Introduction and summary p. 3. The sustainability challenge p. 5. How will we ensure sustainability? p. 6. Clinical service transformations p.

Transcription

1 25 Nov 2016

2 Introduction and summary p. 3 The sustainability challenge p. 5 How will we ensure sustainability? p. 6 Clinical service transformations p. 7 Collaborative productivity p. 10 Delivering savings in the next two years p. 11 2

3 The purpose of this document is to illustrate the approach used to model the financial and activity impact of the South East London Sustainability & Transformation Plan. This includes both the Clinical Service Transformation savings (originally created as part of the Our Healthier South East London strategy and updated more recently) and Collaborative Productivity savings (estimated subsequently). This document does not present a detailed breakdown of the investments that will be required to implement the strategic interventions. The required investments will necessarily depend on the options that are developed through the strategy options appraisal process, as well as the identification of robust supporting strategy baselines. This work remains ongoing. Many of the delivery plans for the interventions are still in the process of being developed in detail. This plan should be seen as one which will develop as plans are finalised. 3

4 The Sustainability and Transformation Plan process has brought organisations together to establish a place based leadership and decision making structure (that is, one which focuses on the population of SEL rather than the individual organisations). The aim of this is to collectively identify our priorities and to help ensure that health and care services are built around the needs of residents. This plan outlines our collective understanding of the challenges we face and sets out our approach and actions to address them. Alongside this, we have set out a strategic framework for financial sustainability that describes how the footprint can continue within its allocated funding, given significant demand and cost growth pressures. This is therefore not about closing a hospital, but about avoiding the need to build a new one, which we could not afford, by improving health and outcomes and delivering services which better meet people s needs. Our focus has been across the totality of NHS expenditure in South East London. As such we have considered: Opportunities to improve pathways through the Clinical Service Transformations (addressing 118m of the 0.9bn affordability challenge). Opportunities to improve back and middle office functions through improved collaboration between providers (addressing 225m of the challenge). Business as usual savings opportunities over and above these areas (addressing 262m of the challenge). In addition to the above, further work is ongoing to address the 202m of collective NHS England (Specialised Commissioning) and London Ambulance Service pressures. We have also taken account of the Sustainability and Transformation Funding available to South East London (worth 134m by 2020/21). 4

5 8,000m 7,500m 7,000m 6,500m 6,000m 5,500m 1,284m projected growth (19%) 6,599m FY 2015/16 Budget 7,883m FY 2020/21 Do Nothing The total budget for 2015/16 was 6,599 million. The total budget is projected to grow by 1,284 million (19%) to 7,883 million by 2020/21 in the do nothing' scenario. The growth is driven by c. 2-4% annual increases in CCG budgets and c 5% increases in specialised commissioning budgets. This budget includes the full budgets of SEL commissioners and providers (as demonstrated in the diagram below). NB: Totals in the diagram above do not equal those shown in the graph due to the treatment of NHSE (Specialised Commissioning) income of 586m notionally allocated to South East London (not shown in the diagram for clarity). 5

6 Hospitals: both in terms of commissioning acute care for the people of South East London and the full budgets of Guy's & St Thomas', King's College Hospital and Lewisham & Greenwich Trusts. Primary Care: both Primary Medical Care commissioned by NHS England (i.e. General Practice) and primary care services commissioned by CCGs (i.e. GP prescribing) are included. Community Care: both in terms of commissioning community health services for the people of South East London and the full budgets of South London & Maudsley and Oxleas Trusts. Specialised Commissioning: services commissioned by NHSE for the people of South East London. The modelling also includes all specialised income at Guy's & St Thomas', King's College Hospital, Lewisham & Greenwich, Oxleas and South London & Maudsley Trusts. Some commissioning of specific services are excluded, i.e. health and justice commissioning, commissioning for members of the armed forces, highly specialised care. London Ambulance Service: a portion of the London Ambulance Service is included in the budget. This relates to 65.2m 2015/16 income outturn. The other portions of London Ambulance Service are assigned to each of the four other London STP footprints. Health Education England: provider income from HEE is included, but not HEE budgets held centrally. Better Care Fund: 122.0m 2015/16 income is included in the budgets above. Other included: Mental health commissioning for people of South East London and the full budgets of South London & Maudsley and Oxleas Trusts. All other services commissioned by South East London CCGs not mentioned above (i.e. Continuing Healthcare). We do not include some other elements of primary care commissioning by NHSE, specifically community pharmacy, optometry and dental commissioning (although some elements of secondary dental care will be included in our acute trust income - this will be small though). 6

7 System-wide income/expenditure ( millions) South east London trusts are crucial not only to the people of who live there but also to the rest of the country. They provide specialist services and are considered centres of excellence in a number of areas including Haematology, Neurosciences, Liver Services and Maternity. They also have expert research centres and train future clinical staff. The cost of running hospitals is expected to grow 9,000 Sustainability challenge FY20/21 faster than government budgets unless action is 8,735 taken. 8,500 Costs across all providers and CCGs in south east London are forecast to grow by 1.8bn in the next 8,000 7,882 5 years whilst revenue increases by 1.1bn. This grows the affordability challenge from 0.2bn in 7,500 FY16 to 0.9bn by FY21. This increase is due to 7,000 Inflation Increasing demand for services 6,500 Revenue Expenditure Increasing availability of advanced, expensive treatments 6,000 In order to keep the system sustainable, the cost 2015/ / / / / /21 increase compared to today must be limited to 0.9bn, half the forecast increase of 1.8bn. 7

8 In order to ensure that quality services can be sustainably delivered in south east London, a number of solutions have been devised to reduce waste where possible and intervene earlier to keep people out of hospital. The diagram below starts with the 0.9bn affordability challenge in FY21 (displayed as the difference between the two lines on the previous slide) and shows how each scheme closes the gap. Clinical Transformation Savings Clinical Transformation Savings relate to plans to transform the way front line care is given. Collaborative Productivity considers how providers can work together to achieve savings in back office and clinical support services. These savings will be displayed in more detail in the following slides 8

9 The ambition is for services in south east London to match some of the best performing parts of the country over the course of the next five years. Hospitals are typically judged on a range of metrics which indicate how efficiently they are being managed, such as how long patients tend to stay after an operation, how frequently patients are readmitted and how often people attend their local A&E department. We have conducted benchmarking of all of these metrics, to understand what level of performance efficient services are able to achieve. The services in south east London have been compared to other services which are most similar, in terms of being comparably sized and treating people who undergo the same types of procedures and have similar diagnoses. The benchmarks which have been used to calculate potential financial savings are based on achieving a level of performance which similar services across the country have managed to achieve. We have assumed these benchmarks would be achieved gradually over 5 years. Savings are relative to the do nothing scenario described on page 3. This would get our services in 2020/21 to the level best performing (but similar) services achieved in 2015/16. Benchmarking process Select provider and CCG peers for comparison Conduct benchmarking of performance metrics Agree benchmarks with doctors and clinical experts Apply benchmarks to local CCG and provider cost base Calculate potential financial savings over 5 years 9

10 CLG Metric Notes Performance benchmark A&E attendances A&E attendances benchmarked based on overall CCG peers using A&E HES data. This then had to be mapped back to Providers (see Appendices for detail) 2 nd best amongst peers* Urgent & Emergency Care Non-elective admissions Non-elective length of stay Non-elective admissions benchmarked based on peers selected using patient case mix similarity for non-elective patients. Non-elective length of stay benchmarked based on peers selected using patient case mix similarity for non-elective patients. Best amongst peers Best amongst peers Re-admissions Re-admissions performance benchmarked based on peers selected using patient case mix similarity for non-elective patients. Best amongst peers A&E attendances A&E attendances benchmarked based on overall CCG peers using A&E HES data (for children under 18). This then had to be mapped back to Providers (see Appendices for detail) Children & Young People Non-elective admissions Non-elective length of stay Non-elective admissions benchmarked based on peers selected using patient case mix similarity for non-elective patients (for children under 18). Non-elective length of stay benchmarked based on peers selected using patient case mix similarity for non-elective patients (for children under 18). Median Re-admissions Re-admissions performance benchmarked based on peers selected using patient case mix similarity for non-elective patients (for children under 18). *Best in class for this peer group was Brent CCG. We chose to treat Brent as an outlier. 10

11 CLG Metric Notes Performance benchmark Elective length of stay [MSK] MSK patients identified using specific HRGs within Trauma & Orthopaedics (see Appendices). Peers selected based on this patient case mix. Planned Care Maternity Cancer First to follow-up ratio [MSK] First to follow-up ratio [Ophthalmology] Cost efficiencies Overall C-section % MSK patients identified using specific HRGs within Trauma & Orthopaedics (see Appendices). Peers selected based on this patient case mix. Peers selected based on Ophthalmology similarity. Cost efficiencies in five specialties have been calculated using unit cost analysis (from Reference Costs) by comparing unit costs with the Shelford group. C-sections have been identified based on HRG codes within the reference costs so impacts are applied directly Best amongst peers Average Best amongst peers Reduced Obstetrics births A reduction of 8% has been applied based on a CLG recommendation. CLG recommendation Length of stay [Obstetrics] Early diagnosis Emergency admissions Average length of stay Length of stay compared with peers with a similar patient case mix. Length of stay reductions only applied to births within obstetrics and not other procedures. CCG diagnosis performance benchmarked based on cancer diagnosis staging data from the National Cancer Intelligence Network for various cancers. Number of admissions for each trust found using primary diagnosis codes of admitted patients (see Appendices). Patients identified using primary diagnosis codes of admitted patients (see Appendices). Best in England Clinical judgment First to follow-up ratio Patients identified by oncology specialties. Best amongst peers 11

12 It is vital that providers collaborate to ensure the same job is not being duplicated many times across south east London. The opportunities below relate to back office functions like finance, HR and procurement and aim to reduce duplication and provide a more consistent service to the south east London trusts. Opportunity area Scheme Description Optimise the workforce Capitalise on our collective buying power Standardise and consolidate non-clinical support Consolidate clinical support services Capitalise on the collective estate 2020/21 saving ( m) Joint agency Set up a shared staff agency to reduce reliance on expensive commercial agency staff Collaborative overall Share information and use collective buying power to reduce commercial agency costs rate reduction 61m Productivity Introduce efficient Lean methodologies in outpatients Unit cost Collaborate to achieve the best possible price for supplies 34m Waste reduction Work together to track supplies within the hospital and reduce waste 28m Consolidation Share back office staff and systems to enable a more consistent service to front line staff and ensure that roles are not unnecessarily duplicated Pharmacy Improve the link between primary and secondary care and use e-prescribing to reduce drugs costs 25m Other clinical support Sharing expensive equipment between trusts and improving internal processes to reduce waste 13m Estates Improve use of existing estate and work together to better manage buildings 27m Total 38m 225m 12

13 CCGs typically agree contracts with local trusts and foundation trusts in order to agree which services hospitals are expected to provide, how many patients they are expected to treat and how much those hospitals will be paid. The STP process has stimulated an unprecedented level of collaboration between local hospitals and CCGs to ensure the financial effectiveness and sustainability of providers and commissioners in south east London. Typically contracts are agreed on an annual basis, but this year, the STP has been asked to agree two year contracts, to give providers and CCGs more certainty about their funding and expenditure and start to deliver some of the savings set out in the STP. Providers and CCG are currently going through an engagement process in order to agree how the priorities set out in the STP are going to start to be delivered over the next two years. Two year contracts are expected to be signed by 23 rd December. two year contracts signed 13