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 2-8) Part 2
Performance report (slides 9-15) Part 3 Acute
commissioning report (slides 16-28) Finance
Appendices 1. Summary Operating Cost Statement
and variances by budget heading 2. Turnaround
reconciliation to budgets 3. Balance sheet 4.
Capital 5. Cash flow
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PART 1 FINANCE REPORTFinancial position -
Summary

• Statutory duties
• Forecast overspend against revenue resource limit
• Forecast under-spend 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 9 year end forecast
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• Reasons for movement in forecast outturn M7 to M9
• Acute Commissioning (0.8 million deterioration)
• Movement mainly accounted for by deterioration
  of NWL Hospitals NHST and
• smaller acute contracts. Lack of routine
  management information and analysis
• of trends being addressed.
• Joint Commissioning (0.5 million improvement)
• Comprises improvements across range of budget
  headings
• Primary care (0.7 million improvement)
• Improvement in prescribing underspend
• Balance Sheet (0.9 million deterioration)
• More prudent view taken of potential bad debts.

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Risk of further movement in forecast outturn

• The month 7 review identified 19 factors that
  could cause a material
• movement in the forecast outturn and of these
  17 were assessed as red or
• amber (i.e. high / medium risk in respect
  of both impact and likelihood).
• At month 8, 15 remained red or amber i.e. the
  level of confidence in the
• forecast outturn remains low.
• At month 9, further progress has been made but
  13 remain red/amber

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Summary of major uncertainties relating to
forecast outturn

• Acute commissioning- understanding of position,
  impact of challenges, 18 weeks position
• Joint Commissioning- outcome of negotiations with
  Brent (and others)
• Provider arm- accuracy of expenditure forecast,
  income risks
• Restructuring costs- actual costs v. estimate
• Balance sheet - debtors, creditors, capital
  charges
• Financial capacity and capability- both within
  the finance team and the wider organisation
• The month 9 forecast is the best forecast
  possible with the information available. Once the
  above issues are addressed, the forecast is
  likely to change. The movement could be in either
  direction.

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Next Steps/Actions re Financial Position

• Review by Directors/EMT of current budgetary
  position and opportunities to
• improve the forecast outturn
• - non-recurrent measures in last
  quarter
• - ongoing delivery of Turnaround
  measures
• - other opportunistic savings.
• Implementation of action plan in respect of
  financial capacity and capability
• - detailed action plan produced
  for EMT/Audit Committee for implementation
• Jan-Mar 2008
• - aims to address weaknesses
  identified by audit, incoming DoF etc
• - includes review of 2008/09
  structure
• - will be reviewed for
  completeness in light of Taylor enquiry.

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Part 2 Performance Report

• Performance dashboard for the period ending
  November 2007 (monthly targets) and Q2 07-08
  (quarterly targets).
• The dashboard is consistent with the Strategic
  Health Authoritys Performance report as at the
  end of Q2 07-08. Brent PCT was rated as RED at
  the end of Q2, based on the combined score of the
  PCTs performance on Key targets (RED) and Other
  targets (AMBER).
• The RED areas are detailed with narrative on
  reasons and the action taken.
• The format and analysis of the Performance report
  will be developed for future reports.

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SHA Performance Regime PCT risk ratings Q2 07-08
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PERFORMANCE DASHBOARD- Key National Priorities
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PERFORMANCE DASHBOARD- Other PSA targets (1)
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PERFORMANCE DASHBOARD- Other PSA targets (2)
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Key National Priorities- Narrative

• 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. Since April
  2007 Brent as lead commissioner for NWLHT
  includes performance targets for HCAIs in its SLA
  and performance against these targets is being
  monitored through contract performance monitoring
  mechanisms, and via the Brent and Harrow HCAI
  group. Universal screening is being established
  for all admissions to the trust, although there
  is considerable progress to be made with rolling
  this out widely for all elective admissions. Good
  progress is reported by NWLHT in screening
  emergency admissions via AE (up to 50) and in
  some surgical specialities (TO 100).
• AE 4 hr wait (Owner Director of Strategic
  Commissioning) NWLHTs AE 4 hr wait
  performance is below target. NWLHT have been
  asked by the SHA to provide action plans and AE
  performance has been the subject of discussion
  between the Chief Executives and remains on the
  agenda of the monthly contract meetings.
• Non Admitted 18 week RTT target (Owner Director
  of Strategic Commissioning) In November 75.6
  of patients completed their pathway in less than
  18 weeks. Weekly monitoring and additional audit
  and validation of the backlog patients is in
  place.
• Admitted 18 week RTT target (Owner Director of
  Strategic Commissioning) - In November 45 of
  patients completed their pathway in less than 18
  weeks. The main risk is in surgical specialties
  at NWLHT, especially Trauma and Orthopaedics.
  Plans in place to reduce the length of time from
  GP referral to decision to place on a waiting
  list for Trauma and Orthopaedics and to manage
  all capacity efficiently for other surgical
  specialties.
• Inpatient waits over 11 weeks (Owner Director of
  Strategic Commissioning) Although above plan
  the variance is small (31), the actual number
  waiting over 11 weeks continues to decrease
  compared to previous months and we will continue
  to monitor.
• Diagnostic waits over 13 weeks (Owner Director
  of Strategic Commissioning) The number of 13
  week breaches is small (14) and is spread out
  over a variety of tests at NWLHT and UCL. The
  average monthly no of 13 week breaches which
  occurred between April 07 and October 07 has been
  238.
• 4 week 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. Smoking cessation
  remains a PCT priority and a multi-pronged
  approach is being developed and implemented to
  increase the number of smoking quitters.
  Engagement with primary care, including pharmacy,
  to encourage ownership and support delivery of
  our local targets lies at the heart of this new
  approach to smoking cessation in Brent. A revised
  community adviser scheme has been re-launched and
  so far 16 pharmacists have signed up to
  participate in the scheme.

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Other PSA Areas - Narrative

• Breast Screening (Owner Director of Public
  Health) - there have been severe problems with
  performance of the North London Breast Screening
  Service, commissioned by Brent, over an eighteen
  month period between 2004-2006, which eventually
  culminated in the temporary suspension of the
  service in December 2006. The expected impact of
  suspension of the service is a delay in enabling
  the target 36 month call/recall guidelines, which
  in effect will result in the inability to meet
  the coverage target of 70 .
• Community Matrons and VHIUs (Owner Director of
  Provider Development and Estates) Q2 was 0 for
  VHIUs because we did not have any community
  matrons at the time. The matrons started patient
  contacts in October and are making progress that
  will be reflected in the Q3 figures.
• 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.
• Patient experience of choosing 4 Providers for
  treatment (Owner Director of Primary and
  Community Commissioning Services) Response rate
  was low for surveys. The PCT submitted a revised
  access improvement plan to NHS London in December
  2007 which included approving practice plans as
  part of the DES which will address areas of
  poorer satisfaction identified within the survey.

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PART 3ACUTE COMMISSIONING REPORT SUMMARY

• Year to date overspend 2.1 million and year end
  extrapolated year end forecast overspend 2.8
  million (1.5)
• Forecast outturn has increased from 1.0 million
  at month 6
• Net YTD overspend comprises
• m
• Overspend on acute contracts 3.4 2.9
• Underspend on other acute spend
• Consortia (0.2) (1.9)
• High cost drugs (0.5) (49.8)
• Non contracted activity - -
• Other budgets (0.5) (15.5)
• 2.1 1.5
• Remainder of this report focuses on acute
  contract position as at month 8

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DATA FLOWS/VALIDATION

• The PCT receives contract monitoring reports from
  each acute provider approx. 4/5 weeks after the
  end of the period (i.e. reports for the period
  ended 30/11 received late December/early
  January).
• The month 9 acute commissioning finance report is
  therefore based on 8 months activity extrapolated
  and includes PCT review and challenge (see
  below).
• There is a set national timetable for quarterly
  finalisation and agreement of acute activity and
  payments, know as the flex and freeze process.
  The dates for validation and agreement for Q2 and
  Q3 are as follows
• Q2 Q3
• Flex 26/08/07 25/01/08
• Freeze 14/12/07 14/03/08
• The PCT has raised a number of queries/challenges
  with NWLH at Q2 and an assessment of the success
  of these has been made in compiling this report.
• More detailed activity information (by
  specialty/practice) is contained within the
  national Secondary User System (SUS). However
  this information is not yet used for the payments
  made to Trusts.

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VARIANCE ANALYSIS BY PROVIDERNORTH WEST LONDON
HOSPITALS
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Outpatient Attendances for NWLH (PbR)06/7
Outturn (M8) vs 07/8 M8 Plan and Actuals
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Accident and Emergency Activity for NWLH
(PbR)06/7 Outturn (M8) vs 07/8 M8 Plan and
Actuals
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VARIANCE ANALYSIS BY PROVIDERHAMMERSMITH
HOSPITALS
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Electives for Hammersmith (PbR)06/7 Outturn (M8)
vs 07/8 M8 Plan and Actuals
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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
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VARIANCE ANALYSIS BY ACTIVITY TYPEALL PROVIDERS
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GP Referrals Analysis

• Analysis of GP referrals per specialty at top 4
  Acute Trusts
• Based on 06/7 Outturn and 07/08 Forecast outturn
  from Q2-2007 data
• Overall decrease in GP referrals of 3
• NWLH decrease by 6
• Analysis to identify shifts in demand per
  provider/specialty

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Changes by Provider and Specialty

• All GP referrals NWL -6 reduction in GP OP
  referrals, all Hosps -3 decrease
• Dermatology NWL -30 decrease, overall -17
  decrease
• Cardiology NWL -27 decrease, overall -17
  decrease
• Gastro NWL -17 decrease, overall -12
  decrease
• ENT NWL -9 decrease , overall -5
  decrease
• Opthalmology NWL -8 decrease, overall -1
  decrease (Shift to RFH
• TO NWL 10 increase, overall 1 increase
• Gynaecology NWL 6 increase overall 5
• Others NWL 5 reduction, overall 3

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Appendix 1 Summary Operating Cost Statement 9
mths ending 31/12/07
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Appendix 1 Summary Operating Cost Statement 9
mths ending 31/12/07
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Appendix 1 Summary Operating Cost Statement 9
mths ending 31/12/07
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Appendix 1 Commissioning of Healthcare Summary
for 9 mths ending 31/12/07 (Acute Commissioning)
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Appendix 1 Commissioning of Healthcare Summary
for 9 mths ending 31/12/07 (Joint Commissioning)
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Appendix 1 Commissioning of Healthcare Summary
for 9 mths ending 31/12/07 (Joint Commissioning)
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Appendix 1 Primary care
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Appendix 1 Primary care
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Appendix 1 Provider services
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Appendix 1 Management HQ
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Appendix 2 Turnaround analysis
25m was taken out of budgets at the start of the
year as per the above analysis
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Appendix 2 Turnaround reconciliation to
Budgetary Performance
The above shows that against the turnaround
reductions to budgets of 25m, the current
forecast achievement is 17.8m. This variance is
then compared with month 9 forecast outturn
variance. The 17.8m compares to the latest
Turnaround Report forecast of 24.4m as
follows Current Budget Forecast
17.8m Continuing Care 3.6m
Prescribing 0.4m Management Costs
0.8m Acute Commissioning/other
1.2m Neasden 0.6m Total 24.4m
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Appendix 3 Balance Sheet for 9 mths ending
31/12/07
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Appendix 4 Capital
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Appendix 4 Capital
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Appendix 5 Cash Flow Report to 31/12/07