FINANCE, PERFORMANCE AND ACUTE COMMISSIONING REPORT

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FINANCE, PERFORMANCE AND ACUTE COMMISSIONING
REPORT
Jonathan Wise, Director of Finance Performance

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Contents
Part 1 Finance report (slides 2-9) Part 2
Performance report (slides 10-14) Part 3 Acute
commissioning report (slides 15-29) Finance
Appendices (slides 30-43) 1. Summary Operating
Cost Statement and variances by budget heading 2.
Balance sheet 3. Capital 4. Cash flow
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PART 1 FINANCE REPORTFinancial position -
Summary

• Statutory duties
• Forecast underspend against revenue resource
  limit
• Forecast underspend against capital resource
  limit
• Forecast achievement of cash limit
• The PCT is not in a position to forecast its
  year-end outturn with confidence
• The PCT is at high risk of receiving a weak
  assessment in respect of a number of the ALE
  criteria.

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Overview of month 11 year end forecast
-2,800
5

• Reasons for movement in forecast outturn M9 to
  M11
• Acute Commissioning (0.3 million deterioration)
• See analysis in section 3 of the report.
• Joint Commissioning (1.8 million deterioration)
• Continuing care savings lower than budgeted (see
  next slide), offset by improvements in other
  joint commissioning budgets
• Primary care (1.1 million improvement)
• Improvement in prescribing underspend (0.6m),
  plus other budget areas (0.5m)
• Provider Arm (2.3 million improvement)
• More realistic forecast outturn (0.8m) plus
  impact of actual capital charges.(1.5m)
• PCT Management (0.2 million improvement)

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CONTINUING CARE -SUMMARY

• The PCT has been in discussion with London
  Borough of Brent (LBB) since November 2006 in
  respect of the funding arrangements for approx
  140 clients
• The basis of an agreement has now been reached
  with LBB officers in principle as follows
• approx 75 clients have been accepted as the
  Councils responsibility, following review by
  social care panels
• approx 50 clients have been accepted as the PCTs
  responsibility (mainly Old Long Stay)
• a small number of clients still remain to be
  agreed
• The 07/08 budget assumed savings of 3.65m ( in
  respect of all Councils)
• The potential agreement with LBB provides the PCT
  with forecast savings as follows
• 07/08 FYE
• m m
• Agreed clients 1.0 2.2
• Disputed clients - 0.2
• Arrangements are being agreed with the Council to
  recognise the 07/08 costs prior to the date of
  LBB panels. This is estimated at 1.4m.
• As prior year debtors included in the PCT
  accounts in 06/07 (1.5m) will not accrue, a
  provision has been made for this (included in the
  risk debtors figure of 2.5m).
• The above relates to the position with LBB.
  Further work is needed in respect of the position
  with other Councils.

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OUTSTANDING AREAS OF UNCERTAINTY

• Previous Board reports identified the areas of
  major variability and why the PCT was not in a
  position to forecast its year-end outturn with
  confidence
• Whilst most of these have been reviewed and
  incorporated in the latest forecast, there remain
  the following risks of material movement in month
  12/final accounts production
• Acute Commissioning the reported position is
  based on month 10 activity extrapolated and there
  remains potential volatility as activity for Q3
  and Q4 is finalised
• Financial systems and processes the continued
  weaknesses across a range of financial accounting
  areas means that the possibility of unpredicted
  year-end movements remains
• The year-end position as per the audited accounts
  could therefore move significantly (in either
  direction) from the month 11 forecast

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BALANCE SHEET,CAPITAL AND CASH

• Balance Sheet (Appendix 2)
• the main in-year movements are as follows
• Fixed assets a reduction of 18m due mainly to
  transfer of assets to CNWL
• Creditors a reduction of 32.8m due mainly to
  the inclusion in 06/07 of an end of year RAB
  adjustment with NW London and a concerted effort
  to address prior year issues
• Capital (Appendix 3)
• an underspend of approx 9m is forecast against
  available capital resources
• capital expenditure has been low due to a lack of
  a Capital/Estates strategy and the consequent
  Business Case approvals
• Cash (Appendix 4)
• the forecast cash position, after full repayment
  of the cash advance (loan) required to finance
  the 06/07 deficit, is for a significant
  under-drawing against the cash limit due to
• Cash impact of forecast capital underspend
• Cash impact of forecast revenue underspend, plus
  other non-cash items
• Cash planning and forecasting during the year has
  been weak, as evidenced by the closing month end
  cash balances

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Next Steps/Actions re Financial Position

• Finalise year end outturn and produce final
  accounts.
• Implementation of action plan in respect of
  financial capacity and capability
• - detailed action plan produced
  for EMT/Audit Committee for implementation
• Jan-Mar 2008
• - being reviewed for completeness
  in light of Taylor enquiry
• - 08/09 plan being developed for
  review at April Audit Committee

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Part 2 Performance Report

• Performance dashboard updated for the period
  ending January 2008 together with forecast
  position at year-end.
• The dashboard is consistent with the Strategic
  Health Authoritys Performance report as at the
  end of Q3 07-08. Brent PCT was rated as RED at
  the end of Q3, based on the combined score of the
  PCTs performance on Key targets (RED) and Other
  targets (RED).
• The RED areas are detailed with narrative on
  reasons and the action taken.

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Performance Report- Q2 07-08, Q3 07-08 and
Current status
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Performance Report- Q2 07-08, Q3 07-08 and
Current status (2)
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Key Targets Narrative

• Non Admitted 18 week RTT target (Owner Director
  of Strategic Commissioning) In January 77 of
  patients completed their pathway in less than 18
  weeks. Great progress has been made at NWLH, our
  largest acute provider, and current performance
  for this target is 95.4. The greatest risk is
  now at other Trusts, especially the Royal Free
  NHS Trust and UCL NHS Trust.
• Admitted 18 week RTT target (Owner Director of
  Strategic Commissioning) - In January 48 of
  patients completed their pathway in less than 18
  weeks. Although, this is not changed much since
  December (at 48), progress continues to be made
  with this target. The greatest risk is at NWLH
  as our largest acute provider, and in the
  surgical specialties, especially Trauma and
  Orthopaedics.
• AE 4 hr wait (Owner Director of Strategic
  Commissioning) The underperformance of the AE
  4hr Wait Target is currently being addressed in
  partnership with NWLHT and has culminated in both
  a performance trajectory plan and strategic
  action plan.  Several operational groups are also
  working to this guide and these include a Daily
  Bed meeting (to review potential discharges for
  the day and available capacity within the
  hospitals both in terms of staffing and bed
  availability) and a Weekly Performance meeting
  (review of last weeks activity, agree associated
  actions to address any particular issues and to
  update on actions already taken).   The AE
  trajectory assumes that the Trust will meet 98
  for All Types in June 2008.  Primary Care
  services at both hospital sites (provided by
  Harrow and Brent PCT) have been assisting the
  Trust in meeting the demand for treating patients
  with a primary care need.
• MRSA (Owner Director of Public Health)
  Cumulative number of MRSA bacteraemias at NWLHT
  has reduced significantly since last year but
  remains above the target number YTD. Root cause
  analysis of bacteraemias to date in 2007/08
  indicate a significant majority are line
  associated infections. The high impact
  interventions around line care are being
  implemented to tackle this at NWLHT and this will
  be a major and challenging piece of work. Another
  key priority is ensuring those patients
  identified as positive on admission are
  decolonised. To support decolonisation of MRSA
  positive patients in the community prior to
  routine admissions to NWLHT, the HCAI group has
  now developed a consistent policy for
  decolonisation in primary care. Other key
  elements of the NWLHT action plan address hand
  hygiene, full implementation of the high impact
  interventions, antibiotic use, cohorting and
  isolation, surveillance, cleaning and
  decontamination, training, leadership and
  governance. As part of its action plan, NWLHT is
  launching an intensive hand hygiene campaign.
• Smoking quitters (Owner Director of Public
  Health) - The drop off in performance YTD in
  2007/08 compared to performance in the latter
  part of 2006/07 is due to discontinuation of the
  community advisor scheme from 1st April 2007 as
  part of the turnaround plan. The PCTs strategy to
  reduce smoking rates focuses on the investment,
  expansion and re-focus of the stop smoking
  service. This will involve-
• Stop before the Op targeting smoking cessation
  at people referred for routine surgery to
  maximise clinical outcomes
• Supporting practices to contribute to smoking
  cessation targets through Practice Based
  Commissioning, referrals and service delivery
• Training a proportion of Health Trainers from
  target communities to become smoking cessation
  community advisers
• Maximising external investment into the service
  e.g. Local Area Agreements.
• The PCT plans to invest a further 520k in 08-09
  to drive forward its smoking cessation
  initiatives. The investment will consist of an
  incentive scheme to encourage GPs to participate
  in smoking cessation initiatives together with
  additional resources for health promotion.

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Other Targets - Narrative

• Inpatient waits over 11 weeks (Owner Director of
  Strategic Commissioning) The number of
  inpatients waiting over 11 weeks has decreased
  in January (542) compared to December (571),
  with a variance from plan of 392. Our largest
  acute provider, NWLH, was unable to maintain a
  normal period of operating over the Christmas and
  New Year period, due to medical and nursing staff
  shortages. There has been some spill-over from
  this into January. Although above plan the trend
  has been that the actual number waiting over 11
  weeks continues to decrease compared to previous
  months. This trend has continued for February
  where the number of patients waiting over 11
  weeks at NWLH was 213,compared to 341 in January.
  
• Outpatient waits over 5 weeks (Owner Director of
  Strategic Commissioning) -The number of
  outpatients waiting over 5 weeks has decreased in
  January (909) compared to December (1365), with a
  variance from plan of 261. Although above plan
  the trend has been that the actual number waiting
  over 5 weeks continues to decrease compared to
  previous months. Looking ahead, this trend has
  continued for February where the number of
  patients waiting over 5 weeks at NWLH was
  223,compared to 541 in January.
• Community Matrons and VHIUs (Owner Director of
  Provider Development and Estates) Late
  recruitment of Community Matrons - 2 started in
  Sept 07, 1 started in Oct 07. Case finding and
  patient list validation process will be
  accelerated to increase number under case
  management to 210 by March 08.
• Choose and Book (Owner Director of Primary and
  Community Commissioning Services) There are
  still concerns regarding slot availability at
  Provider Trusts which affects our current
  performance. It is also apparent that initial IT
  training is not sufficient to ensure that Choose
  and Book is used routinely to deliver maximum
  patient benefit. EMT have agreed that we should
  look at improving the system with our current
  resource this would include reviewing the IT
  infrastructure with GP practices and upgrade any
  noncompliant system, review current training
  capacity, and PEC engagement with raising the
  profile of CB, using the 18 week target as a
  lever.
• Blood pressure and Cholesterol Management (Owner
  Director of Primary and Community Commissioning
  Services)- Recording of this may be less than
  target as CHD prevalence is lower than expected
  in Brent. This will be a priority for QOF reviews
  in 2008/09. QOF reviews have not taken place in
  2007/08 and less than a third of practices were
  visited in 2006/07. All practices will undergo a
  QOF review in 2008/09 when the primary care
  performance regime and team will be fully
  established.
• BMI recording status (Owner Director of Primary
  and Community Commissioning Services)- BMI
  position is poor as it is not part of QOF.
  Currently 22 practices are participating in a
  pilot being supported by Imperial College to
  extract clinical data from practice clinical
  information systems including BMI and smoking.
  We are exploring the feasibility of extending
  this to all practices for 2008/09 as part of the
  incentive scheme to share health status data.
• Crisis Resolution Services (Owner Director of
  Strategic Commissioning)- Verbal Update to be
  provided at meeting.
• Chlamydia Screening (Owner Director of Strategic
  Commissioning)- Plans introduced to increase
  chlamydia screening include -
• Expanding the size and staffing levels within the
  Chlamydia Screening Programme (CSP) by joining
  with Hillingdon PCT and thereby increasing
  overall resources.
• Increasing overall financial contribution of each
  of the 3 PCTs in the CSP for the next two years.
  Brent has introduced incentives to increase
  screening in pharmacies.
• Investigate the potential to develop incentives
  through Locally Enhanced Service for sexual
  health services in primary care.
• Increase the number of testing sites.

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Part 3Acute Commissioning Report Summary

• Year to date overspend 2.9m at month 11 (based
  on 10 months activity
• data)
• Increased from 2.1m at month 9 (based on 8
  months activity data)
• Net YTD overspend movement between month 9 to
  month 11 as follows
• 
  M9
  M11
• 
  m m
• Acute contracts 3.4
  2.9 5.2 3.6
• Other acute spend
• - Consortia
  (0.2) (1.9) (0.4)
  (2.3)
• - High Cost Drugs (0.5)
  (49.8) (0.7) (54.5)
• - Non Contracted activity -
  - (0.1) (3.9)
• - Other budgets (0.5)
  (15.5) (1.2) (30.1)
• 
  2.1 1.5 2.9
  1.7
• The remainder of this report focuses on the acute
  contract activity

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DATA FLOWS/VALIDATION

• The PCT receives contract monitoring reports for
  each acute provider approximate 4/5 weeks
  after the end of the period
• The month 11 acute commissioning report is
  therefore based on 10 months activity
  extrapolated and includes PCT review and
  challenges (see below)
• There is a set national timetable for quarterly
  finalisation and agreement of acute activity and
  payments, known as the flex and freeze
  process. The key dates for validation and
  agreement of Quarter 3 activity are as follows
• March 14 last date by which PbR completed
  spells and attendances relating to Q3 can be
  submitted or amended by providers
• March 28 last date for commissioners to send
  queries
• April 9 date by which invoices for Q3 must be
  agreed for payment
• The PCT raised a number of queries/challenges
  with NWLH at Q1 and Q2 and the agreed outcome of
  these is reflected in the position. An
  assessment of the potential outcome of Q3 has
  been made in compiling this report.

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SUMMARY VARIANCE ANALYSIS BY PROVIDER

• Month 8
  Month 10 Detailed Analysis
• 000
  000
• NWLondon (1438) (2.5)
  (1807) (2.6) Slides 19-22
• Hammersmith (1483) (12.9)
  (2043) (14.3) Slides 23-24
• St Marys 139 0.8
  (71) (0.3) Slide 25
• Royal Free (38) (0.7)
  (282) (4.0) Slide 26
• Other Trusts (214) (1.4)
  (497) (2.7) Slides 27-28
• Total (3033) (2.9)
  (4700) (3.6) Slides 29-30
• The total overspend increased from 3m at Month
  8 to 4.7m at Month 10

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VARIANCE ANALYSIS BY PROVIDERNORTH WEST LONDON
HOSPITALS
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Outpatient Attendances for NWLH (PbR)06/7
Outturn (M10) vs 07/8 M10 Plan and Actuals

• Overall OP Attendances variance against plan
  increased from -6.1 at M8 to to 7.7 at M10
• Reduction on 06/07 outturn of 5

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Accident and Emergency Activity for NWLH
(PbR)06/7 Outturn (M10) vs 07/8 M10 Plan and
Actuals

• Total AE attendances planned was for a 10
  reduction in 06/07 Outturn
• Month 10 actuals are a 7.3 increase on 06/07
  Outturn

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NWLH Excess Bed-days Increase in activity in
Non-Elective Non-emergency M8-M10
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VARIANCE ANALYSIS BY PROVIDERHAMMERSMITH
HOSPITALS
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Electives for Hammersmith (PbR)06/7 Outturn
(M10) vs 07/8 M10 Plan and Actuals

• Variance to plan continues at similar levels to
  month 8
• Total Activity broadly constant 06/07 to 07/08

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VARIANCE ANALYSIS BY PROVIDERST MARYS HOSPITAL
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VARIANCE ANALYSIS BY PROVIDERROYAL FREE HOSPITAL
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VARIANCE ANALYSIS BY PROVIDEROTHER PROVIDERS
Adverse Variance of 100K detailed on next slide
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VARIANCE ANALYSIS BY PROVIDERANALYSIS BY CATEGORY
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VARIANCE ANALYSIS BY ACTIVITY TYPEALL PROVIDERS
29
CHANGE OF VARIANCE BY ACTIVITY TYPE ALL PROVIDERS
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Appendix 1 Summary Operating Cost Statement 11
mths ending 29/2/08
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Appendix 1 Summary Operating Cost Statement 11
mths ending 29/2/08
32
Appendix 1 Summary Operating Cost Statement 11
mths ending 29/2/08
33
Appendix 1 Commissioning of Healthcare Summary
for 11 mths ending 29/2/08 (Joint Commissioning)
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Appendix 1 Commissioning of Healthcare Summary
for 11 mths ending 29/2/08 (Acute Commissioning)
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Appendix 1 Commissioning of Healthcare Summary
for 11 mths ending 29/2/08 (Joint Commissioning)
36
Appendix 1 Primary care
37
Appendix 1 Primary care
38
Appendix 1 Provider services
39
Appendix 1 Management HQ
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Appendix 2 Balance Sheet for 11 mths ending
29/2/08
41
Appendix 3 Capital
42
Appendix 3 Capital
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Appendix 4 Cash Flow Report to 29/2/08