Integrated Quality and Performance Report

Item 6 Integrated Quality and Performance Report Herts Valleys CCG Board 1 st August 2013 Period of {MONTH HERE} 1

Introduction to the Integrated Performance Report 1. Purpose of this Report 1.1 This report represents a new approach to performance reporting by HV CCG by moving towards integrated reporting of performance across a number of domains, namely, quality, contract performance, finance and QIPP. An integrated approach to performance involves coordinating all monthly data collections, producing a standard list of dashboards and then sending subsets of this standard list to Board, Performance and Delivery Committee, and Quality Committee, depending on the remit of each group. This approach brings a number of benefits : i) The overview of performance provided in the reports provides a whole system picture of performance, rather than several reports providing a snapshot of one particular discipline. ii) iii) iv) Board and Committee members are better able to fulfil their responsibilities through improved presentation of performance information. In addition, the principle of management by exception can be followed such that the Board in particular does not review detailed information already reviewed at the Board s sub-committees. An integrated approach should facilitate a move from performance monitoring to performance management by responding to clear evidence of underperformance. The production of reports is administratively efficient. 1.2 The Integrated Performance Report includes new sections not previously provided in performance reports. i) A dashboard for the KPIs in the NHS Outcomes Framework which are applicable to CCGs (the CCG Outcomes Framework). The CCG hasn t previously tracked performance against outcomes and, whilst the underlying information systems to populate this dashboard are evolving, the information provided is significant in monitoring population-wide trends in health outcomes and service satisfaction. ii) Benchmarking information, particularly in relation to the CCG Outcomes Framework, to allow board and Committee members to view HV CCG in a wider context. 2

2. Sections in this Report 2.1 As described above the Integrated Performance Report is a standardised set of dashboards with selected sections going to different groups, as described below : HV CCG Board Performance & Delivery Committee Quality Committee Key Performance Issues Performance against key national indicators (CCG view, Acute and Community Trusts) Performance against CCG Outcomes Framework Quality Dashboard Exception Reports Key performance issues highlighted Finance Overview QIPP (Portfolio) Performance Quality Premium 2.2 Based on comments received from Board and Committee members the information provided to different groups will be revised and will evolve over time. 3. A Note about Data 3.1 The Integrated Performance Report includes a disparate range of indicators supported by a wide range of activity, finance, epidemiological and survey data and information. Whilst some metrics are related to short-term operational activity (e.g. A & E performance against the 4 hour target) others relate to longer term changes in outcomes (e.g. Potential years of life lost from conditions amenable to health care). Consequently, not all metrics are updated monthly, partly due to data availability 3

but also because a particular metric will not change significantly over the period of a month. 3.2 Finance reports are typically more contemporaneous than other performance reports and, as a consequence, there will often be a 1 month disparity between the period covered by finance reports and contract performance reports. Consequently, when compiling key performance messages it may be necessary to refer to previous monthly finance report as well as the ones included in this report. 3.3 As with performance reports in recent months the HV CCG and the CSU are still hampered by non-availability of patient identifiable data. 4. Sections in this Report 4.1 Described below is a description of the main sections in this report. Section Purpose and notes Data Source Key Performance Issues Performance against key national indicators (CCG and provider views) Performance against NHS Outcomes Framework Quality Dashboard Finance Overview QIPP/Portfolio Overview Quality Premium A summary of the main performance issues across the whole report Performance against key contract metrics at CCG and provider levels including those in the NHS Constitution Summary of the latest data for the CCG against metrics within the Outcomes Framework with benchmarking against the UK average and ONS cluster (i.e. areas with similar characteristics that provide a more meaningful comparison than UK mean) Provider-level performance against key quality metrics not contained in the key national indicators An overview of the CCG and provider financial positions Summary of QIPP performance and progress in delivering the Portfolio Summary of the national and local performance areas and associated KPIs that are linked to additional funding through the quality premium Collated from performance dashboards and exception reports Provider activity and performance data Outcomes Benchmarking Support Packs (NHS England, 2013) Provider activity and performance data HV CCG ledger HV CCG ledger Data monitoring arrangements still being developed. 4

Key Performance Issues Listed below are the main performance issues to be reported this month : 1. Contract Performance BCFT have failed to achieve the 4 hour A & E target in May, continuing a trend over recent months. This is linked to the reconfiguration of the A & E services across the trust and an action plan is being implemented to improve performance pending the final configuration being in place. BCFT has around 700 patients not treated within the 18 week RTT target. Work is ongoing to ascertain the number that are from the HV CCG area and an action is being implemented to ensure patients are seen as quickly as possible. WHHT is failing to achieve stroke targets for admitting 90% of patients to a stroke ward within 4 hours. A meeting of the Stroke Strategy Group (provider and commissioners) on the 30 th July 2013 will develop an improvement plan. HPFT are not on target to ensure 10% of patients with depression and/or anxiety disorders receive psychological therapies (Improving Access to Psychological Therapies) although an action plan has been implemented to address this. Recovery rates for those accessing services are, however, well above the national average. EEAST are not meeting their Category A (Red 2) 8 minute targets achieving 74% compared to a target of 75%. EEAST have developed a wide ranging plan for improving performance which was presented to the Performance and Delivery Committee on the 23 rd May 2013. HCT length of stay for non-stroke patients is significantly over the 21 days target. Progress in improving this position will be monitored at the monthly Quality Review Meeting. During April June 2013 739 patients had ambulance turnaround times over 15 minutes and 98 has turnaround times over 30 minutes at WHHT attracting fines of 200 and 1000 respectively. 2. Quality At WHHT the high Summary Hospital Level Mortality Indicator (SHMI) and a deteriorating trend in the Hospital Standardised Mortality Ratio (HSMR) are a cause for concern. A risk summit was held in July, following on from the summit in May to 5

review mortality rates along with patient safety and complaints. An action plan, monitored by the monthly Quality Review Meetings will be implemented. WHHT have reported higher than projected cases of C-difficile (10 to date since April against a projection for the year of 24). An action plan is being implemented which will be reviewed at the monthly Quality Review Meetings. 3. QIPP (Portfolio) Continued progress in establishing PMO resources (including intern appointments having started), scoping programmes and developing robust KPIs. The Planned and Primary Care Programme, which represents the largest opportunity for financial savings, requires further definition and scoping to ensure that projected savings are achievable and robust plans are in place. Around 3m of QIPP delivery is currently at risk, largely relating to the Planned and Primary Care Programme. 4. Finance The CCG is required to report a surplus at the end of the financial year and, at month 3, the surplus is 3m. However, risks to this position include difficulty in making accurate projections so early in the year (further hindered by lack of patient identifiable data), acute contracts that have still to be agreed, uncertainty regarding the receipt of 10.5m for specialist commissioning, continued discussions about Public Health funding and the risks to the full delivery of QIPP. Financial projections for WHHT at month 3 (based on extrapolations from month 2) show a projected deficit of 2.7m, although this is subject to verification as trust figures suggest a lower deficit figure. 5. Outcomes Framework Nationally published data shows that, using the ONS cluster as a comparator (i.e. other areas that have similar characteristics to HV CCG) HV CCG performs relatively poorly in terms of i) under 75 mortality rates from CVD ii) under 75 mortality rates from respiratory disease iii) under 75 mortality rates for cancer and iv) unplanned hospitalisation for chronic ambulatory sensitive conditions. 6

Performance Against Key National Indicators (CCG view) Performance against Key National Indicators - CCG Indicator Period Latest Data Plan May-13 Apr-13 YTD Cancer 2 week waits following urgent GP referral for suspected cancer Apr13-May13 94.70% 93% 94.70% 96.10% 95.40% Cancer 2 week waits - Breast Symptomatic where cancer not suspected Apr13-May13 94.30% 93% 94.30% 91.90% 93.10% Cancer 31 day - 1st definitive treatment from diagnosis Apr13-May13 97.40% 96% 97.4% 97.8% 97.60% Cancer 31 day - Subsequent treatment for cancer - Surgery Apr13-May13 100.00% 94% 100.0% 100.0% 100.00% Cancer 31 day - Subsequent treatment for cancer - Drugs Apr13-May13 98.60% 98% 98.60% 98.50% 98.55% Cancer 31 day - Subsequent treatment - Radiotherapy Apr13-May13 98.90% 94% 98.90% 94.90% 96.90% Cancer 62 days - 1st treatment following an urgent GP referral Apr13-May13 88.80% 85% 88.80% 83.30% 86.05% Cancer 62 days - 1st treatment following referral from Screening Service Apr13-May13 94.10% 90% 94.10% 100.0% 97.05% Cancer 62 days - 1st treatment following consultants decision to upgrade Apr13-May13 87.50% 85% 87.50% 100.00% 93.75% Ambulance Category A - Red 1 ( immediate life threatening and most time critical) response arriving within 8 mins - commissioner Apr13-May13 84.31% 75% 84% 79.76% 82.04% Ambulance Category A - Red 1 ( immediate life threatening and most time critical) response arriving within 8 mins - EEAST Apr13-May13 79.64% 75% 80% 76% 77.70% Ambulance Category A - Red 2 (life threatening but less time critical than Red 1) response arriving within 8 mins - commissioner Apr13-May13 81.28% 75% 81% 81% 81.02% Ambulance Category A - Red 2 (life threatening but less time critical than Red 1) response arriving within 8 mins - EEAST Apr13-May13 74.15% 75% 74% 73% 73.39% Ambulance Category A ambulance arrival within 19 mins - commissioner Apr13-May13 98.63% 95% 99% 97.44% 98.04% Ambulance Category A ambulance arrival within 19 mins - EEAST Apr13-May13 94.56% 95% 95% 94% 94.22% 18 week Referral to Treatment for completed admitted patients Apr13-May13 92.41% 90% 92.41% 90.75% 91.58% 18 week Referral to Treatment for completed non admitted patients Apr13-May13 96.71% 95% 96.71% 96.30% 96.51% 18 week Referral to Treatment - Incomplete pathway Apr13-May13 93.68% 92% 93.68% 94.40% 94.04% Diagnostic tests - % of patients waiting 6 wks or more Apr13-May13 98.62% 99% 98.62% 98.15% 98.39% A&E total time in Department - less than 4 hours Apr13-May13 96.33% 95% 96.33% 94.93% 95.63% Admitted directly onto an acute stroke unit within 4 hours of arrival to hospital Apr13-May13 52.20% 65% 52.20% 55.30% 53.75% Stroke patients spending at least 90% of their time on a stroke unit Apr13-May13 72.30% 80% 72.30% 66.70% 69.50% High risk TIA patients assessed and treated within 24 hrs Apr13-May13 66.70% 60% 66.70% 60.60% 63.65% Receive thrombolysis following an acute stroke Apr13-May13 12.20% 12% 12.20% 11.40% 11.80% Patients with low risk TIA have access to MRI or carotid scan within 7 Apr13-May13 51.60% 65% 51.60% 68.30% 59.95% 7

Performance Against Key National Indicators (Acute Providers) Performance against Key National Indicators - Acute Hospital Providers West Hertfordshire NHS Trust Luton & Dunstable Foundation NHS Trust Barnet and Chase Farm NHS Trust Latest Indicator Period Plan May-13 Apr-13 Latest YTD Plan May-13 Apr-13 Latest YTD Plan May-13 Apr-13 YTD Data Data Data Cancer 2 week waits following urgent GP referral for suspected cancer Apr13-May13 95.30% 93% 95.30% 96.60% 95.95% 93.40% 93% 93.40% 95.90% 94.65% 93.10% 93% 93.10% 93.10% 93.10% Cancer 2 week waits - Breast Symptomatic where cancer not suspected Apr13-May13 94.10% 93% 94.10% 91.60% 92.85% 94.60% 93% 94.60% 94.10% 94.35% 93.50% 93% 93.50% 93.70% 93.60% Cancer 31 day - 1st definitive treatment from diagnosis Apr13-May13 99.20% 96% 99.20% 98.10% 98.65% 100.00% 96% 100.0% 100.0% 100.00% 99.10% 96% 99.10% 100.00% 99.55% Cancer 31 day - Subsequent treatment for cancer - Surgery Apr13-May13 100.00% 94% 100.0% 100.0% 100.00% 100.00% 94% 100.0% 100.0% 100.00% 100.00% 94% 100.00% 100.00% 100.00% Cancer 31 day - Subsequent treatment for cancer - Drugs Apr13-May13 100.00% 98% 100.00% 100.00% 100.00% 100.00% 98% 100.00% 100.00% 100.00% 100.00% 98% 100.00% 100.00% 100.00% Cancer 31 day - Subsequent treatment - Radiotherapy Apr13-May13 0.00% 94% 0.00% 94% 0.00% 100.00% 100.00% 100.00% 94% 0.00% 100.00% 100.00% Cancer 62 days - 1st treatment following an urgent GP referral Apr13-May13 87.50% 85% 87.50% 86.20% 86.85% 88.10% 85% 88.10% 93.90% 91.00% 85.00% 85% 85.00% 86.10% 85.55% Cancer 62 days - 1st treatment following referral from Screening Service Apr13-May13 91.30% 90% 91.30% 100.00% 95.65% 100.00% 90% 100.00% 98.10% 99.05% 100.00% 90% 100.00% 90.00% 95.00% Cancer 62 days - 1st treatment following consultants decision to upgrade Apr13-May13 0.00% 85% 0.00% 100.00% 100.00% 0.00% 85% 0.00% 0.00% 0.00% 100.00% 85% 100.00% 100.00% 100.00% 18 week Referral to Treatment for completed admitted patients Apr13-May13 91.30% 90% 91.30% 89.88% 90.59% 92.60% 90% 92.60% 92.90% 92.75% 90% 93.20% 90.81% 90.81% 18 week Referral to Treatment for completed non admitted patients Apr13-May13 96.00% 95% 96.00% 95.50% 95.75% 97.40% 95% 97.40% 96.62% 97.01% 95% 98.80% 97.90% 97.90% 18 week Referral to Treatment - Incomplete pathway Apr13-May13 93.65% 92% 93.65% 95.03% 94.34% 95.89% 92% 95.89% 96.42% 96.16% 92% 90.25% 89.70% 89.70% Diagnostic tests - % of patients waiting 6 wks or more Apr13-May13 99.28% 99% 99.28% 99.45% 99.37% 97.88% 99% 97.88% 98.40% 98.14% 96.39% 99% 96.39% 94.87% 95.63% A&E total time in department - less than 4 hours Apr13-May13 98.87% 95% 98.87% 94.63% 96.75% 99.05% 95% 99.05% 97.40% 98.23% 89.90% 95% 89.90% 90.32% 90.11% Ambulance turnaround times (number > 15 minutes) Apr13-May14 322 0% 150 267 417 66 0% 66 133 100 Ambulance turnaround times (number > 30 minutes) Apr13-May15 40 0% 8 50 58 3 0% 2 22 24 Admitted directly onto an acute stroke unit within 4 hours of arrival to hospital Apr13-May13 51.90% 65% 51.90% 61.00% 56.45% 65.00% 65% 65.00% 39.50% 52.25% 65% Not a stroke admitting unit Stroke patients spending at least 90% of their time on a stroke unit Apr13-May13 75.90% 80% 75.90% 68.90% 72.40% 87.80% 80% 87.80% 84.00% 85.90% 94.70% 80% 94.70% 89.00% 91.85% High risk TIA patients assessed and treated within 24 hrs Apr13-May13 66.70% 60% 66.70% 60.00% 63.35% 85.70% 60% 85.70% 69.20% 77.45% 81.00% 60% 81.00% 81.00% 81.00% Receive thrombolysis following an acute stroke Apr13-May13 14.90% 12% 14.90% 12.00% 13.45% 17.90% 12% 17.90% 4.40% 11.15% 12% Not a stroke admitting unit Patients with low risk TIA have access to MRI or carotid scan within 7 days onset Apr13-May13 50.00% 65% 50.00% 59.20% 54.60% 79.10% 65% 79.10% 81.50% 80.30% 65% NA NA NA 8

Performance Against Key National Indicators (Community and Mental Health Providers) Performance against Key National Indicators Indicator 18-Weeks RTT: Consultant-led 18_Weeks RTT: Non-Consultant-led JCT Provider View (IAPT): Proportion of people with depression and/or anxiety disorders who received psychological therapies. JCT Commissioner View (IAPT): Proportion of people with depression and/or anxiety disorders who received psychological therapies. Annual Target 10% (7204 Patients). 2013/14 Trajectory 6.8% (4938 patients). Period HPFT Latest Data Plan May Apr YTD HCT Latest Data Plan May Apr YTD Apr-May 95% 98.00% 98.30% 98.00% Apr-May 95% 99.80% 99.80% 99.80% Apr-May 2013 1148pm 783 780 780 Apr-May 2013 411pm 405 418 418 JCT Provider View (IAPT): The proportion of people who are moving to recovery Apr-May 2013 50% 63% 58% 61% JCT Commissioner View (IAPT): The proportion of people who are moving to recovery Apr-May 2013 50% 62% 57% 60% 9

Performance Against CCG Outcomes Framework Performance against Outcome Frameworks Performance Indicator Under 75 mortality rate from cardiovascular disease - rate per 100,000 population - directly age/sex standardised Under 75 mortality rate from respiratory disease - rate per 100,000 population - directly age/sex standardised Under 75 mortality rate from cancer - rate per 100,000 population directly age/sex standardised Unplanned hospitalisation for chronic ambulatory care sensitive conditions - rate per 100,000 population Emergency Admissions for alcohol related liver disease - rate per 100,000 population - directly age/sex standardised Patient reported outcome measure: Hip replacement - Age, sex, and casemix adjusted Patient reported outcome measure: Knee replacement - Age, sex, and casemix adjusted Patient reported outcome measure: Groin Hernia - Age, sex, and casemix adjusted Proportion of People feeling supported to manage their long term condition Patient experience of primary care - GP Out of Hours Services - not standardised for age/sex, but survey responses are weighted for non-response Improving patient experiences of NHS Dental Services - not standardised for age/sex, but survey responses are weighted for non-response Health-related quality of life for people with long-term conditions Potential years of life lost from causes considered amenable to healthcare - adults over 20 - rate per 100,000 population - directly age/sex standardised Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s per 100,000 population Acute emergency admissions not usually requiring hospital admission - rate per 100,000 population Emergency admissions for children with Lower Respiratory Tract Infections under 19 - rate per 100,000 Reduce emergency readmissions within 30 days of discharge from hospital - % indirectly standardised Patient experience of primary care - GP Services - not standardised for age/sex, but survey responses are weighted for non-response Women who have seen a midwife by 12 weeks and 6 days of pregnancy Breastfeeding prevalence at 6-8 weeks People with diabetes who have received nine care processes Improvement in patients' access to GP Services Improvement in patients' access to NHS dental Services Period UK Mean Lowest in same ONS cluster as HVCCG Highest in same ONS cluster as HVCCG Latest HV CCG Data Comments 10/11-11/12 64 32 60 58 Relatively high within ONS cluster 10/11-11/12 29 14 22 22.0 Relatively high within ONS cluster 2011 122 90 112 108.5 Relatively high within ONS cluster 2011/12 930 250 675 633 Relatively high within ONS cluster 10/11-11/12 26 6 25 12 Relatively low within ONS cluster 2010/11-2011/12 0.40 0.40 0.46 0.42 Relatively low within ONS cluster 2010/11-2011/12 0.30 0.30 0.38 0.30 Relatively low within ONS cluster 2010/11-2011/12 0.85 0.08 0.13 0.08 Relatively low within ONS cluster Jul 11- Mar 12 52.00% 50.00% 60.00% 51.1% Relatively low within ONS cluster and compared to UK mean Jul 11- Mar 12 0.70 0.70 0.85 0.69 Relatively low within ONS cluster Jan 12 - Sep 12 0.83 0.80 0.90 0.83 Relatively low within ONS cluster Jul 11- Mar 12 0.74 0.72 0.80 0.78 Relatively high within ONS cluster 2009 & 2010 2150 1350 2000 1616 Mid-range within ONS cluster 2011/12 325 75 300 183 Mid-range within ONS cluster 2011/12 1050 250 1000 773 Mid-range within ONS cluster 2011/12 375 150 375 216 Mid-range within ONS cluster 2010/11 12.00% 8.00% 12.00% 10.3% Mid-range within ONS cluster Jul 11- Mar 12 0.90 0.90 0.93 0.9 Mid-range within ONS cluster Q4 12/13 NA Q4 12/13 NA 2010-11 NA Q3 2013-14 NA Q3 2013-14 NA 10

Quality Dashboard (Page 1) Domain Area National Quality Measures CQC Monitoring CQC Registrations CQC registrations with no conditions Preventing people Summary Hospital Q2 from dying Level Mortality SHMI Overall 2012 prematurely Indicator (SHMI) % of high risk TIA patients who are Helping people recover from episodes of ill health or injury Stroke Care Mixed Sex Accomdation (MSA) % treated patients within admitted 24hrsto a stroke bed within 4hrs from decision to admit % patients spending at least 90% of their time on a stroke unit Barnet & Chase Farm Hospitals NHS West Hertfordshire Hospitals NHS Trust East & North Hertfordshire NHS Trust HCT HPFT Trust Latest Period Benchmark Latest Period Benchmark Latest Period Benchmark Latest Latest Period Period Period Benchmark Period Benchmark Period Period Period Value RAG Value RAG Value RAG Value RAG Value RAG 100 109.3 Q2 2012 100 111.4 Q2 2012 100 85.3 May 60% 86.20% May 60% May 60% 80.8 May 90% 64.70% May 90% 76.30% May 80% 70.60% May 80% 73.80% May 80% 94.7 MSA breaches May 0 0 0 May 0 0 May 0 3 May 0 0 0 May 0 0 0 Complaints Number of complaints Q4 informatio n 165 Q4 informatio n 245 Q4 Not reported informatio n 75 Q4 for information 49 Q4 information 61 Ensuring that people have a positive expereince of care Ensuring that people have a positive expereince of care Friends & Family Length of Stay Number of patients completing a personal health plan with the aim to maximise selfmanagement and confidence To achieve Friends & Family Score Mar-13 a 10 point improveme Average length of stay non-stroke 72 Mar-13 To remain in the top quartile May 80% 100% 71 Unavailiable May 62% 60% May 21 days 35 11

information information information information Quality Dashboard (Page 2) West Hertfordshire Hospitals NHS Trust East & North Hertfordshire NHS Trust Barnet & Chase Farm Hospitals NHS Trust HCT HPFT Treating and caring for people in a safe environment and protect them from avoidable harm % Harm Free Care May 93.1 May 92.8 May 90.73 May 99.00 Pressure ulcers - new May 0.64 May 0.95 May 1.04 May 0.3 Safety Thermometer Catheters Falls with and Harm New May 0.48 May 0.32 Unavailiable May 1.93 May 0.31 UTIs May 0.16 May 0.63 May 0.37 May 0.00 Patient Safety Healthcare Acquired Infections (HCAI) Safeguarding Children New VTEs May 0.48 May 2.21 May 0 May 0.31 VTE screening May 95% 96.3% Apr 98% 97.88% May 90% 95.30% May 100% 99.00% Unavoidable Grade 3 &4 PUs Q1 4 aviod 5 unaviod information 6 TBC Q1 3 aviod 3 unaviod TBC informati on Q1 0 aviod 24 unavoid 5 TBC informatio n Q1 0 Never Events May 0 0 May 0 0 May 0 0 May 0 0 May 0 0 Total Serious Incidents Q1 46 Q1 24 Q1 2 Q1 44 Q1 7 Reported informatio information informatio informati informatio informatio information informatio information No. of C-Diff - Hospital May 24 0 2 YTD May 14 2 May 25 2 5 YTD May 14 0 4YTD May 2 0 acquired No. of MRSA - Hospital acquired Compliant with Childrens Act % of eligible staff trained at appropriated level of safeguarding children May 0 0 1 YTD May 3 0 May 4 0 1 YTD May 4 0 May 0 0 May Y/N Y May Y/N Y Unavailiable May Y/N Y May Y/N Y May 80% unavailiable May 95% in line with trajector y Unvailiable Unvailiable May 95% 85% Provided Quarterly informatio Treating and caring for people in a safe Safeguarding Adults environment and protect them from avoidable harm Workforce Compliance with surgical checklists % of staff who have undertaken level 1 safeguarding adults training (at induction) Compliance with all national standards including CQC and the Safeguarding Adult Assurance Framework (Annual) Use of WHO surgical checklist Total headcount May 95% 100% May 100% 100% May 85% 82% May 90% 79% Unavailiable Unavailiable Unavailiable May 100% 100% May 100% 100% May 100% 100% Not reported Not reported Not reported May information Unavailiable Sickness absence rate May 3.50% 3.10% May 3.50% 3.43% May 3.25% 2.92% May 3.50% 4.53% Indicator Staff turnover rate May 12% 12.20% May 10% 10.31% May 13.47% May 12% 16.40% Only Vacancy rate May 5% 7.30% May 6% Unavailiable May <10% 8.90% Not reported 2908 Unavailiable Unavailiable at this time but will be for future reports 12

Finance Overview 1. Summary Position The year to date position is a surplus of c 3.0m. This is largely the result of the planned surplus and uncommitted reserves including the Transformation Fund and contingency reserves. While the CCG is on course to achieve its required 1% surplus, an overspend is building at WHHT, and this needs to be addressed. It remains too early in the financial year to provide meaningful forecasts of the year-end in other than broad terms. They will be provided in future when information on performance becomes available. At present the best estimate is that the CCG will breakeven against plan. There are a number of risks, particularly around baseline allocation issues in relation to specialist services, and in this context the Governing Body may feel it is wiser to move slowly on further commitments of reserves. 2. Budgetary Position The summary budgetary position by service type is shown below : Description Annual budget (ISFE) ( 000) YTD budget ( 000) YTD Actual ( 000) YTD Variance ( 000) Programme Allocation (638,019) (159,505) (159,505) 0 Programme Costs Acute 373,794 94,525 94,419 106 Mental Health / LD 70,283 17,571 17,540 31 Community Services 53,201 13,300 14,125 (825) Continuing Care / FNC 21,183 5,296 5,296 0 Prescribing 67,252 16,585 18,403 (1,818) Other Primary Care 11,090 2,772 2,662 110 Other Programme Costs 34,250 6,574 4,296 2,278 Total costs 631,053 156,623 156,741 (118) PROGRAMME (SURPLUS) / DEFICIT (6,966) (2,882) (2,764) (118) Running Cost Allocation (14,440) (3,610) (3,610) 0 Running Costs 14,440 3,610 3,382 228 RUNNING COST (SURPLUS) / DEFICIT 0 0 (228) 228 TOTAL (6,966) (2,882) (2,992) 110 13

3. Acute Services Commissioning The acute providers position is shown below. Figures highlighted in red indicate where there is a deficit. HERTS VALLEY CCG FINANCE REPORT - COMMISSIONING OF ACUTE SERVICES CUMULATIVE POSITION AT 30th JUNE 2013 Description Annual Budget Budget to Date Spend to Date Cumulative YTD Surplus/(Deficit) '000 '000 '000 '000 % Local Trusts West Herts Hospitals 206,274 51,569 54,304 (2,736) (5%) Barnet & Chase Farm 33,610 8,402 8,355 47 1% Luton & Dunstable 14,170 3,542 3,696 (154) (4%) East & North Herts (Inc MVCC) 13,520 3,380 3,071 309 9% Buckinghamshire Hospitals 13,000 3,250 3,592 (342) (11%) Other Trusts Royal Free 10,556 2,639 2,345 294 11% UCLH 10,435 2,609 2,346 263 10% Royal National Orthopaedic 8,312 2,078 1,812 266 13% Imperial College 7,021 1,755 1,553 203 12% Royal Brompton 5,521 1,380 862 519 38% Hillingdon 4,510 1,127 1,247 (120) (11%) Moorfields 2,916 729 770 (41) (6%) North West London 2,701 675 675 0 0% Guy's & St.Thomas' 2,004 501 453 48 10% Barts & The London 1,647 412 113 299 73% Great Ormond Street 1,234 308 154 154 50% Oxford University 968 242 201 41 17% Chelsea & Westminster 692 173 173 0 0% Royal Marsden 656 164 164 0 0% King's College 493 123 361 (238) (193%) Whittington 341 85 83 3 3% Bedford 301 75 103 (28) (37%) North Middlesex 291 73 68 5 7% Heatherwood & Wexham Park 250 62 92 (29) (46%) Cambridge University 298 74 92 (17) (23%) St Georges 145 36 36 0 0% SLA Sub-Total 341,866 85,466 86,717 (1,251) (1%) Ambulance Services East of England Ambulance 18,310 4,577 4,578 (1) (0%) Independent Sector BMI 1,839 460 744 (284) (62%) Spire 1,296 324 474 (150) (46%) Other 599 150 147 2 2% Independent Sector Sub-Total 3,734 933 1,365 (432) (46%) Other Healthcare NHS Non Contract 169 42 47 (4) (10%) NCAs 2,891 723 722 1 0% UCC 2,268 567 556.25 11 2% IVF 1,365 341 341 0 0% Indivdual Funding Requests 359 90 89 1 1% Acute Reserve 2,832 1,785 0 1,785 100% Other Healthcare Sub-Total 9,884 3,548 1,756 1,792 51% Grand Total 373,794 94,525 94,417 108 0% 14

QIPP (Portfolio) Performance The dashboard below describes the status of the 5 programmes within the Portfolio as of 19.7.2013. PROGRAAMME NAME Older Peoples and Complex Care PROGRAMME LEAD Mental Health Mark Allen David Evans Urgent Care Keith Hodge Jane Ansell Planned and Primary Care Phil Griffin Marie-Anne Essam PROGRAMME MANAGER Position Vacant. 19/07/2013 Tim Anfilogoff Children, Maternity and Young Peoples Rami Eliad Sarbjit Purewal RAG RATING Amber / Green Amber Red Green Green PROGRESS STATEMENT The Mental Health programme is progressing well, has clearly defined leadership and goals. Further work is needed in respect of considering QIPP for 14/15, conducting a SWOT analysis and engaging patient representation. The group has a well established network and commissioning group meeting regularly. Some work on 14/15 QIPP has already been completed however further work is necessary to develop triggers, risk register, monitoring processes and create a winter pressures plan. The Planned and Primary Programme has not yet been successful in recruiting a Programme Manager and the Clinical Lead is due to step down at the end of July. Substantial progress on strategy and direction despite their lack of resource, however lack of delivery resource now results in current year QIPP targets being rendered undeliverable. Early release of intern support and allocation of low level project support is intended to mitigate this but a far more substantial solution is needed in order to support our largest programme. This group is progressing well, has established it's network, broad stakeholder engagement and has a finalised strategy owned by all stakeholders. Next steps are to review current active schemes, develop triggers and risk mitigation. The programme is making sound progress and has clear vision. Progress of this programme has been strategic in nature facilitated by no QIPP target in 13/14, further work remains in defining the 14/15 QIPP agenda for this programme and moving forward with delivery. DASHBOARD Name QIPP Commissioning Cycle Control of Active Projects Planning of Pending Projects Strategic Operation KPIs Risk Register Triggers Mental Health Urgent Care Planned and Primary Care Older Peoples and Complex Care Children, Maternity and Young Peoples 15

Quality Premium Additions Commissioner View Notes Weighting Domain Indicator Standard April May Domain 1: preventing people from Potential years of life lost from causes considered To earn this portion of the quality premium, the potential years of life lost >3.2% +12.5% dying prematurely. amenable to healthcare: adults, children and young people. ONS data not yet available. (adjusted for sex and age) from amenable mortality for a CCG population reduction will need to reduce by at least 3.2% between 2013 and 2014. +25% +12.5% Domain 2: Enhancing quality of Unplanned hospitalisation for chronic ambulatory care life for people with long term sensitive conditions (all ages) conditions. Domain 3: Helping Unplanned hospitalisation for asthma, diabetes and people to recover from episodes epilepsy in children of ill health or following injury. Emergency admissions for acute conditions that should not usually require hospital admission (all ages) The 2012-13 benchmark is being Emergency admissions for children with lower respiratory developed by Medeanalystics and tract infection. Domain 4: ensuring that people A CCG s local providers deliver the nationally agreed have a positive experience of care. Friends and Family test roll-out plan to the national timetable maternity services by the end of October 2013 and additional services (to be defined) by the end of March 2014. Improvement in average FFT scores for acute inpatient care and A&E services between Q1 2013/14 and Q1 2014/15 for acute hospitals that serve a CCG s population. - or = between 12/13 & 13/14 Or: < than 1000 in 100,000 population 100% Q1 14/15 > than Q1 13/14 92.65 94.84 4.56 7.93 Metric being developed by Medeanalytics. 2.03 1.01 Friends and Family Data will be available in respect of M1 & M2 2013-14 by M3. Thereafter to be reported Quarterly To earn this portion of the quality premium, there will need to be a reduction or a zero per cent change in emergency admissions for these conditions for a CCG population between 2012/13 and 2013/14, or the Indirectly Standardised Rate of admissions in 2013/14 is less than 1,000 per 100,000 population. See Indicators +12.5% Domain 5: treating and caring for there are no cases of MRSA bacteraemia assigned to the people in a safe environment and CCG; protecting them from avoidable C. difficile cases are at or below defined thresholds for the harm. CCG. 0 cases reported 0 0 108 11 10 Cdiff target predefined by NHS England on nasis of rate per 100,000 CCG population. To be confirmed by the CCG. Helping people live well with dementia: ensure that practices have in place 'dementia +12.5% champion' Diabetes: ensure that at least 20% of registered diabetic patients have a personal health plan in +12.5% place Supporting carers to care: increase the number of carers on practice registers by 50% and offer +12.5% 90% of the total an Annual Carers Health Check Dementia champions identified for all but small number of practices (<5). Monitoring arrangements currently being developed Carers champions identified for all but small number of practices (<5). Work progressing to populate registers and support funds identified. Deductions Weighting Domain Indicator Standard General Right to Withdraw Quality Premium. (Up to) -100% (Up to) -100% Serious Quality Failure Financial Gateway NHS E will reserve the right not to make any quality premium payments to a CCG in cases of serious quality failure, ie where the Care Quality Commission judges that a provider is in serious breach of its registration requirements. NHS E will want to understand the steps that the CCG has taken to monitor the quality of the care it has commissioned and the action it has taken, in collaboration with other parts of the system, should serious concerns about quality be identified. A CCG will not receive a quality premium if it has failed to manage within its total resources envelope, or has exceeded the agreed level of surplus drawdown, based on the principle that effective use of public resources should be seen as an integral part of securing high-quality services. The NHS E may also withhold or reduce a quality premium payment if a CCG does not meet requirements in relation to financial propriety -25% -25% -25% -25% 18 Weeks Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral. A&E 4-hour waits Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department. Cancer Wait times Maximum 62 day wait from urgent GP referral to first definitive tretment for cancer Ambulance Category A Red1 ambulance calls resulting in an emergency response arriving within 8 minutes >/= 92% 94% 94% >/= 95% 95% 96% >/= 85% 98% 97% >/= 75% 80% 84% 16