NHS Lewisham CCG Annual Report 2016/17

Transcription

1 NHS Lewisham CCG Annual Report 2016/17 Page 1

2 Contents Performance Report Page 3 Performance Overview 4 Performance Analysis 18 Accountability Report 54 Corporate Governance Report 55 Members Report 55 Statement of Accountable Officer s Responsibilities 60 Governance Statement 62 Remuneration and Staff Report 96 Parliamentary Accountability and Audit Report 111 Financial Statements & Notes Annex 1 Page 2

3

4 Performance Overview Welcome I am pleased to present our annual report and accounts for 2016/17. In this report, we describe how we have fulfilled our duties as laid down in the National Health Service Act 2006 and the work we are doing to improve the health and care of people who live in Lewisham. Since the establishment of the CCG we have developed effective working relationships with partner organisations in Lewisham and across south east London. During 2016/17 we have presented our plans and progress to the Lewisham Health and Wellbeing Board and worked jointly within the Lewisham Health and Care Partners programme on the integration of local services. The year also saw the publication of the south east London five year Sustainability and Transformation Plan which will help to ensure we can meet the health, service quality and financial challenges over the coming years for the local populations in the six boroughs of south east London. Throughout the year we have tracked our performance against the NHS Constitutional Standards and the areas covered in the Improvement and Assessment Framework for CCGs and where necessary put in place actions for improvement. Despite significant action and work across the local system, disappointingly we have continued to experience particular challenges to meet the recovery plans for the accident and emergency 4 hour target, cancer waiting times, and referral to treatment times. We recognise that these must be our highest priorities for improvement for 2017/18, particularly for urgent and emergency care. Our efforts in the year have led to successes in a number of key health areas including successes in mental health access standards, Improving Access to Psychological Therapies (IAPT), Early Intervention in Psychosis (EIP) and Child and Adolescent Mental Health Services (CAMHS), improvements in the care of diabetes and leg ulcers, improvements to the District Nursing service, and the opening of a new Ambulatory Care Centre at University Hospital Lewisham. We have met all of our statutory financial duties, as well as delivering a 1.4% cumulative surplus and ensured compliance for prompt invoice payment requirements against the Better Practice Payments Code (BPPC). I would like to thank our member practices and all of Lewisham s NHS and care staff, for the work they do to treat, care for and support local people. I continue to value comments from Page 4

5

6 1. Introduction NHS Lewisham Clinical Commissioning Group (CCG) is a membership organisation made up of all the GP practices in Lewisham. Our aim is to secure the best possible health and care services for everybody in Lewisham, to reduce health inequalities and improve health outcomes in a cost effective way that provides good value for money. We use what we know about the health needs of our residents to plan how and where to provide care which we commission from hospitals, community services and other providers of care. This information comes from insight and feedback from our public engagement activities, from our colleagues in the Lewisham Public Health team and from national sources such as Public Health England and the Health and Care Information Centre and is summarised in Lewisham s Joint Strategic Needs Assessment. You can find out more about the Joint Strategic Needs Assessment at We plan, buy and monitor most of the health services our residents use including: Community health services (such as district nursing) Hospital care Rehabilitation services (such as physiotherapy) Urgent and emergency care Mental health care (both hospital and community based services) Services to support the most dependent people in the community. We aim to improve care by: Ensuring services in Lewisham are of a high quality, safe and easily accessible and appropriate for the range of diverse communities living in Lewisham Working closely with our local community to plan and improve services Having a good working relationship with the staff and organisations who deliver care and other organisations responsible for local services. Making the most effective use of the money we have been allocated to commission services. Other health services such as pharmacies, opticians, dentists and some specialist health services are commissioned by NHS England. Visit for more information. Page 6

7 Decisions about what we do are made by our Governing Body, which is accountable to our member practices and which meets in public on a regular basis. You can find out who is on our Governing Body on our website ( 2. Health in Lewisham Demographics Lewisham is part of London, the largest, most culturally diverse city in Europe. Lewisham covers an area of 13.4 square miles stretching from the Thames at its most northerly point to Bromley in the south of London. Lewisham has a growing population, projected to increase from 297,300 in 2015 to 318,000 by 2021, and is the 15th most ethnically diverse local authority in England - 46% of the population are from black and ethnic minority groups. Around 27,600 residents are above 65 years of age and over 3,700 are aged over 85 years. This latter group often has the most complex health needs and therefore bears a very high proportion of care costs. The Index of Multiple Deprivation 2015 ranks Lewisham 48th of 326 districts in England and 10th out of 33 London boroughs. People living in the most deprived areas have poorer health outcomes and lower life expectancy compared to the England average: life expectancy for men is five years longer in Crofton Park, than in New Cross. For women the life expectancy gap is even bigger; 8.5 years longer in the joint highest wards of Perry Vale and Crofton Park than the lowest, New Cross. Lewisham has over 800 active voluntary and community sector organisations and more than 200 individual faith groups. All these groups and many others help to strengthen our communities by galvanising our citizens, addressing local concerns and advocating on behalf of some of the most vulnerable in society. There have been some improvements in people s health and care in Lewisham. The life expectancy at birth was 78.8 years for women and 72.3 years for men in ; in it had increased to 83.4 years and 79.0 years respectively. People in Lewisham are living longer because of the success in managing particular conditions such as stroke, heart disease and respiratory disease. More people in contact with mental health services in Lewisham are living independently with or without support in comparison to the national average. Page 7

8 Local Challenges Despite these successes, health and care commissioners and providers jointly recognise that Lewisham s health and care system needs to change. We describe in more detail the challenges we are facing in our section below on the NHS Constitutional Standards, particularly for Cancer and Accident and Emergency (A&E) national targets. The current system is not sustainable and we are not achieving the health and care outcomes we should: Too many people die early from deaths that could have been prevented by healthier lifestyles Cancer is now the main cause of death (28.3%), followed by circulatory disease (28.1%), respiratory disease (13.8%) and dementia (9%) in Lewisham Screening for both breast and cervical cancer is significantly lower than the average for England While life expectancy has been improving, for men at 79.0 years life expectancy at birth remains lower than the England average which is 79.6 years Many of these deaths could have been prevented by healthier lifestyles - 80% of heart disease, stroke and type 2 diabetes and 40% of cancers could be avoided if common lifestyle risk factors were eliminated (WHO 2005) o unhealthy diet o physical inactivity o tobacco use o excess alcohol and drug use. Demand for care is increasing, both in numbers and complexity: 14% of people in Lewisham identify themselves as having limitations in carrying out day-to-day activities. That is equivalent to around 38,000 people. Lewisham s over 60 population is projected to increase by around 15,000 by 2040 which will increase demand for the health and care services More information is available about Lewisham s population at Page 8

9 3. Performance Overview Our aim is to secure the best possible health and care services for the residents of Lewisham, while addressing the significant challenges of the population. Our performance is discussed in more detail in the next section, however as a brief overview this year we have: Made significant quality improvements to local services including: o Community Services: We are developing an ambitious programme to provide high quality diabetes care based in the community. The programme will develop integrated diabetes services which will improve the overall quality of care and the patient experience. We will work with people living with diabetes to design the new pathway together to ensure it best meets the needs of our population in the future. A re-audit of standards of care in our District Nursing service this year identified significant improvements and showed that most issues raised in 2014 s audit around accessibility of the service, staffing levels, competency and attitude of staff have been resolved. Since completing a successful leg ulcer pilot in 2015/16, which demonstrated significant improvements in leg ulcer care including a reduction in recurrent infection rates (from 38% to 3%), a 15% reduction in re-admission to hospital for leg ulcer related issues and an improvement in pain management scores (from 7% to 68%), we are establishing specialist clinics to improve access and healing times. o Care homes: We have developed our quality dashboard which has led to improved quality monitoring in care homes and private providers. o Maternity services: We are working with King s College London to develop a programme designed to support women who have a higher risk of preterm birth to be launched in June Progressed plans to shift elements of urgent and emergency care into the community We know that people who attend A&E are more likely to be admitted into hospital, even when it may not be necessary for them to be treated in hospital. This can lead to greater intervention by specialised and emergency care staff when they could have been seen Page 9

10 in other settings, such as by a GP or community services, which may have avoided a hospital admission. Improving access to primary care (eg GPs) and community services in order to reduce A&E attendances, and help to achieve the 4 hour waiting standard, is ongoing, and this year our progress has included the following: o Promoting access to GP online services which has led to an increase in patients signing up for online services, enabling more direct access to GP services o Developing a programme to improve care and outcomes for children and young people, which has already seen a reduction in hospital admissions o Initiating and implementing programmes to redesign the acute mental health pathway in order to reduce reliance on acute inpatient treatment for adults. Focused on improving the quality of services through supportive and effective monitoring of contracts with local providers Our service providers are contracted to deliver services to an agreed standard and specification. In our role as commissioners, we are committed to working in partnership with each provider to support them in achieving this to ensure optimal outcomes and value for money: o Since identifying issues with response times to complaints, we have supported Lewisham and Greenwich NHS Trust to make significant and sustained improvements o We have strengthened our processes for monitoring the community part of our contract with Lewisham and Greenwich NHS Trust and we continue to deliver a high level of scrutiny and support to our providers. The Performance Analysis section of this annual report details how we have fared against the requirements under the health outcomes framework and NHS Constitutional Standards. We have monitored our performance and, where required, have put in place recovery action plans. Improvements have been made for 62 day cancer waits, and for recovery rates for Improved Access to Psychological Therapies (IAPT). Challenges remain for the 4 hour standard for A&E waits and for 18 weeks referral to treatment. Page 10

11 Under the CCG Improvement and Assessment Framework, we perform well against the indicators for dementia, and are working for further improvement in the other clinical areas of learning disabilities, maternity, mental health, cancer and diabetes. 4. Financial targets and performance for the year The CCG met all of its statutory financial performance duties for 2016/17. The CCG is required to comply with the statutory duties set out under a direction issued by the NHS Commissioning Board (NHS England) under the National Health Service Act 2006 (as amended). Also, the CCG is required to prepare Annual Accounts in accordance with the Government Financial Reporting Manual taking account of the application guidance contained in the Department of Health Group Accounting Manual. Our annual accounts for 2016/17 have been prepared on a going concern basis. Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents. Where a clinical commissioning group ceases to exist, it considers whether or not its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern. If services will continue to be provided the financial statements are prepared on the going concern basis. The CCG has been notified of resource allocations for 2017/18 and 2018/19 and has agreed two year contracts for the same period with its main providers. During the year the Governing Body has considered and approved a number of documents that assume that services will be provided on an on-going basis; including the South East London Sustainability and Transformation Plan, Five year CCG allocations and income plan, Operational plan with two year financial plan. From April 2017 NHS Lewisham CCG will assume full responsibility for contractual GP performance management, budget management and the design and implementation of local incentive schemes under delegated commissioning arrangements approved by NHS England Sound financial management and robust management of financial risks have ensured that we have delivered all of our statutory financial duties as planned. In accordance with NHS England planning guidance, we are required to deliver a cumulative surplus of at least 1% of available resources. CCGs must contain net expenditure within resource allocation limits set by NHS England for the year. There are separate resource allocation limits for capital and revenue Page 11

12 expenditure, with revenue expenditure limits further split between programme spend and running costs. Our results are set out in the table below, with further detail included in note 41 of the full annual accounts: Duty Duty Target Performance Achieved Expenditure not to exceed income Yes 431, ,257 Capital resource use does not exceed the amount specified in Directions Yes 0 0 Revenue resource use does not exceed the amount specified in Directions Yes 427, ,138 Capital resource use on specified matter(s) does not exceed the amount specified in Directions Yes 0 0 Revenue resource use on specified matter(s) does not exceed the amount specified in Directions Yes 0 0 Revenue administration resource use does not exceed the amount specified in Directions Yes 6,608 6, Our Healthier South East London In December 2015, NHS organisations in 44 areas of England were asked to work together to produce a five-year plan (covering up to March 2021) to implement the NHS Five Year Forward View. These plans are called Sustainability and Transformation Plans (STPs). Our STP is called Our Healthier South East London. It has evolved from a commissioner-led strategy established in into a partnership between local commissioners and providers, working with local authorities, patients and the public. The STP is not a blueprint for the next five years: it is a series of plans for different clinical areas that are at different stages of development. The STP (full version and summary) was published on 4 November 2016 and was one of the first in the country to be made public. The plan aims to address a number of challenges, including: A growing and aging population living with long term conditions like diabetes, high blood pressure and mental illness Quality of care and outcomes of treatment differs depending on when and where people access services Page 12

13 Patient experience differs and some people find it difficult to get an appointment or feel they do not have enough information about their condition. NHS funding increases in line with inflation but the costs of providing care are rising much faster which, at the moment, could mean an overspend for south east London of around 1bn by 2021 if we were to do nothing. Our plan is designed to help us avoid spending more than we receive, while making sure services are high quality, more joined up, available closer to home and more efficiently provided. What does the plan mean for local people? Better community based care including: extra 7.5 million a year to ensure that people in south east London can book a GP at a time that suits them including more evening and weekend slots Ensuring A&E and maternity departments all meet high standards of care in the future. Better maternity care dedicated midwives supporting mothers throughout pregnancy, better advice and choice on birth options Developing word-class orthopaedic services fewer cancelled operations, shorter waiting times and more procedures carried out. Detailed work is underway to refine proposals to develop elective orthopaedic centres, which could mean consolidating planned adult procedures onto two or three sites. More material is being developed to allow the public to consider the pros and cons of both options. A public consultation may then take place in 2017 Faster cancer diagnosis new 160 million purpose built cancer centres at Guy s Hospital and 30 million centre at Queen Mary s Sidcup, launch of dedicated oncology support phone line, dedicated clinical nurse specialists for all patients All the different parts of local health and care services working together to use available money and resources in the best way possible - helping us avoid a 1billion overspend by Have local people been involved? The models of care developed through Our Healthier South East London are the product of several years of partnership working between clinicians, commissioners, council social care leads, local hospitals, and have been informed by extensive engagement with local communities, patients and the public. Page 13

14 Engagement activity to date includes a series of events in each borough, publication of an issues paper and emerging thinking paper setting out the challenges we face and ideas to tackle them, 2-3 patient and public representatives and Healthwatch representatives on each of our clinical workstreams, and a programme of local engagement in each borough. We have also carried out a series of equalities analysis and created a dedicated Equalities Steering Group to ensure our work takes account of equalities issues. Our approach has been informed and endorsed by The Consultation Institute (an independent non-profit organisation), who advise on best practice engagement at national level. The engagement programme was also shortlisted for a national award by the Association of Healthcare Communications and Marketing (AHCM). During 2017, we aim to extend the reach of our conversations, inviting more local people and interest groups to find out about our developing plans and contribute their views. A six-month programme of civic engagement a dialogue with the people of south east London will be launched in March. This will create more opportunities for local people to hear about the plans direct from NHS leaders and tell us what they think. All of our engagement activity and information on how we use feedback is routinely published on the Our Healthier South East London website. You can find out how to get involved by visiting 6. Healthy London Partnership We, along with every other London CCG and NHS England (London), have made a commitment through the Healthy London Partnership to unite and amplify the work of our partners to support the transformation of health and care in London. Our partners include the Greater London Authority, Public Health England, London councils and Health Education England and through Healthy London Partnership we are working to deliver changes that are best done once for London. Page 14

15 Collectively we believe it is possible to achieve a healthier, more liveable global city by 2020, by delivering on the ambitions set out in Better Health for London: Next Steps and the national NHS Five Year Forward View. Highlights this year include the development of the London-wide standards for people experiencing a mental health crisis endorsed by all London mental health trusts, London Ambulance Service, London Councils and the Metropolitan Police. During 2016/17 we facilitated a year-long engagement with Londoners on childhood obesity, called the Great Weight Debate, which reached over half a million Londoners on social media, saw 3,900 people fill in our survey, nearly 2,000 people attend roadshows during October half term and culminated in 60 teenagers working through the issues at a Hackathon in January 2017 at City Hall. London s young people also helped us design and launch a mobile health website and app called NHS Go that gives them targeted health information plus health advice and signposts to services approximately 30,000 people are now using NHS Go. Watch their launch video. Healthy London Partnership, on behalf of London CCGs, has also led on the collaboration that saw all 32 CCGs, all 33 borough councils, the Mayor of London, NHS England and Public Health England sign the London Health and Care Collaborative Agreement. Together with the London Devolution Agreement, this paves the way for central government and national bodies to devolve powers and funding to the London system to enable local, sub-regional and London-wide transformation. This year Healthy London Partnership has been in a unique position to support the developing sustainability and transformation plans. Sustainability and transformation plans are subregional place-based plans across commissioners, providers and local authorities within five defined footprints in London. Plans will set out how London s health and care system will improve over the next five years and achieve Better Health for London s 10 aspirations. Read more about this work online at Page 15

16 Glossary A&E BAF BCF BME BPPC CAMHS CBC CCG COPD CQC CQUINS CQRG DNA ED EDS EIA EIP ENT EPRR FCEA HIV HLP HRG IAF IAPT IGC JHOSC JSNA KPI LGT LIMOS LNPCIS LSMS MESCH NCT NHSE NCN NPSA OHSEL PCT PEEF PEG PHSO PI PMS PPG PRG Accident and Emergency Board Assurance Framework Better Care Fund Black and Minority Ethnic Better Practice Payments Code Child and Adolescent Mental Health Services Community Based Care Clinical Commissioning Group Chronic Obstructive Pulmonary Disease Care Quality Commission Commissioning for Quality and Innovation Schemes Clinical Quality Review Group Did Not Attend Emergency Department Equality Delivery System Equality Impact Assessment Early Intervention in Psychosis Ear, Nose and Throat Emergency Preparedness Resilience and Response Financial Control Environment Assessment Human Immunodeficiency Virus Healthy London Partnership Health Resource Group Improvement and Assessment Framework Improving Access to Psychological Therapies (Programme) Integrated Governance Committee Joint Health Overview and Scrutiny Joint Strategic Needs Assessment Key Performance Indicator Lewisham and Greenwich NHS Trust Lewisham Integrated Medicines Optimisation Service Lewisham Neighbourhood Primary Care Improvement Scheme Local Security Management Specialist Maternal Early Childhood Sustained Home Visiting Neighbourhood Community Teams NHS England Neighbourhood Care Networks National Patient Safety Agency Our Healthier SE London Primary Care Trust Public Engagement and Equalities Forum Public Engagement Group Public Health Service Ombudsman Performance Indicator Personal Medical Services Patient Participation Group Public Reference Group Page 16

17 PSED QA QIPP RSS SDMP SELDOC SIRO SLaM STP UCC UHL VSM VTS WRES YTD Public Sector Equality Duty Quality Assurance Quality Innovation Productivity and Prevention Referral Support Service Sustainable Development Management Plan South East London Doctors on Call Senior Information Responsible Officer South London and Maudsley Mental Health Foundation Trust Sustainability and Transformation Plan Urgent Care Centre University Hospital Lewisham Very Senior Managers Vocational Training Scheme NHS Workforce Race Equality Standard Year to Date Page 17

18 Performance analysis 1. Introduction This section describes how we measure our performance. In 2016, the Governing Body agreed the CCG s corporate objectives which would drive the key priority actions for 2016/17. These corporate objectives comprise one developmental objective and two core objectives: Developmental Objective: Urgent and emergency care pathways that shift care to community based care To meet this corporate objective, we have focused on the following key areas. o Developing a framework to commission urgent and emergency care services across the whole system - including health, social care, self-care and third sector. o Redesigning the acute mental health care pathway o Improving asthma admissions and redesigning children s community team. Core Objectives: High quality care and best value Governance planning and development To meet these corporate objectives, we have focused on the following key areas: o Effective management of our service providers contracts o Delivering the agreed trajectories of the NHS constitutional standards o Ensuring effective adult and children safeguarding o Improving the quality of community health services o Improving the quality of GP services These objectives are aligned to support delivery of our operating plan and to meet our strategic aims - Better Health, Best Care and Best Value for Lewisham people, within the framework of South East London s Sustainability and Transformation Plan (STP). The following section describes in detail how we have performed against our corporate objectives. Page 18

19 2. Urgent and Emergency Care Pathways Developing a framework to commission urgent and emergency care services Our Commissioning Framework sets out our shared expectations for all providers by laying out the key principles, priorities and outcomes expected to be delivered by providers of Urgent and Emergency Care across Lewisham. Our strategic aim is to commission urgent and emergency services across the whole system - including health, social care, self-care and third sector - which are coordinated, consistent, clear and affordable, helping people to get the right advice and care in the right place first time, for those with urgent or emergency physical or mental health needs. Currently, there are three interdependent, commissioning priorities areas, which underpin the delivery of Community Based Care, which are: Prevention and Early Action Planned care Urgent and Emergency Care (which includes enhanced care and support) In 2016/17 we developed draft Commissioning Frameworks for two of these areas - Prevention and Early Action and Urgent and Emergency Care. Our framework for urgent and emergency care aims to support the long term sustainability of health and care services in Lewisham. We aim to: Change the historical way we have commissioned and decommissioned services to shift to outcomes and population based contracts. Redefine the traditional commissioning/provider relationship and find new ways of effective collaboration between providers. Achieve health and care delivery around the needs of the population and the individual, irrespective of the existing institutional arrangements and provided in a joined up, safe, effective and sustainable way. The driver behind our framework is to answer specific issues in Lewisham: A review of A&E attendance at University Hospital Lewisham s A&E department and co-located Urgent Care Centre (UCC) identified that 35% of patients presenting were classified as having needs that could be met at the UCC Page 19

20 Of the 35% of UCC attendances nearly half were categorised as having no investigation or treatment, suggesting that they could have been managed in a more appropriate care setting that provides better value for money Providing more appropriate care for people with ambulatory care sensitive conditions - conditions where effective community care and self-management can help prevent the need for hospital admission, e.g. congestive heart failure, diabetes and asthma - to achieve better outcomes and cost savings. The draft Commissioning Framework for urgent and emergency care, along with the framework for Prevention and Early Action were considered at the last Adult Joint Commissioning Group in March The principles will be reflected in the refreshed partnership commissioning intentions and will then be translated into any service redesign and included in the next contractual round of 2018/19. New Ambulatory Care Centre at University Hospital Lewisham (UHL) We commissioned the provision of a new Ambulatory Care Centre (ACC) at UHL to provide assessment and same day discharges for adult patients. The aim of the Centre is to help patients get the right care sooner, including early access to tests (such as X-Ray and ultrasound), with results reviewed by specialist consultants and reduce pressures on the emergency department. The Centre opened in November Page 20

21 Since the Ambulatory Care Centre opened it has seen over 1500 patients. The Consultantled service provides same-day access to medical specialists for advice and treatment without the need for an overnight stay in hospital. This is reducing the number of medical admissions, reducing the number of GP referrals to the Emergency department, and reducing the length of stay for some patients. Because of the way the service runs, the waiting time to see a senior doctor is usually only a few minutes. Patients will find the Ambulatory Care Centre a calm and well organised environment. As a result, feedback has been extremely positive. The latest 'friends and family' survey of nearly 100 responses showed that every patient would recommend the service. There are some conditions that would traditionally been managed as an inpatient that are now almost always treated as an outpatient. For example, a patient recently attended the ACC with a severe kidney infection. She needed three days of intravenous antibiotics, but also needed to look after her young children at home. Rather than bring her into hospital, she was able to receive her antibiotics quickly and went home to her children each evening. Another example is a patient who regularly requires fluid drained from his abdomen. He doesn't like coming into hospitals, so often chooses to remain at home struggling with the discomfort. His GP got in touch with the ACC, and the procedure now takes place at the Centre. The patient is able to go home the same day and is far happier coming into the ACC. GP triaging pilot at UHL Urgent Care Centre The Primary Care Assessment Pilot was developed as part of the Our Healthier South East London initiative to provide GP triaging at the UCC and Emergency Department (ED) and is in line with our vision for an integrated primary and urgent care model. Patients arriving at the UCC will be seen and triaged by a team of GP assessors and Health Care Assistants, with the aim to stream patients to the most appropriate point of care including signposting patients to an alternative care setting or self-care management as appropriate. It seeks to improve patient experience by reducing waiting times and avoiding duplication within their pathway through the UCC/ED. The pilot aims to also support the UCC/ED to meet 4 hour wait times. Page 21

22 The pilot commenced on Monday 6 th October 2016, initially for six months, operating from 10am - 10pm, seven days a week. It is an adult only service. Initial evaluation identified the following findings and feedback: 3,653 patients were seen between 3 October 2016 and 31 January 2017 Pilot activity equates to approximately 9% of UCC/ED activity While some key assumptions were met, some of them, e.g. delivery of the 4 hour standard were not achieved however improvements were seen throughout the duration of the pilot Overall time to assessment from arrival was reduced by 20% since the pilot commenced The pilot was successful in the immediate assessment We are proposing to continue the pilot for a further 12 months to provide continued support to the acute trust (Lewisham and Greenwich NHS Trust) at the front end of the UCC/ED. Continuation of this service will also provide integration with the GP Extended Access Service which went live on 1 April 2017, open seven days a week from 8am to 8pm, and will provide additional bookable appointments with a local GP. This should reduce the waiting times for people who attend the UCC and move them quickly to the most appropriate form of care. Of the 45 patients who were evaluated after being triaged by the GP Assessor, just over 24% of patients reported that they had been seen almost immediately after booking in (within 15 minutes). 53.4% reported that they were seen within 30 minutes. 84.4% were seen within one hour. 84% of the sample rated their treatment and explanations about their treatment as good or excellent. The most positive comments related to shorter waiting times. Other comments included: Sent by own GP but made trip here last week [not seen by GP Assessor] This week, yes, seen by GP Assessor and much better A lot to to-ing and fro-ing last time I came, so good to get done in one go. I wanted reassurance as well from this visit and I got it Page 22

23 Redesign of the acute mental health care pathway Mental health services in Lewisham are provided by South London and Maudsley NHS Foundation Trust (SLaM) under an NHS Standard Contract. We work closely with SLaM to improve adult mental health services through investment in a redesign of the acute mental health care pathway. This includes a number of initiatives that will deliver improved outcomes for people with long-term mental health problems by providing support at home or in the community; reducing reliance on acute inpatient treatment, and delivering person-centred care that has been co-designed with experts by experience. We have tested an admission diversion project for individuals that are known to mental health services and are at risk of requiring admission. The Preventing Crisis Beds project is delivered by supported This means that we are housing providers and offers 24 hour supported housing and providing a viable alternative for patients who daily clinical support through Local Home Treatment teams. may not necessarily require The project is being reviewed to assess its effectiveness with to be admitted to hospital. a view to informing future commissioning intentions. A wider review of SLaM s acute care pathway will be completed within By increasing the capacity 2017/18 and will incorporate the Home Treatment Team of the Psychiatric Liaison We have agreed to fund increased medical time within the team we are better able to A&E Psychiatric Liaison service prior to receiving the outcome meet the needs of patients who attend A&E with mental of the STP transformation funds bidding process. The health needs additional resource will ensure that we have appropriate medical cover at all times and supports our local compliance against the national Core 24 hour operational standard. Mental Health Older Adults SLaM, in conjunction with Southwark, Lambeth and Croydon CCG commissioners have developed a proposal to revise the Mental Health Older Adults inpatient services. The proposal and new model of care will create dedicated inpatient units for Organic (Dementia) and Functional mental health disorders providing more focused care and support for each patient group which is also in line with national clinical evidence. In addition to the revision of the inpatient pathways, initial discussions between Lambeth, Southwark and Lewisham CCGs have been undertaken with an independent provider to increase Nursing Home capacity for those individuals that have ongoing mental health needs but no longer require NHS inpatient care. Page 23

24 The reconfiguration of the Working Age Adults Acute Pathway within SLaM, which included a range of specific interventions to reduce demand for inpatient services and promote improved throughput, has not provided the expected reduction in the use of Mental Health inpatient beds through the year. The key contributing factors have been the delays in transfers of care and a limited reduction in the average length of stay within inpatient units. Preventing admissions and facilitating discharge from hospital We have audited all of our community beds and identified where there are difficulties accessing them. We are redesigning the care pathway to improve access and reduce the need for hospital admission. We have also redesigned how the Rapid Response Team works to maximise their effectiveness. There is further work planned to prevent admission and facilitate discharge from hospital. Redesigning children s community nursing team and improving asthma admissions The Five Year Forward View highlighted the opportunities to run health services more efficiently and models of care that were expected to secure high-quality, more efficient and effective healthcare for the population. In 2016 we began work on the remodelling of the Children Community Nursing Team (CCNT) service with an admission avoidance/early discharge service in Lewisham. We completed this remodelling of emergency department attendances, inpatient admissions and finances in March We are now in the designing phase and are holding a series of workshops with clinicians and patients groups to develop the clinical pathways and test the CCNT model. The aim of this work is to improve care and outcomes for children and young people with acute and long term conditions by remodelling and bringing together an ambulatory care response team to provide rapid response in/outreach into acute, admission avoidance with on-going care provided at home and community settings by the CCNT with the objectives to: Set up an ambulatory care paediatric response team to support early discharge from inpatient settings and reduce length of stay. Provide ambulatory care in acute settings for admission avoidance and rapid response and follow-up care to prevent hospital re-admissions. Provide ambulatory care nurse visits to the emergency department and Short Stay Paediatric Assessment Unit (SSPAU) daily. Support children and families with up to three visits per day for at least two days following discharge to avoid readmission. Page 24

25 Offer extended working hours, 7 days week, from 8am to 10pm and out of hours on call. The Lewisham Children and Young People Community Care Based Transformation Programme Board was established to provide governance and expert advice to the development of these plans, and in line with our QIPP (Quality Innovation Productivity and Prevention programme) and STP. The ambulatory care service model was developed by community teams as well as hospital paediatric teams from University Hospital Lewisham, and endorsed by Evelina Hospital and King s College Hospitals. The new CCNT service will be phased in from September The Hospital@Home service The Hospital@Home service was set up as an 18 month pilot to support effective discharge of children with acute and short term illnesses from the emergency department and SSPAU and early discharge from children s inpatient ward to be managed at home by the Hospital@Home team. Evaluation of the pilot was developed to enable us to have a real life ongoing evaluation of its benefits and financial impact. Results after the initial six months showed: Paediatric emergency activity for Lewisham CCG at LGT, and specifically at UHL, was lower during the first six months of 2016/17 compared with the first six months of 2015/16 Overall paediatric emergency activity at UHL was down by 386 admissions which amounts to a saving of 371,761 against planned costs, equating to 386 admissions Of the 386 admissions saved, we can attribute 273 of them directly to the Hospital@Home service, which is a saving of 261,944 against planned costs. Page 25

26 Both the service and the redesign of the CCNT aim to deliver the following outcomes: Avoiding children having to stay in hospital for too long Avoiding children being admitted or readmitted Avoiding children going to A&E when they don t have to This is done by: moving care closer to home, including at home designing a service with more capacity in community nursing and primary care developing a more integrated primary and urgent care service directing the patient properly in the early stages of need The Community nursing team visiting children at home means that children who may otherwise have had to stay in hospital may be discharged. Before the development of this programme, patients would have to stay in hospital to receive treatment that will be delivered at home or in the community. This service particularly benefits those: presenting with conditions that do not need to be seen in the Emergency Department with conditions that do not need to be managed in hospital who are admitted but can be discharged early and managed in the community who are discharged but readmitted within 28 days with the same condition 3. Contract Management and Best Value We hold the contracts with service providers who provide health services to the population in Lewisham. We are the host for managing the contract with Lewisham and Greenwich NHS Trust and are responsible for ensuring that the trust delivers its services to the agreed specification and standards as laid out in the contract. We do this face-to-face at the Contract Management Board. Page 26

27 The standards expected of acute providers are set out in Schedule 4 of the NHS Standard Contract. The Standard Contract specifies a set of operational standards, a set of National Quality Requirements, Local Quality Requirements, Never Events and Commissioning for Quality and Innovations schemes (CQUINs). Penalties for breaches of the standards are also specified. Assurance for NHS acute providers takes place at the Clinical Quality Review Groups (CQRGs). These meetings constitute a face to face, commissioner to provider quality review meeting. In 2015/16 we identified that Lewisham and Greenwich NHS Trust were underperforming when it came to responding to complaints within the agreed timescale. We provided significant support which has led to an improvement over the last 12 months and an improvement from 20% to over 90% of complaints responded to within the timescale agreed with the complainant. This has been sustained for the last three months. The average response time from the trust varies on a month by month basis as it is determined by the nature of complaints received and what would be appropriate to complete any investigation. We also monitor complaints data from our other providers and work with them to improve their performance in this area. Community services, such as district nursing and adult therapies, are also contracted from Lewisham and Greenwich NHS Trust. Mental health services in Lewisham are provided by South London and Maudsley NHS Foundation Trust (SLaM) under an NHS Standard Contract. Additional services are commissioned from other NHS and voluntary services. Mental health services are commissioned under Section 75 joint commissioning arrangements with the London Borough of Lewisham (LBL). The quality of services provided by SLaM are monitored at a four borough CQRG which we chair. This is attended by clinical directors and senior officers. Some community health services are also commissioned under Section 75 joint commissioning arrangements with LBL. The quality assurance of these services sits within the Section 75 agreement and is managed by LBL on behalf of both partners. We are alerted by exception of potential or actual quality failures in these services. 4. Improving Quality Improving quality in the community and community services We have strengthened our processes for monitoring the community part of our contract with Lewisham and Greenwich NHS Trust. We have also revised all of the individual service Page 27

28 specifications within the contract (including diabetes, tissue viability and Chronic Obstructive Pulmonary Disease (COPD)), to include measurable key performance indicators. We have identified that in Lewisham we do not always recognise the symptoms of COPD early enough and put in place plans to improve in this area. This includes making spirometers available in every practice. We have commissioned a two year pilot to support people with more than one long-term condition to better manage their own health. This will include a flexible range of support options including workshops, courses and online resources. Pressure ulcer (PU) management was a concern in 2014/15 in both acute and community acquired PUs. In order to address this we have set up separate acute and community PU panels where the cause of every ulcer is reviewed and the impact it has on the patient. The lessons learnt have been transferred back into practice and we have seen a reduction in the numbers of ulcers in nursing and residential homes presented at the community PU panel. We also monitor domiciliary care providers. Care homes and private providers We have made some significant improvement in how we monitor quality in non NHS providers. We monitor the quality of services provided in care homes through a quality dashboard that was introduced in 2016 and now forms part of our regular reporting to our Integrated Governance Committee. For example, we became aware of safeguarding and quality of care concerns regarding patients residing at a care home providing acquired brain injury services. We initiated an investigation with NHS England (NHSE), the Care Quality Commission (CQC) and other commissioning groups and made improvement recommendations which the company could not deliver. This, along with other difficulties, led to the provider closing all five of its locations across Lewisham and Bexley. We then undertook a lessons learned review which was shared with all agencies involved in order to inform future responses and provision for people with acquired brain injury, recognising their complex needs and vulnerabilities. Maternity services The POPPIE project (Prevention Of Preterm birth Plus Improving women s Experience (POPPIE): Risk stratification and continuity of care for women at high risk of preterm birth in Lewisham) Page 28

29 There are approximately 5,000 births a year registered in Lewisham each year and 191 of the total were pre-term. This is the highest rate in London and the leading cause of child death in Lewisham and London. Professor Sandall from King s College London and her colleagues want to develop a better way of supporting women who have a higher risk of preterm birth. They are working on trialling a new-style service at University Hospital Lewisham. We are working in collaboration with the team, and have funded the lead midwife. The new service will comprise a dedicated team of midwives who will care for women at risk of premature birth during pregnancy, labour and thereafter at home, and a specialist obstetric preterm surveillance clinic to be set up at the hospital. There is also a parallel study running which will test a tool for identifying psychological stress in pregnant women. We know that stress increases the risk of pre-term birth and stillbirth and may also adversely affect the baby both before and after it is born. The project is to be officially launched in June 2017 and will be the first funded research project in this area at University Hospital Lewisham. District Nursing (DN) We undertook an audit of standards of care in district nursing in 2014 which identified problems around staffing levels, competency and attitude of staff. Communication with external stakeholders was also identified as a key issue. We provided additional support to overcome these issues. The service was re audited in 2015/16 and most of these issues have now been resolved and significant improvements identified. For example for 2016/17 a clear management structure is now in place with an experienced clinical manager in post. Senior nurse vacancies have been filled with a named nurse for each neighbourhood. Telephone access for GPs has been improved and a new referral form is in use. Patients are also now informed of a two hour time slot for their visit. Leg ulcer management Leg ulcer management has been separated out from the DN service and specialist clinics are being established. In 2016 we commissioned Accelerate Community Interest Company to support LGT in improving healing times and access to clinics. Accelerate is an award-winning healthcare social enterprise providing specialist care for those living with chronic wounds Page 29

30 and/or lymphoedema. Evaluation of the pilot that finished in June 2016 showed that for 32 patients, we saved 24,000 by avoiding six admissions and 36,600 for district nursing activity and dressings. We also noted a significant change in patients quality of life. Safeguarding adults and children Identification and Referral to Improve Safety (IRIS) training: We are working alongside the Athena project Lewisham (a service to provide confidential, non-judgemental support to those experiencing gender based violence) supporting the IRIS project in the education of general practice staff in the identification and referral to improve safety of women at risk of domestic violence. Around half of general practices have been engaged with the training and there has been positive feedback from GPs to say that this has given them the confidence to explore and ask the question if women are being hurt and feel safe. The women will then be referred with consent to Athena services. Throughout 2016/17 we have continued to deliver a children s safeguarding training programme to the CCG staff and all GPs and other primary care staff. We are currently developing ways of engaging primary care in adult safeguarding and continue to educate the CCG staff in adult safeguarding. An internal audit of safeguarding took place in 2016 and the only action required was to develop a systematic training record for CCG staff. This has now been completed. Lewisham Diabetes Transformation Programme We have been assessed as needs improvement for some aspects of diabetes care under the CCG Improvement and Assessment Framework, though strong in other areas (see section 6 below). Our ambitious diabetes transformation programme aims to address those improvement needs to make diabetes care more accessible, coordinated, and built around the patient. Over the next few years there will be a dynamic progressive shift of care to a more community based setting focussing on high quality local diabetes care. The transformation programme is looking to ensure diabetes care is: Proactive and place based care: Improved identification, prevention and early action ensuring that patients get access to appropriate care in the right place at the right time Accessible care: Flexible community based care that is wrapped around the patient and is appropriate and of the highest quality Page 30

31 Coordinated and personal: Local skilled teams to deliver personalised care that is tailored to patients needs for an improved patient journey that is closer to home. Page 31

32 NHS Constitutional Standards Set against the improvements we have made over the year, our performance against the NHS Constitutional standards, is summarised in the table below. For certain standards, where there were challenges in 2015/16 performance, the CCG set itself improvement plan levels that were better than 2015/16, still but below the standard level. The table shows that mental Health standards have been achieving or above plan. However, it also indicates the standards that are underachieving, and this is of concern. Standard Our Performance 2016/17 Referral To Treatment waiting times 92% of patients who have not yet started treatment should not be waiting 18 weeks from referral A plan was set of 89.9% given 2015/16 challenges Diagnostic test waiting times 87.7% Underachieving and Under Plan 99% of patients have diagnostic tests within 6 weeks of referral A&E waits 95% of patients in A&E are admitted, transferred or discharged within 4 hours of their arrival. A plan was set for 90.1 given challenges. Cancer waits 85% of patients referred by a GP, diagnosed with cancer, start treatments within 62 days Category A ambulance calls 97.9% Underachieving 84.4% Underachieving and Under Plan 75.9% Underachieving 75% of category A calls resulting in an emergency response arriving within 8 minutes A plan was set for 71.1% given challenges in % Underachieving and Under Plan Mental Health Improved diagnosis of dementia so that over 2/3 of prevalence for those over 65. Psychological therapies are accessed by 15% of the population who might benefit from them 50% of people reaching recovery after psychological therapies by the end of the year A plan of 45.3% was set given challenges in % of people receiving psychological therapies within 18 weeks of referral 75% of people receiving psychological therapies within 6 weeks of referral of referral 50% of people referred for psychosis services start treatment within 2 weeks 73.4% Achieving 15% Achieving 45.5% Under Achieving but Above Plan 99.4 % Achieving 81.7% Achieving 57.6% Achieving Page 32

33 (The above assessment is 2016/17 apart from Improved Access to Psychological Therapies which is April to December 2016 due to a lag in official reporting; the plan for the percentage of people reaching recovery has been adjusted to the same period). Progress and key challenges for the four recovery plans are set out below. Accident and Emergency 4 Hour standard This is the percentage of patients discharged, treated or admitted with 4 hours of arrival. The measure relates to Lewisham and Greenwich NHS Trust with largely Bexley, Greenwich and Lewisham patients. The standard is 95%, but due to challenges an improvement plan for 2016/17 was agreed to bring performance closer to the target, to be an average of 91% for the year. However, this lower trajectory has still not been met, with the system at 84.4%, over 10% below the standard. To free up hospital beds for those who may need to be admitted from A&E, the London Borough of Lewisham and NHS Lewisham CCG have been helping to reduce the number patients who are ready for discharge from hospital, and by January 2017 the number of Lewisham patients ready but not yet discharged, for instance if community based health or care arrangements are not in place, had been reduced to single figures from a peak of 50 in August Similarly, to help treatment and to reduce the need for admissions from A&E, a new Ambulatory Care Unit was launched on the Lewisham site in November There is an A&E Delivery Board comprised of leaders from the organisations across the system that oversees these improvements. There remain challenges both within the hospitals and in the wider system and a refreshed plan is being agreed for 2017/18. Cancer Waiting Times 62 Days from GP Referral to Treatments This is the percentage of people who start treatment within 62 days from GP referral. The standard is 85%. The remaining 15% allows for complexity of patients conditions or patient choice to delay or consider options for treatment. The standard relates to Lewisham patients wherever they are treated. There have been continued challenges in meeting the standard. There has been progress in the year for those people who are diagnosed in Lewisham and Greenwich NHS Trust who are referred in a timely way to the cancer specialists, which are largely at Guys and St Thomas. There are further challenges to reduce longer waits due to administration or capacity for Page 33

34 diagnosis or treatment, as well as continuing to improve referral timeliness. Funding to support improvements in diagnosis has been made available in 2016/17 and they will largely be completed in the final quarter of the year 18 weeks Referral to Treatment Incomplete (i.e. have not yet been treated) This standard requires that at least 92% of patients who are referred for treatment should wait less than 18 weeks. The standard relates to Lewisham patients waiting at any Trust and our performance of 88% reflects the challenges especially at Kings College Hospitals and some key specialties e.g. Trauma and Orthopaedics where there are challenges across providers. Improved Access to Psychological Therapies Recovery Rate This is the percentage of people ending treatment sessions of psychological therapies that reach a recovery level as measured by their own self-assessment of the effect of treatment. The standard is 50% which is planned to be reached for the period January 2017 to March Psychological Therapies are designed to assist people with anxiety and depression symptoms. The number of people seen by the Lewisham service is between 5000 to 6000 people a year. People can refer themselves or be referred by their GP and they can access personal treatment or for some conditions be seen in groups. The service has identified a series of challenges in improving recovery, including understanding those conditions or particular groups of people who have lower recovery rates, and has developed actions to address them. The service has improved in the year and is ahead of last year and the recovery plan set. January 2017 data has confirmed that the service has met the 50% Recovery Rate for the first time in line with the plan. Furthermore, 3 in 5 people assess themselves as having made reliable improvement from their assessment at the beginning to the end of their treatment. 5. CCG Improvement and Assurance Framework In 2016/17 NHS Lewisham CCG, in common with all Clinical Commissioning Groups, has been assessed on the CCG Improvement and Assurance Framework and supports us to ensure that we are meeting our statutory duties to improve the quality of services. This has covered a set of indicators. Set out below are the six clinical areas where the CCG has been assessed on the following scale: Page 34

35 Top Performing Performing Well Needs Improvement Greatest Needs for Improvement The assessment and key reasons are: Clinical Assessment Key Issues Area Dementia Top Performing Both for identifying people in primary care and ensuring that care plans are reviewed Learning Disabilities Needs Improvement The CCG is working across South East London to transform care for those in secondary care for which the number has recently increased all South East London CCGs need Maternity Mental Health Cancer Diabetes Needs Improvement Greatest Needs for Improvement Needs Improvement Needs Improvement improvement. This is rated, because none of the four indicators for Maternity are in the top quartile of CCGs. The CCG will need to select the best metric to improve with partners. It is not so easy as none of the indicators is in the bottom quartile. The assessment is based on two mental health standards for the recovery rate for those completing psychological therapies and people with psychosis beginning treatment within 2 weeks of referral. The assessment of Greatest Need for Improvement was made using data from April to June 2016, when both standards were not meeting standard thresholds. Subsequent improvement on both measures achieved from July 2016 onwards would result in an improvement on this assessment. This is outlined in the NHS Constitutional Standards section of the Annual Report above. The waiting times from GP referral to treatment within 62 days (77% - see constitutional standards section above) and the results of the cancer patient survey are both in the bottom quartile of all CCGs. The CCG is one of the best in the country with regard to people newly diagnosed with diabetes being invited to structured education. However, it is one of the worst in the country for people with diabetes being in control of their blood sugar, blood pressure and cholesterol. The 2016/17 year-end assessment for the CCG will be available on from July Page 35

36 6. Financial Performance In 2016/17 we met all of our statutory financial duties. These are set out below and with our key financial performance indicators and summary financial accounts statements. Duty Duty Target Performance Achieved Expenditure not to exceed income Yes 431, ,257 Capital resource use does not exceed the amount specified in Directions Yes 0 0 Revenue resource use does not exceed the amount specified in Directions Yes 427, ,138 Capital resource use on specified matter(s) does not exceed the amount specified in Directions Yes 0 0 Revenue resource use on specified matter(s) does not exceed the amount specified in Directions Yes 0 0 Revenue administration resource use does not exceed the amount specified in Directions Yes 6,608 6,539 We commission the majority of NHS services for Lewisham people. We spend the money available to us on healthcare for Lewisham patients and we aim to spend it in the best way that will improve the health of and the care for Lewisham people, which delivers value for money to the taxpayer and is sustainable in the long term. In 2016/17 our net annual expenditure was 417.1m. Approximately 80% of our expenditure is on a combination of hospital services, mental health services and community services. Page 36

37 The following chart shows how the breakdown of our expenditure by service type in 2016/17. Our expenditure on commissioned services in 2016/17 Commissioning Expenditure ( m) Mental Health Services, 71.84m, 17.22% Community Services, 29.71m, 7.12% Continuing Care Services, 16.52m, 3.96% Hospital Services, m, 54.34% Others Services, 13.12m, 3.15% Primary Care Prescribing and Other Services, 39.09m, 9.37% Better Care Fund, 20.17m, 4.83% 2016/17 Expenditure on Local Hospital Providers by Service Type Lewisham and Greenwich NHS Trust Guys and St. Thomas' NHSFT Kings College Hospitals NHSFT Provider Service Type m m m A&E Emergency/Non Elective Outpatients Inpatients Maternity Others Total A planned cumulative surplus of 7,643k was agreed with NHS England for the year. The planned surplus for 2016/17 comprised a cumulative brought forward surplus of 7,643k with a planned nil in-year movement. 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 Page 37

38 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 Lewisham CCG has released its 1% reserve to the bottom line, resulting in an additional surplus above plan for the year of 4.05m. This additional surplus has been partially offset against other non-recurrent cost pressures totalling 1.75m from the current financial year. The remainder will be carried forward and for drawdown in future years. 2016/17 expenditure on hospital services above (services from other NHS Trusts in Note 5 to the Annual Accounts) includes non-recurrent expenditure of 1.75m that was paid by the CCG to Lewisham and Greenwich Trust as part of an NHS system-wide contractual commitment, totalling 10.5m, which was agreed by NHS England in 2013 when the Trust was formed. This contractual commitment refers to 2016/17 and 2017/18 only. For 2017/ m is a maximum value and may be reduced through delivery of system wide savings, above those planned for 2017/ Sustainable Development As an NHS organisation, and as a spender of public funds, we have an obligation to work in a way that has a positive effect on the communities for which we commission and procure healthcare services. Sustainability means spending public money well, the smart and efficient use of natural resources and building healthy, resilient communities. By making the most of social, environmental and economic assets we can improve health both in the immediate and long term even in the context of rising cost of natural resources. Spending money well and considering the social and environmental impacts is enshrined in the Public Services (Social Value) Act (2012). In order to fulfil our responsibilities for the role we play, NHS Lewisham CCG has the following sustainability mission statement located in our sustainable development management plan (SDMP): " ensure that the organisation takes a sustainable development approach to its commissioning duties.." Page 38

39 As a part of the NHS, public health and social care system, it is our duty to contribute towards the level of ambition set in 2014 of reducing the carbon footprint of the NHS, public health and social care system by 34% (from a 1990 baseline) equivalent to a 28% reduction from a 2013 baseline by It is our aim to supersede this target by reducing our carbon emissions 34% by 2020/2021 using 2007/08 as the baseline year. Modelled Carbon Footprint The majority of the environmental and social impacts are through the services we commission. Therefore, the following information uses a scaled model based on work performed by the Sustainable Development Unit (SDU) in 2014/15. More information available on the SDU website Resulting in an estimated total carbon footprint of 111,093 tonnes of carbon dioxide equivalent emissions (tco₂e). The majority of this impact is from the services we commission Category % CO 2 e Energy 0% Travel 0% Procurement 9% Commissioning 91% Proportions of Carbon Footprint 91% 0% 9% Energy Travel Procurement Commissioning Page 39

40 Carbon Footprint CO 2 e baseline to 2020 with Climate Change targets kt CO2e NHS Lewisham CCG Modelled 1990 baseline Modelled 2007 baseline 10% target from 2007 Trajectory to 2020 Modelled forecast Year Climate Change Act Trajectory CO 2 Emissions (tco 2 e) Profile 2014/15 Total 111,093 Pharmaceuticals 9,954 Paper products 0 Other procurement 0 Other manufactured products 0 Medical Instruments /equipment 0 Manufactured fuels chemicals and gases 1 Information and communication technologies 263 Freight transport 0 Food and catering 6 Construction 0 Business services 1 Capital spend 0 Water and sanitation 0 Waste products and recycling 0 Travel 21 Imported Heat/Steam 0 Electricity 24 Coal 0 Oil 0 Gas 9 Commissioning 100,814 Page 40

41 Policies In order to embed sustainability within our business it is important to explain where in our process and procedures sustainability features. Area Commissioning (environmental) Commissioning (social impact) Suppliers' impact Business Cases Travel Is sustainability considered? Yes Yes Yes No One of the ways in which an organisation can embed sustainability is through the use of an SDMP. An update to our SDMP is required because it has not been approved by the board in the last 12 months. As an organisation that acknowledges its responsibility towards creating a sustainable future, we help achieve that goal by running awareness campaigns that promote the benefits of sustainability to our staff. Climate change brings new challenges to our business both in direct effects to the healthcare estates, but also to patient health. Examples of recent years include the effects of heatwaves, extreme temperatures and prolonged periods of cold, floods, droughts etc. Our board approved plans to address the potential need to adapt the delivery the organisation's activities and infrastructure to climate change and adverse weather events We have not assessed the social and environmental impacts for the CCG. We have not currently issued a statement on Modern Slavery. Partnerships As a commissioning and contracting organisation, we will need effective contract mechanisms to deliver our ambitions for sustainable healthcare delivery. The NHS policy framework already sets the scene for commissioners and providers to operate in a sustainable manner. Crucially for us as a CCG, evidence of this commitment will need to be provided in part through contracting mechanisms. Page 41

42 We have not currently established any strategic partnerships. For commissioned services here is the sustainability comparator for our providers: Organisation Name SDMP On track for 34% reduction GCC THE LEWISHAM AND GREENWICH NHS TRUST SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST GUY'S AND ST THOMAS' NHS FOUNDATION TRUST KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST No 4. No Sustainable Development Management Plan or Carbon reduction Plan Healthy travel plan Adaptation SD Reporting score No No No Good Yes 1. On track to meet target No Yes Yes Poor Yes 1. On track to meet target Yes No Yes Good Yes 2. Target included but not on track to be met No Yes No Good More information on these measures is available on the SDU website Performance Organisation As a part of the NHS, public health and social care system, it is our duty to contribute towards the level of ambition set in 2014 of reducing the carbon footprint of the NHS, public health and social care system by 34% (from a 1990 baseline) equivalent to a 28% reduction from a 2013 baseline by It is our aim to supersede this target by reducing our carbon emissions 34% by 2020/2021 using 2007/08 as the baseline year. Here's how we have done: Page 42

43 Commissioned activity Organisation Name THE LEWISHAM AND GREENWICH NHS TRUST Building energy use >10% increase Building energy use per FTE 4.0 Water >20% increase Water use per FTE 49 Percent high cost waste >89% high cost Waste cost increase >20% increase SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST 0-10% decrease % decrease 26 >97% high cost >20% decrease GUY'S AND ST THOMAS' NHS FOUNDATION TRUST KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST 0-10% increase >10% increase >20% increase >20% increase >75% high cost >89% high cost 0-20% decrease 0-20% decrease More information on these measures is available on the SDU website Travel We can improve local air quality and improve the health of our community by promoting active travel to our staff, through our providers and to the patients and public that use the services we commission. Every action counts and we are a lean organisation trying to realise efficiencies across the board for cost and carbon (CO2e) reductions. We support a culture for active travel to improve staff wellbeing and reduce sickness. Category Mode 2013/ / / /17 Business Travel miles 9,930 11,016 9,988 7,148 tco 2 e Staff commute miles 48,661 58,598 66,283 54,755 tco 2 e Page 43

44 Energy We have spent 6434 on energy in 2016/17, which is a 60.3% decrease on energy spend from last year. Resource 2013/ / / /17 Gas Use (kwh) 144, , ,326 41,443 tco 2 e Oil Use (kwh) tco 2 e Coal Use (kwh) tco 2 e Electricity Use (kwh) 138, , ,518 46,010 tco 2 e Green Electricity Use (kwh) tco 2 e Total Energy CO 2 e Total Energy Spend 22,886 20,464 16,198 6,434 Carbon Emissions - Energy Use Carbon (tco2e) / / / /17 Gas Oil Coal Electricity Green Electricity 0% of our electricity use comes from renewable sources. Finite resource use Water Water 2013/ / / /17 Mains m , tco 2 e Water & Sewage Spend Page 44

45 Benchmarking Organisation Carbon Footprint by head of population Carbon Emissions (tco 2 e) Energy Travel Commissioning Procurement Benchmark (CCG) / / / /17 Adaptation Events such as heatwaves, cold snaps and flooding are expected to increase as a result of climate change. To ensure that the CCG would continue to meet the needs of our local population during such events we have developed and implemented a number of policies and protocols in partnership with other local which are included in our Business Continuity Plan and includes a Severe Weather Major Incident Plan. To help to reduce the impact on greenhouse gases and finite resources, during 2016/17 the CCG implemented a meeting management system, Modern.Gov. The system streamlines the processes for electronic production of committee papers thereby reducing the impact on the environment and cost of printing and collation of papers. Governing Body members and the Senior Management Team are now able to access the system via the Mod.Gov app on their ipads, or through a web-based solution. Page 45

46 8. Patient and Public Involvement Our vision for engagement We believe engagement goes further than communication or consultation, and involves commissioners in providing opportunities for patients, carers and the public to work alongside them as equal partners in transparent decision-making. Engagement is a two-way process, involving interaction and listening, with the goal of making better decisions and commissioning better services that deliver our strategic vision for all better health, best care and best value. Our public engagement charter We have many ways in which we carry out local involvement. These are outlined in our Public Engagement Charter: We will: 1. listen to people and ensure in every way possible that public views are heard and acted upon 2. involve the public early in developing our strategic plans and how we plan to deliver improvements in local services 3. involve the public early in our decision-making about how we commission new services, and redesign them. 4. demonstrate what impact the public has had on the decisions we make 5. always feed back to people who have worked with us 6. use the information provided to ensure that we improve the quality of our services, support equality and identify inequalities in access to healthcare 7. be honest about when we are engaging, when we are consulting and when we are providing information 8. support the Involvement of patients in decisions about their care 9. make sure that everyone who works with us will recognise and promote the value of involving the public. Lewisham has a diverse population and, in particular, a wide range of Black and Minority Ethnic communities. We seek to ensure that we are engaging with all of our communities, especially seldom heard groups such as our Vietnamese community, faith groups, young Page 46

47 people through the Lewisham Young Mayor and Advisors and Young Mothers group, and with people who are blind or visually impaired. In 2016/17 we engaged with a wide range of charity, faith and community groups including those working with people who are homeless, those working with refugees and migrants, those working with people with a disability, and a network for people who are lesbian, gay, bisexual or transgender. During 2016/2017 we carried out over 80 engagement activities, reaching more than 1,500 people, including at the Phoenix Festival in May 2016, Lewisham s People s Day in July 2016, our Annual General Meeting in September 2016, and in many meetings with local voluntary and community groups throughout the year. We also hosted a pre-consultation event in September 2016 for planned orthopaedic care as part of the Our Healthier South East London programme. We supported the development of neighbourhood patient participation groups (PPGs) for our GP practices. PPGs are made up of patient representatives from each practice. We held eight neighbourhood PPG Events, covering how practices will collaborate across neighbourhoods, primary care extended access and digital innovation. As part of our plans to improve primary and urgent care for people in Lewisham we have introduced a six month Primary Care Assessment pilot which comprises a team of GP assessors and health care assistants based at University Hospital Lewisham Urgent Care Centre (UCC) and Emergency Department (ED). To evaluate the pilot we engaged with patients, health professionals and reception staff. We interviewed 45 patients who had been seen by the GP Assessor during six different visits. This enabled us to record and analyse patient views on their experience of the pilot service which were largely positive (for example 84% rated their treatment and the information they were given as good or excellent, and 84.4% were seen within one hour). We also asked why they chose to attend the UCC/ED and this information is being used to inform further improvements into how people access GP services. Our public engagement team s work plan is overseen by the CCG s Public Engagement and Equalities Forum (PEEF) and supported by the Public Reference Group, a group of local people which is reflective of the borough s diversity. The PRG s role includes: Ensuring that public engagement is integrated into the commissioning cycle. Acting as a critical friend across all commissioning services in respect of patient and public engagement. Page 47

48 Supporting the CGG in engaging and communicating more widely with the public to gather their views, and to inform the public of the challenges facing the NHS and any proposed changes to services. In 2016/17 the PRG has carried out valuable work in a range of areas including carers information, advice and support, maternity services, mental health and wellbeing, end of life care, and integrating health and social care services. They have also been actively involved in our EDS2 (Equality Delivery System) assessment which helps us to review and improve our performance for people with characteristics protected by the Equality Act In response to some negative online feedback and as part of our contract monitoring we carried out an evaluation of the engagement carried out by the provider of the Walk in Centre based at the Waldron Centre. This included interviews with 90 patients and the results will be used to inform future development plans for urgent and emergency care in the borough. We have also engaged widely to obtain people s recent experiences of using GP services in Lewisham and their views on our plans to deliver a new service offering extended access to appointments (8am to 8pm, seven days a week) in the borough. During February and March 2017 we commissioned Healthwatch Lewisham to run five focus groups with seldom heard groups in Lewisham around this area. These included people from Black African and Caribbean backgrounds, those with a physical, sensory or learning disability, and people living in areas of deprivation. In addition we ran sessions on this topic in a range of community groups and events. This work has informed the on-going development and the delivery of an extended access service from 1 April It has also built awareness among patients, public and stakeholders of increased primary care access and gathered views on the information people need to support them to find their way around these services. This engagement also succeeded in forging links with groups we had not previously reached, for example: Lewisham Islamic Centre women s group, Downham Men s Health Group and the Lewisham Young Mothers Group. It has also built upon links to Lewisham s Young Advisors. In another part of our work to improve access to GP services we ran a successful campaign online and in practices to encourage people to sign up for the patient online system which enables people to book appointments, order repeat prescriptions and view their medical records online. We have been promoting this widely using social media, online advertising and at events in the borough. For example we held a stall at an event attended by over 100 people Page 48

49 celebrating Lewisham s Get On scheme which encourages wider digital participation. As a result of the campaign in Lewisham, we now have the highest percentage of practices in London with more than 20% of patients using online services. In March alone, we saw 3772 new registrations for GP online services. This means that a Lewisham resident who may have small children, and is also a carer for a parent, will now be able to select appointments which fit around the commitments of the whole family, without having to spend a lot of time waiting on the phone. Ordering repeat prescriptions is also much more simple. Even when the practice is closed, patients can log on and order medication (repeat prescriptions only) which will be ready to be picked up in the usual way. We are committed to being open and transparent in our decision-making and providing opportunities for the entire population in Lewisham to engage with us. Two areas in which we do this are: public sessions at each of our Governing Body meetings where people can ask questions and at our Annual General Meeting. We are developing plans to increase participation and involvement in both of these forums. We publish an annual engagement report which sets out our engagement work for 2016/2017. NHS England reviewed our engagement and in January 2017 rated us as good for both the individual duty to promote the involvement of patients and carers in decisions relating to their care or treatment and the collective duty for participation in how we design, deliver and improve local health services. 9. Promoting Equality and Reducing Inequalities Our strategic priorities are based on an analysis of Lewisham s Joint Strategic Needs Assessment s (JSNA) which identifies health needs of the local population. This includes disease prevalence amongst different ethnic groups, the health needs of different age groups, and the impact of deprivation and other factors which affect health equality and inequalities. Our ambitions include improving life expectancy, reducing premature mortality from the main causes of death, decreasing infant mortality, and a number of measures of high quality care including emergency admissions, end of life care, and patient experience; further development Page 49

50 is being undertaken of equalities considerations for cancer rates, mental health, and diabetes. These were reflected in the partnership commissioning priorities for 2016/17 that were agreed by the Lewisham Health & Wellbeing Board, informed by the refreshed Lewisham Health and Wellbeing Strategy and the work of the Adult Integrated Care Programme Board on developing and implementing Neighbourhood Care Networks. The Health & Wellbeing Board has also agreed our partnership commissioning intentions for 2017/18, building on this year s commissioning intentions and the work of the Lewisham Adult Integrated Care Programme Board, the Children and Young People s Strategic Partnership Board and the South East London work on Sustainability and Transformation Plan. We published our annual equalities report in January 2017 (here) It describes in detail and provides case studies that show how we are meeting our general and specific duties of the Equality Act 2010, through our commissioning intentions, equalities analyses, public engagement and our equalities objectives. It includes case studies that describe in more detail how we have met the needs of groups from our local population who have shared protected characteristics and/or experience health inequality. Some of the examples are: Maternity services We have worked with Lewisham and Greenwich NHS Trust through a contract quality scheme to develop appropriate care pathways for vulnerable women during pregnancy. The scheme incentivised the trust to develop pathways and information for staff and women to support them accessing support as needed and to improve their experience of maternity services. This has focused on improvements in care delivered to people who have high or complex social risk factors in pregnancy and because of the following protected characteristics: age (including children and young people), pregnancy and maternity and race. Mental Health Home Treatment - Lewisham Home Treatment Team service provides short term care and treatment at home for people in mental health crisis who would otherwise require an inpatient admission. There are a number of features of this service that seek to reduce inequalities for protected groups and others, such as the provision of an out of hours and weekend service which enables service users to stay in employment and / or meet family commitments, a home based assessment and treatment service provides the least restrictive care and enables continuity of family and social support. Home treatment also means that people with physical health and mobility problems can access the service in the same way as anyone else, while Page 50

51 providing care at home avoids some of the social difficulties associated with admission such as loss of tenancy or disruption to benefits. Interpreters are always arranged for service users and carers whose first language is not English, and consideration is paid to issues such as gender and cultural factors when visits are allocated. Community Anti-coagulation Monitoring Service - We commission the Lewisham Health Limited Liability Partnership to provide a Community Anticoagulant Service (CACS) that provides special medication (anticoagulants) used to prevent blood clots in a range of conditions. The importance of this service is because Lewisham residents have lower life expectancy with heart attack and stroke (26% deaths under 75 years) and 46.5% Lewisham population is BME and at greater risk of diabetes, hypertension and stroke that can be reduced by using anticoagulants. A pilot was commissioned to extend the services to improve access for patients with restricted movement, and to establish how the service could be reconfigured for transport and housebound patients. The CCG and pharmacies are developing an action plan to increase the number of BME users accessing the service, provide translations for people whose first language is not English, and improve demographic data collection. grammar As part of our assessment for the NHS Equality Delivery System (EDS2) we asked local stakeholders and service users for their views on how well we had delivered our commissioning responsibilities in these services. Their conclusions were that people from most of the protected groups compared favourably to people overall in: Being informed and supported to be as involved as they wish to be in decisions about their care Reporting positive experiences of the NHS Services are commissioned, procured, designed and delivered to meet the health needs of local communities We will share the learning from these services so that we can achieve improvements in health outcomes and access to services and experience in all areas for our population. For the four goals of the EDS2 the CCG achieved the following gradings: Page 51

52 EDS2 Goals Grading achieved In Better Health Outcomes Achieving 2 Improved patient access and experience Developing 3 A representative and supported workforce Developing 4 Inclusive leadership Developing The grade for EDS2 Goal 3 took into account the results of the Staff Survey which demonstrated that from the data available overall most staff members from most protected groups fare as well as the overall workforce but with some areas for improvement such as access to opportunities for career progression. The CCG grade for Goal 4 was assessed independently. The independent assessor noted the commitment of the CCG s leadership to equality and in particular the improvements that have been made in discussion of equalities issues, increasing levels of knowledge, in participation and in the referencing in reports to focus on getting services right for those who experience the greatest need and barriers due to sharing one or more protected characteristic. However, the CCG recognises that more consistent effort needs to be made to visibly demonstrate the commitment of the Governing Body and senior management to promoting equality. The NHS Workforce Race Equality Standard (WRES) is a benchmarking tool introduced by NHS England to assess the progress of race equality within NHS organisations annually. Analysis of the CCG workforce shows that the percentage of BME staff in bands 8-9 and VSM is close to the CCG representation of BME employees in its workforce. The CCG s Equality & Diversity Steering Group has also assessed the performance against the WRES of the CCG s main provider organisations, in particular to confirm that they have been meeting the reporting requirements and milestones of the WRES and that they have action plans in place. It is recognised that some providers face challenges to redress their board and workforce profiles. The outcomes of the EDS assessment process and the review of the WRES have informed the development of our organisational equalities objectives, helping to ensure that we can build on areas of strength, such as the better health outcomes EDS goal 1, and continue to improve further in the other areas. The objectives cover access and experience for BME patients with Page 52

53

54

55 Corporate Governance Report Members Report Member practices NHS Lewisham CCG was made up of the following member practices during 2016/17: Practice Name Neighbourhood Address Mornington Surgery North 433 New Cross Road, SE14 6TJ Queens Road Practice North 387 Queens Road, New Cross, London, SE14 5HD Kingfisher North Kingfisher Medical Centre, Staunton Street, Deptford, SE8 5DA Clifton Rise North Clifton Rise Family Practice, Waldron Health Centre, Stanley Street, London, SE8 4BG New Cross Health Centre North New Cross Health Centre, 40 Goodwood Road, New Cross, SE14 6BL Grove Medical Centre North Windlass Place, London, SE8 3QH Vesta Road Surgery North 58 Vesta Road, London, SE4 2NH Amersham Vale Training Practice North Waldron Health Centre, Stanley Street, London, SE8 6TJ Deptford Surgery North New Cross Road, London, Se14 6TJ Waldron Family Group Practice North Page 55 Waldron Health Centre, Stanley Street, London, SE8 4BG Deptford Medical Centre North 2 Pearsons Avenue, SE14 6TG Belmont Hill Central The Surgery, 36 Belmont Hill, Lewisham, SE13 5AY Lee High Road Central Lewisham Medical Centre, 308 Lee High Road, Lee, SE13 5PJ Lee Health Centre Central Lee Health Centre, 2 Handen Road, Se12 8NP Morden Hill Central The Surgery, 21 Morden Hill, London, SE13 7NN St Johns Medical Centre Central Loampit Hill, Lewisham, SE13 7SX The Surgery, 20 Lee Road Central The Surgery, 20 Lee Road, Blackheath, SE3 9RT Brockley Road Central Brockley Road, Brockley, SE4 2PJ Hilly Fields Medical Centre Central 172 Adelaide Avenue, Brockley, SE4 1JN Honor Oak Group Practice Central Honor Oak Health Centre, 20 Turnham Road, SE4 2LA Triangle Group Central The Triangle Group Practice, 2 Morley Road, London, SE13 6DQ

56 Practice Name Neighbourhood Address Rushey Green Central The Primary Care Centre, Hawstead Road, London, SE6 4JH Woodlands Health Centre Central 4 Edwin Hall Place, Hither Green Lane, London, SE13 6RN Nightingale Central 2 Handen Road, SE12 8NP Hurley Group Central Waldron Health Centre, Amersham Vale, London, SE14 6LD South Lewisham South East 50 Conisborough Crescent, Catford, London, SE6 2SP The Surgery, Torridon Road South East The Surgery, 80 Torridon Road, Catford, SE6 1RB Downham Family Practice South East Downham Health and Leisure Centre, 7-9 Moorside Road, Downham, BR1 5EP South East The Surgery, Downham Way, The Surgery, Downham Way Downham, Kent, BR1 5HU The Surgery, Winlaton South East 139 Winlaton Road, Bromley, Kent, BR1 5QA ICO Group - The Surgery, Chinbrook South East 32 Chinbrook Road, Grove Park, London, SE12 9TH Parkview Surgery South East 186 Brownhill Road, Catford, London, SE6 1AT ICO Group - Marvels Lane South East 37 Marvels Lane, Grove Park, SE12 9PN Health Centre ICO Group - Moorside South East Downham Health and Leisure Centre, 7-9 Moorside Road, Downham, BR1 5EP ICO Group - The Surgery Boundfield Road Oakview Family Practice Baring Road Medical Centre South East South East South East The Surgery, 103 Bounfield Road, Catford, SE6 1PG 190 Shroffold Road, Downham, Kent, BR1 5NJ Baring Road Medical Centre, 282 Baring Road, London, SE12 0DS 201 Stanstead Road, Forest Hill, London, SE23 1HU Jenner Practice South West Sydenham Green Group South West 26 Holmshaw Close, Sydenham, London, Practice SE26 4TH Woolstone Medical Centre South West Woolstone Road, London, SE23 2TR Sydenham Surgery South West 2 Sydenham Road, Sydenham, SE26 5QW South West The Wells Park Practice, 1 Wells Park Road, Wells Park Practice Sydenham, London, SE26 6JQ South West Bellingham Green Surgery, 24 Bellingham Bellingham Green Surgery Green, Catford, London, SE6 3JB South West The Vale Medical Practice, Perry Vale Medical Centre Vale, Forest Hill, London, SE23 2JF Page 56

57 Composition of the Governing Body The Chair of the CCG Governing Body continues to be Dr Marc Rowland. Mr Martin Wilkinson has been the Accountable Officer. The Membership Body, which at NHS Lewisham CCG has been known locally as the Clinical Directors Committee (supported by wider membership structures as set out in our constitution), has comprised the seven elected GP members of the CCG s Governing Body plus the Accountable Officer (or his deputy). During 2016/17 this included: Dr Marc Rowland (Chair) Dr David Abraham (Senior Clinical Director) Dr Faruk Majid (Senior Clinical Director) Dr Jacky McLeod (Clinical Director) Dr Angelika Razzaque (Clinical Director) Dr Sebastian Kalwij (Clinical Director) Dr Charles Gostling (Clinical Director) Mr Martin Wilkinson (Accountable Officer) The Governing Body during 2016/17 has included the members of the Clinical Directors Committee shown above, the Chief Financial Officer and four independent members: Mr Tony Read (Chief Financial Officer) Prof Ami David (Registered nurse member until 31st October 2016) Mr Ray Warburton (Lay member) Ms Rosemarie Ramsay (Lay member until 9th January 2017) Dr Mark Hamilton (Secondary Care Doctor) Committee(s), including Audit Committee The CCG s Audit Committee comprised the following members during the year ending 31 st March 2017: Mr Ray Warburton (Chair) Page 57

58 Dr Faruk Majid Prof Ami David (until 31 st October 2016) Ms Rosemarie Ramsay (until 9 th January 2017) Dr Mark Hamilton Ms Shelagh Kirkland (independent member) Details of the members of other committees can be found in Annual Governance Statement and further details of the Governing Body and Clinical Director s Committee can be found in the Remuneration and Staff Report. Register of Interests Lewisham CCG is committed to the principles of good governance, leading to open and transparent decision making. We have therefore established a policy to manage Conflict of Interests to ensure that decisions made by the CCG will be taken and seen to be taken without any possibility of the influence of external or private interests. Our updated policy that takes account of the latest statutory guidance was published in November A conflict of interest is defined as: A conflict between the private interests and the official responsibilities of a person in a position of trust A set of conditions in which professional judgement concerning a primary interest (such as patients' welfare or the validity of research) tends to be unduly influenced by a secondary interest (such as financial gain) The creation of a set of circumstances where one party is favoured over another by an inadvertent preferential interest In line with our conflicts of interest policy, arrangements to seek and receive declarations of interest and maintain appropriate Registers of Declared Interests and Gifts and Hospitality have been put in place. We publish our register of interests on our website which can be found at here, with the Gifts and Hospitality register found on our website here. Page 58

59 The register for Governing Body Members is reviewed monthly and updated as required. It is available as part of the pack of papers for Governing Body meetings, which can be found here (Governing Body papers March 2017). Personal data related incidents Information relating to the disclosure of incidents involving data loss and confidentiality breaches can be found in the Annual Governance Statement. 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 Lewisham CCG fully supports the Government s objectives to eradicate modern slavery and human trafficking but does not meet the requirements for producing an annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act Page 59

60 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 Martin Wilkinson to be the Accountable Officer of NHS Lewisham CCG. 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. Page 60

61 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. 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 Page 61

62 Governance Statement Introduction and context NHS Lewisham CCG 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 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, Page 62

63 efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it. The Clinical Commissioning Group Governance Framework Governing Body The National Health Service Act 2006 (as amended), at paragraph 14L(2)(b) states: The main function of the governing body is to ensure that the group has made appropriate arrangements for ensuring that it complies with such generally accepted principles of good governance as are relevant to it. The CCG is governed by its constitution, signed by all the CCG s members. The constitution sets out the CCG s governance structures and processes including the role of the Governing Body and its individual members. During 2016/17 changes to the constitution were approved by NHS England that strengthened the provisions for Conflicts of Interest and to allow the CCG to provide Level 3 of Delegated GP Commissioning from April Each member of the Governing Body shares responsibility as part of a team to ensure that the group exercises its functions effectively, efficiently and economically, with good governance and in accordance with the terms of its constitution. Each Governing Body member brings their unique perspective, informed by their skills, knowledge and experience. During the year, the Governing Body: has approved the CCG s operating plan and corporate objectives for 2016/17 agreed the CCG s budgets for the year approved the annual equalities report approved the sign-off of the Financial Control Environment Assessment approved the Conflicts of Interest Policy approved the Procurement Policy Page 63

64 approved partnership commissioning intentions for integrated care for 2017/18 received and endorsed the Sustainability & Transformation Plan (STP) for south east London made arrangements to meet with the public before its formal meetings received an integrated performance report, with additional exception reports, through which the Governing Body has been advised of the quality and safety of commissioned services and other performance and financial issues. Where necessary the Governing Body has taken appropriate action, for instance in critical areas of performance such as cancer waits and A&E waits received and taken assurance that strategic risks were effectively mitigated ensured that all conflicts of interest or potential conflicts of interest were effectively managed. There were six meetings of the Governing Body held in public during the year. All of the meetings were well attended and were quorate. The table below shows the Governing Body members and attendance record. The Governing Body and all other committees discussed below were supported by the CCG management team, with appropriate attendance, as required. Members Role May July Sept Nov Jan Mar Prof Ami David Registered Nurse Y Y Y Left 31/10/2016 Dr David Abraham Senior Clinical Y Y Y X Y Y Director Dr Faruk Majid Senior Clinical Y Y Y Y Y Y Director Dr Jacky McLeod Clinical Director Y Y X Y Y Y Dr Angelika Razzaque Clinical Director Y Y Y Y Y Y Dr Marc Rowland Chair Y Y Y Y Y Y Mr Martin Wilkinson Chief Officer Y Y Y Y Y Y Mr Ray Warburton Lay Member Y Y Y Y Y Y Mr Tony Read Chief Financial Y Y Y Y Y Y Officer Ms Rosemarie Ramsay Lay Member Y Y Y X Left 09/01/2017 Dr Sebastian Kalwij Clinical Director Y Y Y Y Y Y Page 64

65 Members Role May July Sept Nov Jan Mar Dr Charles Gostling Clinical Director Y X Y Y Y X Dr Mark Hamilton Secondary Care Y X Y Y Y X Doctor Absences are normally agreed with the Chair as members are frequently required to attend other meetings. Where Dr Rowland was unable to attend the meeting was chaired by Mr Ray Warburton. The CCG has also carried out a governance review of its committee structures and decision making processes to ensure that they are fit for purpose and support greater transparency. The specific focus of the review was the Governing Body, (including Governing Body workshops) the Delivery Committee, the Strategy and Development Committees, the Finance and Investment Committee, the Primary Care Programme Board and working groups. The outcome of the review led to recommendations that will support the CCG s decision making being simpler, quicker and more transparent by making the committee structure flatter with fewer layers of committees and groups, and enabling the Governing Body to have greater involvement in developing and overseeing the strategic direction of the CCG. The conclusions of the review were implemented during 2016/17, seeing particular changes to how quality, strategic development, public engagement, and equalities areas are addressed by the Governing Body and its supporting structures. The Integrated Governance Committee was established, taking on the responsibilities of the Delivery Committee and For Learning and Action Group (FLAG), and a committee reporting to the Governing Body to provide oversight of public engagement and of equalities. The Governing Body has also completed an assessment of its own effectiveness. The outcomes of the review have been discussed at the Strategy and Development Workshop and also at individual committees. The assessment included the composition and membership of the Governing Body, roles and responsibilities, decision-making, management of risk and conflicts of interests, meeting statutory responsibilities for equalities and for public engagement, and regard for the CCG s values. Page 65

66 The CCG is a membership organisation with a federated structure. The organisational chart below shows the governance structures in place during the financial year ending 31 March The chart indicates the inter-relationship between membership bodies on the left (the Clinical Directors Committee, Membership Forum and Neighbourhood Meetings) and the key governance committees, headed by the Governing Body in the centre of the chart. The chart also shows the important links with our partner organisations including the Lewisham Health and Well Being-Board and the South East London collaborative arrangements for primary care, strategic decision-making and clinical strategy. Clinical Directors Committee The Clinical Directors Committee is a standing Committee of Lewisham CCG, made up of the seven GPs elected to the Governing Body by the CCG members and including the Chief Officer. It has been the high level membership body to provide a formal connection, transacted through the Membership Forum, between the on-going business of the Governing Body and CCG member practices. It provides a vehicle in Page 66

67 which the Clinical Directors seek and consider ideas, views and concerns from members and galvanised their support and participation to deliver the CCG s objectives. During the year the work of the Clinical Directors Committee included: influenced the development of the CCG s strategic plans and priorities ensuring that the membership s views were incorporated, particularly into urgent care service models and primary care development promoted the CCG s strategic plans with the membership ensuring engagement, support and participation reviewed potential models for developing the local healthcare system assessed the conclusions and recommendations from the Commissioning for Value packs and their implications for the CCG s strategic priorities There were 10 meetings of the Clinical Directors Committee during the year. All of the meetings were well attended. The table below shows the members and attendance record. The Clinical Directors Committee was supported by the CCG management team, with appropriate attendance, as required Members Role Apr May Jun Jul Sep Oct Nov Dec Feb Mar Dr Angelika Razzaque Dr David Abraham Dr Faruk Majid Dr Jacky McLeod Clinical Director Senior Clinical Director Senior Clinical Director Clinical Director Y Y Y Y Y X Y Y Y Y Y Y X Y Y Y Y Y X X X Y Y Y X Y Y Y Y Y Y Y Y Y X Y Y Y Y Y Dr Marc Rowland Chair Y Y X X Y Y Y Y Y Y Dr Charles Gostling Dr Sebastian Kalwij Clinical Director Clinical Director Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y X Y Mr Martin Wilkinson* Chief Officer Y Y X Y Y Y Y X X X Page 67

68 *The Chief Financial Officer and Corporate Director deputised for Mr Martin Wilkinson when he was unable to attend. Absences are normally agreed with the Chair as members are frequently required to attend other meetings. Audit Committee The committee was established to take an independent and objective view of the CCG s financial systems, compliance with laws and compliance with best practice in its arrangements for corporate governance. The committee has reflected on its work and had agreed that it goes about its business in an organised, inclusive and accountable way. In 2016/17: its work programme followed a plan agreed at the start of the year it makes it clear to CCG management and staff what is required from them in the preparation and running of meetings it meets in a private session with the CCG s independent assurance providers at the end of each meeting it reported the headlines of each meeting to the Governing Body, and minutes have also been provided when they have been confirmed Learning and development sessions were held with an independent coach with a strong audit background. During the year, the work of the Audit Committee included: approved the 2015/16 CCG Annual Report and Annual Accounts on behalf of the Governing Body received the Head of Internal Audit Opinion for 2015/16 agreed key performance indicators for External Audit and Internal Audit approved the Internal Audit plan for 2016/17 and commented on the reports of the reviews reviewed Service Auditor Reports Page 68

69 approved the Counter Fraud and the local security management service work plans for 2016/2017 and commented on progress scrutinised and advised on the format and content of the Board Assurance Framework, including deeper dives into specific areas. considered the CCG s Financial Control Environment Self Assessment (FCEA). Reviewed the CCG s self-assessment against the Counter Fraud NHS Standards for Commissioners and was updated on work undertaken since the assessment Discussed and made recommendations to the Governing Body on the terms of reference, and process for establishing, a Local Auditor Panel for the CCG Submitted an Annual Report of its work for 2015/16 to the Governing Body. There were 6 meetings of the Audit Committee during the year. The table below shows the members and attendance record. The Audit Committee was supported by the CCG management team, with appropriate attendance, as required. The Chief Financial Officer was in attendance at all the meetings. Members Role Apr May Aug Oct Jan March Prof Ami David Registered Nurse Y Y Y X Left 31/10/2016 Dr Faruk Majid Senior Clinical Director Y Y Y Y Y Y Mr Ray Warburton Lay Member Y Y Y Y Y Y Mrs Rosemarie Lay Member Y Y X X Left Ramsay 09/01/2017 Ms Shelagh Independent member of the Y Y Y Y Y Y Kirkland Audit Committee Dr Mark Hamilton Secondary Care Doctor X Y Y Y Y Y Absences are normally agreed with the Chair as members are frequently required to attend other meetings. Page 69

70 Local Auditor Panel During 2016/17, a Local Auditor Panel was convened to agree the provider of external audit to the CCG. The panel also commented on the provision of internal audit. This had the same membership and chairing arrangements as the Audit Committee. The Auditor Panel function was to advise the Governing Body on the selection and appointment of an external auditor. There were 4 meetings of the Local Auditor Panel during the year. The table below shows the members and attendance record. The Local Auditor Panel was supported by the CCG management team, with appropriate attendance, as required. The Chief Financial Officer was in attendance at all the meetings. Members Role Apr May Aug Nov Prof Ami David Registered Nurse Y Y Y Left 31/10/2016t Dr Faruk Majid Senior Clinical Director Y X Y Y Mr Ray Warburton Lay Member Y Y Y Y Mrs Rosemarie Lay Member Y Y X X Ramsay Ms Shelagh Independent member of the Y Y Y Y Kirkland Audit Committee Dr Mark Hamilton Secondary Care Doctor Y Y Y Y Remuneration Committee The Remuneration Committee is responsible for approving the terms and conditions, remuneration and travelling or other allowances for Governing Body members, including pensions and gratuities in addition to the terms and conditions of employment for all employees on Very Senior Manager (VSM) grades. During the year, the Remuneration Committee agreed levels of remuneration for Governing Body members. There were two meetings of the Remuneration Committee during the year. The table below shows the members and attendance record. The Remuneration Committee was supported by the CCG management team, with appropriate Page 70

71 attendance, as required. Due process was followed when conflicts of interest occurred during meetings. Members Role June December Prof Ami David Registered Nurse Y Left 31 st October Dr Mark Hamilton Secondary Care Y Y Doctor Mr Ray Warburton Lay Member Y Y Ms Rosemarie Ramsay Lay Member N N Absences are normally agreed with the Chair as members are frequently required to attend other meetings. Strategy and Development Workshop The Strategy and Development Workshop was established to set and maintain the CCG s strategic direction for commissioning and to develop formal strategic and operational plans for approval by the Governing Body. There were six meetings of the Strategy and Development Committee during the year. The table below shows the members and attendance record. The Strategy and Development Committee was supported by the CCG management team, with appropriate attendance, as required. Members Role Apr Jun Aug Oct Dec Feb Mr Charles Head of Strategy & X X X Y Y X Malcolm-Smith Organisation Development Dr David Abraham Senior Clinical Director Y Y Y Y X Y Dr Jacky McLeod Clinical Director Y Y Y Y Y Y Dr Angelika Clinical Director Y Y X Y Y X Razzaque Ms Rosemarie Ramsay Lay Member Y X Y X X Left 09/01 /2017 Dr Marc Rowland Chair of the Governing Body Y Y Y X Y Y Mr Martin Chief Officer X X Y Y Y Y Wilkinson* Ms Susanna Corporate Director Y Y Y Y Y Y Masters Mr Tony Read Chief Financial Officer Y Y Y Y Y X Dr Sebastian Kalwij Clinical Director X X Y Y Y Y Dr Faruk Majid Senior Clinical Director Y Y Y Y Y Y Dr Mark Hamilton Secondary Care Doctor Y X Y Y Y X Page 71

72 Members Role Apr Jun Aug Oct Dec Feb Mr Ray Warburton Lay Member Y Y Y Y Y Y Prof Ami David Registered Nurse Y Y Y X Left 31/10/2016 Dr Charles Gostling Clinical Director Y Y Y Y Y Y Absences are normally agreed with the Chair as members are frequently required to attend other meetings. During the year, the work of the Strategy and Development Workshop included: reviewing the operating plan and financial challenges for the coming year reviewing the draft Sustainability and Transformation (STP) for south east London to feed back to the Committee in Common for Strategic Decision- Making reviewing the strategic approach to the development of community based care in Lewisham reviewing the CCG s strategic outcomes ambitions reviewing the CCG s progress against the Equality Delivery System (EDS2) goals and the public sector equalities duties receiving the outcomes of the CCG Governing Body assessment and organisational development plans Integrated Governance Committee The Integrated Governance Committee was established to monitor the performance of commissioned health services in all aspects and to monitor delivery of our operational plans in year. The committee reviewed our position against key performance, quality and financial metrics, and identified mitigating steps where delivery was off-track. The Integrated Governance Committee received reports from a number of subgroups to monitor performance against plans in detail and these included groups to monitor quality and information governance. Page 72

73 There were 12 meetings of the Delivery Committee during the year. The table below shows the members and attendance record. The Integrated Governance Committee was supported by the CCG management team with appropriate attendance as required. Members Role April May July Jun e Aug Sept Oct Nov Dec Jan Feb Mar Ms Diana Commissioning Director Y X Y Y X X Y Y Y X Y Y Braithwaite* Dr Faruk Majid Senior Clinical Director Y Y X Y Y Y Y Y Y Y Y Y Dr Marc Rowland Chair of the Governing Y Y X Y Y X Y Y Y Y Y Y Body Mr Martin Chief Officer Y Y Y X X Y X Y X Y Y Y Wilkinson Mr Ray Lay Member Y Y Y Y Y Y Y Y Y Y Y Y Warburton Mr Tony Read Chief Financial Officer Y Y Y Y X X Y X Y Y Y Y Dr David Senior Clinical Director Y Y X X X Y Y Y Y Y Y Y Abraham Dr Sebastian Clinical Director Y Y X X Y X Y Y Y Y Y Y Kalwij Dr Angelika Clinical Director Y Y Y X Y X Y Y Y Y Y N Razzaque Ms Alison Director of Nursing & Y Y Y Y Y Y X Y Y Y Y Y Browne Quality Ms Dee Carlin Head of Joint X X * * * * * * * X * * Commissioning Dr Mark Hamilton Secondary Care Doctor X X X X X X Y X X X Y Y *Corinne Moocarme attended on behalf of Ms Carlin Absences are normally agreed with the Chair as members are frequently required to attend other meetings. During the year the work of the Integrated Governance Committee included: receiving the Corporate Objectives priorities for action for 2016/17 monitoring the Board Assurance Framework against the achievement of the Corporate Objectives receiving performance and exception reports against the NHS Constitutional Standards, and in particular ensuring actions are undertaken on A&E performance, cancer waiting times, and referral to treatment times monitoring financial performance monitoring performance of QIPP projects Page 73

74 received confirmation of substantial assurance against the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) Finance and Investment Committee The purpose of the Finance and Investment Committee is to maintain a detailed overview of the CCG s assets and resources in relation to the achievement of financial targets and business objectives and the financial stability of the CCG. This includes: overseeing the development and maintenance of the CCG s financial strategy reviewing and monitoring financial plans and their link to operational performance and quality overseeing financial risk evaluation, measurement and management scrutiny and approval of business cases and oversight of the capital programme maintaining oversight of the key financial policies and other financial issues that may arise There were three meetings of the Finance and Investment Committee during the year. The table below shows the members and attendance record. Members Role Sep Dec Jan Prof Ami David Registered Nurse Y Left 31/10/2016 Dr Faruk Majid Senior Clinical Director Y Y Y Mr Ray Warburton Lay Member Y Y Y Dr Mark Hamilton Secondary Care Doctor X Y Y Dr David Abraham Senior Clinical Director Y Y X Mr Martin Wilkinson Chief Officer Y X Y Mr Tony Read Chief Financial Officer Y Y* Y *The interim Deputy Director of finance attended on behalf of Mr Read Absences are normally agreed with the Chair as members are frequently required to attend other meetings. During the year the committee: Page 74

75 considered and approved a business case on the Integrated Urgent Care programme across South East London reviewed the draft procurement policy reviewed and approved a business case for Leg Ulcer treatment reviewed and approved the business case for End of Life Procurement. Public Engagement and Equalities Forum The Public Engagement and Equalities Forum was established in 2016/17 in order to strengthen engagement in the CCG, support assurance for the Governing Body, and to monitor its impact on the work of the organisation. Equalities aspects in public engagement are also a major consideration for the group. There were five meetings of the Public Engagement & Equalities Forum during the year. The table below shows the members and attendance record. Members Role Jun Aug Oct Dec Feb Ms Rosemarie Ramsay Lay Member Y Y X X Left 09/01/ 2017 Clinical Director Y X Y Y Y Dr Angelika Razzaque Dr Faruk Majid Senior Clinical Director X X X Y X Susanna Masters Corporate Director Y Y X Y Y Russell Cartwright Head of Y Y Y Y Y Communications & Engagement Folake Segun Healthwatch Lewisham Y Y X Y Y Mr Charles Y Y Y Y Y Malcolm-Smith Head of Strategy & Organisation Development During the year the Forum: monitored the development of the CCG s public reference group reviewed approaches to engaging with seldom heard groups approved the CCG s annual engagement report reviewed plans for possible consultation on proposals for changes to elective orthopaedic services Page 75

76 reviewed the outcomes of patient and public engagement on HIV services and muscoskeletal assessment treatment and triage services reviewed the CCG s draft communications and engagement strategy reviewed the emerging outcomes from the equalities analysis of the partnership commissioning intentions for 2017/18. Primary Care Joint Committee From 1 April 2015 we, along with the other CCGs in south east London, have taken greater responsibility and involvement in the design, shaping and commissioning of local general practices, in a joint commissioning arrangement with NHS England. This arrangement allows us to work more closely with those responsible for securing the provision of general practice, NHS England, and will support our local plans to improve primary care services in the borough. This joint approach between our CCG and NHS England is referred to as the Cocommissioning of Primary Care and regular meetings in a joint committee, in public, have been established to consider and take decisions on local services together. The committee meetings are held in public together with the other five CCGs in south east London (Bromley, Bexley, Greenwich, Lambeth and Southwark). The committee is chaired by the CCG lay member lead for patient and public involvement. There were six meetings of the Primary Care Joint Committee during the year. The table below shows the members and attendance record. Members Role Apr Jun Aug Oct Dec Feb Prof Ami David Registered Nurse Y Y Y X Left 31/10/2016 Dr Marc Rowland CCG Chair Y X Y Y Y Y Mr Ray Warburton Lay Member Y Y Y Y Y Y Ms Rosemarie Ramsay Lay Member Y Y Y X X Left 09/01 /2017 Dr Jacky McLeod Clinical Director Y Y Y X X X Mr Martin Chief Officer Y Y Y Y Y Y Wilkinson Dr Charles Gostling Clinical Director X X X Y Y Y Page 76

77 During the year the committee: approved the 2016/17 Lewisham Engagement in Clinical Commissioning Local Improvement Scheme approved the 2016/17 Lewisham Prescribing Incentive Quality Scheme approved the merger between St Johns Medical Centre//Morden Hill Surgery/Hilly Fields Medical Centre/Brockley Road Medical Centre/Honor Oak Group Practice approved a variation to the Woodlands Health Centre contract received the regular NHS England primary care finance reports received the regular NHS England quality and performance reports. Full meeting papers for 16/17 can be found on our website South East London Committee in Common for Strategic Decision-Making The Clinical Strategy Committee of the six Clinical Commissioning Groups (CCGs) in south east London (Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark) agreed the establishment of a Committee in Common for the purpose of strategic decision making, with particular reference to Our Healthier South East London, as a prime committee of each CCG s Governing Body. The committee met twice during 2016/17, the Lewisham CCG members were as follows Members Role Jun Nov Ms Rosemarie Ramsay* Lay Member Y Left 09/01/2017 Dr Marc Rowland CCG Chair Y Y Mr Martin Wilkinson Chief Officer X Y Mr Ray Warburton Lay Member X Y *Mr Warburton deputised for Ms Ramsay when she was not available. The committee reviewed its establishment agreement and terms of reference and received a briefing on development plans for planned orthopaedic care. Page 77

78 UK Corporate Governance Code We are not required to comply with the UK Corporate Governance Code. However, we have reported on our Corporate Governance arrangements by drawing upon best practice available, including those aspects of the UK Corporate Governance Code we consider to be relevant to the CCG and best practice. Discharge of Statutory Functions During establishment, the arrangements put in place by the clinical commissioning group and explained within the Corporate Governance Framework were developed with extensive expert external legal input, to ensure compliance with the all relevant legislation. That legal advice also informed the matters reserved for Membership Body and Governing Body decision and the scheme of delegation. In light of the Harris Review, we have reviewed all of the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. As a result, I can confirm that the clinical commissioning group is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions. Responsibility for each duty and power has been clearly allocated to a lead Director. Directorates have confirmed that their structures provide the necessary capability and capacity to undertake all of the clinical commissioning group s statutory duties. Last, but not least, we take due account of the NHS Constitution and strive to uphold its values. Risk management arrangements and effectiveness In line with good practice, we adopted a risk management process which has been designed to provide continuous identification, assessment, control, communication and monitoring of risk with clear escalation processes. When faced by risks, we take a positive and controlled approach to risk management, acceptable to the Governing Body, as described below. Page 78

79 Risks to achieving our objectives and business plans were identified at project or programme board meetings, at assurance committees when inadequate or no assurances were given or at routine business meetings. Wherever a risk was identified the escalation route was the same. Project and programme risks were assessed and managed at the project or programme management level. Where risks were considered to have an impact on our corporate objectives, these were escalated to the Risk Management Group. The role of the Risk Management Group has been to: review, evaluate and agree exception reports for new and amended risks and instruct that the Risk Register is updated accordingly review and evaluate exception reports for new and very high risks and recommend these to the Governing Body review the Board Assurance Framework (BAF) by scrutinising the existing controls and assurances ensuring that the register is an accurate summary of the risks to the organisation. Risk owners at Director or senior manager level were assigned to all risks and risk owners have been responsible for identifying controls and actions to mitigate risks to target levels. Controls have included the development of policies, for example for the management of conflicts of interest, mandatory training programmes, or actions to mitigate risks to achieving our corporate objectives. All this information has been collated over the year in the Board Assurance Framework which is discussed at each meeting of the Governing Body. The management of risk is the duty of all staff, inclusive of the reporting of incidents and near-misses in accordance with the policies and procedures in place. All managers are accountable for the day-to-day management of risks within their areas of responsibility, ensuring assessments are undertaken and risk registers updated as appropriate. Directors are responsible for providing risk management leadership and sponsorship across the CCG. Page 79

80 The risk controls in place, enable us to determine whether the risks are being managed effectively through: o o o o o o policies, procedures and guidelines training and staff development equipment and facilities staff competency induction programme any other measures deemed necessary The Board Assurance Framework has been improved and developed during the year following discussions with the Audit Committee and Governing Body members. Improvements have included work to identify gaps in assurance, providing more details of evidence of assurance and adding greater details of planned mitigation actions. Equality Impact Assessments (EIA) are a core part of policy, strategy and project development within Lewisham CCG. The NHS Lewisham CCG Policy on Policies ensures that there is a regulated approach to the development of policies and procedural documents. It is a policy requirement for that all policy and procedural documents developed by the CCG describe how they meet the Public Sector Equality Duty. As a key partner, Healthwatch Lewisham provided a representative voice of patients from the many diverse communities in Lewisham into our risk management processes. Their involvement in the CCG structure included membership of our Public Engagement Group, our For Learning and Action Group, which reviewed quality in respect of patient safety, clinical effectiveness and patient experience of the services we commissioned for our population. Page 80

81 Risk Assessment Our Risk Management Framework sets out our risk assessment process and is based on the National Patient Safety Advice (NPSA) guidance and aligned to the adopted internationally recognised AS/NZS 4360:1999 guideline which provides a model for identifying, assessing and controlling risks. Further information on how the CCG manages the principles of Risk Management, can be found under the Risk Management Framework section above. Risks in relation to governance, risk management and internal control were identified and evaluated by the Risk Management Group early in the year. These risks have been incorporated into the Governing Body Board Assurance Framework (BAF) and the CCG s Risk Register for scrutiny. The BAF broadly provides assurance of the controls in place that mitigate the risks that may prevent Lewisham CCG meeting its annual Strategic Objectives. The heat map below is used to show the distribution of all the 39 risks on the CCG Risk Register. Throughout 2016/2017 the Governing Body has received detailed reports of the controls in place, assurances given and further actions being taken to manage or mitigate those risks that have a residual score of 12 or above (score of Likelihood x Impact). These reports are contained within the papers for our Governing Body meetings (found on our website here) Almost certain 5 Likely 4 Moderate High Very High Very High Very High Moderate High High Very High Very High Likelihood Possible 3 Unlikely 2 Rare 1 Low Moderate High High Very High Low Moderate Moderate High High Low Low Low Moderate Moderate Risk Matrix Negligible 1 Minor 2 Moderate 3 Major 4 Catastrophic 5 Impact During the 2016/17, three risks were assessed at the end of the year to have a very high rating in March 2017). Page 81

82 These were: o Acute Providers delivering quality: Referral to Treatment (RTT) o Sustainable Operating Plan and Contracts 2017/18 to 2018/19 (for NHS Lewisham CCG) o Acute Providers delivering quality: A&E 4 hour standard. In response to this risk rating the Governing Body received detailed action plans for how the CCG would work with Lewisham and Greenwich Trust to reduce these. Other sources of assurance Internal Control Framework A system of internal control is the set of processes and procedures in place in the clinical commissioning group to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness. A system of internal control is the set of processes and procedures in place in the CCG to ensure that it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised, the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness. The chart below illustrates how risks have been identified and escalated through the organisation to the Governing Body. The bottom of the chart includes a table which shows the type of risk, shown here as the risk category, the committee or work Page 82

83 group where detailed review of the risk and controls took place and the main assurance committee that held oversight of the risk. The main body of the chart shows how risks are escalated to the Governing Body. Page 83

84 Governing Body Corporate Risk Register includes all high and very high risks Exception Reports for new and very high risks Board Assurance Framework Includes all high and very high risks mapped to corporate objectives Risk Management Group reviews entire corporate Risk Register and exception reports & escalates very high risks exception reports to Governing Body Project and Programme Risks recorded on project and Programme Risk Registers Exception reports prepared for Risk Management Group for all new risks Directorate or team risk registers Include all moderate or low risks Project and Programme Risks Identified and assessed at Project and Programme Boards Risks to corporate objectives identified At groups and committees undertaking detailed review Risk Owners review risk controls, Assurances and actions monthly Risk category Detailed Review Main Assurance Committee Change / Transition Programme Management Meeting Integrated Governance Committee Clinical and Quality Clinical Quality Review Group Integrated Governance Committee Public Engagement and Equalities Forum Core Contract Meetings Patient Safety Advisory Groups NHS Lewisham CCG Health Safeguarding Group Pharmacy and Medicines Management Committee Environmental Senior Management Team Integrated Governance Committee Financial Finance and Investment Committee Integrated Governance Committee Governance Senior Management Team Integrated Governance Committee Information Governance Information Governance Steering Group Integrated Governance Committee Information Management & Senior Management Team Integrated Governance Committee Technology Operations Senior Management Team Integrated Governance Committee Partnership and Contractual Core Contract Meetings Integrated Governance Committee People Senior Management Team Integrated Governance Committee Representation Public Engagement and Equalities Forum Integrated Governance Committee Senior Management Team Strategic Strategy and Development Committee Integrated Governance Committee (in year) Health and Well Being Board Page 84

85 The Assurance Framework is a key process for the identification and control of risks, and is designed to provide the CCG with assurance that the organisation is effectively managing, or has plans in place designed to manage risks that may threaten the achievement of the organisation s corporate objectives which are reviewed annually. The Assurance Framework ensures: a comprehensive method is established for the effective and focussed management of the principal risks to meeting the CCG s objectives the Governing Body is confident that its principal objectives can be achieved. strategic controls are in place to manage those risks the Governing Body is satisfied with assurance that the controls are effective and risks are managed appropriately positive assurances are identified along with gaps in controls and/or assurances Annual audit of conflicts of interest management In June 2016, NHS England published revised statutory guidance on managing conflicts of interest for clinical commissioning groups. The guidance includes a number of strengthened safeguards to mitigate the risk of real and perceived conflicts of interest arising in CCGs. The Governing Body of Lewisham CCG approved the revised policy in November 2016, reflecting the key changes in the revised guidance, which were: Approval of the appointment of a third lay member to the Governing Body The introduction of a conflicts of interest guardian in CCGs The requirement for the CCG to publish its conflicts of interest register on its website The requirement for CCGs to include a robust process for managing any breaches within their conflict of interest policy and for anonymised details of the breach to be published on the CCG s website Strengthened provisions around decision-making Page 85

86 A requirement for all CCG employees, governing body and committee members and practice staff with involvement in CCG business, to complete mandatory online conflicts of interest training The guidance also states that CCGs should undertake an annual internal audit review of conflict of interest arrangements and this review is designed to meet the requirements as laid out within the NHS England publication Managing Conflicts of Interest: Internal Audit Framework for CCGs. This was completed by the end of the financial year. The outcome found significant assurance with minor improvement opportunities. Data Quality In line with the need to know principles set out in the Caldicott 2 Information Governance Review Report, the CCG ensures that information presented to the Governing Body and other governance forums does not identify individuals and is fully anonymised. Senior management diligently reviews information to be set out in governance and decision making information prior to consideration and presentation to the relevant governance forums. The quality of information that the Governing Body and other governance forums receive to consider and direct decision making is also assured through the service level specification arrangements with the South East Commissioning Support Unit and the use of contractual arrangements with the commissioned providers. Information Governance The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an information governance toolkit and the annual submission process provides assurances to the clinical commissioning group, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively. Page 86

87 The NHS Information Governance Framework sets out the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an information governance toolkit and the annual submission process provides assurances to the CCG, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively. The CCG places high importance on ensuring there are robust information governance systems and processes in place to help protect patient, staff and corporate information. We have established an information governance management framework and are developing information governance processes and procedures in line with the information governance toolkit. We have ensured all staff undertake annual information governance training and have implemented a staff information governance handbook to ensure staff are aware of their information governance roles and responsibilities. A Senior Information Risk Owner (SIRO) is accountable for leading the information risk culture and approach of the CCG has been put in place in line with NHS requirements. The Chief Financial Officer of the CCG fulfils the SIRO role. The Senior Information Risk Officer (SIRO) is responsible for: Understanding how the strategic business goals of the CCG may be impacted by information risks: acting as an advocate for information risks on the Governing Body and in internal discussions Ensuring the Governing Body is adequately briefed on information risk issues Overseeing the development of an Information Risk Policy, and a strategy for implementing the policy within the CCG s Information Governance Framework Reviewing the annual information risk assessment to support and inform the Annual Governance Statement Taking ownership of risk assessment processes for information risks, supported by the Information Governance Manager, Information Security Lead, Records Manager and the Caldicott Guardian Page 87

88 Reviewing and agreeing action in respect of identified information risks. Providing a focal point for the resolution and/or discussion of information risk issues A separate Caldicott Guardian role also acts as the conscience of the organisation regarding confidentiality and privacy matters affecting individual persons and to avoid a potential conflict of interest with the organisational responsibilities of the SIRO. The Director of Nursing & Quality fulfils the Caldicott Guardian role. For the year 2016/17 the CCG has satisfied the requirements of the Information Governance Toolkit and achieved an overall score of eighty seven per cent (87%). This is an improvement from the 82% score in 2015/16. For 2017/18 the information governance workplan will prioritise improvements in the CCG s management of data used via mobile devices, IT resilience and continuity and information asset management. Data security breaches The Caldicott 2 Information Governance Review Report published in May 2013 advised a stronger focus on the scope of what constitutes a data breach to include any breach of the eight principles of the Data Protection Act We did not have any data breaches requiring further escalation during 2016/17. Business Critical Models The Macpherson Report on the review of quality assurance (QA) of Government Analytical Models set out the components of best practice in QA making eight key recommendations. We recognise the importance of this and have been working with partners to ensure appropriate quality assurance processes are in place across its analytical work. With other CCGs in South East London, we have continued to monitor the effectiveness of the current Business Intelligence services provided by the South East Commissioning Support Unit (SECSU) to ensure the quality of information received. The CCG will continue to work with the SECSU in the further development of the models, ensuring compliance with the standards set out in the Macpherson report. Page 88

89 In 2016/17, work has also continued on the development the financial model to support the STP for south east London. The model brings together wideranging expertise from all stakeholder organisations in south east London. This includes drawing upon clinical input from the clinical leadership groups covering the key priority areas set out in the strategy. This is overseen by the Senior Responsible Officer and supported by clear governance structure. This includes the finance leads group attended by the lead finance officers from all commissioner and provider organisations across south east London, as well as Local Authorities. This group is responsible for ensuring that there are effective processes underpinning the model, including appropriate guidance, documentation and training, as well as sharing best practice across disciplines and organisations. Control Issues No significant internal control issues have been identified Review of economy, efficiency & effectiveness of the use of resources In year monitoring of performance against our plans, in terms of quality, finance and other performance standards (e.g. NHS constitutional standards) has been carried out by our Integrated Governance Committee. This includes assuring that projects and programmes are delivering economic, effective and high quality services. The Governing Body s scrutiny over finance, investment and procurement was strengthened through the introduction of the Finance and Investment Committee, which replaced the Finance and Risk Management Group. The Committee oversees the CCG s capital expenditure, investment decisions and associated procurements and management of financial risk. During 2016/17 the Chief Financial Officer undertook a formal evaluation of financial controls. The conclusions and evidence were also reviewed by Internal Audit who gave significant assurance to the evaluation. The audit committee used the evaluation to conduct a deep dive into finance controls and management. Page 89

90 Under the CCG Improvement and Assessment Framework indicators, the latest available results (Quarter /17) show that the CCG is rated green for the Quality of Leadership. Year end results for this indicator will be available from July 2017 at Counter fraud arrangements We contract an Accredited Counter Fraud Specialist to provide the full range of anticrime work that is proportionate to the risks identified and fully compliant with the NHS Standards for Commissioners. The annual work-plan is developed from risks identified through the counter fraud risk assessment and discussions with key staff within the CCG. The annual work-plan is agreed with the Chief Financial Officer and ratified by the Audit Committee. Progress is regularly reported to the Chief Financial Officer and the Audit Committee. The Audit Committee reviews the results of the CCG annual self-assessment against the NHS Counter Fraud Standards for Commissioners. The Audit Committee monitors progress on remedial actions against areas of non-compliance or following an NHS Protect Quality Inspection. Head of Internal Audit Opinion Following completion of the planned audit work for the financial year for the clinical commissioning group, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the clinical commissioning group s system of risk management, governance and internal control. The Head of Internal Audit concluded that Significant assurance with minor improvements can be given on the overall adequacy and effectiveness of the organisation s framework of governance, risk management and control. The full head of internal audit opinion for 2016/17 is below: Page 90

91 Head of Internal Audit Opinion 2016/17 Basis of opinion for the period 1 April 2016 to 31 March 2017 Our internal audit service has been performed in accordance with KPMG's internal audit methodology which conforms to Public Sector Internal Audit Standards (PSIAS). As a result, our work and deliverables are not designed or intended to comply with the International Auditing and Assurance Standards Board (IAASB), International Framework for Assurance Engagements (IFAE) or International Standard on Assurance Engagements (ISAE) PSIAS require that we comply with applicable ethical requirements, including independence requirements, and that we plan and perform our work to obtain sufficient, appropriate evidence on which to base our conclusion. Roles and responsibilities The Governing Body is collectively accountable for maintaining a sound system of internal control and is responsible for putting in place arrangements for gaining assurance about the effectiveness of that overall system. The Annual Governance Statement (AGS) is an annual statement by the Accountable Officer, on behalf of the Governing Body, setting out: how the individual responsibilities of the Accountable Officer are discharged with regard to maintaining a sound system of internal control that supports the achievement of policies, aims and objectives; the purpose of the system of internal control as evidenced by a description of the risk management and review processes, including the Assurance Framework process; and the conduct and results of the review of the effectiveness of the system of internal control including any disclosures of significant control failures together with assurances that actions are or will be taken where appropriate to address issues arising. The Assurance Framework should bring together all of the evidence required to support the AGS. The Head of Internal Audit (HoIA) is required to provide an annual opinion in accordance with PSIAS, based upon and limited to the work performed, on the overall adequacy and effectiveness of the CCG s risk management, control and governance processes (i.e. the system of internal control). This is achieved through a risk-based programme of work, agreed with Management and approved by the Audit Committee, which can provide assurance, subject to the inherent limitations described below. Page 91

92 The purpose of our HoIA Opinion is to contribute to the assurances available to the Accountable Officer and the Governing Body which underpin the Governing Body s own assessment of the effectiveness of the system of internal control. This Opinion will in turn assist the Governing Body in the completion of its AGS, and may also be taken into account by other regulators to inform their own conclusions. The opinion does not imply that the HoIA has covered all risks and assurances relating to the CCG. The opinion is derived from the conduct of risk-based plans generated from a robust and Management-led Assurance Framework. As such it is one component that the Governing Body takes into account in making its AGS. A further component will be the assurances provided on the operation of the systems of internal control the service organisations which provide financial services on behalf of the CCG during 2016/17 as follows: NHS South East Commissioning Support Unit (Deloitte); NHS Shared Business Service (Grant Thornton); and IBM: NHS Electronic Staff Records (PwC). Assurances on the operation of these systems is provided by ISAE3402 Service Auditor Reports issued by the internal auditors of these organisations. Opinion Our opinion is set out as follows: Basis for the opinion; Overall opinion; and Commentary. Basis for the opinion The basis for forming our opinion is as follows: An assessment of the design and operation of the underpinning aspects of the risk and assurance framework and supporting processes; and An assessment of the range of individual assurances arising from our risk-based internal audit assignments that have been reported throughout the period. This assessment has taken account of the relative materiality of these areas. Page 92

93 Overall opinion Our overall opinion for the period 1 April 2016 to 31 March 2017 is that: Significant assurance with minor improvements can be given on the overall adequacy and effectiveness of the organisation s framework of governance, risk management and control. Commentary The commentary below provides the context for our opinion and together with the opinion should be read in its entirety. Our opinion covers the period 1 April 2016 to 31 March 2017 inclusive, and is based on the nine audits that we completed in this period and the ISAE3402 reports received. The design and operation of the Assurance Framework and associated processes The CCG s Board Assurance Framework does reflect the CCG s key objectives and risks and is regularly reviewed by the Governing Body. The Executive reviews the Board Assurance Framework on a monthly basis and the Audit Committee provides reviews whether the CCG s risk management procedures are operating effectively. The range of individual opinions arising from risk-based audit assignments, contained within our risk-based plan that have been reported throughout the year We issued no partial assurance reports or no assurance opinions in respect of our 2016/17 assignments. We have raised no high risk recommendations in the period. KPMG LLP Chartered Accountants London 28 March 2017 Page 93

94 During the year, Internal Audit issued the following audit reports: Area of Audit Better Care Fund Financial Management Safeguarding in Adults Data Management Risk Management Managing Conflicts of Interest Level of Assurance Given Significant Assurance Significant Assurance with minor improvement opportunities Significant Assurance with minor improvement opportunities Significant Assurance with minor improvement opportunities Significant Assurance with minor improvement opportunities Significant Assurance with minor improvement opportunities Review of the effectiveness of governance, risk management and internal control My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, executive managers and clinical leads within the clinical commissioning group who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me. My review is also informed by comments made by the external auditors in their annual audit letter and other reports. Our assurance framework provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving its principles objectives have been reviewed. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Governing Body, the Audit Committee and Risk Management Group and a plan to address weaknesses and ensure continuous improvement of the system is in place. The Governing Body and Audit Committee have provided regular feedback on the completeness and effectiveness of our systems of internal control via their comments and feedback on the completeness of the Board Assurance Framework. Control and assurance gaps were identified; resulting in existing controls and assurances being reviewed and strengthened. In order to provide additional assurance, the Audit Committee also carried out detailed reviews into the risks associated with the CCG priorities. The report into risk management from our internal auditors stated that effective risk management provides a structure and process that will enable the CCG to focus on Page 94

95

96 Remuneration and Staff Report Remuneration Report Remuneration Committee The Remuneration Committee comprised four members (one position was unfilled for part of the year) and met on two occasions during the past year. The Remuneration Committee is responsible for approving the terms and conditions, remuneration and travelling or other allowances for Governing Body members, including pensions and gratuities in addition to the terms and conditions of employment for all employees on Very Senior Manager (VSM) grades. Chair of the committee is Mr Ray Warburton, Lay Member of the CCG s Governing Body. A full list of members, their roles and the number of meetings each attended is below. Members Role June December Prof Ami David Registered Nurse Y Left 31 st October Dr Mark Hamilton Secondary Care Y Y Doctor Mr Ray Warburton Lay Member Y Y Ms Rosemarie Ramsay Lay Member N N In addition to the members listed above, the following CCG employees provided the committee with services and/or advice which was material to the committee s deliberations. Name Role Service Mr Martin Wilkinson Chief Officer Advice Mrs Lesley Aitken Board Secretary Administration Mr Charles Malcolm-Smith Deputy Director (Strategy & OD) Advice The following individual who is not an employee of the CCG also provided services and/or advice to the committee. She is an employee of NHS England at South East Commissioning Support Unit and provides specialist Human Resources support to the CCG as part of commissioning support service level agreement agreed with Page 96

97 CCGs in south London. The CCG paid South East Commissioning Support Unit 68k for Human Resources support in 2016/17. Name Role Service Ms Gail Tarburn Head of Human Resources Advice Policy on the remuneration of senior managers The Committee s deliberations are carried out within the context of national pay and remuneration guidelines, local comparability and taking account of independent advice regarding pay structures. The CCG s remuneration policy is consistent with nationally agreed pay awards for very senior managers and Agenda for Change Terms and Conditions of Employment. The Remuneration Committee assesses the performance of staff employed on Very Senior Manager (VSM) Pay in line with the VSM Framework, comparable benchmarking and local pay arrangements and agrees proposed performance assessment ratings. Senior managers performance related pay The CCG does not have a policy of performance related pay for senior managers. Senior managers service contracts The CCG s policy concerning senior managers contracts is that they are on-going (reviewed on an annual basis), with a notice period of 6 months. Termination payments are calculated on the basis of one month s pay for every completed year of service. The CCG may terminate the appointment at any time and with immediate effect by making a payment in lieu of notice, in accordance with the contract of employment, as a lump sum payment equal to that of the basic salary (as at the date of termination) which would have been payable during the notice period, less income tax and national insurance contributions. Payments in lieu of notice are at the sole and absolute discretion of the CCG and with the approval of the CCG s Remuneration Committee. Page 97

98 Payments in lieu of notice do not include: a) any additional payments that might otherwise have been due during the period for which payment in lieu is made; b) any payment in respect of benefits one would have been entitled to receive during the period; c) any payment in respect of any holiday entitlement that would have accrued during the period for which the payment in lieu is made. Remuneration of Very Senior Managers There are no senior managers of the CCG paid more than 142,500 per annum. Page 98

99 Senior manager remuneration, including salary and pension entitlements (audited) (a) (b) (c) (d) (e) (f) 2016/17 Salary Expense Performance pay Long term All pensionrelated benefits (a to e) TOTAL (bands of 5,000) payments and bonuses performance pay (taxable) (bands of 5,000) and bonuses (bands of (bands of 5,000) Name and Title to nearest 100* (bands of 5,000) 2,500) Mr Martin Wilkinson, Chief Officer Mr Tony Read, Chief Financial Officer Ms Diana Braithwaite, Commissioning Director Ms Susanna Masters, Corporate Director Ms Alison Browne, Director of Nursing and Quality Dr Marc Rowland, Chair of the Governing Body Dr David Abraham, Senior Clinical Director Dr Faruk Majid, Senior Clinical Director Dr Seb Kalwij, Clinical Director Dr Charles Gostling, Clinical Director Dr Angelika Razzaque, Clinical Director Dr Jacqueline McLeod, Clinical Director Mr Ray Warburton, Lay Member Dr Mark Hamilton Secondary Care Doctor Member Professor Ami David, Registered Nurse Member Ms Shelagh Kirkland, Audit Committee Member Ms Rosemarie Ramsay, Lay Member *Note: Taxable expenses and benefits in kind are expressed to the nearest 100. These include reimbursement of travel and course/training costs. Page 99

100 (a) (b) (c) (d) (e) (f) 2015/16 Salary Expense Performance pay Long term All pensionrelated benefits (a to e) TOTAL (bands of 5,000) payments and bonuses performance pay (taxable) (bands of 5,000) and bonuses (bands of (bands of 5,000) Name and Title to nearest 100* (bands of 5,000) 2,500) Mr Martin Wilkinson, Chief Officer Mr Tony Read, Chief Financial Officer Ms Diana Braithwaite, Commissioning Director Ms Susanna Masters, Corporate Director Ms Alison Browne, Director of Nursing and Quality Dr Marc Rowland, Chair of the Governing Body Dr David Abraham, Senior Clinical Director Dr Faruk Majid, Senior Clinical Director Dr Seb Kalwij, Clinical Director Dr Hilary Entwistle, Clinical Director Dr Angelika Razzaque, Clinical Director Dr Jacqueline McLeod, Clinical Director Dr Charles Gostling, Clinical Director Mr Ray Warburton, Lay Member Ms Diana Robbins, Lay Member Dr Mark Hamilton, Secondary Care Doctor Member Professor Ami David, Registered Nurse Member Ms Shelagh Kirkland, Audit Committee Member Ms Rosemarie Ramsay, Lay Member *Note: Taxable expenses and benefits in kind are expressed to the nearest 100. These include reimbursement of travel and course/training costs. Page 100

101 Pension benefits as at 31 March 2017 (audited) (a) (b) (c) (d) (e) (f) (g) (h) Real increase Real increase Total accrued Lump sum at Cash Equivalent Real Increase in Cash Equivalent Employers in pension at in pension pension at pension age Transfer Value Cash Equivalent Transfer Value at Contribution to Name and Title pension age (bands of lump sum at pension age pension age at 31 March 2017 related to accrued pension at 31 at 1 April 2016 Transfer Value 31 March 2017 partnership pension 2,500) (bands of (bands of March ,500) 5,000) (bands of 5,000 Mr Martin Wilkinson, Chief Officer Mr Tony Read, Chief Financial Officer Ms Diana Braithwaite, Commissioning Director Ms Susanna Masters, Corporate Director Ms Alison Browne, Director of Nursing and Quality * 0 * 15 * The cash equivalent transfer value (CETV) at 31 st March 2017 is not applicable to Alison Browne as she is over Normal Retirement Age in the existing scheme. Page 101

102 Cash equivalent transfer values A cash equivalent transfer value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member s accrued benefits and any contingent spouse s (or other allowable beneficiary s) pension payable from the scheme. A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies. The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. Real increase in CETV This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period. Compensation on early retirement of for loss of office (audited) No payment for compensation on early retirement or for loss of office were made during the financial year 2016/17. Page 102

103 Payments to past members No awards were made to past senior managers during the financial year 2016/17. Pay multiples (audited) Reporting bodies are required to disclose the relationship between the remuneration of the highest paid member in their organisation and the median remuneration of the organisation s workforce. The banded remuneration of the highest paid member in Lewisham CCG in the financial year 2016/17 was 112,000 (pro rata) (2015/16: 112,500k). This was 2.33 times (2015/16: 2.37) the median remuneration of the workforce, which was 48,034 (2015/16: 47,559). In 2016/17, no employees received remuneration in excess of the highest-paid member. Remuneration ranged from 17,000 to 150,000 (2015/2016: 17,000 to 147,500) Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind, but not severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions. Staff Report Staff numbers, composition and costs In 2016/17 NHS Lewisham CCG employed on average 54 staff; 35 female and 19 male. The numbers of staff who were a grade VSM (Very Senior Manager) was 1 male. The Governing Body was made up of 4 women and 9 men. The Clinical Director s Committee (Membership Body) was made up of 2 women and 5 men. Page 103

104 Total Number Permanently employed Number Other Number Total Number Permanently employed Number Other Number Average number of CCG employed staff Female N/A 35 N/A N/A 42 N/A Male N/A 19 N/A N/A 17 N/A Of the above: Number of whole time equivalent people engaged on capital projects Employee Benefits (audited) The following tables show the values of employee benefits for 2016/17 and 2015/ Total 000 Total Admin Programme Permanent Employees 000 Other 000 Total 000 Permanent Employees 000 Other 000 Total 000 Permanent Employees 000 Salaries and Wages 5,420 2,956 2,464 3,363 2,328 1,035 2, ,428 Social Security Costs Employer contributions to the NHS Pension Scheme Other Pension Costs Other postemployment benefits Termination benefits Other 000 Gross employee benefits expenditure Less recoveries in respect of employee benefits (note 4.1.2) Total - Net admin employee benefits including capitalised costs Less: Employee costs capitalised Net employee benefits excluding capitalised costs 6,178 3,714 2,464 3,982 2,946 1,035 2, , ,178 3,714 2,464 3,982 2,946 1,035 2, , ,178 3,714 2,464 3,982 2,946 1,035 2, ,428 Page 104

105 Total 000 Total Admin Programme Permanent Employees 000 Other 000 Total 000 Permanent Employees 000 Other 000 Total 000 Permanent Employees 000 Salaries and Wages 4,320 3,178 1,142 3,048 2, , Social Security Costs Employer contributions to the NHS Pension Scheme Other Pension Costs Other postemployment benefits Termination benefits Other 000 Gross employee benefits expenditure Less recoveries in respect of employee benefits (note 4.1.2) Total - Net admin employee benefits including capitalised costs Less: Employee costs capitalised Net employee benefits excluding capitalised costs 5,037 3,895 1,142 3,615 3, , ,037 3,895 1,142 3,615 3, , ,037 3,895 1,142 3,615 3, Staff sickness absence and ill health retirements A staff sickness absence data table is included from note 4.3 of the financial statements: Number Number Total Days Lost Total Staff Years Average working Days Lost Page 105

106 The staff sickness information is for the calendar year 2016, whereas the staff sickness information is for the financial year Total days lost for is based on a 225 working day year whereas total days lost for is based on a 365 day year. The two years are consequently not directly comparable due to the different methodologies. For comparison purposes the values compare to restated based on a common methodology would be as follows: Number Number As per note 4.3 of accounts Restated for comparison purposes Total Days Lost Total Staff Years Average working Days Lost values include days lost for a full year in respect of one member on long term sickness leave Number Number Number of persons retired early on ill health grounds Total additional Pensions liabilities accrued in the year 0 0 Ill health retirement costs are met by the NHS Pension Scheme. The CCG's Sickness Absence Policy confirms the importance of promoting and supporting the health and welfare of its employees whilst at the same time being committed to achieving excellence in terms of attendance at work. An employee assistance scheme is provided to support staff. Our policies also confirm that the CCG will ensure that it abides by its duty of care to all staff, and other such legislation in order to provide a supportive environment within which sickness absence levels can be reduced. This can be achieved by the implementation of positive procedures and guidelines. A consistent and pro-active approach to improving attendance is being applied in the following areas: Page 106

107 monitoring the attendance of staff on a regular basis positively reinforcing the good attendance of staff showing an understanding towards those who need to be absent from work on a long term basis through sickness; and dealing fairly and consistently with staff whose attendance is of concern ensuring that managers are supported, trained and encouraged to manage sickness absence competently, fairly and consistently in line with good practice. Sickness absence rates are affected, among other things, by leadership and the working culture. At the CCG, there is an inclusive and supportive leadership style and culture. Our average monthly sickness absence rate was 2.37% (April March 2017). The CCG national average is 2.5%. Sickness absence is recorded, verified, monitored and reported as part of the monthly HR Workforce Report to the CCG management team. Sickness absence data reported includes sickness absence reason, days lost, full time equivalent days lost, and number of episodes. It also categorises the absence by short and long term. The HR Business Partner works closely with managers to ensure that sickness absence cases are managed in a timely way and in accordance with the CCG's Sickness Absence Policy. Staff policies Disabled Persons Disabled employees are protected under the "protected characteristics" of the Equality Act The CCG's Equality & Diversity Policy confirms that the CCG will make reasonable adjustments to working conditions or to the physical working environment where that would help overcome the practical effects of a disability. The policy also confirms that the CCG will provide support to enable disabled members of staff to participate fully in meetings and training courses. Reasonable adjustments will be taken into account and full use will be made of the advice and assistance available via current government employment initiatives when consideration is being Page 107

108 made of a disabled applicant s suitability for a vacant post. The CCG's Sickness Absence Policy confirms that every effort will be made to facilitate an employee s return to work including making reasonable adjustments under the Disability Discrimination Act 1995 which may include applications for grants where appropriate and taking advice from Disability Advisers in the Employment Service. Expenditure on consultancy During 2016/17 the CCG expenditure on consultancy was 1,202k. Off-payroll engagements Table 1: Off-payroll engagements longer than 6 months For all off-payroll engagements as at 31 March 2017, for more than 220 per day and that last longer than six months: Number Number of existing engagements as of 31 March Of which, the number that have existed: for less than one year at the time of reporting for between one and two years at the time of reporting 1 for between 2 and 3 years at the time of reporting for between 3 and 4 years at the time of reporting for 4 or more years at the time of reporting Table 2: New off-payroll engagements For all new off-payroll engagements between 01 April 2016 and 31 March 2017, for more than 220 per day and that last longer than six months: Page 108

109 Number Number of new engagements, or those that reached six months in duration, 1 between 1 April 2016 and 31 March 2017 Number of new engagements which include contractual clauses giving NHS Lewisham CCG the right to request assurance in relation to income tax and 1 National Insurance obligations Number for whom assurance has been requested 1 Of which: assurance has been received 1 assurance has not been received engagements terminated as a result of assurance not being received. Table 3: Off-payroll engagements / senior official engagements For any off-payroll engagements of Board members and / or senior officials with significant financial responsibility, between 01 April 2016 and 31 March Number Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during the financial year Total no. of individuals on payroll and off-payroll that have been deemed board members, and/or, senior officials with significant financial responsibility, during the financial year. This figure should include both on payroll and offpayroll engagements. 17 Exit packages, including special (non-contractual) payments, agreed in the financial year (audited) During 2016/17 NHS Lewisham CCG provided no exit packages or severance payments. The values in the table below relate to 2 instances of payments for annual leave due but not taken before termination of employment Page 109

110 Compulsory redundancies Other agreed departures Total Number Number Number Less than 10, , ,296 10,001 to 25, , ,910 25,001 to 50, ,001 to 100, ,001 to 150, ,001 to 200, Over 200, Total , , Compulsory redundancies Other agreed departures Total Number Number Number Less than 10, , , ,695 10,001 to 25, ,001 to 50, ,001 to 100, ,001 to 150, ,001 to 200, Over 200, Total 2 7, , ,695 Page 110

111 Parliamentary Accountability and Audit Report NHS Lewisham CCG is not required to produce a Parliamentary Accountability and Audit Report. Disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges are included as notes in the following Financial Statements. An audit certificate and report is also included in this Annual Report at pages i to iii of the Financial Statements. Page 111

112 Entity name: NHS Lewisham Clinical Commissioning Group This year This year ended 31-March-2017 This year commencing: 01-April-2016

113 NHS Lewisham Clinical Commissioning Group - Annual Accounts CONTENTS Page Number The Primary Statements: Statement of Comprehensive Net Expenditure for the year ended 31st March Statement of Financial Position as at 31st March Statement of Changes in Taxpayers' Equity for the year ended 31st March Statement of Cash Flows for the year ended 31st March Notes to the Accounts 1 Accounting policies Operating income 9 3 Income 9 4 Employee benefits and staff numbers Operating expenses 14 6 Better payment practice code 15 7 Income generation activities 15 8 Investment revenue 15 9 Other gains and losses Finance costs Net gain/(loss) on transfer by absorption Operating leases Property, plant and equipment Intangible non-current assets Investment property Inventories Trade and other receivables Other financial assets Other current assets Cash and cash equivalents Non-current assets held for sale Analysis of impairments and reversals Trade and other payables Other financial liabilities Other liabilities Borrowings Private finance initiative, LIFT and other service concession arrangements Finance lease obligations Finance lease receivables Provisions Contingencies Commitments Financial instruments Operating segments Pooled budgets NHS Lift investments Related party transactions Events after the end of the reporting period Losses and special payments Third party assets Financial performance targets Impact of IFRS 26

114 INDEPENDENT AUDITOR S REPORT TO THE MEMBERS OF THE GOVERNING BODY OF NHS LEWISHAM CLINICAL COMMISSIONING GROUP We have audited the financial statements of NHS Lewisham Clinical Commissioning Group for the year ended 31 March 2017 under the Local Audit and Accountability Act 2014 (the "Act"). The financial statements comprise the Statement of Comprehensive Net Expenditure, the Statement of Financial Position, the Statement of Changes in Taxpayers Equity, the Statement of Cash Flows and the related notes. The financial reporting framework that has been applied in their preparation is applicable law and International Financial Reporting Standards (IFRSs) as adopted by the European Union, as interpreted and adapted by the Department of Health Group Accounting Manual 2016/17 (the 2016/17 GAM ) and the requirements of the Health and Social Care Act This report is made solely to the members of the Governing Body of NHS Lewisham Clinical Commissioning Group, as a body, in accordance with Part 5 of the Act and as set out in paragraph 43 of the Statement of Responsibilities of Auditors and Audited Bodies published by Public Sector Audit Appointments Limited. Our audit work has been undertaken so that we might state to the members of the Governing Body of the CCG those matters we are required to state to them in an auditor's report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the CCG and the members of the Governing Body of the CCG, as a body, for our audit work, for this report, or for the opinions we have formed. Respective responsibilities of the Accountable Officer and auditor As explained more fully in the Statement of Accountable Officer s Responsibilities, the Accountable Officer is responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view and is also responsible for ensuring the regularity of expenditure and income. Our responsibility is to audit and express an opinion on the financial statements in accordance with applicable law, the Code of Audit Practice published by the National Audit Office on behalf of the Comptroller and Auditor General (the Code of Audit Practice ) and International Standards on Auditing (UK and Ireland). Those standards require us to comply with the Auditing Practices Board s Ethical Standards for Auditors. We are also responsible for giving an opinion on the regularity of expenditure and income in accordance with the Code of Audit Practice as required by the Act. As explained in the Governance Statement the Accountable Officer is responsible for the arrangements to secure economy, efficiency and effectiveness in the use of the CCG's resources. We are required under Section 21 (1)(c) of the Act to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and to report by exception where we are not satisfied. We are not required to consider, nor have we considered, whether all aspects of the CCG's arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively. Scope of the audit of the financial statements An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of: whether the accounting policies are appropriate to the CCG s circumstances and have been consistently applied and adequately disclosed; the reasonableness of significant accounting estimates made by the Accountable Officer; and the overall presentation of the financial statements. In addition, we read all the financial and non-financial information in the Performance Report and the Accountability Report to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially i

115 incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report. In addition, we are required to obtain evidence sufficient to give reasonable assurance that the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them. Scope of the review of arrangements for securing economy, efficiency and effectiveness in the use of resources We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criteria issued by the Comptroller and Auditor General in November 2016, as to whether the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined these criteria as that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the CCG put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2017, and to report by exception where we are not satisfied. We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary. Opinion on financial statements In our opinion: the financial statements give a true and fair view of the financial position of NHS Lewisham Clinical Commissioning Group as at 31 March 2017 and of its expenditure and income for the year then ended; and the financial statements have been prepared properly in accordance with IFRSs as adopted by the European Union, as interpreted and adapted by the Department of Health Group Accounting Manual 2016/17 and the requirements of the Health and Social Care Act Opinion on regularity In our opinion, in all material respects the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions in the financial statements conform to the authorities which govern them. Opinion on other matters In our opinion: the parts of the Accountability Report to be audited have been properly prepared in accordance with IFRSs as adopted by the European Union, as interpreted and adapted by the Department of Health Group Accounting Manual 2016/17 and the requirements of the Health and Social Care Act 2012; and the other information published together with the audited financial statements in the Performance Report and the Accountability Report for the financial year for which the financial statements are prepared is consistent with the audited financial statements. i i

116 Matters on which we are required to report by exception We are required to report to you if: in our opinion the Governance Statement does not comply with the guidance issued by the NHS Commissioning Board; or we have referred a matter to the Secretary of State under section 30 of the Act because we had reason to believe that the CCG, or an officer of the CCG, was about to make, or had made, a decision which involved or would involve the body incurring unlawful expenditure, or was about to take, or had begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency; or we have reported a matter in the public interest under section 24 of the Act in the course of, or at the conclusion of the audit; or we have made a written recommendation to the CCG under section 24 of the Act in the course of, or at the conclusion of the audit; or we have not been able to satisfy ourselves that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March We have nothing to report in respect of the above matters. Certificate We certify that we have completed the audit of the financial statements of NHS Lewisham Clinical Commissioning in accordance with the requirements of the Act and the Code of Audit Practice. Sarah L Ironmonger Sarah Ironmonger for and on behalf of Grant Thornton UK LLP, Appointed Auditor 2nd Floor St John s House Haslett Avenue West CRAWLEY West Sussex RH10 1HS 26 May 2017 i i i

117 NHS Lewisham Clinical Commissioning Group - Annual Accounts Statement of Comprehensive Net Expenditure for the year ended 31 March Note '000 '000 Income from sale of goods and services 2 (3,247) (2,676) Other operating income 2 (872) (117) Total operating income (4,119) (2,793) Staff costs 4 6,178 5,037 Purchase of goods and services 5 414, ,027 Depreciation and impairment charges Provision expense (181) Other Operating Expenditure Total operating expenditure 421, ,010 Net Operating Expenditure 417, ,217 Finance income Finance expense Net expenditure for the year 417, ,217 Net Gain/(Loss) on Transfer by Absorption Total Net Expenditure for the year 417, ,217 Other Comprehensive Expenditure Items which will not be reclassified to net operating costs Net (gain)/loss on revaluation of PPE 0 0 Net (gain)/loss on revaluation of Intangibles 0 0 Net (gain)/loss on revaluation of Financial Assets 0 0 Actuarial (gain)/loss in pension schemes 0 0 Impairments and reversals taken to Revaluation Reserve 0 0 Items that may be reclassified to Net Operating Costs 0 0 Net gain/loss on revaluation of available for sale financial assets 0 0 Reclassification adjustment on disposal of available for sale financial assets 0 0 Sub total 0 0 Comprehensive Expenditure for the year ended 31 March , ,217 1

118