month 10 hammersmith & fulham ccg finance report

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14-Mar-14

Month 10 Hammersmith & Fulham CCG Finance Report

cover

Acronym Full Provider Name

ASP Ashford And St Peter's Hospitals NHS Foundation TrustBLT Barts Health NHS TrustC&W Chelsea And Westminster Hospital NHS Foundation TrustCLCH Central London Community Healthcare NHS TrustCNWL Central And North West London MH NHS Foundation TrustEHT Ealing Hospital NHS TrustESH Epsom And St Helier University Hospitals NHS TrustGOSH Great Ormond Street Hospital For Children NHS Foundation TrustGSTT Guys And St Thomas NHS Foundation TrustHRCH Hounslow And Richmond Community Healthcare NHS TrustHUH Homerton University Hospital NHS Foundation TrustHWP Heatherwood And Wrexham Park Hosps NHS Foundation TrustICHT Imperial College Healthcare NHS TrustKCH Kings College Hospital NHS Foundation TrustKHT Kingston Hospital NHS TrustMEH Moorefield's Eye Hospital NHS Foundation TrustNWLHT North West London Hospitals NHS TrustRBH Royal Brompton And Harefield NHS Foundation TrustRFT Royal Free London NHS Foundation TrustRMH The Royal Marsden Hospital NHS Foundation TrustRNOH Royal National Orthopaedic Hospital NHS TrustRSC Royal Surrey County NHS Foundation TrustSGT St George's Healthcare NHS TrustSLAM South London And Maudsley NHS Foundation TrustSWL&StG South West London And St George's Mental Health NHS TrustTHH The Hillingdon Hospital NHS Foundation TrustUCLH University College London NHS Foundation TrustWHH The Whittington Hospital NHS TrustWLMH West London Mental Health NHS TrustWMUH West Middlesex University Hospital NHS Trust

high quality support to commissioners to improve health and wellbeing

The following acronyms are used throughout this pack.

Key message

Contract Acronyms

acronyms

Executive Summary Page

Executive Summary 3

CCG Finance dashboard 4

Risk and Opportunities 5

Underlying Position 6

Key issues and actions 7

Overall Financial Position Page

Surplus/deficit including running costs 9

Breakdown of programme (commissioning spend) 10

Breakdown of running cost spend 11

Breakdown of reserves 12

Investments 13

QIPP 14

Capital, creditor payments and cash 15


Contents

1

Key messages Page

Executive Summary 3

CCG Finance dashboard 4

Risk and Opportunities 5Underlying Position 6Key issues and actions 7

Section 1: Executive Summary

Overall financial position Executive summary

Overall financial position

2

Status

Amber

Green

Green

Contract

PerformanceAmber

QIPP Amber

Source: Team analysis


Overall

financial

position

At month 10 Hammersmith & Fulham CCG is reporting a year to date surplus of £6.1m which is an adverse position of £2.0m

behind plan. This appears to be a deterioration compared to the month 9 position, however, the YTD position should be a

surplus of £9.2m and the lower figure has been reported through the ledger in error. This is due to how the CCG budgets are

phased as the budget for commissioning reserves only sits in month 12. The error has been flagged to, and noted by, NHS

England.

The forecast outturn remains a surplus of £12.3m, which is £2.5m above the original operating plan target. This is unchanged

from month 6.

Whilst the overall financial position for the CCG is an additional surplus, acute contracts are showing a year to date and forecast

outturn spend above plan of £4.6m and £5.5m respectively. The forecast outturn performance has been mitigated in part by the

application of acute reserves, bringing the reported acute position to a year to date overspend of £3.0m and forecast outturn of

£1.7m worse than plan. Contracts with the main acute providers, ICHT and C&W, continue to over perform. The key pressures

at Imperial relate to outpatients and non electives; at C&W they relate to outpatients and day cases. These are discussed in the

contracts performance section of this report.

The current year to date delivery of QIPP is behind plan by 10%, £0.9m. This is driven by under delivery in unscheduled care

and planned care schemes, largely MSK. The forecast delivery for the year is £9.3m (89%) against a target of £10.5m.

The risks and opportunities assessment at month 10 is a net opportunity of £2.0m in the 'most likely' scenario compared to an

opportunity of £3.1m at month 09. The potential range is an upside of £5.1m and a downside risk of £2.3m. Plans to utilise this

funding are being identified to ensure that the planned surplus is not exceeded.

1) The acute forecast outturn variance has worsened by £0.3m, of which £0.2m is at ICHT and £0.1m at C & W.

2) The overall non acute forecast outturn variance has deteriorated this month by £0.8m. This is across continuing care, £0.7m

and prescribing £0.2m. However, mental health has improved by £0.1m.

Executive summary

3

On plan

Take note

Action required

Indicator Target Actual

Rating this

month

Financial position year to date Agreed surplus £8,032k £6,057k (24.6%) variance from planned position

Financial position forecast outturn Agreed surplus £9,852k £12,332k 25.2% variance from planned position

Running costs forecast outturn Agreed surplus £4,460k £4,347k 0.0% variance from planned position

QIPP year to date £8,711k £7,797k (10.5%) variance from plan

QIPP forecast outturn £10,549k £9,392k (11.0%) variance from plan

Investment spend £3,436k £2,898k (15.6%) year to date variance from plan

Risks and opportunities Risk/opportunity >£0k £2,043k(net risk) / opportunity outside reported position

(likely case)

Creditors - Better Payment Practice Code 95.0% 80.1% (15.6%) of invoice value paid in 30 days

Capital forecast outturn £670k £670k 0.0% White City project

Cash £212,269k £174,378k year to date variance from cash limit

Note


The net opportunity of £2,043k represents risks of £1,845k mitigated by opportunities of £3,888k as shown on the following page.

Key

CCG finance dashboard

4

Amount

£000s Probability Value Probability Value Probability Value

1 Non validation of NCA and contract invoices leads to inability to challenge errors (100) 10% (10) 0% 0 100% (100)

4 CCG spend is currently billed to NHSE and is reattributed (1,000) 0% 0 0% 0 100% (1,000)

5 Imperial improve performance against bond (342) 25% (86) 0% 0 100% (342)

6 Forecast for acute position is understated (1,608) 50% (804) 0% 0 100% (1,608)

Care UK (Farm Lane PFI) 11/12 and 12/13 settlement (745) 25% (186) 0% 0 100% (745)

UCC income from CCGs outside NWL not received (1,018) 32% (326) 0% 0 100% (1,018)

Chelsea & Westminster NEL credit assumption (666) 50% (333) 0% 0 100% (666)

Equipment costs (400) 0% 0 0% 0 100% (400)

New continuing care high cost patients (200) 50% (100) 0% 0 100% (200)

Total risks (6,079) (1,845) 0 (6,079)

9 Investment slippage / other uncommitted funds 3,663 100% 3,663 100% 3,663 100% 3,663

10NCA spend relates to specialist commissioning, so current forecast is overstated 350 50% 175 100% 350 25% 88

11

High cost drugs spend relates to specialist commissioning, so current forecast is

overstated

100 50% 50 100% 100 0% 0

12 NHSE spend is currently billed to CCGs and is reattributed 1,000 0% 0 100% 1,000 0% 0

UCC Income 0 20% 0 0 0% 0

Total opportunities 5,113 3,888 5,113 3,751

Net (Risks) & Opportunities (966) 2,043 5,113 (2,329)


RIS

KS

OP

PO

RT

UN

ITIE

S

Key MessagesA number of risks and opportunities have been identified for 13/14 which will materially impact the final outturn for Hammersmith and Fulham CCG. Due to the element of uncertainty around

whether these risk/opportunities will materialise, they have been captured below but not reflected in the financial position.

The most material risk is the level of over performance on acute contracts, and notably the accuracy of the forecasting model in predicting the year end position. In the worst case, should the

profile of activity over the second six months of the year be in the ratio 51.5% : 48.5% this would have an adverse impact of £1.6m. The risk around the Care UK contract was identified in

M08; further work has established an increase in the potential liability relating to 11/12-12/13, the impact on the current year has been reflected in the forecast outturn. The UCC income from

outside NWL has now been included in the forecast outturn and so a risk has been included to reflect this may not all be recovered. The main opportunity to offset the risks is offered by the

unutilised reserves currently held.

Likely Case Best Case Worst Case

Risks and opportunities

5

Key message

Recurrent Non

recurrent

Total

£'000s £'000s £'000s

239,481 2,074 241,555

218,721 10,503 229,224

Surplus/(Deficit) 20,760 -8,429 12,331

Total Total£'000s %

15,058 6.3%

15,653 7.3%

Improvement / (worsening) -595


Revenue

Expenditure

Underlying Position

Forecast

Planned (per Op Plan 21st May)

The underlying financial position of the CCG shows the recurrent revenue less the recurrent expenditure and excludes all non recurrent or one-off items i.e. return

of the prior year surplus or investments such as the System One rollout. It also factors in the full year effects of any investment or savings schemes that have

started part way through the financial year.

At month 10 (as at month 09), the forecast underlying position for the CCG is a £15.1m surplus, which is a worsening of £0.6m from the operating plan

submission. This is due to reflecting the full year effect of the White City cost pressure, partially offset by an increase in the forecast GP IT spend.

FOT at month 10

Underlying Position

6

Issue Key drivers

Financial

impact

YTD, £m Action Owner Timeline

ICHT £2.0

The main areas of challenge are minor neonatal disorders, coding and counting, and

the internally generated demand metric. A number of challenges have now been

escalated beyond the January PCE for resolution.

Cerith

Lewis

The contract

performance section

of the report includes

an in-depth analysis

ICHT £1.3

The Performance Bond with the Trust was finalised at £5.2m.The NEL CAP 95% credit

has reduced significantly in month across all CCG’s. The previous working assumption

was that £2m would paid to the Trust via a performance bond and an equal £2m NEL

acute credit would be received. However it is now expected that the payment will not be

equally matched by reduced spend. The Trust has released YTD credits £287k across

all NWL CCG and the CSU has raised challenge of £400k a further challenge may be

required if we dispute the 94% activity baseline.

Cerith

LewisMar F&P

C&W £2.3Metrics Q1 and Q2 closedown. Mitigations yield was low in Q1 (7%) and this is

expected to improve in Q2-4.

Joe

Simpson

The contract

performance section

of the report includes

an in-depth analysis

Total £5.6

Continuing

Care£0.6

An increase in the number of placements has resulted in a deterioration of £0.7m to the

forecast in M10.

Robert

KirtonMar F&P

Total £6.2


Acute

contracts

over-

performance

Programme

cost over-

spends

Ac

tio

ns

fo

r C

SU

Key issues and actions relating to financial position

7

Overall Financial Position Page

Surplus/deficit including running costs 9

Breakdown of programme (commissioning spend) 10

Breakdown of running cost spend 11

Breakdown of reserves 12

Investments 13

QIPP 14

Capital, creditor payments and cash 15


Section 2: Overall Financial Position

Overall financial position

Overall financial position Executive summary

8

Key message

2 3 5 6 8 9

Budget Actual Variance Budget Actual Variance Budget Forecast Variance

Allocation Resource limit 22,520 22,520 0 201,256 201,256 0 246,016 246,016 0 0

Acute Services 11,430 12,220 (790) 100,027 103,065 (3,038) 121,012 122,706 (1,695) (1,419)

Continuing Care 1,135 1,483 -348 11,354 11,964 (610) 13,625 14,516 (891) (159)

Community Health 1,835 1,854 (19) 18,359 18,596 (237) 22,028 22,312 (284) (280)

Mental Health 2,758 2,631 128 27,603 27,167 436 33,120 32,420 700 593

Prescribing 1,706 1,991 (285) 16,963 16,732 231 20,238 20,096 142 318

Primary Care 350 344 5 3,236 3,505 (269) 3,936 4,245 (310) (310)

Other 2,067 4,866 (2,800) 11,997 10,600 1,397 17,746 13,041 4,705 3,711

Running Costs Corporate Costs 368 292 76 3,684 3,571 113 4,460 4,347 113 26

Total Expenditure 21,649 25,681 (4,033) 193,223 195,199 (1,976) 236,164 233,684 2,480 2,479

Surplus/Deficit position 871 (3,162) (4,033) 8,032 6,057 (1,976) 9,852 12,332 2,480 2,479


The acute position is the most significant variance with a forecast outturn of £5.4m over performance. Release of acute reserves mitigates this down to £1.6m and other acute services are a net

overspend of £0.1m. This gives an overall adverse year end projection of £1.7m, a worsening of £0.3m from the previous month. C&W has improved marginally by £0.1m, but ICHT has

worsened by £0.3m.

The year to date variance has worsened overall by £4.0 m, due to an incorrect application of the commissioning reserves. This error has been noted and as explained previously, the YTD

position should be £9.2m surplus which is in line with both the month nine position and the forecast outturn.

Commissioned

services

In-month (£k) Year to date (£k) Full year (£k) Forecast

Variance (£k)

at M09

Surplus/deficit including running costs

9

Key message

2 3 5 6 8 9

Budget Actual Variance Budget Actual Variance Budget Forecast Variance REF

Acute Contracts 8,807 9,552 (744) 88,137 91,071 (2,934) 106,751 108,327 (1,576) (1,321) Page 16

Other Acute Activity Services 2,622 2,668 (46) 11,889 11,994 (104) 14,260 14,379 (119) (98)

Total Acute Services 11,430 12,220 (790) 100,027 103,065 (3,038) 121,012 122,706 (1,695) (1,419)

Continuing Care 1,135 1,483 -348 11,354 11,964 (610) 13,625 14,516 (891) (159)

Community Health 1,835 1,854 -19 18,359 18,596 (237) 22,028 22,312 (284) (280)

Mental Health 2,758 2,631 128 27,603 27,167 436 33,120 32,420 700 593

Prescribing 1,706 1,991 (285) 16,963 16,732 231 20,238 20,096 142 318

Primary Care 350 344 5 3,236 3,505 (269) 3,936 4,245 (310) (310)

Total Non Acute Services 7,784 8,304 (520) 77,516 77,963 (448) 92,947 93,589 (643) 161

Commissioning Non Acute 128 156 (28) 1,284 1,480 (196) 1,541 1,768 (227) 3,606

Commissioning Reserves 511 3,962 (3,451) 4,418 3,962 456 7,552 3,960 3,592 (497)

Programme Projects 705 95 610 3,436 2,898 539 5,224 4,533 691 0 Page 13

Recharges 40 30 10 401 404 (3) 520 520 0 (249)

Other - commissioned services 682 623 59 2,457 1,857 601 2,910 2,261 649 3,711

Total Other 2,067 4,866 (2,800) 11,997 10,600 1,397 17,746 13,041 4,705 6,570

Total commissioning spend 21,280 25,389 (4,109) 189,539 191,628 (2,089) 231,704 229,337 2,367 5,312


Across non acute areas of spend, mental health and prescribing budgets present modest cost pressures.

In-month (£k) Year to date (£k) Full year (£k)

Commissioned

services

The forecast for prescribing is £20m, close to budget, although there is a £0.3 m adverse movement in month.

The continuing care forecast has further deteriorated by £0.7m at month 10 as a result of increased placements.

Forecast

Variance (£k)

at Month 09

Breakdown of programme (commissioning) spend

10

Key message

Commissioning

Spend Breakdown Budget Actual Variance Budget Actual Variance Budget Forecast Variance

AllocationResource Limit 368 368 0 3,684 3,684 0 4,460 4,460 0

Running costsPay Costs 137 142 (5) 1,369 1,325 44 1,643 1,579 64

CSU Costs 188 151 38 1,884 2,032 (149) 2,260 2,260 (0)

Other Non Pay Costs 43 (1) 44 431 213 218 556 507 49

Surplus/deficit for

running costs 0 76 76 0 113 113 0 113 113

Source: Financial ledger


The year to date position shows an underspend of £113k. The reason for the underspend includes a backdated pay recharge to the SAHF programme

and non pay underspends. The year end forecast has been revised to show a £113k underspend.

In-month (£k) Year to date (£k) Full year (£k)

Breakdown of running cost spend

11

Key message

Budget Actual Variance Budget Actual Variance Budget Forecast Variance

502 0 502 4,417 3,962 455 7,552 3,963 3,589

• QIPP Slippage 183 0 183 1,833 0 1,833 2,200 0 2,200Released into the position to offset the under delivery of QIPP, in

line with QIPP plan phasing.

• GP Investment 0 0 0 192 299 (107) 750 300 450 OD Project

• Winter Pressures Investment 0 0 0 0 0 0 103 0 103Winter Pressures approved bids are now included in the Acute

position.

• CLCH transfer 0 0 0 123 0 123 123 0 123 Baseline correction in relation to CLCH

• QIPP Investment 57 0 57 367 0 367 1,238 0 1,238 Released at month 06

• Pooled Equipment Reserve 59 0 59 692 0 692 708 0 708 Released to offset CLCH contract overspend on equipment

• Contingency 203 0 203 1,210 3,663 (2,453) 2,430 3,663 (1,233) Increase in reserves held at month 08

0 0 0 0 0 0 0 0 0 Budget transferred to Central for Shaping a Healthier Future.

502 0 502 4,417 3,962 455 7,552 3,963 3,589

Source: Financial ledger


The CCG is projecting spend of £4m against Commissioning reserves which is made up of £0.3m OD and £3.7m contingency which is being held to cover potential risks. All other reserves have been released into the

position. CWHHE approved Winter Pressures bids of £6.8m of which £1.6m is the H&F share which has been reflected in the acute position.

Year to date (£k) Full year (£k)

Commissioning Reserve

Non Recurrent Reserve

Further detailIn-month (£k)

TOTAL Reserves

Breakdown of reserves

12

Budget Actual Variance Budget Forecast Variance Further detail

White City 0 0 0 300 300 0

SystemOne 998 863 135 1,500 1,300 200

SystemOne (migration support) 136 32 104 204 204 0 Additional funding agreed to support the migration.

Non recurrent projects 768 1,039 (271) 1,379 1,282 97

ICP forecast outturn £1.2m. The phasing of the year to date

budget needs to be reviewed further to recent budget

transfers

Recharges 1,533 964 569 1,840 1,447 393

Recharge of CSU and admin spend which should be

classified as programme. In month 9 GP IT costs were

transferred to Primary Care specific cost centre.

3,436 2,898 538 5,223 4,533 690


Programme Projects

Key message

The forecast outturn across programme projects is an underspend of £0.7m.

Year to date (£k) Full year (£k)

Investments

13

QIPP initiatives (Net QIPP)

Year to Date (£k) Full Year (£k)

Initiative Plan Actual Var Plan Forecast Var Further detail

Acute Services 3,167 3,167 0 3,800 3,800 0

There is an element of risk around the Acute Services KPI & Metric schemes largely due to the

uncertainty around the impact of the transfer of activity to specialised commissioning. This has

been offset by additional contract benefits that have been identified and agreed

Community Services 1,250 1,250 0 1,500 1,500 0 As per contract agreed with CLCH

Mental Health 958 958 0 1,182 1,182 0 As per contract agreed with WLMHT

Planned Care 1,236 764 (472) 1,484 923 (561)

Adverse variance ytd and forecast is largely attributed to under performance on MSK scheme of

£264k and £313k respectively. Waiting list initiative clinics have started to reduce the waiting

times to 3 weeks by 31st Mar-14. Network co-ordinators are also working with practices to

influence referral behaviour

Prescribing 720 951 231 900 1,042 142 YTD performance and full year forecast is based on expenditure analysis

Unscheduled Care 1,380 707 (673) 1,683 945 (738)

This scheme relied heavily on case planning activity. This was affected by the roll out of

SystemOne. While it is difficult to prove the impact of care planning on reduction in NEL

admission, there has been a reduction in NEL costs in M10 assumed to be the impact of

increase in care planning activity, which will increase in Q4. The focus now is on rolling out

Virtual ward model in Q4 which will provide a whole package of care for patients at high risk of

admissions identified using care plans completed. Savings anticipated in Q4 from Virtual ward

model are included in the FOT

Total 8,711 7,797 (914) 10,549 9,392 (1,157)

Source:PMO QIPP report

Month 10 QIPP performance year to date is an achievement of 89.5% against plan of £8.7m. Main drivers for the 10.5% under performance continues to be schemes targeting reduction in NEL (£671k)

and Outpatient (£472k- largely MSK). The full year forecast has been reviewed to deliver savings of £9.39m. This represents an 89.0% achievement against a target of £10.54m.

QIPP

14

Key message

Invoice

Count

Invoice

Count

(Passed)

% Passed BPPC

Amount

Invoice

Amount

(Passed)

% Amount

Passed

NHS 652 443 67.9% £143,259,539 £117,891,664 82.3%

Non NHS 3,592 2,654 73.9% £19,656,635 £12,658,023 64.4%

Total 4,244 3,097 73.0% £162,916,173 £130,549,687 80.1%

£000s £000s

Forecast Cash Limit: £216,000k Drawn Down to Date: £67,310k (30%)£174,378k 82%

Planned Cash Limit: £212,269k Under Drawn: £2513k 1%

Planned Draw Down at Month Ten: £176,891k

Source: CSU analysis

Creditor

payments

•

The CCG has not met the Better Payment Practice Code (BPPC) target. This is mainly due to transitional issues and Non-

Contracted Activities invoices disputes . We are currently working with budget holders to ensure that invoices are coded

and outstanding queries are dealt with promptly in order that invoices are paid within payment terms.

Cash

•

•

Capital

NHSE has confirmed the Capital allocation of £670k for the White City project .


Capital, creditor payments and cash

15

month 10 hammersmith & fulham ccg finance report

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