MERTON CLINICAL COMMISSIONING GROUP GOVERNING BODY

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1 MERTON CLINICAL COMMISSIONING GROUP GOVERNING BODY Date of Meeting: 23 rd March 2017 Agenda No: 9.3 Attachment: 15 Title of Document: CCG Governing Body Assurance Report & Scorecards: Month 9 Quality & Performance/ Month 10 Finance & Activity 2016/17 Report Author: Lee Lewis, Senior Performance Manager Contact details: Lee.lewis@mertonccg.nhs.uk Chris.clark@mertonccg.nhs.uk Executive Summary: Purpose of Report: For Approval Lead Director: Chris Clark, Director of Performance, Planning and Informatics 1

2 Key sections for particular note (paragraph/page), areas of concern etc: Page 5: Risks Page 6: A&E 4 hour wait exception report Page 7: 62 day Cancer wait exception report Recommendation(s): The Governing Body is asked to review the performance, finance and quality information within the report. Committees which have previously discussed/agreed the report: Merton Clinical Quality Committee for performance and quality. Audit Committee for the finance information. Financial Implications: Contained within the body of the main report. Implications for CCG Governing Body: The CCG is assessed annually and given an assurance score based upon achievements of the indicators within the four domains and financial position. How has the Patient voice been considered in development of this paper: patientcentric performance and quality indicators. Other Implications: CCG Risk Register Item 802 relates to a failure to deliver constitutional pledges and other priority performance goals 4 x 4 = 16. CCG Risk Register Item 1038 relates to a failure to meet the required standards against the 1617 CCG Improvement and Assessment Framework 3 x 4 = 12 Equality Assessment: The proposals have been assessed against the Merton CCG Equality Statement and found to have no adverse impact on such principles or Public Sector Equality Duty. Information Privacy Issues: Following approval, the quality & performance scorecard will published on the CCG internet website. The scorecard may also be made available to external parties via freedom of information requests. No patient identifiable or commercially sensitive information is held within this report. Communication Plan: (including any implications under the Freedom of Information Act or NHS Constitution) Performance reports shared with the Governing Body are published and available to the general public. Any performance information held by the CCG is available on request by the general public subject to the reasonable limitations set out in the Freedom of Information Act

3 CCG Assurance Report Merton CCG Governing Body 2016/17: Month 09 Quality / Month 10 Finance & Activity

4 Contents Section Page Key Performance Messages: Quality & Safety; Finance & Audit; Contract Activity; Leadership & Sustainability Scorecard: Quality & Safety 4 Quality Risks 5 Quality Exception Reports: A&E 4 hour wait / Cancer 62 day wait 67 Scorecard: Finance 8 Finance Exception Reports & Risks 9 Contract Activity Performance (Acute): Scorecard and charts 1011 Contract Activity Performance (Acute): Variance summary 12 Leadership & Sustainability: Scorecard; Exception reports; risks and issues

5 Key Performance Messages Finance & Audit Performance Summary position (Month 10) This CCG has a control total of a 0.6m deficit and continues to report that plan will be achieved by year end. The acute position had a quieter month than expected. In addition, stability in primary care, prescribing and corporate and estates and some improvement in Mental Health enabled a reduction in the unallocated savings requirement. As reported at M9 that the risked assessed impact of a deterioration in the position stood at 1m that is to say a 1.6m worst case deficit. In view of the M9 data feeding in to the M10 position, this has been reduced to 750k ie a worst case deficit of 1.35m. The major contributors to this would be a worse outturn on acute that forecast, a surge in invoiced activity in CHC and prescribing at year end, an inability to deliver the schemes identified in the unallocated savings section of this report or an inability to find the remaining 254k unallocated savings. Leadership & Sustainability Activity Performance Variance Summary (Month 10) Elective Activity Activity is below plan for most of the elective areas of the acute contracts (referrals; 1 st outpatient attendances; and elective admissions); but a continued increase in followup outpatient appointments. While we are aware of some productivity issues at St. Georges, we are assured that a key driver for this is a consequence of work done with GPs to better manage demand. Nonelective activity This remains above plan: for January the year to date figure is approximately 5.3% above plan for nonelective admissions. We are observed an increase in demand for urgent care over Winter, although variance on attendances to A&E remained below 3%. Good performance: The CCG is rated as Green (2 nd highest tier) overall for Quality of CCG Leadership We have a local Strategic Estates Plan (SEP) in place Challenged performance: Rated as Red for Financial Plan ; and Amber for Inyear financial performance In the third quartile nationally for Digital interactions between primary and secondary care In the third quartile nationally for Effectiveness of working relationships in the local system 3

6 Quality Indicator Scorecard Domain: Better Care IAF Area Cancer Indicator Show Show Show Show Show Show Show Show Show Quality Premium* Cancers diagnosed at early stage 20% 60.0% Annually People with urgent GP referral having first definitive treatment for cancer within 62 days of referral Target Frequency Latest Data Period Previous score Latest score 2014 (remains latest) Change from previous period 13 month / 5 quarter trend Achieved / did not achieve Risk warning 46.0% 48.2% Annual reporting % 25% 85.0% Monthly Dec % 79.3% % Bottom Quartile Nationally Urgent and emergency care Percentage of patients admitted, transferred or discharged from A&E within 4 hours 25% 95.0% Monthly Dec % 87.9% % 4

7 Reference (Date) Cancers diagnosed at early stage Risk Cause / Impact Action(s) Risk owner The CCG will be assessed against this indicator for 2016/17. Currently data are only available to the end of 2014, suggesting that the CCG was at 48.2%. The target is to achieve 62% by Approximately 15% of cases are recorded without the stage at diagnosis. The earlier cancer is diagnosed, the more likely it is to be successfully treated, and survival rates can be dramatically improved. Poor coding of cancer stage at diagnosis impact on the ability to assess how well services are performing against this target. Advice from the Transforming Cancer Services Team is that Commissioners should work with providers to improve staging completeness.the Commissioning lead is reviewing this and will work with providers to improve data. CCG cancer lead Risks % Injuries from falls in people aged 65 and over The CCG has been reported as a national outlier for injuries related to falls. This may indicate an unknown cause for a higher rate of falls or increased nonelective admissions The CCG is currently investigating if the higher reported rate of falls is due to more diligent reporting by our providers, or a real failure of our falls assessment service. This indicator has been selected as a QP (Quality Premium) measure for 2017/18 reporting period in order to prioritise this area. The CCG has engaged with our Community provided falls assessment service to review the effectiveness of the service. Clinical Lead for urgent and unplanned care Additionally the CCG will commission a data audit to benchmark the thresholds for reporting injuries related from falls. 5

8 Issue Cause Action(s) Assurance / Gaps All providers in South West London failed to achieve the national standard in December. All A&E departments in Southwest London have experienced unprecedented high demand over Winter, putting services under additional pressure. In addition to this some ward areas closed beds due to infection. This resulted in severely limited capacity in clinical decision and intensive care wards, leading to admission delays in A&E. All A&E departments are following winter plans to make best use of their capacity and this is monitored through daily system calls with commissioners and the London Ambulance services. Commissioners are also working to facilitate quicker discharges for patients who are ready to leave hospital, to freeup beds on wards. The CCG seeks assurance of progress against improvement plans via regular meetings with the provider. The CCG has rolled out a number of programmes aimed at reducing A&E attendances, including promotion of the Flu vaccination campaign and the Health Help Now app. The committee is asked to note that despite the exceptional pressure on A&E departments, Southwest London performance has remained resilient compared to the rest of London and the wider region. Exception Report A&E 4 hour Waits 6

9 Issue Cause Action(s) Assurance / Gaps Merton CCG has met 7 of the 8 CWT Standards for December (M9) 2016/17. The CCG did not achieve 62 day GP urgent standard 79.3% (6 patients breaching out of 29) The 62 day standard was not achieved due to 6 breaches: 2x delay in workup, 1x administrative, 1x intertrust no information 2x complex diagnostic To address late referrals/ ITTs, SLF are monitoring trusts referrals to the treating trust by day 38. Weekly calls between trusts to agree referral/itt dates are being undertaken and 38 day performance is being monitored on weekly performance calls with the CSU. Trusts are also developing reports to show 38 day breach reasons. (3TP) 3 trust pathways are being monitored through SLF and NHSE London are collating data on 3TP s Head & Neck pathway for SW London is being reviewed by the quality surveillance team. Trusts are developing reports to show 38 day breach reasons. (3TP) 3 trust pathways are being monitored through SLF and NHSE London are collating data on 3TP s Commissioners are awaiting confirmation from SGH of completion of actions following an external review, this is monitored fortnightly. Exception Report Cancer Waits: 62 days waiters 7

10 Scorecard: Finance & Audit Year To Date Full Year Forecast Outturn SUMMARY Budget Actual Variance Budget Forecast Variance Period Jan17 000's 000's 000's 000's 000's 000's Revenue Resource Limit 228, , , ,163 0 EXPENDITURE Acute 113, ,286 (1,510) 136, ,117 (1,507) Non Acute 55,018 55,237 (219) 66,022 66,239 (218) Year To Date Full Year Forecast Outturn Primary Care & Prescribing 48,400 47,357 1,043 57,881 56,542 1,339 ACUTE CONTRACT EXPENDITURE TOP 5 (see table 2) Budget Actual Variance Budget Forecast Variance Corporate & Estate Costs 9,439 10,377 (938) 11,328 12,420 (1,092) 000's 000's 000's 000's 000's 000's Reserves & Other 2, ,542 2,923 1,444 1,479 ST GEORGE'S HEALTHCARE TRUST 50,793 52,205 (1,412) 61,030 62,520 (1,489) Total Expenditure 228, ,041 (81) 274, ,763 0 EPSOM & ST. HELIER UNIVERSITY HOSPITALS NHS TRUST ACUTE 26,733 26, ,080 32,223 (142) In Year Surplus (500) (581) (81) (600) (600) 0 KINGSTON NHS TRUST 8,644 8,916 (272) 10,373 10,760 (387) LAS EMERGENCY SERVICE CONTRACT 5,390 5,481 (91) 6,468 6,577 (109) EPSOM & ST. HELIER UNIVERSITY HOSPITALS NHS TRUST SWLEOC 3,986 3, ,783 4, Year To Date Full Year Forecast Outturn ALL OTHER CONTRACTS + ACUTE NONSLA BUDGETS 18,230 18, ,875 21, NON ACUTE (see tables 3,4) Budget Actual Variance Budget Forecast Variance 113, ,286 (1,510) 136, ,117 (1,507) 000's 000's 000's 000's 000's 000's TOTAL MENTAL HEALTH 19,758 19, ,710 23, TOTAL LEARNING DIFFICULTIES 1,455 1,580 (125) 1,745 1,896 (150) ACUTE CONTRACT VARIANCE BY POD TOTAL END OF LIFE CARE AND HOSPICES (69) (82) Elective (260) 151 (66) (576) (751) TOTAL LONG TERM CONDITIONS Emergency (151) 292 TOTAL URGENT AND INTERMEDIATE CARE 5,670 5, ,804 6, NonElective (47) TOTAL COMMUNITY SERVICES 16,458 16, ,750 19, Maternity Pathway (75) (19) 676 TOTAL CHILDREN SERVICES 2,157 2, ,589 2, A&E (47) (50) (17) TOTAL ADULT CONTINUING CARE 8,635 9,453 (819) 10,362 11,344 (982) Out Patient 1st (21) TOTAL NON ACUTE COMMISSIONING 55,018 55,237 (219) 66,022 66,239 (218) Out Patient Follow Up (58) 122 (60) Out Patient Procedure (744) (570) Unbundled Diagnostics (249) 115 (6) (91) (231) Year To Date Full Year Forecast Outturn Critical Care (20) PRESCRIBING (see table 5) Budget Actual Variance Budget Forecast Variance Other PODs (1,629) (1,074) (224) 981 (1,947) 000's 000's 000's 000's 000's 000's (1,489) (142) (387) 512 (1,507) TOTAL PRESCRIBING 19,680 19, ,616 23, TOTAL PRIMARY CARE DELEGATED BUDGET 25,055 24, ,867 29, LOCAL ENHANCED SERVICES Actual TOTAL OUT OF HOURS 1,625 1, ,950 1, BALANCE SHEET AS AT Jan17 000's TOTAL PRIMARY CARE OTHER 1,759 1, ,111 1, Property, Plant And Equipment 705 TOTAL PRIMARY CARE & PRESCRIBING 48,400 47,357 1,043 57,881 56,542 1,339 Current Trade And Other Receivables 3,033 Cash And Cash Equivalents (139) Current Trade And Other Payables (21,067) Year To Date Full Year Forecast Outturn Current Other Liabilities (574) CORPORATE AND ESTATES (see table 6) Budget Actual Variance Budget Forecast Variance (18,042) 000's 000's 000's 000's 000's 000's General Fund 18,042 TOTAL RUNNING COSTS 3,687 3,688 (1) 4,425 4,425 0 TOTAL CSU CHARGES (55) (66) TOTAL OTHER CORPORATE COSTS 3,635 3,750 (114) 4,362 4,501 (139) PROPERTY COSTS 1,533 2,301 (768) 1,840 2,728 (888) TOTAL CORPORATE & ESTATE COSTS 9,439 10,377 (938) 11,328 12,420 (1,092) STATUTORY DUTIES AND PERFORMANCE Statutory Duty Area YTD Forecast Not to exceed RRL Revenue (581) (600) Not to exceed running cost allocation Running costs (1) 0 Not to exceed CRL Capital 0 0 Deliver a recurrent surplus Revenue (0.7)% (0.7)% Deliver a 0.5% in year surplus Revenue (0.3)% (0.2)% Comply with BPPC # Business conduct 98.3% 98.3% Comply with BPPC Business conduct 99.1% 99.1% Fully deliver planned QIPP QIPP 110.4% 90.4% 8,000,000 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 QIPP Target Gross Savings by month Cumulative Actual SGH ESH KHT Other Providers Total 8

11 Finance & Audit: Exception Reports & Risks Key variances, risks and mitigations Acute The full year forecast (FYF) acute position shows an adverse variance to plan of 1,507k which is 820k better than M9. Much of this is technical as we moved 316k relating the St George s RTT fines from reserves (causing that variance to move adversely) to the acute position. We applied similar logic to estimated 2016/17 CQUIN payments which moved 204k to the acute position and we applied the financial impact of reduced QMH activity on elderly rehabilitation beds worth 83k direct to the acute position and deducted similar from reserves (via the back end loaded QIPP mechanism we have discussed hitherto. Non Acute Overall, the FYF position has improved 514k since M9 to stand at an M10 FYF of 218k adverse. The major contributor to this improved position is in the IAPT contract where the variance has improved by 440k to a FYF favourable variance of 738k. 340k activity reductions have been accounted for and 100k contractual penalties. The CHC forecast has marginally deteriorated by 67k to 982k adverse. The position has remained stable for the last six months, however, our FYF is subject to the last minute invoicing that many providers adopt in this area. Primary Care & Prescribing Overall, the FYF position shows a 1,339k underspend at M10 which is a deterioration of 96k over M9. Prescribing deteriorated by 57k in month reflecting slightly higher activity using the CCG s routine forecasting tool. Again, the FYF has remained very stable all year and we expect this to continue to year end. Corporate and Estates The Corporate and Estates FYF position improved in M10 by 31k to a full year forecast adverse variance of 1,092k. The IAT received in month was 28k higher than anticipated previously which has resulted in a slight improvement to the position. However the full I&E effect of the change in market rents policy remains muddled. Reserves The FYF shows a favourable variance of 1,479k which is an adverse variance of 1,269k. 9

12 Scorecard: Activity Performance (Month 10: January 2017) EM Number EM7 EM Detail Metric Actual 15/16 Apr16 6,050 May16 5,961 Jun16 6,456 Jul16 6,633 Aug16 5,507 Sep16 6,570 Oct16 6,631 Nov16 6,105 Dec16 5,269 Jan17 5,585 Feb17 5,961 Mar17 5,836 Year to Date 60,767 Year End Totals & Forcast Outurn 72,564 Total Referrals (Specific Acute) Plan 16/17 5,926 6,150 6,156 6,457 5,585 6,644 6,533 5,915 5,490 5,639 5,393 6,175 60,495 72,063 Actual 16/17 5,672 5,810 6,125 5,469 5,446 5,424 5,812 5,701 4,950 5,494 55,903 66,756 FOT 16/17 5,484 5,369 55,903 66,756 Variance ,510 % Variance Vs Plan 4.3% 5.5% 0.5% 15.3% 2.5% 18.4% 11.0% 3.6% 9.8% 2.6% 7.6% 7.6% 16/17 Actual Growth 6.25% 2.53% 5.13% 17.55% 1.11% 17.44% 12.35% 6.62% 6.05% 1.63% 8.00% EM8 Consultant Led First Outpatient Attendances (Specific Acute) Actual 15/16 5,660 5,874 6,732 6,340 5,501 6,508 6,464 6,603 5,352 5,290 5,684 5,488 60,324 71,496 Plan 16/17 6,086 6,369 6,402 6,780 5,773 6,934 6,874 6,170 5,741 5,921 5,707 6,387 63,050 75,144 Actual 16/17 5,886 5,871 6,171 5,626 5,759 5,937 5,901 6,412 5,138 5,853 58,554 69,398 FOT 16/17 5,517 5,327 58,554 69,398 Variance ,395 % Variance Vs Plan 3.3% 7.8% 3.6% 17.0% 0.2% 14.4% 14.2% 3.9% 10.5% 1.1% 7.1% 7.2% 16/17 Actual Growth 3.99% 0.05% 8.33% 11.26% 4.69% 8.77% 8.71% 2.89% 4.00% 10.64% 2.93% EM9 Consultant Led Outpatient Follow Up Attendances (Specific Acute) Actual 15/16 11,303 10,893 12,067 11,824 9,993 11,738 11,764 11,623 10,419 10,279 10,802 10, , ,461 Plan 16/17 10,755 10,811 11,096 11,594 9,624 11,359 11,103 10,260 9,789 10,455 9,691 11, , ,598 Actual 16/17 10,725 10,858 11,232 10,718 10,860 11,651 11,490 12,176 10,029 11, , ,774 FOT 16/17 10,746 10, , ,774 Variance ,377 % Variance Vs Plan 0.3% 0.4% 1.2% 7.6% 12.8% 2.6% 3.5% 18.7% 2.5% 10.8% 4.2% 4.2% 16/17 Actual Growth 5.11% 0.32% 6.92% 9.35% 8.68% 0.74% 2.33% 4.76% 3.74% 12.73% 0.51% EM10 Total Elective Admissions (Spells) (Specific Acute) [Ordinary Electives + Daycases] Actual 15/16 1,503 1,498 1,674 1,715 1,467 1,703 1,607 1,756 1,461 1,566 1,647 1,541 15,950 19,138 Plan 16/17 1,637 1,614 1,757 1,848 1,589 1,753 1,743 1,613 1,444 1,616 1,580 1,762 16,614 19,956 Actual 16/17 1,450 1,410 1,579 1,623 1,603 1,653 1,658 1,759 1,462 1,588 15,785 18,940 FOT 16/17 1,630 1,525 15,785 18,940 Variance % Variance Vs Plan 11.4% 12.6% 10.1% 12.2% 0.9% 5.7% 4.9% 9.1% 1.2% 1.7% 5.0% 5.0% 16/17 Actual Growth 3.53% 5.87% 5.68% 5.36% 9.27% 2.94% 3.17% 0.17% 0.07% 1.40% 1.03% EM11 Total NonElective Admissions (Spells) (Specific Acute) Actual 15/16 1,400 1,383 1,454 1,458 1,368 1,377 1,531 1,545 1,594 1,514 1,447 1,493 14,624 17,564 Plan 16/17 1,415 1,460 1,460 1,537 1,437 1,516 1,635 1,479 1,588 1,486 1,288 1,489 15,013 17,790 Actual 16/17 1,496 1,540 1,607 1,586 1,606 1,538 1,548 1,571 1,693 1,625 15,810 18,988 FOT 16/17 1,564 1,614 15,810 18,988 Variance to plan % Variance Vs Plan 5.7% 5.5% 10.1% 3.2% 11.8% 1.5% 5.3% 6.2% 6.6% 9.4% 5.3% 5.4% 16/17 Actual Growth 6.86% 11.35% 10.52% 8.78% 17.40% 11.69% 1.11% 1.68% 6.21% 7.33% 8.11% EM12 Total A&E Attendances excluding planned follow ups Actual 15/16 5,743 6,007 6,033 6,098 5,633 5,775 6,080 6,163 5,984 6,010 6,114 6,767 59,526 72,407 Plan 16/17 5,697 6,054 6,186 6,213 5,594 6,153 6,164 6,082 6,280 5,583 5,236 6,254 60,006 71,496 Actual 16/17 5,907 6,404 6,222 6,518 5,887 6,060 6,137 6,106 6,394 5,839 61,474 74,777 FOT 16/17 6,314 6,988 61,474 74,777 Variance ,762 % Variance Vs Plan 3.7% 5.8% 0.6% 4.9% 5.2% 1.5% 0.4% 0.4% 1.8% 4.6% 2.4% 2.5% 16/17 Actual Growth 2.86% 6.61% 3.13% 6.89% 4.51% 4.94% 0.94% 0.92% 6.85% 2.85% 3.27%

13 1,496 5,907 1,540 1,607 1,586 1,606 1,538 1,548 1,571 1,693 1,625 1,564 1,614 6,404 6,222 6,518 5,887 6,060 6,137 6,106 6,394 5,839 6,314 6,988 1,450 1,410 10,725 10,858 11,232 10,718 10,860 11,651 11,490 12,176 10,029 1,579 1,623 1,603 1,653 1,658 1,462 11,588 10,746 10,701 1,759 1,588 1,630 1,525 5,672 5,810 6,125 5,469 5,446 5,424 5,812 5,701 4,950 5,494 5,484 5,369 5,886 5,871 6,171 5,626 5,759 5,937 5,901 5,138 6,412 5,853 5,517 5,327 Scorecard: Activity Performance (Month 10: January 2017) Total Referrals (Specific Acute) Consultant Led First Outpatient Attendances (Specific Acute) 7,000 6,000 5,000 4,000 3,000 2,000 5,926 6,150 6,156 6,457 5,585 6,644 6,533 5,915 5,490 5,639 5,393 6,175 8,000 7,000 6,000 5,000 4,000 3,000 2,000 6,086 6,369 6,402 6,780 5,773 6,934 6,874 6,170 5,741 5,921 5,707 6,387 1,000 1,000 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Actual 16/17 FOT 16/17 Plan 16/17 Actual 16/17 FOT 16/17 Plan 16/17 14,000 Consultant Led Outpatient Follow Up Attendances (Specific Acute) Total Elective Admissions (Spells) (Specific Acute) [Ordinary Electives + Daycases] 12,000 10,000 8,000 6,000 4,000 10,755 10,811 11,096 11,594 9,624 11,359 11,103 10,260 9,789 10,455 9,691 11,061 2,000 1,800 1,600 1,400 1,200 1, ,637 1,614 1,757 1,848 1,589 1,753 1,743 1,613 1,444 1,616 1,580 1,762 2, Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Actual 16/17 FOT 16/17 Plan 16/17 Actual 16/17 FOT 16/17 Plan 16/17 Total NonElective Admissions (Spells) (Specific Acute) Total A&E Attendances excluding planned follow ups 1,800 1,600 1,400 1,200 1, ,415 1,460 1,460 1,537 1,437 1,516 1,635 1,479 1,588 1,486 1,288 1,489 8,000 7,000 6,000 5,000 4,000 3,000 5,697 6,054 6,186 6,213 5,594 6,153 6,164 6,082 6,280 5,583 5,236 6, , ,000 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Apr16 May16 Jun16 Jul16 Aug16 Sep16 Oct16 Nov16 Dec16 Jan17 Feb17 Mar17 Actual 16/17 FOT 16/17 Plan 16/17 Actual 16/17 FOT 16/17 Plan 16/17 11

14 Activity Performance: Variance Commentary Variance commentary Referrals (7.6% Year to date) The underperformance is an expected direction of travel, and continues to show a downward trend. The main driver for this is a reduction in GP referrals; analysis shows that consultant to consultant referrals have increased, which is limiting the benefit to reducing demand on outpatients. We are therefore confident and assured that this downturn represents a successful campaign to manage demand for acute services. Consultant led 1 st Outpatient Attendances (7.1% Year to date) For Merton CCG has focussed a significant part of its QIPP and Transformation programmes on mitigating historical growth in demand for planned care. We have so far observed a positive effect over and above what we initially planned to deliver. We have observed an overall downturn in outpatient activity at all three of our main acute providers. Whilst we are conscious that acute data quality is not perfect, we are confident that the vast majority of this variance against plan is real reduction in activity, and that this positive change is in part due to our work with primary care to mitigate demand. However we are also conscious that there are significant capacity and operational effectiveness issues declared by St Georges hospital resulting in large backlogs of patients waiting to be seen. This may also be driving some of the underperformance against plan in outpatient activity. Consultant led Followup Outpatient Attendances (+4.2% Year to date) Whilst we have continued to drive down demand on outpatients from new referrals, we are observing an increase in followup attendances. This means demand on outpatient services remains high and it impedes RTT recovery. We are continuing to analyse the source of this demand and will be working with particular Trusts to find a resolution. Elective Admissions (5.0% Year to date) Merton CCG feel assured that this is a positive change, in part due to our work to mitigate demand on acute hospitals. We are assured that this variance is due to actual activity rather than data. Again we are also aware however of a serious productivity issue with St Georges hospital resulting in a significant admitted backlog, and we have observed an increase in inpatient and daycase runrates which is reassuring that the backlog is being cleared. Nonelective admissions (+5.3% Year to date) Activity remains above plan. Merton CCG is aware of an increase in the number of shortstay patients admitted as an emergency, particularly at St Georges. We are observing particular pressure on urgent care during Winter and are managing the situation with our acute providers on a daily basis to ensure they are supported through challenging periods. A&E attendances (+2.4% Year to date) Whilst hospitals have experienced continued pressure throughout Winter the our variance against plan for A&E attendances has reduced significantly to 2.4% 12

15 CCG Improvement & Assessment Framework: Sustainability / WellLed Domain: SUSTAINABILITY IAF Area Indicator Latest Data Period Show Show Show Show Previous score Latest CCG score England Score Change from previous period Financial sustainability Financial plan 2016 Red Red % Allocative efficiency Paperfree at the point of care Inyear financial performance Q2 2016/17 Amber % Outcomes in areas with identified scope for improvement Expenditure in areas with identified scope for improvement Digital interactions between primary and secondary care CCG not included in wave one Risk warning Q3 2016/17 (Q2):57.4% 58.5% % Estates strategy Local strategic estates plan (SEP) in place 2016/17 Yes Yes Domain: WELL LED Show Show Show Show IAF Area Indicator Latest Data Period Change period Previous Latest CCG England from Risk score score Score previous warning Workforce engagement Staff engagement index Progress against workforce race equality standard Effectiveness of working relationships in the CCGs local relationships local system Jul % 2015/ % 66.4% % Quality of leadership Quality of CCG leadership Q2 2016/17 Green Green 13

16 Sustainability & Leadership: Risks Risks and mitigations Domain / Area Issue / Risk Mitigation Sustainability: Financial sustainability ISSUE. The financial plan is rated as Red for 2016/17. This is a default rating as the CCG did not achieve a 1% surplus as required by NHS Business Rules. Sustainability: Financial sustainability RISK. The Inyear financial performance is rated as Amber (Q2 2016/17). The CCG has forecast a yearend deficit of 0.6M, reliant on delivery of QIPP programmes. This again is not with in the business rules requirement of achieving a 1% surplus. The CCG QIPP programme is designed to deliver cost reduction and efficiency in the CCGs business and commissioned services in order to restore financial balances to a sustainable position. Sustainability: Paper free at the point of care RISK. Digital interactions between primary and secondary care are in the third (i.e. second bottom) quartile nationally. This indicator is a composite of: % utilisation of EPS2 (electronic prescribing) Use of the NHS ereferral system; Accessing GP summary information across ambulance, 111 and A&E services; % of care summaries shared with GPs when patients are discharged. As at January 2017, the % usage of electronic prescribing in Merton practices ranged from 89%, down to 17%; the overall average percentage use was 47%. There is a 2016/17 GMS contract target for 80% of repeat prescriptions to be issued electronically. The CCG has a known issue with use of the ereferral system. As at December 2016 CCG Merton scored 12.2% utilisation rate which remains considerably below the London average of 36%. The South West London Performance Group chaired by CCG Merton are actively monitoring performance and will be contacting CCGs achieving best practice to share any lessons learnt. Well led: Effectiveness of working relationships in the local system RISK. Effectiveness of working relationships in the local system (2015/16: 66.4%) shows performance levels are in the third (i.e. second bottom) quartile nationally. This indicator is scored as the average response of each respondent to two of the questions in the 360 degree review of the CCG, that is completed by key local stakeholders. In 2016/17 Merton CCG has embarked on a significant initiative to engage with primary care and work with providers in a more effective way. We are already seeing the benefits of this including buyin to reducing demand and delivering transformation 14 Governing Body CCG Assurance Report 2016/17 January Report