Update Report to Clinical Members Quarter 3; what have we done so far
Introduction: Dr Charlotte Canniff, Clinical Chair Following our Council of Members meeting in October we heard and recognised a clear message from our clinical members to do better in how we keep our GP Practices more connected and up to date with all of the work we do; raising the profile of some of the great things we achieve together. As such we have put together this quarterly update pack to give you a comprehensive overview of the range of work we engage in, what difference it is making and how some of this impacts our practices locally. We want to make this information responsive to what you want to know and have tried to address the themes that came up at the Council of Members meeting but if there are specific things you want to know about I would very much like to hear from you to inform the content of further updates. Overall this has been a highly challenging year so far with that same workload and operational pressure you see every day in primary care being replicated all across the NHS including for those clinical and managerial colleagues who plan and commission our services locally. The pressure and demands placed on us by the Secretary of State for Health, through our regulators in 2017 has been unprecedented with the continuous need to meet NHS constitutional targets for performance, waiting times and outcomes that are increasingly stretched at a national level; at a time in when more and more demand is being placed on all of our services, not least in General Practice. On top of all of this we have been required to deliver efficiency savings of 21m- the equivalent of 262 salaried GPs or 821 ward nurses; while re-organising at an STP level. Under this pressure we realise we need to refocus and redouble our efforts to have strong, meaningful engagement with our clinical members ensuring you have visibility of, and can lead and influence, all of the work we do. But in the face of these challenges we have still achieved so much, as you will see from some of the information presented within, Thank you for your continued engagement and support.
In this update We will try to tailor these updates to the things you want to know and have tried to respond directly to some of the questions raised at our last council of members. Our quarter 3 update includes: The Surrey Heartlands workforce programme and NW Surrey priorities Transformation and winter resilience monies The CCG s overall structure, financial position, assurance and monitoring by NHS England Locality Hub impact to date Primary care investment Approach for 2018/19
1. Workforce & Workload
Surrey Heartlands Primary Care Workforce Plan We recognise and appreciate the huge strain on primary care in terms of workload pressures and the challenges of recruiting and retaining the right workforce locally. We have taken a number of steps both in NW Surrey and across Surrey Heartlands to support our practices including: 166 GP trainees across Surrey Heartlands in from Sept 17 35 nurse mentors, 10 practices active with student nurses, 14 students placed Apr-Aug 12 North West Surrey GPs trained through the GP Leadership Programme Strengthening relationships across primary and secondary care- restarting the Clinical Interface Meetings across primary and secondary care, using specialist GPs to provide triage, support and more responsive feedback from secondary care pathways Building greater skill mix including supporting practices with bids for new primary care pharmacists (3.7 WTE) and paramedic practitioners in local surgeries
10 High Impact Areas to support practice workload
10 High Impact Areas to support practice workload
2. Transformation & Winter Monies
Winter Monies - Highlights Across this quarter we have had the opportunity to bid against central pots of funding held either by the STP or nationally with NHS England. NW Surrey CCG has been successful in securing significant additional national resources for the local system including: Bid for STP winter monies 390k National bid to NHS England winter fund 588k National bid to NHS England Primary Care Access Fund 166k Total Winter Funding 1.14m Winter funds have been deployed in primary care to secure additional clinical capacity across local practices over Christmas. As well as to support GP services in local Walk in Centres. Recent successful bid for funding for additional primary care capacity in the first quarter of the new year, at peak demand times.
Winter Monies Breakdown Total. 1.17m (Bid value 1.14m + 30k CCG contingency) Primary care funding sources additional practice clinics over Christmas (22 Dec 05 Jan). And additional clinics at peak evening and weekends between Jan - Mar
Transformation Monies - Diabetes North West Surrey, as the lead CCG, have also been successful in securing Transformation funding of 1.65m spent over 3 key areas Improving achievement of 3 NICE Treatment Targets (HbA1c, Blood Pressure, Cholesterol) - 963k Enhanced LCS- significant new investment in primary care delivery with the aim of implementation in January following conclusion of negotiations with the LMC in November Comprehensive clinician education curriculum Structured Patient Education- 519k Purchase of additional courses Taster sessions and new mechanisms for increasing uptake Diabetes Inpatient Nursing- 174k New nursing posts across Heartlands Trusts focused on training and specialist care
3. CCG Structure & Financial Position
North West Surrey CCG- Governance Structure The CCG s Governance Structure ultimately reports into its Council of Members and comprises a range of executive level forums (purple): Governing Body: providing final decisions and ratification on overall CCG business PCCC- overseeing primary care commissioning matters Clinical Executive- the main forum for clinical debate and decisions Operational Leadership Teammeeting of clinical and managerial directors used to test and form ideas Executive Team- manages the day to day running of the CCG The CCG s operations are informed by a range of sub-committees (Green) and its Strategic Commissioning Plan areas (Blue)
2017/18 Financial Position Key Performance Indicator Plan Actual Performance Deliver a breakeven position against the CCG Total Revenue Resource Limit (RRL) Remain within Cash Resource Limit (CRL) Better Practice Payment Policy (BPPC) Forecast year end Performance RAG Performance Improving? Key Messages 0.0m 0.5m 0.0m Red Year to date Month 8 (30th November 2017), the CCG reports a deficit of 0.5m against a breakeven plan. The forecast for the year is on plan to deliver breakeven. The red rating is driven by the YTD over performance and the level of risk in the forecast. There are a number of financial risks reported at Month 8 particularly surrounding QIPP delivery which are detailed within the report 1.25% of monthly drawdown 95% of valid invoices paid within 30 days (Volume) Financial Year 2017/18: Month Ending 30th November 2017 - Reporting Month 8 23.60% 1.25% of monthly drawdown Red The CCG cash balance is above the required 1.25% of the value of cash drawn down. This is due to a number of expected invoices not being received and number of issues (particularly with NHS Property Services) that are still under resolution. 93% 95% Amber The CCG is below the BPPC KPI in November 2017 but is expected to meet the target by year end QIPP Programme 19.8m 7.9m 12.8m Red The QIPP programme has a forecast shortfall of 7m. This represents the unidentified gap within the plan of 7.2m Remain within Running Costs Allocation 7.7m 5.1m 7.7m Green The CCG is on plan to meet its running cost target in both the year to date and forecast postions Key Performance Indicator Risk value Mitigation Net Risk RAG Performance Key Messages Risk ( 11.4) 3.3 ( 8.1) improving? The 8.1m net risk represents the value agreed with NHS England. The CCG reports a Month 8 (November 2017) deficit of 0.5m. This is against a plan year to date of breakeven resulting in over performance of 0.5m. The forecast year end performance is breakeven. The CCG reports delivery of 7.9m of savings against the 12.6m programme (63%) year to date with a forecast of 65% ( 12.8m) by the end of the year. The CCG reports delivery against the Corporate running costs target.
QIPP Programme 2017/18 QIPP Programme 2017/18 Annual Plan '000 Plan '000 Year to date Actual '000 Variance '000 Plan '000 Forecast Actual '000 Variance '000 Ashford & St Peters NHS Trust Joint Delivery Programme 7,000 3,429 1,735 1,694 7,000 4,954 2,046 CCG Schemes 5,621 4,404 6,188-1,784 5,621 7,830-2,209 Unidentified 7,200 4,800 0 4,800 7,200 0 7,200 Total QIPP required to deliver financial plan 19,821 12,633 7,923 4,710 19,821 12,784 7,037 63% 64% The total net savings target for the QIPP Programme for 2017/18 to deliver the current financial plan is 19.8m. The target at 30th November 2017 (Month 8) is 12.6m with reported performance of 7.9m resulting in a variance of 4.7m. This represents 63% delivery year to date. This under-achievement is predominantly driven by the unidentified QIPP.
Key CCG Risks 2017/18 North West Surrey CCG is currently forecasting a break even position in 17/18, delivery of this position is thought to be high risk - net risk 8.1m. Acute Contract performance Activity and costs exceeding the plan. Significant risk of over performance predominantly driven by Elective and Non Elective activity across a number of providers. This is the main risk for the CCG in year with significant risk of over performance on the main acute provider contract with limited mitigation to offset the risk. Specialist Activity & National Tariff The CCG has taken on significant additional risks from changes to the national tariff system for paying acute hospitals and the transfer of responsibilities from specialist commissioning Delivery of a significant and challenging QIPP Programme Most probable assessment of outturn is a deficit of c 4m.
4. Locality Hub Evaluation to Date
The Locality Hubs- Context & Update The Council of Members expressed a specific interest in the evaluation conducted to date of the Locality Hub development in Woking: The Locality Hubs have been part of the Royal College of Physician s future hospitals programme and as such have been subject to rigorous evaluation across Finance & Activity Impact Patient Satisfaction & Outcomes Impact on Staff The Bedser Hub currently manages a caseload of c. 2,500 patients, increasing on average by 60 per week. Clinical staff will begin working out of the Ashford Hub and estates work will be completed in mid January and transport services will be expanded to the whole CCG geography from the start of January enabling access for any Locality
Locality Hubs Demographics (Sept 17)
Spend on Locality Hubs The vast majority of clinical inputs provided at the Locality Hub are funding through core contracts that the CCG holds without any additional investment e.g. through the main community services contract with CSH. The CCG does fund additional service elements specific to the Locality Hubs outside of core contracts, which include: 2017/18 Service Element Forecast GP Cover 480,326 Consultant Support 60,349 Pharmacist 35,997 Patient Transport to Hub 121,961 Other Non Pay 62,065 Total 760,699
Bedser Hub - Impact on Admissions & Spend Bedser Hub Open
Bedser Hub - Impact on Admissions & Spend cont. NEL Activity (>75yrs) per 1000 population Two Year Period Jan15-Dec15 Jan17-Dec17* Variance Activity Growth Expenditure Growth SASSE 338 357 +19 +6% +176 + 702,839 Woking 360 362 +3 +1% +61 + 584,401 Thames Medical 337 365 +29 +9% +378 + 1,633,033 *Jan17-Oct17 Pro Rata Growth in NEL activity and cost in the last two years has in the over 75 population has been best contained within the Woking Locality
Bedser Hub Patient Satisfaction Reported drivers of satisfaction
Locality Hubs Next Steps The CCG is working with CSH as the new community services provider and partners all across the health and care system to improve the Locality Hub model including: Opening of the Ashford Hub and expansion of services into all GP Localities with a potential base at Walton and a developed outreach service in Thames Medical Expansion of hub services including outreach to all care homes residents Continued expansion of the caseload We also, however, recognise the opportunity to change, adapt and improve the fundamental clinical model and will work with our GP Localities in their February meetings to establish a preferred direction for Locality Hub services building up to a joint Clinical Commissioning Network with all practices and CSH in February to agree a plan for developing and changing these services that all parties are signed up to.
5. Primary Care Investment
Primary Care Spend Breakdown The CCG has invested significant resources into primary care services and development, broken down across the following areas: GP Forward View Planning Requirments: Primary Care Transformation Fund Invested in full through the Locality Transformation Scheme (LTS) to support forming the Locality Vehicle (NICS), collaborative working with CSH and development of the proposal for delivering GPFV Extended Primary Care Access in 2018/19 547,500 On-line General Practice Consultation Software Systems Money not yet received, in the process of bidding for all practices to have access to e-consultation software 96,000 Training Care Navigators & Medical Assistants Funding HERE to support workflow optimisation, managing documents and practice admin 64,000 Estates and Technology Transformation Fund Bidding to support surgeries with relocation and significant estates improvement 708,000 GPFV Implementation Capacity - Recurrent Funded GP Leadership Programme 41,000 Delivery of additional GP surgeries at evenings, weekends Primary Care Winter Resillience and bank holidays between Dec and Easter 365,200 Total GP Forward View Funding 1,821,700 CCG Led Primary Care Contractual Payments Core GMS contract payments 39,306,597 Contractual Payment Growth Protected reserve and contingency 3,491,000 PMS Premium Release To be reinvested into new LCSs 131,403 Locally Commissioned Services Funding of all LCS contracts in NW Surrey 2,587,856 GP IT Practice WiFI, EMIS anywhere and laptops, MJOG text messaging service, EMIS Enterprise 945,446 Locality Hub GPs GP sessions and clinical leadership in Locality Hubs 480,000 Primary Care Engagment Funding for attendance at GP Locality Meetings and other regular CCG commitments 235,620 Total CCG Led Investment 47,177,922 Total Investment 48,999,622
Locally Commissioned Services One of the most significant areas of CCG direct investment in Primary Care is through Locally Commissioned Services. The CCG invests just under 2.6m across the following LCS contracts: ADHD Medications (LHRHa, Denosumab, Rheumatology drug monitoring) Minor Surgery Doppler INR Phlebotomy Pre-diabetes Register Diabetes Interim Checks 24hr BP Monitoring In addition there are a number of new LCSs that have been agreed and are due for implementation with the following new investment Expanded diabetes LCS c. 400k for North West Surrey ECGs - 131k Ring Pessary fitting - 40k
Approach for 2018/19 We recognise the need to develop a strong programme of service transformation and improvement work in 2018/19 that is genuinely shaped and agreed with our GP Localities. We have set a number of principles by which the 2018/19 Programme will be designed: Clinical engagement will be at the core of the 2018-19 work; the programme will be shaped and agreed with the clinical membership in both primary and secondary care. Strong mechanisms will be established to seek and incorporate wide ranging clinical views and update clinical/operational colleagues on progress A smaller, manageable number of significant transformation initiatives will be agreed which enables both the clinical and managerial workforce the time and capacity to properly engage and deliver Reducing variation, improving clinical quality and driving efficient management of workload will be the main drivers for service transformation- there must be a strong case that clinical outcomes or patient experience will improve; or that there are clear benefits to our local workforce in reducing workload, extending patient facing time and streamlining processes Pathway redesign will consider the whole pathway and the impacts on different parts of the health and care system Projects will be overseen by teams with strong clinical leadership from primary, community and secondary care. A clear and streamlined structure will be put in place to support service improvement and manage the pace of change in practice Better feedback mechanisms- stronger engagement, publicising progress & success, listening, responding and incorporating into work programmes Appropriate resourcing- delivering significant and sustainable service change requires a high managerial and clinical time commitment and must be planned for appropriately
Ideas so far (1) In our discussions with clinicians and provider partners so far a number of key programme areas have come up for consideration in 2018/19. These are not finalised and will need extensive input with Localities but include:
Ideas so far (2) In our discussions with clinicians and provider partners so far a number of key programme areas have come up for consideration in 2018/19. These are not finalised and will need extensive input with Localities but include:
This is our first quarterly update pack to our clinical members, we want them to be valuable and relevant to the things you want to know. If there is any further information you want to know, specific queries you have or if there is something you would like to see in the next CCG update pack please do contact me. Dr Charlotte Canniff Clinical Chair, North Surrey CCG c.canniff@nhs.net