NHS Tower Hamlets. Clinical Commissioning Group. Annual Report and Accounts 2016/17

Transcription

1 NHS Tower Hamlets Clinical Commissioning Group Annual Report and Accounts 2016/17 1

2 Contents PERFORMANCE REPORT... 3 ACCOUNTABILITY REPORT Corporate Governance Report Members Report Statement of Accountable Officer s Responsibilities Governance Statement Remuneration and Staff Report Remuneration Report Staff Report Parliamentary Accountability and Audit Report ANNUAL ACCOUNTS Audit Report

3 Welcome We are proud to present the 2016/17 annual report and accounts for NHS Tower Hamlets Clinical Commissioning Group (CCG). This year's annual report gives an overview of what we have done over the past year to make Tower Hamlets a healthier and happier place to live. Tower Hamlets is a unique, dynamic and diverse borough and we believe our health and social care services should reflect the needs of our community and be of the highest possible quality. Over the last year we have made significant progress working alongside patients, the public, and health and social care providers to gain a better understanding of what our community needs, and to develop services that best meet those needs. We are very proud that we are among the best Boroughs in London for commissioning and delivering patient outcomes for a very deprived population. During 2016/17 we successfully concluded a procurement for community health services, which will offer patients more joined up health services across the borough and reduce duplication. Further information can be found on page 14. Tower Hamlets CCG is one the top three CCGs nationally against 10 of the Quality Outcome Framework (QOF) clinical measures, including being best value for money in England for blood pressure control. And this winter we were top in London in delivering the seasonal flu vaccine to people aged 65 years and over. We were also second highest in London for delivering the flu vaccination to pregnant women and people with long-term conditions such as diabetes. We have also improved dementia diagnosis rates and we are now the second highest in London. A new report released by Health and Social Care Information Centre (HSCIC) shows that Tower Hamlets dementia diagnosis rate is over 86%. You will find more details of our key achievements throughout this report. We would like to thank all of our partners, the London Borough of Tower Hamlets, Public Health, local hospital and mental health trusts, Healthwatch and the voluntary and community groups that we have worked with over the last year. Without these dedicated professionals we would not have achieved all that we have. We would also like to express our immense thanks and appreciation to our primary care members, CCG staff and Patient Leaders for their on-going commitment and dedication to improving the health and wellbeing of local people, ensuring that local people have access to the best quality services possible. We look forward to continuing to work together to innovate, explore and make the most of the opportunities we have. Jane Milligan Accountable Officer NHS Tower Hamlets CCG Simon Hall Acting Chief officer NHS Tower Hamlets CCG Sir Sam Everington Chair NHS Tower Hamlets CCG 3

4 Section One: Performance Report Jane Milligan Simon Hall Henry Black Accountable Officer Acting Chief Officer Chief Finance Officer 25 May May May

5 Services in Tower Hamlets NHS Tower Hamlets CCG commissions the majority of local health services in the borough, including acute hospital care (such as A&E and maternity services), community care (such as physiotherapy and community nursing) and mental health services. From April 2015, the CCG also became responsible for commissioning primary care services. Other healthcare services are commissioned by different organisations. NHS England commissions services from independent contractors such as dentists, pharmacists and optometrists and also specialised acute services. The London Borough of Tower Hamlets (LBTH) commissions public health services that help promote healthy living. Barts Health NHS Trust is the main provider of acute care for Tower Hamlets. Its largest site is the Royal London Hospital where local residents receive most of their hospital care. Most mental health services are provided by East London Foundation Trust (ELFT) and the CCG and LBTH jointly commission some mental health services ensuring a more joined up approach to physical and mental health. The Tower Hamlets GP Care Group represents all GP practices and is responsible for managing the Tower Hamlets Community Education Provider Network (CEPN). Our providers have recently formed a partnership called Tower Hamlets Together which is made up of the GP Care Group, the CCG, Barts Health, East London Foundation Trust and the London Borough of Tower Hamlets. The partnership focuses on delivering and improving integrated care in Tower Hamlets so that patients receive more joined up and person centered services. We also commission services from social enterprises and the community and voluntary sector, including Compass Wellbeing (talking therapies), Accelerate CIC (wound care) and St Joseph's Hospice (last years of life care). 5

6 Our Objectives NHS Tower Hamlets CCG is a clinically-led membership organisation set up in April 2013, made up of the 36 general practices in Tower Hamlets. Our organisation is led by GPs and healthcare professionals who, between them, have many years' experience caring for patients. We want to make a real improvement to the health of our local people. As a clinically-led organisation, we are committed to working with our stakeholders, patients and their families and together make the best use of resources and staff across health and social care. The CCG is responsible for planning and buying most healthcare services in Tower Hamlets. It's our job to identify how health services in Tower Hamlets can best meet the needs of local people, both now and in the future and we have a statutory duty to address and reduce health inequalities in the borough. To do this, we work closely with our local members, council and NHS trusts, patients, carers and their families and the local voluntary and community sector to ensure NHS resources are used efficiently and to deliver the best possible health outcomes for our population. Our GPs and healthcare professionals are involved in setting the CCG's overall aims, strategic commissioning direction and priorities. Responsibility for detailed planning and operational commissioning of local health services is delegated to the CCG's Governing Body. As a CCG we are constantly seeking to improve services and ensure the financial and other resources we are given are used in the best way to commission safe, effective and high quality healthcare for local people. People's experiences and views, good and bad, help us to understand what we are getting right and where improvements can be made. We have a statutory duty to engage with patients and we work hard to ensure that the concerns of patients and feedback we receive is used to help us to learn and continually improve services. Our corporate objectives relate to the CCG in its entirety, providing the organisation with a clear direction for commissioning intentions; they reflect where we are now as a CCG, and where we want to be in the future as well as our obligation to fulfil our statutory duties. The objectives are used to develop our approach to risk management, inform programme priorities and provide a framework for performance management. There are: 1. To work in partnership to commission high quality hospital services that are accessible, provide the appropriate treatment in the right place, and achieve good patient outcomes for people of all ages living in the borough 2. To commission person-centred, integrated health and care service that are sustainable and that equally meet the mental and physical needs of our residents 3. To contribute towards a financially sustainable and responsive health and care economy which delivers value for money and innovation and supports the appropriate use of services 6

7 4. To support local people and stakeholders to have a greater influence on services we commission 5. To promote equality both as an employer and a commissioner of health care services 6. To create a high performing and sustainable workforce that continuously learns and is engaged in delivering our ambitions. Managing Risk The CCG has assessed its key risks and uncertainties of not meeting its above corporate objectives throughout the year using the Board Assurance Framework. The Assurance Framework sets out the principal risks to delivering our objectives and how these risks are managed. There is an established method to identify, monitor, control and mitigate risks throughout the organisation as part of and within the CCG s Risk Management Strategy and Assurance Framework. The Assurance Framework is presented to the Governing Body at every meeting, so members can review the risks and mitigations and receive assurances that the risks are being managed. Further details on risk are included in the governance statement in section two of this report. 7

8 Our Local Area and Population Tower Hamlets is unique in many ways. Home to around 300,000 people, the local community is very ethnically diverse, with 69% the population comprising of Black, Asian and minority ethnic groups, the largest of these (32%) being the Bangladeshi community. Religion continues to play a prominent role in the lives of many local people, with 66% having a religious belief. The borough also has a relatively young population with 41% of people aged 20-34, compared to 20% across England. Tower Hamlets also has one of the fastest growing populations in London and is expected to reach around 345,000 by Commercial development, including the site of the London 2012 Olympic and Paralympic Games, Thames Gateway and Canary Wharf alongside significant residential development, has resulted in a significant increase in housing over the last few years. The vibrancy of Tower Hamlets is also apparent in its physical and cultural assets including the many waterways, Victoria and Mile End parks, a variety of museums and markets, and the Tower of London (from which it derives its name). All of these elements contribute to the borough's unmatched sense of place and identity. The Challenges in Tower Hamlets Deprivation Tower Hamlets is a borough of contrasts, it is both one of the most deprived areas in England yet it is also home to one the country's main financial centres in Canary Wharf. The level of deprivation in the borough has an adverse impact on the health and wellbeing of local people and places a huge demand on the CCG's resources. The picture around deprivation is changing as the population changes due to the level of development with the borough. In 2010, Tower Hamlets was ranked the 7th most deprived borough in the country with 70% of people living in the 20% most deprived areas of the country. In 2015, it was ranked the 10th most deprived with 58% living in the 20% most deprived areas. This change is most likely due to the influx of new populations into the borough and there remain substantial health inequalities within the borough. Life expectancy is 8.8 years lower for men and 3.9years lower for women in the most deprived areas of Tower Hamlets than in the least deprived areas. A significantly higher percentage of people in Tower Hamlets live in social housing (54%) compared to the rest of London (37%) and, despite the substantial housing growth, high levels of overcrowding 8

9 persist. The borough also has less green space than the national average, with 1.1 hectares per 1000 people compared to 2.4 nationally. Unemployment remains an issue and 10.3% of the working age population are jobless, compared to 7% across London. Just over 3% of the borough's population provide more than 20 hours of unpaid care per week and, of that group, more than half provide more than 50 hours. Health Headlines Many people in Tower Hamlets are living with a long-term condition and hospital admission rates for heart disease and stroke are above the national average. According to the Census 2011 results, 13.5% of people in Tower Hamlets stated they had a long-term health problem or disability that limited their day to day activities (34,300 people). This is slightly lower than the regional and national rates (14.1% in London and 17.6% in England). Other health headlines include: We have the highest child poverty rate in the UK with 34% of children living in poverty although adjusting for housing costs the figures rises to 49% Life expectancy in Tower Hamlets remains lower than rest of country (78.1 years compared to 79.6 years nationally for males and 82.5 compared to 83.2 for females) Approximately 9% of babies born in Tower Hamlets have a low birth weight. A quarter (27.1%) of children aged 10 to 11 years old are obese. Premature death rates from circulatory disease, cancer and respiratory disease are amongst the highest in the UK. Healthy Life Expectancy The high levels of deprivation in Tower Hamlets has a direct impact on the number of years that people remain healthy later in their lives. This means that they begin to develop multiple health problems far earlier in life than elsewhere. On average, a man living in the borough starts to develop health problems from the age of 54 compared to 64 in the rest of the country. For a woman, it is 56 compared to 64. Healthy life expectancy ranks second lowest for men and sixth lowest for women amongst local authorities. This has an effect on both the demand for health services and the complexity of health issues. The annual GP consultation rate for adults aged in the most deprived parts of the borough is up to twice as high as in wealthier parts of the country. The problems that people go to their GP for help with are also, on average, more than twice as complex. 9

10 Given the significant health inequalities within the borough, the CCG takes a life course approach to planning and commissioning services, from birth to the last years of life. The Joint Strategic Needs Assessment (JSNA), produced by the London Borough of Tower Hamlets Public Health team supports us to better understand the health needs of our population. A summary of the key health challenges of our population is provided below in figure one - sourced from our most recent JSNA 10

11 How We Spend Your Money We are accountable for how we spend public money and achieve good value for money for our patients. This is the fourth year of the CCG and good financial control and management is vital for the continued development of the organisation. We aim to improve the health and wellbeing of the people in Tower Hamlets by ensuring that patients and their carers experience the highest possible standards of health and social care. We have a commissioning budget of around 417 million to do this work, which is allocated as shown on the chart below. The financial environment continues to be very demanding. Our allocation in 2016/17 increased by 3% and over the four years as a CCG by 8.78%. However, population growth over the two periods has been 2.2% and 12.38% respectively, placing ever greater demands on the system. In addition, as felt across the UK, the increasing healthcare requirements from the increasing elderly population add to the pressures felt on services and e.g. Tower Hamlets has not been exempt from the significant growth in Accident and Emergency attendances, 5.2% in the year. Our main acute service provider, Barts Health, of which the Royal London Hospital is the prime provider in our area, has consequently seen costs of acute services rise above expectations. In the year, we have been working closely with them to improve services for the patient and the efficiency of those services and have managed to effectively reduce the financial pressures in year. Finally, the CCG has also been able to invest in schemes to further develop services to patients, particularly in the community, to help reduce demand on our acute hospitals. These are referred to fully in the key achievements section of the report. The following section shows how we managed our money and how we measure our performance. Our budget includes: 179 million for hospital care, 83% of which is spent at Barts Health NHS Trust 49.6 million spent on community health services, 7 8 % of which is spent on Tower Hamlets Community Health Services currently provided by Barts Health NHS Trust 48.3 million spent on mental health services, 8 2 % provided by East London Foundation Trust 57.5 million spent on Primary care, 74% relates to Primary Care Co-commissioning 31.6 million spent on prescribing 14.1 million spent on the provision of continuing healthcare 9.4 million spent on ambulance services 11

12 As set out in the 2016/17 NHS Planning Guidance, CCGs were required to hold a 1% reserve uncommitted from the start of the year, created by setting aside the monies that CCGs were otherwise required to spend non-recurrently. This was intended to be released for investment in Five Year Forward View transformation priorities to the extent that evidence emerged of risks not arising or being effectively mitigated through other means. In the event, the national position across the provider sector has been such that NHS England has been unable to allow CCGs 1% non-recurrent monies to be spent. Therefore, to comply with this requirement, NHS Tower Hamlets CCG has transferred its 1% reserve of 3.958m to NHS Barking, Havering and Redbridge CCG s as part of the systems risk agreement. 2016/2017 Service Budget ( 000's) 14,660 8,451 11,040 Acute 42,874 Mental Health 31, ,279 Community Continuing Care Other Non Acute 5,955 14,130 49,578 48,295 Prescribing Primary Care Co Commissioning Other Primary Care Reserves Corporate THCCG Allocation growth vs THCCG Population growth cumulative The financial gap Cumulative 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% Percentage population projection movement GLA cumulative Percentage movement in programme baseline allocation cumulative 12.5m 2012/ / / / / % 3.75% 7.81% 10.16% 12.38% 0.00% 2.30% 3.70% 5.79% 8.78% 12

13 The financial statements in section three provide a more detailed overview of the CCG's financial position for 2016/17. Our Achievements We believe through our achievements and championing of new services for local people we are in a good position to ensure better, safer, world-class care for patients now and in the future. Below are some of the achievements and progress we have made over the last year. Listening to Local Residents 2016/17 also saw the launch of the Community Commissioning Panel (CCP) which is a group of 12 local residents who advise Tower Hamlets CCG about plans and projects from a patient s perspective. The CCP is chaired by the PPI Lay Member who acts as a link between the CCP and Governing Body. The CCP has advised Tower Hamlets CCG on a variety of topics including access to Primary Care, Integrated Personal Commissioning and a borough wide Learning Disability Strategy. The CCP further enables Tower Hamlets CCG to keep patients at the heart of all we do by acting as a patient voice and supporting the CCG to commission services that meet the needs of the local community. Patient Leadership Programme Patient Leaders were involved in excess of 500 hours of activity relating to Health and Social Care engagement during the course of 2016/17. The scope of these activities ranged considerably from attending partnership group meetings, sitting on consultation panels, attending briefing and training sessions, peer mentoring activities, one-to-one meetings with commissioners, health professionals, community members, experts and decisions makers. A recent evaluation of the programme identified four key areas of impact: Influencing provision of local services Influencing and shaping commissioning priorities Redefining and influencing Patient & Public Involvement locally Impression and recognition of Patient Leaders by stakeholders We hope to build upon this impact and further support the Patient Leaders to influence positive change in the NHS in Tower Hamlets. 13

14 Innovation in Community Health Services People in Tower Hamlets will have access to improved community health services under a groundbreaking partnership. We have established an alliance partnership agreement between three local healthcare providers: Tower Hamlets GP Care Group Community Interest Company (CIC), Barts Health NHS Trust, and East London NHS Foundation Trust (ELFT). The partnership will enable local GPs to work much closer with hospital and community trusts to offer patients more joined up health services across the borough and reduce duplication. Services within the partnership range from district nurses visiting people at home to speech and language therapists working with children in schools and local health centres, and include a stroke rehab team who support patient rehabilitation in hospital as well as helping people to get well after they have left hospital, and specialist diabetes nurses. By adopting the alliance model, the CCG and the three providers are looking to build on the strong working relationships they have developed as part of the Tower Hamlets Together vanguard. The partnership approach will improve children s and adult services by: Improving accessibility to provide more people with safe and compassionate care at home or in their local community Transforming community health services in a way that would not be possible in a single organisation. For example, implementing new models of care that support early discharge from hospital providing person-centred care at the right place, at the right time based on the needs of the local Tower Hamlets population Helping local people to achieve better health outcomes being supported by a truly multiskilled team. The new alliance arrangement will also aim to: Reduce health inequalities ensuring that people in Tower Hamlets lead more healthy and fulfilling lives through a longer and healthier life expectancy Provide effective signposting of services and pathways so people understand how and when to access the most appropriate care and avoid unnecessary delays Promote self-management ensuring patients are provided with the knowledge and guidance they require to look after themselves where appropriate Encourage innovation in the design of services and the use of technology, including implementation of a paperless system by April

15 Building Resilience in General Practice Over the last year we have successfully piloted a resilience and Quality Improvement (QI) programme, working directly with four practices to empower them to make operational changes that deliver impact to their patients and staff. Our ambition is for Tower Hamlets general practice to be both the best place to work and to receive care. The programme provides general practice with diagnostic and operational support to tackle operational improvements that deliver impact, as well as build up Quality Improvement capabilities of the workforce in order to take on these challenges in the future. The programme is delivering the following: 1. Equips practices with real-time data on business intelligence & the skills to understand/use this data to drive improvement 2. Embedding QI capabilities in every practice (through weekly sessions with an external QI coach and training for practice staff to lead the process themselves) to enable practices to improve autonomously and make effective, strategic, operational and team changes 3. Delivers team development interventions to ensure the team is able to communicate and make decisions to deliver the changes 4. Provides tools, templates, case studies and learnings from other practices so teams can use time for new work and learn from colleagues 5. Uses collaboratives of practices (with QI coaching facilitation) to work on the most complex problems After a one year pilot phase we are taking the programme to a further 22 other practices in Tower Hamlets. During the pilot phase, practices identified opportunities to increase capacity to meet unmet demand. We have been able to measure the impact of the tests of changes for one practice around the three following axis: - Freeing up GP time through streamlining processes 86 appointments released per week (i.e appointments per year, based on a population of 11K patients) - Optimising skill mix freeing up GP time 15.9 % of GP appointments work shifted to other clinicians ( 531 savings per week for 11K patients) - Capturing capacity lost through DNAs Reduction in DNAs (6% HCA, 2% Nurse,2% GP) leading to a released capacity of 39 HCA, 19 nurse and 45 GP sessions per year for the practice Delivering the General Practice Forward View in Tower Hamlets In April last year NHS England published the GP Forward View, committing an additional 2.4 billion a year to support general practice services across England by 2020/21. This financial support is designed to support a range of areas and through 2015/16 it has allowed us to deliver the following: 15

16 1. A bespoke training package for our local receptionist and clerical staff 2. Additional resource to support the uptake of patient online services 3. On-going delivery of primary care extended access hubs, allowing Tower Hamlets residents to access a GP up to 8pm each evening and between 8am 8pm every weekend Further resource in 2017/18 will support the on-going roll-out of online consultations in Primary Care, additional support and mentoring for Practice Managers, and a further package of training for receptionist and clerical staff, and the recruitment and training of clinical pharmacists. Increasing Access to General Practice We commissioned a contract with the GP Care Group on the Prime Minister's GP Access Fund programme (previously called the PM's Challenge fund) which provides extended hours pre-bookable appointments. The service provides 1250 extra GP appointments, 360 nursing and 280 prescribing pharmacist appointments monthly. Appointments are available Monday to Sunday extended hours in four locality hubs, located in existing practices at St Andrews, Blithehale, East One Health and the Barkantine. Transforming Access to Urgent Care During 2016/17, over one thousand local people in Tower Hamlets engaged with the CCG and had their say on plans to reshape health services in the borough. Tower Hamlets Clinical Commissioning Group (CCG) developed transformation plans in partnership with local residents and patient groups which set out proposed changes to local primary and urgent care services. As part of this process, we worked with the voluntary and community sector to engage with seldom heard groups in order to test these plans and gain further feedback about the proposed changes. People were asked to comment on the plans and to outline why they agreed or disagreed with the proposed changes. The primary care transformation proposed changes focused on: simplifying the general practice registration process and enabling this to be delivered at a variety of sites and on a 24 hour basis having a standardised booking system which could be one website or phone number ensuring everyone in Tower Hamlets is able to access the same support, information and services regardless of where they live or are registered in the borough. The urgent care transformation proposed changes that focused on: having a primary care led service at Royal London Hospital opening the urgent care centre at the Royal London Hospital 24 hours a day, seven days a week allowing the urgent care centre to use more hospital equipment ensuring there is more access to specialist clinicians through the NHS 111 service. 16

17 Based on the feedback received from the community, we were better able to understand how the changes might affect certain community groups and were able to ensure the proposed changes were adapted or carried out in a way that reflected the needs and comments raised by the local community. Mental Health Services Adult mental health services support and treat people with mental ill health including depression, anxiety, and long term mental health conditions. Many people with mental health problems also have long term physical health conditions. Our mental health programme works towards our vision to improve people s health and wellbeing alongside their physical health. We have done this in a variety of ways including improving access to psychological therapies along with improved recovery rates for those using services. We ve developed the psychological therapies treatment offer for adults with an eating disorder, resulting in improved patient outcomes. Working closely with the East London NHS Foundation Trust we ve developed the interface between primary and secondary care, with a particular focus on advice and support to practices. During we have continued our focused development of services for children and young people s mental health in Tower Hamlets. In partnership with the Council, Public Health, East London Foundation Trust, voluntary organisations and other partners we have published our Transformation Plan for children s and young people s mental health that sets out an ambitious programme for the next four year period. We have invested heavily in a number of areas including: A new community eating disorders service started in April 2016, delivering assessment and treatment in Tower Hamlets, Newham and City and Hackney. Increased support for children and young people on the autistic spectrum pathway. A new young people s mental health service has been commissioned using a partnership delivery model with the voluntary sector and offering additional wellbeing interventions. We are working with schools to help them meet the mental health needs of pupils. 24 local schools took part in a series of training days to improve joint working with specialist Child and Adolescent Mental Health Services (CAMHS) and we have provided training for school governors on mental health and for school staff on eating disorders. In addition local CAMHS services have achieved visible improvements in service performance. Thanks to local service management and CCG investment, waiting times have improved dramatically in recent years, falling from 11 weeks in 2013/14 to five weeks to first appointment in 2016/17. 17

18 Children and Young people In 2016/17 Tower Hamlets CCG further developed our programmes of work to improve health outcomes for children and young people. We continued to support the successful Bridge pilot project with Barts Health NHS Trust. This project aims to improve outcomes for children and young people with complex health needs who often need many different specialist services to support their care needs. Their cases are proactively managed and monitored at regular multi-disciplinary meetings between health, social care and education professionals. An independent, qualitative evaluation in 2016 demonstrated the positive benefits of the project for families. During the forthcoming year, we intend to work with our partners to make this business as usual for how we provide care for children with the most complex health needs. We started a project to set up closer links between local GPs and consultants to provide immediate expert clinical advice and ongoing education on dealing with the most common childhood conditions. As a result, fewer children will need a referral to an Outpatient appointment, and for those that do need to see a hospital consultant, many are able to attend a rapid access clinic instead of waiting for an appointment. We plan to expand this project in 2017/18, to make it even easier and quicker for children to be assessed and treated by the right clinician locally. Tower Hamlets CCG is seeking to work ever more closely with the London Borough of Tower Hamlets to align local health, care and education services for children in the borough. We recognise that we need to jointly design and deliver services to support children with Special Educational Needs and Disabilities (SEND), and this is a priority for joint working with our council partners. We will also look at other areas where we can do things differently by working together, including as part of the Tower Hamlets Together Vanguard programme. Maternity In 2016 the new Lotus Birth Centre opened at the Royal London Hospital. This midwifery-led birthing unit sits alongside the labour ward at the hospital and offers an alternative option for women seeking a home-from-home environment for mothers-to-be and their partners. Together with the introduction of the initial booking appointments at the Barkantine Birth Centre, this gives Tower Hamlets women a range of choices about their antenatal care and where they would like to give birth. Tower Hamlets CCG is piloting additional support for women with diabetes before they become pregnant. It is shown that without good management, maternal diabetes can seriously affect a mother and her unborn child. The aim of this pilot is to help women with diabetes prepare for pregnancy by providing access via their GP and practice nurse to specialist advice and care as early as possible. In 2106 Tower Hamlets became a national pioneer site for maternity, together with Newham and 18

19 Waltham Forest. As a pioneer, we want to make it easier and simpler for pregnant women to make informed choices about their antenatal care and place of birth, with online tools that can be accessed from anywhere. We continue to work closely with local mothers, families and volunteers, supporting the Maternity Services Liaison Committee and Maternity Mates, a service to support women who need help the most during their pregnancy and as new mums. Delivered in the community, in partnership with the voluntary sector, these projects seek to provide people with the tools, skills and support they need to manage the day to day impact of living with a long-term condition. Following a local review of maternity services and an inspection by the CQC, Barts Health Maternity was identified as requiring improvement. Tower Hamlets CCG is working closely with the Barts Health team of midwives, obstetricians and managers, as well as the London Borough of Tower Hamlets, to ensure the CQC s recommendations to improve maternity services are implemented successfully. This includes bi-monthly meetings between the CCG, local authority and the Barts Health leadership team for maternity to review progress against the improvement plan and ensure the views and experiences of local women using maternity services are shared to inform this improvement work. Long Term Conditions Self Management Projects Social prescribing links people up to activities in the community that they might benefit from. With growing evidence supporting the use of "social interventions" for people with a range of common physical and mental health problems, this approach is increasingly being introduced around the country. In Tower Hamlets, two GP practices (Bromley by Bow and Mission Practice) piloted a social prescribing approach in 2015/16. In Bromley by Bow, 95% of healthcare professionals surveyed reported seeing a benefit to their patients after the service launch and Mission Practice reported a 27% reduction in consultations, telephone calls and home visits three months after the pilot. In 2016/17, we have rolled out self-management across Tower Hamlets, in partnership with the GP Care group. As such, each Practice in Tower Hamlets now has access to a local social prescribing initiative. Mental Health Support the Mental Health Network estimates that in the UK, 30% of people with a long-term condition have a mental health problem. It also estimates that people with one long-term condition are two to three times more likely to develop depression than the rest of the population and that people with three or more long-term conditions are seven times as likely to develop depression. 19

20 For 2016/17, we have been working with local mental health providers to develop an initiative to provide additional psychological support to these patients. This pilot project is due to commence in April 2017 and will run for a period of 18 months. The evaluation will help to inform future provision and support in this area. Performance CCG Performance Analysis As a statutory body we recognise the importance of providing assurance to our stakeholders and the public so that they have confidence in our ability to commission safe, high quality and sustainable services within the resources that we have available. A regular assessment by NHS England of our operational effectiveness forms part of this process of assurance. How we did last year /16 components of assurance Headline Well Led Delegated Finance Performance Planning rating functions Good Good Good Good Requires improvement Good The assurance process is a set framework we are assessed against. We were good in four out of five domains in 2015/16. "Performance" domain was rated as requires improvement on account of acute failure of constitutional standards. The "headline assessment" was "Good". This is because four components were rated good and only one requires improvement. CCG Assessment Framework NHS England introduced a new Improvement and Assessment Framework for CCGs from 2016/17 onwards. This replaced both the existing CCG Assurance Framework and separate CCG performance dashboard. The aim of the new framework is to provide greater visibility and accountability around whole system effectiveness and to provide specific indicators to be incorporated in Sustainability and Transformation Plans. The new Improvement and Assessment framework has been designed to cover four specific domains. These are: Better Health: this section looks at how the CCG is contributing towards improving the health and wellbeing of its population, and bending the demand curve; Better Care: this principally focuses on care redesign, performance of Constitutional standards, and outcomes, including in important clinical areas; 20

21 Sustainability: this section looks at how the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends; Leadership: this domain assesses the quality of the CCG s leadership, the quality of its plans, how the CCG works with its partners, and the governance arrangements that the CCG has in place to ensure it acts with probity, for example in managing conflicts of interest. Each domain comprises a number of indicators (60 indicators in total). The Clinical Priorities covered identified within the framework are: Mental Health Dementia Learning Disabilities Cancer Maternity Diabetes National independent panels oversee the clinical priority assessments. The first assessments of CCGs clinical priorities were published in June These assessments provided a baseline for future assessments of CCGs by NHS England. The CCG annual assessment categories mirror those used for CQC and Ofsted assessments: Outstanding; Good; Requires Improvement; Inadequate. Annual assessment of the six clinical priority domains will use a different set of categories as follows: Top Performing; Performing Well; Needs Improvement; Greatest Need for Improvement. Outlined below is the initial assessment for NHS Tower Hamlets CCG against the clinical priorities. Better Health Diabetes Initial Assessment Top performing Diabetes patients that have achieved all the NICE recommended treatment targets 45.9% (92% participation in the NDA) People with diabetes diagnosed less than a year who attend a structured education session 8.3% (91.7% participation in the NDA). Better Care Mental Health Initial Assess ment Needs improve ment Improving access to psychologic al therapies recovery rate 50.7% of people who finished treatment People with 1 st episode of Psychosis starting treatment within 2 weeks 100.0% of 19 people with first episode of psychosis Children and young people s mental health services - transformatio n Data issue quality Crisis care and liaison mental health services - transformatio n 80.0% compliance with a selfassessed list Out of area placements for acute mental health inpatient care - transformation 100.0%compliance with a self-assessed list of minimum service expectations for Out of 21

22 moving recovery to starting treatment with a NICErecommende d package of care treated within 2 weeks of referral of minimum service expectations for Crisis Care, weighted to reflect preparedness for transformation Area Placements, weighted to reflect preparedness for transformation Dementia Initial Assessment Estimated diagnosis rate for people with dementia Dementia care planning and post diagnostic support Top Performing 86.3% of the estimated number of people with dementia have a recorded diagnosis 84.1% of patients with dementia whose care plan has been reviewed in the preceding 12 months Learning disability Initial Assessment Needs improvement Reliance on specialist inpatient care for people with LD and/or autism 30 per million registered population Proportion of people with a learning disability on GP register receiving a health check 43% of people on the GP Learning Disability Register that received an annual health check during 15/161 Cancer Initial Assessment Greatest need for improvement Diagnosed at early stage People with urgent GP referral having 1 st treatment for cancer within 62 days One year survival rates from all cancers Cancer experience patient is the average score given by patients asked to rate their care on a scale from 1 to 10 (10 being the best) Maternity Initial Assessment Neonatal mortality and still births Women s experience of maternity services Choices in maternity Needs improvement 8 stillbirths and neonatal deaths per 1000 births. A similar rate to most other CCGs 69.8% is the score out of 100 based on six survey questions. Among the CCGs with the lowest scores 60.7% is the score out of 100 based on six survey questions. A similar score to most other CCGs Outlined below is the current performance for NHS Tower Hamlets CCG against the sustainability and well-led domains. Sustainability Financial plan Green rating Digital interactions between primary and secondary care 58% is the composite indicator value Local strategic estates plan in place In place In-year financial performance Green rating Assessment of whether CCG is likely to meet plan Expenditure in areas with identified scope for improvement (wave 1 CCGs only) 50.0% Improvement score for expenditure on primary care, prescribing, elective and Outcomes in areas with identified scope for improvement 40% Improvement score for activity on primary care, prescribing, elective and non-elective Local digital roadmap in place? Yes. The CCG is a member of a footprint that has an approved Local Digital Road Map 22

23 non-elective admissions admissions Well-led Staff Engagement Index 3.71 engagement index on a 1 to 5 scale (5 good) Progress against workforce race equality standard 0.33 score (higher scores indicate higher differences, 0 indicates equality) Effectiveness of working relationships in the local system 74.4% score based on a 45.6% response rate Quality of CCG Leadership Green rating Probity and Corporate Governance Fully compliant rating As of publication of NHS Tower Hamlets CCG Annual Report the CCG were still waiting on outcome of our annual assessment for The overall rating for and metrics will be published on the MyNHS website. Supporting Provider Performance Barts Health NHS Trust In late March 2015, the Care Quality Commission published a report on the quality of services offered at Whipps Cross Hospital, and in late May a report was released on the Royal London Hospital and Newham Hospital. All three reports gave an overall rating of inadequate and the former Trust Development Authority (now merged with Monitor to form NHS Improvement) placed Barts Health in special measures. This resulted in Barts Health developing a robust improvement plan titled Safe and Compassionate Care. In December 2016, the Care Quality Commission published reports for both the Royal London Hospital and Whipps Cross. The Royal London Hospital moved from inadequate to requires improvement category and Whipps Cross Hospital remained in the inadequate category. At the time of writing this report, we are waiting on the publication of Newham Hospital CQC inspection. During the site management structures have embedded at each site and Barts Health refreshed the Safe and Compassionate Care and developed a further improvement plan titled Safe and Compassionate Care 2 building on improvements made in the original plan. The refreshed plan demonstrates how Barts Health plans for quality improvement go hand in hand, with how they will improve their financial position, and it shows how progress will lay the foundations for tackling wider strategic challenges in the years ahead. Although we have seen many improvements, Barts Health still faces many challenges. Referral to Treatment, A&E wait times and the number of 'never events' still need addressing. We will continue to work alongside Barts Health NHS Trust through monthly clinical quality review meetings and 23

24 quality assurance visits to wards to monitor the improvement of the quality of services, patient safety and patient care. Further information about Barts 'Safe and Compassionate' programme and its progress can be found on their website, East London Foundation Trust In September 2016 East London Foundation Trust (ELFT), our provider for Mental health services, was rated by the Care Quality Commission (CQC) as outstanding in their provision of quality care. The CQC stated that ELFT is a well led trust with a visionary leadership that welcomes innovation. The CCG is committed to supporting ELFT to drive improvements so as to ensure patients receive the required quality of care. Primary Care The Care Quality Commission (CQC) has inspected all GP practices in Tower Hamlets. We are pleased to report that we have one of the highest percentage of practices rated as providing an outstanding or good quality of care to patients. See below: General Practices rated as outstanding by CQC: 8% General Practices rated as good by CQC: 83maternity General Practices rated as requires improvement by CQC: 6% General Practices rated as inadequate by CQC: 3% We continue to work with practices to improve quality of services, patient safety and patient care by proactively building supportive relationships with all our GPs and continuously work to promote quality improvement initiatives. NHS Staff Survey Performance Tower Hamlets CCG took part in the national NHS Staff Survey for the second time in The survey, which was completed by 62.5% of staff, asked 88 questions about peoples experience of working for the organisation. As in 2015, the 2016 results showed that staff overall feel very positive about the organisation, with 85% of respondents stating that they would recommend Tower Hamlets CCG as a place to work and 77% of respondents feeling that Tower Hamlets CCG is a very good or excellent place to work. The results showed that the organisation s top five strengths are: The effective use of patient and service user feedback to inform decision making Staff feeling able to contribute towards improvements at work Staff motivation Quality of appraisals Communication between senior management and staff Additionally, we are particularly proud that staff feel very empowered and supported within their 24

25 roles; 97% of respondents feel that it is important for them to be accountable for decisions, 92% feel able to make suggestions to improve their area of work and 92% feel supported by colleagues. Whilst our results overall are very positive, we recognise that there are areas of development. Since 2015, people were less sure of their responsibilities which could be reflective of a time of change within the organisation, additionally more staff than average are working additional unpaid hours and staff feel that they put themselves under pressure to come to work when they aren t feeling well enough. These and other areas will be addressed via a range of project and further staff involvement, in particular we will be applying for the Mayor of London s Healthy Workplace Charter to assure that the health and wellbeing of staff is supported at work. NHS Tower Hamlets CCG 360 Survey 2017 Performance In 2017, a 360 survey was conducted on behalf of NHS England looking retrospectively at the past year. Stakeholders that were interviewed included the 36 GP member practices, Healthwatch and patient groups, NHS Providers, the local council and neighbouring CCGs. The CCG had the opportunity to invite wider stakeholders that it considered to have important relationships with. 59% of stakeholders took part in the survey, which is an improvement from the 2016 survey and compares well against other CCGs that have a similar patient population to Tower Hamlets. Stakeholders were asked: how well they feel the CCG engages their organisation, patients and public involvement; how confident they feel about its leadership; the CCGs competence and decisionmaking abilities; how well it manages the performance and quality of healthcare services that it commissions and about its plans and priorities. The survey results have told us that there is significant improvement since 2016 in a number of areas including: patient and public involvement section, where 92% of respondents said that the CCG is a very/fairly effective local system leader. 86% of stakeholders who took part in the survey thought that the ambitions of the CCGs plan to improve healthcare in Tower Hamlets are very/fairly good. 93% of stakeholders who took part in the survey thought that the CCGs level of innovation to improve healthcare in Tower Hamlets is very/fairly good. 25

26 Working Together with Our Patients, Public and Partners Patient and Public Involvement Tower Hamlets CCG aims to put the voice of local people at the heart of everything we do. We believe services should be based on local need and focus on the priority issues for our community. That is why involving patients and the wider public is central to service planning and provision, vital for service improvement and leads to a more positive experience of care. Involving local people also gives local people a greater sense of ownership of the health services they use and their own health. We have sought to ensure that health services are provided in a way which promotes the NHS Constitution and are in line with our own Public and Patient Involvement Strategy. We have promoted awareness of the NHS Constitution and our Public and Patient Involvement Strategy among patients, staff and members of the public through our website, key meetings and other channels. The CCG has the core values of the NHS Constitution embedded within its own Constitution. We take great care to engage with patients and the wider public to ensure that they have a genuine influence in how their local services are designed and delivered. There are seven key principles and values set out in the NHS Constitution that guide the way it operates. Principle four states that "the NHS aspires to put patients at the heart of everything it does." As part of this principle, we have actively encouraged feedback from the public, patients and staff and use it to improve services. We also strive to include seldom heard voices by working with the community and voluntary sector and other key stakeholders to utilise existing links into communities who might struggle to access services or navigate the health system due to a variety of complex factors. Our aim is to create a system that provides equal access for all, regardless of background, and we recognise the value of community leaders and organisations in helping us to achieve this aim. We have held our providers to account regarding the standard of patient involvement that they offer by embedding key patient experience indicators within contracts and have worked with patient groups to identify meaningful patient experience indicators. We have enabled patients to make choices with respect to the aspects of health services provided to them. We ensure patients are able to make informed decisions regarding their care by giving them robust information about the healthcare services available in the borough and ensuring they have choice and control over their care. We also ensure that information about care is offered in a variety of formats and languages to make sure everyone is able to access and understand information about their care. We have commissioned services that deliver patient centred care and support planning for people with long-term conditions and mental health needs who are most at risk of a hospital admission. A 26

27 key feature of this is the care planning process where the patient and clinician work in partnership to develop a plan addressing the patient's current and future needs. This care plan is then shared across all providers involved in the patient's care. We have also invested heavily to support patients taking control of their health by: Keeping our member GPs informed about quality and performance standards at our local providers, so they can have informed conversations with their patients at the point of referral Undertaking extensive engagement with patients, the public and stakeholders to inform higher standards of co-production in the transformation of primary and urgent care services. Working in partnership with the Tower Hamlets Together partners to establish a system wide approach to engagement and involvement. Securing additional funding for Tower Hamlets as a national pilot site for allowing services to be more accurately tailored around patients' needs. We work closely and share best practice with our neighbouring CCGs and partners on patient and public involvement and have done this increasingly over the past year as a result of the publication of the Sustainability and Transformation Plans (STP). We have collaborated with the seven CCG s within North East London to inform the public about the STP and have collaborated on workshops and events designed to gather insight about how specific services might be improved across the STP footprint. Over the past year we have taken a new approach to public engagement events. We have worked with the Tower Hamlets Together partners (East London Foundation Trust, Barts Health, Healthwatch, Tower Hamlets Council for Voluntary Services, London Borough of Tower Hamlets and the GP Care Group to create a whole system approach to engagement and have combined our efforts to hold quarterly events where the whole system can engage together and create a streamlined mechanism for patients to have their say about all health services in Tower Hamlets. Community Commissioning Panel 2016/17 saw the establishment of the Community Commissioning Panel (CCP) whose aim is to bring a local voice to the CCG and help shape healthcare in Tower Hamlets from a patient s perspective. Members of the CCP were recruited and trained over the past year and the panel is now live and providing input to key pieces of CCG work. Twelve individuals from diverse backgrounds who live in Tower Hamlets make up the CCP. The CCP provides the patients voice and perspective on appropriate committees, focus groups and patient panels that feed into the THCCG decision making process. This enables THCCG to improve and enhance services and identify areas for improvement. The CCP also provides challenge where appropriate to ensure the needs of service users, patients and carers remain central to the way THCCG works while providing support to THCCG to maximise involvement of key community groups and individuals. 27

28 In order for the panel to influence commissioning in a meaningful way, it is integrated into the CCG s formal governance structure and is chaired by the PPI lay member who sits on the Governing Body. The PPI lay member is able to champion the work and purpose of the panel to the Governing Body and to other key stakeholders. The panel will feed into the Transformation Board and will review and suggest improvements to engagement plans and business cases from the perspective of the patient. Although the panel will have a considerable influence, it will remain independent to enable choice and freedom. Health Conversation Event In May 2016, we held a Health Conversation event where local people could learn more about the health services available in Tower Hamlets and learn about opportunities to be involved in shaping local health services. Local health partners also attended the event to gather views and ideas from the public in order to shape the local services they deliver. Local people were able to talk to senior CCG staff members, ask questions and have their say about the plans for the future of health services in the borough. People were able to vote on their local priorities, give their opinions on new projects and let the CCG know what is important to them. Local residents were also invited to take part in workshops where their views on how primary care could be improved in the future were gathered. The feedback gathered in these workshops went on to shape the primary care strategy for the coming year. The full report on how patients helped shape this strategy can be found here. or full address- ( ) Your Voice Counts Events In August and November 2016 Tower Hamlets CCG participated in two Your Voice Counts engagement events which brought together all of the Tower Hamlets Together partners to engage on topics as a health system rather than as individual providers. This was the first time events of this nature were held, as they represent a move toward engaging as a whole system rather than as individual providers. The benefits of engaging as a whole system reduces engagement fatigue for patients, reduces duplication across the system and creates an opportunity for all providers and members of the public to have a shared conversation about improving healthcare across Tower Hamlets. A key principle that all partners who attend the event adhere to is collecting feedback through creative means like drawing, voting systems, games and other interactive methods that appeal to people of all ages and backgrounds. The two events held this year gathered a wide range of valuable feedback from the public and specifically informed THCCG s Urgent Care transformation strategy as well as gathering further evidence for the outcomes framework that is being developed through Tower Hamlets Together. 28

29 Innovation Bursary Scheme This year, 80,000 was made available to voluntary and community sector (VCS) organisations to fund a number of innovative projects that helped to support some of the key health priorities within Tower Hamlets. The CCG partnered with Tower Hamlets Community and Voluntary Sector (THCVS) to promote and administer the Innovation Bursary Scheme. Voluntary sector organisations have extensive experience of working with local people and a great understanding of the health and well-being needs of the local population and their expertise is vital to THCCG in planning and developing efficient and personalised services. The projects that were funded this year looked at a variety of health issues including mental health, end of life care, digital inclusion and dementia awareness. The projects contributed further insight into methods of delivering patient centred care, served to further the development of best practice and innovation in healthcare and will ultimately lead to improvements to care in Tower Hamlets. Patient Leadership Programme In 2016/17 Social Action for Health was commissioned for the third year by the CCG to recruit, develop and support local people to become Patient Leaders. The Patient Leadership Programme enables local people to get involved and take a leadership role in commissioning, reviewing and designing services at a strategic level with the CCG and other health partners. This year, Patient Leaders were given a virtual tour of the NHS which allowed them to directly access and better understand the part of the health care system in which they were interested in leading change. Additionally, Patient Leaders attended workshops and trainings to learn about the variety of services the NHS offers and to meet CCG commissioners and other stakeholders who could support them with their learning and development. Patient Stories We have promoted the involvement of patients, their carers and representatives in decisions that relate to their care in a variety of ways, including filmed patient stories that focus on a specific patient s experience of using a health service in Tower Hamlets. The patient stories are shared at the beginning of each Governing Body meeting and provide a patient s in depth insight into a specific service while providing suggestions for improvement or the opportunity to share best practice and success stories both internally and externally. The patient stories are another way that THCCG ensures that patient s voices and opinions are not only heard but are given the platform to influence change wherever possible. 29

30 In a recent audit of our Public and Patient Involvement strategy, undertaken by NHS England in Sept 2016, we were assessed as Good. This assessment reflects the innovative approaches we have taken to meeting our statutory duty to involve patients in all that we do. Partnership Working Transforming Services Together Tower Hamlets CCG has joined forces with Newham and Waltham Forest CCGs and Barts Health NHS Trust to develop the Transforming Services Together programme that is looking to invest more than 100 million in new health services and buildings over the next five years. Over the next 15 years, more than 270,000 people are expected to move into east London -the equivalent of another London borough. Without change, this would require the equivalent of 550 extra beds and one million more primary care appointments - something that is unsustainable. More than 1,000 people have been involved in the programme so far including clinicians, key stakeholders and members of the public. The work has now been published in a Strategy and Investment Case The programme aims to shift activity into fit-for-purpose settings of care, often close to home, enable better prevention of ill health, help people access high quality, appropriate care earlier and more easily and focus some specialisms in fewer locations to improve patient outcomes and experiences and drive up efficiencies. In Tower Hamlets, there will be a specific focus on developing a plan for the Mile End site, the Royal London Hospital will be a better 'local' hospital as more patients from Newham and Waltham Forest would have their surgery locally and although some people may have to travel to Newham Hospital rather than the Royal London for surgery, outpatients will still be local. The Royal London would also become a better 'specialist' centre as planned and emergency care will be separated. Tower Hamlets Together We are a partner of Tower Hamlets Together (THT), a partnership of local health and social care organisations with an ambition to improve the health and wellbeing of people living in Tower Hamlets. The other organisations involved are: - Local Borough of Tower Hamlets - Tower Hamlets GP Care Group CIC - East London NHS Foundation Trust - Barts Health NHS Trust - Tower Hamlets Council for Voluntary Service 30

31 Recently there have been two significant developments that will strengthen the Tower Hamlets Together partnership even further. Firstly, in 2015, Tower Hamlets was awarded Vanguard status by NHS England for its multi-speciality community provider programme. This means the programme receives support from NHS England to develop innovative models of care which other parts of the country can then learn from. Secondly, in April 2016, Tower Hamlets CCG announced that the partnership was to become the new provider of community health services (such as community nursing) in the borough. This will enable even better coordinated care to be provided to patients, outside of traditional hospital environments. Although Tower Hamlets Together is made up of a number of different partners, we are striving to develop a shared culture which provides person-centred, coordinated care to everyone who uses our services. Health and Wellbeing Strategy There is a recognition from Tower Hamlets Clinical Commissioning Group and the London Borough of Tower Hamlets that both organisations need to work together to tackle the wider determinants of health and wellbeing. Working in partnership will create real opportunities to learn from each other s experiences and lessons and create a more joined up coherent system of care for the residents of Tower Hamlets. This will improve outcomes and service user experience, two of the key priority areas for staff and senior management. It should also drive improvements in the quality of care and services commissioned and in turn deliver efficiencies and savings necessary to keep the system sustainable now and in the future. Tower Hamlets is already moving towards joint working through the work of the Joint Commissioning Executive. We have cooperated with our Health and Wellbeing Board in relation to the discharge of the Health and Wellbeing Board's functions. As part of our ongoing work with Tower Hamlets Council, we work closely with our Health and Wellbeing Board. The CCG has been an active member of the board's executive group and has played a key role in its development of a local mental health strategy and implementation plan, and integrated care programme. Sir Sam Everington, Tower Hamlets CCG Chair is also Vice-Chair of the Health and Wellbeing Board. The CCG has been embedded throughout the entire process to refresh the health and wellbeing strategy, developing the five priority areas: Communities Driving Change changes led by and involving communities Creating a Healthier Place - changes to our physical environment Employment and Health - changes helping people with poor working conditions or who are unemployed Children s Weight and Nutrition -changes helping children to have a healthy weight, encouraging healthy eating and promoting physical activity Developing an Integrated System changes which will join up services so they are easier to understand and access 31

32 Better Care Fund (BCF) The Better Care Fund is a scheme run jointly by the Department of Communities and Local Government and the Department of Health, which requires Clinical Commissioning Groups and local authorities to pool budgets and to agree an integrated spending plan for how they will use their Better Care Fund allocation. The programme was launched in In Tower Hamlets we have used the Better Care Fund to provide a joint commissioning framework for the services that we and the London Borough of Tower Hamlets provide to adult residents within the integrated care programme. In 2016/17 we used the Fund to deliver services including dementia cafes, that provide information, advice, and peer support to people with dementia and their carers; to provide falls prevention training in care homes to prevent unnecessary falls and injuries; to deliver multidisciplinary care coordination and care planning for those with multiple long term conditions and complex needs; and a range of other programmes designed to keep Tower Hamlets residents stay healthy and live independently for as long as possible. In 2017/18 we are planning to use the Better Care Fund programme as a platform for developing closer joint working between London Borough of Tower Hamlets and the Clinical Commissioning Group to improve integrated care, reduce duplication in the way that services are delivered, and ensure that our shared approach to commissioning improves patients experience, delivers improvements in health and wellbeing, and provides value for money. Tower Hamlets Council for Voluntary Services As the umbrella organisation for the third sector in Tower Hamlets we work with the Tower Hamlets Council for Voluntary Services so we can support the sector to help us to commission services that improve the health and wellbeing of our communities and reduce health inequalities. We have done this in a variety of ways in 2016/17 including funding a post to support the roll out a borough wide social prescribing project and to develop capacity and leadership within the sector. Healthwatch Tower Hamlets Tower Hamlets CCG works in close partnership with Healthwatch Tower Hamlets to ensure that local people play a central and meaningful role in improving the health and wellbeing of the local community. We have demonstrated that by working together, alongside partners such as public health, social services and the voluntary and community sector, we can reach further into the local community and engage through a wider and more public-facing approach. 32

33 Looking Ahead The NHS in east London faces the very real challenge of providing care for a growing local population, whilst continuing to meet the health needs of some of the most deprived areas anywhere in the UK. Providing for today whilst planning for a tomorrow, at a time when budgets are unlikely to rise at the same rate as demand, will require us to think differently about how we provide care. We will need to make changes to where and how care is provided if we are to meet the growing needs of local people. Our ultimate goal over the next five years is to move to a new way of working where people are truly at the centre of their care, removing any organisational of professional barriers, in order to make Tower Hamlets the healthiest community it can be. We want to help the population to plan their care proactively, and empower them to play a larger role in their health and care, and at the same time be able to have better access to higher quality, seamless services. To do this, and overcome the challenges we continue to face, we will be shifting our focus to two main areas that involve transforming hospital care, and bringing care close to home. Accountable Care Systems Over the last year, with the freedom that the Five Year Forward View has provided and given our strong history of integrated care work, the CCG Governing Body has been thinking about how we should commission in the future. What has emerged is the concept of an Accountable Care System (ACS) for Tower Hamlets that has the potential to address some of the systemic challenges we face. Accountable Care Systems is an all-encompassing term that brings together a number of different elements of commissioning to facilitate a more systemic and integrated system. It offers a framework for providers to take responsibility for the cost and quality of care for a defined population within an agreed budget. ACSs can take many different forms however what they all have in common is a defined population, a uniform payment mechanism and a clear focus on health outcomes. In Tower Hamlets we are already working on many of the building blocks that make up an Accountable Care System such as paying providers in a different way (capitation), commissioning based on outcomes, and facilitating greater partnership working through commissioning. We are currently exploring how we work with Tower Hamlets Together to bring all these strands together to develop a system wide partnership. East London Health and Care Partnership Sustainability and Transformation Plan (STP) Across north east London (NEL), the health and care system- clinical commissioning groups, providers and local authorities- have come together to form the East London Health and Care Partnership (ELHCP), and have worked together to develop a system-wide sustainability and transformation plan (STP). 33

34 The plan will set out how local health and care services will transform and become sustainable over the next five years, building and strengthening local relationships and ultimately delivering the Five Year Forward View vision. For the NHS to meet the needs of future patients in a sustainable way, we need to close the gaps in health, finance and quality of care between where we are now and where we need to be in 2020/21. The STP is an opportunity to continue to work together over the north east London area and look at how we can do this better. This is a challenging piece of work, but the opportunities to improve care and the quality of health and care services are considerable. Further information can be found at: 34

35 Other CCG Roles and Statutory Responsibilities Safeguarding The CCG has a statutory duty when it comes to the safeguarding of both adults and children. We have discharged our functions with regard to the need to safeguard and promote the welfare of children. The CCG fulfils its safeguarding children and vulnerable adult's responsibilities and we have statements outlining our commitment which forms the basis for our safeguarding activity. We have secured the expertise of all statutory safeguarding children and vulnerable adults' posts and there is a clear line of accountability to the Governing Body through its leads for safeguarding children and vulnerable adults. These leads, along with the designated professionals and named GP, are all represented at local safeguarding children and adults board and its sub-groups. The CCG also has safeguarding children and adults commissioning groups which report into a sub group of the Governing Body. In addition to this, the CCG has its own safeguarding policies to ensure safeguarding children and vulnerable adults is considered throughout the commissioning process. The CCG has completed a section 11 audit for local safeguarding children board to show how it is meeting its statutory obligations and have recently completed a deep dive in which we were assured as meeting our statutory requirements. The CCG ensures that local health providers meet their statutory obligations through a range of monitoring activities: A performance dashboard Attending their respective safeguarding committees Ensuring they have a range of polices in place that enable their staff and their organisation to safeguard children and vulnerable adults Evaluating their section 11 returns Completing quality visits focused on safeguarding children and vulnerable adults Through the designated professionals, providing safeguarding children supervision of the named professionals. Presenting annual safeguard reports for children and vulnerable to the Governing Body Annual safeguarding training for the Governing Body 35

36 The CCG ensures that lessons are learnt from serious case reviews and domestic homicide reviews by disseminating key findings and learning to its Governing Body and staff. The CCG monitors providers on their response to serious case review and domestic homicide review recommendations and on recommendations arising from the CCG's review of the health arrangements. Equality and Diversity One of the key challenges for the CCG is ensuring communities experience equitable health outcomes across the borough. To support the system to achieve this we need to: ensure we effectively identify the needs of our local population using robust analysis of diversity and inclusive engagement commission effectively to meet the of our population by working in partnership working and applying good governance be open and transparent about providing health inequality information and the outcomes we have achieved continuously analyse the impact of our work on protected groups both in the community and our workforce. We have worked closely with our staff, providers, the local authority and the voluntary and community sector to deliver our equality ambitions. We have provided training to our staff and Governing Body members to ensure that our equality objectives have been implemented. A full progress report on how we have implemented our equality objectives can be found in Equality and Diversity Strategy which can be on our website ( Tower Hamlets CCG is committed to working closely with, and supporting, the voluntary sector and we funded a community intelligence bursary scheme in 2015/16 which reached out to over 17 communities to gather intelligence about local people experiences of health and social care services which was fed into our planning for 2016/17. A full report of the scheme can be found on the Healthwatch Tower Hamlets website ( In 2016/17 we developed a new Equalities Strategy which will includes a new set of equality objectives and an action plan is currently being developed which will take a programme-based approach to implementing strategy. 36

37 Education, Training, Research and Development As a CCG we have a key role in developing the commissioning system and improving outcomes by using and promoting innovation, research, education and training. We know high quality commissioning is underpinned by robust research evidence and this is an integral part of managing a healthcare system. In light of this, we have adopted an evidence-based approach and culture with our commissioning functions that promotes research, innovation, education and training as the key delivery mechanisms to achieve improvement and better outcomes for patients. We have promoted innovation, research, education and training through our research and evaluation strategy, led by a Governing Body clinical lead. Its aim is to build a culture of research locally through leadership, partnership and professional development and education. We have supported the development of our Community Education Provider Network (CEPN) which has worked alongside our Governing Body lead for education to ensure our future workforce has the right skills for the NHS of tomorrow. We continue to provide protected learning time sessions for the primary care workforce which is delivered in partnership with CEPN. As part of our ongoing commitment to an evidenced based approach, we commission the Clinical Effectiveness Group and Queen Mary University to undertake research on our behalf and identify best practice in commissioning. We are currently supporting the East London Mental Health Trust with a research project to test a targeted standardised intervention to expand the social networks of people with psychosis which has been part funded by the National Institute for Health Research. We are also members of UCLP, an academic science health partnership, in which we have actively sought to create and develop improvements for local people. Our workforce is our most important resource and we are committed to supporting people to learn, develop and grow. We recognise that people need to learn within their current roles and to have opportunities to develop their potential for new roles and responsibilities. The ongoing learning and development of our workforce is especially important in times of change where adaptability and collaboration is crucial. We support the learning and development of our whole workforce; our staff, the Governing Body and our Clinical Leads. Our appraisal process, which has a focus on performance development through feedback, allows people to identify their learning and development needs and establish a plan of activities that will meet those needs. We encourage people to undertake learning in development in an eclectic way, with a focus on real-life, work based situations, such as undertaking new projects, shadowing or secondments. We have a number of staff who have been 37

38 successful in securing places on centrally funded leadership development programmes run by the NHS Leadership Academy such as the Elizabeth Garrett Anderson and Stepping Up programmes. We run regular Lunch and Learn sessions, where staff have the opportunity to learn about a range of topics pertinent to their role (such as safeguarding children, fraud and bribery). Our Governing Body has monthly Organisational Development sessions which allow them to focus on specific areas of learning or development. For example, this may be learning about new strategic policy or direction, hearing about the work of partners and getting involved in its development or undertaking group learning and development such as team building or understanding financial analysis. NHS Tower Hamlets CCG is committed to the safety and welfare of its staff. To ensure the organisation and new starters comply with the statutory legislation and mandatory requirements identified by national and local guidelines, all employees must undertake and keep up to date with mandatory training requirements. Mandatory training is required of our whole workforce; staff, Governing Body members and Clinical Leads, with six modules required for compliance. Our overall 2016/17 compliance rate for mandatory training was 81%. The table below shows the compliance levels for each of the six mandatory training modules. Mandatory training module Compliance Information Governance 96% Safeguarding Adults level 1 82% Safeguarding Children level 1 83% Equality, Diversity and Human Rights 83% Fire Safety Awareness 76% Health, Safety and Welfare 79% Emergency Preparedness Resilience and Response We have taken appropriate steps to secure that we are properly prepared for dealing with a relevant emergency. The CCG has incident response plans in place, which are compliant with the NHS Commissioning Board Emergency Preparedness Framework As a 'category two responder' w e have defined roles and responsibilities under the Civil Contingencies Act 2004 with a requirement to act in accordance with the NHS Guidance for Emergency Planning

39 We fulfil our responsibilities by having plans and mechanisms in place to cooperate and support NHS England with Emergency, Preparedness, Resilience and Response planning and mobilisation of all providers (that the CCG commissions) should the need arise. We maintain business continuity plans for the CCG and also provide local knowledge and information as needed to NHS England. We also ensure that contracts with NHS-funded provider organisations contain relevant Emergency Preparedness, Resilience (including business continuity) and Response elements. Sustainability We are committed to embedding sustainability into our operations and to encourage key partners and stakeholders to do the same. NHS Tower Hamlets CCG seeks to embed the six principles of sustainability outlined in its Sustainability Policy into its business decisions so that sustainable development objectives are met. 1. Commissioning: The CCG is committed to taking a whole system approach to sustainable commissioning to seek ways to reduce costs and resources, produce health benefits and embrace sustainable procurement. 2. Waste: We continue to move towards our aim of becoming a paperless organisation by reducing the number of printers we have and using 'follow me' printing which cuts down on unnecessary printing and wastage. We have also issued to all staff and Governing Body members mobile devices that enable our meetings to reduce use of paper. 3. Training: The CCG is committed to the ongoing training and education of its staff so it is able to deliver its services in the most effective and sustainable manner possible. 4. Energy: The CCG is committed to minimising its consumption of non-renewable energy sources and to continually research alternative sources and technology to reduce consumption of energy across all activities. We continue to support the widespread use of mobile devices and tablets for all staff in meetings to reduce power consumption and paper usage with the aim of minimising the use of paper. We have also increased the use of recycled paper and toners for printers. Our staff are encouraged to take responsibility for energy consumption and carbon reduction within their work environment, including turning off equipment and lights when not in use. Our motion sensitive lighting means that we do not unintentionally leave lights on overnight. 5. Transport: The CCG is aware of the environmental impacts of its transport operations and will develop a comprehensive management plan to focus on reducing the environmental 39

40 impact of transport, including unnecessary travel. Good practice in sustainable and healthy travel choices is promoted in a number of ways. We encourage and support staff to take up cycling and reduce driving (in turn reducing carbon emissions). Employees also have access to two Brompton folding bicycles for work journeys. 6. Procurement: The CCG advocates that procurement managers and suppliers working with the CCG ensure that products, services and materials it purchases are as sustainable as practical. 40

41 Section Two: Accountability Report Jane Milligan Simon Hall Henry Black Accountable Officer Acting Chief Officer Chief Finance Officer 25 May May May

42 2.1 Corporate Governance Report Membership Details Unless otherwise specified, the time period relating to the membership of all committees is for the financial year and up to the signing of the annual report and accounts. Details of Chair and Chief Officer, our Member Practices and Governing Body The Chair of Tower Hamlets CCG is Sir Sam Everington, a local GP who works in Bromley by Bow. The CCG's Accountable Officer is Jane Milligan, who has worked locally in the NHS for the past 15 years. Simon Hall joined the CCG as Director of Commissioning in May 2016 but has been the Acting Chief Officer since September 2016, as Jane Milligan took up the post of Acting Executive Lead for North East London Sustainability and Transformation Plan. The CCG's membership is made up of all 36 local general practices, who are grouped together to form eight commissioning networks. The member practices and their networks are shown below in figure 2. A full list of these practices can also be found on the CCG website here, Each of the eight networks that make up Tower Hamlets elect a representative to the CCG Governing Body to make decisions on their behalf and the CCG s Chair and Principal Clinical Leads are then elected from these representatives. An overview of the composition of the Governing Body and its committees, including a full list of the Governing Body members, can be found in the Governance Statement included in this report. The CCG demonstrates its accountability to its members by: appointing independent Lay Members and non GP clinicians to its Governing Body holding meetings of its Governing Body in public meeting annually in public to publish and present its annual report and accounts. Figure 2: NHS Tower Hamlets Networks 42

43 43

44 Register of Interests We publish a register of members', employees and interests on the CCG's website: This is updated as and when changes are notified to the CCG. The register gives details of company directorships or other significant interests held by members and senior managers where those companies are likely to do business, or are possibly seeking to do business with the NHS, where this may conflict with their managerial responsibilities. Statement of Disclosure to Auditors Each individual who is a member of the CCG at the time the Members Report is approved confirms: so far as the member is aware, there is no relevant audit information of which the CCG s auditor is unaware that would be relevant for the purposes of their audit report the member has taken all the steps that they ought to have taken in order to make him or herself aware of any relevant audit information and to establish that the CCG s auditor is aware of it. Modern Slavery Act NHS Tower Hamlets CCG fully supports the Government s objectives to eradicate modern slavery and human trafficking but as we do not directly provide goods or services, it is not required to produce an annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act Personal Data Related Incidents NHS Tower Hamlets CCG reported no Serious Untoward Incidents during 2016/17 relating to data security breaches that required Information Commissioner notification. 44

45 2.12 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 Chief Officer to be the Accountable Officer of NHS Tower Hamlets Clinical Commissioning Group. The responsibilities of an Accountable Officer are set out under the National Health Service Act 2006 (as amended), Managing Public Money and in the Clinical Commissioning Group Accountable Officer Appointment Letter. They include responsibilities for: The propriety and regularity of the public finances for which the Accountable Officer is answerable, For 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), For safeguarding the Clinical Commissioning Group s assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities). The relevant responsibilities of accounting officers under Managing Public Money, Ensuring the CCG exercises its functions effectively, efficiently and economically (in accordance with Section 14Q of the National Health Service Act 2006 (as amended)) and with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the National Health Service Act 2006 (as amended)), Ensuring that the CCG complies with its financial duties under Sections 223H to 223J of the National Health Service Act 2006 (as amended). 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 Group Accounting Manual 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 Group Accounting Manual issued by the Department of Health have been followed, and disclose and explain any material departures in the financial statements; and, Prepare the financial statements on a going concern basis. 45

46 To the best of my knowledge and belief, I have properly discharged the responsibilities set out under the National Health Service Act 2006 (as amended), Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter. I also confirm that: as far as I am aware, there is no relevant audit information of which the CCG s auditors are unaware, and that as Accountable 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 CCG s auditors are aware of that information. that the annual report and accounts as a whole is 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 46

47 2.13 Governance Statement Introduction and Context NHS Tower Hamlets Clinical Commissioning Group is a body corporate established by NHS England on 1 April 2013 under the National Health Service Act 2006 (as amended). The clinical commissioning group s statutory functions are set out under the National Health Service Act 2006 (as amended). The CCG s general function is arranging the provision of services for persons for the purposes of the health service in England. The CCG is, in particular, required to arrange for the provision of certain health services to such extent as it considers necessary to meet the reasonable requirements of its local population. As at 1 April 2016, the clinical commissioning group is not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006 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. I also acknowledge my responsibilities as set out under the National Health Service Act 2006 (as amended) and in my Clinical Commissioning Group Accountable Officer Appointment Letter. I am responsible for ensuring that the clinical commissioning group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. I also have responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group as set out in this governance statement. Governance Arrangements and Effectiveness The main function of the Governing Body is to ensure that the group has made appropriate arrangements for ensuring that it exercises its functions effectively, efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it. The overarching governance arrangements are set out in the Constitution which includes the CCG Governance Structure, Standing Orders, Prime Financial Policies and the Scheme of Reservation and Delegation. The CCG has delegated to the Governing Body decision making and responsibility for the delivery of all its duties with the exception of decisions to: Determine the arrangements by which the members of the group approve those decisions that are reserved for the membership. Consider and approve applications to NHS England on any matter concerning changes to the group's Constitution, including terms of reference for the group's Governing Body, its committees, membership of committees, the overarching scheme of reservation and 47

48 delegated powers, arrangements for taking urgent decisions, standing orders and prime financial policies. Approve of the group's overarching scheme of reservation and delegation. Approve the arrangements for identifying practice members to represent practices in matters concerning the work of the group, and Appoint clinical leaders to represent the group's membership on the group's Governing Body, for example through election (if desired). Approve the appointment of Governing Body members, the process for recruiting and removing non- elected members to the Governing Body (subject to any regulatory requirements) and succession planning. Approve arrangements for identifying the group's proposed Chief Officer. The Governing Body has supplemented the governance framework by the formal adoption of the Nolan Principles on Standards in Public Life, the Code of Conduct and Accountability for NHS Boards, the CCG Code of Conduct, Standards of Business Conduct Policy, Gifts and Hospitality Policy, Anti-Bribery Policy, and a Conflicts of Interest Policy. Using the NHS England guidance "The Functions of Clinical Commissioning Groups" and published legal guidance, the CCG has reviewed its statutory duties and is satisfied that it has in place all the necessary complete and lawful arrangements to ensure the proper discharge of those functions. To undertake and ensure the systematic discharge of its functions and duties, the membership established a Governing Body and complementary sub committees. Details of their roles are set out in the following sections. Tower Hamlets CCG's Constitution sets out the principles and processes that the organisation will adhere to in delivering its role and functions. It describes how the Governing Body will operate, confirms matters reserved for Governing Body decision, and other areas where certain powers will be delegated within the organisation. It sets out its key processes for decision making, including arrangements for securing transparency in the decision making of the CCG and its Governing Body, and the arrangements for discharging its duties with regard to registers of interest and managing conflicts of interest. The Clinical Commissioning Group reviews these arrangements each year to ensure they remain fit for purpose, enabling the organisation to do everything within its power to support the commissioning of excellent NHS services for the residents of Tower Hamlets. The CCG governance structure was created to ensure that clinicians and patients remain at the heart of decision making, whilst delivering on the CCG's corporate objectives. The CCG governance structure has been outlined in figure 3 below. 48

49 Figure 3: NHS Tower Hamlets CCG governance structure The Governing Body The Governing Body is comprised of both elected and appointed members who have a duty to ensure the CCG exercises its functions effectively, efficiently and economically. The Governing Body takes responsibility for ensuring the CCG meets all of its financial obligations, including accounting and auditing, and performs its functions in a way which provides good value for money. The members of the Governing Body are as shown below. Chair and Clinical Leads Name Network Responsibilities Dr Judith Littlejohns 1 Mental Health Lead Adult Safeguarding Dr lmrul Kayes 2 Education and Workforce Equality and Diversity 49