Annual Report 2015/16

Transcription

1 Annual Report 2015/16

2 About this report This Annual Report is a statutory document, which must meet the requirements set out by the Department of Health. For the purposes of comparisons with other NHS bodies and with private companies who are governed by the Companies Act, information that would normally be contained in the Director s report can be found in the Performance Report. This section of the report explains the significant issues the CCG experienced in terms of managing its finances during the year. This Annual Report contains the following main sections: Introduction Member Practice s Introduction Performance Report Accountability Report Remuneration and Staff Report Financial statements Appendices By law we are required to publish this Annual Report with our financial accounts and present both in public at an Annual General Meeting. Our accounts have been prepared under a Direction issued by the NHS Commissioning Board under the National Health Service Act 2006 (as amended), and have been subject to internal and external audit. An issue for this year s financial accounts has been the CCG s challenging financial position. The CCG spent 356.7m in 2015/16, which means it reported a cumulative deficit position at the end of 2015/16 of 28.6m (the 328.1m allocation, less the actual expenditure of 356.7m). Whilst this is a significant cumulative deficit, it is as per the budgeted deficit position agreed for 2015/16 with NHS England at the start of the year. As a result of our position we have been placed under formal Directions by NHS England and have had to seek assistance with managing our financial position. As part of this work we have developed a Financial Recovery Plan that we will need to deliver to achieve a sustainable financial position. You can find more information on this in our financial accounts (see page 91). 2

3 Contents Page Welcome from our Clinical Chair and Interim Chief Officer 5 Member Practice s Introduction 7 Introduction 9 About us 10 Our vision 11 Mission and values 11 How we work 12 Balancing corporate and individual interests 12 Performance report 13 Highlights from our year 14 CCG Directions 19 Quality comes first 20 Our performance in 2015/16 21 NHS Constitution Metrics 23 Understanding the local picture 24 Our financial performance in 2015/16 25 Statement of Financial Position 25 Working together to make a difference for patients 29 Our plans for the year ahead 31 Our Financial Recovery Plan 34 How we work 35 Our joint commissioning arrangements 42 Sustainability and taking care of the environment 43 Business continuity and emergency preparedness 44 Accountability Report 45 Corporate Governance Report 46 Members Report 47 Statement of Accountable Officer s Responsibilities 58 3

4 Governance Statement 59 Head of Internal Audit Opinion 71 Remuneration and Staff Report 80 Financial statements 91 Appendices 124 Appendix A Register of 2015/16 Governing Body member interests 125 4

5 Welcome from our Clinical Chair and Interim Chief Officer Dr Claire Fuller Clinical Chair Ralph McCormack Interim Chief Officer Welcome to our third Annual Report as a Clinical Commissioning Group. It s been a busy three years and whilst this year has definitely not been without its challenges, this report is an opportunity for us to reflect on just how much we have achieved together for the local population, working with our staff, practices and our wider partners. From launching thorough reviews of community hospital services and stroke care to delivering major pathway redesign that will improve patient care across a range of areas including joint problems, eye care and heart care there has always been something innovative happening. And that s before we start looking at the year ahead and our ambitious plans to deliver more improvements in care for local people. That s not to say we haven t had some very difficult times too this year, because we have. Being placed under formal directions by NHS England in August, largely due to our challenging financial position, was a difficult time for us all. But we have taken action and we are much stronger as an organisation. Thanks to a great deal of hard work by everyone at the CCG, we have managed to deliver 9.8 million of savings this year without compromising on quality which, given where we were, is a huge achievement. We now have a credible Financial Recovery Plan for 2016/17 and in March NHS England moved us out of the regional assurance process and into local assurance, which recognised and reflected the improvements we have made. Although there is still a long way to go to get our finances back on track, we have made significant progress over the last few months and, if we keep up the momentum, we are confident we will deliver what we need to as an organisation. It s true there has been a focus on our financial position but our real focus is on value, both in terms of achieving the quality we want for patients and in making the best use of our resources. For example, we have worked with providers and our GP medical networks to support the launch of new community hubs that provide extra support for the frail and elderly. We have also teamed up with local partners and charities to form a new Epsom Health and Care Partnership to help join up, and integrate, local services so they are based around patients, not services or organisations. The partnership is in its early days but it has already launched a new Community Assessment and Diagnostic Unit at Epsom Hospital and there are many more initiatives planned. As with any organisation, we want to be as effective and efficient as we can be and this year following a number of independent expert reviews, we have agreed some changes to our governance and committee structure. These changes came into force in April 2016 and have included some changes to our executive team and our Governing Body. We 5

6 believe these changes will improve how we work and will ensure our work remains truly clinically led, with our clinicians driving forward improvements for local people. You can read more about these changes in our Members Report on page 47. Looking ahead, we have some big ideas about where we want to improve care this year and we have already started working with GPs and local clinicians to look at a range of areas including heart care, neurology and urology. We are also supporting our GP medical networks to help them to develop, and deliver, their own plans to improve patient care and provide more services locally, which will be another really big step forward. Creating a sustainable health system for the future is really important and work is also underway with other Surrey clinical commissioning groups and organisations providing healthcare to develop a Sustainability and Transformation Plan. This involves looking for opportunities to work more closely together across the local health system to ensure services are meeting local needs and fit for purpose in the longer term. You can read more about this work on page 18. It s very much a new way of working for us so it will be interesting to see how we can work together to improve care across a wider region. We have recently reviewed our values as an organisation and it was great to see that our staff, Governing Body members and GP colleagues firmly place being patient-centred and clinically led at the top of the list. We firmly believe that patients should be at the heart of everything we do and we hope that, reading this report, you feel we re delivering on that promise. Best wishes Claire Dr Claire Fuller Clinical Chair Ralph Ralph McCormack Interim Chief Officer 6

7 Member Practice s Introduction Surrey Downs Clinical Commissioning Group is made up of 32 member GP practices. As elected GP Chairs of the three localities during 2015/16, we have been invited to provide this introduction to the Annual Report. In seeking the wider views of doctors and practices across the CCG area, this introduction aims to provide a helpful insight into how the practices feel about working with the commissioning group and any opportunities to improve how we work together. We asked practices to tell us what they feel has and hasn t worked well this year and how they felt the CCG had engaged with them. Starting with what has worked well, there was a feeling that the CCG had improved how it works, and engages with the practices, and that it has listened to GPs and acted on their feedback. Firstly, the practices appreciated the time the Clinical Chair had set aside to visit every practice to meet face to face to talk about key issues and hear from GP colleagues and this was echoed across all three localities. Practices welcomed the approach which they felt had been very much a two way conversation, with the CCG seeking the practice s views on how things are going, the support they need and their plans for the future. It was felt that as Clinical Chair Dr Fuller has shown clear leadership in a challenging time and that her approachable manner helps to humanise the issues. It was felt these meetings had improved relationships and practices were keen to see these repeated if possible, even if they were only on an annual basis as it was recognised they were a significant time commitment for the Clinical Chair. It was also recognised that in future, the newly elected Locality Chairs would also be visiting individual practices in their locality, which practices felt would be helpful. Practices also feel they have more contact and better relationships with members of the primary care team, which they have found useful. In terms of engagement, there was positive feedback about the way in which the CCG had sought views on the proposed changes to the CCG s governance structure and the ballot process for appointing the new Locality Chairs. It was felt that the process was well communicated and that engagement with practices on this issue had been particularly good. GPs felt this was reflected in all practices supporting the changes. On leadership, practices also commented that they appreciated Ralph McCormack s attendance at locality meetings. Practices across all three localities were very positive towards Start the Week, the CCG s weekly bulletin to all GPs. Practices said they liked the format, content and timing and that the newsletter has significantly reduced the volume of s they receive, which was appreciated. There were also some suggestions for improving the update, particularly in terms of format and developing a printer friendly version that practice managers could print and share with their GPs if desired. GPs also told us they prefer web links, as opposed to attachments where possible to reduce the size of the publication. We understand these issues have been fed back to the communications team who are working on a revised format to take this feedback on board. In terms of service delivery and delivering improvements for patients, GPs are positive about the CCGs approach, which focuses on innovation and service redesign, and not just cutting services. It is also felt that the Referral Support Service is working well, with two way communication again working well. It was felt that the service is very helpful as a mechanism to pass referrals through to and to get feedback for practices. On the practical side, some GP practices were positive about improved IT systems and recent investment. There was also positive feedback about the CCG supporting the annual GP Update event for all GPs and practice nurses. Attendees said they found the event 7

8 helpful. There were some positive comments relating to the content of the event, with attendees saying they had heard new material, which they found interesting. However, there were also a couple of comments about some of the content not being appropriate or being too focused on one subject, which have been fed into those involved in the event planning. GP practices also reflected on some areas they felt could have worked better. These included some frustrations relating to some contracts with providers and decision-making. There was a view that some areas are seen as too difficult to change because of existing contracts and that the CCG should be doing more to address these issues. There were also some frustration with the initial discussions and decision-making relating to the launch of the community hub service. Whilst GPs were positive about being supported to innovate and launch the new model, it was felt that decisions could have been made more quickly to get the service up and running. It was acknowledged that later on that this did improve and that later conversations had been more productive to get the new service live. It was acknowledged that the CCG s financial position had put some initiatives on hold but there was a feeling that it s been a two way process, with GPs involved in these decisions. However, some felt that last year s engagement to develop commissioning intentions had been better in previous years, with perhaps a greater focus on reducing the deficit this year. In terms of services, there was a feeling that services are not always as equitable as they could be across the CCG and that more needs to be done to address this. Services for children with complex and multiple difficulties and 7 day access to GP services were two examples given. Staying with the equity issue, some practices also felt that the CCG places too much focus on Epsom. Whilst it is recognised that this is the largest locality, it is felt that this leaves the other two localities feeling like they are in the minority. There was also a feeling that projects need to be more thoroughly reviewed following implementation, particularly in relation to pathway and service redesign. It is felt that where there have been teething issues with some new pathways or services, the CCG needs to ensure it learns from these and builds this learning into future projects. Issues relating to procurement, implementation timescales and service specifications were all mentioned. There was also specific feedback relating to the cardiology project and whilst there was support for the piece of work, and the outcomes, it was felt there may be opportunities to make this pathway more efficient. Reflecting on hopes for the future and opportunities for closer working, there was a hope that the new governance arrangements would address some of the issues and make the organisation more effective. For example, it was hoped that the new Locality Chairs will have greater input into decisions through the new Clinical Cabinet. There was also a really strong call for more support for all three localities. While practices generally feel supported there is a strong feeling that if we are to take on more responsibility and develop commissioning plans for their localities, we need more support to make this happen, both in terms of resources and training to develop their skills and we will be asking the CCG to support us with this so we can work together effectively to really make a difference for our patients. Jill Evans Simon Williams Robin Gupta Dr Jill Evans Dr Simon Williams Dr Robin Gupta East Elmbridge Locality Chair Epsom Locality Chair Dorking Locality Chair 8

9 Introduction Who we are and what we do 9

10 About us Clinical Commissioning Groups, or CCGs, as they are sometimes known, were set up in April 2013 following a series of changes across the NHS. CCGs took on much of the work previously done by primary care trusts. Our main job is to plan and buy healthcare services for our local population. As a CCG we: buy and plan healthcare for around 300,000 people living in Mole Valley, Epsom and Ewell, Banstead and east Elmbridge and surrounding villages are made up of 32 GP membership practices, working across 3 local health economies (Epsom, Dorking and east Elmbridge) have a budget of over 350 million to buy healthcare from local hospitals, community services, social care, ambulance services, mental health care and many other services for local people. There are six clinical commissioning groups in Surrey and some CCGs lead on some areas on behalf of the others. We lead on NHS Continuing Healthcare and Adult Safeguarding for the whole of Surrey and we also lead on Individual Funding Requests and medicines management for some areas. You can read more about our joint commissioning arrangements on page 42. Our CCG doesn t commission core primary care services from GP practices, pharmacies, opticians or dental practices. This is done by NHS England. We don t commission specialist care either. This is done by a separate part of the NHS known as NHS Specialised Services. The map to the right shows the area we cover. 10

11 Our vision We want to ensure the NHS in Surrey Downs offers healthcare that meets the needs of local people, gives patients the best chance of the best outcome when they are ill and helps individuals to stay healthy and live healthy lives. We will achieve this by putting local doctors and other healthcare professionals in charge of decisions about how NHS services should be organised, always taking into account the views of patients, the public and other partner organisations (such as charities and voluntary organisations). The NHS has a limited pot of money to spend so we will live within our means. This means we have to work out what services are most important to our local population s health needs and how we can do more for less to make sure we are getting the best value for money. Mission and values Through focused clinical leadership and patient engagement we will revolutionise the delivery of local healthcare through our three geographical localities, whilst living within our means, improving quality of care and health outcomes for our patients. Services will be local, affordable and responsive. We will commission healthcare that meets local needs, improves health and health outcomes for patients, reduces inequalities and promotes well-being. We acknowledge that good corporate governance arrangements are critical to achieving our objectives. We will promote good governance and proper stewardship of public resources in pursuing our goals and in meeting our statutory duties. The values that lie at the heart of our organisation are: To deliver the best quality care within an effective and efficient healthcare system, with care improving health, patient outcomes and the well-being of people living within the CCG area to become a stakeholder owned organisation where responsibility is taken to ensure that national, regional and local commissioning strategies are translated through meaningful local delivery strategies all those that work with the CCG will share its values and will feel empowered to deliver improvements for its population the NHS is free at the point of delivery and the CCG takes a leadership role across the system to ensure all its services enshrine equality and diversity patient engagement and involvement is at the heart of commissioning 11

12 How we work The CCG is led by our Governing Body, which is made up of local doctors, lay members, our executive management team and local authority and public health representatives. Together the Governing Body are responsible for our overall strategy and for decisionmaking. They are supported by an executive management team and other committees, who are responsible for some areas of our work. We also have a Council of Members, which brings together a lead GP from each of our 32 member practices. The Council of Members shapes our vision, strategy and our commissioning plans and sets our CCG Constitution, which governs how we work as an organisation. You can read more about our Governing Body and committee structure in our Members Report on page 47. Balancing corporate and individual interests Everyone who contributes to the work of the CCG brings with them a range of outside interests and connections. It is important, in the public interest, that these are recognised and, in some cases, actively managed. We treat all interests in the same way, regardless of whether they are at GP practice level, involve a member of the Governing Body, or relate to an individual member of staff. As an organisation we want to be open and transparent. We expect any interests to be well managed, in line with our policies relating to conflicts of interest. These state that the CCG recognises that a conflict of interest, or perceived conflict of interest, in its role as a commissioner of healthcare services is a key risk that requires careful management and handling whether this is a direct or indirect conflict, pecuniary or otherwise. As part of our robust policy we: Maintain appropriate registers of interests, both for our Governing Body and our staff Publish these registers on our website and prior to Governing Body meetings Require the prompt declaration of interests by members, practices and employees and ensures that these interests are entered into the relevant register Make arrangements for managing conflicts and potential conflicts of interest and review our policies in light of guidance from NHS England and Monitor in relation to conflicts of interest. Appendix A of this report sets out the interests of all individuals who have been members of the Governing Body during 2015/16. In addition, regularly updated copies of GP practice registers can be found on the CCG s website 12

13 Performance Report How we are improving care, our performance this year and our plans for the future 13

14 Highlights from our year Reflecting back on the year, we ve achieved a lot. Here s a summary of our year and some of the moments that really stood out for us. April Improving community hospital care We started the year by launching a comprehensive review of the services provided at the five community hospitals in the Surrey Downs area. The review looked at where services are located and how they are provided, how many patients they see, the care provided and any opportunities to improve it and the condition of the current buildings. It also took into account expected changes in the local population, demand for services and the likely impact of new services, such as our community hubs, which may affect how care is provided in future. May Celebrating our staff We would be nothing without our staff and in May we held our annual staff awards ceremony, which recognises the valuable contribution they make to the organisation, and to improving local healthcare. The ceremony included recognition for the service redesign work that has taken this year which has resulted in improvements in care for our local population. June New Lay Member appointments Following some changes in our Governing Body, in June we appointed two new Lay Members. Jonathan Perkins joined us as our new Lay Member for Governance and Gill Edelman as our new Lay Member for Patient and Public Engagement. These new Lay Members joined our two existing Lay Members in July, meaning we now have four Lay Members on our Governing Body, providing scrutiny and making sure patient views are heard at the highest level. July Better integration and more support for our frail and elderly population The NHS has seen a huge rise in the number of frail and elderly people needing treatment. In fact, those aged 75 and over now account for 30% of national emergency hospitals admissions - a dramatic increase from under 10% just two years ago. In Surrey Downs we know we have a large elderly population, as well as an ageing population, so we need to be more proactive, identifying those who are more likely to need to go into hospital and providing more support to help keep them well in the community. And our new community hubs, which went live in July, aim to do just that. 14

15 Our community hubs are led by networks of GPs and are supported by a range of other clinicians including nurses, therapists and dieticians, from other local NHS organisations. They focus on supporting the frail elderly, who have multiple and complex conditions. The aim is simple: to reduce emergency hospital admissions, to reduce readmissions, to reduce lengths of stay in hospitals, and to improve the overall care and support patients receive. The three hubs are currently co-located within community hospitals and as part of the service the GP networks provide medical support at the New Epsom and Ewell Community Hospital, Dorking Hospital and Molesey Hospital. This helps ensure every aspect of a patient s care is coordinated and it also means the teams can proactively identify patients who have been admitted to hospital who would benefit from the extra support offered through the hub, helping to prevent them from being re-admitted again in future. We will continue to work with our GP networks and local partners to enhance the support offered through the hubs. As the East Elmbridge hub is currently offering a wider range of services, our immediate focus for this year will be on further integrating services in the Epsom and Dorking areas, as well as introducing a new single referral management centre, which will co-ordinate referrals into the community hubs across the whole CCG area. August Community hospital outcome report published In August we published the findings of our review into community hospital care in the form of an Outcome Report, which is available on our website. The report includes a series of recommendations to improve care and some options for where services could be located in future. From the end of January until early May 2016 we asked local people for their views as part of a public consultation. For details see September Supporting a review of Surrey s stroke services In September we asked local people to give their views on the county s stroke services as part of a comprehensive review being led by all the Surrey Clinical Commissioning Groups. While Surrey s doctors, nurses, therapists and others do a good job for the approximately 3,500 people who require stroke services in the county each year, national and local research shows that providing better care could save more lives, reduce levels of disability and help people feel more supported. Working in partnership, towards the end of 2015 the Surrey CCGs formed a Stroke Change Board, whose members also include stroke survivors, the hospital trusts and providers who currently run stroke services, the Stroke Association and the South East Coast Ambulance Service. 15

16 We know 2,500 people suffer from a stroke in Surrey every year, and while the county s doctors, nurses and therapists do a good job, we know that we re falling behind London and other areas in stroke care. Clinical evidence shows that providing better care could save more lives, reduce levels of disability and help people feel more supported so it s an area we felt we had to look at. We ve asked clinicians from right across the local NHS to work together to come up with a plan to improve stroke care this includes providing seven day consultant ward rounds, reducing mortality rates and making sure people have fast access to brain scans, therapy and rehabilitation. Once we have these plans we will be able to see if they would deliver the improvements we want to see for our patients and think about next steps. Dr Claire Fuller Clinical Chair and clinical lead for the Surrey stroke review October Success in preventing strokes on World Stroke Day On World Stroke Day (29 October), doctors and nurses from across the CCG, CSH Surrey and Epsom and St Helier University Hospitals NHS Trust joined forces in Epsom to raise awareness of strokes and how to prevent them. The team carried out on-the-spot ECGs, pulse checks and blood pressure readings in the Ashley Centre to help identify people who could be at risk of having a stroke. The team saw over 230 people and by carrying out basic checks they found three new cases of Atrial Fibrillation (an irregular heart beat which increases the risk of a stroke), nine people with an irregular pulse and 27 people with high blood pressures. These individuals were all asked to make a follow up appointment with their GP and after the event we heard from one of our practices who had since confirmed the AF diagnosis and put the patient on a proactive treatment plan. So this event really did make a difference and help prevent future strokes. Our special thanks go to all the doctors and nurses who gave up their time to support the event, especially Dr Subo Emanuel and volunteers from the Surrey Arrhythmia Support Group. Due to its success, we hope to run further events in other towns in November New self-referral service helps people suffering from stress, anxiety and depression access help more easily In November we launched a new self-referral service to help those who are suffering from stress, anxiety and depression. This means people who are finding it difficult to cope can now refer themselves directly for free NHS psychology therapies across the Surrey Downs area. Before people could only access these services after a GP referral so being able to refer themselves means they can get help more easily. We know that sometimes people would prefer not to talk to their GP about issues relating to their mental health so we hope this initiative will encourage more people to come forward to get support. The main treatment offered is cognitive behavioural therapy, because there is strong 16

17 evidence that it can really help people, but other therapies including psychodynamic talking therapies, mindfulness, guided self-help, and group sessions are also available. Support is available in person, over the phone, or online, and appointments are also offered during evenings and weekends. HSJ recognises outstanding commitment to carers November also saw a joint HSJ award win as we scooped a prestigious Commissioning for Carers award together with Guildford and Waverley CCG and East Surrey CCG. Chosen as winners from eleven shortlisted CCGs, the judges criteria included evidence of building on best practice, commitment to mental health and wellbeing of carers and working in partnership with GPs, the voluntary sector and local authorities. Surrey has a long history of supporting Carers through the local authority (Surrey County Council) and the voluntary sector. In recent years this partnership approach has been extended to the Surrey CCGs. To win an HSJ award is a privilege and an honour but to be the first to win a health award for Carers working in Health is a landmark moment. Debbie Hustings Partnership Manager for Carers December Towards the end of last year we became part of what is known as the South West London and Surrey Downs Partnership. As we sit close to London, and many of our patients go to Epsom Hospital, Kingston Hospital and other London trusts for their treatment, we work closely with our NHS colleagues in south west London. This new partnership brings together the six south west London CCGs, Surrey Downs CCG and local provider trusts, including Epsom and St Helier University Hospitals NHS Trust. It is also supported by NHS England, Monitor and the Trust Development Authority. The aim is to work together, as a single partnership, to address some of the problems and challenges facing the local health system and to look at ways of making sure health services are sustainable in the longer term. January New Year and a new Chief Officer We started the new year with some new faces in our Executive Management Team. In January we welcomed Ralph McCormack as our new Interim Chief Officer and Steve Hams as Interim Director of Clinical Performance and Service Delivery. Launch of public consultation on community hospital care 17

18 January also saw the launch of our public consultation on proposed changes to how community hospital services are provided, with a series of events and activities across the local area to encourage people to tell us their views. February Working together to develop a Sustainability and Transformation Plan Following on from publication of NHS England s Five Year Forward View strategy, local NHS organisations have been asked to look at how they can work together more closely. As part of this work, clinical commissioning groups and organisations providing healthcare must develop a 5 year Sustainability and Transformation Plan. This work started in February and saw us join forces with North West Surrey CCG and Guildford and Waverley CCG and local healthcare organisations to start to explore the opportunities closer working could bring to patients and the local health system. Seeking feedback through our 360 degree survey February also saw the launch of our 360 degree stakeholder survey. The survey invites our stakeholders to tell us how we re doing as an organisation. We listen to the feedback we receive and we improve how we work as a result. Our thanks to everyone who took part! March New safe haven for people in mental health crisis Demand for emotional wellbeing services across the country is higher than ever before and it s expected to continue to grow over the next ten years. This has led to pressures on some public services, including A&Es, where the majority of patients who frequently reattend do so because of mental health problems and a lack of other options. Surrey has been at the forefront of national efforts to improve the services available for those in mental health crisis or at risk of entering crisis, and together the Surrey clinical commissioning groups and Surrey County Council have been awarded 1.5 million of Government funding to support this work. A major part of our plan to make sure these individuals get the right support is to set up a number of safe havens across the county, where people who are in mental health crisis (or near the point of crisis) can turn for help and support. Acting as a safe and welcoming alternative to A&E, these safe havens can get people the help they need, as well as signposting to other local services. The safe haven, which opened in Epsom in March, offers anyone that visits a friendly welcome and somewhere safe to spend time. Trained professionals are also on hand to provide information and advice to anyone who wants it, as well as signposting to other local services. Strengthening clinical engagement Following a series of changes to our governance and committee structures to help strengthen our clinical leadership, in March we recruited to a range of new roles including new GP Governing Body members, Clinical Leads, to specialise on areas such as planned care and integration, and Clinical Directors to sit on our new Clinical Cabinet. This was ahead of our new structures coming into place from April

19 CCG Directions You ve heard about some of our highlights from the year but this hasn t been an easy year for us. Having overspent on our budget last year and, despite our best efforts, finding ourselves in a similar position this year, in August 2015 NHS England placed formal directions on the CCG. These limited our powers in some areas including our ability to recruit senior manages, and our freedom to make decisions, particularly in relation to contracts and other financial decisions. We were also required to appoint a Turnaround Director and develop a Financial Recovery Plan that sets out how we will get our finances back on track and recover our financial position in the longer term. Whilst we knew we were in financial difficulty, and this wasn t completely unexpected, it was a difficult time for us. Towards the end of the year, following our quarter three assurance meeting with NHS England, we were delighted to be moved from regional assurance to local assurance, reflecting just how far we had come. We continue to work hard to address the challenges we face and now with the help of our Turnaround Director, we have submitted a credible Financial Recovery Plan for 2016/17. You can read more about this on page

20 You ve heard a bit about of year so now we thought we would talk a bit about our role as a CCG and how we work. Quality comes first We want our patients to receive the best possible care so a really important part of our job is monitoring how local services are performing. This tells us whether the services we pay for are meeting the high standards we would want, and expect, for our patients. It also helps ensure that we are getting the quality of care we have paid for. We monitor services in a variety of different ways. There are some national standards that every part of the NHS needs to achieve including targets relating to many planned procedures and operations (such as hip and knee operations) being done within 18 weeks after a GP referral, ambulance response times and making sure people who attend A&E are seen quickly. There are also some performance targets we set locally with the healthcare organisations we buy services from. In 2015/16 these related to the prevention and treatment of pressure ulcers, managing medicines better and prevention and early identification of Sepsis. We receive data on a regular basis from the local acute, community and ambulance trusts and other providers and analyse this carefully to understand how services are performing and whether there are any issues that may affect the quality of care our patients are receiving. If issues are identified we work closely with these providers to ensure that any problems are resolved as quickly as possible. In most cases, there are simple steps that can be taken and performance quickly improves but we can also enforce improvements contractually, for example requiring the provider to develop a Service Improvement Plan, if we don t feel problems are being addressed in the way they should be. To make sure quality is maintained, we also have the power to withhold some money from providers if they have failed to deliver the standards of care we have set out. This year key quality issues for us as a CCG included recruitment issues at some providers, cases of pressure sores for patients staying in hospital and making sure these are prevented where possible and healthcare acquired infection rates, particularly in relation to MRSA and C Difficile. Local trusts also experienced some issues with meeting targets relating to A&E waiting times and urgent cancer referrals. As a CCG we also experienced challenges in meeting our nationally set target in relation to people accessing Improving Access to Psychological Services and our dementia diagnosis rates. These are areas we are working hard to address so we hope to see improvement in these areas in 2016/17. We also worked closely with partners and Surrey County Council on issues relating to local care homes. This included providing support for a small number of nursing homes that closed during the year, helping to place patients and providing any support needed to patients and their families and carers. 20

21 Our performance in 2015/16 This section of the Annual Report looks at how we have performed as an organisation in the last financial year, ending 31 March More specifically, it sets out how well we have done against nationally agreed quality standards. These are very important to patients and the public, as they relate to key areas such as access, treatment times and quality of care. However, they do not cover all aspects of the services that the CCG commissions and you can find information about these other areas throughout this report. Reflecting on our performance in 2015/ 16, overall we performed well against some very challenging targets but there is room for improvement in a number of areas. The key performance issues that the CCG faced during the year are summarised below. A&E waits within four hours Surrey Downs CCG has not achieved the target of 95% of patients seen within 4 hours at A&E year to date, with a performance of 93.7%. March had the lowest performance year to date at 90.1% of patients seen within this target. However, when we compare our performance against other regions, we are performing better than most. The CCG actively monitors the status of A&E departments at its key hospital trusts on a daily basis and this information is shared daily with senior management, as well as being reviewed by the Executive Management Team on a bi-weekly basis and by the Finance and Performance Committee every month. We are active members of local System Resilience Groups (SRGs) and work with partners to share intelligence and ensure actions are taken to improve performance and mitigate any risks. The CCG also attends weekly discharge meetings to facilitate discharges from acute hospital trusts to appropriate onward care, working with community providers, social care and third party providers. Through effective bed management, hospital trusts can better match admissions to discharges. South East Coast Ambulance (SECAmb) ambulance performance There were significant issues with both emergency and patient transport services during the year. In terms of emergency services, performance has been fluctuating around the 75% target for Category A Red 1 (immediately life threatening) and Red 2 (serious but not the most life threatening) responses within 8 minutes. In 2015/16, both Red 1 and Red 2 performance was below national target at trust-wide and local levels. There is a Remedial Action Plan in place for SECAmb because of this and a trajectory has now been set for monthly delivery to recover their current position. Concerns were also raised regarding governance and decision-making within SECAmb following a project known as the R3 pilot and concerns relating to patient care. Whilst the project was stopped as soon as issues were identified, it did highlight some issues within SECAmb, which are being addressed. Cancer waits Cancer treatment times have fluctuated throughout 2015/16. However, we recognise that more work needs to be done to improve the 62 day cancer wait target. There is an action plan in place to improve performance, which is being closely monitored. There was poor 21

22 performance related to 2 week wait referrals for breast symptoms in the first quarter. This issue was resolved and the CCG has achieved this target for 2015/16 with a performance of 94.3%. For 62 day cancer waits, the CCG is actively monitoring an action plan at Epsom and St Helier University Hospitals NHS Trust to ensure that onward referrals to tertiary hospital trusts occur in a timely manner. Since we implemented the action plan, performance has improved but we remain vigilant to ensure improved performance is maintained and sustained. Improving Access to Psychological Therapies (IAPT) In 2015/ % of people with low level anxiety and depression have entered the service. This is against a challenging full year target of 15% of this group accessing support. This is an improvement compared to 2014/15 where performance for the entire year was at 8.4%. The CCG introduced a self referral pathway to IAPT services which has improved uptake and it is hoped this will further improve performance in this area. Dementia diagnosis We are actively implementing the National Dementia Diagnosis Strategy by developing services for people with dementia and their carers that are fit for the 21 st century. A key action in the strategy is to diagnose dementia early to start treatment and to support carers and patients. Working with our partners in the Better Care Fund, our dementia diagnosis rate is 62.8%, however our target is 66.7%. We will continue to work with our GP membership practices and local stakeholders, through training and shared learning, to further improve our diagnosis rates. A detailed list of all the targets and how the CCG finished the year can be seen on the following pages. 22

23 NHS Constitution Metrics The table below shows a summary of how we, and our local healthcare providers, have performed this year against key quality standards. Performance is rated on a green, amber or red basis, with green meaning target achieved, amber meaning cause for concern and red meaning not achieved. 23

24 Understanding the local picture As part of our job we want, and need, to understand how local people are using healthcare. We do this through what we call our business intelligence unit, which analyses healthcare activity data in great detail. This gives us a real insight, telling us about demand for different types of care, and we compare with other areas, which all helps us plan for the future. By comparing our activity and patient flows with other commissioning groups with similar populations we can identify differences, for example areas of high referrals for certain treatments or operations. If we spot something unusual we look into it further and in some cases it highlights care pathways that aren t quite right, leading to a full service review. We have been working with colleagues in the NHS national Right Care team and they are sharing learning right across the NHS to help commissioners identify opportunities to improve care and make sure the right care pathways are in place. You can read more about how we review and redesign care pathways on page

25 Our financial performance in 2015/16 This Statement of Financial Position summarises our financial performance during the year. Statement of Financial Position Overview The CCG receives an annual allocation for healthcare costs which is calculated by NHS England, based on the number of residents in its geographical boundary (also known as a capitation basis). In addition to this, it receives an additional allocation to cover running and administrative costs. The total allocation received for 2015/16 was 328.1m ( 321.7m for healthcare, and 6.4m for running costs respectively). The CCG spent 356.7m in 2015/16, which means it reported a cumulative deficit position at the end of 2015/16 of 28.6m (the 328.1m allocation, less the actual expenditure of 356.7m). Whilst this is a significant cumulative deficit, it is as per the budgeted deficit position agreed for 2015/16 with NHS England at the start of the year. 2015/16 was the first year of the CCGs three year Financial Recovery Plan ( FRP ) which plans for the CCG to be breaking even on a recurrent basis by 2017/18, and, as it exits 2015/16, the CCG is still on track to deliver to this commitment. Expenditure 2015/16 As noted above, the 356.7m spend was in line with the CCG s budget for the year. The 356.7m compares to a total expenditure of 342.9m in 2014/15, an increase of 13.8m or 4%. The main reason for the year on year increase is the CCG s contribution to the Better Care Fund (BCF), which is a pooled budget held by Surrey County Council designed to protect adult social care. The CCG s incremental increase in spend as a result of contributions to BCF in 2015/16 was 11.7m (shown under other in the chart on the following page). The breakdown of expenditure by programme was as follows: 25

26 The majority of the CCG s spend is in the acute area, which accounts for 60% of total expenditure. Acute services are supplied by NHS Foundation Trusts, NHS Trusts and independent providers and are secured through annually negotiated contracts between the CCG and the provider. The CCG s largest provider is Epsom and St Helier University Hospitals NHS Trust which (including both the main acute and renal site and smaller orthopaedic site) accounted for nearly 100m of the CCG s annual spend. The remaining non-acute spend is: Community ( 27m or 8% of annual spend) Community spend is split across a number of smaller providers but the main provider is Central Surrey Health (CHC), which delivers community services on behalf of the CCG through a longer term, block contract. Mental Health ( 24.7m or 7% of annual spend) The majority (over 75%) of mental health expenditure is with Surrey and Borders NHS Partnership Trust which is agreed through an annual block contract with the Trust. As well as this block contract, CCG also commissions and funds Improved Access to Psychological Therapies ( IAPT ) which accounted for 1.2m of expenditure in 2015/16. Primary Care ( 46.2m or 13% of annual spend) The majority ( 40m) of the primary care expenditure relates to the cost of prescriptions, with the remainder being spend on local enhanced services, out of hours services and primary care IT. Core GP services are commissioned and funded directly by NHS England. Continuing Healthcare ( 21.9m or 6% of annual spend) Continuing healthcare (CHC) payments are payments for the living costs (primarily nursing or care home costs) as well as the associated nursing care costs for people whose health needs qualify them for continuing healthcare payments. The CCG administers CHC payments on behalf of all the CCGs in Surrey totalling in excess of 90m. The 21.9m is the element of CHC payments that relates to Surrey Downs only. Other ( 17.6m or 5% of annual spend) As noted above, 11.7m of other spend relates to the CCG s contribution to the BCF, which is a pooled budget held by Surrey County Council designed to protect adult social care. The remainder relates to areas such as patient transport and the CCG s investments in community medical teams (CMTs). 26

27 Financial duties As a statutory organisation there are six main financial duties we are required to meet. Here are the details and how we have performed against them: Our expenditure should not exceed our income: for 2015/16 the CCG reported an in year deficit of 17.9m (cumulative 28.6m), so this requirement was not met. Our capital resource use should not exceed our notified limit: for 2015/16 the CCG had capital resource of 34,000 and the CCG did not exceed this limit therefore this requirement was met. Revenue resource use should not exceed our notified limit: for 2015/16 the CCG reported an in year deficit of 17.9m (cumulative 28.6m), so this requirement was not met. Capital resource use on specified matters should not exceed the notified limit: for 2015/16 the CCG had capital resource of 34,000 and the CCG did not exceed this limit therefore this requirement was met. Revenue resource use on specified matters should not exceed our notified limit: for 2015/16 the CCG had no spend on specified matters, so this requirement was met. Revenue administration resource use should not exceed our notified limit: for 2015/16 the CCG had administrative spend of 6.2m, which was less than revenue administration resource limit of 6.3m, so this requirement was met. Other financial In addition to the six statutory duties above, CCGs are expected to meet the requirements of the Better Payments Practice Code which requires payment of 95% of invoices within 30 calendar days of receipt of goods or a valid invoice. During 2015/16 the CCG achieved 94% against this requirement. Quality, Innovation, Prevention and Productivity (QIPP) The Quality, Innovation, Prevention and Productivity programme (also known as QIPP) is a large scale programme developed by the Department of Health to drive forward improvements in NHS care. For 2015/16 the CCG s QIPP target totalled 12.8m, split between transactional schemes ( 6.8m), and transformational schemes ( 6.0m). In total the CCG achieved 9.8m (approximately 75% of the 12.8m target) of QIPP savings in 2015/16. The reduction against the original 12.8m plan was primarily driven by outpatient / elective schemes where the original planned savings were scaled back to reflect a more gradual activity reduction over the year. 27

28 The delivery of 9.8m of QIPP savings compares to 4.8m delivered in 2014/15 and, despite the shortfall against target QIPP savings in 2015/16, the CGG was able to identify other mitigations and underspends to offset the underachievement of QIPP, which meant overall it still met its budget target for the year. Looking forward into 2016/ /16 represented the first year of the CCGs Financial Recovery Plan ( FRP ) and the reported 17.9m in year deficit ( 28.6m cumulative) is in line with the FRP. In the 2016/17 forthcoming financial year, the CCG is budgeting for an in year deficit of 8.7m, which will take the cumulative deficit position to 37.3m by the end of 2016/17 and is as per the FRP. In 2016/17 the CCG has a target QIPP saving of approximately 20m. It is anticipated that the transformational element of the 2016/17 QIPP plan will recover the CCG s financial position to a recurrent breakeven position as it enters 2017/18, as the cumulative effect of both the 2015/16 and 2016/17 QIPP schemes are realised. As Accountable Officer I confirm that the above is a true and accurate statement of the CCG s financial position. Ralph McCormack Accountable Officer (Interim Chief Officer) 25 May

29 Working together to make a difference for patients Improving mental health services for children and young people From April 2016, children and young people in the area will benefit from improved mental health services. This follows a review of existing services and work with clinicians and service users and their families to identify opportunities to increase the support available to these individuals. Following the review, Surrey s Clinical Commissioning Groups and Surrey County Council are investing an extra 2.3 million a 30% increase - to ensure that these improvements happen. The new and improved Child and Adolescent Mental Health Service (CAMHS) service begins on 1 April 2016 and will be run by Surrey & Borders Partnership NHS Foundation Trust. The decision to award the contract, which has a combined value of 12.9 million per year, was made after a competitive procurement process. The new service will ensure children and young people receive the right service at the right time and it will help reduce waiting times for assessment and treatment. Epsom Health and Care Programme unites health, social care and voluntary services to improve care for the frail and elderly In December 2015 an exciting new Health and Care programme was launched to help support the frail and elderly to live well and live longer. The new partnership, which is the biggest venture of its kind in the region, sees health and care providers working together in collaboration to make it easier for over 65s living in the Epsom area to access health and medical care, and get the support they need. By 2020 the number of people who are 65 years and over in the area is expected to increase by 14% and this will place increasing demands on health and care services in the Epsom locality. The Epsom Health and Care programme puts individuals, their carers and families at the heart of decision-making about the health and care services provided. The programme involves the design of new services and changes to existing services to improve care and make services more efficient. The programme is also exploring opportunities to jointly fund projects to ensure resources are joined up and used to best effect. This new partnership is a real step forward because it brings together all the key partners to look at how we can improve care for our older population. All too often patients are seen by many different health professionals, from different organisations, who are all looking at a different aspects of their care. We want to change this and really put the patient at the centre, with partners working together to co-ordinate the patient s care so they receive a really seamless service from the local NHS. Dr Claire Fuller, Clinical Chair of Surrey Downs Clinical Commissioning Group 29

30 Clinical Assessment Unit opens in Epsom The opening of a new Clinical Assessment and Diagnostic Unit at Epsom Hospital in November 2015 is a great example of the partnership in practice and what it can achieve. The new unit provides rapid, on the day, access to x-rays and scans, assessments, and community care in a one stop shop at Epsom Hospital. The service is aimed at people who are over 65 years and offers an alternative for patients who otherwise would have gone to A&E or had to stay in hospital overnight, with the majority of patients able to return home the same day. People can be referred to the service by their GP, hospital teams or community health workers. The service is led by GPs and run by a single multidisciplinary team who put the patient at the centre, looking at both their health and social care needs. The aim is to fully assess a patient so they can return home, with any ongoing care or support in place. It is truly partnership work in practice here are the organisations involved. 30

31 Our plans for the year ahead We know the financial challenges we face will continue into next year and beyond but we also know that the answer to getting back on track is to look for opportunities to make healthcare more effective and more efficient. That means improving quality and patient care for our local population, which in turn releases savings. Our priorities At the end of last year we asked GPs and local people to help shape our priorities for next year. We visited town centres and held library drop-in events to see what people thought we should focus our efforts on. Here is the list they helped us come up with: Priority area What we plan to do Primary care (GP services) We will support our three GP networks to develop and enhance local primary care services GP practices have joined forces and there are now three GP Networks operating in our area, each aligned to one of our localities. Surrey Medical covers the east Elmbridge area, Dorking Healthcare covers Dorking and surrounding villages and GP Health Partners covers the Epsom area. By joining forces, these networks will be able to provide a wider range of services in the local community, closer to people s homes. Planned care operations and procedures that are booked in advance (eg. hip and knee operations, booked scans and procedures) Introduce new and improved pathways for joint care (musculoskeletal), eye care (ophthalmology), skin care (dermatology), ear nose and throat, heart care (cardiology) and gynaecology. These improvements will see more care delivered in the community, closer to home. Review pathways for gastroenterology, neurology and urology to look at how we can improve care Expand our Referral Support Service to include a wider range of services. GP practices refer patients who need a specialist appointment or test through this service. The RSS then gets in touch with patients to talk them through their choices and help book their appointment. Introduce a new prior approval scheme for some procedures. This will help ensure procedures are only carried out if we agree they are clinically appropriate. 31

32 Cancer Improve cancer care work with McMillan Cancer Care and local partners to improve care. By improving systems, processes and clinical skills we believe we can detect cancer earlier. We also want more cancer treatment to be available in Surrey so people don t have to travel into London for their treatment. Urgent care and integration Children s, young people s and maternity services Integrate services for patients - We will work with each of the three localities to help them develop their priorities around urgent care and integration, as these will differ slightly with the localities looking to different acute hospitals. Plans to enhance our new community hub services, which target people over the age of 65 years with multiple health conditions, and provide additional support to them at home to prevent them from being admitted to hospital. The hubs are already up and running, and are working well, and this year we will be extending them further by bringing in additional specialist staff so the service can look at every aspect of a patient s care and make sure the right support is in place We are also looking to improve the current falls service. We know patients who fall are often admitted to hospital so we want to make sure more is done to identify those most at risk and prevent falls from happening in the first place. We also want to make sure patients coming to the end of their life get the right care. This includes work to make sure end of life care patients have care plans in place so everyone who sees them knows their wishes and how, and where, they want to be cared for. It also includes looking at technology and co-ordinating medical records, Improving stroke care we will work with the other Surrey Clinical Commissioning Groups to improve stroke care in Surrey, which is currently falling behind other areas. We have asked partners to work together to deliver an improved service. Providers have shared initial plans with us and we will shortly be considering next steps. Improving children s services we will work with the other Surrey CCGs as part of a review of children s services to look at how care is provided now, whether there are any gaps, and how care could be improved. This will include improving access to speech and language and occupational health therapy, looking at community nursing services and moving to a Surrey-wide model, focussed work to support children with complex healthcare needs 32

33 Mental health services Medicines management Maternity care this is one of the areas we are looking at as part of our joint Sustainability Transformation Plan, working with partners to ensure women are able to make safe and appropriate choices of maternity care for them and their babies. We will review psychiatric liaison services in our area We will work with other Surrey CCGs on the reprocurement of Improving Access to Psychological Therapy services. This will include work to target the service at carers and the elderly We will work with partners to improve care for people in a mental health crisis, including a central point of access through NHS 111 and 999 We will work with partners (including care homes) to make sure the frail elderly receive regular medicine reviews We will do some focused work to identify more patients with Atrial Fibrillation and improve the way we manage AF by increasing anticoagulation therapy We will support improvements in prescribing for asthma, COPD and diabetes We will work with providers to improve repeat prescribing and hospital discharge processes We will work with partners to increase uptake of biosimilar medicines, which are equally effective, non branded alternatives, which are much cheaper We will improve the management of conditions including Wet AMD by looking at ways of treating the condition earlier Continuing healthcare We will work with care homes to help reduce emergency hospital admissions We will review contracts to ensure we are getting the best rates We will look at other ways of improving efficiency, including the introduction of a paperless system 33

34 Our financial recovery plan We have developed a Financial Recovery Plan that summarises the projects already underway and the new schemes went live from April. These projects build on the high level commissioning priorities we have just talked about. They will improve care for local people and contribute to our savings target for next year, which is close to 20 million. As well as achieving this challenging target we also want to improve our overall financial position, including improving on our CCG deficit position. There are also a number of more general projects that are underway. These include all the other things you would expect us to be doing as an organisation such as negotiating the best deals we can with our providers, monitoring our running costs as an organisation and looking at where we could be more efficient and working with NHS Property Services to look at our estates and making sure they are used to best effect. Ralph McCormack Interim Chief Officer 25 May

35 How we work How we work with our partners and engage with our local population 35

36 A clinically led organisation We work really closely with our 200 doctors and 32 member GP practices to ensure we are a truly clinically-led organisation. Our GPs play a vital role in the CCG by helping us develop our commissioning plans and priorities and highlighting areas where quality of care can be improved. Engaging and involving local people Our patients know and understand what s working well and where care could be even better so it s only right that we involve you in how we plan and buy services and ultimately how we spend taxpayer s money. We also have a legal duty to do so and we take this very seriously. We communicate with, and involve, patients and the public, in a variety of ways and use their feedback to help shape our commissioning plans and priorities. Here is just a flavour of some of the ways we have involved local people in the past year. We have been actively seeking feedback from local people and patients about their experiences of local healthcare and used this feedback to improve the quality of services we commission from local healthcare providers, as well as how we work as an organisation. At the beginning of the year we asked local people to help shape our plans and priorities (we call these our commissioning intentions). We held drop-in sessions at local libraries and also asked people to help by filling in our online questionnaire, telling us what they felt should be the priorities for the local NHS We invited local people and patients to get involved with our service redesign work, feeding in their experiences and views as patient representatives on a series of Patient Advisory Groups. We looked at a range of different pathways including joint problems (sometimes known as musculoskeletal), cardiology and gynaecology. As a direct result of feedback from patients and clinicians we have designed new pathways that will improve care and make local NHS services more efficient. You can read more about our service redesign projects on page 31. We carried out an extensive engagement as part of our community hospital services review. Views and experiences of local people helped shape the final recommendations and options, as well as the criteria we are using to evaluate the options. We continued our conversation with local people as part of our public consultation, which we launched at the end of January We extended our links with local community and carer groups and started working more closely together. This helps us keep an ear to the ground and means we can get wider feedback on local health issues. We can then work together to address them. We also strengthened our links with our Gypsy, Roma and Traveller communities, looking at how we can best engage with these communities 36

37 Listening, improving and responding We have a dedicated Patient Experience Team that listens to your feedback and any concerns and helps to resolve any problems at a local level. The team works as part of the CCG s wider Quality Team, responding to patient queries and any complaints we receive. This involves working very closely with local organisations that provide healthcare so that together we can understand the root cause of complaints and ensure that lessons are leant and improvements are made. When we are responding to concerns and complaints, we follow the approach recommended by the Parliamentary and Health Service Ombudsman in its Principles for Remedy guidance. Acting as a best practice guide on how public bodies should put things right when they have gone wrong, the principles focus on being customer-focused, being open and accountable, acting fairly and seeking continuous improvement. Here are the six key principles and how we are meeting them: 1. Getting it right We want to get it right first time but if things do go wrong we listen and do our best to resolve any problems or concerns quickly, working with other healthcare organisations and the Parliamentary and Health Service Ombudsman s office where needed. 2. Being customer focused If people have had a bad experience of local healthcare we will apologise, investigate and tell them why things went wrong. We will also tell them what we have done to make sure it doesn t happen again. 3. Being open and accountable We will be honest and we will take responsibility for our actions. We will explain what we plan to do and talk people through our complaints process so they know what to expect. 4. Acting fairly and proportionately We will be fair and we will look at each case individually, working with the complaint to agree the action we will take and timescales for resolution. 5. Putting things right We will do our best to resolve any issues and put things right. If we can t, we will explain the other options, including referring the issue to the Parliamentary and Health Service Ombudsman s office. 6. Seeking continuous improvement We will learn from feedback and use it to continually improve our own services, as well as the quality of care we commission. Complaints are sometimes received about local healthcare providers and, in line with the NHS Complaints Procedure, these are passed on to the relevant organisation, with the permission of the complainant, so they can be fully investigated by the organisation that provides that service. We are always happy to provide support to the complainant as part of this process, if they would find that helpful. 37

38 Working with our partners We have big plans for the future but we know we can t do it on our own. That s why it s so important that we have good working relationships with local healthcare organisations and key partners. As a relatively small organisation, we are really keen to work with our partners to share valuable resources and ensure the best possible use of taxpayers money. Our plans for closer integration of services and the introduction of the Better Care Fund, which involves closer working with Surrey County Council and other partners, enable us to pool resources and work together to make real improvements to local services. We have good working relationships with our provider trusts (including our local hospital and community trusts), both directly and through our Local Transformation Boards (there is one for each main hospital). We work closely with our CCG colleagues on Surrey-wide priorities and plans, which helps to reduce duplication and means things are done once for the whole county. The Surrey-wide stroke review is a good example of this (see page 15 for details). We also work with other neighbouring CCGs in Surrey, Sussex and south west London. We also work closely with other key partners such as our four local authorities, Surrey County Council, Surrey Health and Well-being Board, Healthwatch Surrey, the Surrey Well-being and Health Scrutiny Board, NHS England, Public Health England, our Local Medical Committee, local voluntary and carer groups and many other organisations. To help us know how we are doing as an organisation, and how we are engaging with our partners, we invite our key stakeholders to give us feedback through our annual 360 degree survey. We received feedback from this year s survey in April. We will listen to what it told us and we will use the feedback to improve how we work. Surrey Health and Well-being Board Update The Surrey Health and Well-being Board is a committee of Surrey County Council. It is where the NHS, public health, social care, local councillors, district and borough representatives and user representatives work together to improve the health and wellbeing of the people of Surrey. This partnership identifies opportunities for collaboration and integration across agencies, and develops direct links to service users, patients and local stakeholders. It is responsible for developing a Joint Health and Well-being Strategy with priorities for action for Surrey, based on the latest health and demographic data from the Surrey Joint Strategic Needs Assessment (which contains information about the Surrey population and local health needs). Membership of the Board includes every Surrey CCG, Healthwatch Surrey, representatives from Surrey County Council (including from Adult Social Care, Children s Services and Public Health), local authorities and Surrey Police. Our Clinical Chair, Dr Claire Fuller, is an active member of the Surrey Health and Well-being Board and as an organisation we are committed to working in partnership. For example, our high level priorities are closely aligned with the Health and Well-being Board s health priorities so we can focus on tackling these areas together. 38

39 Safeguarding vulnerable adults Safeguarding means protecting an adult s right to live in safety, free from abuse and neglect. It is fundamental to creating high-quality health and social care and we take our responsibilities for protecting and safeguarding vulnerable people very seriously. It is about people and organisations working together to prevent and stop the risks and experience of abuse or neglect, while at the same time making sure that the adults well-being is promoted including, where appropriate, having their views, risks, wishes, feelings and beliefs in deciding any action. Surrey Downs CCG leads on adult safeguarding on behalf of all Surrey CCGs, working closely with us and other local partners including Surrey County Council and Surrey Police. The CCG has a Designated Nurse for Safeguarding Adults who leads on this area for the county and we also have a Safeguarding Lead for the NHS Continuing Healthcare and NHS Funded Healthcare Team. In addition, all Surrey CCGs have a Lead GP for adult safeguarding who works closely with our Designated Nurse. The same applies at GP practice level where all GP surgeries have an identified Lead for Adults Safeguarding and the Mental Capacity Act within their practice. In the last twelve months we have supported a wide range of areas to strengthen safeguarding arrangements across the county. These include: being an active member of the Surrey Safeguarding Adults Board (SSAB) and its sub groups and the five Local Safeguarding Adults Boards. This ensures policy and processes are jointly developed and fully-co-ordinated, with roles and responsibilities of partner agencies clearly defined. This work has included the implementation of the Care Act 2014, which came into effect from 1 April continuing to work closely with partner agencies, especially Surrey County Council, on any quality issues relating to care homes or the potential closure of a home. Where closures do happen, we work very closely with the Area Managers within Adult Social Care at Surrey County Council, and out of area statutory agencies where appropriate to ensure all residents are transferred to appropriate alternative accommodation in neighbouring care homes. By working together we can ensure a smooth transition for both residents and their families. continuing to raise awareness of adult safeguarding and the Mental Capacity Act (MCA) through a series of training events for healthcare staff, including dedicated sessions for GPs. Safeguarding and Mental Capacity Act training is included in Induction for all staff and we have provided additional sessions where these have been requested, for example to the Practices Nurses Forum. Throughout this year we have held a number of MCA training events aimed at GP practice staff, paid for by NHS England, following a successful bid for funding. This has proved very successful with 357 delegates attending events throughout Surrey. This included 133 staff, CHC nurses and GPs from Surrey Downs CCG. contributing to Domestic Homicide Reviews. While no Serious Case Reviews were commissioned this year, a number of Domestic Homicide Reviews are underway. In these cases reports are submitted by the relevant Community Safety Partnership to the Home Office for Quality Assurance Committee for their consideration. Any feedback or subsequent actions come back to us through the Community Safety Partnership. 39

40 contributing to local and regional networks to ensure best practice in safeguarding. This includes making sure that any lessons learnt and recommendations are shared and that our policies and processes are updated as a result. Safeguarding children The Surrey county wide Safeguarding Children team is hosted within NHS Guildford and Waverley CCG and provides a safeguarding service across the county, with a clear line of accountability for safeguarding reflected in each CCG s governance arrangements. The county-wide safeguarding team leads safeguarding children work through an agreed action plan and monitors compliance of agreed safeguarding standards through a performance framework. A safeguarding children report and action plan is developed annually and our Quality Committee have discussed safeguarding children reports as part of their quality discussions. There is a programme for safeguarding training in place which is aligned and complimentary to the Surrey Safeguarding Children Boards and is compliant with the 2014 intercollegiate document. The CCG undertakes a bi-annual audit of safeguarding standards through the Section 11 Audit (Children Act 2004) and an annual health economy wide deep dive. This process allows the organisation to monitor progress against defined standards. The CCG is able to demonstrate its current position against those. The CCG is a key contributor to the work of the Surrey Safeguarding Children Board and its sub-groups and in the past year contributed to an event that focused upon the embedding of learning from serious case reviews which has been further cascaded to relevant staff groups and is used to improve the commissioning and delivery of services. In addition, all general practices within the CCG area have identified a lead for safeguarding children. Serious incidents requiring investigation Serious incidents in healthcare are adverse events, where the consequences for patients, families and carers, staff or organisations are so significant, or the opportunity for learning is so great, that they deserve a higher level of investigation. Serious incidents include acts or failures in care that result in unexpected or avoidable death or injury with serious harm, abuse or Never Events. They also include incidents that threaten the relevant organisation s ability to continue to deliver services or those that cause widespread public concern and a resulting loss of confidence in the services provided. Never Events can occur as the result of a failure to put into place systems to avoid errors and their occurrence can help us understand quality and safety processes that are in place within our providers. As part of our committee structure we have a Serious Incident Review Sub- Committee (as a sub-committee of the Quality Committee). This sub-committee, whose membership includes CCG officers and GP Governing Body members, receives information about all Serious Incidents declared by providers where we are the main commissioner. The role of the sub- 40

41 committee is to scrutinise the investigation, root cause analysis and the action plans that are developed as a result. The Sub-committee also looks for any themes and trends and ensures that any learning is shared across the wider health economy. If a Serious Incident occurs in an organisation where we are not the lead commissioner but it may still affect our population, these incidents are scrutinised by our Quality Team before any recommendation for closure can be made. Healthcare services have always been encouraged to be open and honest with patients when things go wrong and following the introduction of Duty of Candour the CCG has taken a more formal approach to gaining assurance from providers that they are compliant with this duty. The CCG closely monitors themes and trends that emerge from serious incidents to ensure that a collective approach is taken delivering action plans and informing the strategic approach of individual organisations. Pressure ulcer damage classed at Grade 3 or 4 (with 4 being the most serious) is the most frequently reported serious incident, both locally and across our subregion. This year we have been working with providers on the early identification and prevention of these ulcers and we will continue this work into next year. As a result we have seen an increase in reporting but a reduction in the grading and severity of pressure sores and subsequent harm. Equality and diversity Surrey Downs CCG has statutory duties under the 2010 Equality Act as a public sector body, and in the last year we have further strengthened our approach. All CCG policies and new projects have been assessed for equality impact The CCG now has a dedicated Public Engagement Manager whose role includes supporting the equality and diversity agenda and actively promoting equality throughout the organisation The CCG has been represented on the Kent Surrey and Sussex Equality and Diversity Forum and is now networking with other organisations on equality and diversity An online staff training module has been introduced to make staff aware of their duties under the act, giving practical support to applying this in the workplace and in commissioning services. The CCG has agreed a number of actions for improvement including working with stakeholders and partner agencies in 2016/17. A full report of the CCG s work in this area is published every year on our website. 41

42 Our joint commissioning arrangements We work very closely with the five other Clinical Commissioning Groups that cover parts of Surrey (East Surrey CCG, Guildford and Waverley CCG, North West Surrey CCG, North East Hampshire and Farnham CCG and Surrey Heath CCG) and have collaborative commissioning arrangements in place with them. The Surrey CCGs Collaborative Strategy Group has what s known as a Framework for Collaboration Agreement that sets out the scope, governance, risks and responsibilities of the six CCGs under these arrangements. Alongside this overarching agreement there are seven collaborative agreements (or Service Level Agreements) that are Surrey-wide. This is where CCGs lead on different contracts and services on behalf of the other clinical commissioning groups. By working this way, we can pool our resources and reduce duplication, with one CCG leading on a specific work area on behalf of the rest. It also helps with commissioning, where we have a collective CCG voice for the whole of Surrey. Surrey Downs CCG leads on NHS funded and continuing healthcare, adult safeguarding and individual funding requests (for rare or very expensive treatments or drugs). Here s a summary of who does what: commissioner Service area Children s commissioning (including safeguarding children) Safeguarding adults Mental health and learning disability services Virgin Care community contract (some community services are provided Surrey-wide) Medicines management Ambulance services, NHS111 and patient transport NHS continuing healthcare and NHS funded nursing care Individual Funding Requests Lead commissioner (or host service where services are provided in-house by the CCG) Guildford and Waverley CCG Surrey Downs CCG North East Hampshire and Farnham CCG North West Surrey CCG Surrey Downs CCG North West Surrey CCG Surrey Downs CCG Surrey Downs CCG 42

43 Sustainability and taking care of the environment Sustainability has become increasingly important as the impact of people s lifestyles and business choices are changing the world in which we live. As an organisation, we acknowledge our responsibility to our patients, local communities and the environment and this includes minimising our carbon footprint. Climate change brings new challenges, both in terms of the direct impact it can have on healthcare estates and also in terms of patient health. Examples of this in recent years include the effects of heatwaves, extreme temperatures and prolonged periods of cold, floods and droughts. We recognise this is a risk and have identified the need to develop a plan to address climate change and the potential impact it could have on us as an organisation. Our primary ability to influence sustainability is through our contracts for healthcare, in which we specify that providers must meet expected standards of efficiency and good practice in areas such as energy management. We are also doing everything we can through our work with partners on estates strategies and better use of new technologies such as Telehealth to minimise waste and prepare strategically for a future where transport, IT and buildings are integrated in a way that benefits patients and the environment. At a business level we employ over 180 staff at our headquarters and in the community. Examples of how we try to create a sustainable organisation include: Actively encouraging staff to recycle and minimise waste, for example through secure printing and limiting access to colour printers to reduce waste Through team briefings, reminding staff of the actions they can take to help reduce waste, minimise our carbon footprint and promote sustainability Support the use of remote technology to offer staff the chance to work at home and minimise travel where appropriate. Sustainable services and working together to address local challenges As we have already mentioned, we are also working with NHS organisations across Surrey to look at sustainability in its wider sense, through the development of our Sustainability and Transformation Plan. This work will look at how we can address the challenges the local NHS faces together to ensure services are sustainable and fit for purpose in the longer term. 43

44 Business continuity and emergency preparedness We have plans in place to deal with any disruptions that could affect our ability to operate and we also have arrangements whereby local NHS organisations would work together with other agencies if there was a significant threat to the health of a local population. We are also committed to offering mutual assistance to other organisations, where we can. Surrey agencies including health, the police, fire and rescue, local authorities and the county council are all members of Surrey s Local Resilience Forum (LRF). These forums were set up when the Civil Contingencies Act was introduced in They help ensure planning, training and local responses to emergencies are coordinated, effective and well managed. By planning, taking part in exercises and learning from the experiences of others, we ensure we have robust plans that cover different scenarios so that if the worst happens, we can react quickly and work with our partners across Surrey to ensure a well-planned and joined-up response. CCG managers collectively operate an on-call system that enables the CCG to respond 24 hours a day, and in the autumn of 2014 we ran a simulation in conjunction with NHS England on how we would support the threat of a pandemic illness combined with severe winter pressures on local services. The CCG has a full suite of policies for business continuity and major incidents and these were updated during 2015/16. Copies of these are on our website at 44

45 Accountability Report Includes our: Corporate Governance Report Remuneration and Staff Report 45

46 Corporate Governance Report Includes our: Members Report Statement of Accounting Officer s Responsibilities Governance Statement 46

47 Members Report About our Governing Body Our 32 member practices delegate the running of the CCG to our Governing Body. More information about the role of the Governing Body can be found in our Constitution on our website. Between April and 31 March 2016 the Governing Body was made up of 20 voting members and 3 non-voting members as follows: The Clinical Chair 10 GPs 3 voting and 1 non-voting members of the Executive 4 Lay members, 2 for Governance and 2 for patient and public engagement 2 external clinicians, 1 consultant and 1 nurse The CCG s Head of Quality (non-voting) A representative of Surrey County Council (non-voting) During this time there was also an independent observer, Mr Cliff Bush, who attended Governing Body meetings on behalf of the voluntary sector. Mr Bush was formerly a lay member of the CCG. Our Governing Body are ultimately responsible for our wider strategy and the decisions we make as an organisation. 47

48 The 2015/16 Governing Body team Chief Officer changes during the year Prior to January 2016 Miles Freeman was Chief Officer of the CCG. Miles left us in October 2015 to take up a new role with the NHS Right Care Programme. Between October 2015 and January 2016 Dr Claire Fuller took on the role of acting Clinical Chief Officer, supported by Peter Collis who stepped into the role of Acting Chair. Claire and Peter returned back to their respective roles when Ralph McCormack joined us in January Between April 2015 and March 2016 the members of our Governing Body were as follows: Dr Claire Fuller, Clinical Chair As well as her role as Clinical Chair, Claire practices as a GP at the Longcroft Clinic in Banstead and has a wealth of experience in the local NHS. Between April 2015 and March 2016 in her capacity as Clinical Chair Claire was a member of the Governing Body, the Executive Committee, the Quality Committee and the Remuneration and Nominations Committee. During the time Claire was Acting Clinical Chief Officer (October 2015 to January 2016), Claire also attended the Audit Committee. Ralph McCormack, Interim Chief Officer Ralph joined the CCG at the beginning of January 2016 to provide support as Interim Chief Officer. Ralph's previous role was with NHS England, where he worked with Surrey Downs CCG as part of our assurance process. He has also worked as a Chief Officer in primary care trusts and provider organisations. Between January and March 2016 Ralph was a member of the Governing Body, the Executive Committee, the Audit Committee, Finance and Performance Committee, Quality Committee and the Remuneration and Nominations Committee. Matthew Knight, Chief Finance Officer and Deputy Chief Officer Matthew has been with the CCG since March He has a strong financial background and has previously held high profile roles in the software and services industry, both within the UK and internationally. As part of his role, Matthew is the Senior Information Risk Owner for the organisation. Between April 2015 and March 2016 Matthew was a member of the Governing Body, the Executive Committee, the Audit Committee, Finance and Performance Committee and the Remuneration and Nominations Committee. 48

49 James Blythe, Director of Commissioning and Strategy James has worked predominantly in commissioning, most recently for an acute trust in Brighton, and has also carried out policy development for the Department of Health. James is a non-voting member of the CCG Governing Body. Between April 2015 and March 2016 James was a member of the Governing Body, the Executive Committee, the Quality Committee and the Finance and Performance Committee. Steve Hams, Interim Director of Clinical Performance and Delivery Steve joined the CCG in January 2016 and is a trained nurse. His previous roles have included Chief Nurse and Head of Quality roles with regulatory bodies such as the Care Quality Commission and at a number of large acute hospitals. Between January and March 2016 Steve was a member of the Governing Body, the Executive Committee, the Quality Committee and the Finance and Performance Committee. Dr Jill Evans, Locality Chair for East Elmbridge Jill is a GP at Esher Green Surgery and is the locality lead for East Elmbridge, which is made up of seven practices in the Cobham, Esher, Thames Ditton and Molesey area. Between April 2015 and March 2016 Jill was a member of the Governing Body, the Executive Committee and the Finance and Performance Committee. Following changes to our governance arrangements, Jill continues in her role as Locality Chair but is no longer a member of the Governing Body. Dr Simon Williams, Locality Chair for Epsom Simon practices as a GP at the Molebridge Practice. Simon has recently been appointed as GP Director for unplanned care and integration. Between April 2015 and March 2016 Simon was a member of the Governing Body, the Executive Committee, the Audit Committee and the Finance and Performance Committee. Following changes to our governance arrangements, Simon continues in his role as Locality Chair until July 2016 but is no longer a member of the Governing Body. Dr Robin Gupta, Locality Chair for Dorking Robin is a GP partner at Brockwood Medical practice and he also cares for patients with mental health needs and dementia at two local care homes. His experience also includes hospital medicine and emergency medicine. Between April 2015 and March 2016 Robin was a member of the Governing Body, the Executive Committee, the Quality Committee and the Finance and Performance Committee. Following changes to our governance arrangements, Robin continues in his role as Locality Chair but is no longer a member of the Governing Body. 49

50 Eileen Clark, Chief Nurse and Head of Quality Eileen has spent the majority of her career working in community services in Surrey and Sussex, both as a clinician and more recently in operations. In her current role Eileen leads on quality and patient safety and safeguarding. Between April 2015 and March 2016 Eileen was a non-voting member of the Governing Body, and a member of the Quality and Finance and Performance Committees. Following changes to our governance structure, Eileen is no longer on the Governing Body. Dr Ibrahim Wali, GP member Ibrahim is a GP at Fairfield Medical Practice. He qualified as a doctor in December 2000 and has been practicing as a GP since August He has particular interests in medicines management, anticoagulation, information technology and patient engagement. Between April 2015 and March 2016 Ibrahim was a member of the Governing Body. Following changes to our governance structure, Ibrahim is no longer a member of the Governing Body. Dr Andy Sharpe, GP member Andy is a GP at Ashley Centre Surgery in Epsom and is our clinical lead for information governance. He is also the CCG s Caldicott Guardian. Between April 2015 and March 2016 Andy was a member of the Governing Body. Dr Sharpe continues to be a Governing Body member in 2016/17. Dr Hazim Taki, GP member Hazim is a GP at Thorkhill Surgery in Thames Ditton and was a Board Member for the East Elmbridge locality. Between April 2015 and March 2016 Hazim was a member of the Governing Body. Following changes to our governance structure, Hazim is no longer a member of the Governing Body. Dr Kate Laws, GP member Kate is a GP at Shadbolt Park House Surgery in Worcester Park and was a Board Member for the Epsom locality. Between April 2015 and March 2016 Kate was a member of the Governing Body. Following changes to our governance structure, Kate is no longer a member of the Governing Body. 50

51 Dr Suzanne Moore, GP member Suzanne is a GP partner at Tattenham Health Centre in Epsom. During her career she has gained experience in emergency medicine, as well as care of the elderly, paediatrics and obstetrics and gynaecology. In her CCG role Suzanne is clinical lead in a number of areas including leading on children and young people s services and serious incidents. Between April 2015 and March 2016 Suzanne was a member of the Governing Body and Quality Committee. Following changes to our governance structure, Suzanne is no longer on the Governing Body. Dr Russell Hills, GP Member Russell is a GP and Partner with the Integrated Care Partnership at Fitznells Manor Surgery. Russell joined the Governing Body in April Between April 2015 and March 2016 Russell was a member of the Governing Body. Dr Hills continues as a Governing Body member in 2016/17. Dr Louise Keene, GP Member Louise trained as a GP in Surrey and joined the Leith Hill Practice as a partner in Her interests include improving the interface between general practice and emergency care and developing first class care in the community. Between April 2015 and March 2016 Louise was a member of the Governing Body. Dr Keene continues as a Governing Body member in 2016/17. Dr Mark Hamilton, Secondary Care Doctor Mark is a Consultant in Anaesthesia and Intensive Care Medicine at St George's Healthcare NHS Trust. Between April 2015 and March 2016 he was a member of the Governing Body, the Quality Committee and the Finance and Performance Committee. Mark stood down from the Governing Body in March Debbie Stubberfield, Independent Nurse on the Governing Body Debbie joined the CCG in November Debbie is a registered nurse and health visitor and has a broad range of experience as a senior clinical leader having worked in Director of Nursing roles in provider organisations. She currently works at the Trust Development Authority, where she is the Clinical Quality Director for London. Between November 2015 and March 2016 Debbie was a member of the Governing Body, the Quality Committee and Audit Committee. 51

52 Peter Collis, Lay Member for Governance and Deputy Chair Peter Collis has enjoyed a 35 year career in the Civil Service, having spent the last 10 years as Chief Land Registrar and Chief Executive of H M Land Registry for England and Wales. He is currently a Non-Executive Director of GLE Group. Between April 2015 and March 2016 Peter was Deputy Chair of our Governing Body, Chair of the Audit, and a member of the Remuneration and Nominations and Finance and Performance Committees. From October 2015 to January 2016 Peter took on the role of Acting Chair. Jonathan Perkins, Lay Member for Governance Jonathan joined the CCG in July He lives in Esher and is a lawyer. Since retiring as a partner with Linklaters, Jonathan has acted as the Chair of the Fundraising Committee for Princess Alice Hospice and as Vice-Chair of the Trustees. Between July 2015 and March 2016 Jonathan was a member of our Governing Body and Audit Committee and Chair of our Finance and Performance Committee and Chair of the Remuneration and Nominations Committee. Jacky Oliver, Lay Member for Patient and Public Engagement Jacky has lived in Epsom for over 40 years, during which time she has worked in health, charity and social activities across the borough. Her special interests are learning disabilities, mental health, dementia, isolated elderly and the traveller community. Between April 2015 and March 2016 Jacky was a member of the Governing Body and the Quality Committee. Gill Edelman, Lay Member for Patient and Public Engagement Gill is an experienced charity Chief Executive. She qualified originally as a speech and language therapist and has a 20 year NHS career including senior clinical and managerial roles in both acute and community settings, and as a NHS non-exec director at local and national levels. Gill joined the CCG in July Between July 2015 and March 2016 Gill was a member of the Governing Body and Quality Committee. Yvonne Rees, Local Authority Representative Yvonne is the Chief Executive for Mole Valley Borough Council and Surrey County Council's Strategic Director for Communities. 52

53 Other regular attendees at our Governing Body meetings this year included: Cliff Bush O.B.E, our independent patient advisor Ruth Hutchinson, our public health representative Antony Collins, our Turnaround Director Statement on disclosure to auditors On 29 April 2016 at a Governing Body seminar it was confirmed that each Governing Body member knew of no information which would be relevant to the auditors for the purposes of their audit report, and of which the auditors are not aware, and; has taken all the steps that he or she ought to have taken to make himself/herself aware of any such information and to establish that the auditors are aware of it. Thank you and goodbye During the year we said thank you and goodbye to several Governing Body members: In July 2015 we said goodbye to Nick Wilson, who had been our local authority representative on the Governing Body In September 2015 we said goodbye to Alison Pointu, our Independent Nurse on the Governing Body At the end of October 2015 we said goodbye to our Chief Officer, Miles Freeman who stepped down from his role to take on a new position with the national Right Care team In December 2015 Karen Parsons stepped down from her role as Chief Operating Officer and her role on the Governing Body and moved into a new role overseeing the changes to our governance arrangements. Our other committees in 2015/16 As part of our governance structure we have a number of different committees and groups which report to our Governing Body. There is more information on the role of each committee and its delegated powers and responsibilities in the CCG s Constitution, which is on our CCG website. Later we will talk about some changes we have made to our governance and committee structure, which were introduced from 1 April The Council of Members Our Council of Members is made up of one GP clinical lead from each of our 32 member practices. The role of the Council is to shape our vision and strategy, approve our commissioning plans, agree our Scheme of Delegation (how we operate as a CCG), agree any changes to our Constitution. Quality Committee This committee plays an important role in monitoring and seeking assurance on quality of care, patient experience and patient safety. It looks at clinical quality, clinical governance, safeguarding and quality improvements across our main healthcare providers and works with providers to drive forward quality improvements for the Surrey Downs population. 53

54 The membership of this committee during was as follows: Alison Pointu, Nurse on the Governing Body (Chair until September 2015) Debbie Stubberfield, Nurse on the Governing Body (took over as Chair from November 2015) Eileen Clark, Chief Nurse and Head of Quality James Blythe, Director of Commissioning and Strategy Steve Hams, Interim Director of Clinical Performance and Delivery (joined January 2016) Dr Philip Gavins, GP in East Elmbridge Dr Robin Gupta, GP in Dorking and Governing Body member Dr Suzanne Moore, GP in Mid Surrey and Governing Body member Jacky Oliver, Lay Member for Patient and Public Involvement Gill Edelman, Lay Member for Patient and Public Involvement (joined July 2015) A number of other CCG officers, including the Chief Officer and CCG Chair also attended this committee on a regular basis. This committee has one sub-committee which is responsible for reviewing patient safety incidents. Finance and Performance Committee This committee oversees the CCG s performance, both in terms of how we are performing against key quality standards and how we are performing financially. The membership of this committee during 2015/16 was as follows: Miles Freeman, Chief Officer (until October 2015) Ralph McCormack, Interim Chief Officer (from January 2016) Matthew Knight, Chief Finance Officer James Blythe, Director of Commissioning and Strategy Steve Hams, Interim Director of Clinical Delivery and Performance Dr Jill Evans, Chair of East Elmbridge Locality Dr Robin Gupta, Chair of Dorking Locality Dr Simon Williams, Chair of Epsom Locality Dr Mark Hamilton, Secondary Care Doctor (until March 2016) Eileen Clark, Chief Nurse and Head of Quality Peter Collis, Lay Member for Governance (committee Chair until September 2015) Jonathan Perkins, Lay Member for Governance (committee Chair September 2015 onwards) Audit Committee This committee critically reviews the CCG s reporting and internal control principles, monitors financial governance, ensures the CCG has an effective system of integrated checks and balances on its activities, has in place risk management procedures, provides an effective internal audit function, and oversees arrangements for counter fraud. 54

55 The membership of this committee during 2015/16 was as follows: Peter Collis, Lay Member for Governance and Committee Chair Jonathan Perkins, Lay Member for Governance (from July 2015) Alison Pointu, Independent Nurse on the Governing Body (until September 2015) Debbie Stubberfield, Independent Nurse on the Governing Body (from November 2015) A number of other CCG officers, including the Chief Officer, and Chief Finance Officer also attended this committee on a regular basis. These included: Dr Simon Williams, Chair for Mid Surrey Locality (stood down in June 2014 but remains in attendance) Ralph McCormack, Interim Chief Officer (replaced Miles Freeman) Matthew Knight, Chief Finance Officer Justin Dix, Governing Body Secretary The following individuals from internal and external audit and counter fraud also attended some meetings: Christian Heeger, Grant Thornton James Thirgood, Grant Thornton Clarence Mpofu, TIAA Simon Darby, TIAA Grant Bezuidenhout, TIAA Remuneration and Nominations Committee This committee makes recommendations on the remuneration (pay) and conditions of service of staff and other general HR matters. It also advises on contractual arrangements for Governing Body members and senior employees and oversees the appointment and election of Governing Body members (including succession planning, terms of office, performance and review processes). The membership of this committee is: Jonathan Perkins, Lay Member for Governance and committee Chair (from July 2015) Peter Collis, Lay Member for Governance and committee Chair (until July 2016) Miles Freeman, Chief Officer (until October 2015) Dr Claire Fuller as Acting Chief Officer (October to January 2016) Ralph McCormack, Interim Chief Officer (from January 2016) A number of other CCG officers, including the CCG Chair and Chief Finance Officer also attended this committee on a regular basis. 55

56 Executive Committee and localities During 2015/16 The Executive Committee oversaw the day-to-day running of the CCG. Its role was to ensure we operate in line with the NHS Constitution, ensure the delivery of statutory duties, monitor performance, implement strategy and oversee organisational development. The committee acted as a key link with the localities and their local GP representatives. The membership of the Executive committee was: Miles Freeman, Chief Officer (until October 2015) Dr Claire Fuller, Clinical Chair of Surrey Downs CCG Karen Parsons, Chief Operating Officer (until December 2015) Matthew Knight, Chief Finance Officer James Blythe, Director of Strategy and Commissioning Dr Simon Williams, Chair of Epsom Locality Dr Jill Evans, Chair of East Elmbridge Locality Dr Robin Gupta, Chair of Dorking Locality Changes to our Governing Body from April 2016 Following a review of our governance arrangements and other related, independent reviews, we decided to make some changes to the structure and membership of the Governing Body and other committees. These changes included setting up a new Clinical Cabinet to ensure GPs and other clinicians were driving forward service improvement and reducing the membership of our Governing Body and bringing in a range of new clinical roles instead so our clinical members could play a much stronger role in the clinical work of the CCG, including in service redesign projects. From April 2016 the membership of the new Governing Body is as follows: Dr Claire Fuller, Clinical Chair Ralph McCormack, Chief Officer James Blythe, Director of Commissioning and Strategy Matthew Knight, Chief Finance Officer Dr Andrew Sharpe, GP Member Russell Hills, GP Member Dr Louise Keene, GP Member Dr Hannah Graham, GP Member Dr Tim Powell, GP Member Debbie Stubberfield, Independent Nurse on the Governing Body Dr Tony Kelly, Secondary Care Doctor Peter Collis, Lay Member for Governance Jonathan Perkins, Lay Member for Governance Jacky Oliver, Lay Member for Patient and Public Involvement Gill Edelman, Lay Member for Patient and Public Involvement Ruth Hutchinson, Public Health Advisor Yvonne Rees, Local Authority Representative 56

57 A Register of Interests for our current, and former Governing Body members, can be found in our Governing Body papers, available on our website here. Keeping personal data secure During 2015/16 we are pleased to report that there were no personal data related incidents that had to be reported to the Information Commissioner s Office. 57

58 Statement of Accountable Officer s Responsibilities The National Health Service Act 2006 (as amended) states that each Clinical Commissioning Group shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed the Interim Chief Officer to be the Accountable Officer of the Clinical Commissioning Group. The responsibilities of an Accountable Officer include: responsibilities for the propriety and regularity of the public finances for which the Accountable Officer is answerable keeping proper accounting records (which disclose with reasonable accuracy at any time the financial position of the Clinical Commissioning Group and enable them to ensure that the accounts comply with the requirements of the Accounts Direction) and; safeguarding the Clinical Commissioning Group s assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities) Under the National Health Service Act 2006 (as amended), NHS England has directed each Clinical Commissioning Group to prepare for each financial year financial statements in the form and on the basis set out in the Accounts Direction. The financial statements are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Clinical Commissioning Group and of its net expenditure, changes in taxpayers equity and cash flows for the financial year. In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Manual for Accounts issued by the Department of Health and in particular to: Observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis Make judgements and estimates on a reasonable basis State whether applicable accounting standards as set out in the Manual for Accounts issued by the Department of Health have been followed andmdisclose and explain any material departures in the financial statements; and, Prepare the financial statements on a going concern basis. I confirm that, as far as I am aware, there is no relevant audit information of which the entity s auditors are unaware, and as the Accounting Officer I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the entity s auditors are aware of that information. I confirm that the annual report and accounts as a whole are fair, balanced and understandable and that I take personal responsibility for the annual report and accounts and the judgments required for determining that it is fair, balanced and understandable. Ralph McCormack Interim Chief Officer 25 May

59 Governance Statement Our governance structure and policies 59

60 1. 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 1 April 2015, the clinical commissioning group was licensed without conditions. On the 10th August 2015 the CCG was placed under the following directions by NHS England: NHS England prior approval is required for appointments to the Executive Team and next tier of management A Turnaround Director will be jointly appointed by NHS England and the CCG The CCG will co-operate with the capability and capacity review ( Capability and Capacity Review ) commissioned by NHS England The CCG will produce a credible Financial Recovery Plan which includes: - how the CCG will operate within its annual budget for 2016/17 and remain in recurrent balance thereafter; - confirmation that all facts, figures and projections within the Financial Recovery Plan have been subjected to independent scrutiny by an organisation approved by the Board; - a complete analysis of the causes of the current underlying financial position and the reasons for unexpected deterioration in 2014/5 financial position; - a demonstration of clear links to internal budgets, reporting, activity plans, cash plans and contracting; - a clear risk assessment of the Financial Recovery Plan; and any other requirement - The Financial Recovery Plan will be subject to NHSE approval The CCG will implement the Financial Recovery Plan The CCG will conducts a full review and revision of its governance arrangements including - use of information to inform effective governance decisions; and - such other matters as may be required by the Board; The CCG provides to NHSE, on a monthly basis, all reports presented through its governance arrangements within the CCG NHSE may direct Surrey Downs CCG in any other matters relating to the Governance Review The CCG will co-operate with NHSE regarding it s oversight of the CCG s compliance with these Directions, including the prompt provision of information, documents and records requested by NHSE and making senior officers available to meet with NHSE 2. 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. 60

61 I also acknowledge my responsibilities as set out in my Clinical Commissioning Group Accountable Officer Appointment Letter. During 2015/16 the CCG had three Accountable Officers as follows: Miles Freeman, Chief Officer (until October 2015) Dr Claire Fuller, Acting Clinical Chief Officer (October 2015-January 2016) Ralph McCormack, Interim Chief Officer (started January 2016) 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. Given the changes in Chief Officers as set out above, I have taken the advice of the Governing Body and its committees (particularly the Audit Committee), of NHS England, and of individual officers of the CCG in preparing this Annual Governance Statement and providing assurance on governance matters for the whole of the year in question. 3. 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 clinical commissioning group and best practice. Specifically: Leadership. The CCG accepts that one of the key roles for the Governing Body includes establishing the culture, values and ethics of the organisation. It is important that the board sets the correct tone from the top. The various Governance Review and subsequent action plans agreed with NHS England are designed to ensure that the CCG has an effective board. Division of responsibilities. The revised governance arrangements are designed to enshrine the principles in the code that there should be a clear division of responsibilities between the role of the Governing Body and the executive s responsibility for the running of the organisation s business, allowing a healthy balance between constructive challenge and contribution to the development of an agreed strategy and its delivery. Accountability. In line with the code s emphasis on accountability, the CCG has developed and continues to develop better information on the quality and cost of commissioned services, and improved systems for assessing risk to the delivery of its objectives and its operations. These include enhanced performance reports and more descriptive and accessible risk profiles. Relationships with stakeholders. The CCG has put in place significantly improved internal relationships (for instance between the member practices, the Governing Body and the Executive) and has enshrined these in new structures that give clinical stakeholders more ownership of the delivery of safe and effective care. Organisational development. At board level and down through the organisation there is a renewed emphasis on ensuring that the CCG has an appropriate balance of skills, experience, independence and knowledge to enable it to discharge its respective duties and responsibilities effectively 61

62 4. 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 following arrangements exist in Surrey Downs CCG for the discharge of this function. The CCG has a Council of Members that meets regularly and ensures that the 32 member practices determine the overall strategic direction of the organisation, its expectations of how safe and effective care will be commissioned, and how its other functions will be discharged. The member practices delegate the majority of the functions relating to the running of the group to the Governing Body, with the membership having significant engagement and involvement at a more local level through localities. The Council of Members met five times in The Governing Body, which is made up of local GPs, executive officers, external clinicians and lay members, met eleven times during the year (six times formally in public) to provide assurance as to how it was delivering the agreed strategies and plans. The Governing Body during was composed of 23 members. In addition to meeting as a body, the CCG discharged its functions through a number of committees as follows: A Quality Committee; A Finance and Performance Committee; An Audit Committee; A Remuneration and Nominations Committee; A Primary Care Committee; An Executive Committee; The Primary Care Committee did not meet after June 2015 as the CCG was not able to take on the planned co-commissioning of primary care from NHS England whilst it was under directions. The Quality Committee has a patient safety sub-committee. During the CCG also took part in three Committees in Common with other CCGs, for Stroke, CAMHS procurement and community services procurement respectively. These were reported on publicly at the CCG s Governing Body meetings. Full details of the membership of the Governing Body and its committees is given in the Members Report (see page 45) of this Annual Report. The Governing Body and its committees undertake a formal and structured evaluation of their own effectiveness. 5. The Clinical Commissioning Group Risk Management Framework The CCG has a Risk Management Strategy that was refreshed and agreed by the Governing Body in April 2015 and is embedded in our normal management processes and structures and organisational culture. As part of this a statement of risk appetite was agreed which sets out the broad risk tolerances of the organisation but also gives specific guidance to managers on how to score risk. The Strategy uses a common scoring matrix for assessing the likelihood and impact of risk which is then either Treated, Tolerated, Transferred or Terminated (the Four T methodology). This approach complies with best practice, NHS Litigation Authority and National Patient Safety guidance and the Department of Health requirements. It has also been assessed as fit for purpose by internal audit. Risks can be identified at any level of the organisation but are managed by senior staff and all risks have an executive owner who is ultimately accountable. The CCG s incident reporting form specifically highlights the need to identify risks for the CCG s risk register where 62

63 appropriate, and staff are encouraged to be open and honest when reporting incidents and risks. The CCG s committees may also recommend new entries on the CCG s risk register where appropriate. The Assurance Framework (which describes and manages the risks to the CCG s principal objectives) and the Risk Register (which describes and manages more operational risk) are both updated fully for each public Governing Body and also more regularly as new risks are identified. During the Autumn of 2015 over 70 staff at Executive, Senior and middle grade level attended training sessions on the revised risk management strategy and its use within the organisation. Risk management is also covered as part of the governance module of the induction programme for new staff. With all CCG processes, and in particular projects involving service change, risks around quality, equality and privacy impact are assessed using the same risk scoring matrix to determine whether the impact is likely to be Positive, Negative or Neutral. The CCG is also advised on risk by engagement with the public and clinicians on changes to services, including open questions at the start of each CCG Governing Body meeting. The CCG s risk strategy requires anyone charged with managing a risk to identify the key controls and mitigating actions that will reduce the score to agreed and specific tolerance levels. The majority of risks the CCG manages are intrinsic to its operations and only rarely capable of elimination. Risk is prevented by the early use of impact assessments (as above), and by proactive work in specific areas. The CCG commissions a counter fraud service to work with staff to ensure high standards of business conduct and the early identification of fraud. Risk Assessment The Governing Body receives three risk profiles at each meeting: one on risks to its principal objectives, one on operational risk, and one on strategic risk. The profiles set out how many are in the high, medium and low categories and the change since the last reporting period. The following is a summary of how risks changed during the year. At the beginning of the year the CCG s risk register identified 39 risks, of which 10 were deemed to be high risk: Commissioning Continuing Health Care, Contracting, Emergency Planning, Corporate Estates, Finance, Information Governance, Medicines Management and Performance. At the end of the year the CCG was identifying 36 risks of which 9 were deemed to be high risk: Provider development, Failure to achieve quality premium, GP IT infrastructure, Continuing Care Retrospective Reviews, Failure to achieve QIPP, Stroke mortality and morbidity, CHC IT Transition and data management, CHC Safeguarding alerts, CHC File handling and storage* During the course of the year the CCG was placed under Directions and its licence to operate was therefore under scrutiny. There was a high risk of the CCG s Governing Body and Constitution not being fit for purpose. This was mitigated by the reviews of Governance arising from the CCG being placed under Directions, and the subsequent action plan was responsible for putting risk mitigation in place. NHS England has 63

64 oversight of the CCG s actions in this area and the CCG provides assurance that issues relating to the Directions are being addressed. The key actions are in relation to: - Robustness of Governance Arrangements - Timing and frequency of Governing Body meetings - Governing Body role and link from strategy to business - Balance and Challenge of the Governing Body - Roles & Responsibilities including Development & Training of the Governing Body - Governing Body understanding of the issues in the Five Year Forward View - Governing Body Committees including re-writing of terms of reference - Assessment of Quality impact and monitoring initiatives - Stronger focus on quality Improvement - Provider Quality monitoring - Enhanced challenge and escalation - Use of Quality Information 6. The Clinical Commissioning Group 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. 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 CCG uses an industry standard matrix when rating risks which considers the impact of each risk. Each rating is presented as a mitigated score based upon consideration of the controls in place. Actions are recommended to reduce the risk rating. The CCG operates an integrated approach wherein the Governing Body Assurance Framework identifies risks to the CCG s principal objectives and the Risk Register takes a broader and more operational view of risk. The key threshold which identifies risks as significant or red is a score of 15 or higher. Managers are expected to enhance controls and put in place mitigating actions to bring risk down to the agreed level as set out in the statement of risk appetite. The internal control framework is also dependent on having the required policies and procedures in place to give the Governing Body and staff clarity of expectations against which assurance can be measured. Information Governance 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. 64

65 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 framework and a range of additional and specific policies to support this. We have in place and are continuously developing information governance processes and procedures in line with the information governance toolkit, with which we have assessed ourselves as compliant. We have specifically 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. Information Governance is a core module of the CCG s induction programme. There are processes in place for incident reporting and investigation of serious incidents and are working to embed an information risk culture throughout the organisation against identified risks. Review of economy, efficiency & effectiveness of the use of resources Sixty percent of the CCG s spend is on acute care and the CCG uses national tariffs and benchmarks local tariffs to ensure that it is not paying more than economic rates for services. Changes of contracts are rigorously appraised to ensure value for money and a number of changes have been made to improve value for money. Local Enhanced Service arrangements have also been rigorously appraised and benchmarked to increase volume and quality of specification whilst reducing spend. We also use formal procurement processes for spend outside of national tariffs. As part of its work on financial recovery and wider transformation the CCG has developed its Programme Management Office and appointed a turnaround director to pursue the opportunities identified by the various reviews conducted during 2015, particularly in relation to QIPP where there are a number of areas of elective care where national benchmarking indicates that care could be commissioned more effectively. The CCG is also partnered into the Right Care programme to identify further opportunities to maximise efficiency and economy. During the CCG established a Finance and Performance Committee with an NHS England observer to oversee the above and to provide support and challenge to the executive officers in this area. Feedback from delegation chains regarding business, use of resources and responses to risk The CCG seeks to maximise Quality, Innovation, Productivity and Prevention (QIPP) opportunities across all its activities including areas where activities are delegated to other organisations (for instance in respect of hosting of services by other CCGs). The Surrey CCG collaborative seeks to maximise QIPP opportunity collectively in these areas of Surrey, and we also work with other commissioners (specifically in relation to non local acute and mental health trusts) where we can achieve greater efficiencies by working together. 65

66 7. 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 personally review the risk register and assurance framework on a regular basis and before each presentation to the Governing Body. All Heads of Service review the risk register and assurance framework with the Governing Body Secretary on a monthly basis and the Governing Body Secretary advises on potential duplications and inconsistencies in these. Heads of Service and all staff are required to work in accordance with the CCG s risk management strategy, which is updated annually and which is reviewed in team meetings with staff. External training is being procured to provide a higher level of risk management expertise going forward. 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. Our assurance framework provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving its principles objectives have been reviewed. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Governing Body, the Audit Committee, the Finance and Performance Committee and the Quality committee, if appropriate and a plan to address weaknesses and ensure continuous improvement of the system is in place. Specific actions include: An annual review and approval of the risk management strategy The Governing Body and Audit Committee reviewing the risk register and assurance framework at every meeting, with additional reviews by other principal committees where appropriate. Continuous review of the system of internal controls by the Audit Committee Review of policies by the Governing Body and all the principal committees; in particular a review of the core policy suite by the internal auditors with actions agreed by the Audit Committee. Recommendations and actions from the Remuneration and Nominations committee to more effectively engage staff in understanding policies and the system of internal controls. An annual review of the maturity of the internal control system as set out above, which resulted in the adoption of a consistent methodology for categorising risks (the four Ts). 66

67 Head of Internal Audit Opinion 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: Reasonable assurance can be given that there are adequate and effective management and internal control processes to manage the achievement of Surrey Downs Clinical Commissioning Group s objectives. During the year, Internal Audit issued the following limited assurance audit reports: Individual Funding Requests The Individual Funding Requests Review gave limited assurance and recommendations were made as follows: - IFR Panel members be provided with the training stipulated in the 'Policy and operating procedures for IFR'; - Regular management reporting to a committee and stakeholder CCGs be introduced; - The revised 'Policy and Operating Procedures for Individual Funding Requests' be ratified as soon as possible; - The draft 'Individual Funding Requests (IFR) and Procedures of Limited Clinical Effectiveness (POLCE)' document be ratified as soon as possible; - The CCG to ensure that there is evidence that the IFR Panel executed its duties as stipulated in its Terms of Reference be completed. All the above issues were addressed through management action by year end. Information Governance The Information Governance Toolkit v13 Review provide assurance on the integrity of the self-assessment against the information governance toolkit criteria, the overall effectiveness of information governance processes, and wider risk exposures has provisionally been assigned limited assurance. Two key findings were identified as expected. - there are outstanding actions relating to documentation from South East Commissioning Support Unit (SECSU). - IG training was not yet at year end levels. Both of these issues were addressed prior to submission of the toolkit and in all other respects the auditors commended the significant progress the CCG had made on information governance. A follow up audit in April 2016 confirmed that the CCG is compliant. Adult Safeguarding Arrangements This jointly funded review received limited assurance and the outcome of the audit was reported to all the CCGs within the collaborative. The host CCG s framework to provide 67

68 assurance to the Governing Body and wider health economy that it is fulfilling its statutory responsibility to safeguard and promote the welfare of vulnerable adults is immature. The audit identified the relative immaturity of the statutory framework around safeguarding adults including the numerous policies and guidance that needs to be embedded to ensure that risks are mitigated appropriately. The review also highlighted the lack of resources that are available across the CCG collaborative to undertake this work when compared to that available for Safeguarding Children across the collaborative. A detailed action plan was put together by Surrey Downs CCG to address the audit findings and has been shared with all the Quality Leads within the collaborative. A follow up of the audit recommendations has been carried out by Internal Audit and work is ongoing to complete the required actions. Data Quality The CCG buys commissioning support from NHS South East Commissioning Support Unit (CSU). This includes a business intelligence and performance function which monitors how local providers are performing against key performance indicators. This information is reported to the Executive and Governing Body on a regular basis. The CCG seeks to continuously improve the timeliness and quality of data to support strategic and operational decision making and individual information issues are reviewed in the relevant committee. Business Critical Models The CCG undertakes a number of business critical processes in order to deliver its commissioning functions. The way in which these are managed and assured is set out below. The CCG is aware that modelling future trends and risk is a difficult process and seeks to undertake these processes rigorously. The following identifies the key processes and models used, along with sources of assurance and scrutiny: Business critical process Model Assurance Timescales Population planning and need Five year plan Joint Strategic Needs Assessment - statistical and stakeholder data on demographic trends and epidemiological expectations. Developed based on the JSNA, guidance from NICE and other bodies on emerging health technologies, and views from stakeholders, Public Health Team data quality assurance; Reviewed by Area Team of NHS England Signed off by CCG Governing Body Five year planning and annual reviews Five year planning and annual reviews 68

69 Financial modeling Business case / Project Initiation Document development Quality and Performance reporting Finance modelling extrapolated from SBS, SUS, SLAM, prescribing and other data Based on standard templates developed by the Service Redesign team Monthly reports using accredited data sources validated by CSU Monitored by Executive Committee and Audit Committee Reviewed by the Executive Committee CSU validated Data limitations transparent One year and five year, tracked monthly Request specific but normally monthly Monthly reporting Monitored by Quality Committee. Procurement Strictly controlled processes undertaken with the legal and technical support of NHS South CSU procurement team. Executive Committee review procurements monthly. All tenders and contract awards Bespoke according to each tender but in accordance with Official Journal of the European Union (OJEU) requirements Data Security We have submitted a satisfactory level of compliance with the information governance toolkit assessment, having been assessed by the Information Governance Team in our Commissioning Support Unit at level 2. There have been no Serious Incidents Requiring Investigation (SIRIs) relating to data security breaches. The CCG did not report any serious incidents requiring investigation in respect of information governance during Discharge of Statutory Functions As part of the external reviews put in place by the clinical commissioning group and NHS England (as a result of being under Directions), and with extensive expert internal and external legal input, the CCG can provide assurance that it is compliant with the all relevant legislation. Legal advice also informed the matters reserved for Membership Body and Governing Body decision and the scheme of delegation. In light of the work on Directions and the Harris Review (of failure to properly delegate statutory functions Department of Health February 2013), the clinical commissioning group has reviewed its constitution and all of the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. As a result, I can confirm that the clinical commissioning group is clear about the 69

70 legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions. Responsibility for each duty and power has been clearly allocated to a lead Director. Directorates have confirmed that their structures provide the necessary capability and capacity to undertake all of the clinical commissioning group s statutory duties. 8. Conclusion During the year the CCG had significant control issues relating to the issuing of directions by NHS England as set out at the beginning of this document. These related principally to financial recovery, governance, leadership, governing body development, and the use of information and have been, and continue to be, addressed through agreed actions with NHS England. Other than the above, there were, to the best of my knowledge, no other significant control issues which limited the ability of the CCG to meet its objectives and / or carry out its statutory functions. Ralph McCormack Interim Chief Officer (Accountable Officer) 25 May

71 Head of Internal Audit Opinion 71

72 Head of Internal Audit Opinion on the Effectiveness of the System of Internal Control for the Year Ended 31 March 2016 The purpose of my annual HoIA Opinion is to contribute to the assurances available to the Accountable Officer and the Governing Body which underpin the Governing Body s own assessment of the effectiveness of the organisation s system of internal control. This Opinion will in turn assist the Accountable Officer in the completion of the AGS. My opinion is set out as follows: 1. Overall opinion; 2. Basis for the opinion; and 3. Commentary. My overall opinion is that: Reasonable 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, put the achievement of particular objectives at risk; The basis for forming my opinion is as follows: 1. An assessment of the design and operation of the underpinning Assurance Framework and supporting processes; and 2. An assessment of the range of individual opinions arising from risk-based audit assignments, contained within internal audit risk-based plans that have been reported throughout the year. This assessment has taken account of the relative materiality of these areas and management s progress in respect of addressing control weaknesses. Additional areas of work that may support the opinion will be determined locally but are not required for Department of Health/NHS England purposes e.g. any reliance that is being placed upon Third Party Assurances. Design and operation of assurance framework and associated processes As part of our annual core assurance work undertaken we have completed a review of the CCG s Governing Body Assurance Framework (GBAF) and Risk Management process for 2015/16. Reasonable assurance was given regarding the design, adequacy and effectiveness of the CCG s GBAF and Risk Management processes and the extent to which the Governing Body and management determine, assess, manage and monitor risks. A number of good practice areas were also identified, and the following recommendations are being addressed by the CCG as part of the process of further improving and embedding the GBAF and risk management processes: 72

73 Regularly present the GBAF and Risk Register to the Audit Committee, rather than verbal updates. Update the Risk Management Strategy to include the frequency with which the Audit Committee will review the GBAF and Risk Register. Review the adequacy of discussion and challenge in relation to the GBAF and Risk Register at Governing Body meetings, and ensure that these are accurately reflected in the minutes. Conduct a review of the effectiveness of actions to address the GBAF risks. Establish any further risk training needs, through Audit Committee receiving and reviewing outputs from the risk training analysis. Only two recommendations are yet to be fully implemented as follows. CCG conduct a review of the effectiveness of actions/controls in place to address/mitigate the risks on the GBAF. TIAA was informed that this is to be done as part of the review of Risk Management Strategy and implementation of Datix September The Risk Management Strategy be amended to include the frequency with which the Audit Committee will review the GBAF and Risk Register. The update from the CCG states that the Risk Management Strategy is due for annual amendment and will be done at the same time as the implementation of Datix in September Range of individual opinions arising from other core and risk-based audits in the year There was a predominance of reasonable assurance reports issued during 2015/16. Recommendations were made to support the CCG to further strengthen the control environment in these areas and the management responses indicated that the recommendations had been accepted. The following reviews received reasonable assurance: The Contract Management and Monitoring Review gave reasonable assurance. The CCG has put in place many of the expected controls set out within the scope of this audit. Recommendations raised included the following: o Review the effectiveness of actions to address previous deficiencies in the CSU service and report to the appropriate delegated committee. o The redesign of the finance and activity report should be considered in the wider context of information reported across all responsible sub-committees. o The potential risk to the resilience of the CSU Contracting team should be reflected in the CCG's corporate risk register. 73

74 Only one recommendations is yet to be fully implemented and relates to the CCG developing and publishing a Performance Management of Contracts Strategy. The latest update from the CCG states that: The need for this policy was agreed at the end of August 2015 but has not been progressed for capacity reasons. We propose to review this in early 2016 with the new Interim Chief Officer. The Corporate Governance Review (including management of Conflicts of Interest) gave reasonable assurance and found that the CCG s policies and corporate governance processes are in the process of being revised to align them with guidance issued by NHS England. In addition to the areas where controls and processes were found to be operating satisfactorily a number of gaps/improvements in governance have been identified as part of this review including the following. o The resilience and lack of capacity of the governance team is still being addressed and the staffing of the CCG s governance team remains lower than that for comparable CCGs. o There is need to provide relevant training to both the CCG s staff and Governing Body members. Only two recommendations are yet to be fully implemented and lack of capacity was cited as the reasons for the delay in implementation. These relate to the need to ensure that the CCG staff and GP Practices registers of interest be kept up to date, and put in place working with the pharmaceutical industry policy. The QIPP Review gave reasonable assurance and showed that the CCG has implemented many of the expected key controls set out within the scope of this review. A number of routine recommendations have been made to support the CCG as it further develops its processes, as detailed in the Management Action Plan below and include the following: o o The PMO Assurance Process be ratified as soon as possible; and A mechanism be put in place to ensure that each of the opportunities identified in the external report has been adequately explored, and the outcome documented and reported through the PMO. Recommendations raised as part of this review have all been fully implemented. A number of routine (not urgent or important ) recommendations were raised as part of the Performance Reporting Review aimed at supporting the CCG to further develop the CCG s performance reporting arrangements, including: o o Complete the review of the Quality Improvement Strategy as soon as possible. Review the contracting and performance management service specification from the CSU to ensure that all of the services are being received. 74

75 o o o Add the RED-rated under-performance against the Breast Symptom Referrals indicator to the Risk Register. Expand the action logs to show original deadline date and any revised deadline dates. Evaluate and, if necessary, address the potential risks in relation to the resourcing of the Performance and Quality teams as soon as possible. A follow up of the audit recommendations concluded that only the following action (not yet due) is yet to be completed. o The review of the Quality Improvement Strategy to be completed as soon as possible with an implementation date of the 30th June The CCG agreed the action and stated that this was being addressed at the Quality Subcommittee and the subcommittee was expected to approve the strategy. The Critical Financial Assurance Review found that the controls over SBS access and users set up are appropriate and effective. Controls accounts and bank accounts are reconciled in a timely manner and subject to supervisory review. There are controls which ensure that only appropriately authorised journals processed. There is need to strengthen controls over debt management. The controls over SBS access and users set up are appropriate and effective. The only recommendation which is overdue for implementation is one relating to ensure that budget review meetings are structured and minuted. TIAA was informed that budgets are currently being set and uploaded onto the finance system. Budget meetings will begin once the year end final accounts has been completed. The Information Governance Toolkit v13 Review which sought to provide assurance on the integrity of the self-assessment against the toolkit criteria, the overall effectiveness of information governance processes, and wider risk exposures has provisionally been assigned reasonable assurance. The key findings are summarised below: o o o o o Nine of the ten Information Governance requirements included for audit sample testing achieved full compliance at level 2. The IG requirement for Business Continuity reported at level 2 would benefit from stronger evidence to support compliance As a result, a Reasonable Assurance opinion is given. IG staff training completion is above the minimum 95% threshold. The IG Steering Group are meeting regularly. There have been no externally reportable IG incidents. The CCG submitted its assessment against the IG Toolkit by the 31st March 2016 deadline and declared itself as level 2 compliant. 75

76 The following review received a limited assurance opinion: The Individual Funding Requests Review gave limited assurance and recommendations were made as follows: o o o o o IFR Panel members be provided with the training stipulated in the 'Policy and operating procedures for IFR'; Regular management reporting to a committee and stakeholder CCGs be introduced; The revised 'Policy and Operating Procedures for Individual Funding Requests' be ratified as soon as possible; The draft 'Individual Funding Requests (IFR) and Procedures of Limited Clinical Effectiveness (POLCE)' document be ratified as soon as possible; The CCG to ensure that there is evidence that the IFR Panel executed its duties as stipulated in its Terms of Reference be completed. All the audit recommendations have been implemented except for the one relating to the need for the need for CCG to ensure that the IFR Panel complies fully with its Terms of Reference. A revised policy (reflecting current practice) was approved at the Executive Committee on the 15th December 2015 and approved with the new version planned to be added to the CCG s public website in April Other reviews Regular follow up of internal audit recommendations is reported to every meeting of the Audit Committee. There is good progress overall in implementing audit recommendations as reported to the committee at their February 2016 and April 2016 meetings. The lack of capacity has been cited as the reason for the lack of progress in implementing the outstanding recommendations and revised implementation dates have been agreed. None of the outstanding recommendations are considered urgent/high priority. Also see section below with regards to the Adult Safeguarding Arrangements recommendations where urgent action is required regarding to the need to address the capacity issues. Assurances across the CCG Collaborative: Adult Safeguarding Arrangements This jointly funded review received limited assurance and the outcome of the audit was reported to all the CCGs within the collaborative. The implications of the Care Act 2014 are significant, putting adult safeguarding on a statutory basis for the first time. The host CCG s framework to provide assurance to the Governing Body and wider health economy that it is fulfilling its statutory responsibility to safeguard and promote the welfare of vulnerable adults is immature. The audit findings primarily are related to: 76

77 o o o o Risk Management; Safeguarding policy and procedures; Assurance received from providers; and Training. The audit identified the relative immaturity of the statutory framework around safeguarding adults including the numerous policies and guidance that needs to be embedded to ensure that risks are mitigated appropriately. The review also highlighted the lack of resources that are available across the CCG collaborative to undertake this work when compared to that available for Safeguarding Children across the collaborative. A detailed action plan was put together by the Host CCG (NHS Surrey Downs CCG) to address the audit findings and has been shared with all the Quality Leads within the collaborative. In addition to the actions being taken by the other CCGs within the collaborative, the Host CCG has reacted appropriately in raising the profile of this review and also addressing the issues/risks raised within the report. The Audit Committee received a detailed update at their December 2015 meeting from the responsible officers on the progress which has been made etc. with a further update scheduled for the 22nd April 2016 meeting. A follow up of the audit recommendations has been carried out by Internal Audit. Although a number of the recommendations have been implemented the following issues (high risk areas) are yet to be fully addressed. o o o The lack of resources that are available across the CCG collaborative to undertake the work and ensure ongoing compliance with the statutory framework around safeguarding adults including the numerous policies and guidance that also needs to be embedded. TIAA understands there is an ongoing review of the hosted services (including safeguarding) by all the CCGs which is yet to be concluded. The implementation of this and a number of other recommendations depend on the outcome of this review which will determine the future model of provision of this hosted service. Reviewing the policy in relation to the Care Act to ensure alignment. TIAA were informed that this a significant piece of work requiring a lot of staff capacity; hence would require more time to implement. Although progress has been made, an agreed performance framework is yet to be fully developed and embedded. The recommendation also stated that any failure by providers to report data be promptly escalated through an agreed escalation route and a programme of deep dive reviews be agreed. Safeguarding Children (hosted by Guildford and Waverly CCG) The CCG has established a high calibre safeguarding team and is developing a robust framework to provide assurance to the Governing Body and wider health economy that it is fulfilling its statutory responsibility to safeguard and promote the welfare of children. The audit findings primarily related to: 77

78 o o o o Risk management reporting; Safeguarding policy; Assurance-dashboard reporting; and Training Recommendations were made to support the host CCG to further strengthen the control environment in these areas and the management responses indicated that the recommendations had been accepted with clear action plans. A follow up review was carried out and all the recommendations had been implemented. Other assurances from reviews TIAA have carried out across the CCG Collaborative gave the following results: o o o The CCG is a Lead Commissioner for a number of provider contracts. It is also an Associate Commissioner for some of its provider contracts which are led on its behalf by other CCGs within the collaborative. We carried out individual reviews of Contract Management and Monitoring (Provider Contracts) Reviews for a number of CCGs within the collaborative. For each audit we were able to provide reasonable assurance that the lead CCG has effective arrangements for performance managing and monitoring its healthcare providers, including those contracts where NHS Surrey Downs CCG is an Associate Commissioner. North East Hampshire and Farnham CCG lead on the Mental Health and LD contract for Surrey. TIAA carried out a review to provide ongoing assurance on the governance arrangements for the CCG s lead commissioner role for Mental Health and LD Services. The review received reasonable assurance and the key findings are summarised below: o o o A signed Service Level Agreement with stakeholder CCGs has not been in place since 2013/14. It was revised in 2014/15 but was not completed and is in draft. There is good governance and performance monitoring in place via a Mental Health (MH)/Learning Disability (LD) Collaborative Clinical Commissioning (CCC) Forum representing all CCGs. There is an ongoing risk to the composition of the MH/LD CCC Forum due to the high turnover of clinical leads within all of the CCGs. Surrey County Council-Better Care Fund S75 Agreements 2015/16 Review The first Internal Audit Report from the Surrey County Council (SCC) Internal Auditors was shared with all the CCG CFOs in Surrey on the 16th February The first review focused on the Better Care Fund S75 Agreements 2015/16. The scope of the review is as follows: The findings from this audit were based on a review of the S75 Agreements to ensure that they comply with the requirements of NHS England and meet good practice. This audit did not evaluate the controls around the administration of the fund. This will be 78

79 considered as part of a further audit of the BCF planned for Quarter /16. The key findings are summarised below: o The S75 Agreements meet the format required to meet the needs of NHS England. They have been suitably tailored to meet the needs of the local areas. o The agreements commenced on 1 April 2015 and are for 1 year. All were signed on 20 January 2016 except for North West Surrey CCG. This agreement is being amended to include those services being commissioned by the NHS Windsor and Maidenhead CCG and the governance arrangements necessary to reflect their involvement. o There have been significant delays in having the agreements signed and we understand that the delays have not had any detrimental effect on service delivery or outcomes. o The Government has confirmed that the BCF from April 2016 will broadly retain the same emphasis. Local plans will be required to manage further resources in the community to improve the delayed transfers from hospital. Changes will need to be incorporated into the S75 Agreements for 2016/17. o In view of the above and the findings set out in more detail in Section 5 of this report the overall opinion is therefore Some Improvement Needed. The only recommendation raised was for SCC to take all reasonable steps to ensure that the S75 agreements are signed promptly for 2016/17. This is TIAA s corporate opinion and as such it is not required to be signed by the Head of Internal Audit. 79

80 Remuneration and staff report Engaging and developing our CCG team 80

81 Engaging, supporting and developing our staff We directly employ over 179 staff. It sounds a lot but this includes the services we host Surrey-wide (including the medicines management and continuing healthcare teams) which make up over half of this number. Below is a more detailed breakdown. Total staff numbers During 2015/16 our total workforce comprised of an average whole time equivalent of 171 staff. This number excludes Governing Body members, Clinical Directors and clinical leads. The table below shows a breakdown of staff by department or team as of 31 March Team or department Number of staff (whole time equivalent) Referral Support Service 6.0 Individual Funding Request (hosted service) 3.0 Planned care 5.8 Urgent care and integration 1.6 Primary care team 2.0 Medicines management (hosted service) 21.2 Continuing healthcare and NHS funded care (hosted service) 72.6 Executive team 7.0 Quality and patient safety 6.8 Communications and engagement 4.5 Contracts team 4.2 Corporate governance 1.5 Estates and facilities 2.5 Finance 8.3 Human resources 1.6 Operations management 2.0 Programme Management Office 1.0 This table shows a breakdown by gender of CCG employees. Male Female The gender breakdown for the 2015/16 Governing Body as of 31 March 2016 was as follows: Male Female

82 The number of senior staff by band can be summarised as follows: Band Number of staff 8a 13 8b 10 8c 6 8d Very Senior 3 Managers We also work with a number of agency and specialist staff as and when we need them. This gives us more flexibility in how we manage our workforce and it also helps to keep our costs down by only bringing in specialists when we need them for specific projects. We also buy some additional support services (including some contracting, IT and finance support) from South East Commissioning Support. In many cases these staff are based with us so we engage with them in the same way as we would with directly employed staff. That way everyone is up to speed on what s happening and how they are contributing to our wider strategy and objectives. We know how important it is that our staff know, and understand, the bigger picture and what we are trying to achieve together as an organisation so we do our best to take them with us on the journey. We keep them updated on everything we are up to at our face-to-face Team Brief sessions, which happen every other week. They are led by our Chief Officer Ralph McCormack or another member of the Executive Team, and include a welcome to any new faces, an update on the business headlines, a project lead talking about their area of work and any other news we want to share. These sessions are very informal and are also a chance for staff to ask questions and share any news they may have with the rest of the organisation. After each Team Brief we circulate an to all staff with the headlines for anyone who missed it. We also engage with our staff and colleagues through: Regular team meetings teams have regular meetings to help focus and prioritise workloads. These are also a chance for staff to hear about what s happening in other parts of the CCG. Staff appraisal processes as part of our commitment to learning and development every member of staff has a performance setting meeting, a mid year review and an end of year review meeting with their manager. This is an opportunity to talk through how staff are doing against their work programme and to discuss their training and development needs. Through staff surveys we do a survey every year and it s really helpful in telling us how staff are feeling about their job and working for the CCG. Every year we analyse all the feedback we receive and use it to develop an action plan to address key areas and make improvements for our staff. Via our Staff Forum - which meets regularly and is an opportunity for us to engage with a smaller group of staff on a regular basis and to seek their views and input 82

83 on issues as they arise. We want to be recognised as a good employer and that means making sure no job applicants or employees are unfairly disadvantaged. We are committed to equal opportunities for all employees and our employment practices, policies and procedures ensure we meet our responsibilities. We are also committed to tackling discrimination, promoting equality and diversity and protecting human rights. These principles are at the heart of the NHS - they underpin the NHS Constitution and we believe all our staff have a role to play. We have an Equality and Diversity Policy which sets out how we meet our legal duties in this area and we have also developed an action plan, which summarises the key areas we want to focus on. We want to be a caring employer and have a range of policies in place to support our staff, both in terms of their health and well-being and professional development. We actively manage staff sickness and have real time reporting system where staff report any sickness directly through a dedicated HR phone line. When a staff member returns to work following a period of sickness, they meet with their manager to discuss their absence and any help or support they may need to return to work. The graph below shows staff sickness during 2015/16: Developing our staff We believe it s really important to develop our staff and help them to reach their full potential. This year we focussed on the following areas: Our new Leadership Development Programme supports the ongoing development of our middle and senior managers, who will be the leaders of the future. The programme contains a number of modules focused around leadership, communication, managing change, emotional intelligence and negotiation. Developing a Talent Management Strategy 83

84 Supporting the NHS Graduate Scheme Succession planning Training needs are discussed as part of the appraisal process, where specific training needs are identified in line with individual s current role and their future development needs. The type of training, how it will be delivered and the effectiveness measures all form part of this process. Setting a good example and being a good employer We want to be recognised as a good employer and that means making sure no job applicants or employees are unfairly disadvantaged on the grounds of age, disability, sex, gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity or trade union membership, or any other factors that are not relevant to their capability or potential because that would be wrong. We are committed to equality of opportunity for all employees and our employment practices, policies and procedures ensure we meet our responsibilities. For example, we actively promote equality and diversity in our workforce through our policies and practices, ensuring that staff, and potential employees, receive fair, equitable and consistent treatment and are not subject to direct or indirect discrimination. We also believe diversity is a good thing. We recognise everyone is different and equally value the contribution every individual makes to our organisation. As an organisation, we are committed to tackling discrimination, promoting equality and diversity and protecting human rights. These principles are at the heart of the NHS - they underpin the NHS Constitution and we believe all our staff have a role to play. We have an Equality and Diversity Policy which sets out how we will meet our legal duties in this area and we have also developed an action plan, which summarises the key areas we want to focus on in 2014/15. Meeting the needs of any staff, or potential staff, with disabilities and ensuring they are treated equally is part of our duty under the Disability Discrimination Act and this year we have worked with staff to raise awareness about equality issues and the need to consider our protected characteristic groups in how we work, both internally and externally through service redesign. We have a variety of policies that support learning and development, flexible working and many other areas and in line with our equality duties, these are designed with all our staff, including disabled employees, in mind. During 2015/16 we introduced a number of new policies for our staff. These included: Adverse weather and travel disruption policy Alcohol and substance abuse policy Appraisal policy Attendance management policy Clinical appraisal policy 84

85 Disciplinary policy Equality and diversity policy Grievance and dignity at work policy Health and safety policy Lone worker policy Maternity policy Performance management policy Remuneration policy Remuneration for Governing Body members is determined on the basis of reports to the Remuneration and Nominations Committee, taking into account national guidance on pay rates, any independent evaluation of the post and national and market rates. All other managers are covered by terms and conditions set out in the national NHS Agenda for Change arrangements. Individual staff performance is assessed as part of our staff appraisal process, where staff receive objective setting and annual reviews with their managers. In line with national guidance and the Agenda for Change programme, staff progress through an incremental pay scale if their performance during the year has been in line with agreed targets and objectives. Our Remuneration and Nominations Committee has overseen and advised on remuneration issues during 2015/16, ensuring any changes in national guidance or best practice are taken into account. The membership of the committee and further information on its role can be found on page 55. In 2015/16 the membership of the Remuneration and Nominations Committee was: Jonathan Perkins, Lay Member for Governance, Chair (from July 2015) Peter Collis, Lay Member for Governance Miles Freeman, Chief Officer (until October 2015) Dr Claire Fuller as Acting Chief Officer (October to January 2016) Ralph McCormack, Interim Chief Officer (from January 2016) A number of other CCG officers, including the CCG Chair and Chief Finance Officer also attended this committee on a regular basis. The tables on the following pages set out the following information: Salaries and allowances of members of the CCG s Governing Body Pension benefits Cost of other compensation schemes including exit packages 85

86 Remuneration Report Salaries and allowances Name and title Alison Pointu, Independent Nurse on the Governing Body (Until September 15) Antony Collins, Interim Director of Turnaround (From October 15) Note 1 Cliff Bush, Lay Member/Observer (Left 2015/16) Debbie Stubberfield, Independent Nurse on the Governing Body (From November 15) Denise Crone, Lay Member (Left 2015/16) Dr Andrew Sharpe, Epsom Locality GP Member, Caldicott Guardian, Telecare health and COP Lead, IT Lead for Surrey Note 5 Dr Claire Fuller, Clinical Chair of Surrey Downs CCG Note 2 Dr Hazim Taki, East Elmbridge Locality GP Member Note 5 Dr Ibrahim Wali, Epsom Locality GP Member (a) (b) (c) (d) (e) (f) Expense Performance Long-term All pensionrelated payments pay and performance (taxable) to bonuses pay and benefits nearest 100 bonuses Salary (bands of 5,000) (bands of 5,000) (bands of 5,000) (bands of 2,500) TOTAL (a to e) (bands of 5,000) Re-stated (bands of 5,000) Nil Nil Nil Nil Nil Nil Dr Jill Evans, East Elmbridge Locality Chair and Clinical Lead Note Dr Kate Laws, Epsom Locality GP Member and Deputy Chair for GP Commissioning Note 5 Dr Louise Keene, Dorking Locality GP Member Note 5 Dr Robin Gupta, Dorking Locality Chair Note 5 Dr Simon Williams, Epsom Locality Chair and Clinical Lead Note 5 Dr Steve Loveless, Locality Chair (Left 2014/15) Dr Suzanne Moore, Epsom Locality GP Member Note 5 Eileen Clark, Chief Nurse (Previously known as Head of Clinical Quality, Clinical Governance and Patient Safety) Gavin Cookman, Lay Member (Left 2014/15) Gill Edelman, Lay Member for Patient and Public Engagement (2 days per Month from July 15) Jacky Oliver, Lay Member for Patient and Public Engagement (3 days per Month) James Blythe, Director of Commissioning Jonathan Perkins, Lay Member for Governance (4 days per Month from July 2015) Karen Parsons, Chief Operating Officer (Until 30 November 15) Note 6 Dr Mark Hamilton, Secondary Care Consultant Matthew Knight, Chief Finance Officer Miles Freeman, Chief Officer (Until 31 October 15) Note 6 Nicholas Wilson, Local Authority Representative Nil Nil Nil (5-7.5) Nil Nil Nil Nil Nil Nil Nil Nil Peter Collis, Lay Member for Governance and Deputy Chair (4 days per Month) Note 2 Ralph McCormack, Interim Chief Officer (From January 16) Note 1 Dr Russell Hills - Epsom Locality GP Member Note 5 Steve Hams, Interim Director of Clinical Performance and Delivery (From January 16) Note Nil Nil Nil Yvonne Rees, Local Authority Representative Nil Nil Nil Note 3 Note 3 Note 3 Note 4 86

87 Note 1 - The services of these individuals were provided by an interim provider company and the disclosed costs include irrecoverable value added tax, the interim provider's margin, employer national insurance costs and pension contributions. Note 2 - During the period of 1st November 2015 to 4th January 2016, Dr Fuller stepped down from her role of Clinical Chair to become Acting Chief Clinical Officer. Peter Collis became the acting Chair during this period. Note 3- There are no performance pay and bonuses or long term performance related bonus arrangements in place. The taxable expense payments shown relate to the taxable element of the Business Miles rate and are shown in hundreds rather than thousands. Note 4 - The pension related benefits figure (column e) is a prescribed HMRC calculation and excludes the current year's employee contribution to pension. Note 5 - The practices invoice the clinical commissioning group for these services Note 6 - Additional notes below regarding exit packages and payments to past Directors. Payments for Exit Packages Name and title Salary (bands of 5,000) All Pension Related Benefits (bands of 2,500) Other (bands of 5,000) Total (band of 5,000) 2014/ Miles Freeman, Chief Officer (left 31 October 15) Karen Parsons, Chief Operating Officer (until 30 November 15), Director of Transition (from 1 December 15) Payments to past Directors Name and title Salary (bands of 5,000) 2014/ Karen Parsons, Chief Operating Officer (until 30 November 15), Director of Transition (from 1 December 15)

88 Pay Multiples Reporting bodies are required to disclose the relationship between the remuneration of the highest paid Director in their organisation and the median remuneration of the organisation s workforce. The banded remuneration of the highest paid Director of the Governing Body in the Clinical Commissioning Group in the financial year was k. This was 3.77 times the median remuneration of the workforce which was 36,508. In 2014/15, the banded remuneration for the highest paid Director of the Governing Body was k. This was 5.16 times the median remuneration of the workforce, which was 27,624. Therefore, in 2015/16, the median remuneration has increased by 8,884 (32%), mainly driven by an increase in Interim Managers supporting the CCG through NHSE directions to enable a return to financial balance. 2015/ /15 Band of Highest Paid Director's Total Remuneration Median Total Remuneration of the Staff 36,508 27,624 Ratio Total remuneration includes salary, non-consolidated performance-related pay, benefits in-kind, but not severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions. Pension benefits Name and title Real increase in pension at pension age (bands of 2,500) Real increase in pension lump sum at pension age (bands of 2,500) Total accrued pension at pension age at 31 March 2016 (bands of 5,000) Lump sum at pension age related to accrued pension at 31 March 2016 (bands of 5,000) Cash Equivalent Transfer Value at 31 March 2016 Cash Equivalent Transfer Value at 31 March 2015 Real increase in Cash Equivalent Transfer Value Employer's contribution to partnership pension Karen Parsons, Chief Operating Officer (Until 30 November 15) Miles Freeman, Chief Officer (Until 31 October 15) Matthew Knight, Chief Finance Officer Eileen Clark, Head of Clinical Quality, Clinical Governance and Patient Safety Dr Claire Fuller, Chair/Locality Chair/Chief Officer James Blythe, Director of Commissioning Certain Members do not receive officer pensionable remuneration therefore there will be no entries in respect of pensions for certain Members. 88

89 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 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. Off payroll engagements 2015/ /15 Number of existing engagements as of 31 March Of which, the number that have existed: for less than one year at the time of reporting 6 38 for between one and two years at the time of reporting 20 5 for between 2 and 3 years at the time of reporting Nil Nil for between 3 and 4 years at the time of reporting Nil Nil for 4 or more years at the time of reporting Nil Nil All existing off-payroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax, and, where necessary, that assurance has been sought. 89

90 2015/ /15 Number of new engagements, or those that reached six months in duration, between 1 April 2015 and 31 March Number of new engagements which include contractual clauses giving the Clinical Commissioning Group the right to request assurance in relation to income tax and National Insurance obligations Nil Nil Number for whom assurance has been requested Nil Nil Of which: assurance has been received Nil Nil assurance has not been received Nil Nil engagements terminated as a result of assurance not being received Nil Nil Off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1 April 2015 and 31 March 2016 are as follows: 2015/ /15 Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during the financial year. Total no. of individuals on payroll and off-payroll that have been deemed board members, and/or, senior officials with significant financial responsibility, during the financial year * 26 All existing off-payroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax, and, where necessary, that assurance has been sought. *All individuals referenced above are detailed within the Salaries and Allowances table referred to earlier in this report. Spend on consultancy In 2015/16 the CCG spent 636,000 on consultancy costs. This is slightly above the 578,000 we spent on consultancy costs last year. Ralph McCormack Interim Chief Officer 25 May

91 Independent Auditor s Report 91

92 Independent Auditor s Report to the Members of the Governing Body of NHS Surrey Downs Clinical Commissioning Group We have audited the financial statements of NHS Surrey Downs Clinical Commissioning Group for the year ended 31 March 2016 under the Local Audit and Accountability Act 2014 (the Act). The financial statements comprise the Statement of Comprehensive Net Expenditure, the Statement of Financial Position, the Statement of Changes in Taxpayers Equity, the Statement of Cash Flows and the related notes. The financial reporting framework that has been applied in their preparation is applicable law and International Financial Reporting Standards (IFRSs) as adopted by the European Union, and as interpreted and adapted by the 2015/16 Government Financial Reporting Manual (the 2015/16 FReM) as contained in the Department of Health Group Manual for Accounts 2015/16 (the 2015/16 MfA) and the Accounts Direction issued by the NHS Commissioning Board with the approval of the Secretary of State as relevant to the National Health Service in England (the Accounts Direction). We have also audited the information in the Remuneration and Staff Report that is subject to audit, being: the table of salaries and allowances of senior managers and related narrative notes on page 86 the table of pension benefits of senior managers and related narrative notes on page 88 the table of exit packages on page 87. the analysis of staff numbers on pages 81 and 82; and the tables of pay multiples on pages 88. This report is made solely to the members of the Governing Body of NHS Surrey Downs Clinical Commissioning Group, as a body, in accordance with Part 5 of the Act and as set out in paragraph 43 of the Statement of Responsibilities of Auditors and Audited Bodies published by Public Sector Audit Appointments Limited. Our audit work has been undertaken so that we might state to the members of the Governing Body of the CCG those matters we are required to state to them in an auditor's report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the CCG and the members of the Governing Body of the CCG, as a body, for our audit work, for this report, or for the opinions we have formed. Respective responsibilities of the Accountable Officer and auditor As explained more fully in the Statement of Accountable Officer s Responsibilities, the Accountable Officer is responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view and is also responsible for ensuring the regularity of expenditure and income. Our responsibility is to audit and express an opinion on the financial statements in accordance with applicable law and International Standards on Auditing (UK and Ireland). Those standards require us to comply with the Auditing Practices Board s Ethical Standards for Auditors. We are also responsible for giving an opinion on the regularity of expenditure and income in accordance with the Code of Audit Practice prepared by the Comptroller and Auditor General as required by the Act (the "Code of Audit Practice"). As explained in the Annual Governance Statement the Accountable Officer is responsible for the arrangements to secure economy, efficiency and effectiveness in the use of the CCG's resources. We are required under Section 21 (1)(c) of the Act to be satisfied that the CCG 92

93 has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and to report our opinion as required by Section 21(4)(b) of the Act. We are not required to consider, nor have we considered, whether all aspects of the CCG's arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively. Scope of the audit of the financial statements An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of: whether the accounting policies are appropriate to the CCG s circumstances and have been consistently applied and adequately disclosed; the reasonableness of significant accounting estimates made by the Accountable Officer; and the overall presentation of the financial statements. In addition, we read all the financial and non-financial information in the Annual Report to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report. In addition, we are required to obtain evidence sufficient to give reasonable assurance that the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them. Scope of the review of arrangements for securing economy, efficiency and effectiveness in the use of resources We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criterion, issued by the Comptroller and Auditor General in November 2015, as to whether the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined these criterion as that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the CCG put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2016, and to report by exception where we are not satisfied. We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to form a view on whether, in all significant respects, the CCG had put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources. Opinion on financial statements In our opinion the financial statements: 93

94 give a true and fair view of the financial position of NHS Surrey Downs Clinical Commissioning Group as at 31 March 2016 and of its expenditure and income for the year then ended; and have been prepared properly in accordance with IFRSs as adopted by the European Union, as interpreted and adapted by the 2015/16 FReM as contained in the 2015/16 MfA and the Accounts Direction. Basis for qualified opinion on regularity The CCG reported a deficit of 17.9 million in its financial statements for the year ended 31 March 2016, thereby breaching its duty under the National Health Service Act 2006, as amended by paragraph 223I of Section 27 of the Health and Social Care Act 2012, to break even on its commissioning budget. Qualified opinion on regularity In our opinion, except for the effects of the matter described in the basis for qualified opinion on regularity paragraph, in all material respects the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions in the financial statements conform to the authorities which govern them. Opinion on other matters In our opinion: the parts of the Remuneration and Staff Report to be audited have been properly prepared in accordance with IFRSs as adopted by the European Union, as interpreted and adapted by the 2015/16 FReM as contained in the 2015/16 MfA and the Accounts Direction; and the other information published together with the audited financial statements in the annual report and accounts is consistent with the financial statements. Matters on which we are required to report by exception We are required to report to you if we refer a matter to the Secretary of State under section 30 of the Act because we have reason to believe that the CCG, or an officer of the CCG, is about to make, or has made, a decision which involves or would involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency. On 17 May 2016 we referred a matter to the Secretary of State under section 30 of the Act to NHS Surrey Downs Clinical Commissioning Group's breach of its revenue resource limit for the year ending 31 March We are required to report to you if: in our opinion the governance statement does not comply with the guidance issued by the NHS Commissioning Board; or 94

95 we issue a report in the public interest under section 24 of the Act; or we make a written recommendation to the CCG under section 24 of the Act 2014; or we are not satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of its resources for the year ended 31 March We have nothing to report in these respects. Certificate We certify that we have completed the audit of the accounts of NHS Surrey Downs Clinical Commissioning Group in accordance with the requirements of the Act and the Code of Audit Practice. Christian Heeger for and on behalf of Grant Thornton UK LLP, Appointed Auditor Crawley 25 May

96 Financial statements 96

97 Statement of Comprehensive Net Expenditure for the year ended 31 March Note Total Income and Expenditure Employee benefits ,603 8,142 Operating Expenses 5 356, ,999 Other operating revenue 2 (9,087) (11,239) Net operating expenditure before interest 356, ,902 Total Net Expenditure for the year 356, ,902 Of which: Administration Income and Expenditure Employee benefits ,274 2,987 Operating Expenses 5 3,136 4,777 Other operating revenue 2 (232) (311) Net administration costs before interest 6,178 7,454 Programme Income and Expenditure Employee benefits ,329 5,155 Operating Expenses 5 353, ,221 Other operating revenue 2 (8,855) (10,929) Net programme expenditure before interest 350, ,448 Total comprehensive net expenditure for the year 356, ,902 The notes on pages 96 to 122 form part of this statement 97

98 Statement of Financial Position as at 31 March Note Non-current assets: Property, plant and equipment Total non-current assets 34 0 Current assets: Trade and other receivables 9 4,055 6,080 Cash and cash equivalents Total current assets 4,106 6,098 Total current assets 4,106 6,098 Total assets 4,140 6,098 Current liabilities Trade and other payables 11 (44,982) (49,197) Provisions 12 (120) (81) Total current liabilities (45,102) (49,278) Non-Current Assets plus/less Net Current Assets/Liabilities (40,962) (43,180) Non-current liabilities Provisions 12 (235) (161) Total non-current liabilities (235) (161) Assets less Liabilities (41,197) (43,341) Financed by Taxpayers Equity General fund (41,197) (43,341) Total taxpayers' equity: (41,197) (43,341) The notes on pages 96 to 122 form part of this statement The financial statements on pages 91 to 122 were approved by the Audit Committee on 20 May 2016 under the delegated authority of the Governing Body and signed on its behalf by Ralph McCormack, Interim Chief Officer. Ralph McCormack 25 May 2016 Interim Chief Officer 98

99 Statement of changes in taxpayers equity for the year ended 31 March 2016 Changes in taxpayers equity for General Total fund reserves Balance at 1 April 2015 (43,341) (43,341) Transfer between reserves in respect of assets transferred from closed NHS bodies 0 0 Adjusted NHS Clinical Commissioning Group balance at 1 April 2015 (43,341) (43,341) Changes in NHS Clinical Commissioning Group taxpayers equity for Net operating expenditure for the financial year (356,741) (356,741) Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Y (400,082) (400,082) Net funding 358, ,885 Balance at 31 March 2016 (41,197) (41,197) Changes in taxpayers equity for General Total fund reserves Balance at 1 April 2014 (32,398) (32,398) Transfer of assets and liabilities from closed NHS bodies as a result of the 1 April 2013 transition 0 0 Adjusted NHS Commissioning Board balance at 1 April 2014 (32,398) (32,398) Changes in NHS Commissioning Board taxpayers equity for Net operating costs for the financial year (342,902) (342,902) Net Recognised NHS Commissioning Board Expenditure for the Financial Year (375,300) (375,300) Net funding 331, ,959 Balance at 31 March 2015 (43,341) (43,341) The notes on pages 96 to 122 form part of this statement 99

100 Statement of Cash Flows for the year ended 31 March Note Cash Flows from Operating Activities Net operating expenditure for the financial year (356,741) (342,902) (Increase)/decrease in trade & other receivables 9 2,025 (2,914) Increase/(decrease) in trade & other payables 11 (4,215) 13,695 Provisions utilised 12 (62) (21) Increase/(decrease) in provisions Net Cash Inflow (Outflow) from Operating Activities (358,818) (332,003) Cash Flows from Investing Activities (Payments) for property, plant and equipment (34) 0 Net Cash Inflow (Outflow) from Investing Activities (34) 0 Net Cash Inflow (Outflow) before Financing (358,852) (332,003) Cash Flows from Financing Activities Grant in Aid Funding Received 358, ,959 Net Cash Inflow (Outflow) from Financing Activities 358, ,959 Net Increase (Decrease) in Cash & Cash Equivalents (44) Cash & Cash Equivalents at the Beginning of the Financial Year Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year The notes on pages 96 to 122 form part of this statement 100

101 Notes to the financial statements 1 Accounting Policies 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 (despite the issue of a report to the Secretary of State for Health under Section 30 of the Local Audit and Accountability Act 2014). 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. Whilst the Clinical Commissioning Group has reported a deficit in 2015/16, it considers the going concern criteria to be met given a) it is operating to the first year of a proposed 3 year recovery plan that achieves recurrent break even by 2017/18 that has been approved by NHS England and b) it anticipates the continuation of services as recorded in its operating plan and commissioning intentions documents. 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 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. In 2016/17 The Clinical Commissioning Group has entered into three pooled budget arrangements in respect of i) BCF, ii) Community Equipment and iii) Child and Adolescent Mental Health. Further details of each arrangement are contained in Note 15, Pooled Budgets. 1.5 Accounting for Continuing Healthcare (CHC) The Clinical Commissioning Group hosts Continuing Healthcare (CHC) on behalf of a collaborative of Surrey CCGs (Guildford and Waverley CCG, North West Surrey CCG, North East Hants and Farnham CCG, Surrey Heath CCG and East Surrey CCG). As host commissioner, the Clinical 101

102 Commissioning Group administers the CHC service on behalf of the other CCGs in the collaborative, and both the costs of administration and the costs of healthcare are split amongst the collaborative members under a 'risk share' arrangement which is documented in the CHC collaborative agreement. Expenditure on CHC healthcare costs is recorded 'net' in the Clinical Commissioning Groups I & E statement, that is, the Clinical Commissioning Group does not show healthcare provision costs reallocated to other collaborative members under the risk share agreement as income, nor does it show the associated healthcare cost as expenditure: the two are matched off against each other to give the net cost to Surrey Downs CCG only. (See Note 21 Continuing Healthcare) Conversely, receivables and payables in the CCG's balance sheet are shown gross i.e. at their value to the collaborative, not just the Surrey Downs CCG. This balance sheet presentation is consistent with the principle that Surrey Downs is the contracting body with the healthcare provider and Surrey Downs has the legal responsibility for any amount owing and, as such, contractually the receivable or payable belongs in the first instance to the Clinical Commissioning Group. 1.6 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. 1.7 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: Accounting for Accruals Various methods are used for calculating different types of accruals. They include: Trend analysis Expert judgement of Finance Managers Supplier statements Formulaic approach based upon historic cost information Provisions A provision is recognised when the CCG has a legal or constructive obligation as a result of past events and it is probable that an outflow of economic benefits will be required to settle an obligation. In addition to widely used estimation techniques, judgement is required when determining the probable outflow of economic benefits. Any estimates have been made in line with IAS 37: Provisions, Contingent Liabilities and Contingent Assets. Better Care Fund NHS Surrey Downs CCG and Surrey County Council (SCC) jointly run a pooled budget under section 75 of the NHS Act 2006 for the Better Care Fund for which Surrey County Council is the lead commissioner. The financial statements include gross income and expenditure in relation to this pooled budget (see note 15 "Pooled budgets") for further details. Continuing Healthcare As detailed in Note 1.5 above - Expenditure on CHC healthcare costs is recorded 'net' in the Clinical Commissioning Groups I & E statement, that is, the Clinical Commissioning Group does not show healthcare provision costs re-allocated to other collaborative members under the risk share agreement as income, nor does it show the associated healthcare cost as expenditure: the two are matched off against each other to give the net cost to Surrey Downs CCG only. 102

103 Conversely, receivables and payables in the CCG's balance sheet are shown gross i.e. at their value to the collaborative, not just the Surrey Downs CCG. This balance sheet presentation is consistent with the principle that Surrey Downs is the contracting body with the healthcare provider and Surrey Downs has the legal responsibility for any amount owing and, as such, contractually the receivable or payable belongs in the first instance to the Clinical Commissioning Group. Provision for Impairment of Receivables Management will use their judgement to decide when to write off revenue or to provide against the probability of not being able to collect a debt 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: Current Assets Included in the receivables balance are a number of prepayments and accrued income. These may inevitably require an element of estimation. Where estimates have been applied, the CCG has adhered to guidance stipulated in the NHS Manual for Accounts. Payables Trade payables include a number of NHS and non-nhs accruals which will require an element of judgement. Where applicable, the CCG adheres to guidance set out in the NHS Manual for Accounts and relevant financial standards. Prescribing Accrual Prescribing information is sent to the CCG monthly in arrears by the relevant prescribing authorities. This is always at least two months behind the current month. Each month including year end, the CCG has to estimate the year to date expenditure based on the last set of available data. At the year end, the CCG will be estimating prescribing expenditure based on 10 months data, but with information about profiling and extrapolated trends. Non-Contract Activity Non-Contract Activity, tends, by the nature of the activity, to be invoiced late. The CCG has made an estimate of the likely uninvoiced value of the NCAs and accrued for them. Clinical Work in Progress This relates to clinical work being carried out by the providers which is in progress at year-end. The CCG, through discussion with providers, has made a judgement to whether the work in progress should be included in the accounts, based upon materiality. The work in progress is calculated based upon cost of treatment, the number of patients being treated, and the proportion of days in progress against average length of treatment. Contract Monitoring Several of the CCG s contracts with provider Trusts are relatively straightforward as block payments are agreed at the start of the year. However, contracts with acute providers can be complex and information in relation to performance on the contracts may not be fully available when the accounts are being prepared. Negotiations take place with the provider Trusts at yearend and payments / accruals /deferrals for any over or under-performance are agreed. The process is facilitated by an NHS Agreement of Balances (AoB) process at year end whereby respective debit/credit balances between NHS bodies are reconciled at a national level 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. 103

104 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, - 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 Valuation All property, plant and equipment are measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. 104

105 1.12 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. 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 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 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 was 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. 105

106 1.18 Contingencies A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or non-occurrence 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. A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the Clinical Commissioning Group. A contingent asset is disclosed where an inflow of economic benefits is probable. Where the time value of money is material, contingencies are disclosed at their present value 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. Financial assets are classified into the following categories: Financial assets at fair value through profit and loss; Held to maturity investments; Available for sale financial assets; and, Loans and receivables. The classification depends on the nature and purpose of the financial assets and is 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 is determined by reference to quoted market prices where possible, otherwise by valuation techniques. 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. 106

107 1.21 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 de-recognised 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 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 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) 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 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. 107

108 2. Other operating revenue Total Admin Programme Total Education, training and research Non-patient care services to other bodies (A) 8, ,196 8,646 Other revenue ,577 Total other operating revenue 9, ,855 11,239 (A) Of the non-patient care revenue of 8.2m, 5.2m relates to amounts invoiced to other Surrey CCGs for services hosted by Surrey Downs CCG (Continuing Healthcare, Medicines Management IFR and Safeguarding). The remaining 3.0m relates to amounts received from Surrey County Council ( 1.4m) and NHS England ( 1.6m) as contributions to community healthcare services. 3. Revenue Total Admin Programme Total From rendering of services (B) 9, ,855 11,239 Total 9, ,855 11,

109 4. 1 Employee benefits and staff numbers Employee benefits 2015/ Total Admin Programme Total Permanent Employees Other Total Permanent Employees Other Total Permanent Employees Other Employee Benefits Salaries and wages 8,251 5,596 2,655 2,591 1, ,660 3,659 2,001 Social security costs Employer Contributions to NHS Pension scheme Termination benefits Gross employee benefits expenditure 9,603 6,948 2,655 3,275 2, ,328 4,327 2, Employee benefits 2014/ Total Admin Programme Total Permanent Employees Other Total Permanent Employees Other Total Permanent Employees Other Employee Benefits Salaries and wages 7,110 4,781 2,329 2,554 1, ,556 2,930 1,626 Social security costs Employer Contributions to NHS Pension scheme Gross employee benefits expenditure 8,143 5,814 2,329 2,987 2, ,156 3,530 1,

110 4.2 Average number of people employed Total Permanently employed Other Total Number Number Number Number Total Staff sickness absence and ill health retirements Number Number Total Days Lost Total Staff Years Average working Days Lost Staff sickness absence is based on a calendar year i.e. January to December, whereas the rest of the note relates to the financial period April to March 4.4 Exit packages agreed in the financial year Compulsory redundancies Other agreed departures Total Total Number Number Number Number Less than 10, ,001 to 25, ,001 to 50, ,001 to 100, , , ,001 to 150, ,001 to 200, , , Over 200, Total , ,

111 Analysis of Other Agreed Departures Other agreed departures Other agreed departures Number Number Voluntary redundancies including early retirement contractual costs (A) 1 53, Mutually agreed resignations (MARS) contractual costs (B) 1 170, Total 2 223, (A) Relates to a redundancy package of 53K in respect of the former Chief Operating Officer (COO) (B) Relates to Former Chief Officer (CO) and constitutes twelve months salary including on-costs 4.5 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. The Scheme is subject to a full actuarial valuation every four years (until 2004, every five years) and an accounting valuation every year. An outline of these follows: 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 to be paid by employers and scheme members. The last such valuation, which determined current contribution rates was undertaken as at 31 March 2012 and covered the period from 1 April 2008 to that date. Details can be found on the pension scheme website at For , employers contributions of 736,043 ( : 473,587) were payable to the NHS Pension Scheme at the rate of 14.3% of pensionable pay. The scheme s actuary reviews employer contributions, usually every four years and now based on HMT Valuation Directions, following a full scheme valuation. The latest review used data from 31 March 2012 and was published on the Government website on 9 June These costs are included in the NHS pension line of note 4.1 and include Chair's pension costs. 111

112 5. Operating expenses Total Admin Programme Total Gross employee benefits Employee benefits excluding governing body members 8,591 2,447 6,144 7,624 Executive governing body members 1, Total gross employee benefits 9,603 3,275 6,328 8,142 Other costs Services from other CCGs and NHS England 3,375 1,679 1,696 3,608 Services from foundation trusts 99, ,101 96,469 Services from other NHS trusts 119, , ,584 Purchase of healthcare from non-nhs bodies 83, ,520 79,300 Chair and Non Executive Members Supplies and services clinical Supplies and services general 1, ,578 Consultancy services Establishment 1, Transport Premises 4, ,284 4,976 Impairments and reversals of receivables Audit fees Other non statutory audit expenditure Other services Prescribing costs 39, ,797 39,038 General ophthalmic services GPMS/APMS and PCTMS Other professional fees (A) ,669 Education and training Provisions CHC Risk Pool contributions 1, , Other expenditure Total other costs 356,225 3, , ,999 Total operating expenses 365,828 6, , ,141 (A) Includes 70K for TIAA (Internal Audit) Services 112

113 6.1 Better Payment Practice Code Measure of compliance Number 000 Number 000 Non-NHS Payables Total Non-NHS Trade invoices paid in the Year 26, ,253 26, ,923 Total Non-NHS Trade Invoices paid within target 24, ,908 24, ,081 Percentage of Non-NHS Trade invoices paid within target 94.1% 96.8% 93.9% 94.7% NHS Payables Total NHS Trade Invoices Paid in the Year 3, ,706 3, ,019 Total NHS Trade Invoices Paid within target 3, ,682 3, ,430 Percentage of NHS Trade Invoices paid within target 92.0% 98.3% 92.3% 99.3% 6.2 The Late Payment of Commercial Debts (Interest) Act Compensation paid to cover debt recovery costs under this legislation (A) 5 0 Total 5 0 (A) This amount relates to a 'responsible commissioner' dispute where Surrey Downs CCG became liable for late payment costs incurred by another public body. 113

114 7.1.1 Payments recognised as an Expense Buildings Other Total Buildings Other Total Payments recognised as an expense Minimum lease payments 3, ,236 3, ,578 Total 3, ,236 3, ,578 Note: Whilst our arrangements with Community Health Partnership's Limited and NHS Property Services Limited fall within the definition of operating leases, rental charge for future years has not yet been agreed. Consequently this note does not include future minimum lease payments for these arrangements Future minimum lease payments Buildings Other Total Buildings Other Total Payable: No later than one year Between one and five years After five years Total

115 115

116 9 Trade and other receivables Current Non-current Current Non-current NHS receivables: Revenue ,233 0 NHS prepayments NHS accrued income Non-NHS receivables: Revenue 1, ,229 0 Non-NHS prepayments Non-NHS accrued income 1, Provision for the impairment of receivables (929) 0 (192) 0 VAT Total Trade & other receivables 4, ,080 0 Total current and non current 4,055 6, Receivables past their due date but not impaired By up to three months 5 26 By three to six months 98 0 By more than six months Total

117 9.2 Provision for impairment of receivables Balance at 01-April-2015 (192) (20) Amounts written off during the year 20 0 Amounts recovered during the year 0 0 (Increase) decrease in receivables impaired (757) (172) Transfer (to) from other public sector body 0 0 Balance at 31-March-2016 (929) (192) Note: most of the 929K provision for receivables relates to a provision against invoices raised in respect of Continuing Healthcare where there is uncertainty over total payment. Surrey Downs CCG hosts the service on behalf of the other Surrey CCGs as part of a collaborative agreement and the stated provision is the gross amount for the whole collaborative (the amount attributable to Surrey Downs only would be approximately 220K). The accounting treatment for CHC is further explained in the Notes to the Financial Statements (1.5) Receivables are provided against at the following rates: NHS debt 0% 0% Over 1 year 100% 100% Over 6 months 50% 33% Over 3 months 25% 17% 117

118 10 Cash and cash equivalents Balance at 01-April Net change in year 33 (44) Balance at 31-March Made up of: Cash with the Government Banking Service Cash in hand 1 1 Cash and cash equivalents as in statement of financial position Balance at 31-March Trade and other payables Current Current NHS payables: revenue 6,674 9,371 NHS accruals 2,665 6,426 NHS deferred income Non-NHS payables: revenue 14,302 11,111 Non-NHS accruals 19,717 21,258 Social security costs Tax Other payables Total Trade & Other Payables 44,982 49,197 Total current and non-current 44,982 49,

119 12 Provisions Current Non-current Current Non-current Continuing healthcare Other Total Total current and non-current Pensions Relating to Former Directors Pensions Relating to Other Staff Restructuring Redundancy Continuing Healthcare Other Total 000s 000s 000s 000s 000s 000s 000s Balance at 01-April Arising during the year Utilised during the year (62) 0 (62) Balance at 31-March Expected timing of cash flows: Within one year Between one and five years After five years Balance at 31-March Note: Under the accounts direction issued by NHS England on 12 February 2014, NHS England is responsible for accounting for liabilities relating NHS Continuing Healthcare claims relating to periods of care before the establishment of the Clinical Commissioning Group (although the legal liability remains with the Clinical Commissioning Group). The total value of legacy NHS Continuing Healthcare provisions accounted for by NHS England on behalf of this clinical commissioning group at 31 March 2014 is 1,248k. The provision in the financial statements relates to retrospective periods of care dating from April 2013 onwards for which the Commissioning Group is financially liable. 119

120 13 Commitments 13.1 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 (A) 1, In more than one year but not more than five years 0 0 In more than five years 0 0 Total 1, (A) NHS England has established a risk pool arrangement for retrospective claims relating to Continuing Healthcare. This pool is funded by charges to Clinical Commissioning Groups and covers all claims prior to April The CCG's contribution in 2015/16 was 1.046m. The level of contribution to be made 2016/17 has yet to be agreed. 120

121 14 Financial assets Loans and Receivables Available for Sale Total Embedded derivatives Receivables: NHS 1, ,224 Non-NHS 2, ,975 Cash at bank and in hand Other financial assets (0) 0 (0) Total at 31-March , ,250 Loans and Receivables Available for Sale Total Embedded derivatives Receivables: NHS 3, ,233 Non-NHS 2, ,229 Cash at bank and in hand Other financial assets Total at 31-March , , Financial liabilities Other Total Payables: NHS 9,339 9,339 Non-NHS 34,547 34,547 Total at 31-March ,886 43,886 Other Total Payables: NHS 15,797 15,797 Non-NHS 33,260 33,260 Total at 31-March ,057 49,

122 15 Pooled budgets BCF Inc (dec) '000 '000 '000 Income 16, ,033 Expenditure (16,062) 0 (16,062) Community Equipment Inc (dec) '000 '000 '000 Income Expenditure (454) (454) 0 Child and Adolescent Mental Health Inc (dec) 0 '000 '000 Income Expenditure (424) (388) (36) The CCG is a party to three pooled budgets (BCF, Community Equipment, and Child and Adolescent Mental Health) BCF NHS Surrey Downs CCG and Surrey County Council (SCC) jointly run a pooled budget under section 75 of the NHS Act 2006 for the Better Care Fund for which Surrey County Council is the lead commissioner. NHS Surrey Downs CCG contributed m to the pooled budget in , this was after adjusting for 365k retained by the CCG against non-delivery of Non- Elective admission avoidance m of the m was retained by the CCG to fund Out of Hospital Services and a further 1,432m was returned to the CCG for investment in joint Health and Social Care initiatives where the contract was held by the CCG. The balance of m included 6.261m which was used by Surrey County Council for protection of Adult Social Care services. The pooled budget overspend was 29k. The financial statements include gross income and expenditure in relation to this pooled budget. The transactions as described above are summarised below: m Original Contribution Non-elective adjustment (0.365) Revised contribution Out of Hospital services Contracted by CCG Paid to SCC Subtotal (Over)/Underspend (0.029) Community equipment The six Surrey Clinical Commissioning Groups as set out below collectively purchase equipment from a pooled budget under section 75 of the National Health Service Act 2006 jointly run by three Surrey community providers (Virgin Community Healthcare, First Community Healthcare and Central Surrey Health who operate on behalf of the Clinical Commissioning Groups) and Surrey County Council. The legal parties to the pooled budgets are NHS North West Surrey Clinical Commissioning Group (which inherited the contract from its predecessor body, NHS Surrey Primary Care Trust) and Surrey County Council but all Surrey Clinical Commissioning Groups make their payments into the pooled budget. In these financial statements we have recognised Surrey Down's expenditure to the pooled budget only. 122

123 Child and Adolescent Mental Health The Child and Adolescent Mental Health Services Pooled Budget is hosted on behalf of the Surrey Clinical Commissioning Groups by NHS Guildford and Waverly Clinical Commissioning Group. The legal parties to the pooled budget are NHS Guildford and Waverly Clinical Commissioning Group (which inherited the contract from its predecessor body, NHS Surrey Primary Care Trust) and Surrey County Council. In these financial statements we have recognised Surrey Downs expenditure to the pooled budget only. The six Surrey Clinical Commissioning Groups in the pooled Community Equipment and Child and Mental Health Services are: NHS North West Surrey Clinical Commissioning Group NHS East Surrey Clinical Commissioning Group NHS North East Hampshire Clinical Commissioning Group NHS Guildford and Waverly Clinical Commissioning Group NHS Surrey Downs Clinical Commissioning Group NHS Surrey Heath Clinical Commissioning Group 16 Intra-government and other balances Current Receivables Non-current Receivables Current Payables Non-current Payables '000 '000 '000 '000 Balances with: Other Central Government bodies 0 0 3,714 0 Local Authorities ,562 0 Balances with NHS bodies: NHS bodies outside the Departmental Group NHS bodies within the NHS England Group NHS Trusts and Foundation Trusts 1, ,730 0 Total of balances with NHS bodies: 1, ,277 0 Public Corporations and Trading Funds Bodies external to Government 2, ,429 0 Total CCG at 31 March , ,982 0 Current Receivables Non-current Receivables Current Payables Non-current Payables '000 '000 '000 '000 Balances with: Other Central Government bodies ,201 0 Local Authorities 1, ,856 0 Balances with NHS bodies: NHS bodies outside the Departmental Group 2, NHS bodies within the NHS England Group NHS Trusts and Foundation Trusts 1, ,930 0 Total of balances with NHS bodies: 3, ,797 0 Public Corporations and Trading Funds Bodies external to Government ,343 0 Total CCG at 31 March , ,

124 17 Related party transactions Details of related party transactions with member practices and other organisations with which members of the governing body have an interest are as follows Payments to Related Party 2015/ /2015 Amounts owed to Related Party Amounts due from Related Party Payments to Related Party Receipts from Related Party Receipts from Related Party Amounts owed to Related Party Amounts due from Related Party Alison Pointu Consultancy Ltd Ashlea Medical Practice Ashley Centre Surgery Ashtead Hospital 4, Auriol Medical Centre Brockwood Medical Practice Broome Park Nursing Home 1,226 Capelfield Surgery Central Surrey Health Ltd 24, Cobham Health Centre Derby Medical Centre Dorking Healthcare LLP 48 Dorking Healthcare Ltd 7, , Dorking Medical Practice Downs Cottage 85 Eastwick Park Medical Practice Epsomedical Ltd 6, Esher Green Surgery; Fairfield Medical Centre Fountain Practice Glenlyn Medical Centre GP Health Partners Ltd 270 Heathcote Medical Centre Honeywood House Nursing Home 128 Integrated Care Partnership 1, , Lantern Surgery Leith Hill Practice, Capel 1, Littleton Surgery Medwyn Surgery Molebridge Practice Nork Clinic Old Wall Cottage Residential and Nursing Home 249 Oxshott Medical Practice Princess Alice Hospice 1, Shadbolt Park House Surgery St Stephen's House Surgery Stoneleigh Surgery, Stoneleigh Surrey Choices 29 3 Surrey Medical Network 364 Surrey Ultrasound Services Ltd Tadworth Medical Centre Tattenham Health Centre The Longcroft Clinic The Vine Medical Centre Thorkhill Surgery

125 The terms and conditions of these transactions are consistent with transactions with non-related parties. Provision is made for debt where the Clinical Commissioning Group considers it prudent to do so. The Department of Health is also regarded as a related party. During the year the Clinical Commissioning Group has entered into transactions with a number of entities for which the Department of Health is regarded as the parent. The list below sets out those entities where the aggregate spend exceeded 2m, a value which the governing body considers to be material. There has been no change to this list of high value entities from 2014/15 Epsom and St Helier University Hospitals NHS Trust Kingston Hospital NHS Foundation Trust Surrey and Borders Partnership NHS Foundation Trust Surrey and Sussex Healthcare NHS Trust South East Coast Ambulance Service NHS Foundation Trust St Georges University Hospitals NHS Foundation Trust Royal Surrey County Hospital NHS Foundation Trust Ashford and St Peters Hospitals NHS Foundation Trust The Royal Marsden NHS Foundation Trust Guys and St Thomas' NHS Foundation Trust In addition, the Clinical Commissioning Group has had transactions with other government departments and other central and local government bodies. 18 Events after the end of the reporting period There were no events after the reporting period that require disclosure. 19 Losses and special payments 19.1 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 (A) Fruitless payments Store losses Book Keeping Losses Constructive loss Cash losses Claims abandoned Total (A) The administrative write offs relate to debt provisions which are explained further at note

126 19.2 Special payments Total Number of Cases Total Value of Cases Total Number of Cases Total Value of Cases Number '000 Number '000 Compensation payments (B) Extra contractual Payments (A) Ex gratia payments Extra statutory extra regulatory payments Special severance payments Total (A) See note 4.4 for details of extra contractual payments (B) See note 6.2 for details of compensation payment made 20 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 Variance Target Met? Expenditure not to exceed income 337, ,828 (28,607) (A) No Capital resource use does not exceed the amount specified in Directions Yes Revenue resource use does not exceed the amount specified in Directions 328, ,741 (28,607) No Capital resource use on specified matter(s) does not exceed the amount specified in Directions Yes Revenue resource use on specified matter(s) does not exceed the amount specified in Directions Yes Revenue administration resource use does not exceed the amount specified in Directions 6,358 6, Yes (A) Equates to the cumulative deficit currently reported by the CCG to NHS England of 28.6m Target Performance Variance Target met? Expenditure not to exceed income 343, ,141 (10,745) No Capital resource use does not exceed the amount specified in Directions Yes Revenue resource use does not exceed the amount specified in Directions 332, ,902 (10,745) No Capital resource use on specified matter(s) does not exceed the amount specified in Directions Yes Revenue resource use on specified matter(s) does not exceed the amount specified in Directions Yes Revenue administration resource use does not exceed the amount specified in Directions 7,582 7, Yes 126

127 21 Continuing Healthcare Details of the revenue and expenditure relating to Surrey CCGs collaborative Surrey CCGs Collaborative Total Revenue (68,455) (68,257) Total Expenditure 90,271 90, Surrey Downs CCG only Revenue included on Note 2 (3,829) (3,895) Expenditure included on Note 5 25,646 26,

128 Appendices 128

129 Appendix A Governing Body members 2015/16 Register of Interest First name Surname Position on Governing Body James Blythe Director of Commissioning and Strategy, Non voting member Eileen Clark Head of Clinical Quality, Clinical Governance and Patient Safety (Registered Nurse) - Non Voting Antony Collins Interim Director of Turnaround Peter Collis Lay member for Governance Gill Edelman Lay Member for Patient and Public Engagement Dr Jill Evans East Elmbridge Commissioning Locality Chair Miles Freeman Executive Member - Chief Officer Details of interest(s) held during the financial year No interests to declare No interests to declare Director, Canto LTd Non-Executive Director of GLE Group. Self-employed consultant, lecturer and coach, including (but not limited to) services provided under call-off contracts to Civil Service Learning/Capita and to GL Group. Interim Director King s College Hospital Charity. Director Gill Edelman Consulting Ltd. Partner in Esher Green Surgery which holds medical management contract for Dorking and Leatherhead Hospitals (until July 2015). GP Appraiser. Husband works at British Association of Counselling and Psychotherapy. Practice holds shares in Surrey Medical Network Ltd (part year). Clinical Lead for East Elmbridge CMT / Community Hub which provides services to Molesey Hospital (part year). Shareholder in Medics (<5%). Company Secretary LDM Ltd (small legal and project management consultancy operating in financial sector). This company has no current or previous NHS work. Chair 129

130 of Pathways - a charity aiming to provide accommodation, education and mentoring for ex-offenders, based in Kennington, London. Dr Claire Fuller Clinical Chair GP at Longcroft Clinic. Practice holds shares in GP Health Partners Ltd (part year). Governor at Frensham Heights School (part year). Dr Robin Gupta Dorking Locality Chair Shareholder in "DHC" (formerly Dorking Healthcare) and Director of Edge Hill Court Ltd; named GP where Practice has retainers for Broome Park Nursing Home and Old Wall Cottage Nursing Home. Dr Mark Hamilton External Clinical Member - Secondary Care Doctor Steve Hams Interim Director of Clinical Performance and Delivery Dr Russell Hills Epsom Locality Member Dr Louise Keene Dorking Locality Member Employed as a Consultant in Anaesthesia and Intensive Care Medicine at St George's Healthcare NHS Trust. Clinical Director for Critical Care at St George's Healthcare NHS Trust. Also works at Ashtead, Parkside, St. Anthony's and King Edward VII Hospitals as a private anaesthetist. Also undertakes work for Critical Care Ltd at St. Anthony's hospital as an intensive care doctor. Critical Care Services Physician at St George's and Epsom and St Helier hospitals (part year). Director of Curhams Limited and partner is employed by University College London Hospitals. Shareholder in EDICS and Epsomedical. Practice holds shares in GP Health Partners Ltd (part year). Private GP attached at St Anthony's and partner at ICP (part year). GP Partner at Leith Hill Practice, Capel. Shareholder in "DHC" (formerly Dorking Healthcare). Practice has a retainer with Honeywood House Nursing Home in Rowhook (part year). Matthew Knight Chief Finance Officer No interests to declare 130

131 Dr Kate Laws Epsom Locality Member GP Partner at Shadbolt Park House Surgery and EDICS Shareholder Joint owner of Surrey Ultrasound Services. Shadbolt Surgery is also in a partnership with a management company called Integral Medical Holdings (IMH) (part year). Practice holds shares in GP Health Partners Ltd (part year). Ralph McCormack Interim Chief Officer Director of McCormack Health Consulting Limited Dr Suzanne Moore Epsom Locality Member Jacky Oliver Lay Member for Patient and Public Engagement Karen Parsons Interim Director of Transition Jonathan Perkins Lay member for Governance Alison Pointu External clinical member - Nursing GP Partner at Tattenham Health Centre and shareholder in EDICS. The partners of Tattenham Health Centre receive a retainer from Downs Cottage Nursing Home every month for work done over and above the PMS contract. Practice receives income from CSH Surrey as tenants at Tattenham Health Centre (part year). Practice holds shares in GP Health Partners Ltd (part year). Family member employed by Epsom St Helier NHS Trust with whom the CCG contracts, but not in a capacity that raises direct conflicts of interest Related by marriage to another member of staff within the CCG (part year). A trustee of Princess Alice Hospice, a charity which receives some of its NHS grant funding from Surrey Downs CCG, and Director of two subsidiary fundraising companies for Princess Alice, PAH Trading Ltd and PAH Lottery Ltd. Associate with Verita, a company providing independent consultancy to the NHS. Has own consultancy company, Alison Pointu Consulting. Yvonne Rees Surrey County Council Employee of Surrey County Council; Chief Executive of Mole Valley District Council 131

132 Dr Andrew Sharpe Epsom Locality Member Managing Partner at Ashley Centre Surgery and shareholder in EDICS (<5%). Ashley Centre Surgery holds shares in GP Health Partners Ltd (part year). Debbie Stubberfield External Clinical Member - Nurse Clinical Quality Director at NHS Trusts Development Authority (NHS Improvement from 01/04/16); Relative is a clinical negligence solicitor at Hempsons. Dr Hazim Taki East Elmbridge Locality Member Dr Ibrahim Wali Epsom Locality Member. Dr Simon Williams Epsom Commissioning Locality Chair Nick Wilson Local Authority Member - non-voting GP Partner at Thorkhill Surgery. Shareholder in MEDICS (<5%). Hosts community clinics at Thorkhill Surgery (paediatrics, neurology and dermatology). Wife is Director of HT Medical Services Ltd. Practice holds shares in Surrey Medical Network Ltd (part year). Employed as Prescribing Lead for Surrey Downs CCG. GP Partner at Fairfield Medical Centre. Practice holds shares in GP Health Partners Ltd (part year). GP Partner at Molebridge Practice and shareholder in EDICS. Practice holds shares in GP Health Partners Ltd (part year). Employed by Surrey County Council; Director of Surrey Careers Ltd; Trustee of Surrey Education Trust; Director of Surrey Choices Ltd. 132

133 Are we speaking your language? If you would like a copy of this report in large print, on audio tape or translated into your own language please call us on We welcome your feedback If you have any comments about this report we would very much like to hear from you. You can call us on , us at contactus.surreydownsccg.nhs.uk or you can write to us: Communications team NHS Surrey Downs Clinical Commissioning Group Cedar Court Guildford Road Leatherhead Surrey KT22 9AE To find out more about Surrey Downs CCG see our website 133