barking and dagenham, havering and redbridge system

BHR System Financial Recovery Plan

Barking and Dagenham, Havering and Redbridge

System Financial Recovery Plan

March 2019


Statement of Intent

This document sets out a challenging transformational change programme that

focuses on improving quality and outcomes for the patients we serve whilst

concurrently returning the system to financial balance thus allowing the NHS

partners within Barking and Dagenham, Havering, and Redbridge (BHR) to

continue to meet the current and future needs of our population, and also to

facilitate the move toward a true Integrated Care System across health and care.

We do not underestimate the scale of the cultural, clinical and managerial

challenge that the plans laid out in this document will bring to the NHS partners

in BHR and the need throughout this process to bring our public, partners (in the

widest possible sense) and our respective teams with us on the transformational

journey we are committing to.

We will be relentless in ensuring that as we move toward financial recovery for

the BHR system that quality, safety, access and delivery of our constitutional

standards are at the heart and centre of our system recovery and at no point will

they be compromised in pursuit of financial efficiencies alone.


Contents Section One: Introduction .............................................................................................................................................................................. 4

Section Two: Drivers of the BHR System Deficit ......................................................................................................................................... 6

Section Three: Purpose and Principles for NHS Financial Recovery within BHR ................................................................................... 14

Section Four: Current State Financial Position .......................................................................................................................................... 17

Section Five: ‘Do Something’ Financial Scenario ...................................................................................................................................... 21

Section Six: Delivery Risk Mitigations ........................................................................................................................................................ 38

Section Seven: Implementation ................................................................................................................................................................... 47

Section Eight: System Enablers .................................................................................................................................................................. 54

Section Nine: Asks from Regulators ........................................................................................................................................................... 55

Section Ten: Next Steps............................................................................................................................................................................... 55

Appendices

Appendix Title Related Section of System FRP

1 Barking, Havering and Redbridge University Hospitals NHS Trust’s Financial Recovery Plan Section One: Introduction

2 Evidence to support the Drivers of the Deficit Section Two: Drivers of the BHR System Deficit

3 System Level Programmes and supporting projects backing data Section Five: ‘Do Something’ Financial Scenario


Section One: Introduction

On the 16 October 2018 the main NHS partners covering Barking and Dagenham, Havering and Redbridge (BHR) were set the task of

producing a joint System Recovery Plan that would bring the system back into balance. In response this Financial Recovery Plan (FRP) is

jointly submitted by the BHR NHS partners namely the BHR Clinical Commissioning Groups (CCGs), Barking, Havering and Redbridge

University Hospitals NHS Trust (BHRUT) and North East London NHS Foundation Trust (NELFT), although as part of the workup of this

document the partners have also engaged with the three GP Federations in BHR and with Local Authority colleagues.

The BHR system FRP aims to address the £186m ‘current state’ financial gap that will exist by March 2021 if no further action is taken by the

partner organisations. The current state financial position takes into account existing Quality, Innovation, Productivity and Prevention (QIPPs)

and Quality and Cost Improvement Programme (QCIPs) and other related efficiencies that have been identified already, including any full year

effect into 2019/20. In closing the financial gap we have put forward three system level programmes aimed at tackling significant areas of

concern for the system, and a challenging Cost Efficiency and Effectiveness Programme that returns the system to financial balance by March

2021. However, we also recognise that within this challenging plan we have significant delivery risk so have included a section outlining how we

intend to mitigate as much of this as possible.

It cannot be understated that this will be a challenging endeavour for the BHR partners and will involve significant shifts in income and activity

as well as the need to rebase costs across our system in response. We cannot also underestimate the impact of the lag between the

introduction of a system efficiency that reduces activity and the time at which partners have the confidence to remove the associated capacity

and costs (accepting that some costs such as medication spend etc. will occur almost immediately).

In delivering system recovery we will need to consider transition funding and different contract payment mechanisms to ensure the viability of

the partners as our agreed areas of focus progress and the ongoing support from our North East London partners, and even more importantly

regulators, in this matter will be a necessity.

The document should be seen as the start of the journey toward financial recovery, rather than the end as there is much work to do looking at

the cost impact of income and expenditure changes and also working up and mobilising the various projects that underpin the recovery. The

scale of the challenge is vast and will involve multiple projects (given there is no magic bullet that would solve the problems faced in BHR)

requiring collaboration on a scale and scope not seen in BHR before and rarely seen across the NHS.


With all of the above challenges the BHR NHS partners are both confident that we will be able to resolve any issues that arise and committed

to ensuring that financial recovery occurs not at the expense of patient care but through dramatic and enduring improvements in both care and

outcomes. Before we enter into the detail of the pack BHRUT and BHR CCGs (as the partners in financial special measures) would like to

issue the following joint statement to regulators.

Joint Statement for Regulators from BHR CCGs and BHRUT

BHRUT and BHR CCGs are committed to working together to realise £60m of real cash savings and to sharing this equally between them to bring both parties back to break-even. The scope of the savings will be all areas of joint spend (i.e. where both parties have income/expenditure) and will need the parties to work together on both how the savings are realised and how the rewards are shared between them through contractual mechanisms. This programme of work will be achieved whilst ensuring we protect the financial integrity and sustainability of NELFT.


Section Two: Drivers of the BHR System Deficit In coming to an understanding of the current system deficit within BHR we have looked at a wide range of factors that have potentially

contributed to the deficit. From these contributory factors we created of a number of ‘assumptions’ that were then tested against available

evidence to determine whether or not these items have contributed in part to the current deficit. A summary of the results of this work is shown

in the table below with the detailed text provided within the main body of this chapter along with supporting evidence in Appendix 2.

Assumption Summary of Analysis Appx

2

1. Our population is different and more complex than our peers leading to increased health and care costs.

The local population has many challenges including rising ethnic diversity, areas of severe poverty and poor long term health outcomes when compared to other parts of London. However, the available evidence suggests that these factors do not explain the variance in activity and spend compared to our North, Central and East London (NCEL) peers as they too suffer from many of the same issues. Therefore whilst this is clearly a contributory factor in terms of other areas of London it does not explain the variance in NCEL.

Slides 2-4

2. There has been historic underfunding within the system.

Over the period from 2014/15 to 2017/18 the system was underfunded by more than £40m (considering both CCG allocations and Primary Care co-commissioning budgets). Whilst the distance from target for the BHR system is mostly negligible apart from Primary Care in Redbridge we cannot ignore the impact of historic underfunding (and for Redbridge current funding).

Slide 5

3. Primary Care capacity has been constrained leading to increased secondary care demand.

BHR has low levels of full-time equivalent GPs and Practice Nurses creating issues with capacity and access. BHR has consistently had the highest number of referrals into secondary care of the 12 CCGs in NCEL.

Slides 6-9

4. We have large prevalence gaps driving increased non-elective secondary care activity associated with key Long-Term Conditions.

We have identified that the BHR system has substantial prevalence gaps associated with key Long-Term Conditions (LTCs). Whilst the gaps are not significantly different to other parts of London they are a contributory factor both in terms of increased non-elective activity and poorer outcomes for patients.

Slides 10-15

5. The BHR system has reduced activity in the community compared to the NCEL average.

This assumption has not been proven. Activity and investment within BHR appear consistent with our North East London peers. This would imply that the investment being made is possibly incorrectly targeted and/or we have the wrong service model.

Slide 16

6. There is increased secondary care activity and costs compared to our NCEL peers.

BHR CCGs have spent on average £90m more per year for the last three years in secondary care compared to our peers in NCEL.

Slides 17-28

7. There are additional issues affecting BHRUT’s operating cost model.

BHRUT has many of the same cost pressures as other acute Trusts but specifically some less common issues such as excess Private Finance Initiatives (PFI) costs that have contributed to the current deficit position.

N/A

8. Historically difficult relationships have hindered system working.

Historically difficult and complex relationships between the partners, and between the partners and regulators has made true system working difficult.

N/A


Assumption One: Our population is different to NCEL The three London Boroughs that make up BHR are both demographically and ethnically diverse and have been becoming more diverse over

time. The London Borough of Barking and Dagenham (B&D) in particular is the second most deprived borough in London after Newham

(considering gross annual income as a main indicator) and this drives poor outcomes with high levels of mortality due to preventable conditions

and very low healthy life expectancies compared to much areas in London.

Whilst the London Boroughs of Havering and Redbridge are in the mid-range for London boroughs for both deprivation and healthy life

expectancy, they have pockets of extreme deprivation, also Havering currently has the ‘oldest’ population in London (although it is set to have a

significant increase in younger people going forward). Havering also has a large cluster of care homes and that will make the area a net

recipient of Older People moving in from elsewhere within and outside of London.

The impact of the local demographics across BHR on the NHS is multi-factorial, including the early onset of disease and frailty driven by

deprivation, increased numbers of Older People requiring support in the community because of the age of the population and increased

prevalence of key diseases (most notably diabetes) due to large populations with increased genetic prevalence of developing Long-Term

Conditions. There are also cultural challenges to overcome such as a proportion of our population from Eastern Europe who do not historically

use Primary Care to access health services and instead present via A&E.

A further aspect that we need to consider not only in how we have arrived at our current position, but for the future, is the rapid growth and

change in our population demographics. The population is set to grow in BHR from 770,000 in 2017 to 871,000 in 2027 (both based on Greater

London Authority population projections although lower than identified as part of the strategic estates plan based on housing growth).

Specifically, for the purposes of the FRP, the Sustainability and Transformation Plan (STP) agreed growth projection for BHR over the period to

2020/21 is 6.03%.

However, despite all of the above being a contributory factor to excess spend were we to compare ourselves to the whole of London, when we

look at our main peer group (the 12 CCGs of North Central and East London (NCEL)) many of these population health issues are equally

prevalent and therefore the excess activity and spend within the BHR system compared to NCEL cannot be explained by any noticeable

population health factors.

Conclusion: Whilst the population challenges have contributed to strain across the health system when compared to the wider population in

London it does not explain the variance in activity and spend to our NCEL peers who have broadly the same population level challenges.


Assumption Two: There has been historic underfunding within the system Over the period from 2014/15 to 2017/18 BHR CCGs were underfunded compared to our target allocation by more than £32m. When we

include historic co-commissioning funding levels over the same period the funding gap grows to more than £40m.

Within the detail of the CCG allocations we can see that Barking and Dagenham CCG were ‘over’ capitated by £21.8m over the period but both

Havering and Redbridge CCGs were ‘under’ capitated by £22.8m and £30.5m respectively giving the net deficit of £32m for the system. This

historic underfunding continues today with regards to Primary Care funding for Redbridge.

Conclusion: The system has been historically under-funded and this continues for Redbridge in terms of Primary Care funding. As a % of the

total budget for the system the under-funding is not significant but may have driven a reluctance to invest in Out of Hospital services that in turn

now contribute to excess secondary care activity.

Assumption Three: Primary Care capacity has been constrained leading to increased secondary care

demand All data in this section is based on 2017/18 information but the situation is not felt to have changed substantially since that period.

Comparing the number of full time equivalent (FTE) GPs across the seven CCGs in North East London (NEL) the BHR CCGs come in as 7th

lowest (B&D), 6th lowest (Redbridge) and 4th lowest (Havering). This contributes to significantly increased patients per GP ratios (1,741:1 for

Redbridge, 1,736:1 for Havering and 1,621:1 for B&D compared to Tower Hamlets of 1,346:1).

In addition, there is a significant number of single-handed practices and also a large cohort of locum medics used to support BHR particularly

within B&D CCG where the percentage of locums is significantly above the North East London average. This leads to issues with access and a

lack of familiarity with local pathways and services.

Primary Care nursing ratios are also extremely poor in BHR with all three CCGs having a higher patient to nurse ratio than the national average

(1:3,600) and only Havering having a lower ratio than the London average (1:5,800). The issue is particularly acute in Redbridge with a ratio of

one nurse per 7,000 patients.


As mentioned earlier, funding for Primary Care has been an issue with income per weighted patient across BHR a problem. Comparing BHR to

the rest of NEL Redbridge has a weighted income of £96.50 per patient and is the lowest in NEL followed closely by Havering as the 2nd lowest

(£99.70 per patient) and B&D has the 4th lowest (£111.50 per patient). This compares unfavourably to Newham (£114.10 per patient).

To partially offset the relatively low levels of investment in Primary Care the CCGs have attempted to directly commission services through

Local Incentive Schemes (LISs) putting in between £1.7m (B&D) and £2.3m (Havering) compared to £7.3m in Tower Hamlets and £10.7m in

City and Hackney. Newham by contrast has only invested £1.1m through LISs but we must offset this against the fact they have the highest

funding on a weighted patient basis in NEL. Only Waltham Forest has similar issues in Primary Care to the BHR system with both relatively low

investment levels (£0.5m) and modest income per weighted patient (£105.40 per patient).

The impact of this is that consistently over the last three years BHR CCGs have had more referrals into secondary care per 1,000 population

than our NCEL peers and have extremely high spend associated with non-elective attendances and admissions associated with Older People

and people with Long-Term Conditions.

To rectify this situation and achieve a ‘reasonable’ figure of one GP per 1,500 patients would need BHR to increase by 50 GPs as detailed

below:

B&D – ‘ideal’ of 105 verses actual of 98 (-7)

Havering – ‘ideal’ of 165 verses actual of 143 (-22)

Redbridge – ‘ideal’ of 157 verses actual of 136 (-21).

In terms of Practice Nurses, whilst Havering is below the London average ratio of one nurse to 5,300 patients it would require an additional 17

nurses across Barking and Dagenham and Redbridge to achieve the London average as follows:

B&D – ‘ideal’ of 43 verses actual of 40 (-3)

Redbridge – ‘ideal’ of 60 verses actual of 46 (-14).

Conclusion: Primary Care capacity and a historic infrastructure deficit are both key drivers of increased secondary care activity and costs.


Assumption Four: We have large prevalence gaps that are contributing to Non-Elective activity

associated with key Long-Term Conditions (LTCs) Within our population we have identified substantial prevalence gaps associated with key Long-Term Conditions (LTCs). The fact that these

patients are not receiving active treatment drives increased non-elective activity associated with unmanaged conditions. Example gaps for key

diseases and conditions are diabetes (c14,000 unidentified patients in BHR), atrial fibrillation (AF) (c7,000), chronic obstructive pulmonary

disease (COPD) (c10,000) and hypertension (c70,000). Although it is impossible to map LTCs to specific specialties (for example diabetes can

drive problems related to everything from eyes to dementia) we can see increased spend and non-elective activity in specialties related to

these conditions such as stroke (AF), respiratory (COPD) and cardiology etc.

Conclusion: The prevalence gaps, whilst not unique to BHR, appear to be a significant contributory factor in elevated non-elective attendances

and admissions in secondary care and therefore represent a significant cost pressure to the system.

Assumption Five: The BHR system has underfunded community services Available analysis on spend and activity (measured as £/1,000 population and contacts/1,000 population) show that our investment and activity

levels for BHR are broadly in line with those within North East London although there is relatively wide variation with B&D substantially above

the average and Redbridge below the average. This assumption is only partially supported but does suggest our investment may be incorrectly

targeted or we have the wrong service models for our population needs.

Conclusion: We invest (on average) at the same rate as North East London and have the same contact rates implying that our service models

may need to be refined but under-funding of community services is not a contributory factor to the deficit.

Assumption Six: There is increased secondary care activity and cost compared to our NCEL peers Comparing the amount spent and the activity levels per 1,000 population across the top 50 specialties (accounting for more than 95% per year

of all secondary activity and spend) shows that BHR CCGs have an elevated spend in secondary care of £94m per year on average over each

of the last three years compared to our NCEL peers. This analysis also considers the small number of specialties where BHR CCGs spend less

than this NCEL average to arrive at the £94m net excess annual spend.

We have already excluded from this any drivers associated with population health disparities compared to our peer group but have seen that

capacity in Primary Care, referral rates into secondary care and issues associated with patients with LTCs are contributing to the overspend.


Considering elective activity first the over-referral into secondary care mostly manifests itself in referrals into BHRUT as the main acute provider

for the BHR system. Whilst the Trust has discharged patients at a rate equivalent to their peers given the excess referral rate means that

overall more of the Trust capacity is targeted at lower acuity patients. This limits the amount of income the Trust can earn per patient and

contributes to the declining financial performance for the Trust.

Concurrently because the capacity is constrained within BHRUT by the excess of low acuity patients a significant cohort of patients flow into the

independent sector where analysis we have undertaken shows that the NHS incurs a 30-40% incremental cost compared to NHS providers.

Alternatively, the referrals have historically flowed into Barts Health NHS Trust or the Homerton University Hospital where there is a market

forces factor (MFF) impact of between 3% (Barts) and 4% (Homerton) as well as flowing out of sector to Essex (where there is a MFF benefit to

the BHR CCGs but BHRUT lose the revenue associated with high acuity patients). Although the proposed MFF changes going forward will

mostly mitigate these excess costs at Barts and Homerton we cannot ignore the historic impact of them, and nor can we ignore the ongoing

cost differential between the NHS providers and independent sector providers.

In terms of non-elective activity, there is extremely high activity associated with Older People with non-elective admissions for geriatric

medicine alone accounting for £14m per year of the £94m per year excess spend alone. We can also see increased non-elective

attendances/admissions (and spend) for Older People in specialties such as urology, cardiology and gastroenterology. In addition, the system

has around 45% of all predictable deaths occurring in hospital. Considering patients aged over 65 who die in hospital (excluding those who die

within the first 24 hours to exclude as far as possible trauma and other unpredictable deaths) the system incurs a cost of £21m per year

admitting these patients non-electively in the last 12 months of life (average of around 2.5 admissions per patient) with a cohort of 418 patients

from across NCEL (210 from BHR) over the last 12 months to October 2018 being admitted between four and 12 times to either Barts or

BHRUT.

Although the BHRUT average length of stay for Older People is about the same as their NCEL peers (albeit much higher than the national

average) the fact that the absolute number of admissions is above that of NCEL peers is placing significant pressure on beds. Taking the

average length of stay for people aged over 65 of 7.2 days and multiplying this by the number of excess geriatric medicine non-elective

admissions compared to the NCEL average alone of 3,133 gives a total excess bed pressure (compared to NCEL peers) of 22,558 bed days

(>60 beds), noting that not all of this excess will be at BHRUT. This is only an indicative impact given the bed pressures for Older People

arising in other specialties. When we consider non-elective admissions for people over 65 across all specialties this number increases to >70

beds.

For BHR (not just limited to BHRUT) a greater percentage of Older People admitted non-electively do not return to their normal place of care

and/or need elevated levels of social care compared to our peers placing pressures across the wider health and care system.


A second cohort of patients attending non-electively are those with Long-Term Conditions (LTCs) evidenced in specialties such as cardiology,

respiratory, stroke, nephrology, endocrinology and gastroenterology where the combined excess spend compared to the NCEL average

associated with non-elective admissions for these specialities alone equates to c£9m per year. With LTCs such as diabetes and hypertension

causing issues across a range of specialties it is likely that our excess spend in other specialties is also driven to some degree by patients with

LTCs given the large prevalence gaps in our population referred to earlier.

Finally, we cannot ignore the impact of Consultant to Consultant referrals which are in excess of the comparable rate with NCEL peers.

Conclusion: The BHR system has an excess of secondary care activity and spend driven by multiple factors and contributing significantly to

the system deficit.

Assumption Seven: There are additional issues affecting BHRUT’s operating cost model In comparing BHRUT to other similar sized acute Trusts there are several specific issues that affect the overall financial performance of the

trust. The most obvious of these is the excess PFI costs that cause an annual £6m cost pressure over and above the central contribution that is

provided. Less obviously were the costs associated with the move out of quality special measures following the Care Quality Commission

(CQC) review where additional staffing requirements drove costs up by £9m. Further factors include the difficulty of recruiting high quality

substantive staff locally given the opportunity of clinical staff to work within nearby higher profile organisations further into London and to work

in less urbanised areas in Essex that leads to issues with both recruitment and retention. This adds a further £12.5m per year to BHRUT’s

operating costs.

Conclusion: BHRUT have some specific financial pressures that are less common within similar NHS organisations.

Assumption Eight: Historically difficult relationships have hindered system working Given the complex and inter-related issues described above we must also consider the historic working relationships which have frequently

been difficult. Some examples of the difficulties experienced are outlined below.

For the CCGs, the historic infrastructure deficit in Primary Care has driven increased secondary care activity at an increased cost compared to

an out of hospital setting. Numerous procurements undertaken by the CCGs has introduced new providers into the system whilst leaving the

existing overheads to be managed by providers.


For BHRUT, the excess referral rates have led to an increased percentage of low acuity patients that has reduced the earning potential per

patient for the Trust. Recognising the capacity deficit in BHR there is still much that could have been delivered through system working. Going

forward, one of the major programmes is to reduce the amount of low acuity care provided in a secondary care setting and this will need the full

cooperation of all partners including the GP Networks and Federations in BHR.

Finally, the focus on transactional issues (including claims/challenges, coding, procurements etc.) resulted in a reluctance for partners to share

information openly. Going forward, recognising that this will take time to rectify, the formation of the NHS Recovery Board and joint programme

management office plus a commitment to building ‘one version of the truth’ around data will remove any residual barriers.

Conclusion: Historic difficulties between the partners has hindered system working.

Other Potential Factors Not Tested In addition to the eight assumptions outlined above there are clearly other factors that may have contributed more or less to the current deficit

but that have not been tested as part of the process of producing this Financial Recovery Plan. These include:

The potential impact on health services of changes in Social Care investment levels.

The potential effects of either under-investment or the wrong service model in Mental Health services.

Contractual forms that drive unexpected and counter-productive behaviours.

The focus on one-year planning cycles without a longer-term focus.

The BHR system Financial Recovery Plan aims to address the various reasons for the current deficit and return the system to balance whilst

improving outcomes for patients.

Summary What is clear from the above is that the reasons for the deficit in BHR are multi-factorial and factors have combined to create a ‘perfect storm’

that has hindered our ability to reach financial balance and support the patients that we serve.


Section Three: Purpose and Principles for NHS Financial Recovery within BHR In this section we set out the purpose and principles that we will be working to as we put into place the plans outlined within this document and the updates that will follow it. This section has been written in a manner that makes it easy to communicate the key messages about how we will work together to achieve financial recovery with staff, partners and our public.

Purpose Within the London Boroughs of Barking and Dagenham, Havering, and Redbridge (BHR) the healthcare services are predominantly delivered by three main NHS partner organisations (BHRUT, NELFT and BHR CCGs) plus our Primary Care Federations but we must also recognise the important contribution played in the delivery of high-quality care by both other NHS providers, independent sector providers, Local Authorities and the voluntary and charitable sector partners to the population we serve. The main purpose of the NHS partners in BHR is to improve the lives of the c800,000 people living within BHR and others who are entitled to access our services but who live outside of BHR. We also recognise that NHS financial recovery in BHR must be completely aligned to the emerging Integrated Care System (ICS) involving both health and care organisations and that the work we need to do to achieve NHS financial recovery cannot be at the expense of increased costs to our Local Authority partners. At the time of writing (2019) BHR CCGs spend nearly an average of £94m more per year on secondary care services than their peers in NCEL whilst concurrently BHRUT has a deficit of c£60m. The overall financial challenge across our local health economy by the 31 March 2021 including that attributable to specialist commissioning is around £186m (considering efficiency schemes and programmes that have already been put in place). To close this significant financial gap will require the NHS partners to work together to deliver financial recovery whilst also working in an increasingly interdependent system with our Local Authority partners as part of the Integrated Care System (ICS). This is our collective challenge and to achieve this we will be working together and adopting the principles set out below.


Principles The principles we are adopting as part of the NHS Financial Recovery in BHR and our role in the wider ICS are:

Principle One: Collective responsibility, clear accountability Financial recovery needs to benefit the patient and must be clinically led. Individual services and their host organisations must be accountable for the delivery of both system wide financial recovery and improvements in patient care. This requires us to: 1. Have transparency between services and between organisations about our financial positions and pressures. This includes having an open

book approach to how we manage our finances when changes to our system affect more than one organisation. 2. Ensure that organisations are rewarded appropriately for the work they are doing to deliver patient care whilst at the same time ensuring we

are managing flows and demand so that care is delivered in the most appropriate settings. 3. Throughout the journey ensuring that whatever improvements we make do not have unintended consequences and that we are collectively

held accountable for improving outcomes for our patients.

Principle Two: Ambitious, sustainable cost savings NHS Financial Recovery will need to focus on transformation both because it is motivational to staff and beneficial to patients, but also because in a shared system accounting adjustments or cost shunting is a ‘zero sum game’. To incentivise transformation we will be seeking to put in place an innovation fund that will motivate teams within our organisations to both participate in and lead transformation for the benefit of our patients and receive in return funds for reinvestment in services that they can direct.

Principle Three: Evidence not eloquence Transformational change needs to be built on strong evidence and a shared understanding of data to enable the current situation to be diagnosed correctly before sizing the opportunity to improve. Accordingly: 1. We need to look at patient pathways on an end to end basis understanding in detail current patient flows, variation and costs at each stage. 2. Data to support this needs to present a single version of the truth to enable partners to agree the most effective way of implementing the

required improvements. 3. We will use data to evidence and celebrate our achievements and improvements and through this help both to demonstrate to patients that

we are working in their best interest and also to motivate current and future staff about working within the BHR system.


Principle Four: Prioritised plans, dedicated resource None of the improvements in care or finances can be achieved without dedicated resource, including clinical, managerial and digital resource. Whilst recognising that all of this resource is finite and constrained it is critical to the delivery of our plan hence we need to prioritise. We believe as an NHS system that there are three main programmes that we must target our limited resources in the short to medium term: 1. Supporting Older People by keeping them healthier for longer in their normal place of care, reducing non-elective attendances and

admissions where possible and also supporting patients who do need to be admitted returning safely to their normal place of care wherever possible. This work will align to the wider ICS frailty programme.

2. Reducing inappropriate referrals and outpatient activity wherever possible to focus our resources on providing care closer to home for those with lower acuity needs and ensuring those with the highest needs receive prompt, effective secondary care treatment.

3. Identifying, managing and supporting patients with Long-Term Conditions to remain well and therefore converting high levels of non-elective

activity (and resulting poor outcomes) into elective care delivered out of hospital with the support of secondary care expert ise. These are all clearly multi-organisation programmes of work with much need to engage both Local Authorities and the VCS. There is a fourth system priority being focused on complex children but as there will be limited financial impact and it is more about ensuring care is provided in the most appropriate (and effective) setting it has not been included within this Financial Recovery Plan.


Section Four: Current State Financial Position This section is concerned with presenting the financial bridge based on the current QIPPs and QCIPs identified by the partners including any full year effect of existing schemes into 2019/20. The bridge, shown below, shows that the overall financial gap that the partners need to close from the current state position is £186m by March 2021.

Graph 1: BHR Current State Financial Bridge.


The annualised tables underpinning the bridge above are shown below and on the following two pages.

2018/19 CCG BHRUT NELFT Spec. Comm Consol Adj Consolidated Bridge I&E Bridge £m £m £m £m £m

2017/18 Out-turn (10.6) (49.0) (9.4) (5.5) 0.0 (74.5)

Non-Recurrent Adjustment (5.3) (9.2) 5.9 0.0 0.0 (8.6)

Impact FYE 17/18 QIPP 0.0 0.0 0.0 0.0 0.0 0.0

2017/18 Recurrent Out-turn (15.9) (58.2) (3.5) (5.5) 0.0 (83.1)

Allocation Increase 45.3 0.0 0.0 5.9 0.0 51.3

Income Inflation

Tariff 0.0 0.0 0.0 0.0 0.0 0.0

Other 0.0 0.0 5.7 0.0 0.0 5.7

0.0 0.0 5.7 0.0 0.0 5.7

Cost Inflation

Commissioning costs (52.8) 0.0 0.0 (2.3) (55.1)

Pay/ Non Pay (1.1) (12.8) (6.7) 0.0 0.0 (20.7)

Cost Pressures (9.3) (17.3) (3.9) (1.6) 0.0 (32.1)

(63.2) (30.1) (10.6) (3.9) 0.0 (107.9)

Below the line Costs 0.0 0.0 1.3 0.0 0.0 1.3

Non-Recurrent Prior Year Adjustment (12.0) (12.0)

Forecast Savings 33.8 28.3 8.7 2.4 0.0 73.2

2018/19 Deficit 0.0 (72.0) 1.5 (1.1) 0.0 (71.5)



2018/19 Out-turn 0.0 (72.0) 1.5 (1.1) 0.0 (71.5)

Non-Recurrent Adjustment (10.3) 7.0 (6.1) 0.0 (9.4)



Income Inflation

Tariff 0.0 21.7 0.0 0.0 0.0 21.7

Other 0.0 (16.8) 6.5 0.0 0.0 (10.3)

0.0 4.9 6.5 0.0 0.0 11.4

Cost Inflation


Pay/ Non-Pay (0.2) (22.8) (6.5) 0.0 0.0 (29.5)

Cost Pressures (29.4) (15.9) (3.0) (0.2) 0.0 (48.5)

(92.7) (38.7) (9.5) (1.3) 0.0 (142.2)


Forecast Savings 0.0 0.0

Other Non-Recurrent 0.0 0.0 0.0 0.0 0.0 0.0

2019/20 Deficit (29.4) (87.2) (6.2) (1.8) 0.0 (124.6)



2019/20 Deficit (29.4) (87.2) (6.2) (1.8) 0.0 (124.6)




Income Inflation

Tariff 0.0 5.5 0.0 0.0 0.0 5.5

Other 0.0 10.1 4.0 0.0 0.0 14.1

0.0 15.6 4.0 0.0 0.0 19.6

Cost Inflation


Pay/ Non Pay (0.2) (12.3) (3.3) 0.0 0.0 (15.8)

Cost Pressures (19.8) (18.6) (4.4) (0.2) 0.0 (43.0)

(81.1) (30.9) (7.7) (1.3) 0.0 (121.0)


Forecast Savings 0.0 0.0

Other Non-Recurrent 0.0 0.0 0.0 0.0 0.0 0.0

2020/21 Deficit (67.6) (102.5) (12.9) (2.5) 0.0 (185.6)


Section Five: ‘Do Something’ Financial Scenario

In this section we explore the resulting financial position when we consider two specific areas of focus:

1. Internally Generated Efficiencies – These are the efficiencies that each partner can generate that has no I&E impact on the rest of the

system. This includes such things as reductions in running costs, reducing purchasing costs and agency fees as well as such things (for the

CCGs) as reducing prescribing spend (without pushing the burden elsewhere) and reducing continuing healthcare (CHC) costs etc.

2. System Level Programmes – These are the agreed areas of focus for the NHS BHR partners (and to an ever-increasing degree our Local

Authority partners) and cover Older People, Long-Term Conditions and Outpatient Reduction, as referred to earlier in this document.

Each of these two areas are considered separately in this section before coming together at the end to give the overall financial position.


Internally Generated Efficiencies In developing our plans to close the £186m current state financial gap we have put forward planning assumptions associated with achieving

internally generated efficiencies for 2019/20 and 2020/21.

Internally generated efficiency assumptions: BHR CCGs

BHR CCGs believe they will be able to deliver c£23m of internally generated efficiencies, as detailed below. At present we have not included

any additional assumptions around the reduction in running costs of 20% that has been proposed, and this may stretch the proposed

efficiencies further.

2019/20 2020/21

Scheme £000's £000's

Becketts House back office consolidation 14 -

CHC Efficiency Programme 1,000 1,000

CHC placements 2,000 2,000

Children and Young People CHC 200 200

Post diagnosis dementia advisory service 77 26

Primary Care prescribing efficiencies 2018/19 1,266 1,000

Primary Care prescribing efficiencies 2019/20 3,000 3,000

Primary Care prescribing efficiencies 2019/20 business case 2,030 2,000

Review contract - chiropody service 20 -

Review contract - IT and other schemes 1,500 1,000

Review contract - osteopathy service 78 -

Annual impact 11,185 10,225

It should be noted that some of this impact may be required to support the additional resourcing required to secure the delivery of the system-

wide efficiency programme.


Internally generated efficiency assumptions: BHRUT

The Trusts approach to building a recovery plan is driven by clinical engagement across the Trust and wider system. The initial plans have

been built with good data and service line reporting and are cognisant with the evidence of model hospital/get it right first time (GIRFT) and

reinvigorating the Trust’s ‘Pride’ principles as per the Virginia Mason Institute. This has allowed the Trust to check and identify the potential

schemes, as well as assess the size of the opportunities and assess deliverability. The internally generated efficiency assumptions for BHRUT

are detailed within Appendix 1.

Internally generated efficiency assumptions: NELFT

NELFT believes that it will be able to deliver c£14m over the two years attributed to the BHR system element of the Trust business, due to it

covering a number of different commissioners. This takes account of the non-recurrent support within the 2018/19 QCIP.

Specialist Commissioning

As mentioned earlier, we have assumed that specialist commissioning will deliver all its residual efficiencies required without impacting on the

income and expenditure (or costs) of the BHR system partners.


System Level Programmes Working together, the BHR system partners agreed that we should focus on three system level programme areas to coordinate limited

resources on the areas felt to have the greatest system benefit. A fourth programme area around Complex Children will mostly focus on work

between NELFT, the CCGs and local authorities, and will have an extremely low impact on finances so is not included. A summary of each of

the three main programme areas is given in the sections below and the detail of the underpinning projects is provided within Appendix 3.

It should be noted that all costs are priced using payment by results/national tariff payment scheme (NTPS) and this creates a residual variance

with BHRUT where we have an average pricing-based contract for activity above/below the baseline. We have also used 18/19 NTPS/PbR

pricing for all Programme Planning Assumptions and will refine the actual values for schemes that are not already worked up.

A summary of the impact of the system level programmes across BHR is shown on the following three pages. More detail is provided in the

following sections and in Appendix 3.

In addition, the Transformational Programmes are primarily concerned with income and expenditure flows and we will be working through the

cost impacts for partners as part of our Shared PMO processes detailed later within this document.


2019/20 BHRUT Barts NELFT Federations/Primary

Care Local Authorities VCS Others

SYSTEM NET POSITION

OLDER PEOPLE

Income Reduction

-£6,637,820 -£867,851 £0 £0 £0 £0 £0 -£7,505,670

Increased Income

£577,668 £0 £818,510 £531,224 £157,444 £69,356 £0 £2,154,201

NET POSITION -£6,060,152 -£867,851 £818,510 £531,224 £157,444 £69,356 £0 -£5,351,469

LONG TERM CONDITIONS

Income Reduction

-£3,124,430 -£551,370 £0 £0 £0 £0 £0 -£3,675,800

Increased Income

£288,516 £0 £192,344 £666,837 £105,000 £45,000 £0 £1,297,696

NET POSITION -£2,835,914 -£551,370 £192,344 £666,837 £105,000 £45,000 £0 -£2,378,104

OUTPATIENT REDUCTION

Income Reduction

-£6,948,698 -£8,167,429 £0 £0 £0 £0 £0 -£15,116,127

Increased Income

£7,604,018 £0 £0 £601,968 £0 £0 £0 £8,205,986

NET POSITION £655,320 -£8,167,429 £0 £601,968 £0 £0 £0 -£6,910,141

SUMMARY POSITION

2019/20 INCOME LOSS

-£16,710,947 -£9,586,649 £0 £0 £0 £0 £0 -£26,297,597

2019/20 INCOME GAIN

£8,470,202 £0 £1,010,853 £1,800,028 £262,444 £114,356 £0 £11,657,883

2019/20 NET POSITION

-£8,240,746 -£9,586,649 £1,010,853 £1,800,028 £262,444 £114,356 £0 -£14,639,714


2020/21 BHRUT Barts NELFT Federations/Primary


SYSTEM NET POSITION

OLDER PEOPLE

Income Reduction

-£12,576,848 -£1,834,817 £0 £0 £0 £0 £0 -£14,411,665

Increased Income

£1,412,822 £0 £1,655,736 £1,135,009 £267,712 £105,759 £0 £4,577,038

NET POSITION -£11,164,026 -£1,834,817 £1,655,736 £1,135,009 £267,712 £105,759 £0 -£9,834,628


Income Reduction

-£5,459,741 -£963,484 £0 £0 £0 £0 £0 -£6,423,225

Increased Income

£453,711 £0 £302,474 £878,709 £0 £0 £0 £1,634,894

NET POSITION -£5,006,031 -£963,484 £302,474 £878,709 £0 £0 £0 -£4,788,332


Income Reduction

-£11,485,277 -£21,468,001 £0 £0 £0 £0 £0 -£32,953,279

Increased Income

£18,379,510 £0 £0 £1,203,936 £0 £0 £0 £19,583,446

NET POSITION £6,894,233 -£21,468,001 £0 £1,203,936 £0 £0 £0 -£13,369,833

SUMMARY POSITION

2020/21 INCOME LOSS

-£29,521,866 -£24,266,302 £0 £0 £0 £0 £0 -£53,788,169

2020/21 INCOME GAIN

£20,246,042 £0 £1,958,210 £3,217,654 £267,712 £105,759 £0 £25,795,377

2020/21 NET POSITION

-£9,275,824 -£24,266,302 £1,958,210 £3,217,654 £267,712 £105,759 £0 -£27,992,792


Total 2019/21 BHRUT Barts NELFT Federations/Primary


SYSTEM NET POSITION

OLDER PEOPLE

Income Reduction

-£19,214,667 -£2,702,668 £0 £0 £0 £0 £0 (£21,917,335)

Increased Income

£1,990,490 £0 £2,474,246 £1,666,232 £425,156 £175,115 £0 £6,731,239

NET POSITION -£17,224,178 -£2,702,668 £2,474,246 £1,666,232 £425,156 £175,115 £0 (£15,186,097)


Income Reduction

-£8,584,171 -£1,514,854 £0 £0 £0 £0 £0 (£10,099,025)

Increased Income

£742,226 £0 £494,818 £1,545,546 £105,000 £45,000 £0 £2,932,590

NET POSITION -£7,841,945 -£1,514,854 £494,818 £1,545,546 £105,000 £45,000 £0 (£7,166,436)


Income Reduction

-£18,433,975 -£29,635,430 £0 £0 £0 £0 £0 (£48,069,405)

Increased Income

£25,983,528 £0 £0 £1,805,904 £0 £0 £0 £27,789,432

NET POSITION £7,549,553 -£29,635,430 £0 £1,805,904 £0 £0 £0 (£20,279,973)

SUMMARY POSITION

2 YEAR INCOME LOSS

-£46,232,814 -£33,852,952 £0 £0 £0 £0 £0 -£80,085,765

2 YEAR INCOME GAIN

£28,716,244 £0 £2,969,063 £5,017,682 £530,156 £220,115 £0 £37,453,260

2 YEAR NET POSITION

-£17,516,570 -£33,852,952 £2,969,063 £5,017,682 £530,156 £220,115 £0 -£42,632,505


System Level Programme One: Older People

BHR System Programme Aspirations

To reduce the overall number of non-elective admissions per day across the BHR system by 12 per day (10 per day for BHRUT). This

will bring the BHR system to the NCEL average admission rate for Older People (aged over 65) and realise a gross saving of £10.5m

per year (3,650 admissions at £2,850 per admission) as well as freeing up 26,280 bed days (more than 70 beds in total) at an average

of 7.2 days length of stay per admission.

In addition, we want to reduce the percentage of predictable deaths occurring in an acute setting from the current 45% to 35% or

below, and reduce the number of non-elective admissions for patients at end of life from 2.5 to below 1.5 in the last 12 months of life.

Background to Programme

Compared to the NCEL average, BHR CCGs would need to reduce the number of non-elective admissions for Older People by more than

4,000 per year in geriatric medicine alone to reach the NCEL average rate at a system cost of £14m per year. In addition, Older People feature

non-electively in many other specialties where BHR CCGs have increased activity compared to the NCEL average including cardiology,

nephrology, urology, gynaecology and others. Many of the presenting conditions are ones that more targeted and effective intervention ‘out of

hospital’ could have prevented the conveyance/attendance and subsequent admission. In addition, once admitted the BHR system has

elevated numbers of people who do not return to their normal place of care placing much wider impacts on our system than just the NHS.

Finally, nearly 50% of all predictable deaths occur in hospital and in the preceding 12 months these patients have an average of c2.5 non-

elective admissions (with some people having up to 12).

Clinical Oversight and Ownership

This programme area and the associated aspirations were initially agreed by the BHR Health and Care Cabinet (HCC) on 8 November 2018

and by the Older People’s Transformation Board on 26 November. It was subsequently presented in summary to the HCC on 6 December

2018. This programme is being clinically and professionally led via the Older People Transformation Board.

A summary of the schemes within this programme are shown below. The detail concerning the schemes can be found in Appendix 3.


Projects Narrative Expected

Start Activity Reduction

Aspiration 19/20 PYE Impact

FYE Impact of 19/20 into 20/21

Stretch in 20/21

Integrated Nursing Home

Service

The previous Health 1000 programme showed the benefit of a multidisciplinary approach covering GPs, therapies and community nursing and geriatrician input to patients in Nursing Homes across 4 Homes and we are seeking to extend this to all 39 Nursing Homes in BHR although the new model may not include a geriatrician.

Q1 19/20 Already in planning although

assumptions may need revision

Acute Activity Reduction

210 Attendances & Admissions



Other Activity Reduction

- - -

Reprovision - - -

Narrative Reduction in Nursing Home admissions by 10% from Q1 increasing to 30% (approve 1/day) from Q3. Additional reduction of a further

20% in 20/21.

End of Life Programme

Identifying patients approaching the End of Life, identifying their preferred place of death and assisting them to remain in their normal place of care for as long as possible. In addition, we will provide system-wide coordinated planning and care to people in EOL. Currently the average number of admissions in the last 12 months is 2.5 per patient with a cost of ~£21m per year. Also focusing on Hospice Prescribing. This needs to link to MDT Programme for LTC Patients and will utilise and enhance the existing services delivered by NELFT and BHRUT and must also work with LAS.

Q3 19/20






- - -

Reprovision - - -

Narrative 15% Reduction in EoL Patients admitted in last 12 months of life from home or Care Home Setting from Q3 19/20. Further 15%

reduction in 20/21.

Falls Programme (including

existing Age UK Programme)

Early identification and management of patients at risk of falling and provide multi-disciplinary support to avoid primary and recurrent falls. In addition, we will involve voluntary and community sector to provide early prevention interventions. Currently BHR admit circa 800 patients non-electively per year following a fall at an average cost per admission of £4,180. There is felt to be stretch in this programme as many patients who fall do not end up being coded as a fall for example being recorded as a break or contusion). This will also need to link to the emerging Falls Strategy and will be informed following the current audit. This will consider early intervention and the role of the VCS, Social Care and Community Pharmacy.

Q1 19/20 Already in planning although







- - -

Reprovision - - -

Narrative

15% Reduction in patients who fall at home or a Care Home coded as falls plus a further 240 other attendances and admissions for

patients who fall but are not coded as fallers. Ramping up from Q1 19/20. Further 15% reduction in 20/21.






Stretch in 20/21

Home is Best Programme

This project will focus on supporting older peoplewho have arrived at hospital to avoid an admission and to return home to their normal place of care through enhanced support from the existing Community Treatment Team (CTT) plus input from specialist medics. This may also include effective routing of patients direct to rehab and step down beds rather than into an acute bed. Programme due to start in Dec 18 including 'in-reach' into Ambulance Queues, Geriatric Support in A&E and coordinated working between NELFT CTT Therapists and the Nurse Led Frail Older People Advice & Liaison (FOPAL) Service run by BHRUT. This will include increased usage and availability of Hot Clinics.

Ramping up from Q1 and

achieving the effective

run rate from Q3


500 Admissions 730 Admissions 365 Admissions


100 Readmissions 132 Readmissions 132 Readmissions

Reprovision TBA TBA TBA

Narrative Assumes 2/day reduction plus 20% of patients needing either ambulatory or a ZLOS Admission. Ramping up from Q1 to Q3.

Additional 1 ZLOS reduction in 20/21.

Community Acquired

Pressure Ulcers

BHRUT (and most likely Barts but evidence is less available) have substantial numbers of patients arriving with Community Acquired Pressure Ulcers. There is an estimated annual cost of managing these of ~£2.5m and it is expected that for a 10% investment this could be halved. This will link to and will eventually merge with the SIgnificant 7 Programme.

Q2 19/20


375 Admissions 500 Admissions 500 Admissions


- - -

Reprovision - - -

Narrative Numbers are a planning assumption pending information from

BHRUT with an assumed start from Q2 19/20 with stretch in 20/21.

LAS Alternative Care Pathways

Working with the London Ambulance Service (LAS) to maximise the use of Alternative Care Pathways (such as routing some patients to UTCs etc) and keeping patients at home. This is part of the Urgent & Emergency Care programme and sits under the responsibility of the Unplanned Care Programme Board rather than the Older People Transformation Board but is provided here because it is expected this programme will have a significant impact on Older People.

Q3 19/20 (Ramping up from Q1 but

allowing time for teething

issues to be resolved)


180 Attendances and Admissions




- - -

Reprovision 180 (Non A&E

Setting) 365 (Non A&E

Setting) 365 (Non A&E

Setting)

Narrative Assumes a 1/day reduction in conveyances ramping up from Q1

with the full run rate starting from Q3 19/20 onwards. Additional 1/day reduction in 20/21.


System Level Programme Two: Long-Term Conditions

BHR System Programme Aspirations

To close the prevalence gaps for key Long-Term Conditions (LTCs) (diabetes, AF, COPD, and asthma) by at least 10% to improve

long-term outcomes for patients.

To proactively manage patients with LTCs and reduce the number of non-elective admissions in key specialties acting as a proxy for

LTC admissions (cardiology, respiratory, endocrinology, vascular surgery and nephrology). Reducing non-elective admissions to the

NCEL average will mean a reduction of 1,500 non-elective admissions per year.

To move more care out of hospital for patients and provide this in the community using a multi-disciplinary team approach. The

aspiration is to reduce the hospital-based activity in key specialties to bring this down to the NCEL average meaning a reduction of

24,500 OPFA, OPFUP and OPPROC across cardiology, respiratory, endocrinology, rheumatology, vascular surgery and nephrology.


BHR has substantial prevalence gaps associated with key LTCs and also significant gaps in effective management of patients with LTCs that

both affect the long-term outcomes and health costs associated with these patients. These issues manifest themselves non-electively with

significant variances in key specialities aligned to LTCs such as cardiology (AF, CHD, CVD, etc.), stroke medicine (AF), vascular

surgery/endocrinology (diabetes) and nephrology (CKD/CKI). However, given that diabetic patients (for example) can present with conditions

and complications as varied at ophthalmic disorders or the need for emergency amputations we can reliably equate a large percentage of the

significant overspend in non-elective activity compared to the NCEL average to patients with LTCs.



and by the Long-Term Conditions Transformation Board on 29 November. It was subsequently presented in summary to the HCC on 6

December 2018. This programme is being clinically and professionally led via the Long Term Conditions (LTC) Transformation Board.







Stretch in 20/21

Primary Care Long Term

Conditions (LTC) Local Incentive Scheme (LIS)

Funding Primary Care to provide enhanced support to patients with Diabetes, AF, COPD, CKD and other key diseases including extra care clinics and achievement of recommended treatment targets. This also includes focusing on appropriate use of Advice & Guidance to support patients with LTCs Out of Hospital.

Ramping up from Q1

19/20 with full

effectiveness from Q3 onwards


400 Non-Elective Admissions




600 OPFA & 300 OPFUP



Reprovision - - -

Narrative

Assumes excess non-elective admissions compared to NCEL Average for four main specialties drop by 50% plus 10% reduction in excess OPFA/OPFUP activity (after removing impact of Improving Referrals Together Programme) with a further 25% and 10% respectively in Yr

2.

Whole System Clinical Pathway

Development

Coordinated support for patients with LTCs incorporating Specialist Community Nursing, Secondary Care Support and Education and Primary Care input. This will also focus on Patient Activation, Health Coaching and Health Psychology and will involve working with the Voluntary & Community Sector. This will also include Secondary Care education and support for Primary Care clinicians and support for patients with multiple co-morbidities.

In place but will ramp up from Q2 and

be fully operational

by Q4 19/20.


3,144 Mixed Outpatient Activity







Reprovision Primary/Community

Services Primary/Community

Services Primary/Community

Services

Narrative

Assumes a further 30% reduction on the excess OPFA/OPFUP activity compared to the NCEL Average associated with key specialties related

to LTCs spread over the two years after removing the Improving Referrals Together impact plus an impact on a number of Non-

Elective Admissions.

Prevention LIS To invest in proactively identifying patients at risk of or who may already have developed one of our key focus LTCs.

Q3 19/20


0 0 0


- - -

Reprovision - - -

Narrative The reductions for this scheme will not be realised by 20/21.

Assumed start Q3 19/20.


System Level Programme Three: Outpatient Reduction

BHR system programme aspirations

In line with the aspirations within North East London (NEL) we aim to reduce the amount of outpatient activity by 30% overall. In the

medium term (to 2020/21) our aspiration is to reduce activity within the BHR system to the NCEL across the main specialties where

we are an outlier.

Concurrently this project also supports the achievement of constitutional standards (specifically referral to treatment (RTT) and

diagnostics) and the repatriation of work from high cost settings where delivery of care within the BHR system offers a substantial

cost saving whilst delivering care nearer (in most cases) to the patient's home or normal place of care.


The three BHR CCGs are consistently the top three CCGs for referrals per 1,000 population into secondary care out of the 12 CCGs in NCEL.

Most of these referrals are to BHRUT as the major acute provider for the system. The Trust itself has an equivalent discharge rate and FUP

rate compared to its peers, but the fact that they receive more referrals on average means that a greater percentage of the total capacity is

occupied with patients who have an overall lower acuity need than the equivalent cohorts of patients within peer Trusts. This has been shown

to be a contributory factor to the Trust’s inability to earn the same per patient as many of its peers and therefore directly affects the system

deficit position. There are further impacts of the capacity tied up dealing with outpatient activity in that many more referrals are having to be

sent to the Independent Sector and other NHS Acute providers where, in the main, we incur a price pressure compared to work being

undertaken at BHRUT either through MFF differentials or for the Independent Sector where the differential can be up to 40%. By freeing up

outpatient capacity within BHRUT we have the opportunity to repatriate high acuity (and therefore more financially beneficial) work from high

cost settings to BHRUT and therefore achieve a true win-win for the system.



and by the Planned Care Programme Board on 28 November. It was subsequently presented in summary to the HCC on 6 December 2018.

This programme is being clinically and professionally led via the Planned Care Programme Board.







Stretch in 20/21

Improving Referrals

Together (IRT)

This project includes both the realisation of benefits from Phase 1 and an expanded Phase 2 for the IRT Programme to cover more specialties and would also cover an increasing effectiveness and access to Advice & Guidance. This would work in tandem with many of the other projects detailed below to deliver a reduction. This includes expanding the number and usage of Single Points of Access (SPAs).

Already in progress with

savings ramping up

from Q1 19/20.






- - -

Reprovision Mostly Primary Care Mostly Primary Care Mostly Primary Care

Narrative

Assumes a 20% reduction in the excess activity compared to the NCEL Average in the top 13 specialties in year 1 with a further 30%

reduction in year two with benefits ramping up from Q1 19/20. Savings span OPFA, OPFU and OPPROC.

Integrated Approach to

Referall Management

This scheme combines Primary Care Peer Review with support to GPs for them to use the IRT Pathways (see above) and enable BHRUT to facilitate the new models of care outlined below. There are no specific savings associated with this scheme as it is an enabler for other programmes.

Went Live Q4 18/19


0 0 0


- - -

Reprovision - - -

Narrative Activity reductions and savings for this will be rolled up into the

Improving Referrals Together and Single Points of Access Programmes.

New Models of Care for

Outpatients

This is a joint programme between BHRUT and the Primary Care Federations across BHR to reduce Outpatient Care provided in a hospital setting. This supports the North East London Programme to reduce Outpatient demand by moving care Out of Hospital and closer to home. This will involve such things as Virtual Clinics and also ensuring that patients are promptly discharged at the end of their episode of care.

Q2 19/20






- - -

Reprovision 50% as Virtual Clinics 50% as Virtual Clinics 50% as Virtual Clinics

Narrative

Assumes that 20% of the excess Outpatient activity compared to the NCEL Average (10% in Year 2) will be reduced with half of this being

reprovided in secondary care via Virtual Clinics and further reprovision occurring in Primary Care. Assumed start Q2 19/20.






Stretch in 20/21

New Consultant to Consultant (C2C) Policy

To reduce the growing demand associated with C2C referrals whilst ensuring patient care is not compromied and excessive burdens are not placed on primary care to re-refer. This programme will focus on the Top 20 pathways (ie referral from Speciality A to Specialty B) as a priority and will aim to better define when a C2C referral is required clinically rather than simply shunt activity back to Primary Care for re-referral.

Q3 19/20






- - -

Reprovision - - -

Narrative

Assumes a 5% reduction on the 17/18 Referral Rates (183,254) within BHRUT on the basis of 1 OPFA and 0.5 OPFUP being

eliminated starting from Q3 19/20 with a further 5% reduction in 20/21.

Expansion to Spending Money

Wisely Programme

Expanding the existing service restrictions and procedures/treatments deemed to be PoLCE both as part of the existing London/North East London programme and also specifically for BHR.

Benefit starting from

Q4 18/19


1,500 Procedures 1,500 Procedures 1,500 Procedures


- - -

Reprovision - - -

Narrative Assumes 1,500 Procedures will be stopped in Year 1 with an increase

of a further 1,500 in Year 2. Assumed start in Q2 19/20.

Repatriation of Care from High Cost Settings

The freeing up of capacity within BHRUT will be utilised to repatriate higher acuity work from high cost settings resulting in a net financial saving to the BHR System. This programme will need to continue to respect Patient Choice where expressed.

Q2 19/20


- - -


- - -

Reprovision - - -

Narrative TBD


System Level Programme Four: Complex Children As mentioned at the start of this section there is a fourth system level programme that we have agreed to progress around Complex Children,

but as this is mostly a matter between BHR CCGs and local authorities and also is unlikely to realise significant savings, we have not included

this within the Financial Recovery Plan, but it will be part of our system level programmes for the Integrated Care System.

Joint Cost Reduction and Effectiveness Programme At the start of this Financial Recovery Plan the BHR CCGs and BHRUT provided a joint statement of intent for the parties to work together to

reduce costs by £60m and to share the benefits equally. Some of the areas we will be focusing on for this are included in the table below:

Area of Potential Focus Narrative

Understanding the loss-making elements of the BHRUT’s activity and working out either how we improve productivity or remove the work

The trust spends £25m/Year on Bank/Agency and a significant amount on Weekend/Evening Clinics plus there will be services that cannot fully recover costs irrespective of these issues as well a theatre utilisation issues that could all contribute to this area of savings.

Selective and/or increased repatriation

There is an MFF Savings from Barts/Homerton and an apparent cost differential from repatriation from the Independent Sector to the system (albeit MFF may be negated through the current consultation) and we need to review the services that we want to selective target for repatriation (respecting patient choice) for the services that provide the best balance in terms of contribution to BHRUT and reduction in spend.

Collective work on shutting capacity and the management of any stranded costs

This will cover the areas of focus for closing capacity and the management of any stranded costs. This is the most important area with regards to transition funding ‘asks’ from Regulators to bridge the financial gap that will arise between activity changes and the ability of the system to reduce costs.

Joint outsourcing arrangements (ie agreeing packages of work with IS Providers to limit the financial risk)

This will see us working together to packages of care to be outsourced to the Independent Sector utilising the current contract arrangements between BHRUT and the IS Providers and possibly a new contract arrangement between the CCGs and the IS Providers.

New Models of Care – for example, moving from consultant led clinics to nurse led, using enhanced triage instead of OPFA, delivering care in the community rather than from fixed estate

It is clear that supporting repatriated and existing work using the existing clinical model is not fully covering the trust’s costs and therefore we need to agree new models of care to reduce the recurrent cost of delivering services.

Estate management and reduction in spend/void spend

We need to develop a shared approach to managing clinical and other estate to reduce costs. This will need to align to the ELHCP Estates Programme.

Reduction in incidental costs such as diagnostic wastage, medicines and equipment etc

This will cover everything from optimising pathology and radiology capacity, reducing duplicated testing, optimising medication spend and better utilising equipment.

Increasing the utilisation of assets (for example reducing DTOCs to free up beds for new work)

This is concerned with maximising the utilisation of internal assets such as beds by looking at such things as the ‘earnings per bed day’ and ensuring that beds are filled with the right casemix of patients. This may also include reclassifying beds and clinical areas to balance income/cost/needs.


‘Do Something’ Financial Bridge Taking into account all the benefits of the Internally Generated Efficiencies, the System Level Programmes and the expected two-year impact

of the Joint Cost Reduction and Effectiveness Programme we expect to both close the system financial gap and also improve outcomes for

patients. However, there is clearly a large amount of delivery risk associated with the expected benefits detailed in this section and this is the

subject of section six. The detail behind the bridge is provided on the following sheets.

Graph 2: ‘Do Something’ Financial Bridge.


The annualised tables underpinning the bridge above are shown below and on the following two pages.

2018/19 CCG BHRUT NELFT Spec. Comm Consolidated

Bridge I&E Bridge £m £m £m £m

2017/18 Out-turn (10.6) (49.0) (9.4) (5.5) (74.5)

Non-Recurrent Adjustment (5.3) (9.2) 5.9 0.0 (8.6)

Impact FYE 17/18 QIPP 0.0 0.0 0.0 0.0 0.0

2017/18 Recurrent Out-turn (15.9) (58.2) (3.5) (5.5) (83.1)

Allocation Increase 45.3 0.0 0.0 5.9 51.3

Income Inflation

Tariff 0.0 0.0 0.0 0.0 0.0

Other 0.0 0.0 5.7 0.0 5.7

0.0 0.0 5.7 0.0 5.7

Cost Inflation


Pay/ Non-Pay (1.1) (12.8) (6.7) 0.0 (20.7)

Cost Pressures (9.3) (17.3) (3.9) (1.6) (32.1)

(63.2) (30.1) (10.6) (3.9) (107.9)

PSF Income 0.0 0.0 1.3 0.0 1.3

Non-Recurrent Prior Year Adjustment (12.0) (12.0)

Forecast Savings 33.8 28.3 8.7 2.4 73.2

2018/19 Deficit 0.0 (72.0) 1.5 (1.1) (71.5)




2018/19 Out-turn 0.0 (72.0) 1.5 (1.1) (71.5)




Income Inflation

Tariff 0.0 26.0 0.0 0.0 26.0

Other 0.0 (16.8) 6.5 0.0 (10.3)

0.0 9.2 6.5 0.0 15.7

Cost Inflation

Tariff & Demographic Growth (50.7) 0.0 0.0 (1.1) (51.8)

Pay/ Non-Pay & CQUIN (2.1) (22.8) (6.5) 0.0 (31.4)

Non-Demo/Cost Pressures & Inv’ts (39.9) (15.9) (3.0) (0.2) (59.0)

(92.7) (38.7) (9.5) (1.3) (142.2)

PSF Income 0.0 11.6 1.4 0.0 13.0

Forecast Savings 0.0

System Wide Efficiencies 10.0 10.0 1.3 21.3

System Wide (Costs)/Cost Reduction 4.0 (1.3) 2.7

Net Transformation Costs 0.0

Internal Efficiencies 15.5 22.0 8.2 1.0 46.7

Unidentified QIPP 10.9 10.9

Other Non-Recurrent 0.0 0.0 0.0 0.0 0.0

2019/20 Deficit Before PSF 10.9 (50.8) 2.0 (0.8) (38.7)

PSF 27.7 27.7

2019/20 Deficit After PSF 10.9 (23.1) 2.0 (0.8) (11.0)




2019/20 Deficit 10.9 (23.1) 2.0 (0.8) (11.0)

Non-Recurrent Adjustment (11.2) (27.7) (4.4) 0.0 (43.3)



Income Inflation

Tariff 0.0 5.5 0.0 0.0 5.5

Other 0.0 10.1 4.0 0.0 14.1

0.0 15.6 4.0 0.0 19.6

Cost Inflation

Tariff & Demographic Growth (50.9) 0.0 0.0 (1.1) (52.0)

Pay/ Non-Pay & CQUIN (2.1) (12.3) (3.3) 0.0 (17.7)

Non-Demo/Cost Pressures & Investments

(28.2) (18.6) (4.4) (0.2) (51.3)

(81.1) (30.9) (7.7) (1.3) (121.0)

PSF Income 0.0 0.0 1.4 0.0 1.4

Forecast Savings

System Wide Efficiencies 20.0 20.0 2.4 42.3

System Wide Repatriation 19.5 19.5

System Wide (Costs)/Cost Reduction 8.0 (19.6) (2.4) (14.0)

Net Transformation Costs

Internal Efficiencies 10.2 18.5 6.1 1.5 36.3

Other Non-Recurrent 0.0 0.0 0.0 0.0 0.0

2020/21 Deficit Before PSF 10.9 (27.7) 1.4 (0.0) (15.5)

PSF 27.7 27.7

2020/21 Deficit After PSF 10.9 (0.0) 1.4 (0.0) 12.2


Section Six: Delivery Risk Mitigations

The ‘Do Something’ Financial Position brings the system back to financial balance, but with significant (and as at the present time unquantified)

delivery risk. This section deals with potential mitigations to offset the delivery risk inherent within the plan covering the following four areas:

1. Stretch on Existing System Level Programmes – This would see the partners seeking to stretch the potential efficiencies for the existing

System Level Programmes. At this stage we are only able to provide some high-level assumptions as there is still a need to work through

the cost impact of further activity changes and also to assess the associated delivery risk of stretching already challenging schemes.

2. Additional ‘Top Down’ Opportunities – The partners have agreed a number of additional schemes that will be used, where possible, to

mitigate the delivery risk inherent in the FRP.

3. Alternative Approaches – This section considers alternative approaches to the BHR system Financial Recovery Plan other than adding

further schemes in to bring the system back to balance.

In addition to the three issues above, we would be remiss in not presenting some unpalatable options for regulators to consider, but

we need to make it clear that the BHR system partners are not in favour of considering the unpalatable options as it goes against our

explicit statement of intent set out at the start of this document.

4. Unpalatable/High-Risk Mitigations – These are areas of potential consideration that may be unpalatable but need to be considered as

part of the Financial Recovery Programme.


Stretch on Existing System Level Programmes Earlier we presented the three main System Level Programmes and the underpinning projects that we have agreed we will focus on for the

main part of the Financial Recovery Plan. However, as was noted this does not fully close the ‘Current State’ financial gap and therefore as the

first step toward achieving this we propose to explore potential stretch on the existing projects. This is still very much ‘work in progress’ and we

recognise that the delivery risk will be even higher on any stretch than it is on the existing proposed activity/cost reductions. We still need to

both agree clinically and managerially that the proposed stretch is both realistic and delivers the expected cost reductions with any further

activity reductions. Therefore, the results for this section are presented as a very high-level opportunity.

Area Potential stretch Potential net impact

Older People Stretching the current aspiration of a net reduction of 12 per day to 14 per day day across the BHR system (with potentially 12 a day coming from BHRUT and the remainder from Barts).

£2.25m additional potential gross saving per year with a possible £1m net system saving

per year

Long-Term Conditions Increase the proposed impact from 1,500 non-elective admission to 2,250 non-elective admissions per year (with the increased impact clustered into year two).

Approximately £2m of additional gross saving for year two with a possible £1m of

net system saving

Outpatient Reduction Reduce outpatient activity to the NCEL average across the top 20 specialties. This could potentially increase gross

savings by c£4m per year with a net system saving of potentially £2m per year.

Potentially the stretch might add £3m in year one and £4m in year two (£7m total) but with significantly elevated delivery risk that will need to be

attached to these planning assumptions.

The table below gives regulators and partners a view on the potential scale of opportunity if we were to reduce activity to the NCEL average.

Area Current aspiration in system level

programme Proposed further stretch

Gap to NCEL average

Older People £20m net reduction per year £1m net reduction per year

c£20m per year Long-Term Conditions

£9.5m net reduction per year £1m net reduction per year

Outpatient reduction

£27m net reduction per year £2m net reduction per year

However, this would require further restructuring of the system and is outside the scope of a two-year Financial Recovery Plan.


Additional ‘Top Down’ Opportunities The partners are currently working on additional opportunities but present four that have been agreed in addition to the System Level

Programme detailed in Appendix 3.

Scheme Narrative Potential Start Status Potential Scale

Sepsis & Infections

Programme

Aimed to reducing the number of patients needing unplanned treatment associated with infections (mainly pneumonia and UTIs but also AKI). This scheme will not

now focus on sepsis and the SHMI has reduced to a much better level but this may be revisited.

Q4 19/20 Pipeline £2m+

Integrated Homecare

Support Programme

Looking at providing a consistent offer to people in a Care (rather than a Nursing Home) setting.


Reducing Bed Days

Lost to DTOCs and Medically Optimised

Patients

BHRUT and the BHR CCGs working to reduce the number, frequency and impact of DTOCs.


T&O Pilot There is significant interest between the partners to

specifically look at transforming T&O Services. This may expand to include both Pain and Rheumatology.

TBD Pipeline £5m+

High Intensity

Users

Focused on reducing the demand arising from high intensity users on secondary care where their needs can

be met in another setting. Already underway but needs to ramp up Mobilising TBD

Diagnostic Duplication Reduction

Reducing diagnostic duplication and also repatriating work from Barts Health where is makes sense.

Q2 19/20 Pipeline TBD


Scheme Narrative Potential Start Status Potential Scale

Non-Emergency

Patient Transport (NEPTS)

Consistent approach to providing NEPTS within BHR and with providers outside of our local system (such as Essex based acute providers).

Q2 19/20 Mobilising £1m+

Dressings Consider the transfer of the dressings budget associated with

domiciliary patients to NELFT or introduce a risk-share with them. TBD Pipeline TBD

Step-Down A multi-agency approach to managing step-down and rehab capacity TBD Pipeline TBD

Patients with

Undiagnosed Symptoms

A specific programme focused on patients who have symptoms that cannot be diagnosed. This will include such things as unexplained

breathlessness and other similar conditions. TBD Pipeline TBD


Alternative Approaches Finally, we have included some points for discussion about how we may manage the financial recovery in the BHR system differently for

discussion although these are present for discussion and apart from support with transition funding are not expected to be part of the overall

system recovery.

Alternative Approaches

Allow the system to run with a deficit

Provide additional finance to support transition and/or reduce the delivery risk inherent in this plan

Extending the recovery period to March 2023 (see note below).

Note: As part of our modelling we have considered what the impact would be of extending the period to March 2023. In terms of the f inancial

ask this would increase making the extension a ‘zero sum game’ in terms of finances but what it does do is decrease the delivery risk of the

identified programmes.


Unpalatable/High Risk Mitigations It is important to note that whilst we have included unpalatable options for completeness and discussion we are not proposing to

proceed with these as they go against our explicit statement of intent set out at the start of this document.

Unpalatable options for discussion

Failure to deliver Referral to Treatment standard or other constitutional standards

Fail to deliver on our Mental Health investment standard and/or improving access to psychological therapies (IAPT) targets

Implement service restrictions based on finance needs rather than clinical evidence

The BHR system partners do not want to put a quantifiable value on the financial benefits that may arise from the above as we do not wish to

consider them but the above list is included for completeness.

Summary The delivery risk inherent in the ‘Do Something’ plan can be mitigated to some degree (and potentially in its entirety) based on the additional

schemes detailed within this section without the need to consider the Unpalatable Options and/or alternative approaches. A key on-going task

will be to assess the delivery risk and continue to work up additional schemes and approaches to mitigate the risk.


Section Seven: Implementation

In this section we consider the key issues that will affect the implementation of the BHR System Financial Recovery Plan.

Risks and Issues As can be gathered there are a number of significant risks associated with the delivery of the System Financial Recovery plan for BHR. The

most significant risks are detailed below with some narrative around potential mitigations provided.

Risk/Issue Description Impact Likelihood Narrative and Mitigation

There will be a lag between activity reductions and the changes in cost or increases in alternative activities that will affect the deliverability of the plan.

High High We will need to look at both transition funding and some mechanisms for risk sharing to prevent any disproportionate impact to any one partner.

The Primary/Community capacity to reduce secondary care activity and bring it closer to home does not exist.

High Medium to

High

We need to look at different models of care and closer alignment between Primary Care and Community Services to leverage the resource that exists. Also, we may need to see secondary care expertise delivered more frequently in the community to bolster the resources.

The delivery risk inherent in the programmes of work detailed within this document have not been quantified fully. This includes looking at both the cost impact as well as income/expenditure.

High High This work will need to be undertaken at pace following agreement of the plan by regulators. It will be an ongoing theme though throughout the duration of the Financial Recovery Plan.

Some or all of the elements of this plan may cause concern and issues with the public, other partners (including NHS organisations) and others.

Unknown High

We will need an effective communications and engagement plan and will require support from regulators in response to any significant issues arising from this plan and the subsequent changes that will need to be made.

We need to be clear that the changes we are proposing do not introduce any inadvertent quality or safeguarding issues.

Unknown Unknown

We will need to do an early piece of work to assess the plan in terms of potential areas of concern and then monitor each scheme during workup producing the relevant Quality and Equality Impact Assessments as well as any needed safeguarding reports.

There is a risk that the Financial Recovery Plan for the BHR System and the Clinical Strategy for BHRUT diverge from each other whereas they need to be fully integrated.

High Low

The development of the BHRUT Clinical Strategy for the two Hospitals will be done collaboratively and coordinated via the Joint PMO and NHS Recovery Board. Additional support may be required from Regulators to help manage any adverse concerns from the public, politicians or other stakeholders.


Risk/Issue Description Impact Likelihood Narrative and Mitigation

Changes in people within any of the organisations involved (including regulators) could change the behaviours and dynamics of the system.

Low to High High

It is likely that there will be numerous changes in the senior leadership across the system and regulators over the period of this Financial Recovery Plan and we will use the NHS Recovery Board and the Joint Oversight Meetings to ensure that new senior leaders entering our system fully understand what the system is committed to.

The cultural change required across the system cannot be underestimated and may impact negatively on the ability of the system to progress programmes.

High High

Some of this will be mitigated by the communications and engagement plan detailed above and another mitigation will be ensuring consistency in the messages coming from system leaders. However, a large part of this can only be mitigated through time and the evidence of practice (i.e. the things we do and how we act).

Our planning assumptions are significantly wrong and adds substantially to the local financial challenge.

TBC TBC At this stage we are unclear on what the mitigations for this would be and would need to consider this when the scale of any adjustments we need to make are included.

Business As Usual (BAU) requirements overtake transformation.

Medium High

We recognise that many of the same people who will be instrumental in the delivery of transformational change also have a day job delivering clinical and support services hence the inclusion of a Transformation Programme Budget and dedicated resource to maintain consistency in the delivery of our plan.

Focus on system recovery destabilises long-term transformation partnerships and ambitions across the BHR health and care system

TBC TBC

Transfer of short-term cost pressures between NHS and partner organisations as a result of the system recovery focus, principally but not exclusively local authorities, causes disruption and problems in agreeing and maintaining the long-term transformation partnership that will deliver the sustainable health and care system. We will continue to work to share savings and transformation plans, understand impacts, build pooled and shared risk arrangements, and manage conversations with regulators and other external partners jointly.

The schemes we are putting forward still need to be worked up at pace and could have different projected impacts to the planning assumptions included.

Medium to high

Variable

We will be working on multiple schemes at pace to understand any variance to our planning assumptions. There will be a resource limitation to this but we are also working to align our existing resource to the Financial Recovery Plan to mitigate this.


Governance of Recovery This section outlines the key Governance Structures that are associated with the ownership and delivery of the BHR System Financial

Recovery Plan.

NHS Recovery Board

This consists of the Clinical and Executive Leaders of all NHS organisations within BHR including GP Federations and will oversee the delivery

of the FRP and support the resolution of any issues blocking progress. Ultimately, as the BHR FRP moves from being purely agreed by the

NHS partners to also being fully aligned and integrated with our Local Authority partners we may move this responsibility to the Joint

Commissioning Board or change the remit of the NHS Recovery Board.

Shared Programme Management Office (PMO)

The Shared PMO has been established to enable the programme management and finance teams from the partner organisations to meet and

discuss the shared programmes of work. In addition, the Shared PMO will take responsibility for tracking the impact/benefit of schemes and for

managing the assurance and approval process for new schemes that will be put in place and that is detailed later within this document.

BHR Health and Care Cabinet (HCC)

This group consists of the Senior Clinical and Professional Leaders from across BHR and will set the clinical agenda for Financial Recovery

and monitor the progress of the Transformation Boards.

Transformation Boards

These will provide the clinical/professional ‘engine’ to progress the transformation workstreams that underpin the BHR NHS FRP. The System

Level Programmes within the FRP are aligned to the Transformation Boards as detailed below. The Transformation Boards are clinically

accountable to the BHR HCC and financially accountable to the NHS Recovery Board (and in time the Joint Commissioning Board).

Older People System Level Programme is managed via the Older People Transformation Board

LTC System Level Programme is managed via the LTC Transformation Board

Outpatient Reduction System Level Programme is managed via the Planned Care Programme Board

All Transformation Boards are supported by resource from the Shared PMO and to ensure consistency in how Transformation Boards operate

we are establishing an assurance process that is detailed on the following page.


Transformation Board

Chair

Board Assurance Date

Next Assurance Due

Requirement Description/Content Review

Frequency

Assurance

Date

Assurance

RAG

Terms of

Reference (ToR)

Each Transformation (or Programme Board) needs to have an agreed Terms of Reference that is customised from the standard Terms of Reference and has been agreed by the Board as well as the Health & Care Cabinet.

6 Monthly

Membership List

& Roles

A list of the current membership of the Transformation/Programme Board must be maintained including the names of the Clinical and Management Leads from each partner organisation who are on the membership plus the details of the Chair (who must be a clinician or professional). The Membership List should also include details of any administrative or officers supporting the Transformation/Programme Board.

As changes to membership

occur

Logistics Details of meetings, venues and times for at least the next four months and an up to date Action Tracker capturing the actions arising from each meeting and the progress made to close the actions. The Action Tracker should form part of the standing items for noting on the Health & Care Cabinet.

Monthly

Plan on a Page

A Plan on a Page must be agreed setting out the strategic objectives and the expected outcome improvements for the Transformation/Programme Board for at least the next 2 years (and possibly up to 5 years). As an Appendix to the Plan on a Page each Transformation/Programme Board should also maintain a map/summary or narrative of the Current State service provision supporting the population being served and a proposed Future State model of how service provision will change over the next 2-5 years (as per the Plan on the Page timeline)

At least every 3 Months

Dashboard

A Dashboard of agreed outputs and outcomes for the population being served by the Transformation/Programme Board needs to be put together and updated at least every two months. These measures need to be agreed by the Transformation Board and also by the Health & Care Cabinet and will be shared as an item for noting as part of the Health & Care Cabinet on a regular basis.

At least every 2 Months

System

Efficiencies

A comprehensive list of System Efficiencies (QIPPs/QCIPs) needs to be maintained along with robust tracking of each scheme (including the impact of the scheme during mobilisation and delivery) and the details and membership of any Task & Finish Groups established to progress schemes. A remedial action plan to bring schemes back on track in terms of timing or impact should form part of the Action Tracker covered under the Logistics section above.

Monthly or even

fortnightly


Resourcing the Financial Recovery Plan (FRP) We have agreed additional resource to support the delivery of the FRP amongst the major NHS organisations. We are still to agree any

additional resources that may be required by other partners and how that may be funded. A summary of the additional resources for each

partner organisation is detailed below along with the shared resource.

Partner PMO Resources Delivery Resources

BHRUT No additional resources required over and above existing PMO Resource.

No additional resource required over and above existing delivery resource.

NELFT Funding for a VSM/Band 9 Director of the BHR PMO and a Band 6 has been agreed with the funds coming from the 19/20 and 20/21 Demographic Growth

Funding agreed for 2 x 8B Programme Managers to support the Older People and LTC System Level Programme and an analyst dedicated to the BHR System. Again this will come from the 19/20 and 20/21 Demographic Growth.

BHR CCGs No additional resources required over and above existing PMO Resource.

The BHR CCGs have agreed a £1m/year Transformation Budget to fund the delivery resources below and a large percentage of the Shared PMO detailed below. The additional delivery resources are 1 x 8B to support the GP Federations in addition to existing Primary Care support to enable them to support Financial Recovery and 1.5 x 8A roles to support the Older People System Level Programme.

Shared PMO Resourcing

Partner PMO Resources Funding the Shared PMO

Leadership This will consist of the PMO Leads for each partner organisations and a Director of System Recovery.

Funding will come from the BHR CCGs £1m/Year Transformation Budget plus a £300k/Year contribution from NELFT (via Demographic Growth) and a similar amount from BHRUT.

Transformation Board Support

3 x Band 8Cs and 3 x Band 6 will be recruited to support the main Transformation Boards. Each 8C/6 ‘team’ will also support a second Transformation Board to ensure coverage.

Clinical Resource

Most clinical resource (ie backfill) will come from existing partner budgets to enable clinicians to engage in the transformation work required. A small budget for any additional clinical resource has been allocated.

External Support We have budgeted £250k in the first year (19/20) to obtain external support to target specific issues relevant to the FRP around Bed Base, A&E Demand and Diagnostics.

Communications A budget of £50k has been allocated to augment existing communications support if required.


The proposed structure for the delivery of Financial Recovery as summarised above is shown in the diagram below:


Financial Recovery also requires a different approach to how business cases are agreed across multiple partners and how we collectively track

benefit to the system and avoid cost shunting. A proposed approach to the assurance process for Financial Recovery schemes is shown below:


Section Eight: System Enablers

Delivery of Financial Recovery within BHR relies on a number of interrelated enablers that are covered below:

System Enablers

Enabler Narrative

Clinical Strategy BHRUT will be updating their Clinical Strategy in 2019 and this needs to be aligned to the FRP. The NELFT Business Strategy was updated in 2018. The BHR CCGs will review whether the original Devolution Pilot Strategy will need to be updated in light of the BHRUT Clinical Strategy and the NHS FRP.

Workforce All partner organisations in BHR (including GP Federations) have workforce issues and there is a collective appetite for a shared workforce strategy across our NHS system.

Estates The partners collectively own substantial estate and there exists opportunities to share both estates resource and estate itself. This will be evaluated further.

Digital Work being undertaken at a North East London level needs to be localised and rolled out at pace. This is a key focus for 19/20.

Business Analytics The partners have agreed in principle to share Business Analytics and are working out how this will be put into practice. For the purposes of progressing the FRP partners are already sharing available data and producing deep dive reports on areas a diverse as MSK, Pressure Ulcers and Infections.

Regulatory Environment

Maintaining a Joint Regulatory Environment and moving toward a Shared Control Total is felt to be a key system enabler for NHS Financial Recovery.


Section Nine: Asks from Regulators

This final section lays out some specific requests to regulators to support financial recovery within BHR.

Maintain the Joint Regulatory Environment: Managing the system on a shared control total and having single, joint meetings with the BHR

partners will support system working and reduce the risk of relationships between the partners fragmenting again.

Support the System with Transformation/Transition Funding: As transformation and/or transition funding is made available the BHR

partners ask regulators to consider putting our system at the front of the queue given the scale of ambition we have displayed in pulling this

Recovery Plan together.

Ensure there is a consistent message across the wider North East London System: With the BHR system partners now aligned around

this Financial Recovery Plan it is necessary for the wider system within North East London to be working toward the same principles The

biggest single financial risk to the BHR system remains Barts and ensuring that they are being given the same messages about system working

and ensuring the financial health of the wider North East London system would be extremely useful.

Recognise the need to invest in resource to secure delivery: The partners are putting forward an ambitious and challenging plan and it

needs to be recognised that this will need resourcing. The proposed Transformation Programme Budget can only partly be funded through the

reprovision costs and will ultimately need to be underwritten by one of the parties (most likely BHR CCGs) and set against this is the

requirement for CCGs to reduce spend by 20% and support from regulators to unpick this dilemma is needed.

Support with Capital Investment & Specific Financial Pressures: Part of the longer-term need is for BHR to have support for capital

investment and regulators are asked to give support to prioritising investment in the BHR system and to the bids and proposals already put

forward. In addition, Regulator support to help the system address the interest charges for BHRUT and the £10.9m Control Total for the BHR

CCGs for 19/20 is needed.

Support with managing any public concerns: We are proposing a radical programme of change in a relatively limited period of time and

expect to be (rightly) challenged by our public, partners and others throughout this process. We will require support from regulators to the

challenges raised at points and a general level of support for our overall direction of travel. This will be of particular concern during the revisiting

of the BHRUT Clinical Strategy that is likely to raise concerns both with the public and with politicians. The strategy has to align to the overall

BHR System Recovery Plan and will aim to optimise the use of all estate to achieve the best clinical outcomes for the patients we serve as well

as supporting financial recovery.


Section Ten: Next Steps An outline of the key actions/milestones to be achieved over the 90 days from 1st March to 31st May 2019 are shown below:

Mar 19

Joint Oversight Meeting

Final System FRP in Public Domain

Finalise Aggregate Impact of FRP on BHRUT and identify mitigations

Agree Contracts for 19/20 including

QIPPs/QCIPs

Final Operating Plan Submissions

Task Provider Alliance with key ‘asks’ to support System FRP

Rollout Communications &

Engagement Plan

Apr 19

Continue engagement with Local Authorities to align plans

On-going discussions between

Federations and BHRUT take form

Finalise outsourcing and repatriation strategies

Procurement for targeted support for A&E Demand, Beds and Diagnostics

as part of FRP

Finalise plans with Provider Alliance based on Tasking

Commence proactive engagement

with partners and our public

May 19

Target for aligned plans with Local Authorities

Agreed Out of Hospital agenda for BHR agreed between BHRUT and

Federations

Start to track impact of FRP Schemes

Start development of System

Intentions for 20/21

Work up further Pipeline Schemes to mitigate in-year and 20/21 Delivery

Risk

Update to be produced for Partner Boards on progress

Tracking of Impact of the FRP to be

finalised

BHRUT - FRP21 1

Financial Recovery Plan to March 2021: FRP21

January 2019

1

BHRUT - FRP21

Contents

2

I. Overview

II. Financial context and plan to end FY20/21

III. Key Pillars of our Financial Recovery Plan in FY19/20 and FY20/21

IV. Integrated Care System - progress to date

V. Risks and Next steps

BHRUT - FRP21

I. Overview

3

Patient safety and quality of care remain at the heart of the Trust, however

there is a clear understanding that this needs to be delivered in a way which is

financially sustainable. This is not a trivial exercise for the Trust or the

Integrated Care System (ICS), and this document seeks to answer “what would

need to be achieved to breakeven by March 2021?”, in line with our Board

Undertakings. It will also inform our clinical strategy and five year plans due to

be developed in 2019.

BHRUT has a long history of poor financial performance, which is forecast to

reach a deficit of around £100m by March 2021 before mitigation (our “do

nothing” scenario). Helpfully, our diagnosis shows there are no material

“structural” drivers of this deficit which cannot be fixed. We will need to be

ambitious with our cure.

Our internal aim needs to target upper quartile Model Hospital cost

performance with c.£60m of savings over two years, or 5% per annum, which

we estimate will cost £20m to deliver. Recurring themes include the need to

reduce our staff vacancy rates and improve our culture as part of a substantial

workforce agenda. At the same time we need to improve our core processes to

support highly efficient, profitable elective pathways, overhaul the way we look

after outpatients and increase the resilience of our A&E performance.

We also need to redesign pathways across our ICS for the benefit of our

patients and be one of the first ICS’s to deliver financial value. Our Trust and

the CCG are serious about working together, demonstrated by an agreement to

stop “intercompany squabbling” and pursue “real savings” of £60m, which will

then be shared equally to send a clear message that working together is good.

This would bring us to a residual deficit of c.£30m by March 2021 which we

expect to be closed through a combination of transformation funding through

tariff and reduction in interest costs from the centre.

As always in these plans, risks abound. For BHRUT, these include the need for

change in culture and clinical engagement; the inability to recruit; insufficient

capital and change in leadership. For the ICS, key risks are ability to redesign

pathways with digital support and then delivery of benefits given scarcity of

success in other ICS. Other risks include macro assumptions given we have not

received planning guidance, and much work needs to be undertaken to turn

this document into a programme which is ready to deliver from 1 April 2019.

This all leads to the final and probably most significant risk - the reality check

that some of this recovery is likely to take longer than two years given the need

for deep, enduring change.

BHRUT - FRP21

II. Financial context and plan to end FY20/21

4

BHRUT - FRP21

This FRP21 seeks to show what it would take for BHRUT to breakeven by March 2021, in line with

our Board commitments. It will also inform our broader clinical strategy and five year plans, due to

be developed in 2019.

The Trust has reported significant financial deficits for a number of years, as set out in the chart to the right. This culminated in an outturn deficit of £49m post PSF (£67m before PSF). This led to the Trust being placed into Financial Special Measures (“FSM”) in February 2018.

Since then, the financial position of the Trust has been stabilised, and we are targeting a reported deficit of £60m and underlying deficit of £65m for FY18/19.

Our financial performance has been compounded by significant and sustained operational performance and other challenges, including:

• RTT - full recovery plan in place with a plan to return to achieving 88% from March 2019 from the current performance of 82%.

• A&E - sustained high attendance figures have impacted on performance. Work is on-going to improve patient flow through initiatives such as Red2Green, and multi-agency discharge events are now embedded practice.

• Diagnostics - following a fire in our Queen’s endoscopy suite in May 2018, diagnostic waiting times have lengthened with 87% of patients receiving diagnostic within six week against a target of 99%. We plan to return to compliance from April 2019.

• High levels of employee vacancy - with 16.6% of staff WTE employed on a temporary contract against a target of 8%.

• Cultural conflict, weak clinical engagement and poor system wide relationships.

The system in which the Trust operates is also financially challenged, with Barking and Dagenham, Havering and Redbridge CCGs (“BHR CCGs”) currently in FSM and forecasting a “do nothing” deficit of £179.4m by end of FY20/21. Continued financial pressure has led to a historically challenging relationship with our primary commissioner, however, we are working together to find collaborative solutions to the issues faced in our health system as set out in sections 11 - 15.

5

BHRUT - FRP21

Deficit driver £'m

Structural

Excess PFI v market 6

Strategic Historic local health economy infrastructure deficit 30

Financing costs 5

Split / underutilised sites 3

Total strategic 38

Operational Clinical negligence costs 2

Overseas visitors 1

PELC losses 3

Excess cost of temp staff 11

Other costs 46

Total costs (vs. upper quartile) 63

Total drivers 107

Our diagnosis of the key drivers of our deficit indicate that there are no material structural drivers,

and rather that our deficit represents a combination of internal operational efficiency challenges

and strategic health economy issues, all of which can be addressed over time to support our

ambition in reaching upper quartile.

We have worked through the causes of our deficit, as set out in the table to the right, which we have considered through three lenses; structural, strategic and operational causes.

Structural deficit

After the rebate of £16m from Department of Health, the net cost of our PFI contract is estimated to be £6m above the reference cost. We also face an annual increase c.£0.8m in PFI costs, due to the underlying complex structure.

Strategic deficit

The key driver of our strategic deficit relates to our local health economy. It is estimated that we undertake c.£30m of work per year which is unaffordable to the system. The system estimates that the Trust delivers c.£60m more activity than would be expected in secondary care in our region.

The Trust incurs £5m of interest costs more than our peers, due to £150m more debt than peers. This relates to the Trust’s history, and paying a higher rate of interest on borrowings (6% vs 1.5%).

At this stage, we do not believe there is a material additional cost of operating on two sites (currently it is estimated to be c.£3m). As part of a broader strategic analysis, we will refine the actual value of the additional costs.

Operational deficit

In order to achieve financial sustainability and deliver c.£60m of gross improvements to support our financial recovery, we need to target upper quartile performance. This will address:

• higher than national average clinical negligence costs due to the high value of historical claims;

• under-recovery of overseas visitors income; • stranded cost pressure due to contractual arrangements with PELC; • our large temporary staffing costs; and • various other operational inefficiency.

6

BHRUT - FRP21

Our FY18/19 forecast outturn of £64.8m underlying deficit will grow to c.£100m deficit by end

FY20/21 in our “do nothing” scenario. This cannot be closed solely through internal efficiency and

productivity improvements and will need new system collaboration and savings for BHRUT to

successfully deliver this plan. Having developed our “do nothing” scenario, it is clear that ongoing internal efficiency improvements (i.e. our “QCIP” programme) activity will not be enough to get us to breakeven by the end of FY20/21. As such, we have worked through the target shape of our cure.

Broadly, our recovery is driven through three areas:

1. Self-help - Ongoing QCIP and productivity improvements, based on sustainable, clinically led change, of c.£36m (5%). This is after £10m per annum for cost of delivery, and includes dedicated resource and a 10% quality and innovation incentive fund (as set out on page 25 );

2. Integrated Care System (“ICS”) - The Trust and the BHR CCGs are committed to working together to realise £60m of real cash savings and to sharing this equally between them to bring both parties back to break-even whilst ensuring we protect the financial integrity and sustainability of NELFT. Priority areas are better system provision and management of Outpatients, Long Term Conditions and Older People; and

3. National - £30m, with £25m assumed from Provider Sustainability Funding (“PSF”) embedded in tariff, and £5m reduction in interest charges.

Financial Plan to FY20/21

The chart to the right sets out our financial plan for the next two years, using our forecast FY18/19 underlying outturn deficit of £64.8m as a base, with a steadily improving run rate through each half year to end FY20/21.

Having set out a high level plan for the next two years, there are a number of next steps for us to now take:

• Detailed work up of the FY19/20 QCIP plan, including monthly financial phasing. In particular, our focus will be on fully worked up, detailed and deliverable plans for the first half of the year;

• Work through detailed a demand and capacity modelling exercise to assure the growth assumptions included in our plan; and

• Bottom up financial planning and agreement of divisional budgets.

7

Outlook before mitigation actions

FY18/

19

FY19/

20

FY20/

21

H119/20

H219/20

H120/21

H220/21

£'m £'m £'m £'m £'m £'m £'m

Brought forward (65) (65) (81) (35) (30) (27) (22)

Efficiency requirement (2%) (11) (11) (6) (6) (6) (6)

Annual cost pressures (5) (5) (3) (3) (3) (3)

Deficit before actions (65) (81) (97)

Cumulative cost savings

5% QCIP 28 57 14 14 14 14

Cost of delivery (10) (20) (5) (5) (5) (5)

ICS 10 30 5 5 10 10

Add. phasing stretch requested 4 0 2 2 (2) (2)

Net cost savings 32 67 16 16 17 17

Deficit before PSF/interest improvements

(65) (49) (30) (27) (22) (18) (13)

Run rate (H2 for 2019) (5.0) (4.1) (2.5) (4.5) (3.6) (2.9) (2.1)

BHRUT - FRP21

III. Key pillars of our financial recovery plan

8

BHRUT - FRP21

To date, we have identified key priority themes, supported by a series of enablers. Inevitably,

specific workstreams are at different stages of maturity, however we are clear on the detailed next

steps which we need to take in each area.

Approach to Trustwide Recovery

Our approach starts with a clear top down Case for Change – we need to save £100m in the next two years, at a broadly linear pace, and there is little which is structural preventing this recovery.

The plans, summarised on page 11, start with a recognition in section 1 that we need to embed cultural change, making the most of the Virginia Mason based PrideWay to help avoid the failed delivery attempts in the past.

We have then built up a recovery plan (summarised on page 11) based on:

• Plans for each division (detailed in sections 1 to 6). These are led by the divisional triumvirate and a senior finance manager sponsor, through a process of diagnosing the root cause behind current performance, with a particular focus on loss making service lines and Model Hospital benchmarking.

• This use of evidence rather than eloquence should result in a more robust basis for our financial cure. That in turn is then based on a “what would it take” ambition, rather than a “what do we feel safe committing to” approach to establish a set of initiatives which will turn these specialties around. Each initiative is RAG rated based on Opportunity, Deliverability and Resource (What, How and Who).

• We have then focused on corporate areas (section 7) and Trust wide initiatives (section 8) including non-divisional, non-pay, estates and workforce schemes.

• Following this we have summarised the cost of delivery and Trust enablers (digital strategy, PMO and Finance) (section 9). Cost of delivery is currently estimated at £10m pa and consists of £4m for dedicated resource, £2m contingency for headcount changes and £4m pa for a quality and innovation fund. In addition to this, the capital cost of digital is estimated at £10m over two years. We have not yet refined other capital costs of delivery but these are estimated at £10m pa. This total of £30m capital over two years

compares to a Capital Resource Limit of £10m (£5m pa).

• Income opportunities (section 10) seek to both grow certain specialist services and private patient activity, and reduce low acuity work. These are in addition to the £100m of cost savings, in effect rewarding “cure” rather than encouraging an attempt to “grow out of trouble”.

• Finally we have considered system savings (Sections 11-15) to show the potential opportunity collaboration with our system partners presents across the two year recovery.

9

BHRUT - FRP21

Summary of key pillars of recovery

10

Note 1: “Other Savings” consist of procurement (£5.5m), estates (£3.8m), CNST, training, overseas patients and EPR savings (together £2.1m), and the unallocated balance of workforce schemes (£2.73m), all of which sit outside divisions. Note 2:Through our Trustwide analysis of Workforce, we have identified opportunities of £5.48m. We have worked through the makeup of these savings with divisions, (i.e. items 2-7 above), and of the £5.48m, £2.74m fall within these divisional lines above. Of the remaining £2.73m, we have held this within “Other Savings”, whilst we work through the detail with the divisions. We have and will continue this Trustwide focus on workforce, as an enabler for divisional delivery as well as to further stretch ourselves and achieve our ambition for workforce improvement.

OVERVIEW OF FINANCIAL RECOVERY PLAN FRP21

RAG rated plans Planned Gap Target

Targ

et £

'm

Pla

n

H1

20

H2

20

2020

H1

21

H2

21

2021

Tota

l

H1

20

H2

20

2020

H1

21

H2

21

2021

Tota

l

H1

20

H2

20

2020

H1

21

H2

21

2021

Tota

l

BHRUT - self help

1 Culture change

2 Acute Medicine 14.0 13.0 1.2 1.5 2.7 4.8 5.5 10.3 13.0 2.3 2.0 4.3 (1.3) (2.0) (3.3) 1.0 3.5 3.5 7.0 3.5 3.5 7.0 14.0

3 Surgery & Anesthetics 20.0 18.4 2.2 2.2 4.5 7.0 7.0 14.0 18.4 2.8 2.8 5.5 (2.0) (2.0) (4.0) 1.6 5.0 5.0 10.0 5.0 5.0 10.0 20.0

4 Women's and Child Health 10.0 3.7 1.6 1.9 3.6 0.1 0.1 0.2 3.7 0.9 0.6 1.5 2.4 2.4 4.8 6.3 2.5 2.5 5.0 2.5 2.5 5.0 10.0

5 Specialist Medicine 4.7 4.0 1.0 1.2 2.2 0.9 1.0 1.9 4.0 0.2 0.1 0.3 0.3 0.1 0.4 0.7 1.2 1.2 2.4 1.2 1.1 2.3 4.7

6 Cancer & Clinical Support 5.0 3.9 0.8 0.8 1.5 1.2 1.2 2.3 3.9 0.5 0.5 1.0 0.1 0.1 0.2 1.1 1.3 1.3 2.5 1.3 1.3 2.5 5.0

7 Corporate Services 5.0 4.3 0.9 0.9 1.9 1.2 1.3 2.5 4.3 0.3 0.3 0.6 0.0 0.0 0.0 0.7 1.3 1.3 2.5 1.3 1.3 2.5 5.0

8 Other savings (Notes 1 and 2) 0.0 14.6 3.5 3.9 7.4 3.4 3.8 7.2 14.6 (3.5) (3.9) (7.4) (3.4) (3.8) (7.2) (14.6) 0.0 0.0 0.0

Other risks (2.0) (2.0) (0.5) (0.5) (1.0) (0.5) (0.5) (1.0) (2.0) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (0.5) (0.5) (1.0) (0.5) (0.5) (1.0) (2.0)

Gross savings 56.7 60.0 10.8 11.9 22.7 18.1 19.2 37.3 60.0 3.4 2.3 5.7 (3.9) (5.1) (9.0) (3.3) 14.2 14.2 28.4 14.2 14.1 28.3 56.7

9 Cost of delivery

Contingency (4.0) (4.0) (1.0) (1.0) (2.0) (1.0) (1.0) (2.0) (4.0) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (1.0) (1.0) (2.0) (1.0) (1.0) (2.0) (4.0)

Dedicated resource (8.0) (8.0) (2.0) (2.0) (4.0) (2.0) (2.0) (4.0) (8.0) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (2.0) (2.0) (4.0) (2.0) (2.0) (4.0) (8.0)

Quality and innovation (8.0) (8.0) (2.0) (2.0) (4.0) (2.0) (2.0) (4.0) (8.0) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (2.0) (2.0) (4.0) (2.0) (2.0) (4.0) (8.0)

Total cost of delivery (20.0) (20.0) (5.0) (5.0) (10.0) (5.0) (5.0) (10.0) (20.0) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (5.0) (5.0) (10.0) (5.0) (5.0) (10.0) (20.0)

Net benefit 36.7 40.0 5.8 6.9 12.7 13.1 14.2 27.3 40.0 3.4 2.3 5.7 (3.9) (5.1) (9.0) (3.3) 9.2 9.2 18.4 9.2 9.1 18.3 36.7

10 Income / portfolio 5.0 14.6 1.8 2.6 4.3 5.6 4.8 10.3 14.6 (0.5) (1.3) (1.8) (4.3) (3.5) (7.8) (9.6) 1.3 1.3 2.5 1.3 1.3 2.5 5.0

INTEGRATED CARE SYSTEM

11 Older People 10.0 1.5 0.1 0.5 0.6 0.5 0.5 0.9 1.5 1.6 1.2 2.8 2.9 2.9 5.7 8.5 1.7 1.7 3.3 3.3 3.3 6.7 10.0

12 Long Term Conditions 10.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.7 1.7 3.3 3.3 3.3 6.7 10.0 1.7 1.7 3.3 3.3 3.3 6.7 10.0

13 Outpatients 10.0 7.3 0.1 2.7 2.8 1.8 2.8 4.6 7.3 1.6 (1.0) 0.6 1.6 0.5 2.1 2.7 1.7 1.7 3.3 3.3 3.3 6.7 10.0

14 Other system wide initatives 0.0 1.9 0.2 0.5 0.7 0.6 0.6 1.2 1.9 (0.2) (0.5) (0.7) (0.6) (0.6) (1.2) (1.9)

15 Repatriation of activity 0.0 8.3 0.6 1.9 2.5 2.9 3.0 5.9 8.3 (0.6) (1.9) (2.5) (2.9) (3.0) (5.9) (8.3)

30.0 19.0 1.0 5.5 6.5 5.7 6.8 12.5 19.0 4.0 (0.5) 3.5 4.3 3.2 7.5 11.0 5.0 5.0 10.0 10.0 10.0 20.0 30.0

Total (before PSF, Int. and

income schemes) 66.7 59.0 6.8 12.3 19.2 18.8 21.0 39.8 59.0 7.4 1.9 9.2 0.4 (1.9) (1.5) 7.7 14.2 14.2 28.4 19.2 19.1 38.3 66.7

Income upside 5.0 14.6 1.8 2.6 4.3 5.6 4.8 10.3 14.6 (0.5) (1.3) (1.8) (4.3) (3.5) (7.8) (9.6) 1.3 1.3 2.5 1.3 1.3 2.5 5.0

NATIONAL

PSF 25.0 25.0 25.0

Interest 5.0 5.0 5.0

Net benefit (excl. income) 96.7 89.0 96.7

Plus income upside 5.0 14.6 5.0

BHRUT - FRP21

IV. Integrated care system (“ICS”)

BHRUT - FRP21

System collaboration is essential to improve patient outcomes, and is also essential to our

achievement of a break-even position by end FY20/21.

Key next steps

I

To date, we have:

- Agreed a joint intent to pursue c£60m of real savings to be shared equally between CCG and BHRUT

- Developed a series of ideas across Older People, Long term conditions and Outpatients with clinical and systems wide involvement

- Started to try to quantify the real savings possible in these three areas plus repatriation opportunities, looking at external cost savings net of estimated cost of alternative pathways. This is still at an early stage off development and is constrained by current data quality issues

- To date, we have identified initiatives with estimated net savings or just over half the £60m target (£33m)

Next steps:

- Work to date is intended to form the basis of selecting two or three areas to pilot and prove concept, process and resource. The aim is to then replicate this across other areas.

- Governance will need to support this new way of joint working

- Delivery teams will need to be properly resourced

- Our aim remains to start delivering benefit from 1 April 2019

50:50

share

agreed Ideas

Identify

real

savings

Pilot

areas

Benefit

delivery

Governance

Delivery teams We are here

We have been focused on working with our system partners as part of the ICS to deliver sustainable pathway redesign and system change, in the interest of better patient care and outcomes as well as benefiting the Trust’s financial position by c.£30m by FY20/21 (as assumed in our financial modelling).

System drivers of deficit

We now better understand the key drivers behind our system deficit, which at a high level comprise of:

• Underfunding of our system historically, of over £40m when considering primary care co-commissioning budgets and CCG allocations;

• Primary care capacity constraints, specifically FTE GPs and nurses at low levels. We have consistently had the highest number of referrals (per 1000) into secondary care of the 12 CCGs in NCEL; and

• A significant cohort of the population from Eastern Europe who do not historically utilise primary care and present at acute hospital.

Our joint ambition

Through our work, we have agreed with our CCG to speak with one voice on our approach to the system challenge, along the lines of the following joint statement:

“BHRUT and the BHR CCGs are committed to working together to realise £60m of real cash savings and to sharing this equally between them to bring both parties back to break-even. The scope of the savings will be all areas of joint spend (i.e. where both parties have income/expenditure) and will need the parties to work together on both how the savings are realised and how the rewards are shared between them through contractual mechanisms. This programme of work will be achieved whilst ensuring we protect the financial integrity and sustainability of NELFT.”

Our ambition is to be amongst the first ICS’s to deliver real cash savings nationally

BHRUT - FRP21

V. Risks and next steps

13

BHRUT - FRP21

We have identified a number of risks to our financial recovery and are taking steps to mitigate these

14

Risk Mitigation Impact (after

mitigation)

Likelihood (after

mitigation)

1 Cultural change and clinical engagement Continued work with PrideWay, early engagement of clinicians throughout transformation schemes

High Med

2 Inability to recruit, given national shortages Intelligent recruitment, good process and develop

reasons to join BHRUT High Med

3 Insufficient capital Will need to agree best approach with NHSI/E Med High

4 Change in leadership FRP based on evidence and widespread buy-in, with

board and NHSI/E support Med High

5 Inability to design and embed new processes and supporting

systems and information across the Trust and ICS PrideWay, dedicated resource, expert IM&T High Med

6 Benefit delivery in ICS (given little precedent elsewhere) Clear intent, good co-operation; needs to be supported by governance and delivery teams

High High

7 Change in macro assumptions / tariff etc Outside ICS control Med Med

8 Insufficient capacity or capability Will need to convert these plans into fully costed and resourced programmes

Med Med

9 In sufficient mental health provision to allow parity of esteem

in the system

Need NELFT as core ICS partner and link to drive wider system support

Med Med

10 Time to deliver, particularly need to embed cultural change

and lead times to change areas such as primary care

Dedicated resource and PMO, proven VMI quality

improvement High High

BHRUT - FRP21

Next steps

15

We are committed to delivering this strategic financial plan

We need to deliver c.£100m savings by FY20/21 to achieve financial sustainability.

Based on the Trust’s financial model and the advised inflation rates, known and estimated unknown cost pressures, we forecast a deficit challenge of c.£100m if no further action is taken.

Based on our work to date, and after taking into account of investments required to deliver savings, consider that we need c.£40m Trust savings, c.£30m system savings, and achieve £30m PSF and national funding.

This plan maps out our progress to date and areas of saving that we are focusing on to deliver savings within our control.

We have performed detailed diagnostics across our organisation, both in clinical divisions as well as corporate functions, to identify financial opportunities which we can deliver ourselves.

These indicate that we can deliver c.£40m of net benefit across the next two years, with further work to be done in Q4 FY18/19 to make them deliverable.

We need to continue to work with our system partners to improve patient outcomes and support our financial recovery.

We recognise that traditional QCIP within our four walls will not be sufficient to close our financial gap.

We have invested significant time and resource to work closer with our system partners, and build strong relationships which historically have not existed.

This has resulted in three key pathways to be focused upon, namely; outpatients, long term conditions and frail & elderly.

To successfully deliver this ambitious plan, we have and continue to address several enablers.

Additional resource: the level of resource available to deliver our plan is insufficient. We will continue to strategically invest.

Governance framework: we will need a best in class PMO, which will support the Trust to deliver this FRP.

Operational engagement: we need engaged clinical and operational leads throughout the development of this plan.

System change needs to take place to release significant savings from system collaborations

We will continue to work with our system partners to develop a clear system vision and governance structure to continue to focus on pathway redesign and to coordinate regulatory messages.

We would like to work closely with our system partners to rapidly develop a shared system view and coordinated delivery structure to deliver the system schemes, align clinical models and act together in the interest of the system.

1 2 3 4 5


Appendix 2

Drivers of the Deficit

Our Population

There is a significant population growth predicted across BHR both

for JSNA and GLA Projections. The net impact on demand is shown

on the next slide.

Gross Annual Pay (£)England 27,500

London 32,781

Newham 25,815

Barking and Dagenham 27,252

Waltham Forest 27,893

Ealing 30,137

Hounslow 30,158

Enfield 30,410

Brent 30,648

Haringey 30,684

Greenwich 30,800

Havering 31,087

Hillingdon 31,229

Harrow 31,308

Sutton 31,332

Croydon 32,000

Lewisham 32,005

Barnet 32,044

Hackney 32,269

Bexley 32,724

Lambeth 32,751

Merton 32,982

Southwark 32,983

Redbridge 33,121

Tower Hamlets 35,276

Islington 36,449

Bromley 36,546

Kingston upon Thames 36,700

Hammersmith and Fulham 36,823

Camden 37,071

Wandsworth 39,014

Richmond upon Thames 39,868

Westminster 40,389

Kensington and Chelsea 45,263

Harrow 41.8

Waltham Forest 39.0

Enfield 34.8

Sutton 34.8

Bexley 32.2

Newham 30.0

Haringey 29.5

Brent 29.4

Ealing 28.7

Bromley 28.2

Croydon 26.9

Wandsworth 26.8

Havering 25.7

Redbridge 25.5

Merton 25.0

Lewisham 24.9

Greenwich 24.8

Barnet 24.4

Barking and Dagenham 23.4

Kensington and Chelsea 23.1

Kingston upon Thames 23.1

Hounslow 22.3

Richmond upon Thames 21.1

Hammersmith and Fulham 19.9

Hillingdon 19.3

Hackney 18.5

Lambeth 15.3

Westminster 15.3

Islington 13.8

Southwark 12.9

Camden 12.2

Tower Hamlets 9.3

City of London 5.2

% Earning Less Than London

Minimum Wage

Our Population (Income)

Many of the comparisons

within the Financial Recovery

Plan are based on the North

Central & East London

(NCEL) Average across 12

CCGs. What this slide and the

next show is whilst our

population has challenges

related to poverty and

deprivation, mortality due to

preventable causes and

shortened healthy life

expectancy these are common

across much of NCEL and

therefore the comparisons

with our NCEL Peers is

deemed valid.

Mortality Due To Preventable CausesEngland 184

London 172

Tower Hamlets 242

Hackney 225

Barking and Dagenham 218

Southwark 212

Islington 209

Hammersmith and Fulham 209

Lambeth 205

Lewisham 202

Newham 200

Greenwich 196

Wandsworth 180

Waltham Forest 180

Haringey 180

Camden 179

Hounslow 179

Croydon 174

Westminster 172

Hillingdon 169

Ealing 166

Bexley 165

Brent 165

Havering 162

Merton 161

Sutton 160

Enfield 151

Kingston upon Thames 148

Bromley 146

Kensington and Chelsea 141

Redbridge 141

Richmond upon Thames 138

Barnet 137

Harrow 132

City of London 125

Healthy Life Expectancy (F) Healthy Life Expectancy (M)Area Name

HLE

Tower Hamlets 55.4

Lambeth 57.9

Newham 58.3

Hackney 58.4

Southwark 58.6


Greenwich 60.0

Islington 60.1

Waltham Forest 61.3


Ealing 62.9

Redbridge 63.0

Camden 63.6

Lewisham 64.0

Havering 64.0

Croydon 64.1

Haringey 64.1

Hounslow 64.1

Merton 64.3

Brent 65.1

Sutton 65.2

Hillingdon 65.5

Wandsworth 65.6

Bexley 65.9

Westminster 67.0

Barnet 67.1

Enfield 67.5


Bromley 67.9


Harrow 68.8


Males


Tower Hamlets 56.5

Hackney 58.1

Waltham Forest 59.4

Southwark 59.7

Newham 61.0

Islington 61.3

Haringey 61.5


Hounslow 62.3

Lewisham 62.4

Lambeth 62.5

Ealing 62.6

Redbridge 63.0

Hillingdon 63.2

Greenwich 63.5

Westminster 63.6

Croydon 63.9

Wandsworth 63.9

Enfield 65.0

Bexley 65.1

Sutton 65.4

Camden 65.9

Brent 66.0

Bromley 66.2

Merton 66.4

Havering 66.4

Barnet 69.1


Harrow 69.6



Our Population (Health)

Historic System Funding

CCG NHS Barking and Dagenham CCG

2014-15 2015-16 2016-17 2017-18 2018-19Allocation £k 242,638 254,444 262,332 270,303 282,762Allocation per capita £ 1,171 1,202 1,202 1,215 1,236Target per capita £ 1,138 1,138 1,181 1,198Closing DfT £ 6,842 6,536 4,561 3,893

CCG NHS Havering CCG

2014-15 2015-16 2016-17 2017-18 2018-19Allocation £k 301,311 320,316 342,047 352,441 369,262Allocation per capita £ 1,158 1,215 1,269 1,293 1,317Target per capita £ 1,188 1,187 1,315Closing DfT £ -7,826 -1,729 -7,374 -5,875

CCG NHS Redbridge CCG

2014-15 2015-16 2016-17 2017-18 2018-19Allocation £k 294,092 319,524 335,688 345,428 358,722Allocation per capita £ 1,003 1,068 1,096 1,108 1,121Target per capita £ 1,057 1,056 1,109 1,124Closing DfT £ -15,729 -5,654 -3,967 -5,144

Whilst B&D were

above target by

£21.8m over the

period 2014-2018 both

Havering & Redbridge

were under target by

£22.8m and £30.5m

respectively.

Therefore the system

under-funding

amounted to £32m.

When Primary Care

Co-Commissioning is

included this increases

to more than £40m.

Key Primary Care StatisticsCCG FTE GPs

07T NHS City and Hackney CCG 190

08M NHS Newham CCG 182

08V NHS Tower Hamlets CCG 177

08F NHS Havering CCG 143

08W NHS Waltham Forest CCG 138

08N NHS Redbridge CCG 136

07L NHS Barking and Dagenham CCG 98

CCGPatients

Per GP

08N NHS Redbridge CCG 1,741

08F NHS Havering CCG 1,736

08W NHS Waltham Forest CCG 1,663

07L NHS Barking and Dagenham CCG 1,621

08M NHS Newham CCG 1,612

08V NHS Tower Hamlets CCG 1,346

07T NHS City and Hackney CCG 1,290

BHR have amongst the

lowest absolute GPs in

FTE terms in North East

London and

correspondingly the

highest GP to Patient

Ratios.

In addition, Barking and

Dagenham and Redbridge

both have more patients

per practice nurse than the

London and national

average, whilst Havering

have more than the

national average. This will

be contributing both to

reduced access to Primary

Care and an increased

pressure on GPs.

Key Primary Care Statistics

The workforce breakdown (showing total population rather than FTEs) shows that B&D have a

significantly greater number of Locums than the North East London Average.

All GP Provider Salaried &

Other GPs

GP

Retainers

GP

Registrars

GP Locums Locums % of

All

Practitioners

NHS Barking and

Dagenham CCG 138 56 42 1 3 3726.8%

NHS City and Hackney

CCG 247 107 101 1 14 249.7%

NHS Havering CCG 160 97 36 - 18 10 6.3%

NHS Newham CCG 247 111 90 1 11 35 14.2%

NHS Redbridge CCG 184 92 52 2 12 27 14.7%

NHS Tower Hamlets

CCG 241 108 110 1 10 135.4%

NHS Waltham Forest

CCG 187 102 51 - 9 2613.9%

Primary Care InvestmentInvestment in primary care has varied across NEL. Most CCGs are struggling to invest upfront to support transformational change. There are differences in core contract income to practices (often based on take up of enhanced services/QOF and numbers of PMS/APMS practices) and the ability of CCGs to invest in local incentive schemes. This table is a high level summary of income to practices in North East London:

Notes:1. Based on 17/18 apart from LIS investment 18/192. BHR CCGs LIS investment includes primary care provider development monies

Apart from Tower Hamlets, figures on core income do not include full QOF payments (include aspiration not achievement). Will be update to include this at end June when known so under reporting in all areas apart from TH.

8

Barking & Dag City and Hackney

Havering Newham Redbridge Tower Hamlets Waltham Forest

No of Practices 37 41 44 53 45 35 42

RAW List Size (,000)

222.3 316.3 277.3 392.7 319.2 311.0 310.1

Weighted List Size (,000)

208.0 314.8 269.5 376.5 280.9 302.2 287.1

Average income by RAW patient (£)

104.4(4th Highest)

105.0(3rd Highest)

96.9(6th Highest)

109.3(Highest)

84.9(Lowest)

107.1(2nd Highest)

97.5(5th Highest)

Average income by weighted patient (£)

111.5(4th Highest)

105.5(3rd Highest)

99.7(6th Highest)

114.1(Highest)

96.5(Lowest)

110.2(2nd Highest)

105.4(5th Highest)

LIS Investment (total)1,2

£1.7m(5th Highest)

£10.7m(Highest)

£2.3m(3rd Highest)

£1.1m(6th Highest)

£2.1m(4th Highest)

£7.3m(2nd Highest)

£0.5m(Lowest)

GP Referrals

Through the issues raised earlier the BHR CCGs have consistently

referred more patients per 1000 population than our peers in North Central

& East London over the last 3 years.

Expected

Prevalence

Total

T1 / T2

Observed

Prevalence

(QOF 16/17)

Gap Pts

B&D CCG(207,968 Pop)

9.2%

5% / 95%8.91% 0.3% 624

Havering CCG(271,977 Pop)

8.7%

7% / 93%6.53% 2.2% 5,983

Redbridge CCG(296,474 Pop)

10.9%

4% / 96%8.40% 2.5% 7,412

Benchmark 8.8% (England)

Prevalence

SourceHealth Surveys for England - https://www.gov.uk/government/publications/diabetes-

prevalence-estimates-for-local-populations

Notes Data on Type 1/ Type 2 split is taken from the National Diabetes Audit

Prevalence Gaps (Diabetes)

https://www.gov.uk/government/publications/diabetes-prevalence-estimates-for-local-populations

Expected

Prevalence

Observed

Prevalence

(QOF 15/16)

Gap Pts


1.5% 0.8% 0.7% 1,456


2.6% 1.6% 1.0% 2,720


1.8% 0.9% 0.9% 2,668

Benchmark

England2.4% 1.7% 0.7% 983,254

Prevalence

Sourcehttps://www.gov.uk/government/publications/atrial-fibrillation-


Prevalence Gaps (AF)

Estimate

Prevalence

16+Total popn /

16+ popn

Observed

Prevalence

(QOF 16/17)

Gap* Pts


4.6% / 6.3% 1.6% 3% 3327


4.3% / 5.4% 1.7% 2.6% 4624


3.3% / 4.3% 0.8% 2.5% 2372

Benchmark England 1.9%, STP 1.2%

Prevalence

SourceAPHO Prevalence model (2011), PHE Fingertips

NotesThe expected prevalence model only shows those aged 16+, as such prevalence is

shown as a % of total population and as a % of the 16+ population,

Prevalence Gaps (COPD)

Expected

Prevalence (16+)

As % of total

popn / as % of

16+ popn

Observed

Prevalence

(QOF 16/17)

Gap(based on total

expected

prevalence as a

proportion of total

popn)

Pts


4.7% / 6.5% 2.6% 2.1% 4,367


6.7% / 8.3% 3.0% 3.7% 10,063


5.5% / 7.1% 2.6% 2.9% 8,598

Benchmark 4.1% England, 2.5% STP

Prevalence

Sourcehttps://www.gov.uk/government/publications/ckd-prevalence-estimates-for-local-and-

regional-populations

NotesThe expected prevalence model only shows those aged 16+ as such prevalence is

shown as a % of total population and as a % of the 16+ population.

Prevalence Gaps (Asthma)

https://www.gov.uk/government/publications/ckd-prevalence-estimates-for-local-and-regional-populations

Expected

Prevalence

Observed

Prevalence

(QOF 16/17)

Gap Pts


19.9% 13.0% 6.9% 14,350


23.8% 13.7% 10.1% 27,470


20.7% 11.8% 8.9% 26,386

BenchmarkEngland: QOF prevalence: 13.8% estimated observed

prevalence 23.6%

Prevalence

Sourcehttps://www.gov.uk/government/publications/hypertension-


Prevalence Gaps (Hypertension)

https://www.gov.uk/government/publications/hypertension-prevalence-estimates-for-local-populations

LTCs BHR Total

Reduction Required

Treatment Function POD Activity Cost

Cardiology

OPFA 8542 £528,921

OPFU 135 £9,124

OPPROC 6988 £1,131,102

ELECTIVE 521 £831,376

NON-ELECTIVE 107 £582,174

Pain Management

OPFA 1346 £288,463

OPFU 2613 £208,451

OPPROC 0 £0

ELECTIVE 1617 £1,218,006


Respiratory Medicine

OPFA 0 £0

OPFU 48 £0

OPPROC 1722 £568,384

ELECTIVE 94 £14,039

NON-ELECTIVE 270 £1,193,613

Vascular Surgery

OPFA 105 £15,882

OPFU 461 £33,588

OPPROC 142 £17,280

ELECTIVE 131 £272,946


Nephrology

OPFA 25 £4,026

OPFU 2196 £289,576

OPPROC 5 £580

ELECTIVE 0 £2,894


Rheumatology

OPFA 1038 £255,918

OPFU 4586 £433,323

OPPROC 225 £31,228

ELECTIVE 477 £78,007


Endocrinology

OPFA 171 £25,750

OPFU 0 £0

OPPROC 0 £0

ELECTIVE 0 £0

NON-ELECTIVE 322 £1,532,015

AF

CHD/CVD/HF

COPD

Asthma

CKD/AKI

Diabetes

Hyp

erte

nsio

n

Diabetes

Condition

This slide

attempts to

line up some

key LTCs with

some (not all)

of the

specialties

where activity

might arise to

give an

indication of

the issues we

have with

managing Pts

with LTCs.

Community Activity

This shows that activity and investment are at a level equivalent to our

peers in NEL apart from in Redbridge which is below the average.

North East London Community BenchmarkingActivity data source: Trust performance reports 1718

B&D TH HAV NEW C&H WF RED BHR AverageRest of NEL

AvgNumber of community contacts

(excluding therapies) 265529 360297 238625 305920 231211 204456 188888882 826

NHS Digital GP population 224111 317334 276995 396086 314937 309632 3147111000 per population 1185 1135 861 772 734 660 600

NEL CCGS CHS Contracts Values 2018/19 and per 1000 population

B&D RED HAV WF C&H NEW TH NELCommunity Health Services-CCG Annual Contract Value

£33,748,003 £26,637,362 £32,430,325 £37,108,900 £36,054,177 £35,004,638 £39,184,285 £240,167,690

NHS Digital GP population 224,111 314,711 276,995 309,632 314,937 396,086 317,334 2,153,806

Value £ per 1000 GP Population £150,586 £84,641 £117,079 £119,848 £114,481 £88,376 £123,480 £111,509

Caveat:

B&D, Redbridge and Havering CCGs Financial Values were taken from the 'BHR CHS Contracts 201819' data sheet supplied by Sharif Ahmed. As the NELFT contract value was not divided into services it was not possible to split out the value of the Therapy services, so therapy services are included in this value.

Tower Hamlets CCG financial values were provided by Jig Tailor at a total contract value for each of the 3 elements of the Community Alliance Contract. Therapy services are included in this value.

City and Hackney CCG financial figures were provided by Amit Shah of the CCG and include all community contracts. Therapy services are included in this value.

Waltham Forest CCG financial values were provided by Eisen Daley of WF CCG and is for Community Block Contracts only. Therapy services are included in this value.

OPFA Activity Comparison

The BHR CCGs have substantially more OPFA activity than the NCEL

Average (all figures are /1000 population)

Specialty_Code Specialty_Desc 2015/16 2016/17 2017/18 2015/16 2016/17 2017/18 2015/16 2016/17 2017/18

110 Trauma & Orthopaedics 22 23 24 16 16 16 6 7 8

501 Obstetrics 25 22 20 20 18 15 5 4 5

320 Cardiology 20 21 21 12 15 17 7 5 4

100 General Surgery 16 18 16 11 11 10 5 7 7

502 Gynaecology 15 16 15 17 18 17 -2 -2 -2

120 Ent 14 14 14 13 13 12 2 1 2

130 Ophthalmology 15 13 12 11 11 11 4 2 1

330 Dermatology 12 13 11 14 14 14 -1 -1 -2

560 Midwife Episode 12 11 11 9 8 7 3 4 4

101 Urology 9 9 10 8 8 9 1 1 1

301 Gastroenterology 9 10 9 7 8 8 1 2 1

103 Breast Surgery 9 9 9 8 9 10 0 -0 -0

650 Physiotherapy 8 8 8 2 3 2 5 6 5

420 Paediatrics 6 7 6 7 8 8 -1 -1 -2

840 Audiology 3 5 8 3 3 4 1 2 4

410 Rheumatology 6 5 5 5 5 4 1 1 1

340 Respiratory Medicine (Also Known As Thoracic Medicine)4 5 5 4 4 5 0 0 0

400 Neurology 4 5 5 3 5 5 1 0 0

191 Pain Management 3 4 3 2 3 2 1 1 1

303 Clinical Haematology 2 2 3 2 2 2 0 0 0

VarianceBHR CCGs NCEL CCGs

Outpatient Activity

This table, extracted from a much

larger document, shows that

BHRUT discharge patients at the

first outpatient appointment at a

rate equivalent to their peers

(although there is further

opportunity as shown on the next

slide).

This remains consistent when we

also include discharges from all

outpatient first activity included

OPPROCFA.

BHRUT New:FUP Ratios are also

the same as their peer group.

POD Specialty Total ActivityWeightin

g

Weighte

d %

OPFA

General Surgery 23,328 6.6% 0.7%

Trauma & Orthopaedics 46,542 13.3% -0.2%

Ophthalmology 21,127 6.0% -0.8%

Cardiology 67,266 19.2% 3.2%

Neurology 8,913 2.5% 0.0%

Rheumatology 10,133 2.9% 0.0%

Gynaecology 66,350 18.9% -6.2%

Pain Management 5,625 1.6% 0.0%

Nephrology 2,184 0.6% 0.0%

Vascular Surgery 4,422 1.3% -0.1%

Stroke Medicine 3,533 1.0% -0.4%

ENT 19,509 5.6% -0.5%

Clinical Haematology 10,317 2.9% 0.5%

Physiotherapy 40,423 11.5% 0.9%

Breast Surgery 17,851 5.1% 0.9%

Gynaecological Oncology3,375 1.0% 0.0%

350,898 100.0% -0.13%

Impact/Year -460

OPFA Discharges

BHRUT has opportunity to increase OPFA Discharges.

Outpatient Activity

13 Specialities account

for £17m of excess

spend compared to the

NCEL Average.

BHR CCGs

Reduction Required

Treatment Function POD Activity Cost

Trauma & Orthopaedics

OPFA 7285 £1,155,534

OPFU 18990 £1,460,672

OPPROC 3766 £1,012,519

General Surgery

OPFA 5724 £1,175,929

OPFU 10117 £778,925

OPPROC 2243 £592,599

Gynaecology

OPFA 12469 £2,126,624

OPFU 385 £0

OPPROC 0 £0

Ophthalmology

OPFA 4880 £671,533

OPFU 12868 £772,718

OPPROC 762 £78,431

Cardiology

OPFA 12036 £823,117

OPFU 0 £0

OPPROC 6802 £1,155,973

Urology

OPFA 263 £34,365

OPFU 3908 £282,803

OPPROC 1522 £485,922

ENT

OPFA 1741 £206,743

OPFU 6136 £361,384

OPPROC 2697 £260,279

Nephrology

OPFA 68 £43,430

OPFU 2663 £467,610

OPPROC 5 £818

Rheumatology

OPFA 1170 £288,538

OPFU 4467 £455,274

OPPROC 6 £15,223

Pain Management

OPFA 1575 £320,797

OPFU 1574 £143,181

OPPROC 0 £0

Stroke Medicine

OPFA 846 £358,182

OPFU 2039 £315,070

OPPROC 0 £0

Neurology

OPFA 493 £245,723

OPFU 839 £151,854

OPPROC 334 £52,183

Oral Surgery

OPFA 1266 £259,531

OPFU 492 £42,234

OPPROC 725 £103,483

Elective Admissions

11 Specialities account

for £27m of excess

spend compared to the

NCEL Average.

BHR CCGs

Reduction Required

Treatment Function Activity Cost

Trauma & Orthopaedics 3293 £9,913,305

General Surgery 3594 £3,955,140

Gastroenterology 3218 £1,368,542

Ophthalmology 1750 £1,617,626

Cardiology 603 £1,196,496

Urology 1956 £1,265,524

ENT 1568 £1,871,269

Interventional Radiology 3092 £2,467,276

Neurosurgery 611 £1,744,061

Pain Management 1809 £1,269,204

Gynaecological Oncology 1082 £1,071,096

Non-Elective Admissions

BHR CCGs

Reduction Required

Specialty Activity Cost

Geriatric Medicine 3133 £9,060,429

General Medicine 6700 £6,739,686

General Surgery 1385 £3,500,074

Gastroenterology 454 £1,977,505

Respiratory 513 £1,934,987

T&O 296 £1,864,756

Urology 1076 £1,341,073

ENT 1160 £1,126,270

Endocrinology 222 £1,037,693

Stroke Medicine 106 £995,499

Cardiology 361 £961,982

Neurosurgery 120 £825,772

Nephrology 246 £681,568

13 Specialities account for £32m

of excess spend.

Independent Sector Analysis

CARE UK

T&O Unique Patients New:FUP Ratio % Unique Pts with DC

or Elective

Cost Per Unique

Patient

Care UK 4,786 1:1.44 43% £1,346

BHRUT 15,893 1:1.81 16% £680

BARTS 3,565 1:1.43 23% £889

Gastro Unique Patients New:FUP Ratio % Unique Pts to

DC/Elective

Cost Per Unique

Patient

Care UK 1,496 1:0.37 271% £1,284

BHRUT 3,997 1:2.13 277% £1,456

BARTS 1,026 1:2.81 206% £1,219

General Surgery Unique Patients New:FUP Ratio % Unique Pts to

DC/Elective

Cost Per Unique

Patient

Care UK 3,000 1:1 50% £307

BHRUT 9,297 1:1.66 39% £169

BARTS 1,074 1:1.35 58% £266


SPIRE

T&O Unique Patients New:FUP Ratio % Unique Pts with

DC or

Elective

Cost Per Unique

Patient

Spire Roding 2,267 1:1.69 69% £1,847

Spire Hartswood 460 1:1.76 52% £1,700

BHRUT 15,893 1:1.81 16% £680

BARTS 3,565 1:1.43 23% £889

Pain Management Unique Patients New:FUP Ratio % Unique Pts to

DC/Electiv

e

Cost Per Unique

Patient

Spire Roding 575 1:1.49 130% £1,063

Spire Hartswood - - - -

BHRUT 1,855 1:1.79 95% £885

BARTS 447 1:1.69 96% £910

Neurosurgery Unique Patients New:FUP Ratio % Unique Pts to

DC/Electiv

e

Cost Per Unique

Patient

Spire Roding 227 1:2.55 157% £1,175

Spire Hartswood - - - -

BHRUT 1,942 1:0.97 5% £178

BARTS 141 1:2.72 8% £192


HOLLY

T&O Unique Patients New:FUP Ratio % Unique Pts with DC

or Elective

Cost Per Unique

Patient

Holly 1,653 1:1.96 60% £1,316

BHRUT 15,893 1:1.81 16% £680

BARTS 3,565 1:1.43 23% £889

Gynaecology Unique Patients New:FUP Ratio % Unique Pts to

DC/Elective

Cost Per Unique

Patient

Holly 942 1:1.29 28% £604

BHRUT 12,485 1:0.59 10% £489

BARTS 3,612 1:0.82 11% £416

Pain Management Unique Patients New:FUP Ratio % Unique Pts to

DC/Elective

Cost Per Unique

Patient

Holly 301 1:1.69 67% £1,320

BHRUT 1,855 1:1.79 95% £885

BARTS 447 1:1.69 96% £910

C2C Referrals (Spend/1000 Pop)

Across these 11 Specialties there is an opportunity of £4.7m.

2015/16 2016/17 2017/18

Opportunity

£ based on

17/18 dataSpecialty

BHR per

1000

NCEL per

1000

BHR per

1000

NCEL per

1000

BHR per

1000

NCEL per

1000

Ophthalmology - 130 £3,285 £2,998 £3,383 £2,803 £3,245 £2,584 £529,637

Respiratory - 340 £1,881 £1,875 £2,313 £2,074 £2,514 £2,154 £287,863

Clinical Haematology - 303 £1,789 £1,851 £2,437 £2,219 £2,415 £2,017 £318,889

Cardiology - 320 £3,635 £1,980 £3,715 £1,974 £3,656 £1,714 £1,556,293

Nephrology - 361 £1,571 £1,167 £1,717 £1,310 £1,513 £1,159 £283,538

General Surgery - 100 £1,784 £1,081 £1,837 £1,153 £1,761 £1,032 £584,172

Rheumatology - 410 £1,075 £611 £1,278 £645 £1,307 £628 £544,173

Ent - 120 £856 £710 £1,013 £794 £838 £599 £191,488

Pain Management - 191 £281 £175 £333 £220 £484 £295 £151,472

Paediatric Clinical Haematology - 253 £239 £108 £286 £145 £262 £103 £127,696

Neonatology - 422 £162 £190 £299 £112 £313 £92 £177,223

BHR CCGs (Average)

Falls Activity 2015/16 2016/17 2017/18

Falls Activity for Care Homes patients 79 76 74

Falls Activity for Non-Care Homes patients 653 632 729

Total number of falls (All patients) 732 708 803

% of falls from care homes 10.8% 10.8% 9.2%

(i) 65+ patients only

BHR CCGs (Average)

Falls Cost 2015/16 2016/17 2017/18

Falls Cost for Care Homes patients £346,211 £325,274 £333,706

Falls Cost for Non-Care Homes patients £2,438,883 £2,441,481 £3,025,463

Total cost for falls (All patients) £2,785,095 £2,766,754 £3,359,168

Cost % of falls from care homes 12.4% 11.8% 9.9%

(i) 65+ patients only

Falls

BHR has a

rising

number of

falls with

most

occurring

outside of a

Care

Setting.

End of LifeThe BHR CCGs spent £21m/Year admitting people >60 who go on to die in hospital.

This covers 2,195 Pts who had a total of 4,948 Non-Elective Admissions in total

(2.25/Pt). This increases to £38m when the total number of patients dying in

hospital at either Barts or BHRUT are included.

However, there were 203 BHR Pts that had 4+ non-elective admissions in the last

12 months of life (see below) totalling 1,456 admissions in total. This increases to

418 patients when all pts dying at Barts and BHRUT are included.

Values Provider 4 5 6+ Grand Total

Patients Count

R1H-Barts Health NHS Trust 28 9 27 371

RF4-Barking, Havering and Redbridge University Hospitals NHS Trust 81 36 86 1,787

Others 2 1 2 37

Activity

R1H-Barts Health NHS Trust 88 27 123 749

RF4-Barking, Havering and Redbridge University Hospitals NHS Trust 365 196 650 4,155

Others 2 1 4 44

Cost

R1H-Barts Health NHS Trust £421,867 £90,205 £542,141 £3,635,323

RF4-Barking, Havering and Redbridge University Hospitals NHS Trust £1,397,818 £696,367 £2,058,719 £17,084,878

Others £14,125 £2,495 £23,675 £133,998

Total Patients Count 93 39 95 2,029

Total Activity 455 224 777 4,948

Total Cost £1,833,810 £789,067 £2,624,535 £20,854,199

Income Reduction -£6,637,820 -£867,851 £0 £0 £0 £0 -£7,505,670Increased Income £577,668 £0 £818,510 £531,224 £157,444 £69,356 £2,154,201

NET POSITION -£6,060,152 -£867,851 £818,510 £531,224 £157,444 £69,356 -£5,351,469Income Reduction -£3,124,430 -£551,370 £0 £0 £0 £0 -£3,675,800Increased Income £288,516 £0 £192,344 £666,837 £105,000 £45,000 £1,297,696

NET POSITION -£2,835,914 -£551,370 £192,344 £666,837 £105,000 £45,000 -£2,378,104Income Reduction -£6,948,698 -£8,167,429 £0 £0 £0 £0 -£15,116,127Increased Income £7,604,018 £0 £0 £601,968 £0 £0 £8,205,986

NET POSITION £655,320 -£8,167,429 £0 £601,968 £0 £0 -£6,910,1412019/20 INCOME LOSS -£16,710,947 -£9,586,649 £0 £0 £0 £0 -£26,297,5972019/20 INCOME GAIN £8,470,202 £0 £1,010,853 £1,800,028 £262,444 £114,356 £11,657,8832019/20 NET POSITION -£8,240,746 -£9,586,649 £1,010,853 £1,800,028 £262,444 £114,356 -£14,639,714

Income Reduction -£12,576,848 -£1,834,817 £0 £0 £0 £0 -£14,411,665Increased Income £1,412,822 £0 £1,655,736 £1,135,009 £267,712 £105,759 £4,577,038

NET POSITION -£11,164,026 -£1,834,817 £1,655,736 £1,135,009 £267,712 £105,759 -£9,834,628Income Reduction -£5,459,741 -£963,484 £0 £0 £0 £0 -£6,423,225Increased Income £453,711 £0 £302,474 £878,709 £0 £0 £1,634,894

NET POSITION -£5,006,031 -£963,484 £302,474 £878,709 £0 £0 -£4,788,332Income Reduction -£11,485,277 -£21,468,001 £0 £0 £0 £0 -£32,953,279Increased Income £18,379,510 £0 £0 £1,203,936 £0 £0 £19,583,446

NET POSITION £6,894,233 -£21,468,001 £0 £1,203,936 £0 £0 -£13,369,8332020/21 INCOME LOSS -£29,521,866 -£24,266,302 £0 £0 £0 £0 -£53,788,1692020/21 INCOME GAIN £20,246,042 £0 £1,958,210 £3,217,654 £267,712 £105,759 £25,795,3772020/21 NET POSITION -£9,275,824 -£24,266,302 £1,958,210 £3,217,654 £267,712 £105,759 -£27,992,792

Income Reduction -£19,214,667 -£2,702,668 £0 £0 £0 £0 (£21,917,335)Increased Income £1,990,490 £0 £2,474,246 £1,666,232 £425,156 £175,115 £6,731,239

NET POSITION -£17,224,178 -£2,702,668 £2,474,246 £1,666,232 £425,156 £175,115 (£15,186,097)Income Reduction -£8,584,171 -£1,514,854 £0 £0 £0 £0 (£10,099,025)Increased Income £742,226 £0 £494,818 £1,545,546 £105,000 £45,000 £2,932,590

NET POSITION -£7,841,945 -£1,514,854 £494,818 £1,545,546 £105,000 £45,000 (£7,166,436)Income Reduction -£18,433,975 -£29,635,430 £0 £0 £0 £0 (£48,069,405)Increased Income £25,983,528 £0 £0 £1,805,904 £0 £0 £27,789,432

NET POSITION £7,549,553 -£29,635,430 £0 £1,805,904 £0 £0 (£20,279,973)2 YEAR INCOME LOSS -£46,232,814 -£33,852,952 £0 £0 £0 £0 -£80,085,7652 YEAR INCOME GAIN £28,716,244 £0 £2,969,063 £5,017,682 £530,156 £220,115 £37,453,2602 YEAR NET POSITION -£17,516,570 -£33,852,952 £2,969,063 £5,017,682 £530,156 £220,115 -£42,632,505

Local AuthoritiesBHRUT Barts NELFT Federations/Primary Care2019/20

OLDER PEOPLE



SUMMARY POSITION

Federations/Primary Care Local Authorities

OLDER PEOPLE



2020/21 BHRUT Barts NELFT

SUMMARY POSITION

Total 2019/21 BHRUT Barts


SUMMARY POSITION

NELFT Federations/Primary Care Local Authorities

OLDER PEOPLE


VCS SYSTEM NET POSITION







Gross Saving (£) £835,170 £1,451,605 £954,480 £3,241,255


- - - Reprovision (£) £250,551 £435,482 £286,344 £972,377

Reprovision - - - Net Saving (£) £584,619 £1,016,124 £668,136 £2,268,879





Gross Saving (£) £1,551,600 £3,103,200 £3,103,200 £7,758,000


- - - Reprovision (£) £465,480 £930,960 £930,960 £2,327,400

Reprovision - - - Net Saving (£) £1,086,120 £2,172,240 £2,172,240 £5,430,600





Gross Saving (£) £1,198,400 £1,412,400 £1,412,400 £4,023,200


- - - Reprovision (£) £359,520 £423,720 £423,720 £1,206,960

Reprovision - - - Net Saving (£) £838,880 £988,680 £988,680 £2,816,240


500 Admissions 730 Admissions 365 Admissions Gross Saving (£) £1,720,000 £2,469,900 £1,429,650 £5,619,550


100 Readmissions 132 Readmissions 132 Readmissions Reprovision (£) £587,250 £844,995 £480,908 £1,913,153

Reprovision TBA TBA TBA Net Saving (£) £1,132,750 £1,624,905 £948,742 £3,706,397


375 Admissions 500 Admissions 500 Admissions Gross Saving (£) £1,687,500 £2,250,000 £2,250,000 £6,187,500


- - - Reprovision (£) £337,500 £675,000 £675,000 £1,687,500



180 Attendances and Admissions



Gross Saving (£) £513,000 £1,040,250 £1,040,250 £2,593,500


- - - Reprovision (£) £153,900 £312,075 £312,075 £778,050

Reprovision 180 (Non A&E Setting)

365 (Non A&E Setting)

365 (Non A&E Setting) Net Saving (£) £359,100 £728,175 £728,175 £1,815,450

TOTAL Gross Saving (£)

£7,505,670 £11,727,355 £10,189,980 £29,423,005

TOTAL Reprovision (£)

£2,154,201 £3,622,232 £3,109,007 £8,885,440

TOTAL Net Saving (£)

£5,351,469 £8,105,124 £7,080,973 £20,537,566

FYE Impact of 19/20 into 20/2119/20 PYE Impact

Assumes an average £2,850/admission or readmission (given these patients will have slightly lower acuity needs). Assumed to start Q2 19/20.

19/20 PYE ImpactFYE Impact of

19/20 into 20/21

Reduction in Nursing Home admissions by 10% from Q1 increasing to 30% (approve 1/day) from Q3. Additional reduction of a further

20% in 20/21.

15% Reduction in EoL Patients admitted in last 12 months of life from home or Care Home Setting from Q3 19/20. Further 15%

reduction in 20/21.

15% Reduction in patients who fall at home or a Care Home coded as falls plus a further 240 other attendances and admissions for

patients who fall but are not coded as fallers. Ramping up from Q1 19/20. Further 15% reduction in 20/21.

Assumes 2/day reduction plus 20% of patients needing either ambulatory or a ZLOS Admission. Ramping up from Q1 to Q3.

Additional 1 ZLOS reduction in 20/21.

Stretch in 20/21Financial Activity

Aspiration

Narrative

Total Recurrent Benefit 19/20 to

20/21

Based on average Nursing Home admission of £3,877 plus £100 as an average attendance cost. Reprovision planned at 30% of gross saving.

Stretch in 20/21

Narrative

OLDER PEOPLE PROGRAMME

OVERALL OBJECTIVEProjects Narrative



To reduce the overall number of non-elective

admissions per day across the BHR System by 12/Day (10/day for BHRUT). This will bring the BHR System to the North Central & East

London average admission rate for Older People (>65) and realise

a Gross Saving of £10.5m/year (3,650

Admissions at £2.85k/Admission) as

well as freeing up 26,280 Bed Days (72 Beds in Total) at an

average 7.2 Days LoS per admission.

In addition, we want to reduce the % of

predictable deaths occurring in an acute

setting from the current 45% to 35% or below

and reduce the number of non-elective

admissions for patients at End of Life from 2.5 to below 1.5 in the last

12 months of life.



Service








Community Acquired

Pressure Ulcers


Activity Reduction Aspiration

Expected Start

Q1 19/20Already in planning although


Q3 19/20



Ramping up from Q1 and achieving the effective run rate from Q3

Narrative

Narrative

Narrative

Narrative

Narrative


allowing time for teething issues to be

resolved)

Narrative

Q2 19/20

Assumes a 1/day reduction in conveyances ramping up from Q1 with the full run rate starting from Q3 19/20 onwards. Additional

1/day reduction in 20/21.

Numbers are a planning assumption pending information from BHRUT with an assumed start from Q2 19/20 with stretch in

20/21.

Based on average Care Home or Admission from Home of £4,210 plus £100 as an average attendance cost. Reprovision planned at 30% of gross saving.

Assumes an average £4,180 admission cost per patient falling plus £100 as an average attendance cost. Reprovision planned at 30% of gross saving. People who

fall and are not coded as a faller assumed to have the same admission cost.Narrative

Narrative Assumes an average £2,850/admission and a 30% reprovision cost.

Narrative Assumed cost of £4,500 per admission and a reprovision cost of 20%. Figures subject to verification by BHRUT.

Narrative

OLDER PEOPLE PROGRAMME

OVERALL OBJECTIVEProjects Narrative



To reduce the overall number of non-elective

admissions per day across the BHR System by 12/Day (10/day for BHRUT). This will bring the BHR System to the North Central & East

London average admission rate for Older People (>65) and realise

a Gross Saving of £10.5m/year (3,650

Admissions at £2.85k/Admission) as

well as freeing up 26,280 Bed Days (72 Beds in Total) at an

average 7.2 Days LoS per admission.

In addition, we want to reduce the % of

predictable deaths occurring in an acute

setting from the current 45% to 35% or below

and reduce the number of non-elective

admissions for patients at End of Life from 2.5 to below 1.5 in the last

12 months of life.



Service








Community Acquired

Pressure Ulcers


Expected Start



Q3 19/20



Ramping up from Q1 and achieving the effective run rate from Q3


allowing time for teething issues to be

resolved)

Q2 19/20

Income Reduction -£2,755,067 -£486,188 £0 £0 £0 £0 -£3,241,255

Increased Income £0 £0 £486,188 £486,188 £0 £0 £972,377

NET POSITION -£2,755,067 -£486,188 £486,188 £486,188 £0 £0 -£2,268,879

Income Reduction -£6,594,300 -£1,163,700 £0 £0 £0 £0 -£7,758,000

Increased Income £698,220 £0 £930,960 £698,220 £0 £0 £2,327,400

NET POSITION -£5,896,080 -£1,163,700 £930,960 £698,220 £0 £0 -£5,430,600


Increased Income £241,392 £0 £724,176 £241,392 £0 £0 £1,206,960

NET POSITION -£3,178,328 -£603,480 £724,176 £241,392 £0 £0 -£2,816,240

Income Reduction -£5,619,550 £0 £0 £0 £0 £0 -£5,619,550

Increased Income £382,631 £0 £573,946 £382,631 £382,631 £191,315 £1,913,153

NET POSITION -£5,236,919 £0 £573,946 £382,631 £382,631 £191,315 -£3,706,397


Increased Income £1,012,500 £0 £421,875 £0 £200,000 £53,125 £1,687,500

NET POSITION -£4,246,875 -£928,125 £421,875 £0 £200,000 £53,125 -£4,500,000


Increased Income £233,415 £0 £155,610 £389,025 £0 £0 £778,050

NET POSITION -£1,971,060 -£389,025 £155,610 £389,025 £0 £0 -£1,815,450

2 YEAR INCOME LOSS

-£25,852,487 -£3,570,518 £0 £0 £0 £0 -£29,423,005

2 YEAR INCOME GAIN

£2,568,158 £0 £3,292,755 £2,197,456 £582,631 £244,440 £8,885,440

2 YEAR NET POSITION

-£23,284,329 -£3,570,518 £3,292,755 £2,197,456 £582,631 £244,440 -£20,537,566

This assumes that 50% of the reprovision cost goes to NELFT and the remaining 50% to GP Federations. BHRUT would lose 85% of the total income (the remainder assumed to come from Barts) but would be able to offset this against repatriated work or through reducing costs.

This assumes that 85% of the lost income will be from BHRUT with the remaining 15% from Barts. Reprovision assumes 30% goes to BHRUT, 40% to NELFT and 30% to Primary Care Federations.

This assumes that 85% of the lost income will be from BHRUT with the remaining 15% from Barts. Reprovision assumes 20% goes to BHRUT, 60% to NELFT and 20% to Primary Care Federations.

SYSTEM NET POSITIONBHRUT NELFT

Federations/Primary CareBarts VCSLocal Authorities

This assumes BHRUT will lost 85% of the income (balance from Barts) but will receive 60% of the reprovision cost with NELFT getting a further 25% of the reprovision cost and other partners (iSocial Care and the Voluntary & Charitable Sector) getting the final 15%.

This assumes BHRUT lose 85% of the income (Barts 15%). 30% of the reprovision cost will go to BHRUT, 20% to NELFT and the remaining 50% to Primary Care.

This assumes that 100% of the lost income will come from BHRUT (as the service will be embedded within BHRUT). This assumes that BHRUT get 20% of the reprovision cost, NELFT 30%, Primary Care 20%, Local Authorities 20% and the VCS the final 10%





Gross Saving (£) £1,188,500 £2,185,300 £1,092,025 £4,465,825





Reprovision (£) £356,550 £655,590 £327,608 £1,339,748

Reprovision - - - Net Saving (£) £831,950 £1,529,710 £764,418 £3,126,078




3,190 Mixed Outpatient Activity Gross Saving (£) £2,487,300 £3,688,850 £3,132,850 £9,309,000





Reprovision (£) £641,146 £908,096 £741,296 £2,290,538

Reprovision Primary/Community Services

Primary/Community Services

Primary/Community Services

Net Saving (£) £1,846,154 £2,780,754 £2,391,554 £7,018,462


0 0 0 Gross Saving (£) £0 £0 £0 £0


- - - Reprovision (£) £300,000 £0 £300,000 £600,000

Reprovision - - - Net Saving (£) -£300,000 £0 -£300,000 -£600,000


£3,675,800 £5,874,150 £4,224,875 £13,774,825

TOTAL Reprovision (£)

£1,297,696 £1,563,686 £1,368,904 £4,230,286

TOTAL Net Saving (£)

£2,378,104 £4,310,464 £2,855,972 £9,544,540

Q3 19/20

19/20 PYE Impact FYE Impact of 19/20 into 20/21

Stretch in 20/21 Total Recurrent Benefit 19/20 to

19/20 PYE ImpactActivity Reduction Aspiration


Financial Activity Aspiration

Expected Start

Stretch in 20/21

Narrative

LTC PROGRAMMEOVERALL OBJECTIVE

Projects Narrative

To close the prevalence gaps for key LTCs (Diabetes, AF, COPD, Asthma) by at least 10% to improve long-term

outcomes for patients.

To proactively manage Pts with LTCs and reduce the number of non-elective

admissions in key specialties acting as a proxy for LTC admissions (Cardiology,

Respiratory, Endocrinology, Vascular Surgery and

Nephrology). Reducing non-elective admissions to the

North Central & East London average will mean a 1,500

admission per year reduction.

To move more care Out of Hospital for patients and

provide this in the community using a Multi-Disciplinary

Team approach. The aspiration is to reduce the

hospital based activity in key specialties to bring this down to the NCEL Average meaning a reduction of 24,500 OPFA, OPFUP and OPPROC across

Cardiology, Respiratory, Endocrinology,

Rheumatology, Vascular Surgery and Nephrology.


Development






Ramping up from Q1

19/20 with full




by Q4 19/20.

Assumes excess non-elective admissions compared to NCEL Average for four main specialties drop by 50% plus 10%

reduction in excess OPFA/OPFUP activity (after removing impact of Improving Referrals Together Programme) with a

further 25% and 10% respectively in Yr 2.

Assumes a further 30% reduction on the excess OPFA/OPFUP activity compared to the NCEL Average associated with key specialties related to LTCs spread over the two years after removing the Improving Referrals Together impact plus an

impact on a number of Non-Elective Admissions.

Narrative Narrative

Assumes an average £2,720 for a non-elective admission, an average OPFA of £125 and an average OPFUP of £85. Reprovision estimated at 30%. Investment for Long

Term LIS will also part fund the support for Complex Patients and the Prevention LIS referred to below.

Assumes an average £2,720 for a non-elective admission, an average OPFA of £125 and an average OPFUP of £85 (Average for OPD Activity of £105). Reprovision

estimated at 40%.

The savings associated with this scheme will not be realised by 20/21. Assumed start Q3 19/20.

Narrative The reductions for this scheme will not be realised by 20/21. Assumed start Q3 19/20.

NarrativeNarrative

Q3 19/20

Expected Start

LTC PROGRAMMEOVERALL OBJECTIVE

Projects Narrative

To close the prevalence gaps for key LTCs (Diabetes, AF, COPD, Asthma) by at least 10% to improve long-term

outcomes for patients.

To proactively manage Pts with LTCs and reduce the number of non-elective

admissions in key specialties acting as a proxy for LTC admissions (Cardiology,

Respiratory, Endocrinology, Vascular Surgery and

Nephrology). Reducing non-elective admissions to the

North Central & East London average will mean a 1,500

admission per year reduction.

To move more care Out of Hospital for patients and

provide this in the community using a Multi-Disciplinary

Team approach. The aspiration is to reduce the

hospital based activity in key specialties to bring this down to the NCEL Average meaning a reduction of 24,500 OPFA, OPFUP and OPPROC across

Cardiology, Respiratory, Endocrinology,

Rheumatology, Vascular Surgery and Nephrology.


Development






Ramping up from Q1

19/20 with full




by Q4 19/20.


Increased Income £0 £0 £0 £1,339,748 £0 £0 £1,339,748

NET POSITION -£3,795,951 -£669,874 £0 £1,339,748 £0 £0 -£3,126,078


Increased Income £1,030,742 £0 £687,161 £572,635 £0 £0 £2,290,538

NET POSITION -£6,881,908 -£1,396,350 £687,161 £572,635 £0 £0 -£7,018,462

Income Reduction £0 £0 £0 £0 £0 £0 £0

Increased Income £0 £0 £0 £300,000 £210,000 £90,000 £600,000

NET POSITION £0 £0 £0 £300,000 £210,000 £90,000 £600,000

2 YEAR INCOME LOSS

-£11,708,601 -£2,066,224 £0 £0 £0 £0 -£13,774,825

2 YEAR INCOME GAIN

£1,030,742 £0 £687,161 £2,212,382 £210,000 £90,000 £4,230,286

2 YEAR NET POSITION

-£10,677,859 -£2,066,224 £687,161 £2,212,382 £210,000 £90,000 -£9,544,540

Local Authorities VCSNELFTBarts Federations/Primary Care

SYSTEM NET POSITION

BHRUT

Assumes there will be no income reduction before March 20/21 and that 50% of the investment will go to Primary Care and the remaining 35% to Public Health and 15% to the VCS.

85% of income reduction assumed to be from BHRUT with the remainder from Barts. Reprovision is 100% for Primary Care.

85% of income reduction assumed to be from BHRUT with the remainder from Barts. Reprovision assumes 45% for BHRUT, 30% for NELFT and 25% for Primary Care.


20,000 Mixed Outpatient

Activity


Activity


ActivityGross Saving (£) £2,508,200 £3,762,300 £3,762,300 £10,032,800


- - - Reprovision (£) £752,460 £1,128,690 £1,128,690 £3,009,840

Reprovision Mostly Primary Care

Mostly Primary Care

Mostly Primary Care

Net Saving (£) £1,755,740 £2,633,610 £2,633,610 £7,022,960


0 0 0 Gross Saving (£) £0 £0 £0 £0


- - - Reprovision (£) £0 £0 £0 £0

Reprovision - - - Net Saving (£) £0 £0 £0 £0



Activity


Activity




- - - Reprovision (£) £1,078,526 £1,417,133 £739,919 £3,235,578

Reprovision 50% as Virtual Clinics

50% as Virtual Clinics

50% as Virtual Clinics

Net Saving (£) £2,088,077 £2,595,987 £1,580,166 £6,264,230



Activity


Activity




- - - Reprovision (£) £0 £0 £0 £0



1,500 Procedures 1,500 Procedures 1,500 Procedures Gross Saving (£) £787,500 £1,050,000 £1,050,000 £2,887,500


- - - Reprovision (£) £0 £0 £0 £0

Reprovision - - - Net Saving (£) £787,500 £1,050,000 £1,050,000 £2,887,500


- - - Gross Saving (£) £7,500,000 £12,500,000 £15,000,000 £35,000,000


- - - Reprovision (£) £6,375,000 £10,625,000 £12,750,000 £29,750,000



£15,116,127 £23,631,220 £24,438,185 £63,185,532

TOTAL Reprovision £8,205,986 £13,170,823 £14,618,609 £35,995,418TOTAL Net Saving

(£)£6,910,141 £10,460,397 £9,819,576 £27,190,114

OUTPATIENT REDUCTIONOVERALL OBJECTIVE

Projects NarrativeActivity Reduction

AspirationStretch in 20/2119/20 PYE Impact


Financial Activity Aspiration

19/20 PYE ImpactFYE Impact of

19/20 into 20/21Stretch in 20/21

In line with the aspirations within North East London

(NEL) we aim to reduce the amount of Outpatient

activity by 30% overall. In the medium term (to

2020/21) our aspiration is to reduce activity within the BHR System to the North Central & East

London across the main specialties where we are an outlier. This would lead to a

reduction in activity equating to more than

£20m/year.

Concurrently this project also supports the achievement of

constitutional standards (specifically Referral to

Treatment (RTT) and Diagnostics) and the

repatriation of work from high cost settings where

delivery of care within the BHR System offers a

substantial cost saving whilst delivering care

nearer (in most cases) to the patient's normal place

of care.

Assumes an average cost of £125.41 (a blended assumption across the 13 specialties combining OPFA, OPFUP, OPPROCFA and OPPROCFU). Reprovision

costs assumed at 30% of the savings and includes on-going costs of the Integrated Approach to Referral Management programme (see project below).

This is an enabler for the Improving Referrals Together Programme and the New Models of Care for Outpatients Programme.

Assumes an average cost of £125.41 (a blended assumption across the 13 specialties combining OPFA, OPFUP, OPPROCFA and OPPROCFU). Reprovision costs based on local tariffs that are yet to be agreed. Assumed start Q2 19/20.

An assumption that £35m of activity over the 2 Year Period is repatriated from high cost settings with a net reduction in cost of 15% for the system ramping up

from Q1 19/20. This may include a joint review of outsourcing costs to the Independent Sector to realise further benefits to BHRUT.

Narrative Narrative

Narrative

Expanding the existing service restrictions and procedures/treatments deemed to be PoLCE both as part of the existing London/North East London programme and also specifically for BHR.

Narrative Narrative

Narrative

Narrative

Assumes 1,500 Procedures will be stopped in Year 1 with an increase of a further 1,500 in Year 2. Assumed start in Q2

19/20.

Assumes a 5% reduction on the 17/18 Referral Rates (183,254) within BHRUT on the basis of 1 OPFA and 0.5 OPFUP being eliminated starting from Q3 19/20 with a

further 5% reduction in 20/21.


Assumes a 20% reduction in the excess activity compared to the NCEL Average in the top 13 specialties in year 1 with a

further 30% reduction in year two with benefits ramping up from Q1 19/20. Savings span OPFA, OPFU and OPPROC.

Activity reductions and savings for this will be rolled up into the Improving Referrals Together and Single Points of

Access Programmes.

Expected Start

Already in progress

with savings ramping up

from Q1 19/20.

Went Live Q4 18/19


Referall Management

This scheme combines Primary Care Peer Review with support to GPs for them to use the IRT Pathways (see above) and enable BHRUT to facilitate the new models of care outlined below. There are no specific savings associated with this scheme as it is an enabler for other programmes. Narrative

Improving Referrals

Together (IRT)


Assumes that 20% of the excess Outpatient activity compared to the NCEL Average (10% in Year 2) will be

reduced with half of this being reprovided in secondary care via Virtual Clinics and further reprovision occurring in

Primary Care. Assumed start Q2 19/20.


The freeing up of capacity within BHRUT will be utilised to repatriate higher acuity work from high cost settings resulting in a net financial saving to the BHR System. This programme will need to continue to respect Patient Choice where expressed. Narrative

Expansion to Spending

Money Wisely Programme


Narrative


Outpatients


Q2 19/20

Q3 19/20


Q4 18/19Assumed at an average cost of £733.33/Procedure. No reprovision required.

Assumed start Q2 19/20.

Q2 19/20

TBD Narrative

Narrative

Assumes an OPFA Cost of £125 and an OPFU of £85 on a ratio of 1 New to 0.5 FUP = (£125 + £85/2) = £168.

Total Recurrent Benefit 19/20 to

20/21

OUTPATIENT REDUCTIONOVERALL OBJECTIVE

Projects Narrative

In line with the aspirations within North East London

(NEL) we aim to reduce the amount of Outpatient

activity by 30% overall. In the medium term (to

2020/21) our aspiration is to reduce activity within the BHR System to the North Central & East

London across the main specialties where we are an outlier. This would lead to a

reduction in activity equating to more than

£20m/year.

Concurrently this project also supports the achievement of

constitutional standards (specifically Referral to

Treatment (RTT) and Diagnostics) and the

repatriation of work from high cost settings where

delivery of care within the BHR System offers a

substantial cost saving whilst delivering care

nearer (in most cases) to the patient's normal place

of care. Expanding the existing service restrictions and procedures/treatments deemed to be PoLCE both as part of the existing London/North East London programme and also specifically for BHR.


Expected Start

Already in progress

with savings ramping up

from Q1 19/20.

Went Live Q4 18/19


Referall Management

This scheme combines Primary Care Peer Review with support to GPs for them to use the IRT Pathways (see above) and enable BHRUT to facilitate the new models of care outlined below. There are no specific savings associated with this scheme as it is an enabler for other programmes.

Improving Referrals

Together (IRT)



The freeing up of capacity within BHRUT will be utilised to repatriate higher acuity work from high cost settings resulting in a net financial saving to the BHR System. This programme will need to continue to respect Patient Choice where expressed.

Expansion to Spending

Money Wisely Programme



Outpatients


Q2 19/20

Q3 19/20


Q4 18/19

Q2 19/20


Increased Income £601,968 £0 £0 £2,407,872 £0 £0 £3,009,840

NET POSITION -£7,925,912 -£1,504,920 £0 £2,407,872 £0 £0 -£7,022,960


Increased Income £0 £0 £0 £0 £0 £0 £0

NET POSITION £0 £0 £0 £0 £0 £0 £0

Income Reduction -£9,499,808 £0 £0 £0 £0 £0 -£9,499,808

Increased Income £3,235,578 £0 £0 £0 £0 £0 £3,235,578

NET POSITION -£6,264,230 £0 £0 £0 £0 £0 -£6,264,230



NET POSITION -£4,900,610 -£864,814 £0 £0 £0 £0 -£5,765,424



NET POSITION -£2,454,375 -£433,125 £0 £0 £0 £0 -£2,887,500


Increased Income £29,750,000 £0 £0 £0 £0 £0 £29,750,000

NET POSITION £29,750,000 £0 £0 £0 £0 £0 £29,750,000

2 YEAR INCOME LOSS

-£25,382,673 -£2,802,859 £0 £0 £0 £0 -£28,185,532

2 YEAR INCOME £33,587,546 £0 £0 £2,407,872 £0 £0 £35,995,4182 YEAR NET POSITION

£8,204,873 -£2,802,859 £0 £2,407,872 £0 £0 £7,809,887

This assumes that 85% of the reduction comes from BHRUT and 15% from Barts. This assumes there is no reprovision cost as the activity will not occur.

Activity assumed to be returned from the Independent Sector (with a net reduction of ~40% in cost) or from other NHS Providers with a (small and possibly disappearing) MFF impact to give an overall 15% system saving. At present the impact on Barts has not been assessed but is not likely to be material.

Assumes 85% of the reduction will come from BHRUT with 15% from Barts. 20% of the reprovision cost to go to BHRUT for education and A&G supporting Primary Care with 80% to Primary Care to fund the Integrated Approach to Referral Management.

No additional costs associated with this scheme as they are included in the above.

This assumes that all of the income reduction comes from BHRUT but also that 100% of the reprovision cost goes to BHRUT. These assumptions may need to be revisited if activity needs to be undertaken in Primary Care as this may impact on the reprovision costs.

This assumes that 85% of the reduction comes from BHRUT and 15% from Barts. This assumes there is no reprovision cost and that activity is not shunted back to Primary Care for re-referral.

SYSTEM NET POSITION

Local Authorities VCSBartsBHRUT NELFTFederations/Prima

ry Care

barking and dagenham, havering and redbridge system

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