GOVERNING BODY. 2. To ensure the CCG financial position recovers to meet all statutory financial duties. X

Transcription

1 Enclosure: E Agenda item: 9 GOVERNING BODY Title of paper: QIPP Report Date of meeting: 27 th July 2016 Presented by: Regina Shakespeare Prepared by: Regina Shakespeare and Nick Varney Title: Turnaround Director Title: Turnaround Director And Director of PMO Corporate Objective addressed by this paper (please select one or more with an X): 1. To commission sustainable high quality services to meet the health needs of the population of Greenwich and reduce health inequalities. 2. To ensure the CCG financial position recovers to meet all statutory financial duties. X 3. To continue to ensure that the CCG is a clinically driven organisation. 4. To ensure diverse patient and public voices are fully considered. Purpose of the report: The attached monthly QIPP report has been presented to FRB and FPQ as appropriate. FPQ has been asked to assure itself as to the delivery and implementation of the QIPP Programme to support the CCG in delivering its financial position as agreed in the Operating Plan. Therefore this report is presented to this meeting for information and noting only. No decisions are required. Issues arising: 1. The QIPP Process and assured financial value has been externally assured by Deloitte, and had been subject to an 8% abatement to take account of the risk of delay; the FRB has accepted this. 2. The QIPP Programme is moving its main focus from developing QIPP schemes to managing their implementation and delivery 3. A Formal launch to staff of QIPP templates, guidance and processes took place on 7 th July 2016; this has been well attended and well received. Summary of actions, if any, following this meeting: None

2 Previous committee involvement: The Governing Body receives a QIPP report at each of it s meetings. Recommendations to the Greenwich CCG Governing Body To note the content of the report. (Please provide details below where Yes is indicated ) Impact on Governing Body Assurance Framework (x) Yes No X N/A Impact on Environment (x) Yes No X N/A Legal Implications (x) Yes No X N/A Resource and or financial implications (x) Yes X No N/A Equality impact assessment (x) Yes No X N/A Privacy impact assessment (x) Yes No X N/A Impact on current NHS Outcomes Framework areas (x) Yes No X N/A Patient and Public Involvement (x) Yes No X N/A Communications and Engagement (x) Yes No X N/A Impact on CCG Constitution (x) Yes No X N/A There are financial implications arising from the delivery of QIPP which impact upon the CCG s delivery and its statutory duty to balance and achieve its Operational Plan for 2016/17. Attachments: (i) QIPP Report for July 2016 (ii) Deloitte Financial Recovery and QIPP Plan External Review 2

3 QIPP Presentation for Governing Body Editor: Nick Varney July 2016 version 1.0

4 1. Executive Summary QIPP target for 2016/17 assured by Deloitte as 15.45m QIPP schemes totalling 11.9m (At the date of the Deloitte review) assured subject to a 1.03m adjustment for possible scheme delivery slippage. This has been adjusted for in all reports. QIPP plans and delivery assured by FPQ on 13 July 2016 PMO, QPDM and FRB are moving their QIPP focus from developing schemes to delivering schemes, and a suite of templated delivery documents and processes was launched to staff on 7 July This includes assuring QIPP scheme delivery seperately to the existing financial planning assurance ratings. This move is supported by the Deloitte recommendations. The current assured value of QIPP which was being presented to FRB on 17 July is 11.15m. (This report has been based upon that figure)

5 2. Financial Background The objectives of financial recovery are: recurrent balance by the end of 2016/17; additional savings of 2% of the resource limit in 2016/17 such that the savings plan is delivered in full in 2017/18; and a maximum planned deficit in 2016/17 of 2.1m. Greenwich CCG therefore needs to reduce its spend by 15.45m (4.3%) recurrently in 2016/17. The CCG s FRB has developed a QIPP plan, which has been externally assured by Deloitte, that identifies how the CCG will achieve this objective The Deloitte review assured the 15.45m QIPP target and reviewed the QIPP schemes already included in the plan totalling 11.9m (At 17 June) Deloitte stated that the assured programme is a strong programme of projects, with a high degree of planning and deliverability around them. They also concluded that they were all valid, but that there were risks to delivery timescales in 5 of the QIPP schemes. To cover this risk they assured the 11.9m subject to a reduction of 1.03m to cover slippage in 2106/17. This has been accepted by the CCG and adjusted in its figures. Highlights of their findings are included in Section 3 below

6 3.a Highlights of Deloitte Assurance - Value The assured programme is a strong programme of projects, with a high degree of planning and deliverability around them. Our review of the schemes in scope has identified a revised BRAG rating which is 1m less that the CCGs assured value of these schemes. Whilst the value of these schemes has been downgraded following our observations, this is predominantly due to the absence of supporting milestone information and project action lists, therefore making it difficult to assess whether the delivery is on track and whether the associated BRAG assigned is appropriate.

7 3.b Highlights of Deloitte Assurance - Governance The CCG has a meeting structure in place that currently provides assurance around the development of the QIPP programme and has a role in approving all projects. The CCG has purposely focussed on establishing a deliverable QIPP programme in time for delivery in 2016/17. As such, it is now prioritising the development of action and milestone plans for each project to facilitate ongoing monitoring. The meeting structure has not yet had a focus on providing assurance on the delivery of the QIPP programme and needs to ensure that challenge is applied throughout the governance process to hold appropriate parties to account and ensure the delivery of the QIPP programme.

8 4. How the CCG will achieve 15.45m QIPP FRB s programme, as adjusted for the Deloitte slippage, as at 15 July 2016, includes: 1. QIPP already delivered: 2.5m. This includes Public Health decommissioning, Patient Transport scheme to align spend to appropriate CCGs and the repayment of a capital loan to the CCG. 2. QIPP which has been secured in 2016/17 contracts: 2.9m. 3. CCG assured QIPP schemes: 5.75m This total of 11.15m requires the FRB to assure additional financial planning QIPP of 4.3m. FRB has two strategies to secure the further QIPP: 1. Increasing the assurance level of schemes in 3) above: there is scope to add 3m using this approach. 2. Assuring schemes in the development pipeline estimated value 9.25m

9 5. QIPP Financial Planning Assurance as at 15 July 2016 Pipeline 12.2m Identified as high level opportunity 4.3m 4.65m 5.75m Identified, assured and in implementation ( 5.5m Assured by Deloitte) 10.1m 2.9m Achieved in 16/17 contracts Gap 13.0m 2.5m Already delivered Development of opportunity into QIPP business case subject to assurance. Assurance controls: Named clinical lead Named project manager Contract due diligence Assured business case Implementation plan & milestones Tracking of delivery and benefits QIPP schemes secured in signed 2016/17 contracts with key providers Actions Note: Deloitte Assured figures shown in amber totalling 10.9m No further action required, the saving is already removed from budget line

10 6. QIPP: Financial Planning Assurance as at 15 July 2016 Scheme Title Type of Scheme Start Date 16/17 QIPP Initial Plan Finaicial Planning Assurance 16/17 QIPP (Assured) Scheme Title Non-Recurrent '000 Rating '000 '000 Rating '000 Patient Transport Transactional Apr Intermediate Care Beds - Seasonality QIPP Flexing Aug-16 1, Acute Hospital Productivity QIPP Apr Extension to current evidence based policy QIPP Aug Atlas House - (Phase 1) Decomm'g Apr Stroke Association Decomm'g Aug Children s services QIPP Apr Intermediate Care Beds, Utilisation, Demand and Capacity. Decomm'g Sep Jackwood House Decomm'g Apr Children's Therapies Reprocurement QIPP Sep Medicines Management (Over The Counter) QIPP Apr Consultant Connect QIPP Sep Staffing Interim to Permanent Transactional Apr Malnutrition Services QIPP Oct Public Meeting Adverts Transactional Apr The Source QIPP Oct Public Health Services Decommissioned Decomm'g May Falls Services QIPP Oct Staffing - Natural Wastage Transactional May Long Term Conditions - Demand Management - Paediatric Asthma QIPP Oct Return of Development Grant Long Term Conditions - Demand Transactional Jun (Non Recurrent) Management - COPD QIPP Oct Long Term Conditions - Demand Atlas House (Phase 2) Decomm'g Jun Management - Heart Failure, QIPP Oct Hypertension and Diabetes Care Home Blood Tests QIPP Jun MCCH Decommissioning Decomm'g Oct Review Care Packages & Controls - * One to One QIPP Jun Medicines Management (Community pharmacy medicines optimisation QIPP Oct * Out of Area * High Value scheme ) Medicines Management QIPP Jun GP Access Decomm'g Oct Pathology Services (stopped) QIPP Jun Termination of Pregnancy Service (TOPS) QIPP Oct Adherence to current Referral Management & Booking QIPP Jul evidence based policy Service (RMBS) Decomm'g Oct GP Long Term Conditions Contract (Non Recurrent) Decomm'g Jul Musculoskeletal services QIPP Dec Medicines Management (PbR Excluded drugs) QIPP Jul Dermatology Services QIPP Jan Contract Due Diligence Initial Target Transactional Jul Estates Voids (Stopped) Transactional N/A Type of Scheme Start Date 16/17 QIPP Initial Plan Finaicial Planning Assurance 16/17 QIPP (Assured) Total to Assure Still to Find QIPP Total

11 7. QIPP Delivery Assurance Having moved more fully into the implementation phase of the 2016/17 QIPP Programme the CCG has established a detailed project tracker which is updated weekly following meetings with project leads. The CCG has established a detailed project tracker which is updated weekly following meetings with project leads. This tracker manages the projects under three headings: Savings assumption, which identifies where the saving will come from. Progress update and next steps, which updates on delivery Risk mitigation, which identifies any imminent risks and actions required. The tracker is also BRAG rated in terms of delivery assurance on the following basis: It should be noted that the delivery assurance BRAG rating may differ from the financial planning assurance BRAG. In addition the CCG is also tracking (i) the activity impact of the QIPP schemes and (ii) expenditure against major contracts and cost codes to ensure that any potential cost pressures are noted and addressed early. In addition QPDM meetings are now formally holding project leads to account through rolling programme of project lead attendance.

12 8. Project Templates The Project templates which were launched to staff on 7 th July were: Project Plan Business Case Templates ( Main / Short / Decommissioning) Risk Register Reporting Template Guidance note on process These templates are version controlled and can be accessed by staff from a shared drive. It was explained that this was required to ensure consistent development and delivery of schemes, and to assure that delivery. It also allows for project continuity should staff change. This is again supported by regular meetings with the PMO to ensure that processes are being used correctly and project leads understand their importance.

13 Greenwich CCG Financial recovery and QIPP plan External review 13 th June 2016

14 Responsibility statement In accordance with our Engagement Letter dated 25 th May 2016 (the Contract ) to support Greenwich CCG in undertaking a review of the CCG s Financial Recovery Programme (FRP) and QIPP Programme, we enclose our report dated 13 th June 2016 (the Report ). This Report summarises our findings and observations with respect to the CCG s FRP and QIPP programme in line with the responsibilities set out within the Contract. The Report is confidential to the CCG and is subject to the restrictions on use specified in the Contract. No party, except the addressee, is entitled to rely on the Report for any purpose whatsoever and we accept no responsibility or liability to any party in respect of the contents of this Report. This report is prepared for the CCG as an organisation alone, and our responsibility is to the CCG only. The Report must not, save as expressly provided for in the Contract (including, inter alia, in clauses 5.3 and 5.4 of the Terms of Business) be recited or referred to in any document, or copied or made available (in whole or in part) to any other person. The CCG is responsible for determining whether the scope of our work is sufficient for its purposes and we make no representation regarding the sufficiency of these procedures for the CCG s purposes. If we were to perform additional procedures, other matters might come to our attention that would be reported to the CCG. We have assumed that the information provided to us and management's representations are complete, accurate and reliable; we have not independently audited, verified or confirmed their accuracy, completeness or reliability. In particular, no detailed testing regarding the accuracy of the financial information has been performed. The matters raised in this report are only those that came to our attention during the course of our work and are not necessarily a comprehensive statement of all the strengths or weaknesses that may exist or all improvements that might be made. Any recommendations for improvements should be assessed by the CCG for their full impact before they are implemented. 2

15 Contents Contents Page 1. Background and scope 4 2. Executive summary 6 3. QIPP Review Capacity and Capability Governance arrangements 25 Appendices 39 Appendix A: 2016/17 GCCG QIPP Programme 40 Appendix B: Business case summaries 42 3

16 Background and scope 4

17 Background and Approach Greenwich Clinical Commissioning Group (The CCG) are currently working towards developing and implementing their Financial Recovery Plan and QIPP Programme. As part of this, the CCG commissioned an external assurance review on whether the Financial Recovery Plan is credible, whether it addresses the key issues identified, whether it is doing what it can to achieve the NHS England mandated actions, and exploring further opportunities where this is not the case. This report details the work that Deloitte has undertaken in completing the review, which has focussed on the Financial Recovery Plan, the QIPP programme, capacity and capabilities within the CCG and the governance processes in place to ensure delivery. Our approach combined stakeholder interviews with a documentation review of key information provided by the CCG. Approach Discussions with key members of the CCG including Project Leads, PMO and Governance Team, Clinical Leads and Executive Officers. The interviews were used to ascertain the key issues pertinent to the scope of the review; Identification of control weaknesses and potential improvement opportunities in line with good practice; Review of CCG documentation, such as Project documentation, meeting papers and reports, Financial Recovery Plan and policy documents. Further to the identification of any issues relevant within the scope of the review, the documentation review was used to inform stakeholder interviews and validate any issues raised; and Preparation and agreement of a draft report with the key sponsor of the review. Scope Review the 15.45m QIPP plan. This included a desktop review of the QIPP documentation to review the credibility of QIPP schemes and considered how realistic the savings targets are based on our experience and the supporting evidence. Review of the actions taken to address capacity and capability gaps identified within the Finance Recovery Plan with a focus on contract management, project management and clinical commissioning. Review the governance arrangements in terms of the meetings and also reviewing the governance framework for the appropriate level of scrutiny, challenge, accountability, support and escalation. 5

18 Executive Summary 6

19 QIPP Summary The key findings and issues identified following the review are summarised below. QIPP QIPP Programme The QIPP target of 15.45m will be delivered through a combination of an assured programme totalling 11.9m, unassured programme totalling 3m and pipeline schemes of 9.1m. The CCG is working to strengthen the unassured schemes by undertaking a range of further actions, before incorporating and subsequently increasing the assured programme value. The assured programme is a strong programme of projects, with a high degree of planning and deliverability around them. The CCG has given each project within the assured programme a BRAG rating which subsequently informs the assured financial QIPP value. Our review identified that the assured value is optimistic for some schemes given the stage of development and implementation. Our review of the schemes in scope has identified a revised BRAG rating which is 1m less that the CCGs assured value of these schemes. Whilst the value of these schemes has been downgraded following our observations, this is predominantly due to the absence of supporting milestone information and project action lists, therefore making it difficult to assess whether the delivery is on track and whether the associated BRAG assigned is appropriate. Significant work is required on the pipeline schemes to deliver the QIPP target including prioritisation, project planning and local data analysis. 7

20 Capacity and Capability Summary The key findings and issues identified following the review are summarised below. Capacity and Capability Capacity and Capability From our interviews we identified that the CCG currently has some gaps in their capacity and capability which they have filled on a short term basis with external support and interim staff. Attain Consultancy have been used by the CCG to undertake a contract due diligence review which has identified savings for the CCG, and to support the delivery of the Financial Recovery Plan. In this role, the team have acted as Project Leads and have kept track of the pipeline projects. Senior roles around the delivery of QIPP are filled as Interim posts currently, including the Turnaround Director, PMO Director and Chief Finance Officer. The CCG is in the process of undertaking an organisational restructure to address the current gaps in capacity and capability on a more permanent basis which is due to be in place from September In the meantime, the CCG has adopted a temporary structure to fill the key gaps in capacity and capability to develop and deliver the Financial Recovery Plan. The CCG has made use of external and interim support to achieve this. 8

21 Executive Summary The key findings and issues identified following the review are summarised below. Review of Governance Arrangements Planning The CCG has a clear process in place for the maturity and approval of all projects, including obtaining clinical sign off prior to approval at Financial Recovery Board. The development of implementation plans is documented to be completed post approval at the governance meetings. This does not provide sufficient information for the members of those meetings for them to approve the projects. Implementation plans should be developed alongside the business cases prior to submission for approval. The CCG has purposely focussed on establishing a deliverable QIPP programme in time for delivery in 2016/17. As such, it is now prioritising the development of action and milestone plans for each project to facilitate ongoing monitoring. The business case template in use by the CCG covers the majority of aspects that are considered best practice when developing a project. However, it does not include a section to review interdependencies between both the QIPP projects and any projects or agreements with external organisations. Governance The CCG has a meeting structure in place that currently provides assurance around the development of the QIPP programme and has a role in approving all projects. The meeting structure has not yet had a focus on providing assurance on the delivery of the QIPP programme and needs to ensure that challenge is applied throughout the governance process to hold appropriate parties to account and ensure the delivery of the QIPP programme. The current outputs from the meetings provide the appropriate information for their audience. However, the CCG does not record the actions in the form of a log from the QIPP Planning, Delivery and Monitoring meeting. Whilst an action note is captured by the PMO Director, a more formal logging process, which is then circulated to attendees and project leads will support ongoing monitoring and ensure that they are completed as appropriate. 9

22 Executive Summary The key findings and issues identified following the review are summarised below. Review of Governance Arrangements Reporting The CCG has a standard report template in place for reporting on the programme to the Financial Recovery Board. This includes all aspects that best practice would expect to be reported on and to inform the Financial Recovery Board of any risks or issues. The CCG does not currently have anything in place to monitor the delivery of the finances and milestones of the QIPP Programme as a whole. However, the CCG has developed individual project packs to monitor each project s delivery separately. These are still to be completed for each project. The CCG has an escalation process in place with respect to the QIPP programme as a whole. However, there is no process in place for individual projects that are not delivering. QIPP Management Structure The CCG has recently developed its PMO and as such does not yet have a Standard Operating Procedure setting out processes, responsibilities, and the roles and responsibilities of its members. The PMO is currently operated by the PMO Director which is a temporary post. There is agreement for a PMO manager and Programme Officer Support as substantive posts. However, both roles are currently vacant. 10

23 QIPP Review

24 QIPP Summary The key findings and issues identified following the review are summarised below. QIPP QIPP Programme The QIPP target of 15.45m will be delivered through an assured programme of 11.9m and current pipeline schemes of 9.1m. The CCG is working to strengthen the pipeline schemes by undertaking a range of further actions, before incorporating and subsequently increasing the assured programme value. The assured programme is a strong set of projects, with a high degree of planning and deliverability around them. Significant work is required relating to the pipeline schemes to deliver the QIPP target. CCG Assured programme The assured programme is made up of a number of transactional, decommissioning and contractual schemes. The schemes and financial opportunity appears in line with QIPP programmes developed by other CCGs. The BRAG rating applied which subsequently informs the assured value is optimistic for some schemes given the stage of development and implementation. There is an absence of milestones and actions recorded at individual project level. This creates difficulty in monitoring whether key schemes are on track to deliver and at what point they should be escalated. Feedback from interviews has identified that there are not project plans or business cases for all schemes predominantly those that are transactional or contractual which have not yet been implemented. Pipeline schemes The pipeline list of projects is maintained separately to the list of assured schemes informing the current programme. Our interviews with CCG leads identified that there is a focus on ensuring that these projects are developed into full schemes. A number of the projects are informed by the CCG s Right Care data pack, with values often being directly transferred from the pack to outline indicative values. The CCG should identify which schemes may be realised in 2016/17 by rapidly assessing and prioritising which opportunities should be pursued further. and therefore should be developed as a matter of urgency. 12

25 QIPP Summary The CCG has an ambitious QIPP programme equating to 4% in 2016/17 The CCG has confirmed a QIPP requirement of 15.45m for 2016/17 to help deliver the financial position in line with national planning requirements. This ambitious programme represents 4% of the CCG s allocation. Whilst 4% is ambitious, this is against the backdrop of limited recurrent QIPP delivery in prior years, and a revised Financial Recovery Process which has been initiated prior to this financial year. Based on this, 4% should be an achievable target. The CCG has developed a number of schemes, including decommissioning, contractual and some service change to help deliver against this target. The CCG has grouped the schemes into a range of categories as follows: Full Value Approved CCG Assured Value CCG Unassured Value 14.9m 11.9m 3m Pipeline 9.1m The CCG s approved programme equates to a total value of 14.9m, which has subsequently been assured and risk adjusted by the CCG to 11.9m using a BRAG approach (blue, red, amber, green). As a result, the scheme value has been revised depending on the rating applied to each scheme (blue 100%, red 0%, amber 50% and green 80%). This is summarised further over pages The CCG is looking to mitigate any risks within the unassured programme of schemes, before revising the confidence levels and subsequently increasing the assured programme value. The CCG has identified opportunities to maximise the assured value as well as a range of pipeline schemes which are in the process of being developed before being incorporated into the live QIPP programme. Approved programme Assured schemes The CCG has broken the assured value into categories based on the type of scheme: 2.5m has been delivered at the start of through transactions or decommissioning; 2.9m has been agreed in Provider contracts; Remaining 6.5m is being delivered on an ongoing basis. Our observation of the documentation available identifies that the 2.5m and 2.9m is made up of 5 and 8 projects respectively. We have reviewed two schemes within the 2.9m group that are assured subject to provider contracts being signed (Atlas House phase 1 and 2). Pipeline & unassured Assured value ( 11.9m) 13

26 QIPP Assured programme findings and observations The assured programme consists of 39 schemes totalling 11.9m in value Assured programme: The assured programme of 14.9m has been risk adjusted to 11.9m by the CCG according to the BRAG rating applied, with the categories being as follows: Rating Description Number of projects Value % Proportion of assured value Blue Complete assurance of delivery.100 percent of the value included in the assured total m 75% Green Assured that the project will deliver but delivery is not yet confirmed. 80 percent of the value included in the assured total Amber The project will deliver some of the savings but more work is required to achieve this. 50 percent of the value included in the assured total. Red Little or no confidence in the delivery of the project at this stage of development. 0 percent of the value included in the assured total 5 1.9m 16% m 9% 4 0m 0 The 2.5m transactional and 2.9m contractual schemes have been rated as blue according to the CCG s assessment scale above. Our interviews with Executive leads have confirmed that budgets have been reflected to account for the transactional schemes ( 2.5m). Budgets will be reflected for the contractual schemes once contracts are formally signed ( 2.9m) although the schemes have been agreed with providers and documented in respective Heads of Terms. There are some schemes rated blue whereby 100% delivery has not yet been achieved or budgets have not yet been reflected for new service costs. However, the CCG has applied a blue rating following internal confidence over the deliverability of such schemes. Delivery profile The graph to the opposite outlines the delivery profile of the assured programme. A significant proportion of the schemes are planned for delivery over the course of the last 8 months of the financial year ( 9.8m, 83%). A back-ended profile such as this is recommended to ensure that projects have sufficient lead time into delivery. Review of project documentation has identified that the profile of savings is not included within the business cases. This should be identified at each project level and tracked as part of ongoing monitoring arrangements to help assess whether the individual schemes are on track to deliver full year efficiencies. 14

27 QIPP Assured programme findings and observations The assured programme is made up of strong projects with sound rationale, however there are risks to the programme which are not reflected in the CCG s BRAG ratings. Schemes reviewed We have only reviewed a sample of high value schemes where accompanying business cases were made available. These are summarised in the table below. Based on our high level review of project documentation available and 1:1 conversations with project leads, we have provided our BRAG assessment. This subsequent assessment has been used to estimate the potential savings using the BRAG methodology adopted by the CCG. We have provided one page summaries detailing our findings and observations in Appendix B. Project Clinical Priority Policy (beyond SEL TAP) Clinical Priority Policy (beyond SEL TAP) - extension GP Long Term Conditions Decommissioning Business Case Atlas House Phase 1 Atlas House Decommissioning Phase 2 CCG BRAG Rating CCG Assured View Programme Value ( 000s) Assured Value ( 000s) Deloitte BRAG Rating Adjusted Value ( 000s) Deloitte Assessed View Rationale Green 1, Green 800 The TAP policy is in place and CCG has undertaken analysis as to the level of expenditure that could be avoided / prevented in line with the policy. The total opportunity equates to 25% of the total expenditure within the analysis, which would appear to be reasonable. Delivery will be dependent on ensuring robust monitoring arrangements are in place for the activities / procedures subject to the policy. The extended opportunity is dependent on the CCG being able to introduce additional thresholds and procedures in line with practice Amber Red 0 across other CCGs. Our experience would suggest that such policy amendments may take time to implement, particularly with respect to clinical buy in and sign off. The CCG has agreed to decommission part of the Long Term Blue Blue 625 Conditions (LTC) enhanced service effective from July The CCG is in discussions as to remaining part of the enhanced service and is considering this as part of the pipeline programme of schemes. Blue Blue 613 The CCG has agreed to decommission 6.5 beds across the Atlas House Assess and Treat service. This has been agreed with the Blue Blue 227 provider and incorporated within the Terms of Agreement which are to be reflected in the contract which is due to be signed imminently. 15

28 QIPP Assured programme findings and observations The assured programme is made up of strong projects with sound rationale, however there are risks to the programme which are not reflected in the CCG s BRAG ratings. Project CCG BRAG Rating CCG Assured View Programme Value Assured Value 000 Deloitte BRAG Rating Adjusted Value 000 MSK Blue Green 426 Demand management - Adult LTC- Non-elective Respiratory and COPD Demand management - Long term conditions-diabetes, Heart Failure and Hypertension Demand Management - Paediatric Non-elective Respiratory Medicines Management Medicines Management - Medicines Optimisation Medicines Management - Deprescribing OTC Medicines Management - CMOS Medicines Management - PbR excluded drugs Green Amber 225 Blue 1,000 1,000 Green 800 Blue Amber 375 Green Green 240 Red Red 0 Deloitte Assessed View Rationale The scheme is dependent on a new prime contractor model being implemented in October Whilst the project is supported by a detailed plan, and appears to be on track for procurement in June, the service is not yet live and a blue rating would appear to be optimistic. The scheme is dependent on the Community Trust utilising capacity across specific LTC teams to support a reduction in non elective (NEL) admissions. The CCG has agreed a block contract with Lewisham and Greenwich NHS Trust for non-elective activity for the first 6 months of the year to help mitigate against a phased implementation of the scheme. However the new care pathway models are yet to be fully implemented and that further work is required around identifying the most appropriate cohort and subsequent activity monitoring arrangements. The scheme is in line with priority areas that are being monitored across a number of other CCGs, including wound care, repeat prescribing and respiratory drugs. However, given delays around prescribing cost information and that budgets have not been reduced, a blue rating is optimistic for this scheme at this stage. The scheme is in line with initiatives being explored across other CCGs. The CCG has identified a list of drugs whereby over the counter alternatives are available at no cost to the NHS. However, our experience of delivery across other CCGs would indicate that influencing GP behaviour can take considerable time and monitoring before being realised. The CCG is looking to incentivise community pharmacists to undertake medication reviews of inappropriate medication. Our observations indicate that the budget has not been reduced and success of the project would depend on the scale and timing of such optimisation being implemented. The CCG is in the process of confirming support from the CSU and data sharing information with providers to inform the implementation of this scheme in absence of supporting systems (e.g. Blueteq). Total 6,177 5,362 4,331 16

29 QIPP Assured programme findings and observations The assured programme is made up of strong projects with sound rationale, however there are risks to the programme which are not reflected in the CCG s BRAG ratings. Programme rationale Our review of the schemes as set out on the tables on pages have identified a revised BRAG assessed financial value for the schemes in scope. It is important to note that the revised assessment is based upon our review of the project documentation available and subsequent stakeholder interviews. Whilst the value of the potential efficiencies has been downgraded following our observations, this is predominantly due to the absence of milestone information and supporting action lists which subsequently make it difficult to assess whether the delivery is on track and whether the associated BRAG assigned is appropriate. Our review of the assured programme and specifically the 10 business cases has not identified any projects which do not appear to have a sufficient evidence base. Moreover, the ambition of the CCG and the schemes reviewed are in line with QIPP programmes being implemented by other CCGs, and the CCG has made considerable progress in ensuring that the schemes are sufficiently documented to support delivery from 1 st April Next steps Next step Area Ratings and risk adjusted position Phasing Project documentation Ongoing tracking and monitoring Next Step Action The CCG should consider the BRAG criteria and reflect only 100% delivered schemes and budgets transacted as blue rated initiatives. This will ensure that any delivery risk associated with other projects is identified earlier and mitigated as soon as possible. The CCG should profile the phasing of delivery at individual project level. This information should be captured by the PMO tracker which in turn should use this to detail the monthly delivery run rate at each scheme and programme level. Each business case should be accompanied by a detailed project plan setting out milestones, activities and interdependencies. This project level detail should be used to monitor delivery on an ongoing basis by the PMO. Feedback from our interviews has identified that the CCG is currently looking to develop dedicated project packs for each scheme in the assured programme and subsequently for future schemes documented in business cases. Opportunity to cease monitoring / more focussed escalation of high priority schemes i.e. Red and Amber to increase assured value in line with full value identified for the live programme. 17

30 QIPP Pipeline programme findings and observations Further work is required on the pipeline programme Pipeline Programme The CCG s pipeline list of schemes includes a total of 40 projects, with 23 of these having indicative values totalling 9.1m. A schedule is provided in Appendix A. Source of opportunity The opportunities with outline values have largely been compiled using analysis from the CCG s Right Care opportunity pack. There are a range of projects which have originated from other ideas within the CCG and are not directly attributable to the Right Care pack. There are plans in place to review these pipeline projects through the course of the year and develop them into full projects where appropriate. The outline schemes span a range of areas including elective, non elective and medicines management. However, other than the analysis from Right Care, there appears to be limited further supporting data available at this stage. Interviews with CCG leads has identified that this work is ongoing in the form of deep dives across high value areas. It is not clear as to when this work will be completed. Development of project documentation The pipeline list identifies that project and executive leads have been confirmed for the 23 schemes with indicative values. There are currently no clinical leads identified for all but two of the pipeline list of schemes. There is an absence of project documentation in the form of outline PIDs or draft business cases as the opportunities are being validated locally by each commissioning team in the first instance. As such, we have been unable to review or assess the risk and deliverability of the outline values proposed at this stage. Next step Area Prioritisation Next Step Action The CCG should rapidly prioritise which projects are to be taken forward into full schemes. Business cases should be developed as a matter of priority and schemes subject to the assurance arrangements so that relevant schemes can be monitored as part of ongoing implementation and delivery. Detailed validation Pipeline projects need to have more robust data and analysis informing the full scope of the opportunity. 18

31 Capacity and Capability

32 Capacity and Capability Summary The key findings and issues identified following the review are summarised below. Capacity and Capability Capacity and Capability From our interviews we identified that the CCG currently has some gaps in their capacity and capability which they have filled on a short term basis with external support and interim staff. Attain Consultancy have been used by the CCG to undertake a contract due diligence review which has identified efficiency opportunities for the CCG, and to support the delivery of the Financial Recovery Plan. Attain have also provided Project Lead support and capacity, as well maintaining the schedule of pipeline projects. Senior roles around the delivery of QIPP are filled as Interim posts currently, including the Turnaround Director, PMO Director and Chief Finance Officer. The CCG is in the process of undertaking an organisational restructure to address the current gaps in capacity and capability on a more permanent basis which is due to be in place from September In the meantime, the CCG has adopted a temporary structure to fill the key gaps in capacity and capability to develop and deliver the Financial Recovery Plan. The CCG has made use of external and interim support to achieve this. 20

33 Review of Capacity and Capability The CCG has commissioned external and interim support and proposed a new organisational structure in response to capacity and capability gaps Criteria Observation The CCG has taken steps to address previous capacity and capability issues identified in previous external reviews. Specifically, the CCG has commissioned external support to provide additional capacity in key areas of contracting and project management support. Furthermore, the CCG has identified interim support to provide additional commissioning capacity at Executive and Senior Management level. This additional external and interim support is alongside the organisation undertaking a wider organisational development programme focussed on design and implementation of a new structure and an internally led capacity and capability assessment. External Support The CCG has contracted Attain Consultancy to provide support and capacity within the CCG and the delivery of QIPP. Capacity and capability Attain s remit has included the undertaking of a contract due diligence review which has identified a number of contracts that may present opportunities for efficiencies through better contract management or reducing overlaps with other potential services. This contract due diligence review has been used to inform potential pipeline opportunities which are currently being scoped further before being incorporated within the assured QIPP programme. Whilst this contract management resource has been able to identify areas of opportunity, there remains ongoing capacity challenges to lead on the implementation of these opportunities until the organisation re-structure is completed. The CCG is addressing this through interim support (see overleaf). In their delivery role, Attain have deployed project managers to develop business cases and project plans for the projects on the assured QIPP list. In addition, they maintain the schedule of pipeline projects and potential schemes identified by CCG staff, before working with the PMO and QPDM to identify a plan as to how to approach the further development of these projects. Interviews with CCG leads have identified that the support provided has significantly strengthened project management capacity and addressed gaps in key areas. It is clear that the Attain team are supporting the CCG or some of the more significant QIPP schemes, including MSK and SEL TAP. With the support only commissioned up until July, there is a risk that there is insufficient capacity within the CCG to take on delivery of such schemes. 21

34 Review of Capacity and Capability The CCG has commissioned external and interim support and proposed a new organisational structure in response to capacity and capability gaps Criteria Observation Interim Support The CCG currently has a number of experienced individuals fulfilling key Interim roles, including the Turnaround and Interim Director of Commissioning role, the Chief Finance Officer role and the PMO Director role. Interviews with a CCG Clinical Lead has identified that this senior capacity across these domains has provided much necessary leadership to support the CCG in key areas, which has resulted in improvements in governance arrangements as well as greater transparency and buy in to the financial recovery and QIPP programme. Further to the interim support in place, the CCG is in the process of recruiting additional commissioning support in the form of an Interim Director of Commissioning, who will work alongside a full time Turnaround Director from July onwards. These are all areas in which the CCG has identified weaknesses and is a step in the process to strengthening this capacity and capability until the posts can be filled substantively as appropriate. Capacity and capability Organisational development and structure The CCG has commenced an organisational development programme focussed on implementing a fit for purpose structure, undertaking a cross department capacity and capability assessment, as well as a Make, Share or Buy review to assess areas where the CCG will look to operate services in house, share or co-provide with other stakeholders or commission externally from providers or the CSU. This programme of work has begun and is being led by the substantive Director of Integrated Governance. The CCG is in the process of finalising it s new organisational structure, and is due to go out to consultation by the end of June We have not reviewed the new structure as part of this review as it is not available until the consultation period has been initiated. Interviews with Executive leads has identified that the CCG has developed the structure on the back of findings compared to structures across high performing CCGs as well as identifying what is required internally as a result of the Make, Share or Buy assessment. The CCG is looking to mirror the structures observed across other CCGs where appropriate, whilst also considering what is required at a local level. 22

35 Review of Capacity and Capability The CCG has commissioned external and interim support and proposed a new organisational structure in response to capacity and capability gaps Criteria Observation The CCG started the Organisational Change Programme in May 2016 and has identified an implementation plan to roll out the new organisational structure. We have observed the implementation plan which sets out key dates and milestones, and interviews with Executive leads have confirmed that these are on track. The CCG will be going out to consultation from July, after which the new structure will be confirmed and available from 8 th August. The process to developing the new structure has involved a staff survey, one to one meetings and appraisals, as well as objective setting workshops which are due to take place with support from the CSU Learning and Development Team. Capacity and capability The progress of the restructure is reported to the Financial Recovery Board and as of May 2016, no slippage has been identified. The restructure does have some high level risks attached which themselves relate to capacity and capability. However, these have been mitigated through the use of both Interim and External support to ensure the delivery of the project. The CCG has verbally expressed confidence in the timely delivery of the organisational restructure as per its plan, although this is not currently reflected in the reports. In addition, a project manager and senior HR consultant will be appointed week commencing 6 th June 2016 to support the delivery of the organisational change plan. In order to bridge the gap until the new structure is put in place, the CCG has implemented a temporary structure. This has identified the key posts required to ensure the CCG is able to deliver its Financial Recovery Plan and business as usual including the posts of Turnaround Director, PMO Director, Associate Directors for Transformation, Delivery and Commissioning, Director of Commissioning and Joint Commissioning Manager. These roles have all been filled by interim resource. Make, Share or Buy The CCG has undertaken a review across key functions, including commissioning and contracting, PMO, finance, HR, IT and other support functions. The findings from this review are not yet finalised. Interviews with CCG leads has identified that the review forms a key pillar of the organisational development programme and subsequent new CCG structure. The approach adopted includes undertaking group assessments of key functions to identify improvement opportunities and consider potential models of delivery. Such an approach is in line with good practice. However, given the programme is currently in draft stage, there have been no confirmed decisions as to the future delivery models that may be deployed. 23

36 Review of Capacity and Capability Next Steps A number of actions are required to sustain the work undertaken to strengthen capacity and capability Next step Area Project management support New organisational structure Review of support functions Interim roles Next Step Action With the forthcoming end of the Attain contract, the CCG should urgently assess and identify project management capacity across key projects including knowledge transfer and handover arrangements. Continue to monitor the progress of the consultation exercise and the subsequent development and implementation of the new structure. Conclude the review currently underway and agree on future delivery models for key support functions including PMO, contracting, finance, HR and IT. Ensure that the new organisational structure incorporates a plan to fill current interim roles or equivalent roles on a substantive basis where required. 24

37 Governance Arrangements

38 Review of QIPP Governance Arrangements - Summary The key findings and issues identified following the review are summarised below. Review of QIPP Governance Arrangements The CCG has a number of key components of QIPP planning in place including: Comprehensive business case template; Clinical sign off; and BRAG and assurance ratings. The CCG has strengthened its governance arrangements with respect to QIPP and financial recovery planning with the establishment of the Financial Recovery Board and the QIPP Planning, Delivery and Monitoring meeting (QPDM). This structure provides key levels of scrutiny, escalation and oversight assurance between QPDM, FRB and the Finance, Performance and Quality Committee. The CCG has focussed on establishing deliverable schemes for the start of the financial year. Implementation plans are now being developed for each project. This is particularly key for transformational projects, and as such, implementation plans should be developed earlier in the business case process. Improvements could be made to the reporting at overall QIPP programme level to FRB and FPQ Committee to ensure sufficient oversight and focus on key actions to mitigate risks. Monitoring of project delivery and milestones is not yet taking place as focus is currently on business case approval the CCG needs to move quickly into delivery mode to ensure optimum delivery in