Quality, Performance and Finance Report May 2014

1. Quality, Performance and FinanceReportMay 2014

2. Contents

3. Background and Timetable Please find attached the Quality, Performance and Finance report (QPF) for NHS Durham Dales, Easington and Sedgefield CCG for May 2014. Activity and finance data used in the report is for month 12 (March 2014) . The report uses the latest published metric data for quality and performance, and where possible if later unpublished data (white text) is available this has been included. If information is not available it has been flagged within the report. NECS will continue to work with the CCG to ensure the content and format of the report fits with the needs of the organisation. In addition to the formal QPF report the Quality and Performance published data is now available in RAIDR.

4. Executive Summary Report Amendments Future developments: On-going development as per CCG requirements Recommendation:This report is for the CCG to note current performance and the risks to national indicators in 2013/14. The committee is asked to endorse the actions to address underperformance and suggest further remedial action if appropriate.

5. Quality Performance

6. Exception Report QER01 – CQC Enforcement Performance Update: NEAS The CQC published their report on 26.04.14 following their inspection visit to the Trust in February 2014. The CQC found that 4 of the 6 standards inspected were not being met and enforcement action has been issued against the Trust. The areas of concern identified by the CQC are as follows: • Management of Medicines – the CQC found that medicines, other than controlled drugs, were not always stored safely. Medications requiring refrigeration were not always stored properly and securely, fridge temperatures not maintained and stored in vehicles at room temperature. The CQC judged that this has minor impact on people who use the services and advised the Trust that action is required. • Requirement Relating to Workers – the CQC found that since 2009 effective recruitment procedures have not been in place and as a result DBS checks had not been carried out on staff at time of employment or on a rolling basis. The CQC were reassured by the recovery plan and actions in place which was on target for completion by the Trust in April. The CQC judged this moderate impact on people who use the services and issued enforcement action to the Trust. The Trust is also required to provide weekly updates on progress until the recovery plan has reached a conclusion. • Supporting Workers – the CQC found that a significant number of staff had not received one to one supervision sessions. The CQC judged this to have minor impact on people who use the services and advised the Trust that action is required. • Accessing and monitoring the quality of service provision – the CQC found that there was no effective governance process in place to monitor/oversee the complaints system and ensure that all complaints were dealt with in a timely manner in line with Trust policy. A shortfall in availability of investigating officers was also identified. The CQC judged that this had a moderate impact on people who use the service and advised the Trust that action is required. Remedial actions: NEAS The CQC findings will be discussed at the next NEAS CQRG in May 2014. . CCG Comments

7. Exception Report QER02 – Monitor Performance Update: NEAS Monitor are currently investigating concerns in relation to the recent CQC visits outlined in exception report QER01 Remedial actions: NEAS Concerns will be reviewed at the forthcoming CQRG in May 2014. . . CCG Comments

8. Exception Report QER03 – Mortality (SHMI) Performance Update: The North of England Quality Dashboard March 2014 (published April 2014), indicates for the period January 2013 to December 2013 that • CHSFTs overall HSMR rate is worse than expected at 117.8 and • NTHFTs overall rate is worse than expected at 113.4. Remedial actions: CHSFT: A number of actions have been taken by the Trust to improve the reported rates for HSMR including: • all deaths are discussed regionally and peer reviews are carried out to identify any preventable actions, • all case notes are reviewed and deaths scored, • Review of coding underway as differences with approach to use of palliative care coding is main contributing factor NTHFT: • The Trust is continuing to review each death as part of a planned mortality review process to ensure that lessons are learned from avoidable deaths. The tool used as part of this process has been provided from the national team involved in the Keogh review to facilitate local monitoring and national benchmarking. • The Trust is developing a Trust policy to support the activity for ensuring reviews are undertaken; ensuring appropriate structures are in place to ensure information obtained and lessons learned are shared across all levels. Regular updates are provided to clinical teams regarding the current information, which assists in providing an early warning of any changes in mortality. • NHS England and NEQOS are providing support to the Trust in introducing a Pneumonia process measures project; which will allow the Trust to introduce a different approach towards the management of Pneumonia. A deep dive for some re-admissions will commence as part of the Pneumonia process. The project commenced in February 2014 and will run for the duration of 2014 /15. • The Trust is involved with regional work on mortality which is being supported externally by NEQOS. This work has a focus on the overall health within the region and how this has an affect on mortality. The regional group is developing a tool to support reviewing across all Trusts in order to allow direct comparisons as well as peer review. Queries have been raised with the Trust in relation to the anticipated impact of the regional work; the Trust assures that the benefits of the work of the Task and Finish group established following the Keogh report should be visible over the summer period. • The CCG attended an NTHFT review, with 39 patient records reviewed using a criteria based tool and further analysis undertaken as necessary. For the cases reviewed, it was reported that one case out of the 39 could have had an avoidable death outcome. • Trust report to Board to be shared with CCG following Board approval which includes the timeline for the impact of current actions. • CCG requested in May 2014 clarification of coding ( including ambulatory coding), and consideration of any gaps in the context of wider health and social care factors or required actions. Trust have confirmed ambulatory coding is not included CCG Comments

9. Exception Report QER04 – Mortality (HSMR) Performance Update: The North of England Quality Dashboard March 2014 (published April 2014), indicates for the period December 2012 to November 2013 that • CHSFTs overall SHMI rate is worse than expected at 108.98 and • NTHFTs overall SHMI rate is worse than expected at 111.82 Remedial actions: CHSFT: A number of actions have been taken by the Trust to improve the reported rates for SHMI including: • all deaths are discussed regionally and peer reviews are carried out to identify any preventable actions, • all case notes are reviewed and deaths scored, • As reported with HSM a review of coding is underway NTHFT: • Monitoring of HSMR continues through the CQRG. The Trust has identified a target review of cases within the diagnosis groups (within the HSMR indicator set), these are; Pneumonia, Aspiration Pneumonitis, Congestive Heart Failure and Urinary Tract Infection. • The Trust is continuing to review each death as part of the planned mortality reviews, where all deaths in hospital are reviewed to ascertain if an individuals death was avoidable. The tool used as part of this review has been provided from the national team involved in the Keogh review. • The Trust is developing a Trust policy to support the activity for ensuring reviews are undertaken; ensuring appropriate structures are in place to ensure information obtained and lessons learned are shared across all levels. Regular updates are provided to clinical teams regarding the current information, which assists in providing an early warning of any changes in mortality. • NHS England and NEQOS are providing support to the Trust in introducing a Pneumonia process measures project; which will allow the Trust to introduce a different approach towards the management of Pneumonia. A deep dive for some re-admissions will commence, as part of the Pneumonia process. Monitoring continues through the respective CQRGs. CCG Comments

10. Exception Report QER05 - Friends and Family Test Performance Update: March published indicates the following concerns : CDDFT: In patient response rates - UHND at 29.67% remains below the England average of 34.8. In patient score - DMH obtained a score of 69, UHND 71 both sites continue to remain slightly below the England average of 73. A&E response rates - DMH increased their response to 14.79% but still remain below the national average and target. A&E Scores - both hospitals scored 41 which is an improvement on previous month but these still continue to remain significantly below the national average of 54. CHSFT: only area to highlight in relation to FFT is that the A&E response rate for CHSFT fell to 14.66 taking it below the national target of 15%. NTHFT: only area to highlight is that the in-patient score at North tees hospital site at 68 fell below the England average of 73. Remedial actions: CDDFT: FFT remains a standing agenda item at the CQRG. As reported previously CDDFT identified an issue regarding the accuracy of the FFT in-patient and A&E data. A re-count of the Trust’s FFT data from April 2013 has taken place and NHS England is expected to publish the revised data in late May 2014. This will be shared with CCGs when this is available. CHSFT: Performance regarding A&E response rate will be monitored through forthcoming FFT data and discussed at the CQRG. NTHFT: Performance regarding the In patient score at the North Tees site will be monitored through forthcoming FFT data and discussed at the CQRG. CCG Comments

11. Exception Report QER06 - Unclosed Serious Incidents Performance Update: Remedial actions: The majority of providers nationally continue to experience problems in achieving the 45 and 60 day targets. Breaches are a consequence of internal governance systems within providers delaying the release of reports to the Commissioner. Performance related activity continues to be monitored through the serious incident panel and informal 1:1 meetings with providers. The CQRGs are also responsible for formally monitoring this activity. CCGs have incorporated SI performance into the quality requirements of the 2014/15 contract with providers. CCG Comments

12. Exception Report QER07 - HCAI Performance Update: MRSA There is a zero tolerance of MRSA which means that all commissioner and provider targets are zero. DDES CCG reported 1 case in September and 1 case in January CDDFT reported 1 case in September CHSFT reported 1 case in April, August, September and 1 unpublished case in March – 4 in total NTHFT are reporting zero cases C.Diff DDES CCG – 73 cases identified to 31st March against an annual target of 87 CDDFT – 27 cases identified to 31st March against an annual target of 40 CHSFT – 40 cases identified to 31st March against an annual target of 36 NTHFT – 30 cases identified to 31st March against an annual target of 40 Remedial actions: All breaches are discussed through monthly Clinical Quality Review Group meetings. The post infection review process has been followed for all identified cases with relevant lessons learnt identified and actions implemented as appropriate. CCG or Director Comments 12 12

13. NHS Constitution Performance Summary

14. NHS Constitutional Indicators by month - DDES CCG

15. NHS Constitutional Indicators by month - CDDFT

16. NHS Constitutional Indicators by month - CHSFT

17. NHS Constitutional Indicators by month - NTHFT

18. NHS Constitutional Indicators by month - NEAS NHS Constitutional Indicators by month – TEWV / MH

19. Exception Report CDDFT ER01 Performance Update CDDFT were below the target in January ( 92.4%) and February (93.3%), while the performance trend improved during March (96.6%) this wasn’t enough to achieve the 95% target, and Q4 Performance to week 52 (30th March 2014) is 94.1%. Year end performance is 94.9%. CDDFT have sustained an improvement in A&E performance since 3rd March. 2014/15 YTD and Q1 performance is 95.5% as at week ending 4th May 2014. Remedial actions: • CDDFT – The Emergency Care Intensive Support Team (ECIST) visited the Trust in December 2013 and their initial feedback and recommendations included within the ‘Whole System Letter’ has now been shared. The ECIST recommendations, together with the Trust’s Acute and Long Term Conditions Emergency Department (ED) Recovery Plan have been considered by the County Durham and Darlington Urgent Care Working Group (UCWG) and agreement has been reached that the remit of the Front of House Task Force will change to become an ECIST implementation Project Group, accountable to the UCWG. • CCG and NECS colleagues are continuing to support CDDFT to implement the ECIST recommendations. • A working group now meets monthly to review delayed transfers of care. A multidisciplinary team (MDT) pilot is being implemented at specific wards at UHND to support discharge management processes and following evaluation will be considered for roll out across the Trust. • A bed predictor tool is being developed to improve the management of inpatient beds and a new bed management IT system is being implemented later in 2014. • Visits to other providers have taken place including North Tees & Hartlepool NHS FT ED and Emergency Assessment Unit (EAU) and City Hospitals Sunderland NHS FT Intermediate Care Beds to learn from examples of good practice. • CDDFT have successfully reviewed and improved their ED Ambulatory and Rapid Assessment & Treatment (RAT) Streams for patients arriving at Emergency Departments at Darlington Memorial Hospital and University Hospital North Durham. The aim of both streams is to ensure that each patient is seen by the right clinician in the Emergency Department, first time, every time. Beginning with an initial decision by a Nurse Navigator (senior nurse/doctor), patients are guided to the most appropriate practitioner for their needs. Successful pilots of this initiative across both hospital sites resulted in full implementation from 1st April 2014. • CCG Chief Officers are continuing to monitor A&E Performance and will re-introduce fortnightly meetings with the Trust and Area Team Chief Executives, to agree actions if A&E Performance falls below the 95% target. 19

20. Exception Report CDDFT ER02 Performance Update CDDFT continues to experience consistently high levels of handover delays, resulting in poor performance in relation to the Ambulance handover target. Whilst Performance in December, January and February remained high, there was a marginal improvement during March. However the provider continues to be an outlier across the region. During March 2014, CDDFT are reporting 61.7% of handovers taking place within 15 minutes. 6.2% (256) experiencing 30-60 minute delays and 2.0% (84) experiencing 60-120 minute delays There were 7 instances where handover delays exceeded 2 hours • Remedial Actions: • The recommendations from a recent jointly commissioned review of handover and turnaround issues (the Pease Report) are taken into account in the Whole System Unscheduled Care Action Plan. CDDFT have also confirmed their intention to implement “quick win” recommendations from the recent ECIST review to improve patient flow and reduce pressure ‘Front of House’. • Additional winter monies were allocated to NEAS & CDDFT during 2013/14 to support close management of patient flow from the Ambulance Handover queue into urgent/emergency care and additional PTS discharge ambulance support for the University Hospital of North Durham to transport patients who are being discharged from Hospital. • The CDDFT Patient Safety Team have produced all Root Cause Analysis (RCA) reports for ambulance handover delays of 2 hours and over. CDDFT are required to share these RCA reports with Durham, Darlington and Tees Area Team. • NEAS are providing Hospital Ambulance Liaison Officer (HALO) at UHND to manage ambulance handover delays. • From 1st April 2014, a Senior Nurse or ED Consultant has responsibility for managing ambulance handovers. • CDDFT have successfully reviewed and improved their ED Ambulatory and Rapid Assessment & Treatment (RAT) Streams for patients arriving at Emergency Departments at Darlington Memorial Hospital and University Hospital North Durham. The aim of both streams is to ensure that each patient is seen by the right clinician in the Emergency Department, first time, every time. Beginning with an initial decision by a Nurse Navigator (senior nurse/doctor), patients are guided to the most appropriate practitioner for their needs. Successful pilots of this initiative across both hospital sites resulted in full implementation from 1st April 2014. 20

21. Exception Report CHSFT ER01 Performance Update City Hospitals Sunderland (CHSFT) have continued to experience significant pressures within their A&E department due to an increased number of ambulance arrivals and more acute Type 1 attendances. Improvements have continued to be made from February onwards with March reaching 96.22% giving a year to date position of 94.44%. The Trust attribute this position to the inability to recruit to additional medical and nursing staff in addition to the higher level of acuity patients presenting. Remedial actions: • Work continues between Provider and Commissioner to improve this position. Whilst Pallion Health centre is available to redirect patient for treatment, the acuity of patients presenting means that this is not always possible and has therefore not had the desired impact expected. • CHS are continuing with recruitment plans for both medical and nursing staff and confirm that an additional A&E consultant has been appointed. The Trust have flagged that recruitment of staff is still the main issue with ensuring the target is achieved. • The Trust met with Sunderland CCG and the Area Team in the week commencing 11th May.  It was agreed that CHS would compile a report to present the current position in terms of A&E generally.  This report will be presented to the next QRG (June) and will cover activity comparisons from 12/13 against 13/14 as well as key quality metrics, what further work needs to be undertaken to assist in performance, narrative against the measure taken to date and how these have helped i.e. the opening of Pallionetc as well as details around complaints and incidents. • The Trust identified that some Sunderland GP practices were sending patients in via ambulance that could be managed in an alternative setting and this has been dealt with by Sunderland CCG who are working with practices to resolve this.   21

22. Exception Report CHSFT ER02 Performance Update City Hospitals Sunderland have experienced significant pressures within their A&E department and have continued to highlight the large volume of batched ambulance arrivals. The Trust highlighted they had received 28 within a 5 hour period during a week in April. These pressures have resulted in an increase in the number of ambulance delays. Although the target has been breached there have been significant improvements in comparison to last year although the volume of ambulance arrivals have increased. In addition, although performance improved in November there was a spike in handovers waiting over 30 minutes and 60 minutes through December to March. This is being investigated by the Trust. Remedial actions: • Commissioners are working closely with CHSFT through the Unscheduled Care workstream to identify solutions to the high volumes of activity. The meeting has representation from a number of organisations including stakeholders from Sunderland and DDES CCG’s, CHSFT and NEAS. • The Trust have implemented a joint action plan with NEAS. GP awareness of ambulance categories has been improved, rapid sign on has been established, additional staff have been appointed and are awaiting a start date. Further work is ongoing with CHSFT reviewing ED nursing staff to ensure availability matches the streams in the service and the Trust are working with NEAS to ensure they can feed in directly to specific services, the governance issues for this are currently being addressed. • Sunderland CCG are working with NEAS, funding two specific schemes to help stream ambulances to alternative dispositions such as Minor Injury Units, Urgent Care Teams and district nurses etc.  These schemes are now operational and work is ongoing with NEAS to understand the impact. In addition the unscheduled care board are working to allow 7 day discharges, funding additional ambulances to get patients home, commissioning 7 day working for social workers and a readmissions avoidance team. These have improved delayed transfers of care with the current delays being the lowest number in years which is improving flow in the Trust. • To ensure focus remains on achieving this target, a specific indicator has been included within the 14/15 CQUIN scheme within which the trust will be looking to achieve hitting a target based on a local average performance for each quarter. 22

23. Exception Report CHSFT ER03 Performance Update City Hospitals Sunderland continue to experience significant pressures within Urology resulting in breaches in cancer waiting times in January, February and March. Remedial actions: • CHS have placed the Directorate into internal escalation in order to resolve the ongoing issues. Weekly meetings are held with the Directorate to look at current waiting times, capacity and breaches. • The Directorate are continuing to utilise all available theatre capacity to reduce inpatient waiting times and have made personnel changes within the administrative team to enhance scheduling and waiting list management. • Commissioners, working with Sunderland CCG to ensure a joint approach, plan to meet with the Trust at the end of May / start of June to discuss what further actions can be taken and offer support to explore innovative solutions to resolve the ongoing issues. 23

24. Exception Report DDES ER01 Performance Update: DDES CCG have failed this target in each of the last 9 months (Jun-Feb). Performance improved in March to 87.3% but the CCG still failed the 4thQtr overall (84%). Patient level breach information is not yet available. However there still remain issues in respect of Urology capacity at CHS where patient choice of robotic surgery is causing delay and Upper GI surgery referrals to Newcastle are also failing to achieve the target. In 4thQtr, 26 patients breached the 62 day target in DDES CCG across the following specialties – Breast (1), Lung (7), Gynaecology (2), Upper GI (2), Lower GI (1), Urology (9), Head & Neck (2) Sarcoma (1) and Skin (1). CHS and STHT both failed to achieve the 62 day target in 4 Qtr with 80% and 83.5% respectively. Remedial actions: • South Tees FT has been reviewing a 12 months worth of cancer breaches in an attempt to identify the main themes within those breaching: The themes identified are: • Late referrals - including those patients that are not fully worked up before being referred • Patient choice • Slow pathways (14 day for 2ww and 14 day for diagnostic) • Complex pathways (more than 1 tumour site or unknown primary). • This analysis is to be used within the Trust to identify what can be done to resolve these issues going forward. In addition to this the Trust is working collaboratively with other Providers to try and understand cancer pathways further to try and ascertain where changes are required to make a patients journey as efficient as possible. • Although South Tees and Newcastle are liaising regarding how late referrals should be managed, any movement in where the breach should be apportioned does not resolve the problem. Further work is required to review pathways at a Network level to fully understand how/if pathways can be rationalised to ensure the target is achieved wherever possible, patient choice not withstanding. • CHS are known to have an internal escalation process in place in respect of Urology. Weekly meetings are in place to discuss current activity, performance, breaches etc and a copy of their Urology action plan has been requested, along with any other cancer related action plans. • Breaches at a specialty level will be discussed with the Providers through the contract / performance meetings. CCG or Director Comments 24 24

25. Exception Report NEAS ER01 Performance Update: The North East Ambulance Service (NEAS) continues to meet its regional contract-wide target to achieve response to 75% of Red1 and Red2 calls in 8 minutes and 95% in 19 minutes. NEAS is not contractually obliged to meet those targets at CCG level. DDES, North Durham and Northumberland CCGs rarely met the regional 75% target and it was agreed within the 2013/14 contract that NEAS would have a target of 71% R8 for those three CCGs. Local performance for Quarter 3 & 4 is detailed below. Performance in DDES for March is above historical performance. Performance is consistent with the seasonal trend experienced in previous years, though performance for the yearend, 67.79%, is above previous years’ performance. Overall, during March, the 71% level of performance was missed by 113 incidents. Remedial actions: • Discussions continue with NEAS regarding initiatives to assist performance, including taking action to reduce conveyance rates to hospital and increasing the number of patients that can be seen and treated by NEAS. The Paramedic/GP 5 minute ring back initiative went live on Monday 2nd December 2013, providing rapid GP telephone support to paramedics across County Durham and Darlington. Feedback suggests that this initiative is having a positive impact in reducing the number of patients being conveyed to hospital. • NEAS are also performing significant work to focus on ‘frequent callers’ and identify how these patients can be supported to avoid frequent ambulance call-outs where possible. • Additional Winter Monies have been allocated to a range of organisations, including NEAS to assist in managing pressures over the winter period. • For 2014/15 and a separate contract for the Durham, Darlington and Tees CCGs is now being negotiated, rather than the current single North-East wide contract, to allow greater focus on the performance issues that exist in the south of the region. CCG or Director Comments 25 25

26. Exception Report MH ER01 Performance Update: The proportion of people entering therapy target continues to be underachieved with the YTD figure reported as 8.23% against a target of 12.00% which is a rising trajectory. The number of people moving to recovery has seen a further improvement and the target of 50.0% was exceeded in March, the reported position was 59.84%. It should be noted, as previously reported, that the CCG commissions additional talking therapies by way of a counselling service, which are not included in these figures. Therefore an additional proportion of the local population are receiving treatment above that reported via the IAPT service. It should be noted that the target for the proportion of people entering therapy is to achieve 15% of an estimated prevalence by 2015. Remedial actions: • A contract query was issued to the provider following the Quarter 1 contract meeting (1st August 2013). • The information was received within requested deadlines (23rd September 2013) • This data was presented and discussed at an interim contract performance meeting (4th October 2013). • The resulting action was to issue the provider with a formal performance notice requesting improved staffing levels, service promotion, caseload monitoring and analysis of the number of people not entering therapy from those referred. A remedial action plan was presented and agreed on 29th October and this was distributed to CCG chief officers for information. • The first review of the action plan took place on 8th December and a further reviews have been scheduled. • The year end position has seen the remedial action plan rectifying the mid-year reduction in performance. The target remains unachieved and as such the performance notice and remedial action plan will remain in place during 2014/15. Some actions have longer term implications, and an increase in performance is expected from 1st May following the implementation of actions to tackle service user retention on the scheme. CCG or Director Comments 26

27. Quality Premium Introduction The 'quality premium’ is intended to reward CCGs for improvements in the quality of the services that they commission and the associated improvements in health outcomes and reducing inequalities. The quality premium paid to CCGs in 2014/15 will reflect the quality of the health services commissioned by them in 2013/14 and will be based on four national measures and three local measures. It will be a pre-qualifying criterion for any payment that a CCG manages within its total resources envelope for 2013/14 and does not exceed the agreed level of surplus drawdown. The total payment for a CCG based on performance against the four national measures and the three local measures will be reduced if providers do not meet the NHS Constitutional rights or pledges for patients (RTT 18 week, A&E 4 hr, Cancer 62 day & 8 min Cat A ambulance calls). The total amount possible for CCGS to receive in achievement of the Quality Premium will be £5 per patient in the CCG, according to the same formula as the payment of the running cost allowance. For DDES CCG this amounts to £1,439,290. The following page highlights the indicators against which the quality premium will be determined, together with the relevant financial value attributed to each indicator and the latest assessment of performance. 27

28. National and Local Quality Premium Indicators

29. Quality Premium Information

30. DDES CCG - Outcome Framework Indicators

31. Finance & Activity Overview This report provides an update on the position of the contracts held by NHS Durham Dales, Easington and Sedgefield CCG for the 2013/14 financial year. Finalised performance for the acute contracts is not yet known as the data contained within this report is based on 11 months freeze and one months flex data. This report is intended to provide an understanding of the underlying contractual position, without risk share arrangements applied in order to provide an understanding of the likely impact of current year performance on 2014/15 contract negotiations. Risk share arrangements are in place for the three largest providers of commissioned services – County Durham and Darlington FT, North Tees and Hartlepool FT and City Hospitals Sunderland FT. The County Durham and Darlington FT contract is currently showing a significant over performance at this point in the year. The risk share arrangement mitigates this overperformance in year, but any overtrade will inform negotiations for the next financial year. City Hospitals Sunderland FT and Gateshead FT are both experiencing significant issues with their PAS systems at this point. South Tees, Newcastle and BMI Woodlands acute contracts are all overperforming. Patients appear to be exercising patient choice more frequently in choosing independent sector providers, possibly due to better facilities and waiting time. Prescribing costs and Continuing Healthcare are two areas of significant in year risk to the CCG. The transformation fund is currently significantly underspent. Referrals data for CDDFT has been included at the end of this section of the QPF for the first time this month. Referrals into CDDFT are showing a year on year increase at aggregate level.

32. Finance & Activity County Durham And Darlington NHS FT Overview • Contract Update • This contract is risk share for 2013/14. The contract has now been signed. • Negotiations are ongoing with the provider for 2014/15. Significant differences exist between commissioner and provider positions covering a range of items. • Data Issues • Known business rules have been applied to the data. Work is still ongoing on smaller reconciliation issues. Data is currently being reconciled at patient record level to resolve the remaining issues. • High levels of uncoded data are currently being submitted to SUS by this provider. Flex data (of which there is one month included in this report) is potentially understated. • Financial Performance • The underlying position on the contract is £2,005k overspent at the end of month 12 before readmissions, penalties and threshold adjustments are applied. • No demand plan was agreed with the provider for 2013/14, resulting in differences in variances reported by commissioner and provider. • Pressure areas across the contract include Outpatient procedures (£1,091k) (mainly ophthalmology) and excess bed days £1,250k (predominantly general medicine). • Referrals are significantly up on 2012/13 (c9.9% in total) across a number of specialties including dermatology, general surgery, cardiology and general surgery. • Despite ongoing negotiations around new to review ratios as part of 14/15 contracting, the Trust have agreed to progress the new to review outpatient workstreamfrom commissioning intentions. Initial meetings are happening in May. • Action Points • Continue work around new to review ratios with the Trust

33. Finance & Activity City Hospitals Sunderland NHS FT Overview • Contract Update • This contract has a risk share arrangement for 2013/14. Negotiations for 14/15 are ongoing with only minor issues now preventing contract sign off at time of publication. • Data Issues • This provider is experiencing serious ongoing problems with its Patient Administration System and data submissions should be treated as incomplete. The analysis below is based on the information available. • Financial Performance • This contract is underperforming by £124k YTD. This underperformance is offset by the risk share agreement in place with this provider. No adjustments have been made for readmissions or penalties. • Key areas of overperformanceare within excess bed days (specifically non elective) within admissions recorded via A&E (£142k), T&O (£66k) and Geriatric Medicine (£40k). Outpatient follow ups also show as a pressures area (£1,275k) particularly in Ophthalmology(c£250k), Rheumatology (£228k), T&O (£114k) and Physio £427k (Physio contacts have been recorded with Outpatients, but the plan sits within ‘other services’ this will be resolved for 14/15 reporting. • Key areas of under performance are non elective, outpatient first and ‘Other services’ – specifically Therapies, Physio and SALT services. • Non elective T&O admissions are significantly below plan (£284k) as are Nephrology (£319k), Geriatric Medicine (£467k) and Cardiology (£569k). Admissions recorded via A&E are significantly over performing (£1,342k) – indicating a change in the way non elective inpatients have been recorded is likely.

34. Finance & Activity North Tees and Hartlepool NHS FT Overview • Contract Update • This contract has a risk share arrangement for 2013/14. However, additional costs of circa £124k have arisen in respect of specialist respiratory activity, where the commissioning responsibility has transferred back to CCGs in 2013/14. • Data Issues • None identified • Financial Performance • This contract is underperforming by £3.510m as at M12 flex. This underperformance is offset by the risk share agreement in place with this provider. The plan for North Tees & Hartlepool NHS FT was based on 7 months of data from the previous financial year. • Key areas of underperformance are Non Elective (£2.382m), Outpatient Diagnostics (£321k) and Maternity Pathways (£307k). • One area of over-performance is elective admissions (£180k) over, with orthopaedics accounting for most of this over-performance.. • Forecast outturn • Specialist respiratory activity is outside of the risk share and represents an additional cost of circa £124k including CQUIN (to be confirmed at final M12 freeze).

35. Finance & Activity Newcastle Upon Tyne Hospitals NHS FT Overview • Contract Update • This contract is based on full PbR principles and as such any over/underperformance will be a pressure/benefit to the CCG’s financial position. • Data Issues • Business rules not yet applied have been identified and were applied at month 10, these business rules seemed to be working as expected, ongoing work continues to ensure that all business rules have been applied correctly • Financial Performance • Day Cases has over performed by £241k at month 12, the main HRG Chapters where this is occurring are H Musculoskeletal System, L Urinary Tract & Male Reproductive System and Q Vascular Syste,; • High Cost Drugs (£125k), ITU (£107k) and Medical Devices (£65k) are also areas where there has been an overspend at month 12; • Outpatient Procures is an area where over performance has occurred, the main HRG Chapters where this is occurring is E Cardiac Surgery and J Skin, Breast & Burns.

36. Finance & Activity South Tees Hospitals NHS FT Overview • Contract Update • This contract is based on full PbR principles and as such any over/under performance will be a pressure/benefit to the CCGs financial position. • Contractual penalties such as RTT and ambulance handovers are built in to the position, as is the CQUIN amounts not achieved. • Diagnostic imaging risk shares is built in to the position. • Data Issues • Work is being carried out with the trust to produce a final reconciliation of the data for the year end. • Financial Performance • The current YTD position is £713k above contract at the end of month 12 (flex), including readmissions and risk share adjustments. • A number of areas are showing pressure on this contract: • Other services – drugs (£90k), neurorehab (£175k), ITU (£112k), HDU (£91k) • Non elective are over plan by £202k. Pressures are in: HRG chapter V – multiple trauma, emergency and urgent care procedures (136K), H – musculoskeletal (121K), D – respiratory system (72k) and A – nervous system (51k). • Outpatient procedures are over plan by £156k. Pressures are in: HRG chapter E - cardiac surgery procedures (£66k) and in C – month, head, neck and ears (£47k).

37. Finance & Activity BMI Woodlands Overview • Contract Update • DDES USS pilot is being utilised by many practices. It’s review will help the CCG to determine if they wish to formally commission the service. • Data Issues • None identified • Financial Performance • Costs are higher than plan in all PODs, particularly elective lines and daycase. The year end costs are overspent by £935k. • Year to date pressures are within, trauma and orthopaedics (£201k), pain management (£31k) and gastroenterology (£23k) for the daycase POD. Within the elective POD, the pressures are trauma and orthopaedics (£315k) and gynaecology (£41k). • Forecast Outturn • The outturn was over plan at year end by £935k. • Action Points • The demand file has been set correctly for 2014/15.

38. Finance & Activity North East Ambulance Services POD Analysis • Contract Update • This contract is a block, with activity driven element, penalties and a risk share arrangement • Data Issues • None identified • Financial Performance • The activity element of the NEAS contract has over performing £234k at month 12. This over performance is taken into account any marginal rates within the contract and the risk share agreement. • £30k of penalties have been issued for Durham Dales, Easington and Sedgefield CCG.

39. Finance & Activity Tees, Esk and Wear Valleys FT Finance

40. Finance & Activity Tees, Esk and Wear Valleys FT Activity

41. Finance & Activity Northumberland Tyne and Wear NHS FT Northumberland Tyne & Wear NHS FT Full Year Overspend £265k The activity and finance reports have been received for Month 12 showing a further increase in the overspend to £265k over contract (M11 £249k). The final outturn for this contract is an improvement of £6k from the M11 forecast ( £271k) due to continued reduced activity in the Roker unit and a range of smaller reductions in activity., The accompanying schedule sets out the major over and under spending services.

42. Finance & Activity Continuing Care Packages of Care • Financial Performance • The year end position is showing an overspend of £578k which includes a cost for the risk share arrangement of £352k • During the month of March we have been notified of 76 new CHC packages with a cost impact of £870k, 15 new FNC clients with a cost of £26k, 79 deaths and 17 discharges giving an overall reduction in cost of £741k • Action Points • The validation of the finance spreadsheet is complete however this has resulted in a number of patient queries which are currently being investigatedby the CHC team. • Finance staff have received training to enable access to the QA system which is proving very useful in resolving provider queries and will be used to perform regular validation checks.

43. Finance & Activity Continuing Care High Cost Packages and Restitution • The above table shows the current calculation for the Risk Sharing scheme resulting in a cost of £352k • Based on the latest information available for restitution cases of 319 initial requests 173 have been completed or closed with 176 remaining in the system for a full assessment. 8 cases have been agreed and 7 cases have appealed the original decision. • During the financial year we have paid £119,903 in reimbursements for 8 cases • The current provision stands at £5.3m

44. Finance & Activity Mental Health and Learning Disability Packages

45. Finance & Activity Risk Share Impact – CHC, Mental Health and LD Packages

46. Finance & Activity Community Services – County Durham and Darlington • Contract Update • This is a risk share contract. Most elements of this contract are block, with the exception of Urgent Care. Urgent care overperformance is built into the block value for 2013/14 • Data Issues • We have now received activity for this contract. • Financial Performance • The contract for this year is 100% risk share, so there will be no variance from plan. • The percentage change since 2012/13 shows the change for North Durham, DDES & Darlington as the data from previous years is not split by CCG. • Overall, activity is up by 7% against the previous year’s figures. • Forecast Outturn • The contract will breakeven this year

47. Finance & Activity Non NHS Community Services Services continue to operate on trend as previously reported and illustrate a £385k potential forecast outturn variance. A large overspend is anticipated on the Intrahealth Walk in Centre contract where no budget has been identified. This is eased by underspends on Oral Surgery, ENT, Gynae, OOH, CHD and Healthcare at Home.services. A significant overspend is anticipated on Children’s OT however this service is currently out for procurement which should drive savings and improve service quality. Hospice Services Hospice Services continue to operate on trend with Marie Curie and St Teresa’s continuing to show forecast outturn underspends as previously reported.

48. Finance & Activity Primary Care - Prescribing Financial Performance • 10 months of data is now available for prescribing. • Prescribing costs per head of weighted population has increased since 2012/13 across all localities. • Costs relating to services commissioned by other public bodies (substance misuse, smoking cessation etc.) are still included within the prescribing numbers, agreement on levels of recharging to LA has been reached with the result that only LARC cost will be funded by the LA. • The latest forecast outturn from the PPA indicates that GP Practice prescribing will amount to £52,821k driving an overspend in 2013/14 of £3,887. • The overall prescribing forecast outturn is anticipated to amount to £55,532k with an overspend of £3,658k in 2013/14.

49. Finance & Activity Primary Care – Prescribing – Durham Dales

50. Finance & Activity Primary Care – Prescribing – Easington