEs, BT, TPP etc. 24

26 As part of the vision the CCG have been working internally and with partners as part of the pioneer programme to develop its version of New Models of Care in line with the five year forward view to its population. The projects developed targeting the following areas these being a Complex Care Model; Enhanced Primary Care; Self Care and the long term vision of creating an Accountable Care organisation which will be an integrated provider of most services that will allow patients to have a seam-less level of care, the financial plan developed and outlined here are in line with the overall strategic direction of the organisation. The first stage of this road map of delivery is introducing a Complex Care system which stems from the work the CCG under took with Oliver Wyman. This work identified that a small number of patients generated the most cost in the system. The CCG as part of the evaluation of this project has carried out comprehensive modelling around this cohort of patients this service will capture and the where the areas of service costs are derived. Below in table 9 it demonstrates the areas identified in the overall of spend of the CCG which will be affected by this new proof of concept, it also estimates the investments projected breakeven point against its initial return on investment. Table 9 Complex Care Evaluation and Breakeven point 25

27 As advised previously the potential for savings have been incorporated recognised from 16/17 onwards, below provides a more detailed outline of expected investment and return for the next 3 years New Models of Care Investment Year 1 Year 2 Year 3 Financial Year 15/16 16/17 17/18 18/19 Investment 0.9m 0.9m 0.9m 0.9m Return on Investment 0.0m 1.0m 1.0m 0.5m Assumptions ROI will not be realised until August 16 anticipated breakeven point and at a reduction of 40% activity Year 2 Enhanced Care will be introduced savings yet to be quantified The CCG has ring fenced investment for 16/17 onwards to support to transition to Accountable Care Organisation anticipated year 3 of plan onwards Cash releasing savings will be used to improve CCG position from 16/17 and will savings will be built with contract from 17/18 onwards Cash releasing target expected to plateau in 18/19 as reinvestment from Acute services to other areas of commissioning spend expected from this time Prudent ROI recognised in plan to ensure no lack of financial stability to local health economy in order to protect organisations moving to Accountable Care within CCG planned road map ROI only forecasts current activity driven contracts, work underway to develop savings in block contracts which are impacted by this work. 4.3 Long Term Vision As a CCG it has a very clear vision of the direction of travel in needs to make to ensure it has a sustainable and efficient health economy it has a clear road map of the direction of travel in needs to make to get to its long term goal of having an Accountable Care Organisation providing a seamless and quality focussed service for its population. As discussed previously the CCG is developing the complex care pilot which tackles a cohort of patients whom have been identified generate the most costs in the system, the next stages in its overall road map are - Develop an Enhanced Care Model tacking the next tier down of patients requiring additional care Work with providers in the interim to develop block contracts to create financial stability in the health economy Work in developing a weighted price per head of population looking at all costs in the system Work towards developing a Accountable Care Organisation (ACO) 26

28 The overall national direction in travel is developing these ACO systems. There are many types of these type care organisations emerging and CCG hopes to learn from models seen in the United States and Spain and other countries including Integrated Delivery Systems; Multi Group Speciality; Physician hospital organisation and Independent Practice Organisations. The challenge for the CCG will be create an ACO which suits our local population and current health infrastructure. The CCGs overall priority is to get to an ACO and has been working closely with not only NHSE colleagues but has visited sites in Spain who run this type of organisation successfully. 27

29 5. Management and governance arrangements The CCG has a good governance structure in place to deliver its core business and sees partnership working as key to deliver the key objectives across the health economy. The CCG has completed the financial control environment assessment (Appendix 2) and highlighted those areas to improve. These areas include the utilisation of information for forecasting/planning and improving capacity within our internal finance function to support transformation. Recognising there are always opportunities for improvements the CCG is reviewing its Governance structure to avoid duplication of effort for our small management functions, ensuring we remained focused on the priority areas. This review is due to for completion by December 2015 for implementation in January 2016 to ensure the appropriate timetabling of meeting and ensuring more efficient and effective of reporting to our Executive and Governing Body. The CCG has also seen a significant impact on its capacity to delivery transformation and QIPP as a result of the failing CSU. To recognise these challenges the CCG has created a number of posts to support our New Model of Care transformation programme. These include an embedded analyst and project accountant thus ensuring we have a dedicated resource to support our Design and Delivery teams outside of our existing core financial and performance teams. To further embed financial recovery and QIPP the CCG has asked the Senior Management Team (SMT) to act as the Programme Management Office (PMO) for QIPP and financial recovery. SMT meet weekly but will report progress on a fortnightly basis providing assurance to our monthly Finance and performance Group and our Executive team. This will enable robust monitoring and reporting of our plans, however the CCG recognise that the Executive Group have the accountability of the QIPP plan, Within our plans each QIPP scheme has a designated manager and executive clinical lead. This enables clear lines of responsibly for delivery of schemes and separation of monitoring functions. Clear accountability and joint ownership between clinicians and managers is vital to the delivery of financial recovery. Detailed in the table below are our internal and health assurance meetings. Below is a brief outline of roles. SMT Chaired by the Chief Operating Officer, with all Heads of Service and Chief Finance Officer in attendance. All updates and progress will be scrutinised and constructively challenged with clear actions noted. Escalation will be to the Executive Group. Finance Performance and Governance Group this is chaired by our Lay member for Governance with our exec finance lead, CFO and CCO in attendance. The FPGS role is to challenge our programme delivery and be assured of progress against plans. Executive Group chaired by our Clinical Accountable Officer, with the Chief Finance Officer, Chief Operating Officer and all clinical executives in attendance. Delivery and ownership of our overall strategy and QIPP plan is held by the group. In additional the group has responsibility for scoping new ideas and clinical leadership. The overall responsibility of the delivery of the financial recovery plan lays with the Accountable Officer, with the support of the Executive Team. 28

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