Contents Chair s introduction... 4 Accountable Officer s introduction... 5 Strategic Report... 7 About us... 7 Our population (social, community and

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2 Contents Chair s introduction... 4 Accountable Officer s introduction... 5 Strategic Report... 7 About us... 7 Our population (social, community and human rights issues)... 9 Human rights Sustainability report Key risks and uncertainties Improving quality in services Reducing inequalities Public involvement and consultation Partnership working Finance review Managing performance Clinically led commissioning Looking ahead to Members Report Our member practices Our Governing Body members Our Audit and Governance Committee members Statement as to disclosure to auditors Pension liabilities Governing Body member interests External auditor s remuneration Sickness absence data Cost allocation and charges for information Employee consultation Equality and diversity within our workforce Employees with a disability Equal opportunities Health and safety Preventing fraud Better payments practice code Prompt payments code Emergency preparedness

3 Principles for remedy Exit packages agreed in the financial year Off-payroll engagements Remuneration Report Remuneration Committee Report Senior managers service contracts Audited Remuneration Report detail Salary entitlements Pension liabilities Pay multiples Accountable Officer statements Statement of Accountable Officer s responsibilities Sandwell and West Birmingham Clinical Commissioning Group Governance Statement Primary financial statements and notes Audit opinion and report Glossary

4 Chair s introduction Sandwell and West Birmingham CCG has plenty to be proud of during our second year. We have taken steps to become a truly GP-led organisation. We gave our local commissioning groups (LCGs) the power to manage key contracts and work programmes. CCG staff are now more closely aligned to these groups, so they can provide practices with extra help to deliver their new responsibilities. In July we got the go-ahead to develop a brand new hospital in Smethwick. This is the result of 10 years hard work through the Right Care Right Here programme, a partnership between the NHS and local authorities in Birmingham and Sandwell to provide services closer to people s homes. Now we must keep the momentum going through the Right Care Right Here Partnership in preparation for Midland Met Hospital, opening in This leads me on nicely to our work developing excellence in primary care. Bringing care closer to home is a key element of our Right Care Right Here vision. Throughout the year we have focussed on primary care development; with targeted protected learning time events to address quality priorities and working collaboratively with our practices to identify new ways of working, for example in diabetes and respiratory care. This puts us in a strong position as we prepare to take on responsibility for commissioning primary care in April Throughout the year, with the support of our GP members, we have been preparing for this new responsibility and we are one of just 64 CCGs nationally to be taking this on. I believe commissioning primary care will ultimately support us to deliver our local commissioning priorities and importantly improve care for patients. Being fit for the future means learning to adapt, and during our GP practices and providers have been looking at new ways to provide care to patients. We will build on this in the coming year and help practices and providers change, so that our local NHS system is sustainable and delivers quality care to meet our population s needs. In November we received national recognition for our work, as we were named Commissioner of the Year by Pulse, the country s leading magazine for general practice. Congratulations and thanks go to our GP members and staff you deserve this accolade. Dr Nick Harding Chair 4

5 Accountable Officer s introduction This past year has seen us build really solid foundations for the CCG s work, based on a clear focus on patients and an innovative and proactive approach to meeting the challenges ahead. We ve been praised by NHS England for our system leadership and financial management. Throughout we ve made significant progress towards meeting commissioning priorities that need to be delivered by Our commissioning teams and clinical leads have reviewed data on existing services and worked with patients and providers so we are ready to put new schemes and services in place. The changes we ve already made to improve how we work and become more efficient have saved us money, which means there is funding available to invest in new services and more improvements. For example, the Healthy Communities pilot programme saw practices pull together to look at local needs and develop individual practice action plans to help patients manage their own health, get more support at home and avoid having to be admitted to hospital. The savings we ve made this year will pay for the practices actions plans to be implemented in and in turn lead to further savings for reinvestment in new services. It will be really exciting to see what locally-led schemes like these can achieve next year. An important feature of our work during has been working with local partners. Thanks to this collaboration we were able to relieve the pressure on nearby hospitals to help them cope with the usual extra pressure caused by winter weather. Another success story has been the West Midlands NHS 111 telephone advisory and support service, for which we re the lead commissioner. It has managed an increasing number of calls so well that we re now looking at expanding the service so people can use it online and to book GP appointments. We ve also led local and national discussions about the future development of NHS 111. One of our priorities in has been to reduce health inequalities, especially to help the migrant community in Sandwell and West Birmingham access services more easily and receive the right care. We ve worked with voluntary groups to understand the particular challenges facing this community and to train GP practices to better meet their health needs. Congratulations go to the team for their work in this area, which has received national interest. And I ve been very impressed by other voluntary and statutory sector projects around equality and diversity, which were showcased at our successful Equality Awards in March All our staff have done a great job during the year they have risen to the challenges we set them and helped us meet our targets. 5

6 They ve also let us know what they think of the CCG and how we could improve. Our new vision and values, due to be launched in early , are based on staff feedback. And I want to build on the results of our staff survey people say we re a supportive and approachable organisation, which is nice to hear, but there s always room for improvement. Andy Williams Accountable Officer 6

7 Strategic Report About us Set up in April 2013, we are a clinically-led membership group of 103 GP surgeries across the Sandwell and West Birmingham areas, caring for more than 547,400 patients. Led by experienced GPs, we are responsible for improving, designing and commissioning (buying) local health services including: Hospital services (including accident and emergency departments) Community healthcare e.g. district nursing and rehabilitation services Mental health and learning disability services Children s services From April 2015 we will take on responsibility for commissioning primary care (GP services). We are regulated by NHS England. The CCG was licenced from 1 April 2013 under provisions enacted in the Health and Social Care Act 2012, which amended the National Health Service Act As at the 1 April 2014, the clinical commissioning group was licenced without conditions. Our vision Our vision is simple to understand but more challenging to deliver: healthcare without boundaries. We want to work across boundaries to improve your health and the quality of health and social care services provided to you, by: Giving you the opportunity to benefit from healthier lifestyles Bringing appropriate elements of care closer to home Designing services to meet the needs of our local population. Working as a membership organisation As a membership organisation, involving our GP practices in our decisions is essential. To enable this we developed five local commissioning groups (LCGs) who address the needs of the population at a very local level. All our member practices belong to one of the LCGs, with an elected Chair and Vice Chair acting as a voting member on our Governing Body. These local commissioning groups (LCGs) are: Black Country HealthWorks Intelligent Commissioning Federation (ICoF) Pioneers for Health Sandwell Health Alliance. Later in this document you will hear a report from each of the LCG Chairs. 7

8 Core providers As we span two local authority boundaries, we often work with multiple providers. Our core contracts are with: Acute hospital (e.g. A&E, surgery) Community services, such as district nursing teams Mental health Ambulance services NHS 111 Out-of-hours GP services Sandwell and West Birmingham Hospitals NHS Trust (SWBH) Sandwell and West Birmingham Hospitals NHS Trust (Sandwell area) Birmingham Community Healthcare NHS Trust (BCHC) (West Birmingham area) Black Country Partnership NHS Foundation Trust (BCPFT) (Sandwell area) Birmingham and Solihull Mental Health NHS Foundation Trust (BSMH) (West Birmingham area) West Midlands Ambulance Service NHS Foundation Trust (WMAS) West Midlands Ambulance Service NHS Foundation Trust Primecare Our staff We employ 148 members of staff (including Governing Body members) who work within four key directorates: Quality: Safeguarding, Continuing Healthcare, Risk, Customer Care and Medicines Quality Partnerships: Engagement, Healthy Communities Pilot Development, Equality and Diversity Commissioning and Service Redesign Finance including Performance Management. Staff analysis by gender Headcount by gender Percentage by gender Staff grouping Female Male Totals Female Male Governing Body % 78.6% Other senior management (Band 8C+) % 36.4% All other employees % 13.0% Grand total % 20.95% Commissioning support We buy support, including IT, HR and communications, from the NHS Midlands and Lancashire Commissioning Support Unit. 8

9 Our structure We have worked to embed clinical membership, lay and patient representation throughout all of our committees, which include: Audit and Governance Committee Finance and Performance Committee Organisational Development Committee Partnerships Committee Quality and Safety Committee Remuneration Committee Strategic Commissioning and Redesign Committee Primary Care Co-commissioning Committee (a shadow committee established in February 2015 to prepare for taking on responsibility for primary care commissioning). Our population (social, community and human rights issues) Our area extends across two council areas covering the old boundaries of Sandwell Primary Care Trust and parts of Heart of Birmingham Primary Care Trust. It is evident from the profiles presented below that Sandwell and West Birmingham have very different age, ethnic and religious profiles. These characteristics inform the cultures and behaviours of local communities and, alongside the wider determinants of health, shape the need for health services and health information. This is a particular challenge for us. Demographics Age Age Group Sandwell & West Birmingham CCG's GP Registered Population, July 2014 and Mid-year Population Estimates for England 2013 S & WB CCG Males S & WB CCG Females England Males England Females % of Total Population Source: Health and Social Care Information Centre (CCG Data) and ONS (England Data) Overall there is a younger registered population than England as a whole. The age profile of our resident population is markedly different across the area. While Sandwell has a relatively older population, West Birmingham is comparably younger with about three quarters of its population under 45 years of age. 9

10 Deprivation The CCG consists of some of the most deprived areas nationally. Birmingham is ranked 9th most deprived and Sandwell 12th most deprived population in England. The proportion of the population unemployed in Sandwell is 10.5%, Birmingham is 11.6% whereas the average for the United Kingdom is 6.5%. Ethnicity The ethnic profile of residents within our boundaries is depicted in the chart on the right. The aggregated picture is one of a super-diverse region, with the largest ethnic group reflected by White British (50%), followed by Asian Indian (12%), Asian Pakistani groups (8%) and Black British/Caribbean groups (6%). 10

11 Map of the CCG population classified as minority ethnic (17.7%) are the largest minority ethnic groups in these wards. The map shows that there is a great variation within the CCG by ward, of the proportion of residents who are from a minority ethnic group. Wards including Handsworth Wood and Lozells and East Handsworth show particularly high proportions of their populations being minority ethnic groups. Asian Indian (23.1%) and Asian Pakistani New migrant communities The diverse populations of Sandwell and West Birmingham include migrants who will have recently entered and settled within the UK. Migrants will be reflected within the ethnic groups identified above and may account for some of the increases among black and minority ethnic and other white groups. Migrants are not a homogenous group and include economic migrants, asylum seekers, and refugees, refused asylum seekers, illegal immigrants and individuals who entered the UK with visa clearance for study, tourism, family visits, employment or marriage. Supporting new migrants to access primary care has been a key priority for us, as highlighted later in this report. Sandwell data relating to hospital emergency admissions appears to confirm anecdotal evidence of the increased percentage of black and minority ethnic (BME) groups accessing this service. The highest percentage of emergency admissions is among other ethnic groups. 11

12 Health needs The health of people in Sandwell and West Birmingham is generally worse than the England average. Figure 17 shows the proportion of people in very bad health, based on the Census High level of health inequality between the most deprived and least deprived areas in Sandwell and Birmingham (male life expectancy over 10 years and female life expectancy over five years) Childhood obesity Teenage pregnancy Smoking- 22% of our population over 18 smoke Adult obesity- 28% of people over 16 are obese Alcohol- 35.2% of emergency admissions were for alcohol related liver disease 9.7% of our population report having a limiting long-term condition, which limits their day-to-day activity a lot. Examples of long-term conditions include cardiovascular disease, diabetes, chronic lung conditions and mental health problems. Our thanks go to the Research Sandwell Team, Sandwell Metropolitan Borough Council for allowing us to use these demographic charts. Our commissioning priorities In the latter part of we set our commissioning priorities for These were developed following a detailed review of our demographics, data and patient feedback. We believe that these priorities will help us to drive quality of care as well as delivering our challenging quality, innovation, productivity and prevention (QIPP) targets. Our commissioning priorities : Outpatient modernisation Mental health Enhanced services Stroke Intermediate care Pathway management Long-term conditions System usage Urgent care Community services 12

13 Readmissions Children and maternity services End of life care. From the 1 April 2014 we realigned our staff to work alongside our five local commissioning groups, who are responsible for delivering these priorities. Human rights The Human Rights Act is underpinned by the core values of fairness, respect, equality, dignity and autonomy for all. These values are at the heart of high-quality health and social care. We have embedded human rights through all of our planning and decision making processes. This enables us to meet the legal requirements of the Human Rights Act 1998 as well as supporting all our population to access the best healthcare for their needs. Throughout our work we undertake equality impact assessments, which consider human rights needs including ensuring fair treatment and access. We also seek assurance from our provider organisations that they comply with human rights best practice, including: Human Rights Act 1998 NHS Constitution Equality Act 2010 Health and Social Care Act We have embedded Equality Monitoring Schedule requirements into contracts this includes a focus on the treatment of vulnerable patients when taking up and experiencing healthcare services. We also work within the NHS Equality Delivery System (EDS 2), which is a performance framework for commissioners and providers. In 2013 we worked with local communities, partners and providers to seek views on how we ensure fair treatment and access for all protected groups. This helped us to develop our five year Equality and Diversity Strategy. During 2015 we will engage our communities, partners and providers again to assess how we have performed and to set priorities for the next 12 months. Information on our local performance against the Equality and Delivery System is included on our website and provider websites. The Equality Delivery System will be mandated by NHS England in April We are proactive in our approach to the Human Rights Act, in our role to proactively respect and promote people s human rights. Later in this report, you will hear about our Equality and Diversity Strategy and work around migrant health. A human rights-based approach (HRBA) to healthcare risk assessment balances the human rights of patients and members of their communities. This is so healthcare staff can, in effect, manage risk more positively. A HRBA looks at risk through a human rights lens, identifies relevant equality and diversity issues, and maximises patient participation and 13

14 empowerment. Human rights principles are now explicit in not only the NHS Constitution but also in informing the approach of the Care Quality Commission (CQC). Sustainability report Policies In order to embed sustainability within our business it is important to explain where sustainability features in our processes and procedures. We consider the key areas of impact to be: Estates Travel Procurement (environmental and social impact of decisions) Suppliers impact. One of the ways in which an organisation can embed sustainability is through the use of a Sustainable Development Management Plan (SDMP). During we will decide whether to produce an SDMP for consideration by the Governing Body. Climate change brings new challenges to our business not only in direct effects to the healthcare estates, but also to patient health. Examples in recent years include the effects of heat waves, extreme temperatures and prolonged periods of cold, floods, droughts etc. The organisation has identified the need for the development of a board approved plan for future climate change risks affecting our area. Under our Right Care Right Here programme we are committed to bringing care closer to home, which will have a positive impact on the environment with the potential for reduced travelling for patients. A number of other initiatives are also based on a local area, including the Healthy Communities and Community Offer pilots, which will support the local economy and environment. See the Partnership working section to find out more on these schemes. Estates Since the 2007 baseline year, the NHS has undergone a significant restructuring process and one which is still ongoing. As a part of the NHS, it is our duty to contribute towards the goal set in 2009 of reducing the carbon footprint of the NHS by 10% (from a 2007 baseline) by was the second operational year of the CCG. Following the recent NHS reorganisation, CCGs are not responsible for the direct management of the estates that they occupy; this responsibility transferred to NHS Property Services and NHS Community Health Partnerships. We occupy two main premises: Kingston House in West Bromwich is our main headquarters, with some space also being occupied at the Lyng Centre, also in West Bromwich. Both of these properties are managed by NHS Property Services, and we are charged for this. They are developing the dataset of information they provide to enable our performance against the planned reduction of 10% noted above to be measured. The initial 14

15 information confirms that our Kingston House energy use has declined by over 17% in in comparison with Fuller information will be available in Travel Our staff give consideration to the requirement to travel as part of their job requirements, avoiding the need wherever possible. The use of information technology to support this in the form of voice conferencing is encouraged, and the potential for other technologies is considered. Where travel is necessary, staff make use of public transport where practical and car sharing wherever possible. Procurement and suppliers impact As part of the procurement process, the sustainability of potential suppliers is considered by seeking information on their approach to environmental and social issues. Where contracts are awarded, the NHS Standard Contract is used. This contract requires the providers of services to take all reasonable steps to minimise any adverse environmental impacts and to demonstrate progress against the NHS carbon reduction strategy, climate change adaptation, mitigation and sustainable development. We are also committed to working with providers to ensure the minimum wage is adhered to. Supporting our local community We recognise the influential role we play within the local community, and as a result corporate social responsibility is a key priority for us. We know the invaluable contribution played by the voluntary and social enterprise sector, both in supporting patients and helping to alleviate pressure on NHS services. We are proud of our strong relationships with the social sector, whether it is playing an active role in our local voluntary networks, working with them contractually or exploring new and innovative ways to pay for services, for example through social investments. There is a wealth of local knowledge and expertise in the social sector, and greater collaboration presents benefits for both the NHS and local support networks. During we have worked closely with a number of local voluntary organisations, including: Sandwell Council of Voluntary Organisations and Birmingham Voluntary Sector Council continuing to be represented on our committees to ensure the sector s voice is represented We commission a variety of local community and voluntary organisations to deliver services, to the value of 4.844m Commissioning Rights and Equality Sandwell to lead our exciting migrant health programme, which is featured later in this report Working with Sandwell Metropolitan Borough Council to deliver the Community Offer project, which commissioned six local organisations to deliver our health and social care priorities. For further information see our Partnership working section. 15

16 Charity work Our staff have carried out a range of activities during to raise money for local charities. We would like to thank everyone who baked, collected food for local food banks and organised these events. Silly socks competition and bake-off for STEPSraising 167 Christmas bake-off- raising 148 for Sandwell Parents for Disabled Children Race for Life- raising 880 for Cancer Research UK Sandwell Women s Aid- in the run up to Christmas staff brought in food items, clothing and bedding for the local food bank At Christmas staff collected 73 worth of Advent Calendars for the Smethwick Foodbank In March staff contributed over 40 Easter eggs for the Smethwick Foodbank collection. In staff have voted to support Sandwell Parents for Disabled Children as their charity of the year. This will be changed on an annual basis. Key risks and uncertainties We have worked throughout to ensure controls and mitigation are in place to minimise risks. The principal risks are built into our Assurance Framework, which is audited by internal audit and has been awarded significant assurance: Insufficient infrastructure, capacity and skills in primary care to enable provision of quality services to be drawn out of secondary care Failure to evaluate the impact of service redesign and/or failure to deliver redesign effectively, resulting in poor delivery, performance and diminished health outcomes Failure to work collaboratively with partners and stakeholders (particularly the two local authorities) could result in poor use of limited resources, particularly with regard to the Better Care Fund (BCF) Lack of financial resources within the local authorities and known expenditure reductions will impact on health-related budgets with respect to social care, which may result in poor and/or reduced services to patients Failure to re-commission and decommission services effectively to release savings for the BCF may affect the CCG s ability to meet its statutory financial duties Failure to effectively identify and deliver the QIPP agenda may result in financial unsustainability Failure of care in a large collaborative leadership arrangement (such as NHS 111 and stroke services) results in nationwide adverse impact on CCG reputation Unable to work effectively with partners to deliver the required conditions to successfully commission the new Midland Met Hospital 16

17 There is a risk that persistent failure to achieve core performance measures/targets (e.g. access targets) by our providers impacts us financially through reduced quality premiums, or causes us reputational damage, or results in NHS England intervention Ofsted/ Care Quality Commission review of safeguarding arrangements at Birmingham Children s Hospital NHS Foundation Trust (BCH) highlighted significant risk for vulnerable, looked after children and wider safeguarding issues. A further inspection in September 2012 highlighted poor partnership working and quality of referrals/understanding of access/thresholds. For more information on how we manage risks in the organisation and health system see our Accountable Officer s Governance Statement. Statutory duties We certify that the clinical commissioning group has complied with the statutory duties laid down in the National Health Service Act 2006 (as amended).this is highlighted in the following sections: Improving quality in services Reducing inequalities Public involvement and consultation Partnership working (including Health and Wellbeing Board Strategy). Improving quality in services We have a proactive approach to quality focussing on: getting the basics right, putting the patient first and going beyond the minimum requirements. At the heart of our approach is delivering the 6Cs : Care, Compassion, Competence, Communication, Courage and Commitment. To deliver this we have invested in a strong in-house quality department, with over 80 staff working in safeguarding, continuing healthcare, medicines quality and risk management. By bringing all of these teams under the quality directorate, it enables us to have a strong grip on quality across the local health system. We have embedded systems and processes, which enable us to commission high quality and safe services for registered patients. Focus on customer care In 2013 we set up our Time2Talk team, which is the centre of our quality department. Throughout we have promoted Time2Talk to encourage people to report any compliments, concerns and complaints. This intelligence is logged on our Datix reporting system, and is viewed daily to help us respond to any serious incidents and identify trends to improve the quality of services in the local health system. Importantly, this information is directly fed into our contractual and quality meetings with providers, so customer feedback is leading to real improvements within health services. Case study: The quality team regularly review the Datix system, and identified a trend of correspondence letters being sent to the wrong GP practices. As the practices all reported this to the same system, the team identified a trend and intervened by carrying out a deep 17

18 dive review. New processes have now been put in place within the provider, and incidents have reduced from an average of eight a month (May 2014) to one incident a month (March 2015). The CCG has set up a Learning from Experience Group, which reviews the outcomes of these deep dives and takes forward this learning. We will want to strengthen our Time2Talk service in as we take on further responsibilities for commissioning primary care. By handling minor concerns proactively through our Time2Talk team, we are seeing a reduction in the number of concerns escalating to complaints. During we have seen a significant improvement in the proportion of complaints to concerns (33% to 67%). Safeguarding It has been a busy year for our safeguarding team, who has been working to support vulnerable adults and children. CQC inspection In the autumn our safeguarding team had a visit from the Care Quality Commission (CQC). We re pleased that overall the feedback for the CCG was positive, and this is a reflection of the hard work our safeguarding team has put in. We've a lot to be proud of, in making safeguarding a priority for everyone. Over the past two years we've strengthened local safeguarding: with increased partnership working, supporting the launch of the multi-agency safeguarding hubs and raising awareness through training and campaigns. We do, however, recognise that the report highlights a number of areas for development across the local health system. The health and wellbeing of children and young people is a priority for us and we will work with our partners and service providers to address these matters. Ofsted inspection At the end of January, Ofsted began a four week inspection in Sandwell looking at children's social care and child protection across all agencies, including health. As a statutory partner of the Sandwell Safeguarding Children s Board we took part and shared our work with the inspectors. Across the area a tremendous amount of work has been done to raise standards. However, we also recognise there is still more to be done and there will be recommendations we need to take forward. We are expecting any reports to be published after the election. Development of the Health Passport Our looked after children team work with children and young adults in the care system either through fostering and adoption in Sandwell and West Birmingham. We know that leaving care can be a challenging experience, and we want to support young adults to access the right health services, including registering with a GP and dentist. 18

19 Working with young people, we have developed a Health Passport to help guide them through the complex NHS system. In developing the passport young people told us: Look after us through thick and thin Help us to stand on our own two feet Listen to us and tell us the truth Give us the best education possible Keep us healthy and safe Have high hopes for us Help us to realise our dreams. Sandwell and West Birmingham Hospitals NHS Trust CQC Report We ve been working closely with Sandwell and West Birmingham Hospitals Trust (SWBH) since their Care Quality Commission (CQC) inspection in Overall the CQC rated the hospital trust as requires improvement. The CQC praised the Trust for their adult community-based teams, maternity services, critical care and end of life services which all achieved a good rating. Within the CCG and SWBH, our priority is to ensure this is consistent across the Trust. The Trust has had some real achievements in improving quality with reductions in pressure ulcers and never events, and we need to continue this momentum. The inspectors saw some individual examples of poor practice in some departments around hand washing, security of medicines and completion of patient records. Since the CQC s visit last year, the Trust, supported by our quality team, has put in place an improvement plan and a lot of improvements have already happened. In particular, the Trust has completed a comprehensive review of nurse staffing levels in late 2014 and since January 2015 has implemented those changes. Improving quality in primary care Primary care development is identified as a key priority in improving quality in the health system. The CCG has had a number of successes in its primary care education programme: More than 400 GPs, nurses and practice managers attended the quarterly protected learning time events The CCG led a new Training Needs Assessment and Mentorship programme around diabetes. Training sessions were fully booked, with over 300 places available to GPs and nurses. Feedback from clinicians was positive with many of the delegates going forward to take part in the ongoing mentorship programme A new website is being developed to create an online needs assessment. This will support clinicians to identify their personal learning needs, and help us to identify trends and future learning opportunities for primary care Our medicines quality team organised a nutritional sip feeds event attended by around 150 health professionals. As an immediate result, the CCG has gone from 19

20 being the fifth highest spending CCG in the country to 19th; importantly more patients are receiving regular reviews and this will lead to improved outcomes for patients. Medicines quality Our medicines quality team led by our clinical lead Dr Gwyn Harris, has worked on a number of targeted campaigns to support improved medicines prescribing. We have an innovative model for medicines quality, which enables a small, though highly skilled, in-house medicines quality team to deliver significant change in terms of reducing inefficiency in prescribing and importantly, raising the standards of quality. Clinical pharmacists and pharmacy technicians are aligned to the LCGs, to offer bespoke support and analysis. These technicians work at an area level to review and share the prescribing data and review current practices and procedures for GP practices. However, it is the GP practices that take this forward; with their understanding of their individual practice s processes. Advice and support is provided, however practices have taken ownership for delivering the change. During the team has: Implemented a new wound formulary working with SWBH s tissue viability and the district nursing teams. District nurses have reported around 90% compliance of using the formulary and it has led to a significant reduction in the spending on dressings. We have also been working with care homes to introduce a care home order form to support GPs in managing dressing prescribing in care homes, which we know traditionally has a high spend Over the past three years the team has led a targeted programme around type 2 diabetes. Diabetes is a key health priority for the CCG. In the last 12 months the medicines quality team has organised a series of events to enhance primary care knowledge around diabetes medication Sip feeds. The medicines quality team has successfully worked in partnership with Sandwell community dieticians to produce an agreed malnutrition pathway with updated clinical guidance. In addition to the successful GP event mentioned earlier in this report, we have been working with care homes, which our data shows are high spenders of sip feeds Lipid management: The team is working to develop a new lipid management pathway for primary care and clear referral and discharge pathways following the publication of the updated National Institute for Health and Care Excellence (NICE) guidelines. The team has continued to deliver around 1m savings by ensuring the appropriate use of ezetimibe and high dose statins. Use of omega-3 has reduced by around 25% producing a further 50% of QIPP savings. Continuing healthcare and personal health budgets In Sandwell and West Birmingham we are offering personal health budgets to people who live in their own home, are registered with a Sandwell and West Birmingham GP, and are eligible for fully funded NHS continuing healthcare (CHC), a package of care that is arranged and funded by the NHS for people who are not in hospital but have complex ongoing healthcare needs and a primary need for health interventions). 20

21 Patients, or their representatives, work in partnership with their continuing healthcare coordinator to plan and agree the budget that is right for them. Patients can now directly take control of this budget to pay for their healthcare services. At the centre of every personal health budget is the patient s care plan. This helps patients, or their carers, to decide their health and wellbeing goals and sets out how the budget will be spent to enable them to achieve these aims. There is a lot to consider, and our dedicated CHC team will work with patients and carers to help decide if a personal health budget is right for them. Even if a patient chooses not to have a personal health budget, they can still have greater involvement in planning their healthcare through developing a care plan. Already some patients are benefitting and are managing their own personal health budget. In summary our approach to quality has led to: Positive patient feedback A 50% increase in incident reporting, and importantly an increase of insignificant incidents reported (from 9% of insignificant reports in April 2014 to 54% in January 2015). This shows more GPs are proactively reporting smaller incidents and concerns, which enables us to identify trends Eliminated grade four pressure ulcers Significant reduction in grade three pressure ulcers, from an average of six a month to an average of two Trend towards zero serious incidents reported in general practice. By encouraging practices to use Datix we hope to see increased reporting with less significant incidents and more lower grade incidents No never events reported in SWBH for 12 months Improved prescribing, as a result of GP education. Reducing inequalities Sandwell and West Birmingham has some of the most disadvantaged communities in the country, with many areas having high levels of deprivation and health inequalities. We want to reduce these inequalities for our population. Our Equality and Diversity Strategy builds upon our commitment to equality, diversity and human rights as described in our constitution. It profiles the picture of diversity across our area and sets out our plans to address the needs of some of our most vulnerable groups. In building our strategy we used intelligence from the joint needs assessment. It is integral to our governance arrangements and is subject to regular review. Through this mechanism, we ensure that equality considerations and valuing difference are embedded throughout our organisation and decisions. Our strategic priorities and Operational Plan address the variations in health outcomes and improve the patient experience by improving the quality of care received and bringing care closer to home. We have already incorporated equality analysis into key processes for commissioning including service reconfiguration, business case and project development, contract specifications and service evaluations. 21

22 During our key focus was to improve access to primary care for new migrant communities. Key to this was supporting staff and clinicians to understand the challenges new migrants face when accessing healthcare. To help deliver this, we commissioned Rights and Equality Sandwell to: Pilot a new patient registration pathway within four GP practices ensuring equitable access for the most vulnerable in our communities Raise awareness with our voluntary and community sector partners of the rights and entitlements of migrant communities to healthcare, including appropriate use of services Deliver a dedicated course in July 2014 for our GP practices, which will consider the impact of immigration status, welfare, housing, entitlements and rights etc. Support links between GP practices and the voluntary sector Deliver peer-led training to workers in the voluntary sector that will enable them to deliver appropriate messages to migrant communities on how and when to access NHS services. We also commissioned West Midlands Ambulance Service to extend its Community Ambassador Scheme to deliver six peer training sessions to migrant groups locally. The trained ambassadors will cascade the training to migrant communities. We consider equality in all aspects of our work, and other key highlights for include: Undertaking equality impact assessments, for example of our community based contracts and services, ophthalmology, minor surgery and infertility treatments Promoting the Alzheimer s Society s Dementia Friends Campaign and raising the profile of dementia throughout the CCG Reviewing services that may impact on protected groups; access to welfare advice though Citizens Advice services in GP practices, home from hospital support services, interpreting and communication services as well as religious circumcision and assisted conception Improving dementia pathways for patients recognising the specific needs of black and minority ethnic (BME) dementia patients. Equality Awards 2015 We had a fantastic response to our first ever Equality Awards. Working with voluntary sector and equality and diversity partners we set up the awards to recognise and showcase local organisations and groups that are making a difference to the health and wellbeing of diverse and vulnerable communities. This year s awards recognised organisations and groups that have: Improved access to services 22

23 Improved patient or service user experience Improved the knowledge and skills of the workforce or members Improved migrant health. The winners were announced at a dedicated awards ceremony held at the West Bromwich Albion Football Ground on the 19 March Equality is everyone s business, and these awards were an opportunity to celebrate our collective achievements, network with partners and consider new innovations to help make equality a priority for us all. To see the winners visit our website at Public involvement and consultation Our engagement team has worked hard during to ensure the patient voice is captured at every stage of our service redesign work. A member of the engagement team has been aligned to each of our local commissioning groups and commissioning priorities, with a range of different engagement activities taking place. Our team has attended a range of community events to help capture patient feedback to feed into our decisions. 23

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25 Patient voice We have also continued to embed patient representation throughout all of our governance committees and local commissioning group boards. Our patient advisors Mango Hoto Diane Charles Chris Vaughan John Cash Deska Howe Pam Jones Ruth Leech Ranjit Sondhi Geoff Foster Jason Meredith Mark Davis Tarlochan Singh Graham Price ICoF Patient Representative HealthWorks Patient Representative ICoF Patient Representative HealthWorks Patient Representative SHA Patient Representative Black Country Patient Representative Pioneers for Health Patient Network Chair CCG Vice Chair and Patient Representative Partnership Representative Partnership Representative Partnership Representative Pioneers for Health Patient Representative Partnership Representative 25

26 Together all of these representatives belong to our Patient and Partnership Advisory Group, sharing their experiences from each of the committees. We would like to thank all of our patient representatives who have given up their time to support our committees and individual service redesign programmes. Their insight has been invaluable in ensuring our decisions are right for patients in Sandwell and West Birmingham. Public involvement and consultation Throughout this report, we hope that you see examples of how we have engaged with patients and the public. We wanted to highlight some of the key consultations and patient involvement activity during : Cardiology, emergency surgery and trauma assessment At the heart of our Right Care Right Here work is the development of the new single site acute hospital, the Midland Met Hospital in Smethwick by We have already begun working towards this and are starting to make improvements to our existing hospitals. We are working closely with our clinical experts, who have told us that by bringing services onto single sites, to create specialist centres, we will deliver better care for our patients. This is why we are proposing to locate all urgent cardiology services at City Hospital and all emergency general surgery and trauma assessment at Sandwell Hospital (alongside the existing inpatient wards for these specialties). We believe these improvements will bring a number of benefits for patients, including: Faster access to treatment Better quality care Fewer cancelled appointments. It will also support the Trust to: Invest in the latest technologies and treatments Recruit and retain staff. Between January and March 2015 we held a listening exercise with patients, public, partners and clinicians to understand their views on the proposals and find out how we can support them if the proposals go ahead. People took part in the engagement activity by completing our online and paper survey, attending our public events and speaking to us at a range of community network meetings. This feedback will be developed into a report, which will be taken to the CCG s Governing Body and Sandwell and West Birmingham Hospital Trust s Board meeting in the summer

27 Urgent and emergency care listening exercise Urgent and emergency care reviews are currently taking place across the whole of England, due to the increasing pressure being faced by the services. In Sandwell and West Birmingham, patients have already said they find the services confusing, with many unsure of the best place to go for care. During February and March 2015, we held a listening exercise to understand patients, partners and clinicians views on urgent and emergency care services. There was a range of ways to get involved, including attending public meetings, speaking to our teams who were in Aston and West Bromwich or completing our online and paper surveys. We also presented the information to a range of community and voluntary sector networks. We are using this feedback in developing our five year Urgent and Emergency Care Strategy. We will want to work with clinicians and patients and our wider stakeholders to develop this into our proposed option(s) in autumn If significant changes are needed, we will want to carry out a formal consultation. Stroke review Over the past year we have been leading a review of stroke services across Birmingham, Solihull and Black Country CCGs. By working with providers to deliver quality care, in line with the National Stroke Strategy and regional best practice, we can save lives and improve patient outcomes. Our engagement team has supported this work programme, with a Patient Advisory Committee established. Patient representatives, including representatives from stroke associations in the area, have advised the programme team at every stage of the review. Throughout the review we have worked hard to keep key stakeholders informed and involved, including overview and scrutiny committees and Healthwatch organisations. Regular updates have been given to these stakeholders at every step of the review. Primary care mental health consultation From March to June 2014 we worked with the CCGs across Birmingham to consult local people on a proposed model for primary care mental health services and changes to accessing specialist mental health services. These aim to improve people s experience of services, making it easier for them to access mental health services in the community - including when people no longer require specialist mental health support and are discharged back to their GP and to improve access to information about the availability of services. The services consulted on were talking therapies (psychological therapies and counselling services), community mental health teams to co-ordinate assessments, plan treatment and deliver care, along with recovery, enablement and prevention services. There were a number of ways people could get involved and have their say, including attending public events across Birmingham. 27

28 Get Involved This year we launched our Get Involved membership programme. This is a free membership, which anyone can join to: Share your experiences of local healthcare services Find out about our work and the latest events/consultations Get involved in designing services. Members receive regular updates on the different consultations and events as well as receiving our quarterly bulletin. To become a member us at swbccg.engagement@nhs.net or phone Partnership working By Dr Basil Andreou, Chair of the Partnerships Committee Partnerships have been leading on a number of exciting initiatives, including the Better Care Fund (BCF) and primary care development through the Healthy Communities pilots. It s a challenging portfolio of work, but will help us achieve our future challenges through clinical engagement and innovation. Health and wellbeing board members We work closely with both health and wellbeing boards, actively participating in developing strategy, improving services for patients. Throughout our service redesign programmes and every day working, we have aimed to keep the health and wellbeing boards informed and involved. Our plans are cognisant of the strategic priorities of both health and wellbeing boards (HWBs) across our areas. Sandwell HWB has identified four key priorities: Early years and adolescent health Long-term conditions and integrated care Frail elderly and dementia Alcohol. Birmingham HWB has agreed three strategic priorities in its joint health and wellbeing strategy: Improve the health and wellbeing of its most vulnerable adults and children in need Improve the resilience of its health and care system Improve the health and wellbeing of its children. 28

29 Case study: supporting patients with long-term conditions In Sandwell the Health and Wellbeing Board divided its priorities between partners. The CCG led on the review of long-term conditions. For the past two years the CCG has worked with patients, carers and health professionals to review the long-term conditions experience. Using the experience led commissioning technique our engagement team supported the groups to develop a joint vision for the future. In October we organised a challenge workshop, with the participants, to consider how we make this vision a reality. Participants told us we need to: Invest in peer support/ self-help groups Provide support for carers Move towards outcomes based contracting Implement patient activation measures (PAM) monitoring patient control Create a Long-term Conditions Charter for organisations to sign up to Invest in front line training (not just for clinicians) Explore a compassionate communities approach. Work is now ongoing to develop a plan for the future and consider what is achievable for Sandwell and West Birmingham. Membership and voting rights We are strategic partners and board members on both the Sandwell and Birmingham HWBs: We have four Governing Body member positions on Sandwell HWB with three voting rights We have one Governing Body member position on Birmingham HWB, with voting rights. Leadership Our HWB members and staff are actively leading and contributing to the delivery of the strategic priority work streams for both boards In Sandwell, we led one of the four HWB priorities: long-term conditions and integrated care In Birmingham our Chair, Dr Nick Harding, led one of the three Birmingham HWB priorities around resilience. Working together during In November we co-organised a stakeholder workshop for the Sandwell Health and Wellbeing Board to update stakeholders on our progress against the priorities Our staff and leaders have actively influenced the development of the health and wellbeing strategies. A refreshed strategy is being developed for Sandwell and we are working in partnership in its development We have involved the health and wellbeing boards in the development of the BCF. 29

30 Better Care Fund We have worked extensively with both local authorities to agree our BCF submissions. Locally 34 million will be transferred from our existing budgets to the two local authorities from , creating pooled budgets to help increase integration between health and social care. There are a number of initiatives taking place in both areas to prepare for , including: Transforming health and social care through community working Increasing integrated care, with a focus on multidisciplinary working, single points of access and triage services Increased focus on early prevention Enhancing the role of primary care in promoting self-care and effectively managing vulnerable groups Working towards seven-day working. Sandwell Better Care In Sandwell a number of work streams are in place to support joint working, including: Community Offer support people in the community and transform health and social care through innovative community-based solutions Primary care development enhance the primary care offer which will focus on early identification and prevention, early targeted interventions, self-care, education, effective proactive management of vulnerable groups and seven-day working Prevention develop a prevention-focused delivery model built upon the principles of the Multi-Agency Prevention Platform (MAPP) Integrated assessment and reablement align intermediate care and enablement home care services to ensure the rehabilitation and enablement offer is built around the service user Intermediate care management deliver a single point of access and nurse-led triage services designed to streamline assessments and referrals Integrated care deliver a carefully focused, multi-disciplinary care management process that will significantly reduce acute care attendances and admissions Acute bed based services improve community and A&E interventions to reduce demand for acute beds and equivalent fair access to social care (FACS) services Timely and effective discharge integrate the discharge planning process ensuring people get the right health and social care support in the community Integration enablers ensure a single patient identification number, seven-day working and risk stratification. Case study: Community Offer The Community Offer is a pilot programme within the Sandwell Better Care Fund. It aims to provide community-based support to vulnerable people, to help them maintain their health and wellbeing and reduce demand on health and social care services. This is achieved by strengthening community capacity, through increased provision of localised support services, information, advice and signposting. 30

31 Funded by Sandwell Council, the Community Offer includes six pilot schemes covering thirteen wards in Sandwell. By creating local services through the coordination of volunteers, local carers and commissioned services, the Community Offer enables the development of a support structure to help manage people s diverse needs in the community. As a CCG we are proactively supporting the programme. By establishing GPs at the heart of the Community Offer we can ensure that the support delivered is joined up and connected between health, social care and the voluntary and community sector. For more information on the Community Offer see our website. Birmingham Better Care Birmingham Better Care has four core priorities: 1. Keeping people well where they live 2. Making help easier to get 3. Better care at times of crisis 4. Making the right decisions when people can no longer cope. These four priorities are being delivered through a number of programmes: Governance and delivery Developing and agreeing the case for change. Work includes undertaking As Is system diagnosis, including quality, spend, activity and performance. The programme will identify opportunities for improvement to deliver best practice and commissioning intentions for Creating the impetus for change Developing and implementing a communication and engagement programme including shared tools to support the conversation. We want to engage people in the challenge, listen to and build upon their ideas to meet our objectives and empower them to change. Accountable community professionals Put in place the appropriate activities to ensure the role is recognised and embedded across the city including required processes, assessment and documentation. This is part of our commitment to support multidisciplinary working closer to home. Place based integration This programme will review current community support and voluntary sector services commissioned across the whole system. It will look to develop integrated commissioning business cases, which deliver models of care based around general practices. It focusses on proactive, preventative care. Step up/step down and improving discharge Develop a service delivery model e.g. co-ordination hub to ensure effective admissions avoidance and discharge into lower levels of care. A number of initiatives will be developed, including procuring a clinical assessment tool and improving early discharge planning. 31

32 Day services Develop seven-day services between hospitals and out of hospital alternatives. To ensure all services are in place to enable timely admission avoidance or discharge seven days a week. Combined point of access To enhance and expand a city wide combined point of access to support selfassessment and management, early identification of need and proactive care. This will align service response times to community alternatives for urgent care and link with NHS 111. Data sharing This programme has three key objectives: first to ensure the NHS number is used consistently across the system, second to deliver the Midlands Central Care Record and third to procure the Pi dashboard. Healthy Communities During we ve been working closely with 35 of our member practices, who formed ten pilot healthy community sites. The patients in these communities make up half of our population. GPs are best placed to understand the needs of their local communities, and have been working with us to review data and develop local plans to reduce unplanned and avoidable admissions to secondary care (hospitals). The plans include dedicated case management, extended multidisciplinary teams focused on patients at greatest risk of admission, telephone triage and weekend clinics. We re really excited about this project, as it is truly supporting commissioning at a local level. It is hoped that the schemes will be implemented from April Right Care Right Here For over ten years your local health and social care organisations have worked together under the Right Care Right Here partnership, to improve people s health and the quality of health and social care services provided to them. This has involved: Bringing care closer to home with more services in the community Providing high quality care in high quality places Making Sandwell and West Birmingham a healthier place to live and work Delivering Midland Met Hospital. 32

33 In July 2014, the Treasury and Department of Health approved the development of a new state of the art hospital in Smethwick. The Midland Met Hospital, due to open in autumn 2018, will be the centrepiece of a new and exciting future for healthcare within our community. We have been working towards this moment, since the Right Care Right Here public consultation in Reaffirming our commitment to Right Care Right Here Following the Treasury approval we have strengthened the partnership, with regular programme board meetings. Our Right Care Right Here partners include: Sandwell Metropolitan Borough Council Birmingham City Council Sandwell and West Birmingham Hospitals NHS Trust Birmingham Community Healthcare NHS Trust Black Country Partnership NHS Foundation Trust Birmingham and Solihull Mental Health NHS Foundation Trust Sandwell and West Birmingham CCG Healthwatch representatives Community and voluntary sector. Led by Dr Nick Harding, Chair of the Right Care Right Here programme board, partners have reaffirmed their commitment to the partnership. During 2014 partners agreed their guiding principles: Organisational sustainability Strong partnership Inclusivity across the health and social care economy Synthesis with existing workgroups Regular, scheduled meetings Public awareness and communication Working with both health and wellbeing boards. During we have focused on building momentum within Right Care Right Here to plan ahead for Midland Met Hospital. A number of work streams have been established to help us realise our vision: Public health (maximising intervention, understanding trends) 33

34 Better Care Fund (BCF, community development, integrated care, primary care development) Delivery (system resilience, workforce, voluntary sector) Communications and engagement (keeping partners, stakeholders and the public informed and involved) Workforce (developing a comprehensive workforce strategy) Regeneration (employment, business, neighbourhoods) Provider resilience/ organisational sustainability (finance and activity modelling, expenditure profiling and market management shaping and development) Transition management (develop, plan and implement a programme of change across the partners) Clinical reference group (assurance and expert intelligence to support the Transition Management work stream) Capital and estates (primary care and community infrastructure integral to the delivery of Midland Met Hospital, including transport). In we will be recruiting a number of roles to drive forward the work of the Right Care Right Here programme, including a Programme Chair, Programme Director and Programme Support. Finance review Statutory financial duties We have six statutory financial duties as detailed in the table below. We met or exceeded all six of our statutory financial duties in Statutory Financial Duties Performance Duty Maximum Target 000s Actual Performance 000s Expenditure not to exceed income 8,000 8,778 Yes (underspend) Capital resource use does not exceed the Yes amount specified in Directions Revenue resource use does not exceed the 634, ,357 Yes amount specified in Directions Capital resource use on specified matter(s) Yes does not exceed the amount specified in Directions Revenue resource use on specified matter(s) 0 0 Yes does not exceed the amount in Directions Revenue administration resource use does not exceed the amount specified in Directions 12,700 10,347 Yes Note: Directions are the financial limits set by NHS England for CCGs. Duty Achieved? 34

35 Our finances Total income for was 634m (circa 1,158 per patient) Total expenditure in was 625.3m Expenditure on commissioning healthcare was 615m Expenditure on running costs (i.e. management and administration) was 10.3m We achieved a surplus for the year of 8.7m. How did we spend our money? CCG Expenditure in Millions 4m 96m 10m Acute Community 87m 92m 336m Mental Health & Learning Difficulties Prescribing Other (including reserves, etc.) Running Costs CCG running costs We had a running cost allowance for the year of 12.7m. We employed an average of 135 staff. The cost of these staff for the year was 6.4m. We only spent 10.3m of this allowance, with the remainder being invested in patient services. Challenges ahead We face the following changes: From the 1 April 2015 we need to transfer 34m each year into the BCF An increasing demand for services We need to deliver 8m QIPP in From the 1 April 2015 we have taken on delegated responsibility for cocommissioning circa 75m of local GP services. This provides an opportunity to better develop GP services to meet local needs. 35

36 What does this mean for us? We need to ensure patient services remain high quality We need to stay in financial balance We need to invest in improving quality and working more efficiently We need to continue our partnership approach to transformation (Right Care Right Here). Annual accounts We can confirm that these accounts have been prepared under a direction issued by the NHS Commissioning Board under the National Health Service Act 2006 (as amended). Managing performance Our contracts and performance teams regularly collect data from providers, so we can monitor how the CCG is performing against its agreed targets. There is a range of national and local indicators, which we are asked to achieve; ultimately these work towards improving quality care and access for patients. In particular the NHS Constitution sets out a series of promises to patients, that CCGs are expected to achieve. The below table highlights how Sandwell and West Birmingham CCG and, where appropriate, Sandwell and West Birmingham Hospitals NHS Trust, has performed against these national pledges. Through regular contractual meetings, any missed targets are discussed with providers and action plans are put in place. Level of reporting Period Target 36 Actual CCG achieve ment NHS Constitution indicators Category A calls resulting in an emergency response arriving within 8 minutes Red 1 YTD 75% 84.76% Category A calls resulting in an emergency Mar- CCG YTD response arriving within 8 minutes Red % 76.80% Category A calls resulting in an ambulance arriving at the scene within 19 minutes YTD 95% 99.10% Patients should be admitted, transferred or Mardischarged within four hours of their arrival at an SWBH YTD 15 A&E department 95% 92.40% Percentage of patients seen within two weeks for an urgent GP referral for suspected cancer YTD 93% 94.10% Percentage of patients seen within two weeks for an urgent referral for breast symptoms YTD 93% 94.18% Maximum one month (31-day) wait from Feb- CCG diagnosis to first definitive treatment for all YTD 15 96% 97.22% cancers Maximum 31-day wait for subsequent treatment where that treatment is surgery YTD 94% 89.79% Maximum 31-day wait for subsequent treatment YTD 98% 99.68% Ambulance A&E Cancer waits

37 RTT Diag HCAI MSA Cancelled Operations MH where that treatment is an anti-cancer drug regime Maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers Maximum 62-day wait for first definitive treatment following a consultant's decision to upgrade the priority Referral to Treatment - Admitted patients to start treatment within a maximum of 18 weeks from referral Referral to Treatment - Non-admitted patients to start treatment within a maximum of 18 weeks from referral Referral to Treatment - Patients on incomplete pathways waiting no more than 18 weeks from referral Referral to Treatment - Number of incomplete pathways waiting >52 weeks Percentage of patients waiting 6 weeks or more for a diagnostic test CCG CCG YTD 94% 98.56% YTD 85% 86.57% YTD 90% 95.76% YTD n/a 94.24% YTD 90% 90.22% YTD Mar- 95% 95.27% 15 YTD 92% 93.54% March 0 4 YTD Mar- 15 1% 0.76% Breaches of same sex accommodation CCG YTD All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the patient s treatment to be funded at the time and hospital of the patient s choice. Breaches of Standard Care Programme Approach (CPA): The proportion of people under adult mental illness specialities on CPA SWBH CCG QTR YTD Healthcare Acquired Infection (HCAI) measure Mar- 0 7 (MRSA) CCG YTD 15 HCAI measure (Clostridium difficile infections) Mar- 15 Dec- 14 Dec Reduce from 13/14 YTD (0.31%) 0.86% 95% 95.45% 37

38 Key SWBH: Sandwell and West Birmingham Hospitals NHS Trust YTD: Year to date QTR: Quarter MSA: Mixed sex accommodation HCAI: Healthcare Acquired Infections MH: Mental health The below paragraphs highlight our performance against these standards for Figures are based on the latest data available at the time of the writing this report. Mixed sex accommodation Up to the end of March 2015, 97 of our patients experienced mixed sex accommodation breaches. This was across all the local hospitals that serve our population. 88 of these were at SWBH, mostly at the beginning of the year, following the introduction of a new electronic bed management system that provided tighter control of reporting. Cancelled operations At the end of quarter three (December) SWBH reported 116 cancelled operations for nonclinical reasons. The Trust failed to meet the standard of being offered another confirmed date within 28 days for one patient. We are working with the Trust to ensure that patients are inconvenienced as little as possible, and that safe care is provided. Referral to treatment Patients have the right to expect to wait no longer than 18 weeks from their GP referral to treatment, when clinically appropriate. Between April 2014 and the end of March 2015, 90% of our patients were treated in hospital within 18 weeks and 95% who did not need to be admitted were seen within 18 weeks. We are working with our SWBH to achieve this target across all specialties consistently throughout the year. Cancer referral to treatment There are a number of targets within the NHS Constitution relating to cancer treatment: Two week wait for an urgent appointment: for all cancers for the year up to the end of February, we exceeded the 93% national target 31 day cancer diagnosis to treatment: patients have the right to expect their first treatment within one month of diagnosis. For the year (up until the end of February) we exceeded the 96% national target 62 day wait from urgent referral to treatment: improvements have been seen in this category and for the year (until the end of February) we exceeded the 85% national target. 38

39 52 week waits for operations For the full year April to the end of March, nine patients had to wait over 52 weeks for their operation. This is an improvement on last year when 27 patients waited over 52 weeks for the same period. In order to address this issue and learn lessons moving forward, we undertake a root cause analysis report for each individual case. Outcomes measures Improving outcomes and securing high quality care is the primary purpose of the NHS in England. We have set baseline plans for five key measures to help us improve outcomes for our communities. Secure additional years of life potential years of life lost (PYLL) from causes considered amenable to healthcare: 2012 (Baseline year) 2013 During the first year of monitoring against the new baseline, unfortunately, we were not able to achieve the required reduction. Increase the quality of life for people with long-term conditions health related quality of life score for people with long-term conditions: The health related quality of life score improved from the baseline year. Reduce the amount of time people unnecessarily spend in hospital composite of all avoidable emergency admissions: As planned, avoidable admissions reduced in the figures published for Reduce the number of people reporting very bad care in hospitals patient experience of hospital care average number of negative responses per 100 patients: 2012 (Baseline year) 2013 The average number of negative responses reduced as planned, from the baseline year. Reduce the number of people reporting very bad primary care (GP, out of hours and dentistry) patient experience of primary care average number of negative responses per 100 patients: 2012/13 (Baseline year) /13 (Baseline year) /13 (Baseline year) The average number of negative responses reduced as planned, from the baseline year. 39

40 West Midlands Ambulance Service West Midlands Ambulance Service (WMAS) is the provider of urgent and emergency responses to people who call 999 in the West Midlands region. We manage the contract with WMAS on behalf of all 22 CCGs across the region. The 999 service experienced a significant rise in demand, which directly affected the service s ability to meet and sustain its response time Key Performance Indicators (KPIs), however the KPI for the most serious category of patients (Red 1) continues to be met and exceed the national KPI. CCGs are working with the ambulance service to better understand what causes the increased demand. About 40% of calls made to WMAS do not require conveying to hospital, suggesting that services available in the community can provide responsive alternatives to calling 999. This winter we have invested additional funding in the ambulance service and within alternative services, to help manage demand and support the Trust to meet key targets. You will read more about this in our local commissioning group updates, including the launch of the mental health crisis car. Infertility services In partnership with the CCGs across Birmingham, Solihull and the Black Country, we ve been working to harmonise our offer for infertility services. This follows engagement with patients and partners earlier this year. This now means we can provide a fairer offer, which includes: Earlier clinical assessment and investigation and fertility treatment after one year Reducing the minimum age for fertility treatment to 20 Fertility treatment offered to all eligible single women and same sex couples. The revised policy came into force on 1 December 2014, with Birmingham Women s NHS Foundation Trust as the service provider. Following feedback from our overview and scrutiny committees we have agreed to postpone any changes to the number of cycles offered until So, for the meantime, we are retaining one cycle in West Birmingham and two cycles in Sandwell. Mental health services for children, young people and young adults A new community mental health service is being commissioned for children, young people and young adults in Birmingham. The service, which will be based around prevention, choice and personalised care, is designed to address problems currently faced in the city. These include disjointed and fragmented care provision, complicated service models, long waiting lists and increasing patient demand. 40

41 Birmingham is the youngest city in Europe, with under-25s accounting for nearly 40 per cent of the population. At least one in ten of those aged from five to 16 suffers from a diagnosable mental health disorder around three in every classroom. Aimed at 0 to 25 year olds, with inpatient beds for those aged 18 to 25, the new service was put out to tender by Birmingham South Central CCG on behalf of Birmingham Cross City and Sandwell and West Birmingham CCGs, and Birmingham City Council. Forward Thinking Birmingham, a new mental health partnership, has been named as the preferred bidder for the 124m, five-year contract. The partnership is led by Birmingham Children s Hospital (Child and Adolescent Mental Service), with the other partners being Worcestershire Health and Care NHS Trust (community adult mental health care), The Priory Group (inpatient and rehabilitation), Beacon UK (care management), and The Children s Society (voluntary sector knowledge and experience). The preferred bidder has been identified following an evaluation of tenders. It is recommended they are awarded the contract, should a contract be awarded by the commissioners. Under the service, a single 24/7 phone number will provide immediate access to experts. They will support children, young people, young adults, families, health professionals and those who work with children and young adults in getting the services they need. These could be anything from online or flexible community support, to home-based care and urgent services. It s hoped the new service will go live in October When it does, it will completely change the way mental health is viewed and delivered in the city, giving it the same priority as physical health and wellbeing. NHS 111 NHS 111 is a free non-emergency service for the West Midlands that is provided by WMAS. It is one of many national initiatives implemented to try to reduce pressure on hospital A&E departments. The service delivers free healthcare advice and signposting to the correct service for patients on a 24/7 basis and is growing month by month as patients recognise its value. NHS 111 assesses patients needs and directs them to the local service that can help them best, for example, community pharmacy, out-of-hours GP, or urgent care centre. The 999 service is still there for life-threatening emergencies. As lead commissioners for the NHS 111 service across the West Midlands we are pleased with the progress the service has made. We have been working at a national level to review the service. The NHS 111 service has grown by 30 per cent over the past year in the West Midlands alone, and has trialled a number of new initiatives across the UK such as having a GP in the call centre, marketing campaigns urging people to call 111 before they visit Accident and Emergency (A&E) and, more recently, digital projects that aim to reach younger audiences. 41

42 Clinically led commissioning In 2014 we took our membership to a new level, as we delegated authority for delivering our key work programmes and contracts to our five local commissioning groups. This section includes a report on their key achievements during Black Country Local Commissioning Group By Dr George Solomon, Chair Mental health It s certainly been a busy year and I m really pleased with the progress we ve made on our priorities, particularly around mental health and outpatient modernisation. The Black Country LCG covers general practices mainly within the Tipton and Rowley areas, with a small number of practices in Warley and Wednesbury. The Malling Health practices also fall within the Black Country LCG. Our clinical leads Dr Arun Saini and Dr Elizabeth England have done a tremendous amount of work with commissioners on three key priorities: Improving access to psychological therapies During the past year we have been working to improve access to psychological therapy services to meet the national target of 15%. We know from feedback from GPs and patients that there s an issue with waiting times. We have been working with providers and practices to support faster responses to referrals. Activity has included working with providers to increase capacity and planning additional investment. We hope this will make a real difference to some of our most vulnerable patients. Improving mental health access in urgent care This winter a number of initiatives were launched to support patients with underlying mental health concerns to receive timely and appropriate urgent care. I m particularly pleased with the launch of the mental health car in November. We recognised that the ambulance service and NHS 111 receive a large number of calls from patients who require mental health specialist support. Working in partnership with the Police, and other CCGs in the Black Country area we launched the car, which includes a paramedic, police officer and community psychiatric nurse to do a mental health assessment. So far the car has been a real success with prompt responses and positive feedback. We also increased resources for the Crisis Response and Home Treatment teams for adults, strengthening access overnight in the Oak Units at both Sandwell and City hospital sites. In December we introduced a Crisis Response and Home Treatment Team for under-18s. This is available to people at home, in A&E and paediatric wards. The service is available seven days a week. Outside these hours there will be access to 42

43 a children and adult mental health on-call psychologist. This is a fantastic project and we hope it will make a huge difference to young people. Over the winter months we also recognised a need to strengthen early intervention in the psychosis team through increased operating hours - 9am to 8pm Monday to Friday - to support people in work or education. During early 2015 we will be evaluating all of these schemes to build into our planning for Winter Improving diagnosis rates for dementia Improving dementia diagnosis is a real priority for us in the CCG. We ve made some significant improvements but still have a way to go to reach the national target of 67%. At the time of writing this report we are currently at 59.3%. A range of new initiatives were launched in to support practices to improve diagnosis, including working with practices to encourage a data audit to ensure all patients diagnosed with dementia are included on the dementia register. By helping patients to be diagnosed early, we can support them to access the right treatment. Learning disabilities We have been working to deliver quality and fair services for people with learning disabilities within the community. This involved working with the Black Country Partnership NHS Foundation Trust to implement the Health Equalities Framework (HEF). The Trust has been piloting the HEF with several of their teams. Our clinical leads are also preparing criteria for autism spectrum disorder (ASD) diagnosis, to identify suitable local ASD diagnostic providers. Outpatient modernisation I m particularly pleased with the progress we have made on improving outpatient services. Over the past 12 months we have reviewed services to help build specifications for the future. During November we held events for patients and providers to understand what change is needed and what is achievable for Sandwell and West Birmingham. These events were really useful, and during early 2015 we have gone out to procurement for three new services: Ophthalmology, including Primary Eye-care Assessment and Referral Service (PEARS), intra ocular pressure repeat measures and direct cataract referrals Community extended minor surgery service Community direct access non-obstetric ultrasound service. This will help us deliver consistent services closer to home and at the same time support efficient and effective services. 43

44 We have also been looking at bringing a number of other outpatient services into the community: Community anticoagulation service Community cardiology diagnostic and outpatient service An electrocardiogram (ECG) local improvement scheme and ECG interpretation service Community dermatology service. We are working with Sandwell and West Birmingham Hospitals NHS Trust (SWBH) to carry out an audit of a typical week s worth of outpatient clinics in cardiology and dermatology, to test assumptions on the percentage shift of activity into the community. We re also doing further scoping of the impact of introducing Novel Oral Anticoagulants (NOACs) to anticoagulation services. Deliver the Lipids Service Development Improvement Plan (SDIP) We re working with SWBH to improve medicines quality, in particular in Lipids. We hope to support more patients to have their medication reviewed by their local practice, rather than needing to visit the hospitals. This will help increase capacity within the hospitals, enabling them to focus on specialist care. Pathways have been developed and agreed with the Trust and we ve reached an initial agreement with clinicians to reduce the level of Omega 3 prescribing in line with NICE guidance. We have been working with the medicines quality team to identify the number of patients per practice under follow up and agree criteria for discharge back to the GP. Following this we will be communicating the new processes and pathways to member practices. HealthWorks Local Commissioning Group By Dr Nick Harding, Chair We ve made significant progress this year in reviewing services, including stroke and musculoskeletal services. The work so far has largely involved analysing existing provision and engaging with providers and patients to consider the potential for change. This work has really shown the benefits of our tripartite model; our clinical leaders working with commissioners have taken an in depth look at these challenging areas and some of the ideas being progressed are really exciting to see. HealthWorks is a large local commissioning group of 24 GP surgeries covering a diverse region within Sandwell and West Birmingham. Our GP members represent patients in Handsworth, Lozells, Handsworth Wood, Aston, Ladywood, Smethwick, West Bromwich, Great Barr, Rowley Regis and Oldbury. 44

45 Stroke We have been leading a review of stroke services across the Birmingham, Solihull and Black Country CCGs. We know that by ensuring all providers are delivering quality care, in line with the National Stroke Strategy and regional best practice, we can save lives and improve patient outcomes. Work has been progressing at pace to review long-term stroke support services and determine the optimum number of hyperacute stroke units (care provided in the first 72 hours post stroke). A programme board was set up to drive forward the programme. The programme team has undertaken detailed analysis to identify if improvements can be made to stroke services. The next milestone for the project is to continue working with providers during 2015 to take forward the findings of the programme, and agree what is achievable. Looking forward to we will then start planning implementation of any improvements. The programme is about much more than just the hyperacute stroke unit phase. It focusses on the entire stroke pathway, and aims to provide fully integrated stroke services from prevention through to end of life care. A number of best practice specifications were developed for: Inpatient bed based rehabilitation Early supported discharge and community rehabilitation Long-term care support. The best practice specifications are being taken forward in contracts for in the future. A great deal of work has taken place by the programme team, patients, voluntary sector representatives and clinicians. We re also really fortunate to have had Professor Tony Rudd, a national stroke expert, working with us at every stage of the review. Locally, at a CCG level, plans are being developed to support other areas of the pathway, in particular, primary prevention of stroke. Much emphasis is being placed on Atrial Fibrillation (AF) and should see some exciting initiatives being implemented. Musculoskeletal services Throughout the year we have been engaging with patients and providers to identify improvements to Musculoskeletal (MSK) services. Led by our clinical lead Dr Ram Sugavanam, clinicians from rheumatology, pain management, orthopaedics and physiotherapy attended a series of workshops to discuss how we reduce variation and encourage integration across the specialties. Our vision is to develop sustainable and equitable local MSK services for across the area, and encourage improved performance through integrated MSK care. Above all we want to improve the patient journey by reducing unnecessary referrals to secondary care, and encourage inter-specialty referrals. In parallel we have been carrying out activity and financial modelling to understand what is achievable and scope the potential Quality Innovation Productivity and Prevention (QIPP) efficiencies. 45

46 An action plan has been developed, to improve services locally. During we will be implementing these short, medium and long-term improvements, working closely with providers and patients. Demand and pathway management We know there s more we can do to streamline the patient journey by localising pathways and targeting some of the high cost/high usage specialties. By improving demand and pathway management we hope to reduce outpatient referrals and variance in primary care and improve quality. We know that to make this a success we need to improve access to consultant advice and guidance for primary care. We have been working with Sandwell and West Birmingham Hospitals Trust (SWBH), to develop a Virtual Consultant Triage model. This model will give GPs access to consultant advice and guidance, helping reduce unnecessary hospital visits for patients. Patients will be assured that they are getting the best advice locally, and that they will receive the right care, in the right place by the most appropriate person. We recognise that the Choose and Book service can support practices to have access to the latest advice and guidance and referral pathways. Working with the hospital trust we reviewed the information available on Choose and Book to ensure it is up-to-date and relevant for practices. We also undertook a survey with practices, to look at how Choose and Book could be improved locally, and how we can support practices to utilise the system to be most effective. This work will also support practices in readiness for the new e-referral system when it is launched. A key element of this work is implementing a risk stratification tool, to help practices identify patients at risk of unplanned admissions to hospital as well as supporting practices to focus on their local practice population and tailor services and interventions to suit their patient s needs. We hope to be able to roll out the tool during It s a big piece of work, but will make a real difference to targeting outpatient expenditure and activity by providing tailored services in the community and closer to home for patients. By identifying patients early, practices will be able to support patients to manage their condition and reduce unnecessary referrals to hospital. In parallel we re looking to collaborate with secondary care consultants to deliver GP educational sessions, to upskill both primary and secondary clinicians to ensure that we are working in unison across the patient pathway to deliver an enhanced patient experience. We re working to launch these sessions during the next financial year. Summary Although many of our priorities are targeted around delivering QIPP efficiencies, it s important to remember this is first and foremost about improving care for patients. When we implement the changes, patients will experience better care, faster responses and in the case of the stroke work, we will save lives. 46

47 Intelligent Commissioning Federation (ICoF) Local Commissioning Group By Dr Sam Mukherjee, Chair We ve made significant progress over the last year by focusing on six key areas, to ensure we see improved quality of services for patients and realise QIPP savings. This work will help inform our future commissioning intentions and importantly help us improve care and the quality of services patients receive. The Intelligent Commissioning Federation (ICoF) is a large local commissioning group of 23 GP surgeries covering a diverse region. Our GP members represent patients in Aston, Ladywood, Handsworth, Lozells, Handsworth Wood, Great Barr, Erdington, Birmingham city centre, Sparkbrook and Erdington. Cardiac rehabilitation programme We have been working with the University of Birmingham and Sandwell and West Birmingham Hospitals Trust (SWBH) to trial a home based cardiac rehab programme. This involved a research trial and we worked with the hospital trust to identify 54 suitable participants with heart failure. 27 participants will be funded for excess treatment costs. The trial and evaluation will take place between January 2015 and June This will help us to reduce the number of cardiac rehab related admissions as well as improve the patient s psychological health and quality of life. Telehealth Through increased usage of telehealth across primary and secondary care, we hope to reduce unnecessary follow up appointments, system wastage and reduce chronic obstructive pulmonary disease, asthma and hypertension related hospital admissions through closer integration of services. From a patient perspective, it can help you to self-manage your condition, ensure better concordance with medication and care regimes and increase patient satisfaction. We ve already had discussions with providers and practices to consider how telehealth can be used within primary care during the pilot. Respiratory Dr Saj Sarwar and clinical lead Elaine Cook have done fantastic work around improving outcomes for respiratory patients. This includes streamlining pathways across primary and secondary care to improve services. The respiratory steering group working with our clinical lead have reviewed the primary care pathways, which were shared with practices in early In addition, the service specifications for Sandwell Community Respiratory and Long-Term Oxygen Therapy have been reviewed. For West Birmingham, we are working towards aligning the oxygen service to the Sandwell Oxygen Service. Diagnostic spirometry was 47

48 identified as a gap for both Sandwell and West Birmingham, and we are working towards commissioning a community spirometry service for both areas to ensure patients receive care closer to home where appropriate. A real highlight for us this year was our community respiratory day held in July Organised by our clinical lead, Elaine Cook, clinicians attended to hear the latest respiratory guidance and best practice. This is part of our commitment to primary care development, to improve quality for patients. Building on the success of this event, we coordinated a chronic obstructive pulmonary disease (COPD) course in partnership with Keele University which ran during November to February. Almost 20 practices benefitted from this course and we look forward to seeing the difference it will make in the management of COPD patients in these practices. A training needs analysis has also been completed to capture the gaps in respiratory education and experience. An education and training programme is now being developed to upskill primary care colleagues for better diagnosis, management and care of patients with respiratory illnesses. Home Oxygen Service/ long-term oxygen We want to ensure all patients receive a safe and high quality service, and over the past year have completed a primary care audit, as well as a review of all patients on the old contract. This information has now been given to our provider so they can update their records. An overall review of all patients receiving home oxygen therapy was also commissioned, which was completed by the end of March This project will ensure all patients receiving long-term oxygen therapy receive periodic reviews and receive a safe and high quality service. As lead commissioner of the Home Oxygen Service across the West Midlands, a key milestone for us was signing the collaborative agreement between the 22 CCGs in the West Midlands and the CSU. Diabetes I m really pleased with our progress to develop an education and training programme to upskill primary care and deliver care closer to home for patients. Working with the medicines quality team we are in the process of developing a training needs analysis and organised a number of training courses during : PITstop course (injectable therapy)- this includes train the trainer PREDICT course (Programme of Education Diabetes in Core Training)- an advanced course in injectable therapy Setting up a mentorship programme to support PITstop and PREDICT courses Refresher sessions for diabetes related issues. We have also been working to develop a business-to-business tool to identify practices needing further support and to ensure the development and promotion of NICE guidance pathways. 48

49 In addition to the above work streams, the Diabetes Steering Group has also reviewed the diabetes pathways which have now been signed off. Once the revised pathways are ratified by the Demand and Pathway Management Steering Group, they will be shared with all practices. Vaccine preventable illness By encouraging more patients to have their free flu and pneumococcal vaccines, we can help reduce hospital admissions and help patients to keep well during the winter months. During last winter, we launched a number of initiatives to support practices to increase uptake: Developing the SWIFT (Specialist Winter Immunisation Teams), who were able to support practices with low uptake by: o Carrying out additional immunisation clinics for homeless people and people with no fixed abode o Extra evening clinics offered Sharing information packs with GP practices on how to identify high risk patients for flu and pneumococcal vaccines, including letter templates Liaising with NHS England to obtain the local uptake data on a regular basis to identify any practices that might benefit from additional support Securing support from Agewell to support practices to engage with over 65s Information pack shared with voluntary and community sector to raise the awareness of the importance of flu and pneumococcal vaccines. We want to improve immunisation uptake for Winter and will be working with practices, care homes and NHS England to develop a robust flu and pneumococcal vaccination campaign. Pioneers for Health By Dr Vijay Bathla, Chair Pioneers for Health is a relatively small LCG of seven practices caring for 46,000 patients. The LCG holds monthly board meetings involving at least one representative from each practice and is represented on various committees throughout the CCG. We have some very challenging priorities to deliver within Pioneers for Health, and I think we can be proud of how far we have progressed. Our priorities focused on tackling pressures on the urgent care system both for last winter and for the years to come. I want to start by thanking our clinical leaders Dr Manir Aslam and Dr Sirjit Bath (Urgent Care) and Dr Obaid Farooqui (Intermediate Care) and the commissioning team for their hard work last winter to help reduce pressure on urgent and emergency care services. 49

50 Urgent and emergency care This winter ( ) we invested 6.4m in schemes to help manage demand. We ve seen some innovative ideas coming from the CCG and partners and it s been exciting to be part of the work. To mention just a few: Reducing delayed hospital discharges Delayed transfers of care (DTOC) is a real issue not just for us but across the country. Working together with social care, our continuing healthcare team and Sandwell and West Birmingham Hospitals Trust (SWBH), a new pathway was introduced in the Trust s hospitals, with a multi-disciplinary team (ADAPT) in place to reduce delays in discharge. ADAPT brings nurses, consultants, continuing healthcare and social care together on the wards to support joint working. This is a new culture and way of working for all organisations. Patients are reviewed regularly to see if there is any risk of a delayed discharge from hospital. This remains a key priority for us and we re continuing to work will all partners to regularly monitor delayed discharges and try to reduce this further. Own Bed Instead We know delayed discharges occur when there is not enough support for patients in their own home; working with social care and community providers we commissioned additional support in the home to provide 20 virtual beds across Sandwell and West Birmingham. The programme included a range of extra services to help patients to stay in their own home, which may include night visits, therapy support to adapt houses (e.g. moving beds downstairs) and quicker access to equipment. All partners have been involved, and the service was managed by ICARES in Sandwell and SPA in Birmingham. Primary Care Assessment and Treatment Centre This is the second winter we have commissioned the Primary Care Assessment and Treatment Centre (PCAT) at Rowley Regis Hospital in partnership with SWBH. The centre brings together the different clinical teams a patient may need, including local GPs, community matrons, nursing and therapy staff. We identified a gap in the local system, as patients who may need further assessment or treatment have no choice but to go to A&E. GPs and other NHS services can refer patients to this centre for treatment or diagnostic tests (such as blood tests or x-ray). They can also monitor patients, and admit them to hospital if their condition deteriorates. This winter we took the service one step further, by piloting a Bed Bureau service with Black Country LCG (as the closest LCG to the centre). All GP referrals for urgent assessment were triaged through the PCAT service, to provide one gateway into the hospital. The PCAT service could then support patients to be referred into the right service, including into the PCAT centre where appropriate. Results from the pilot were encouraging and this was then offered to all the LCGs. 50

51 Longer term urgent and emergency care strategy Our Clinical Leads have been working towards developing a five year Urgent and Emergency Care Strategy. During January and March 2015 we undertook a listening exercise with patients, partners and the wider public. The listening exercise aimed to identify what works well and what could be improved in our urgent and emergency care services locally. This feedback will be taken forward as we develop options for the future. This is a big project, and depending on our findings will likely require a public consultation later in Ultimately, we want to ensure that our urgent and emergency care services are fit for the future. In particular, we are reviewing these services now to prepare for the Midland Met Hospital in We want to ensure the right level of support is available in the community when the new hospital opens. Access to primary care We know from feedback from patients and GPs, that urgent access to GP appointments remains an issue locally. We commissioned the Primary Care Foundation to support our practices in reviewing their services with the aim of improving access. The Primary Care Foundation supported practices to review how patients access the surgery and provide tailored advice at an individual practice level on potential improvements. We have also been working closely with NHS 111 to pilot direct booking for GP appointments with our practices. We know that other areas of the country have introduced this and our clinical leads have been working with all LCGs to look at whether this is feasible /appropriate locally. Intermediate care Another priority for us is to review our intermediate care services to ensure quality and equitable services are provided across our area. We have made good progress in reviewing and auditing all of our intermediate care services. Through carrying out these audits, the team has been able to identify issues that result in delayed discharges and put in place new processes to minimise this. We have taken this one step further and have used this intelligence to help us decommission beds that are not in our geographical boundary or are not value for money. This has helped us to reinvest this money to bring care closer to home. In particular, I m really excited that we were able to commission an intermediate care facility in the middle of the West Birmingham patch, which previously had no dedicated intermediate support. SWBH won the tender and refurbished a ward on the Sheldon Block at City Hospital. The new ward gives patients their own rooms and has kitchen and dining areas where patients will self-serve themselves. It is a GP managed facility and will give a true re-ablement focus with health and social care staff. Finally in March 2015 our LCG Board was due for re-election. I am pleased to have been reappointed as the Chair for the LCG and will again be joined by Dr Sirjit Bath as the Vice Chair. We are both looking forward to next year and continuing to improve services for our local patients. 51

52 Sandwell Health Alliance Local Commissioning Group By Dr Basil Andreou, Chair Sandwell Health Alliance (SHA) has 32 practices with a population of 139,971. The LCG covers a wide geographical area, predominantly in Sandwell including the areas of Oldbury, West Bromwich and Wednesbury although a small number of our practices are in West Birmingham as well. Over the past 12 months our focus has been on reducing hospital readmissions and reviewing all community contracts, both in the statutory and nonstatutory sector. Our work is closely connected to the Better Care Fund (BCF) including connecting with clinicians in the Healthy Community pilots, who will play a key role in reducing readmissions. Community contracts During the past year we have worked to review our community contracts, by establishing a Community Contracts Performance Group (CCPG) chaired by Dr Pri Hallan. A key part of our work has been the review of Sandwell and West Birmingham Hospitals Trust (SWBH s) community service specifications to meet the Service Development and Improvement Plan (SDIP) requirements, including: Community respiratory service Long-term oxygen therapy MSK services Tissue viability (specialist nurses) Wheelchair services Foot health service (SHA LCG led) Continence service (SHA LCG led) Gynaecology service. The review of these service specifications was achieved through collaboration with clinicians and staff from the CCG. We also worked in partnership with other LCGs who were leading on the individual programme areas. Our LCG also led the review of non-statutory contracts, with a full service evaluation carried out. A number of schemes were evaluated by our LCG taking into consideration value for money, demand for the service and how they contribute to our commissioning priorities. Community contracts performance Our LCG is responsible for monitoring the community contracts with SWBH and BCHC. Working closely with finance and performance colleagues, regular updates have been given to the LCG board. By involving GPs in the reviews, it has led to increased dialogue between the CCG and providers. 52

53 We are looking forward to the new national community minimum dataset, which is being introduced by April This will improve performance management through better reporting, which will enable us to understand every patient contact with the service. We are working with the providers to ensure this is in place by April Both local providers are working towards having this ready before the national deadline. We are proud of our work to establish an assurance mechanism for the CCG, in relation to contract management and performance for all non-statutory community contracts, which was not in place during The work plan for the next financial year is being developed at the moment and we will continue to: Work with community NHS providers to access more detailed service information Identify services where there are opportunities to work differently and organising service quality reviews in conjunction with the quality and safety team Ensure the integration of the Community Contracts Performance Group with corporate contracting and performance management regimes Achieve our community QIPP target of 1m by Reducing hospital readmissions Work continues to develop a mechanism to track the impact of individual projects on reductions in readmissions. However, difficulties remain in being able to establish the causal effect within projects i.e. that a single particular service change resulted in the reduction in readmissions. This is because there are a multitude of actions being taken and scheduled across the health and social care economy that contribute to ensuring local residents remain well and able to stay in their own homes. We are working closely with Sandwell and West Birmingham Hospitals NHS Trust to consider how we can reduce readmissions through their Readmissions Taskforce. A key priority for us has been reducing cardiac readmissions. We have been working closely with Sandwell and West Birmingham Hospitals Trust, agreeing funding to enable the Trust to recruit additional community heart failure nurses, which will be required to set up the community IV diuretics service and provide service cover seven days a week that is consistent and equitable for patients who are admitted to Sandwell and City hospitals. Sandwell Health Alliance has been working closely with the other LCGs and the Healthy Communities pilots to understand how their projects will contribute to reducing readmissions. For we have a QIPP target of 3.7m and we will be leading on a number of programmes to try and achieve this, as well as working with other LCGs who are leading programmes that can contribute towards this. Falls prevention SHA were also asked to pick up the falls prevention remit for the CCG. We are currently working with a University of Birmingham final year student to scope current services and identify the level of need. This will help inform our future priorities and action plan, aimed at reducing hospital admissions through improved management and services for patients at 53

54 risk of falling. We are working with both local authorities who are the lead commissioners, to align our work priorities with their initiatives. SHA elections At the end of our LCG Board was due for re-election. I am delighted to say that I have been re-appointed as Chair of the LCG. We have many challenging priorities to deliver in as well as continuing discussions around progressing work on the Five Year Forward View, in particular the future of primary care. I am committed to supporting our LCG practices throughout this work and keeping them informed and involved. In this task, I m pleased to be joined by our new Vice Chair Dr Ayaz Ahmed. Looking ahead to Co-commissioning primary care From the 1 April 2015 we will take on responsibility for commissioning GP services. In December 2014 we undertook a full membership vote, where 70% of practices voted for us to take on full delegated responsibility from NHS England. A lot of work has taken place within the CCG to prepare for this new responsibility, including: Appointing 20 new posts, to strengthen our staffing structure to manage this increased workload Establishing a Primary Care Co-commissioning Committee, to ensure we have appropriate governance arrangements in place to manage any conflicts of interest as a membership organisation. This committee will be chaired by Ranjit Sondhi, Vice Chair of the CCG Establishing an operational group, to prepare for the handover from NHS England. We believe taking on responsibility for commissioning primary care will bring many benefits to our practices and importantly our patients: It will help us to protect primary care funding from other system pressures It will enable us to move towards place-based commissioning (decisions based on the needs of local communities) Our quality team will be able to further support practices to improve quality within primary care Importantly, it will improve the patient experience. Five Year Forward View In 2014 Simon Stevens, Chief Executive of NHS England, released the Five Year Forward View, which outlines how the NHS needs to adapt at a national level. The report also highlights potential new models of delivering NHS services. Locally, the CCG has been facilitating discussions with NHS providers and general practices to consider what is appropriate for Sandwell and West Birmingham. These discussions are still at an early stage, and will need to be a key priority for us in

55 Accountable care organisations The Five Year Forward View also outlined how CCGs could commission services differently, through accountable care organisations. The aim is to improve the quality of services and support integration. Accountable care organisations would be able to have a contract with the CCG to take responsibility for delivering care for a given population. It could be GP federations, acute hospitals or even social enterprises. This relationship goes beyond the traditional provider role, with these providers actively planning services. This has several benefits: It will improve quality It will encourage greater integration and joint working It frees up capacity in the CCG to focus on system-wide performance It supports local commissioning, based on the needs of local communities and experience of providers Local organisations with an interest in a particular commissioning priority, for example, end of life are able to deliver innovation and transformation in services. There is a lot to think about and we don t know yet if this is an avenue we will progress. However, we are starting to think about how it could work and during the early months of 2015 we held a number of workshops to start discussions with providers, patients and partners to see if this is appropriate for Sandwell and West Birmingham. This is not a quick process and will take us a couple of years to progress. Improved integration with social care As mentioned previously in this report, a lot of work has taken place to prepare for the BCF and further integrate health and social care services. This will continue to be a priority for us during 2015 as we work with both local authorities to look for new opportunities to promote integration and reduce pressure on hospital services. Operating Plan At the end of we submitted our draft Operating Plan to NHS England, this highlighted our key priorities for This is in essence the second year of the plan we set out last year. We had always intended the plan to run over two years and so there is a great deal of continuity in the priorities and objectives for The key target areas remain the: Achievement of quality standards including preventing never events, controlling preventable harm such as healthcare acquired infections and pressure ulcers Delivering access standards around A&E, cancer treatment and referral to treatment times for planned care. 55

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57 Members Report Our member practices Practice name Address Black Country Local Commissioning Group (17 practices) Horseley Heath Surgery Warley Medical Centre Regis Medical Centre Oakham Surgery Swanpool Medical Centre (Practice merger between Dr Leadbeater and Bhimji s surgery and Dr Sharma s surgery during ) Black Country Family Practice Old Hill Medical Centre Portway Family Practice (Formerly known as Tividale Family Practice) 14 Horseley Heath, Tipton, West Midlands, DY4 7QU Ambrose House, Kingsway, Oldbury, B68 0RT Darby Street, Rowley Regis, West Midlands, B65 0BA 213 Regent Road, Tividale, West Midlands, B69 1RZ Swanpool Medical Centre, St Marks Road, Tipton, West Midlands, DY4 0SZ Black Country Family Practice, Neptune Health Park, Sedgley Road West, Tipton, DY4 8PX Priest House, Priest Street, Cradley Heath, B64 6JN Portway Lifestyle Centre Newbury Lane Oldbury B69 1HE (Previous address 51a New Birmingham Road, Tividale, West Midlands, B69 2JQ) Church View Surgery 239 Halesowen Road, Cradley Heath, B64 6JE Whiteheath Medical Centre Badsey Road, Oldbury, B69 1JE Haden Vale Surgery 50 Barrs Road, Cradley Heath, B64 7HG The Victoria Surgery Victoria Road, Tipton, DY4 8SS Glebefields Surgery St Mark s Road, Tipton, West Midlands, DY4 0SN Walford Street 19 Walford Street, Tividale, West Midlands, B69 2LD The Spires Health Centre Victoria Street, Wednesbury, WS10 7EH Malling Health Great Bridge 18 The Great Bridge Centre, Charles Street, West Bromwich, B70 0BF Malling Health Wednesbury High Bullen, Wednesbury, WS10 7HP Closed during Malling Health Parsonage Street Parsonage Street, West Bromwich, B71 4DL HealthWorks Local Commissioning Group (24 practices) St James Medical Practice Enki Medical Practice Zero Tolerance Project Handsworth Wood Medical Centre Laurie Pike Health Centre Handsworth Medical Practice Dr Bickley Grove Lane Surgery The Health Exchange 85 Crocketts Road, Handsworth, Birmingham, B21 0HR 55 Terrace Road, Lozells, B19 1BP Enki Medical Practice, 55 Terrace Road, Lozells, B19 1BP Church Lane, Handsworth Wood, Birmingham, B20 2ES 2 Fentham Road, Aston, B6 6DD 4 Trafalgar Road, Handsworth, B21 9NH Shanklin House, 190 Aston Lane, Handsworth, B20 3HE 153 Grove Lane, Handsworth, Birmingham, West Midlands, B20 2HE Avoca Court, 27 Moseley Road, Digbeth, Birmingham, B12 57

58 0HJ Five Ways Health Centre Ladywood Middleway, Ladywood, B16 8HA The Smethwick Medical Centre Regent Street, Smethwick, B66 3BQ Norvic Family Practice 110 Norman Road, Smethwick, B67 5PU Carters Green Medical Centre High Street, Town Centre, West Bromwich, B70 9LB Great Barr Group Practice 912 Walsall Road, Great Barr, Birmingham, B42 1TG Dr Paramanathan 348 Bearwood Road, Smethwick, West Midlands, B66 4ES Dr Pal 33 Newton Road, Great Barr, Birmingham, B43 6AA Rowley Health Centre Hawes Lane, Rowley Regis, West Midlands, B65 9AF New Street Surgery New Street, Hill Top, B70 0HN Linkway Lyng Centre, Frank Fisher Way, West Bromwich, West Midlands, B70 7AW Dr Arora Lyng Centre For Health, Frank Fisher Way, West Bromwich, West Midlands, B70 7AW Hill Top Medical Centre 15 Hill Top Rd, Oldbury, B68 9DU Rood End Medical Practice Western Road, Oldbury, B69 4LZ The Ann Jones Family Health 52 Chesterton Road, Sparkbrook, B12 8HE Centre Joined SWB CCG City Road Medical Centre 5 City Road, Edgbaston, Birmingham, B16 OHH Joined SWB CCG Intelligent Commissioning Federation (23 practices) Summerfield Family Practice Bloomsbury Health Centre Newtown Health Centre Aston Pride Franchise Dr Khan Rotton Park Medical Centre Church Road Surgery Dr Sidhom Closed during Heathfield Family Centre Lozells Medical Practice City Health Centre Al-Shafa Medical Practice Dr Alam Cavendish Medical Practice Dr Salim Halcyon Medical Centre Summerfield Group Practice Victoria Road Medical Centre The Hyman Practice Dr Ramarao Summerfield Primary Care Centre, Winson Green Road, Winson Green, Birmingham, B18 7AL 63 Rupert Street, Nechells, B7 5DT 171 Melbourne Avenue, Newtown, B19 2JA Aston Pride Health Centre, 74 Victoria Road, Aston, B6 5HA 93 Crompton Road, Handsworth, Birmingham, B20 3QP 264 Rotton Park Road, Edgbaston, B16 0LU 28 Church Road, Aston, B6 5UP Ladywood Surgery, 35 Morville Street, Ladywood, B16 8BU Heathfield Road, Handsworth, B19 1HL Finch Road Primary Care Centre, Finch Road, Lozells, B19 1HS City Health Centre, 449 City Road, Edgbaston, B17 8LG 5-7 Little Oaks Road, Aston, B6 6JY 311 Burbury Street, Lozells, Birmingham, B19 1TT 2a Cavendish Road, Birmingham, B16 0HZ Summerfield Primary Care Centre, 134 Heath Street, Winson Green, B18 7AL Lower Ground Floor, Boots the Chemist, High St, Birmingham, B4 7TA Summerfield Primary Care Centre, 134 Heath Street, Winson Green, B18 7AL Victoria Road, Aston, B6 5HP Colston Health Centre, 10 Bath Row, Lee Bank, Birmingham, B15 1LZ Sparkbrook Health Centre, 32 Farm Road, Sparkbrook, B11 58

59 Closed during LS Newport Medical Practice 1 Newport Road, Balsall Heath, B12 8QE Broadway Health Centre Cope Street, Ladywood, Birmingham, B18 7BA Dr Saini Soho Health Centre, Soho Road, Handsworth, B21 9RY Summerfield GP and Urgent 134 Heath Street, Winson Green, B18 7AL Care Centre Finch Road Surgery Finch Road PCC, Finch Road, Lozells, B19 1HS Pioneers for Health Local Commissioning Group (7 practices) Dr Vijay Bathla Dr Abhyankar Holyhead Primary Healthcare Centre Dr Sinha s practice merged with Enki Medical Practice Dr Chitre Tower Hill Partnership Soho Health Centre, Soho Road, Handsworth, B21 9RY 139 Hamstead Road, Handsworth, Birmingham, B20 2BT 1 St James Road, Handsworth, Birmingham, B21 0HL Orsborn House, 55 Terrace Road, Handsworth, Birmingham, B19 1BP 168 Hamstead Road, Handsworth, Birmingham, B20 2QR 435 Walsall Road, Perry Barr, Birmingham, B42 1BT (Practice merger between Dr Bhattacharyya and Dr Soyannwo and Dr Bath and Partners) Hockley Medical Practice 60 Lion Court, Carver Street, Birmingham, B1 3AL Dr Fawcett 2 The Slieve, Handsworth Wood, Birmingham, B20 2NR Sandwell Health Alliance Local Commissioning Group (32 practices) Dr SA Ahmed Dr TS Bassan 158a Crankhall Lane, Wednesbury, WS10 0EQ Lyng Centre for Health, West Bromwich, B70 7AW Dr NK and S Agarwal Dr BS Bhadauria Dr VK Dewan Dr S Ghosh Dr VS Gudi and Partner Dr N Haque Dr Omar Hassouna Dr D Manivasagam Dr RM Patel and Partners Dr ND Pathak Dr A Rahman Dr M Singh West Bromwich Partnership Great Bridge Partnership Yew Tree Partnership Dr R Akhtar Dr BA Andreou Dr JS Chaggar Dr HS & S Chawla The Surgery, Clifton Lane, West Bromwich, B71 3AS Jubilee Health Centre, Wednesbury, WS10 7AR Lyng Centre for Health, West Bromwich, B70 7AW Jubilee Health Centre, Wednesbury, WS10 7AR 68 Hill Top, West Bromwich, B70 0PU Primary Care Centre, 6 High Street, West Bromwich, B70 6JX 88 Hill Top, West Bromwich, B70 0RT 291 Walsall Road, Stone Cross, West Bromwich, B71 3LN 1 Richard Street, West Bromwich, B70 9JL Primary Care Centre, 6 High Street, West Bromwich, B70 6JX 156 Crankhall Lane, Wednesbury, WS10 0EB 1 Cambridge Street, West Bromwich, B70 8HQ Oakswood Surgery, 40 Izons Road, B70 8PG 10 Slater Street, Great Bridge, Tipton, DY4 7EY Redwood Road, Walsall, West Midlands, WS5 4LB Sundial Lane, Great Barr, B43 6PA Oldbury HC, Albert St, Oldbury, B69 4DE 222 St Paul s Rd, Smethwick, B66 1HB 176 Milcote Road, Smethwick, B67 5BP 59

60 Dr BP Choudhary Dr P Hallan Dr VK Jhanjee Dr S Kaur Dr A Naeem Dr AKM Rahman Dr SA Tillu and Partners Dr C S Sikka and Partners Dr Vatish Dr Bhalla Dr M S Mashicharan Saraphed Medical Centre, 60 Arden Rd, Smethwick, B67 6AJ 134 Newton Road, Great Barr, B43 6BT The Surgery, Lodge Road, Smethwick, B67 7LU 118 Warley Road, Oldbury, B68 9SZ 64 Dog Kennel Lane, Oldbury, B68 9LZ Marshall Street Surgery, Smethwick, B67 7NA Hawthorns Medical Centre, B66 2DD Oakeswell Health Centre, Brunswick Park Road, WS10 9HP Soho Health Centre, Soho Road, Birmingham, B21 0RY Soho Health Centre, Soho Road, Birmingham, B21 0RY 158 Causeway Green Road, Oldbury, B68 8LJ Our Governing Body members Name Role Dr Basil Andreou Chair, Sandwell Health Alliance LCG Ms Jyoti Atri Public Health Representative Dr Sirjit Bath Vice Chair, Pioneers for Health LCG Dr Vijay Bathla Chair, Pioneers for Health LCG Dr Felix Burden Secondary Care Specialist Doctor Mr Jon Dicken Chief Officer (Operations) Mr James Green Chief Finance Officer Dr Pri Hallan Vice Chair Sandwell Health Alliance LCG (end march 2015) Dr Nick Harding Chair Mrs Julie Jasper Lay Member Mrs Sharon Liggins Chief Officer (Partnerships) Dr Inderjit Marok Vice Chair, ICoF LCG Dr Sam Mukherjee Chair, ICoF LCG Mr Richard Nugent Independent Committee Member Mrs Claire Parker Chief Officer (Quality) Ms Janette Rawlinson Independent Committee Member Dr George Solomon Chair, Black Country LCG Mr Ranjit Sondhi CBE Lay Member (Vice Chair) Dr Ram Sugavanam Vice Chair, HealthWorks LCG Dr Ian Sykes Vice Chair, Black Country LCG (appointed November 2014) Dr Ian Walton Vice Chair, Black Country LCG Mrs Margot Warner Board Nurse (left May 2014) Mr Andy Williams Accountable Officer To see biographies for each of our Governing Body members please see our website 60

61 Our Audit and Governance Committee members Mrs Julie Jasper Dr Felix Burden Mr Ranjit Sondhi Ms Janette Rawlinson Mr Richard Nugent Lay Member of the Governing Body (Audit Lead) Chair Secondary Care Specialist Doctor (Vice Chair) Lay Member of the Governing Body (Patient and Public Involvement) Independent Committee Member Independent Committee Member For details of the Remuneration Committee please see the Remuneration Report. For details of and membership of all other Governing Body and membership body committees please see the Governance Statement. Statement as to disclosure to auditors Each individual who is a member of the Governing Body at the time the Members Report is approved confirms: So far as the Governing Body member is aware, there is no relevant audit information of which the CCG s auditor is unaware. That the member has taken all the steps they should have taken to make themselves aware of any relevant audit information and to establish that the CCG s auditor is aware of that information. Pension liabilities For information on pension liabilities see the Remuneration Report. Governing Body member interests To view the declarations of interest for our Governing Body members please see our website at alternatively, please contact our Time2Talk team on or write to us at: Sandwell and West Birmingham CCG Kingston House High Street West Bromwich B70 9LD 61

62 External auditor s remuneration Name of external auditor: KPMG Andrew Bostock KPMG LLP Audit One Snowhill Snow Hill Queensway Birmingham B4 6GH Cost of work completed 114,000 total cost for external audit to be completed for financial year Disclosure There are no conflicts of interest to declare. In addition to audit work the CCG did commission KPMG to review a redundancy case at a cost of 2,400. Sickness absence data Sickness absence data for the CCG is included in the audited financial statements (accounts note 4.3). Cost allocation and charges for information We do not set charges for information. We certify that the CCG has complied with HM Treasury s guidance on cost allocation and the setting of charges for information. Disclosure of personal data related incidents In there were no personal data related incidents reported. Employee consultation We have a number of mechanisms to meaningfully engage and consult with staff. We have a formal Partnership Recognition Agreement that recognises four unions to negotiate with us on conditions relating to staff, including formal consultation. In addition to the formal mechanisms we have a well-established Staff Council that is made up of representatives from each department and the Accountable Officer. The Staff Council is chaired by an elected member of the council and membership is reviewed annually. The council meets monthly and considers all aspects of staff satisfaction. 62

63 Key highlights for : We introduced an organisational development lead In December we held a staff survey to seek feedback on the leadership, communication and other issues important to our staff During early 2015 we worked with staff to review our induction processes, including developing an induction film and welcome pack and refreshing our staff handbook We have worked hard to prioritise mandatory training and appraisals throughout the organisation, and are pleased to see improvements in uptake Our staff have been actively engaged in the development of our staff vision and values. These will be formalised in as we continue our focus on organisational development. Equality and diversity within our workforce Our workforce has grown since last year as we have taken on greater commissioning responsibility. A detailed analysis of our workforce can be found on our website. In summary the analysis shows we: Employ 148 staff, 79% of whom are female and 21% are male Have seen positive changes to the diversity of staff employed, with slight increases over the last 12 months in the percentage of Black and Mixed/Multiple Ethnic background staff working for our organisation. There has also been a decline in the percentage of White (3%) and Asian (1%) groups employed Employ considerably more women than men which is comparable to the national trend within the NHS. During , we employed 4% more men into the organisation than previous years Have seen non-governing Body black and minority ethnic members of staff remain under-represented at bands 9+ and this position has not changed since last year Employ very few staff with a disability, but this figure may be misleading due to high numbers of staff that have chosen not to declare or define their disability status Know the sexual orientation, religion and beliefs of about 50% of the workforce, but need to understand why so many staff have decided not to disclose or define their status Employ staff that are mostly aged between We have seen a decline in the number of staff under 20 and a 2% increase in the percentage of staff over 60. To view our equality and diversity workforce profile, visit our website Workforce priorities Following this analysis, we are committed to: Developing an equality and diversity workforce action plan to include a commitment to delivering the Workforce Race Equality Standard Raising awareness amongst staff of why the equality and diversity data is important and what we use it for 63

64 Launching an apprenticeship scheme Improving confidence amongst staff of disclosing disability, sexual orientation and religion and belief data. Apprenticeship scheme We currently work in partnership with Learning Works to attract and retain business administration apprentices. Learning Works is a community based NHS project dedicated to helping local people access employment in the health sector via a range of work experience, apprenticeship, volunteering and adult learning opportunities. Learning Works is also supported by a partnership of agencies (community, voluntary and public sector) committed to ensuring that those who will most benefit from the opportunity being offered are able to access it. We are really excited to be launching an apprentice programme during summer 2015, which will involve four placements across the CCG. Employees with a disability Employing people with a disability is important for any organisation providing services for the public as they need to reflect the many and varied experiences of the public they serve. In the provision of health services it is perhaps even more important, as people with disabilities make up a significant proportion of the population, and those with long-term medical conditions use the services of the NHS. Our commitment to people with disabilities includes: People with disabilities who meet the minimum criteria for a job vacancy are guaranteed an interview The adjustments that people with disabilities might require in order to take up a job or continue working in a job are proactively considered Our mandatory equality and diversity training includes awareness of a range of issues impacting on people with disabilities The organisation ensures any employee who needs training, either because they work with people with disabilities, or because they have acquired an impairment or medical condition, receives the necessary training. Equal opportunities We ensured we were compliant with the Public Sector Equality Duty set out in the Equality Act This means we had to: Eliminate unlawful discrimination, harassment and victimisation, and other conduct prohibited by the Act Advance equality of opportunity between people who share a protected characteristic and those who do not Foster good relations between people who share a protected characteristic and those who do not Protected characteristics include age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, gender, sexual orientation, and marriage and civil partnership. 64

65 Throughout we have been working closely with the Staff Council to review a number of our policies for staff. Several of these outline how we expect our staff to behave and the values we expect them to uphold; these policies cover topics, including bullying and harassment, flexible working and managing sickness absence. We will be continuing to review our other policies during and will also be developing an Equal Opportunities Policy for staff. We publish an annual Equality Report on our website that sets out how we have met the public sector equality duty. Health and safety We are fully committed to providing a vibrant working environment that values wellbeing and diversity. We recognise our wider legal and moral obligation to provide a safe and healthy working environment for our employees, visitors and members of the public that may be affected by our activities. We are in the process of adapting a Health and Safety Management System based on the HSG65 model and also adopting a positive pro-active stance on health and safety that aims to promote an accountable culture, which is just and fair to our employees. This will enable us to learn from incident reports and risk assessments in order to continuously improve our health and safety management and where necessary, change policy/procedure to enable this to happen. To help us achieve compliance we currently commission Midlands and Lancashire CSU to provide us with competent health and safety support, advice and guidance. It is a statutory requirement to keep a record of all accidents, incidents and near misses that occur out of work activities. Our health and safety record for was very good. There were no RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013) reportable accidents across our organisation. Preventing fraud We commission counter fraud services from CW Audit Services and have an annual plan in place setting out the counter fraud work to be undertaken. This is approved by the Audit and Governance Committee. The CCG has a number of policies in place which consists of the Counter Fraud and Corruption Policy, the Anti-bribery Policy, the Communicating and Embedding an Anti-Fraud Culture Policy and the Sanctions and Redress Policy. These policies inform staff on how to identify and report fraud and set out the CCG s approach to tackling fraudulent activity which can result in individuals being criminally prosecuted. We have a zero-tolerance policy on economic crime, which means that every referral received by our dedicated Local Counter Fraud Specialist (LCFS) is fully investigated to ensure that our resources are protected. We actively promote the reporting of incidents of potential fraud through our website, staff and GP member newsletters. We also have a Whistle Blowing Policy in place which ensures that individuals who report fraud receive the relevant support. In 2014 we carried out a survey with our staff and Governing Body members to identify the level of understanding 65

66 around fraud awareness. The findings of this survey will be used to help direct future counter fraud resources in the most effective way. For more information on our policy and approach to preventing fraud see our website. Better payments practice code Details of compliance with the code are given in note 6.1 to the accounts. Prompt payments code We have signed up to the CBI Better Practice Code, which means we aim to pay all non- NHS trade creditors within 30 days of receipt of goods or a valid invoice (whichever is later) unless other payment terms have been agreed. Emergency preparedness The NHS needs to plan for, and respond to, any incidents and emergencies that could affect health or patient care. These could be anything from extreme weather, a major transport incident or an infectious disease outbreak. As the local leaders of the health system, we would play an active role in handling a collective response to any emergency. We have a duty to be prepared for such incidents and emergencies, and during resilience was a real priority for us. We formally nominated an Accountable Emergency Officer, who has the responsibility for ensuring we are prepared and can respond effectively in any scenario. We have refreshed our self-assessment against the national emergency preparedness, resilience and response (EPRR) core standards. We targeted any areas which were highlighted as requiring immediate attention, and are pleased to report these have been completed. As part of this work we have developed plans for training and exercises, to ensure our staff and partners know their role in any emergency. This work has also involved updating our plans, including our: Major Incident Plan Business Continuity Plan Incident Response Plan. We recognise the importance of partnership working during emergencies, and have established an EPRR working group with local authority colleagues and Sandwell and West Birmingham Hospitals NHS Trust (SWBH). All of this work has put us in a strong position and we are pleased to report we are compliant with the requirements of NHS England s Emergency Preparedness Framework 2013 and associated guidance. 66

67 Principles for remedy Our complaints procedures reflect the Parliamentary Health Service Ombudsman s six principles for remedy: Getting it right Being customer focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement. Getting it right: We are committed to acknowledging and investigating complaints in a timely manner, and sharing lessons learnt with the complainant and the wider organisation. This may mean acknowledging responsibility, issuing an apology and offering assurance that we have taken action to reduce the likelihood of it happening again. Being customer focused: We aim to ensure that we issue an apology or express sympathy in response to concerns raised about our activities or provider services, always thinking about the complainant s wishes and needs, and managing their expectations. An appropriate response involves considering who the apology should come from within the CCG and how they should apologise (in person, by phone or in writing). Being open and accountable: We keep in regular touch with the complainant to clarify the process and reasons for any decisions made, for example if NHS England would be better placed to handle their complaint. Acting fairly and proportionately: We will always consider how the circumstances of the case have affected the complainant (and others) in all ways to ensure the best outcome for them, and address any unfairness. Putting things right: We will consider adopting a range of remedies, including an apology, explanation, acknowledgement of responsibility and remedial action plan from the provider, covering actions such as staff training or revising procedures. Seeking continuous improvement: We aim to ensure that lessons learned are put into practice, and to gain assurance from providers (at clinical quality meetings) that lessons have been applied. Exit packages agreed in the financial year Exit package cost band (including any special payment element) Number of compulsory redundancies Cost of compulsory redundancies Less than 10,000 10,000-25, ,950 Totals 1 13,950 67

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69 Remuneration Report Remuneration Committee Report Remuneration and Terms of Service Committee The committee was established in order to determine the remuneration and terms of service for the Governing Body members. The membership details for the committee are set out below: Member Ranjit Sondhi Julie Jasper Felix Burden Janette Rawlinson Richard Nugent Margot Warner Title CCG Vice Chair; Chair of the Remuneration Committee Chair of Audit and Governance Committee Secondary Care Specialist Doctor Independent Committee Member Independent Committee Member Board Nurse The Remuneration Committee met four times during Name April September October March Ranjit Sondhi X X Julie Jasper X X Felix Burden X X X X Janette Rawlinson X X Richard Nugent X X X X Margot Warner Note: Margot Warner was a member of the committee until May Pay for Governing Body members and other senior staff was mainly on nationally determined pay rates. Where pay was determined locally this was agreed by the committee. It was the responsibility of the committee in its discussions to: Determine the remuneration and conditions of service of the senior team Review the performance of the Chief Accountable Officer and other senior team members and determine annual salary awards, if appropriate Ensure proper calculation and scrutiny of termination payments taking account of appropriate national guidance, along with advising on and overseeing appropriate contractual arrangements for such staff Consider any severance payments of the Accountable Officer and other senior staff, seeking HM Treasury approval as appropriate in accordance with the guidance Managing Public Money Advise on and oversee appropriate contractual arrangements for staff, including redundancy arrangements in line with national or local contracts of employment and appropriate guidance or legislation 69

70 To review the Terms of Reference of the committee for submission to the Governing Body Agree any recruitment and retention premiums or any retention schemes, subject to national guidance and/or relevant terms and conditions of service. The policy on Governing Body members and senior staff contracts was that they were permanent, except where an explicit fixed-term role was identified. The standard notice period was six months. The contract was a standard contract used for all CCG staff so there were no end dates. Senior managers service contracts Directors Directors are on permanent contracts with six months notice. Should a contract need to be terminated it would be ended in accordance with employment law. Lay members Lay members and their appointment end dates are detailed in the table below. Elected GP members of the local Appointment end Member commissioning groups date Sandwell Health Alliance Dr Basil Andreou Dr Pri Hallan Pioneers for Health Dr Vijay Bathla Dr Sirjit Bath HealthWorks Dr Nick Harding Dr Ram Sugavanam Black Country Dr George Solomon Dr Ian Walton Dr Ian Sykes Intelligent Commissioning Federation Dr Samar Mukheriee Dr Inderjit Marok Independent committee members Mr Richard Nugent Ms Janette Rawlinson Lay Members Mrs Julie Jasper Mr Ranjit Sondhi Secondary Care Specialist Doctor Dr Felix Burden Public Health Representative Ms Jyoti Atri Ongoing Board Nurse Mrs Margot Warner May-14 70

71 Audited Remuneration Report detail Bonus payments for performance in the year There were no bonus payments made for the year. Senior managers performance related pay There were no performance related payments made in Payments to past senior managers There were no payments to past senior managers in Compulsory redundancies In there was one compulsory redundancy at a cost of 13,

72 Salary entitlements Salary & Fees (bands of 5,000) Taxable Benefits (Rounded to the nearest 00) Annual Performa nce Related Bonuses (bands of 5,000) Longterm Performa nce Related Bonuses (bands of 5,000) All Pension Related Benefits (bands of 2,500)* Total (bands of 5,000 ) Salary & Fees (bands of 5,000 ) Taxable Benefits (Rounde d to the nearest 00) Annual Performa nce Related Bonuses (bands of 5,000) Longterm Perform ance Related Bonuses (bands of 5,000) All Pension Related Benefits (bands of 2,500)* Total (bands of 5,000) Name and title Title Dr Nick Harding*1 Chair Mr Ranjit Sondhi Vice Chair Mrs Julie Jasper Lay Director Dr Felix Burden Clinical member Secondary Care Specialist Doctor Mrs Margot Warner Board Nurse Left May Ms Janette Rawlinson Independent Committee Member Mr Richard Nugent Independent Committee Member Mr Andy Williams*2 Accountable Officer Mr James Green*2 Chief Finance Officer Dr Vijay Bathla Chair, Pioneers for Health LCG Dr Sirjit Bath*1 Vice Chair, Pioneers for Health LCG Dr George Solomon*1 Chair, Black Country LCG Dr Ian Walton Vice Chair, Black Country LCG Dr Ian Sykes Vice Chair, Black Country LCG started November n/a n/a n/a n/a n/a n/a Dr Basil Andreou Chair, Sandwell Health Alliance LCG Dr Pri Hallan*1 Vice Chair, Sandwell Health Alliance LCG Dr Sam Mukherjee Chair, ICoF LCG Dr Inderjit Marok Vice Chair, ICoF, LCG Dr Ram Sugavanam Vice Chair of HealthWorks Mr Jon Dicken*3 Chief Officer - Operations n/a Mrs Claire Parker*3 Chief Officer Quality n/a Mrs Sharon Liggins*3 Chief Officer Partnerships n/a

73 The content and notes to the salary entitlements table and pension liabilities table have been audited. *1 The comparators for all pension related benefits included in the table for these GP directors are changed from the values within the Annual Report, to comply with the NHS Manual for Accounts This requires disclosure only of pension benefits arising from pension contributions paid by the CCG to the NHS Pensions Agency. Pension contributions for GP directors are included in the payments which the CCG makes to the GPs for their services. The GPs pay these over with their practice pensions. *2 The comparators for all pension related benefits for the Executive directors are changed from the values within the Annual Report which were incorrect. The correct figures are as stated within the All Pension Related Benefits column for in the table. *3 The disclosure of the pensions related benefit amounts for these senior managers were excluded from last year s table as it was the CCG s policy then only to disclose the pension benefits of board directors. This policy has been changed so that the same level of disclosure is made for the senior managers as it is for directors comparators of the pensions related benefits for these senior managers are not provided in the table as not all the information is available to calculate the amounts. Pension liabilities As non-executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for non-executive members. Name Title Real increase in pension at age 60 Real increase in pension lump sum at age 60 Total accrued pension at age 60 at 31 March 2015 Lump sum at age 60 related to accrued pension at 31 March 2015 Cash Equivale nt transfer Value at 31 March 2014 Cash Equivalent transfer Value at 31 March 2015 Real Increase in cash Equivalent transfer Value Employer s contribution to partnership pension (bands of 2,500) (bands of 2,500) (bands of 5,000) (bands of 5,000) Mr Andy Williams Mr James Green Mr Jon Dicken* Mrs Claire Parker* Mrs Sharon Liggins* Accountable Officer Chief Finance Officer Chief Officer Operations Chief Officer Quality Chief Officer Partnerships

74 The table discloses the pension entitlements of the CCG executive directors and senior managers at the end of the year, and the changes during the year. The same table included in last year s annual report also included the GP directors. The GP directors are omitted from this year s table to comply with the NHS Manual for Accounts This requires disclosure only of pension benefits arising from CCG pension contributions paid by the CCG to the NHS Pensions Agency. Pension contributions for GP directors are included in the payments which the CCG makes to the GPs for their services. The GPs pay these over with their practice pensions. The GPs are on the CCG payroll to comply with the HM Revenue and Customs requirement for income tax and national insurance to be deducted from the GPs service payments and paid to HMRC by the CCG. *These senior managers were excluded from last year s table as it was the CCG s policy only to disclose the pension benefits of board directors. The policy has been changed to be consistent with the disclosure of the salary entitlements of the senior managers on page 72. Cash equivalent transfer values A cash equivalent transfer value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member s accrued benefits and any contingent spouse s pension payable from the scheme. A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their membership of the pension scheme. This may be for more than just their service in a senior capacity to which disclosure applies (in which case this fact will be noted at the foot of the table.) The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. Real increase in CETV This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period. 74

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77 Sandwell and West Birmingham Clinical Commissioning Group Governance Statement Introduction and context The clinical commissioning group was licenced from 1 April 2013 under provisions enacted in the Health and Social Care Act 2012, which amended the National Health Service Act As at the 1 April 2014, the clinical commissioning group was licenced without conditions. The CCG is a membership organisation involving 103 GP practices serving around 547,400 patients across the Sandwell and West Birmingham areas. The CCG is broken down further into five local commissioning groups: Black Country, HealthWorks, ICoF, Pioneers for Health and Sandwell Health Alliance. These groups address the needs of the population on a very local level. The CCG's mission is to work across boundaries to improve the health of the communities we serve, and the quality of health and social care services provided to those communities. We do this by giving patients and the wider population the opportunity to benefit from healthier lifestyles, bringing appropriate elements of care closer to home, and designing services to meet the needs of the local population. Scope of responsibility As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the clinical commissioning group s policies, aims and objectives, whilst safeguarding the public funds and assets for which I am personally responsible, in accordance with the responsibilities assigned to me in Managing Public Money 1. I also acknowledge my responsibilities as set out in my clinical commissioning group Accountable Officer appointment letter. I am responsible for ensuring that the clinical commissioning group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. Compliance with the UK Corporate Governance Code We are not required to comply with the UK Corporate Governance Code. However, we have reported on our corporate governance arrangements by drawing upon best practice available, including those aspects of the UK Corporate Governance Code we consider to be relevant to the CCG and best practice. We comply with the key principles of the code, which set out good practice in the areas of leadership; effectiveness; accountability; remuneration and relationships with key stakeholders of the CCG. 1 Managing Public Money HM Treasury publication July

78 The Clinical Commissioning Group Governance Framework The National Health Service Act 2006 (as amended), at paragraph 14L (2) (b) states: The main function of the governing body is to ensure that the group has made appropriate arrangements for ensuring that it complies with such generally accepted principles of good governance as are relevant to it. The constitution, including standing orders, prime financial policies and scheme of reservation and delegation have been reviewed by both the Audit and Governance Committee and Governing Body to ensure they accurately reflect the governance context in which the CCG operates. The amendments made to the constitution have not fundamentally altered the way the CCG operates, nor how it meets its statutory duties, but have enabled the CCG to ensure it works effectively and meets the requirements of its members. The Governing Body has the following voting members: Chair (a GP) Accountable Officer Chief Finance Officer Nine GP members Two lay members (one acts as Vice Chair) One secondary care doctor One nurse representative. The following non-voting members: Chief Officer (Quality) Chief Officer (Partnerships) Chief Officer (Operations) Two independent committee members Public health representative. In addition the following individuals regularly attend the meeting: Communications lead Head of Quality, Safety and Risk. The Governing Body has appointed the following individuals to key governance posts: Caldicott Guardian - Dr Sam Mukherjee Senior Information Risk Officer - Claire Parker. The Governing Body is responsible for the overall management and performance of the CCG and approves its long-term objectives and strategy. The CCG is a GP led organisation, which is reflected at a Governing Body level through our LCG chairs and vice chairs. We also recognise the valuable impartial role played by our lay members and independent committee members, ensuring our decisions are fair and reflective of our local population at both a Governing Body and committee level. While day-to-day management is delegated to the chief officers, there is a formal schedule of matters reserved for the board within the 78

79 CCG constitution. This provides a framework for the Governing Body and members to oversee the CCG s business. The scheme of reservation and delegation clearly outlines the breakdown of responsibilities reserved by members and those delegated to the Governing Body, its committees and other senior managers within the CCG. The Governing Body members bring a range of skills and experience to their roles to ensure the balance, completeness and appropriateness of discussions and determinations. The Governing Body meets in public every month and actively encourages questions from the public as part of the agenda. Attendance at the Governing Body meetings during has been recorded as follows ( x denotes attendance): Apr 14 May Jun Jul Aug Sept Oct Nov Dec Jan 15 Feb Mar Dr Nick Harding, Chair X X X X X X X X X X Mr Ranjit Sondhi, Vice Chair X X X X X X X X X X Dr Felix Burden, Secondary Care X X X X X X X X X X X X Specialist Doctor Mr James Green, Chief Finance X X X X X X X X X X X Officer Dr Vijay Bathla, Chair, Pioneers for X X X X X X X X X X X X Health LCG Dr Sirjit Bath, Vice Chair, Pioneers for X X X X X X X X X X X Health LCG Dr George Solomon, Chair, Black Country X X X X X X X X LCG Dr Ian Walton, Vice Chair, Black Country X LCG Dr Ian Sykes, Vice Chair, Black Country LCG (from Nov X X X X X 2014) Dr Basil Andreou, Chair, Sandwell X X X X X X X X X X Health Alliance LCG Dr Pri Hallan, Vice Chair, Sandwell X X X X X X X X Health Alliance LCG Dr Sam Mukherjee, Chair, ICoF LCG X X X X X X X X X X X Dr Inderjit Marok, Vice Chair, ICoF LCG X X X X X X X X X X 79

80 Dr Ram Sugavanam, Vice Chair, HealthWorks LCG Mr Andy Williams, Accountable Officer Mrs Sharon Liggins, Chief Officer, Partnerships Mr Jon Dicken, Chief Officer, Operations Mrs Claire Parker, Chief Officer, Quality Mrs Julie Jasper, Lay Member Mrs Margot Warner, Board Nurse Ms Janette Rawlinson, Independent Committee Member Mr Richard Nugent, Independent Committee Member Ms Jyoti Atri, Public Health Representative Apr 14 May Jun Jul Aug Sept Oct Nov Dec Jan 15 X X X X X X X X Feb Mar X X X X X X X X X X X X X X x X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Left X X X X X X X X X X X X X X X X X X X X X X X X Governing Body committee structure The Governing Body committee structure was reviewed on a regular basis throughout , to ensure it was appropriately supported to effectively discharge its functions. Each committee has terms of reference which have been approved by the Governing Body and provides a robust framework for the functions and duties of these committees to be discharged in a manner that ensures the Governing Body retains sufficient oversight of the proper performance of their delegated functions. Each committee receives a regular set of reports, as outlined within their terms of reference and reports to the Governing Body after each meeting. The Governing Body committees include: Audit and Governance Committee The Audit and Governance Committee, chaired by the lay member for governance, has approved terms of reference that are in line with the Audit Committee Handbook, as published by the Healthcare Financial Management Association (HFMA) and Department of Health. The committee provides the Governing Body with an independent and objective view of the CCG s financial systems, financial information and compliance with laws, regulations and directions governing the CCG. The Audit and Governance Committee gives assurance to the Governing Body that risk is being managed appropriately within the CCG. During the 80

81 financial year the Audit and Governance Committee focused particular attention to; the scrutiny of organisational risks, the oversight and development of the CCG s Procurement Strategy, review of the controls relating to payments to mental health providers and holding the Midlands and Lancashire Commissioning Support Unit to account. The committee has delegated authority from the Governing Body to approve the Annual Financial Statements; the draft Annual Report and the annual accounts. Remuneration Committee The Remuneration Committee, chaired by a lay member, determines the remuneration, fees and other allowances for Governing Body members and clinical leads, employees and/or persons who provide services to the CCG. Quality and Safety Committee The Quality and Safety Committee, is chaired by the GP lead for quality. It meets monthly and is accountable to the Governing Body. This committee assures the Governing Body on the management of quality, safety and risk within the CCG. It monitors the work of the clinical quality review meetings with our main providers and the work of the Care Quality Commission (CQC) locally (for example their assessments of nursing homes). It also reviews the red risks associated with quality and the serious incident reports. Strategic Commissioning and Redesign Committee The Strategic Commissioning and Redesign Committee, chaired by the GP lead for commissioning, meets monthly and is accountable to the Governing Body. This committee drives forward the strategic commissioning objectives of the CCG and considers proposals for the redesign of clinical services. The committee assures the Governing Body that the commissioning intentions of the CCG are being implemented in accordance with the strategy, and that the necessary procurement processes are being adhered to when services are being commissioned. Finance and Performance Committee The Finance and Performance Committee is chaired by the GP lead for finance and meets on a monthly basis. It is accountable to the Governing Body for the effective oversight of financial performance and performance against healthcare standards. The committee receives monthly reports regarding the financial position of the CCG with analysis of significant variances, along with a forecast outturn position for the financial year. It also receives a detailed analysis of both CCG and main NHS Trust providers' performance against operational standards which covers constitutional rights of patients access to healthcare. Where necessary the Finance and Performance Committee will take corrective action to ensure robust delivery against required standards. Partnerships Committee The Partnerships Committee, chaired by the GP lead for partnerships, is in place to ensure that the Governing Body has appropriate arrangements to improve the quality of care and the health and wellbeing of patients, through effective partnership working. The committee 81

82 has a role to develop partnerships with key stakeholders including Birmingham City Council, Sandwell Metropolitan Borough Council, local NHS providers, other CCGs, Healthwatch representatives, the voluntary and independent sectors and the Right Care Right Here partners to further the Governing Body s key objectives. The committee also reviews the arrangements to consult and engage with patients and the public. The relationship between the Governing Body and its committees is shown through the committee structure below: This also highlights the introduction of the Primary Care Co-commissioning Committee from 1 April 2015, to take responsibility for decision making regarding the commissioning of primary care medical services under delegated arrangements from NHS England. These arrangements are subject to assurance by the Audit and Governance Committee, which receives independent reports from internal and external auditors regarding these arrangements. I am confident that these arrangements are suitable to adequately discharge the statutory and regulatory functions of the CCG. The CCG s Risk Management Framework The CCG has a Risk Management Strategy and policy requiring a department level identification, assessment and management of risks with escalation of significant and /or persistent risks through the committees of the Governing Body. The Audit and Governance 82

83 Committee reviews the risk register regularly and reports to the Governing Body, providing assurance that risks are being monitored and mitigated, and highlighting any exceptions. The CCG s risk management strategy sets out the role and responsibility of the Accountable Officer and other key officers in relation to risk management. The chief officer and GP lead for quality provide clinical leadership for clinical governance and in particular quality and safety within the providers that the CCG commissions from. Equality impact assessments are embedded in our core business case procedures Decisions relating to the management of risk are now able to occur as close as practicable to the risk source. Root cause analyses are undertaken for all serious incidents (SIs). SIs that occur within commissioned services are monitored as are the resulting root cause analyses. All never-events occurring in commissioned services are closely monitored by the CCG and representatives from the quality and safety team attend all table-top reviews to ensure the root causes are identified and lessons are learnt to avoid the event occurring again. The CCG has reviewed the mechanism for learning lessons to ensure that this happens across the health economy. Being accountable to our local population and our members, our appetite for risk is shaped by our approach to commissioning and our values, by: Being open and transparent in our decision making Keeping quality and safety as the foundation for everything we do Having strong clinical leadership and engaging clinicians from all parts of the system Valuing our relationships with our patients and stakeholders, recognising and using what they bring to the CCG and its work. We recognise that living with, and understanding, risk is an everyday part of commissioning the highest standards of healthcare and to this end we will look to innovate and improve services and their quality wherever possible. Successful healthcare commissioning is dependent on the views of our stakeholders being heard. To achieve this we are open about risks, actively seek to get an understanding of the risks in the wider health and social care system and keep stakeholders informed of our position. The red risk register holds the high operational risks and the financial consequences of the risk are identified where appropriate. These are categorised as red on the 5x5 risk scoring matrix. Again, there is a lead director identified who puts an action plan in place and ensures that the risk is mitigated. The red risk register is reviewed regularly at the responsible committee, who in turn provide assurance through to the Audit and Governance Committee. The CCG s Internal Control Framework A system of internal control is the set of processes and procedures in place in the clinical commissioning group to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. 83

84 The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control has been in place at the CCG for the year ended 31 March 2015 and up to the date of approval of the annual report and accounts. The Governing Body takes the risk of fraud very seriously, and commissioned the service of a local counter-fraud specialist throughout , and there are cases currently being investigated. This service is pro-active in identifying and investigating potential fraudulent activities. The counter-fraud specialist attends the Audit and Governance Committee on a quarterly basis to provide updates on the current plan, highlight any relevant guidance and to give assurance of any investigations. The CCG and its members recognise the importance of managing conflicts of interest. Accordingly, a register of members' interests is maintained and updated regularly. All meeting agendas of the Governing Body and committees include guidance and definitions of interests, and time is allocated at the start of the meeting for such declarations to be made. This follows the agreed process of dealing with conflicts of interest under the committees terms of reference. As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the scheme regulations are complied with. This includes ensuring that deductions from salary, employer s contributions and payments into the scheme are in accordance with its rules, and that member pension scheme records are accurately updated in accordance with the timescales detailed in the regulations. Control measures are in place to ensure that all the CCG s obligations under equality, diversity and human rights legislation are complied with. The CCG has undertaken risk assessments, and carbon reduction delivery plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this clinical commissioning group s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. Information governance Risks to data security are managed through the implementation of good information governance practice, including staff training and awareness, effective system security, appointment of a senior information risk owner and Caldicott Guardian, and development of data flow mapping and the assignment of data owners and administrators. The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an information governance toolkit and the annual submission process provides assurances to the clinical commissioning group, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively. 84

85 We place high importance on ensuring there are robust information governance systems and processes in place to help protect patient and corporate information. We have established an information governance management framework and are developing information governance processes and procedures in line with the information governance toolkit. We have ensured all staff undertake annual information governance training and have implemented a staff information governance handbook to ensure staff are aware of their information governance roles and responsibilities. There are processes in place for incident reporting and investigation of serious incidents. We are developing information risk assessment and management procedures and a programme will be established to fully embed an information risk culture throughout the organisation. Risk assessment in relation to governance, risk management and internal control The CCG has adopted a risk management strategy which clearly explains how to assess risk. All risks are captured on the web-based Datix system and each committee of the Governing Body has appropriate risks allocated to them. Risk management is undertaken proactively to address every element of the CCG s activities. The CCG has adopted the NHS Litigation Authority risk matrix to score risks against consequence and likelihood. The risks have been identified with the Governing Body and the register developed by requesting each risk owner to describe; the risk, current controls, and action to mitigate or reduce the risk. Through this process, the governing body has identified its high level current and potential risks. It has assessed them for potential frequency and severity, and attributed a score to each. Mitigating actions are identified and each risk is then reassessed in order to derive a revised score. These scores indicate the level of residual risk that applies to a particular activity, and are used to identify where further mitigating actions may be required. The risk assessment process is overseen by the Audit and Governance Committee. The identified risk owners review and update their risks on a periodic basis. The Audit and Governance Committee is responsible for the monitoring and review of the assurance framework and associated processes, and provides assurance to the Governing Body. The CCG also receives assurance that risk management activities and systems are being appropriately identified and managed through the following: Progress against its strategic and operational objectives Statistical and trend reporting of incidents, along with reporting of complaints and claims to the Governing Body and relevant committees Correlation between incidents/near miss reporting and dates of their occurrence Receiving assurance from internal and external audit that the CCG s risk management systems are effective Information governance toolkit compliance 85

86 The CCG successfully managed and mitigated a number of significant risks during , in particular those relating to the delivery of performance standards in urgent care and patient treatment waiting times. In accordance with the CCG s Risk Management Strategy, risks with a residual score of 16 and above are presented to the Governing Body for their consideration. The key themes of risk reported to the Governing Body during the year are shown below: Insufficient infrastructure, capacity and skills in primary care to enable provision of quality services to be drawn out of secondary care Failure to evaluate the impact of service redesign and/or failure to deliver redesign effectively, resulting in poor delivery, performance and diminished health outcomes Failure to work collaboratively with partners and stakeholders (particularly the two local authorities) could result in poor use of limited resources, particularly with regard to the Better Care Fund (BCF) Lack of financial resources within the local authorities and known expenditure reductions will impact on health-related budgets with respect to social care, which may result in poor and/or reduced services to patients Failure to re-commission and decommission services effectively to release savings for the BCF may affect the CCG s ability to meet its statutory financial duties Failure to effectively identify and deliver the QIPP agenda may result in financial unsustainability Failure of care in a large collaborative leadership arrangement (such as NHS 111 and stroke services) results in nationwide adverse impact on CCG reputation Unable to work effectively with partners to deliver the required conditions to successfully commission the new Midland Met Hospital There is a risk that persistent failure to achieve core performance measures/targets (e.g. access targets) by our providers impacts us financially through reduced quality premiums, or causes us reputational damage, or results in NHS England intervention Ofsted/ Care Quality Commission review of safeguarding arrangements at Birmingham Children s Hospital NHS Foundation Trust (BCH) highlighted significant risk for vulnerable, looked after children and wider safeguarding issues. A further inspection in September 2012 highlighted poor partnership working and quality of referrals/understanding of access/thresholds. No risks have materialised that would prevent us from complying with our licence. Review of economy, efficiency and effectiveness of the use of resources Through its monthly reporting arrangements the CCG produces a comprehensive finance report which covers financial performance for the year to date, and an assessment of the forecast out-turn position. In addition the finance report provides: RAG ratings (scoring risks as red, amber, green) against a number of key metrics as set out in the NHS England Assurance Framework 86

87 Summary analysis of variances against the financial plan and mitigating actions where appropriate Detailed commentary for major areas of commissioning expenditure A risks and mitigations statement relating to the forecast out-turn A Statement of Financial Position (Balance Sheet) Detail of the CCG s compliance against the Better payment practice code. The finance report is reviewed in detail at the CCG s Finance and Performance Committee each month, with a summary of the key highlights presented to the Governing Body. The finance report features as part of the monthly Governing Body papers. During the annual financial planning process, regular updates and presentations are provided to the Governing Body to outline progress against contracting targets and provide an assessment of the level of savings that will be required to finance the organisation s expenditure commitments for the year ahead and over the medium-term. The Governing Body then considers its approach to meeting savings accordingly. A number of key internal audit reviews have been undertaken to provide additional assurance, and suggested control enhancements captured on an action plan, the implementation of which is monitored. The Head of Internal Audit has provided a significant assurance opinion on the effectiveness of the system of internal control. The external auditor has undertaken a value for money assessment to inform their formal opinion of the CCG. Both internal and external reviews have reported positively on the use of resources in terms of the CCG s economy, efficiency and effectiveness. Review of the effectiveness of governance, risk management and internal control As Accountable Officer I have responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group. Capacity to handle risk As Accountable Officer, I have overall responsibility for risk management and the arrangements to support this are clearly articulated to all staff through the CCG Board Assurance Framework and Risk Management Strategy. The Governing Body is responsible for overseeing the delivery of our strategy and is supported in this regard by the work of its committees, which review risks related to their remit. The Governing Body gains independent assurance of the effectiveness of its risk management processes through the work of internal audit and the external audit programmes of work. Our strategy clearly details the leadership, responsibility and accountability for risk management activities throughout the CCG. To this end, I am supported by the senior management team who oversee risk management activities for their areas of responsibility. The CCG operates an open culture and all staff are encouraged to openly discuss and share 87

88 concerns which may relate to risks, serious incidents and near misses through discussions with managers, quality and governance teams. Review of effectiveness My review of the effectiveness of the system of internal control is informed by the work of the internal auditors and the executive managers and clinical leads within the clinical commissioning group, who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me. My review is also informed by comments made by the external auditors in their annual audit letter and other reports. The Board Assurance Framework itself provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving its principal objectives, have been reviewed. In reviewing the effectiveness of our system of internal control, I have taken on board advice from the Governing Body, Audit and Governance Committee and Quality and Safety Committee and, where appropriate, plans are in place to address any weaknesses and to ensure continuous improvement of the system. All committees and groups involved in the management, scrutiny and oversight of internal control have clear terms of reference and reporting processes relating to key relationships. Any instances of significant internal control weaknesses would be reported to the Audit and Governance Committee; however there have been no issues to report to date. Following completion of the planned audit work for the financial year for the clinical commissioning group, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the clinical commissioning group s system of risk management, governance and internal control. The Head of Internal Audit concluded that: My overall opinion is that significant assurance can be given that there is a generally sound system of internal control, designed to meet the organisation s objectives, and that controls are generally being applied consistently. However, some weakness in the design and/or inconsistent application of controls puts the achievement of particular objectives at risk. The Head of Internal Audit highlighted concerns regarding the systems in place for the delivery of QIPP; procurement strategy and delivery and business intelligence. He provided only moderate assurance with regard to these areas. During the year, internal audit issued no audit reports with a conclusion of either limited or no assurance. Internal audit arrangements to review processes within the CSU were in place during , utilising a service auditor reporting approach. The CSU Service Auditor reports received in December 2014 and April 2015 did not highlight any significant control issues. Neither did the Service Auditor Report received from NHS Shared Business Services. Those areas not covered by service auditor reporting were reviewed by the CCG s internal auditors. 88

89 The internal audit plan of work not only addresses key system controls but also addresses key areas of risk identified through the assurance framework. Executive managers within the organisation who have responsibility for the development and maintenance of the system of internal control also provide the Accountable Officer with assurance. The Assurance Framework itself provides evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed. Data quality The Governing Body regularly reviews the adequacy of the data quality utilised to support decision making. Business critical models The CCG has determined that it uses the following business critical models in its decision making: Local financial plan model Service quality performance review Finance and activity data from providers. The CCG has recognised that key decisions are made based on the outputs from these models and therefore there is a high level of validation both internally and externally. This includes senior officer oversight of the outputs from the financial plan model and NHS England assurance processes; CCG finance and performance staff challenge of service quality performance data; and the validation of provider finance and activity data. I can confirm an appropriate framework and environment is in place to provide quality assurance of business critical models, in line with the recommendations in the Macpherson Report and that all business critical models have been identified and that information about quality assurance processes for those models has been provided to the Analytical Oversight Committee, chaired by the Chief Analyst in the Department of Health. This framework is informed by the role of the Audit and Governance Committee and internal audit programme to review systems of internal control to identify areas for improvement. The CCG also has a rigorous performance management framework which it uses to monitor delivery of services from its third party contractors. The CCG has developed its business continuity arrangements, which identify those business processes which need to be recovered as a priority in the event of business disruption. Data security We have submitted a satisfactory level of compliance with the information governance toolkit assessment. There were no data security breaches that required reporting to the Information Commissioner. 89

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91 Primary financial statements and notes NHS Sandwell & West Birmingham CCG - Annual Accounts CONTENTS Page Number The Primary Statements: Statement of Comprehensive Net Expenditure for the year ended 31st March Statement of Financial Position as at 31st March Statement of Changes in Taxpayers' Equity for the year ended 31st March Statement of Cash Flows for the year ended 31st March Notes to the Accounts Accounting policies 96 Other operating revenue 101 Revenue 101 Employee benefits and staff numbers 102 Operating expenses 106 Better payment practice code 107 Income generation activities 107 Investment revenue 108 Other gains and losses 108 Finance costs 108 Net gain/(loss) on transfer by absorption 109 Operating leases 109 Property, plant and equipment 110 Intangible non-current assets 110 Investment property 110 Inventories 110 Trade and other receivables 111 Other financial assets 112 Other current assets 112 Cash and cash equivalents 113 Non-current assets held for sale 113 Analysis of impairments and reversals 113 Trade and other payables 114 Other financial liabilities 114 Other liabilities 114 Borrowings 115 Private finance initiative, LIFT and other service concession arrangements 116 Finance lease obligations 116 Finance lease receivables 116 Provisions 117 Contingencies 118 Commitments 119 Financial instruments 119 Operating segments 120 Pooled budgets 121 NHS Lift investments 121 Intra-government and other balances 122 Related party transactions 123 Events after the end of the reporting period 124 Losses and special payments 124 Third party assets 125 Financial performance targets 125 Impact of IFRS 125 Analysis of charitable reserves 125 Net Parliamentary funding

92 NHS Sandwell & West Birmingham CCG - Annual Accounts Statement of Comprehensive Net Expenditure for the year ended 31 March Note Total Income and Expenditure Employee benefits ,460 5,863 Operating Expenses 5 635, ,117 Other operating revenue 2 (16,165) (10,751) Net operating expenditure before interest 625, ,229 Investment Revenue Other (gains)/losses Finance costs Net operating expenditure for the financial year 625, ,229 Net (gain)/loss on transfers by absorption Total Net Expenditure for the year 625, ,229 Of which: Administration Income and Expenditure Employee benefits ,109 4,271 Operating Expenses 5 7,809 7,219 Other operating revenue 2 (1,574) (940) Net administration costs before interest 10,344 10,550 Programme Income and Expenditure Employee benefits ,351 1,592 Operating Expenses 5 627, ,898 Other operating revenue 2 (14,591) (9,811) Net programme expenditure before interest 615, ,679 Other Comprehensive Net Expenditure Impairments and reversals Net gain/(loss) on revaluation of property, plant & equipment 0 0 Net gain/(loss) on revaluation of intangibles 0 0 Net gain/(loss) on revaluation of financial assets 0 0 Movements in other reserves 0 0 Net gain/(loss) on available for sale financial assets 0 0 Net gain/(loss) on assets held for sale 0 0 Net actuarial gain/(loss) on pension schemes 0 0 Share of (profit)/loss of associates and joint ventures 0 0 Reclassification Adjustments 0 0 On disposal of available for sale financial assets 0 0 Total comprehensive net expenditure for the year 625, ,229 The notes on pages 96 to 125 form part of this statement 92

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94 NHS Sandwell & West Birmingham CCG - Annual Accounts Statement of Changes In Taxpayers' Equity for the year ended 31 March 2015 Changes in taxpayers equity for General Revaluation Other Total fund reserve reserves reserves Balance at 1 April 2014 (43,204) 0 0 (43,204) Transfer between reserves in respect of assets transferred from closed NHS bodies Adjusted NHS Clinical Commissioning Group balance at 1 April 2014 (43,204) 0 0 (43,204) Changes in NHS Clinical Commissioning Group taxpayers equity for Net operating expenditure for the financial year (625,361) (625,361) Net gain/(loss) on revaluation of property, plant and equipment 0 0 Net gain/(loss) on revaluation of intangible assets 0 0 Net gain/(loss) on revaluation of financial assets 0 0 Total revaluations against revaluation reserve Net gain (loss) on available for sale financial assets Net gain (loss) on revaluation of assets held for sale Impairments and reversals Net actuarial gain (loss) on pensions Movements in other reserves Transfers between reserves Release of reserves to the Statement of Comprehensive Net Expenditure Reclassification adjustment on disposal of available for sale financial assets Transfers by absorption to (from) other bodies Reserves eliminated on dissolution Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (625,361) 0 0 (625,361) Net funding 630, ,807 Balance at 31 March 2015 (37,758) 0 0 (37,758) Changes in taxpayers equity for General Revaluation Other Total fund reserve reserves reserves Balance at 1 April Transfer of assets and liabilities from closed NHS bodies as a result of the 1 April 2013 transition (1,149) 0 0 (1,149) Adjusted NHS Commissioning Board balance at 1 April 2013 (1,149) 0 0 (1,149) Changes in NHS Commissioning Board taxpayers equity for Net operating costs for the financial year (615,229) (615,229) Net gain/(loss) on revaluation of property, plant and equipment 0 0 Net gain/(loss) on revaluation of intangible assets 0 0 Net gain/(loss) on revaluation of financial assets 0 0 Total revaluations against revaluation reserve Net gain (loss) on available for sale financial assets Net gain (loss) on revaluation of assets held for sale Impairments and reversals Net actuarial gain (loss) on pensions Movements in other reserves Transfers between reserves Release of reserves to the Statement of Comprehensive Net Expenditure Reclassification adjustment on disposal of available for sale financial assets Transfers by absorption to (from) other bodies Reserves eliminated on dissolution Net Recognised NHS Commissioning Board Expenditure for the Financial Year (616,378) 0 0 (616,378) Net funding 573, ,174 Balance at 31 March 2014 (43,204) 0 0 (43,204) The notes on pages 96 to 125 form part of this statement 94

95 NHS Sandwell & West Birmingham CCG - Annual Accounts Statement of Cash Flows for the year ended 31 March Note Cash Flows from Operating Activities Net operating expenditure for the financial year (625,361) (615,229) Depreciation and amortisation Impairments and reversals Movement due to transfer by Modified Absorption 0 0 Other gains (losses) on foreign exchange 0 0 Donated assets received credited to revenue but non-cash 0 0 Government granted assets received credited to revenue but non-cash 0 0 Interest paid 0 0 Release of PFI deferred credit 0 0 Other Gains & Losses 0 0 Finance Costs 0 0 Unwinding of Discounts 0 0 (Increase)/decrease in inventories 0 0 (Increase)/decrease in trade & other receivables 17 3,408 (8,455) (Increase)/decrease in other current assets 0 0 Increase/(decrease) in trade & other payables 23 (8,897) 48,864 Increase/(decrease) in other current liabilities 0 0 Provisions utilised 30 (326) 0 Increase/(decrease) in provisions ,629 Net Cash Inflow (Outflow) from Operating Activities (630,523) (573,190) Cash Flows from Investing Activities Interest received 0 0 (Payments) for property, plant and equipment 0 0 (Payments) for intangible assets 0 0 (Payments) for investments with the Department of Health 0 0 (Payments) for other financial assets 0 0 (Payments) for financial assets (LIFT) 0 0 Proceeds from disposal of assets held for sale: property, plant and equipment 0 0 Proceeds from disposal of assets held for sale: intangible assets 0 0 Proceeds from disposal of investments with the Department of Health 0 0 Proceeds from disposal of other financial assets 0 0 Proceeds from disposal of financial assets (LIFT) 0 0 Loans made in respect of LIFT 0 0 Loans repaid in respect of LIFT 0 0 Rental revenue 0 0 Net Cash Inflow (Outflow) from Investing Activities 0 0 Net Cash Inflow (Outflow) before Financing (630,523) (573,190) Cash Flows from Financing Activities Grant in Aid Funding Received 630, ,174 Other loans received 0 0 Other loans repaid 0 0 Capital element of payments in respect of finance leases and on Statement of Financial Position PFI and LIFT 0 0 Capital grants and other capital receipts 0 0 Capital receipts surrendered 0 0 Net Cash Inflow (Outflow) from Financing Activities 630, ,174 Net Increase (Decrease) in Cash & Cash Equivalents (16) Cash & Cash Equivalents at the Beginning of the Financial Year (16) 0 Effect of exchange rate changes on the balance of cash and cash equivalents held in foreign currencies 0 0 Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year 268 (16) The actual cash book balance of the Clinical Commissioning Group at the balance sheet date was 109k. However, in accordance with the requirements of IAS 31: Interests in Joint Ventures, the CCG is required to reflect its share of the income, expenditure, assets and liabilities associated with the pooled budget arrangements in which it partakes (see note 35). As the host of the Sandwell Mental Health Pooled budget, this technical adjustment requires 159k cash to be recognised and a reduction in CCG debtors seen. 95

96 NHS Sandwell & West Birmingham CCG - Annual Accounts Notes to the financial statements 1 Accounting Policies NHS England has directed that the financial statements of clinical commissioning groups shall meet the accounting requirements of the Manual for Accounts issued by the Department of Health. Consequently, the following financial statements have been prepared in accordance with the Manual for Accounts issued by the Department of Health. The accounting policies contained in the Manual for Accounts follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to clinical commissioning groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Manual for Accounts permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the clinical commissioning group for the purpose of giving a true and fair view has been selected. The particular policies adopted by the clinical commissioning group are described below. They have been applied consistently in dealing with items considered material in relation to the accounts. 1.1 Going Concern These accounts have been prepared on the going concern basis. Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents. Where a clinical commissioning group ceases to exist, it considers whether or not its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of Financial Statements. If services will continue to be provided the financial statements are prepared on the going concern basis. 1.2 Accounting Convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities. 1.3 Acquisitions & Discontinued Operations Activities are considered to be acquired only if they are taken on from outside the public sector. Activities are considered to be discontinued only if they cease entirely. They are not considered to be discontinued if they transfer from one public sector body to another. 1.4 Movement of Assets within the Department of Health Group Transfers as part of reorganisation fall to be accounted for by use of absorption accounting in line with the Government Financial Reporting Manual, issued by HM Treasury. The Government Financial Reporting Manual does not require retrospective adoption, so prior year transactions (which have been accounted for under merger accounting) have not been restated. Absorption accounting requires that entities account for their transactions in the period in which they took place, with no restatement of performance required when functions transfer within the public sector. Where assets and liabilities transfer, the gain or loss resulting is recognised in the Statement of Comprehensive Net Expenditure, and is disclosed separately from operating costs. Other transfers of assets and liabilities within the Department of Health Group are accounted for in line with IAS 20 and similarly give rise to income and expenditure entries. 1.5 Charitable Funds From , the divergence from the Government Financial Reporting Manual that NHS Charitable Funds are not consolidated with bodies own returns is removed. Under the provisions of IAS 27: Consolidated & Separate Financial Statements, those Charitable Funds that fall under common control with NHS bodies are consolidated within the entities accounts. 1.6 Pooled Budgets Where the clinical commissioning group has entered into a pooled budget arrangement under Section 75 of the National Health Service Act 2006 the clinical commissioning group accounts for its share of the assets, liabilities, income and expenditure arising from the activities of the pooled budget, identified in accordance with the pooled budget agreement. If the clinical commissioning group is in a jointly controlled operation, the clinical commissioning group recognises: The assets the clinical commissioning group controls; The liabilities the clinical commissioning group incurs; The expenses the clinical commissioning group incurs; and, The clinical commissioning group s share of the income from the pooled budget activities. If the clinical commissioning group is involved in a jointly controlled assets arrangement, in addition to the above, the clinical commissioning group recognises: The clinical commissioning group s share of the jointly controlled assets (classified according to the nature of the assets); The clinical commissioning group s share of any liabilities incurred jointly; and, The clinical commissioning group s share of the expenses jointly incurred. 1.7 Critical Accounting Judgements & Key Sources of Estimation Uncertainty In the application of the clinical commissioning group s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods Critical Judgements in Applying Accounting Policies The following are the critical judgements, apart from those involving estimations (see below) that management has made in the process of applying the clinical commissioning group s accounting policies that have the most significant effect on the amounts recognised in the financial statements: Premises occupied by the Clinical Commissioning Group are owned and managed by NHS Property Services Limited and NHS Community Health Partnerships Limited, and a charge is levied from these Companies to the CCG. Management treats these arrangements as operating leases, as substantially all of the risks and rewards of ownership reside with the premises owners. 96

97 NHS Sandwell & West Birmingham CCG - Annual Accounts Notes to the financial statements The Clinical Commissioning Group participates in a pooled budget arrangement under Section 75 of the National Health Services Act. Management deems this to be a joint operation, and accounts for it accordingly under IAS 31. The Clinical Commissioning Group is responsible for meeting the costs associated with the care of eligible patients' under the Continuing Healthcare criteria. Claims received during the year but not formally assessed by the year end are reviewed against key criteria, and judgements are made in respect of their likely success. Provision is made for those deemed probable under IAS 37, whilst those for which a possible payout is likely are disclosed as contingenct liabilities Key Sources of Estimation Uncertainty The following are the key estimations that management has made in the process of applying the clinical commissioning group s accounting policies that have the most significant effect on the amounts recognised in the financial statements: The CCG reviews all outstanding debts for recoverability, and makes specific provision for 100% of the value of non NHS debts for which settlement is uncertain. The Clinical Commissioning Group recognises the cost of drug prescribing based on data received from the NHS Prescription Pricing Authority (PPA). Reports are received on a monthly basis, but reflect transactions up to the end of February only. March costs are estimated using PPA forecast levels of expenditure during March. The value of expected claims for Continuing Healthcare are estimated based on the number of days a patient has spent in a care home, multiplied by the daily charge of that provider and provided for within gross expenditure. The CCG receives charges for the treatment of registered patients at out of area providers with which the CCG does not have a formal contract (as activity levels are low). Estimates are made in respect of the value of activity for which invoices have not been received by the year end based on detailed analysis of historical performance. The costs of this activity are provided for within gross expenditure. Healthcare providers raise charges for patient care activity, once the patient has been discharged. CCGs and providers recognise that some patients will have received treatment at the year end, but not yet discharged. Provision is made for the estimated cost of these "Partially Completed Spells" delivered within the financial year based on the time a patient has been admitted for as a proportion of the overall expected length of stay. The value is agreed with the healthcare provider. National Payment by Results rules under which providers are reimbursed for the costs of provision of maternity services require an advance payment for the full costs of antenatal and postnatal care upon initial registration with a midwife. An element of the care for some patients will be delivered after the year end. The value of this prepayment is estimated based on the amount of treatment each patient has received in the financial year as a proportion of the overall expected treatment cost, recognising that costs do not accrue equally throughout the ante and post natal terms. The value is agreed with the providers of maternity care. The cost of healthcare provision included within gross expenditure is based on activity monitoring information maintained by healthcare providers and validated by the CCG. Final data is not available until after the CCG has published its financial statements, and therefore costs in respect of this activity are estimated based on historical activity performance levels. The estimates are agreed with provider organisations, and reflected within gross income in their financial statements. 1.8 Revenue Revenue in respect of services provided is recognised when, and to the extent that, performance occurs, and is measured at the fair value of the consideration receivable. Where income is received for a specific activity that is to be delivered in the following year, that income is deferred. 1.9 Employee Benefits Short-term Employee Benefits Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees, including bonuses earned but not yet taken. The cost of leave earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period Retirement Benefit Costs Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the clinical commissioning group of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period. For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to expenditure at the time the clinical commissioning group commits itself to the retirement, regardless of the method of payment Other Expenses Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable. Expenses and liabilities in respect of grants are recognised when the clinical commissioning group has a present legal or constructive obligation, which occurs when all of the conditions attached to the payment have been met Property, Plant & Equipment Recognition Property, plant and equipment is capitalised if: It is held for use in delivering services or for administrative purposes; It is probable that future economic benefits will flow to, or service potential will be supplied to the clinical commissioning group; It is expected to be used for more than one financial year; The cost of the item can be measured reliably; and, The item has a cost of at least 5,000; or, 97

98 NHS Sandwell & West Birmingham CCG - Annual Accounts Notes to the financial statements Collectively, a number of items have a cost of at least 5,000 and individually have a cost of more than 250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or, Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives Intangible Assets Recognition Intangible assets are non-monetary assets without physical substance, which are capable of sale separately from the rest of the clinical commissioning group s business or which arise from contractual or other legal rights. They are recognised only: When it is probable that future economic benefits will flow to, or service potential be provided to, the clinical commissioning group; Where the cost of the asset can be measured reliably; and, Where the cost is at least 5,000. Intangible assets acquired separately are initially recognised at fair value. Software that is integral to the operating of hardware, for example an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software that is not integral to the operation of hardware, for example application software, is capitalised as an intangible asset. Expenditure on research is not capitalised but is recognised as an operating expense in the period in which it is incurred. Internally-generated assets are recognised if, and only if, all of the following have been demonstrated: The technical feasibility of completing the intangible asset so that it will be available for use; The intention to complete the intangible asset and use it; The ability to sell or use the intangible asset; How the intangible asset will generate probable future economic benefits or service potential; The availability of adequate technical, financial and other resources to complete the intangible asset and sell or use it; and, The ability to measure reliably the expenditure attributable to the intangible asset during its development Depreciation, Amortisation & Impairments Freehold land, properties under construction, and assets held for sale are not depreciated. Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible noncurrent assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the clinical commissioning group expects to obtain economic benefits or service potential from the asset. This is specific to the clinical commissioning group and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over their estimated useful lives. At each reporting period end, the clinical commissioning group checks whether there is any indication that any of its tangible or intangible noncurrent assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount of the asset is estimated to determine whether there has been a loss and, if so, its amount. Intangible assets not yet available for use are tested for impairment annually. A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Where an impairment loss subsequently reverses, the carrying amount of the asset is increased to the revised estimate of the recoverable amount but capped at the amount that would have been determined had there been no initial impairment loss. The reversal of the impairment loss is credited to expenditure to the extent of the decrease previously charged there and thereafter to the revaluation reserve Donated Assets Donated non-current assets are capitalised at their fair value on receipt, with a matching credit to Income. They are valued, depreciated and impaired as described above for purchased assets. Gains and losses on revaluations, impairments and sales are as described above for purchased assets. Deferred income is recognised only where conditions attached to the donation preclude immediate recognition of the gain Government Grants The value of assets received by means of a government grant are credited directly to income. Deferred income is recognised only where conditions attached to the grant preclude immediate recognition of the gain Non-current Assets Held For Sale Non-current assets are classified as held for sale if their carrying amount will be recovered principally through a sale transaction rather than through continuing use. This condition is regarded as met when: The sale is highly probable; The asset is available for immediate sale in its present condition; and, Management is committed to the sale, which is expected to qualify for recognition as a completed sale within one year from the date of classification. Non-current assets held for sale are measured at the lower of their previous carrying amount and fair value less costs to sell. Fair value is open market value including alternative uses. The profit or loss arising on disposal of an asset is the difference between the sale proceeds and the carrying amount and is recognised in the Statement of Comprehensive Net Expenditure. On disposal, the balance for the asset on the revaluation reserve is transferred to the general reserve. Property, plant and equipment that is to be scrapped or demolished does not qualify for recognition as held for sale. Instead, it is retained as an operational asset and its economic life is adjusted. The asset is de-recognised when it is scrapped or demolished Leases Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases. 98

99 NHS Sandwell & West Birmingham CCG - Annual Accounts Notes to the financial statements The Clinical Commissioning Group as Lessee Property, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the clinical commissioning group s surplus/deficit. Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term. Contingent rentals are recognised as an expense in the period in which they are incurred. Where a lease is for land and buildings, the land and building components are separated and individually assessed as to whether they are operating or finance leases The Clinical Commissioning Group as Lessor Amounts due from lessees under finance leases are recorded as receivables at the amount of the clinical commissioning group s net investment in the leases. Finance lease income is allocated to accounting periods so as to reflect a constant periodic rate of return on the clinical commissioning group s net investment outstanding in respect of the leases. Rental income from operating leases is recognised on a straight-line basis over the term of the lease. Initial direct costs incurred in negotiating and arranging an operating lease are added to the carrying amount of the leased asset and recognised on a straight-line basis over the lease term Private Finance Initiative Transactions HM Treasury has determined that government bodies shall account for infrastructure Private Finance Initiative (PFI) schemes where the government body controls the use of the infrastructure and the residual interest in the infrastructure at the end of the arrangement as service concession arrangements, following the principles of the requirements of IFRIC 12. The clinical commissioning group therefore recognises the PFI asset as an item of property, plant and equipment together with a liability to pay for it. The services received under the contract are recorded as operating expenses. The annual unitary payment is separated into the following component parts, using appropriate estimation techniques where necessary: Payment for the fair value of services received; Payment for the PFI asset, including finance costs; and, Payment for the replacement of components of the asset during the contract lifecycle replacement Inventories Inventories are valued at the lower of cost and net realisable value using the first-in first-out cost formula. This is considered to be a reasonable approximation to fair value due to the high turnover of stocks Cash & Cash Equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value. In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the clinical commissioning group s cash management Provisions Provisions are recognised when the clinical commissioning group has a present legal or constructive obligation as a result of a past event, it is probable that the clinical commissioning group will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties. When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised as an asset if it is virtually certain that reimbursements will be received and the amount of the receivable can be measured reliably Clinical Negligence Costs The NHS Litigation Authority operates a risk pooling scheme under which the clinical commissioning group pays an annual contribution to the NHS Litigation Authority which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although the NHS Litigation Authority is administratively responsible for all clinical negligence cases the legal liability remains with the clinical commissioning group Non-clinical Risk Pooling The clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to the NHS Litigation Authority and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due Continuing healthcare risk pooling In a risk pool scheme has been introduced by NHS England for continuing healthcare claims, for claim periods prior to 31 March Under the scheme clinical commissioning group contribute annually to a pooled fund, which is used to settle the claims Carbon Reduction Commitment Scheme Carbon Reduction Commitment and similar allowances are accounted for as government grant funded intangible assets if they are not expected to be realised within twelve months, and otherwise as other current assets Contingencies A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or nonoccurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group, or a present obligation that is not recognised because it is not probable that a payment will be required to settle the obligation or the amount of the obligation cannot be measured sufficiently reliably. A contingent liability is disclosed unless the possibility of a payment is remote. ds detarmined at the time of initial recognition purpose Where the time value of money is material, contingencies are disclosed at their present value. 99

100 NHS Sandwell & West Birmingham CCG - Annual Accounts Notes to the financial statements 1.27 Financial Assets Financial assets are recognised when the clinical commissioning group becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred. All of the CCGs financial assets are classified as loans and receivables based on their nature and purpose as determined at the time of initial recognition Loans & Receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. After initial recognition, they are measured at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method. Fair value reflects the amount receivable on the due date, as agreed at the point of transaction. The effective interest rate is the rate that exactly discounts estimated future cash receipts through the expected life of the financial asset, to the initial fair value of the financial asset. At the end of the reporting period, the clinical commissioning group assesses whether any financial assets, other than those held at fair value through profit and loss are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset. For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset s carrying amount and the present value of the revised future cash flows discounted at the asset s original effective interest rate. The loss is recognised in expenditure and the carrying amount of the asset is reduced through a provision for impairment of receivables. If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through expenditure to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised Financial Liabilities Financial liabilities are recognised on the statement of financial position when the clinical commissioning group becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are derecognised when the liability has been discharged, that is, the liability has been paid or has expired. Loans from the Department of Health are recognised at historical cost. Otherwise, financial liabilities are initially recognised at fair value Other Financial Liabilities After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method, except for loans from Department of Health, which are carried at historic cost. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method Value Added Tax Most of the activities of the clinical commissioning group are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT. 1.3 Foreign Currencies The clinical commissioning group s functional currency and presentational currency is sterling. Transactions denominated in a foreign currency are translated into sterling at the exchange rate ruling on the dates of the transactions. At the end of the reporting period, monetary items denominated in foreign currencies are retranslated at the spot exchange rate on 31 March. Resulting exchange gains and losses for either of these are recognised in the clinical commissioning group s surplus/deficit in the period in which they arise Third Party Assets Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the clinical commissioning group has no beneficial interest in them Losses & Special Payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had the clinical commissioning group not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure) Joint Operations Joint operations are activities undertaken by the clinical commissioning group in conjunction with one or more other parties but which are not performed through a separate entity. The clinical commissioning group records its share of the income and expenditure; gains and losses; assets and liabilities; and cash flows Research & Development Research and development expenditure is charged in the year in which it is incurred, except insofar as development expenditure relates to a clearly defined project and the benefits of it can reasonably be regarded as assured. Expenditure so deferred is limited to the value of future benefits expected and is amortised through the Statement of Comprehensive Net Expenditure on a systematic basis over the period expected to benefit from the project. It should be re-valued on the basis of current cost. The amortisation is calculated on the same basis as depreciation Accounting Standards That Have Been Issued But Have Not Yet Been Adopted The Government Financial Reporting Manual does not require the following Standards and Interpretations to be applied in , all of which are subject to consultation: IFRS 9: Financial Instruments IFRS 13: Fair Value Measurement IFRS 14: Regulatory Deferral Accounts IFRS 15: Revenue for Contract with Customers The application of the Standards as revised would not have a material impact on the accounts for , were they applied in that year. 100

101 NHS Sandwell & West Birmingham CCG - Annual Accounts Other Operating Revenue Total Admin Programme Total Recoveries in respect of employee benefits Patient transport services Prescription fees and charges Dental fees and charges Education, training and research Charitable and other contributions to revenue expenditure: NHS Charitable and other contributions to revenue expenditure: non-nhs Receipt of donations for capital acquisitions: NHS Charity Receipt of Government grants for capital acquisitions Non-patient care services to other bodies 14,694 1,200 13,494 9,571 Income generation Rental revenue from finance leases Rental revenue from operating leases Other revenue Total other operating revenue 16,165 1,574 14,591 10,751 Items included in other revenue include: Non Recurrent revenue for specific projects, virtual wards & evaluation of premises 110k Stroke Project revenue as CCG is currently host 240k NHS 111 revenue to develop the online directory 64k Non-patient care services to other bodies: NHS 111 income amounted to 13,339k Additional revenue received in relation to NHS 111 Pliots 1,348k 3 Revenue Total Admin Programme Total From rendering of services 16,165 1,574 14,591 10,751 From sale of goods Total 16,165 1,574 14,591 10,751 Revenue is totally from the supply of services. The Clinical Commissioning Group receives no revenue from the sale of goods. 101

102 NHS Sandwell & West Birmingham CCG - Annual Accounts Employee benefits and staff numbers Employee benefits Total Admin Programme Total Permanent Employees Other Total Permanent Employees Other Total Permanent Employees Other Employee Benefits Salaries and wages 5,382 5, ,396 3, ,986 1, Social security costs Employer Contributions to NHS Pension scheme Other pension costs Other post-employment benefits Other employment benefits Termination benefits Gross employee benefits expenditure 6,460 6, ,109 3, ,351 2, Less recoveries in respect of employee benefits (note 4.1.2) Total - Net admin employee benefits including capitalised costs 6,460 6, ,109 3, ,351 2, Less: Employee costs capitalised Net employee benefits excluding capitalised costs 6,460 6, ,109 3, ,351 2, Recoveries in respect of employee benefits The Clinical Commissioning Group did not receive any recoveries in respect of employee benefits during the year to 31st March

103 NHS Sandwell & West Birmingham CCG - Annual Accounts Average number of people employed Total Permanently employed Other Total Number Number Number Number Total Of the above: Number of whole time equivalent people engaged on capital projects Staff sickness absence and ill health retirements Number Number Total Days Lost Total Staff Years Average working Days Lost Number Number Number of persons retired early on ill health grounds Total additional Pensions liabilities accrued in the year 0 0 Ill health retirement costs are met by the NHS Pension Scheme 4.4 Exit packages agreed in the financial year Compulsory redundancies Other agreed departures Total Number Number Number 10,001 to 25, , ,950 Total 1 13, ,

104 NHS Sandwell & West Birmingham CCG - Annual Accounts Pension costs Past and present employees are covered by the provisions of the NHS Pension Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at The scheme is an unfunded, defined benefit scheme that covers NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the clinical commissioning group of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period. In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that "the period between formal valuations shall be four years, with approximate assessments in intervening years." An outline of these follows: a) Accounting valuation A valuation of the scheme liability is carried out annually by the scheme actuary as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and are accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2015, is based on valuation data as 31 March 2014, updated to 31 March 2015 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretaions, and the discount rate prescribed by HM Treasury have also been used. The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Pensions Accounts, published annually. These accounts can be viewed on the NHS Pensions website. Copies can also be obtained from The Stationery Office. b) Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the scheme (taking into account its recent demographic experience), and to recommend the contribution rates. The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March The Scheme Regulations allow contributions rates to be set by the Secretary of State for Health, with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and appropriate employee and employer representatives as deemed appropriate. 104

105 NHS Sandwell & West Birmingham CCG - Annual Accounts c) Scheme Provisions The NHS Pension Scheme provided defined benefits, which are summarised below. This list is an illustrative guide only, and is not intended to detail all the benefits provided by the Scheme or the specific conditions that must be met before these benefits can be obtained: The Scheme is a final salary scheme. Annual pensions are normally based on 1/80th for the 1995 section and of the best of the last three years pensionable pay for each year of service, and 1/60th for the 2008 section of reckonable pay per year of membership. Members who are practitioners as defined by the Scheme Regulations have their annual pensions based upon total pensionable earnings over the relevant pensionable service. With effect from 1 April 2008 members can choose to give up some of their annual pension for an additional tax free lump sum, up to a maximum amount permitted under HM Revenue & Customs rules. This new provision is known as pension commutation. Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act 1971, and are based on changes in retail prices in the twelve months ending 30 September in the previous calendar year. From the Consumer Price Index (CPI) has been used and replaces the Retail Prices Index (RPI). Early payment of a pension, with enhancement, is available to members of the Scheme who are permanently incapable of fulfilling their duties effectively through illness or infirmity. A death gratuity of twice final year s pensionable pay for death in service, and five times their annual pension for death after retirement is payable. For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to the employer. Members can purchase additional service in the NHS Scheme and contribute to money purchase AVC s run by the Scheme s approved providers or by other Free Standing Additional Voluntary Contributions (FSAVC) providers. 105

106 NHS Sandwell & West Birmingham CCG - Annual Accounts Operating expenses Total Admin Programme Total Gross employee benefits Employee benefits excluding governing body members 6,135 3,784 2,351 5,553 Executive governing body members Total gross employee benefits 6,460 4,109 2,351 5,863 Other costs Services from other CCGs and NHS England 35,674 3,267 32,407 40,203 Services from foundation trusts 151, , ,239 Services from other NHS trusts 295, , ,254 Services from other NHS bodies Purchase of healthcare from non-nhs bodies 55, ,178 55,030 Chair and Non Executive Members Supplies and services clinical Supplies and services general ,252 Consultancy services 2,001 1, ,250 Establishment Transport Premises 4, ,143 4,347 Impairments and reversals of receivables Inventories written down Depreciation Amortisation Impairments and reversals of property, plant and equipment Impairments and reversals of intangible assets Impairments and reversals of financial assets Assets carried at amortised cost Assets carried at cost Available for sale financial assets Impairments and reversals of non-current assets held for sale Impairments and reversals of investment properties Audit fees Other non statutory audit expenditure Internal audit services Other services General dental services and personal dental services Prescribing costs 83, ,130 80,834 Pharmaceutical services General ophthalmic services GPMS/APMS and PCTMS 3, ,142 2,081 Other professional fees excl. audit Grants to other public bodies Clinical negligence Research and development (excluding staff costs) Education and training Change in discount rate Provisions CHC Risk Pool contributions Other expenditure Total other costs 635,066 7, , ,117 Total operating expenses 641,526 11, , ,980 Admin expenditure is expenditure incurred that is not a direct payment for the provision of healthcare or healthcare services. Details of movements include: Services from foundation trusts Increase in expenditure relates to NHS 111 service delivered by West Midlands Ambulance Service. CHC Risk Pool Contributions On 1st April 2014 NHS England established a National Risk Share with regard to CHC Retrospective cases. Provisions Provisions have been identified as a separate category of expenditure for Expenditure for provisions in 2013/14 comparator figures was recorded in services from NHS Trusts. Foundation Trusts and Non NHS Expenditure. Further detail on provisions can be found in note 30. Clinical Negligence This cost relates to NHS Litigation Authority annual subscription fees. 106

107 NHS Sandwell & West Birmingham CCG - Annual Accounts Better Payment Practice Code Measure of compliance Number 000 Number 000 Non-NHS Payables Total Non-NHS Trade invoices paid in the Year 11,249 62,643 7,212 44,825 Total Non-NHS Trade Invoices paid within target 10,835 57,475 6,836 35,635 Percentage of Non-NHS Trade invoices paid within target 96.32% 91.75% 94.79% 79.50% NHS Payables Total NHS Trade Invoices Paid in the Year 3, ,195 2, ,375 Total NHS Trade Invoices Paid within target 3, ,548 2, ,950 Percentage of NHS Trade Invoices paid within target 93.62% 98.26% 88.35% 99.05% The Better Payment Practice Code requires the Clinical Commissioning Group to aim to pay 95% of invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. 6.2 The Late Payment of Commercial Debts (Interest) Act Amounts included in finance costs from claims made under this legislation 0 0 Compensation paid to cover debt recovery costs under this legislation 0 0 Total Income Generation Activities The Clinical Commissioning Group does not undertake any income generation activities. 107

108 NHS Sandwell & West Birmingham CCG - Annual Accounts Investment revenue The Clinical Commissioning Group did not receive investment revenue during the year to 31 March Other gains and losses The Clinical Commissioning Group did not incur any other gains or losses during the year to 31 March Finance costs The Clinical Commissioning Group did not incur any finance costs during the year to 31 March

109 NHS Sandwell & West Birmingham CCG - Annual Accounts Net gain/(loss) on transfer by absorption The CCG did not incur any other gains or losses on transfer by absorption during the year to 31 March Operating Leases 12.1 As lessee The CCG has payments with NHS Property Services Ltd and NHS Community Health Partnerships Ltd during the year in relation to the occupation of premises transferred to those companies on 1 April Although there are no formal lease agreements in place, the CCG, NHS Property Services Ltd and Community Health Partnerships Ltd deem these to be operating leases, and account for them as such Payments recognised as an Expense Land Buildings Other Total Total Payments recognised as an expense Minimum lease payments 0 4, , Contingent rents Sub-lease payments Total 0 4, ,531 4, Future minimum lease payments Land Buildings Other Total Total Payable: No later than one year Between one and five years After five years Total At present, the lease arrangements between Sandwell and West Birmingham CCG, NHS Property Services Ltd and Community Health Partnerships Ltd are not covered by a formal agreement. Future minimum lease payments cannot therefore be quantified. However, the existing arrangements are expected to continue for the forseeable future, with the CCG making payments to both companies at market rates in respect of properties occupied Rental revenue The Clinical Commissioning Group did not receive any rental revenue during the year to 31 March Future minimum rental value The Clinical Commissioning Group does not have any future rental revenue during the year to 31 March

110 NHS Sandwell & West Birmingham CCG - Annual Accounts Property, plant and equipment The Clinical Commissioning Group had no property, plant or equipment assets as at 31 March Intangible non-current assets The Clinical Commissioning Group had no intangible assest as at 31 March Investment property The Clinical Commissioning Group had no investment property as at 31 March Inventories The Clinical Commissioning Group had no inventories as at 31 March

111 NHS Sandwell & West Birmingham CCG - Annual Accounts Trade and other receivables Current Non-current Current Non-current NHS receivables: Revenue ,037 0 NHS receivables: Capital NHS prepayments and accrued income 2, ,915 0 Non-NHS receivables: Revenue ,247 0 Non-NHS receivables: Capital Non-NHS prepayments and accrued income ,436 0 Provision for the impairment of receivables (171) 0 (255) 0 VAT Private finance initiative and other public private partnership arrangement prepayments and accrued income Interest receivables Finance lease receivables Operating lease receivables Other receivables Total Trade & other receivables 5, ,454 0 Total current and non current 5,046 8,454 Included above: Prepaid pensions contributions 0 0 The great majority of trade is with other NHS bodies, including other Clinical Commissioning Groups as commissioners for NHS patient care services. As Clinical Commissioning Groups are funded by Government to buy NHS patient care services, no credit scoring of them is considered necessary Receivables past their due date but not impaired By up to three months 1,021 1,175 By three to six months By more than six months 36 0 Total 1,104 1, k of the amount above has subsequently been recovered post the statement of financial position date, The Clinical Commissioning Group did not hold any collateral against receivables outstanding at 31 March Provision for impairment of receivables Balance at 1 April 2014 (255) 0 Amounts written off during the year Amounts recovered during the year 0 0 (Increase) decrease in receivables impaired (18) (255) Transfer (to) from other public sector body 0 0 Balance at 31 March 2015 (171) (255) 102k has been formally written off in year from the bad debt provision made during Further bad debts of 18k have been provided for in year relating to Birmingham City Council of 9k and 9k Non NHS Providers % % Receivables are provided against at the following rates: NHS debt 0 0 Non NHS

112 NHS Sandwell & West Birmingham CCG - Annual Accounts Other financial assets The Clinical Commissioning Group had no other financial assets as at 31 March Other current assets The Clinical Commissioning Group had no other current assets as at 31 March

113 NHS Sandwell & West Birmingham CCG - Annual Accounts Cash and cash equivalents Balance at 1 April 2014 (16) 0 Net change in year 284 (16) Balance at 31 March (16) Made up of: Cash with the Government Banking Service Cash with Commercial banks 0 0 Cash in hand Current investments 0 0 Cash and cash equivalents as in statement of financial position Bank overdraft: Government Banking Service 0 (16) Bank overdraft: Commercial banks 0 0 Total bank overdrafts 0 (16) Balance at 31 March (16) Patients money held by the clinical commissioning group, not included above 0 0 The actual cash book balance of the Clinical Commissioning Group at the balance sheet date was 109k. However, in accordance with the requirements of IAS 31: Interests in Joint Ventures, the CCG is required to reflect its share of the income, expenditure, assets and liabilities associated with the pooled budget arrangements in which it partakes (see note 35). As the host of the Sandwell Mental Health Pooled budget, this technical adjustment requires 159k cash to be recognised which is disclosed as Cash in hand. 21 Non-current assets held for sale The Clinical Commissioning Group had no other non-current assets as at 31 March Analysis of impairments and reversals The Clinical Commissioning Group had no impairments or reversals as at 31 March

114 NHS Sandwell & West Birmingham CCG - Annual Accounts Trade and other payables Current Non-current Current Non-current Interest payable NHS payables: revenue 4, ,977 0 NHS payables: capital NHS accruals and deferred income 4, ,272 0 Non-NHS payables: revenue 13, ,619 0 Non-NHS payables: capital Non-NHS accruals and deferred income 18, ,908 0 Social security costs VAT Tax Payments received on account Other payables Total Trade & Other Payables 41, ,013 0 Total current and non-current 41,116 50,013 Other payables include 95k outstanding pension contributions at 31 March 2015 ( 75k 31 March 2014) current Trade and Other Payables includes an opening balance of 1.149m in respect of partially completed spells. 24 Other financial liabilities Current Non-current Current Non-current Embedded derivatives at fair value through the statement Financial liabilities carried at fair value through profit and lo Amortised cost Total Total current and non-current Other liabilities The Clinical Commissioning Group had no other liabilities as at 31 March

115 NHS Sandwell & West Birmingham CCG - Annual Accounts Current Non-current Current Non-current 26 Borrowings Bank overdrafts: Government banking service Commercial banks Total overdrafts Loans from: The Department of Health Other entities Total loans Private finance initiative liabilities: Main liability Lifecycle replacement received in advance Total private finance initiative liabilities LIFT liabilities: Main liability Lifecycle replacement received in advance Total LIFT liabilities Finance lease liabilities Other [give detail] Total Borrowings Total current and non-current Repayment of principal falling due Department of Health Other Total Within one year Between one and two years Between two and five years Between one and five years After five years Total

116 NHS Sandwell & West Birmingham CCG - Annual Accounts Private finance initiative, LIFT and other service concession arrangements The Clinical Commissioning Group had no private finance initiative, LIFT or other service concession as at 31 March Finance lease obligations The Clinical Commissioning Group had no finance lease obligations as at 31 March Finance lease receivables The Clinical Commissioning Group had no finance lease receivables as at 31 March

117 NHS Sandwell & West Birmingham CCG - Annual Accounts Provisions Current Non-current Current Non-current Continuing care Other 1, ,012 0 Total 1, ,629 0 Total current and non-current 1,956 1,629 Pensions Relating to Former Directors Pensions Relating to Other Staff Restructuring Redundancy Agenda for Continuing Change Equal Pay Legal Claims Care Other Total 000s 000s 000s 000s 000s 000s 000s 000s 000s 000s Balance at 1 April ,012 1,629 Arising during the year ,557 1,694 Utilised during the year (326) (326) Reversed unused (355) (686) (1,041) Balance at 31 March ,557 1,956 Expected timing of cash flows: Within one year ,557 1,956 Between one and five years After five years Balance at 31 March ,557 1,956 Items Included In Provisions: Continuing Healthcare Brought forward cases from amounting to 262,441 Further additional continuing healthcare appeal cases 124,993 Learning Disabilities provision for patients assessed but disputed 12,171 Other Provision for healthcare costs for long stay patients at Birmingham Children s Hospital 81,184 Provision for healthcare activities with out of area NHS providers 788,122 Provision for healthcare activities with out of area NHS providers relating to mental health services 115,762 Provision for stranded costs relating to reprocurement of mental health services 572,000 Under the Accounts Direction issued by NHS England on 12 February 2014, NHS England is responsible for accounting for liabilities relating to NHS Continuing Healthcare claims relating to periods of care before establishment of the clinical commissioning group. However, the legal liability remains with the CCG. The total value of legacy NHS Continuing Healthcare provision accounted for by NHS England on behalf of this CCG at 31 March 2015 is 390,

118 NHS Sandwell & West Birmingham CCG - Annual Accounts Contingencies Contingent liabilities CHC Appeals Learning Disabilities Disputed Cases Net value of contingent liabilities Contingent assets Net value of contingent assets 0 0 Other CHC Appeals The continuing healthcare contingent liability relates to 3 patients with an estimated retrospective healthcare cost of 160,154. These claims arose during and the CCG considers a successful claim is possible. Learning Disabilities Disputed Cases A contingent liability has been calculated to assess the cost of healthcare for patients who have been declined continued funding from Social Care. The local authority deemed that these patients are eligible for NHS funded care. An independent assessment has taken place which deemed the patients did not meet the criteria for NHS funded Continuing haelth Care. This information has been reported to the local authority but they remain in disagreement with the outcome. The CCG therefore considers there to be a possibility of funding required for these patients. 118

119 NHS Sandwell & West Birmingham CCG - Annual Accounts Commitments The Clinical Commissioning Group had no capital or other non-cancellable financial commitments as at 31 March Other financial commitments The NHS Clinical Commissioning Group has entered into non-cancellable contracts (which are not leases, private finance initiative contracts or other service concession arrangements) which expire as follows: In not more than one year 0 0 In more than one year but not more than five years 0 0 In more than five years 0 0 Total Financial instruments 33.1 Financial risk management Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities. Because NHS Clinical Commissioning Group is financed through parliamentary funding, it is not exposed to the degree of financial risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The clinical commissioning group has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the clinical commissioning group in undertaking its activities. Treasury management operations are carried out by the finance department, within parameters defined formally within the NHS Clinical Commissioning Group standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by the NHS Clinical Commissioning Group and internal auditors Currency risk The NHS Clinical Commissioning Group is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The NHS Clinical Commissioning Group has no overseas operations. The NHS Clinical Commissioning Group and therefore has low exposure to currency rate fluctuations Interest rate risk The Clinical Commissioning Group borrows from government for capital expenditure, subject to affordability as confirmed by NHS England. The borrowings are for 1 to 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The clinical commissioning group therefore has low exposure to interest rate fluctuations Credit risk Because the majority of the NHS Clinical Commissioning Group and revenue comes parliamentary funding, NHS Clinical Commissioning Group has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed in the trade and other receivables note Liquidity risk NHS Clinical Commissioning Group is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. The NHS Clinical Commissioning Group draws down cash to cover expenditure, as the need arises. The NHS Clinical Commissioning Group is not, therefore, exposed to significant liquidity risks. 119

120 NHS Sandwell & West Birmingham CCG - Annual Accounts Financial instruments cont'd 33.2 Financial assets At fair value through profit and loss Loans and Receivables Available for Sale Total Embedded derivatives Receivables: NHS Non-NHS Cash at bank and in hand Other financial assets Total at 31 March , ,872 At fair value through profit and loss Loans and Receivables Available for Sale Total Embedded derivatives Receivables: NHS 0 1, ,037 Non-NHS 0 1, ,247 Cash at bank and in hand Other financial assets Total at 31 March , , Financial liabilities At fair value through profit and loss Other Total Embedded derivatives Payables: NHS 0 8,708 8,708 Non-NHS 0 32,221 32,221 Private finance initiative, LIFT and finance lease obligations Other borrowings Other financial liabilities Total at 31 March ,929 40,929 At fair value through profit and loss Other Total Embedded derivatives Payables: NHS 0 18,249 18,249 Non-NHS 0 31,527 31,527 Private finance initiative, LIFT and finance lease obligations Other borrowings Other financial liabilities Total at 31 March ,793 49, Operating segments The Clinical Commissioning Group and consolidated group consider they have only one segment: commissioning of healthcare services. 120

121 NHS Sandwell & West Birmingham CCG - Annual Accounts Pooled budgets The clinical commissioning group was party to a pooled budget arrangement during the year, with NHS Birmingham Cross City CCG and Sandwell Metropolitan Borough Council. The pool is hosted by NHS Sandwell and West Birmingham CCG. Under the arrangement funds are pooled under Section 75 of the NHS Act 2006 for community mental health services. The NHS Clinical Commissioning Group shares of the income and expenditure handled by the pooled budget in the financial year were: Income Expenditure (285) (321) Please Note This Includes SWBCCG Contributions The memorandum account for the pooled budget is: Birmingham Sandwell & West Cross City CCG Birmingham CCG Sandwell MBC Contributions to Pool Total Share % 7.0% 57.0% 36.0% Budgeted Contributions to Pool /15 39, , , ,775 Share of Underspend (6,540) (40,178) (46,705) (93,423) Budget 2014/15 33, , , , NHS Lift investments The Clinical Commissioning Group had no NHS LIFT investments as at 31 March

122 NHS Sandwell & West Birmingham CCG - Annual Accounts Intra-government and other balances Current Receivables Non-current Receivables Current Payables Non-current Payables Balances with: Other Central Government bodies Local Authorities ,803 0 Balances with NHS bodies: NHS bodies outside the Departmental Group 1, ,406 0 NHS Trusts and Foundation Trusts 2, ,302 0 Total of balances with NHS bodies: 3, ,708 0 Public corporations and trading funds Bodies external to Government ,321 0 Total balances at 31 March , ,116 0 Current Receivables Non-current Receivables Current Payables Non-current Payables Balances with: Other Central Government bodies Local Authorities ,695 0 Balances with NHS bodies: NHS bodies outside the Departmental Group NHS Trusts and Foundation Trusts 5, ,249 0 Total of balances with NHS bodies: 5, ,249 0 Public corporations and trading funds Bodies external to Government 1, ,069 0 Total balances at 31 March , ,

123 NHS Sandwell & West Birmingham CCG - Annual Accounts Related party transactions Details of related party transactions with individuals are as follows: Payments to Related Party Receipts from Related Party Amounts owed to Related Party Amounts due from Related Party Mr Andrew Williams - Accountable Officer 4,917 (35) 8 0 Mr James Green - Chief Finance Officer Dr Nick Harding - Governing Body Member 1, Dr George Solomon - Governing Body Member 1, Dr Ian Walton - Governing Body Member 1, (153) Dr Sam Mukherjee - Governing Body Member Dr Inderjit Marok - Governing Body Member Dr Vijay Bathla - Governing Body Member Dr Sirjit Bath - Governing Body Member Dr Basil Andreou - Governing Body Member Dr Priyanand Hallan - Governing Body Member Mrs Julie Jasper - Governing Body Member 0 (1,051) 0 (33) Mrs Jyoti Atri - Governing Body Member 7,471 (389) 1,249 (465) Dr Ram Sugavanam - Governing Body Member 1, Dr Ian Sykes - Governing Body Member Payments shown against Mr Andy Williams relate to NHS Midlands & Lancashire CSU, in which his partner was employed as a senior manager. Other payments to GPs on the Governing Body have been to their GP Practices, or to companies in which they have an influential position. These figures exclude payments made to individuals for Governing Body membership. All transactions were undertaken under NHS Terms and Conditions. The Department of Health is regarded as a related party. During the year the clinical commissioning group has had a significant number of material transactions with entities for which the Department is regarded as the parent Department. These entities are listed below. NHS Birmingham Cross City CCG NHS Birmingham South Central CCG NHS Coventry & Rugby CCG NHS Dudley CCG NHS England NHS Herefordshire CCG NHS Redditch & Bromsgrove CCG NHS South Warwickshire CCG NHS South Worcestershire CCG NHS Solihull CCG NHS Walsall CCG NHS Warwickshire North CCG NHS Wolverhampton CCG NHS Wyre Forest CCG Birmingham Community Healthcare NHS Trust Sandwell & West Birmingham Hospitals NHS Trust University Hospitals Coventry & Warwickshire NHS Trust Walsall Healthcare NHS Trust Birmingham & Solihull Mental Health NHS Foundation Trust Birmingham Children's Hospital NHS Foundation Trust Birmingham Women's NHS Foundation Trust Black Country Partnership NHS Foundation Trust Heart of England NHS Foundation Trust The Royal Orthopaedic Hospital NHS Foundation Trust The Dudley Group NHS Foundation Trust University Hospitals Birmingham NHS Foundation Trust West Midlands Ambulance Service NHS Foundation Trust In addition, the clinical commissioning group has had a number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with Birmingham City Council and Sandwell Metropolitan Borough Council. 123

124 NHS Sandwell & West Birmingham CCG - Annual Accounts Events after the end of the reporting period There are no post balance sheet events which will have a material effect on the financial statements of the Clinical Commissioning Group or consolidated group. However, with effect from 1st April 2015, the CCG will commence the commissioning of GP primary care services (primary care co-commissioning). The CCG will receive an allocation of 75m in 2015/16 to commission these services. The allocation received is consistent with costs incurred by NHS England in 2014/15 in respect of these services. 40 Losses and special payments 40.1 Losses The total number of NHS Clinical Commissioning Group losses and special payments cases, and their total value, was as follows: Total Number of Cases Total Value of Cases Total Number of Cases Total Value of Cases Number '000 Number '000 Administrative write-offs Fruitless payments Store losses Book Keeping Losses Constructive loss Cash losses Claims abandoned Total Special payments The Clinical Commissioning Group had no special payments during the year to 31 March

125 NHS Sandwell & West Birmingham CCG - Annual Accounts Third party assets The Clinical Commissioning Group had no third party assets as at 31 March Financial performance targets NHS Clinical Commissioning Group have a number of financial duties under the NHS Act 2006 (as amended). NHS Clinical Commissioning Group performance against those duties was as follows: Target Performance Target Performance Expenditure not to exceed income (underspend) 8,000 8,778 6,300 6,441 Capital resource use does not exceed the amount specified in Directions Revenue resource use does not exceed the amount specified in Directions 634, , , ,229 Capital resource use on specified matter(s) does not exceed the amount specified in Directions Revenue resource use on specified matter(s) does not exceed the amount specified in Directions Revenue administration resource use does not exceed the amount specified in Directions 12,700 10,347 12,700 10, Impact of IFRS Accounting under IFRS had no impact on the results of the clinical commissioning group during the financial year. 44 Analysis of charitable reserves The Clinical Commissioning Group had no charitable reserves as at 31 March Net parliamentary funding Cash Limited Drawdown 548,918 PPA Drawdown 81,889 Total balances at 31 March ,

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