NHS Trafford CCG. Annual Report 2016 / 2017

Transcription

1 NHS Trafford CCG Annual Report 2016 / 2017

2 Contents Foreword 3 Performance Report 4 Performance Overview 5 Performance Analysis 15 Accountability Report 40 Corporate Governance Report 40 Members Report 40 Statement of Accountable Officer s Responsibilities 50 Governance Statement 52 Remuneration Report 75 Annual Accounts 84 Page 2

3 Foreword Welcome to Trafford Clinical Commissioning Group s (CCG) Annual Report for 2016/17. All NHS organisations are required to publish an annual report and financial statements at the end of each financial year and this is the fourth report for Trafford CCG, since the organisation was created on the 1 April The CCG is a clinically led member organisation made up of Trafford s 32 GP practices. Members are responsible for determining our governance arrangements, which is covered in greater detail as part of CCG s Constitution document and referred to within the Corporate Governance section of this report. The budget for the CCG, which covers a population of circa 238,000, comes from the Government and was 340m for 2016/17. The CCG has had a challenging year financially but with some great successes and this report summarises both the challenges and key highlights of the last year. We are keen for the Trafford public to get involved in future commissioning, if you would like to know more please contact us at: TRCCG.Mail@nhs.net Matthew Colledge Chair - NHS Trafford Clinical Commissioning Group Page 3

4 Performance Report The purpose of the overview section of the annual report is to provide a brief summary of the Trafford Clinical Commissioning Group (CCG) over 2016/17, to describe how it has performed, and the key risks the CCG has managed in achieving its objectives. Cameron Ward Accountable Officer - NHS Trafford Clinical Commissioning Group 30 May 2017 Page 4

5 Performance Overview Summary 2016/17 has been a particularly challenging year in delivery of the CCG s statutory requirements and delivery of our commissioning plan under an increasingly financial and demanding delivery environment. The CCG has proactively performance managed its providers for the services it commissions in delivery of its commissioning operational plan, with accident and emergency targets set under the NHS constitution for example being amongst the biggest challenges. The CCG has achieved its financial targets, from its allocation of funds at the outset of 2016/17 and achieved substantially its cash releasing efficiency gains achieving an overall surplus as part of achieving financial balance as a statutory requirement in agreement of overall financial plans on an ongoing basis with the Greater Manchester Health and Social Care Partnership. Key commissioning areas the CCG has delivered during 2016/17 include the further strengthening of Trafford Co-ordination Centre s (TCC) referral management strand and the partner collaboration with Trafford Council, in response to the integration challenge in the NHS 5 Year Forward View guidance and Greater Manchester Devolution. From 1 April 2016, Greater Manchester took responsibility for Health and Social Care spending in excess of 6bn. Health and social care partners are working closely with other public service providers to deliver a vision, designed to: Improve the health and wellbeing of all of the residents of Greater Manchester, moving from having some of the worst health outcomes to having some of the best; Close the health inequalities gap within Greater Manchester and between Greater Manchester and the rest of the UK faster; Deliver effective integrated health and social care across Greater Manchester; Continue to redress the balance of care to move it closer to home where possible; Strengthen the focus on wellbeing, including greater focus on prevention and public health; Contribute to growth and to connect people to growth, e.g. supporting employment and early years services; and Forge a partnership between the NHS, social care, universities and science and knowledge industries for the benefit of the population. Page 5

6 A Strategic Plan for Greater Manchester has been developed, setting out a framework for long-term health and social care reform. The plan has been endorsed by all 34 organisations involved in the devolution partnership, together with other partners, such as primary care providers. It provides a framework to direct the application of the 450m Greater Manchester transformation fund. This fund provides Greater Manchester with the ability to make strategic investments to support the creation of a sustainable and successful health and social care system by The Greater Manchester Strategic Plan is underpinned by ten Locality Plans, one for each of the Greater Manchester Districts. These plans are a critical aspect of the process as they describe the specific work which will take place in each area to make Greater Manchester s vision for transformed health and care a reality. To support the delivery of the programme, an Accountability Agreement with NHS England has been agreed. This agreement describes how Greater Manchester will be assured once, as a place, for delivery of the NHS Constitution and mandate, financial control and quality. Trafford s Locality Plan, The Trafford Plan to taking charge of our health and social care, sets out Trafford s collaborative commissioning plans. The CCG has worked throughout 2016/17 in delivery of the NHS Five Year Forward View to improve outcomes for the patients of Trafford whilst preparing for delivery of Devolution Greater Manchester and further improved outcomes for the patients of Trafford. This has been done by working towards achieving; a shift towards early intervention and prevention; delivering high quality of services; making the best use of resources; working effectively and collaboratively across Greater Manchester; integrating Health and Social Care services; Further detail on the performance of the CCG is outlined in the following pages. Page 6

7 Purpose and Activities of the CCG In the NHS, commissioning is the term given to the process of identifying what healthcare services local people need and then arranging and procuring these services from local providers. Commissioners are responsible for deciding how local healthcare budgets are used. Commissioning involves developing a detailed understanding of local healthcare needs, arranging contracts with providers, managing those contracts, and engaging with local people to understand how services can be improved. Clinical Commissioning Groups are clinically led membership organisations made up of General Practices and Trafford CCG has the responsibility of the following for the benefit of Trafford s population for 2016/17 which relate to: a) Commissioning certain health services (hospital, community ambulance and co-commissioning primary care medical services) to meet the reasonable needs of: i) All people registered with member GP practices, and ii) People who are usually resident within the area and are not registered with a member of any Clinical Commissioning Group; b) Commissioning emergency care for anyone present in the group s area. The group in discharging these functions in delivering on the CCG s Constitution commissioning responsibilities have acted to: Promote a comprehensive health service; Meet the public sector quality duty; Develop a joint health and wellbeing strategy with the Local Authority; Secure public involvement in the planning, development and consideration of proposals for changes and decisions affecting the operation of commissioning arrangements; Promote awareness of, and acted with a view to securing that health services are provided in a way that promotes awareness of, and have regard to the NHS Constitution; Act effectively, efficiently and economically; Secure continuous improvement to the quality of services; Improve the quality of primary medical services in supporting NHS England; Have regard to the need to reduce inequalities; Promote the involvement of patients, their carers and representatives in decisions about their healthcare; Act with a view to enabling patients to make choices; Page 7

8 Obtain appropriate advice from persons who, taken together, have a broad range of professional expertise in healthcare and public health; Promote innovation; Promote research and the use of research; Have regard to the need to promote education and training, and Act with a view to promoting integration of both health services with other health services, and health services with health-related and social care services, where the group considers that this would improve the quality of services or reduce inequalities. The CCG s intention on 1 April 2013 was to establish a healthcare system locally in Trafford, which would combine improvements in patient experience, better health outcomes for these patients from healthcare providers, and make better use of the available NHS resources. The aim has been for local GPs to be at the centre of this system to commission appropriate services and lead the changes necessary to deliver the future aspirations of the public within the resources available. Under the Health and Social Care Act 2006 (Amended 2012) the CCG is required to demonstrate the above through discharging a number of duties which are included within this annual report. These include for example: Requirements in relation to sustainable development of providers in terms of progress, adaptation and mitigation. Requirements in relation to Patient and Public Involvement in line with section 14Z2 of the Health and Social Care Act 2006 in respect of its arrangements to involve patients and public in commissioning, planning, decision making and changes to proposals and plans that will impact upon individual or groups of how services are provided to them. Requirements in relation to Section 14T of the Health and Social Care Act 2012 in relation to reducing inequalities. The overall aim for the CCG is to ensure that the health services we manage for the people of Trafford are provided at the right place and at the right time, and that services are safe, of a high quality and are value for money. This vision is underpinned by four strategic objectives: 1. Consistently achieve local and national quality standards 2. Deliver an increasing proportion of services from primary care and community services in an integrated way 3. Reduce the gap in health outcomes between the most and least deprived communities in Trafford Page 8

9 4. Ensure a financially sustainable health economy The CCG has continued to work hard to improve the health and wellbeing of every person living in Trafford. It is important to note that the CCG s work is not just about treating illness. It aims to help patients stay healthy and help to prevent them from becoming unwell. The CCG works closely with other NHS organisations, healthcare professionals, the Local Authority and many partners across the community to ensure the CCG responds to patients needs and aspirations, and to make sure that the right services are available to them. Key Issues and Risks The health and social care economy of Trafford and across Greater Manchester is changing considerably to enable true integrated care and the CCG s Trafford Co-ordination Centre (TCC) is a vital part of its delivery across Trafford. The CCG has faced many challenges during 2016/17 and will continue to face these challenges in future years, most notably; Availability of Resources; Fragmented Healthcare Clinical Variation; Over Reliance on Acute (Hospital) Services Growing Elderly Population; and, Poor Health Risk Taking Behaviours The CCG has developed the TCC which will aim to combat these significant challenges in reforming the way in which Trafford patients are treated and improving overall patient experience. In delivering strategies to meet these challenges and subsequently achieve the CCG s strategic objectives, key strategic risks have been identified and proactively managed on the CCG s Board Assurance Framework. Further detail on the CCG s risk profile is in the Governance Statement section of the report. Page 9

10 Key Achievements Primary Care CQC achievement: Trafford CCG works closely with general practices, as a part of its quality improvement programme. The hard work has seen Trafford CCG secure its 2 nd practice rated as outstanding by the Care Quality Commission (CQC). This is in addition to Trafford s nineteen other practices rated as good. Cervical Screening: Trafford Clinical Commissioning Group (CCG) and Trafford Council and have achieved a High Commendation for their work to increase the number of women attending potentially life-saving cervical screening (smear tests). The Trafford team devised their One Minute campaign to increase awareness of cervical screening among groups where attendance was particularly low, this included women from black, asian and minority ethnic backgrounds and those living in areas of deprivation. The judging panel commented that the project demonstrated good understanding of local differences in population screening ; commended the multi-partner approach and full GP practice engagement across the borough and called the evaluation impressive. Infection Control: A voluntary Infection prevention and control (IPC) inspection programme in general practice has seen high levels of uptake in Trafford. Performance has increased significantly with an average score of over 90% in the most recent inspections. Flu vaccination: Trafford CCG supports its member practices in the delivery of the flu vaccination programme. As a result of the co-ordinated approach utilised in Trafford between providers and commissioners Trafford is rated 2 nd out of 211 CCGs national and 1 st out of 12 CCG s in Greater Manchester. Award of Clinical Pharmacists: Following the submission of a bid to NHS England for the funding of additional pharmacists posts NHSE have informed the CCG and Trafford Primary Health (TPH) that the bid has been successful. This will mean that the CCG & TPH can move forward with recruiting an additional 10 clinical pharmacists to support all practices in Trafford. Safeguarding - The Journey of Trafford Adult Safeguarding Board over the last 12 months The last 12 months have been very exciting for the Adults Safeguarding Board. The ethos and vision of the partners connected to the Board have joined to produce an atmosphere of proactive transformation. Page 10

11 The vision of Trafford Multi-Agency Partnership promotes safety and inclusion, aiming to improve life experiences of individuals and families. Leading the vision is our recently appointed interim joint Chair Mrs Maureen Noble, supporting Mrs Noble is Mrs Catherine Randall Chief Nurse for Trafford CCG and Vice Chair of the Adult Safeguarding Board. Additionally an Adult Safeguarding Board manager has been appointed; commencing their role in September The Board has strengthened the internal and external structures that support and maintain its aims and objectives. Professionals and providers have benefited from training which adheres to the Care Act 2014, policy development, national guidance relating to case law, serious adult reviews (SARs) and learning reviews, ensuring that individuals and families access an appropriately skilled workforce. In addition, four subgroups have been established, these groups consist of: The Strategic subgroup; The Policy Development and training subgroup; The Serious Adult Review Subgroup and, The Quality and Assurance Subgroup Each of the subgroups benefits from the membership and commitment of professionals from the multi-disciplinary arena. The fusion of core skills, values and knowledge unite to create forums that seek to ensure the Trafford Partnership does not only meet but exceeds its statutory duties through effective service delivery. Safeguarding Adults: The New Designated Nurse for Safeguarding Adults has been in post since February 2017 and the Designated Nurse has now been operational since April Working with the Designated Nurse for Safeguarding Children and Children in Care, a Safeguarding Supervision Framework is now in place together with a CCG Safeguarding Training Strategy. In respect of training, the intercollegiate training document for adults is in abeyance so no clear guidelines are available for adult safeguarding training. However, level three training has been developed and delivered to GPs, with more training planned. This is now delivered in conjunction with the Senior Adult Practitioners from the Local Authority following feedback from GPs that they would like to understand the processes put in place following their referrals or enquiries. With regards to safeguarding supervision, dates have now been offered to Primary Care on a drop-in basis to gauge uptake, there are considerations to offer these sessions as evening sessions if there is a clear need and demand. This supervision will also be offered to the Continuing Healthcare team within the CCG. Page 11

12 The Safeguarding team have now offered dates to Homecare Providers for safeguarding training. Within this planned session, the safeguarding team will offer the providers a child safeguarding and an adult safeguarding policy for them to adopt. This will offer a consistent approach with all homecare providers and offer assurance for the CCG on the quality of the policy the providers are using. In addition, Safeguarding Training has now been offered to Nursing Home providers. Both the training for the Nursing Homes and the Homecare providers will be supported by the Local Authority, for the Nursing Homes this will also be supported by the Mental Capacity Act Senior Practitioner. As part of the United Kingdom s Counter-terrorism strategy, the CCG is required to be complaint with the fourth aspect which looks at identifying and supporting individuals who may be vulnerable and at risk of radicalisation. Trafford CCG is complaint with this requirement and has a PREVENT lead. Training is delivered quarterly and is incorporated into the Adult safeguarding training. Safeguarding Children and Children in Care: Due to the retirement of previous post holders, the new Designated Nurse for Safeguarding Children and Children in Care and the new Named GP for Safeguarding Children commenced in post in January The new Designated Doctor for Safeguarding Children commenced in post April A programme of level 3 safeguarding training has been delivered to primary care colleagues in collaboration with the Named GP for safeguarding children, and a calendar of training for is underway. The Designated Nurse continued to support the delivery of Trafford Safeguarding Children Board (TSCB) multi-agency training and has facilitated two sessions of Female Genital Mutilation (FGM) training for CCG and primary care colleagues. The team have continued to work closely with our Looked After Children (LAC) health providers in Pennine Care NHS Foundation Trust; and have worked hard to deliver health Initial Health Assessments (IHA) and Review Health Assessments (RHA), meeting set key performance indicators. Once health needs are identified; health and social care colleague s work in partnership to ensure that Trafford s LAC receive timely access to the services they need. Work is underway across the Greater Manchester footprint to develop a LAC benchmarking tool to identify areas to focus improvement strategies upon as a collective. Health providers who work with Trafford residents have continued to work together using the Trafford Safeguarding Children Health Network as a forum to share learning and focus on providing assurance that services are safe and effective for our Page 12

13 residents. For the coming year health providers will work to support the TSCB 6 point challenge and TSCB strategic priorities which are outlined below. TSCB 6 Point challenge Evidence of use of neglect tool Evidence of sound risk assessments for children where domestic abuse is a feature Evidence of sound risk assessments where alcohol/substance misuse feature Minutes from plenary sessions which evidence reflection and challenge Children and Families Assessments for all Child Protection/Child in Need/Child Sexual Exploitation cases Evidence of professional thinking time in practice TSCB Strategic Priorities for 2016/2018 Provide assurance to the TSCB that there is an efficient, effective and well co-ordinated response to the identified needs of children across the continuum of need that results in improved outcomes for children Provide assurance that our most vulnerable children are effectively safeguarded To continually develop and improve the way we work so that outcomes for children improve and the child s voice is always heard Evidence the impact of early help on the de-escalation of risk and need across the thresholds Performance Summary The performance and quality of commissioned services is managed by the Performance, Quality and Improvement (PQI) Team (shared between North Manchester, Central Manchester, South Manchester and Trafford CCGs). The core function of the PQI team is to monitor and manage the performance and quality of commissioned providers in order to provide assurance to CCG Boards and Committees. A robust operational framework is in place across the CCGs and partner organisations where appropriate to support the management of performance and quality, and associated escalation of issues arising. In simple terms, this involves: Having well developed and embedded governance structures, with leadership from CCG Quality and Performance Committees; CCG Boards; and health economy Urgent Care Delivery Boards Having SMART objectives for provider and CCG work programmes, through which providers and CCGs can be held to account Page 13

14 Having robust data about all providers both quantitative and qualitative. This includes, but is not exclusive to, delivery against agreed performance and quality standards; feedback from incident reporting procedures; patient feedback; findings from CCG walkrounds; and progress against improvement/recovery plans where applicable. This forms the basis of assurance reporting and escalation where necessary via the governance structures described above. The 2016/17 year-end assessment for the CCG will be available on: from July Page 14

15 Performance Analysis How Performance is Measured At every meeting the CCG Governing Body receives reports on performance against local and national measures and performance of the CCG s main providers, University Hospital of South Manchester Foundation Trust (UHSM), Central Manchester University Hospitals NHS Foundation Trust (CMFT) and Pennine Care NHS Foundation Trust (PCFT). In the 2016/17 contract, Sustainability and Transformation Fund (STF) Performance Improvement Trajectories were agreed for the following constitutional standards: A&E 4 hours: Percentage of A&E attendances where the patient spent 4 hours or less in A&E from arrival to transfer, admission or discharge. Diagnostics 6 weeks: The number of patients waiting six weeks or more for a diagnostic test (fifteen key tests) based on monthly diagnostics data provided by NHS and independent sector organisations and signed off by NHS commissioners as a percentage of the total number of patients waiting at the end of the period. Referral to Treatment (RTT) Incomplete: The percentage of patients waiting for treatment on an incomplete pathway who have not waited more than 18 weeks at the end of the reporting period. Cancer 62 Days: Percentage of patients receiving first definitive treatment for cancer within two months (62 days) of an urgent GP referral for suspected cancer. The NHS outcomes framework sets out clearly the five domains against which all CCGs are working to deliver, which are also aligned to our strategic aims. The document Delivering the Five Year Forward View: NHS Planning Guidance 2016/ /21 sets out the triple aim for CCGs and their partners: Page 15

16 i) Improving the health and wellbeing of the whole population ii) Better quality for patients, through care redesign iii) Better value for taxpayers in a financially stable system CCG progress towards delivering these aims will be measured through the CCG Improvement and Assessment Framework (CCGIAF). The CCGIAF draws together in one place NHS constitution and other core performance and finance indicators, outcome goals and transformational challenges. Performance against NHS Constitutional Standards Referral to Treatment (RTT): Trafford CCG is slightly under the national RTT Incomplete Operational Standard, this is primarily due to under-performance at UHSM. During 2016/17 significant validation work was completed on the Trust s RTT data. This was the culmination of an issue first identified in March 2015 which meant that there was no assurance on the accuracy of the RTT performance data being reported by the Trust. Now that the issue of the accuracy of the reported data has now been resolved, the Trust can focus on recovering performance. Specialty level improvement trajectories have been developed and the Trust anticipate recovering RTT incomplete performance by July A consequence of this significant validation work is the identification of a number of patients that had been on an RTT pathway for more than 52 weeks. The Trust have worked to agree treatment dates for these patients and there have been both internal and external clinical reviews for harm, with no harm identified as a result of pathway delays. UHSM have delivered a number of actions to improve both clinical and administrative processes around the management of RTT pathways and have established an ongoing programme of education and training on RTT for all staff groups. At CMFT, RTT incomplete performance has been consistent during 2016/17, with a slight dip during Q3, reflecting urgent care pressures. Cancer Waiting Times (CWT): During 2016/17 Trafford CCG has achieved the CWT standards. However, there have been pressures at the CCG s main providers. Two week wait (Breast Symptomatic) - patient choice is a significant factor in breaches of this standard which applies to patients referred with breast symptoms that are not thought to be cancer. At UHSM full-year performance is at risk. 62-day (GP referred) - The complex nature of cancer pathways in Greater Manchester means that for many tumour types, patients receive their treatment (chemotherapy/radiotherapy/specialist surgery) at a different provider from the one to which they were originally referred. For treating Trusts this means that their performance against the 62-day Page 16

17 standard relies on receiving timely referrals from the providers carrying out the initial diagnostic and staging investigations. National guidance states that for patients referred from one provider to another, breaches of the 62-day standard are automatically shared and treated on a 50:50 basis. This means that figures from NHS England do not take delays in diagnostic and staging investigations at the first-seen Trust into account when attributing breaches of the 62-day standard. As a consequence of this, tertiary treatment centres may appear to be performing less well against this standard if only nationally reported figures are taken into account. The local health economy in Greater Manchester recognises this and there is local agreement to attribute the breach to the Trust which has incurred most of the delay, if the national waiting time is breached. In short, where the first-seen Trust does not refer to the treating Trust by day 42 of the 62-day pathway, they will be allocated the whole breach. This has a most significant impact on the performance of The Christie; however this reallocation is not applied to CCG performance, which is based on the 50:50 allocation of breaches. CMFT experienced particular challenges in delivering this standard during Q3. Both Upper and Lower Gastrointestinal (GI) were affected by a breakdown in endoscopy decontamination equipment. Urology was affected by capacity challenges for diagnostics and treatment following a consultant retirement. Radiology capacity represents a further challenge for the Trust. The radiology department is delivering against internal standards of ten days for a scan and a further seven days for reporting, but these turnaround times do not meet the timescales described in agreed cancer pathways. 62-day screening - As there is no breast screening service at CMFT, a small number effect impacts on the Trust ability to achieve this standard consistently. A single breach in a quarter will prevent the Trust from achieving the 90 per cent operational standard. A&E Performance: Performance against the A&E four hour standard at CMFT and UHSM has deteriorated in 2016/17 however, both Trusts successfully achieved in excess of 90 per cent in March 2017, an improvement trajectory agreed with the Trusts. Urgent care provision and performance remains the key focus of the Manchester and Trafford systems and progress with improvement actions is monitored through the A&E Operational Delivery Group (ODG). Weekly tactical conference calls led by the CCG remain and provide all partner organisations an opportunity to escalate any issues across the whole Manchester Urgent Care system. 2017/2018 resilience planning is underway. Page 17

18 Ambulance: Ambulance response time targets are not currently being met in Trafford. In November 2016, in light of reducing performance, Blackpool CCG as lead commissioner of North West Ambulance Service NHS Trust (NWAS) issued an improvement notice. This has created an action plan to improve response times across the North West. The ambulance service can experience significant challenges in the Manchester localities as a result of pressures on A&E departments and handover delays. The timeliness of ambulance handover and turnaround time continues to be a particular challenge as pressures on our emergency and urgent care systems continue to impact on the time it takes patients to be handed over by the ambulance service to the receiving hospital. NWAS and acute providers continue to work in partnership to facilitate the timely receipt of patients conveyed by ambulances to the hospital. The Task and Finish Group continues to target handover improvements and response times. Diagnostics: CMFT has not delivered this operational standard since September 2013 but has been working during 2016/17 to reduce the number of patients waiting in excess of six weeks and deliver the Constitutional Standard. The Trust have a detailed action plan which is monitored on a weekly basis. Alongside the short term improvement actions, the Trust is working on a longer term plan to provide more robust assurances to Commissioners. In February 2017, CMFT made significant improvements in waiting times, this meant the CCG achieved the standard for the first time in five months. Mental Health: The CCG has a good track record against the national mental health measures including access to Improving Access to Psychological Therapies (IAPT) and Early Intervention Psychosis (EIP) services. At the time of writing this report all the key targets are being met, these include: Access IAPT services Recovery rates following intervention First episode of psychosis or ARMS (at risk mental state) treated with a NICE approved care package within two weeks of referral Dementia diagnosis rate (aged 65+) was another successful year for the Mental Health and Learning Disability commissioning directorate. Mental Health performance across the board was strong, as reflected in the CCG s Improvement and Assessment Framework and other returns which align key objectives and priorities. Children and Young People s Mental Health Services: The CCG has worked closely with its partners to build sustainable, system wide, transformation with particular achievements noted as: 887 more children and young people have received mental health support in due to CCG investment Page 18

19 New online support website launched New community eating disorder service developed in conjunction with Tameside and Stockport CCGs Investment in early help services for mental health through the charity 42nd Street 262 training places on specific mental health issues has been provided to universal health and social care professionals to increase their confidence and competence to support children and young people with mental health needs at an earlier stage 262 training places on specific mental health issues has been provided to universal health and social care professionals to increase their confidence and competence to support children and young people with mental health needs at an earlier stage Review and redesign of Attention Deficit Hyperactivity Disorder (ADHD) pathway through a collaborative multi-agency approach Special Educational Needs and / or Disabilities Services (SEND) Report: A positive Ofsted and CQC inspection report was received by Trafford CCG and Trafford Council following an inspection of the effectiveness of how we are implementing the reforms for children and young people who have SEND as set out in the Children and Families Act of Among other strengths the inspectors noted: Trafford s strong joint working and commissioning between the council and healthcare services and providers The clear procedures and assessment systems that are in place. Crises Care and Liaison Services: Trafford CCG commissions a fully compliant crisis resolution and home treatment team and has also worked with its partners such as Self Help Services to provide places of safety for people when they are in crisis. The CCG has commissioned an excellent psychiatric liaison service for patients using Trafford General Hospital and Wythenshawe Hospital and this service is now being used as the basis for a whole system transformation of psychiatric liaison services across all of Greater Manchester s acute hospital trusts. Out of Area Placements for Mental Health Inpatient Care: In many areas of Greater Manchester and more widely across the country pressure on beds has been exacerbated by a lack of early intervention and crisis care, with the resulting shortage leading to people being transferred long distances outside of their area. Trafford performs strongly in this area due in large part to the quality and hard work of its main provider, Greater Manchester Mental NHS Health Foundation Trust allied to the CCG s investment in crisis care and liaison services. Page 19

20 In an extremely challenging environment only a small number of short-term out of area placements have been necessary comparing more than favourably to other Greater Manchester CCGs. Individual Mental Health and Disability Budget: More widely Trafford CCG supports patients with exceptional mental health and learning disability needs, where their needs cannot be met by our commissioned services. Again, considering the very challenging circumstances we have operated in during it is noteworthy that spend on this business area has been controlled to within 1 per cent of the agreed annual budget. Dementia Diagnosis: Trafford CCG exceeded its target for by reaching a dementia diagnosis rate of 72 per cent on 31 March 2017, against a target of 66.6 per cent. This exceeds the national average of 67.6 per cent. Early Intervention in Psychosis: The NHS target for people to have access to Early Intervention in Psychosis services was 50 per cent by April 2016, rising to at least 60 per cent by 2020/21. Trafford CCG achieved 64.3 per cent in February 2017, increasing to 74.3 per cent for March Improving Access to Psychological Therapies: The Improving Access to Psychological Therapies (IAPT) programme began in 2008 and has transformed treatment of adult anxiety disorders and depression in England. Trafford CCG has achieved its targets for waiting times with both six and 18 week targets being exceeded. The recovery target has also been exceeded for with 52 per cent of IAPT patients achieving recovery against a target of 50 per cent. The latest published IAPT access data shows Trafford CCG exceeding its 12.5 per cent target at month 10 and data available to commissioners from its providers indicates the CCG will achieve its overall 15 per cent access rate by year end. Learning Disabilities Transforming Care: Transforming Care emerged as a response to the shocking catalogue of systematic abuse conducted at Winterbourne View, a nursing home that was supposed to provide care for people with a learning disability and/or autism. Transforming Care aims to ensure that people with a learning disability and/or autism in hospital who could be supported in the community are discharged into a community setting as soon as possible to avoid the long-term damage associated with unnecessary admissions and promote independence, self-esteem and the achievement of a fulfilling life. Page 20

21 Trafford was set a performance target of having no more than four patients with a learning disability and/or autism in non-secure hospital beds and no more than four patients from this cohort in secure beds. Trafford CCG has delivered on its commitment to Transforming Care and exceeded this target at year end. Mixed Sex Accommodation: Throughout 2016/17 there were no reported breaches, this means all Trafford registered patients were treated in single sexed accommodation, except where it was in the overall best interest of the patient, or reflects their personal choice. CCG Improvement and Assessment Framework (CCGIAF): The CCG has a robust process in place for monitoring performance against the areas set out in the CCGIAF. The CCG produce a quarterly assurance pack that: Summarises CCG performance in comparison to the national picture Assesses performance against the 6 clinical priority areas (Cancer, Dementia, Diabetes, Learning Disabilities, Maternity and Mental Health) and identifies the nationally assigned performance rating. Sets out the work being undertaken to maintain and improve against the performance measures. Identifying key issues, actions and risks to delivery. Current Ratings Cancer Performing well Dementia Performing well Diabetes Needs improvement Learning Disabilities Needs improvement Maternity Needs improvement Mental Health Performing well There are three areas requiring improvement. Diabetes Key Improvement Actions Include: Further training for nurse practitioners and GPs aimed at motivating patients to take up the offer of education Delivery of a Primary Care Rolling Monthly Electronic Performance Dashboard for EMIS enterprise practices to highlight areas for improvement Page 21

22 Implementing the Improving Data Recording of Attendance at Diabetes Structured Education Guidance November 2016 to: - Ensure that the standardised system of recording Diabetes Structured Education outcome is shared across the commissioning area - Ensure that providers of Diabetes Structured Education can demonstrate that they will follow the standardised Read Codes Supporting and Up-skilling Primary Care Scheme, each Practice will be given the opportunity to have two face to face meetings and two follow-up telephone / skype calls facilitated by the Diabetes Clinical Lead. Learning Disabilities Key Improvement Actions Include: Maternity Continued alignment with Greater Manchester programme via the Greater Manchester Transforming Care Fast Track Delivery Board including development of GM resources such as Crisis bed availability / Crisis Outreach teams and provider capacity and expertise Use of Commissioning for Quality and Innovation (CQUIN) / Greenlight Toolkit / Pennine Care contract arrangements to develop LD (at) Risk (of admission) Register to predict and where possible prevent admissions Commissioner to work with performance team to ensure accurate reconciliation of LD registers Use of contract, quality and performance management to ensure continued focus upon the physical health needs of people with a learning disability living in Trafford Key Improvement Actions Include: Ensure maternity services are delivered in line with the Greater Manchester Maternity service specification to promote best practice services Support pregnant women who smoke to access support to quit services via their GP or Pharmacist or access the Trafford One You Service which offers tailored smoking cessation support Financial Performance In terms of financial performance, it is pleasing to report that the CCG has delivered all of its financial targets for the 2016/17 have faced a particularly challenging year. Page 22

23 Last year, the Clinical Commissioning Group delivered 10.6m of savings enabling it to invest further into mental health, community, acute and primary care services and as Trafford Care Co-ordination service. Specifically in terms of financial duties, the CCG was able to: Deliver an in-year surplus of 4.7m against a revenue resource limit of 340m, delivering a surplus of 1.4 per cent as agreed with Greater Manchester Health & Social Care Partnership. Underspent on its administration costs allocation by 360k, releasing this resource into healthcare services for patients. Remained within its notified cash limit for the year as well as finishing the financial year with bank balance of 33k at year-end, complying with treasury requirements. To pay suppliers promptly, meeting the NHS standards for payment of Invoices; achieving payment of 98 per cent of invoices within 30 days. The CCG s annual accounts and summary financial statements are subject to audit by external auditors and begin on page 82 of this report. The continuation of effective financial and operational delivery throughout 2016/17 has not only resulted in significant cost savings but performance, quality of services and patient outcomes have improved in a number of areas across Trafford and these are covered elsewhere within the annual report. It is particularly pleasing as indicated above that the CCG was able to re-invest a significant proportion of its savings into healthcare within Trafford to improve outcomes. Specifically, the CCG has made a number of investments during the year, with major areas highlighted as follows: 2m investment into the Trafford Co-ordination Centre. 600k extra for improving mental health services; parity of esteem requirements. 5.5m invested into the Better Care Fund hosted by Trafford Metropolitan Borough Council, to improve the integration of health and social care for the population of Trafford. 1m invested in Primary Care, to support the implementation of the Trafford Care Co-Ordination Centre, 7 day patient access and the development of New models of primary care delivery along with other local services. Page 23

24 Sustainable Development Sustainability has become increasingly important as the impact of peoples lifestyles and business choices are changing the world in which we live. We acknowledge this responsibility to our patients, local communities and the environment by working hard to minimise our footprint. The following tables are the CCG s position in delivery of its activities: CCG Spend ( ) Building Name Tenant/Bill Payer CROSSGATE HOUSE NHS TRAFFORD CCG BODMIN ROAD HEALTH CENTRE DR SIMPSON & PARTNERS BROOMFIELD LANE CLINIC PENNINE CARE NHS FOUNDATION TRUST CHAPEL ROAD CLINIC PENNINE CARE NHS FOUNDATION TRUST BRIDGEWATER COMM HEALTHCARE FOUNDATION CONWAY ROAD MEDICAL PRACTICE CONWAY ROAD HEALTH CENTRE NHS ENGLAND NHS TRAFFORD CCG PENNINE CARE NHS FOUNDATION TRUST CORNHILL CLINIC NHS TRAFFORD CCG PENNINE CARE NHS FOUNDATION TRUST DR A CLARK & PARTNERS DELAMERE HEALTH CENTRE NHS TRAFFORD CCG Invoiced For (Status) Tenant Tenant Tenant Tenant Tenant Tenant Tenant Void Space Tenant Void Space Tenant Tenant Void Space Tenant Occupancy (%) PENNINE CARE NHS FOUNDATION TRUST FM Electricity 34,056 7, , , ,384 2,358 3,697 6,104 6,399 Gas 6, , , ,767 1,749 1,605 2,650 2,778 Water 1,386 2, , ,136 1,191 Grand Total 35,442 16, , , , ,678 4,628 5,990 9,890 10,368 Building Name Tenant/Bill Payer ONE STOP RESOURCE CENTRE PENNINE CARE NHS FOUNDATION TRUST BRIDGEWATER COMM HEALTHCARE FOUNDATION TRUST SEYMOUR GROVE HEALTH CENTRE DR N ACHAREKAR NHS TRAFFORD CCG OLD TRAFFORD MEDICAL PRACTICE PENNINE CARE NHS FOUNDATION TRUST CENTRAL MANCHESTER UNI HOSPITAL NHS FT DR C WESTWOOD TIMPERLEY HEALTH CENTRE GROVE MEDICAL PRACTICE NHS TRAFFORD CCG PENNINE CARE NHS FOUNDATION VILLAGE SURGERY TRUST Invoiced For (Status) Tenant Tenant Tenant Void Space Tenant Tenant Tenant Tenant Tenant Void Space Tenant Tenant Subsidised Amount (blank) (blank) (blank) (blank) (blank) (blank) (blank) (blank) (blank) (blank) (blank) (blank) Occupancy (%) FM Electricity 8,701 2,932 1,884 4,582 1,372 2, ,209 5,846 4,587 1, ,051 Gas 5,280 1, , , ,467 1, ,269 Water 794 1, , , ,799 Grand Total 14,775 5,502 3,536 8,599 2,575 4, ,225 3,559 9,418 7,389 2, ,119 Grand Total Improve quality Quality incorporates patient safety, clinical effectiveness and patient experience and is at the heart of everything we do. We recognise that strong clinical leadership and engagement is critical in improving quality and improving outcomes for patients. We are working with providers and other commissioners collaboratively to achieve the best possible outcomes for patients within the present climate and the financial pressures all sectors of the health system are under. Page 24

25 At every meeting the CCG Governing Body receives updates on key issues in relation to quality. These include issues related to primary care quality, medicine management, patient experience and quality issues in hospital, such as patient safety, serious incidents and contractual performance of our providers against key quality measures. The CCG has a framework in place for the monitoring, assurance and improvement of quality and performance within all of our commissioned providers. This ensures that the services we commission are as safe as possible, in line with best practice and achieve the best outcomes for patients (see diagram on page 26). We have made good progress in working to improve the quality and safety of the care provided to our patients from the providers with whom we commission services from. We have made several achievements this year in respect of quality. These have included: Implemented a robust framework for monitoring and improving quality within commissioned providers. Ensured robust and detailed quality standards are included in every NHS contract with our providers. These cover areas such as safe staffing, culture, leadership, mortality etc. The standards are monitored on a quarterly basis. With smaller NHS funded providers we have facilitated workshops on governance, safeguarding, equality and diversity, patient safety, clinical effectiveness and audit. We have worked with these providers to ensure that they have the right systems and processes in place to provide safe, clinically effective care that provides a positive patient experience. We have supported the development of a culture of continuous improvement and innovation in the quality of clinical services, through a financial incentive framework called CQUIN (Commissioning for Quality & Innovation Framework). This framework enables the CCG to financially reward providers for achieving local quality improvement goals. We have worked with our providers to ensure high quality and robust, reporting, investigation and learning from incidents and serious incidents, including Never Events. We have further expanded our CCG walk/round programme covering acute settings, community settings and smaller NHS funded providers. We have undertaken 9 walk-rounds of smaller providers, 11 walk/rounds of our acute providers and six walk/rounds in our community providers in 2016/17. These walk/rounds have given CCG assurance around quality and safety of services being provided. Ongoing Monitoring A: Intelligence Gathering Throughout the year the CCG monitors Trust performance against these agreed measures and standards drawing from quantitative and qualitative data. Page 25

26 Fig 1: Intelligence Gathering, Information Review and Analysis Ongoing Monitoring B: Information Review and Analysis There is a systematic approach to reviewing quality and performance indicators and intelligence. The Business Intelligence team will gather information using the indicators set out at the beginning of the year. The Quality and Performance team will correlate data with themes and trends from various sources including complaints, serious incidents themes and contact with the providers including information gleamed from walk round. This information will be reviewed in detail at the Monthly Provider Analysis Meetings. The Provider Analysis Meeting This meeting is an opportunity for the whole team to come together as a group and share areas of concern, improvements, themes and trends in relation to the services the CCG commissions from providers. Ongoing Monitoring C: Assurance and Challenge On receipt of quality and performance information from the Trust the team will raise with them any variances between expected and actual performance. Appropriate information on the issue and any immediate actions will be agreed and implemented. Page 26

27 Any unsolved issues will continue to be monitored through the monthly one to one meeting the CCG Quality and Performance team has with the provider and monthly formal contracting meeting. Formal contract meetings take place with providers; the frequency is determined by the risk associated with the contract. Risk is a combination of financial value and any identified quality or performance concerns. Areas of concern are reported internally through the CCG governance structure and included specifically at Quality and Performance Committee. Fig 2: Assurance and Challenge The CCG IAF Performance Dashboard is published quarterly. Detailed analysis and benchmarking is undertaken to provide the Quality and Performance Committee with a comprehensive view of the CCG s performance compared to national average and statistical peers. C. Assurance and Challenge Issues and concerns raised with providers and assurance requested through: Immediate contact with the provider Monthly one to one meetings Quarterly/monthly formal contract monitoring meeting Where necessary improvement programme put in place Formal reporting to the CCG Board and Quality and Performance Committee (escalation and assurance is described in more detail on pages of this report) Commissioning leads are required to ensure the CCG has plans to deliver the desired outcomes identifying any risk to delivery. There is particular focus on those areas where the CCG is benchmarked in the bottom quartile. Patient and Public Involvement Trafford CCG recognises the importance of the need to engage with patients and the wider public to ensure they have a genuine influence in how their health local services are designed and delivered. Need for further assurance identified by CCG Committee and Board Issues and concerns detailed in papers for CCG Committee and Board Assurance reviewed and challenged by CCG Page 27

28 Good patient and public engagement that incorporates best practice, helps us to truly understand and focus on what matters to patients, carers and our local communities. During the autumn, to further strengthen the good work that has been undertaken, our patient experience staff and engagement lead were integrated into the same team Patient Experience Matters. This has enabled a more joined-up approach to ensure the voice of the people is listened to and considered as part of the commissioning cycle. Involving others to shape health services Planning health services for the People of Trafford cannot be undertaken by Trafford CCG alone. As well as listening to public and patients, we work with a range of commissioners, partners, statutory organisations and the voluntary, community and social enterprise sector. We outline some of the key highlights below: Public Reference and Advisory Panel (PRAP) Our PRAP is a committee of local people established to represent the views of the Trafford population. Membership is sought from each of the different localities in Trafford (North, South, Central and West) and from various third sector / voluntary groups in Trafford, including Healthwatch. The panel of volunteers meet monthly to discuss, feedback and inform CCG programmes of work. This assurance group reports directly to the CCG Governing Body. The panel is now in its second year and continues to grow in confidence to question, challenge and ultimately influence CCG commissioning plans and decisions. PRAP representation is truly valued and we have have extended PRAP involvement to other CCG meetings, including: Cancer Local Implementation Group; Locally Commissioned Services Group; Quality Walk/around Visits and Trafford Co-ordination Centre Implementation Board. To find out more about this panel contact Elizabeth Walker, Governance Support Officer: Elizabeth.walker4@nhs.net Page 28

29 Patient stories During 2016, we started to introduce patient stories at the beginning of our public Governing Body meetings. These have focussed on: December: Mental health / emotional wellbeing February: Personal Health Budgets / Special Educational Needs / Disability April: Bowel cancer / Volunteer Cancer Practice Champions The patients shared their stories, followed by Governing Body members being given the opportunity to ask the patient questions. This has been extremely well-received by the Governing Body members and the public who attend the meetings. These stories give valuable insight into the lives and views of our patients and often highlight the impact of their personal circumstance on their family/carers and friends. To share your story please contact the Patient Experience Matters Team: customercare.trafford@nhs.net GP-led Electro Cardiogram (ECG) Pilot Views and experiences of our patients were sought to help measure, track and demonstrate the impact of the new service/service development on patient experience. We had a great response, with 122 patients sharing their experiences which were mainly positive. Results were shared with GPs to highlight how well received the service has been. As the pilot was successful, there is now a locally commissioned ECG and 24 hour blood pressure service at a number of Trafford GP practices. Myalgic Encephalomyelitis (ME) / Chronic Fatigue Syndrome (CFS) Together with Salford CCG, Manchester CCGs and Healthwatch Trafford, we have been liaising with patients to understand their needs. Following a meeting with the Salford and Trafford ME Group and after receiving a report produced by Healthwatch Trafford on the experiences of people living with ME / CFS, Trafford CCG developed an action plan to help address some of the issues raised. We will be working together with Healthwatch Trafford and the support group to take this forward. Page 29

30 Phlebotomy service audit After reviewing patient experience reports from the two providers of the phlebotomy service in Trafford and hearing feedback from the local population through various channels, an audit of the service was undertaken. This included an engagement exercise which was carried out to gather the views of Trafford GPs. This useful information fed into the audit of the service which ultimately led to changes to the phlebotomy services. One very simple but effective change included a list of all the phlebotomy services (including clinic times) on one page being compiled which GPs could promote with their patients and be available online. This gave patients more choice and flexibility of where they could visit. Review and transformation of services which support child and adolescent mental health (CAMHS) As part of the ongoing review and reform, we have worked with our partners (Trafford Council, Pennine Care NHS Foundation Trust and Healthwatch Trafford) to gain further insight. A number of engagement activities were undertaken, including: Stakeholder feedback event to outline: the transformational changes that have occurred in children s mental health services in Trafford; hear the views of young people and give the opportunity to feedback on the changes and share ideas of what else needs to happen. The event was attended by over 100 people including teachers, police, housing, health visitors, mental health professionals and third sector organisations. Public / Family Survey to obtain views of pubic (including young people, carers and professionals). There were 48 respondents to the survey. Professional survey to obtain views of training needs of professionals Feedback was used to help inform further developments of the service. Quality walk/around visits Visits have been undertaken to several sites where Trafford CCG commissions services for its patients. A member of our Public Reference and Advisory Panel was involved in some of these visits. Those undertaking the walkaround met staff and patients to hear of their experiences. Following the visits, reports were produced which outlined areas of good practice and those which may need further improvement, with action plans developed. More PRAP members will be trained to undertake these visits during 2017/18. Page 30

31 Healthier Together Two Patient Participation Group events have been held with Manchester and Trafford patients / organisations representing patients from certain protected characteristics. The aim was for patients to learn more about the upcoming plans, hear about pathways and assist in identifying the potential impact upon patients / carers and their families. Trafford CCG has been working in partnership with Manchester CCGs, University Hospitals of South Manchester NHS Foundation Trust and Central Manchester Hospitals Foundation Trust and Healthwatch Trafford to develop these sessions and will continue to develop further engagement sessions over the next year. 360 o stakeholder survey NHS Trafford took part in the CCG 360 o stakeholder survey which allows to provide feedback on working relationships with the CCG. This is commissioned by NHS England. The feedback received feeds into improvement and assessment conversations between NHS England and Trafford CCG. Evidence is used to assess whether stakeholder relationships continue to be central to the effective commissioning of services by the CCG and in do so, improve quality and outcomes for patients. EDS2 event See Reducing Health Inequalities section of the report. How you can have your say: Patient Participation Groups Many GP surgeries in Trafford have Patient Participation Groups. These meet in different ways (from regular meetings, updates or annual surveys). To join your GP Patient Participation Group, contact your local GP surgery. Trafford Talks Health Network Our Trafford Talks Health Network is made up of hundreds of local people who want to keep up to date with local health issues, and to have their say about the services available for people in Trafford. Anyone can join the network: it s completely free and you can sign up for as much or as little involvement as you like. Members can cancel their registration at any time. To join the network and be added to our mailing list, log onto: or contact our engagement team on , or tracy.clarke8@nhs.net and provide your details. Page 31

32 Share Your Story: A Matter of Experience If you or someone you care for has had a good or poor experience of NHS care in Trafford and you would like to share your story with us, please contact the Patient Experience Matters Team. You can customercare.trafford@nhs.net quoting Patient Story or you can telephone us, details given below. With appropriate consent we have used anonymised patient stories in our Matter of Experience newsletter which is circulated to our staff, stakeholders and within the community to provide an insight into how patient / carer feedback can influence service change. Comments, Compliments, Concerns or Complaints Trafford CCG welcomes suggestions, queries, comments, compliments, concerns or complaints. Telling us what you think about your experience is important and helps us to improve what we do and share good practice where we do things well. We are committed in Trafford to improving patients / carers experiences and always aim, and also expect our providers to deliver a high quality service. To contact the Patient Experience Matters Team call (text relay then ) or customercare.trafford@nhs.net Reducing Health Inequalities The CCG is working proactively towards meeting its requirements to show due regard under the Public Sector Equality Duty (PSED) as defined by the Equality Act 2010 and reporting on its progress in this area. Trafford CCG has to show that they are considering the needs of protected Characteristic groups throughout their functions as a CCG. These include: Commissioning processes Consultation and engagement Procurement functions Contract specifications Quality contract and performance schedules Governance systems We will continue to work internally, and in partnership with our providers, community and voluntary sector and other key organisations, to ensure that we advance equality of opportunity and meet the requirements of the Equality Act. Page 32

33 We engage with local groups to identify any adverse impacts upon those groups from the key changes in healthcare that CCG are considering and to consider mitigation on any feedback received. Engagement with patients, families, carers and stakeholder groups, helps the CCG to shape fair, accessible services that take account of individual needs. It is a key challenge across all CCGs to identify and address health inequalities, specifically for local protected characteristic groups and Inclusion Health groups. The local Joint Strategic Needs Assessment (JSNA) represents a summary of detailed work that has been undertaken. It is underpinned by a core data set defined in statutory guidance, and by needs assessments which have been undertaken in relation to various client groups and localities. Our use of the JSNA and other key intelligence sources will continually inform our planning, our priority setting and our commissioning. Through the adoption and implementation of the NHS Equality Delivery system (EDS2) the CCG aims to demonstrate to the people we serve how we are delivering on our Public Sector Equality Duty. This covers the following protected characteristics: Age (including children and young people) Disability Gender re-assignment Marriage and civil partnership Pregnancy and maternity Race including nationality and ethnic origin Religion or belief Sex Sexual orientation EDS2 can also be readily applied to people from other disadvantaged groups, including people who fall into Inclusion Health groups, who experience difficulties in accessing, and benefitting from, the NHS. These other disadvantaged groups typically include but are not restricted to: People who are homeless People who live in poverty People who are long-term unemployed People in stigmatised occupations (such as women and men involved in prostitution) People who misuse drugs Page 33

34 People with limited family or social networks People who are geographically isolated As with the protected groups, the CCG may assess and grade how well other disadvantaged groups fare compared with people overall, with a view to improving NHS performance, where there is local evidence that indicates the need to do so. For some of the above groups there are significant overlaps with people whose characteristics are protected by the Equality Act. These links are borne in mind when work on either protected or other disadvantaged groups is taken forward. Equality Objectives We are required to prepare and publish Equality Objectives to meet our Specific Duty as outlined in the Equality Act. Our plan is specific and measurable, and is updated on an annual basis. The CCG understands that at some times in our lives we may face barriers in relation to accessing health services or experience different outcomes. The CCG wants to reduce the health differences across our diverse communities and our Equality Objectives will support us to do this. Our Equality Objectives are to: Objective 1: Embed equality, diversity and human rights considerations into our commissioning decisions and the culture of Trafford CCG. Objective 2: Ensure senior leadership is fully understanding of equality, diversity and human rights and effective in ensuring awareness and delivery of the EDHR agenda across Trafford CCG and its membership practices. Objective 3: Ensure that health inequalities as they affect protected groups are measurably reduced. Good practice on Equality Diversity and Human Rights across Trafford CCG in 2016 Following GP awareness raising on Mental health issues in 2015, the CCG has made a 28 minute film with a service user-which discussed her experience of mental health services and highlights factors of access and information sharing Review of Wet Age Related Macular Degeneration (WAMD) service Review of Child and Adolescent Mental Health Services (CAMHS) Workshop and review of Palliative Care and End of Life review Development of the local community learning disability team service specification which includes a new selfassessment framework. Page 34

35 Involvement of people with learning disabilities and their families in the design and review of local health and social care services. This includes support, for example, to take part in Patient and Carer Engagement Forums and to use of services such as Patient Advice and Liaison Services. Capturing patient experience when measuring the impact of a service that is new or has been re-designed. E.g.: Respiratory condition Chronic Obstructive Pulmonary Disease (COPD) (adults aged 17 and over), stroke survivors and their carers, and GP practices carrying out their own ECGs on site. Assessing and monitoring the NHS Equality Delivery System (EDS2) The EDS2 process generates evidence of the CCG s compliance with the PSED and this evidence is then reviewed by local people and stakeholders against the goals. EDS2 provides the local stakeholder group representatives and the CCG Governing Body with an assurance mechanism for compliance with the Equality Act 2010 and links our equality objectives with users of services, to ensure improvements in patient experience. The four EDS2 goals are: 1. Better health outcomes for all 2. Improved patient access and experience 3. Empowered, engaged and included staff 4. Inclusive leadership at all levels A grading event to assess the CCG s performance was undertaken in October 2016.The focus of the event was Goal 1 Better Health Outcomes. Representatives from protected groups were invited to assess the evidence provided by the CCG. The EDS2 findings identified a range of actions for CCGs Equality Objective Plan and fair EDS 2 grading. This process also informed the preparation of our EDS2 Summary Submission to NHS England for 2016/17, which explains some of our processes. Provider performance All our key NHS providers have undertaken the EDS2 assessment and have set equality objectives in accordance with their requirements. We are working closely with our providers to improve equality performance and access and outcomes for protected groups through robust contract monitoring, via the quality contract schedule. Page 35

36 All our commissioned NHS Providers have to undertake a number of actions which are part of the monitored Quality contract schedule. This includes: Equality Diversity and Human Rights governance structure, engagement with stakeholder groups, staff surveys, Workforce Race Equality Scheme report, EDS2, Equality Impact Analysis on any changes which are being undertaken, annual report, data collection and human rights analysis. With smaller providers the plan is to identify and spot check a percentage of these organisations each year and implement SMART action plans where necessary. This will be a risk based framework based on contract value and activity. Achievements in 2016/17 Workforce: The CCG has commissioned Midlands and Lancashire Commissioning Support Unit s (CSU) Human Resources and Equality and Inclusion Team who support the CCG in ensuring that it has in place fair and equitable employment and recruitment practices in place. The CCG aims to fully understand the diversity of the workforce to ensure non-discriminatory practice, working with staff and staff representatives to identify and eliminate barriers and discrimination in line with the Public Sector Equality Duty, Equality Act 2010 and the Employment Statutory Code of Practice. The CCG has a small workforce and as such is not required under the Specific Equality Duty to publish its workforce data, however the CCG reviews its data on a quarterly basis through the Quality and Performance committee and promotes transparency in all of its work aims to carry out regular reviews and analysis of the workforce profile in line with best practice. Training: Staff working within the CCG undertake annual equality and diversity training. The training is designed as an introduction to diversity and cultural awareness, and as a practical guide to making organisational culture an inclusive one. Staff training uptake is monitored by Electronic Staff Records. Equality and Diversity Training is mandatory for all CCG employees every three years. Programme / Commissioning leads within the CCG who are responsible for transforming health services have received one to one coaching on undertaking Equality Impact and Risk Assessments. Workforce Race Equality Standard (WRES): The WRES report sets out the CCG performance information profile and Board composition, by ethnicity, The CCG submits its WRES return to NHS England as required. Workforce Disability Equality Standard (WDES): It has been recommended that a Workforce Disability Equality Standard (WDES) should be mandated via the NHS Standard Contract in England from April 2018, with a preparatory year from NHS England has agreed to do so. The NHS Equality and Diversity Council (EDC) has also agreed to support a programme of work to support this. Page 36

37 Showing Due Regard to the Public Sector Equality Duty: In order to deliver high quality inclusive health services, the CCG aims to ensure that protected groups have the same access, experiences and outcomes as the general population. A way of achieving this is through Equality Impact and Risk Assessments; in order to support the transformational and Quality Innovation Productivity and Prevention (QIPP) programme, the CCG has adopted an Equality Impact and Risk Assessment (EIRA). This enables the CCG to show due regard to the Public Sector Equality Duty by ensuring that all requirements around equality, human rights and privacy are given advanced consideration prior to any policy decisions that the CCG s Governing Body or Senior Managers make that may be affected by these issues. CCG Commissioners continue to ensure that the EIRA is integral to the decision making process. Whilst Equality Assessments (EAs) are not a means for ensuring or delivering legal compliance, they are a receptacle for capturing all the considerations made and evidence during key activities such as: Policy development and review Budget planning and allocation Service planning, review and redesign Projects and work programmes Commissioning and procurement Next steps A large amount of work has commenced and been achieved in 2016/17, however a number of priorities have been identified in for 2017/18. To focus on areas within the EDS2 where it is developing with the aim to moving to achieving level. To develop robust mechanisms to ensure that NHS commissioned services comply with EDS2 and any non-compliance is reported and acted upon. To ensure Equality and Inclusion is embedded within the values of the CCG through the implementation of the CCG improvement plan via the new Equalities and Inclusion strategy. Further focus on embedding the process of Equality Analysis to ensure that the CCG is showing due regard to the Public Sector Equality Duty by ensuring that all requirements around equality, human rights and privacy are given advanced consideration. Develop Equalities and Inclusion champions: to support the development and embedding of EDHR work across the CCG and increase ownership of the agenda Workforce Race Equality Scheme (WRES): to further develop work around the Workforce Race Equality Scheme so highlighting improvements in race equality within the workforce as well as equality generally within the NHS. Through Page 37

38 this the CCG can demonstrate good leadership, identify concerns within their workforces, and set an example for their providers. The NHS has indicated that a Workforce Disability Equality Scheme (WDES) will be introduced in Strengthened links with stakeholders: it is advised that proactive engagement and relationship building is carried out to support the CCG in its EDHR activities and knowledge base. It is suggested that the business partner with the communications team support develop links with communities and organisations which are sometimes viewed as harder to engage. Work with GP s on awareness raising of the value of protected characteristics monitoring of patients this is an area for development for the CCG and the practices. EDHR training to focus on three areas for 2017/18: 1. Equality impact training to consist of one to one coaching, small group work and lunchtime sessions. 2. Training for the Governing Body to ensure the Governing Body are clear about their responsibilities around the EDHR agenda and will enthuse board members about championing equalities. 3. Lunchtime sessions on Equality and Inclusion delivered by local providers Health and Wellbeing Strategy The Health and Wellbeing Board is chaired by Councillor Alex Williams, Deputy Leader for Trafford Council. In 2016/17 the Board approved the Health and Social Care Locality Plan which will help develop a place based, partnership approach to health and social care in Trafford, and will encompass all aspects of wellbeing such as work and skills, housing, physical activity, and crime and offending. The CCG has contributed in collaboration with its partners into producing the Trafford Joint Health and Wellbeing Strategy as a member of the Trafford Health and Wellbeing Board. It is our overarching plan to improve the health and wellbeing of children and adults in our borough and to reduce health inequalities between the north and south of the borough. Our strategy outlines: Our vision, aims, intended outcomes and priorities Our partnership approach and guiding principles to improving health and wellbeing Our local challenges around health and wellbeing How we will respond to these challenges It is intended to be used as a working tool which concentrates on highlighting Trafford s challenges and provides vision for a coherent approach for partners involved in improving health and wellbeing across the borough and is available at Page 38

39 The Health and Wellbeing Board has revised its strategy this year and is focussing particularly on activities that will increase healthy life expectancy (HLE) in the borough, and will reduce the existing inequalities in this measure. HLE is a key summary measure of a population's health, and is an important indicator of the need for health and social care services in an area. Five objectives which will support this improvement have been agreed, these are: 1. To reduce the impact of mental illness 2. To reduce physical inactivity 3. To reduce the number of people who smoke or use tobacco 4. To reduce harms from alcohol 5. To improve early diagnosis and cancer prevention, and in particular the uptake of screening. Page 39

40 Accountability Report Corporate Governance Report Members Report The CCG has progressed well in a complex and challenging healthcare economy as it has continued to deliver the Five Year Forward View, and has developed and continues to deliver its Devolution Greater Manchester Locality Plan in partnership with Trafford Council in response to greater autonomy of the Greater Manchester region. At the outset of the year, as a membership based commissioning organisation, the CCG s mission needed to reflect the challenge the CCG with its membership had in its commissioning environment. This was agreed by its member practices at the CCG s inception in 2013/14 and remains the same: To ensure that the health services we manage for the people of Trafford are provided at the right place and at the right time, and that services are safe, of a high quality and are value for money. In addition, the Trafford Plan to 2020: Taking charge of health and social care, in partnership with the Trafford Council has its vision identified as we seek to work collaboratively in integrating health and social care in the future, as: The vision for Trafford as part of the devolution of Greater Manchester: By health and social care working together we will improve the quality, range and access to services for the people of Trafford. These visions are a central component of discussions at the Council of Members meetings. The Council of Members is a collective body that represents CCG member practices to ensure that effective clinical decision making processes are in place within the CCG. These responsibilities are delegated as appropriate to the Governing Body and its Committees. Further details in relation to the Committee Structure are provided in the Corporate Governance section of this report. Page 40

41 Member Profiles The geographical area covered by NHS Trafford Clinical Commissioning Group is fully coterminous with Trafford Metropolitan Borough Council. Providers of primary medical services within the area covered by NHS Trafford Clinical Commissioning Group who provide essential primary medical services to registered patients during core hours are its eligible members of the group. Member practices The group consists of 32 member practices that comprise NHS Trafford Clinical Commissioning Group as at 31 March 2017 as follows: Practice Name Altrincham Medical Practice Barrington Medical Centre Bodmin Road Health Centre Boundary House Medical Centre Brooks Bar Medical Centre Conway Road Health Centre Davyhulme Medical Centre Firsway Health Centre Flixton Road Medical Centre Gloucester House Medical Centre Gorse Hill Medical Centre Grove Medical Practice Lostock Medical Centre & Pharmacy North Trafford Group Practice Address Lloyd House, 7 Lloyd Street, Altrincham, Cheshire,WA14 2DD 68 Barrington Road, Altrincham, Cheshire, WA14 1JB Bodmin Road, Ashton-On-Mersey, Sale, Cheshire,M33 5JH 462 Northenden Road, Sale, Cheshire, M33 2RH Chorlton Road, Old Trafford, Manchester,M16 7WW 80A Conway Road, Sale, Cheshire, M33 2TB 130 Broadway, Davyhulme, Urmston, Manchester,M41 7WJ 121 Firsway, Sale, Cheshire, M33 4BR 132 Flixton Road, Urmston, Manchester, M41 5BG 17 Station Road, Urmston, Manchester, M41 9JS 879 Chester Road, Stretford, Manchester, M32 0RN Timperley Health Centre, 169 Grove Lane, Timperley, Altrincham, Cheshire, WA15 6PH 431 Barton Road, Stretford, Manchester, M32 9PA Chester Road, Stretford, Manchester, M32 0PA Page 41

42 Old Trafford Medical Practice Park Medical Practice Partington Central Surgery Partington Family Practice Primrose Surgery Riddings Family Health Centre Shay Lane Medical Centre (Kelman) Shay Lane Medical Centre (Patel) St. Johns Medical Centre The Delamere Medical Practice The Family Surgery The Surgery The Village Surgery The Urmston Group Practice Timperley Health Centre (Westwood) Trafford Health Centre Washway Road Medical Centre West Timperley Medical Centre Seymour Grove Health Centre, 70 Seymour Grove, Old Trafford, Manchester, M16 0LW 119 Park Road, Timperley, Altrincham, Cheshire, WA15 6QQ Partington Health Centre, Central Road, Partington, Manchester, M31 4FY Partington Health Centre, Central Road, Partington, Manchester, M31 4FY 59, Old Crofts Bank Road, Urmston, Manchester M41 7AB 34 Riddings Road, Timperley, Altrincham, Cheshire, WA15 6BP Shay Lane, Hale, Altrincham, Cheshire, WA15 8NZ Shay Lane, Hale, Altrincham, Cheshire, WA15 8NZ St. Johns Road, Altrincham, WA14 2NW Delamere Avenue, Stretford, Manchester, M32 0DF 94 Navigation Road, Altrincham, Cheshire, WA14 1LL 12 Derbyshire Road South, Sale, Cheshire, M33 3JP Timperley Health Centre, 169 Grove Lane, Timperley, Altrincham, Cheshire, WA15 6PH Woodsend Crescent Road, Urmston, Manchester M41 8AA 169 Grove Lane, Timperley, Altrincham, Cheshire, WA15 6PH Trafford General Hospital, Moorside Road, Davyhulme, Manchester, M41 5SL 67 Washway Road, Sale, Cheshire, M33 7SS 21 Dawson Road, Altrincham, WA14 5PF Page 42

43 Composition of the Governing Body Mr Matthew Colledge, Chair: Matthew lives in Trafford with his wife and young children. He has previously served as leader of Trafford Council, Vice Chair of Greater Manchester Combined Authority, Chair of Trafford Partnership and has been a board member of Trafford Housing Trust. Alongside his work with Trafford CCG, Matthew sits on the board of Trafford Leisure and also provides strategic insight about the devolution of powers to city regions. He is also a governor of Wellington School in Timperley. As a local resident he passionately believes that everyone in Trafford has the right to the best health and social care provision. He recognises that Trafford CCG is uniquely positioned to help make our borough a healthy and happy place to live, work and relax for all residents. Dr Nigel Guest, Chief Clinical Officer: Nigel studied in Liverpool and has been a GP since He was previously involved with fund holding and subsequently Total Purchasing Piloting in Ellesmere Port before moving to a Trafford practice in Since 1999 he has been involved in Trafford's health economy occupying various roles, including chair of Trafford South PBC, co-chair of NHS Trafford's Professional Executive Committee, chair of Trafford Commissioning Consortium, and subsequently as Chief Clinical Officer for Trafford CCG. He works as a GP at Park Medical Centre in Timperley. Accountable Officer until 1 November Dr Michael Gregory, Clinical Director for Strategy & Policy (member until 30 May): Michael has been a GP in Altrincham for 19 years, and is a partner at West Timperley Medical Centre. He is a member director of the AQuA board, and the Trafford Nominated Governor to CMFT. He is also an AQuA Affiliate and over the last year was an AQuA Integration Fellow. Previously, he has been involved with the Local Medical Committee and was one of the first GPs to become involved with the formation of practice based commissioning in Trafford. He went on to become the prescribing lead for Trafford South Commissioning. He was medical director of Trafford Provider Services between 2008 and 2012, and he joined Trafford PCT as associate medical director before becoming a clinical director. Page 43

44 Dr Mark Jarvis, Clinical Director for Quality & Performance: Mark has been a GP partner at Washway Road Medical Centre in Sale since He was on the executive of Trafford South Primary Care Trust until 2003, and joined the Local Medical Committee in 2007, where he learned about the need to develop integrated care. He then joined Trafford Primary Care Trust as the Associate Medical Director in 2010, before progressing to Trafford Clinical Commissioning Group. Audit Committee member. Chair of Quality and Performance Committee and Executive Lead for Safeguarding. Dr Liz Clarke, GP Member: Liz is a Trafford resident and has worked as a GP in Trafford since 2001 (10 years in Sale, one year in Urmston). She was a board member of the Trafford Commissioning Consortium until January 2010, and represented primary care on the board of Trafford Healthcare NHS Trust. Liz has a particular interest in mental health and currently works on the integration mental health panel (alongside service users) where the focus is dementia care. She has been involved in commissioning alcohol services and in clinical input to the Alcohol LES. She is an active supporter of Trafford Carers. Dr Ann Harrison, GP Member: Ann has been a GP in North Trafford since She became a member of Trafford Clinical Commissioning Group, having previously been on the Trafford North PBC Board and a member of Trafford Primary Care Trust Clinical Executive Committee. She has an interest in medicines management and cancer care. Page 44

45 Ms Sam Sherrington, Governing Body Nurse Member: Sam is an experienced registered nurse and leader within the NHS and is a CEO of her own business. Most recently Sam spent over 3 years in the national team for NHS England, leading on nursing, midwifery, care and finance portfolios. Sam holds a clinical masters degree and a post graduate diploma in leadership and management. Sam is a member of the Exec for National Association for Primary Care, Chair of UK Association for Prescribers, founding Director of Health Education Cooperative. Her interests include leadership, transformation and delivering outstanding care for patients, families and communities. Sam is a member of Quality and Performance Committee, Audit Committee, Renumeration Committee, Primary Care Commissioning Committee and Clinical Directors providing scrutiny and oversight to the CCG on the strategic developments for the people of Trafford. Dr Priscilla Nkwenti, Vice Chair and Lay Member for Patient and Public Engagement: Priscilla is the Chief Executive of BHA for Equality - a leading health and social care charity, addressing inequalities and championing human rights in health and well-being. Priscilla is the Vice Chair of the Governing Body; Chair of the Remuneration Committee and the Public Reference and Advisory Panel; Lay Lead for Patient and Public Involvement; a member of the Primary Care Commissioning Committee and also of the Clinical Commissioning and Finance Committee. Mr Alan Foster, Lay Member for Audit, Finance and Governance: Alan holds a Master s Degree in Business Administration. After an early career in finance and corporate planning, he moved to the chemicals division of British Aluminium (later British Alcan) in various commercial roles, spending the last fifteen years of his career as managing director of the international zirconium chemicals business. He was a non-executive director of NHS Northwest from 2006 to 2013 and is a director of Bright Futures Education Trust. Alan is the chair of the Trafford Clinical Commissioning Group Audit Committee, a member of the Remuneration Committee. Clinical Commissioning and Finance Committee, along with the Primary Care Commissioning Committee. Page 45

46 Mr Jim Liggett, Lay Member for Partnerships & Integration: Jim has recently completed a policing career, having held a senior leadership position in a number of areas across Greater Manchester. He has been an active member of a wide range of statutory boards throughout his career and has experience of forging strong and effective working relationships across a broad spectrum of partnership agencies. Jim joined the Governing Body in January 2017 as Lay Member for Partnerships and Integration, and is also a member of Primary Care Commissioning Committee. Ms Gina Lawrence, Chief Operating Officer and Director of Commissioning: Gina started in the NHS working as a nurse for both children and adults. Having worked across the acute sector, including as a specialist in stroke care, she then moved to Manchester Primary Care Trust to work as a commissioner. Following this, Gina moved to Trafford Primary Care Trust, and has been the Director of Commissioning both for the primary care trust and subsequently Trafford Clinical Commissioning Group for the past four years. She was the Chief Operating Officer for Trafford CCG and Accountable Officer from 1 November until 31 March Mr Joe McGuigan, Chief Finance Officer: Joe has been working in the NHS since 1983, and has been a Trafford resident since He joined Trafford South Primary Care Trust in 2001 as Head of Finance, before becoming Deputy Director of Finance for Trafford Primary Care Trust in Joe was appointed to the role of Chief Finance Officer for Trafford Clinical Commissioning Group in May 2015, after successfully leading the finances within the organisation as the Interim Chief Finance Officer from September He recognises and welcomes this opportunity as part of the CCG leadership team, at such an important time of change in Trafford that strong financial leadership is required to ensure Trafford CCG will use its money wisely to deliver the best health care for our people. Page 46

47 Catherine Randall, Chief Nurse: Catherine holds the positions of Chief Nurse / Director of Nursing for Trafford CCG and a Governing Body member. Catherine has executive responsibility for Safeguarding, Continuous Health Care, SEND Lead, Personal Health Budgets, Mental Health and Patient Engagement. She also leads the Professional Nursing agenda and fulfils the role of Caldicott Guardian for the CCG. Catherine is also the Senior Responsible Officer for the Care Complex work stream of the Trafford Transformation programme. Catherine is a Registered Nurse, Midwife, Family Planning Nurse, Health Visitor and Nye Bevan Graduate. She has held the post of Chief Nurse for Trafford CCG since February Her special interests include Management, Leadership, Whole System transformation and Mentoring. As an Executive Nurse on the Governing Body, Catherine will bring a broader view, from her perspective as a registered nurse, on health and care issues to underpin the work of the CCG especially the contribution of nursing and compassionate patient. Chris Tower, Council of GP Members Chair: Chris is a Trafford resident & has been a GP at Davyhulme Medical Centre since He chairs the CCG s Council of Members, and is interested in Unscheduled Care, the 111 service and is the named GP for Child Safeguarding. Cameron Ward, Interim Accountable Officer: Cameron is an independent management consultant providing support to the public and independent sector. He has been Interim Accountable Officer since 2 May Cameron has over 25 years of experience in the NHS in a variety of senior leadership positions in various areas of the NHS including hospitals, commissioning organisations and health authorities. His most recent position was Area Director in NHS England ending in January He is passionate about many aspects of working life including staff and stakeholder engagement, supporting staff development and empowerment with a focus on culture and behaviours. Page 47

48 Cameron lives in the north east of England and resides in Trafford during the working week, he is married to Sharon a community midwife with two grown-up children. Governing Body Vacancies: Secondary Care Doctor There are also a number of representatives who were invited to attend the Governing Body in a non-voting / advisory capacity as listed below: Health and Wellbeing Board representative Children and Young People Service representative, Trafford Council Local Medical Committee representative Healthwatch representative Public Health Representative, Trafford Metropolitan Council Committee(s), including Audit Committee For information on the CCG s Committees see the Governance Statement section of the report. Register of Interests Governing Body Members are required to declare interests and conflicts in line with Section 14O of the National Health Service Act 2006 (as amended) and Section 8 of the CCG s Constitution Further guidance is available on the nature of interests to be declared in detail as part of the CCG s Constitution and Conflicts of Interest Policy Document. A copy of the Governing Body Register of interests is included at Personal data related incidents The CCG complies with the Information Governance Toolkit as set by the Health and Social Care Information Centre (HSCIC), and is required to submit a comprehensive self-assessment submission by 31 st March each year. There have been no instances of Personal Data reportable incidents during 2016/17. Page 48

49 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 Trafford CCG fully supports the Government s objectives to eradicate modern slavery and human trafficking but does not met the requirements for producing an annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act Cameron Ward Accountable Officer NHS Trafford Clinical Commissioning Group 30 May 2017 Page 49

50 Statement of Accountable Officer s Responsibilities The National Health Service Act 2006 (as amended) states that each Clinical Commissioning Group shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed the Chief Clinical Officer (1 April 31 October) and Chief Operating Officer (1 November 31 March) to be the Accountable Officer of NHS Trafford 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. 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: Page 50

51 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. Cameron Ward Accountable Officer NHS Trafford Clinical Commissioning Group 30 May 2017 Page 51

52 Governance Statement Introduction and context Trafford 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 The geographical area covered by NHS Trafford Clinical Commissioning Group is made up of 138 Lower Super Output Areas (LSOA) with a population of 236,568 of which 221,654 are registered with its CCG s practices. The total registered population of the CCG practices is 233,143. The geographical area covered by NHS Trafford Clinical Commissioning Group is fully coterminous with Trafford Metropolitan Borough Council. Scope of responsibility As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the clinical commissioning group s policies, aims and objectives, whilst safeguarding the public funds and assets for which I am personally responsible, in accordance with the responsibilities assigned to me in Managing Public Money. I also acknowledge my responsibilities as set out under the National Health Service Act 2006 (as amended) and in my Clinical Commissioning Group Accountable Officer Appointment Letter. I am responsible for ensuring that the clinical commissioning group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. I also have responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group as set out in this governance statement. Governance arrangements and effectiveness The main function of the governing body is to ensure that the group has made appropriate arrangements for ensuring that it exercises its functions effectively, efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it. The Council of Members decides on agreement of the vision, values and overall strategic direction of the Group and on the matters that amend the Group s constitution, including terms of reference for the Governing Body it s committees, the membership of those committees, the overarching scheme of reservation and delegation and the standing orders and prime financial policies. Page 52

53 The Council of Members approves the arrangements for the identifying the proposed Accountable Officer and the process for appointing of Governing Body members. The membership of the Governing Body comprises the following voting members, with their attendance over 2016/17: Governing Body Voting Members Summary Attendance Chair 11 of 12 Representative of member practice 1 9 of 12 Representative of member practice 2 10 of 12 Clinical Director of Quality & Performance 9 of 12 Clinical Director of Strategy & Policy (left post May 2016, position not 2 of 2 replaced) Lay Member - Audit, Governance & Finance 12 of 12 Lay Member - Patient and Public Participation 10 of 12 Governing Body Nurse 9 of 12 Chief Clinical Officer (Accountable Officer until October 2016) 12 of 12 Chief Finance Officer 10 of 12 Chief Operating Officer (Accountable Officer from October 2016) 10 of 12 Chief Nurse 4 of 6 Lay Member for Partnerships & Integration 3 of 3 Council of Members Chair 5 of 6 The Governing Body may determine any matter for which it has been given delegated authority and at a high-level determines the Group s operating structure and its commissioning plans, with the Council of Members reserving the approval of the Group s operational scheme of delegation. The Governing Body has the approval to discharge the Group s statutory financial duties, approval of and variations to its annual budgets, approving arrangement for securing continuous improvement to quality of patient services and its overarching approval of the Group s risk management arrangements including clinical, quality, financial, information governance, and business continuity risks. The Governing Body is also responsible for the overarching comprehensive system of internal control, and receiving the annual letter from the External Auditors. The governing body has appointed the following committees and sub-committees: Audit Committee - the Audit Committee, which is accountable to the CCG s Governing Body, provides the Governing Body with an independent and objective view of the CCG s financial systems, financial information and compliance with laws, regulations and directions governing the CCG in so far as they relate to finance. The Governing Body has approved and keeps under review the terms of reference for the Audit Committee, which includes information on the membership of the Audit Committee. In addition the Governing Body has conferred or delegated the following functions, connected with the Governing Body s main function, to its audit committee: i) Probity of procurement decisions and processes; and, ii) Oversight of risk management processes Page 53

54 Membership and attendance of the Audit Committee over 2016/17 is as follows: Audit Committee Members Summary Attendance Lay Member for Audit, Finance and Governance (Chair) 5 of 5 Clinical Director for Quality Finance and Performance 5 of 5 Clinical Director for Policy and Strategy (left post May 2016) 1 of 1 Lay Member for Patient and Public Involvement* N/A Governing Body Nurse 5 of 5 *Agreed as an Associate Member during 2016/17. The key highlights and achievements from the Audit Committee include: Internal Audit Plan delivered with all associated reports provided for Committee assurance; Conflicts of Interest implementation of new guidance; Role in appraising external audit for the awarding of a new contract to conduct external audit services for the CCG, as part of a Greater Manchester review; and, Challenging and ensuring robust systems to manage risk is embedded across the CCG Remuneration Committee - the Remuneration Committee, which is accountable to the Governing Body, makes recommendations to the Governing Body on determinations about the remuneration, fees and other allowances for employees and for people who provide services to the CCG and on determinations about allowances under any pension scheme that the group may establish as an alternative to the NHS pension scheme. The Governing Body has approved and keeps under review the terms of reference information about any committees, sub-committees and joint committees established by the clinical commissioning group constitution, including membership, attendance records and coverage of its work (terms of reference) for the Remuneration Committee, which includes information on the membership of the Remuneration Committee. Membership and attendance of the Remuneration Committee over 2016/17 is as follows: Remuneration Committee Members Summary Attendance Lay Member for Patient and Public Involvement (Chair) 2 of 2 Lay Member for Finance, Audit and Governance 2 of 2 Governing Body Nurse 2 of 2 GP Member 2 of 2 Governing Body Chair 2 of 2 The key highlights and achievements from the Remuneration Committee include: Overseeing the interim arrangements for the change in accountable officer arrangements Ensuring the CCG has adequate arrangements in place moving forward for its leadership in delivering the integrated agenda Clinical Commissioning and Finance Committee - the Clinical Commissioning and Finance Committee is accountable to the CCG s Governing Body for the commissioning of Page 54

55 services, in line with the strategic, operational and financial plans of the group. The Governing Body has approved and keeps under review the terms of reference for the Clinical Commissioning and Finance Committee, which includes information on the membership of the committee. The Governing Body has conferred or delegated the following functions, connected with the Governing Body s main function, to its Clinical Commissioning and Finance Committee: i) To be the accountable body for the CCG responsible for design in delivery of the Strategic, Operational and Financial plans; ii) To develop and oversee the necessary programmes of commissioning and/or programme arrangements as outlined in the ratified Strategic and Operational Plans; iii) To ensure the delivery of the financial strategy including QIPP schemes across the CCG aligned to the Strategic and Operational Plan; iv) To ensure robust clinical oversight in the design of commissioning schemes; v) To ensure robust review and compliance with the Strategic Plan Policy in approving Business Cases/Project Initiation Documents (PID) for commissioning schemes in line with the Strategic, Operational and Financial plans; and vi) To ensure the review and approval of Commissioning Schemes in compliance with the Standard Financial Instructions ratified by the Governing Body. Membership and attendance of the Clinical Commissioning and Finance Committee over 2016/17 is as follows: Clinical Commissioning and Finance Committee Members Summary Attendance Chair - Chief Clinical Officer (until October 2016) 5 of 6 Vice Chair - Chief Operating Officer (Chair as Accountable Officer 5 of 6 from October 2016) Chief Financial Officer (including representative) 6 of 6 Clinical Director for Strategy and Policy (including representative) 1 of 1 GP Governing Body Representative 5 of 6 Lay Member for Audit, Finance and Governance 5 of 6 Lay Member for Public and Patient Participation 3 of 6 Associate Director for Commissioning 1 of 3 Deputy Chief Finance Officer 3 of 3 Associate Director for Quality and Performance (including representative) 5 of 6 The key highlights and achievements from the Clinical Commissioning and Finance Committee include: Trafford Co-ordination Centre benefits realisation challenged, focused and being delivered as a key part of CCG strategy Financial plans (including in-year revised recovery plans) achieved in delivering overall savings targets Medicines Management work programme, Resource Allocation Panel and Effective Use of Resources policy adherence Page 55

56 Quality and Performance Committee - the Quality and Performance Committee is accountable to the Governing Body for monitoring the quality and performance of service providers from which the CCG commissions services and initiating performance interventions. The Governing Body has approved and keeps under review the terms of reference for the Quality and Performance Committee, which includes information on the membership of the committee. The Governing Body has conferred or delegated the following functions, connected with the Governing Body s main function, to its Quality and Performance Committee: i) To be the accountable body for the CCG responsible for assurance of the implementation of the Strategic and Operational Plans in achieving the Governing Body objectives of the CCG; ii) Oversee, assess and evaluate the implementation of necessary programmes of commissioning and / or programme arrangements as outlined in the Governing Body ratified Strategic Plan; iii) To ensure robust monitoring of quality of service in commissioned services; iv) To ensure robust monitoring of performance of commissioned services; and, v) To ensure robust monitoring of clinical governance and best practice in commissioned providers. Membership and attendance of the Quality and Performance Committee over 2016/17 is as follows: Quality and Performance Committee Members Summary Attendance Chair - Clinical Director for Quality and Performance 5 of 6 Vice Chair - Chief Operating Officer 5 of 6 Chief Clinical Officer (as Accountable Officer until October 2016) 2 of 6 Clinical Director for Strategy and Policy (left post May 2016) 2 of 6 GP Governing Body Representative 6 of 6 Chief Nurse 6 of 6 Governing Body Nurse 6 of 6 Associate Director for Corporate Services and OD (left post November 2016) 2 of 3 Associate Director for Commissioning (left post November 2016) 3 of 3 Associate Director for Performance and Quality (including representative) 6 of 6 Deputy Director of Finance 0 of 1 The key highlights and achievements from the Quality and Performance Committee include: Quality and performance data risk assessed across all providers and scrutiny provided where the greatest risk resides, with oversight of further providers on an ongoing basis as and when required Mental Health services monitored and improved with the national scorecard resulting in increased quality of services by Greater Manchester West Foundation Trust for example Full Safeguarding requirements and responsibilities fulfilled in holding providers to account Page 56

57 Senior Management Team Committee - the Senior Management Team Committee is accountable to the CCG s Governing Body for developing the Strategic, Operational and Financial plans of the CCG, ensure compliance with statutory duties of the CCG and being responsible for day to day operations. The Governing Body has approved and keeps under review the terms of reference for the Senior Management Team, which includes information on the membership of the committee. The Governing Body has conferred or delegated the following functions, connected with the governing body s main function, to its Senior Management Team: i) To be the accountable body for the CCG responsible for overall day to day operations; ii) To develop the operational and strategic plan based on the CCG s strategy and vision, subsequently devolving directorate / team objectives and ensure management of their overall performance; and, iii) To ensure compliance with statutory duties of the CCG in compliance with the National Health Service (Clinical Commissioning Groups) regulations (2012 No. 1631) Membership and attendance of the Senior Management Team Committee over 2016/17 is as follows: Senior Management Team Committee Members Summary Attendance Chair - Chief Clinical Officer (Accountable Officer until October 2016) 15 of 15 Vice Chair - Chief Operating Officer (Accountable Officer & Chair from October 2016) 13 of 15 Chief Financial Officer 12 of 15 Clinical Director for Quality and Performance 10 of 15 Clinical Director for Strategy and Policy (left post May 2016) 2 of 5 Associate Director for Commissioning (left post November 2016) 7 of 12 Associate Director for Corporate Services and OD (left post November 2016) 8 of 12 Associate Director for Quality and Performance 8 of 12 Deputy Chief Finance Officer 13 of 15 Chief Nurse 5 of 11 Head of Governance, Planning and Risk 2 of 3 Associate Director of Transformation 2 of 3 Associate Director of Primary Care 3 of 3 The key highlights and achievements from the Senior Management Team Committee include: Adherence to all statutory duties Trafford Co-ordination Centre further developed across the CCG, with patients currently registered generating referral savings Enacting the CCG s financial plan and revised plan across the year as agreed by the Governing Body Delivering the challenge of the Board Assurance Framework to risk owners and aligning the corporate risk register with the gaps in control of strategic risks. Page 57

58 Public Reference and Advisory Panel - the Committee is established to represent the views of the Trafford population in respect of clinical and commissioning decisions, policy and performance. The Governing Body has approved and keeps under review the terms of reference for the Public Reference and Advisory Panel, which includes information on the membership of the committee. The Governing Body has authorised the Public Reference and Advisory Panel to provide a view of the Trafford public and its representative groups on the following: i) Clinical Policy; ii) Clinical Redesign; iii) Clinical Commissioning iv) Prioritisation; v) Performance; vi) Public Engagement; and, vii) Culture and Values Membership and attendance of the Public Reference and Advisory Panel over 2016/17 is as follows: Public Reference and Advisory Panel Members Summary Attendance Lay Board Member for Public and Patient Participation (Chair) 10 of 11 Neighbourhood Participation Group Representative (North) 9 of 11 Neighbourhood Participation Group Representative (West) 3 of 11 Neighbourhood Participation Group Representative (South) 10 of 11 Neighbourhood Participation Group Representative (Central) 1 of 5 Third Sector Organisation Representative (Age UK) 5 of 11 Third Sector Organisation Representative (Counselling and Family Centre) 9 of 11 Third Sector Organisation Representative (Voice of BME, Trafford) 8 of 11 Third Sector Organisation Representative (42 nd Street) 0 of 11 Public Representative (North) 6 of 11 Public Representative (West) 10 of 11 Public Representative (South) 5 of 11 Public Representative (Central) 7 of 11 Healthwatch Representative 10 of 11 Third Sector Representative (Phoenix Futures) 3 of 11 The key highlights and achievements from the Public Reference and Advisory Panel include: Trafford Co-ordination Centre involvement and comments incorporated by the PRAP in delivery in patient information leaflet with greater detail on public impact Medicines Management strategy implemented in engagement with the PRAP and comments subsequently incorporated Dermatology services delivered differently following PRAP comments of engagement following review of business case Page 58

59 North sector developments in challenging delivery over the area Measuring value of the PRAP overall The CCG in late 2015/16 applied for full delegated commissioning arrangements and was successful in its application for commissioning arrangements for Primary Medical Services with NHS England. Subsequently, a Committee of the Group was established, the Primary Care Commissioning Committee with the primary purpose of commissioning primary medical services for the people of Trafford. The Group and NHS England have authorised the Committee with the following activities; GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing breach/remedial notices, and removing a contract); Newly designed enhanced services ( Local Enhanced Services and Directed Enhanced Services ); Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF); Decision making on whether to establish new GP practices in an area; Approving practice mergers; and Making decisions on discretionary payment (e.g., returner/retainer schemes). Membership and attendance of the Primary Care Commissioning Committee over 2016/17 is as follows: Primary Care Commissioning Committee Voting Members Summary Attendance Primary Care Lay Member (Chair) 5 of 6 Chief Clinical Officer 6 of 6 Chief Operating Officer 4 of 6 Chief Finance Officer 5 of 6 Clinical Director for Quality and Performance 5 of 6 Greater Manchester Health & Social Care Representative 6 of 6 Governing Body Nurse 4 of 6 Lay Member for Governance, Audit and Finance 5 of 6 Lay Member for Public and Patient Participation 6 of 6 Associate Director of Commissioning (left post November 2016) 2 of 3 Associate Director of Corporate Services and OD (left post November 2016) 1 of 3 Associate Director of Primary Care 3 of 3 The key highlights and achievements from the Primary Care Commissioning Committee include: New Models of Care initiation and reporting of progress in delivering across Trafford in the future Responses and oversight of stability and issues of primary care practice quality e.g. CQC inspections and supporting delivery of subsequent requirements Working with GP provider organisations in delivering key services e.g. 7 day access Page 59

60 UK Corporate Governance Code NHS Bodies are not required to comply with the UK Code of Corporate Governance. Whilst the detailed provisions of the UK Corporate Governance Code are not mandatory for public sector bodies, compliance is considered to be good practice. This Governance Statement is intended to demonstrate the clinical commissioning group s compliance with the principles set out in Code. For the financial year ended 31 March 2017, and up to the date of signing this statement, 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 In light of recommendations of the 1983 Harris Review, the clinical commissioning group has 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. Risk Management Arrangements and Effectiveness The overall process for managing risk designed for the CCG ensures that risk is managed effectively across the organisation by using a defined risk management framework in risk governance, risk assessment, risk quantification, monitoring and reporting and risk and control optimisation: Risk Governance - The CCG has a clear Governing Body approved risk strategy as a vision for managing risk across the organisation and with external stakeholders, and a clear methodology for managing risk, its Governing Body approved risk policy. This provides an overall risk management approach for embedding across the organisation. Risk Assessment - Identifying, analysing and evaluating risk across the organisation embedded in organisation activities. Assessment is provided throughout the commissioning cycle with clear risk accountabilities in place. Emphasis is placed on those areas of risk with low tolerance of the CCG s appetite (those areas that the CCG Governing Body assess as risk-averse), for example Quality and Finance. Risk Quantification - The measurement in terms of consistent risk appetite (maximum risk rating accepted for each identified risk) based upon likelihood and impact descriptors. Risk interdependency in rating risks collectively, impacting commissioning activities across different categories of risk are considered, with a complete risk profile managed throughout the organisation structure. Page 60

61 Monitoring and Reporting - Risk is captured, managed and reported via the Board Assurance Framework (for strategic risk) and Directorate/Corporate Risk Register (operational risk). Both registers work together to report risk effectively across the CCG. Risk reviews are frequently conducted and reported via the BAF to the Governing Body and throughout its committee structure. The Audit Committee reviews the risk management process to provide the Governing Body with assurance on the effectiveness of its risk management processes. Risk and Control Optimisation - Risk information is fed into the commissioning cycle to improve performance of future commissioning plans and develop new ways of working based on the management of risk. Risk analysis is used to review controls in operation and provide assurance on the management of risk overall, based on appetites of risk by category e.g. quality, clinical, performance, financial, information, patient experience and reputation. These are all reported throughout the risk framework and form a balanced risk profile of the CCG. Reviews of ongoing identified risk assure a process of continued development of the embedding of risk management in the organisation. The CCG recognises that incidents can occur and as such an incident reporting culture has been developed through an Incident Management Policy being approved by the Quality and Performance Committee, in delegation from the Governing Body. Incidents are reported, trends developed where applicable and learning shared. In defining appetite of risk further to the above as specific areas of low-appetite risk, the CCG manages: Information risk - via a specific policy, which as part of the Information Governance Toolkit, embeds information risk management in the organisation. The CCG has a specific Information Governance Management Group (IGMG) providing assurance to the Senior Management Team on the management of information risk. No serious untoward incidents regarding information have been raised during the reporting period. Anti-Fraud - via an Anti-Fraud, Bribery and Corruption Policy which provides the Governing Body with assurance of the management of fraud risk via the Audit Committee and internal audit reviews conducted on anti-fraud. Public Stakeholder Risk via the Board Assurance Framework in identifying how the public should and can be engaged in managing risk, and through the Public Reference and Reporting Panel (PRAP) in understanding from members of the Trafford public the management of risk appropriately. Equality Impact Assessments are conducted at the outset of setting strategy and delivering services across the Commissioning cycle and in assuring a control and assurance culture through Risk, Incident and Complaints management which ensures a clearly defined culture of equality across the CCG s activities. Capacity to Handle Risk Risk is captured throughout the organisation with risk being the responsibility of all staff. Risk Management forms part of the induction process for all new staff members, and there are operational risk registers for each directorate that feed into the corporate risk register (risks rated greater than 12) reported to the Governing Body, Senior Management Team and Audit Committee, for oversight of the risk management process. Page 61

62 Strategic risks are identified initially at the start of the year as part of a risk management workshop where risks are identified by the Governing Body in the context of the strategic objectives of the year, to create an initial risk profile. Strategic risks are owned by individual Governing Body members with action owners typically a further delegated resource to ensure that mitigating actions are driven in the system to robustly manage risk. Heads of Service for each area are required to complete periodic reviews of their risks to provide assurance to the Audit Committee of the effectiveness of the risk management process and to the Governing Body overall. To support this, risk assessment training is provided at least annually for each department in the context of their own department objectives to inform their own risk registers. Each Committee of the Governing Body has a dedicated risk register for its respective risks delineated from the Board Assurance Framework in providing assurance to the Governing Body that risk is managed appropriately and robustly. Risk Assessment Risk has been assessed in accordance with the Group s risk management strategy and risk management policy. Risk is assessed by capturing the following information: Description - An identity by which the risk is known throughout the life of the risk in the organisation. Owner - Who is the owner of the risk? Causes - What has to happen for the risk to occur? Consequences - Should the risk materialise, what will occur as a result? Gross Risk Rating (BAF level only) - What is the assessment of likelihood and impact of the risk before controls are considered? Controls - What controls are currently in place to mitigate the causes identified? Net Risk (BAF level only) / Risk Rating - What is the assessment of likelihood and impact of the risk after controls are considered? / What is the assessment of likelihood and impact? Actions - What actions are in place to drive the risk down to a more acceptable level within risk appetite? Action Owners - Who are the personnel who are to complete the actions assigned to the risk? Action Due Dates - When are the due dates by which the actions will be completed by? Target Rating - What is the risk assessment rating once the action identified have been achieved? The CCG s risk management framework is designed to identify risk across the organisation to provide a balanced and complete risk profile over the following areas: Two Dimensions - External Risk - Internal Risk Four Areas - Operational Risk - Current NHS Risk - Horizon Scanning - NHS Change Page 62

63 All risk is then reported across the governance structure with actions driving the risk mitigations to manage risk within the defined risk appetites set for each category of risk e.g. quality, clinical, performance, financial, information, patient experience and reputation. At 2016/17 year end the strategic risks recorded on the BAF are identified as follows: ID Risk Description Mitigations 2016/17 Year End Status 1 Failure to adapt to the new ways of working to ensure the CCG is fit for purpose and secures the best outcomes for the population of Trafford (Links to Risk 7 - Workforce) Risk revised in Q2 to reflect the focus of the CCG to be fit for purpose to facilitate the wider changes in the environment in which the CCG operates. Memorandum of Understanding (MOU) with all GM CCGs CCG Senior Management Team & Local Authority Leadership Locality Plan approved by Health and Wellbeing Board March 2016 Increased influence of the AGG (Assoc of GM CCG's) of which Trafford CCG are members Partnership Board representation Established dialogue with Trafford Council leadership team Actions for further control will not be complete by the end of March and the target risk score will not be achieved. Risk will be carried forward to 2017/18 BAF. 2 Inability of the CCG to deliver effective Primary Care 3 New Model of Primary Care (NMoC) is not sufficiently developed to deliver what is needed for the residents of Trafford from 1st April Unable to effectively implement the TCC and realise full benefits and maximise value Experienced CCG Primary Care team in place Engaged Council of Members and GP Community Collaborative working amongst GPs in Trafford Robust governance process around Primary care (Primary Care Commissioning Committee - PCCC) Primary Care Operational Risk Register MOU in place for delegated commissioning with NHS England. PCCC Annual Workplan Primary Care team Operational Workplan Plan submitted to NHS England outlining strategic and local context of delivery and commissioning intentions. Engagement with GP community produced clear mandate to develop new model NMoC Project Board and terms of reference Engaged Council of Members and GP Community NMoC Management team with programme plan in place NMoC Risk Assessment/ Project Risk Register Outline Prospectus in place to support implementation of locality plan (and NMoC transition funding application) Contract in place with delivery partner CSC (financial penalties linked to project milestones) Financial and qualitative outcomes aligned to CCG contractual and financial Risk closed at year end. Delivered 2016/17 Primary Care intentions under delegated commissioning arrangements and target risk score achieved. Primary Care risks will be considered in conjunction with risks associated with the implementation of NMoC for addition to the 2017/18 BAF. Net risk has reduced at year end. However, all actions for further control will not be complete by the end of March and the target risk score will not be achieved. NMoC Transformation Funding Submission will be completed in Q1 2017/18 and risks to implementation will be assessed as part of the submission and carried forward to 2017/18 BAF. Risk closed at year end. Page 63

64 5 Current models of Secondary Care provision unable to effectively deliver role as part of the integrated health and social care agenda and impacting on Provider performance 6 CCG unable to maintain financial balance and achieve in-year surplus as defined by Greater Manchester Health and Social Care Partnership (HSCP) 7 Inadequate capacity and capability of resources to deliver reporting. TCC governance structure (CCG and CSC) TCC overarching programme plan in place, reviewed and monitored Dedicated CCG Leads working alongside Clinical and Operational TCC staff to support implementation and improve performance. TCC Programme Risk and Issues Log GP and Provider Engagement Strategy TCC Implementation Public Health Strategy Commissioned Service Schemes - Prevention/Early Diagnosis Clear, evidence based out of hospital model Commissioning Approvals Process/Review Panel Partnership working with stakeholders including; clinicians, public, commissioners, providers. A&E Ops Delivery Groups (ODG's) - Core member of South, member of Central and Salford Pennine Care Community Service Provision Primary Care Integration Performance Recovery Plans (A&E, RTT) with realistic trajectories in place Quality and Performance Committee Risk Register Unscheduled Care Ops Risk Register (inc. Delayed transfer of Care risk and mitigation) HSCP - Assumptions/Scenario Planning Financial Modelling Action plans and mitigations Regular monitoring of forecast spend Vs budget for monitoring position and intervention, prioritisation of future spend developments, actions to reduce spend identified and implemented across all areas (e.g. Primary Care, Prescribing, Personalised Care/CHC) TCC - monitoring of CRES/Savings planned through optimisation of TCC 2016/17 Robust contracting arrangements with Providers Robust performance management arrangements and relationships with providers well established Financial Recovery Plan in place to address projected CRES shortfall (approved Nov 16 Governing Body and submitted to HSCP Dec 16) Core Mandatory Training (regulatory all areas) Role Specific Mandatory training Net risk remains high and risk areas will be considered in conjunction with integration/ transformational work for the 2017/18 BAF. Risk has remained high throughout the year in recognition of the issues relating to delayed transfers of care with Providers. Target risk score will not achieved. Risk will be carried forward to 2017/18 BAF. Target risk score achieved and risk closed at year end. Risk was revised in Q4 to reflect revised financial deliverable agreed with GM HSCP. Reported 4.7m surplus which includes 0.5m support from the wider GM system and 1% system reserve ( 3.2m) for 2016/17. Financial risks, both in-year and longer term sustainability, will be assessed for the 2017/18 BAF. Risk reduced as far as possible with target risk score achieved. However the net Page 64

65 the strategic priorities 8 Inappropriate/ insufficient stakeholder engagement and collaborative working 9 Inability to deliver themes of the Health and Social Care Partnership (GM Devo Plan) - 'Start well, live well, age well' 10 Failure to deliver key statutory duties and/or breach legislation 11 Lack of engagement with the population of Trafford impacting the ability of the CCG to implement change (regulatory areas e.g safeguarding) One to ones and day to day line management support Appraisal process to identify skills / knowledge gap Communications to staff (Employee Voice, Staff Briefings etc) Corporate Management Team (CMT) regularly review team outputs, finance and best use of resources to ensure fit for purpose and integration Developing Workforce Strategy in conjunction with Trafford Council Health and Wellbeing Board Trafford Joint Commissioning Board Integrated Care Redesign Board Annual Stakeholder Survey Trafford Locality Plan Greater Manchester Health and Social Care Partnership; Enabler workstreams Trafford leads for IM&T, Estates, Mental Health, Cancer, Contracting & Procurement (Incentivised Reform), Personalised Care Team, Safeguarding, Nursing and Quality Personalised Healthcare budgets Alignment of locality commissioning to GM Strategic Plan #taking charge outcomes Prevention agenda Governance plan and operational framework Performance management response plans to achieve regulatory submissions to NHS England, Department of Health etc. Quality Surveillance Group Policy Monitoring Framework/ Rolling Schedule Emergency Resilience/ Continuity Planning policies and procedures Declaration of Interests, gift and hospitality register Public Reference Advisory Panel (PRAP) with agreed terms of reference Integrated Care Reference Group (ICRG) with agreed terms of reference Council of Members Education forum - GPs and Nurses Comms and Engagement Strategy (Jun risk remains high as full impact of integration in 17/18 is unknown. Risk areas will be considered for 2017/18. Net risk score increase midyear to reflect the criticality of engagement and partnership to facilitate the strategic direction of the CCG. Actions for further control will not be complete by the end of March and the target risk score will not be achieved. Risk will be carried forward to 2017/18 BAF. Planning for full implementation of the Trafford Plan has been ongoing throughout the year. Net risk score remains high and target has not been achieved. Risk will be carried forward to 2017/18 BAF. Robust mitigation in place to enable the net risk to be at target and consistently low across the year. Risk areas will be considered for 2017/18. Net risk has reduced during the year but the Target risk score not achieved. Risk will be carried forward to 2017/18 BAF. Page 65

66 2016) Trafford CCG Website (News and Events page, Trafford Talks Health etc.) These risks have for 2016/17 and will (where relevant as future risks for 2017/18) be managed and mitigated through the Board Assurance Framework, with controls, assurances, positive assurances, gaps in control and gaps in assurance providing overall assurance of the management of the risks identified. Where gaps in assurance and control are identified these will be mitigated appropriately through actions. Accountability for these risks will reside solely with individual Governing Body members, reportable to the Governing Body. The Governing Body has oversight, scrutiny and challenge on the Board Assurance Framework at each meeting, with assurance provided by oversight and challenge of individual risks at assigned Committees of the Governing Body. The CCG has an overarching risk on the Board Assurance Framework (BAF) of failure to meet statutory requirements causes of which include failing to deliver the NHS and CCG s Constitutions. The CCG achieved authorisation with no outstanding conditions, and the CCG has planned through its governance arrangements to maintain this through its standing orders, scheme of reservation and delegation and prime financial policies. As a mitigating action the CCG has a governance work plan and operational framework, which the Governing Body has achieved throughout the year as a base of agenda setting, discussion and decision making. The CCG s Constitution in delivering the NHS Constitution, sets out responsibilities of Directors and Committees in those delegations and additional responsibilities conferred by the Governing Body in fulfilling statutory obligations. Clear reporting lines are explicitly set out in the CCG s constitution from Committees of the Governing Body and the Council of Members with work plans set for each Committee and subsequently robust timely, accurate and complete management information delivered. As mitigating actions to ensuring delivery of regulatory returns as evidence of demonstrating meeting statutory requirements the CCG has performance management response plans to satisfactorily deliver Operational, Strategic and Financial plans to NHS England as well as responding to ad hoc regulator requirements. The Governing Body has rigor of oversight of the Group s performance, through overview at its own meetings and through further scrutiny by delegation to its Committees, receiving minutes as a record at each meeting. In line with principles of good governance, annual reviews are conducted on the governance structure and any learning applied to further strengthen the CCG s governance arrangements and in delivering the CCG s commissioning plans. An ongoing understanding of performance of statutory requirements is achieved at Governing Body level, through its robust governance work plan and operating framework. Where risks to statutory requirements are identified, gaps in control of the overarching BAF risks are scrutinised, operational risk assessments conducted and risk mitigations subsequently delivered. The CCG s in year submissions to the Greater Manchester Health and Social Care Partnership have provided ongoing assurance in relation to the CCG complying with the Page 66

67 licence to operate. This assurance was based on the following four domains and six clinical priority areas for 2016/17: Domain 1: Better-Health Domain 2: Better-Care Domain 3: Sustainability Domain 4: Leadership Priority 1: Mental Health Priority 2: Dementia Priority 3: Learning Disabilities Priority 4: Cancer Priority 5: Diabetes Priority 6: Maternity 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. Risks are identified in the context of objectives; strategic for the organisation and operational subsequently derived into Directorate work plans. Controls are identified in four different categories; preventative, detective, directive and corrective/contingency controls. The CCG s internal control processes and procedures are based around these four categories. The control mechanisms work at a strategic level, with risks owned by the accountable Governing Body members being initially assessed in terms of likelihood and impact at a gross risk rating (without controls being applied). This ensures that an understanding of the likelihood and impact of the identified risk is achieved before controls are applied. Any controls then applied with an assessment of likelihood and impact are made, to understand the reliance on the controls operating as intended mitigating risks. This is the assessment of risk with controls at the current time; net risk. The risk if not then managed to within appetite for that category of risk - quality, clinical, performance, financial, information, patient experience and reputation, further control mitigating actions are applied to define a target risk rating. The target risk rating is achieved once the mitigating actions are completed. The control mechanisms form part of the Board Assurance Framework (BAF) reported to the Audit Committee for objective appraisal of the risk management process and to the Governing Body for overall oversight and assurance of the managing of individual risks. Further specific assurances are captured and maintained as part of the control framework; assurances, positive assurance with gaps in assurance and gaps in control identified. Page 67

68 At operational level controls are applied and an assessment of current and target risk identified managing each risk. The BAF works with the operational (corporate) risk register in identifying gaps in control and subsequently capturing these as risks in the context of operational objectives. Risks are managed to within appetite with mitigating actions completed to manage risks to within the appetite defined. The BAF and operational (corporate) risk register work together as part of the control framework of the CCG. A full picture of the CCG s risk profile can then be understood managing risk to provide reasonable assurance of effectiveness. Annual audit of conflicts of interest management The revised statutory guidance on managing conflicts of interest for CCGs (published June 2016) requires CCGs to undertake an annual internal audit of conflicts of interest management. To support CCGs to undertake this task, NHS England has published a template audit framework. The CCG has concluded its conflict of interest internal audit for 2016/17 according to the NHS England audit template. The results are as follows, with minor recommendations being implemented for partially compliant areas: 1) Governance Arrangements: Partially Compliant 2) Declarations of Interest and Gifts and Hospitality: Fully Compliant 3) Register of interests, gifts and hospitality and procurement decisions: Partially Compliant 4) Decision making processes and contract monitoring: Partially Compliant 5) Reporting concerns and identifying and managing breaches/non-compliance: Fully Compliant Data Quality The Group in exercising its functions to commission health services consistently with the discharge of the secretary of state and NHS England of their duty to promote a comprehensive health service and with the objectives and requirements placed on NHS England through the mandate, puts data quality at the heart of its decision making. The CCG s Performance and Quality team review the business intelligence data in providing assurances to the Governing Body and its committees, so that informed and correct decisions can be made. The Governing Body in delivering its statutory duties relies upon the quality of data provided to inform decision making, and subsequently following an ongoing review of commissioning support arrangements, provider performance management continues to be delivered through existing shared service arrangements with Central, South and North Manchester CCGs during 2016/17. Robust procedures are in place to review the quality of data being submitted throughout the organisation ensuring that management information is complete, accurate and timely for effective decision making. 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 Page 68

69 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. The NHS Information Governance Toolkit has achieved at least a level 2 for each area of assessment. Risks to data security are managed in-line with the CCG Risk Policy and also by annual assurance report from GM Shared Service who provide the IT network and other systems of Key Information assets. These are reported throughout the governance structure as determined by the context of the specific data security and information risk. We place high importance on ensuring there are robust information governance systems and processes in place to help protect patient and corporate information. We have established an information governance management framework and have developed information governance processes and procedures in line with the information governance toolkit. We have ensured all staff undertake annual information governance training and have implemented a staff information governance handbook to ensure staff are aware of their information governance roles and responsibilities. There are processes in place for incident reporting and investigation of serious incidents. We are developing information risk assessment and management procedures and a programme will be established to fully embed an information risk culture throughout the organisation against identified risks. Business Critical Models The CCG, in line with its annual Information Governance toolkit requirements has produced and maintains an Information Asset Register which identifies business critical models and their asset owners in the organisation. The Senior Information Risk Owner (SIRO) has formally nominated Information Asset Owners covering all areas of the organisation. The SIRO and Caldicott Guardian have responsibility for data as part of the overall model including quality assurance. Data Flow mapping has also been conducted which enables an understanding of the flows of information related to these key business critical models to be identified, and Information Asset Owners are responsible for all quality checking of these processes which informs key decision making. Third party assurances The CCG receives third party assurances in relation to its IT network acquired from internal audits carried out as part of the overall audit plan, in reviewing the effectiveness of the control environment of the Greater Manchester Shared Service. Control Issues Following submission of the Month 9 Governance Statement return, there have been no significant control issues currently facing the CCG, and no remedial action has needed to be taken as a result. Page 69

70 Review of Economy, Efficiency and Effectiveness of the Use of Resources The Group has well developed systems and processes for managing its resources. The annual budget setting process for 2016/17 was approved by the Governing Body before the start of the financial year and was communicated to all managers in the organisation. The Director of Finance has worked closely with budget holders to ensure that a robust annual budget was prepared and delivered and the planned surplus achieved. Regular financial and contracting reports are prepared by the Director of Finance and reported to the Clinical Commissioning and Finance Committee with overall scrutiny and oversight by the Governing Body. In addition, an ongoing Losses, Waivers and Balances report is reported to the Audit Committee in accordance with the financial policies of the CCG. Internal Audit provides independent assurance on the processes in place as part of the annual internal audit plan, approved by the Audit Committee in delegation from the Governing Body. External audit as part of their annual work plan also provide an oversight of assurance of the CCG s value for money; economy, efficiency and effectiveness. The CCG informs its control framework by the work over the year of the Internal and External Audit functions to ensure that controls are operating effectively and to advise on areas for improvement. Audit action plans are monitored and implementation reviewed and reported to the Audit Committee, following risk assessed individual recommendations of reviews conducted. The scope of agreed Internal Audit plans approved by the Audit Committee at the outset of the year broadly covers the risk profile of the CCG including financial related audits and governance and risk. The CCG s latest available results for its performance from the CCG Improvement and Assessment Framework are available on the MyNHS website. This includes the Quality of Leadership indicator (assessed as at Quarter 2 of 2016/17 as green ) which will be available for the full year from July 2017 on the MyNHS website at: Delegation of functions The CCG has a defined scheme of reservation and delegation in the CCG s constitution approved by its GP members, the Council of Members. This identifies which functions are reserved for the Council of Members and Governing Body and which are delegated for discharge across the CCG in line with effective use of resources and risk management processes. In support of this the CCG has Financial Operational Arrangements which identify what financial responsibilities the following levels of authority have: Governing Body (level 1) Clinical Commissioning and Finance Committee (level 2) Accountable Officer (level 3) Chief Operating Officer (level 4) Chief Financial Officer (level 5) Budget Holders, in accordance with specific levels of authority granted to individuals (level 6) Page 70

71 The Governing Body receives at each formal meeting assurance from financial reporting of current position vs budget and minutes of the delegated function committee meetings are presented to members from the Chairs of respective committees. Counter fraud arrangements The CCG has an Anti-Fraud, Corruption and Bribery Policy which was updated and approved by the Audit Committee in February The CCG s Local Counter Fraud Specialist conducts an anti-fraud work plan in line with the NHS Protect Standards for Commissioners; Fraud, Bribery and Corruption across the CCG each year and reports progress and any findings to the CCG s Audit Committee, monitored by the Audit Committee Chair. Appropriate action is taken by the Audit Committee and as recommended by the Local Counter Fraud Specialist regarding NHS Protect quality assurance recommendations. There have been no instances of fraud reported in the CCG during 2016/17. 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, can be given that that there is a generally sound system of internal control designed to meet the organisation s objectives, and that controls are generally being applied consistently. During the year, Internal Audit issued the following audit reports: Area of Audit Information Governance Toolkit Serious Untoward Incidents and Investigations Public Health Trafford Coordination Centre IG Toolkit Gap Analysis System Resilience Groups (SRGs) Prescribing Quality, Innovation, Productivity and Prevention (QIPP) Primary Care Commissioning Conflicts of Interests Level of Assurance Given High Assurance Significant Assurance Significant Assurance Significant Assurance Significant Assurance Significant Assurance Significant Assurance Significant Assurance Fully Compliant / Partially Compliant During the year, Internal Audit issued the following audit reports which identified governance, risk management and/or control issues which were significant to the organisation: Page 71

72 Quality, Innovation, Productivity and Prevention (QIPP) Issue 1 The CCG should complete and record an analysis of potential QIPP schemes against ideas in Right Care reports, joint working with Trafford Council and NHS England guidance ( A Menu of Opportunities ) to ensure the CCG can evidence that it has considered options to maximise opportunities. To aid the identification of QIPP schemes the CCG needs to embed ownership of QIPP schemes across its functions (finance, clinical and operational areas). This would be facilitated by the establishment of the QIPP group. Action Agreed The CCG will develop a strengthened process coordinated by the newly established QIPP group to ensure there is an assessment of potential schemes as identified in reports from NHS England, Right Care or other identified best practice. As part of the strengthened processes to identify QIPP schemes, roles and responsibilities to identify schemes will be clarified with key leads across the CCG. Status as at March 2017 The CCG has agreed a Recovery Plan with the Manchester Health and Social Care Partnership to bring the overall financial position into an agreed year end position. 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, the Clinical Commissioning and Finance Committee, Quality and Performance Committee and Senior Management Team, and if appropriate a plan to address weaknesses and ensure continuous improvement of the system is in place. The Chairs of the Committees have provided assessment of their respective Governance forums in regard the effectiveness in delivering the agreed terms of reference. These have concluded as follows: The Governing Body has achieved against its duties well over the reporting period. In particular in delivering on innovative working practices the Trafford Coordination Centre (TCC) and all duties delegated to committees have been completed successfully over the year and reported to each meeting. Finally scrutiny of the financial position of the CCG has been challenging throughout the year, culminating in agreement of a recovery plan which the CCG has worked towards achieving reported to Governing Body meetings. The 2017/18 work plan will include a focus Page 72

73 on further intensity of integrated working with the Council, further engagement with the public in future commissioning and around the integrated agenda, ensure key projects increasing their reporting rigour to the Governing Body and that further clinical focus to stakeholders and partnership forums e.g. Joint Commissioning Board is in place. The Audit Committee has overseen the external and internal audit plans that have been delivered throughout 2016/17, with active discussion has taken place particularly around the internal audits plans and subsequent reports provided to the Committee. The Committee has challenged the process of risk management across the CCG for strategic and operational risks and has ensured that robust assurances are provided in key areas that the CCG relies on in carrying out its statutory duties. The work plan for 2017/18 will include a focus on seeking industry insight for CCG future developments from appropriate expertise at future meetings. The Remuneration Committee has delivered on its duties in the times it has been required to meet over the course of the year. The work plan for 2017/18 will include a focus on proactivity regarding carrying out its duties further into 2017/18 when the CCG demands it as the integrated agenda is further delivered. The Clinical Commissioning and Finance Committee has performed well in relation to the duties in delivering for example the revised financial plan in challenging financial circumstances and ensuring the benefits realisation of the Trafford Coordination Centre has progressed. The work plan for 2017/18 will increase the focus on delivery of the integrated agenda in ensuring transformation plans are relevant for the patients of Trafford and improve patient outcomes whilst maintaining financial balance. The Quality and Performance Committee has performed well against its duties especially in relation to its new evolving responsibilities of the quality and performance agenda of commissioned services in addressing any identified gaps i.e. children s services. The work plan for 2017/18 seeks to re-focus on an ongoing basis regarding those services that are most appropriate for the limited Committee s time and to focus on delivery of key areas and limit the amount of quality and performance data where applicable for more efficient ways of working. The Senior Management Team Committee has performed well in ensuring that all statutory duties have been adhered to and monitored through the Committee, risks have been reported to key accountable officers on a frequent basis. Throughout the year with the financial pressures that the CCG has experienced, the SMT Committee has ensured that financial strategy has been discussed and delivered as agreed by the Governing Body and working to deliver the Trafford Coordination Centre effectively. The work plan for 2017/18 will include further delivery of the transformation agenda and integration with the council, and oversight of future transformational funding bids in this regard whilst maintaining the overall challenging financial balance. The Public Reference and Advisory Panel has performed well in delivering its duties in questioning and challenging commissioning activity to ensure a patient and public perspective on Trafford commissioned services, measuring value creation of the PRAP in its influencing of commissioning delivery and further understanding achieved in why some areas of work are required to be progressed at a further rate Page 73

74 than others in the context of delivering the CCG s strategy. The work plan for 2017/18 will include further more focussed engagement with the public, learning for the Committee on integration with the council and value that the committee can bring to this and ensure executive oversight for public and patient involvement in Trafford commissioning. The Primary Care Commissioning Committee has performed well in delivery of its duties in service improvements to Primary Care having been overseen through the monitoring of quality in Primary Care, the Committee overseeing the innovative approach to Primary Care in the future with New Models of Care and Conflicts of Interest have been overseen and managed accordingly. The 2017/18 work plan will include being proactive in handing regular items and whilst being available to react to CQC inspections for example and the subsequent balance required and in the context of the wider healthcare requirements further perspectives of care such as that of the new Secondary Care Clinician will bring. Conclusion No significant internal control issues have been identified in the reporting period. Cameron Ward Accountable Officer - NHS Trafford Clinical Commissioning Group 30 May 2017 Page 74

75 Remuneration Report (Audited) 2016/ /16 Governing Body Total Salary Other Remuneration Pension Benefits Total Salary Other Remuneration Name Title (bands of 5000) (bands of 5000) (bands of 5000) (bands of 2500) (bands of 5000) (bands of 5000) (bands of 5000) (bands of 2500) Dr Kath Sutton Chair Mr Matthew Colledge Chair Dr Priscilla Nkwenti Vice Chair and Lay Member for Patient and Public Engagement Mr Alan Foster Lay Member for Finance Mrs Julie Langton Secondary Care Clinician Dr Liz Clarke GP Member Dr Ann Harrison GP Member Dr Nigel Guest Chief Clinical Officer Dr Michael Gregory Clinical Director for Strategy and Policy Dr Mark Jarvis Clinical Director for Quality Finance and Performance Dr Marik Sangha Clinical Director for Primary Care Interface and Member Relations Ms Gina Lawrence Chief Operating Officer and Director of Commissioning Mr Joe Mcguigan Chief Finance Officer Ms Sam Sherrington Nurse Member Mrs Catherine Randall Chief Nurse Ms Julie Crossley 1/4/16 to Associate Director of Commissioning Paul Hulme Associate Director of Corporate Services and OD Dr Chris Tower GP Member Mr Jim Liggitt Lay Member for Partnerships & Integration Pension Benefits Note 1: Dr Ann Harrison s Other Remuneration relates to an Off Payroll Arrangement. Note 2: Dr Chris Tower s Other Remuneration relates to an Off Payroll Arrangement. Page 75

76 Pension-related benefits (See table on p81) Pension related benefits will apply to those senior managers who are members of the Pension scheme. For defined benefit schemes, the amount included in the disclosure is the annual increase in pension entitlement determined in accordance with the HMRC method. This is calculated as follows: Increase in entitlement for the year comprises: ((20 x PE) + LSE, minus (20 x PB) + LSB) less Employee pension contributions made in the year. Where: PE is the annual rate of pension that would be payable to the senior manager if they became entitled to it at the end of the year. PB is the annual rate of pension, adjusted for inflation, that would be payable to the senior manager if they became entitled to it at the beginning of the year. LSE is the amount of lump sum that would be payable to the senior manager if they became entitled to it at the end of the year. LSB is the amount of lump sum, adjusted for inflation, that would be payable to the senior manager if they became entitled to it at the beginning of the year. Pension related benefits data is provided by the NHS Pensions Agency under Greenbury disclosure requirements. The calculation of benefits under this heading is mandated by Department for Health Manual For Accounts guidance. Remuneration Remuneration disclosure is required for those persons in senior positions having authority or responsibility for directing or controlling the major activities of the CCG. Trafford CCG has a Remuneration Committee appointed from amongst its Governing Body members. The Committee makes decisions on behalf of the Governing Body on determinations about the remuneration, fees and other allowances for Governing Body members, Very Senior Managers and Directors and for people who provide services to the CCG, and on determinations about allowances under any pension scheme the CCG may establish as an alternative to the NHS Pension Scheme. Page 76

77 Statement of the policy on the remuneration of senior managers for current and future financial years Trafford CCG Remuneration Committee has considered appropriate remuneration levels for its Governing Body including Executive Directors which incorporates external advice, benchmarking across the sector, the financial position of the organisation and the performance of the CCG and key individuals. Summary and explanation of policy on duration of contracts, and notice periods and termination of payments: All Executive Directors are appointed on permanent contracts with contractual notice periods of three months. There are no contractual termination provisions associated with these contracts. All other Governing Body positions are appointed to on contracts for services of fixed term duration (normally 3 years). There are no contractual termination provisions associated with these contracts. Pay Multiples Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation s workforce. For this disclosure, salary is based on the full-time equivalent and is the salary half way between the highest and lowest salary. The banded salary remuneration of the highest paid director in Trafford CCG in the financial year 2016/17 was 130k to 135k (2015/16, 140k to 145k). This was 3.6 times (2015/16, 4.8 times) the median remuneration of the workforce, which was 37k (2014/15, 35k). In 2016/17, no employees received remuneration in excess of the highest-paid director (2015/16, Nil). Remuneration ranged from 18k to 130k full-time equivalent (2015/16, 16k to 171k). Total remuneration includes salary and, where applicable, non-consolidated performance-related pay, taxable benefits-in-kind and pension related benefits, but not severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions. During 2015/16, the CCG made no performance-related payments or taxable benefits-in-kind for its senior managers. Details of severance and exit packages for senior managers and other staff, where applicable, are shown at Note 4.4 in the statement of accounts. Page 77

78 Grant Thornton, the CCG s statutory auditors, under the terms of the audit, has audited the figures showing the senior managers Remuneration. Staff Numbers and costs Whole Time Equivalent (WTE) 2016/ /16 Staff Group Male Female Male Female Governing Body Admin and Clerical Total Staff Costs 2016/ /16 Permanent Permanent Total 000 Employees 000 Other 000 Total 000 Employees 000 Salaries and wages 4, , , , , , Social security costs Employer Contributions to NHS Pension scheme Termination benefits Gross employee benefits expenditure 5, , , , , , Exit packages and severance pay Compulsory redundancies Other agreed departures Total Number Number Number Less than 10, , ,800 10,001 to 25, , ,000 25,001 to 50, , ,492 Total , ,292 Other 000 Page 78

79 Redundancy and other departure costs have been paid in accordance with the provisions of the NHS Scheme. Exit costs in this note are accounted for in full in the year of departure. Analysis of other departures Other agreed departures Number Voluntary redundancies including early retirement contractual 0 0 costs Mutually agreed resignations (MARS) contractual costs 0 0 Early retirements in the efficiency of the service contractual costs 0 0 Contractual payments in lieu of notice 4 95,292 Exit payments following Employment Tribunals or court orders 0 0 Non-contractual payments requiring HMT approval* 0 0 Total 4 95,292 Off-payroll engagements The Treasury Paper PES2012/17 requires the CCG to disclose all off payroll engagements. The following table shows the numbers of new off-payroll engagements between 1 April 2016 and 31 March 2017, earning more than 220 per day and for a duration of more than 6 months: For all off-payroll engagements as of 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 4 for between one and two years at the time of reporting 3 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 Total 7 Page 79

80 For all new off-payroll engagements between 1 April 2016 and 31 March 2017, for more than 220 per day and that last longer than six months: Trafford CCG Number of new engagements, or those that reached six months in duration, between 1 April 2015 and 31 March 2016 NIL Number of new engagements which include contractual clauses giving the CCG the right to request assurance in relation NIL to income tax and National Insurance obligations Number for whom assurance has been requested Of which: Assurance has been received Assurance has not been received Engagements terminated as a result of assurance not being received Number of Off-payroll engagements of Governing Body members, and/or senior officers with significant financial 2 responsibility, during the year. Number of individuals that have been deemed Governing Body members, and/or senior officers with significant financial responsibility during the year. This figure includes both off-payroll and on-payroll engagements. 10 Total 12 Clinical Commissioning Groups are required to seek assurance regarding the income tax and national insurance obligations of their appointees, as recommended by the Chief Secretary to the Treasury (CST) Review of Tax Arrangements of Public Sector Appointees. Following a review of contractual arrangements of engagements, the above table details the numbers of appointees falling into this category, and shows how many of these assurance have been requested, accepted and received. Page 80

81 Pension Disclosure Real increase in pension at pension age Real Increase in Lump Sum at pension age Pension disclosure is required for those persons in senior positions, receiving pensionable remuneration, having authority or responsibility for directing or controlling the major activities of the CCG. Inflation on pension and lump sum growth figures between 2016 and 2017 is 0%. Total Accrued pension at pensionage at 31/03/2017 Lump sum at pension age related to accrued pension 31/03/2017 Cash equivalent transfer value Real increase in cash equivalent transfer value Members who have service in the 2008 or 2015 Pension sections do not automatically receive a lump sum on retirement but may convert some of their pension to a lump sum. Cash equivalent transfer value A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member s accrued benefits and any contingent spouse s pension payable from the scheme. A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their membership of the pension scheme. This may be for more than 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. Employers contribution to stakeholder pension 31/03/ /03/ Bands of 2,500 Bands of 2,500 Bands of 5,000 Bands of 5,000 Name and Title Position Dr Liz Clarke GP Member Dr Nigel Guest Chief Clinical Officer Dr Michael Gregory - to 30/06/2016 Clinical Director for Strategy and Policy Dr Mark Jarvis Clinical Director for Quality Fiance and Performance Dr Marik Sangha - to 31/05/15 Clinical Director for Primary Care Mr Joe Mcguigan Chief Finance Officer Ms Sam Sherrington Nurse Member Ms Catherine Randall - from 25/10/2016 Chief Nurse Page 81

82 The real increase in CETV reflects the increase in CETV effectively funded by the employer. It does not include 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. Included in the CCG s statutory accounts at Note 4.5 are details of the provisions of the NHS Pension Scheme. Grant Thornton, the CCG s statutory auditors, under the terms of the audit, has audited the figures showing the senior managers pension disclosure. Better Payment Practice Code The Better Payment Practice Code requires the CCG to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. The NHS aims to pay at least 95% of invoices within 30 days of receipt, or within agreed contract terms. The CCG has exceeded the requirements of the code. Details of compliance with the Code are shown at Note 6.1 in the statement of accounts. The CCG is also a signatory to the Institute of Credit Management Prompt Payment Code which requires the CCG to pay suppliers on time, give clear guidance to suppliers when invoicing the CCG and to encourage good practice throughout its supply chain. External Audit Grant Thornton LLP are the CCG s appointed external auditors for 2016/17. The cost of statutory audit services provided to the CCG during 2016/17 was 59,000. Provision of any non-audit services, where applicable, is carried out in compliance with the CCG s Detailed Financial Policies, which ensures that the auditor s independence is not compromised. There have been no non-statutory services provided during the year by Grant Thornton. Sickness Absence Data Total Days lost through sickness: 521 days (2015/ days) Total Average Staff number: 91 staff (2015/16 : 84 staff) Average working days lost: 5.7 days (This equates to a sickness level of 2.6%) (2015/16 : 4.8 days equating to 2.2%) Page 82

83 Cost Allocation and Setting of Charges for Information We certify that the Clinical Commissioning Group has complied with HM Treasury s guidance, where applicable, on cost allocation and the setting of charges for information provided to third parties. Cameron Ward Accountable Officer - NHS Trafford Clinical Commissioning Group 30 May 2017 Page 83

84 Annual Accounts Cameron Ward Accountable Officer - NHS Trafford Clinical Commissioning Group 30 May 2017 Page 84

85 Data entered below will be used throughout the workbook: Entity name: NHS Trafford CCG This year Last year This year ended 31-March-2017 Last year ended 31-March-2016 This year commencing: 01-April-2016 Last year commencing: 01-April-2015 Page 85

86 NHS Trafford CCG - Annual Accounts CONTENTS Page Number The Primary Statements: Statement of Comprehensive Net Expenditure for the year ended 31st March Statement of Financial Position as at 31st March Statement of Changes in Taxpayers' Equity for the year ended 31st March Statement of Cash Flows for the year ended 31st March Notes to the Accounts Accounting policies 5-8 Other Operating Revenue/ Revenue 9 Employee benefits and staff numbers 10 Operating expenses 13 Better payment practice code 14 Operating leases 15 Trade and other receivables 16 Cash and cash equivalents, Trade and other payables 17 Provisions 18 Contingencies, Commitments, Financial Instruments 19 Financial assets, Financial Liabilities 20 Related party transactions 21 Events after the end of the reporting period, losses, Special Payments 22 Financial performance targets 23 Page 86

87 NHS Trafford CCG - Annual Accounts Statement of Comprehensive Net Expenditure for the year ended 31 March 2017 NHS Trafford CCG Note '000 '000 Income from sale of goods and services 2 (90) (520) Other operating income 2 (1,845) (2,814) Total operating income (1,935) (3,334) Staff costs 4 5,398 5,361 Purchase of goods and services 5 332, ,786 Depreciation and impairment charges 0 0 Provision expense 5 (988) 0 Other Operating Expenditure Total operating expenditure 337, ,147 Net Operating Expenditure 335, ,813 Finance income Finance expense 0 0 Net expenditure for the year 335, ,813 Net Gain/(Loss) on Transfer by Absorption 0 0 Total Net Expenditure for the year 335, ,813 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 , ,813 1

88 NHS Trafford CCG - Annual Accounts Statement of Financial Position as at 31 March Note '000 '000 Non-current assets: Property, plant and equipment 0 0 Intangible assets 0 0 Investment property 0 0 Trade and other receivables 0 0 Other financial assets 0 0 Total non-current assets 0 0 Current assets: Inventories 0 0 Trade and other receivables 8 3,432 2,964 Other financial assets 0 0 Other current assets 0 0 Cash and cash equivalents Total current assets 3,465 3,041 Non-current assets held for sale 0 0 Total current assets 3,465 3,041 Total assets 3,465 3,041 Current liabilities Trade and other payables 10 (17,516) (17,552) Other financial liabilities 0 0 Other liabilities 0 0 Borrowings 0 0 Provisions 11 0 (2,190) Total current liabilities (17,516) (19,742) Non-Current Assets plus/less Net Current Assets/Liabilities (14,050) (16,701) Non-current liabilities Trade and other payables 0 0 Other financial liabilities 0 0 Other liabilities 0 0 Borrowings 0 0 Provisions 0 0 Total non-current liabilities 0 0 Assets less Liabilities (14,050) (16,701) Financed by Taxpayers Equity General fund (14,050) (16,701) Revaluation reserve 0 0 Other reserves 0 0 Charitable Reserves 0 0 Total taxpayers' equity: (14,050) (16,701) The notes on pages 5 to 23 form part of this statement The financial statements on pages 1 to 23 were approved by the Governing Body on [date] and signed on its behalf by: Chief Accountable Officer 2

89 NHS Trafford CCG - Annual Accounts Statement of Changes In Taxpayers Equity for the year ended 31 March 2017 NHS Trafford CCG Changes in taxpayers equity for General Revaluation Other Total fund reserve reserves reserves '000 '000 '000 '000 Balance at 01 April 2016 (16,701) 0 0 (16,701) Transfer between reserves in respect of assets transferred from closed NHS bodies Adjusted NHS Clinical Commissioning Group balance at 31 March 2017 (16,701) 0 0 (16,701) Changes in NHS Clinical Commissioning Group taxpayers equity for Net operating expenditure for the financial year (335,555) (335,555) Net gain/(loss) on revaluation of property, plant and equipment 0 0 Net gain/(loss) on revaluation of intangible assets 0 0 Net gain/(loss) on revaluation of financial assets 0 0 Total revaluations against revaluation reserve Net gain (loss) on available for sale financial assets Net gain (loss) on revaluation of assets held for sale Impairments and reversals Net actuarial gain (loss) on pensions Movements in other reserves Transfers between reserves Release of reserves to the Statement of Comprehensive Net Expenditure Reclassification adjustment on disposal of available for sale financial assets Transfers by absorption to (from) other bodies Reserves eliminated on dissolution Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Y (352,256) 0 0 (352,256) Net funding 338, ,206 Balance at 31 March 2017 (14,050) 0 0 (14,050) Changes in taxpayers equity for General Revaluation Other Total fund reserve reserves reserves '000 '000 '000 '000 Balance at 01 April 2015 (16,710) 0 0 (16,710) Transfer of assets and liabilities from closed NHS bodies as a result of the 1 April 2013 transition Adjusted NHS Clinical Commissioning Group balance at 31 March 2016 (16,710) 0 0 (16,710) Changes in NHS Clinical Commissioning Group taxpayers equity for Net operating costs for the financial year (294,813) (294,813) Net gain/(loss) on revaluation of property, plant and equipment 0 0 Net gain/(loss) on revaluation of intangible assets 0 0 Net gain/(loss) on revaluation of financial assets 0 0 Total revaluations against revaluation reserve Net gain (loss) on available for sale financial assets Net gain (loss) on revaluation of assets held for sale Impairments and reversals Net actuarial gain (loss) on pensions Movements in other reserves Transfers between reserves Release of reserves to the Statement of Comprehensive Net Expenditure Reclassification adjustment on disposal of available for sale financial assets Transfers by absorption to (from) other bodies Reserves eliminated on dissolution Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Y (311,523) 0 0 (311,523) Net funding 294, ,822 Balance at 31 March 2016 (16,701) 0 0 (16,701) The notes on pages 5 to 23 form part of this statement 3

90 NHS Trafford CCG - Annual Accounts Statement of Cash Flows for the year ended 31 March 2017 NHS Trafford CCG Note '000 '000 Cash Flows from Operating Activities Net operating expenditure for the financial year (335,555) (294,813) Depreciation and amortisation 0 0 Impairments and reversals 0 0 Movement due to transfer by Modified Absorption 0 0 Other gains (losses) on foreign exchange 0 0 Donated assets received credited to revenue but non-cash 0 0 Government granted assets received credited to revenue but non-cash 0 0 Interest paid 0 0 Release of PFI deferred credit 0 0 Other Gains & Losses 0 0 Finance Costs 0 0 Unwinding of Discounts 0 0 (Increase)/decrease in inventories 0 0 (Increase)/decrease in trade & other receivables 8 (468) (1,025) (Increase)/decrease in other current assets 0 0 Increase/(decrease) in trade & other payables 10 (36) (149) Increase/(decrease) in other current liabilities 0 0 Provisions utilised 11 (1,276) (670) Increase/(decrease) in provisions 11 (915) 1,838 Net Cash Inflow (Outflow) from Operating Activities (338,249) (294,819) Cash Flows from Investing Activities Interest received 0 0 (Payments) for property, plant and equipment 0 0 (Payments) for intangible assets 0 0 (Payments) for investments with the Department of Health 0 0 (Payments) for other financial assets 0 0 (Payments) for financial assets (LIFT) 0 0 Proceeds from disposal of assets held for sale: property, plant and equipment 0 0 Proceeds from disposal of assets held for sale: intangible assets 0 0 Proceeds from disposal of investments with the Department of Health 0 0 Proceeds from disposal of other financial assets 0 0 Proceeds from disposal of financial assets (LIFT) 0 0 Loans made in respect of LIFT 0 0 Loans repaid in respect of LIFT 0 0 Rental revenue 0 0 Net Cash Inflow (Outflow) from Investing Activities 0 0 Net Cash Inflow (Outflow) before Financing (338,249) (294,819) Cash Flows from Financing Activities Grant in Aid Funding Received 338, ,822 Other loans received 0 0 Other loans repaid 0 0 Capital element of payments in respect of finance leases and on Statement of Financial Position PFI and LIFT 0 0 Capital grants and other capital receipts 0 0 Capital receipts surrendered 0 0 Net Cash Inflow (Outflow) from Financing Activities 338, ,822 Net Increase (Decrease) in Cash & Cash Equivalents 9 (44) 3 Cash & Cash Equivalents at the Beginning of the Financial Year Effect of exchange rate changes on the balance of cash and cash equivalents held in foreign currencies 0 0 Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year The notes on pages 5 to 23 form part of this statement 4

91 NHS Trafford CCG - Annual Accounts Notes to the financial statements 1 Accounting Policies NHS England has directed that the financial statements of clinical commissioning groups shall meet the accounting requirements of the Group Accounting Manual issued by the Department of Health. Consequently, the following financial statements have been prepared in accordance with the Group Accounting Manual issued by the Department of Health. The accounting policies contained in the Group Accounting Manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to clinical commissioning groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Group Accounting Manual permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the clinical commissioning group for the purpose of giving a true and fair view has been selected. The particular policies adopted by the clinical commissioning group are described below. They have been applied consistently in dealing with items considered material in relation to the accounts. 1.1 Going Concern These accounts have been prepared on the going concern basis. Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents. Where a clinical commissioning group ceases to exist, it considers whether or not its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of Financial Statements. If services will continue to be provided the financial statements are prepared on the going concern basis. 1.2 Accounting Convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities. 1.3 Acquisitions & Discontinued Operations Activities are considered to be acquired only if they are taken on from outside the public sector. Activities are considered to be discontinued only if they cease entirely. They are not considered to be discontinued if they transfer from one public sector body to another. 1.4 Movement of Assets within the Department of Health Group Transfers as part of reorganisation fall to be accounted for by use of absorption accounting in line with the Government Financial Reporting Manual, issued by HM Treasury. The Government Financial Reporting Manual does not require retrospective adoption, so prior year transactions (which have been accounted for under merger accounting) have not been restated. Absorption accounting requires that entities account for their transactions in the period in which they took place, with no restatement of performance required when functions transfer within the public sector. Where assets and liabilities transfer, the gain or loss resulting is recognised in the Statement of Comprehensive Net Expenditure, and is disclosed separately from operating costs. Other transfers of assets and liabilities within the Department of Health Group are accounted for in line with IAS 20 and similarly give rise to income and expenditure entries. 1.5 Pooled Budgets Where the clinical commissioning group has entered into a pooled budget arrangement under Section 75 of the National Health Service Act 2006 the clinical commissioning group accounts for its share of the assets, liabilities, income and expenditure arising from the activities of the pooled budget, identified in accordance with the pooled budget agreement. If the clinical commissioning group is in a jointly controlled operation, the clinical commissioning group recognises: The assets the clinical commissioning group controls; The liabilities the clinical commissioning group incurs; The expenses the clinical commissioning group incurs; and, The clinical commissioning group s share of the income from the pooled budget activities. If the clinical commissioning group is involved in a jointly controlled assets arrangement, in addition to the above, the clinical commissioning group recognises: The clinical commissioning group s share of the jointly controlled assets (classified according to the nature of the assets); The clinical commissioning group s share of any liabilities incurred jointly; and, The clinical commissioning group s share of the expenses jointly incurred. 1.6 Critical Accounting Judgements & Key Sources of Estimation Uncertainty In the application of the clinical commissioning group s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods Critical Judgements in Applying Accounting Policies Management has made no critical judgements, apart from those involving estimations, in the process of applying the clinical commissioning group s accounting policies that have the most significant effect on the amounts recognised in the financial statements Key Sources of Estimation Uncertainty There are no key estimations that management has made in the process of applying the clinical commissioning group s accounting policies that have the most significant effect on the amounts recognised in the financial statements. 1.7 Revenue Revenue in respect of services provided is recognised when, and to the extent that, performance occurs, and is measured at the fair value of the consideration receivable. Where income is received for a specific activity that is to be delivered in the following year, that income is deferred. 5

92 1.8 Employee Benefits Short-term Employee Benefits Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees, including bonuses earned but not yet taken. The cost of leave earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period Retirement Benefit Costs Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the clinical commissioning group of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period. For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to expenditure at the time the clinical commissioning group commits itself to the retirement, regardless of the method of payment. Some employees are members of the Local Government Superannuation Scheme, which is a defined benefit pension scheme. The scheme assets and liabilities attributable to those employees can be identified and are recognised in the clinical commissioning group s accounts. The assets are measured at fair value and the liabilities at the present value of the future obligations. The increase in the liability arising from pensionable service earned during the year is recognised within operating expenses. The expected gain during the year from scheme assets is recognised within finance income. The interest cost during the year arising from the unwinding of the discount on the scheme liabilities is recognised within finance costs. Actuarial gains and losses during the year are recognised in the General Reserve and reported as an item of other comprehensive net expenditure. 1.9 Other Expenses Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable. Expenses and liabilities in respect of grants are recognised when the clinical commissioning group has a present legal or constructive obligation, which occurs when all of the conditions attached to the payment have been met. 1.1 Leases Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases The Clinical Commissioning Group as Lessee Property, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the clinical commissioning group s surplus/deficit. Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term. Contingent rentals are recognised as an expense in the period in which they are incurred. Where a lease is for land and buildings, the land and building components are separated and individually assessed as to whether they are operating or finance leases The Clinical Commissioning Group as Lessor Amounts due from lessees under finance leases are recorded as receivables at the amount of the clinical commissioning group s net investment in the leases. Finance lease income is allocated to accounting periods so as to reflect a constant periodic rate of return on the clinical commissioning group s net investment outstanding in respect of the leases. Rental income from operating leases is recognised on a straight-line basis over the term of the lease. Initial direct costs incurred in negotiating and arranging an operating lease are added to the carrying amount of the leased asset and recognised on a straight-line basis over the lease term Cash & Cash Equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value. In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the clinical commissioning group s cash management Provisions Provisions are recognised when the clinical commissioning group has a present legal or constructive obligation as a result of a past event, it is probable that the clinical commissioning group will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties. Where a provision is measured using the cash flows estimated to settle the obligation, its carrying amount is the present value of those cash flows using HM Treasury s discount rate as follows: Timing of cash flows (0 to 5 years inclusive): Minus 2.70% (previously: minus 1.55%) Timing of cash flows (6 to 10 years inclusive): Minus 1.95% (previously: minus 1.%) Timing of cash flows (over 10 years): Minus 0.80% (previously: minus 0.80%) When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised as an asset if it is virtually certain that reimbursements will be received and the amount of the receivable can be measured reliably. A restructuring provision is recognised when the clinical commissioning group has developed a detailed formal plan for the restructuring and has raised a valid expectation in those affected that it will carry out the restructuring by starting to implement the plan or announcing its main features to those affected by it. The measurement of a restructuring provision includes only the direct expenditures arising from the restructuring, which are those amounts that are both necessarily entailed by the restructuring and not associated with on-going activities of the entity. 6

93 1.13 Clinical Negligence Costs The NHS Litigation Authority operates a risk pooling scheme under which the clinical commissioning group pays an annual contribution to the NHS Litigation Authority which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although the NHS Litigation Authority is administratively responsible for all clinical negligence cases the legal liability remains with the clinical commissioning group Non-clinical Risk Pooling The clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to the NHS Litigation Authority and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due Continuing healthcare risk pooling In a risk pool scheme was been introduced by NHS England for continuing healthcare claims, for claim periods prior to 31 March Under the scheme clinical commissioning group contribute annually to a pooled fund, which is used to settle the claims. The risk pool will cover close-down NHS CHC claims. These are claims for previously unassessed periods of care up to 31 March 2012, there may also be a limited number of requests for reviews for periods of care between 1st April 2012 and 31st March Any claims that do not comply with this national guidance would not be expected to be paid and would not be funded through the risk pool. NHS England is holding a provision of 0.735m at 31st March 2017 to meet potential liabilities of 'legacy' claims against the former Trafford PCT for the period up to 31st March Contingencies A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group, or a present obligation that is not recognised because it is not probable that a payment will be required to settle the obligation or the amount of the obligation cannot be measured sufficiently reliably. A contingent liability is disclosed unless the possibility of a payment is remote. A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or nonoccurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group. A contingent asset is disclosed where an inflow of economic benefits is probable. Where the time value of money is material, contingencies are disclosed at their present value Financial Assets Financial assets are recognised when the clinical commissioning group becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred. Financial assets are classified into the following categories: Financial assets at fair value through profit and loss; Held to maturity investments; Available for sale financial assets; and, Loans and receivables. The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition Financial Assets at Fair Value Through Profit and Loss Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial assets at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in calculating the clinical commissioning group s surplus or deficit for the year. The net gain or loss incorporates any interest earned on the financial asset Held to Maturity Assets Held to maturity investments are non-derivative financial assets with fixed or determinable payments and fixed maturity, and there is a positive intention and ability to hold to maturity. After initial recognition, they are held at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method Available For Sale Financial Assets Available for sale financial assets are non-derivative financial assets that are designated as available for sale or that do not fall within any of the other three financial asset classifications. They are measured at fair value with changes in value taken to the revaluation reserve, with the exception of impairment losses. Accumulated gains or losses are recycled to surplus/deficit on de-recognition Loans & Receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. After initial recognition, they are measured at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method. Fair value is determined by reference to quoted market prices where possible, otherwise by valuation techniques. The effective interest rate is the rate that exactly discounts estimated future cash receipts through the expected life of the financial asset, to the initial fair value of the financial asset. At the end of the reporting period, the clinical commissioning group assesses whether any financial assets, other than those held at fair value through profit and loss are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset. For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset s carrying amount and the present value of the revised future cash flows discounted at the asset s original effective interest rate. The loss is recognised in expenditure and the carrying amount of the asset is reduced through a provision for impairment of receivables. If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through expenditure to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised. 7

94 1.18 Financial Liabilities Financial liabilities are recognised on the statement of financial position when the clinical commissioning group becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are de-recognised when the liability has been discharged, that is, the liability has been paid or has expired Financial Guarantee Contract Liabilities Financial guarantee contract liabilities are subsequently measured at the higher of: The premium received (or imputed) for entering into the guarantee less cumulative amortisation; and, The amount of the obligation under the contract, as determined in accordance with IAS 37: Provisions, Contingent Liabilities and Contingent Assets Financial Liabilities at Fair Value Through Profit and Loss Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial liabilities at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the clinical commissioning group s surplus/deficit. The net gain or loss incorporates any interest payable on the financial liability Other Financial Liabilities After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method, except for loans from Department of Health, which are carried at historic cost. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method Value Added Tax Most of the activities of the clinical commissioning group are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT Foreign Currencies The clinical commissioning group s functional currency and presentational currency is sterling. Transactions denominated in a foreign currency are translated into sterling at the exchange rate ruling on the dates of the transactions. At the end of the reporting period, monetary items denominated in foreign currencies are retranslated at the spot exchange rate on 31 March. Resulting exchange gains and losses for either of these are recognised in the clinical commissioning group s surplus/deficit in the period in which they arise Third Party Assets Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the clinical commissioning group has no beneficial interest in them Losses & Special Payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had the clinical commissioning group not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure) Accounting Standards That Have Been Issued But Have Not Yet Been Adopted The Government Financial Reporting Manual does not require the following Standards and Interpretations to be applied in , all of which are subject to consultation: IFRS 9: Financial Instruments ( application from 1 January 2018) IFRS 14: Regulatory Deferral Accounts ( not applicable to DH groups bodies) IFRS 15: Revenue for Contract with Customers (application from 1 January 2018) IFRS 16: Leases (application from 1 January 2019) The application of the Standards as revised would not have a material impact on the accounts for , were they applied in that year. 8