The professional voice of general practice in Ealing, Hammersmith and Hounslow Londonwide LMCs is the brand name of Londonwide Local Medical Committees Limited Registered and office address: Tavistock House North, Tavistock Square, London WC1H 9HX. T. 020 7387 2034/7418 F. 020 7383 7442 E. info@lmc.org.uk www.lmc.org.uk Registered in England No. 6391298. Londonwide Local Medical Committees Limited is registered as a Company Limited by Guarantee Chief Executive: Dr Michelle Drage

AGENDA

1.0 Welcome, Apologies and Declarations of Interest

2.0 Additional Items Not Listed on the Agenda Members to notify the Chair of urgent additional matters for discussion under any other business

3.0 Minutes and Matters Arising (not listed elsewhere on the agenda)

3.1 To confirm the minutes of the Ealing SJLC meeting on 28 November 2012 (pages 3-8)

3.2

To update on matters arising from the Ealing SJLC meeting on 28 November 2012 - Enhanced Services: Explanation of payment breakdown/Exeter system - 111 Service - Anti-coagulation LES proposed change for NOACs - Shared care/ Near Patient Testing LES - OPD Discharge Policies in Local Hospitals - Public Health Invoicing Process - GP revalidation feedback - NWL premises survey – site visits report

4.0 Primary Care Development Update

4.1 4.2 4.3

NHS Ealing Month 7 Financial Position (pages 9-79) Procurement

- Verbal update on care home tender Premises

- Improvement Grants

4.4 4.5 4.6 4.6 4.7 4.8

Enhanced Services QOF GP Clinical System Consultation (Dr Robert McClaren) Ealing Council and Public Health Transition (Ms Sally Beauchannon) (pages 80-84) Ealing Ulcer Services (Dr Ric Naish)

CVS Screening LES (Dr Sapna Chauhan)

5.0 5.1 6.0 6.1

Clinical Commissioning Group To receive an update on Clinical Commissioning Group development

- Authorisation - CSU development

Items to Receive Report from Meetings with NHS NWL and NWL LMCs

- Strategic Meeting, 3 December 2012 (pages 85-87) - Operational Meeting, 20 November 2012 (pages 88-89)

7.0 8.0

To Confirm LMC Newsletter Items Date of the Next Meeting 27 March 2013 - Conference room B

Ealing LMC / CCG Liaison

Wednesday 23 January 2013

Conference Room B, Armstrong Way, Southall

12.45pm Lunch will be provided

1

9.0

Any Other Business NB: Please give the Secretary 24 hours notice of any subject to be raised under this heading

2

DRAFT

Page 1 of 7

Draft Minutes from the Ealing Standing Joint Liaison Committee Meeting on 28

November 2012 at NHS Ealing, Armstrong Way, Southall

Present LMC Members: Dr M Alzarrad Dr S Datta Dr S Gautam Dr D Heavey Dr A Jenkins (Chair) Dr R Naish Dr S Yin Londonwide LMCs: Mrs A Michaels Ms A Ayamah Mr S Pick

NHS Representatives: Ms S Beauchannon Dr R Chandok Mr A Dhillon Dr F Fouladinejad Ms F Horne Dr R McClaren Ms J Murfitt Dr M Parmar Ms S Pascoe Dr V Tailor Dr S Vijay Observers Ms K Charles

1.0 Welcome Apologies and Declarations of Interest Apologies were received from Dr Bhatt, Dr Sandhu and Dr Chin. There were no new Declarations of Interest.

2.0 Additional Items Not Listed on the Agenda Additional items not listed on the agenda were as follows:- Co-ordinate My Care added to item 4.3 The Introduction of New Drugs into Ealing CCG added to item 4.5 Child health 6-8 week baby check added to item 5.1

3.0 Minutes and Matters Arising from 26 September 2012 3.1 Minutes

It was requested that the following amendments be made to the minutes: Page 3 - 4.1 Substitute ‘Imperial College Trust’ with ‘NWL Trust’. Page 4 – Public Health responsibility will move to Ealing Council in April 2013. Page 4 – remove ‘find’ from penultimate paragraph Page 5 – payment by referral to be substituted for payment by results Page 5 – remove paragraph beginning with Ms Pascoe. Page 6 – Fourth paragraph should read ‘his’ practice. Page 7 - remove ‘in’ from second paragraph.

SDP SDP SDP SDP SDP SDP SDP

3.2 Matters Arising 3.0 – Nursing Home Tender The LMC confirmed that it had been unable to nominate a representative. It was noted that Steve Loud is the GP rep (not an elected LMC Member) and this was felt to be sufficient GP representation.

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3.0 – Adult Audiology Ms Pascoe advised that Adult Audiology was a different specification and would require a new tender. 3.0 - Ealing Council and Public Health Transition Ms Beauchannon advised that a letter was almost ready to go to GPs and that she will confirm if the LES budget is ringfenced. 4.5 NHS Ealing Enhanced Services Review Explanation of payment breakdown/Exeter system It was noted that a new electronic form has been launched which will facilitate the smooth processing of claims. Claims will be processed through Open Exeter, which will allow for practises to receive an explanation of the payment breakdown. Ms Horne and Ms Murfitt will arrange for an officer to attend the next meeting who can advise further. Ms Horne advised that she can circulate a paper on processes and that she will add as an action required for enhanced services. Ms Horne will write to all practices confirming that all payments are now up to date. She asked to be informed if there are any challenges.

SB FH/JM FH FH

4.0 Primary Care Development Update

4.1 Outer North West London Board Financial Position The NHS North West London Cluster Board – Month 6 Finance Report dated 5 November 2012 was noted. The transfer of £15m of resource on a repayable basis from Brent PCT to Hillingdon PCT was noted. North West London Trust was showing a negative variance against its deficit plan. Dr Jenkins asked that the Ealing CCG specific papers be supplied in future rather than the NHS NWL position, ideally an A4 overview of NWL together with the Ealing CCG position.

JM

4.2 Procurement Nursing Home Tender Ms Pascoe advised that consultation had taken place. The outcome of the tender was scheduled for April 2013. Ms Murfitt and Ms Pascoe advised that the intention was that all patients would move under the care of the successful winner of the tender. However, patient choice would be accounted for. The system would be two tier, in that the care for any patient that declined to move to the new provider would be able to stay with their GP and the care would be funded under the GMS contract. The LMC expressed concern that in this scenario there would be pressure on GPs to provide an extended service for a GMS price. Ms Murfitt noted those concerns but advised that the intention was to keep such cases to a minimum.

4

DRAFT

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4.3 111 Service – Update

LW LMCs tabled a paper and proposed LES in relation to CMC Coordinate My Care. Ms Michaels asked the Committee to note the recommendation from LW LMCs to GPs that they should sign up to the draft LES produced by Londonwide LMC for Coordinate My Care (CMC) before taking on CMC work and that this LES is being submitted to borough LMCs. The LW LMC was to circulate draft LES concerning CMC to LMC members. Dr Shanker was to provide 111 lead names to Andy Michaels. Dr Shanker advised that 111 was viewed as a more memorable number than NHS Direct. Training and governance were seen as key. Four pilots had taken place. Members expressed concern that the current call logs sent to practices were very long and lacked clarity on outcomes/triage. Dr Shanker advised that 111 had looked to address this issue and that summaries would be provided by 111 to practices by mailshot. Members saw the setting of expectations in terms of when to see your GP as important. It was noted that at launch, GP appointment bookings could not be made through 111, but that functionality could be developed. Members expressed concern regarding a possible conflict of interest between Harmoni providing both 111 and out of hours services.

SDP

SV

4.4 Premises Improvement Grants Ms Murfitt advised that she was confident that there was money remaining in the improvement grants fund, although it was believed to be less than 100k. She was confident that another panel would be held. She advised that each GP would either have received a letter that they were successful, unsuccessful or that they would need to provide more information. Dr Naish reported that he had attended the Improvement Grant decision panel meetings for Ealing, Hounslow, Hammersmith & Fulham (H&F) and Kensington, Chelsea & Westminster (KCW). He outlined that Ealing and Hounslow had been allocated £300,000 each, even though there are fewer patients in Hounslow. Whereas, Kensington and Chelsea, Hammersmith and Fulham and Westminster had each been allocated £500,000. He commented that these areas were a third of the size of Ealing and that the funding level was five times more per patient. Dr Naish felt that Ealing’s allocation of improvement grant funding had not been equitable and transparent. He commented that the criteria to be eligible for funding in Ealing were particularly narrow. Hounslow, H&F and KCW had had looser eligibility criteria. A paper was to be submitted to the next cluster meeting setting out what

5

DRAFT

Page 4 of 7

each individual Finance Director bid for and were allocated. MP 4.5 Enhanced Services

Anti-Coagulation LES proposed change for new Oral Anticoagulants (NOACs) Arjun Dhillon spoke to a tabled discussion document regarding Anti-Coagulation LES proposed change for new Oral Anticoagulants (NOACs). He advised that at its meeting on 25 October, the NWL Integrated Formulary New Drugs Panel removed rivaroxaban and dabigatran from the NWL ‘red list’ of drugs that hospital doctors should not ask GPs to prescribe; the drugs do not meet the criteria for inclusion on the list. Following discussion at the local Medicines Management Working Group (MMWG) and initial discussion with the anticoagulation LES providers, it was felt that the most effective way of ensuring an informed decision between the patient and the clinician was for initiation of these drugs to be in line with the current anticoagulant LES. The proposal specifically was to amend the LES to add the NOACs as an option for initiation, with the same remuneration as warfarin. These drugs then require minimal monitoring, after the initial 8 weeks of monitoring the patients will transfer back to the care of the registered GP. The tabled papers were an amalgam of paperwork that the medicines management team and the Anticoagulation group had suggested as the necessary information needed to make this decision and initiate the preferred NOAC together with standardised information back to the registered GP. It was agreed that a copy of the letter that went to hospitals should be sent to all GPs. The introduction of New Drugs into Ealing CCG Mr Dhillon spoke to a tabled discussion document regarding the introduction of New Drugs into Ealing CCG. The preferred option was to clearly define governance for the introduction of new drugs. A diagram representing a potential flow of how a new drug could be managed into the Ealing health economy was set out. Dr Jenkins felt that Enhanced service monitored and GP monitored needed to be in one combined box, as the patient needs to be under specialist care, not the GP doing monitoring separately. Dr Jenkins felt that it needed to be understood that it is the CCG that has the ultimate responsibility. Mr Dhillon advised that:- It is important that clear systems are defined so that Trust clinical staff and GPs are aware of the arrangements and they are implemented appropriately. As CCG Prescribing Lead he would seek to work with the LMC to agree this communication. The Criteria for assessing each drug needs to be agreed eg: safety, s/e,

AD/SP/AM

6

DRAFT

Page 5 of 7

costs, training, resources required for monitoring, skill sets. He would seek to work with the LMC to ensure these criteria are robust and transparent. The standard for communication for initiating drugs needs to be agreed as part of the transition of a new drug from one pathway to another. These could include: Indication, intended duration of therapy, previous drugs used, extent of patient counselling and consent, monitoring required, indication for GP or specialist review. He would seek to work with the LMC to establish these standards, communicate them to GPs and to monitor them. There needs to be clear documentation with appropriate patient information explaining arrangements to patients and/or carers. This was an existing role of the medicines management team and should continue regardless. If agreed, as CCG Prescribing Lead he would like to use denosumab as an example of how this process could work. Shared Care/Near Patient Testing LES It was agreed that shared care should be part of the LES. Dr Parmar would bring a paper to a future meeting.

MP

4.6 QOF

It was noted that QOF was being replaced by QMAS from July 2013.

4.7 GP Clinical System Consultation (Robert McClaren) Dr McClaren advised that there were a number of different GP Clinical Systems in use and that a large number of GPs wished to move to a new system. Options had been identified and practices had been consulted. An informal vote had been held and of the 49 practices that had voted, there was a clear majority in favour of moving to one system across Ealing. The options for one system were System One and EMISWEB. It was noted that practises could stay with whichever system they preferred as all systems would be supported, but that those practices not on the main system would not receive enhanced support. It was noted that Hounslow had experienced confidentiality issues with System One and that it operated under a consent model. It was noted that System One is a single record system and that EMISWEB is a multi record system. A paper should be brought together that sets out the pros and cons of the two systems being considered. The paper should be circulated to all GPs.

FF/RM

4.8 Ealing Council and Public Health Transition Public Health Invoicing Process Ms Murfitt would refer back the need for a monthly and quarterly facility.

JM

4.9 OPD Discharge Policies in Local Hospitals Dr Jenkins queried the Did Not Attend (DNA) discharging process at Ealing Hospital Trust as he felt that GP’s workloads had increased. Examples were given of discharges after one missed appointment. It was understood that

7

DRAFT

Page 6 of 7

Hillingdon Hospital discharge after two DNAs. Dr Parmar understood that the discharging process required a final clinical decision. It was noted that every hospital would have a DNA policy and that the issue with Ealing Hospital Trust might be the way the policy is being applied or the policy itself. Dr Jenkins felt that there was a need to investigate DNA policies across the country and that it was important to have clinical sign off of a DNA discharge.

SDP

4.10 Sub Fractionated heparin injection arrangements (for pre-op patients on warfarin) GPs need a letter confirming that GPs won’t be offering the clinical service or administrating the heparin injection.

AD

4.11 GP Validation Feedback Charles Parkes gave a verbal update on GP Validation feedback outlining the process followed and checks undertaken. Members advised that every month practices are presented with a data set and raise a number of queries, which are sent to Comm Support at Marylebone, but that no feedback is received. Members felt that it was important that feedback was sent to GPs on their feedback data.

5.0 CCG Update 5.1 Authorisation

6-8 week children health review checks It was agreed that a joint letter from NHS NWL and LMC should be sent to GPs reminding them that they need to return the yellow form to Child Health. Commissioning Support Unit (CSU) development Ms Murfitt advised that CSU development had been through the 2nd gateway and that KPIs are being developed. JM to share service specifications.

AJ/JM

JM

6.0 Items to Receive 6.1 Report from Meetings with NHS NWL and NWL LMCs

Strategic Meeting with NHS NWL, 23 October 2012 This meeting had been cancelled. Operational Meeting with NHS NWL, 30 October 2012 The notes from this meeting were received.

7.0 To confirm items for LMC newsletter

8.0 Date of the Next Meeting The date of the next meeting was noted as 23 January 2013, Conference Room B.

9.0 Any Other Business NWL Premises Survey SDP to email Tessa Sandall regarding receiving a report back from the site visits.

SDP

8

FINANCE REPORT (including QIPP)

MONTH 7

Jonathan Wise,

CFO, BEHH CCGs

9

NHS Ealing 2

NHS EALING FINANCE REPORT 12/13 - CONTENTS

1. Summary [Slides 3-8]

2. M7 Position [Slides 9-49]

3. Forecast outturn position [slides 50 - 57]

Appendices

A. Detailed finance schedules [Slides 58-64]

B. Balance sheet analysis [Slides 65 – 72]

C. Capital [slides 73-74]

10

NHS Ealing 3

SECTION 1 – SUMMARY

11

NHS Ealing 4

EXECUTIVE SUMMARY

• The financial position for Ealing PCT improved this month with a reduction in the

year to date deficit to £541k, a reduction of £60k from last month. The month 07 islargely due to Acute overperformance (£3.8m) which is principally offset by

favourable positions on Prescribing (£0.5m) Community (£0.4M) and Primary Care

(£0.7m), use of 7/12th of the contingency (£1.7m).

• QIPP schemes are showing a £899k (9% of plan) adverse variance year to date.

Whilst Dental, Continuing Care and Prescribing schemes are delivering above planyear to date, this is offset by slippage on 11 of the 30 schemes. The most significant

variances remain due to delays in commencement of both the Referral Management

and ICES schemes which are set to deliver later than planned. A major componentof the shortfall is due to non -achievement of savings from the West London Mental

Health scheme, but we think we are close to achieving an agreement which will

provide a substantial benefit to the PCT but which does not achieve 100% of theinitial target.

• The overspend year to date on CCG delegated budgets is £947k and the related variance on QIPP totals £1,275k

12

NHS Ealing 5

FINANCIAL PERFORMANCE SUMMARY (1)

� PCT Statutory duties

– Underspend against revenue resource

limit

– Achievement of capital resource limit

– Achievement of cash limit

� Underlying recurrent position (PCT)

� Achievement of overall financial plan (PCT)

� Achievement of public sector payment policy

(PCT)

� Achievement of QIPP plan (PCT)

� CCG Delegated Budgets

� CCG Delegated QIPP

YTD FOT

G

G

R A

G

G

R R

R A

GR

R

R

R

A

A

A

13

NHS Ealing 6

SUMMARY OF MONTH 7 AND FORECAST OUTTURN

The month 7 report includes performance against QIPP. The Month 7 variances have been analysed between QIPP / non-QIPP as per the table below:

A breakeven forecast has been reported in the Month 7 returns to NWL cluster and London SHA. This is in line with the forecast outturn assessment completed, and in-year recovery plan agreed by the Finance and Performance Committee on 28th September

QIPP variance relates to actual performance of schemes before the impact of block contracts. The impact of block contracts is adjusted by the non-QIPP column.

The detailed position by scheme in shown on slide 43

QIPP variance* Non-QIPP Total

£000s £000s £000s

CCG Delegated (1,275) 328 (947)

Other 376 30 406

Total (899) 358 (541)

QIPP variance Non-QIPP Total

£000s £000s £000s

CCG Delegated (668) (429) (1,097)

Other 30 1,067 1,097

Total (638) 638 (0)

Year to date

Forecast Outturn

14

NHS Ealing 7

� In order to understand the financial position of the PCT, it is important to distinguish

between recurrent ( underlying / run rate) and non-recurrent (one-off) income and expenditure items. The recurrent position determines on-going financial sustainability.

� The recurrent position as per the 12/13 plan, adjusted for major one-off items, is set out

below:

� The underlying position based on the in-year run-rate is being reviewed as part of the

work currently being undertaken on the forecast outturn.

UNDERLYING (RECURRENT) FINANCIAL POSITION

£m

12/13 breakeven plan -

- 12/13 cluster support (10.5)

- non-recurrent QIPP (2.2)

+ non-recurrent expenditure 2.9

12/13 recurrent position (9.7)

15

NHS Ealing 8

Budgets totalling £465.5m have been delegated to the CCG and £393.9m has been allocated to Practices.

Practice level reporting (including access to patient level detail through the portal) is under development.

The Month 5 year to date position for Ealing CCG practice budgets was a deficit of £2,726k.

PRACTICE BUDGETS IN 12/13

Network Name

Annual Delegated

Budget

Year to date

Budget

Year to date

Actual

Year to date

Variance

£'000 £'000 £'000 £'000

North Southall 74,979 31,058 30,591 467

South Southall 46,372 19,210 19,818 (608)

North North 58,796 24,356 24,698 (342)

South North 58,518 24,233 25,279 (1,046)

Central Ealing 47,286 19,591 20,648 (1,057)

West Ealing 42,603 17,651 18,222 (571)

Acton 65,391 27,077 27,489 (412)

Sub-total 393,945 163,176 166,745 (3,569)

Other Budgets held at CCG level

Acute SLA exclusions (Devices, High cost Drugs

etc)61,881 23,263 22,485 778

Other planned care (Physiotherapy, GUM etc) 3,122 1,309 1,352 (43)

Sub-total 458,948 187,748 190,582 (2,834)

Unregistered Patients 6,562 2,622 2,514 108

TOTAL 465,510 190,370 193,096 (2,726)

Note: Practice reports do not include PCT Contingency or other non-delegated PCT budgets such as Primary Care, Public Health and Corporate budgets, which had an overall net underspend of c£2.4m at M5.

16

NHS Ealing 9

SECTION 2 – MONTH 7 POSITION

17

NHS Ealing 10

OVERVIEW OF BUDGET POSITION AT MONTH 7

Month 6 Changes Month 7

£'000 £'000 £'000

Issued Budgets 617,260 192 617,452

Contingency & Reserves 2,979 2,979

Planned surplus 0 0

Total Allocation 620,239 192 620,431

Internal Allocation

Transfers adjustments Total

£'000 £'000 £'000

M7 adjustments:

Community reinvestment transferred to MSK 80 80

Community reinvestment transferred from RFS (80) (80)

Inner ICP Funding 103 103

PH-LA Transition 96 96

National Comm Grp Adjustment (7) (7)

Total Allocation 0 192 192

18

NHS Ealing 11

SUMMARY OF YEAR TO DATE VARIANCES - MONTH 7

+ve= underspend –ve= overspend

Explanations for the main variances are included on the following slide.

*QIPP variance relates to actual performance of schemes before impact of block contracts.

PCT PCT CCG CCG

Variance QIPP Variance QIPP

£'000 £'000 £'000 £'000

Commissioning of Healthcare

Acute Contracts (3,631) 46 (3,631) 46

Other Acute Commissioning (156) 66 (16) 66

Joint Working Commissioning 114 (397) 114 (397)

Community 358 (1,483) 358 (1,483)

Prescribing 516 493 516 493

Sub-total: (2,799) (1,275) (2,658) (1,275)

Primary Care

Medical Contract (163) 287

Primary Care Projects 35

Dental Contract 967 376

Pharmacy Contract 12

Out of Hours 68 68

Ophthalmic (239)

Sub-total: 680 376 356 0

Public Health (235)

Corporate & Estates Costs 75

TOTAL (2,279) (899) (2,303) (1,275)

Reserves and Contingency

Contingency 1,738 1,355

Investments / Reserves

RESERVES Total: 1,738 0 1,355 0

Total (541) (899) (947) (1,275)

19

NHS Ealing 12

SUMMARY OF YEAR TO DATE VARIANCES (1)

Acute Commissioning

In Cluster Contracts £1.6m unfavourable – Ealing, NWLHT and Imperial are block contracts; the pressure is focused on Royal Brompton ( £863k, possibly stabilising) and Hillingdon Hospitals (£464K,

trend deteriorating)

Out of Cluster Contracts £2.5 unfavourable – The largest variances are with UCLH (£1,059k) GOSH (£431k) and Guys (£317k).

Other Acute Commissioning £0.2m unfavourable – this has deteriorated in month, largely due to increased spend on high cost drugs..

Non acute commissioning

Joint working £0.1m favourable – includes overspending within Adult (£126k) and Children’s (£396k)

services offset by underspending in Continuing Care services (£636k).

Community Services £0.4m favourable – includes Ealing ICO, Urgent Care and other community services including budgets set aside for QIPP reinvestment – which are underspent year to date.

20

NHS Ealing 13

SUMMARY OF YEAR TO DATE VARIANCES (2)

Prescribing £516k favourable – GP Prescribing is £493k underspent offset by a net overspend on Enteral Feeds and Wound Dressing costs.

Primary Care £680k favourable – Dental, GP Medical and Pharmacy contracts are £967k, £60k and £12k underspent respectively, however Ophthalmic costs are £239k overspent.

Public Health £235k unfavourable - this is mainly due to a one off redundancy cost, however there is an on-going pressure within Sexual health services.

Corporate Services £124k unfavourable - the unbudgeted increase in charges from NWL cluster have been offset by under-spending across other areas of Corporate budgets.

Estates Services £199k favourable – this is mainly due to a reduction in the anticipated costs of PCT owned properties.

General Reserve/ Contingency £1,738k favourable – 7/12th of the Contingency budget has been phased in to the year to date position.

21

NHS Ealing 14

ACUTE CONTRACT POSITION – MONTH 7

Analysis of Year to date Acute SLA over / under performance as at Month 7

22

NHS Ealing 15

ACUTE CONTRACT POSITION – MONTH 7

Analysis of year to date Acute SLA Over/(Under) Performance

PCT Description Provider Description

NHS Ealing University College London Hospitals NHS Foundation Trust 5,080,312 758,752 829,451 1,059,026 ↑

Royal Brompton & Harefield NHS Foundation Trust 9,341,091 453,854 845,123 863,305 ↑

Ealing Hospital NHS Trust 92,193,000

The Hillingdon Hospital NHS Foundation Trust 11,852,309 305,127 295,856 464,192 ↑

Great Ormond Street Hospital For Children NHS Trust 2,595,162 405,912 455,262 431,308 ↓

North West London Hospitals NHS Trust 25,050,759

Guy's And St Thomas' NHS Foundation Trust 2,319,396 259,589 295,392 317,102 ↑

Royal National Orthopaedic Hospital NHS Trust 1,570,202 19,348 88,347 225,177 ↑

The Barts & The London NHS Trust 773,400 138,984 170,976 206,753 ↑

The Royal Marsden NHS Foundation Trust 894,794 112,627 169,694 159,121 ↓

Chelsea And Westminster Hospital NHS Foundation Trust 8,603,800 190,510 130,022 132,399 ↑

West Middlesex University Trust Hospital 8,342,881 259,776 151,138 104,456 ↓

Royal Free Hampstead NHS Trust 2,212,453 72,887 87,580 72,937 ↓

Heatherwood And Wexham Park Hospitals NHS Foundation Trust 436,695 61,051 60,823 64,460 ↑

Moorfields Eye Hospital NHS Foundation Trust 5,854,586 36,267 56,078 63,523 ↑

Kingston Hospital NHS Trust 136,676 21,451 22,614 28,030 ↑

King's College Hospital NHS Foundation Trust 604,769 37,104 17,356 17,627 ↑

Homerton University Hospital NHS Trust 65,844 2,247 5,398 3,713 ↓

Ashford And St Peter's Hospitals NHS Trust 422,009 (8,598) (14,598) (14,384) ↓

St George's Healthcare NHS Trust 683,044 (28,809) (13,441) (27,298) ↓

East And North Hertfordshire NHS Trust 818,498 (39,018) (36,287) (45,521) ↓

The Whittington Hospital NHS Trust 370,557 (43,063) (49,978) (70,054) ↓

Imperial College Healthcare NHS Trust 96,917,011

NHS Ealing Total 277,139,249 3,015,998 3,566,804 4,055,872

M5 reported

Variance

M7 reported

Variance

In

month

move

Total Annual

Plan Cost

M6 reported

Variance

23

NHS Ealing 16

Analysis of NHS Ealing with

Providers

In sector Providers

24

NHS Ealing 17

Provider YTD over

Performance

Key areas of over/under performance Actions

Ealing Hospital NHS Trust

£654,830

Non-Elective. Over performance continues to trendupwards. Of the total variance of £1,173k, £867k relatesto the mismatched QIPP plan profile versus actualimplementation timetable.

Long stays cost is increasing at 4%. Three highest overperforming sub chapters are Digestive SystemProcedures and Disorders, Thoracic Procedures andDisorders and Cardiac Disorders, which together accountfor 39% of admissions.

A high level of transfers from the Trust to RBH for cardiacpatients has been noted. EHT are investigating.

• Complete NEL Audit. Results thus farshow ¼ of admissions are avoidable.

• Verification of the emergency marginalrate credit received of £108k for accuracy

• Resolve apparent cardiology pathwaychange to Royal Brompton.

• Follow-up on frequent flyer analysis withCCG.

POD YTD

Plan Cost

YTD

Actual Cost

YTD

Variance

Cost

Variance

Movement

M5-M6

Non Elective Short Stay £3,648,713 £4,338,457 £689,744 £57,673

Non Elective Inpatients £15,273,622 £15,757,798 £484,176 £119,190

Elective Excess Bed Days £165,666 £344,746 £179,080 £30,081

Outpatient First Attendance £4,500,449 £4,674,714 £174,265 £14,813

Outpatient Follow Up Attendance £3,850,566 £3,980,839 £130,273 £56,220

Outpatient Procedures £1,497,741 £1,614,299 £116,557 £23,312

High Cost Drugs £1,304,867 £1,380,035 £75,168 £15,070

Direct Access £767,555 £797,205 £29,649 £5,090

Community £945,250 £945,250 £0 £0

Non Elective Excess Bed Days £1,335,778 £1,314,275 -£21,503 -£50,886

Accident and Emergency £2,380,297 £2,297,554 -£82,743 -£32,187

Critical Care £1,713,145 £1,594,030 -£119,115 -£77,412

Elective Inpatients £2,804,581 £2,643,293 -£161,288 -£5,484

Daycase £4,083,401 £3,727,681 -£355,721 -£113,936

Other £1,724,406 £1,240,692 -£483,714 -£459,933

Grand Total £45,996,036 £46,650,866 £654,830 -£418,388

Ealing Hospital NHS Trust (slide 1)

25

NHS Ealing 18

Ealing Hospital NHS Trust (slide 2)

Provider YTD Month

7

Over/Under Performance

Key areas of over/under performance Actions

Ealing Hospital NHS Trust

£654,830 Elective Excess Bed days over performance is caused by a peak in high LOS patients in July. There were 4 patients with 134, 127, 111, and 110 LOS costing £116k. Elective spells trend is declining.

Outpatient procedures over performed by £166. Theover performance is due to cardiology procedures,including ECG diagnostics. All other outpatientprocedures are below plan. Obstetrics ante natal andpost natal investigations and Dermatologyphototherapy procedures are increasing but notcausing over performance.

Critical Care variance is reducing – long LOS patients now discharged.

Outpatients, both New and Follow-up attendancesover performed with variances totaling £100k. Thisprimarily reflects the change made to how Cardiologyoutpatients are allocated to PODs. Underlying activitylevels are unchanged from M5. RFS QIPP scheme tostart in November.

Day Cases declining trend continues unabated.

• Trust have been challenged on CC codingissue re decrease in single organ andincrease in two & three organ HRGs

• Trust have been challenged on anti-coagulation over performance, and the slowQIPP progress.

• Trust have been challenged on slow QIPPprogress with diabetes community clinics.

• Follow-up on pathways associated withoutpatient challenges for multiple same dayattendances, and non pre-bookedattendances.

• The Challenge programme, similar to Q1 isbeing pursued. Challenge values in Q2 aresimilar to Q1.

• PPwT audit to be conducted in December.

• Trust have missed the target for 95% codingof NHS Numbers in A&E. Q2 penalty of£300k anticipated (Trust wide).

26

NHS Ealing 19

CUTE CONTRACT POSITION –Month 5 (4/13)North West London Hospital Trust (slide 1)

Provider YTD over Performance

Areas of over performance Actions

NWLH £363k Note: The NWLH 2012-13 contract is operating as a block contract

Month 6 Trust reported unmitigated position is over performance of £363k; a favourable movement of £82k from month 5. Month 6 position includes receipt of £290k credit for challenges raised.

QIPP adjustment at M6 is £329k, of which:

• £233k Outpatient attends

• £96k NEL Spells

Mitigations outstanding of £227k reduce the adverse variance to £136k

Significant areas of over performance:

Outpatients £302k

•Significant pressures: clinical haematology (£128k) & urology (£30k)

•£25k additional charges in month against GUM services due to incorrect implementation of sexual health tariffs

•£91k credits received for non-compliant outpatient follow up ratios (although this is a £116k shortfall below expected plan)

•QIPP deduction YTD £233k.

Non Elective

Audit will be undertaken focusing on clinical decision-making around short stay admissions. ToR yet to be agreed by Trust. Expect to be conducted in 2012 when clinician availability is arranged.

A&E pathway discussions taking place via CQG, particularly regarding admit-to-assess process and potential charging for registration on hospital system.

Productivity & Efficiency Metrics

Challenges have been raised for adverse performance over agreed thresholds.

Challenges

Credits secured of £290k including Q1 PPwT challenges (£56k).

Potential further credits pending of £227k.

27

NHS Ealing 20

North West London Hospital Trust (slide 2)

Provider YTD over Performance

Areas of over performance Actions

NEL Inpatients (inclusive of excess bed days)

•Over performance £271k; a favourable movement of £73k

•QIPP deduction YTD of £96k

High cost drugs

•Over performance of £131k (in month favourable movement of £6k

•YTD prescribing increases, particularly for cytotoxics. Increased presentation of haematology patients (linked to higher attendance volumes) and guidance changes on the number of doses per regimen.

Outpatients follow-up ratio credit

£91k is already reflected in position.

An activity review is being undertaken in key specialties. Discussions are taking place in CQG, led by CCGs around delivery of ratios and run-rate leading towards 2013-14.

High Cost Drugs.

A Medicines Management Commissioning Group has been re-established, providing a forum to monitor performance. This forum needs to be integrated into current CCG governance arrangements.

28

NHS Ealing 21

The Hillingdon Hospital Foundation Trust (slide 1)

Provider YTD Over Performance

Position Actions

THHFT £398k,mitigated to

£218k

Main areas of over performance are:

Day case and elective £21k

• Outpatients 1st attendances over performed by £71k. General surgery continues to be the main area of over performance £21k

• Outpatient follow up £ 40k

• Outpatient procedures are above plan by £52k the most significant factor being an over performance on phototherapy of £18k or in activity terms 241 actual at M6 against a plan of 32 for the YTD

• There is an adverse variance of 59k relating to non elective excess bed days which is 70% above plan; this is spread across all specialties with no obvious area for investigation.

• Critical care over performed by £62k

• There is a positive variance of £87k for elective activity in favour of Ealing commissioners

• Rehabilitation over performed by £147k

The following actions are being taken

• NHS NWL has already secured credits and refunds of £249k for NHS Ealing through performance and efficiency metrics, other challenges and acute contract levers. A further challenge of £66k is being pursued.

• Patient level information sent to NHS Ealing to check if there are any DoTC.

• There is an audit taking place to understand if there are any coding issues related to Rehab patients.

• Activity management plan. See below.

29

NHS Ealing 22

The Hillingdon Hospital Foundation Trust (slide 2)

Activity Management Plan:The contact agreement with THHFT provides for an activity management plan. It complemented QIPP. It is intended

that the implementation will have an impact on activity from 1 January. • Undertake analysis to verify if conversion rates are changing or not • Benchmark intervention rates • Investigate whether activity was previously reported as outpatient procedures and verify if it qualifies as a day case

procedure.• Understand whether THH can bring activity back to planned levels taking into account the impact on the 18 week

RRT• Improve understanding of the longer term impact of the bowel and lung screening programmes• Scrutinise referral data to ascertain drivers of growth.• Gain a thorough understanding of patient pathways and the implications for supply generated demand• Understand the causes of increased activity for the HRG All Patients older than 69 years with a Mental Health

Primary Diagnosis and if this can be mitigated • Undertake further activity analysis to identify any new areas of focus for over performance

30

NHS Ealing 23

West Middlesex Hospital Trust (WMUH)

Provider YTD Over Performance

Position Actions

WMUH £90k, mitigated to £64k

Summary: Over performance from Ealing patients at WMUH has reduced from £126k last month to £90k in month 6. Whilst activity growth is up 12%; cost is just 2.2% over plan.

Main areas of over performance include

• Non Elective Inpatients over performed by £233k (inclusive of credit for activity above the threshold) due to activity being 56% higher than plan. The main HRG chapters over performing are: Digestive £89k; MSK £65k; and Respiratory £64k

• Outpatients first appointments have over performed by £94k and follow ups by £41k year to date.

• Podiatry specialty appears to over perform by £115k whilst general surgery is down -£99k. This is because commissioners asked the Trust to split out podiatry recording from gen surgery.

• Other OP specialties over performing include Obstetrics £26k; GUM £17k; and Respiratory £15k.

• A&E over performed by £77k

• High Cost Drugs by £16k

• Non elective, non-emergency admissions under performed by -£164k; of which obstetrics admissions were down £79k; and nervous system down £69k

The following actions are being taken.

The CSU continues to challenge the Trust Emergency marginal rate threshold value.

NHS NWL has already secured credits and refunds of £265k for NHS Ealing through performance and efficiency metrics, other challenges and acute contract levers.

Recent negotiations on a capped contract for NHS Hounslow, between commissioners and WMUH, have led to a set of agreements to control activity during 2013-14.

There will be a reduced NEL baseline. Also greater transparency on outpatient clinic capacity, demand levels by specialty.

Supply side initiatives to control non-elective activity will benefit other affected CCGs including Ealing CCG.

31

NHS Ealing 24

Royal Brompton & Harefield NHS FT (slide 1)

Provider YTD over Performance

Areas of over performance Actions

RBH £740k, mitigated to £680k

Over performance at M6 includes an adverse movement of £35k from M5.

Non-electives are over performing against plan by £316k, a £15k movement.

RBH is the NWL Cardiac and Cystic Fibrosis tertiary centre. These activities make up most of the RBH activity and cost.

Both Cardiac Surgery and Cystic Fibrosis are over performing substantially.

NHS Ealing has seen a 75% increase in cardiac surgery activity between 2011-12 M1-5 and 2012-13 M1-5.

This is driving over performance in:

• Non-electives (including the “New” complex cardiac procedures, including implanting of ICD devices)

• Critical care (overperforming by £217k). There continues to be un-discharged CC patients with WIP over £300k, which are included in the forecast.

• ICD devices (over performing by £36k). This is a reduction on last month but this is due to only 1 ICD being charged for in month 6 against a plan of 2.

In turn, the NEL overperformance is starting to affect elective over performance, when cardiac surgery (particularly transplant) patients return for their “redos”

New, more stringent metrics from M4, including

• OP metrics will increase yield for full year. Projected yield for full year is £170k.

• ICD metric, which will cap over performance. Effect will not be known until later in the year.

• Non-GP referral metric started in M4. FY yield estimate is £30k.

Actions being taken.

• Audit of critical care HRG organ coding, and whether HDU criteria are being met. In progress, with final report due mid November. Financial value not yet estimable.

• PbR Challenge of critical care charging relating to HRG between ITU and HDU. Trust have conceded the challenge from October. Negotiations continue for back dating. Estimated affect of £50k.

32

NHS Ealing 25

Royal Brompton & Harefield NHS FT (slide 2)Provider YTD over

PerformanceAreas of over performance Actions

• Electives are over plan by £100k (an in month movement of £20k)

• Outpatient activity slightly over performing, though mitigated by F:Fup ratio cap.

Together, these all drive overperformance in drugs and devices, which are over performing by £14k.

NHS NWL analysis shows that:

• Activity is very variable between months (relatively low volume, but high cost). Hence the big variance swings.

• NHS Ealing activity increase is driven by an RBH consultant who does sessions at EHT, and who is currently training consultants within EHT and therefore complex cases are being referred on to RBH.

FOT forecast has reduced from £1,561k to £1,411k. This is an effect of the extrapolation method of forecasting. The activity by month is very variable. The activity in month 6 was lower than the average of Month 1-5.

This is mainly down to a reduced level of activity in Month 6 on Non Elective activity.

The main movement in variance from M5 to M6 was the increase in WIP, mainly due to the long stay patient.

Forecast includes £200K contingency for winter pressures.

Cardiac procedure (HRG Chapter EA) trends show that since December 2011:

• Imperial activity has been declining

• Ealing activity has been declining

• RBH is showing an upturn.

• Work with Cardiac Network to ensure assessment criteria are consistently applied. This work is starting, and will have impact in 2013-14.

• Sector analysis of where cardiac surgery is being performed to assess whether activity should/could be performed at Trusts other than Imperial.

• Review of drugs and devices charges to verify accuracy.--

33

NHS Ealing 26

Chelsea & Westminster NHS Foundation Trust

Provider YTD Over Performance

Position Actions

C&W £113k mitigated to £87k

• Elective activity over performing by £72k

• Excess bed days over performing by £54k

• Day case over performing by £82k

• One complex Paediatric surgery case

• T&O – small number of complex Knee procedures with complications and long stay

• Outpatient activity op (£156k)

• 1st Op £37k

• FU Op £59k

• Procedures £63k

Over performance offset in part by:

• Non Elective under performing by £119k

• Critical Care under performing by £16k

New more stringent metrics introduced from M4

• Outpatient metric will increase yield for M4-12. Projected yield for year of £65-£75k

• Day case to Outpatient metric

• Maternity metric to reduce OP 1st/FU ratio and number of OP Procs

• T&O metric to reduce length of stay

• C to C and Non-GP referrals metric from M4 to deliver 15% reduction

Major impact of new metrics will be seen in future months.

Ongoing challenges to coding & counting. £11k yield YTD, with further challenges include to include Non GP Referral Metrics to the value of £23.6k

34

NHS Ealing 27

Imperial College Healthcare NHS TrustProvider YTD Month 7 Key areas of over/under performance Actions

Imperial College Healthcare NHS Trust

M6 TYD under performance: -£1,773k

• £938k of the under performance is due to contractual adjustments

• £1.5m of GP led validations have yielded £3k to date.

• Accident & Emergency over performing by £135k with a 18.8 per cent increase in activity when compared to the previous year.

• Outpatients is over performing by £411k spread across a number of specialties with the largest over performance in Medical Oncology (£77k). The actual number of GP referred activity is down 1.6 per cent when compared to the previous year.

• Elective work under performing by £420k

•£147k under performance with regards to Orthopaedic Non-Trauma Procedures

•£135k under performance with regards to

Cardiac Procedures

Trust failed to achieve 3 of the 9 cancer standards in Month 6. Remedial plan in action with financial penalties to be applied

Trust not achieving the admitted standard for 18 weeks due to backlog and achieving the standard still remains a challenge. Financial penalties will be applied as per contract schedule

Review the GP led validations

YTD

P la n

YTD

Ac tua l

YTD

V a r ia nc e

V a r ia nc e

m ove m e nt

Ea ling P CT O P FA £ 3 ,2 7 6 ,4 7 4 £ 3 ,6 5 1 ,4 8 9 £ 3 7 5 ,0 1 5 £ 4 3 ,9 2 5

A& E £ 8 9 4 ,2 6 0 £ 1 ,0 2 9 ,5 2 8 £ 1 3 5 ,2 6 8 £ 2 7 ,6 2 0

R e n a l £ 4 ,3 0 3 ,0 5 5 £ 4 ,4 1 0 ,7 3 8 £ 1 0 7 ,6 8 4 £ 3 6 ,7 2 5

D e vic e s £ 3 6 4 ,0 0 1 £ 4 3 7 ,9 3 3 £ 7 3 ,9 3 2 -£ 9 9 6

R A £ 7 2 8 ,5 4 0 £ 7 7 3 ,4 5 2 £ 4 4 ,9 1 2 £ 1 5 ,1 1 8

O P FU P £ 4 ,0 5 2 ,2 9 6 £ 4 ,0 8 8 ,3 3 6 £ 3 6 ,0 4 0 -£ 1 1 ,4 7 7

N E L S T £ 3 4 9 ,1 9 1 £ 3 6 6 ,7 7 6 £ 1 7 ,5 8 5 £ 7 ,4 7 8

C o m m u n ity £ 2 1 1 ,6 2 4 £ 2 1 1 ,6 2 4 £ 0 £ 0

R e h a b £ 1 3 2 ,9 1 3 £ 1 2 8 ,1 5 9 -£ 4 ,7 5 4 -£ 5 ,3 8 2

D i re c t Ac ce s s £ 9 1 2 ,6 0 0 £ 8 8 1 ,9 9 4 -£ 3 0 ,6 0 7 -£ 1 8 ,1 1 6

C ritica l C a re £ 3 ,6 2 8 ,4 0 8 £ 3 ,5 4 5 ,6 4 7 -£ 8 2 ,7 6 1 -£ 1 9 1 ,4 4 7

N E L £ 1 2 ,3 1 0 ,3 6 3 £ 1 2 ,2 0 9 ,6 2 4 -£ 1 0 0 ,7 3 9 -£ 7 1 ,0 1 1

O P P R O C £ 7 9 9 ,9 8 0 £ 6 4 6 ,2 5 9 -£ 1 5 3 ,7 2 1 -£ 1 0 ,7 7 3

D C £ 4 ,5 5 2 ,6 6 3 £ 4 ,3 2 0 ,6 2 9 -£ 2 3 2 ,0 3 3 -£ 4 ,9 6 6

O th e r £ 3 ,5 3 2 ,7 1 8 £ 3 ,2 5 5 ,4 1 4 -£ 2 7 7 ,3 0 5 -£ 8 2 ,7 2 6

H ig h C o s t D ru g s £ 3 ,1 9 8 ,6 0 4 £ 2 ,8 7 4 ,6 1 1 -£ 3 2 3 ,9 9 3 -£ 6 5 ,9 6 1

E L £ 5 ,0 8 9 ,3 7 0 £ 4 ,6 6 9 ,0 4 1 -£ 4 2 0 ,3 3 0 -£ 1 6 1 ,9 4 7

Ad ju s tm e n ts £ 1 2 4 ,4 7 4 -£ 8 1 3 ,2 0 7 -£ 9 3 7 ,6 8 0 -£ 5 ,3 8 5

Ea ling P CT Tota l £ 4 8 ,4 6 1 ,5 3 4 £ 4 6 ,6 8 8 ,0 4 7 -£ 1 ,7 7 3 ,4 8 7 -£ 4 9 9 ,3 2 1

P CT P O D

35

NHS Ealing 28

Analysis of NHS Ealing with

providers

Out of Sector Providers

36

NHS Ealing 29

University College London Hospitals NHS Foundation

Provider YTD Over Performance

Position Actions

University College London Hospitals NHS Foundation Trust

Variance (YTD)

£907k (36%)

Areas of over performance

£350K of Critical Care costs relate to a patient discharged in June 2012. Critical Care WIP plans from UCLH show a total of £220k yet to be charged, of which £210k is for one patient.

QIPP of £1,344 in contract.

Critical Care £390k

Non Elective Inpatients £136k

• (Intracranial Procedures for

Trauma with Minor £35k

Diagnosis

• Intracranial Procedures Except

Trauma with Haemorrhagic

Cerebrovascular Disorders -

category 3 £29k

Elective Inpatients

• Intracranial telemetry

High Cost Drugs £123k

£40k

£91k

37

NHS Ealing 30

Great Ormond Street Hospital for Children NHS Trust

Provider YTD Over Performance

Position Actions

Great Ormond Street Hospital for Children NHS Trust

£370k Areas of over performance

There is one Ealing patient on the GOSH Long Term Patient list. However, this admission is linked to a bone marrow transplant so we should not see the cost of this spell being reported against the acute contract.

QIPP of £6,697 has been removed from the contract baseline.

Elective Inpatients £160k

• Cochlear Implants £140k

• Cardiac Surgery £52k

Non Elective Inpatients £76k

• Cardiac Surgery £35k

Rehab £53k

• Transitional Care £82k

• Rheumatology -£29k

38

NHS Ealing 31

Guy's and St Thomas' NHS Foundation Trust

Provider YTD Over Performance

Position Actions

Guy's and St Thomas' NHS Foundation Trust

Variance (YTD)

£270k

Areas of over performance

QIPP of £3,929 in contract.

Referrals are above out-turn on 2011/12.

New Outpatient Referrals (all Specialties) are up 40% this year on the same period of 11-12.

Elective Inpatients £100k

• Paediatric Trauma &

Orthopaedics £46k

• Trauma &

Orthopaedics £37k

Daycase £34k

• Oral Surgery £14k

High Cost Drugs £28k

39

NHS Ealing 32

Royal National Orthopaedic Hospital NHS Trust

Provider YTD Over Performance

Position Actions

Royal National OrthopaedicHospital NHS Trust

Variance (YTD)

£190k

Areas of over performance

OP New Outpatient Referrals for T&O are up 13% this year on the same period of 11-12.

No QIPP in this contract.

Elective Inpatients £186k

• Trauma &

Orthopaedics £190k

Critical Care £29k

Devices £24k

40

NHS Ealing 33

The Barts & The London NHS Trust

Provider YTD Over Performance

Position Actions

The Barts & The London NHS Trust

Variance (YTD)

£180k

Areas of over performance

No QIPP on this contract.

There is HEMS Consortia cost of £104k and HEMS fixed element cost £29k. Total of all this together gives variance of £74k over.

Non Elective Inpatient £51k

• Paediatrics £14k

Other £41k

• Accident and Emergency (HEMS Consortia) £74k

Oral Surgery – Cancers -£46k

• Daycase £40k

41

NHS Ealing 34

ACUTE ACTIVITY ANALYSIS

• The following graphs compare monthly activity levels in 2012/13 with 2011/12 and 2010/11. There may be differences to the financial variances due to:

• Activity slides do not take into account case-mix and the impact of contract levers e.g. outpatient follow-up ratios

• Non PbR spend areas such as Critical Care, Excluded Drugs & Devices, Direct Access, Renal and Other Exclusions are not reflected in the graphs. Accident and Emergency spend is also not reflected in the graphs.

• The following slides show actual activity changes across all providers for the first six months of this year compared to the same period last year:

– elective admissions decrease of 2.9%;

– emergency admissions increase of 5%;

– outpatients first attendances (GP referrals) decrease of 3.3%

– outpatients first attendances (all referrals) increase of 1.0%

– outpatients follow-up attendances (GP referrals) increase of 1.0%

– outpatients follow-up attendances (all referrals) decrease of 1.5%

42

NHS Ealing 35

ACUTE ACTIVITY ANALYSIS (1) – ELECTIVE

43

NHS Ealing 36

ACUTE ACTIVITY ANALYSIS (2) – EMERGENCY

44

NHS Ealing 37

ACUTE ACTIVITY ANALYSIS (3) – OUTPATIENTS

45

NHS Ealing 38

ACUTE ACTIVITY ANALYSIS (3) – OUTPATIENTS

46

NHS Ealing 39

ACUTE ACTIVITY ANALYSIS (5) – OUTPATIENTS

47

NHS Ealing 40

ACUTE ACTIVITY ANALYSIS (5) – OUTPATIENTS

48

NHS Ealing 41

SPECIALIST COMMISSIONING – REPORT M7

• The reported position for Specialist Commissioning is based on 7/12th of the risk adjusted

forecast outturn from the latest LSG Report (as at Month 6) - the overall reported year to date position is an overspend of £138k, and adverse movement in month of £145k .

49

NHS Ealing 42

JOINT WORKING VARIANCES – MONTH 7

• Joint Working year to date is £0.1m favorable- is made up as follows:

• Adult Services £126k unfavorable.

• Continuing Care services £636k favorable –The renegotiation of beds prices with a key provider continues to give a favorable impact.

• Children's Services £396k unfavorable - this has not moved significantly ; the pressure coming from increase in the number and

cost of placements.

50

NHS Ealing 43

COMMUNITY SERVICES VARIANCES – MONTH 7

• Community Services year to date underspend of £358k - is made up as follows:

• Ealing ICO year to date overspend of £18k.

• Ealing Urgent Care service year to date overspend of £77k- higher than

expected Radiology charges from Ealing Hospital Trust

• Other Community year to date underspend of £454k, mainly due to under-spending on QIPP reinvestment budgets and the Health and Wellbeing

services.

51

NHS Ealing 44

PRIMARY CARE VARIANCES - MONTH 7

Prescribing £516k favorable - local GP prescribing is £151k underspent and PPA

prescribing is £342k underspent, and there is a reduced overspend Enteral feeds (

down by £70k to £128k)

Other Primary Care £680k favorable– the underspend on dental contracts has

increased by £140k to £967k, but this is balanced by in month adverse movements

on the pharmacy contract ( now £12k, adverse movement of £121k) and an

increased spend on ophthalmic contract of (£86k in month movement). The balance is made up the variances on the GP medical contract.

52

NHS Ealing 45

CORPORATE, ESTATES & PUBLIC HEALTH VARIANCES – MONTH 7

• Public Health £235k unfavorable - there is an on-going pressure on the Marie

Stopes contract.

• Corporate Services £124k adverse - this reflects the increase in charges from

NWL cluster.

• Estates Services £199k favorable - this is mainly due to a Health Centre charges

relating to GP occupancy being correctly charged to the Primary Care budgets.

• General Reserves / Contingency £1,738k favorable - 7/12th of the Contingency

budget has been phased into the year to date position.

53

NHS Ealing 46

BALANCE SHEET AT 31 OCTOBER

Further analysis of balance sheet

movements is contained in appendix B

Statement of Financial Position

B/Fwd

31.03.12 M7 YTD FOT

£000s £000s £000s

NON-CURRENT ASSETS:

Property, Plant and Equipment 45455 44,909 46,760

Intangible Assets 167 127 95

Other Financial Assets 477 476 476

Trade and Other Receivables 63 73 78

TOTAL Non Current Assets 46162 45,585 47,409

CURRENT ASSETS:

Inventories 131 131 131

Trade and Other Receivables 9162 12,727 3,234

Cash and Cash Equivalents 14 19 15

TOTAL Current Assets 9307 12,877 3,380

TOTAL ASSETS 55469 58,462 50,789

CURRENT LIABILITIES

Trade and Other Payables (49,390) (46,825) (47,285)

Provisions (1,537) (2,013) (400)

Borrowings (198) (258) (200)

Total Current Liabilities (51,125) (49,096) (47,885)

NET CURRENT ASSETS/(LIABILITIES) (41,818) (36,218) (44,505)

TOTAL ASSETS LESS CURRENT LIABILITIES 4,344 9,367 2,904

NON-CURRENT LIABILITIES:

Trade and Other Payables 0 (1,216) (1,193)

Provisions (4,983) (4,196) (4,649)

Borrowings (10,606) (10,436) (10,504)

Total Non-Current Liabilities (15,589) (15,848) (15,153)

ASSETS LESS LIABILITIES (Total Assets

Employed) (11,245) (6,481) (12,249)

TAXPAYERS EQUITY

General Fund (21,996) (17,234) (21,820)

Revaluation Reserve 10751 10,753 9,571

Total (11,245) (6,481) (12,249)

54

NHS Ealing 47

BETTER PAYMENT PRACTICE CODE (BPPC)

Action Plan

NHS

Disputes are not always recorded. A reminder has

now been given to the NCA team to ensure they

record disputed invoices and these are now being

excluded from failing the 30 day target.

Non NHS

Some budget holders do not verify and authorise

invoices promptly. Finance Managers have been

asked to remind budget managers of the

importance of this during their regular meetings.

Closure project

There is a project underway to clear all creditors

ready for PCT closedown. This results in the BPPC

worsening as old invoices are being paid.

55

NHS Ealing 48

QIPP PROGRAMME M7 YTD SUMMARY

56

NHS Ealing 49

QIPP ANALYSIS

The majority of schemes are reported to be delivering to plan.

As at Month 7, the following schemes are over-delivering against the QIPP plans:- Productive community services (£256K YTD, £438K projected over-delivery at year- end)- Continuing Care services (£366K YTD, but only £50K favourable forecast at year-end)- Primary Care Prescribing ( £493K YTD, but breakeven at year-end)- Primary Care Dentistry ( £376K YTD, but only £30K at year-end).

For three of the four schemes the favourable YTD performance is not anticipated to continue through to the end of the year; whether this reflects too pessimistic forecasting or a sound assessment of risk will be looked at more closely for next months reporting.

Other comments on schemes:

Intermediate Care Service (Integrated Community Response) – the service is scaling up and is expected to be fully mobilised by early November and able to accept referrals from all GP practices in Ealing.

Urgent Care Pathway Redesign – the UCC at Ealing Hospital is at full benefits realisation stage

Pulmonary Rehabilitation - the tender has now been awarded and mobilisation is underway. The new service is expected to beaccept patients from 1st November 2012.

MSK pathway redesign – Full deployment of the new pathway is expected for early November 2012, but two months will beneeded to help clear the backlog; benefits realisation should flow substantially for quarter 4.

Productive Mental Health services – part of this saving will be made by closure of a WLMHT ward which is not unlikely to by achieved until February-March 2013. The remaining savings will result from removal of inappropriate workload from WLMHT. Work is currently underway with the Trust to review the patients of two pilot practices mapped into the first 2 Mental Health care clusters. To date £900K has been secured, leaving £600K at risk.

Referral Facilitation Service – implementation of the new service is progressing to plan in relation to training, IT development andpathway implementation. There is a delay in recruitment to the vacancies. Both the Service Manager and Lead Clinician have takenup their roles. Roll-out of IT across all practices is underway and due for completion at the end of November. This will allow some ofthe adverse YTD position to be recovered, but the scheme is not expected to achieve the whole of the planned saving this year.

57

NHS Ealing 50

SECTION 3 - FORECAST OUTTURN (FOT)

58

NHS Ealing 51

12/13 FORECAST AND RISK ASSESSMENT

Budget headingBest£m

ML£m

Worst£m

Acute SLA (5.4) (5.9)* (6.4)

Other acute (0.4) (0.4) (0.5)

Joint working (0.8) (0.8) (1.2)

Community 1.4 1.4 1.0

Prescribing 0.8 0.6 0.4

Primary Care 1.7 1.7 1.2

Public Health (0.2) (0.3) (0.4)

Corporate - (0.3) (0.5)

Estates 0.7 0.7 0.7

Continuing Care Claims (1.5) (1.5) (2.0)

Contingency 1.9 1.9 1.9

Balance sheet - (1.2) (2.0)

TOTAL (1.8) (4.1) (7.8)

Variance to budget

*see next slide ( ) = overspend

Note: excludes PCT closure costs (assumed funded separately)

59

NHS Ealing 52

ACUTE SLA PERFORMANCE FORECAST – MONTH 07

a b c d e f g h i=( b-h) j= i-a k=( i+f)

PCT View by Trust - M6 2012/13 - NHS Ealing

Automated

challenges

Contract

levers

QIPP

Adjustment

Provider Description

Ealing Hospital NHS Trust £92,193,000 £654,830 £95,250,240 £233,885 £502,210 £0 £21,000 £2,321,146 £3,078,240 £92,172,000 -£21,000 £94,493,145

Royal Brompton & Harefield NHS Foundation Trust £9,341,091 £739,976 £10,864,933 £4,579 £135,034 £4,579 £144,191 £10,720,742 £1,379,650 £10,720,742

University College London Hospitals NHS Foundation Trust £5,080,312 £907,737 £6,895,785 £9,587 -£555 £42,960 £221,861 -£5,046 £268,808 £6,626,977 £1,546,665 £6,626,977

North West London Hospitals NHS Trust £25,050,759 £363,169 £25,849,448 £9,777 £220,169 £101,841 £10,963 £503,718 £846,468 £25,002,980 -£47,779 £25,506,698

Great Ormond Street Hospital For Children NHS Trust £2,595,162 £369,692 £3,334,547 £3,909 £3,478 £0 £95,000 -£100,036 £2,351 £3,332,197 £737,034 £3,332,197

The Hillingdon Hospital NHS Foundation Trust £11,852,309 £397,879 £12,770,745 £10,211 £103,513 £164,386 £40,729 £318,840 £12,451,905 £599,596 £12,451,905

Guy's And St Thomas' NHS Foundation Trust £2,319,396 £271,802 £2,863,000 £1,082 £0 £0 -£18,005 -£16,923 £2,879,923 £560,527 £2,879,923

The Barts & The London NHS Trust £773,400 £177,217 £1,127,834 £325 £2,978 £0 -£11,199 -£7,896 £1,135,730 £362,330 £1,135,730

The Royal Marsden NHS Foundation Trust £894,794 £136,389 £1,167,572 £858 £4,339 £0 -£827 £4,370 £1,163,202 £268,409 £1,163,202

West Middlesex University Trust Hospital £8,342,881 £89,534 £8,428,180 £0 £7,747 £14,264 £22,011 £8,406,169 £63,288 £8,406,169

Chelsea And Westminster Hospital NHS Foundation Trust £8,603,829 £113,485 £8,796,472 £0 £49,172 £3,400 £52,573 £8,743,899 £140,070 £8,743,899

Royal National Orthopaedic Hospital NHS Trust £1,570,202 £193,009 £1,956,220 £3,155 £57,022 -£12,729 £47,447 £1,908,772 £338,570 £1,908,772

Royal Free Hampstead NHS Trust £2,162,547 £62,517 £2,287,582 £1,953 £14,916 £9,271 -£5,333 £20,806 £2,266,775 £104,228 £2,266,775

Heatherwood And Wexham Park Hospitals NHS Foundation Trust£436,695 £55,251 £547,197 £12,874 £0 -£3,635 £9,239 £537,958 £101,263 £537,958

Moorfields Eye Hospital NHS Foundation Trust £5,854,586 £54,448 £5,963,482 £35,330 £0 -£178,904 -£143,574 £6,107,057 £252,471 £6,107,057

Kingston Hospital NHS Trust £136,676 £24,025 £184,727 -£30 £0 -£983 -£1,013 £185,740 £49,064 £185,740

King's College Hospital NHS Foundation Trust £604,769 £15,109 £634,987 £0 £0 -£9,867 -£9,867 £644,854 £40,085 £644,854

Homerton University Hospital NHS Trust £65,844 £3,182 £72,208 £0 £0 -£2,166 -£2,166 £74,375 £8,531 £74,375

St George's Healthcare NHS Trust £683,044 -£23,398 £636,248 £560 £0 -£19,087 -£18,528 £654,776 -£28,268 £654,776

Ashford And St Peter's Hospitals NHS Trust £422,009 -£12,329 £397,351 £0 £0 -£11,921 -£11,921 £409,271 -£12,738 £409,271

East And North Hertfordshire NHS Trust £818,498 -£39,018 £740,462 £0 £0 -£4,791 -£4,791 £745,254 -£73,244 £745,254

The Whittington Hospital NHS Trust £370,557 -£60,046 £250,466 £0 £0 -£2,091 -£2,091 £252,557 -£118,001 £252,557

Imperial College Healthcare NHS Trust £96,917,011 -£1,773,487 £93,993,496 £10,286 £485,278 £0 £0 £0 -£3,419,078 -£2,923,515 £96,917,011 £0 £93,497,933

NHS Ealing Total £277,089,372 £2,720,974 £285,013,181 £286,452 £1,580,166 £397,723 £357,590 -£354,659 -£594,215 £0 £1,673,059 £283,340,123 £6,250,751 £282,745,908

Total

Mitigations

Full year

mitigated

forecast Actual

Full year

mitigated

forecast

Variance

Full year

mitigated

forecast Actual

(excl block adj)

Mitigations

Total Annual

Plan Cost

Total YTD

Variance Cost

Full year

unmitigated

forecast actual

Other

challenges

Adjustment

for

exceptional

items

Adjustment

for CQUIN

Adjustment

to match

back to block

agreement

Overall SLAM report summary for NHS Ealing, including all Out of Sector Trusts, with full year adjusted projections

60

NHS Ealing 53

12/13 QIPP – UPDATED FORECAST AND PHASING (1/2)

( ) = reduction in savings

61

NHS Ealing 54

12/13 QIPP – UPDATED FORECAST AND PHASING (2/2)

Gross savings £’000 %

Q1 April – June 3,702 17

Q2 July – September 3,829 17

Q3

October

November

December

1,438

2,184

2,484

28

Q4

January

February

March

2,606

2,887

2,917

38

TOTAL 22,047 100

62

NHS Ealing 55

•This table has been updated to reflect additional measures, the latest best estimate of outturn and a risk assessment (based on achievement of the scheme, and likely value to

be achieved)

UPDATED RECOVERY PLAN

Actions Proposed to achieve break-even Manager

RAG rating

of scheme

Best Case

£'000

Likely

£'000

Worse

Case £'000

Lastest forecast

outturn £'000

-£1,500 -£4,100 -£8,100 -£4,100

Agree contract variation with EHT re ICES

slippage

Ian Jackson amber £0 £500 £500 £500

Agree with providers that all readmissions

funding has already been re-invested

Jo Murfitt amber £0 £700 £1,500 £700

Public Health to be tasked with achieving

break-even

Jackie Chan amber £200 £300 £400 £300

UCC contract management Ian Jackson amber £125 £125 £200 £125

WLMH Contract - agreement of QIPP

withdrawal from contract

Bridgitte Moess amber £600 £600 £300 £500

Agree additional saving with EMHWB

services

Jo Murfitt amber £100 £75 £50 £50

Reduction in Pathology tests Jo Murfitt amber £100 £100 £50 £50

Tighter management of corporate budgets Sue Pascoe amber £200 £150 £50 £50

Tighter management of non-acute budgets Leanda Richardson

/ Maggie Wilson

red £150 £150 £150 -

Maximise estates underspend Sue Hardy red £100 £100 £100 -

Implement all planned QIPP measures in

September onwards and review potential to

further maximise benefits

Peter Kottler red 250 £500 £750 -

Bring forward 2013/14 QIPP plans Peter Kottler red - - - -

Non-recurrent allocations green £800 £800 £800 £800

Additonal reducition in payments to Trusts

for non-achievement of CQUINS ( assumes

90% achievement

amber £337

Contract benefit re STARRs with ISO -

impact of risk share for non-delivery of

reductions in emergency admissions

amber £700

£875 -£500 -£3,250 £12

Effect on forecast Range

Total

63

NHS Ealing 56

NEXT STEPS TO 31/12

• Review the M7 position, including further work on understanding the reasons for budget variances

• Work with ACV to understand what challenges and mitigations possible to abate acute overspend, and to refine forecasts for year end.

• Update the forecast outturn and the impact of recovery actions as set out on slide 55

• Continue to seek full implementation of QIPP schemes and early introduction of 2013/14 schemes where achievable.

• Review the impact of all other risks and opportunities

64

NHS Ealing 57

APPENDIX A – FINANCIAL SCHEDULES

65

NHS Ealing 58

SUMMARY - MONTH 7NHS Ealing

Commissioning of Healthcare

Acute Contracts 282,622 460 283,082 164,941 168,571 (3,631) (3,198) 46 (3,631) 46

Other Acute Commissioning 61,626 (1,292) 60,334 35,264 35,420 (156) (157) 66 (16) 66

Joint Working Commissioning 67,401 1,649 69,050 40,383 40,270 114 (419) (397) 114 (397)

Community 52,764 2,070 54,834 29,902 29,543 358 413 (1,483) 358 (1,483)

Prescribing 44,645 (1,075) 43,570 25,585 25,069 516 237 493 516 493

Sub-total: 509,058 1,812 510,870 296,075 298,874 (2,799) (3,124) (1,275) (2,658) (1,275)

Primary Care

Medical Contract 50,351 (5,475) 44,876 26,002 26,166 (163) 115 0 287 0

Primary Care Projects 4,879 4,879 2,846 2,811 35 (9) 0 0 0

Dental Contract 17,837 0 17,837 10,405 9,438 967 821 376 0 0

Pharmacy Contract 9,414 0 9,414 5,491 5,479 12 133 0 0 0

Out of Hours 1,373 1,373 801 733 68 56 0 68 0

Ophthalmic 2,419 0 2,419 1,411 1,650 (239) (153) 0 0 0

Sub-total: 80,020 777 80,797 46,957 46,277 680 962 376 356 0

Public Health 8,048 (282) 7,766 4,530 4,765 (235) (191) 0 0 0

Corporate & Estates Costs 14,094 3,925 18,019 9,108 9,033 75 262 0

TOTAL 611,219 6,233 617,452 356,670 358,949 (2,279) (2,091) (899) (2,303) (1,275)

Reserves and Contingency

Contingency 2,979 (0) 2,979 1,738 0 1,738 1,490 0 1,355

Investments / Reserves

RESERVES Total: 2,979 (0) 2,979 1,738 0 1,738 1,490 0 1,355 0

Total 2012-13 Initial Approved Budgets 614,198 6,233 620,431 358,408 358,949 (541) (602) (899) (947) (1,275)

PCT Planned Surplus 0 0 0

Total 614,198 6,233 620,431 358,408 358,949 (541) (602) (899) (947) (1,275)

£000

614,198.

In year NR alllocations (notified )

Reduction in one pot one purpose funding (118)

Net increase in funding from M2 IATs 11

Transition funding 950

Pathfinder funding 764

Outer ICP funding 1,926

Inner ICP Funding 103

National Comm Grp Adj (6)

IFRIC 12 Funding Adjustment (93)

Ph-La Transition 96

3,633

(Please List )

Additional Transition Funding 2,000

Impairment Funding 300

Cap To Rev (Gp Improve Grants) 300

0

3,633

620,431

Sub total NR anticipated allocations

Total Resource Limits

Total Budgets in report

Reconciliation to Resource Limit

Recurrent Initial Budgets

Sub total - Notified Allocations

In year NR allocation (anticipated )

YTD CCG

Deleg

Budgets

variance

(£000)

YTD CCG

Delegated

QIPP

variance

(£000)

Year to Date Position

Annual

Budgets (£000)

Presented to

April Board

In-year

movements

£000

Final

Budgets

£000

YTD

Budget

£000

YTD

Actual

£000

Variance

Sur/(deficit)

£000

Previous

Month's

YTD

Variance

YTD

QIPP

variance

£000

66

NHS Ealing 59

ACUTE - MONTH 7NHS Ealing

Imperial 96,401 516 96,917 56,538 56,538 (0) (0) (0) 0

Ealing Hospital 92,192 0 92,192 53,662 53,662 0 (0) 0 0

Hillingdon Hospital 11,910 -58 11,852 6,985 7,450 (464) (296) (464) 0

North West London Hospitals 25,051 0 25,051 14,563 14,563 0 0 0 0

Royal Brompton and Harefield 9,411 -69 9,341 5,475 6,338 (863) (845) (863) 0

Chelsea And Westminster 8,589 15 8,604 4,999 5,131 (132) (130) (132) 0

West Middlesex 8,343 0 8,343 4,791 4,896 (104) (151) (104) 0

Sub Total - in Sector SLAs 251,897 403 252,300 147,014 148,578 (1,564) (1,422) 0 (1,564) 0

Out of Sector SLAs

St Georges Healthcare 508 175 683 398 371 27 13 27 0

West Herts Hospitals 0 0 0 0 0 0 0 0 0

Whittington Hospital 371 0 371 216 146 70 50 70 0

East and North Herts Trust 0 0 0 0 0 0 0 0 0

Barts and the Royal London 773 0 773 451 658 (207) (171) (207) 0

Guys & St Thomas 2,319 0 2,319 1,353 1,670 (317) (295) (317) 0

The Homerton 63 3 66 38 42 (4) (5) (4) 0

Ashford & St. Peters 465 -43 422 246 232 14 15 14 0

Heatherwood & Wexham Park 441 -4 437 255 319 (64) (61) (64) 0

Kingston Hospital 153 -17 137 80 108 (28) (23) (28) 0

Kings Healthcare 647 -42 605 353 370 (18) (17) (18) 0

Moorfields Eye Hospital 5,778 76 5,855 3,415 3,479 (64) (56) 90 (64) 90

The Royal Marsden 967 -72 895 522 681 (159) (170) (159) 0

UCL Hospitals 4,974 106 5,080 2,964 4,023 (1,059) (829) (1,059) 0

Other Trusts 7,323 -127 7,196 4,169 4,853 (684) (595) (684) 0

Pass through/hosted budgets 0 0 0 0 0 0 0 0 0

Sub-total - Others 24,782 57 24,838 14,460 16,951 (2,492) (2,145) 90 (2,492) 90

Independent Sector Providers 4,401 0 4,401 2,567 3,042 (474) (402) (44) (474) (44)

Pass through /hosted budgets 0 0 0 0 0 0 0 0 0

Sub total 4,401 0 4,401 2,567 3,042 (474) (402) (44) (474) (44)

25% Readmission / In Year Risk Reserves1,542 0 1,542 900 0 900 771 900 0

Readmission / In-year Risk Reserve 1,542 0 1,542 900 0 900 771 0 900 0

Sub Total - Acute SLAs 282,622 460 283,082 164,941 168,571 (3,631) (3,198) 46 (3,631) 46

Specialist Consortia 36,435 0 36,435 21,215 21,355 (141) 7 0 0

High Cost Drugs 5,595 -860 4,735 2,762 2,995 (233) (96) (233) 0

London Ambulance 10,162 0 10,162 5,928 5,970 (42) (36) (42) 0

NCAs / Acute Cost per Case 5,434 911 6,345 3,810 4,039 (229) (170) 66 (229) 66

Other 4,000 -1,343 2,657 1,550 1,061 489 138 489 0

Sub-total Other Commissioning 61,626 -1,292 60,334 35,264 35,420 (156) (157) 66 (16) 66

Total Acute 344,248 -832 343,416 200,205 203,991 (3,787) (3,355) 112 (3,646) 112

YTD

QIPP

variance

£000

Annual

Budgets

(£000)

Presented

to April

Board

In-year

movements

£000

YTD CCG

Deleg

Budgets

variance

£000

YTD

CCG

Delegate

d QIPP

variance

£000

Variance

Sur/(deficit)

£000

Year to Date Position

Final

Budgets

£000

YTD

Budget

£000

YTD

Actual

£000

Previous

Month's

YTD

Variance

67

NHS Ealing 60

NON-ACUTE & PRIMARY CARE - MONTH 7

68

NHS Ealing 61

PUBLIC HEALTH – MONTH 7

69

NHS Ealing 62

ESTATES & CORPORATE – MONTH 7

70

NHS Ealing 63

CCG DELEGATED BUDGETS – MONTH 7

71

NHS Ealing 64

APPENDIX B – BALANCE SHEET ANALYSIS

72

NHS Ealing 6565

ANALYTICAL REVIEW 11/12 v M7 12/13

•Statement of Financial Position (ex Balance sheet)

– Property , Plant and Equipment (fixed assets) – slide 66– Trade and Other Receivables (debtors) – slide 67

– Trade and Other Payables (creditors) – slide 68– Provisions– slide 69

73

NHS Ealing 6666

PROPERTY, PLANT & EQUIPMENT

31/03/12 31/10/12

£’000 £’000

Tangible assets:

Balance (post IFRS) 44,117 45,457

Additions 1,551 633

Indexation 2,017 0

Impairment -261 0

Depreciation -1,905 -1,181

Disposals -62 None

Reclassification None None

Total 45,457 44,909

Intangible asset 211 167

Additions 34 0

Depreciation -78 -40

Total 167 127

74

NHS Ealing 67

TRADE & OTHER RECEIVABLES

31/03/12 30/09/12 31/10/12

£’000 £’000 £’000

NHS 6,126 8,320 9,840

Other debtors, prepayments etc. 3,582 8,178 3,426

Provision for irrecoverable debts -483 -470 -466

Total 9,225 16,028 12,800

Aged debtor analysis

£’000 £’000 £’000

0-30 days 767 28 1,05331-60 days 49 244 86

61-90 days 98 88 131

Over 90 days 39 2,160 1,564

Sub Total 953 2,780 2,834

Less Bad debts Provision -483 -470 -466 Total 470 2,310 2,368

.

75

NHS Ealing 68

TRADE & OTHER PAYABLES

31/03/12 30/09/12 31/10/12

£’000 £’000 £’000

NHS 19,241 21,258 20,219

Non-NHS/trade creditors 9,256 4,823 4,149Accruals and deferred income 5,775 8,722 8,937

Other (FHS, SS, Tax and Capital) 15,118 16,381 14,736

TOTAL 49,390 51,284 48,041

76

NHS Ealing 6969

PROVISIONS

There has been little movement on provisions at this stage of the year.

£’000

31/03/12 6,520

Arising during the year -383

Utilised during the year 0

Reversed unused 0

Change in Discount Rate 0

Unwinding of discount 72

31/10/12 6,209

Comments

� The provisions largely relate to a) pensions in respect of former staff pre-dating

1995 and Back to Back pension provisions b) Continuing Care provisions. The

Department of Health did not require us to agree the provisions in the month 6

exercise – this is undertaken annually at the year end.

77

NHS Ealing 70

APPENDIX C – CAPITAL

78

NHS Ealing 71

CAPITAL PROGRAMME 12/13

Notes :

A - Health and safety improvements to various Health Centres as per action plan

from H&S assessments

B - Fire system improvements to various Health centres as per action plan from

Fire RRO Assessment

C - PEAT and CQC compliance work to various health centres

D - Upgrading windows across a number of sites, new heating and pipework at

Clayponds Hospital, other backlog maintenance work at various sites.

PLANCOMMITTED

EXPENDITURE

SPEND TO

M07

2012/13 2012/13 2012/13

£'000 £'000

A Health & Safety Compliance 148 0 0 ESTATES

B Fire Safety Compliance 158 36 68 ESTATES

C Other Statutory Compliance 153 0 0 ESTATES

D Backlog Maintenance 387 0 0 ESTATES

E Major Estates Projects (EHT UCC

phase 3)350 350 47

ESTATES

F Other Estates Projects 101 101 0 ESTATES

G IT Projects 890 890 518 IT

H Capital Grants 300 0 0 BOROUGH

I Unallocated Capital Resource Limit 483 0 0

J Transfer of CRL to Provider Services 330 330 0 BOROUGH

K Transfer of CRL from Brent PCT for

Ravenor Park refurbishment500 0 0

ESTATES

TOTAL 3800 1707 633

TITLE OF SCHEMEPCT LEAD DIRECTOR

FOR DELIVERY

79

LES AND PUBLIC HEALTH Confirmation received from Sally Beauchannon:-

From: Safia Khan [mailto:KhanS@ealing.gov.uk]

Sent: 10 December 2012 16:50 To: Michael Taylor; Sally Beauchannon

Subject: (info) LES & Public Health

Hi Both

Here is the NHS Factsheet as promised….

Regs

Safia

From: Safia Khan Sent: 30 November 2012 12:33

To: Michael Taylor; Sally Beauchannon

Subject: (info) LES & Public Health

The public health grant 13/14 and future years (until DH decides otherwise) is indeed ringfenced. The

LES is included in the LA's baseline funding - so is effectively also ringfenced. There is an nhs factsheet on this - i will dig out and circulate on Monday

thx

safia

From: Michael Taylor Sent: 30 November 2012 12:05

To: Safia Khan Subject: Public Health

Safia

Sally Beauchannon has just come round to check if the 13/14 Public Health Grant would be ring

fenced and within that whether the Local Enhanced Services would be ringfenced.

I said I thought the overall grant would be but thought I would check. Not sure about the LES though.

Cheers

Michael

80

Enhanced Services Commissioning Fact Sheet July 2012 Purpose

This fact sheet sets out the new commissioning arrangements for enhanced services from April 2013, including the transition of existing schemes. Background Enhanced services are currently commissioned through each of the primary medical care contracting vehicles (GMS, PMS, APMS) and can be commissioned from a range of other service providers (e.g. community pharmacies).

They currently comprise:

Local enhanced services (LESs) schemes agreed by PCTs in response to local needs and priorities, sometimes adopting national service specifications.

Directed enhanced services (DESs) - schemes that PCTs are required to establish or to offer contractors the opportunity to provide, linked to national priorities and agreements.

As with any services, PCTs have always been expected to follow procurement guidelines when commissioning enhanced services to ensure decisions are on the basis of quality and value for money and, where possible, support patients in making choices. So LESs should only have been commissioned exclusively from general practice where no other provider was appropriate. New commissioning arrangements

T will be responsible from April 2013 for commissioning services under the GP contract. It will operate as a single organisation with a single operating model, replacing 151 ways of doing business. While the Board will retain the ability to commission LESs through the GP contract, it is unlikely to use this function since the intention is that clinical commissioning groups (CCGs) should decide how best to use local resources to invest in community-based services that go beyond the scope of the GP contract.

Local authorities will be responsible, from April 2013, for taking the lead in improving the health of local communities. This will include most of the health promotion and public health services currently commissioned as LESs.

81

National arrangements for enhanced services The Board will commission some enhanced services nationally, equivalent to DESs. Where it is agreed that current DESs should roll forward to 2013/14, the Board will become responsible for them. The Board may devolve to CCGs the responsibility for managing some of these enhanced services. National directions

1 currently cover eight DES schemes:

childhood immunisation influenza and pneumococcal

violent patients minor surgery

extended access alcohol reduction

health checks for people with learning disabilities

patient participation.

PCTs will need to plan for these to be carried over to the Board for 2013/14, subject to any changes arising from GP contract negotiations in relation to time-limited DESs and any confirmed plans to devolve responsibility for management to CCGs. CCG commissioning arrangements CCGs will be free to commission a wide range of community-based services funded from their overall budgets. With the exception of any local improvement schemes commissioned on behalf of the Board (see below) and proposed transitional arrangements for current LESs (see below), they will commission these services through the NHS standard contract. Like PCTs, CCGs will need to decide whether these services could be delivered by a number of potential providers (which may include general practice) or whether they could only be provided by general practice. As now, for services that can be delivered by a number of potential providers, CCGs will need to decide whether to undertake competitive procurements to identify a single provider (or limited group of providers) or whether to allow patients to choose from a range of qualified providers by using the Any Qualified Provider route. As now, for services for which there are no other possible providers, for instance because they require list-based primary medical care, or for services of a minimal value, CCGs will be able to commission services through single tender from GP practices.

Whilst CCGs will have the power to contract directly for most services, they will not have direct powers to pay for improvements in the quality of services provided under the GP contract. We envisage that the Board will, however, give delegated powers

provide where appropriate:

incentives for improvements in the quality of primary medical care services

funding to support activities such as clinical audit and peer review

1 http://www.dh.gov.uk/en/Healthcare/Primarycare/PMC/Enhanced/index.htm

82

We envisage that any such local improvement schemes should be agreed between the CCG and the Local Area Team of the NHSCB. Local Authority commissioning arrangements Local Authorities will be responsible for commissioning services to meet their new public health responsibilities. The baseline funding for public health LESs will be included in the ring-fenced grants that local authorities receive for their public health responsibilities.

2

include Implanon (contraceptive implant), sexual health services (e.g. chlamydia screening, Emergency Hormone Contraception), NHS Health Checks, fitting and removal of IUCDs, alcohol misuse or substance misuse services, and smoking cessation services.

Transitional arrangements for current enhanced services While PCTs remain legally responsible for commissioning local enhanced services in 2012/13, any decisions to commission or de-commission enhanced services during 2012/13 should be agreed with emerging CCGs or (for public health services) with local authorities. Local enhanced services where funding is devolved to CCGS To ensure stability during the initial move to the new system:

PCTs will be asked to agree with CCGs whether to extend current LESs (excluding public health LESs) into 2013/14: we recommend that LESs are extended in this way unless there is compelling evidence for adopting a new approach

where current LESs are extended, PCTs will be asked to build in a review point after six months, so that CCGs can if they wish use funding in different ways after this point

the Board will devolve responsibility for managing these LESs to CCGs and

from April 2014, it will be fully up to CCGs to decide how to funding to commission community-based or practice-based services under the NHS standard contract.

PCTs will need to work with CCGs to plan and manage the transfer of LESs that are set to continue beyond 31 March 2013. Details of all existing LESs (including those

2 http://healthandcare.dh.gov.uk/public-health-system/

83

which PCTs and CCGs have agreed will expire on or before 31 March 2013) will be notified to the NHS Commissioning Board through the contract transition exercise. Local enhanced services where funding is moving to Local Authorities PCTs should already be planning with local authorities the transfer of pre-existing agreements that are set to continue beyond 31 March 2013 and providing details of those schemes set to end on or before 31 March 2013. It will be for local authorities to decide whether to re-commission these services. Managing conflicts of interests CCGs must manage any conflicts of interest and ensure that such conflicts do not corrupt the integrity of the decision-making process. CCGs are advised to follow the best practice set out in the draft Code of Conduct3 when commissioning services for which GP practices (or any provider in which GPs have an interest) are potential providers. Conclusion In essence then:

LES funding will be devolved to CCGs and Local Authorities so that they can commission services based on local needs and decisions

The contracting vehicle will not be a LES since this is a specific element of the GP contract which the NHS CB will hold

The rules around determining whether services are best delivered by practices or other providers have not changed

Like PCTs, CCGs will be expected to ensure that the services they commission deliver the best quality and outcomes for patients, provide value for money, give patients choice wherever appropriate, and adhere to procurement guidelines

This document is intended as a helpful summary to inform local planning and is not a substitute for legislation or any guidance issued in due course by the NHS Commissioning Board.

3 http://www.commissioningboard.nhs.uk/resources/resources-for-ccgs/

84

Actions arising from the North West London Cluster Meeting held on Monday 3 December 2012 at NHS Westminster, 15 Marylebone Road, NW1 5JD

ACTIONS ATTRIBUTED TO:-

AS – Ariadne Siotis

FM – Dr Fergus McCloghry

GR - Gill Rogers

MS – Dr Mark Spencer

NR – Nicola Roberts

TG – Tony Grewal

TK – Dr Theodora Kalentzi

TS – Thirsa Sawtell

SP – Stuart Pick

Item Action Responsible

2.0 Patient Medical Passport 3.1 Minutes

Karen Clinton’s proposed amends to be circulated via email for approval

NR/SP Done

3.2 Matters Arising 3.2 Matters Arising (5.3 – Delivery Support Unit (DSU) Update) TS to send again to the LW LMCs Office a copy of the details of the programmes that will receive DSU funding in 2012/13. 4.2 CCG Development Update Non contractual payments To include in the minutes Dr Grewal’s guidance – “For the avoidance of doubt any funding allocated to contract/agreement should be considered as NHS funding”. To include the statement as an item in the next Ealing SJLC papers. Site visits TS to confirm that feedback would go to GPs via the NWL Cluster. 4.9 Effective Commissioning MS to resend the report to LW LMCs that outlined the exact savings made as a result of Effective Commissioning. LW LMCs to circulate to LMC Members.

TS TG/SP SP TS MS SP

4.2 Clinical Commissioning Group Update GR and TS to liaise regarding setting up an evening meeting for LMC and CCG Chairs to take place in January

GR/TS

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2013 to discuss the future use of these Strategic Liaison meetings and future working in general

4.3 DSU Update When Commissioning Intentions Report finalised, TS to send LW LMCs a copy. TG – Would like them to be circulated to borough LMCs.

TS LMC - SP

4.6 Out of Hospital Strategy TS to provide LW LMC with full list of who will be interviewed. LMC happy to be interviewed. Noted GR happy to help re Practice Nurses. TS to write formally to LMCs to invite LMC input and to confirm that will share all drafts. Ms A Siotis to lead on this on behalf of the sector team. LMC office to send an email to all GPs in NW London recommending that as members of CCGs, they ask to see a copy of the relevant commissioning intentions which CCGs are in the process of drawing up and to be prepared to submit ideas about things to be commissioned to their CCG. TS and GR to liaise outside the meeting before a communication is sent to GPs.

TS GR TS/AS TG/ LMC/ SP

4.4 Intergrated Care Project (ICP) TS to feedback concerns that at the Harrow ICP meeting non-anonymised information had been circulated to all who attend and it is not clear if patient consent has been given for future use of this information. Dr McCloghry to feedback to ICP meeting the next day that this is not appropriate.

FM

4.5 Shaping a Healthier Future To send a reminder to GPs to use LMC/CCG communications teams when asked to give comments by the media on the Shaping a Healthier Future project.

SP

4.7 111 Update To note recommendation from LMC to GPs – that should sign up to draft LES for CMC before taking on CMC work. Taking to borough LMCs. Concerns regarding the funding and maintenance of the records were noted as doesn’t take info from current system.

LMC/ SP

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5.0 Primary Care Development MS to confirm who will be responsible for commissioning occupational health on behalf of GPs and their staff. Once confirmed, MS will ask those responsible to write to Gill, noting that LMC would like an input.

MS

7.0 2013 Meeting arrangements To set January 2013 meeting only at this point – for second half of Jan. MS and TD in favour – invite David Finch to attend.

SP

8.0 AOB Patient Medical Passport To include information regarding the patient medical passport in the NWL newsletter.

SP

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Londonwide LMCs and NHS North West London Primary Care Contracting team interim meeting

Action notes from Tuesday 20 November 2012

1.0 In attendance: Rachel Donovan (RD) Julie Sands (JS) Gill Rogers (GR) Alison Dalal (AD) Ariadne Siotis (AS) Kathryn Charles (KC) – on the telephone

2.0 Apologies: Andy Michaels

3.0 Matters arising from meeting 30 October 2012

AS to amend previous minutes to read “St. Mary’s” instead of “Queen Mary’s”.

4.0 NHS NWL 4.1 To receive an update on any NWL structural changes and appointments – JS reported that she

had been appointed as Deputy Head of Primary Care for NW London and that RD had been appointed as Assistant Deputy Head although it was not yet certain that she would be based in the NW team. David Finch had been appointed as Medical Director for London and Mark Spencer had taken a different role with the NCB.

5.0 Enhanced Services

5.1 LESs - JS reported that it is a requirement for CCGs to review all LESs and then to re-commission any required as Locally Commissioned Services which would have to be offered to any qualified provider unless they met certain criteria which were still unclear. Pertussis NES – RD noted that the issue about the additional reporting requirements had been escalated nationally and that practices should continue to provide the original data required for the NES and the EDD information would be collected separately.

6.0 Contracts

6.1 CQC – RD reported that all practices had now submitted the necessary information for CQC registration.

7.0 QoF 7.1 RD reported that she was attending all the Practice Managers fora to talk about the change from

QMAS to CQRS and to emphasise the importance of claiming all non-clinical indicators before the 31 March and signing everything off by 2 April. She agreed to share her slides with LwLMCs so that AS could include an item in local newsletters. (RD/AS) KC asked for an update on the MED 10 issue and RD noted that it had been resolved in Brent, Harrow and INWL but that they were still working on it for Ealing. RD agreed to feedback in time for the standing joint and that the general issue of Ealing approving points for Med 10 and QP indicators would be raised at the standing joint on the 28th. (RD)

8.0 Occupational Health 8.1 JS noted that the occupational health service would be re-commissioned in the near future but

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that it was unclear what the available budget would be. AD and KC volunteered to be involved in developing the service specification with the HR team at NHS NWL. JS undertook to feed that back to the Maggie Gibb, Head of HR, and to let the LMC know what the timescale would be for commissioning the new service. (JS)

9.0 List Maintenance 9.1 AS raised a number issues with the FP69 process which had been brought to the attention of

LwLMCs by practices in KCW. The first was the fact that a certain number of flags had been set to expire after 5.5 months instead of the 6 months specified by the regulations. JS noted that she was aware of the issue and that it was in the process of being resolved. The second issue was around the PCSS insisting that practices provide evidence that a patient had been seen in the last 3 months before agreeing to remove the flag. JS indicated that the team at PCSS did know that that went against the Once for London guidance and that this was probably a case of the message not getting through to the staff on the ground. She agreed to raise this at the next management meeting of PCSS and to report back. (JS) In the meantime AS agreed to re-circulate the agreed Once for London guidance on list maintenance to all practices in NW London. It was also agreed that this may be good opportunity to inform practices that the official list maintenance programme would be starting in the New Year and to give them an idea of what to expect. (AS)

10.0 Practice Vacancies and Procurement 10.1 RD noted that the Grove Medical Centre in Hounslow will be going out for procurement. Before

Christmas with the PQQs due back by the end of January. RD also reported that The Practice in Hillingdon had found a partner to take over the contract.

11.0 Any Other Business KC raised an issue about the performers list for trainees as one of her trainees was obliged to stop working for a week because they were not added to the performers list on time. RD reported that there was now a robust system in place to ensure that trainees were placed on the list within 2 months of being in the practice. She undertook to send a reminder to all trainees to apply for the performers list as the next batch were due to start in February.

12.0 Date of Next Meeting – it was agreed that the December meeting would be cancelled and that the following dates would be put in the calendar for 2013 and be reviewed on a meeting by meeting basis. January 22nd 2013 February 26th 2013 March 19th 2013 All meetings would take place at LwLMCs’ offices and would begin at 3:30pm.

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