Joint Commissioning Board – Stockport Council and NHS Stockport CCG

1. APOLOGIES FOR ABSENCE To note any apologies submitted from Members of the Board.

2. DECLARATIONS OF INTEREST Board Members to declare any interests which they have in any of the items to be considered as part of the agenda.

3. MINUTES OF THE PREVIOUS MEETING To approve the minutes of the meeting held on12 May 2017 as a correct record

4. PUBLIC QUESTIONS To consider and respond to any questions submitted by Members of the Public related to the remit of the Health and Care Integrated Commissioning Board no later than 24 hours prior to the meeting. Questions should be submitted in writing to laura.latham1@nhs.net

*Any questions requiring detailed response will be shared with the Board and responded to following the meeting in writing.

5. REPORT OF THE DIRECTOR OF INTEGRATED COMMISSIONING To receive an update from the Director of Integrated Commissioning

6. INTEGRATED FINANCE AND PERFORMANCE REPORT

To consider a report detailing the finances of the Pooled Budget and the related performance indicators and measures.

7. DATE OF NEXT MEETING

The next meeting of the Health and Care Integrated Commissioning Board will take place on 27 November 2017

Health and Care Integrated Commissioning Board

AGENDA

Tuesday 18 July 2pm – 4pm

To be held in Room 6, Town Hall, Edward Street, Stockport

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Present

• Councillor Alex Ganotis, Stockport Metropolitan Borough Council • Councillor Wendy Wild, Stockport Metropolitan Borough Council • Councillor Tom McGee, Stockport Metropolitan Borough Council • Ms Jane Crombleholme, Stockport Clinical Commissioning Group • Dr Ranjit Gill, Stockport Clinical Commissioning Group

In Attendance

• Mrs Gaynor Mullins, Director of Integrated Commissioning, Stockport Clinical Commissioning Group and Stockport Metropolitan Borough Council and Chief Operating Officer, Stockport Clinical Commissioning Group

• Mr Mark Chidgey, Chief Finance Officer, Stockport Clinical Commissioning Group • Mr Michael Cullen, Borough Treasurer, Stockport Metropolitan Borough Council • Mrs Laura Latham, Associate Director Corporate Governance, Stockport Clinical Commissioning

Group • Mrs Sally Wilson, Senior Head of Service Redesign and Market Management

1. APOLOGIES FOR ABSENCE Apologies were received from Dr Andrew Johnson.

2. DECLARATIONS OF INTEREST There were no declarations of interest on this occasion.

3. MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on 6 April 2017 were agreed as a correct record.

4. PUBLIC QUESTIONS There were none received on this occasion.

Health and Care Integrated Commissioning Board

DRAFT MINUTES

Friday 12 May 2017

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5. REPORT OF THE DIRECTOR OF INTEGRATED COMMISSIONING G Mullins provided an overview of a number of matters related to integrated commissioning which had been the subject of significant work in recent months. In particular she noted the continued focus on urgent care performance and the establishment of a Discharge Board.

*Councillor Wild joined the meeting.

The Board considered the proposal regarding the creation of a strategy for adult social care to bring together existing strands of work and to focus on social care service development, current and future demand and capacity, quality improvement of care home / home care capacity, approach to management of transitions from children’s to adult services, workforce development needs and future approach to commissioning. She noted the importance of ensuring the strategy was fully aligned to the Stockport Together Transformation and Business Cases. It was confirmed that the development of a strategy in Stockport would be fully aligned to work being undertaken at a Greater Manchester Level.

M Cullen confirmed that it was proposed that the Pooled Budget for 17/18 would remain broadly the same with only minor amendments being proposed. The Section 75 Agreement was being refined to reflect the current position on the integration journey.

In response to questioning, G Mullins confirmed that the Discharge Board required strong focus and governance and the right representation from partner organisations to ensure business was managed effectively at the required pace and actions implemented.

Resolved: That the Health and Care Integrated Commissioning Board note the updates contained within the report and agree with pulling together strategic approach to adult social care issues, across partnership taking into account Greater Manchester perspective.

6. BUDGET MONITORING REPORT

M Cullen presented the provisional financial position at the end of 2016/17 for the pooled budget in place as part of the Section 75 Agreement in place between the Joint Commissioners. He confirmed that the provisional year end position included a deficit of £1.198million and highlighted the specific areas where a deficit or surplus had been reported. He noted in particular that there had been a £257k non-recurrent increase from the Council position on the basis of one off severance costs relating to the public health service.

He confirmed that as per the terms of the Section 75 Agreement, both organisations will include as part of organisational accounts for the 2016/17 year a pooled budget statement as aligned to the approach to risk agreed by Commissioners.

Resolved: That the Heath and Care Integrated Commissioning Board note the outturn position of £1.198m deficit.

7. STOCKPORT SEGMENTATION AND OUTCOMES FRAMEWORK The Board considered an update report from Mark Chidgey on the approach to segmentation in Stockport and the development of the Outcomes Framework at Phase One and outlined the proposed Phase 2 developments. He noted the whole population approach which had been undertaken, including the role of Expert Reference Groups, in developing the detailed clinical and personal measures.

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He noted the focus in shifting the Commissioning approach and the delivery of integrated services from one focused on acitivty to one focussed on patient outcomes. The next steps were outlined as finalisation of the clinical measures and development of an approach to monitoring and testing the delivery of outcomes in real time supported with a proposed IT platform. The Board was informed of the significant engagement work which had been undertaken to date and would continue to take place. The following elements were highlighted in detail by the Board:

• The importance of ensuring that the Stockport and Greater Manchester approaches to commissioning for outcomes were aligned and Stockport continued proactive engagement and communication with Greater Manchester Health and Social Care Partnership.

• Recognising that, where risks exist, the mitigations which are in place to ensure they are managed effectively.

• Acknowledgement of where there are differences between the Stockport strategy and its implementation and the wider Greater Manchester approach.

• Consideration by the Expert Reference Groups that obesity not be defined as a long term condition within the definition of outcomes framework measures.

• The importance of developing and managing the value chain as linked to the delivery of the model of care.

• The link between the segmentation included within the Outcomes Framework and the link to NICE guidance.

• The need to ensure continued alignment of the development of the Outcomes Framework to the wider Stockport Together Programme and the importance of balancing pace of delivery and the innovative nature of Vanguard work

J Crombleholme acknowledged the progress which had been made in this area of work and its role as fundamental component of the future approach to commissioning in Stockport. The Board confirmed it wished to be kept appraised of continued progress and the development of the framework as part of the implementation of the new care models.

In response to questioning, M Chidgey confirmed that the level of payment attached to the delivery of the outcomes measures within the Framework had to be of a suitable level to incentivise provider organisations to deliver. He explained that there was no clear Greater Manchester view on this at the current time but that Stockport were actively engaged in the ongoing discussions.

Resolved: That the Health and Care Integrated Commissioning Board:

1. Re-confirms that an Outcomes Framework approach is core to the future model of commissioning. 2. Confirms that the work completed to date as Phase 1 progresses the Stockport system towards that goal. 3. Endorses the progression to towards Phase 2 as outlined in the report. 4. Agrees that continued alignment of approaches to Outcomes Framework Development between Stockport and Greater Manchester be proactively undertaken and where differences of strategy emerge, they are fully considered in the light of benefits to the Stockport population. 5. Requests to be kept appraised of the continued development of the Outcomes Framework.

8. DATE OF NEXT MEETING The next meeting of the Health and Care Integrated Commissioning Board will take place on 18 July 2017

Closed 09.28am

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Data Set for HCICB

Context The 2015/16 JSNA for Stockport describes a population that is generally healthy, however one which is older than average and where the proportion of older people is forecast to grow faster than average. Stockport has health outcomes that are better than the North West averages but also has challenging health inequalities. A&E and non-elective care performance has been poor for a significant time and the economy collectively forecasts a c£157m deficit by 2020/21 unless delivery of care is transformed. The overall objectives for health and wellbeing in Stockport are to improve life expectancy and reduce health inequalities. These remain unchanged since the previous JSNA review in 2011. Following the 2015/16 JSNA analysis of key trends across a range of themes, work has been undertaken to identify the key priorities for health and wellbeing in Stockport for the next three years. These are the major issues that leaders, commissioners and providers of health, care and wider services will need to consider or address:

The outcomes framework that the JSNA priorities were developed against has been updated and reissued in April 2017. Whilst the local outcomes framework remains in development we will continue to use the national framework as an indicator of changes to our population’s health and care outcomes. The updated framework is attached as Appendix 1 and a summary of the key changes is set out below.

Priorities 2016-2019

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All Ages Start Well Live Well Age Well

Prev

entio

n Increasing levels of physical activity as an effective preventative action at any age.

Taking action to improve the outcomes in early years health and education in deprived communities.

Prioritising a whole systems approach to reducing smoking, alcohol consumption and obesity as the key causes of preventable ill health and early death.

Supporting healthy ageing across Stockport, recognisingthat preventative approaches that promote self care and independence are essential at every life stage.

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Focus on improving healthy life expectancy for all as the priority, focussing especially inthe most deprived areas and in a person and family centred way.

Promoting the mental wellbeing of children and families, especially for older children and young adults.

Improve the prevention, early detection and treatment of both cancer, now the major cause of premature death, andliver disease, which is increasing.

Aim to prevent and delay the need for care whilst responding to the complexity of needs that older people with multiple long term conditions may have.

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Continue work to integrate and improve care systems,especially minimising the use of unplanned hospital care -ensuring that the healthy economy is sustainable and prevention focussed.

Ensuring that the acute care needs of children and young people, especially for injuries, asthma and self harm are dealt with appropriately and opportunities to promote prevention are maximised.

Giving equal weight to mental wellbeing as a key determinant of physical health and independence; especially for people of working age.

Providing services and housingthat are suitable for the changing needs of our ageing population and those with specialist needs.

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Understanding the size and needs of our vulnerable and at risk groups, especially carers, and using JSNA intelligence to inform the appropriate levels of response.

Supporting and safeguarding the most vulnerable children and young people and families, especially looked after children and those with autism, so that they have the opportunity to thrive.

Improving the physical health and lifestyles of those with serious mental health conditions.

Continuing to improve the identification of and support available to those with dementia and their carers.

The overall objectives for health and wellbeing in Stockport are to improve life expectancy and reduce health inequalities. The priorities identified in 2015/16 JSNA to help us achieve these objectives are set out below, and are developed in further at http://www.stockportjsna.org.uk/2016-2019-priorities/

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Overview of Data

The charts below show the trends in key outcomes/indicators in recent years. In summary they reflect the outcomes data above, i.e. an economy with good mortality rates for the non-deprived areas, good patient experience but no discernible improvement in reducing our dependency on hospital based care. This represents the opportunity for Stockport Together and this report aims to support HCICB to monitor improvement in outcomes quarterly and annually as we invest in integrated health, mental health and social care. In advance of this investment and implementation of new models of care we draw the attention of the HCICB to the following areas for improvement; mortality in deprived areas and in mental health and in reduced hospital admissions.

Existing data sets have been used and can be updated quarterly. A key progression will be replacing this data set with the Stockport Outcomes Framework.

Better Health? Is the health of the population of Stockport improving?

1. Are Mortality rates improving? The graphs below show the trend in mortality rates for men and women has improved consistently since 2005 and has stabilised since 2014. We should expect to see the downward trend continuing, so therefore need to be concerned about the plateauing out of this trend for males. Stockport benchmarks as average nationally.

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Significant Change since 2015 Upper Quartile

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1.4 Myocardial infarction, stroke and stage 5 CKD in people with diabetes. 1.2 Under 75 mortality rates from cardiovascualar disease1.5 Mortality within 30 days of hospital admission for stroke 1.10 1 year survival from all cancers1.7 Under 75 mortality rates from liver disease 1.11 1 year survival from breast, lung and colorectal cancers1.8 Emergency admissions for alcohol related liver disease 1.24 Referrals to cardiac rehab within 5 days of admission2.6 Unplanned hospitalisation for chronic Amb care sensitive conditions 2.9 Access to community Mental Health by people from BME groups2.7 Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s 2.10 Access to Pschological Therapies by people from BME groups. Yes2.8 Complications associated with diabetes 2.16 Health related QuALYS for people with long term MH condition2.11a % of referrals to IAPT which indicated a reliable recovery 3.3 Elective hip replacement PROM measure.2.11b % of referrals to IAPT which indicated a reliable improvement. 3.3 Elective knee replacement PROM measure.3.1 Emergency admissions for acute conditions that should not usually require hospitilisation Yes 3.5 People who have had a stroke who are admitted to an acute stroke unit within 4 hours3.6 People who have had an acute stroke receiving thrombolysis 3.9 People who have had an acute stroke who spend 90% on time on dedicated stroke unit Yes3.14 Alcohol specific hospital admissions 3.12 Hip fracture timely surgery3.15 Emergency alcohol specific readmission within 30 days 4.1 Patient experience of OOH GP services3.16 Unplanned readmissions to MH services within 30 days3.17 % of adults in contact with secondary MH services in employment Yes5.4 Incidence of Health Care Associated Infections C-Diff

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2. Is the mortality rate in deprived areas improving more than for Stockport overall?

The graphs below show that the trend in mortality rates in deprived areas has also improved in the long term. However mortality rates are still significantly higher in deprived areas, and the pace of change has meant gaps have not narrowed. The HCICB queried the trend for women’s mortality in deprived areas since 2008. There is no evidence that as yet there is a sustained improvement. Comparisons for benchmarking are not readily available.

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3. Is mortality for people with mental illness improving? The graph below shows that there has not been a significant improvement in reducing premature mortality in adults with serious mental health, and that the mortality rate for this group is more than three times higher than average. Stockport benchmarks as average nationally.

Better Care? Are more people being treated closer to home?

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4. Are fewer people attending A&E? The chart below shows that the number of A&E attendances for the Stockport CCG population has increased since March 16. We would expect to see these numbers reduce as we invest in primary care access.

5. Are fewer people being admitted to hospital? The heath and care economy aims to reduce emergency hospital admissions by 30% for those most at risk of admission. Stockport is an outlier nationally in emergency admissions. Since September 16, the control chart shows an increase in emergency admissions. This can be demonstrated to be restricted to 0-1 day length of stay admissions. We are assessing the causal link between this increase and recent increases in ambulatory care capacity. If proven this would represent progress in Stockport Together implementation.

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A&E Attendances - Stockport CCG

Actual A&E Attendances CCG Average A&E Attendances CCGUCL A&E Attendances CCG LCL A&E Attendances CCG

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Emergency Admissions - Stockport CCG

Actual All Emergency Admissions CCG Average All Emergency Admissions CCGUCL All Emergency Admissions CCG LCL All Emergency Admissions CCG

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6. Are fewer people being readmitted to hospital as an emergency? The chart below shows that there has been a reduction in emergency readmissions at Stockport FT for the Stockport CCG population, since late 2014. The recent trend since November 2016, is for an increase in readmissions but this is not yet sufficient to amend the control limits.

7. Are people being discharged from hospital when they should be?

In Q4 2016/17 Stockport’s DTOC rate per 100,000 OF population was above the national average and was also high in relation to its peer group, as shown in the chart below. The second chart below shows that we should expect this benchmarked position to improve in Q1 2017/18 if the March 2017 levels are maintained and improved.

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Occupied Bed Days (CCG) - 0-1 day LoS

Actual Occupied Bed Days (CCG) - 0-1 day LoS Average Occupied Bed Days (CCG) - 0-1 day LoSUCL Occupied Bed Days (CCG) - 0-1 day LoS LCL Occupied Bed Days (CCG) - 0-1 day LoS

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Emergency Readmissions at SFT - Stockport CCG

Actual Emergency reattendances Average Emergency reattendancesUCL Emergency reattendances LCL Emergency reattendances

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The chart below shows that the increase in the number of days that patients are delayed in the transfer of care from hospital peaked in September 2016. Since then, the number of delayed days has reduced and by March 17 had returned to a level that should be consistent with the peer group average. The March 17 level is anticipated to be maintained and improved upon in Q1 2017/18.

There remain a number of challenges within the current care market in relation to capacity not meeting requirements both in relation to volume, suitability and quality. There are a number of factors that have led to this situation and a number of risks that have been identified that will need to be addressed and managed in the short term and in the longer term through the development of the Adult Social Care commissioning strategy. Challenges identified include the ability to recruit and retain a quality workforce; the significant self-funder customer base that are able to pay for their own care or that of a family member at a premium rate; the volume and complexity of individuals needs that require support from the market.

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Stockport Council spends more on Adult Social Care per head of Adult population than other GM Authorities. It is ranked first in the North West in relation to the proportion of people receiving long term support in the community and the proportion receiving community based services through a direct payment. Over the two years there has been a year on year growth in the provision of home care in excess of 10% per annum. This has included additional services being commissioned specifically to support DTOC. The council continues to prioritise the identification of packages to support discharges form hospital and continues to agree fee rates significantly above its usual fee rates to support discharge.

Priority areas have been agreed in the short, medium and longer term to address immediate capacity issues, to understand the reason for what appears to be the greater demand for services, and to develop the market to deliver the requirements for the future linked to the Stockport Together new models of care.

8. Are more people accessing Intermediate Care services (instead of being in hospital)? The charts below shows that there is a declining trend in the number of people using ‘step-up’ and ‘step-down’ services. We would expect the ‘step-up’ trend to increase and the ‘step-down’ trend to decrease as more people are supported outside of hospital.

9. Are people still at home after reablement/rehabilitation services? The chart below shows a consistent proportion of people still at home 91 days of receiving reablement services.

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10. How many of the Stockport population are admitted to residential and nursing care? The chart below shows the number of admissions to residential and nursing care has not shown a statistical change since April 2015.

11. Are falls resulting in harm reducing? The graph below shows that there has been a reduction in the number of admissions for the Stockport CCG population for injuries and harm resulting from a fall in the last two years. The most recent four months have been above the average but this is not yet significant.

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2017

02

Care Home Admissions / Placements

Actual Admissions to Care Homes Average Admissions to Care HomesUCL Admissions to Care Homes LCL Admissions to Care Homes

015

12. Are people reporting an improved experience of services? Patient experience is shown by Provider and is not possible to aggregate into a summary chart. The charts below show Friends and Family results for Stockport Foundation Trust, University Hospital of South Manchester, Pennine Care Foundation Trust and Stockport GPs. Each line represents the proportion of people/carers who are ‘extremely likely’ or ‘likely’ to recommend the service.

It is difficult to discern clear trends on the majority of data but it appears that SFT community and outpatient services have been consistently below the England average. GP services have consistently remained at or above the national average.

50

70

90

110

130

150

170

2014

04

2014

05

2014

06

2014

07

2014

08

2014

09

2014

10

2014

11

2014

12

2015

01

2015

02

2015

03

2015

04

2015

05

2015

06

2015

07

2015

08

2015

09

2015

10

2015

11

2015

12

2016

01

2016

02

2016

03

2016

04

2016

05

2016

06

2016

07

2016

08

2016

09

2016

10

2016

11

2016

12

2017

01

2017

02

2017

03

Injuries from falls in people aged 65 and over

Actual Injuries due to falls Average Injuries due to falls UCL Injuries due to falls LCL Injuries due to falls

016

75%

80%

85%

90%

95%20

15 0

420

15 0

520

15 0

620

15 0

720

15 0

820

15 0

920

15 1

020

15 1

120

15 1

220

16 0

120

16 0

220

16 0

320

16 0

420

16 0

520

16 0

620

16 0

720

16 0

820

16 0

920

16 1

020

16 1

120

16 1

220

17 0

120

17 0

220

17 0

320

17 0

4

A&E Services

England SFT UHSM

88%90%92%94%96%98%

100%

2015

04

2015

05

2015

06

2015

07

2015

08

2015

09

2015

10

2015

11

2015

12

2016

01

2016

02

2016

03

2016

04

2016

05

2016

06

2016

07

2016

08

2016

09

2016

10

2016

11

2016

12

2017

01

2017

02

2017

03

2017

04

Inpatient Services

England UHSM SFT

80%

85%

90%

95%

100%

2015

04

2015

05

2015

06

2015

07

2015

08

2015

09

2015

10

2015

11

2015

12

2016

01

2016

02

2016

03

2016

04

2016

05

2016

06

2016

07

2016

08

2016

09

2016

10

2016

11

2016

12

2017

01

2017

02

2017

03

2017

04

Outpatient Services

England UHSM SFT

84%86%88%90%92%94%96%

2015

04

2015

05

2015

06

2015

07

2015

08

2015

09

2015

10

2015

11

2015

12

2016

01

2016

02

2016

03

2016

04

2016

05

2016

06

2016

07

2016

08

2016

09

2016

10

2016

11

2016

12

2017

01

2017

02

2017

03

2017

04

GP Services

England Stockport GPs Overall

70%75%80%85%90%95%

100%105%

2015

04

2015

05

2015

06

2015

07

2015

08

2015

09

2015

10

2015

11

2015

12

2016

01

2016

02

2016

03

2016

04

2016

05

2016

06

2016

07

2016

08

2016

09

2016

10

2016

11

2016

12

2017

01

2017

02

2017

03

2017

04

Community Services

England UHSM SFT

70%

75%

80%

85%

90%

95%

2015

04

2015

05

2015

06

2015

07

2015

08

2015

09

2015

10

2015

11

2015

12

2016

01

2016

02

2016

03

2016

04

2016

05

2016

06

2016

07

2016

08

2016

09

2016

10

2016

11

2016

12

2017

01

2017

02

2017

03

2017

04

Mental Health Services

England Pennine Care FT

017

018

CCG Outcome Framework – April 2017 - http://ccgtools.england.nhs.uk/ccgoutcomes/flash/atlas.html

019

020

021

022

To: Health & Care Integrated Commissioning Board (HCICB) From: Stockport Council Financial Services, Stockport CCG Finance Subject: 2017/18 Budget Monitoring – Quarter One Date: 18th July 2017

1. Introduction

This report focuses on the financial performance at Quarter 1 for the 2017/18 Section 75 pooled budget between Stockport Council and Stockport CCG. The s.75 agreement for 2017/18 is in the process of being finalised.

2. Budget Position at Quarter One

The table below provides a summary by commissioning organisation of the total draft budget resources available at Quarter 1 2017/18. Using the budget reported in the Outturn budget report discussed at HCICB on the 12th May 2017 as a starting point.

Table One – Draft Budget Position at Quarter 1

Commissioner 2016/17

Outturn Budget

£000

Movement(s)

£000

2017/18 s.75 Indicative

budget contributions

Movement(s)

£000

Quarter 1 2017/18 Budget

£000

Stockport Council 84,792 (2,553) 82,239 2,196 84,435 Stockport CCG 114,323 550 114,873 0 114,873 Total 199,115 (2,003) 197,112 2,196 199,308

Stockport Council: The pooled budget has decreased by £2.553m from the Outturn budget to reflect the opening agreed pooled budget contribution by the Council of £82.239m which is being included within the s.75 agreement for 2017/18:

• (£0.054m) remove the transition fund for schemes within Health Policy which

was non recurrent funding into 2016/17. • (£0.203m) remove 2016/17 non recurrent funding for redundancies within the

Public Health service. • (£2.596m) saving target aligned to Adult Social Care service rephased from

2016/17. • (£1.616m) balance of brought forward saving requirement for Adult Social Care. • (£0.220m) advanced payment of superannuation aligned to Adult Social Care

and Health. • (£0.358m) saving target aligned to Adult Social Care and Health for staff travel

and overtime following review of policies. • (£0.406m) Public Health grant cut for 2017/18. • £1.616m corporate funding of saving requirement aligned to Adult Social Care • £1.000m additional recurrent funding into Adult Social Care for Demographics. • £0.273m 1% Pay award for Adult Social Care and Council employed Health staff.

Page 1 of 10 023

• £0.011m additional Adult Social Care precept.

During Quarter 1 a net additional contribution of £2.196m has been made into the pooled budget, these adjustments are outlined below;

• (£0.047m) centralisation of mail budgets. • (£0.015m) centralisation of Multi-functional devices. • £2.151m additional investment into Adult Social Care for additional

demographics, demand and known price inflation e.g. agreed home care price increase

• £0.076m Additional funding into Stockport Local Assistance Scheme (SLAS) for clothing grant transfer.

• £0.031m income transfer for Newbridge Lane into the Investment and Development account.

Including all of the adjustments illustrated above the Q1 contribution into the pooled budget from the Council is £84.435m. It is noted that not all contingent amounts for price and demand increases set aside for Adult Social Care have been formerly allocated to the budget, as not all contractual agreements have been finalised. These amount to £1.917m and are likely to be confirmed at Q2. Stockport CCG has a rolled forward budget equating to the final recurrent 16/17 out-turn of £114.873m

3. Quarter 1 position by service 2017/18

The table below provides a summary by Commissioner of the provisional outturn

position. In summary, this illustrates a £0.677m deficit. (+0.3% variance).

Table Two: Quarter 1 Position by Service 2017/18

Commissioner Service / Portfolio Quarter 1 2017/18 Budget

£000

Forecast Q1

£000

Variance

£000 Stockport Council Adult Social Care 68,029 68,679 650 Stockport Council Health 16,406 16,406 0 Stockport CCG Acute - NHS

Providers 66,369 66,369 0

Stockport CCG Acute – Independent sector

3,299 3,334 35

Stockport CCG Non Acute and Other Health

45,205 45,197 -8

Total 199,308 199,985 677 4. Budget Position at Quarter 1 by POD 2017/18

Page 2 of 10 024

The table below illustrates the pooled budget resource based on Points of Delivery

(PODs) and includes any budget realignments between 2016/17 Outturn and Quarter 1 2017/18.

Table Three: Resource changes by Point of Delivery

Points of Delivery Commissioner 2016/17 Outturn Budget

£000

Movements

£000

Quarter 1 2017/18 Budget

£000 Prevention SMBC 22,159 (933) 21,226 SCCG 368 0 368 Boroughwide Services SMBC 7,277 (6) 7,271 SCCG 4,660 0 4,660 Community / Out of Hospital

SMBC 69,556

582

70,138

SCCG 41,817 (1,640) 40,177 Acute SMBC 0 0 0 SCCG 67,478 2,190 69,668 Better Care Fund SMBC (14,200) 0 (14,200) Total 199,115 193 199,308

See Section 2 for movements to Stockport Council budgets.

5. Quarter 1 Forecast by POD 2017/18

The provisional Quarter 1 position by POD is reflected in the table below. Further analysis is illustrated in Appendix 1 of this report.

Table Four: Quarter 1 forecast by Point of Delivery Points of Delivery Commissioner Quarter 1

2017/18 Budget

£000

Forecast Q1

£000

Variance

£000 Prevention SMBC 21,226 21,177 (49) SCCG 368 368 0 Boroughwide Services

SMBC 7,271 6,938 (333)

SCCG 4,660 4,660 0 Community / Out of Hospital

SMBC 70,138 71,170 1,032

SCCG 40,177 40,169 -8 Acute SMBC 0 0 0 SCCG 69,668 69,703 35

Page 3 of 10 025

Better Care Fund SMBC (14,200) (14,200) 0 Total 199,308 199,985 677

Prevention (SMBC) surplus: £0.049m

The Public Health service is forecasting a breakeven position at Q1. There has been an additional recurrent cut to the grant of £0.406m (2.5%) in 2017/18.

The response from the service to these ongoing cuts was to create a revised staffing structure at a reduced cost base. It has also renegotiated the Sexual Health contract and is still in the process of renegotiating its remaining contracts with Stockport Foundation Trust (FT) for School Nursing, Health Visitors and Family Nurse Partnership.

Whilst these negotiations continue there are pressures within current contracts in addition to pressures from the grant cut still to find. These pressures are currently being partly offset by forecast staffing underspends, due to vacant posts within the service.

It is currently anticipated that £0.205m of the Public Health reserve totalling £0.766m will be utilised in 2017/18 to mitigate the above pressures to achieve the balanced forecast position.

Health and Wellbeing is forecasting a breakeven position at Q1. The savings aligned to the service came from agreed staffing and non-pay surpluses.

The small surplus is forecasted within Preventative services within the Integrated Neighbourhood Service and relates to a vacancy within the Step out Service.

Boroughwide (SMBC) surplus: £0.333m

The surplus forecast within the service is predominantly due to vacancies within social care and health posts for Non Acute – Intermediate Tier of £0.223m. In addition to this is a £0.104m surplus within the CADLs equipment contract. The balance of £0.006m relates to other minor staffing variances.

Community / Out of Hospital (SMBC) deficit £1.032m

The Integrated Neighbourhood service is forecasting a significant overspend within its care management services for Residential and Nursing Care and Non Residential Services. It is understood this is due to a number of factors including;

• Increase in transfer of clients back into the community from Delayed Transfers of

Care (DTOC) out of hospital.

• Temporary enhanced rates payable to secure bed provision within Residential & Nursing Care to minimise DTOC and support clients back into the community.

Page 4 of 10 026

• Increased demand, in part due to a reduction in clients awaiting assessment and

subsequent commissioning of services.

It is currently illustrated that the net deficit reported within care management of £1.239m is offset by a contribution from the £5.111m Improved Better Care Fund (iBCF) the Council has received in 2017/18. This is on the basis it is supporting more individuals to be discharged from hospital (the High Impact Change Model of Managing Transfers of Care) and to meet ongoing Adult Social Care need requirements for current and new clients.

Following the announcement of the iBCF the Adult Social Care service is developing a business case to further invest into services; in line with the grant conditions and planning guidance with a focus on investing in the currently fragile local social care provider market. The potential cost and benefit of this investment needs to be considered alongside the current financial pressures which are being experienced that relate to the implementation of the new High Impact Change Model. The development of the business case is being discussed through the Joint Commissioning Board.

The balance within the iBCF allocation of £3.872m is reflected within Strategy & Performance. It is currently anticipated this is fully committed in year pending a full costing exercise of the draft business case and is therefore not currently allocated to specific schemes. It is worth noting that the current financial deficit will also need to be considered when investment plans are developed.

The Learning Disability Internal Tenancy service is reflecting a deficit of £0.124m at Q1. This includes the balance of the unachieved saving of £0.579m offset by recurrent surpluses which will be aligned to the saving in Q2. This will in part offset the balance of the saving requirement, once a review of any residual recurrent pressures within the service has been completed. Separate to this is the financial pressures which exist within Heys Court. A business case for Heys Court continues to be developed to agree the future provision and staffing requirements for the Tenancy outlining the proposed investment required. Further investment has been earmarked for the tenancy pending business case approval.

External tenancy provision within Learning Disabilities is forecasting a deficit of £0.484m following the outsourcing of the majority of tenancies. The deficit is due to an increase in demand and anticipated contract values for 2017/18 which is above the investment initially aligned to cover predominantly National Living Wage increases.

Learning Disability care management services are forecasting a net deficit of £0.506m, this is predominantly within Non-residential services. The deficit is due to a net increase in demand and an increase in cost of service provision above what was initially anticipated.

The Mental Health service is forecasting a £0.228m pressure within residential and nursing services due to an increase in demand, this is in part offset by a reduction in demand for non-residential services totalling £0.145m. A further offset of the deficit forecast relates to in year surpluses of £0.194m within operations staffing services due to vacancies and in year recruitment to posts. The net deficit balance of £0.029m predominantly relates to a minor deficit in Non Acute Reablement due to an anticipated increase in bed rates. Rapid Response is illustrating

Page 5 of 10 027

a breakeven position as the current surplus forecast from previous bed decommissioning is being reinvested into workforce as illustrated within the Intermediate Tier business case.

Community / Out of Hospital (SCCG) surplus: £0.008m The small surplus relates to the Age UK contract which is forecast to underspend by £0.014m. This underspend is offset in part by a £0.006m over spend in the GP Development contract due to inflation and practice list size increases The net impact of both of these contracts gives rise to an underspend of £0.008m.

Acute (SCCG) deficit: £0.035m For the main NHS Providers, CCG activity is reported one month in arrears. The forecast at M02 does indicate the risk of variances to the plan, However, at this stage in the year the CCG is recording these as net risk and we are yet to include any element of variance within the forecast. This will continue to be reviewed on a monthly basis. Therefore, we are forecasting no variance to plan for the main Acute contracts at this stage. A contract with an independent provider, GM Primary Eyecare, that delivers minor eye conditions services, is over performing to date. This gives rise a forecast overspend of £35k.

6. Reserves

The Q1 position where the Council (SMBC) is the lead commissioner is anticipating the following transfers from reserves totalling £2.057m.

• £1.500m to support the Intermediate Tier saving requirement non recurrently as it is not anticipated benefits from Stockport Together will be realised in year.

• £0.167m to support the Councils neighbourhood services investment initially agreed in 2016/17.

• £0.139m to support Care Act funding aligned to the BCF contribution. • £0.025m balance from 2016/17 to fund 3.00 fte Social Worker posts supporting

the LD tenancy outsourcing project. • £0.205m funding from the Public Health reserve to reflect a break even position

for the service. • £0.021m funding for Employment Support Advisors to support Younger Adults

In addition to this the Council is holding £2.854m in reserves on behalf of Stockport Together partners relating to the balance of Transformation Funding received by the locality held for investment in 2017/18.

7. Savings

Page 6 of 10 028

Below is a summary of savings / Continuous Improvement Plan (CIP) affecting the

pooled budget in 2017/18 and their status: Table Five: 2017/18 Saving Proposals

Proposal Risk Rating

Value

£000

Value Achieved

£000

Additional Information

Learning Disability Tenancy Outsourcing

Red 1.000 0.421 Value achieved will increase from Q2 monitoring from post reductions and further outsourcing.

ASC Rebasing of operational staffing budgets to midpoint

Green 0.500 0.500 As per savings plan agreed with ASC

ASC Support Service Redesign

Green 0.390 0.390 As per savings plan agreed with ASC

ASC Commissioning and Contracts

Green 0.644 0.644 As per savings plan agreed with ASC

ASC Unachieved saving balance from 16/17

Red 0.558 0 No agreed savings plan currently in place

ASC Staff Travel – policy review

Red 0.251 0.028

The savings from the change in policy have yet to materialise and are being closely monitored. £0.028m minor balances aligned at budget setting 17/18. Options appraisal underway to achieve this saving.

ASC Overtime - policy review

Red 0.091 0 As above

ASC Superannuation advanced payment

Green 0.217 0.217 Achieved

Health Policy Commissioning and Contracts and staffing

Green 0.062 0.062 As per savings plan agreed with ASC

Public Health Grant Reduction

Amber 0.406 0.262 £0.144m saving still to be identified

Total 4,119 2,524 Acute Health - Demand

Green 2,114 2,114 Reported as delivered in full non-recurrently as a result of agreeing 17/18 contracts at 16/17 outturn and agreeing block contracts for A&E attendances, non-elective admissions and outpatient attendances with Stockport FT. If

Page 7 of 10 029

activity levels increase above planned levels a recurrent financial pressure will be carried forward into 2018/19.

Grand Total 6,233 4,638

Also to note for Adult Social Care is the Intermediate Care saving requirement of £1.500m which was funded non-recurrently in 2015/16 and 2016/17. It is currently illustrated this is funded non recurrently from reserves in 2017/18 as illustrated in Section 6 of this report.

Risk rating • Green – good confidence (90% plus) the saving is/will be delivered or minor variances

(<£0.050m) that will be contained within the portfolio. • Amber – progressing at a reasonable pace, action plan being pursued may be some

slippage across years and/or the final position may also be a little unclear. • Red – Significant issues arising or further detailed consultation required which may be

complex/ contentious

8. Recommendations

The Board are asked to:

1. Note the outturn position £0.677m deficit.

Page 8 of 10 030

Appendix 1: HCICB Pooled Budget Report Q1 2017/18

Budget Q1

Forecast Q1

Variance Q1

Provider Service £000's £000'sPreventionPennine Care Dementia / Memory Services £56 £56 £0GP Flu Services £91 £91 £0SMBC Dementia Services £8 £8 £0SMBC People Powered Health £213 £213 £0Various Public Health £16,081 £16,081 £0Various Health and Wellbeing £325 £325 £0Various ASC Preventitive Services £4,820 £4,771 -£49Total £21,594 £21,545 -£49

Community / Out of HospitalStockport FT Community District Nursing, Palliative Care and Teir Two Services £10,718 £10,718 £0Pennine Care Crisis Resolution, Mental Health Teams, Liason £657 £657 £0GP Care Homes Development and Care Home Planning £1,701 £1,707 £6SMBC FNC, Neighbourhood Services, ESS, Reablement, R Response £10,305 £10,305 £0Various Care Homes Continuing Care / Domiciliary £5,393 £5,393 £0Mastercall IV Therapy and Pathfinder £1,313 £1,313 £0Beechwood and St Ann's Hospices £826 £826 £0Various 3rd Sector Carers / Alzheimer's £631 £617 -£14Various Programme Management Services £262 £262 £0SMBC Learning Disabilities £1,617 £1,617 £0SMBC Mental Health £293 £293 £0SMBC S256 - FACs & Demograpics £3,746 £3,746 £0SMBC S256 - Care Integration £255 £255 £0SMBC S256 - Social Care Protection £124 £124 £0SMBC S256 - ASC Demograpics / FACS £1,537 £1,537 £0SMBC Care Act £730 £730 £0SMBC Programme Management Services £69 £69 £0Care Home Providers Integrated Locality Services - Residential & Nursing care £16,892 £17,738 £846Homecare / Community Providers Integrated Locality Services - Non Residential Services £11,716 £12,070 £354Integrated Neighbourhood Services Reablement and Rapid response £2,164 £2,229 £65

Contribution from improved Better Care Fund -£1,239 -£1,239Care Home Providers Learning Disability - Residential & Nursing care £3,852 £3,607 -£245Homecare / Community Providers Learning Disability - Non Residential Services £17,058 £18,293 £1,235Learning Disability Internal Tenancy provision £6,767 £6,891 £124Care Home Providers Mental Health - Residential & Nursing care £2,016 £2,244 £228Homecare / Community Providers Mental Health - Non Residential Services £1,127 £982 -£145Various Operational staffing support £7,183 £6,989 -£194Various Other services incl ASC support services £1,363 £1,366 £3Better Care Fund Contribution BCF -£14,200 -£14,200 £0Total £96,115 £97,139 £1,024

AcuteStockport FT Acute A&E, Medicine, Ophthalmology, ENT, T&O and Other £41,659 £41,659 £0Pennine Care General Psychiatry £6,764 £6,764 £0Various Independent Sector A&E, Medicine, Ophthalmology, ENT, T&O and Other £3,299 £3,334 £35NHS Trusts A&E, Medicine, Ophthalmology, ENT, T&O and Other £17,946 £17,946 £0Total £69,668 £69,703 £35

Stability / Recovery / BoroughwidePennine Care Rehabilitation and Recovery Services £67 £67 £0SMBC Non Acute Services for Older People and Equipment £4,593 £4,593 £0Various Boroughwide Services £7,271 £6,938 -£333Total £11,931 £11,598 -£333

Grand Total £199,308 £199,985 £677 Page 9 of 10

031

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