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Finance Report
Month 3 2012-13
Ealing CCG Finance and Performance
Committee
QIPP
Progress Update
30th August 2013
Kathryn Magson, Chief Operating Officer, Ealing CCG
Peter Buckman, Deputy Chief Finance Officer, Ealing CCG
Charles Wheatcroft, QIPP Programme Director, Ealing CCG
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• Month 2 initial deliverability assessments highlighted a shortfall in savings
achievement of £6.5m.
• Formal month 3 and month 4 assessment of the deliverability of Ealing QIPP
schemes showed improved forecast to a shortfall of £2.9m
• The CCG continues to strengthen the rigor around its QIPP governance
process. In particular the weekly PMO meeting in August have taken a
milestone by milestone approach to test whether the QIPP are on track, or at
risk.
• Overall, the CCG is maintaining the month 4 forecast of £2.9m.
• Risks remain as:
−Identifying schemes and resources to close the remaining £2.9M.
−Project Manager Capacity, though now being addressed through
recruitment.
−QIPP specific risks in ICE, Prescribing, CVD, Pulmonary Rehab and
Paediatrics
−Constraints in the expansion of capacity in primary care and in the
development of GP networks
−Further engagement with member practices to promote delivery of existing
schemes
QIPP: Position summary
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QIPP current performance (M4)
The current reported QIPP forecast reflected in the month 4 financial returns and
reviewed by Finance and Performance Committee
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Remedial actions taken in previous month to
improve QIPP performance against target
• Planned a complete reorganisation of the CDM team complete with matrix
programme management. This has been announced and implemented.
See slides 5 & 6.
• Recruited a new CDM for Mental Health and have commenced
recruitment for a new CDM for End of Life Care, Diabetes and Falls.
• Commenced recruitment of three Network Relationship Managers to help
build capacity in the networks and help the networks to deliver.
• Completed the first iteration of the QIPP output based report which
measures actual attainment against the QIPP objectives based on SUS
data. Commenced work on the practice level version of this report.
• Continued the regular weekly PMO meeting, and conducted Executive
“deep dives” in Mental Health.
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Imperative One:
Supporting Network Development
Supporting the development of networks across Ealing Borough.
Supporting the implementation of CCG out of Hospital strategy
Bringing the CCG QIPP programme to life in a language that makes sense for practices.
Visibility amongst our member practices and building stronger relationships.
CDM TEAM DEVELOPMENT
Imperative Two: Programme Management
QIPP Programme Director to be appointed (interim appointment) until March 2014
New Initial appraisal and business case preparation
Managing the delivery of QIPP and CCG projects and delivery of CCG Plans and assurance responsibilities
Track the CCG performance of QIPP and monitoring progress.
Project planning and reporting
Manage the programme management office (PMO) and interface with the Federation PMO team
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Ealing CCG
A Matrix Management Organisation Date 15th August 2013
COO
Programme Director
Business Mgr (8c)
Business Office Mgr (5)
Information Analyst (CSU)
Execs Business Office
Mgr
Des. Nurse – Safeguarding
Children
Deputy COO
Localities Mgr
CDM Women & Child (8b)
CDM Planned Care (8b)
CDM Urgent Care (8b)
CDM Mental Health (8b)
CDM Diabetes, Falls, EOL (8b)
Network Relationship
Mgr (7)
Network Relationship
Mgr (7)
Network Relationship
Mgr (7)
Head of Medicines
Management
RFS Team
Med Mgmt team
Integrated Commissioner
– Adults
Integrated Commissioner
- Children
Office Admin (4)
Office Admin (4)
Office Admin (4)
Receptionist (3)
Programme
Office
Deputy CFO
Head of Continuing
Care
Mgr PPE
Ldr External Comms
Secondee: ICP Secondee:
RFS
GP Network 1 GP Network 2 GP Network 3 GP Network 4 GP Network 7 GP Network 6 GP Network 5
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QIPP Schemes by Stages of Development
PROJECT LIFECYCLE ANALYSIS STATUS Bubble sizes gives forecast QIPP saving, other than schemes in 'Idea' and 'Appraisal' stages
EOLC Pathway
Paeds Community Nursing, £0.3m
Active Case Mgmt - Nursing Homes, £1.0m
Paediatric Phlebotomy, £0.1m
Remote follow up of Secondary Patients
Closure of 12 Jubilee ward beds in WLMHT , £0.2m
Prescribing, £3.3m
Productive CommunityServices
Gastro
Productive Community Services, £0.7m
Gynaecology, £0.1m
Continuing Care - Mental Health
Shifting Settings of Care - Mental Health, £0.8m
Community Ophthalmology
Paediatric Oral Health
CVD Anticaogualtion, £0.2m
Dermatology Pathway Redesign
MSK Pathway Redesign
Diagnostics - Radiology and Pathology, £0.1m
MSK Pathway Redesign, £0.5m
Pulmonary Rehab, £0.4m
Cardiology redesign
Ealing Falls Service
ICP: IntegratedCare Programme, £0.1m
Urgent and Unscheduled Care Pathway
Intermediate Care Service(ICE), £0.8m
Mental Health -Continuing Care, £0.5m
NCA Validations, £0.1m
Referral Facilitation Service, £0.1m
Continuing care, £0.9m
0
100
200
300
400
500
600
700
800
900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
Idea Appraisal & Develpmt Design Delivery Live Benefits
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QIPP: Schemes; YTD & Forecast Delivery
Scheme Name Target
M4+
forecast
saving
M4+
Mitigations
M4+
Variances
(+/-)
Commentary
Intermediate Care Service (ICE) £2,876 -£639 -£1,920 £317
The performance managemeent of EHT ICO to improve the levels of referrals into ICE (and thus avoided admissions) is in progress. The trust have
put forward a trajectory which offer a major improvement through the year. Referrals in june increased to 176 from 143 &142 in April and May.
Saving is based on one admission avoided for every 3 ICE referrals.
Productive Community Services £1,125 -£736 £0 £389 The contract negotiations with EHT ICP over the productive community services has been concluded in August.
Closure of Jubilee beds £0 -£201 £0 -£201 Agreed as part of WLMHT contract discussions
Shifting Settings of Care (Mental
Health)£1,000 -£799 £0 £201
The plans to move the stable patients into primary care are progressing, with the first group of approx 180 by October.
GP Service for Nursing Homes £1,505 -£991 -£394 £120Additional mitigation identified due to lower provision costs as a result of delayed implementation. The registration of nursing home residents in
progressing.
Referral Facilitation Service (RFS) £279 £0 £0 £279
The SUS analysis to estimate the actual saving from RFS has been concluded, and presented to Execs. The scheme is estimated to be saving
approximately £1m per year. The next development is to enforce an agreement in the EHT contract that the Trust not accept direct referrals, but
divert them to RFS.
Paediatric Community Nursing £1,347 -£345 £0 £1,002CCG and EHT clinicians have determined that the Non-elective admissions avoidance element (£92k) cannot be safely delivered. The CCG is now
working on a mityigation and alternative, which inncluded the non funding of £100k pa for specialist community nursing.
Paediatric Phlebotomy ( part of
paedtirc community QIPP)£0 -£95 £0 -£95
On track
Pulmonary rehabilitation £389 -£396 £0 -£7 PR service is up and running, and being promoted to GPs. Analysis of GPs who are not referring has been done, and they are now being targetted.
Anticoagulation Schemes £309 -£184 £0 £125Working with EHT to ensure that number of agreed discharges from EHT to community crystallise, with little scope to increase this. CCG working
GPs to encourage moving patients into primary care - a combination of Acute "push" and primary care "pull".
MSK Pathway £1,771 -£469 -£386 £916Only half year effect now likely due to delays start from April/May to October; some mitigation of reduced reproving costs. Waiting list initiative being
run prior to scheme start and this is on track. Expected that service will commence in October as per plan.
Diabetes £494 -£668 £0 -£174 Augmentation of existing scheme.
Prescribing £3,269 -£3,269 £0 £0A suite of prescribing reports will be delivered in September which will enable detail by drug, by practice and other complex analysis. This is a key
deliverable, and will give the medecines management team a capability to target savings they have not had before.
ICP £138 -£138 £0 £0 Progressing. There is evidence that savings are greater than presently forecast. Data over more months is needed to corroborate
Redesign of EOLC Pathway £574 £0 £0 £574Scheme needs redesign - new pathways required e.g. heart failure, COPD, Requires strong ICO & GP engagement. A new EOL CDM is being
recruited.
Diagnostics – radiology and
pathlology£204 -£100 £0 £104
The QIPP is focussed on negotiating rebates against the TDL contract. To date a rabate of £67k have been achieved, and a futher £65k is presently
being targetted. There is further opportunity for rebates applicable to later in 2013-14.
NCA Validations £75 -£75 £0 £0 Achievement of NCA saving depends upon the CSU addressing major delivery problems. These have been escalated.
Continuing Care £900 -£900 £0 £0 The work necessary to achieve these saving is in place.
Prescribing Stretch £0 -£50 -£50the CCG has decided not to fund additional staff in the medecines management team, but instead is focussed on the focused targetting sttatgety
enable by the new reporting system.
Mental Health CC £0 -£500 -£500 The work necessary to achieve these saving is in place
Gynaecology £0 -£100 -£100The Gynae scheme business case has been approved by the CCG. The QIPP is due to be implemented from September, when the RFS will start
triaging the target patient group.
Total £16,255 -£10,005 -£3,350 £2,900
New schemes shaded orange
Initial schemes shaded grey £2,900
Schemes - line by line analysis (£ 000s)
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Interpretation of first QIPP Report
QIPP Scheme Performance M1-3
Intermediate care service There is a strong reduction (500 spells) in NEL admissions across all
providers. EHT is flat reflecting the slow take up of the QIPP.
Paediatric Community Nursing Oupatients: Is on track to exceed the target reduction on 196 first OP
attendances
Inpatients: Despite the difficulties in agreeing clinical criteria, there is a
reduction and is on track to exceed target.
Ward attenders. Of the target of 993 avoidances, 234 have thus far been
reduced
Pulmonary Rehab Service Report still in development.
CVD Pathway Development Activity in anti-coagulation is not reducing. A major cause for concern
Diabetes Pathway Development Report still in development.
• In August, the CCG has delivered the first full report on actual QIPP
performance, based from the most recent available SUS data.
• The report requires additional development and the information is in its infancy,
but is now giving the CCG the first direct data driven view of actual QIPP
performance for the QIPP schemes that are both in progress and measurable
using SUS data.
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QIPP: Schemes in development
The CCG is actively developing new schemes with potential in 2013-14. Four
schemes presently in full development,
Scheme Name
Savings target (£
000s) - Less
Favourable
Savings target (£
000s) - Expected
value
Savings target (£
000s) - More
Favourable
SLT OwnerCOMMENTS ON SCHEME : Goals and objectives,
development and timelines, risks and issues.
Prescribing Stretch £0 £50 £100 Beryl BevanStretch target which could produce £200k saving from a £100k
investment.
Cardiology (Heart Failure) £0 £0 £30 Michelle Elston
This is the first thread of the reshaping of cardiology services to
be developed; the possibility of implementing it later in the year
with a confederation of existing providers is being explored.
Mental Health – CC funding £250 £500 £1,000 Nicky Bradley A patient cohort has been identified that should be funded by LA.
Gynaecology £50 £100 £150The scheme aims to make greater use of RFS and diverting more
activity into primary care.
Total £300 £650 £1,280
QIPP: Schemes in evaluation with forecast savings beyond 13/14
Scheme NameCOMMENTS ON SCHEME : Goals and objectives, development and timelines, risks and
issues.
Target date for
assessment of
potential savings
Cardiology (Community)
Identifying cohorts of patients who could be safely and more conveneintly be treated in a communtiy
setting. Progress: case for change and options for procurement to be reviewed by Execs on 2nd
October.
2nd October
Urgent / Unscheduled Care
(frail & elderly)
With a focus on the elerly, frail patient what more could be done to provide alternative services,
diverting activity from secondary care. Progress: Opportunity assessments to be reviewed by Execs
on 18th September
18th September
Falls prevention An ICP Innovation Fund scheme this should be launched in 2nd half of 2013/14. 30 September 2013
Imperial Open Access Contract Review the value and validity of continuing this scheme 31 October 2013
Remote follow up of secondary
patients
Scheme has been assessed, and decision taken not to persue for 2012-13Complete.
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Action Date Owner RAG
Action across all QIPP schemes
Review at Finance & Performance Committee each month, and weekly at
QIPP Programme meetings. Focused on structured management of risks,
issues and progress to milestones
Any requirements for any senior leadership and exec support are being
identified.
Ongoing
F&P: Monthly
QIPP: Weekly
F&P: Kathryn Magson
QIPP: Sue Pascoe & Peter
Buckman
Development of QIPP KPIs and performance measures:
a. Output (outcome) measures: Measurement of activity an cost as per
the QIPP Targets.
b. Input measures: Measurement of specific service changes that the
QIPP implementation is aiming to deliver.
c. Clinical quality measures
Completed.
Input Measures – in progress
Quality measures – 31st October
Peter Buckman
Sue Pascoe
Executive Deep dive reviews on existing schemes by COO (monthly)
Completed: Mental Health, Paediatrics, Diabetes, CVD, MSK
August: ICE, RFS, Mental Health
September: Cardiology, Urgent Care
Ongoing: Others, and 2nd round reviews
Kathryn Magson
Creation of a new Role of Programme Director, and implementation of a
cross functional matric structure with all QIPP delivery reporting to Prog Dir.
Completed Kathryn Magson
Actions across all existing schemes:
Identification of additional resources to help support enhanced delivery, and
reorganization of CDM team: e.g. Continuing Care, Mental Health, Urgent
Care and ICE.
Interim staff by 30th September Relevant CDM, with Sue Pascoe
and Michelle Elston
Improvement to delivery management processes, including recruitment. Recruitment: By 30th September
Process: Stepped improvements through Q2
and Q3
Sue Pascoe
Provider performance management e.g. ICE, CVD Anti Coag, Diabetes. Ongoing via regular provider meetings by
QIPP scheme.
Kathryn Magson
Provider (specifically EHT ICO) manager to manager meetings Ditto CDMs
Address engagement barriers with secondary care providers. In progress CDMs with Kathryn Magson
Actions across all new and augmented schemes:
Conduct workshops to develop the full 2014/15 QIPP plan Workshop 11th September Sue Pascoe
Complete opportunity assessment and complete business cases Dates as per slide CDMs for each QIPP schemes
QIPP: On-going actions Update
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QIPP: Risks
Through the PMO process and the executive reviews, in the past month, the
CCG has identified several material risks.
The risks all have mitigation plans which are already in progress.
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QIPP: Update on QIPP quality indicators development
The CCG has an established basis for tracking the clinical quality impacts of the
QIPP schemes:
Clinical Working Groups agree specialty pathways and quality/outcome
objectives.
Formal Quality Impact Assessments.
The driving force for QIPP schemes are the dual goals of better patient care and
safety, and better patient experience.
CCG Federation Quality Leads review quality markers for QIPP programme.
CDMs regularly monitor quality metrics
Quality metrics are built into provider agreements where applicable.
Formal governance is in place:
Reviews at Executive and Innovation Committees
Quality, Safety & Clinical Risk Committee quality problem areas by exception.
Governing Body review quality performance of QIPP programme via CSU
reports.
Consolidated Reporting:
Currently focussed on setting up full reporting of finance and activity reporting of
both “output” (outcome) and “input” measures for QIPP.
Once these are established (in August), the focus will progress to establishing
consolidated reporting associated quality metrics for each QIPP scheme. Target
date for this reporting is by end of September.
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Appendixes
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QIPP: Main reasons for the adverse YTD and forecast outturn
• Ealing CCG has four schemes in particular that have lead to the adverse variance:
Intermediate Care Service (ICE) –The service is having a more limited impact that was envisaged
in the original business case and is reflected in the contract variation with Ealing Hospital. The value
reflects activity assumptions agreed with the clinical; these suggest that only 1/3 of patients
processed by ICE are “avoided admissions”. This is reflected in the QIPP figures, along with the
value of the penalty payable under the contract.
Paediatric Community Schemes –This QIPP covers sub schemes paediatric phlebotomy, and
specialist community nursing, In light of the increasing paediatric demand, and the current quality
issues faced in this service, it has been agreed at CCG Executives that £1m of the schemes
currently identified will not be pursued for now.
MSK Schemes– This scheme was due to start early in the new financial year but this was delayed
due to contract discussions, the delays in recruitment of staff by EHT ICO, and the need to clear the
existing waiting list. October is now scheduled for implementation. The impact of the delay is
mitigated by the reduced re-provisioning costs. This scheme should also see a reduction in the
number of MRIs carried out by InHealth.
Redesign EOLC Pathway– The EOL QIPP budget was based on a detailed opportunity
assessment. However the timing and pace at which a complex and sensitive pathway could be
changed were too fast. It is recognised that there are opportunities to develop new clinical pathways
which improve the quality of care for patients at the end of their lives. The ECCG Exec has laid a
vision for how this QIPP can be formulated and taken forward. The next stage is to re-assess the
real opportunity and design a deliverable QIPP scheme.
Other Smaller Schemes- Five other schemes are contributing towards the adverse forecast.
Appendix 1
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