The Financial Plan 2013/14 was re balanced in July to reflect agreed contract values, expected QIPP savings and known over performance.

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1 Number: 5 NHS VALE OF YORK CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING Meeting Date: 3 October 2013 Report Sponsor: Kevin Howells Interim Chief Finance Officer Report Author: Andrew Wilson Interim Deputy Chief Finance Officer Title of Paper: Mid - Year Financial Review 1. Strategic Objectives supported by this paper 1. Improve healthcare outcomes No 2. Reduce health inequalities No 3. Improve the quality and safety of commissioned services No 4. Improve efficiency No 5. Achieve financial balance Yes 2. Executive Summary The Financial Plan 2013/14 was re balanced in July to reflect agreed contract values, expected QIPP savings and known over performance. The CCG now has five months expenditure and unvalidated activity data available to it, therefore it is now appropriate to review the financial position 2013/14 A fundamental review of all contracts, reserves and expenditure and activity trends has been undertaken. Financial balance is achievable by the year end, including 0.57% recurrent surplus. However it cannot be over stressed that there remain considerable risks and challenges in the local health economy and that no flexibility remains within the existing budgets. 1

2 3. Evidence Base 4. Risks relating to proposals in this paper 5. Summary of any finance / resource implications 6. Any statutory / regulatory / legal / NHS Constitution implications Failure to achieve financial balance at the year-end will breach the CCG s statutory requirement 7. Equality Impact Assessment 8. Any related work with stakeholders or communications plan 2

3 9. Recommendations Members are asked to; - Note the contents of this report. - Note that the CCG is still awaiting validated activity data. - Note the challenging financial position of the CCG. - Note that financial balance can still be achieved, but that significant risks and challenges exist. - Ensure that staff resources are focused on management of the major identified risks most notably; a) Management of York Teaching Hospital NHS FT contract b) Delivery of QIPP savings c) Management of Continuing Care - Ensure that management resources be focused on the delivery of a balanced financial position. 10. Assurance 3

4 Governing Body Meeting: 3 October, 2013 Report Title: Mid - Year Financial Review 1. Introduction 1.1 The Financial Plan 2013/14 was re balanced in July to reflect agreed contract values, expected QIPP savings and known over performance at that date. 1.2 The CCG now has five months expenditure and unvalidated activity data available to it, therefore it is now appropriate to review the financial position 2013/14 and consider if a balanced financial position can still be delivered by the year end. 2. Plan Re basing 2.1 The financial plan originally adopted by the CCG was based upon forecast contract values for 2013/14 derived from actual expenditure to month 8, 2012/13: Once the 2013/14 contracting round was completed, actual contract values were substituted into the financial plan to assess plan robustness and whether financial balance was still achievable. The opportunity was also taken to review achievement of the QIPP target and known over / under performance on contracts at that time. 2.2 The exercise identified that the plan was no longer in balance: Actual contract values exceeded plans by 7m, only 5.7m of QIPP savings were expected against a target of 10.7m and the York Teaching Hospital NHS Foundation Trust (York Acute FT) contract was forecast to over trade by 1m. 2.3 The financial plan was re based through a combination of measures restoring financial balance and delivering a 0.57% recurrent surplus: This revised plan was discussed and agreed with both the Governing Body and Area Team. 2.4 The rebased plan acknowledged however that delivery of financial balance by the year end would be dependent upon retaining financial control, particularly in regard to the risk areas of York Acute FT, Continuing Health Care and Prescribing. 1

5 3. Mid - Year Financial Review 3.1 Introduction The month 4 Finance Report indicated that financial pressures over and above those identified during re - basing of the plan were emerging. Therefore a fundamental review of year to date contract performance, expenditure and reserves has been undertaken to determine whether financial balance can still be delivered at the year end. 3.2 Commitments against Flexibility to Month In re basing the financial plan a degree of flexibility ( 3.1m) was retained. However, the month 4 Finance Report indicated that whilst a small surplus was still forecast for the year end, the flexibility in the re based plan was now fully committed on the following pressures; - York Acute FT Over trade 1m - Other Acute Contract pressures 1.5m - NHS m - Mental health 0.2m The Month 4 Executive Summary to the Finance report also identified areas of potential concern in regard to Prescribing ( 588k overspent year to date) and Continuing Care (1,450k under spent year to date). The cause of these variances was not fully understood at the time of reporting requiring further investigation. The forecast outturn was therefore left at breakeven till the cause of the variances was better understood. 3.3 Commitments identified in Month 5 review A fundamental review of all contracts, reserves and expenditure and activity trends has been undertaken at month 5, including further investigation of the year to date variances on Prescribing and Continuing Care. As a consequence of this review, the CCG still believes that financial balance is achievable by the year end, including 0.57% recurrent surplus The commentary below considers the key expenditure and risk arising from the review and risks remaining in the local health economy which will pose a significant challenge to delivery of financial balance. 2

6 York Acute FT following review of trends and contract challenges it is now forecast that the contract will over perform by 3.2m against the original contract value of 166m. 2m of this relates to the non-delivery of QIPP, the remainder representing the net balance of over performance at the Foundation Trust after including contract challenges ( 2.2m) and penalties. Additionally, a significant increase above plan in both Out Patient activity and referrals has been noted from the Service Level Activity Management (SLAM) data, whilst there are concerns regarding delivery of the First : Follow Up Outpatient ratio embodied in the York Acute FT QIPP. Without the flex / freeze data it is not possible to determine the cause of this increase or its implications in regard to the forecast outturn. Other Acute These contracts are expected to broadly breakeven / underspend. Mental Health Services This budget area is expected to underperform by 2.28m, the significant variances being the Leeds and York Partnership contract and Specialist Mental Health services budget ( 1.44m and 0.85m forecast underspend respectively). The forecast outturn on Leeds and York Partnership FT includes the non-recurrent impact of a 1.16m Business Transfer Agreement which reduces expenditure in 2013/14 and contributes to the delivery of financial balance. Specialist Mental Health services activity to date is below plan and is forecast to remain so for the remainder of the year, however there are issues regarding the basis on which the forecast has been constructed and this is considered further within Risks, Section 4. Continuing Care The month 4 finance report indicated that the Continuing Care budget was under spent which was unexpected given previous years financial performance allied to a growing population of clients requiring such services. Following an in depth review it has now been confirmed that this budget is indeed under spending and at the yearend is forecast to be 1.2m underspent. The under spend is accounted for by a re-attribution of patients between the York and North Yorkshire CCG s combined with setting the 2013/14 budget on forecast expenditure from the previous year which did not reflect this change. NHS 111 this service is expected to overspend by 401k and given the nature of the contract, no mitigation factors exist to facilitate management to break even. 3

7 Prescribing The prescribing budget is forecast to overspend by 1.27m principally due to cost pressures from centrally funded drugs. Following investigation, it has been discovered that the CCG was being charged for drug costs where responsibility had transferred with Public Health to the Local Authority. Arrangements are now in place to re charge the Local Authority, which has reduced the previously recorded overspend. The 2013/14 Practice level budget is challenging as it includes the requirement for a 0.95m QIPP target to be delivered. This target is back loaded and therefore the forecast overspend of 1.27m will only be achieved if the QIPP target is delivered and current level of spend maintained. QIPP the review identified that progress against the QIPP targets has slipped further with only 5.2m of savings now expected against an initial target of 10.7m: During re basing of the plan, slippage against the QIPP target was expected however, this is continuing to increase. The savings of 5.2m are attributed to the following schemes; 4. Risks - First to follow up Out Patients - Prescribing - Lucentis See appendix 1 The review indicates that financial balance remains achievable by the year end however there remains significant risk the system. York Acute FT Considerable risk remains around delivery of the forecast outturn: The CCG has still not received from the Commissioning Support Unit (CSU) month 4 freeze data or month 5 flex data. Given that the trust is already recording a substantially higher level of income than the CCG has built into its forecast, it is difficult at this stage without the flex / freeze data to attribute a high degree of confidence to the CCG s forecast outturn. It is imperative therefore that flex / freeze data starts to flow on a regular and timely basis and that the data is analysed internally by the CCG to identify areas of contract challenge, trends requiring intervention, etc. Only with this data and subsequent analysis can the CCG hope to successfully manage this contract. 4

8 Other Acute Contracts the comments relating to the availability of flex / freeze data and identification / management of adverse trends referred to for York Acute apply equally to Other Acute Contracts. Mental Health Services This budget represents non contracted Out of Area specialist mental health services commissioned by the Partnerships Commissioning Unit (PCU). The current forecast outturn is based upon expenditure recorded in the ledger. An exercise is underway to validate the position recorded in the ledger against data held by PCU. Continuing Care this budget represents an area of significant risk to the CCG due to the high cost of care packages: A relatively small increase in the number of patients requiring high cost care packages could cause the forecast outturn to vary significantly. In 2012/13 a provision of 12m was created within the final accounts for Retrospective Payments across York and North Yorkshire: The provision was created to provide funding for instances where the Client or their family, successfully claims against the NHS that the cost of their care should have been funded by the NHS. It will be necessary to ensure all activity attributable to this provision is resolved and expenditure charged to this provision before the year end. Prescribing - The 2013/14 practice level prescribing budget is challenging as it includes the requirement to deliver a 0.945m QIPP saving. This target is back loaded towards the end of the year and therefore, the current forecast outturn is based on the assumption that the required QIPP saving will be delivered. It will not be possible to confirm that this is the case till later in the financial year. QIPP Delivery of the financial position in this review is also dependent upon delivery of a further 1.5m of QIPP savings; the need to deliver this target was set out in the Plan re basing exercise undertaken earlier in the year. Given that a review of QIPP schemes indicates that delivery has now slipped even further to 5.2m, delivery of a further 1.5m of savings by March 2014 looks challenging. Yet, without delivery, the CCG will fail to breakeven. To breakeven and deliver the required surplus of 1% QIPP savings of 3m are required plus. Specialised Commissioning Specialised Services are advising that Specialist Cancer Nurse activity is being wrongly charged to specialised commissioning and should be re charged to CCG s, and that funding for Bone Anchored Hearing Aids needs transferring from CCG s. The financial consequences have yet to be evaluated, but could add additional cost to the CCG and reduce available resources, impacting negatively on the forecast outturn. 5

9 GP IT Systems - on dis-aggregation of PCT budgets in readiness for the new NHS structures, funding for maintaining GP IT systems was transferred to NHS England, however, the contract for providing such services has remained with CCG s, with the expectation that funding to match expenditure would eventually be transferred from NHS England to CCG s. The Area Team are co-ordinating the analysis of the required resource transfers and are indicating that a resource transfer will be actioned shortly and which will be resource neutral. GP IT Depreciation The CCG s financial Plan 2013/14 includes 0.8M budget in regard to the depreciation charge on GP IT systems. The need to continue to hold this reserve has been discussed with the Area Team and further information is awaited, however initial indications are that this reserve is required for this purpose. 5. Conclusion and Recommendations 5.1 Conclusion Since re basing the 2013/14 financial plan, significant financial pressures have emerged within the local health economy, however it is still considered that financial balance, including a 0.57% recurrent surplus can be delivered after consideration of all known pressures. This however is a best case scenario. It cannot be over stressed however, that there remain considerable risks and challenges in the local health economy and that no flexibility remains within the existing budgets: Details of these risks and challenges have been considered at length in section 4 above. Key to managing the financial position to the year end is access to Flex / Freeze data, timely analysis and mitigation strategies which are agreed with provider trusts to manage activity within affordable limits. The continuing role of QIPP must also not be forgotten. Since the Confirm and Challenge exercise undertaken in July, the predicted savings have slipped further. Should the Prescribing QIPP fail to deliver the required savings and additional schemes to save 1.5m in the current financial year not be realised, then a balanced financial position will not be achieved. 5.2 Recommendations Members are asked to; 1. Note the contents of this report. 6

10 2. Note that the CCG is still awaiting validated activity data. 3. Note the challenging financial position of the CCG. 4. Note that financial balance can still be achieved, but that significant risks and challenges exist. 5. Ensure that staff resources are focused on management of the major identified risks most notably; a) Management of York Teaching Hospital NHS FT contract. b) Delivery of QIPP savings. c) Management of Continuing Care 6. Ensure that management resources be focused on the delivery of a balanced financial position. 7

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