Airedale, Wharfedale & Craven CCG X Bradford City CCG X Bradford Districts CCG X Minutes of the Joint Finance and Performance Committee Meeting Thursday 3 rd May 2018, 10.30 12.30, Douglas Mill Present: Neil Fell (Chair) Lay Member for Governance AWC CCG Liz Allen Director of Accountable Care BC CCG & Clinical Board Representative BC CCG Julie Lawreniuk Chief Finance Officer 3 CCGs Bryan Millar Lay Member for Finance 3 CCGs Sue Pitkethly Director of Accountable Care AWC CCG Dr Colin Renwick Clinical Executive Representative AWC CCG Dr Dave Tatham Clinical Board Representative BD CCG Apologies: Kerry Weir Deputy Director, Planning, Performance & Assurance 3 CCGs In Attendance: John Young Secondary Care Consultant BC/BD CCG (attended to observe the meeting) Theresa Birks Performance Manager 3 CCGs (attending on behalf of Kerry Weir) Robert Maden Deputy Chief Finance Officer 3 CCGs Alison Needham Deputy Director of Financial Strategy 3 CCGs Richard Wall Deputy Director of Contracting 3 CCGs Clare Smart Deputy Director Strategic Partnerships BC/BD CCGs (for agenda item 11 only) Nadine Newton Head of Personalised Commissioning 3 CCGs (for agenda item 11 only) Sharon Wood (minutes) PA to Chief Finance Officer 3 CCGs 1. Apologies Apologies had been received as noted above. 2. Declarations of Interest There were no declarations of interest relating to the items on the agenda. The register of interests records all interests declared and is available at: http://www.airedalewharfedalecravenccg.nhs.uk/ for Airedale, Wharfedale and Craven CCG http://www.bradfordcityccg.nhs.uk/ for Bradford City CCG http://www.bradforddistrictsccg.nhs.uk/ for Bradford Districts CCG 3. Minutes of the Meeting held on 5 th April 2018 The minutes of the Joint Finance and Performance Committee meeting held on the 5 th April 2018 were agreed to be an accurate record. Liz asked that any specific items which other Committees should have oversight or take actions on are highlighted within the individual agenda item. 4. Action Log Self-Assessment process is on the agenda for discussion.
5. Performance Report Theresa Birks gave an update. Key points to note are: Both Trusts failed to deliver the A&E standard in March; BTHFT came in at 78.7% and ANHST came in at 93.4%. Reporting issues continue following implementation of the new EPR system at BTHFT and the latest CCG scorecard position is therefore not a true reflection of performance; RTT remains a concern for BTHFT as there has been a significant rise in patients waiting over 18 weeks which continued into March 2018. However, for the first time since reporting, the overall waiting list position has reduced due to a decrease in the number of patients waiting under 18 weeks; All 3 CCGs have received confirmation from Leeds CCGs of 52 week breaches for patients at LTHT; Diagnostic performance at both Trusts and cancer waiting times standards at BTHFT also continue to be a challenge; Vacancies and staff absences in BDCFT s Bradford Districts Early Intervention in Psychosis team is having an impact upon delivery of the 2 week waiting time standard; Quality Premium guidance for 2018/19 has been refreshed to reflect national planning requirements. In particular, the majority of funding is now dependent upon delivering a suite of emergency demand management indicators, which are linked to their 2018/19 operational plans; and CQUIN guidance for 2018/19 has also been refreshed, with the proactive discharge CQUIN being suspended and funding for acute Trusts re-allocated to delivering STP engagement requirements. Bryan raised concerns about CCGs reporting being passive and the need to make more reference to the actions CCGs are taking to manage performance. Julie assured the committee work was ongoing and will pull this work into the reports at the next meeting, as it doesn t take into account the conversations that are happening at Contract Board and the actions CCGs are taking as a system to do something about it. Julie confirmed that the Joint Clinical Committee discussed a number of concerns at BTHFT that have been followed up individually and a Joint Quality Committee meeting with BTHFTs Quality Committee has been arranged to discuss a number of issues relating to quality and safety and what assurance can CCGs get from BTHFT re the actions they are taking to address them.. Neil raised concerns re the overlap with contracting and Richard confirmed he is meeting next week to discuss. Julie confirmed both Trusts have set a trajectory to get to 95% by March 2019 and the CCGs were assured there was a process in place to try and deliver. Recommendations; Noted the update on performance against the constitutional targets; Noted the changes to national guidance on the Quality Premium and CQUINS; Highlighted there are issues around a number of performance issues, some of which are as a consequence of EPR and not understanding the numbers but some of them are real performance issues. 6. Contracting Report Richard Wall gave an update. Key points to note are:
Although CCGs 18/19 provider contracts have been issued and signed, a number of key areas still require finalising. These include 18/19 CQUIN indicators, national guidance is only now available, as well as the anticipated contractual requirements in respect of General Data Protection Areas (GDPR) and other local and national agreed changes to key contract schedules. The expectation from NHSE is that all existing contracts are updated to reflect the new guidance by 25 th May 2018 (Subject to a National NHSE Contract Variation Consultation exercise). CCGs have had the added difficulties of agreeing a contract to very specific deadlines while still finalising outturn, and resolving two key issues; Airedale issues with orthopaedics and coding and BTHFT aligning CCG and Trust forecasts has been exasperated by the EPR issues at BTHFT. BTHFT were adamant during negotiations that they wanted to retain a PbR contract for the remainder of this 2 year term and they are confident their action plan to produce data by the contracting reporting deadline dates will be met. CCGs are expecting that by 19 th / 20 th May that they will get month 12 outturn from them in terms of the data. BTHFT are adamant that in terms of supporting a PBR contracting approach they will be producing data on a monthly basis going forward. This raises some risks in terms of what EPR produces. To try to mitigate against any potential coding changes, Richard has drafted a letter that sets out a code of conduct CCGs will work to with the Trust. Julie highlighted that CCGs hadn t reached agreement on the use of aligned incentive contracts this year but that they would be looking at how they work towards them for 2019/20. Recommendations; Noted the contents of the report Highlighted there are still issues with EPR and difficulties around moving contracting forward to an aligned incentive contract model. Further work is ongoing on agreeing final outturn and the implications of this going forward. 7. Operational Plan 18 / 19 Julie Lawreniuk gave an update This report presents an update on progress against delivery of the 2 year operational plan and the 3 CCGs commitments to deliver the national expectations for 2018/19. Key points to note are: All 3 CCG s have committed to deliver the national requirements; Where national targets are not currently being achieved, trajectories reflect recovery plans for their main acute Providers e.g. A&E, RTT and 62 day cancer standards; Julie confirmed this report should provide the committee with some assurance of the work that is going on in those programme areas to in order to meet these trajectories and noted that some content from the report would also be contained in the annual reports that have been produced for the 3 CCGs. The 3 CCGs have been working jointly in their approach to align both elective and nonelective activity across commissioner and provider plans and these now align with their main PbR contracts; Bradford Teaching Hospitals Foundation Trust s in year move from one patient record system to another has created some significant data quality issues and subsequent challenges in aligning outturn and 2018/19 plans; There has been significant progress in 2017/18, as part of their Programme work, to move
towards delivering all national requirements by March 2019; and The main risk to delivery is the capacity of BTHFT and other providers to deliver the activity included in contracts. The Committee raised concerns around BTHFT and Julie gave assurance that CCGs have alerted NHSE and NHSI, sent performance notices and have arranged a Joint Quality Committee meeting between CCGs and BTHFT. Recommendations; Noted the update on their work to deliver the 3 CCGs 2 year operational plan; and Noted refreshed plans for 2018/19; 8. QIPP Report Alison Needham gave an update. The paper provides an update of QIPP of all 3 CCGS as at 31 st March 2018. This is the final report for 17 /`8 on QIPP and its achievements. Key Headlines The paper provides details of the schemes currently underway within all CCGs and how they are performing by programme board and scheme. The data issues at BTHT following the EPR implementation have still not been resolved and as such, the CCG is still unable to update the QIPP reports with any BTHT information after month 6. For Airedale, Wharfedale and Craven, the majority of acute QIPP activity goes through the Airedale FT contract and so it has been possible to update this and reflect in the forecast outturn. Current reported position of the 3 CCGS is - Airedale Wharfedale and Craven CCG QIPP Plan - 6.04m Forecast Achievement - 6.08m Overachievement - 0.03m Movement improvement of 0.3m Bradford City CCG QIPP Plan - 3.5m Forecast Achievement - 3.42m Shortfall - 0.1m Movement prior month decline of 0.03m Most of the savings are in Prescribing and Planned Care. Bradford District CCG QIPP Plan - 13.3m Forecast Achievement - 7.7m Shortfall - 5.7m Movement prior month decline of 0.1m During 17/18, the three CCGs have undergone an internal audit of their QIPP programmes with the final report published in March. While the full report is to be presented to the Audit Committee, a summary of the key findings is detailed below:
The CCGs decision flowchart needs strengthening with a gateway process to provide authority to proceed on new schemes. Additional documentation supporting how the CCG has considered achievability and the impact of the schemes. Benefits templates and PIDs were not consistently completed with no supporting calculations and assumptions around savings. Where these were in completed, they are not regularly updated. To assist continued alignment of processes across all CCGs, there needs to be consistent processes and central repositories. Formal milestones of plans to manage the delivery of schemes had not been used in AWC CCG during 17/18 Overall the CCGs received a significant assurance rating from internal audit. In addition to their own internal audit review, during February, the CCGs were notified by NHSE that as part of the national QIPP support programme, they would be conducting a review of all CCG QIPP schemes, which would be undertaken by a team from Price Waterhouse Cooper. The team were onsite at Douglas Mill for a week at the end of February and focused on the CCGs governance structure around QIPP including implementation and monitoring documentation and then looked in detail at the top 10 schemes for each CCG (by value), meeting with the scheme leads where appropriate. The key findings across the 3 CCGs are detailed below: There is no formal process for developing QIPP or a documented gateway process. QIPP schemes are discussed at their relevant programme board (e.g. planned care) where they are critiqued and approved prior to implementation. However, it is clear the majority of work streams undertake significant work to monitor progress and risks as the projects continue. Whilst the CCGs have formal QIPP targets, there are no formal targets communicated to the respective programme areas e.g. elective, non-elective. There is no QIPP pipeline; as schemes are thought up are taken to the respective programme boards for discussion. Scheme documentation is not held centrally by the PMO but retained by the individual programme areas. Whilst there is a PID template in existence at the CCG it is not required to be completed and is therefore rarely used. However the CCG does have the majority of the correct documentation to support scheme delivery although it is not usually all represented in one document. QIPP schemes generally lacked detail in the planning and risk management areas. Whilst there was evidence that risk was being managed in schemes there was a lack of formally completed QIA/EIAs. In addition a number of the prescribing schemes lacked detailed activity/financial modelling. Across both of these reviews there are consistencies in the findings relating to programme documentation and so the below actions have been agreed to address this: 1. Develop the governance and reporting framework to incorporate the clinical forums engaged in the QIPP process - CCG adapt the governance structure and develop flow chart process 2. The GB should consider agreeing a timeframe for the identification of additional schemes beyond which additional decisions may need to be considered 3. A gateway process (PID) for the authority to proceed for new schemes should be incorporated into the decision flowchart process 4. Create a process diagram to capture the expected controls in relation to identifying, approving and documenting individual schemes 5. A standard approach to the documentation of project plans to manage the delivery of schemes should be adopted. For 18 /19 the plan CCGs have now are all schemes that have been quantified and either built into a contract or agreed there is an actual scheme there.
AWC They have identified schemes to date of 4m but still have a gap of 2.5m in identifying QIPP plans. There is lots of work being progressed to close this gap and there is a list of schemes that are currently being progressed where they haven t as yet identified the financial saving. Julie confirmed CCGs signed the financial plan off on the basis that the meeting in June would be crucial for understanding the QIPP gap in Airedale. Bryan asked the committee what specific element caused a significant change in the Airedale QIPP plan target from that agreed in the two year plan, Julie confirmed this was the 17/18 financial position and the deficit they have carried forward, because when they originally set the Airedale plan, they set the 2 year plan out on the basis that Airedale would balance in 17/18. Bradford Districts & Bradford City For Bradford Districts and Bradford City CCGs, QIPP schemes to the value of the full plan have been identified. Recommendations: The Finance and Performance Committee Noted the contents of the report Highlighted there are still challenges for QIPP but for 17/18 there had been good achievement. 9. Finance Report Airedale, Wharfedale & Craven CCG Robert Maden gave an update. The full year forecast overspend has increased slightly by 63k to 5,662k mainly due to final adjustments to the year-end settlement for the Airedale contract and increased continuing care spend, offset by underspends on some locality schemes. The reported position shows that the CCG has achieved its financial performance targets for the year (statutory and NHS England) as follows: 000 In year surplus 1,857 Release of national risk reserve 1,028 Release of Category M drugs savings 238 Total Reported In Year Surplus 3,123 (Subject to audit) A significant part of the reserves used to support the financial position in 2017/18 are nonrecurrent and as a result are currently forecasting that they will take an underlying deficit of 3.77m into 2018/19. Recommendations: Noted the CCG s reported financial performance for 2017/18 and the achievement of its statutory and NHS England financial targets (subject to audit); and Noted that the current assessment of the CCG s financial position is that there will be an underlying deficit of 3.77m taken forward into 2018/19. Bradford Districts CCG The full year forecast overspend has increased by 1.4m to 9.4m due to further adjustments to the year-end settlement for the Airedale and Bradford contracts. Continuing care costs have also shown a significant increase which has only been partially offset by underspends elsewhere. The reported position shows that the CCG has achieved its financial performance targets for the
year (statutory and NHS England) as follows: 000 In year surplus 3 Release of national risk reserve 2,204 Release of Category M drugs savings 521 Total Reported In Year Surplus 2,728 (Subject to audit) Recommendations: Noted the CCG s reported financial performance for 2017/18 and the achievement of its statutory and NHS England financial targets (subject to audit). Bradford City CCG The forecast net budget overspend has increased by 0.8m to 3.3m mainly due to the finalisation of GP SLA and non-contracted activity costs. Also, continuing care and mental health costs have increased significantly and only partially offset by underspends elsewhere. The reported position shows that the CCG has achieved its financial performance targets for the year (statutory and NHS England) as follows: 000 In year surplus 0 Release of national risk reserve 671 Release of Category M drugs savings 151 Total Reported In Year Surplus 822 (Subject to audit) Recommendations: Noted the CCG s reported financial performance for 2017/18 and the achievement of its statutory and NHS England financial targets (subject to audit) ); 10 Self-Assessment Process Julie Lawreniuk gave an update As part of reporting to Audit and Governance Committee each sub-committee has been asked to do a review of its effectiveness for 17/18. The questionnaire was sent to 11 individuals, and a total of 7 responses were received. 5 from committee members (71%) and 2 from regular attendees (50%) as agreed with the Committee Chair. The review found that the Joint Finance & Performance Committee works effectively, is well led and has a good level of support. The review also highlighted some areas where improvement or further development is required. These include: Succession planning Not all members become fully involved in discussions Minutes need to record more fully the challenges and assurance discussions leading to acceptance of recommendations Points for discussion. Is the length of meetings sufficient to cover the 3 CCGs in sufficient detail? The Committee agreed 2 hours was sufficient to cover the 3 CCGs in sufficient detail.
Do we need to adjust the timings of the meeting / other meetings? The Committee agreed the timings of the meeting would now start at 11am until 1pm. This would allow attendees who attended meetings prior to this meeting sufficient time to get from one meeting to the next. Have we got the right balance between finance, contracting, performance and QIPP in agendas and the work plan? the committee agreed they believe this is appropriate. How do we improve succession planning? As this was a common theme across all committees it was agreed it would be discussed at Governing Body and Audit and Governance. Points raised in the meeting were around training / induction and this needs to be picked up in the appraisal process. 11 RAG Activity Reporting Clare Smart and Nadine Newton attended to give an update to the Committee. The new national framework goes live from October this year and the recommendation is that the very high cost decisions CCGs make should be reported through the Governing Body. Clare had a discussion with Julie around whether the Joint Finance and Performance Committee was the appropriate forum to oversee spending decisions in this area some of which are of extremely high value. Julie confirmed CCGs need to look at their standing orders and standing financial instructions for the approval of this, if CCGs could enhance their reporting in the finance report to capture some better reporting of it, they might ask the Committee of what amounts they would want to see, in the reporting they can show that flow through the RAG group to F&P to Governing Body. Julie asked if the committee would be happy if the finance team considered the issue outside this meeting and agree what they may bring back a proposal for how this area might be managed and reported through finance and or Quality governance mechanisms. The Committee agreed. 12 Issues to highlight to CB, CE & GB A number of performance issues, some of which are as a consequence of EPR and not understanding the numbers but some of them are real performance issues. EPR and difficulties around moving contracting forward to an aligned incentive. There are still challenges for QIPP but for 17/18 there was very good performance and achievement. 13 Any Other business The committee agreed that future meetings would commence at 11.00 am in order to allow members of the Urgent care group more time to move between meetings. 14 Date and Time of Next Meeting The next meeting will be held on Thursday 7 th June 2018, 11am 1pm, Millennium Business Park, meeting rooms 2 & 3