QIPP Programme Report

Transcription

1 QIPP Programme Report NHS West Cheshire CCG

2 Executive Summary QIPP Plan as at 27 February 2017 Review of Governance Summary of opportunities Scheme Value Priority Oncology specialist dietician Low Primary care support to care homes Low Specialised Commissioning Low Alcohol 4,700 (across the LDS)* Medium Antimicrobial resistance (AMR) TBC Medium Hypertension 2,800 (across the LDS)* Medium MSK pathway High Prescribing High Review of existing high priority schemes Continuing Healthcare High BMI South Cheshire lower threshold Medium MM11 - Action monitoring outlier practices MM01 - Optimisation and switching scripts MM09 - Repeat prescribing EC - Referral facilitation costs CC04 - Continuing healthcare / FNC EC05 - PLCV outside of CoCH EC05 - PLCP MH - MH commissioning 10,943 9,617 N.B. - The unassessed QIPP value includes QIPP schemes which are incorporated within the block contract that the CCG holds with CoCH. Of the unassessed 4.9m, 4.3m sit within the block contract with CoCH. 2.9m of these schemes have been assessed as part of the review. Demand for diagnostics direct access Low Genitourinary Elective admissions 1,712 Medium Circulation Elective admissions 1,139 Medium Cancer Elective admissions 1,062 Medium Circulation Non-elective admissions 1,481 Medium Respiratory Non-elective admissions 1,336 Medium Next Steps Implementation of LDS Transformation Board Implementation of LDS Task and Finish Groups (MSK / Medicines Management / CHC) BW08 - Grant reviews Implementation of LDS Delivery Support Unit 2

3 1. Baseline and Context 2. QIPP Deliverability: Review of Governance 3. QIPP Deliverability: Review of existing high priority schemes 4a. Opportunity Development: National Priorities 4b. Opportunity Development: Right Care 4c. Opportunity Development: Menu of Opportunities 5. Opportunity Development: Summary of Opportunity 6. Action Planning 3

4 CCG Background NHS West Cheshire CCG ( the CCG ) was placed into Legal Directions on 1 September 2016 due to its deteriorating financial position and is forecasting a cumulative year end deficit financial position of 7.9m for 2016/17. The CCG has an annual allocation of 341.4m for 2017/18 and is required to achieve a breakeven position during the 2017/18 financial year as part of its Legal Directions requirements. The financial allocation for 2017/18 has a Distance from Target (DfT) of -2.39% and a per capita allocation of 1,282. The value of the DfT is circa 8m for 2017/18. Since entering Legal Directions they have been subject to a rigorous review and turnaround programme. This has included a capability and capacity review and further governance and assurance reviews of the QIPP programme. As a result of this turnaround programme the CCG has introduced a more robust governance structure and invested heavily in a newly defined PMO function. The CCG has continued to receive ongoing external support from a number of interim staff in order to develop their QIPP delivery and to support them during their turnaround programme. They have refrained from making substantive appointments for the past 18 months. The CCG has developed a number of high impact QIPP schemes as a result of their turnaround programme which were implemented towards the end of 2016/17. The impact of these schemes are to continue into the next financial year. The changes experienced by the CCG have resulted in a stepped change to the deliverability of their QIPP schemes and also created a significant cultural change for the organisation. The CCG are now working collaboratively with its neighbouring CCGs across the Local Delivery System (LDS) and also with its main acute provider (the Countess of Chester Hospital NHS FT (CoCH)) in the lead up to establishing an Accountable Care Organisation (ACO) to enhance delivery of QIPP schemes. The collaborative approach to working across the LDS is evidenced by the implementation of a joint working team for Continuing Care and the introduction of a single PLCV policy across the LDS. 4

5 QIPP Programme as at 23 December At 23 December the CCG had a 10.5m QIPP target established for 2017/18. This is equivalent to 3.1% of their total recurrent revenue resource allocation. The CCG s QIPP target is based on the requirement for the CCG to end the year in a breakeven position as per their Legal Directions requirements. 7.2m of the QIPP programme is deemed to be recurrent QIPP and is predominantly built from the net full year effect of schemes begun during 2016/17. The CCG did not identify the 2016/17 net full year effect impact within their financial plan and all schemes were reported as being 2017/18 schemes. The remaining 3.3m of QIPP is to be achieved non-recurrently as confirmed by the Chief Finance Officer. A range of QIPP schemes have been developed across all of their key programme areas. 5

6 QIPP Phasing as at 23 December The CCG s plan showed QIPP delivery to begin in April, this is evidenced from the majority of the CCG s schemes being already implemented during 2016/17 financial year. The CCG is planned to achieve a stepped change in QIPP delivery during December from their Other Programme activity. At 23 December, the CCG had no unidentified QIPP within their programme and so this is not evidenced on the chart. The CCG has included a 5.2m under delivery risk within their financial plan which is equivalent to 50% of their overall programme. An assumed 50% realisation of this risk was included. The CCG has not planned to mitigate any of its risk in year by the use of further QIPP extensions as the team are currently in the process of delivering those schemes which have been established. There is no further requirement for the CCG to expand its programme as the business rule requirements have been met within the plan. 6

7 The CCG had an initial 6.0m QIPP programme linked to Acute expenditure. The impact of the block contract agreement with CoCH and revisions to some of the QIPP programmes has resulted in a reduction in the Acute QIPP programmes from 6.0m to 4.2m. Primary Care Prescribing schemes have been included within the CCG financial plan at 1.9m at both 23 December and 27 February. Revised information from the CCG now shows this opportunity as being 2.7m across three schemes. The overall QIPP plan for West Cheshire CCG has remained at 10.5m between the 23 December submission and 27 February submission. Continuing Care schemes have reduced to 0.6m at 27 February and now consists of two schemes. Additional schemes have been removed from the programme include: Reconfiguration of health funded respite beds Closure of West Cheshire Previously Unassessed Periods of Care (PUPoC) cases. Revisions to the Acute and Continuing Care QIPP programmes has resulted in the CCG having a 2.2m unidentified QIPP in their 27 February plan submission. The CCG is in the process of developing additional schemes to close this gap. 7

8 1. Baseline and Context 2. QIPP Deliverability: Review of Governance 3. QIPP Deliverability: Review of existing high priority schemes 4a. Opportunity Development: National Priorities 4b. Opportunity Development: Right Care 4c. Opportunity Development: Menu of Opportunities 5. Opportunity Development: Summary of Opportunity 6. Action Planning 8

9 QIPP Deliverability: QIPP Governance Monitoring and Reporting The CCG has a strong monitoring and reporting system in place. It utilises a Programme Delivery Group (PDG) for the agreement of new schemes, monitoring of QIPP scheme progress and to identify and report key risks to delivery. The PDG reports directly to the Finance, Performance and Commissioning Committee (FPCC) on a monthly basis. A robust gateway process is followed to develop QIPP ideas into robust schemes. There is a clear formal reporting line from the PDG to the CCG s Governing Body. Stakeholder and Provider Engagement The CCG has a Service Delivery Improvement Plan (SDIP) in place with its main acute provider CoCH and mental health/community provider (Cheshire and Wirral Partnership NHS FT (CWP)). In addition across the LDS there is a System Leaders Group looking at issues such as PLCV. CHC is managed collaboratively across the patch. CHC and FNC has a Committee in Common for the LDS operating on behalf of the Governing Bodies. The CCG is looking to set up a joint PMO with its main providers to deliver the SDIP collectively. Clinical leads are identified for all programme areas of expenditure. Programme Management Capacity The PMO is led by a PMO lead and a support member. The PMO uses the VERTO Project management system to track scheme progress and utilises GlassCubes to manage its documentation. The CCG is challenged to deliver the scale of the transformation and ACO with its current Programme Lead capacity. In addition to their local plans, the CCG is working collectively across their LDS. There is clear evidence of a stepped change in QIPP governance and the team are focused on QIPP delivery. Planning Cycle The 2016/17 programme was largely transformational in nature and savings delivery was back ended towards the end of the financial year. Only some of the anticipated benefits of schemes were available to be included within the negotiated block contract with CoCH however the CCG has managed to agree a zero growth contract with for 2017/18 based on the QIPP schemes being implemented. The CCG identified QIPP areas as part of their Commissioning Intentions paper (3 November 2016). The current QIPP programme for 2017/18 requires a refresh of PIDs and prioritisation of schemes for delivery based on current capacity. A number of schemes have been altered or removed from the original 2016/17 QIPP programme following further refinement of these schemes. QIPP Documentation The CCG is in the process of refining its PIDs for all of the 2016/17 schemes, with most of the QIPP programme rolling over into 2017/18. The PID documentation is fairly comprehensive including milestones which are then tracked via the VERTO system. Risk logs and action plans are collated outside of the PIDs. The CCG undertakes a detailed gateway review to approve and review each scheme. This process identified the engagement process and documentation required at each stage. Schemes are reviewed and approved by the PDG and FPCC before final sign off by the Governing Body. QIPP documentation contains activity and financial information. 9

10 QIPP Deliverability: QIPP Governance Priorities The CCG has significantly improved its QIPP governance arrangements since entering Directions. The governance processes can be improved further by greater collaborative working and the streamlining of its QIPP programme Monitoring and reporting Stakeholder and Provider Engagement QIPP Deliverability QIPP Governance: Priorities to improve governance 1. Schemes are individually RAG rated although there is no evidence of mitigations being employed by the CCG and impact of these against each scheme risks and mitigations should be clearly defined and monitored. 2. PIDs are still being developed for 2017/18 and these should be fully completed by the beginning of the financial year where schemes are due to begin. 3. Pipeline schemes are included within the main CCG programme; these should be collated and monitored separately to aid programme monitoring and reporting with a clear gateway review process. 1. A Joint Delivery Team with CoCH should be implemented as an enabler to the delivery of the SDIP and the joint QIPP/CIP programmes. Programme Management Capacity 1. A Transformation Board should be implemented across the Cheshire and Wirral LDS for major schemes. This has been agreed at the workshop on 17/03/17 with a focus initially on Medicines Management, CHC and the MSK pathway. 2. Focussing management time on fewer schemes which have a greater opportunity potential. 3. Current use of an interim workforce has allowed the CCG to employ additional capacity although this could lead to risks in loss of system knowledge the CCG should consider substantive appointments and succession planning. 4. Collaborative working and delivery of major schemes at an LDS or ACO level will help to free up management time to focus on local schemes; this approach has already been adopted in Complex Care at an LDS level. Planning Cycle 1. The CCG has managed to negotiate a zero growth contract with CoCH however some QIPP schemes are still under development and are being refined by the CCG. Identification and planning of schemes needs to happen earlier in the year to allow plans to be effectively incorporated into contracts. 2. Schemes should be tracked and monitored (with CoCH) to assess deliverability and to include activity adjustments within contract negotiations. The CCG has already identified its intentions and plans to undertake this. QIPP Documentation 1. QIPP documentation should be completed for all 17/18 schemes as a priority. 2. Clarity of scheme impacts and saving profiles needs to be established for monitoring purposes. 10

11 1. Baseline and Context 2. QIPP Deliverability: Review of Governance 3. QIPP Deliverability: Review of existing high priority schemes 4a. Opportunity Development: National Priorities 4b. Opportunity Development: Right Care 4c. Opportunity Development: Menu of Opportunities 5. Opportunity Development: Summary of Opportunity 6. Action Planning 11

12 QIPP Deliverability: High Priority Schemes The CCG has 32 QIPP schemes within its QIPP tracker of which 21 have identified savings targets. Due to the agreed block contract with CoCH the review of these QIPP schemes has only covered those which will generate QIPP savings outside of the CoCH block contract The CCG has a 10.5m QIPP plan for 2017/18, of which 4.3m of the programme sits within the CoCH block contract. The CCG has identified a further 6.6m of the QIPP programme which is to be achieved from expenditure taking place outside of CoCH. 6.3m (95%) of the 6.6m planned savings, outside of CoCH, are made up from the CCG s top 10 schemes. The remaining 0.3m (5%) is spread across eight schemes all with an associated savings target of under 0.1m. There are a further 14 schemes, 11 of which do not have an associated savings value and three which will only impact on activity with CoCH. These are identified as pipeline schemes. The CCG is in the process of refining the 11 schemes which currently do not have an identified savings target. These schemes will be used to support the overall QIPP programme in year. Of the 6.6m planned QIPP savings outside of CoCH, 6.3m (95%) are included within the top 10 schemes. Key LDS applicable scheme Local scheme Eight schemes make up only 0.3m (5%) of the total identified QIPP programme outside of CoCH. There are a further 14 schemes which are included within the block contract with CoCH or are still being developed by the CCG. CoCH schemes only Scheme values still being identified 12

13 QIPP Deliverability: High Priority Schemes Despite having a 10.5m QIPP plan for 2017/18, 4.3m of the programme sits within the CoCH block contract and a further 6.6m of this programme is to be achieved from expenditure outside of CoCH. 95% of the 6.6m planned savings outside of CoCH are made up from the CCG s top 10 schemes. The majority of schemes within the CCG were initiated during 2016/17 and are in the process of delivery. Whilst 7 out of the 10 schemes assessed are delivering, the high value schemes are predominantly rated as Low or Medium Risk. Quality Impact Assessments (QIAs) and risk logs for most of these schemes are held outside of the PIDs. The assessment of the QIPP documentation has not identified any High Risk schemes within the programme. Medium Risk schemes require some strengthening of their documentation and processes to aid delivery. Key areas needing to be improved include the following documentation, milestone planning, scoping of finance and activity and risk management processes. Programme risk vs. implementation timeframe assessment, showing how the existing CCG programme has been assessed. RAG adjusted QIPP programme value, based on ratings assigned in scheme assessment 10,943 9,617 Key Unassessed QIPP High Risk Medium Risk Low Risk N.B. - The unassessed QIPP value includes QIPP schemes which are incorporated within the block contract that the CCG holds with CoCH. Of the unassessed 4.9m, 4.3m sit within the block contract with CoCH. 2.9m of these schemes have been assessed as part of the review. 13

14 QIPP Deliverability: High Priority Schemes The CCG s 2017/18 programme is split across a number of different areas. The overall risk to delivery varies significantly between schemes. The schemes below have been identified as high priority schemes for delivery in 2017/18 Scheme Name 2017/18 value MM11 - Action monitoring outlier practices 2017/18 Risk adjusted value 1,333, ,000 Overall Risk Commentary Analysis shows particular GP practices that are outliers for activity. High level milestones identified but these are not broken down. Risks are also identified and RAG rated; mitigations and risk owners are also identified. Activity variances have been developed to a high level but financial targets are not fully scoped. Priorities to enhance deliverability 1) To have a clear action plan written and signed up to by the outlying practice(s) MM01 - Optimisation and switching scripts 1,249,000 1,124,100 The scheme is already operational and over delivering against its 2016/17 savings targets. Continuation of monitoring is required during 2017/18 to ensure delivery. 1) To be delivered at an LDS level MM09 - Repeat prescribing 1,200,000 1,080,000 Scheme is currently in a pilot stage with some providers opting in to join the service. Savings and activity changes have been assumed based on pilot scheme achievements. Further scoping of the service needs to be undertaken. 1) To be delivered at an LDS level EC - Referral facilitation costs 713, ,038 Scheme has been fully developed and implemented by the CCG. 10% of activity is being rejected based on policies and this is at the lower end of their assumptions. Clinical buy-in has been achieved. 1) Track activity against these procedures and discuss with providers. 14

15 QIPP Deliverability: High Priority Schemes The CCG s 2017/18 programme is split across a number of different areas. The overall risk to delivery varies significantly between schemes. The schemes below have been identified as high priority schemes for delivery in 2017/18 Scheme Name 2017/18 value 2017/18 Risk adjusted value Overall Risk Commentary Priorities to enhance deliverability CC04 - Continuing healthcare / FNC 575, ,000 Whilst this programme has been implemented there are still some risks evident from the PID provided. Savings are based on a reduction of 10% of activity and does not factor in growth assumptions. 1) To be delivered at an LDS level EC05 - PLCV outside of CoCH 400, ,000 The PLCV policy has been implemented and is being enabled via the Referral Facilitation service. The opportunity is based on an audit of April-July 2016 activity levels. 1) Further monitoring of the opportunity within its Providers outside of CoCH EC05 - PLCP 320, ,000 The LDS are looking at implementing a PLCP policy. This has received varying levels of engagement at local CCGs. There are still risks in the delivery of this scheme across the system. 1) Agree a plan for delivery MM07 - Rebate schemes 217,000 NA Information relating to this scheme was not made available due to its commercial sensitivity and therefore this scheme was not reviewed for the purposes of this report. 15

16 QIPP Deliverability: High Priority Schemes The CCG s 2017/18 programme is split across a number of different areas. The overall risk to delivery varies significantly between schemes. The schemes below have been identified as high priority schemes for delivery in 2017/18 Scheme Name 2017/18 value 2017/18 Risk adjusted value Overall Risk Commentary Priorities to enhance deliverability MH - MH commissioning 175, ,000 A three phase model to improve efficiency and quality of mental health, LD and dementia packages. The scheme has broad assumptions around the activity and finance savings potential with outcomes still in the initial scoping stage. 1) Further scoping and identification of areas where efficiencies can be realised need to be undertaken BW08 - Grant reviews 90,000 81,000 CCG has engaged with recipients of grants and identified where efficiencies can be achieved. Scheme is approved by the Finance and Performance Committee. Risks have been identified but there is no clear ownership of these. 16

17 1. Baseline and Context 2. QIPP Deliverability: Review of Governance 3. QIPP Deliverability: Review of existing high priority schemes 4a. Opportunity Development: National Priorities 4b. Opportunity Development: Right Care 4c. Opportunity Development: Menu of Opportunities 5. Opportunity Development: Summary of Opportunity 6. Action Planning 17

18 National Priorities: Continuing Healthcare Potential Interventions We have identified a set of potential interventions that could provide benefits to CHC and FNC in 2017/18. This is not an exhaustive list and there may be further opportunities in other areas as well as other interventions that may be feasible over a longer timeframe particularly if implementation has not yet begun. # Name Description Local CCG Context Time to implement 1 FNC governance 2 Market Management 3 Care Brokerage 4 Eligibility Reviews 5 Case Management Introduce checks ahead of approving FNC payments for patients who are not eligible for Standard CHC funding following a DST assessment Review individuals on FNC post 3 months and annually Market Management involves proactively shaping the provider market to improve value for money care at the levels needed. It can include a number of alternative or additive actions: Implement a Dynamic Purchasing System Re-negotiate top contracts (Dom Care vs. Nursing Homes) Price benchmarking / collaborative commissioning across CCGs Implement a brokerage function with dedicated resource to build capability in specific negotiation skills and provider knowledge to achieve better upfront rates for new packages of care Develop a reviews "taskforce" team to tackle backlogs in 3 month and annual eligibility reviews to identify individuals no longer eligible for CHC standard or fasttrack funding Develop case management taskforce to reassess patient needs against current package of care. Where needs have reduced since setting up the package, renegotiate the cost of the package with the provider The CCG is ranked as having the second lowest expenditure per 50,000 of population for FNC amongst the LDS but sits above average compared to the national CCGs There could be some opportunity to release savings in this area following a review of FNC eligibility The CCG has benchmarked as having the second highest expenditure for CHC standard patients within their local LDS. The CCG s expenditure in this area is gradually increasing and ranks as average when compared against the national CCGs There is potentially some opportunity to generate efficiencies in this area West Cheshire CCG is also currently ranked as having the highest expenditure for Fast Track eligible CHC patient per 50,000 of population when compared to their LDS. However when compared nationally in this area the CCG is within the upper quartile which shows little opportunity for improvement The CCG is working collectively across the LDS in this area and could look to implement a cross LDS care brokerage function The analysis illustrates that 61% to 80% of CHC standard cases are assessed in an acute setting Over 40% of referrals have taken greater than 28 days West Cheshire CCG is the second highest CCG in Cheshire and Wirral for the number of people who are eligible for standard CHC per 50,000 of population and sit within the lower quartile nationally This indicates that the CCG currently have more CHC standard eligible patients per 50,000 of population than three of the four local CCGs Short term (Implemented by the end of Q1 2017/18) Medium Term (Implemented by end of Q3 2017/18) Medium Term (Implemented by end of Q3 2017/18) Short term (Implemented by the end of Q1 2017/18) Short term (Implemented by the end of Q1 2017/18) 18

19 Opportunity Development: CCG Population and CHC Expenditure Overview 19

20 Opportunity Development: CHC Eligibility and Expenditure per 50,000 population 20

21 Opportunity Development: CHC Additional Metrics 21

22 National Priorities: Continuing Healthcare Benefits Estimated Summary Options The table below highlights the potential benefits ranges (Low, Medium and High) for the prioritised interventions. The low scenario is conservative whereas the high scenario is a stretch scenario. These indicative benefits are based upon a short review, using market experience and the source data to propose potential benefits. There may also be additional opportunities for benefits in each of these areas. Local due diligence will therefore be essential in order to assess the feasibility of delivering these financial benefits within your local system. The potential benefits have been calculated on an annualised basis. CCGs will need to consider the time they will take to deliver these (over and above the indicative time to implement specified) and the level of saving they may be able to deliver in 2017/18 and in subsequent years. It is not anticipated that all CCGs will implement all interventions. Specifically in 2017/18 it has been assumed that CCGs would choose between implementing Market Management and Care brokerage. Information on the methodology and assumptions used to develop these potential benefits can be found in the Appendix CHC Benefits Model Assumptions. Low scenario ( '000s) Medium scenario ( '000s) High scenario ( '000s) Int. 1 FNC Governance Int. 2 Market Management Int. 3 Care Brokerage Int. 4 Eligibility Reviews 0 0 1,265 Int. 5 Case Management Total estimated impact of interventions 509 1,068 2,947 Note: The data source utilised for this analysis is Continuing Healthcare - Quarterly National Funded Care Returns (submitted by CCGs to NHS England for the financial year 2015/16) and FOI request April CCGs should undertake a validation locally that the data provided is representative 22

23 CHC standard expenditure CHC fast track expenditure FNC expenditure Costs Total net savings Net savings Additional opportunity CHC standard expenditure CHC fast track expenditure FNC expenditure Costs Total net savings Net savings Additional opportunity CHC standard expenditure CHC fast track expenditure FNC expenditure Costs Total net savings Net savings Additional opportunity National Priorities: Continuing Healthcare Benefits Estimated Detailed The table below details the potential benefits for CHC standard, CHC Fast track and FNC and the associated costs to implement across the benefit ranges. Discussion with the CCGs may have identified QIPP plans already in place in each area and the costs associated with achieving the benefits which may differ from the assumptions applied below. These indicative benefits are based upon a short review, using market experience and the source data to propose potential benefits. There may also be additional opportunities for benefits in each of these areas. Local due diligence will therefore be essential in order to assess the feasibility of delivering these financial benefits within your local system. The potential benefits have been calculated on an annualised basis. CCGs will need to consider the time they will take to deliver these (over and above the indicative time to implement specified) and the level of saving they may be able to deliver in 2017/18 and in subsequent years. It is not anticipated that all CCGs will implement all interventions. Specifically in 2017/18 it has been assumed that CCGs would choose between implementing Market Management and Care brokerage. Information on the methodology and assumptions used to develop these potential benefits can be found in the Appendix CHC Benefits Model Assumptions. Low scenario ( '000s) Medium scenario ( '000s) High scenario ( '000s) Potential benefits identified through CHC benchmarking exercise Current CCG identified QIPP relating to interventions Potential benefits identified through CHC benchmarking exercise Current CCG identified QIPP relating to interventions Potential benefits identified through CHC benchmarking exercise Current CCG identified QIPP relating to interventions 1. FNC governance 2. Market Management 3. Care Brokerage 4. Eligibility Reviews 5. Case Management Total estimated impact , , , , , , , Additional QIPP savings identified relating to CHC not covered by the above interventions Additional QIPP savings identified relating to CHC not covered by the above interventions Additional QIPP savings identified relating to CHC not covered by the above interventions Note: The data source utilised for this analysis is Continuing Healthcare - Quarterly National Funded Care Returns (submitted by CCGs to NHS England for the financial year 2015/16) and FOI request April CCGs should undertake a validation locally that the data provided is representative 23

24 1. Baseline and Context 2. QIPP Deliverability: Review of Governance 3. QIPP Deliverability: Review of existing high priority schemes 4a. Opportunity Development: National Priorities 4b. Opportunity Development: Right Care 4c. Opportunity Development: Menu of Opportunities 5. Opportunity Development: Summary of Opportunity 6. Action Planning 24

25 Opportunity Development: Right Care Analysis shows that the CCG has opportunities from Right Care to further enhance their QIPP plan Speciality Sum of Average 16/17 Sum of Stretch 16/17 Right Care QIPP Plan 17/18 Cancer 1,062,000 1,418,000 - Circulation 2,620,000 3,653,000 - Endocrine, Nutritional & Metabolic 51, ,000 - Gastrointestinal 673,000 1,579,000 - Genitourinary 1,712,000 2,040,000 - Musculoskeletal Neurological 727,000 1,338,000 88,000 Respiratory 1,488,000 2,224,000 - Trauma and Injuries 558,000 1,294,000 - Grand Total 8,891,000 13,798,000 88,000 Plan 17/18 CCG Prescribing QIPP Plan 17/18 2,666,000 Net Prescribing Budget (after QIPP) 17/18 37,953,000 % of Prescribing Budget 6.7% The CCG has 2.7m of QIPP schemes badged against their prescribing budget which equates to an overall QIPP saving target in Primary Care Prescribing of 6.7%. The CCG has three schemes making up their Prescribing QIPP plan. As per the Elective and Non Elective Right Care opportunities, the CCG has not linked their Primary Care Prescribing Right Care opportunities to their schemes and therefore there could be greater opportunity for the CCG in this area. Right Care data currently shows an opportunity of between 0.6m and 1.9m in Primary Care Prescribing. *Source: 2017 NHS Right Care Where to Look pack The CCG has between 8.9m and 13.8m opportunity identified by Right Care in both Elective and Non Elective activity. Currently, the CCG has only 0.1m of QIPP schemes which can be specifically aligned to their Right Care opportunities. The CCG has identified that they have not addressed Right Care within their QIPP programme and see this as an opportunity to further strengthen their QIPP programme moving forward. Currently, all of the QIPP schemes are based outside of Right Care and are focussed predominantly on the ACO and LDS work. Therefore, the CCG has considerable opportunity to expand on their QIPP programme through Right Care. This opportunity is limited for 2017/18 due to the block contract held with CoCH. 25

26 Opportunity Development: Right Care Opportunity Mapping The CCG is in the early stages of their Right Care programme and recognise this as an opportunity moving forward. The CCG plans to develop the Right Care opportunities alongside their ACO model with CoCH and CWP Speciality Activity Type Sum of Average 16/17 Sum of Stretch 16/17 Comments Genitourinary Elective admissions 1,712,000 2,040,000 Circulation Elective admissions 1,139,000 1,462,000 Cancer Elective admissions 1,062,000 1,418,000 Circulation Non-elective admissions 1,481,000 2,191,000 The CCG has previously considered this area but have identified a number of pathways which could be impacted. Circulation is recognised by the CCG for development. Cancer poses a significant opportunity for the CCG although further understanding of this variation needs to be undertaken. Circulation is recognised by the CCG for development. Respiratory Non-elective admissions 1,336,000 1,931,000 Respiratory is recognised by the CCG for development. Grand Total 6,730,000 9,042,000 The 2017 NHS Right Care Where to Look pack has identified a total opportunity of between 9.6m and 16.1m for West Cheshire CCG across Elective, Non Elective and Primary Care Prescribing. Right Care indicates that the CCG s top five areas of opportunity lie within Genitourinary, Circulation, Cancer and Respiratory. Circulation is featured twice as an opportunity in the top five for both Elective and Non Elective activity types. The top five opportunities make up 70% of the Average and 56% of the Stretch opportunities. On this basis, if the CCG targeted these five outlying areas they could significantly reduce their variation in Right Care data. *Source: 2017 NHS Right Care Where to Look pack The CCG recognises that there are opportunities that they can explore within Circulation, Neurology and Respiratory which they have not developed currently. The CCG has previously considered opportunities in Genitourinary but have not extensively developed this due to the wide range of pathways within this speciality. The CCG plans to develop its Right Care plan in the future alongside their main acute provider (CoCH) and community provider (CWP) as part of their ACO model. This will enhance delivery as a result of collaborative working across these pathways. 26

27 1. Baseline and Context 2. QIPP Deliverability: Review of Governance 3. QIPP Deliverability: Review of existing high priority schemes 4a. Opportunity Development: National Priorities 4b. Opportunity Development: Right Care 4c. Opportunity Development: Menu of Opportunities 5. Opportunity Development: Summary of Opportunity 6. Action Planning 27

28 Opportunity Development: Menu of Opportunities Alongside reviewing the Menu of Opportunities, an LDS level workshop was held with CCGs from across Cheshire and Wirral to identify additional schemes and opportunities for the CCGs to collectively develop. The outcomes of these are collated below Opportunity Source Area of Impact Description Oncology specialist dietician Primary care support to care homes Menu of Opportunities Menu of Opportunities Non Elective Primary Care Provide specialised dietary intervention to manage symptoms of nausea, vomiting, diarrhoea, constipation, and weight loss to reduce unnecessary admissions for those on this patient pathway. Opportunity to expand this across other specialities. Local enhanced service to support care homes to create a new dedicated GP service which will improve the quality of primary medical services to residents of older people s homes, by providing a pro-active, specialist and more intensive service than is commissioned from local GP practices by NHS England through the standard GP contract. Estimated Financial Impact ( 000s) Weighted priority 6 2 Specialised Commissioning LDS Workshop Specialised Commissioning LDS revision to specialised commissioning pathways to reduce current service costs. - Alcohol LDS Workshop Non Elective / Emergency An STP level scheme which is in the processes of development. System wide objective to develop a multi-agency approach to support change and reduce alcohol related activity across the STP (Cheshire and Merseyside). 4,700 (across the LDS)* - Antimicrobial resistance (AMR) LDS Workshop Medicines Management An STP level scheme which is in the processes of development. Focus on ensuring AMR action plans and Stewardship Committee s are implemented. Implementation of back up prescribing via a practitioner centred or patient centred approach. TBC - Hypertension LDS Workshop Non Elective / Emergency An STP level scheme which is in the process of development. Early identification and intervention of people with high blood pressure to reduce non elective activity. 2,800 (across the LDS)* - *Taken from the Cheshire & Merseyside Sustainability and Transformation Plan 15 Nov 2016 issue version

29 Opportunity Development: Menu of Opportunities Alongside reviewing the Menu of Opportunities, an LDS level workshop was held with CCGs from across Cheshire and Wirral to identify additional schemes and opportunities for the CCGs to collectively develop. The outcomes of these are collated below Opportunity Source Area of Impact Description Estimated Financial Impact ( 000s) Weighted priority MSK pathway LDS Workshop Elective Revision to MSK pathway across the LDS to reduce variation and to establish synergies in pathways and with providers. - BMI South Cheshire lower threshold LDS Workshop Elective South Cheshire have adopted a lower BMI threshold for elective surgery. Consideration of whether this should be applied across the LDS. - Demand for diagnostics direct access LDS Workshop Diagnostics Identification that the CCG is an outlier on diagnostics and further work needs to be undertaken in this area. This should also be explored through GP benchmarking to identify outlier practices and agree a plan. - 29

30 1. Baseline and Context 2. QIPP Deliverability: Review of Governance 3. QIPP Deliverability: Review of existing high priority schemes 4a. Opportunity Development: National Priorities 4b. Opportunity Development: Right Care 4c. Opportunity Development: Menu of Opportunities 5. Opportunity Development: Summary of Opportunity 6. Action Planning 30

31 Opportunity Development: Summary of Opportunity A range of additional opportunities have been identified by the CCG and have been prioritised across their local footprint, LDS level and STP Source Menu of Opportunities Menu of Opportunities Scheme Financial scale ( 000s if available) Indicative Timescales for this CCG Agreed Opportunity Priority Oncology specialist dietician Medium Term Low Primary care support to care homes Medium Term Low Rationale for agreed priority Opportunity to roll out across a number of specialities not difficult to achieve but unlikely to see significant savings. Block contract with CoCH will not be impacted Opportunity to enhance this service but already undertaking similar activity LDS workshop Specialised Commissioning Medium Term Low Potentially a significant opportunity in this area across the LDS however difficult to realise these savings LDS workshop Alcohol 4,700 (across the LDS)* Medium Term Medium Part of the STP plan and in the process of working this programme up LDS workshop Antimicrobial resistance (AMR) TBC Medium Term Medium LDS workshop Hypertension 2,800 (across the LDS)* Medium Term Medium LDS workshop MSK pathway Short Term High LDS workshop Prescribing Short Term High LDS workshop Continuing Healthcare Short Term High *Taken from the Cheshire & Merseyside Sustainability and Transformation Plan 15 Nov 2016 issue version 4.4 Part of the STP plan and in the process of working this programme up Part of the STP plan and in the process of working this programme up Identified by the LDS as a key scheme to develop. Significant opportunity across the LDS joint working via a Transformation Board across the LDS Identified by the LDS as a key scheme to develop. Significant opportunity across the LDS joint working via a Transformation Board across the LDS Identified by the LDS as a key scheme to develop. Significant opportunity across the LDS joint working via a Transformation Board across the LDS 31

32 Opportunity Development: Summary of Opportunity A range of additional opportunities have been identified by the CCG and have been prioritised across their local footprint, LDS level and STP Source LDS workshop LDS workshop Right Care Scheme BMI South Cheshire lower threshold Demand for diagnostics direct access Genitourinary Elective admissions Financial scale ( 000s if available) Indicative Timescales for this CCG Agreed Opportunity Priority Short Term Medium Medium Term Low 1,712 Medium Term Medium Right Care Circulation Elective admissions 1,139 Medium Term Medium Right Care Cancer Elective admissions 1,062 Medium Term Medium Right Care Right Care Circulation Non-elective admissions Respiratory Non-elective admissions 1,481 Medium Term Medium 1,336 Medium Term Medium Rationale for agreed priority South Cheshire have adopted a new BMI threshold for elective surgery CCG to review CCG recognises issues with diagnostics but this will impact a significant number of pathways which will all need to be reviewed CCG focus is currently on establishing their LDS and ACO models. Once the ACO is established the CCG is planning to develop Right Care collaboratively with CoCH CCG focus is currently on establishing their LDS and ACO models. Once the ACO is established the CCG is planning to develop Right Care collaboratively with CoCH CCG focus is currently on establishing their LDS and ACO models. Once the ACO is established the CCG is planning to develop Right Care collaboratively with CoCH CCG focus is currently on establishing their LDS and ACO models. Once the ACO is established the CCG is planning to develop Right Care collaboratively with CoCH CCG focus is currently on establishing their LDS and ACO models. Once the ACO is established the CCG is planning to develop Right Care collaboratively with CoCH 32

33 1. Baseline and Context 2. QIPP Deliverability: Review of Governance 3. QIPP Deliverability: Review of existing high priority schemes 4a. Opportunity Development: National Priorities 4b. Opportunity Development: Right Care 4c. Opportunity Development: Menu of Opportunities 5. Opportunity Development: Summary of Opportunity 6. Action Planning 33

34 Action Planning: LDS Level On the 17 th April 2017 a workshop was held with all the AOs and FDs for the three CCGs across Cheshire and Wirral. At this meeting it was agreed that a joint committee will be established with delegated functions that can transact business on behalf of the CCGs. The initial focus was identified as MSK, CHC, and Medicines Management. The patch already has shared arrangements for CHC but this requires greater pace. The actions in this plan require final signoff from the Group but are included to start the process. The first priority is to establish the Joint Committee and agree the work programme. The work programme and arrangements for the joint committee should include consideration of programmes that should be delivered as: Cheshire Only this could be considered part 1 of the committee and may be the most appropriate mechanism for MSK; Cheshire and Wirral this could be considered part 2 of the committee and could include Medicines Management and CHC; and STP Footprint this could be considered part 3 and may include AMR, for example. The structure requires further discussion and work-up across the CCGs. The programme across the three areas should be supported by a Delivery Support Unit (DSU) which includes project managers, Business Intelligence input and financial input. Alongside the DSU, the proposal is to have task and finish groups for each area (CHC, MSK, MM) led by a project manager across the patch. The current CHC arrangements will move into the task and finish group. 34

35 03-Apr 10-Apr 17-Apr 24-Apr 01-May 08-May 15-May 22-May 29-May 05-Jun 12-Jun 19-Jun 26-Jun 03-Jul 10-Jul 17-Jul Action Planning: LDS The below actions are recommended to the CCG to enhance the delivery of their joint LDS programmes Action Completion Date Status Establish a Joint Committee Define Terms of Reference for the Joint Committee 28/04/2017 Action Define remit 28/04/2017 Action Identify members of the Joint Committee and communicate 28/04/2017 Action Identify frequency of meetings 28/04/2017 Action Agree communication strategy to key stakeholders and reporting requirements/mechanisms 28/04/2017 Action Agree the dedicated functions and sign off 28/04/2017 Action Approval of Terms of Reference by Governing Bodies of each CCG 05/05/2017 Action Commence meetings and monitoring of programme delivery Establish Task and Finish Groups for CHC; MM; and MSK 12/05/2017 (ongoing) Action Review current CHC Joint Committee and where required strengthen 28/04/2017 Action Establish Task and Finish Groups (MSK / CHC / Medicines Management) - CHC will use the current structure 26/05/2017 Action Define Terms of Reference 26/05/2017 Action Identify members of individual Task and Finish Groups and communicate 26/05/2017 Action Define priority areas of individual Groups 26/05/2017 Action Identify frequency of individual Group meetings and reporting to the Joint Committee 26/05/2017 Action Agree communication strategy to key stakeholders and reporting requirements/mechanisms Approval of Terms of Reference by Governing Bodies of each CCG and the Joint Committee Commence Task and Finish Group meetings 26/05/2017 Action 01/06/2017 Action 10/06/2017 (ongoing) Action 35

36 03-Apr 10-Apr 17-Apr 24-Apr 01-May 08-May 15-May 22-May 29-May 05-Jun 12-Jun 19-Jun 26-Jun 03-Jul 10-Jul 17-Jul Action Planning: LDS The below actions are recommended to the CCG to enhance the delivery of their joint LDS programmes Establish a Delivery Support Unit Action Completion Date Status Agree role and scope of Delivery Support Unit 12/05/2017 Action Identify resource requirements of Delivery Support Unit and implement 19/05/2017 Action Agree performance monitoring structures - reporting, tracking processes management of risk. Document and sign off. 19/05/2017 Action Identify members of Delivery Support Unit and appoint to roles where required 26/05/2017 Action Communicate role of Delivery Support Unit to stakeholders 26/05/2017 Action Undertake supporting analysis to drive key programme areas (some of this may already be in place) 26/05/2017 Action Identify key priority programmes based on available analysis (where required) 02/06/2017 Action Identify interventions and establish QIPP schemes (where these are not already defined) 23/06/2017 Action Agree QIPP scheme efficiency targets across the patch (CHC already have this) 23/06/2017 Action Produce detailed action plans for each QIPP programme and sign off (some areas e.g. CHC may have this detail already) 23/06/2017 Action Agree reporting requirements and mechanisms for Delivery Support Unit 02/06/2017 Action Implement action plan and monitor delivery 05/06/2017 (ongoing) Action 36

37 Action Planning: Local Level The below actions are recommended to the CCG to enhance the delivery of their key QIPP schemes and for the governance of their overall QIPP programme Area/Scheme Action Completion Date Status 03-Apr 10-Apr 17-Apr 24-Apr 01-May 08-May 15-May 22-May 29-May 05-Jun 12-Jun 19-Jun 26-Jun 03-Jul 10-Jul 17-Jul 24-Jul 31-Jul 07-Aug 14-Aug 21-Aug 28-Aug QIPP Governance Monitoring and Reporting All QIPP reporting for schemes due to be active from 1 April should be refined to include key risks, mitigations and risk owners, key performance indicators and next steps 03/04/2017 Action Monitoring and Reporting CCG to extract current pipeline schemes from their QIPP programme and monitor seperately 03/04/2017 Action Stakeholder and Provider Engagement Programme Management Capacity Programme Management Capacity QIPP Documentation Joint Delivery Team with CoCH needs to be implemented as an enabler to the delivery of the SDIP and the joint QIPP/CIP programmes. Small schemes should be reviewed and management time focussed on the delivery of key QIPP schemes Review appointment of substantive staff to ensure delivery of schemes and establish a clear defined succession plan PID workbooks should be completed for all schemes. PIDs should be reviewed and approved through the CCG Gateway process to ensure corporate ownership and agreement. 30/06/2017 Action 03/04/2017 Action 28/04/2017 Action 30/04/2017 Action QIPP Documentation Activity and finance detail needs to be identified for all schemes to allow monitoring of delivery 03/04/2017 Action Existing Schemes N N N N N N N N N N MM11 - Action monitoring outlier practices EC - Referral facilitation costs EC - Referral facilitation costs Establish clear actions plans which are written and signed up to by outlying practices 30/04/2017 Action Undertake an audit of current activity rejections and acceptances to confirm application of policies Consider opportunity to further enforce policies following audit review to achieve further savings based on current 10% rejection rate 02/06/2017 Action 30/06/2017 Action EC05 - PLCV outside of CoCH Further scoping of PLCV opportunity with providers outside of CoCH to confirm savings potential 30/04/2017 Action EC05 - PLCP Ensure sign up of all CCGs to PLCP policy 14/04/2017 Action EC05 - PLCP Communicate PLCP policy to all Providers 14/04/2017 Action EC05 - PLCP Communicate PLCP policy to all General Practices 14/04/2017 Action EC05 - PLCP Ongoing monitoring and review of PLCV and PLCP policies and activity Ongoing Action 37

38 Appendix 1: 27 February QIPP Plan Submission

39 Appendix 1: Current QIPP Programme QIPP Programme as at 27 February Since the 23 December financial plan submission the CCG has agreed a block contract with CoCH. Based on the current QIPP programme and aligned working practices with CoCH the CCG has negotiated a zero growth uplift within the contract. This has meant that the CCG has been able to maintain its current QIPP target of 10.5m. The block contract has restricted the opportunity for the CCG to develop additional QIPP schemes with CoCH. As a result 6.5m of the QIPP programme needs to be identified from only 57% of their expenditure. The CCG are planning to monitor the impacts of their QIPP schemes with CoCH to inform contract negotiations for 2018/19. Any additional QIPP schemes developed in year which impact on CoCH activity will be incorporated into subsequent contract negotiations. Refinement of schemes and the block contract has resulted in 2.2m of QIPP now being classed as Unidentified at 27 February. 39