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ANNUAL REPORT

AND ACCOUNTS 2017/18

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Contents Accessibility ................................................................................................................ 3

Welcome .................................................................................................................... 4

Section 1 Performance Report ................................................................................... 6

Who we are ................................................................................................................ 7

Challenges in Greenwich ........................................................................................... 7

Risk management .................................................................................................... 11

Our achievements in 2017/2018............................................................................... 12

Challenges addressed .............................................................................................. 23

Focus on mental health ............................................................................................ 27

Integrated working and Better Care Fund ................................................................ 30

Financial overview .................................................................................................... 31

Quality, improvement, productivity and prevention (QIPP ........................................ 34

Sustainable development ......................................................................................... 35

Quality and safety ..................................................................................................... 36

Engaging people and communities - patient and public involvement ....................... 42

Annual 360-degree stakeholder survey .................................................................... 45

Clinical engagement ................................................................................................. 45

Sustainability and transformation partnership........................................................... 46

Equality and diversity ............................................................................................... 50

Emergency preparedness, resilience and response (EPRR) ................................... 53

Section 2 Accountability Report ................................................................................ 56

Members’ Report ..................................................................................................... 57

Register of interests ................................................................................................. 62

Personal data related incidents ................................................................................ 62

Statement of disclosure to auditors .......................................................................... 62

Modern slavery statement ........................................................................................ 63

Statement of Accountable Officer’s responsibilities .................................................. 63

Governance statement ............................................................................................. 65

Final Head of Internal Audit Opinion 2017/2018 ....................................................... 81

Remuneration and staff report .................................................................................. 87

Our staff ................................................................................................................... 95

Parliamentary Accountability and Audit Report ...................................................... 100

Section 3 Annual Accounts .................................................................................... 101

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Accessibility If you would like a copy of this annual report in an alternative format, please contact the communications team: Telephone: 020 3049 9000 Email: GRECCG.NHSGreenwichCCG@nhs.net

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Welcome Welcome to the 2017/18 Annual Report and Accounts of NHS Greenwich Clinical Commissioning Group (CCG).

The overarching themes of 2017/18 have been challenge and progress. The year was challenging for the CCG and the NHS as a whole, and we have sought to improve patient care while delivering within our financial means.

One of the biggest challenges has been the performance of local urgent and emergency care services. Through the year we worked with local partners to address areas for improvement in performance and quality standards.

In the year NHS England used their formal powers of direction and from 1 September 2017 some of our responsibilities for acute commissioning and contracting were temporarily transferred to NHS Southwark CCG. This has helped to galvanise the urgent and emergency care system to keep a sharp focus on improving clinical safety and quality, improve year on year performance and be relatively well prepared for one of the most challenging winters for emergency care.

Despite some improvement we continue to experience challenges to meet the accident and emergency four-hour target, and will continue our efforts so that with the recovery plans that have been put in place since the application of legal directions we will achieve further step-change improvements during 2018/19. The immediate aims of our organisational recovery plan are to secure a rating of ‘requires improvement’ for 2017/18 and ensure the lifting of the legal directions placed upon the CCG.

I am pleased to confirm that the CCG has achieved its financial duties for 2017/18. The 2017/18 Annual Accounts show a surplus of around £0.7 million, which is in line with the CCG’s financial target for the year. This is a result of sustained determination by our local and South East London contracting and finance teams; the efforts by all in the CCG to develop our savings schemes and support from our providers in implementing them. We still need to deliver savings programmes of around £14.3 million in 2018/19. The progress we have made will significantly help the CCG to improve our inadequate rating.

Along with the other CCGs in South East London, we reviewed our collaborative working arrangements in the year, resulting in the establishment of new executive leadership arrangements that took effect from 1 April 2018. Andrew Bland was appointed as Accountable Officer. The return to financial balance is underpinned by this new model of working and will enable us to strengthen collaborative commissioning arrangements and to consolidate leadership and accountability arrangements.

Staying on the subject of people moves, I would like to record my appreciation for the work of Dr Hany Wahba and Dr Nayan Patel who are stepping down from the Governing Body, having served as GP commissioners since the beginning of the

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CCG in shadow form and onward since authorisation in 2013. They are both coming to the end of their second terms in July 2018. They have been tireless in giving advice and support, whilst also providing appropriate challenge whenever needed.

Dr Sylvia Nyame will also be leaving the Governing Body this summer and her role as mental health and patient and public participation lead has been greatly appreciated and she will be much missed.

I also want to thank Jo Murfitt for her work as Chief Officer from November 2016 to September 2017, and to Neil Kennett-Brown who joined us as interim Managing Director after Jo moved to a new role with NHS England. Neil, a long time Greenwich resident, has now taken on the reins as the CCG’s permanent Managing Director.

I would also like to thank our staff and partners. We have made steady progress on our goals, thanks in large part to partnership working with Royal Borough of Greenwich, with NHS providers and other clinical commissioning groups in South East London, with the third sector, and most importantly, with Greenwich people.

2018/19 will continue to be challenging for Greenwich CCG, however, we have weathered tougher times in the past. It has been an honour to serve as Clinical Chair and as I step down from my post this year, I know I am leaving a very good team in place, who have the commitment and drive to commission the highest-quality NHS services for Greenwich people.

Dr Ellen Wright Clinical Chair, NHS Greenwich CCG

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Section 1 Performance Report

Andrew Bland

Accountable Officer

25 May 2018

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Who we are

We are a membership organisation made up of all 35 GP practices in Greenwich,

organised into four local care networks and one GP federation. We plan, buy and

monitor most of the health services Greenwich people use including:

primary care (fully delegated since April 2017)

acute (Lewisham and Greenwich NHS Trust

community (Oxleas NHS Foundation Trust)

mental health (Oxleas NHS Foundation Trust)

learning disabilities (Oxleas NHS Foundation Trust)

voluntary sector - various

We work with a range of partner organisations in Greenwich to improve health and

wellbeing. We also work closely with our neighbouring CCGs in South East London

and with NHS England, on shared plans to improve health and deliver high quality

and sustainable services for our populations. This is our Sustainability and

Transformation Partnership (STP).

NHS England commissions other primary care services such as pharmacists,

opticians, dentists and some specialist health services. The Royal Borough of

Greenwich commissions public health, health visiting and school nursing services.

We are part of the Greenwich Health and Wellbeing Board, where we work with

elected councillors and other partners, including community and voluntary sector

partners such as Healthwatch Greenwich and METRO GAVS, to make sure local

services meet our communities’ needs.

Challenges in Greenwich Main areas of poor health In Greenwich, like many other areas nationally, we have a growing and ageing population with growing health and care needs.

According to the Joint Strategic Needs Assessment (JSNA) for Greenwich, the major causes of death in Greenwich are cancer and cardiovascular diseases, especially heart attacks and strokes. However, overall death rates from these causes are improving, meaning that fewer people are dying prematurely from these diseases. Respiratory diseases, including chronic obstructive pulmonary disease (COPD), are the next biggest cause of preventable deaths in the borough. The biggest burden on morbidity (poor health) is mental ill health, followed by musculoskeletal health conditions such as back pain, arthritis and other joint conditions.

The JSNA priorities include six major conditions, six risk factors and seven underlying determinants of health as shown below.

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With our partners, we have identified the key underlying determinants of health that impact on the health of people in Greenwich. These are shown in the boxes called “causes of the causes” in the diagram above. There is ample evidence that social and environmental factors, including employment, income level and the suitability of housing have a big influence on health.

The second main row in the table then shows the major risk factors for disease for the conditions listed in the boxes below, called major conditions (Greenwich’s avoidable burden of ill health). We describe these conditions as the avoidable burden of ill health, as with the right help and support; for example, to give up smoking or supporting people back into employment, the development of some of the diseases may be prevented.

Reducing health inequality To deliver high quality care and improve the health of our local population, we need to take action to promote equality and reduce the gap in health inequalities for all our communities.

We use the JSNA to map out the needs of our population, so we can target our resources and services to best effect. We systematically consider the impact of our work on reducing health inequalities. We develop equality impact assessments to support the delivery of our programmes, and make sure that our public engagement approach considers equalities information.

Over the last year, our work to narrow the gap in health inequalities has included:

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Partnership work with Royal Borough of Greenwich to implement a new social prescribing (Live Well Greenwich) programme to better meet the needs of vulnerable people with the poorest health. Part of this includes funding of care navigator roles.

Supporting the Public Health team’s community blood pressure outreach initiative which has identified hundreds of residents with previously undiagnosed hypertension and atrial fibrillation and linked them into treatment.

Working with Royal Borough of Greenwich in the successful implementation of a latent tuberculosis (TB) testing scheme in primary care, identifying and treating patients with undiagnosed TB from countries with a high prevalence of the disease.

Work to develop the frail elderly pathway, resulting in the establishment of the Community Assessment Unit at Eltham Hospital.

Supporting people with learning disabilities and or autism to live in the community with the appropriate level of care through our transforming care programme.

Promoting awareness of learning disabilities to colleagues in primary care and targeting NHS health checks to local people with learning disabilities.

Partnering with Public Health to improve access to smoking cessation services and weight management services to improve the targeting of residents with the greatest need and in the areas of greatest deprivation in the borough.

Creating a mental health A&E liaison nurse role based in the emergency department at Queen Elizabeth Hospital, who identifies patients with mental health needs, ensuring they have timely access to appropriate support and services.

The Greenwich Health and Wellbeing Strategy (2015-2018) The Greenwich Health and Wellbeing Board strategy aims to improve the health of the population and focuses on these priorities:

Tackling obesity, as a major driver of poor health outcomes including heart disease, cancers and musculoskeletal health problems.

Improving mental health and wellbeing, including the implementation of a Thrive Greenwich programme, linked to the Mayor’s Thrive London scheme.

Enhancing the role of staff across our agencies to ‘makeevery opportunity count’ in improving the health and wellbeing of the population.

Promoting and supporting the mental and physical health and wellbeing of employees across the borough through healthy workplace initiatives.

The JSNA will be updated in 2018/19 which will support a refresh of the Greenwich Health and Wellbeing Strategy beyond 2018. The Health and Wellbeing Board is committed to its existing priorities which are still relevant, and will focus on updating the action plans to deliver these priorities. A core commitment is to scale-up the Live Well Greenwich approach which cuts across all the health and wellbeing strategy priorities.

The diagram provides a summary of some of the main areas in which health is poorest in the borough and some of the associated factors (such as poverty and obesity) when compared with England.

It shows where improvements are being seen (for example, in early deaths from cardiovascular diseases), as well as where outcomes are getting worse (such as life expectancy).

It also shows improvements in outcomes where the impact affects small numbers of the population (such as late HIV diagnosis) versus impact on large numbers (e.g. under 75s deaths from cancer.

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Risk management The CCG has assessed its key risks and uncertainties throughout the year using the Governing Body Assurance Framework. The Assurance Framework sets out the principal risks to delivering our strategic objectives and how these risks are managed. There is an established methodology in place to identify, monitor, control and mitigate risks throughout the CCG as part of, and within, the CCG’s Risk Management Strategy and Assurance Framework.

The Assurance Framework is presented at each Governing Body meeting, so members can review the risks and mitigations and receive assurances that the risks are being effectively managed and minimised. The top risks for Greenwich CCG identified in 2017/18 were:

Risk of a reducing primary care GP workforce (due to retirement, natural wastage and difficulty recruiting and retaining GPs nationally and locally) set against an increasing population thus impacting on primary care resilience.

Risk of breaching the national cancer target of 85% for 62-day referral to treatment.

Risk of breaching the 18-week referral to treatment standard for planned care. Risk of loss of organisational memory due to the turnover of senior manager

roles in the organisation in the preceding year.

Risk of the demand for hospital care exceeding the available budgeted levels. Risk of failure to deliver the transformation work of the South East London

Sustainability and Transformation Partnership (STP).

As the CCG was unable to meet its full statutory financial duties in 2016/17, we met

regularly with NHS England in 2017/18 to provide assurance on our financial

recovery plan and to discuss progress in achieving financial balance. The CCG has

worked throughout the year on managing our money so that we deliver high quality

care and value for money. We will continue to make sure we manage our financial

position as effectively as we can.

Further details on risk are included in the governance statement in section 2.

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Our achievements in 2017/2018 Medicines management Medicines optimisation is an evidence-based approach to prescribing, which underpins our aim to ensure safe and effective use of medicines. This includes minimising risks associated with the use of medicines for patients and staff. Optimisation of medicines by healthcare professionals for patients with long term conditions, as well as acute clinical presentations, delivers overall health improvement and underpins many of the current initiatives to improve quality of patient care. The CCG medicines management team:

provides unbiased information about medicines and treatments

supports healthcare professionals and patients to make best use of medicines minimises harm caused by medicines and improves the safety of medicines

Despite a challenging year the team has delivered the following programmes:

Promotion of self-care to empower patients to seek advice from their community pharmacist if they have a minor or self-limiting ailment.

De-prescribing drugs of limited clinical value, e.g. items lacking in robust evidence of clinical effectiveness, or which have significant safety concerns.

Delivery of the national quality premium to reduce inappropriate antibiotic prescribing for urinary tract infections (UTI).

Successfully supporting practices to implement various National Institute for Health and Care Excellence (NICE) guidelines and technology appraisals into the local health economy.

Supporting training for clinical and non-clinical staff at GP practices in relation to medicines and evidence-based management of diseases.

Implementation of asthma review clinics in primary care to optimise medicine use in complex asthma patients.

Extensive engagement with stakeholders, e.g. community pharmacy and community providers.

Integrating medicines optimisation into services and care pathways, for example biologic treatment for inflammatory bowel disease.

Diversifying the role of a prescribing advisor to care homes to enable safe provision of medicines and potentially reduce hospital admissions linked to medicines use.

Collaboration as a member of the South East London area Prescribing Committee and leading on stoma proposals for the South East London Medicines Management Sustainability and Transformation Partnership (STP).

Publication of the well-established “Prescribing Matters” newsletter for clinical and practice staff.

Delivery of the financial QIPP target of £1 million set for the year. Undertaken an audit evaluating waste and safety issues associated with

medicines, including care home medication reviews and clinical audits as part of QIPP plan.

Supporting the individual funding request (IFR) panel to screen and assess payment by results excluded drug (PbR excluded) applications when a

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treatment or service that is not routinely offered by the NHS is the best treatment for the patient, given their exceptional or rare clinical circumstances.

Collaboration with acute trust pharmacists and the CCG contract team to agree arrangements to introduce and increase uptake of biosimilar drugs for the CCG.

The controlled drugs Accountable Officer follows up incidents involving controlled drugs with community pharmacies, GP practices and care homes to ensure root cause analysis has been undertaken and the learning has been taken on board.

Monitoring of non-medical prescribers’ database and scope of practice to ensure high medicines management standards are attained.

Primary care In April 2017 commissioning of primary care services was delegated to Clinical Commissioning Groups in South East London from NHS England, recognising that CCGs are best placed to deliver transformation within primary care. GP contracts have been standardised to help address variation and there is now an opportunity to further address some of the quality indicators in Quality Outcomes Framework (QOF) to make them more meaningful and improve the quality of patient care.

The General Practice Forward View (GPFV), a national five-year programme, puts primary care at the heart of transformation, recognising that health and social care need to work differently to address the challenges of an increasing and ageing population, financial instability and patient expectations. Care closer to home and increasing patient access to care outside of core hours impacts on how primary care has historically been delivered. The GPFV focuses on building resilience in primary care through addressing workforce capacity; working at scale; and better use of technology. The South East London STP provides direction through its Community Based Care (CBC) programme to deliver these initiatives through ‘shared standards, local delivery’.

We have made good progress in local delivery of the CBC programme. Greenwich now offers extended primary care access from 8am to 8pm Saturday and Sunday and 4pm to 8pm Monday to Friday at our two GP Access Hubs in Eltham and Thamesmead. The GP Hubs can access patient records ensuring continuity of care. Appointments are made through GP practices and NHS 111.

The number of patients with online accounts has increased at each of our 35 practices, enabling patients to book their own appointments and order repeat prescriptions. The CCG is working with practices and the Local Medical Committee on solutions to enable e-consultations to be rolled out during 2018/19 so that patients can access GP advice without needing to have a face-to-face consultation.

Greenwich was successful in a combined bid with Bexley, Lewisham and Bromley CCGs to recruit an additional 45 GPs through the NHS International GP Recruitment Programme. We will continue to re-assess CCG requirements as the programme develops and do not expect to see the fruits of the programme until later in 2018/19.

We have worked closely with the Royal Borough of Greenwich Public Health department to support primary care in the Network Woolwich and Thamesmead

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locality to host wellbeing coaches within practices. These coaches take a holistic approach to patient care by signposting to services available across the borough. We aim to roll out this initiative to our other three localities in Greenwich, providing full coverage across our registered population.

In partnership with Royal Borough of Greenwich we are working on primary care estate developments to make sure that GP premises are fit for purpose and future proof. Gallions View in Thamesmead has been allocated funding and an architectural company commissioned to develop drawings to show how Gallions View could be re-modelled to improve the environment for patients and staff. Kidbrooke Village will have a new health centre built, linking to a community building with access to a pharmacy and a dental surgery.

The CCG and Local Medical Committee agreed a new Primary Medical Services (PMS) contract for 31 of our 35 practices as part of the national programme to reduce variation across primary care services in England. The remaining four practices have a different contract, one of which (Clover Health Centre in Woolwich) will go out to procurement during 2018.

The friends and family test is carried out at all our 35 practices and is an important element of quality assurance for the CCG. The results are reviewed by the CCG primary care team and form part of the regular review process for primary care committees. In 2017/18, 86% of respondents said that they would recommend their practice to a family member or friend. The national target is 89%, which we have not achieved this year, although we have improved from 85% in 2016/17.

Connect Care Connect Care allows patient information to be shared securely between health and social care professionals directly involved with the care of patients, which enables more informed decision-making about care and treatment.

We improved the Connect Care programme in 2017/18 so that GPs and community teams have easier access to patient records by integrating into their respective clinical systems. This has significantly increased usage by clinicians. Development of additional functionality to improve access to population health data and reporting is being trialled and expected to be available in Greenwich in 2018/19, as is a function which enables patients to access their own records.

Connect Care covered care records across Greenwich, Bexley and Lewisham until February 2018, and is now joined up with the Local Care Record system in Lambeth, Southwark and Bromley as a South East London-wide system. This system also includes data access for local providers of NHS 111 and GP out of hours’ services. Patients can opt out of the system if they wish.

More information about Connect Care is available on the Lewisham and Greenwich trust website.

Whole system emergency care pathway Throughout 2017/18 the CCG has worked with partners to develop a whole system response to supporting the emergency care pathway across Bexley, Greenwich and

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Lewisham. An improvement plan was submitted to regulators in September 2017 and is overseen by the A&E Delivery Board, with an independent Chair.

Commissioners and providers have achieved improvements by ensuring that the entire system has worked more effectively with a strong focus on improving pathways, increasing community capacity and flow. A key element was improving discharge processes at Queen Elizabeth Hospital, and a Transfer of Care Collaborative programme has been running since November 2017.

Partners have worked closely together to support the hospital by working as a multi- disciplinary team (MDT) over weekend periods to facilitate discharging people home. A hospital improvement working group has been established and meets weekly with all partners from health and social care to review and improve performance. Overall patient flow from acute to community services and community services to home has been streamlined with the alignment of MDT sessions in each facility organised to provide timely discharge information for each patient.

The urgent care centre was expanded and refurbished before winter, and the improved facility was able to support the expected increase in activity over winter, which was very challenging across the country, with high hospital attendance and admissions.

During 2018/19 we plan to progress the Transfer of Care Collaborative which will enable partners to further to improve patient flow. In partnership with Royal Borough of Greenwich, we will commission winter resilience services ready for the 2018/19 winter period.

Frailty The Community Assessment Unit (CAU) at Eltham Community Hospital was set up as a hospital avoidance service as part of an improvement programme following the CQC review of Lewisham and Greenwich NHS Trust. The review meant we needed to provide more support for frail elderly people within the community.

The aim of the CAU is to provide a comprehensive assessment service to build the physiological, psychological, cognitive and social resilience of the frail patients of Greenwich and Bexley, to maintain their independence for longer. The unit aims to prevent inappropriate emergency department attendance and subsequent acute admission, with referrals from GPs, community services, care homes and the London Ambulance Service. The unit opened in the summer 2017, and became a seven-day service in October, with 10 chairs (for same day assessment/discharge) and 10 beds (for short term 24-72-hour admission). In December 2017 this unit was flexed to provide more discharge support to support Queen Elizabeth Hospital and the pressures facing the local system during the winter months.

Discharge to assess unit In addition to the CAU we commissioned a new short-term facility with Royal Borough of Greenwich, as part of the discharge to assess pathway. This opened in January 2018 and aims to move patients who are medically optimised into the community for assessment instead of remaining in the hospital.

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Duncan House is a 20-bedded unit which provides a home-like environment for patients to be assessed after time in hospital before either returning home with a package of care or returning to a residential or nursing home. The service works on the ethos of “get up, get dressed, get moving” and is supported by a multi- disciplinary team from social care, GP, physiotherapy, occupational therapy and nursing.

Other developments for older people’s services Over recent months, the partners providing community services have joined forces to consider how to best align older peoples’ services. During 2017/18 services were developed and implemented to support winter pressures. While these have been effective in supporting people, we recognise that the system would benefit from greater integration. In response to this and to support the development of the CCG’s clinical commissioning strategy, we have established an older peoples’ service re- design workstream. Work to progress an agreed vision and model for older peoples’ services will take place in the first quarter of 2018/19 and provide a blueprint of how urgent and emergency care services will operate as part of the whole system.

End of life (EOL) care As part of the whole system redesign, the Greenwich multi-agency end of life working group met monthly. The working group has strong representation and committed attendance by partners. Existing end of life pathways and gaps have been mapped and an ideal end of life pathway developed, resulting in an end of life project plan. Initial discussions have begun with Lewisham and Bexley CCGs to identify common work themes which can be progressed collectively.

Care homes Care home support is integral to ensuring good quality outcomes for service users, improving system flow and reducing adverse impact on the London Ambulance Service. A task and finish group was set up with providers and Royal Borough of Greenwich. This group has reviewed the status, data and best practice and will report with recommendations in June 2018. We have seen a reduction by over 200 call outs to care homes in 2017/18 (compared to 2016/17). Three current projects are:

Medicine management, a rolling programme of individual medication reviews

across all care homes in Greenwich which began in July 2017.

The introduction of “Red Bags” to facilitate discharge from hospital for care

home patients. All the patient’s medicines and a summary of their records are

placed in a red bag which is taken with them when they are admitted to

hospital from a care home, and then transferred from hospital when they are

discharged back to their care home. This project is due to start in May 2018

and is expected to reduce the length of stay in hospital.

The adoption of telehealth kits in care homes and training of care home staff

to increase knowledge and confidence in managing complex cases. This

project started in early April 2018 and should significantly reduce hospital

admissions and London Ambulance Service callouts.

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Musculoskeletal service (MSK) Greenwich CCG commissioned a new MSK service which went live in April 2017. Circle Health has come together with the local community and hospital providers to deliver the new musculoskeletal pathway for the whole Greenwich population. The service promotes informed patient choice and drives providers to achieve excellent clinical standards and high-quality outcomes. The vision is to:

Make sure patients receive the best quality care, with excellent clinical

outcomes.

Be at the forefront of innovation in promoting patient choice.

Make sure every patient is involved in their care, embodying the principles of shared decision-making – ‘no decision about me without me’.

Help patients see the right clinician, first time.

Improve MSK health across the population.

Enhance the overall management of the MSK system.

Offer excellent patient experience.

The new service has received good patient feedback. Since summer 2017, GPs have been able to refer patients to Eltham Community Hospital for X-ray, ultrasound and blood tests.

Continuing healthcare NHS continuing healthcare (CHC) has been a key area for improvement in Greenwich and nationally in 2017/18.

The work programme in the year included mapping end to end processes within the service to reflect best practice. This has strengthened the systems and processes within continuing healthcare. The benefits have improved both the quality of service and financial efficiencies for Greenwich clients who are eligible for continuing healthcare services.

The CHC nurses have introduced case management involving regular and coordinated oversight of the care provided to individuals and their families. This ensures that assessments take place in a timely way and that care provision is reviewed regularly to ensure it still appropriately meets the clinical needs of the patient at that point in time.

The team is establishing a separate brokerage function to improve the cost effectiveness of commissioning care and free up CHC nursing time which previously incorporated this function and was not best use of their time. During 2017/18 we have put in place the building blocks for a brokerage function and the service will become fully operational in September 2017. This will drive up quality and deliver potential efficiencies.

Underpinning this has been the development of the South East London policy to assist CCGs to provide a common and shared understanding of their commitments in relation to individual choice and resource allocation for individuals who have been assessed as eligible for NHS Continuing Healthcare.

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The CHC team has adopted a standard operating process to NHS contract management. Quality performance indicators have been developed to monitor the quality and safety of individual care which providers are responsible for delivering to CHC clients. A programme of provider contract monitoring meetings has been developed for 2018/19 so that we have good oversight and monitoring of provider performance to strengthen our assurance processes. Currently we are exploring opportunities to monitor out of area placements with reciprocal arrangements from local CCGs to ensure the same robust monitoring arrangements are in place for Greenwich residents placed out of borough.

We have worked throughout the year with our neighbouring CHC teams across South East London CCGs to develop shared guidelines for assessors to CHC services. Peer review audits will ensure consistent applications of the CHC national framework to establish equity for eligibility of funding across all South East London CCGs, and will support the development of shared guidelines for assessors to CHC services.

A review of all patients who received CHC Fast Track care in 2017/18 indicated that Greenwich had 98% compliance with patients being appropriately placed in a timely way on the fast track pathway.

Percentage of CHC Decision Support Tool Assessments completed within 28 days

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Trajectory N/A N/A N/A 50% 50% 50% 51% 55% 60% 65% 75% 82%

Actual Performance 67% 69% 52% 28% 42% 55% 44% 64% 77% 36% 78% 100%

Percentage of Decision Support Tool completed in Acute Setting

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Trajectory <15% <15% <15% <15% <15% <15% <15% <15% <15% <15% <15% <15%

Actual Performance 0% 6% 0% 10% 7% 8% 7% 5% 8% 14% 11% 7%

Number of incomplete referrals exceeding 28 days by 12+ weeks

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Trajectory <5 <5 <5 <5 <5 <5 <5 <5 <5 <5 <5 <5

Actual Performance 5 3 5 0 0 0 0 0 0 0 0 0

Greenwich was originally a pilot site for the implementation of Personal Health Budgets in 2009. We have one of the highest uptakes of Personal Health Budgets (PHB) across London and continue to offer every patient who is eligible for CHC, the opportunity to have a PHB. Research evaluation on PHBs has shown that they improve outcomes, giving individuals more choice and control by working alongside health services professionals to develop and execute how their care is delivered. Additional findings from the evaluation of PHBs, demonstrated a significant improvement in the care related to quality of life (ASCOT), psychological well-being (GHQ-12) and patient confidence. Other areas where the CHC team has supported individual choice around PHBs include:

A Direct Payment (DP) event held with PHB holders and Royal Borough of Greenwich, discussing different aspects of DPs (e.g. payroll, financial monitoring, personal assistant recruitment, pre-paid cards).

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Skills for Care funding: the personalisation partnership assists people to make individual applications, pooling the funding and offering tailored courses to employers’ and personal assistants’ needs.

We are committed to transforming CHC services over the next two years (2017/19) by continuing to work with other CCGs across the Sustainability and Transformation Partnership. This will deliver improvements in quality, patient experience and optimum use of finite resources, through adopting a standardised approach to best practice.

Improved constitutional standards The focus remains on improving performance across all acute and non-acute NHS

constitutional standards. With regard to cancer standards, there has been continued

progress on the two-week wait targets. However, the 62-day target was not met for

the year. Cancer performance continues to be monitored through the 62 day

leadership group, and a South East London cancer delivery plan has been

developed to ensure that South East London providers can improve performance

and improve treatment times for tertiary referrals. Revised cancer recovery plans for

the South East London acute trusts, along with revised trajectories, were approved

by regulators in November 2017. ‘Return to Trajectory’ plans were reviewed again in

March 2018, resulting in further changes to all South East London trajectories.

Performance analysis: improving quality and performance CCG performance is measured against a set of national and local standards that reflect the timeliness, quality and safety of care delivered to patients. These standards help to monitor how well the CCG is performing. Areas of care that fall short of targets have robust action plans in place to ensure improvement. The CCG has three major reports that provide patients and interested parties with performance-related information. All of these reports are presented to the Governing Body and are available on our website:

Quality Report focuses on quality, safety, patient experience and outcomes Performance Report focuses on NHS constitutional standards (e.g.

nationally set waiting times) and the targets that are nationally required to demonstrate that the CCG is delivering timely, high quality, safe and responsive care.

Finance Report covers the activity and care that the CCG purchases from its providers (hospitals, community and mental health services and the voluntary sector) and provides information on how the CCG manages resources for the local population.

This information is closely monitored by NHS England, primarily through the CCG assurance process, as set out in the CCG Improvement and Assessment Framework. During 2017/18 the CCG developed an integrated performance report which covers acute and non-acute activity performance. For 2018/19, the CCG has incorporated quality metrics into the report.

The table on the next page shows the CCG’s position against national performance measures for the 2017/18 financial year.

Greenwich CCG rolling twelve-month performance on national standards

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Key to the performance table above Incomplete pathways: The waiting times for patients waiting to start treatment at the end of the month. The incomplete waiting time standard is 92%.

RTT 52+ week waiters: This is the count of patients on the incomplete pathways who were waiting more than 52 weeks to start treatment at the end of the month. NHS England introduced a zero tolerance of any referral to treatment waits of more than 52 weeks in 2013/14.

Diagnostics 6+week standard: The proportion of patients waiting six weeks or longer for a diagnostic test, from time of referral. The national standard is set at 1%.

A&E total time 4 hour wait: Proportion of patients who have a total time in A&E over 4 hours from arrival to admission, transfer or discharge. The national standard is set at 95%.

A&E 12 hour trolley wait: Total number of patients who have waited over 12 hours in A&E from decision to admit to admission. There is a zero tolerance of any of these long waits. . Cancer 2 week wait: A patient should wait a maximum of two weeks to see a specialist after being urgently referred with suspected cancer by their GP. The operational standard specifies that 93% of patients should be seen within this time.

Cancer breast symptom 2 week wait: Those patients urgently referred with breast symptoms (where cancer was not initially suspected) should experience a maximum waiting time of two weeks to see a specialist. The operational standard for this measure is 93%.

Cancer 31 day first definitive treatment: Patients should experience a maximum wait of one month (31 days) between receiving their diagnosis and the start of first definitive treatment, for all cancers. This is measured from the point at which the patient is informed of a diagnosis of cancer and agrees their package of care. The operational standard for this measure is 96%.

Cancer 31 day sub treatment – surgery: Patients should experience a maximum wait of 31 days for a second or subsequent surgical treatment. The operational standard for this measure is 94%.

Cancer 31 day sub treatment – drug: Patients should experience a maximum wait of 31 days for a second or subsequent treatment. Where that treatment is an anti-cancer drug regimen, the operational standard is 98%.

Cancer 31 day sub treatment – radiotherapy: Patients should experience a maximum wait of 31 days for a second or subsequent treatment if that treatment is a course of radiotherapy. The operational standard for this requirement is 94%.

Cancer 62 day standard: The operational standard for this requirement specifies that 85% of patients should wait a maximum of 62 days to begin their first definitive treatment following an urgent referral for suspected cancer from their GP.

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Cancer 62 day screening: The operational standard states that 90% of patients would wait a maximum of 62 days to begin first definitive treatment following referral from an NHS cancer screening service.

Cancer 62 day upgrade: 62-day wait for first treatment following a consultant’s decision to upgrade a patient’s priority. There is no current operational standard for this measure.

Ambulance Red 1 (8 mins): Proportion of Red 1 calls resulting in an emergency response arriving at the scene of the incident within 8 minutes. The operational standard is at 75%.

Ambulance Red 2 (8 mins): Proportion of Red 2 calls resulting in an emergency response arriving at the scene of the incident within 8 minutes. The operational standard is at 75%.

Ambulance Cat A (19 mins): Proportion of Category A calls resulting in an ambulance arriving at the scene of the incident within 19 minutes. The operational standard is set at 95%.

Mixed sex accommodation: This is the number of occurrences of unjustified mixing in relation to NHS sleeping accommodation. There is a zero tolerance for these breaches.

Cancelled Ops for non-clinical reasons rebooked >28 days: The number of patients not treated within 28 days of the last minute cancellation.

CPA follow up within 7 days: The proportion of people under adult mental illness specialties on care programme approach (CPA) who were followed up (either by face to face contact or by phone discussion) within 7 days of discharge from psychiatric in-patient care during the quarter. The national standard is set at 95%.

Dementia diagnosis rate: The indicator compares the number of people thought to have dementia with the number of people diagnosed with dementia, aged 65 and over. The target is for at least two thirds (66.7%) of people with dementia to be diagnosed.

IAPT 6 weeks first treatment: Proportion of people who waited less than 6 weeks for a course of treatment (for those finishing a course of treatment). Standard set at 75%.

IAPT 18 weeks first treatment: Proportion of people who waited less than 18 weeks for a course of treatment (for those finishing a course of treatment). Standard set at 95%.

F&F Inpatient % who recommend: Friends and Family Test (F&F) gives patients the opportunity to submit feedback to providers of NHS funded care or treatment, The Inpatient dataset includes F&F responses for NHS funded acute inpatient services.

F&F A&E % who recommend: Friends and Family Test (F&F) gives patients the opportunity to submit feedback to providers of NHS funded care or treatment, The A&E dataset includes F&F responses for all types of A&E departments.

F&F Maternity % who recommend: Friends and Family Test (F&F) gives patients the opportunity to submit feedback to providers of NHS funded care or treatment, The Maternity dataset includes F&F responses from NHS funded maternity services. Responses to the

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maternity F&F are captured at four points: antenatal care, birth, postnatal ward and postnatal community.

MRSA: Monthly counts of MRSA bacteraemia cases attributed to the CCG. There is a zero tolerance for MRSA breaches.

C. Difficile: Monthly counts of C. difficile infection for patients aged 2 years and over.

Venous Thromboembolism (VTE) risk assessment:The proportion of admitted adult patients in England who have been risk assessed for VTE. The national standard is set at 95%.

Manage demand and provide sufficient capacity Last year, the CCG worked with its Urgent Care Centre (UCC) provider Greenbrook, and Lewisham and Greenwich NHS Trust to increase front door assessments (streaming), thus providing a faster pathway for patients to see an appropriate clinician. The performance target for Greenbrook is to ensure that more than 50% of all attendances to the Emergency Department at Queen Elizabeth Hospital are streamed to the UCC. For 2017/18, the UCC treated an average of 47.5% of all patients, not quite hitting the 50% target. Building work impacted service during the months of August to October 2017, resulting in a low average performance over those months, of 44.4%. Across the year an average of 6.5% of patients were directly referred to specialty treatments from the UCC. The UCC is performing at approximately 30% above the numbers expected when the contract was originally set up, with out-of-hours performance roughly at expected levels. During the coming year, commissioners will work with Greenbrook to review performance and to identify further areas for improvement.

Challenges addressed Accident and emergency four hour standard The national standard states that 95% of patients should be seen and treated and then admitted or discharged within four hours of arriving into the accident and emergency (A&E) department. The graph below demonstrates that this was another challenging year for Lewisham and Greenwich NHS Trust as the national target of 95% was not delivered. However, in April, June, July and August, Lewisham and Greenwich NHS Trust did deliver against its locally-agreed target trajectory.

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Greenwich CCG has been working closely with the trust and other partners to develop and deliver action plans to improve performance, patient safety and experience. The themes that have arisen reflect the national position and a work programme continues into 2018/19 to manage demand, provide sufficient capacity and free up hospital bed capacity.

Freeing up hospital bed capacity During the year an arrangement with “Hospital at Home” was initiated by Lewisham and Greenwich NHS Trust to increase capacity in the community by 30 cases. This capacity is now being moved to the community provider, Oxleas NHS Foundation Trust, to ensure a consistent approach. Alongside hospital at home services, the existing Intermediate Care Unit at Eltham Hospital with 20 rehabilitation beds continues to provide services for those requiring therapeutic rehabilitation before returning home.

In addition to Intermediate Care, in July 2017, we commissioned a Community Assessment Unit (CAU) at Eltham Community Hospital and Duncan House was set up in January 2018 to provide a 20-bedded Discharge to Assess (D2A) facility to support winter pressures. During peak winter demand, the CAU unit was converted to 20 beds for hospital step-down and the Duncan House D2A facility was expanded from 20 to 25 beds. Despite all these arrangements, Queen Elizabeth Hospital continued to experience extreme pressures throughout the winter period.

Referral to treatment times for surgery The referral to treatment (RTT) target requires 92% of patients to be treated in 18 weeks from the time of referral. Achieving this target has been particularly challenging this year. Lewisham and Greenwich NHS Trust has not met the target yet this year, the CCG is working closely with the trust to ensure that it is able to achieve the target next year.

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During 2017/18, a small number of Greenwich patients waited more than 52 weeks for treatment, each month. Appropriate root cause analysis has been applied, followed by speedy remedial action, in each case, to ensure that barriers amenable to intervention can be identified and mitigated.

Cancer Greenwich CCG measures waiting times performance against eight specific indicators and, as of the end of 2017/18, has met national standards for five of these measures, on a year-to- date basis. These are: cancer 2-week wait, breast cancer symptom 2-week wait, cancer 31- day definitive treatment, Cancer 31-day sub treatment – surgery, cancer 31-day sub treatment – drug.

The CCG has been challenged in meeting the 62 day cancer wait at its provider trusts. This standard measures the wait from an urgent GP referral for suspected cancer to first treatment and covers all types of cancer. The target has proved particularly challenging when patients are referred from one trust, usually Lewisham and Greenwich NHS Trust, to a tertiary provider, such as King’s College Hospital NHS Foundation Trust and Guy’s and St Thomas’ NHS Foundation Trust. Cancer performance continues to be monitored through the 62 Day Leadership Group, and a South East London cancer delivery plan has been developed to ensure that South East London providers can improve performance and improve treatment times for tertiary referrals. Revised cancer recovery plans for the South East London acute trusts, along with revised trajectories, were approved by regulators in November 2017. ‘Return to trajectory’ plans were developed to describe how trusts would return to recovery by March 2018. These plans were further revised to ensure return to recovery in 2018/19.

Diagnostics Greenwich CCG achieved the diagnostic waiting time standard during 2017/18 as 99.1% of Greenwich patients were seen for a diagnostic test such as endoscopy, CT scan or plain film x-ray within six weeks of referral, ensuring swift diagnosis and treatment in a timely manner.

London Ambulance Service (LAS) To keep up with the evolving needs of the NHS and to support staff to provide the best possible service to patients, there has been a change to the national ambulance response time standards.

The previous standards had a response time of 8 minutes for urgent calls, with half of all calls being classed into this category. The threshold for meeting this standard was 75%, with no national response target set for non-urgent calls. As a result, in the last two years response times for non-urgent calls have doubled in some localities. Over the last 18 months, the Ambulance Response Programme (ARP) have developed a new operating model and has set a new range of targets which went live in November 2017:

Change the dispatch model of the ambulance service, giving staff slightly more time to identify patients’ needs and allowing quicker identification of urgent conditions.

Introduce new target response times which cover every single patient, not just those in immediate need. For the most urgent patients we will collect mean response time in addition to the 90th percentile, so every response is counted.

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Change the rules around what “stops the clock”, so targets can only be met by doing the right thing for the patient.

Performance reporting at London level is currently under review by LAS and commissioners. Locally, challenges and mitigation at LGT are addressed through the A&E Delivery Board and the LGT Contract Management Board (CMB).

Healthcare acquired infections (HCAIs) There are three national targets for infection control:

Clostridium difficile (C.Diff)

Methicillin resistant staphylococcus aurens (MRSA)

Escherichia coli bacteraemia (E.coli) this national target was introduced, following a five-year national ambition launched in 2016 to achieve a 50% reduction across the entire health sector by March 2021.

All can be acquired in the community or in hospital and MRSA especially is becoming more difficult to treat with antibiotics, so prevention is a priority area for all NHS staff.

C.Diff The Greenwich C.Diff target threshold for 2017/18 was 62.

In 2017/18 the figures to date show 34 cases of C.Diff in Greenwich-registered patients, including 28 community acquired and six hospital acquired C.Diff cases.

The target for 2018/19 is 61.

NHS Greenwich CCG has an action plan to manage C.Diff in the community, working closely with the acute trusts and local general practices. All Greenwich member practices have undertaken infection control training including learning from post-infection reviews of C.Diff cases that have occurred in the community. The Health Protection Programme Manager works closely with local practices to advise and ensure learning from reported cases.

MRSA The Greenwich MRSA target threshold for 2017/18 was zero and remains the

same for 2018/19.

In 2017/18 the figures to date show six cases of MRSA attributed to Greenwich CCG commissioned services.

An ongoing process for post-infection review for all MRSA cases is in place to enable learning and action planning.

E.coli The Greenwich E.coli target threshold for 2017/18 was a 10% reduction from the

2016/17 figure which was 189.

In 2017/18 the figures to date show 173 cases of E.coli associated with Greenwich CCG commissioned services.

The 2018/19 target is a 10% reduction from the 2017/18 figure.

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Tuberculosis (TB) TB case numbers and rates in Greenwich continue to decline, although at a slower rate since 2015. In 2017, 70 active cases of TB were notified in Greenwich residents, a rate of 25 per 100,000 populations. The TB rate varied as shown in the table below, and rates were higher in some areas in the north of the borough.

2014 2015 2016 2017

N Rate N Rate N Rate N Rate

Greenwich 97 36.1 92 33.5 64 22.9 70 25

Latent TB Infection (LTBI) testing and treatment by Greenwich GP practices Greenwich CCG and Royal Borough of Greenwich support the NHS England and Public Health England National LTBI testing and treatment programme 2015-2020 and rolled out the scheme across all Greenwich CCG practices from 2016. The LTBI testing and treatment is offered to new and existing patients who are at a higher risk of developing TB. Greenwich has made good progress and is expecting to be testing a further 1200 patients during the year 2018/19, having successfully applied to NHS England for further funding. Out of 1156 tests between 2016 and 2017, 254 (22%) tests were LTBI positive.

Focus on mental health In 2017/18 CCG embarked on a mental health review with stakeholders across the system. This involved a deep dive in to every element of our acute and community mental health provision to identify areas of success, challenges and where improvements could reasonably be made to meet the ambitions of the Five Year Forward View. The output of the review was a transformation programme focusing on two key workstreams of prevention and alternatives to admissions.

What have we achieved? We made significant steps to encourage wide engagement and consultation in all our commissioning activities with special efforts made to build relationships within the voluntary sector and capitalise on the diverse skill sets on offer. We have worked with the Sustainability and Transformation Partnership to make sure we are delivering ambitious and high-quality services.

Improving access to psychological therapies (IAPT) Greenwich CCG has achieved and maintained one of the highest recovery rates in the country for people accessing IAPT services (56% against a 50% national target). In 2018/19 we will capitalise on this success and expand the service to treat 19% of the population, up from 15%. Two thirds of the additional clients are expected to have a long-term condition (LTC) and to enter the service via integrated IAPT and LTC teams.

Dementia There have been challenges with reaching the dementia diagnosis targets this year. Dementia diagnosis is a priority and we commissioned a GP clinical lead to support Oxleas NHS Foundation Trust and Royal Borough of Greenwich to work with primary care to increase access, while also seeking to improve the post-diagnostic pathways of support for people with

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dementia. Recent actions taken include working with GPs to ensure that patients are being added to the dementia register in a timely manner (post diagnosis) and cross-checking memory service contacts against GP dementia registers to ensure that all patients are being recorded. These actions have resulted in an additional 25 newly diagnosed cases added to the dementia registers for March 2018, with a few more expected in the first part of 2018/19.

People with learning disabilities and or autism Transforming Care is the national response to the crises at Winterbourne View and other inpatient units for people with learning disabilities (LD) and or autism. The programme runs from April 2016 to March 2019. The Transforming Care initiative is now setting the agenda for all services for people with LD or autism. NHS England’s monitoring and assurance of services for people with LD or autism is increasingly under the Transforming Care agenda and moving to a footprint through the South East London Transforming Care Partnership (TCP). The South East London TCP already has a relatively low number of in-patients (currently between 40 and 45 adults in beds paid for by the six CCGs).

The local supporting schemes are ones we either commission directly (Oxleas NHS Foundation Trust services, Community Learning Disabilities Team) or work jointly with Royal Borough of Greenwich and other partners to deliver, e.g. transition, housing strategy. Through developing the work plan and conducting a mini review we have already established some service gaps and will explore solutions for in 2018/19, e.g. lack of service provision for service users with more challenging behaviours and those with complex physical health needs.

Annual health checks People with learning disabilities often have poorer physical and mental health than other people. The annual health check scheme is for adults and young people aged 14 or above with learning disabilities who need more health support and who may otherwise have health conditions that go undetected.

The annual health check is also a chance for the person to get used to going to their GP practice, which reduces their fear of going at other times. We are undertaking work to increase the uptake of annual health checks by providing training to GPs and promoting health checks within the learning disability population.

Learning disability mortality review The learning disability mortality review programme (also known as LeDeR) was established to drive improvement in the quality of health and social care services for people with learning disabilities. It focuses on why people with learning disabilities typically die much earlier than average. People with learning disabilities are four times as likely to die of preventable causes compared with the general population (Disability Rights Commission, 2006).

NHS England is committed to making sure that people with learning disabilities receive the right care in the right settings, with the right support. This is one of several national priorities which supports our understanding and drive to reduce health inequalities amongst this group. We have worked with Royal Borough of Greenwich and Oxleas NHS Foundation Trust during 2017/18 and now have 15 reviewers in Greenwich.

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Child and adolescent mental health services (CAMHS) The 2017/18 Greenwich CAMHS transformation plan outlines our commitment to improving mental health and emotional well-being services for children and young people (CYP) with local and regional partners and a focus on priority areas including providing urgent and emergency care for children and young people experiencing a mental health crisis.

As part of a tri-borough partnership including Bexley and Bromley CCGs, we agreed funding to develop of an out-of-hours children and young people mental health liaison service in 2017/18 which will be launched in early 2018/19. The service will provide direct access to specialist mental health support for children and young people presenting in mental health crisis at acute hospitals outside of working hours and is a significant milestone in achieving parity in access and quality of care for CYP in Greenwich.

In the year the South London Partnership1 launched the New Models of Care initiative for CAMHS, aiming to improve the experience of young people and their families using acute and specialist CAMHS services (Tier 4) in South London.

In the first quarter of operation (January to March 2018), the partnership has delivered a 25% reduction in the number of Tier 4 CAMHS out-of-partnership bed days (against the baseline year). This has been achieved largely through improved working relationships and bed management functions across the provider organisations.

In 2017/18 Greenwich CAMHS was selected as a ‘beacon site’ for the children and young people Improving Access to Psychological Therapies (IAPT) programme in recognition of the service’s success in fully embedding CYP IAPT principles and in achieving good clinical outcomes for children, young people and families. The service also reported improvements as 85.4% of children with recorded outcome measures were reviewed between July and September 2017.

In 2017/18 the CCG maintained focus on helping children and families to access appropriate support and building capacity across children’s services. We continued to develop the wide network of preventative clinical in-reach support services, with Greenwich CAMHS providing 164 clinical in-reach sessions across a range of children’s services between October and December 2017. We are committed to further improving national access rate targets.

Liaison Across Bexley, Bromley and Greenwich 59-77% of children and young people (CYP) who present with a mental health crisis to A&E do so outside of normal working hours resulting in high admission rates to acute mental health inpatient beds. A children’s and young person’s liaison nurse has been commissioned to support the staff at Queen Elizabeth Hospital. This post will provide more robust care coordination across the acute hospital setting and contribute to a reduction in the current length of stay – in addition to mental health-related A&E breaches.

1 Partnership comprised of three provider organisations, South West London and St. George’s Mental Health NHS Trust, Oxleas NHS Foundation Trust and South London and Maudsley NHS Foundation Trust.

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Integrated working and Better Care Fund In 2017/18 Greenwich shared a pooled budget of approximately £19 million with Royal Borough of Greenwich. The central focus of the Better Care Fund (BCF) programme is to jointly commission health and social care services that enable people access to high quality care in their community. The programme aims to improve the lives of some of the most vulnerable people, placing them at the heart of their care and support, and providing them with ‘wraparound’ fully integrated health and social care, resulting in an improved experience and better quality of life.

The BCF plan includes the following four metrics: non-elective admissions (NEAs), delayed transfers of care (DToC), residential admissions and reablement. The Better Care Fund programme schemes are designed to reduce non-elective admissions, admissions to residential care, improve patient satisfaction with services and increase the number of patients living at home after a discharge from hospital.

In our BCF plans (submitted in September 2017 to NHS England) we committed to reducing DToCs: Greenwich has made significant progress in managing the increase in delayed transfers of care leading to an over 25% projected reduction in DToCs. Further reductions are projected based on scrutiny processes developed across acute and mental health provision. We have achieved this with both Oxleas NHS Foundation Trust and Lewisham and Greenwich NHS Trust and consequently have strengthened how we anticipate and resolve process issues within the system.

We committed to reducing non-elective admissions (NEAs) based on the redesign of the “front end” urgent care pathway, and although work has started we have not seen the impact of new services yet. We committed to maintaining our level of residential admissions, based on baseline low levels. While data is not available on the latest position, a proxy measure captured through service activity indicates that we are not far off achieving the anticipated target. We have seen a slight increase in our 91-day readmissions to hospital. Further work is underway to understand this trend and will continue to be scrutinised. We developed mental and physical health scrutiny panels involving health and social care colleagues and providers and have successfully worked together to reduce delayed transfers of care.

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Financial overview The CCG commissions and provides healthcare services to meet the needs and improve the health of the population of Greenwich. The main NHS providers are Lewisham and Greenwich Healthcare NHS Trust, Guy’s and St. Thomas’ NHS Foundation Trust and Oxleas NHS Foundation Trust. In addition, the CCG funds the prescribing costs of Greenwich GP practices and from April 2017, NHS England delegated responsibility for the commissioning of primary care services to the CCG.

A pie chart showing how the CCG spent its budget in 2017/18 is shown below.

Overall, the CCG has delivered a surplus of £0.713 million for 2017/18. The financial target for the CCG was to achieve a surplus of £0.644 million so we have delivered a slightly better financial position (£0.069 million) than planned.

2017/18 CCG Expenditure £415.6 million Other Programme

Costs 4%

Primary Care 9%

Primary Care Co Commissioning

9%

Running Costs 1%

Continuing Care Children

2%

Acute Services 52%

Continuing Care 4%

Community Health

Services 6%

Learning Disabilities

1%

Mental Health Services 12%

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The CCG is required to achieve several specific financial targets. These are summarised in the table below:

Target

(£’000’s) Actual (£000’s)

Achieved

Agreed Surplus 644 713 Achieved

Expenditure not to exceed income

423,608 422,896 Achieved

Deliver statutory

Operate Under Resource Revenue Limit

416,299 415,586 Achieved

financial duties Not to exceed Running Cost Allowance

6,093 6,092 Achieved

Operate under Capital Resource Limit

0 0 Achieved

Deliver administrative duty under the better payments practice

95% of NHS creditor payments within 30 days

95% 99.77% Achieved

95% of non-NHS creditor payments within 30 days

95% 98.99% Achieved

As reported above, we are pleased to confirm that the CCG has delivered all its financial performance targets for 2017/18.

A financial risk-share agreement is in place across the six CCGs in South East London. It was agreed through the governance of each CCG that the risk-share agreement be enacted in 2017/18. The final revenue resource limit values included in the 2017/18 annual accounts of each CCG reflect the outcome of the risk-share agreement.

CCG running costs The CCG’s running cost allocation in 2017/18 was £6.093 million. Following a high use of interim staff in 2016/17, the CCG has focused on recruiting to its permanent structure, using interims only where necessary to deliver the CCG overall operating plan. This has enabled the CCG to reduce its spend on interim staff and ensure that it has incurred expenditure in line with its running costs budget for the year.

Future years 2018/19 represents the second year of the CCG’s two-year operating plan. This forecasts that the CCG will deliver a surplus of £0.30 million in year as its share of an overall £3.221 million South East London control total. The achievement of the plan is dependent upon the delivery of significant QIPP savings of £14.30 million in 2018/19 together with the management of other key financial risks.

The overall CCG budget for 2018/19 is £423.1 million which includes additional funding of £12.6 million from that received in 2017/18.

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The pie chart below shows the CCG plans to spend its budget in 2018/19.

Other matters Remuneration paid to external auditors in relation to audit work for 2017/18 was £52,000 (including non-recoverable VAT). Remuneration for non-audit work was nil. The CCG has complied with HM Treasury’s guidance on setting charges for release of information.

Annual Accounts The full annual accounts together with the Statement of Accountable Officer’s responsibilities and Independent Auditors Report are included in section 3.

Audit Committee highlights Approved an annual internal audit plan with RSM UK to provide the Audit Committee and

Governing Body with the assurance that Greenwich CCG is operating effectively and productively and monitored any actions arising from the audits.

Monitored and reviewed financial and other risks and associated controls, corporate governance and financial assurance.

Finance, Performance and QIPP (FPQ) Committee highlights Provided assurance to the Governing Body that affordable and appropriate budgets

were set.

Effectively monitored the finance and QIPP performance throughout 2017/18 and advised on corrective actions where appropriate.

Maintained the QIPP Planning Delivery and Monitoring Group reporting to the Financial Recovery Board for QIPP business plans.

2018/19 CCG Expenditure £423.1 million Primary Care Co Commissioning

Other Programme Running Costs

Costs

2%

4%

Contingency and Earmarked Reserves

1% Primary Care

9%

9%

Continuing Care Children

2%

Continuing Care 4%

Community Health Services

5%

Learning Disabilities 1%

Acute Services 52%

Mental Health Services

11%

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Finance Recovery Board (FRB) highlights The purpose of FRB is to lead and drive the financial recovery of the CCG, so it can

return to recurrent financial balance and ensure that patient safety and quality are not compromised.

During 2017/18, the FRB oversaw the delivery of the CCG QIPP efficiencies of £15.8 million and approved the QIPP plan for 2018/19.

Quality, improvement, productivity and prevention (QIPP)

Quality, improvement, productivity and prevention (QIPP) is a programme designed to support clinical teams and NHS organisations to improve quality of care whilst making efficiency savings that can be reinvested into the NHS.

The CCG had a fully identified QIPP plan of £19.3 million for 2017/18. The schemes relate to improving the quality of care and efficiencies in the services that we are required to commission and securing better value for money.

Acute schemes included demand management and referral management to the appropriate healthcare setting and shifting activity from hospitals to community to allow hospitals to be more efficient in treating those requiring attendance or admission.

Community schemes included the re-design of the community district nursing service, the re- design and implementation of an integrated COPD/asthma/respiratory service in the community, and the increased utilisation and more flexible use of intermediate care and nursing home beds.

Mental health schemes included a mental health clinical audit, and more effective commissioning of Mental Health services by the responsible Commissioner.

Primary Care and prescribing schemes related to increasing access to GPs for Greenwich- registered patients and more efficient primary care prescribing using best practice approaches.

£15.8 million (representing 82% of the target) of QIPP efficiencies was delivered in 2017/18 leaving a shortfall of £3.5 million against the plan.

The table below summaries the delivery of each scheme in £000s

QIPP performance 2017/18 Validated Plan

Actual Variance

Acute 7,619 2,822 (4,797)

Sub-total acute QIPP 7,619 2,822 (4,797)

CHC, community 4,237 3,521 (716)

Mental health 1,002 766 (237)

Primary care 1,607 2,131 524

Other 4,825 4,834 (81)

Sub-total Non-Acute QIPP 11,671 11,252 (509)

Total QIPP 19,290 15,812 (3,568)

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Sustainable development The NHS Carbon Reduction Strategy for England provides a framework which addresses sustainability in how we operate as an organisation in our own right, and in terms of how we contract for services from providers of healthcare. The plan aims to:

drive down direct C02 emissions and energy usage whilst also reducing revenue expenditure

influence commissioned services to reduce their carbon footprint in support of the 10% target reduction

ensure that all new buildings and other initiatives are developed with reference to the plan.

Local plans focus on the same areas and some of the key actions are detailed below.

Energy and carbon management: our office in based in the Woolwich Centre, a modern building with many sustainable features including automatic lighting that switches off when no one is present, electricity generation from solar PV to offset the buildings electrical costs and solar water heating. Cooling to the main areas of the building is run by state of the art energy efficient chiller system via chilled beams, and heating in the building is run by 96% energy efficient condensing gas boilers.

Procurement and food: our main strategy is to influence the carbon footprint of NHS services using our procurement framework, which addresses environmental issues. All contracts for healthcare services include clauses requiring providers to demonstrate their measured progress on climate change adaptation, mitigation and sustainable development, and include performance against carbon reduction management plans.

Low carbon travel, transport and access: we have implemented a range of new services, and developed existing services, to bring them closer to the home. Cycling has been promoted actively for employees now we have moved to The Woolwich Centre with excellent cycle storage and related facilities. The Council operates a cycle hire scheme that allows employees to make use of one of six Brompton bicycles for work travel.

Water: efficient use of water is embedded in new capital projects. For example, Eltham Community Hospital and The Woolwich Centre harvest rainwater for use in the building. The Woolwich Centre also has integral filtered watered in all its kitchens for drinking.

Waste: recyclable waste is appropriately disposed of and we are part of the Royal Borough of Greenwich’s active strategies to reduce waste and promote recycling. We continue to focus on reducing our use of printing.

Organisational and workforce development: staff can use low carbon travel options, with walking and cycling encouraged and aligned business mileage processes. Audio, video and web conferencing technology and remote working capability are in place and promoted to avoid going into Central London for meetings. We are also promoting online services in GP practices, so patients can also reduce their journeys.

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Role of partnerships and networks: the Greenwich Core Strategy commits us to working in partnership with stakeholders under Local Strategic Partnerships, in particular the Royal Borough of Greenwich.

Finance: as part of the exercise to calculate the carbon footprint, carbon reduction targets will be set to achieve the NHS target and take advantage of schemes which support investment in energy efficiency initiatives.

Quality and safety Quality and safety of services is a priority for Greenwich CCG to ensure the best possible care for our population. We have systems and processes to support quality and safety, providing assurance through regular reports to the Governing Body and key sub-committees. The Quality Committee receives detailed reports on quality and safety challenges, improvements and innovations in commissioned services and partnership agencies. The reports highlight plans and actions being taken to improve service quality and reduce patient safety risks.

Monthly Clinical Quality Review meetings take place with large service providers holding them to account for patient safety, the clinical effectiveness of services and ensuring a good patient experience. For hospital trusts these meetings are held with our partner CCGs: for example, Bexley and Lewisham CCGs depending on the hospital provider; this arrangement further strengthens the CCG’s scrutiny and accountability of the services provided to examine the quality and safety of services in a wider context.

Improving quality and safety of services needs good information and the information used to support quality and safety comes from a variety of sources including CCG quality visits, information from commissioned services and external bodies such as the Care Quality Commission (CQC) who inspect health providers on a regular basis to comply with their registration requirements.

2017/18 quality highlights We have continued to maintain good oversight of provider quality, including our small

providers, e.g. Out of Hours GP Services and the Urgent Care Centre at Queen Elizabeth Hospital through regular information, quality reviews and detailed deep dives into commissioned services.

We have maintained a programme of provider announced and unannounced site “Quality Visits” to our providers. These are undertaken by our Quality Team through an agreed protocol and with our neighbouring CCG partners for large commissioned services.

Sepsis is a rare but serious reaction to an infection and can be life threatening. It is recognised by the NHS as a significant cause of mortality and morbidity. In 2015 the Secretary of State announced several initiatives and the CCGs through commissioning have sought to improve and extend measures for the recognition and treatment of sepsis.

Sepsis is an important health issue for Greenwich CCG. It is also a National Commissioning for Quality and Innovation (CQUIN) for the acute hospital commissioned services. The trust’s progress with the delivery of the CQUINs is monitored through regular CQUIN reviews between the trust and CCG.

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The National Early Warning Score (NEWS) is an important tool to identify the signs of sepsis at an early stage and this is in use at Lewisham and Greenwich NHS Trust and audited on a regular basis and reviewed at Clinical Quality Review Group. A variation of NEWS for mental health patients is in use by Oxleas NHS Foundation Trust for in- patient services and this will change to the use of NEWS in 2018.

As an innovation for 2018 the CCG is looking to support the use of a telehealth NEWS system with care homes, supported by a trainer. It is anticipated this project will be rolled out to all care homes in the CCG area in 2018/19.

Oxleas NHS Foundation Trust Following the CQC inspection report for Oxleas NHS Foundation Trust in 2016 where the trust was rated “Requires Improvement”, an action plan was put in place by the trust and the subsequent revisit by CQC upgraded the trust rating to Good. Oxleas NHS Foundation Trust has continued to work on improvements reporting to Greenwich, Bromley and Bexley CCGs through the Clinical Quality Review Group.

The trust has implemented an improved process to review deaths and promote learning in line with CQC recommendations arising from the Learning Candour and Review Report published in December 2016. This prioritises learning from deaths in a clear and consistent way focusing on systems and effective dissemination of learning; at the same ensuring caring support for families.

Lewisham and Greenwich Hospitals NHS Trust The CQC inspected the trust in March 2017. Following publication of the inspection report in August 2017 the trust was rated overall as “Requires Improvement”. Within the report the trust was rated as good for the effective and caring domains as were the trust critical care and services for children and young people. Action plans have been agreed by the trust with the CQC to address the concerns identified in the report. The trust continues to work on the improvements needed to address the recommendations.

The trust has been and continues to be an active participant in the Sign up to Safety campaign, an initiative launched by NHS England in 2014 to save 6,000 lives nationally. The programme now encompasses approximately 500 organisations nationally with the aim of making care safer through learning and improvement.

The CQC maternity survey was carried out during the summer of 2017. A questionnaire was sent to all women who gave birth in February 2017 (and January 2017 at smaller trusts). Responses were received from 222 patients at Lewisham and Greenwich NHS Trust and overall the trust results were comparable with other trusts.

The Patient Reported Outcome Measure (PROM) participation rates at Lewisham and Greenwich NHS Trust remain at 100% as does the trust participation rate in National Audits and Confidential Enquiries.

Patient safety NHS Greenwich CCG has a robust process in place to review pressure ulcers from

both Oxleas NHS Foundation Trust and Lewisham and Greenwich NHS Trust, in partnership with NHS Bexley CCG. The CCG receives further assurance via reports

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presented at Clinical Quality Review Group (CQRG) meetings on the management of pressure ulcers both in the community and in the acute setting.

The CCG continues to support providers to improve the quality of serious incident (SI) reports through cooperative working, feedback and robust monitoring of the implementation of all action plans.

Having reviewed the findings from serious incident reports, we have classified them as follows:

Diagnostic incidents including delays and failure to act on test results. Pressure ulcers: Grade 3 and 4. We have seen an improvement in reporting and are

able to ensure that learning takes place which then helps to reduce the incidence of ulcers and reduce re-occurrence. Grade 3 and 4 are the most serious type of ulcers.

Apparent, actual or suspected self-inflicted harm, e.g. attempted suicide.

NHS Improvement (NHSI) published a revised Never Events policy and framework in January 2018. Never Events are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. The main changes to the revised policy and framework are:

Removed the option for commissioners to impose financial sanctions on trusts

reporting Never Events. Alignment of the Never Events policy and framework with the Serious Incident

framework, to achieve consistency across the two documents (a revised Serious Incident framework will be published later in 2018).

Revisions to the list of Never Events, including two additional types of Never Events:

(i) Unintentional connection of a patient requiring oxygen to an air flowmeter and (ii) Undetected oesophageal intubation.

There were no never events for Greenwich residents reported by the CCG’s acute or mental health provider for 2017/18.

Safeguarding adults and children We work in partnership with Royal Borough of Greenwich and providers so that effective safeguarding arrangements are in place for all services.

Safeguarding children In 2017/18 NHS Greenwich CCG fulfilled its statutory responsibility to safeguard children and young people as defined in the ‘safeguarding vulnerable people in the reformed NHS; accountability and assurance framework’ (2015). The CGG has continued to work with local health services and the Greenwich Safeguarding Board to monitor the effectiveness of safeguarding systems ensuring they meet statutory requirements and national guidelines through the section 11 audit processes.

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We have worked alongside Local Authority commissioners of universal children’s services and other partners to improve the health and wellbeing of all children, young people and their families living in Greenwich. Commissioning acute services and the health of looked after children remain the responsibility of the CCG.

We took on full level 3 delegated responsibilities for primary care contracting with effect from 1 April 2017. The safeguarding children team has supported local GP practices to improve the wellbeing of children, through the provision of training, good practice guidance, and facilitating reflective sessions at local GP practices to improve safeguarding practices. The CCG has also ensured appropriate contributions from primary care to safeguarding enquiries and serious case reviews.

This year important legislative changes impacting the structure and function of local safeguarding children’s boards emerged through the Wood Review which recommended a tripartite partnership of health, police and social services to replace local safeguarding children boards. The Children and Social Work Bill 2017 received Royal Assent in April 2017. This new arrangement will take 12-18 months to set up and we are complying with the new legislation, working with our partners to support the development and transition to new arrangements.

We use learning from safeguarding children reviews by embedding it into training for GPs, community pharmacists and other professionals and to bolster local safeguarding practice in line with good practice.

The following Greenwich health and social services for children had inspections in 2017/18:

Ofsted inspection of children’s services.

Special educational need and disability. Joint targeted area inspection focused on childhood sexual exploitation, missing from

home, education, gangs and criminal exploitation. We have developed action plans from inspection recommendations and will continue to monitor their implementation through the safeguarding committees. We successfully recruited a designated doctor for safeguarding children in September 2017 which was positive after the post had been vacant for over a year and previous recruitment attempts had not been fruitful.

Safeguarding adults Adult safeguarding activity has continued to increase in Greenwich following the further implementation of the Care Act 2014 and associated statutory guidance relevant to safeguarding. As previously, deprivation of liberty safeguards applications have seen sustained growth, and authorising these within statutory timeframes remains challenging.

Together with Royal Borough of Greenwich we monitor the quality of care in nursing homes across Greenwich, with focus on care homes which have been rated as inadequate or requiring improvement by the CQC. This is within the context of a fragile care home market with workforce, changing ownership and clinical leadership challenges.

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In 2017/18 the Safeguarding Adult Board (now on a statutory footing) asked the CCG to look at a small number of deaths that occurred in care homes where choking risks had been identified. Together with Royal Borough of Greenwich, Oxleas NHS Foundation Trust and the care home sector, we have acted to reduce risks of further choking incidents and improve care home staff awareness and management of risks.

Responsibilities in safeguarding identified high risk areas of Prevent and Modern Slavery have also increased: Greenwich has a well-defined multi-agency referral and management system for Prevent referrals (Channel Panel) to reduce the risks associated with extremist radicalisation. The CCG has also teamed with the Royal Borough of Greenwich safeguarding and community safety to provide multi-agency Modern Slavery awareness training to staff.

Clinical effectiveness Quality Alert Management System (QAMS) relies on GP practices identifying one or more individuals - usually GPs and practice managers but also administrative staff and healthcare professionals - to log in and raise an alert to the CCG when an issue occurs related to the quality of a service supplied by one of our provider organisations.

Greenwich GPs have been using the QAMS for two years now and we can see an increase in uptake from Greenwich practices. Currently the number of Greenwich GP practices using QAMS is 16. The trajectory for 2018/19 is for all 35 practices to utilise the system. More GPs are now using QAMS as they can see the impact that their shared intelligence has on improving patient services. Practices can now have a more comprehensive overview of the alerts they raise and of any patterns in the alerts raised by their peers.

The QAMS user group comprises Greenwich CCG, Bexley CCG, Lewisham and Greenwich NHS Trust and Oxleas NHS Foundation Trust. With the system’s software developers, we have made improvements aimed at getting more GP practices to use the system. This year we launched a new application in the Vision operating system used by many GP practices, which makes QAMS more user-friendly and accessible. This work continues, and we hope to provide the same facility for GP practices currently using the EMIS electronic patient record system soon.

This year has also seen the introduction of ‘reverse reporting.’ Under reverse reporting, our providers are now able to use QAMS to report to the CCG any quality issues they have encountered. The functionality that enables reverse reporting from our provider services is called QAMS Provider Plus and was implemented in July 2017, initially with Lewisham and Greenwich Trust, and to date it has highlighted the need to improve the quality of referral information from our GPs. We plan a wider roll-out of QAMS Provider Plus with our other health service providers in 2018. Some local care homes and community pharmacists have expressed an interest in being able to log in into the system to deal with alerts more quickly.

Examples of the benefits of using QAMS:

It has highlighted the problems GPs experience with patient discharge summaries. This was discussed at the Lewisham and Greenwich NHS Trust Clinical Quality Review Group and an internal audit of the hospital electronic discharge system (EDS) which

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sends discharge information back to the patient’s GP is being conducted to identify and resolve the problem.

GPs have raised issues about Lewisham and Greenwich NHS Trust not providing patients with fitness to work certificates on discharge. This has resulted in GPs’ time being taken up issuing certificates when they should be provided by the trust in line with the Service Level Agreement. The trust has written to all consultants and doctors to remind them of their responsibilities to do this.

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Engaging people and communities - patient and public involvement Our approach Engagement is a key priority for the CCG, and one of our corporate objectives. Effective engagement is an important part of everybody’s role, with the communications and engagement team providing guidance and support. We strive to actively involve local people and service users to plan, design and feedback on local services, and we are committed to building relationships with our communities to understand their needs, so that we can plan services accordingly.

We engage with our local communities to:

identify health needs and aspirations, develop our commissioning intentions and priorities

design and improve services

take patients’ views into account when we buy services

use patients’ experience to improve safety and quality of care

Our Patient and Public Engagement Strategy, launched in September 2017, sets out our vision, approach and infrastructure for delivering our legal duties to engage patients and the public in our work. By engaging with the local community, we understand the needs, concerns and experiences of residents so we can deliver the best possible health services. We understand that the best way to achieve positive health outcomes for the people of Greenwich is by putting local people at the heart of our decision making.

We involve Greenwich patients, partners and residents throughout the commissioning cycle to ensure that local people have a strong voice. We are committed to continually improve in this important area of focus for the CCG.

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Our Governing Body meetings are held in public and we host a dedicated session at each Governing Body meeting giving local people ongoing opportunity to engage with the CCG leadership and raise their concerns first hand. All Governing Body agendas and papers are published on our website.

Two of our Governing Body members have responsibilities for patient and public engagement - one lay member as lead on the Governing Body, and one GP lead who has patient and public engagement in their portfolio. Meetings see regular attendance from members of the public and Healthwatch Greenwich, and the dedicated session is popular, with questions raised at each meeting.

We use our stakeholder networks and existing channels and groups as forums for discussion. We have strong links with Healthwatch Greenwich, METRO GAVs, the Royal Borough of Greenwich and other local groups and are constantly working to build and extend our stakeholder network.

Our Patient Reference Group (PRG) is made up of members of local Patient Participation Groups (patient groups attached to GP practices) and community and voluntary sector partners. It advises on and provides assurance that the CCG is meeting its statutory obligations around patient involvement and engagement. The PRG reports into the Governing Body, and communications and engagement activity and impact is reported regularly to the Greenwich Executive Group.

We are committed to making our communications which support engagement as accessible and appealing as possible for each of our audiences. Some examples include:

Developing Easy Read materials for people with learning disabilities.

Creating a plain English and visually appealing annual review of the year as an accessible alternative to this annual report.

Using translator services for community engagement events - most recently in our Nepalese outreach work.

Providing visual and audible accessible presentations for our engagement events.

Considering the many and varied needs of our communities.

Offering our publications in alternative formats on request.

The list below gives a flavour of some of our engagement activity during 2017/18:

Commissioning intentions workshops in September 2017 to hear feedback and plan services across all commissioning areas, with a follow up workshop focusing on learning disabilities and mental health.

Three clinical commissioning strategy workshops in March 2018 badged ‘the Greenwich Big Conversation’, bringing together 144 service users, carers, community and voluntary sector partners, service providers and commissioners to discuss and deliberate future models of healthcare.

Greenwich News launched in 2017 to update stakeholders on key CCG initiatives and projects.

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Outreach work with our Nepalese community (seldom heard group), using local materials and a translator. Roughly 5,500 Nepali people live in the borough. From our engagement work, the CCG found that the Nepalese community were not aware of the GP Access Hubs, which offer residents access to GP appointments in the evenings and on weekends.

12 outreach events running from 12 December 2017 to 25 January 2018 to promote the GP Access Hubs, self-care and alternatives to A&E. We successfully engaged with 620 local people.

School outreach work with families, signposting local mental health support services, and raising awareness and promoting wellbeing to primary age pupils and their parents and carers. Follow up on issues identified from outreach work, between mental health commissioning team and the local child and adolescent mental health service provider, who are working together to address some of the issues raised by parents.

Demonstrating the impact of patient feedback / information received from engagement activity with regular “you said, we did” reports.

Public consultation on Treatment Access Policy – see case study below.

Ways for patients to get involved There are several ways that patients can get involved and influence services, including:

Taking part in engagement events.

Joining a Patient Participation Group.

Joining the CCG’s Patient Reference Group (PRG). The PRG oversees the CCG’s

engagement and equalities activities. Please contact Patricia Kanneh-Fitzgerald for

more information. 020 3049 9042 p.kanneh-fitzgerald@nhs.net.

Attending Governing Body meetings.

Case study public consultation on Treatment Access Policy (TAP) In 2017, Greenwich CCG sought to make changes to the South East London Treatment Access Policy (TAP) for Greenwich. Our proposed changes, based on clinical evidence, centred on changing access to planned (elective) surgery and treatment. The proposal the CCG consulted on included:

Smoking cessation (help giving up smoking before surgery)

Weight management (help with losing weight before surgery)

Whether specific treatments or procedures should be available on a routine or

exceptional basis only.

Before making any changes, the CCG conducted a thorough public consultation in 2017/18, consulting a range of stakeholders and local partners including the Royal Borough of Greenwich, members of the Health Overview and Scrutiny Committee (HOSC), Healthwatch Greenwich and GAVs (Greenwich Action for Voluntary Services). In addition, we held 13 public engagement sessions at popular venues across the borough, including a focus group with residents with learning disabilities.

A survey was available online and in print. Members of the public were invited to send in responses by email and post. In addition, we produced an Easy Read leaflet about the

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consultation, information documents and a list of engagement opportunities were available on a dedicated web page. The Patient Reference Group assured the engagement process.

The CCG received 753 responses to the public consultation and commissioned an independent report on our engagement. As a result of the public feedback, the CCG agreed to make several changes to the Treatment Access Policy for Greenwich. Two examples of how public feedback impacted Greenwich’s Treatment Access Policy are:

Smoking cessation The CCG had originally proposed that smokers should be referred for help to quit smoking or stop smoking before a referral for planned / elective surgery. However, in response to feedback to our consultation, the CCG amended the policy so that surgical procedures are not withheld for patients who need them. The CCG will not require for someone to stop smoking as a condition of receiving their surgery, however the CCG does require that they attend at least one session aimed at helping them stop before they are referred for routine elective surgery.

Weight management The CCG had originally proposed that patients with a BMI of 30+ should be supported to lose weight before having planned surgery. However, following feedback to the consultation, the CCG agreed that surgical procedures should not be withheld for patients who need them based on their BMI. Instead, it was decided that patients who are obese should be referred to weight management support services as part of normal care.

Full details of the TAP consultation can be found on our website

Annual 360-degree stakeholder survey We strive to build and nurture strong relationships with our partners to shape and support effective local commissioning. A key component of our planning and engagement work is the annual 360-degree stakeholder survey, commissioned by NHS England and delivered by Ipsos MORI.

The survey allows stakeholders to provide feedback on our working relationship, and the results provide intelligence to help with our organisational development, and relationship management. Fieldwork took place between 15 January and 28 February 2018 mainly across our 35 member practices, along with other providers, and stakeholders.

The uptake rate in 2016/17 annual survey was low at 41% (member practice participation 42%) and the feedback from respondents was often critical. The CCG has proactively managed the process this year. Our approach returned a much-improved response rate in 2017/18 of 92% (member practice participation 91%). This gives us a wealth of information to inform the development of our plans and activity.

Clinical engagement As a clinically led organisation, part of the CCG’s remit is to ensure that we have clinical leadership and engagement on all our pathway work. The CCG achieves this through several clinical engagement mechanisms.

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Each GP on the Governing Body carries a portfolio which is segmented into the following areas: Urgent and Emergency Care; Planned Care; Mental Health; Primary Care and Children’s services. We employ GP project leads to work alongside commissioning staff. During 2017/18 the CCG had GP engagement in the development and planning of pathways in the following areas:

GP project lead Session/ week

GP project lead Session/ week

End of life and cancer

1-2 Workforce and education

1

Children and younger People

2 Planned care 2

Quality 1 Long term conditions

2

Independent funding requests (IFR)

1 Primary care 2

Urgent care 1 Medicine management

2

Mental health 2

We engage with our GP members through local syndicate meetings and the quarterly Greenwich wide forum meeting. GP leads are involved in engagement events too.

GP leads represent Greenwich on South East London Sustainability and Transformation Partnership committees and work programmes, and at regular Clinical Cabinet meetings with Lewisham and Greenwich NHS Trust.

Sustainability and transformation partnership Our Healthier South East London (OHSEL) OHSEL is South East London’s Sustainability and Transformation Partnership (STP) and is a coming together of our health and social care partners in South East London to make sure we are doing all we can to work in partnership to get the best health outcomes for our population. It has evolved from a commissioner-led strategy – established in 2013 - into a partnership between local commissioners and providers, working with local authorities, patients and the public.

The STP is not a blueprint for the next five years: it is a series of plans for different clinical areas and enablers, such as workforce and estates, which are at different stages of development. The STP (full version and summary) was published on 4 November 2016 and was one of the first in the country to be made public. Our STP has set the following five priorities:

1. Developing consistent and high-quality community-based care (CBC), primary care development and prevention This includes promoting self-care, prevention and cooperative structures across parts of the system

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2. Improve quality and reducing variation across both physical and mental health This includes better integration of mental health, and reducing the pressure on and simplifying urgent and emergency care

3. Reducing cost through provider collaboration This includes consolidation of some non-clinical support services, including pathology and finance back office

4. Developing sustainable specialised services This includes mental health collaboration, renal and cardiac work

5. Changing how we work together to deliver transformation This includes the development of integrated care. It also focused on how we can make sure that we are able to provide care for the population of South East London as it grows and ages in a way that is affordable and meets the needs of a 21st century population.

Engagement In the summer of 2017, the STP held a series of six public events, one in each of the boroughs. The aim was to further engage with our communities about how they would like health services to develop in South East London, and to get feedback on our existing plans. The overall message was that we need to focus more on prevention, partnership working and better coordination of services. There was also a strongly held view that we need to do more to explain and engage on the STP. We published an independent feedback report from these events and also our response to how we will adapt to this feedback. In addition:

We have patient and public voices and Healthwatch representatives on each of our clinical and decision making workstreams influencing all our key programmes of work and feeding into our Patient and Public Advisory Group

We are working with Maternity Voice Partnerships from each borough to co-produce our Better Births Implementation Plan, setting our maternity transformation priorities for the whole of South East London.

We also continue to hold South East London wide Equalities Steering and Stakeholder Reference Group meetings to ensure our plans are assured around patient and public engagement and equalities issues.

Our approach has been informed and endorsed by The Consultation Institute, who advise on best practice engagement at national level. The engagement programme was also shortlisted for a national award by the Association of Healthcare Communications and Marketing (AHCM).

Some highlights from 2017/18 Better access to GPs: An extra £7.5 million has gone into primary care in South East London so that patients can book a GP at a time that suits them – including more evening and weekend slots. South East London has now delivered extended GP access at 100 per cent compliance. From 2018, all practices will offer online as well as telephone booking, allowing every single patient who chooses to, to manage their prescription and medical records online. We are developing community-based teams of family doctors, nurses and others to respond rapidly to people in crisis in their own homes and other settings to address. These teams

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deliver immediate care and put coordinated care plans in place to help manage ongoing care, so that people can stay at home when they would otherwise have been taken to hospital.

GP workforce: South East London Sustainability and Transformation Partnership secured national funding to recruit 45 international GPs to the boroughs of Bexley, Bromley, Greenwich and Lewisham. The first 25 recruits are anticipated to arrive in the South East London in autumn 2018. Lambeth and Southwark have since indicated that they too wish to participate in this programme and a further bid has been made to the national programme.

Faster cancer diagnosis: A rapid access diagnostic clinic based at Guy’s and St Thomas’ Hospital was launched to provide swift access to a range of diagnostic tests for patients presenting with vague symptoms. They have received over 400 referrals, with 31 of those resulting in a cancer diagnosis. Following a successful pilot in Lambeth and Southwark, the service is being extended to Bromley, Bexley, Lewisham and Greenwich from April 2018.

Mental health services: We are improving the link between physical and mental health and mental health support and liaison team in A&Es 24/7 and working towards no out- of-area placements for non-specialist care by 2021. We introduced an initiative to improve the mental health of people with diabetes through the ‘three dimensions for diabetes’ pilot. The overall aim is to integrate medical, psychological and social care for people with persistent and poorly controlled diabetes

Digitalisation of GP patient records: OHSEL secured funding to help 38 GP practices across South East London to digitalise their paper records. This will mean space can be made available for further clinical care and end reliance on paper records.

NHS 111: The online service was launched at www.111.nhs.uk, enabling patients to self-assess, receive self-care advice, be signposted to an appropriate service or receive a call back from an NHS 111 clinician, the pan London Dental Nurse Triage Service or one of the out of hours GP services.

Healthy London Partnership NHS Greenwich CCG, along with all London CCGs and NHS England (London), funded Healthy London Partnership (HLP) in 2017/18 to bring together the NHS in London and our partners to deliver London’s 10 ambitions to transform health and care for all Londoners. Partners include the Mayor of London, Greater London Authority, Public Health England, London Councils and Health Education England. We believe that collectively we can make London the healthiest global city in the world by uniting all of London to deliver the ambitions set out in Better Health for London: Next Steps and the national NHS Five Year Forward View.

During 2017, HLP were tasked with setting up the Urgent and Emergency Care Improvement Collaborative on behalf of NHS England (London), NHS Improvement (London) and the Association of Directors of Adult Social Services to transform the way that Londoners receive unplanned urgent care and support. This includes preventing the need to go to hospital, supporting them to become medical fit and well in hospital and then helping them to go home

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as soon as possible. The aim of the collaborative is to bring together leaders from health and social care working to define what improvement work needs to happen in London, drawing on the best practice around sustainable improvement and working with the leaders in this field. Key to this has been providing data to drive change, and as part of this work we ran three days of surveys of hospital bed occupants across 17 London hospital sites to understand where our improvement efforts need to be targeted.

Other highlights during 2017/18 include working with partners to launch Thrive LDN, a joint new citywide movement with the Mayor of London to improve mental health and wellbeing. Community workshops and problem-solving booths were held across London as part of Thrive’s ‘Are we okay London?’ campaign which has reached 15.5 million people so far.

The findings from the HLP year-long engagement with Londoners on childhood obesity, the Great Weight Debate, were published in 2018. Nine out of 10 Londoners who responded to the Great Weight Debate survey said tackling London’s childhood obesity epidemic should be either the top or a high priority for the capital. The findings are being used to inform every London borough’s childhood obesity strategy and have informed the Mayor’s London Plan which includes a policy to prevent new hot food takeaways from opening within 400 metres of a school. Following on from this, HLP are now working with fast food shops, businesses and communities in three London boroughs (Southwark, Lambeth and Haringey) to pilot their ideas for making high streets healthier for children and young people through the Healthy High Streets Challenge.

In 2017 HLP worked with Bexley and north and central London CCGs, along with NHS England, to trial the first NHS online pilots in the country. NHS online offers local people an alternative way to contact their GP and access online GP consultations when necessary. HLP also worked on behalf of London CCGs with NHS England (London region) to raise awareness of GP online services and GP extended access services across London. Nearly two million Londoners are now registered for GP online services and every London borough offers evening and weekend appointments to people in their local area.

Through partnership working, the Mayor of London, Secretary of State for Health Jeremy Hunt, London Councils and NHS, Public Health and wider health and care leaders signed the London Health and Care Devolution Memorandum of Understanding in November 2017. This deal paves the way for improving the health and wellbeing of all nine million Londoners. Devolution provides the foundations to enable us to improve the way health and care services are delivered in the capital at a faster pace. Through the work of the pilots over the past year it is evident that much more can be done to prevent ill-health, support people to make healthier choices and to join up health and care particularly when we work closely together. HLP are now leading engagement with system leaders to co-design the future of health and care across London which began with an event in December 2017. The London Health and Care Strategic Partnership Board (SPB) has been established to provide strategic and operational leadership for London-level health and care activities. HLP will continue to support the board and the wider system to implement devolution and wider health and care transformation goals and is committed to ensuring health and care leaders are updated on progress and are also involved in shaping the next steps for London.

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In 2017 HLP developed and published online training for GP receptionists to help people who are homeless access GP practices and produced 60,000 ‘my right to access healthcare’ cards for people who are homeless to make sure they can get equal access to healthcare given that they are much more likely to use A&E services than other Londoners.

At the beginning of 2018 HLP began working with partners including the Mayor of London, London Councils, Public Health England and the NHS, on a joint plan to cut rates of new HIV infection and eliminate associated discrimination and stigma. This followed the signing of the 'Paris Declaration on Fast-Track Cities Ending the AIDS Epidemic' in January 2018.

During 2018 HLP will evolve to formally support all the health and care partners to work together and strengthen their governance and delivery arrangements, so as a city we can implement the devolution agreement and our wider health and care transformation goals, to make sure we deliver on our commitments to make London the world's healthiest city.

Equality and diversity Public sector equality duties The public sector equality duties are of both general and specific duties. The broad aim of the general equality duty is to ensure consideration and the advancement of equality into the everyday business of all bodies subject to the duty. The general equality duty is intended to accelerate progress towards equality for all, placing a responsibility on bodies to consider how they can work to tackle systemic discrimination and disadvantage affecting people with particular protected characteristics.

Race

Disability

Sex

Age

Religion or belief

Sexual orientation

Gender reassignment

Pregnancy and maternity

The first aim of the general equality duty is to have due regard to the need to eliminate discrimination, harassment, victimisation and any other conduct prohibited by the Act because of any of these protected characteristics. The second aim of the duty requires the CCG to have due regard to the need to minimise or remove disadvantages, to take steps to meet the different needs of people with different protected characteristics and to encourage participation in activities by those whose participation is disproportionately low.

Meeting the public sector equality duties in 2017/18 The challenges to make NHS services inclusive and ‘fit for purpose’ for Greenwich’s diverse population cannot be underestimated within the current financial constraints on health and social care expenditure. Our focus for 2017/18 was to consolidate our equality, human rights and health inequalities work. Protecting human rights and promoting inclusion are integral to our core business and are reflected throughout everything that we do. The Equality Act 2010 provides a legal framework to strengthen and advance equality and human rights. The Act

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consists of general and specific duties. The general duty requires public bodies to show due regard to:

Eliminate unlawful discrimination

Advance equality of opportunity

Foster good relations

We must comply with this general duty when ‘exercising a function’, when formulating policy and to any decisions made in applying policy in individual cases. Compliance with the duty should result in:

Better-informed decision-making and policy development.

Clearer understanding of the needs of service users, resulting in better quality services which meet varied needs.

More effective targeting of policy, resources and the use of regulatory powers.

Better results and greater confidence in, and satisfaction with, public services.

A more effective use of talent in the workforce.

A reduction in instances of discrimination.

Equality, diversity and human rights obligations Control measures are in place to ensure that the CCG complies with the required public sector equality duty set out in the Equality Act 2010. Through these the CCG aims to:

Improve access and involvement to all services for all public, patients, carers and seldom heard groups.

Develop and implement twenty first century integrated, patient-focused health and care.

Reduce health inequalities through a targeted approach.

Achieve better outcomes for all.

Understand what constitutes a good patient experience.

Continue to develop an inclusive working culture and ensure the CCG values are incorporated in to all the work we do.

Empower, engage and support our staff.

Achieve an inclusive leadership at all levels.

All Greenwich CCG’s policies and procedures include an equality statement and all decisions made by the CCG undergo an equalities impact check list and / or full equality analysis, where appropriate. The learning from 2017/18 will be taken forward to strengthen the equality impact and analysis to achieve more timely and informed decisions in commissioning health services.

Our communities It is essential that we know our local population in Greenwich well as this allows us to make informed commissioning decisions. We map out local populations to understand health needs in specific communities or areas. Our overarching operational plan has been derived from key strategies. These include a joint health and wellbeing strategy, which identifies three key imperatives:

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A focus on prevention as the most cost effective approach to health and wellbeing.

The need for new approaches to tackling health inequalities.

Greater integration in the commissioning and delivery of local services.

The Joint Health and Wellbeing Strategy together with the Greenwich Joint Strategic Needs Assessment (JSNA), forms our integrated plan setting out our priorities and associated commissioning intentions. There is more information about this from page 8.

Partnership working We are working with our partners across South East London to develop plans for future services. The Sustainability and Transformation Plan (STP) aligns with Greenwich CCG’s equality objectives, and we play an active role along with other South East London CCGs, in the Our Healthier South East London (OHSEL) Equalities Steering Group. The Equalities Steering Group ensures that the latest intelligence and insight on health inequalities is shared across all CCGs and addressed by the programme. It identifies risks to the STP and its associated programmes whilst maintaining an overview of health inequalities and related public health insights. In 2018/19 the focus of this group will be more on the risks to the programme if equalities issues are not identified and resolved.

NHS Greenwich CCG works in partnership with provider organisations to include equality, diversity and human rights clauses within our contracts. Clinical Quality Review Groups (CQRGs) are established with providers which allow scrutiny of this work. A Healthwatch representative is on both CQRGs and the NHS Greenwich CCG Quality Committee.

We determine assurance of our trusts meeting their Public Sector Equalities Duty through monitoring NHS Equality Delivery Systems (EDS2) and the NHS Workforce Race Equality Standard (WRES) of our service providers. As part of our performance monitoring we work closely with trusts to improve their demographic data collection, to enable them to assess equalities and to measure success in addressing inequalities.

Equality is central to the CCG, both internally and externally, to ensure that all staff are considered in engagement. A staff health and wellbeing group has been established within the CCG to inform policies and procedures, appraisal and performance, organisational development, and health and wellbeing. We are committed to ensuring that staff are recruited and retained from diverse backgrounds, provided with a positive and valuing work environment and given training and support to achieve their maximum career development potential.

Workforce The CCG collects and analyses workforce statistics by groups of staff with protected characteristics enabling us to complete our Workforce Race Equality Standards annual return and produce a detailed Workforce Race Equality Standards Action Plan.

The collection of data on the workforce by ethnicity covers both workforce data and staff survey data to enable data analyses on staff employed and regular reports on workforce to Greenwich Executive Group.

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The CCG serves an ethnically diverse population which is reflected in its workforce. It is predominantly female. There is more information about this in our staff report.

Equality objectives 2017/21 As part of the Public Sector Equality Duty of the Equality Act 2010, we have continued to work on our equality objectives set out in our Equality and Diversity Strategy 2017/2021. The purpose of these objectives is to strengthen our performance against this general equality duty. The CCG focuses on the things that matter the most for patients, communities and staff, with an emphasis on genuine engagement, transparency and the effective use of evidence. The equality objectives reflect local equality priorities for our community. They reflect the key equality priorities pertinent at that time. Our most recent equality objectives report can be found on our website.

The Equality Delivery System (EDS2) The Equality Delivery System (EDS2) is the NHS equalities reporting framework. It helps us to identify what we are doing well, what we need to improve on, and the equality gaps/risks that we need close or mitigate. It is a comprehensive analysis focusing on four goals (better health outcomes, improved patient access and experience, a representative and supported workforce, and inclusive leadership) measured against eighteen equality and health inequalities outcomes.

Like most CCG’s, we have taken a two-stage approach to implement EDS2. During stage one, we self-assessed our progress made against EDS2’s four goals and 18 outcomes, using a Red, Amber, Green (RAG) rating. A draft of our stage one self-assessment report includes what evidence exists to support the RAG rating, equality gaps and actions that may need to be taken to ensure that we are making progress. Stage two will involve working with local organisations. However, more work is required in the way that the CCG presents the demographic data relating to access, outcomes and experience.

This year the CCG EDS2 self-assessment will maintain an overall rating of Amber (Developing). This is because there is still more work to be undertaken in the collection of patient demographic data specifically regarding the different protected characteristics by our service providers. Therefore, the CCG cannot fully assure itself that the EDS2 outcomes are reported for all protected characteristic groups. The EDS2 action plan now considers these equality gaps and risks identified in the EDS2 summary report. The NHS Greenwich CCG Equality Report 2017/18 is available on the CCG website.

Emergency preparedness, resilience and response (EPRR) Along with other CCGs, Greenwich CCG was required to submit its EPRR assurance to NHS England in October 2017. In accordance with the requirements laid out in the National assurance process documentation, an organisation’s overall level of compliance is based on the total number of amber and red ratings agreed at the review.

In respect of NHS Greenwich CCG, for core standards 1-51, the CCG had two amber ratings:

Core standard 5 - ‘Assess the risk, no less frequently than annually, of emergencies or business continuity incidents occurring which affect or may affect the ability of the organisation to deliver its functions’.

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Core standard 6 - ‘There is a process to ensure that the risk assessment(s) is in line with the organisational, Local Health Resilience Partnership, other relevant parties, community (Local Resilience Forum/Borough Resilience Forum), and national risk registers’.

The CCG received 0 red ratings for the governance deep dive.

NHS Greenwich CCG is assessed overall for the 2017 EPRR assurance as achieving a ‘substantial’ level of compliance.

NHS England noted that Greenwich CCG has demonstrated an ongoing high standard of EPRR and had appropriate documentation alignment with ISO 22301 standard, which sets out the requirements for a business continuity management system (BCMS) and is considered the only credible framework for effective business continuity management in the world. The CCG action plan submitted had two outstanding actions for areas rated amber:

Core standard Outstanding action to be taken

Timeframe for completion

Lead

Core standard 5 Assess the risk, no less frequently than annually, of emergencies or business continuity incidents occurring which affect or may affect the ability of the organisation to deliver its functions

Action plan has been drawn up for 18/19

30 January 2018 Emergency Planning Lead Officer (EPLO) Director of Quality and Integrated Governance

Core standard 6 There is a process to ensure that the risk assessment(s) is in line with the organisational, Local Health Resilience Partnership, other relevant parties, community (Local Resilience Forum/ Borough Resilience Forum), and national risk registers

An EPRR risk register has been created and will link in with Corporate and other relevant parties risk registers

30 January 2018 EPLO Director of Quality and Integrated Governance

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Exercises and training

Our staff undertook a range of training and exercise initiatives to support EPRR during 2017.

Date Exercise Attended by

28.03.17 RBG multi-agency desktop exercise flood plan/flood warden scheme exercise

EPLO

19.06.17 Communication exercise

Call cascade to all staff All staff

18.07.17 RBG multi-agency desktop exercise carmine pipeline

EPLO

15.08.17 Communication exercise

Call cascade to work mobile phone All staff with work mobile phone

17.10.17 and 31.10.17 Major incident and business continuity training

All staff

17.11.17 Table top exercise testing the pandemic flu policy

One member of staff from each team across the CCG

15.12.17 RBG multi-agency desktop exercise humanitarian assistance in response to and recovery from a major incident

EPLO

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Section 2 Accountability Report

Andrew Bland Accountable Officer 25 May 2018

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Members’ Report Our members These are the 35 member practices which form the membership body of the CCG.

Blackheath and Charlton Excel (Plumstead and Abbeywood)

Blackheath Standard PMS Abbey Wood Surgery

Burney Street PMS All Saints Medical Centre PMS

Greenwich Peninsula Practice Bannockburn Surgery

Manor Brook PMS Waverley PMS

Plumbridge Medical Centre Clover Health Centre

Primecare PMS (South Street) Glyndon PMS

Fairfield PMS Mostafa PMS

Vanbrugh Health Centre Plumstead Health Centre PMS

Woodland Surgery Abbeyslade PMS (Dr Chand) Triveni PMS

Eltham Network (Woolwich and Thamesmead)

Dr V Sandrasagra’s Conway PMS

Briset Corner Surgery Valentine Health Partnership

Dr Baksh’s Practice TMA PMS (Gallions Reach Health Centre)

Dr J Lal’s Practice Royal Arsenal PMS

Eltham Medical Practice St Marks PMS

Eltham Palace Surgery Thamesmead Health Centre

Eltham Park Surgery The Trinity Medical Centre

Primecare PMS (Coldharbour)

Sherard Road Medical Centre

Practices are formed in four syndicates: Blackheath and Charlton, Eltham, Excel and Network. Each syndicate covers a geographical area and practices within the syndicate work together through peer review and regular meetings.

Each practice has signed the CCG’s Constitution. This states how member practices will be engaged through regular syndicate meetings and with the GP Executive through the quarterly Greenwich wide forum meetings. A GP Syndicate Lead for each of the four syndicates is voted in by the members of their syndicate. Syndicate Leads act as the conduit between the CCG and its GP membership body to deliver messages and get feedback on commissioning decisions. Syndicate meetings are held bi-monthly in line with the Constitution and the four GP Syndicate Leads meet monthly with the GP Executive.

There are monthly meetings of Syndicate and Clinical Project Leads with the GP Executive and each practice is represented at the quarterly Greenwich wide forums.

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The table below demonstrates the growth in GP list sizes.

Greenwich CCG - Syndicate List Sizes 100,000

90,000

80,000

70,000

60,000

50,000

40,000

Blackheath & Charlton

Eltham

Excel

Network

30,000

20,000

10,000

April 2014 April 2015 April 2016 April 2017 March 2018

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Greenwich Executive Committee The Executive Committee consists of the GP Executive (elected Governing Body members) and the CCG senior management team and is made up of the following staff:

Name Role

GP Executive

Dr Sylvia Nyame GP elected member

Dr Nayan Patel GP elected member

Dr Ranil Perera GP elected member

Dr Sabah Salman (until 17.1.18) GP elected member

Dr Krishna Subbarayan GP elected member

Dr Jaisun Vivekanandaraja (from 17.1.18)

GP elected member

Dr Hany Wahba GP elected member

Dr Ellen Wright GP elected member and Chair of the Governing Body

Senior Management Team

Andrew Bland (from 11.9.17) Chief Officer

Vanessa Fowler (from 1.10.17 to 15.12.17)

Director of Commissioning

Liz James (until 30.9.17) Director of Commissioning

Neil Kennett-Brown (from 25.9.17) Managing Director

Yvonne Leese Director of Quality and Integrated Governance

David Maloney Chief Finance Officer

Virginia Morley (from 27.11.17) Director of Commissioning Development

Joanne Murfitt until 10.9.17) Chief Officer

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Governing Body The Governing Body oversees the delivery of the CCG’s commissioning plan, sets and leads the strategy for the CCG, and is accountable for the delivery of Greenwich CCG’s functions as a statutory body. It monitors performance against objectives, provides effective financial stewardship and makes sure that high standards of corporate governance are achieved. Having GPs and other clinical members of the Governing Body ensures all our decisions are made with clinical leadership and considering Greenwich patients.

The Governing Body meets on alternate months in public, with extra meetings as necessary. Papers and minutes of the meetings are published on the CCG website. All meetings have declarations of interests as an agenda item and these are recorded. All members are required to record any interests relevant to their role on the Governing Body. The register of interests is a public document which is open to public scrutiny and published on the CCG website.

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The composition of the Governing Body in 2017/18 (including advisory and non-executive members) is as follows:

Name Role

Andrew Bland # (from 11.9.17)

Chief Officer

Maggie Buckell # Registered Nurse

Vanessa Fowler (from 1.10.17 to 15.12.17)

Director of Commissioning

Councillor David Gardner

Local Authority Member

Amana Humayun # + (from 12.6.17)

Vice Chair and Lay Member for Audit and Remuneration and Conflicts of Interest Guardian

Liz James (until 30.9.17)

Interim Director of Commissioning

Neil Kennett-Brown (from 25.9.17) Managing Director

Yvonne Leese Director of Quality and Integrated Governance

David Maloney # Chief Financial Officer

Virginia Morley (from 27.11.17) Director of Commissioning Development

Joanne Murfitt # (until 10.9.17)

Chief Officer

Dr Sylvia Nyame # GP Member

Dr Nayan Patel # + GP Member Dr Ranil Perera # GP Member Richard Rice # Lay Member Primary Care Commissioning Lead Dr Sabah Salman # (on sabbatical from 17.1.18 and returned 1 May 2018)

GP Member

Dr Krishna Subbarayan # GP Member

Dr Greg Ussher # + Lay Member for Patient and Public Engagement

Dr Iyngaran Vanniasegarum # + Secondary Care Doctor Governing Body

Dr Jaisun Vivekanandaraja # (seconded from 17.1.18 to cover Dr Sabah Salman’s sabbatical)

GP Member

Dr Hany Wahba # GP Member

Steve Whiteman Director of Public Health, Royal Borough of Greenwich

Jim Wintour # (until 11.6.17)

Vice Chair and Lay Member for Audit and Remuneration and Conflicts of Interest Guardian

Dr Ellen Wright # Chair of the Governing Body and GP Member

# = Voting member + = Member of the Audit Committee

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Register of interests Greenwich CCG is committed to the principles of good governance, leading to open and transparent decision making. We have therefore established a policy to manage conflicts of interests to ensure that decisions made by the CCG will be taken and seen to be taken without any possibility of the influence of external or private interests. Our policy was updated in December 2017 and takes account of the latest statutory guidance. A conflict of interest is defined as:

A conflict between the private interests and the official responsibilities of a person in a position of trust.

A set of conditions in which professional judgement concerning a primary interest (such as patients’ welfare or the validity of research) tends to be unduly influenced by a secondary interest (such as financial gain).

The creation of a set of circumstances where one party is favoured over another by an inadvertent preferential interest.

In line with our conflicts of interest policy, arrangements to seek and receive declarations of interest and maintain Registers of Declared Interests and Gifts and Hospitality have been put in place. We publish our register of interests on our website, as well as a gifts and hospitality register.

The CCG’s conflicts of interest policy and procedures were independently audited in 2017/18. The CCG was given an overall rating of “substantial assurance”, the highest rating, with the comment that the CCG “can take substantial assurance that the controls upon which the organisation relies to manage the identifies risk(s) are suitably designed, consistently applied and operating effectively”.

The audit noted that two members of staff from the audit sample, had not submitted a recent declaration and the CCG was asked to ensure that those individuals did not vote on CCG decisions until fresh declarations had been received. It was also noted that, at the time of the audit, the NHS England Conflict of Interest training programme had only just been released and CCG had been asked to ensure relevant CCG staff had completed the first module by 31 May 2018. Both items were assessed as low risk.

Personal data related incidents Information relating to the disclosure involving data loss and confidentiality breaches can be found in the Annual Governance Statement.

Statement of disclosure to auditors Each individual who is a member of the CCG at the time the Members’ Report is approved confirms:

So far as the member is aware, there is no relevant audit information of which the CCG’s auditor is unaware that would be relevant for the purposes of their audit report.

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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 statement NHS Greenwich CCG fully supports the Government’s objectives to eradicate modern slavery and human trafficking but does not meet the requirements for producing an annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act 2015. However, in line with best practice we publish a statement detailing our local approach on our website.

Statement of Accountable Officer’s responsibilities The National Health Service Act 2006 (as amended) (the NHS Act 2006) states that each Clinical Commissioning Group (CCG) shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed Joanne Murfitt to be the Accountable Officer of Greenwich CCG who held the position from 1 April 2017 to 10 September 2017. Andrew Bland was appointed as Accountable Officer with effect from 11 September 2017 to 31 March 2018.

The responsibilities of an Accountable Officer are set out under the NHS Act 2006, 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;

Keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the CCG and enable them to ensure that the accounts comply with the requirements of the Accounts Direction;

Such internal control as they determine is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error;

Safeguarding the CCGs 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 NHS Act 2006 and with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the NHS Act 2006; and

Ensuring that the CCG complies with its financial duties under Sections 223H to 223J of the NHS Act 2006.

Under the NHS Act 2006, NHS England has directed each CCG 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 CCG and of its net expenditure, changes in taxpayers’ equity and cash flows for the financial year.

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In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Group Accounting Manual issued by the Department of Health and in particular to:

Observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis;

Make judgements and estimates on a reasonable basis;

State whether applicable accounting standards as set out in the Group Accounting Manual issued by the Department of Health have been followed, and disclose and explain any material departures in the financial statements; and,

Assess the CCGs ability to continue as a going concern, disclosing, as applicable, matters related to going concern; and

Use the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity.

To the best of my knowledge and belief, and subject to the disclosures set out below, I have properly discharged the responsibilities set out under the NHS Act 2006, Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter.

Disclosures NHS England issued legal directions to help address long standing performance problems with local urgent and emergency care services. Under these directions from 1 September 2017 our responsibility for acute commissioning and contracting has been temporarily transferred to Southwark CCG. This has also supported our ambitions as a CCG and helped us address areas found to require improvement in 2017/18. High quality healthcare and patient experience are of paramount importance to Greenwich CCG and we have worked closely with local NHS partners to ensure that patients receive the very best standards from the NHS. The Integrated Contracts Delivery Team (ICDT) hosted by Southwark CCG has provided regular performance monitoring reports to our Finance Performance and QIPP Committee.

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; and

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.

Andrew Bland Accountable Officer 25 May 2018

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Governance statement Introduction and context NHS Greenwich 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 September 2017, the clinical commissioning group is subject to directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006 as follows:

NHS England issued legal directions to help address long standing performance problems with local urgent and emergency care services. Under these directions from 1 September 2017 our responsibility for acute commissioning and contracting has been temporarily transferred to Southwark CCG.

You can read more about the legal directions here.

You can access the latest published information about the CCG’s performance against the improvement and assessment framework (IAF) here.

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.

Greenwich CCG is responsible for the procurement of services on behalf of the residents of Greenwich. We are responsible for creating suitable arrangements with providers of services that are in the best interests of the service users, and also represent value for money.

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Considering the complexity and range of services offered it is vital that we have a governance structure with sufficient delegation to ensure that decisions can be made but also sufficient oversight to prevent any deviation from the statutes of the constitution.

Greenwich CCG is accountable for exercising its statutory functions. It may delegate authority to act on its behalf to:

any of its members

the Governing Body

employees

any committees or sub-committees established by Greenwich CCG for the purpose of exercising its statutory functions

The extent of the authority of the respective bodies and individuals depends on the powers delegated to them by Greenwich CCG as expressed through:

1. Its Scheme of Reservation and Delegation; and 2. for committees, their terms of reference.

The Scheme of Reservation and Delegation sets out:

1. Those decisions that are reserved for the membership as a whole 2. Those decisions that are the responsibilities of the Governing Body (and its committees),

and sub-committees, individual members and employees. However, Greenwich CCG remains accountable for all of its functions, including those that it has delegated.

Greenwich CCG has a robust corporate governance structure with the roles and responsibilities of the members of the Governing Body and supporting Committees clearly set out.

Each member of the Governing Body shares responsibility as part of a team to ensure that the group exercises its functions effectively, efficiently and economically, with good governance and in accordance with the terms of its constitution. Each Governing Body member brings their own unique perspective, informed by their skills, knowledge and experience.

During the year the Governing Body has:

Approved the CCG’s operating plan and corporate objectives for 2017/18.

Agreed the CCG’s budget for the year.

Approved the annual equalities report.

Received and endorsed the plan for collaborative working across South East London.

Made arrangements to take questions from the public before its formal meetings.

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Received a performance report and a quality report, with additional exception reports, through which the Governing Body has been advised of the quality and safety of commissioned services and other performance and financial issues.

Received and taken assurance that strategic risks were effectively mitigated.

Received confirmation of “substantial” assurance against the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR).

Ensured that any conflicts of interest were appropriately managed.

Approved the CCG’s Organisational Recovery Plan.

Approved the CCG’s Organisational Development Strategy 2018 to 2021 and detailed plan for 2018/19.

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Governing Body meeting attendance 2017/18 26.4

D 31.5 P

28.6 D

26.7 P

30.8 D

20.9 P

27.9 AGM

25.10 D

29.11 P

20.12 D

24.1 P

28.2 D

28.3 P

%

Andrew Bland (from 11.9.17)

Y Y Y Y Y Y Y Y 100

Maggie Buckell Y Y Y Y Y Y Y Y Y Y N Y Y 92

Vanessa Fowler (from 1.10.17 until 15.12.17)

N Y 50

Councillor David Gardner

Y Y Y Y Y Y Y Y Y Y Y Y Y 100

Amana Humayun (from 12.6.17)

Y Y Y Y Y Y Y Y Y N Y 91

Liz James (until 30.9.17)

Y Y N Y Y Y Y 86

Neil Kennett- Brown (from 25.9.17)

Y N Y Y Y Y Y 86

Yvonne Leese Y Y Y Y Y Y Y Y Y Y Y Y Y 100

David Maloney Y Y Y Y Y Y Y N Y Y Y Y Y 92

Virginia Morley (from 27.11.17)

N Y Y Y Y 80

Joanne Murfitt (until 10.9.17)

Y Y Y Y Y 100

Dr Sylvia Nyame Y Y Y Y Y N Y Y Y Y Y Y Y 92

Dr Nayan Patel Y N Y N Y Y Y Y Y Y Y Y Y 85

Dr Ranil Perera N Y Y N Y Y Y Y Y Y Y N N 69

Richard Rice Y Y Y Y N Y Y N Y Y Y Y Y 85

Dr Sabah Salman (until 17.1.18)

Y Y Y Y Y N Y Y Y Y 90

Dr Krishna Subbarayan

Y Y Y Y Y Y N Y Y Y Y Y N 85

Dr Greg Ussher Y N N N Y Y Y N Y Y Y Y Y 69

Dr Iyngaran Vanniasegarum

Y Y N Y Y Y N Y Y Y N Y Y 77

Dr Jaisun Vivekanandaraja (from 17.1.18)

N Y Y 67

Dr Hany Wahba Y Y Y N Y Y N Y Y Y Y Y Y 85

Steve Whiteman Y Y N Y Y Y Y Y Y Y Y Y N 85

Jim Wintour (until 11.6.17)

N Y 50

Dr Ellen Wright Y Y Y Y Y Y Y Y Y Y Y N Y 92

Members must attend at least 75% of meetings of the Governing Body or, where this is not possible, the Chair must be satisfied as to the reasons. Key: E = Extraordinary Meeting, P = Public Meeting, D = Development Meeting, AGM = Annual General Meeting.

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Greenwich CCG uses a number of committees to provide challenge and assurance over specific areas, for example Quality, Improvement, Productivity and Prevention (QIPP) delivery through the Financial Recovery Board and Financial Performance and QIPP Committee.

All committees are formed with a membership that provides a sufficient range of skills, including clinical expertise and lay membership, to provide effective management and oversight. The committees are referenced within the NHS Greenwich CCG Constitution. For those committees which report directly to the Governing Body, minutes are available in the Governing Body papers.

The performance of the Governing Body includes development workshops held throughout the year, some with external facilitation. All GP Governing Body members and the Chief Officer have a review halfway through the year and an appraisal at the end of the year with the CCG Chair.

Governing Body Officers, i.e. the Chief Finance Officer and all directors have an appraisal with the Accountable Officer or the Managing Director as appropriate.

GP Syndicate Leads and Clinical Project Leads (CPLs) meet with their GP Executive through a formal clinically led meeting to review performance as well as support and guidance outside

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of the meeting, e.g. to develop and lead on QIPP programmes. The NHS England CCG 360 degree stakeholder survey is undertaken annually.

Committees are accountable to either the Governing Body or the committee that established them. Control is exercised through the receipt of their minutes by either the Governing Body or the relevant sponsoring committee. Reports can also be made to these meetings by the Committee Chairs where required and the Chairs can also bring matters onto the agendas of their sponsoring body/committee whenever they believe this is necessary. The minutes and reports of committees that report to the Governing Body (unless they are confidential) are published on the CCG website with the Governing Body papers.

The terms of reference for committees are approved by their sponsoring body/committee and cannot be exceeded without further subsequent approval.

The Nolan principles are embedded within the CCG’s governance arrangements.

The Risk Register is maintained to a good standard giving adequate details on risks, controls and action plans in place.

The Governing Body Assurance Framework comprehensively addresses strategic risks to the organisation.

Audit Committee The committee was established to take an independent and objective view of the CCG’s financial systems, compliance with laws and compliance with best practice in its arrangements for corporate governance. The committee has reflected on its work and had agreed that it goes about its work in organised, accountable and informed way. In 2017/18:

Its work programme followed a plan agreed at the start of the year.

It makes it clear to CCG management and staff what is required from them in the preparation and running of meetings.

It reports to the Governing Body via provision of minutes of the meetings once confirmed.

During the year, the work of the Audit Committee included:

Approved the 2016/17 Annual Report and Annual Accounts on behalf of the Governing Body.

Received the Head of Internal Audit Opinion for 2016/17.

Approved the Internal Audit Plan for 2017/18 and commented on reports of the reviews.

Reviewed Service Auditor Reports.

Approved the counter fraud work plan for 2017/18 and commented on progress.

Scrutinised and advised on the format and content of the Board Assurance Framework, including detailed discussions in to specific areas.

Reviewed the local security management workplan for 2017/18 and commented on progress.

There were four meetings of the Audit Committee during the year. The committee was supported by the CCG management team, with appropriate attendance as required. The Chief Finance Officer attended all meetings.

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UK Corporate Governance Code We are not required to comply with the UK Corporate Governance Code. However, we have reported on our corporate governance arrangements by drawing upon best practice available, including those aspects of the UK Corporate Governance Code we consider to be relevant to the CCG.

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 risk management framework sets out the overarching approach to the management of risk in the organisation. The Governing Body is aware of all significant risks and has sufficient information to enable it to make decisions on the implementation of appropriate controls and the allocation of appropriate resources.

The risk management framework outlines definitions, accountabilities and responsibilities of all staff, the risk management process and its governance, including managing risk across organisational boundaries and training.

All directors and managers are required to identify risks specific to their own activities and circumstances. Risks may be identified from a number of sources, both internal and external. No valid risk will be excluded from the register due to its identification source. Staff are encouraged to be risk aware. The Director of Quality and Integrated Governance maintains a strategic overview of risk.

Zero tolerance risks are clearly identified on the CCG’s risk register and in all reporting. The Governing Board assurance framework provides the Governing Body with a clear understanding of the principal risks which may affect the achievement of performance objectives for the financial year and therefore informs the annual statement of internal control declaration. The Governing Body assurance framework is formally reviewed at every meeting of the Governing Body and Greenwich Executive Group (monthly basis).

Control measures are in place to ensure that obligations under equality, diversity and human rights legislation are complied.

The CCG’s integrated risk management framework sets out the overarching approach to the management of risk in the CCG. The CCG adopted the risk management framework in July 2013. The framework was updated and changes approved by the CCG Governing Body in November 2016. The strategy outlines the CCG’s approach to risk and the manner in which

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the CCG seeks to prevent, eliminate and control risks and the successful management of the risks that impact most upon the CCG’s objectives.

Risk management is embedded within all activities of the CCG. The CCG is able to ensure accountability of risk at all levels of the organisation.

The purpose of this framework is to define and document the CCG’s approach to risk and risk management and to:

Enable the Governing Body to have an overview of the risks it faces, taking into account all aspects of its business.

Provide assurance to the Governing Body that action is being taken to mitigate risk to acceptable levels.

Assure the public, patients, practices, partner organisations and staff that the CCG is managing its risks effectively.

Enable the strategic deployment of resources to meet risk, beyond allocations made if necessary, including financial funding, human resources, capacity and knowledge.

Enable constant and consistent improvement of healthcare provision and patient experience.

Below is the risk appetite statement which was agreed by the Governing Body and is included in the CCG’s risk management framework: NHS Greenwich CCG is working toward a ‘mature’ risk appetite. The CCG has no appetite for financial risk and zero tolerance for fraud and regulatory breaches (e.g. safeguarding breaches, poor professional conduct of its staff and information governance [data protection] breaches).

Greenwich CCG may take considered risks, where the long-term benefits outweigh any short- term losses. The CCG supports well managed risk taking and will ensure that the skills, ability and knowledge are there to support innovation and maximise service improvement. The Governing Body commits to review its risk appetite statement on an annual basis.

Zero tolerance risks are clearly identified on the CCG’s risk register and in all reporting. All risks are recorded on the Risk Register and clearly identify the responsible director and clinical lead with the levels of risk including actions which should be taken to mitigate the risks. These are reviewed monthly and discussed at appropriate committees. The CCG also identifies and manages risks via internal and external methods such as complaints, claims, serious incidents, audits, patient satisfaction surveys, risk assessments, staff surveys, whistle blowing, new legislation, and review from partnership working.

The CCG is responsible for overseeing the commissioning of healthcare and other services from a wide variety of providers. One of the key purposes of the CCG’s risk management process is to ensure that services are commissioned from providers who themselves operate high standards of risk management processes.

By ensuring that all staff are aware of their responsibilities in regard to both governance and health and safety, a substantial amount of progress has been made towards ensuring the ownership of risk by staff and the wider membership of each of the sub-committees.

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The CCG places a 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 that all staff undertake annual information governance training. There are processes in place for incident reporting and investigation of serious incidents.

Public involvement in managing risk We use a variety of patient experience data to understand how different services are performing. Whilst these are individually addressed, a thematic analysis is undertaken regularly. The results are presented to the Greenwich Executive Group and the Quality Committee and used to inform our commissioning intentions. There are a number of methods used to ensure our public stakeholders are involved in managing any risks that impact on them:

Quality alerts raised by GPs and other healthcare professionals on behalf of their patients. Alongside our ‘quality alert’ system, there are many other routes through which the public can make us aware of any concerns. They can raise issues through their GP practice’s Patient Participation Group.

Lay members sit on the Governing Body and a number of committees. Through their attendance they are involved in the review of the risk register and challenge/input into the way in which the organisation mitigates those risks.

The risk register detailing all identified risks and plans for how they will be addressed is published on our public website.

Prior to Governing Body meetings held in public there is a question and answer session where any issues can be raised. All questions are answered at the time, where possible, and then taken away to be answered more fully, where necessary. The feedback is then published on our public website and fed back in person at the next Governing Board meeting.

A Patient Reference Group, that includes representation from Healthwatch and METRO GAVS has been established to seek assurance and monitor engagement, and to review progress on our patient and public engagement strategy. This group also provides guidance to our commissioners to ensure involvement is embedded into every stage of the commissioning cycle, including identifying risks and their mitigation.

Public stakeholders inform service redesign and the issues and concerns they raise are picked up during this process.

We have built relationships with our local MPs who can raise constituents’ issues for us to address and we have a system in place to respond appropriately.

We attend the Royal Borough of Greenwich Healthier Communities and Adult Social Care Scrutiny Panel. This gives elected Council members and the public the opportunity to question and challenge the CCG. The committee has reviewed our QIPP plan for the year, the performance of the whole system emergency care pathway, the implementation of a new musculoskeletal service in April 2017 and the outcome of our consultation on extensions to the current treatment access policy.

Deterrents to risk arising: counter fraud During 2017/18 the CCG commissioned TIAA, a local counter fraud specialist, to deliver a counter fraud service. The TIAA follows the guidance and standards, set by NHS

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Protect. The local counter fraud specialist TIAA provides the CCG with assurance through regular meetings with the Chief Finance Officer to review the counter fraud plan and discuss cases. The local counter fraud specialist also presented regular reports to the CCG Audit Committee and also provides training regarding counter fraud, bribery and corruption to all CCG Staff. Counter fraud policies and services are provided by internal audit. Regular updates and alerts are communicated to all staff.

The following arrangements are in place:

Proactive and reactive measures are taken by the counter fraud services to deter and identify fraud as well as to encourage staff to report fraud.

The CCG’s standing orders, standing financial instructions and the scheme of reservation and delegation.

Conflicts of interests (CoI) are declared at all Governing Body and Committee meetings and subcommittee meetings. The CCG is compliant with CoI guidance and the Governing Body and Senior Management Team participate in development sessions on CoI.

Management notifies the local counter fraud service and/or Chief Finance Officer of any concerns of fraud. At the conclusion of an investigation, the local counter fraud service forwards recommendations to the Chief Finance Officer, which are also reported to the Audit Committee. internal audit and the local counter fraud service hold liaison meetings during the year in order to discuss high risk areas.

Where management identifies any risk of fraud they are able to introduce appropriate controls to counter the risk.

Risks relating to fraud and bribery will be added to the risk register when they occur and then reviewed by the Governing Body as appropriate.

Capacity to handle risk The capacity to handle risk is clearly described within the risk management framework. Leadership is given to the risk management process through the roles and responsibilities set out within the strategy from the Accountable Officer, directors, senior managers, lead managers with specific remits for risk, patient safety and compliance through to all staff.

Staff are trained or equipped to manage risk in a way appropriate to their authority and duties. The Datix system is established and utilised across the organisation in risk management. The Greenwich CCG risk management framework is available on the CCG intranet under the section of policies. All staff are encouraged to access this and familiarise themselves with the strategy whilst developing an understanding of what is expected of them in line with risk management within the CCG.

To enable the integrated risk management framework to be fully implemented, training sessions and workshops are delivered to managers, staff and clinical professionals. The sessions include:

Introductory and refresher training for risk management and governance as appropriate to the roles and responsibilities of staff within Greenwich CCG and the Governing Body.

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The provision of appropriate resources to ensure the ongoing development of risk management capacity and capability within the Governing Body.

Greenwich CCG staff have embedded learning events with providers to ensure shared learning and good practice with regard to serious incidents. The CCG culture is such that it encourages openness and transparency throughout the system about matters of concern. This is in line with the recommendations from the Francis Report (Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry 2013).

Where risk is created by deliberate failure to adhere to policy or acting outside professional codes of conduct, action may be taken against individuals under the disciplinary committee. Greenwich CCG fosters a risk aware culture shared by all in the services in putting patients first.

To support the culture of listening, learning and responding within the organisation, the CCG will:

Be open and fair.

Approach all incidents, complaints and issues fairly and equally.

Ensure transparency in the review of incidents and complaints and other issues and transfer the learning both internally and externally.

Ensure all staff are aware of this strategy and processes and all other associated policies that complement robust risk management and internal control within the CCG.

Support and advise staff with matters relating to risk management.

Provide relevant training and information resources.

Acknowledge reports received and provide feedback on actions and decisions to demonstrate that the CCG has listened.

Ensure there is a framework through which staff can raise concerns, malpractice and impropriety in a supportive manner.

Respond to gaps in policy and processes to improve outcomes, experience and the overall management of risk.

Risk assessment Our risk management framework sets out our risk assessment process and is based on the national patient safety advice (NPSA) guidance and aligned to the adopted internationally recognised AS/NZS 4360:1999 guideline which provides a model for identifying, assessing and controlling risks. Further information on how the CCG manages the principles of risk management, can be found under the risk management framework section above. Risks in relation to governance, risk management and internal control were identified and have been incorporated into the Governing Body board assurance framework (BAF) and the CCG’s risk register for scrutiny.

The BAF broadly provides assurance of the controls in place that mitigate the risks that may prevent Greenwich CCG meeting its annual strategic objectives. Throughout 2017/18 the Governing Body has received detailed reports of the controls in place, assurances given and further actions being taken to manage or mitigate those risks that have a residual score of 12

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or above (score of likelihood x impact). These reports are contained within the papers for our Governing Body meetings which are published on our website.

During 2017/18, four risks were assessed at the end of the year to have a ‘very high’ rating in March 2018. These were:

Breaching of 62 day referral to treatment cancer target may create delays in accessibility and impact on treatment.

Breaching of the 18 week referral to treatment (RTT) standard which may impact on patients’ diagnoses and treatment.

Potential loss of organisational memory due to the transition process of senior manager roles in the organisation.

Acute contracts may over perform in 2017/8, which may impact on the CCG’s ability to deliver its core functions.

In response to this risk rating the Governing Body received detailed action plans for how the CCG would work in conjunction with partners or internally to reduce these. .

Risk assessment matrix used within the CCG

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.

NHS Greenwich CCG’s system of internal control is intended to manage risks and not to eliminate risks. To this effect, we have different committees who are responsible for

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overseeing the process of risk management within the CCG. Overall responsibility for risk management rests with the Governing Body.

Our system of internal control has been maintained through the monitoring and delivery of its Governing Board assurance framework (GBAF) by the Governing Body. Led by the Director of Quality and Integrated Governance, the GBAF provides a structure and process that enables the CCG to focus on those risks that might compromise achieving its most important (principal) annual objectives. It maps out both the key controls that should be in place to manage those objectives and confirms that the Governing Body has gained sufficient assurance about the effectiveness of those controls.

The effectiveness of the system of internal control is informed by the work of internal auditors, external auditors, Governing Body, committees, directors and clinical leads within the CCG who have responsibility for the development and maintenance of the internal control framework. The Governing Body assurance framework provides the evidence that the effectiveness of controls that manage the risks of the CCG achieving its strategic corporate objectives have been reviewed. The framework has been actively managed and reviewed regularly by the Executive Team, Governing Body and Audit Committee.

The risk management framework sets out the overarching approach to the management of risk in the organisation. The Governing Body is aware of all significant risks and has sufficient information to enable it to make decisions on the implementation of appropriate controls and the allocation of appropriate resources.

The CCG’s aims and objectives are aligned to the Governing Body assurance framework, which is presented at each meeting of the Governing Body in public. Organisational objectives are embedded in the annual objectives of CCG staff at all levels within the organisation and success in achievement of them is measured through the staff appraisal process. All CCG policies follow a standard operating procedure and adhere to the CCG’s policy on policies. The policy on policies outlines the appropriate governance route for approval of policies.

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 carried out their annual internal audit of conflicts of interest in 2017/18 and was assessed as having “substantial” assurance. The extract from the auditor report sets out their recommendations and the actions the CCG will be taking to address them.

To make staff across CCGs more aware of their duty to make true declarations, NHS England has developed online training that was launched in January 2018 and is mandatory for all decision-makers in the CCG to complete by the end of May 2018.

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Data quality In line with the “need to know” principles set out in the Caldicott 2 Information Governance Review Report, the CCG ensures that information presented to the Governing Body and other governance fora does not identify individuals and is fully anonymised.

Senior management diligently reviews information to be set out in governance and decision- making prior to consideration and presentation to the relevant governance fora.

The quality of information that the Governing Body and other governance fora receive to consider and direct decision making is also assured through service level specification arrangements with the North East London Commissioning Support Unit and the use of contractual arrangements with commissioned providers.

Information governance

The NHS information governance framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS information governance framework is supported by an information governance (IG) 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 CCG demonstrated a high level of compliance by completion of the IG Toolkit which was published in March 2018 with a score of 89%.

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.

The Director of Quality and Integrated Governance is the executive lead on the Governing Body for information governance and also the senior information risk owner (SIRO). The Caldicott Guardian is a GP and Governing Body member. The Information Governance Steering Group meets bi-monthly.

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 NHS England recognises the importance of quality assurance across the full range of its analytical work. In partnership with analysts in the Department of Health we have developed an approach that is fully consistent with the recommendations in Sir Nicholas Macpherson's review of quality assurance of government models. The framework includes a programme of mandatory workshops for NHS England analysts, which highlights the importance of quality assurance across the full range of analytical work.

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The Macpherson Report on the review of quality assurance (QA) of Government Analytical Models set out the components of best practice in QA making eight key recommendations. We recognise the importance of this and have been working with partners to ensure appropriate quality assurance processes are in place across its analytical work.

For 2017/18 Greenwich CCG has continued to work with other CCGs and NHS providers in South East London, through the Sustainability and Transformation Partnership (STP), to develop the business and financial modelling for the five year strategic plan. The modelling is led through South East London project management office (PMO) and reports back to the South East London finance leads group. The group includes directors of finance and chief financial officers from all organisations within the STP. The group is chaired by the Chief Financial Officer of Southwark CCG, who acts as the senior responsible officer (SRO) for the development of the model. The output of the financial modelling is reviewed by a varied number of stakeholders from different disciplines, both internal and external, and underpins the modelling of the impact of service changes over the next five years.

Locally Greenwich CCG has developed a number of business and financial models which underpin areas such as local financial planning, QIPP delivery and service transformation. The identified senior responsible officer is the Chief Financial Officer, who ensures that there are effective processes underpinning the modelling, including appropriate guidance, documentation and training, as well as sharing best practice. This includes ensuring that appropriate assurance processes are in place to govern the robustness of any modelling.

Control issues No significant control issues have been identified.

Review of economy, efficiency and effectiveness of the use of resources In year monitoring of performance against our plans, in terms of quality, finance and other performance standards (e.g. NHS constitutional standards) has been carried out by our Quality Committee and Finance, Performance and QIPP Committee. This includes assuring that projects and programmes are delivering economic, effective and high quality services. Under the CCG improvement and assessment framework indicators leadership ratings are reviewed on a quarterly basis, the latest available results (to the end of December 2017) show that the CCG is rated red for the Quality of Leadership. The CCG is optimistic that this rating will improve in early 2018. Year end results for the Improvement and Assessment Framework are published by NHS England.

Counter fraud arrangements We contract an accredited counter fraud specialist to provide the full range of anti-crime work that is proportionate to the risks identified and fully compliant with the NHS Standards for Commissioners. The annual work-plan is developed from risks identified through the counter fraud risk assessment and discussions with key staff within the CCG. The annual work-plan is agreed with the Chief Financial Officer and ratified by the Audit Committee. Progress is regularly reported to the Chief Financial Officer and the Audit Committee. The Audit Committee reviews the results of the CCG annual self-assessment against the NHS counter fraud standards for commissioners. The Audit Committee monitors progress on remedial actions against areas of non-compliance or following an NHS Protect Quality Inspection.

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The accredited counter fraud specialists also delivered training to staff, which complies with the CCG mandatory training requirements.

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Final Head of Internal Audit Opinion 2017/2018 The head of internal audit opinion In accordance with Public Sector Internal Audit Standards, the head of internal audit is required to provide an annual opinion, based upon and limited to the work performed, on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes. The opinion should contribute to the organisation's annual governance statement.

1.1 The opinion For the 12 months ended 31 March 2018, the head of internal audit opinion for Greenwich Clinical Commissioning Group is as follows:

The enhancements relate to our findings from the reviews of Better Care Fund, Continuing Healthcare,

Financial Planning and QIPP Delivery, and Cyber Security.

Please see appendix A for the full range of annual opinions available to us in preparing this report and opinion.

1.2 Scope and limitations of our work The formation of our opinion is achieved through a risk-based plan of work, agreed with

management and approved by the audit committee, our opinion is subject to inherent limitations, as detailed below:

the opinion does not imply that internal audit has reviewed all risks and assurances relating to the organisation;

the opinion is substantially derived from the conduct of risk-based plans generated from a robust and organisation-led assurance framework. As such, the assurance framework is one component that the board takes into account in making its annual governance statement (AGS);

the opinion is based on the findings and conclusions from the work undertaken, the scope of which has been agreed with management / lead individual;

the opinion is based on the testing we have undertaken, which was limited to the area being audited, as detailed in the agreed audit scope;

where strong levels of control have been identified, there are still instances where these may not always be effective. This may be due to human error, incorrect management judgement, management override, controls being by-passed or a reduction in compliance;

due to the limited scope of our audits, there may be weaknesses in the control system which we are not aware of, or which were not brought to attention; and

Head of internal audit opinion 2017/18

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it remains management’s responsibility to develop and maintain a sound system of risk management, internal control and governance, and for the prevention and detection of material errors, loss or fraud. The work of internal audit should not been seen as a substitute for management responsibility around the design and effective operation of these systems.

1.3 Factors and findings which have informed our opinion We have issued reasonable or substantial assurance opinions in relation to the following reviews:

Primary Care Delegated Commissioning (reasonable assurance)

Risk Management Board Assurance Framework (reasonable assurance)

Conflicts of Interest (substantial assurance)However, we issued partial assurance opinions in relation to the following reviews:

Better Care Fund: Our review found there was an absence of a Better Care Fund Plan (BCF) for 2017/18, and there were instances where it was not clear how the schemes met BCF requirements. Specifications for schemes were not always in place, were sometimes out of date, and/or specifications did not have specific information included i.e. exit arrangements, safeguarding policies. Furthermore, there was a lack of transparency over the financial and non-financial arrangements, for example, invoicing was based on expenditure rather than actual, lack of financial reporting via the Joint Commissioning Executive committee, underperformance on BCF KPIs, and a lack of a value for money exercise on schemes.

There were a total of five actions (two high, two medium and one low) raised during the review, of which three actions had been implemented (two medium and one low), and two actions were in the process of being implemented (two high).

Continuing care Testing identified that in instances there was no evidence of any three-month review, and one example where a patient had also not had their twelve-month review. There was also a lack of provider contracts for providers, no formal performance monitoring of providers and an absence of verification check procedures and of conflict of interest declarations when selecting providers. In addition, there were no formal periodic review of data quality of Caretrack system.

There were a total of eight actions (one high, five medium and two low) raised during the review, of which five actions (one high, two medium and two low) were implemented. There are three medium action open and overdue.

Financial planning and QIPP delivery controls (effectiveness)

We raised a partial assurance rating in relation to the overall effectiveness, this was in relation to the £5.3m risk delivery gap within the QIPP programme at the time of the review, a significant proportion of risk-assessed savings identified being back-ended and were forecast to deliver later in the year.

There were a total of two actions (one high and one medium) raised during the review, of which both had been implemented.

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Joint working across South London - cyber assurance An advisory audit of Cyber Security was undertaken as part of the 2017/18 approved internal audit periodic plans for Lambeth, Southwark, Lewisham, Greenwich, Croydon, Merton, Richmond, Sutton and Wandsworth CCGs.

Based upon the evidence available at the time of our fieldwork, we are able to agree that 21 of the 34 requirements for the five cyber essentials control themes had evidence to support the CSU self-assessment that controls are established. Of the remaining 13 requirements there were four where the CSU is categorised as ‘Self-assessed as implemented but not tested’, one where we ‘Agree not fully implemented’, seven where ‘Evidence does not fully support the self-assessment score’, and one ‘Not applicable’. All 13 were across the following theme areas: boundary firewalls and internet gateways, secure configuration, user access controls and patch management.

The validated self-assessment scores generate an overall status of “Working Towards Implementation for the CSU’s implementation of cyber essentials” for this domain.

Follow up

During 2017/18, there were a total of 62 actions (eight high, 39 medium and 15 low) open, which included actions outstanding from previous years’ Internal Audit work (30 actions – four high, 17 medium and nine low), as well as actions raised during 2017/18 (32 actions – four high, 22 medium and six low). Of these 62 actions, five actions (three medium and two low), were not yet due for implementation at the time of drafting this opinion. A total of 38 actions (six high, 21 medium and 11 low) had been implemented. There are 19 actions (two high, 15 medium and two low) open and overdue.

1.4 Further issues relevant to this opinion We have reviewed the Service Auditor Report for National Shared Business Services, who provide financial transactional support to the CCG, via its contract with NHS England. No notable exceptions were reported.

The Service Auditor Report for NHS Digital did not raise any exceptions. NHS Digital (the trading name of the “Health and Social Care Information Centre”) provides IT services as part of the end to end service alongside other organisations to support processing of NHS payments and deductions to providers of general practice (“GP”) services in England. The service auditor report was for the year ending 31 March.

We reviewed the Service Auditor Reports for Capita, who process payments to providers of general practice via a contract with NHS England, from whom the CCG has delegated primary care commissioning responsibilities. Whilst there has been some improvement in the number of control exceptions, there remained seven out of sixteen key controls assessed as suitably designed but not appropriately complied with over the period October 2017 to March 2018. Management action plans are in place to remedy the issues identified.

We have reviewed the Service Auditor Report for NEL Commissioning Support Unit, who provide some financial and payroll services to the CCG. We reviewed reports covering the eleven months to 28 February 2018 and the accompanying bridging letter to take the period

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covered up to 31 March 2018. Whilst we noted a number of exceptions were identified, we do not consider amongst these there are any which represent a significant risk to the CCG’s control environment.

1.5 Topics judged relevant for consideration as part of the annual governance statement Based on the work we have undertaken on the CCG’s system on internal control, we do not consider that within these areas there are any issues that need to be flagged as significant control issues within the Annual Governance Statement (AGS). However, we would expect the CCG to consider in the formulation of the AGS the internal control weaknesses identified within our partial assurance opinions summarised above, along with the actions being taken to address the issues identified.

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Appendix A: Annual opinions The following shows the full range of opinions available to us within our internal audit methodology to provide you with context regarding your internal audit opinion.

The factors which are

considered when influencing

our opinion are:

inherent risk in the

area being audited;

Limitations in the

individual audit

assignments

The adequacy and

effectiveness of the

risk management

and / or governance

control framework

The impact of

weakness identified

The level of risk

exposure

The response to

management actions

raised and

timeliness of actions

taken

RSM Risk Assurance Services LLP

May 2018

Annual opinions Factors influencing our opinion

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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 this review by the Governing Body, the Audit Committee, the Quality Committee, Internal Audit and a plan to address weaknesses and ensure continuous improvement of the system is in place.

The Governing Body and Audit Committee have provided regular feedback on the completeness and effectiveness of our systems of internal control via comments and feedback on the completeness of the Board Assurance Framework. Control and assurance gaps were sometimes identified, resulting in existing controls and assurances being further reviewed and strengthened. The Audit Committee also carried out reviews in to the risks associated with the CCG priorities.

The report into the Board Assurance Framework (BAF) process from our Internal Auditors stated that there is reasonable assurance that the controls in place to manage the risks are suitably designed and consistently applied. Issues were identified that need to be addressed in order to ensure that the control framework is effective in managing the identified risks. The risk management arrangements at Greenwich CCG were reviewed and an overall assessment of reasonable assurance was provided.

Conclusion In conclusion I can confirm that no significant internal control issues have been identified.

Andrew Bland Accountable Officer Date: 25 May 2018

Remuneration and staff report Remuneration Committee The Remuneration Committee comprises of four members and has met on occasion during the past year.

A full list of the NHS Greenwich CCG members and their roles is below.

Name Role

Jim Wintour Lay Member / Vice Chair (Audit and COI) until 11 June 2017

Maggie Bucknell Governing Body Registered Nurse

Greg Ussher Lay member (PPI)

Dr Iyngarun Vanniasegarum Secondary Care Doctor

Amana Humayun Lay Member/ Vice Chair (Audit and COI) from 12 June 2017

In addition to the members listed above, the following CCG employees provided the committee with advice which was material to the committee’s deliberations.

Name Role Service

Joanne Murfitt Chief Officer Advice

Yvonne Leese Director of Quality and Integrated Governance

Advice

The North East London Commissioning Support Unit (CSU) provides HR advice and support to the CCG in accordance with an agreed Service Level Agreement. This includes advice and support to the Remuneration Committee including agreeing agendas with the Chair of the Committee and preparing and presenting papers at Committee meetings. The advice given to the Remuneration Committee is based on national guidance and benchmarking information. The HR Business Partner is appointed by the CSU.

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Remuneration policy The committee’s deliberations are carried out within the context of national pay and remuneration guidelines, local comparability and taking account of independent advice regarding pay structures. Business expenses are reimbursed in accordance with the CCG policy based on national guidelines. There are no benefits in kind. This policy remains the same for 2018/19.

Senior managers’ performance related pay The CCG does not have a policy of performance related pay for senior managers.

Senior managers’ service contracts Senior managers’ contracts are permanent with a notice period of six months. There have been no termination payments in year or any awards to current or former members of the Governing Body, although the CCG made a settlement agreement with one person.

Senior managers’ salaries and allowances 2017/18 (audited) All members of the Governing Body are deemed to be individuals with significant financial responsibility during the financial year and are therefore regarded as ‘senior managers’. No other CCG senior managers have significant financial responsibility.

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Name

Title

Salary &

Fees

Taxable

Benefits

Annual

Performance

Related

Bonuses

Long-term

Performance

Related

Bonuses

All Pension

Related

Benefits

Total

bands of

£5,000

Disclosed in

£ to the

nearest £100

bands of

£5,000

bands of

£5,000

bands of

£2,500

bands of

£5,000

£000 £000 £000 £000 £000 £000

Joanne Murfitt

Chief Officer from 1 November 2016 to 10 September

2017

50-55

0

0

0

0

50-55

Annabel Burn Chief Officer until 31 October 2016 Not Applicable

David Maloney Chief Financial Officer from 20 February 2017 120-125 0 0 0 37.5 - 40 120-125

Neil Kennett-Brown Managing Director from 25 September 2017 65-70 0 0 0 0 65-70

Ian Fisher

Interim Chief Financial Officer From 1st October 2015 to

3 February 2017

Not Applicable

Liz James

Interim Director of Commissioning Until 30 September

2017

70-75

0

0

0

377.5-380

70-75

Vanessa Fowler

Director of Commissioning from 1st October to 15th

December 2017

20-25

0

0

0

0

20-25

Regina Shakespeare

Interim Turnaround director and Acting Director of

Commissioning - From 3 February 2016 to 31 October

2016

Not Applicable

Simon Hall

Deputy Chief Officer and Director of Strategy and

Performance Until 3 May 2016

Not Applicable

Yvonne Leese Director of Quality and Integrated Governance 100-105 0 0 0 90 - 92.5 100-105

Virginia Morley Director of Commissioning from 27 November 2017 20-25 0 0 0 0 20-25

Diane Jones

Director of Integrated Governance from 24 August 2015

to 28 February 2017

Not Applicable

Dr Ellen Wright

Chair and GP Member of the NHS Greewich CCG

Governing Body

55-60

0

0

0

0

55-60

Dr Hany Wahba GP Member of the NHS Greewich CCG Governing Body 40-45 0 0 0 0 40-45

Dr Nayan Patel

GP Member of the NHS Greewich CCG Governing Body

40-45

0

0

0

0

40-45

Dr Sylvia Nyame

GP Member of the NHS Greewich CCG Governing Body -

From 1 August 2015

40-45

0

0

0

0

40-45

Dr Ranil Perera

GP Member of the NHS Greewich CCG Governing Body -

From 1 May 2014

40-45

0

0

0

280 - 282.5

40-45

Dr Krishna Subbarayan

GP Member of the NHS Greewich CCG Governing Body -

From 1 July 2014

40-45

0

0

0

75-77.5

40-45

Dr Sabah Salman

GP Member of the NHS Greewich CCG Governing Body

from 1 August 2015

30-35

0

0

0

0

30-35

Dr Iyngaran Vanniasgarum

Secondary Care doctor on the NHS Greewich CCG

Governing Body from 08 January 2014

15-20

0

0

0

0

15-20

Maggie Buckell

Registered Nurse on the NHS Greewich CCG Governing

Body from 08 January 2015

10-15

0

0

0

0

10-15

Dr Greg Ussher

Lay Member on the NHS Greewich CCG Governing Body

from 01 April 2013

10-15

0

0

0

0

10-15

Mr Jim Wintour

Lay Member on the NHS Greewich CCG Governing Body

from 01 April 2013 until 11 June 2017

0-5

0

0

0

0

0-5

Mr Richard Rice

Lay Member on the NHS Greewich CCG Governing Body

from 20 March 2017

10-15

0

0

0

0

10-15

Dr Jaisun Vivekanandaraja

GP Member of the NHS Greewich CCG Governing Body

from 17 January 2018

5-10

0

0

0

0

5-10

Amana Humayun

Vice Chair and Lay Member for Audit and Remuneration

and Conflicts of Interest Guardian from 12 June 2017

0

0

0

0

0

0

90

Mr Andrew Bland held the position of Accountable Officer for Greenwich CCG from 11/09/2017. During that time he also held Accountable Officer roles at Southwark CCG and Bexley CCG. His salary was paid in full by Southwark CCG.

No Governing Body member, or any other manager, received any performance related pay or bonus, or taxable benefit.

Pension Benefits 2017-18

Name

Real Increase in

pension at age 60

(bands of

£2,500)

Real Increase in

pension lump sum at

age 60 (bands of

£2,500)

Total

accrued pension

at age 60 at 31

March 2018

(bands of £5,000)

Lump Sum at age 60

related to accrued

pension at 31 March

2018 (bands of £5,000)

Cash

equivalent

Transfer Value

at 31 March

2018

Cash

equivalent

Transfer

Value at 31

March 2017

Real Increase in

Cash

(Proportion of

time in Post)

Equivalent

Transfer Value

Employer

contribution to

stakeholder

pension

£000 £000 £000 £000 £000 £000 £000 £000

David Maloney

Chief Financial Officer

2.5 - 5

0 - 2.5

35 - 40

95 -100

669

591

71

Nil

Liz James

Director of Commissioning

15 - 17.5

22.5 - 25

15 - 20

45 - 50

354

0.00

177

Nil

Yvonne Leese

Director of Quality and

Integrated Goverance

2.5 - 5

12.5 - 15

35 - 40

105 - 110

786

645

138

Nil

Joanne Murfitt

Chief Officer

0

0

20 - 25

65 - 70

498

1,090

-270

Nil

Ranil Perera

Member of Governing Body

10 - 12.5

35 - 37.5

10 - 15

35 - 40

166

0

166

Nil

Krishna Subbarayan

Member of Governing Body

2.5 - 5

7.5 - 10

0 - 5

5 - 10

46

0

46

Nil

The pension benefit figure is based on the HMRC method for calculating the increase in the annual pension entitlement for deferred benefit schemes. It is not the same as the cost to the CCG of its contribution in respect of the individual concerned (the employer’s contribution).

NHS organisations are required to disclose the pension benefits for those persons disclosed as senior managers of the organisation, where the clinical commissioning group has made a direct contribution to a pension scheme.

Pay multiples (audited) 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.

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The banded remuneration of the highest paid member of the Governing Body in NHS Greenwich CCG in financial year 2017/18 was £127,500 (in 2016/17 it was £285,000, including VAT and agency premium). This is 2.65 times higher than the median remuneration of the workforce, which was £48,106 (2016/17 was 6.95 and £47,171.)

The change in ratio relates to a period of turnaround in the previous year, in which it was necessary to use a turnaround director who incurred higher costs than the chief officer role.

In 2017/18 no employees received remuneration in excess of the highest-paid member of the Governing Body. Remuneration ranged from £17,613 to £126,176 (annualised estimated earnings of highest paid director).

In calculating the relationship between the highest paid person in the organisation and the median remuneration, the CCG has to remove VAT and an estimate of agency premiums from the payments for all contractors and treat all appointments and employments as if they were full-time and for twelve months.

Total remuneration includes salary and pensionable benefits. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions.

Off-payroll engagements Off-payroll engagements existing at 31 March 2018 for more than £245 per day and have lasted longer than six months are as follows:

The number that have existed:

For less than one year at 31/3/18 1

For between one and two years 0

For between two and three years 0

For between three and four years 0

For four years or more 0

Total number of existing engagements at 31/3/17 4

All existing off-payroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax and, where necessary, that assurance has been sought.

92

For all off-payroll engagements in 2017/18 for more than £245 per day and more than six months:

Number

Total number of new engagements, or those that reached six months in duration, between 1 April 2017 and 31 March 2018

3

Of which

Number assessed as caught by IR35 0

Number assessed as NOT caught by IR35 3

Number engaged directly (via PSC contract to department) and are on departmental payment

0

Number of engagements reassessed for consistency/ assurance purposes during the year

0

Number of engagements that saw a change to IR35 following the consistency review

0

Off-payroll engagement of Governing Body members and senior officials with “significant financial responsibility” between 1 April 2017 and 31 March 2018

Number of off-payroll engagements of Governing Body members, and senior officials with “significant financial responsibility” during the financial year

1

Number of individuals who have been deemed Governing Body members, and senior officials with “significant financial responsibility”, during the financial year (payroll and off-payroll)

6

The off-payroll engagement relates to a one month period whilst the individual was brought on to the CCG’s payroll where they remained until their employment ceased.

I hereby sign off the Remuneration Report element of the NHS Greenwich CCG Annual Report 2017/18.

Andrew Bland Accountable Officer 25 May 2018

Exit packages, including special (non-contractual) payments Table 1: Exit packages

Exit package

cost band (inc. any special

payment element

Number of compulsory

redundancies

Cost of compulsory

redundancies

Number of other

departures agreed

Cost of other departures

agreed

Total number of

exit packages

Total cost of exit packages

Number of departures

where special payments have been

made

Cost of special payment element

included in exit packages

WHOLE NUMBERS

ONLY

£s

WHOLE NUMBERS

ONLY

£s

WHOLE NUMBERS

ONLY

£s

WHOLE NUMBERS

ONLY

£s

Less than £10,000

£10,000 - £25,000

£25,001 - £50,000

£50,001 - £100,000

1 67,974

£100,001 - £150,000

£150,001 – £200,000

>£200,000 TOTALS 1 67,974 These tables report the number and value of exit packages agreed in the financial year. In 2017/18 the CCG made a settlement agreement with a member of CCG staff. This was approved by the Remuneration Committee and is accounted for in accordance with relevant accounting standards.

93

94

Table 2: Analysis of other departures

Agreements Total value of agreements

Number £000s

Voluntary redundancies including early retirement contractual costs

Mutually agreed resignations (MARS) contractual costs

1 67,974

Early retirements in the efficiency of the service contractual costs

Contractual payments in lieu of notice

Exit payments following Employment Tribunals or court orders

Non-contractual payments requiring HMT approval

TOTAL 1 67,974

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Our staff Communicating and engaging There are a number of ways in which we communicate and engage with staff and member practices including:

Weekly staff briefs which are shared on the intranet and where staff are encouraged to pose questions, celebrate success and share ideas.

Intranet.

Newly introduced monthly lunch and learn sessions offering a chance to network and share knowledge across the organisation.

Staff away days and events.

Team and directorate meetings.

Regular 1:1s.

Annual staff survey with collective all-staff action planning.

Annual awards which were relaunched for 2017/18 to include staff and member practices and built around our organisational values.

Training and development We offer a comprehensive training package online via e-learning with some opportunities for face to face training. All staff are required to complete their statutory and mandatory training, and compliance is monitored through the workforce system. Staff have regular 1:1s and appraisals and are offered training and support through personal development plans. Objective-setting takes place in quarter 1 of the year and is linked to the corporate objectives to ensure that each member of staff understands the role they and their team plays in achieving the CCG’s objectives.

Employee consultation Organisational change is managed in accordance with the principles and procedures contained within the CCG's organisational change policy. The CCG also informally communicates and consults with employees via regular staff briefings.

Policy on disabled employees Disabled employees are protected under the protected characteristics of the Equality Act 2010, one of which is disability. The CCG ensures that requirements and reasonable adjustments necessary for employees with disabilities are managed during their employment and that people with disabilities are not discriminated against on the ground of their disability at any stage of the recruitment process or in their employment with the CCG.

The CCG's sickness absence policy confirms that where an employee becomes disabled as a result of sickness, the CCG will make any necessary reasonable adjustments, as required, and in accordance with the Equality Act to enable the employee to return to work. The types of adjustments may include adjustments to work base, working hours, redeploying the employee to another suitable position and providing any necessary equipment to assist the employee to perform their role.

Equalities for staff The CCG promotes a working environment in which all parties and procedures relating to recruitment, selection, training, promotion and employment are free from

96

unfair discrimination, ensuring that no employee or prospective employee is discriminated against, whether directly or indirectly on the grounds of age; disability; gender reassignment; pregnancy and maternity; race including ethnic or national origins, colour or nationality; religion or belief; sex (gender); sexual orientation; marriage and civil partnership; trade union membership; responsibility for dependents or any other condition or requirement which cannot be shown to be justifiable.

Trade union facility time As a CCG with a full time equivalent employee number of more than 49 people, we are obliged to report on paid time off for union representatives to carry out trade union activities. In 2017/18, one member of staff was a relevant union official, with 0.1 whole time equivalent (WTE) of their paid time allocated for union activities. This accounts for 0.061% of the CCG total pay bill.

Staff composition In 2017/18 our headcount was 86, and full time equivalent was 63.43.

This table shows staff numbers, with a gender breakdown for Governing Body, Senior Management Team and all staff for 2017/18. Female Male Grand Total

Director/VSM 3 3 6

Employee 44 20 64

Governing Body 7 9 16

Grand Total 54 32 86

This table shows staff breakdown by gender and NHS band for 2017/18. Female Male

Band 3 1

Band 4 6 1

Band 5 5 1

Band 6 2 1

Band 7 10 5

Band 8A 7 2

Band 8B 6 3

Band 8C 5 3

Band 8D 3 1

Band 9 3 1

Other - Local Salary 7 13

Grand Total 54 32

97

The following tables are a profile of CCG staff relating to the main protected characteristics as at 31 March 2018. Tables do not include Governing Body members and clinical leads.

98

99

100

Sickness absence data 2017/18 Total days lost 655.80

Total staff years 65.29

Average working days lost 10.04

Cumulative % absence rate (FTE) 2.74%

Number of sickness episodes 80

Number of persons retiring on ill health grounds 0

Parliamentary Accountability and Audit Report NHS Greenwich CCG is not required to produce a Parliamentary Accountability and Audit Report. Disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges are included as notes in the financial statements of this report at section 3 Annual Accounts. An audit certificate and report is also included in this Annual Report at page 81.

1

ANNUAL REPORT AND ACCOUNTS 2017/18

2

Contents Accessibility ................................................................................................................ 3 Welcome .................................................................................................................... 4 Section 1 Performance Report ................................................................................... 6 Who we are ................................................................................................................ 7 Challenges in Greenwich ........................................................................................... 7 Risk management .................................................................................................... 11 Our achievements in 2017/2018............................................................................... 12 Challenges addressed .............................................................................................. 23 Focus on mental health ............................................................................................ 27 Integrated working and Better Care Fund ................................................................ 30 Financial overview .................................................................................................... 31 Quality, improvement, productivity and prevention (QIPP ........................................ 34 Sustainable development ......................................................................................... 35 Quality and safety ..................................................................................................... 36 Engaging people and communities - patient and public involvement ....................... 42 Annual 360-degree stakeholder survey .................................................................... 45 Clinical engagement ................................................................................................. 45 Sustainability and transformation partnership........................................................... 46 Equality and diversity ............................................................................................... 50 Emergency preparedness, resilience and response (EPRR) ................................... 53 Section 2 Accountability Report ................................................................................ 56 Members’ Report ..................................................................................................... 57 Register of interests ................................................................................................. 62 Personal data related incidents ................................................................................ 62 Statement of disclosure to auditors .......................................................................... 62 Modern slavery statement ........................................................................................ 63 Statement of Accountable Officer’s responsibilities .................................................. 63 Governance statement ............................................................................................. 65 Final Head of Internal Audit Opinion 2017/2018 ....................................................... 81 Remuneration and staff report .................................................................................. 87 Our staff ................................................................................................................... 95 Parliamentary Accountability and Audit Report ...................................................... 100 Section 3 Annual Accounts .................................................................................... 101

3

Accessibility If you would like a copy of this annual report in an alternative format, please contact the communications team: Telephone: 020 3049 9000 Email: GRECCG.NHSGreenwichCCG@nhs.net

4

Welcome Welcome to the 2017/18 Annual Report and Accounts of NHS Greenwich Clinical Commissioning Group (CCG).

The overarching themes of 2017/18 have been challenge and progress. The year was challenging for the CCG and the NHS as a whole, and we have sought to improve patient care while delivering within our financial means.

One of the biggest challenges has been the performance of local urgent and emergency care services. Through the year we worked with local partners to address areas for improvement in performance and quality standards.

In the year NHS England used their formal powers of direction and from 1 September 2017 some of our responsibilities for acute commissioning and contracting were temporarily transferred to NHS Southwark CCG. This has helped to galvanise the urgent and emergency care system to keep a sharp focus on improving clinical safety and quality, improve year on year performance and be relatively well prepared for one of the most challenging winters for emergency care.

Despite some improvement we continue to experience challenges to meet the accident and emergency four-hour target, and will continue our efforts so that with the recovery plans that have been put in place since the application of legal directions we will achieve further step-change improvements during 2018/19. The immediate aims of our organisational recovery plan are to secure a rating of ‘requires improvement’ for 2017/18 and ensure the lifting of the legal directions placed upon the CCG.

I am pleased to confirm that the CCG has achieved its financial duties for 2017/18. The 2017/18 Annual Accounts show a surplus of around £0.7 million, which is in line with the CCG’s financial target for the year. This is a result of sustained determination by our local and South East London contracting and finance teams; the efforts by all in the CCG to develop our savings schemes and support from our providers in implementing them. We still need to deliver savings programmes of around £14.3 million in 2018/19. The progress we have made will significantly help the CCG to improve our inadequate rating.

Along with the other CCGs in South East London, we reviewed our collaborative working arrangements in the year, resulting in the establishment of new executive leadership arrangements that took effect from 1 April 2018. Andrew Bland was appointed as Accountable Officer. The return to financial balance is underpinned by this new model of working and will enable us to strengthen collaborative commissioning arrangements and to consolidate leadership and accountability arrangements.

Staying on the subject of people moves, I would like to record my appreciation for the work of Dr Hany Wahba and Dr Nayan Patel who are stepping down from the Governing Body, having served as GP commissioners since the beginning of the

5

CCG in shadow form and onward since authorisation in 2013. They are both coming to the end of their second terms in July 2018. They have been tireless in giving advice and support, whilst also providing appropriate challenge whenever needed.

Dr Sylvia Nyame will also be leaving the Governing Body this summer and her role as mental health and patient and public participation lead has been greatly appreciated and she will be much missed.

I also want to thank Jo Murfitt for her work as Chief Officer from November 2016 to September 2017, and to Neil Kennett-Brown who joined us as interim Managing Director after Jo moved to a new role with NHS England. Neil, a long time Greenwich resident, has now taken on the reins as the CCG’s permanent Managing Director.

I would also like to thank our staff and partners. We have made steady progress on our goals, thanks in large part to partnership working with Royal Borough of Greenwich, with NHS providers and other clinical commissioning groups in South East London, with the third sector, and most importantly, with Greenwich people.

2018/19 will continue to be challenging for Greenwich CCG, however, we have weathered tougher times in the past. It has been an honour to serve as Clinical Chair and as I step down from my post this year, I know I am leaving a very good team in place, who have the commitment and drive to commission the highest-quality NHS services for Greenwich people.

Dr Ellen Wright Clinical Chair, NHS Greenwich CCG

6

Section 1 Performance Report

Andrew Bland

Accountable Officer

25 May 2018

7

Who we are We are a membership organisation made up of all 35 GP practices in Greenwich, organised into four local care networks and one GP federation. We plan, buy and monitor most of the health services Greenwich people use including:

primary care (fully delegated since April 2017) acute (Lewisham and Greenwich NHS Trust community (Oxleas NHS Foundation Trust) mental health (Oxleas NHS Foundation Trust) learning disabilities (Oxleas NHS Foundation Trust) voluntary sector - various

We work with a range of partner organisations in Greenwich to improve health and wellbeing. We also work closely with our neighbouring CCGs in South East London and with NHS England, on shared plans to improve health and deliver high quality and sustainable services for our populations. This is our Sustainability and Transformation Partnership (STP).

NHS England commissions other primary care services such as pharmacists, opticians, dentists and some specialist health services. The Royal Borough of Greenwich commissions public health, health visiting and school nursing services. We are part of the Greenwich Health and Wellbeing Board, where we work with elected councillors and other partners, including community and voluntary sector partners such as Healthwatch Greenwich and METRO GAVS, to make sure local services meet our communities’ needs.

Challenges in Greenwich Main areas of poor health In Greenwich, like many other areas nationally, we have a growing and ageing population with growing health and care needs.

According to the Joint Strategic Needs Assessment (JSNA) for Greenwich, the major causes of death in Greenwich are cancer and cardiovascular diseases, especially heart attacks and strokes. However, overall death rates from these causes are improving, meaning that fewer people are dying prematurely from these diseases. Respiratory diseases, including chronic obstructive pulmonary disease (COPD), are the next biggest cause of preventable deaths in the borough. The biggest burden on morbidity (poor health) is mental ill health, followed by musculoskeletal health conditions such as back pain, arthritis and other joint conditions.

The JSNA priorities include six major conditions, six risk factors and seven underlying determinants of health as shown below.

8

With our partners, we have identified the key underlying determinants of health that impact on the health of people in Greenwich. These are shown in the boxes called “causes of the causes” in the diagram above. There is ample evidence that social and environmental factors, including employment, income level and the suitability of housing have a big influence on health.

The second main row in the table then shows the major risk factors for disease for the conditions listed in the boxes below, called major conditions (Greenwich’s avoidable burden of ill health). We describe these conditions as the avoidable burden of ill health, as with the right help and support; for example, to give up smoking or supporting people back into employment, the development of some of the diseases may be prevented.

Reducing health inequality To deliver high quality care and improve the health of our local population, we need to take action to promote equality and reduce the gap in health inequalities for all our communities.

We use the JSNA to map out the needs of our population, so we can target our resources and services to best effect. We systematically consider the impact of our work on reducing health inequalities. We develop equality impact assessments to support the delivery of our programmes, and make sure that our public engagement approach considers equalities information.

Over the last year, our work to narrow the gap in health inequalities has included:

9

Partnership work with Royal Borough of Greenwich to implement a new social prescribing (Live Well Greenwich) programme to better meet the needs of vulnerable people with the poorest health. Part of this includes funding of care navigator roles.

• Supporting the Public Health team’s community blood pressure outreach initiative which has identified hundreds of residents with previously undiagnosed hypertension and atrial fibrillation and linked them into treatment.

Working with Royal Borough of Greenwich in the successful implementation of a latent tuberculosis (TB) testing scheme in primary care, identifying and treating patients with undiagnosed TB from countries with a high prevalence of the disease.

Work to develop the frail elderly pathway, resulting in the establishment of the Community Assessment Unit at Eltham Hospital.

Supporting people with learning disabilities and or autism to live in the community with the appropriate level of care through our transforming care programme.

Promoting awareness of learning disabilities to colleagues in primary care and targeting NHS health checks to local people with learning disabilities.

Partnering with Public Health to improve access to smoking cessation services and weight management services to improve the targeting of residents with the greatest need and in the areas of greatest deprivation in the borough.

Creating a mental health A&E liaison nurse role based in the emergency department at Queen Elizabeth Hospital, who identifies patients with mental health needs, ensuring they have timely access to appropriate support and services.

The Greenwich Health and Wellbeing Strategy (2015-2018) The Greenwich Health and Wellbeing Board strategy aims to improve the health of the population and focuses on these priorities:

Tackling obesity, as a major driver of poor health outcomes including heart

disease, cancers and musculoskeletal health problems. • Improving mental health and wellbeing, including the implementation of a

Thrive Greenwich programme, linked to the Mayor’s Thrive London scheme. • Enhancing the role of staff across our agencies to ‘make

every opportunity count’ in improving the health and wellbeing of the population.

Promoting and supporting the mental and physical health and wellbeing of employees across the borough through healthy workplace initiatives.

The JSNA will be updated in 2018/19 which will support a refresh of the Greenwich Health and Wellbeing Strategy beyond 2018. The Health and Wellbeing Board is committed to its existing priorities which are still relevant, and will focus on updating the action plans to deliver these priorities. A core commitment is to scale-up the Live Well Greenwich approach which cuts across all the health and wellbeing strategy priorities.

The diagram provides a summary of some of the main areas in which health is poorest in the borough and some of the associated factors (such as poverty and obesity) when compared with England.

It shows where improvements are being seen (for example, in early deaths from cardiovascular diseases), as well as where outcomes are getting worse (such as life expectancy).

It also shows improvements in outcomes where the impact affects small numbers of the population (such as late HIV diagnosis) versus impact on large numbers (e.g. under 75s deaths from cancer.

10

11

Risk management The CCG has assessed its key risks and uncertainties throughout the year using the Governing Body Assurance Framework. The Assurance Framework sets out the principal risks to delivering our strategic objectives and how these risks are managed. There is an established methodology in place to identify, monitor, control and mitigate risks throughout the CCG as part of, and within, the CCG’s Risk Management Strategy and Assurance Framework.

The Assurance Framework is presented at each Governing Body meeting, so members can review the risks and mitigations and receive assurances that the risks are being effectively managed and minimised. The top risks for Greenwich CCG identified in 2017/18 were:

Risk of a reducing primary care GP workforce (due to retirement, natural wastage and difficulty recruiting and retaining GPs nationally and locally) set against an increasing population thus impacting on primary care resilience.

Risk of breaching the national cancer target of 85% for 62-day referral to treatment.

Risk of breaching the 18-week referral to treatment standard for planned care. Risk of loss of organisational memory due to the turnover of senior manager

roles in the organisation in the preceding year. Risk of the demand for hospital care exceeding the available budgeted levels. Risk of failure to deliver the transformation work of the South East London

Sustainability and Transformation Partnership (STP). As the CCG was unable to meet its full statutory financial duties in 2016/17, we met regularly with NHS England in 2017/18 to provide assurance on our financial recovery plan and to discuss progress in achieving financial balance. The CCG has worked throughout the year on managing our money so that we deliver high quality care and value for money. We will continue to make sure we manage our financial position as effectively as we can.

Further details on risk are included in the governance statement in section 2.

12

Our achievements in 2017/2018 Medicines management Medicines optimisation is an evidence-based approach to prescribing, which underpins our aim to ensure safe and effective use of medicines. This includes minimising risks associated with the use of medicines for patients and staff. Optimisation of medicines by healthcare professionals for patients with long term conditions, as well as acute clinical presentations, delivers overall health improvement and underpins many of the current initiatives to improve quality of patient care. The CCG medicines management team:

provides unbiased information about medicines and treatments supports healthcare professionals and patients to make best use of medicines minimises harm caused by medicines and improves the safety of medicines

Despite a challenging year the team has delivered the following programmes:

Promotion of self-care to empower patients to seek advice from their community pharmacist if they have a minor or self-limiting ailment.

De-prescribing drugs of limited clinical value, e.g. items lacking in robust evidence of clinical effectiveness, or which have significant safety concerns.

Delivery of the national quality premium to reduce inappropriate antibiotic prescribing for urinary tract infections (UTI).

Successfully supporting practices to implement various National Institute for Health and Care Excellence (NICE) guidelines and technology appraisals into the local health economy.

Supporting training for clinical and non-clinical staff at GP practices in relation to medicines and evidence-based management of diseases.

Implementation of asthma review clinics in primary care to optimise medicine use in complex asthma patients.

Extensive engagement with stakeholders, e.g. community pharmacy and community providers.

Integrating medicines optimisation into services and care pathways, for example biologic treatment for inflammatory bowel disease.

Diversifying the role of a prescribing advisor to care homes to enable safe provision of medicines and potentially reduce hospital admissions linked to medicines use.

Collaboration as a member of the South East London area Prescribing Committee and leading on stoma proposals for the South East London Medicines Management Sustainability and Transformation Partnership (STP).

• Publication of the well-established “Prescribing Matters” newsletter for clinical and practice staff.

• Delivery of the financial QIPP target of £1 million set for the year. Undertaken an audit evaluating waste and safety issues associated with

medicines, including care home medication reviews and clinical audits as part of QIPP plan.

Supporting the individual funding request (IFR) panel to screen and assess payment by results excluded drug (PbR excluded) applications when a

13

treatment or service that is not routinely offered by the NHS is the best treatment for the patient, given their exceptional or rare clinical circumstances.

Collaboration with acute trust pharmacists and the CCG contract team to agree arrangements to introduce and increase uptake of biosimilar drugs for the CCG.

The controlled drugs Accountable Officer follows up incidents involving controlled drugs with community pharmacies, GP practices and care homes to ensure root cause analysis has been undertaken and the learning has been taken on board.

• Monitoring of non-medical prescribers’ database and scope of practice to ensure high medicines management standards are attained.

Primary care In April 2017 commissioning of primary care services was delegated to Clinical Commissioning Groups in South East London from NHS England, recognising that CCGs are best placed to deliver transformation within primary care. GP contracts have been standardised to help address variation and there is now an opportunity to further address some of the quality indicators in Quality Outcomes Framework (QOF) to make them more meaningful and improve the quality of patient care.

The General Practice Forward View (GPFV), a national five-year programme, puts primary care at the heart of transformation, recognising that health and social care need to work differently to address the challenges of an increasing and ageing population, financial instability and patient expectations. Care closer to home and increasing patient access to care outside of core hours impacts on how primary care has historically been delivered. The GPFV focuses on building resilience in primary care through addressing workforce capacity; working at scale; and better use of technology. The South East London STP provides direction through its Community Based Care (CBC) programme to deliver these initiatives through ‘shared standards, local delivery’.

We have made good progress in local delivery of the CBC programme. Greenwich now offers extended primary care access from 8am to 8pm Saturday and Sunday and 4pm to 8pm Monday to Friday at our two GP Access Hubs in Eltham and Thamesmead. The GP Hubs can access patient records ensuring continuity of care. Appointments are made through GP practices and NHS 111.

The number of patients with online accounts has increased at each of our 35 practices, enabling patients to book their own appointments and order repeat prescriptions. The CCG is working with practices and the Local Medical Committee on solutions to enable e-consultations to be rolled out during 2018/19 so that patients can access GP advice without needing to have a face-to-face consultation.

Greenwich was successful in a combined bid with Bexley, Lewisham and Bromley CCGs to recruit an additional 45 GPs through the NHS International GP Recruitment Programme. We will continue to re-assess CCG requirements as the programme develops and do not expect to see the fruits of the programme until later in 2018/19.

We have worked closely with the Royal Borough of Greenwich Public Health department to support primary care in the Network Woolwich and Thamesmead

14

locality to host wellbeing coaches within practices. These coaches take a holistic approach to patient care by signposting to services available across the borough. We aim to roll out this initiative to our other three localities in Greenwich, providing full coverage across our registered population.

In partnership with Royal Borough of Greenwich we are working on primary care estate developments to make sure that GP premises are fit for purpose and future proof. Gallions View in Thamesmead has been allocated funding and an architectural company commissioned to develop drawings to show how Gallions View could be re-modelled to improve the environment for patients and staff. Kidbrooke Village will have a new health centre built, linking to a community building with access to a pharmacy and a dental surgery.

The CCG and Local Medical Committee agreed a new Primary Medical Services (PMS) contract for 31 of our 35 practices as part of the national programme to reduce variation across primary care services in England. The remaining four practices have a different contract, one of which (Clover Health Centre in Woolwich) will go out to procurement during 2018.

The friends and family test is carried out at all our 35 practices and is an important element of quality assurance for the CCG. The results are reviewed by the CCG primary care team and form part of the regular review process for primary care committees. In 2017/18, 86% of respondents said that they would recommend their practice to a family member or friend. The national target is 89%, which we have not achieved this year, although we have improved from 85% in 2016/17.

Connect Care Connect Care allows patient information to be shared securely between health and social care professionals directly involved with the care of patients, which enables more informed decision-making about care and treatment.

We improved the Connect Care programme in 2017/18 so that GPs and community teams have easier access to patient records by integrating into their respective clinical systems. This has significantly increased usage by clinicians. Development of additional functionality to improve access to population health data and reporting is being trialled and expected to be available in Greenwich in 2018/19, as is a function which enables patients to access their own records.

Connect Care covered care records across Greenwich, Bexley and Lewisham until February 2018, and is now joined up with the Local Care Record system in Lambeth, Southwark and Bromley as a South East London-wide system. This system also includes data access for local providers of NHS 111 and GP out of hours’ services. Patients can opt out of the system if they wish.

More information about Connect Care is available on the Lewisham and Greenwich trust website.

Whole system emergency care pathway Throughout 2017/18 the CCG has worked with partners to develop a whole system response to supporting the emergency care pathway across Bexley, Greenwich and

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Lewisham. An improvement plan was submitted to regulators in September 2017 and is overseen by the A&E Delivery Board, with an independent Chair.

Commissioners and providers have achieved improvements by ensuring that the entire system has worked more effectively with a strong focus on improving pathways, increasing community capacity and flow. A key element was improving discharge processes at Queen Elizabeth Hospital, and a Transfer of Care Collaborative programme has been running since November 2017.

Partners have worked closely together to support the hospital by working as a multi- disciplinary team (MDT) over weekend periods to facilitate discharging people home. A hospital improvement working group has been established and meets weekly with all partners from health and social care to review and improve performance. Overall patient flow from acute to community services and community services to home has been streamlined with the alignment of MDT sessions in each facility organised to provide timely discharge information for each patient.

The urgent care centre was expanded and refurbished before winter, and the improved facility was able to support the expected increase in activity over winter, which was very challenging across the country, with high hospital attendance and admissions.

During 2018/19 we plan to progress the Transfer of Care Collaborative which will enable partners to further to improve patient flow. In partnership with Royal Borough of Greenwich, we will commission winter resilience services ready for the 2018/19 winter period.

Frailty The Community Assessment Unit (CAU) at Eltham Community Hospital was set up as a hospital avoidance service as part of an improvement programme following the CQC review of Lewisham and Greenwich NHS Trust. The review meant we needed to provide more support for frail elderly people within the community.

The aim of the CAU is to provide a comprehensive assessment service to build the physiological, psychological, cognitive and social resilience of the frail patients of Greenwich and Bexley, to maintain their independence for longer. The unit aims to prevent inappropriate emergency department attendance and subsequent acute admission, with referrals from GPs, community services, care homes and the London Ambulance Service. The unit opened in the summer 2017, and became a seven-day service in October, with 10 chairs (for same day assessment/discharge) and 10 beds (for short term 24-72-hour admission). In December 2017 this unit was flexed to provide more discharge support to support Queen Elizabeth Hospital and the pressures facing the local system during the winter months.

Discharge to assess unit In addition to the CAU we commissioned a new short-term facility with Royal Borough of Greenwich, as part of the discharge to assess pathway. This opened in January 2018 and aims to move patients who are medically optimised into the community for assessment instead of remaining in the hospital.

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Duncan House is a 20-bedded unit which provides a home-like environment for patients to be assessed after time in hospital before either returning home with a package of care or returning to a residential or nursing home. The service works on the ethos of “get up, get dressed, get moving” and is supported by a multi- disciplinary team from social care, GP, physiotherapy, occupational therapy and nursing.

Other developments for older people’s services Over recent months, the partners providing community services have joined forces to consider how to best align older peoples’ services. During 2017/18 services were developed and implemented to support winter pressures. While these have been effective in supporting people, we recognise that the system would benefit from greater integration. In response to this and to support the development of the CCG’s clinical commissioning strategy, we have established an older peoples’ service re- design workstream. Work to progress an agreed vision and model for older peoples’ services will take place in the first quarter of 2018/19 and provide a blueprint of how urgent and emergency care services will operate as part of the whole system.

End of life (EOL) care As part of the whole system redesign, the Greenwich multi-agency end of life working group met monthly. The working group has strong representation and committed attendance by partners. Existing end of life pathways and gaps have been mapped and an ideal end of life pathway developed, resulting in an end of life project plan. Initial discussions have begun with Lewisham and Bexley CCGs to identify common work themes which can be progressed collectively.

Care homes Care home support is integral to ensuring good quality outcomes for service users, improving system flow and reducing adverse impact on the London Ambulance Service. A task and finish group was set up with providers and Royal Borough of Greenwich. This group has reviewed the status, data and best practice and will report with recommendations in June 2018. We have seen a reduction by over 200 call outs to care homes in 2017/18 (compared to 2016/17). Three current projects are:

Medicine management, a rolling programme of individual medication reviews

across all care homes in Greenwich which began in July 2017. • The introduction of “Red Bags” to facilitate discharge from hospital for care

home patients. All the patient’s medicines and a summary of their records are placed in a red bag which is taken with them when they are admitted to hospital from a care home, and then transferred from hospital when they are discharged back to their care home. This project is due to start in May 2018 and is expected to reduce the length of stay in hospital.

The adoption of telehealth kits in care homes and training of care home staff to increase knowledge and confidence in managing complex cases. This project started in early April 2018 and should significantly reduce hospital admissions and London Ambulance Service callouts.

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Musculoskeletal service (MSK) Greenwich CCG commissioned a new MSK service which went live in April 2017. Circle Health has come together with the local community and hospital providers to deliver the new musculoskeletal pathway for the whole Greenwich population. The service promotes informed patient choice and drives providers to achieve excellent clinical standards and high-quality outcomes. The vision is to:

Make sure patients receive the best quality care, with excellent clinical

outcomes. Be at the forefront of innovation in promoting patient choice. • Make sure every patient is involved in their care, embodying the principles of

shared decision-making – ‘no decision about me without me’. Help patients see the right clinician, first time. Improve MSK health across the population. Enhance the overall management of the MSK system. Offer excellent patient experience.

The new service has received good patient feedback. Since summer 2017, GPs have been able to refer patients to Eltham Community Hospital for X-ray, ultrasound and blood tests.

Continuing healthcare NHS continuing healthcare (CHC) has been a key area for improvement in Greenwich and nationally in 2017/18.

The work programme in the year included mapping end to end processes within the service to reflect best practice. This has strengthened the systems and processes within continuing healthcare. The benefits have improved both the quality of service and financial efficiencies for Greenwich clients who are eligible for continuing healthcare services.

The CHC nurses have introduced case management involving regular and coordinated oversight of the care provided to individuals and their families. This ensures that assessments take place in a timely way and that care provision is reviewed regularly to ensure it still appropriately meets the clinical needs of the patient at that point in time.

The team is establishing a separate brokerage function to improve the cost effectiveness of commissioning care and free up CHC nursing time which previously incorporated this function and was not best use of their time. During 2017/18 we have put in place the building blocks for a brokerage function and the service will become fully operational in September 2017. This will drive up quality and deliver potential efficiencies.

Underpinning this has been the development of the South East London policy to assist CCGs to provide a common and shared understanding of their commitments in relation to individual choice and resource allocation for individuals who have been assessed as eligible for NHS Continuing Healthcare.

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The CHC team has adopted a standard operating process to NHS contract management. Quality performance indicators have been developed to monitor the quality and safety of individual care which providers are responsible for delivering to CHC clients. A programme of provider contract monitoring meetings has been developed for 2018/19 so that we have good oversight and monitoring of provider performance to strengthen our assurance processes. Currently we are exploring opportunities to monitor out of area placements with reciprocal arrangements from local CCGs to ensure the same robust monitoring arrangements are in place for Greenwich residents placed out of borough.

We have worked throughout the year with our neighbouring CHC teams across South East London CCGs to develop shared guidelines for assessors to CHC services. Peer review audits will ensure consistent applications of the CHC national framework to establish equity for eligibility of funding across all South East London CCGs, and will support the development of shared guidelines for assessors to CHC services.

A review of all patients who received CHC Fast Track care in 2017/18 indicated that Greenwich had 98% compliance with patients being appropriately placed in a timely way on the fast track pathway.

Percentage of CHC Decision Support Tool Assessments completed within 28 days Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Trajectory N/A N/A N/A 50% 50% 50% 51% 55% 60% 65% 75% 82% Actual Performance 67% 69% 52% 28% 42% 55% 44% 64% 77% 36% 78% 100%

Percentage of Decision Support Tool completed in Acute Setting Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Trajectory <15% <15% <15% <15% <15% <15% <15% <15% <15% <15% <15% <15% Actual Performance 0% 6% 0% 10% 7% 8% 7% 5% 8% 14% 11% 7%

Number of incomplete referrals exceeding 28 days by 12+ weeks Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Trajectory <5 <5 <5 <5 <5 <5 <5 <5 <5 <5 <5 <5 Actual Performance 5 3 5 0 0 0 0 0 0 0 0 0

Greenwich was originally a pilot site for the implementation of Personal Health Budgets in 2009. We have one of the highest uptakes of Personal Health Budgets (PHB) across London and continue to offer every patient who is eligible for CHC, the opportunity to have a PHB. Research evaluation on PHBs has shown that they improve outcomes, giving individuals more choice and control by working alongside health services professionals to develop and execute how their care is delivered. Additional findings from the evaluation of PHBs, demonstrated a significant improvement in the care related to quality of life (ASCOT), psychological well-being (GHQ-12) and patient confidence. Other areas where the CHC team has supported individual choice around PHBs include:

A Direct Payment (DP) event held with PHB holders and Royal Borough of

Greenwich, discussing different aspects of DPs (e.g. payroll, financial monitoring, personal assistant recruitment, pre-paid cards).

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• Skills for Care funding: the personalisation partnership assists people to make individual applications, pooling the funding and offering tailored courses to employers’ and personal assistants’ needs.

We are committed to transforming CHC services over the next two years (2017/19) by continuing to work with other CCGs across the Sustainability and Transformation Partnership. This will deliver improvements in quality, patient experience and optimum use of finite resources, through adopting a standardised approach to best practice.

Improved constitutional standards The focus remains on improving performance across all acute and non-acute NHS constitutional standards. With regard to cancer standards, there has been continued progress on the two-week wait targets. However, the 62-day target was not met for the year. Cancer performance continues to be monitored through the 62 day leadership group, and a South East London cancer delivery plan has been developed to ensure that South East London providers can improve performance and improve treatment times for tertiary referrals. Revised cancer recovery plans for the South East London acute trusts, along with revised trajectories, were approved by regulators in November 2017. ‘Return to Trajectory’ plans were reviewed again in March 2018, resulting in further changes to all South East London trajectories.

Performance analysis: improving quality and performance CCG performance is measured against a set of national and local standards that reflect the timeliness, quality and safety of care delivered to patients. These standards help to monitor how well the CCG is performing. Areas of care that fall short of targets have robust action plans in place to ensure improvement. The CCG has three major reports that provide patients and interested parties with performance-related information. All of these reports are presented to the Governing Body and are available on our website:

Quality Report focuses on quality, safety, patient experience and outcomes Performance Report focuses on NHS constitutional standards (e.g.

nationally set waiting times) and the targets that are nationally required to demonstrate that the CCG is delivering timely, high quality, safe and responsive care.

Finance Report covers the activity and care that the CCG purchases from its providers (hospitals, community and mental health services and the voluntary sector) and provides information on how the CCG manages resources for the local population.

This information is closely monitored by NHS England, primarily through the CCG assurance process, as set out in the CCG Improvement and Assessment Framework. During 2017/18 the CCG developed an integrated performance report which covers acute and non-acute activity performance. For 2018/19, the CCG has incorporated quality metrics into the report.

The table on the next page shows the CCG’s position against national performance measures for the 2017/18 financial year.

Greenwich CCG rolling twelve-month performance on national standards

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Key to the performance table above Incomplete pathways: The waiting times for patients waiting to start treatment at the end of the month. The incomplete waiting time standard is 92%.

RTT 52+ week waiters: This is the count of patients on the incomplete pathways who were waiting more than 52 weeks to start treatment at the end of the month. NHS England introduced a zero tolerance of any referral to treatment waits of more than 52 weeks in 2013/14.

Diagnostics 6+week standard: The proportion of patients waiting six weeks or longer for a diagnostic test, from time of referral. The national standard is set at 1%.

A&E total time 4 hour wait: Proportion of patients who have a total time in A&E over 4 hours from arrival to admission, transfer or discharge. The national standard is set at 95%.

A&E 12 hour trolley wait: Total number of patients who have waited over 12 hours in A&E from decision to admit to admission. There is a zero tolerance of any of these long waits. . Cancer 2 week wait: A patient should wait a maximum of two weeks to see a specialist after being urgently referred with suspected cancer by their GP. The operational standard specifies that 93% of patients should be seen within this time.

Cancer breast symptom 2 week wait: Those patients urgently referred with breast symptoms (where cancer was not initially suspected) should experience a maximum waiting time of two weeks to see a specialist. The operational standard for this measure is 93%.

Cancer 31 day first definitive treatment: Patients should experience a maximum wait of one month (31 days) between receiving their diagnosis and the start of first definitive treatment, for all cancers. This is measured from the point at which the patient is informed of a diagnosis of cancer and agrees their package of care. The operational standard for this measure is 96%.

Cancer 31 day sub treatment – surgery: Patients should experience a maximum wait of 31 days for a second or subsequent surgical treatment. The operational standard for this measure is 94%.

Cancer 31 day sub treatment – drug: Patients should experience a maximum wait of 31 days for a second or subsequent treatment. Where that treatment is an anti-cancer drug regimen, the operational standard is 98%.

Cancer 31 day sub treatment – radiotherapy: Patients should experience a maximum wait of 31 days for a second or subsequent treatment if that treatment is a course of radiotherapy. The operational standard for this requirement is 94%.

Cancer 62 day standard: The operational standard for this requirement specifies that 85% of patients should wait a maximum of 62 days to begin their first definitive treatment following an urgent referral for suspected cancer from their GP.

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Cancer 62 day screening: The operational standard states that 90% of patients would wait a maximum of 62 days to begin first definitive treatment following referral from an NHS cancer screening service.

Cancer 62 day upgrade: 62-day wait for first treatment following a consultant’s decision to upgrade a patient’s priority. There is no current operational standard for this measure.

Ambulance Red 1 (8 mins): Proportion of Red 1 calls resulting in an emergency response arriving at the scene of the incident within 8 minutes. The operational standard is at 75%.

Ambulance Red 2 (8 mins): Proportion of Red 2 calls resulting in an emergency response arriving at the scene of the incident within 8 minutes. The operational standard is at 75%.

Ambulance Cat A (19 mins): Proportion of Category A calls resulting in an ambulance arriving at the scene of the incident within 19 minutes. The operational standard is set at 95%.

Mixed sex accommodation: This is the number of occurrences of unjustified mixing in relation to NHS sleeping accommodation. There is a zero tolerance for these breaches.

Cancelled Ops for non-clinical reasons rebooked >28 days: The number of patients not treated within 28 days of the last minute cancellation.

CPA follow up within 7 days: The proportion of people under adult mental illness specialties on care programme approach (CPA) who were followed up (either by face to face contact or by phone discussion) within 7 days of discharge from psychiatric in-patient care during the quarter. The national standard is set at 95%.

Dementia diagnosis rate: The indicator compares the number of people thought to have dementia with the number of people diagnosed with dementia, aged 65 and over. The target is for at least two thirds (66.7%) of people with dementia to be diagnosed.

IAPT 6 weeks first treatment: Proportion of people who waited less than 6 weeks for a course of treatment (for those finishing a course of treatment). Standard set at 75%.

IAPT 18 weeks first treatment: Proportion of people who waited less than 18 weeks for a course of treatment (for those finishing a course of treatment). Standard set at 95%.

F&F Inpatient % who recommend: Friends and Family Test (F&F) gives patients the opportunity to submit feedback to providers of NHS funded care or treatment, The Inpatient dataset includes F&F responses for NHS funded acute inpatient services.

F&F A&E % who recommend: Friends and Family Test (F&F) gives patients the opportunity to submit feedback to providers of NHS funded care or treatment, The A&E dataset includes F&F responses for all types of A&E departments.

F&F Maternity % who recommend: Friends and Family Test (F&F) gives patients the opportunity to submit feedback to providers of NHS funded care or treatment, The Maternity dataset includes F&F responses from NHS funded maternity services. Responses to the

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maternity F&F are captured at four points: antenatal care, birth, postnatal ward and postnatal community.

MRSA: Monthly counts of MRSA bacteraemia cases attributed to the CCG. There is a zero tolerance for MRSA breaches.

C. Difficile: Monthly counts of C. difficile infection for patients aged 2 years and over.

Venous Thromboembolism (VTE) risk assessment:The proportion of admitted adult patients in England who have been risk assessed for VTE. The national standard is set at 95%. Manage demand and provide sufficient capacity Last year, the CCG worked with its Urgent Care Centre (UCC) provider Greenbrook, and Lewisham and Greenwich NHS Trust to increase front door assessments (streaming), thus providing a faster pathway for patients to see an appropriate clinician. The performance target for Greenbrook is to ensure that more than 50% of all attendances to the Emergency Department at Queen Elizabeth Hospital are streamed to the UCC. For 2017/18, the UCC treated an average of 47.5% of all patients, not quite hitting the 50% target. Building work impacted service during the months of August to October 2017, resulting in a low average performance over those months, of 44.4%. Across the year an average of 6.5% of patients were directly referred to specialty treatments from the UCC. The UCC is performing at approximately 30% above the numbers expected when the contract was originally set up, with out-of-hours performance roughly at expected levels. During the coming year, commissioners will work with Greenbrook to review performance and to identify further areas for improvement.

Challenges addressed Accident and emergency four hour standard The national standard states that 95% of patients should be seen and treated and then admitted or discharged within four hours of arriving into the accident and emergency (A&E) department. The graph below demonstrates that this was another challenging year for Lewisham and Greenwich NHS Trust as the national target of 95% was not delivered. However, in April, June, July and August, Lewisham and Greenwich NHS Trust did deliver against its locally-agreed target trajectory.

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Greenwich CCG has been working closely with the trust and other partners to develop and deliver action plans to improve performance, patient safety and experience. The themes that have arisen reflect the national position and a work programme continues into 2018/19 to manage demand, provide sufficient capacity and free up hospital bed capacity.

Freeing up hospital bed capacity During the year an arrangement with “Hospital at Home” was initiated by Lewisham and Greenwich NHS Trust to increase capacity in the community by 30 cases. This capacity is now being moved to the community provider, Oxleas NHS Foundation Trust, to ensure a consistent approach. Alongside hospital at home services, the existing Intermediate Care Unit at Eltham Hospital with 20 rehabilitation beds continues to provide services for those requiring therapeutic rehabilitation before returning home.

In addition to Intermediate Care, in July 2017, we commissioned a Community Assessment Unit (CAU) at Eltham Community Hospital and Duncan House was set up in January 2018 to provide a 20-bedded Discharge to Assess (D2A) facility to support winter pressures. During peak winter demand, the CAU unit was converted to 20 beds for hospital step-down and the Duncan House D2A facility was expanded from 20 to 25 beds. Despite all these arrangements, Queen Elizabeth Hospital continued to experience extreme pressures throughout the winter period.

Referral to treatment times for surgery The referral to treatment (RTT) target requires 92% of patients to be treated in 18 weeks from the time of referral. Achieving this target has been particularly challenging this year. Lewisham and Greenwich NHS Trust has not met the target yet this year, the CCG is working closely with the trust to ensure that it is able to achieve the target next year.

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During 2017/18, a small number of Greenwich patients waited more than 52 weeks for treatment, each month. Appropriate root cause analysis has been applied, followed by speedy remedial action, in each case, to ensure that barriers amenable to intervention can be identified and mitigated.

Cancer Greenwich CCG measures waiting times performance against eight specific indicators and, as of the end of 2017/18, has met national standards for five of these measures, on a year-to- date basis. These are: cancer 2-week wait, breast cancer symptom 2-week wait, cancer 31- day definitive treatment, Cancer 31-day sub treatment – surgery, cancer 31-day sub treatment – drug.

The CCG has been challenged in meeting the 62 day cancer wait at its provider trusts. This standard measures the wait from an urgent GP referral for suspected cancer to first treatment and covers all types of cancer. The target has proved particularly challenging when patients are referred from one trust, usually Lewisham and Greenwich NHS Trust, to a tertiary provider, such as King’s College Hospital NHS Foundation Trust and Guy’s and St Thomas’ NHS Foundation Trust. Cancer performance continues to be monitored through the 62 Day Leadership Group, and a South East London cancer delivery plan has been developed to ensure that South East London providers can improve performance and improve treatment times for tertiary referrals. Revised cancer recovery plans for the South East London acute trusts, along with revised trajectories, were approved by regulators in November 2017. ‘Return to trajectory’ plans were developed to describe how trusts would return to recovery by March 2018. These plans were further revised to ensure return to recovery in 2018/19.

Diagnostics Greenwich CCG achieved the diagnostic waiting time standard during 2017/18 as 99.1% of Greenwich patients were seen for a diagnostic test such as endoscopy, CT scan or plain film x-ray within six weeks of referral, ensuring swift diagnosis and treatment in a timely manner.

London Ambulance Service (LAS) To keep up with the evolving needs of the NHS and to support staff to provide the best possible service to patients, there has been a change to the national ambulance response time standards.

The previous standards had a response time of 8 minutes for urgent calls, with half of all calls being classed into this category. The threshold for meeting this standard was 75%, with no national response target set for non-urgent calls. As a result, in the last two years response times for non-urgent calls have doubled in some localities. Over the last 18 months, the Ambulance Response Programme (ARP) have developed a new operating model and has set a new range of targets which went live in November 2017:

• Change the dispatch model of the ambulance service, giving staff slightly more time to

identify patients’ needs and allowing quicker identification of urgent conditions. • Introduce new target response times which cover every single patient, not just those

in immediate need. For the most urgent patients we will collect mean response time in addition to the 90th percentile, so every response is counted.

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• Change the rules around what “stops the clock”, so targets can only be met by doing the right thing for the patient.

Performance reporting at London level is currently under review by LAS and commissioners. Locally, challenges and mitigation at LGT are addressed through the A&E Delivery Board and the LGT Contract Management Board (CMB).

Healthcare acquired infections (HCAIs) There are three national targets for infection control:

• Clostridium difficile (C.Diff) • Methicillin resistant staphylococcus aurens (MRSA) • Escherichia coli bacteraemia (E.coli) this national target was introduced, following a

five-year national ambition launched in 2016 to achieve a 50% reduction across the entire health sector by March 2021.

All can be acquired in the community or in hospital and MRSA especially is becoming more difficult to treat with antibiotics, so prevention is a priority area for all NHS staff.

C.Diff

• The Greenwich C.Diff target threshold for 2017/18 was 62. • In 2017/18 the figures to date show 34 cases of C.Diff in Greenwich-registered

patients, including 28 community acquired and six hospital acquired C.Diff cases. • The target for 2018/19 is 61.

NHS Greenwich CCG has an action plan to manage C.Diff in the community, working closely with the acute trusts and local general practices. All Greenwich member practices have undertaken infection control training including learning from post-infection reviews of C.Diff cases that have occurred in the community. The Health Protection Programme Manager works closely with local practices to advise and ensure learning from reported cases.

MRSA

• The Greenwich MRSA target threshold for 2017/18 was zero and remains the same for 2018/19.

• In 2017/18 the figures to date show six cases of MRSA attributed to Greenwich CCG commissioned services.

An ongoing process for post-infection review for all MRSA cases is in place to enable learning and action planning.

E.coli

• The Greenwich E.coli target threshold for 2017/18 was a 10% reduction from the 2016/17 figure which was 189.

• In 2017/18 the figures to date show 173 cases of E.coli associated with Greenwich CCG commissioned services.

• The 2018/19 target is a 10% reduction from the 2017/18 figure.

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Tuberculosis (TB) TB case numbers and rates in Greenwich continue to decline, although at a slower rate since 2015. In 2017, 70 active cases of TB were notified in Greenwich residents, a rate of 25 per 100,000 populations. The TB rate varied as shown in the table below, and rates were higher in some areas in the north of the borough.

2014 2015 2016 2017 N Rate N Rate N Rate N Rate Greenwich 97 36.1 92 33.5 64 22.9 70 25

Latent TB Infection (LTBI) testing and treatment by Greenwich GP practices Greenwich CCG and Royal Borough of Greenwich support the NHS England and Public Health England National LTBI testing and treatment programme 2015-2020 and rolled out the scheme across all Greenwich CCG practices from 2016. The LTBI testing and treatment is offered to new and existing patients who are at a higher risk of developing TB. Greenwich has made good progress and is expecting to be testing a further 1200 patients during the year 2018/19, having successfully applied to NHS England for further funding. Out of 1156 tests between 2016 and 2017, 254 (22%) tests were LTBI positive.

Focus on mental health In 2017/18 CCG embarked on a mental health review with stakeholders across the system. This involved a deep dive in to every element of our acute and community mental health provision to identify areas of success, challenges and where improvements could reasonably be made to meet the ambitions of the Five Year Forward View. The output of the review was a transformation programme focusing on two key workstreams of prevention and alternatives to admissions.

What have we achieved? We made significant steps to encourage wide engagement and consultation in all our commissioning activities with special efforts made to build relationships within the voluntary sector and capitalise on the diverse skill sets on offer. We have worked with the Sustainability and Transformation Partnership to make sure we are delivering ambitious and high-quality services.

Improving access to psychological therapies (IAPT) Greenwich CCG has achieved and maintained one of the highest recovery rates in the country for people accessing IAPT services (56% against a 50% national target). In 2018/19 we will capitalise on this success and expand the service to treat 19% of the population, up from 15%. Two thirds of the additional clients are expected to have a long-term condition (LTC) and to enter the service via integrated IAPT and LTC teams.

Dementia There have been challenges with reaching the dementia diagnosis targets this year. Dementia diagnosis is a priority and we commissioned a GP clinical lead to support Oxleas NHS Foundation Trust and Royal Borough of Greenwich to work with primary care to increase access, while also seeking to improve the post-diagnostic pathways of support for people with

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dementia. Recent actions taken include working with GPs to ensure that patients are being added to the dementia register in a timely manner (post diagnosis) and cross-checking memory service contacts against GP dementia registers to ensure that all patients are being recorded. These actions have resulted in an additional 25 newly diagnosed cases added to the dementia registers for March 2018, with a few more expected in the first part of 2018/19.

People with learning disabilities and or autism Transforming Care is the national response to the crises at Winterbourne View and other inpatient units for people with learning disabilities (LD) and or autism. The programme runs from April 2016 to March 2019. The Transforming Care initiative is now setting the agenda for all services for people with LD or autism. NHS England’s monitoring and assurance of services for people with LD or autism is increasingly under the Transforming Care agenda and moving to a footprint through the South East London Transforming Care Partnership (TCP). The South East London TCP already has a relatively low number of in-patients (currently between 40 and 45 adults in beds paid for by the six CCGs).

The local supporting schemes are ones we either commission directly (Oxleas NHS Foundation Trust services, Community Learning Disabilities Team) or work jointly with Royal Borough of Greenwich and other partners to deliver, e.g. transition, housing strategy. Through developing the work plan and conducting a mini review we have already established some service gaps and will explore solutions for in 2018/19, e.g. lack of service provision for service users with more challenging behaviours and those with complex physical health needs.

Annual health checks People with learning disabilities often have poorer physical and mental health than other people. The annual health check scheme is for adults and young people aged 14 or above with learning disabilities who need more health support and who may otherwise have health conditions that go undetected.

The annual health check is also a chance for the person to get used to going to their GP practice, which reduces their fear of going at other times. We are undertaking work to increase the uptake of annual health checks by providing training to GPs and promoting health checks within the learning disability population.

Learning disability mortality review The learning disability mortality review programme (also known as LeDeR) was established to drive improvement in the quality of health and social care services for people with learning disabilities. It focuses on why people with learning disabilities typically die much earlier than average. People with learning disabilities are four times as likely to die of preventable causes compared with the general population (Disability Rights Commission, 2006).

NHS England is committed to making sure that people with learning disabilities receive the right care in the right settings, with the right support. This is one of several national priorities which supports our understanding and drive to reduce health inequalities amongst this group. We have worked with Royal Borough of Greenwich and Oxleas NHS Foundation Trust during 2017/18 and now have 15 reviewers in Greenwich.

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Child and adolescent mental health services (CAMHS) The 2017/18 Greenwich CAMHS transformation plan outlines our commitment to improving mental health and emotional well-being services for children and young people (CYP) with local and regional partners and a focus on priority areas including providing urgent and emergency care for children and young people experiencing a mental health crisis.

As part of a tri-borough partnership including Bexley and Bromley CCGs, we agreed funding to develop of an out-of-hours children and young people mental health liaison service in 2017/18 which will be launched in early 2018/19. The service will provide direct access to specialist mental health support for children and young people presenting in mental health crisis at acute hospitals outside of working hours and is a significant milestone in achieving parity in access and quality of care for CYP in Greenwich.

In the year the South London Partnership1 launched the New Models of Care initiative for CAMHS, aiming to improve the experience of young people and their families using acute and specialist CAMHS services (Tier 4) in South London.

In the first quarter of operation (January to March 2018), the partnership has delivered a 25% reduction in the number of Tier 4 CAMHS out-of-partnership bed days (against the baseline year). This has been achieved largely through improved working relationships and bed management functions across the provider organisations.

In 2017/18 Greenwich CAMHS was selected as a ‘beacon site’ for the children and young people Improving Access to Psychological Therapies (IAPT) programme in recognition of the service’s success in fully embedding CYP IAPT principles and in achieving good clinical outcomes for children, young people and families. The service also reported improvements as 85.4% of children with recorded outcome measures were reviewed between July and September 2017.

In 2017/18 the CCG maintained focus on helping children and families to access appropriate support and building capacity across children’s services. We continued to develop the wide network of preventative clinical in-reach support services, with Greenwich CAMHS providing 164 clinical in-reach sessions across a range of children’s services between October and December 2017. We are committed to further improving national access rate targets.

Liaison Across Bexley, Bromley and Greenwich 59-77% of children and young people (CYP) who present with a mental health crisis to A&E do so outside of normal working hours resulting in high admission rates to acute mental health inpatient beds. A children’s and young person’s liaison nurse has been commissioned to support the staff at Queen Elizabeth Hospital. This post will provide more robust care coordination across the acute hospital setting and contribute to a reduction in the current length of stay – in addition to mental health-related A&E breaches.

1 Partnership comprised of three provider organisations, South West London and St. George’s Mental Health NHS Trust, Oxleas NHS Foundation Trust and South London and Maudsley NHS Foundation Trust.

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Integrated working and Better Care Fund In 2017/18 Greenwich shared a pooled budget of approximately £19 million with Royal Borough of Greenwich. The central focus of the Better Care Fund (BCF) programme is to jointly commission health and social care services that enable people access to high quality care in their community. The programme aims to improve the lives of some of the most vulnerable people, placing them at the heart of their care and support, and providing them with ‘wraparound’ fully integrated health and social care, resulting in an improved experience and better quality of life.

The BCF plan includes the following four metrics: non-elective admissions (NEAs), delayed transfers of care (DToC), residential admissions and reablement. The Better Care Fund programme schemes are designed to reduce non-elective admissions, admissions to residential care, improve patient satisfaction with services and increase the number of patients living at home after a discharge from hospital.

In our BCF plans (submitted in September 2017 to NHS England) we committed to reducing DToCs: Greenwich has made significant progress in managing the increase in delayed transfers of care leading to an over 25% projected reduction in DToCs. Further reductions are projected based on scrutiny processes developed across acute and mental health provision. We have achieved this with both Oxleas NHS Foundation Trust and Lewisham and Greenwich NHS Trust and consequently have strengthened how we anticipate and resolve process issues within the system.

We committed to reducing non-elective admissions (NEAs) based on the redesign of the “front end” urgent care pathway, and although work has started we have not seen the impact of new services yet. We committed to maintaining our level of residential admissions, based on baseline low levels. While data is not available on the latest position, a proxy measure captured through service activity indicates that we are not far off achieving the anticipated target. We have seen a slight increase in our 91-day readmissions to hospital. Further work is underway to understand this trend and will continue to be scrutinised. We developed mental and physical health scrutiny panels involving health and social care colleagues and providers and have successfully worked together to reduce delayed transfers of care.

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Financial overview The CCG commissions and provides healthcare services to meet the needs and improve the health of the population of Greenwich. The main NHS providers are Lewisham and Greenwich Healthcare NHS Trust, Guy’s and St. Thomas’ NHS Foundation Trust and Oxleas NHS Foundation Trust. In addition, the CCG funds the prescribing costs of Greenwich GP practices and from April 2017, NHS England delegated responsibility for the commissioning of primary care services to the CCG.

A pie chart showing how the CCG spent its budget in 2017/18 is shown below.

Overall, the CCG has delivered a surplus of £0.713 million for 2017/18. The financial target for the CCG was to achieve a surplus of £0.644 million so we have delivered a slightly better financial position (£0.069 million) than planned.

2017/18 CCG Expenditure £415.6 million Other Programme

Costs 4%

Primary Care

9%

Primary Care Co Commissioning

9%

Running Costs 1%

Continuing Care Children

2% Acute Services

52%

Continuing Care 4%

Community Health Services

6% Learning

Disabilities 1%

Mental Health Services 12%

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The CCG is required to achieve several specific financial targets. These are summarised in the table below:

Target

(£’000’s) Actual (£000’s)

Achieved

Agreed Surplus 644 713 Achieved Expenditure not to exceed

income 423,608 422,896 Achieved

Deliver statutory

Operate Under Resource Revenue Limit

416,299 415,586 Achieved

financial duties Not to exceed Running Cost Allowance

6,093 6,092 Achieved

Operate under Capital Resource Limit

0 0 Achieved

Deliver administrative duty under the better payments practice

95% of NHS creditor payments within 30 days

95% 99.77% Achieved

95% of non-NHS creditor payments within 30 days

95% 98.99% Achieved

As reported above, we are pleased to confirm that the CCG has delivered all its financial performance targets for 2017/18.

A financial risk-share agreement is in place across the six CCGs in South East London. It was agreed through the governance of each CCG that the risk-share agreement be enacted in 2017/18. The final revenue resource limit values included in the 2017/18 annual accounts of each CCG reflect the outcome of the risk-share agreement.

CCG running costs The CCG’s running cost allocation in 2017/18 was £6.093 million. Following a high use of interim staff in 2016/17, the CCG has focused on recruiting to its permanent structure, using interims only where necessary to deliver the CCG overall operating plan. This has enabled the CCG to reduce its spend on interim staff and ensure that it has incurred expenditure in line with its running costs budget for the year.

Future years 2018/19 represents the second year of the CCG’s two-year operating plan. This forecasts that the CCG will deliver a surplus of £0.30 million in year as its share of an overall £3.221 million South East London control total. The achievement of the plan is dependent upon the delivery of significant QIPP savings of £14.30 million in 2018/19 together with the management of other key financial risks.

The overall CCG budget for 2018/19 is £423.1 million which includes additional funding of £12.6 million from that received in 2017/18.

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The pie chart below shows the CCG plans to spend its budget in 2018/19.

Other matters Remuneration paid to external auditors in relation to audit work for 2017/18 was £52,000 (including non-recoverable VAT). Remuneration for non-audit work was nil. The CCG has complied with HM Treasury’s guidance on setting charges for release of information.

Annual Accounts The full annual accounts together with the Statement of Accountable Officer’s responsibilities and Independent Auditors Report are included in section 3.

Audit Committee highlights • Approved an annual internal audit plan with RSM UK to provide the Audit Committee and

Governing Body with the assurance that Greenwich CCG is operating effectively and productively and monitored any actions arising from the audits.

• Monitored and reviewed financial and other risks and associated controls, corporate governance and financial assurance.

Finance, Performance and QIPP (FPQ) Committee highlights • Provided assurance to the Governing Body that affordable and appropriate budgets

were set. • Effectively monitored the finance and QIPP performance throughout 2017/18 and

advised on corrective actions where appropriate. • Maintained the QIPP Planning Delivery and Monitoring Group reporting to the

Financial Recovery Board for QIPP business plans.

2018/19 CCG Expenditure £423.1 million Primary Care Co Commissioning

Other Programme Running Costs Costs 2%

4%

Contingency and Earmarked Reserves

1% Primary Care

9%

9%

Continuing Care Children

2% Continuing Care

4% Community Health

Services 5%

Learning Disabilities 1%

Acute Services 52%

Mental Health Services

11%

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Finance Recovery Board (FRB) highlights • The purpose of FRB is to lead and drive the financial recovery of the CCG, so it can

return to recurrent financial balance and ensure that patient safety and quality are not compromised.

• During 2017/18, the FRB oversaw the delivery of the CCG QIPP efficiencies of £15.8 million and approved the QIPP plan for 2018/19.

Quality, improvement, productivity and prevention (QIPP) Quality, improvement, productivity and prevention (QIPP) is a programme designed to support clinical teams and NHS organisations to improve quality of care whilst making efficiency savings that can be reinvested into the NHS.

The CCG had a fully identified QIPP plan of £19.3 million for 2017/18. The schemes relate to improving the quality of care and efficiencies in the services that we are required to commission and securing better value for money.

Acute schemes included demand management and referral management to the appropriate healthcare setting and shifting activity from hospitals to community to allow hospitals to be more efficient in treating those requiring attendance or admission.

Community schemes included the re-design of the community district nursing service, the re- design and implementation of an integrated COPD/asthma/respiratory service in the community, and the increased utilisation and more flexible use of intermediate care and nursing home beds.

Mental health schemes included a mental health clinical audit, and more effective commissioning of Mental Health services by the responsible Commissioner.

Primary Care and prescribing schemes related to increasing access to GPs for Greenwich- registered patients and more efficient primary care prescribing using best practice approaches.

£15.8 million (representing 82% of the target) of QIPP efficiencies was delivered in 2017/18 leaving a shortfall of £3.5 million against the plan.

The table below summaries the delivery of each scheme in £000s QIPP performance 2017/18 Validated

Plan Actual Variance

Acute 7,619 2,822 (4,797) Sub-total acute QIPP 7,619 2,822 (4,797) CHC, community 4,237 3,521 (716) Mental health 1,002 766 (237) Primary care 1,607 2,131 524 Other 4,825 4,834 (81) Sub-total Non-Acute QIPP 11,671 11,252 (509) Total QIPP 19,290 15,812 (3,568)

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Sustainable development The NHS Carbon Reduction Strategy for England provides a framework which addresses sustainability in how we operate as an organisation in our own right, and in terms of how we contract for services from providers of healthcare. The plan aims to:

drive down direct C02 emissions and energy usage whilst also reducing revenue

expenditure influence commissioned services to reduce their carbon footprint in support of the 10%

target reduction ensure that all new buildings and other initiatives are developed with reference to the

plan. Local plans focus on the same areas and some of the key actions are detailed below.

Energy and carbon management: our office in based in the Woolwich Centre, a modern building with many sustainable features including automatic lighting that switches off when no one is present, electricity generation from solar PV to offset the buildings electrical costs and solar water heating. Cooling to the main areas of the building is run by state of the art energy efficient chiller system via chilled beams, and heating in the building is run by 96% energy efficient condensing gas boilers.

Procurement and food: our main strategy is to influence the carbon footprint of NHS services using our procurement framework, which addresses environmental issues. All contracts for healthcare services include clauses requiring providers to demonstrate their measured progress on climate change adaptation, mitigation and sustainable development, and include performance against carbon reduction management plans.

Low carbon travel, transport and access: we have implemented a range of new services, and developed existing services, to bring them closer to the home. Cycling has been promoted actively for employees now we have moved to The Woolwich Centre with excellent cycle storage and related facilities. The Council operates a cycle hire scheme that allows employees to make use of one of six Brompton bicycles for work travel.

Water: efficient use of water is embedded in new capital projects. For example, Eltham Community Hospital and The Woolwich Centre harvest rainwater for use in the building. The Woolwich Centre also has integral filtered watered in all its kitchens for drinking.

Waste: recyclable waste is appropriately disposed of and we are part of the Royal Borough of Greenwich’s active strategies to reduce waste and promote recycling. We continue to focus on reducing our use of printing.

Organisational and workforce development: staff can use low carbon travel options, with walking and cycling encouraged and aligned business mileage processes. Audio, video and web conferencing technology and remote working capability are in place and promoted to avoid going into Central London for meetings. We are also promoting online services in GP practices, so patients can also reduce their journeys.

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Role of partnerships and networks: the Greenwich Core Strategy commits us to working in partnership with stakeholders under Local Strategic Partnerships, in particular the Royal Borough of Greenwich.

Finance: as part of the exercise to calculate the carbon footprint, carbon reduction targets will be set to achieve the NHS target and take advantage of schemes which support investment in energy efficiency initiatives.

Quality and safety Quality and safety of services is a priority for Greenwich CCG to ensure the best possible care for our population. We have systems and processes to support quality and safety, providing assurance through regular reports to the Governing Body and key sub-committees. The Quality Committee receives detailed reports on quality and safety challenges, improvements and innovations in commissioned services and partnership agencies. The reports highlight plans and actions being taken to improve service quality and reduce patient safety risks.

Monthly Clinical Quality Review meetings take place with large service providers holding them to account for patient safety, the clinical effectiveness of services and ensuring a good patient experience. For hospital trusts these meetings are held with our partner CCGs: for example, Bexley and Lewisham CCGs depending on the hospital provider; this arrangement further strengthens the CCG’s scrutiny and accountability of the services provided to examine the quality and safety of services in a wider context.

Improving quality and safety of services needs good information and the information used to support quality and safety comes from a variety of sources including CCG quality visits, information from commissioned services and external bodies such as the Care Quality Commission (CQC) who inspect health providers on a regular basis to comply with their registration requirements.

2017/18 quality highlights

We have continued to maintain good oversight of provider quality, including our small providers, e.g. Out of Hours GP Services and the Urgent Care Centre at Queen Elizabeth Hospital through regular information, quality reviews and detailed deep dives into commissioned services.

• We have maintained a programme of provider announced and unannounced site “Quality Visits” to our providers. These are undertaken by our Quality Team through an agreed protocol and with our neighbouring CCG partners for large commissioned services.

Sepsis is a rare but serious reaction to an infection and can be life threatening. It is recognised by the NHS as a significant cause of mortality and morbidity. In 2015 the Secretary of State announced several initiatives and the CCGs through commissioning have sought to improve and extend measures for the recognition and treatment of sepsis.

• Sepsis is an important health issue for Greenwich CCG. It is also a National Commissioning for Quality and Innovation (CQUIN) for the acute hospital commissioned services. The trust’s progress with the delivery of the CQUINs is monitored through regular CQUIN reviews between the trust and CCG.

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The National Early Warning Score (NEWS) is an important tool to identify the signs of sepsis at an early stage and this is in use at Lewisham and Greenwich NHS Trust and audited on a regular basis and reviewed at Clinical Quality Review Group. A variation of NEWS for mental health patients is in use by Oxleas NHS Foundation Trust for in- patient services and this will change to the use of NEWS in 2018.

As an innovation for 2018 the CCG is looking to support the use of a telehealth NEWS system with care homes, supported by a trainer. It is anticipated this project will be rolled out to all care homes in the CCG area in 2018/19.

Oxleas NHS Foundation Trust Following the CQC inspection report for Oxleas NHS Foundation Trust in 2016 where the trust was rated “Requires Improvement”, an action plan was put in place by the trust and the subsequent revisit by CQC upgraded the trust rating to Good. Oxleas NHS Foundation Trust has continued to work on improvements reporting to Greenwich, Bromley and Bexley CCGs through the Clinical Quality Review Group.

The trust has implemented an improved process to review deaths and promote learning in line with CQC recommendations arising from the Learning Candour and Review Report published in December 2016. This prioritises learning from deaths in a clear and consistent way focusing on systems and effective dissemination of learning; at the same ensuring caring support for families.

Lewisham and Greenwich Hospitals NHS Trust The CQC inspected the trust in March 2017. Following publication of the inspection report in August 2017 the trust was rated overall as “Requires Improvement”. Within the report the trust was rated as good for the effective and caring domains as were the trust critical care and services for children and young people. Action plans have been agreed by the trust with the CQC to address the concerns identified in the report. The trust continues to work on the improvements needed to address the recommendations.

The trust has been and continues to be an active participant in the Sign up to Safety campaign, an initiative launched by NHS England in 2014 to save 6,000 lives nationally. The programme now encompasses approximately 500 organisations nationally with the aim of making care safer through learning and improvement.

The CQC maternity survey was carried out during the summer of 2017. A questionnaire was sent to all women who gave birth in February 2017 (and January 2017 at smaller trusts). Responses were received from 222 patients at Lewisham and Greenwich NHS Trust and overall the trust results were comparable with other trusts.

The Patient Reported Outcome Measure (PROM) participation rates at Lewisham and Greenwich NHS Trust remain at 100% as does the trust participation rate in National Audits and Confidential Enquiries.

Patient safety

NHS Greenwich CCG has a robust process in place to review pressure ulcers from both Oxleas NHS Foundation Trust and Lewisham and Greenwich NHS Trust, in partnership with NHS Bexley CCG. The CCG receives further assurance via reports

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presented at Clinical Quality Review Group (CQRG) meetings on the management of pressure ulcers both in the community and in the acute setting.

The CCG continues to support providers to improve the quality of serious incident (SI) reports through cooperative working, feedback and robust monitoring of the implementation of all action plans.

Having reviewed the findings from serious incident reports, we have classified them as follows:

Diagnostic incidents including delays and failure to act on test results. Pressure ulcers: Grade 3 and 4. We have seen an improvement in reporting and are

able to ensure that learning takes place which then helps to reduce the incidence of ulcers and reduce re-occurrence. Grade 3 and 4 are the most serious type of ulcers.

Apparent, actual or suspected self-inflicted harm, e.g. attempted suicide. NHS Improvement (NHSI) published a revised Never Events policy and framework in January 2018. Never Events are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. The main changes to the revised policy and framework are:

Removed the option for commissioners to impose financial sanctions on trusts

reporting Never Events. Alignment of the Never Events policy and framework with the Serious Incident

framework, to achieve consistency across the two documents (a revised Serious Incident framework will be published later in 2018).

Revisions to the list of Never Events, including two additional types of Never Events:

(i) Unintentional connection of a patient requiring oxygen to an air flowmeter and (ii) Undetected oesophageal intubation.

There were no never events for Greenwich residents reported by the CCG’s acute or mental health provider for 2017/18.

Safeguarding adults and children We work in partnership with Royal Borough of Greenwich and providers so that effective safeguarding arrangements are in place for all services.

Safeguarding children In 2017/18 NHS Greenwich CCG fulfilled its statutory responsibility to safeguard children and young people as defined in the ‘safeguarding vulnerable people in the reformed NHS; accountability and assurance framework’ (2015). The CGG has continued to work with local health services and the Greenwich Safeguarding Board to monitor the effectiveness of safeguarding systems ensuring they meet statutory requirements and national guidelines through the section 11 audit processes.

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We have worked alongside Local Authority commissioners of universal children’s services and other partners to improve the health and wellbeing of all children, young people and their families living in Greenwich. Commissioning acute services and the health of looked after children remain the responsibility of the CCG.

We took on full level 3 delegated responsibilities for primary care contracting with effect from 1 April 2017. The safeguarding children team has supported local GP practices to improve the wellbeing of children, through the provision of training, good practice guidance, and facilitating reflective sessions at local GP practices to improve safeguarding practices. The CCG has also ensured appropriate contributions from primary care to safeguarding enquiries and serious case reviews.

This year important legislative changes impacting the structure and function of local safeguarding children’s boards emerged through the Wood Review which recommended a tripartite partnership of health, police and social services to replace local safeguarding children boards. The Children and Social Work Bill 2017 received Royal Assent in April 2017. This new arrangement will take 12-18 months to set up and we are complying with the new legislation, working with our partners to support the development and transition to new arrangements.

We use learning from safeguarding children reviews by embedding it into training for GPs, community pharmacists and other professionals and to bolster local safeguarding practice in line with good practice.

The following Greenwich health and social services for children had inspections in 2017/18:

• Ofsted inspection of children’s services. Special educational need and disability. Joint targeted area inspection focused on childhood sexual exploitation, missing from

home, education, gangs and criminal exploitation. We have developed action plans from inspection recommendations and will continue to monitor their implementation through the safeguarding committees. We successfully recruited a designated doctor for safeguarding children in September 2017 which was positive after the post had been vacant for over a year and previous recruitment attempts had not been fruitful.

Safeguarding adults Adult safeguarding activity has continued to increase in Greenwich following the further implementation of the Care Act 2014 and associated statutory guidance relevant to safeguarding. As previously, deprivation of liberty safeguards applications have seen sustained growth, and authorising these within statutory timeframes remains challenging.

Together with Royal Borough of Greenwich we monitor the quality of care in nursing homes across Greenwich, with focus on care homes which have been rated as inadequate or requiring improvement by the CQC. This is within the context of a fragile care home market with workforce, changing ownership and clinical leadership challenges.

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In 2017/18 the Safeguarding Adult Board (now on a statutory footing) asked the CCG to look at a small number of deaths that occurred in care homes where choking risks had been identified. Together with Royal Borough of Greenwich, Oxleas NHS Foundation Trust and the care home sector, we have acted to reduce risks of further choking incidents and improve care home staff awareness and management of risks.

Responsibilities in safeguarding identified high risk areas of Prevent and Modern Slavery have also increased: Greenwich has a well-defined multi-agency referral and management system for Prevent referrals (Channel Panel) to reduce the risks associated with extremist radicalisation. The CCG has also teamed with the Royal Borough of Greenwich safeguarding and community safety to provide multi-agency Modern Slavery awareness training to staff.

Clinical effectiveness Quality Alert Management System (QAMS) relies on GP practices identifying one or more individuals - usually GPs and practice managers but also administrative staff and healthcare professionals - to log in and raise an alert to the CCG when an issue occurs related to the quality of a service supplied by one of our provider organisations.

Greenwich GPs have been using the QAMS for two years now and we can see an increase in uptake from Greenwich practices. Currently the number of Greenwich GP practices using QAMS is 16. The trajectory for 2018/19 is for all 35 practices to utilise the system. More GPs are now using QAMS as they can see the impact that their shared intelligence has on improving patient services. Practices can now have a more comprehensive overview of the alerts they raise and of any patterns in the alerts raised by their peers.

The QAMS user group comprises Greenwich CCG, Bexley CCG, Lewisham and Greenwich NHS Trust and Oxleas NHS Foundation Trust. With the system’s software developers, we have made improvements aimed at getting more GP practices to use the system. This year we launched a new application in the Vision operating system used by many GP practices, which makes QAMS more user-friendly and accessible. This work continues, and we hope to provide the same facility for GP practices currently using the EMIS electronic patient record system soon.

This year has also seen the introduction of ‘reverse reporting.’ Under reverse reporting, our providers are now able to use QAMS to report to the CCG any quality issues they have encountered. The functionality that enables reverse reporting from our provider services is called QAMS Provider Plus and was implemented in July 2017, initially with Lewisham and Greenwich Trust, and to date it has highlighted the need to improve the quality of referral information from our GPs. We plan a wider roll-out of QAMS Provider Plus with our other health service providers in 2018. Some local care homes and community pharmacists have expressed an interest in being able to log in into the system to deal with alerts more quickly.

Examples of the benefits of using QAMS:

It has highlighted the problems GPs experience with patient discharge summaries. This

was discussed at the Lewisham and Greenwich NHS Trust Clinical Quality Review Group and an internal audit of the hospital electronic discharge system (EDS) which

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sends discharge information back to the patient’s GP is being conducted to identify and resolve the problem.

• GPs have raised issues about Lewisham and Greenwich NHS Trust not providing patients with fitness to work certificates on discharge. This has resulted in GPs’ time being taken up issuing certificates when they should be provided by the trust in line with the Service Level Agreement. The trust has written to all consultants and doctors to remind them of their responsibilities to do this.

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Engaging people and communities - patient and public involvement Our approach Engagement is a key priority for the CCG, and one of our corporate objectives. Effective engagement is an important part of everybody’s role, with the communications and engagement team providing guidance and support. We strive to actively involve local people and service users to plan, design and feedback on local services, and we are committed to building relationships with our communities to understand their needs, so that we can plan services accordingly.

We engage with our local communities to:

identify health needs and aspirations, develop our commissioning intentions and

priorities design and improve services • take patients’ views into account when we buy services • use patients’ experience to improve safety and quality of care

Our Patient and Public Engagement Strategy, launched in September 2017, sets out our vision, approach and infrastructure for delivering our legal duties to engage patients and the public in our work. By engaging with the local community, we understand the needs, concerns and experiences of residents so we can deliver the best possible health services. We understand that the best way to achieve positive health outcomes for the people of Greenwich is by putting local people at the heart of our decision making.

We involve Greenwich patients, partners and residents throughout the commissioning cycle to ensure that local people have a strong voice. We are committed to continually improve in this important area of focus for the CCG.

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Our Governing Body meetings are held in public and we host a dedicated session at each Governing Body meeting giving local people ongoing opportunity to engage with the CCG leadership and raise their concerns first hand. All Governing Body agendas and papers are published on our website.

Two of our Governing Body members have responsibilities for patient and public engagement - one lay member as lead on the Governing Body, and one GP lead who has patient and public engagement in their portfolio. Meetings see regular attendance from members of the public and Healthwatch Greenwich, and the dedicated session is popular, with questions raised at each meeting.

We use our stakeholder networks and existing channels and groups as forums for discussion. We have strong links with Healthwatch Greenwich, METRO GAVs, the Royal Borough of Greenwich and other local groups and are constantly working to build and extend our stakeholder network.

Our Patient Reference Group (PRG) is made up of members of local Patient Participation Groups (patient groups attached to GP practices) and community and voluntary sector partners. It advises on and provides assurance that the CCG is meeting its statutory obligations around patient involvement and engagement. The PRG reports into the Governing Body, and communications and engagement activity and impact is reported regularly to the Greenwich Executive Group.

We are committed to making our communications which support engagement as accessible and appealing as possible for each of our audiences. Some examples include:

• Developing Easy Read materials for people with learning disabilities. • Creating a plain English and visually appealing annual review of the year as an

accessible alternative to this annual report. • Using translator services for community engagement events - most recently in our

Nepalese outreach work. • Providing visual and audible accessible presentations for our engagement events. • Considering the many and varied needs of our communities. • Offering our publications in alternative formats on request.

The list below gives a flavour of some of our engagement activity during 2017/18:

• Commissioning intentions workshops in September 2017 to hear feedback and plan

services across all commissioning areas, with a follow up workshop focusing on learning disabilities and mental health.

• Three clinical commissioning strategy workshops in March 2018 badged ‘the Greenwich Big Conversation’, bringing together 144 service users, carers, community and voluntary sector partners, service providers and commissioners to discuss and deliberate future models of healthcare.

• Greenwich News launched in 2017 to update stakeholders on key CCG initiatives and projects.

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• Outreach work with our Nepalese community (seldom heard group), using local materials and a translator. Roughly 5,500 Nepali people live in the borough. From our engagement work, the CCG found that the Nepalese community were not aware of the GP Access Hubs, which offer residents access to GP appointments in the evenings and on weekends.

• 12 outreach events running from 12 December 2017 to 25 January 2018 to promote the GP Access Hubs, self-care and alternatives to A&E. We successfully engaged with 620 local people.

• School outreach work with families, signposting local mental health support services, and raising awareness and promoting wellbeing to primary age pupils and their parents and carers. Follow up on issues identified from outreach work, between mental health commissioning team and the local child and adolescent mental health service provider, who are working together to address some of the issues raised by parents.

• Demonstrating the impact of patient feedback / information received from engagement activity with regular “you said, we did” reports.

• Public consultation on Treatment Access Policy – see case study below. Ways for patients to get involved There are several ways that patients can get involved and influence services, including:

• Taking part in engagement events. • Joining a Patient Participation Group. • Joining the CCG’s Patient Reference Group (PRG). The PRG oversees the CCG’s

engagement and equalities activities. Please contact Patricia Kanneh-Fitzgerald for more information. 020 3049 9042 p.kanneh-fitzgerald@nhs.net.

• Attending Governing Body meetings. Case study public consultation on Treatment Access Policy (TAP) In 2017, Greenwich CCG sought to make changes to the South East London Treatment Access Policy (TAP) for Greenwich. Our proposed changes, based on clinical evidence, centred on changing access to planned (elective) surgery and treatment. The proposal the CCG consulted on included:

• Smoking cessation (help giving up smoking before surgery) • Weight management (help with losing weight before surgery) • Whether specific treatments or procedures should be available on a routine or

exceptional basis only. Before making any changes, the CCG conducted a thorough public consultation in 2017/18, consulting a range of stakeholders and local partners including the Royal Borough of Greenwich, members of the Health Overview and Scrutiny Committee (HOSC), Healthwatch Greenwich and GAVs (Greenwich Action for Voluntary Services). In addition, we held 13 public engagement sessions at popular venues across the borough, including a focus group with residents with learning disabilities.

A survey was available online and in print. Members of the public were invited to send in responses by email and post. In addition, we produced an Easy Read leaflet about the

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consultation, information documents and a list of engagement opportunities were available on a dedicated web page. The Patient Reference Group assured the engagement process.

The CCG received 753 responses to the public consultation and commissioned an independent report on our engagement. As a result of the public feedback, the CCG agreed to make several changes to the Treatment Access Policy for Greenwich. Two examples of how public feedback impacted Greenwich’s Treatment Access Policy are:

Smoking cessation The CCG had originally proposed that smokers should be referred for help to quit smoking or stop smoking before a referral for planned / elective surgery. However, in response to feedback to our consultation, the CCG amended the policy so that surgical procedures are not withheld for patients who need them. The CCG will not require for someone to stop smoking as a condition of receiving their surgery, however the CCG does require that they attend at least one session aimed at helping them stop before they are referred for routine elective surgery.

Weight management The CCG had originally proposed that patients with a BMI of 30+ should be supported to lose weight before having planned surgery. However, following feedback to the consultation, the CCG agreed that surgical procedures should not be withheld for patients who need them based on their BMI. Instead, it was decided that patients who are obese should be referred to weight management support services as part of normal care.

Full details of the TAP consultation can be found on our website

Annual 360-degree stakeholder survey We strive to build and nurture strong relationships with our partners to shape and support effective local commissioning. A key component of our planning and engagement work is the annual 360-degree stakeholder survey, commissioned by NHS England and delivered by Ipsos MORI.

The survey allows stakeholders to provide feedback on our working relationship, and the results provide intelligence to help with our organisational development, and relationship management. Fieldwork took place between 15 January and 28 February 2018 mainly across our 35 member practices, along with other providers, and stakeholders.

The uptake rate in 2016/17 annual survey was low at 41% (member practice participation 42%) and the feedback from respondents was often critical. The CCG has proactively managed the process this year. Our approach returned a much-improved response rate in 2017/18 of 92% (member practice participation 91%). This gives us a wealth of information to inform the development of our plans and activity.

Clinical engagement As a clinically led organisation, part of the CCG’s remit is to ensure that we have clinical leadership and engagement on all our pathway work. The CCG achieves this through several clinical engagement mechanisms.

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Each GP on the Governing Body carries a portfolio which is segmented into the following areas: Urgent and Emergency Care; Planned Care; Mental Health; Primary Care and Children’s services. We employ GP project leads to work alongside commissioning staff. During 2017/18 the CCG had GP engagement in the development and planning of pathways in the following areas:

GP project lead Session/

week GP project lead Session/

week End of life and cancer

1-2 Workforce and education

1

Children and younger People

2 Planned care 2

Quality 1 Long term conditions

2

Independent funding requests (IFR)

1 Primary care 2

Urgent care 1 Medicine management

2

Mental health 2 We engage with our GP members through local syndicate meetings and the quarterly Greenwich wide forum meeting. GP leads are involved in engagement events too.

GP leads represent Greenwich on South East London Sustainability and Transformation Partnership committees and work programmes, and at regular Clinical Cabinet meetings with Lewisham and Greenwich NHS Trust.

Sustainability and transformation partnership Our Healthier South East London (OHSEL) OHSEL is South East London’s Sustainability and Transformation Partnership (STP) and is a coming together of our health and social care partners in South East London to make sure we are doing all we can to work in partnership to get the best health outcomes for our population. It has evolved from a commissioner-led strategy – established in 2013 - into a partnership between local commissioners and providers, working with local authorities, patients and the public.

The STP is not a blueprint for the next five years: it is a series of plans for different clinical areas and enablers, such as workforce and estates, which are at different stages of development. The STP (full version and summary) was published on 4 November 2016 and was one of the first in the country to be made public. Our STP has set the following five priorities:

1. Developing consistent and high-quality community-based care (CBC), primary care

development and prevention This includes promoting self-care, prevention and cooperative structures across parts of the system

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2. Improve quality and reducing variation across both physical and mental health This includes better integration of mental health, and reducing the pressure on and simplifying urgent and emergency care

3. Reducing cost through provider collaboration This includes consolidation of some non-clinical support services, including pathology and finance back office

4. Developing sustainable specialised services This includes mental health collaboration, renal and cardiac work

5. Changing how we work together to deliver transformation This includes the development of integrated care. It also focused on how we can make sure that we are able to provide care for the population of South East London as it grows and ages in a way that is affordable and meets the needs of a 21st century population.

Engagement In the summer of 2017, the STP held a series of six public events, one in each of the boroughs. The aim was to further engage with our communities about how they would like health services to develop in South East London, and to get feedback on our existing plans. The overall message was that we need to focus more on prevention, partnership working and better coordination of services. There was also a strongly held view that we need to do more to explain and engage on the STP. We published an independent feedback report from these events and also our response to how we will adapt to this feedback. In addition:

• We have patient and public voices and Healthwatch representatives on each of our

clinical and decision making workstreams influencing all our key programmes of work and feeding into our Patient and Public Advisory Group

• We are working with Maternity Voice Partnerships from each borough to co-produce our Better Births Implementation Plan, setting our maternity transformation priorities for the whole of South East London.

We also continue to hold South East London wide Equalities Steering and Stakeholder Reference Group meetings to ensure our plans are assured around patient and public engagement and equalities issues.

Our approach has been informed and endorsed by The Consultation Institute, who advise on best practice engagement at national level. The engagement programme was also shortlisted for a national award by the Association of Healthcare Communications and Marketing (AHCM).

Some highlights from 2017/18 Better access to GPs: An extra £7.5 million has gone into primary care in South East London so that patients can book a GP at a time that suits them – including more evening and weekend slots. South East London has now delivered extended GP access at 100 per cent compliance. From 2018, all practices will offer online as well as telephone booking, allowing every single patient who chooses to, to manage their prescription and medical records online. We are developing community-based teams of family doctors, nurses and others to respond rapidly to people in crisis in their own homes and other settings to address. These teams

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deliver immediate care and put coordinated care plans in place to help manage ongoing care, so that people can stay at home when they would otherwise have been taken to hospital.

• GP workforce: South East London Sustainability and Transformation Partnership

secured national funding to recruit 45 international GPs to the boroughs of Bexley, Bromley, Greenwich and Lewisham. The first 25 recruits are anticipated to arrive in the South East London in autumn 2018. Lambeth and Southwark have since indicated that they too wish to participate in this programme and a further bid has been made to the national programme.

• Faster cancer diagnosis: A rapid access diagnostic clinic based at Guy’s and St

Thomas’ Hospital was launched to provide swift access to a range of diagnostic tests for patients presenting with vague symptoms. They have received over 400 referrals, with 31 of those resulting in a cancer diagnosis. Following a successful pilot in Lambeth and Southwark, the service is being extended to Bromley, Bexley, Lewisham and Greenwich from April 2018.

• Mental health services: We are improving the link between physical and mental health

and mental health support and liaison team in A&Es 24/7 and working towards no out- of-area placements for non-specialist care by 2021. We introduced an initiative to improve the mental health of people with diabetes through the ‘three dimensions for diabetes’ pilot. The overall aim is to integrate medical, psychological and social care for people with persistent and poorly controlled diabetes

• Digitalisation of GP patient records: OHSEL secured funding to help 38 GP practices

across South East London to digitalise their paper records. This will mean space can be made available for further clinical care and end reliance on paper records.

• NHS 111: The online service was launched at www.111.nhs.uk, enabling patients to

self-assess, receive self-care advice, be signposted to an appropriate service or receive a call back from an NHS 111 clinician, the pan London Dental Nurse Triage Service or one of the out of hours GP services.

Healthy London Partnership NHS Greenwich CCG, along with all London CCGs and NHS England (London), funded Healthy London Partnership (HLP) in 2017/18 to bring together the NHS in London and our partners to deliver London’s 10 ambitions to transform health and care for all Londoners. Partners include the Mayor of London, Greater London Authority, Public Health England, London Councils and Health Education England. We believe that collectively we can make London the healthiest global city in the world by uniting all of London to deliver the ambitions set out in Better Health for London: Next Steps and the national NHS Five Year Forward View.

During 2017, HLP were tasked with setting up the Urgent and Emergency Care Improvement Collaborative on behalf of NHS England (London), NHS Improvement (London) and the Association of Directors of Adult Social Services to transform the way that Londoners receive unplanned urgent care and support. This includes preventing the need to go to hospital, supporting them to become medical fit and well in hospital and then helping them to go home

49 1.25

as soon as possible. The aim of the collaborative is to bring together leaders from health and social care working to define what improvement work needs to happen in London, drawing on the best practice around sustainable improvement and working with the leaders in this field. Key to this has been providing data to drive change, and as part of this work we ran three days of surveys of hospital bed occupants across 17 London hospital sites to understand where our improvement efforts need to be targeted.

Other highlights during 2017/18 include working with partners to launch Thrive LDN, a joint new citywide movement with the Mayor of London to improve mental health and wellbeing. Community workshops and problem-solving booths were held across London as part of Thrive’s ‘Are we okay London?’ campaign which has reached 15.5 million people so far.

The findings from the HLP year-long engagement with Londoners on childhood obesity, the Great Weight Debate, were published in 2018. Nine out of 10 Londoners who responded to the Great Weight Debate survey said tackling London’s childhood obesity epidemic should be either the top or a high priority for the capital. The findings are being used to inform every London borough’s childhood obesity strategy and have informed the Mayor’s London Plan which includes a policy to prevent new hot food takeaways from opening within 400 metres of a school. Following on from this, HLP are now working with fast food shops, businesses and communities in three London boroughs (Southwark, Lambeth and Haringey) to pilot their ideas for making high streets healthier for children and young people through the Healthy High Streets Challenge.

In 2017 HLP worked with Bexley and north and central London CCGs, along with NHS England, to trial the first NHS online pilots in the country. NHS online offers local people an alternative way to contact their GP and access online GP consultations when necessary. HLP also worked on behalf of London CCGs with NHS England (London region) to raise awareness of GP online services and GP extended access services across London. Nearly two million Londoners are now registered for GP online services and every London borough offers evening and weekend appointments to people in their local area.

Through partnership working, the Mayor of London, Secretary of State for Health Jeremy Hunt, London Councils and NHS, Public Health and wider health and care leaders signed the London Health and Care Devolution Memorandum of Understanding in November 2017. This deal paves the way for improving the health and wellbeing of all nine million Londoners. Devolution provides the foundations to enable us to improve the way health and care services are delivered in the capital at a faster pace. Through the work of the pilots over the past year it is evident that much more can be done to prevent ill-health, support people to make healthier choices and to join up health and care particularly when we work closely together. HLP are now leading engagement with system leaders to co-design the future of health and care across London which began with an event in December 2017. The London Health and Care Strategic Partnership Board (SPB) has been established to provide strategic and operational leadership for London-level health and care activities. HLP will continue to support the board and the wider system to implement devolution and wider health and care transformation goals and is committed to ensuring health and care leaders are updated on progress and are also involved in shaping the next steps for London.

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In 2017 HLP developed and published online training for GP receptionists to help people who are homeless access GP practices and produced 60,000 ‘my right to access healthcare’ cards for people who are homeless to make sure they can get equal access to healthcare given that they are much more likely to use A&E services than other Londoners.

At the beginning of 2018 HLP began working with partners including the Mayor of London, London Councils, Public Health England and the NHS, on a joint plan to cut rates of new HIV infection and eliminate associated discrimination and stigma. This followed the signing of the 'Paris Declaration on Fast-Track Cities Ending the AIDS Epidemic' in January 2018.

During 2018 HLP will evolve to formally support all the health and care partners to work together and strengthen their governance and delivery arrangements, so as a city we can implement the devolution agreement and our wider health and care transformation goals, to make sure we deliver on our commitments to make London the world's healthiest city.

Equality and diversity Public sector equality duties The public sector equality duties are of both general and specific duties. The broad aim of the general equality duty is to ensure consideration and the advancement of equality into the everyday business of all bodies subject to the duty. The general equality duty is intended to accelerate progress towards equality for all, placing a responsibility on bodies to consider how they can work to tackle systemic discrimination and disadvantage affecting people with particular protected characteristics.

• Race • Disability • Sex • Age • Religion or belief • Sexual orientation • Gender reassignment • Pregnancy and maternity

The first aim of the general equality duty is to have due regard to the need to eliminate discrimination, harassment, victimisation and any other conduct prohibited by the Act because of any of these protected characteristics. The second aim of the duty requires the CCG to have due regard to the need to minimise or remove disadvantages, to take steps to meet the different needs of people with different protected characteristics and to encourage participation in activities by those whose participation is disproportionately low.

Meeting the public sector equality duties in 2017/18 The challenges to make NHS services inclusive and ‘fit for purpose’ for Greenwich’s diverse population cannot be underestimated within the current financial constraints on health and social care expenditure. Our focus for 2017/18 was to consolidate our equality, human rights and health inequalities work. Protecting human rights and promoting inclusion are integral to our core business and are reflected throughout everything that we do. The Equality Act 2010 provides a legal framework to strengthen and advance equality and human rights. The Act

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consists of general and specific duties. The general duty requires public bodies to show due regard to:

• Eliminate unlawful discrimination • Advance equality of opportunity • Foster good relations

We must comply with this general duty when ‘exercising a function’, when formulating policy and to any decisions made in applying policy in individual cases. Compliance with the duty should result in:

• Better-informed decision-making and policy development. • Clearer understanding of the needs of service users, resulting in better quality services

which meet varied needs. • More effective targeting of policy, resources and the use of regulatory powers. • Better results and greater confidence in, and satisfaction with, public services. • A more effective use of talent in the workforce. • A reduction in instances of discrimination.

Equality, diversity and human rights obligations Control measures are in place to ensure that the CCG complies with the required public sector equality duty set out in the Equality Act 2010. Through these the CCG aims to:

• Improve access and involvement to all services for all public, patients, carers and

seldom heard groups. • Develop and implement twenty first century integrated, patient-focused health and

care. • Reduce health inequalities through a targeted approach. • Achieve better outcomes for all. • Understand what constitutes a good patient experience. • Continue to develop an inclusive working culture and ensure the CCG values are

incorporated in to all the work we do. • Empower, engage and support our staff. • Achieve an inclusive leadership at all levels.

All Greenwich CCG’s policies and procedures include an equality statement and all decisions made by the CCG undergo an equalities impact check list and / or full equality analysis, where appropriate. The learning from 2017/18 will be taken forward to strengthen the equality impact and analysis to achieve more timely and informed decisions in commissioning health services.

Our communities It is essential that we know our local population in Greenwich well as this allows us to make informed commissioning decisions. We map out local populations to understand health needs in specific communities or areas. Our overarching operational plan has been derived from key strategies. These include a joint health and wellbeing strategy, which identifies three key imperatives:

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• A focus on prevention as the most cost effective approach to health and wellbeing. • The need for new approaches to tackling health inequalities. • Greater integration in the commissioning and delivery of local services.

The Joint Health and Wellbeing Strategy together with the Greenwich Joint Strategic Needs Assessment (JSNA), forms our integrated plan setting out our priorities and associated commissioning intentions. There is more information about this from page 8.

Partnership working We are working with our partners across South East London to develop plans for future services. The Sustainability and Transformation Plan (STP) aligns with Greenwich CCG’s equality objectives, and we play an active role along with other South East London CCGs, in the Our Healthier South East London (OHSEL) Equalities Steering Group. The Equalities Steering Group ensures that the latest intelligence and insight on health inequalities is shared across all CCGs and addressed by the programme. It identifies risks to the STP and its associated programmes whilst maintaining an overview of health inequalities and related public health insights. In 2018/19 the focus of this group will be more on the risks to the programme if equalities issues are not identified and resolved.

NHS Greenwich CCG works in partnership with provider organisations to include equality, diversity and human rights clauses within our contracts. Clinical Quality Review Groups (CQRGs) are established with providers which allow scrutiny of this work. A Healthwatch representative is on both CQRGs and the NHS Greenwich CCG Quality Committee.

We determine assurance of our trusts meeting their Public Sector Equalities Duty through monitoring NHS Equality Delivery Systems (EDS2) and the NHS Workforce Race Equality Standard (WRES) of our service providers. As part of our performance monitoring we work closely with trusts to improve their demographic data collection, to enable them to assess equalities and to measure success in addressing inequalities.

Equality is central to the CCG, both internally and externally, to ensure that all staff are considered in engagement. A staff health and wellbeing group has been established within the CCG to inform policies and procedures, appraisal and performance, organisational development, and health and wellbeing. We are committed to ensuring that staff are recruited and retained from diverse backgrounds, provided with a positive and valuing work environment and given training and support to achieve their maximum career development potential.

Workforce The CCG collects and analyses workforce statistics by groups of staff with protected characteristics enabling us to complete our Workforce Race Equality Standards annual return and produce a detailed Workforce Race Equality Standards Action Plan.

The collection of data on the workforce by ethnicity covers both workforce data and staff survey data to enable data analyses on staff employed and regular reports on workforce to Greenwich Executive Group.

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The CCG serves an ethnically diverse population which is reflected in its workforce. It is predominantly female. There is more information about this in our staff report.

Equality objectives 2017/21 As part of the Public Sector Equality Duty of the Equality Act 2010, we have continued to work on our equality objectives set out in our Equality and Diversity Strategy 2017/2021. The purpose of these objectives is to strengthen our performance against this general equality duty. The CCG focuses on the things that matter the most for patients, communities and staff, with an emphasis on genuine engagement, transparency and the effective use of evidence. The equality objectives reflect local equality priorities for our community. They reflect the key equality priorities pertinent at that time. Our most recent equality objectives report can be found on our website.

The Equality Delivery System (EDS2) The Equality Delivery System (EDS2) is the NHS equalities reporting framework. It helps us to identify what we are doing well, what we need to improve on, and the equality gaps/risks that we need close or mitigate. It is a comprehensive analysis focusing on four goals (better health outcomes, improved patient access and experience, a representative and supported workforce, and inclusive leadership) measured against eighteen equality and health inequalities outcomes.

Like most CCG’s, we have taken a two-stage approach to implement EDS2. During stage one, we self-assessed our progress made against EDS2’s four goals and 18 outcomes, using a Red, Amber, Green (RAG) rating. A draft of our stage one self-assessment report includes what evidence exists to support the RAG rating, equality gaps and actions that may need to be taken to ensure that we are making progress. Stage two will involve working with local organisations. However, more work is required in the way that the CCG presents the demographic data relating to access, outcomes and experience.

This year the CCG EDS2 self-assessment will maintain an overall rating of Amber (Developing). This is because there is still more work to be undertaken in the collection of patient demographic data specifically regarding the different protected characteristics by our service providers. Therefore, the CCG cannot fully assure itself that the EDS2 outcomes are reported for all protected characteristic groups. The EDS2 action plan now considers these equality gaps and risks identified in the EDS2 summary report. The NHS Greenwich CCG Equality Report 2017/18 is available on the CCG website.

Emergency preparedness, resilience and response (EPRR) Along with other CCGs, Greenwich CCG was required to submit its EPRR assurance to NHS England in October 2017. In accordance with the requirements laid out in the National assurance process documentation, an organisation’s overall level of compliance is based on the total number of amber and red ratings agreed at the review.

In respect of NHS Greenwich CCG, for core standards 1-51, the CCG had two amber ratings:

• Core standard 5 - ‘Assess the risk, no less frequently than annually, of emergencies or

business continuity incidents occurring which affect or may affect the ability of the organisation to deliver its functions’.

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• Core standard 6 - ‘There is a process to ensure that the risk assessment(s) is in line with the organisational, Local Health Resilience Partnership, other relevant parties, community (Local Resilience Forum/Borough Resilience Forum), and national risk registers’.

The CCG received 0 red ratings for the governance deep dive.

NHS Greenwich CCG is assessed overall for the 2017 EPRR assurance as achieving a ‘substantial’ level of compliance.

NHS England noted that Greenwich CCG has demonstrated an ongoing high standard of EPRR and had appropriate documentation alignment with ISO 22301 standard, which sets out the requirements for a business continuity management system (BCMS) and is considered the only credible framework for effective business continuity management in the world. The CCG action plan submitted had two outstanding actions for areas rated amber:

Core standard Outstanding

action to be taken Timeframe for completion

Lead

Core standard 5 Assess the risk, no less frequently than annually, of emergencies or business continuity incidents occurring which affect or may affect the ability of the organisation to deliver its functions

Action plan has been drawn up for 18/19

30 January 2018 Emergency Planning Lead Officer (EPLO) Director of Quality and Integrated Governance

Core standard 6 There is a process to ensure that the risk assessment(s) is in line with the organisational, Local Health Resilience Partnership, other relevant parties, community (Local Resilience Forum/ Borough Resilience Forum), and national risk registers

An EPRR risk register has been created and will link in with Corporate and other relevant parties risk registers

30 January 2018 EPLO Director of Quality and Integrated Governance

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Exercises and training

Our staff undertook a range of training and exercise initiatives to support EPRR during 2017. Date Exercise Attended by 28.03.17 RBG multi-agency desktop

exercise flood plan/flood warden scheme exercise

EPLO

19.06.17 Communication exercise

Call cascade to all staff All staff

18.07.17 RBG multi-agency desktop exercise carmine pipeline

EPLO

15.08.17 Communication exercise

Call cascade to work mobile phone All staff with work mobile phone

17.10.17 and 31.10.17 Major incident and business continuity training

All staff

17.11.17 Table top exercise testing the pandemic flu policy

One member of staff from each team across the CCG

15.12.17 RBG multi-agency desktop exercise humanitarian assistance in response to and recovery from a major incident

EPLO

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Section 2 Accountability Report

Andrew Bland Accountable Officer 25 May 2018

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Members’ Report Our members These are the 35 member practices which form the membership body of the CCG.

Blackheath and Charlton Excel (Plumstead and Abbeywood) Blackheath Standard PMS Abbey Wood Surgery Burney Street PMS All Saints Medical Centre PMS Greenwich Peninsula Practice Bannockburn Surgery Manor Brook PMS Waverley PMS Plumbridge Medical Centre Clover Health Centre Primecare PMS (South Street) Glyndon PMS Fairfield PMS Mostafa PMS Vanbrugh Health Centre Plumstead Health Centre PMS Woodland Surgery Abbeyslade PMS (Dr Chand)

Triveni PMS Eltham Network (Woolwich and Thamesmead) Dr V Sandrasagra’s Conway PMS Briset Corner Surgery Valentine Health Partnership Dr Baksh’s Practice TMA PMS (Gallions Reach Health Centre) Dr J Lal’s Practice Royal Arsenal PMS Eltham Medical Practice St Marks PMS Eltham Palace Surgery Thamesmead Health Centre Eltham Park Surgery The Trinity Medical Centre Primecare PMS (Coldharbour) Sherard Road Medical Centre

Practices are formed in four syndicates: Blackheath and Charlton, Eltham, Excel and Network. Each syndicate covers a geographical area and practices within the syndicate work together through peer review and regular meetings.

Each practice has signed the CCG’s Constitution. This states how member practices will be engaged through regular syndicate meetings and with the GP Executive through the quarterly Greenwich wide forum meetings. A GP Syndicate Lead for each of the four syndicates is voted in by the members of their syndicate. Syndicate Leads act as the conduit between the CCG and its GP membership body to deliver messages and get feedback on commissioning decisions. Syndicate meetings are held bi-monthly in line with the Constitution and the four GP Syndicate Leads meet monthly with the GP Executive.

There are monthly meetings of Syndicate and Clinical Project Leads with the GP Executive and each practice is represented at the quarterly Greenwich wide forums.

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The table below demonstrates the growth in GP list sizes.

Greenwich CCG - Syndicate List Sizes 100,000

90,000

80,000

70,000

60,000

50,000

40,000

Blackheath & Charlton

Eltham

Excel

Network 30,000 20,000 10,000

April 2014 April 2015 April 2016 April 2017 March 2018

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Greenwich Executive Committee The Executive Committee consists of the GP Executive (elected Governing Body members) and the CCG senior management team and is made up of the following staff:

Name Role GP Executive Dr Sylvia Nyame GP elected member Dr Nayan Patel GP elected member Dr Ranil Perera GP elected member Dr Sabah Salman (until 17.1.18) GP elected member Dr Krishna Subbarayan GP elected member Dr Jaisun Vivekanandaraja (from 17.1.18)

GP elected member

Dr Hany Wahba GP elected member Dr Ellen Wright GP elected member and

Chair of the Governing Body Senior Management Team Andrew Bland (from 11.9.17) Chief Officer Vanessa Fowler (from 1.10.17 to 15.12.17)

Director of Commissioning

Liz James (until 30.9.17) Director of Commissioning

Neil Kennett-Brown (from 25.9.17) Managing Director Yvonne Leese Director of Quality and Integrated

Governance

David Maloney Chief Finance Officer Virginia Morley (from 27.11.17) Director of Commissioning

Development Joanne Murfitt until 10.9.17) Chief Officer

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Governing Body The Governing Body oversees the delivery of the CCG’s commissioning plan, sets and leads the strategy for the CCG, and is accountable for the delivery of Greenwich CCG’s functions as a statutory body. It monitors performance against objectives, provides effective financial stewardship and makes sure that high standards of corporate governance are achieved. Having GPs and other clinical members of the Governing Body ensures all our decisions are made with clinical leadership and considering Greenwich patients.

The Governing Body meets on alternate months in public, with extra meetings as necessary. Papers and minutes of the meetings are published on the CCG website. All meetings have declarations of interests as an agenda item and these are recorded. All members are required to record any interests relevant to their role on the Governing Body. The register of interests is a public document which is open to public scrutiny and published on the CCG website.

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The composition of the Governing Body in 2017/18 (including advisory and non-executive members) is as follows:

Name Role Andrew Bland # (from 11.9.17)

Chief Officer

Maggie Buckell # Registered Nurse Vanessa Fowler (from 1.10.17 to 15.12.17)

Director of Commissioning

Councillor David Gardner

Local Authority Member

Amana Humayun # + (from 12.6.17)

Vice Chair and Lay Member for Audit and Remuneration and Conflicts of Interest Guardian

Liz James (until 30.9.17)

Interim Director of Commissioning

Neil Kennett-Brown (from 25.9.17) Managing Director

Yvonne Leese Director of Quality and Integrated Governance

David Maloney # Chief Financial Officer

Virginia Morley (from 27.11.17) Director of Commissioning Development

Joanne Murfitt # (until 10.9.17)

Chief Officer

Dr Sylvia Nyame # GP Member Dr Nayan Patel # + GP Member Dr Ranil Perera # GP Member Richard Rice # Lay Member Primary Care Commissioning Lead Dr Sabah Salman # (on sabbatical from 17.1.18 and returned 1 May 2018)

GP Member

Dr Krishna Subbarayan # GP Member

Dr Greg Ussher # + Lay Member for Patient and Public Engagement Dr Iyngaran Vanniasegarum # + Secondary Care Doctor Governing Body Dr Jaisun Vivekanandaraja # (seconded from 17.1.18 to cover Dr Sabah Salman’s sabbatical)

GP Member

Dr Hany Wahba # GP Member

Steve Whiteman Director of Public Health, Royal Borough of Greenwich

Jim Wintour # (until 11.6.17)

Vice Chair and Lay Member for Audit and Remuneration and Conflicts of Interest Guardian

Dr Ellen Wright # Chair of the Governing Body and GP Member

# = Voting member + = Member of the Audit Committee

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Register of interests Greenwich CCG is committed to the principles of good governance, leading to open and transparent decision making. We have therefore established a policy to manage conflicts of interests to ensure that decisions made by the CCG will be taken and seen to be taken without any possibility of the influence of external or private interests. Our policy was updated in December 2017 and takes account of the latest statutory guidance. A conflict of interest is defined as:

• A conflict between the private interests and the official responsibilities of a person in a

position of trust. • A set of conditions in which professional judgement concerning a primary interest (such

as patients’ welfare or the validity of research) tends to be unduly influenced by a secondary interest (such as financial gain).

• The creation of a set of circumstances where one party is favoured over another by an inadvertent preferential interest.

In line with our conflicts of interest policy, arrangements to seek and receive declarations of interest and maintain Registers of Declared Interests and Gifts and Hospitality have been put in place. We publish our register of interests on our website, as well as a gifts and hospitality register.

The CCG’s conflicts of interest policy and procedures were independently audited in 2017/18. The CCG was given an overall rating of “substantial assurance”, the highest rating, with the comment that the CCG “can take substantial assurance that the controls upon which the organisation relies to manage the identifies risk(s) are suitably designed, consistently applied and operating effectively”.

The audit noted that two members of staff from the audit sample, had not submitted a recent declaration and the CCG was asked to ensure that those individuals did not vote on CCG decisions until fresh declarations had been received. It was also noted that, at the time of the audit, the NHS England Conflict of Interest training programme had only just been released and CCG had been asked to ensure relevant CCG staff had completed the first module by 31 May 2018. Both items were assessed as low risk.

Personal data related incidents Information relating to the disclosure involving data loss and confidentiality breaches can be found in the Annual Governance Statement.

Statement of disclosure to auditors Each individual who is a member of the CCG at the time the Members’ Report is approved confirms:

• So far as the member is aware, there is no relevant audit information of which the

CCG’s auditor is unaware that would be relevant for the purposes of their audit report.

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• 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 statement NHS Greenwich CCG fully supports the Government’s objectives to eradicate modern slavery and human trafficking but does not meet the requirements for producing an annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act 2015. However, in line with best practice we publish a statement detailing our local approach on our website.

Statement of Accountable Officer’s responsibilities The National Health Service Act 2006 (as amended) (the NHS Act 2006) states that each Clinical Commissioning Group (CCG) shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed Joanne Murfitt to be the Accountable Officer of Greenwich CCG who held the position from 1 April 2017 to 10 September 2017. Andrew Bland was appointed as Accountable Officer with effect from 11 September 2017 to 31 March 2018.

The responsibilities of an Accountable Officer are set out under the NHS Act 2006, 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; • Keeping proper accounting records which disclose with reasonable accuracy at any

time the financial position of the CCG and enable them to ensure that the accounts comply with the requirements of the Accounts Direction;

• Such internal control as they determine is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error;

• Safeguarding the CCGs 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 NHS Act 2006 and with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the NHS Act 2006; and

• Ensuring that the CCG complies with its financial duties under Sections 223H to 223J of the NHS Act 2006.

Under the NHS Act 2006, NHS England has directed each CCG 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 CCG and of its net expenditure, changes in taxpayers’ equity and cash flows for the financial year.

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In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Group Accounting Manual issued by the Department of Health and in particular to:

• Observe the Accounts Direction issued by NHS England, including the relevant

accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis;

• Make judgements and estimates on a reasonable basis; • State whether applicable accounting standards as set out in the Group Accounting

Manual issued by the Department of Health have been followed, and disclose and explain any material departures in the financial statements; and,

• Assess the CCGs ability to continue as a going concern, disclosing, as applicable, matters related to going concern; and

• Use the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity.

To the best of my knowledge and belief, and subject to the disclosures set out below, I have properly discharged the responsibilities set out under the NHS Act 2006, Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter.

Disclosures NHS England issued legal directions to help address long standing performance problems with local urgent and emergency care services. Under these directions from 1 September 2017 our responsibility for acute commissioning and contracting has been temporarily transferred to Southwark CCG. This has also supported our ambitions as a CCG and helped us address areas found to require improvement in 2017/18. High quality healthcare and patient experience are of paramount importance to Greenwich CCG and we have worked closely with local NHS partners to ensure that patients receive the very best standards from the NHS. The Integrated Contracts Delivery Team (ICDT) hosted by Southwark CCG has provided regular performance monitoring reports to our Finance Performance and QIPP Committee.

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; and

• 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.

Andrew Bland Accountable Officer 25 May 2018

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Governance statement Introduction and context NHS Greenwich 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 September 2017, the clinical commissioning group is subject to directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006 as follows:

• NHS England issued legal directions to help address long standing performance

problems with local urgent and emergency care services. Under these directions from 1 September 2017 our responsibility for acute commissioning and contracting has been temporarily transferred to Southwark CCG.

• You can read more about the legal directions here. • You can access the latest published information about the CCG’s performance against

the improvement and assessment framework (IAF) here. 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.

Greenwich CCG is responsible for the procurement of services on behalf of the residents of Greenwich. We are responsible for creating suitable arrangements with providers of services that are in the best interests of the service users, and also represent value for money.

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Considering the complexity and range of services offered it is vital that we have a governance structure with sufficient delegation to ensure that decisions can be made but also sufficient oversight to prevent any deviation from the statutes of the constitution.

Greenwich CCG is accountable for exercising its statutory functions. It may delegate authority to act on its behalf to:

• any of its members • the Governing Body • employees • any committees or sub-committees established by Greenwich CCG for the purpose of

exercising its statutory functions

The extent of the authority of the respective bodies and individuals depends on the powers delegated to them by Greenwich CCG as expressed through:

1. Its Scheme of Reservation and Delegation; and 2. for committees, their terms of reference.

The Scheme of Reservation and Delegation sets out:

1. Those decisions that are reserved for the membership as a whole 2. Those decisions that are the responsibilities of the Governing Body (and its committees),

and sub-committees, individual members and employees. However, Greenwich CCG remains accountable for all of its functions, including those that it has delegated.

Greenwich CCG has a robust corporate governance structure with the roles and responsibilities of the members of the Governing Body and supporting Committees clearly set out.

Each member of the Governing Body shares responsibility as part of a team to ensure that the group exercises its functions effectively, efficiently and economically, with good governance and in accordance with the terms of its constitution. Each Governing Body member brings their own unique perspective, informed by their skills, knowledge and experience.

During the year the Governing Body has:

• Approved the CCG’s operating plan and corporate objectives for 2017/18. • Agreed the CCG’s budget for the year. • Approved the annual equalities report. • Received and endorsed the plan for collaborative working across South East

London. • Made arrangements to take questions from the public before its formal meetings.

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• Received a performance report and a quality report, with additional exception reports, through which the Governing Body has been advised of the quality and safety of commissioned services and other performance and financial issues.

• Received and taken assurance that strategic risks were effectively mitigated. • Received confirmation of “substantial” assurance against the NHS England Core

Standards for Emergency Preparedness, Resilience and Response (EPRR). • Ensured that any conflicts of interest were appropriately managed. • Approved the CCG’s Organisational Recovery Plan. • Approved the CCG’s Organisational Development Strategy 2018 to 2021 and

detailed plan for 2018/19.

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Governing Body meeting attendance 2017/18 26.4

D 31.5 P

28.6 D

26.7 P

30.8 D

20.9 P

27.9 AGM

25.10 D

29.11 P

20.12 D

24.1 P

28.2 D

28.3 P

%

Andrew Bland (from 11.9.17)

Y Y Y Y Y Y Y Y 100

Maggie Buckell Y Y Y Y Y Y Y Y Y Y N Y Y 92 Vanessa Fowler (from 1.10.17 until 15.12.17)

N Y 50

Councillor David Gardner

Y Y Y Y Y Y Y Y Y Y Y Y Y 100

Amana Humayun (from 12.6.17)

Y Y Y Y Y Y Y Y Y N Y 91

Liz James (until 30.9.17)

Y Y N Y Y Y Y 86

Neil Kennett- Brown (from 25.9.17)

Y N Y Y Y Y Y 86

Yvonne Leese Y Y Y Y Y Y Y Y Y Y Y Y Y 100 David Maloney Y Y Y Y Y Y Y N Y Y Y Y Y 92 Virginia Morley (from 27.11.17)

N Y Y Y Y 80

Joanne Murfitt (until 10.9.17)

Y Y Y Y Y 100

Dr Sylvia Nyame Y Y Y Y Y N Y Y Y Y Y Y Y 92 Dr Nayan Patel Y N Y N Y Y Y Y Y Y Y Y Y 85 Dr Ranil Perera N Y Y N Y Y Y Y Y Y Y N N 69 Richard Rice Y Y Y Y N Y Y N Y Y Y Y Y 85 Dr Sabah Salman (until 17.1.18)

Y Y Y Y Y N Y Y Y Y 90

Dr Krishna Subbarayan

Y Y Y Y Y Y N Y Y Y Y Y N 85

Dr Greg Ussher Y N N N Y Y Y N Y Y Y Y Y 69 Dr Iyngaran Vanniasegarum

Y Y N Y Y Y N Y Y Y N Y Y 77

Dr Jaisun Vivekanandaraja (from 17.1.18)

N Y Y 67

Dr Hany Wahba Y Y Y N Y Y N Y Y Y Y Y Y 85 Steve Whiteman Y Y N Y Y Y Y Y Y Y Y Y N 85 Jim Wintour (until 11.6.17)

N Y 50

Dr Ellen Wright Y Y Y Y Y Y Y Y Y Y Y N Y 92

Members must attend at least 75% of meetings of the Governing Body or, where this is not possible, the Chair must be satisfied as to the reasons. Key: E = Extraordinary Meeting, P = Public Meeting, D = Development Meeting, AGM = Annual General Meeting.

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Greenwich CCG uses a number of committees to provide challenge and assurance over specific areas, for example Quality, Improvement, Productivity and Prevention (QIPP) delivery through the Financial Recovery Board and Financial Performance and QIPP Committee.

All committees are formed with a membership that provides a sufficient range of skills, including clinical expertise and lay membership, to provide effective management and oversight. The committees are referenced within the NHS Greenwich CCG Constitution. For those committees which report directly to the Governing Body, minutes are available in the Governing Body papers.

The performance of the Governing Body includes development workshops held throughout the year, some with external facilitation. All GP Governing Body members and the Chief Officer have a review halfway through the year and an appraisal at the end of the year with the CCG Chair.

Governing Body Officers, i.e. the Chief Finance Officer and all directors have an appraisal with the Accountable Officer or the Managing Director as appropriate.

GP Syndicate Leads and Clinical Project Leads (CPLs) meet with their GP Executive through a formal clinically led meeting to review performance as well as support and guidance outside

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of the meeting, e.g. to develop and lead on QIPP programmes. The NHS England CCG 360 degree stakeholder survey is undertaken annually.

Committees are accountable to either the Governing Body or the committee that established them. Control is exercised through the receipt of their minutes by either the Governing Body or the relevant sponsoring committee. Reports can also be made to these meetings by the Committee Chairs where required and the Chairs can also bring matters onto the agendas of their sponsoring body/committee whenever they believe this is necessary. The minutes and reports of committees that report to the Governing Body (unless they are confidential) are published on the CCG website with the Governing Body papers.

The terms of reference for committees are approved by their sponsoring body/committee and cannot be exceeded without further subsequent approval.

• The Nolan principles are embedded within the CCG’s governance arrangements. • The Risk Register is maintained to a good standard giving adequate details on risks,

controls and action plans in place. • The Governing Body Assurance Framework comprehensively addresses strategic

risks to the organisation. Audit Committee The committee was established to take an independent and objective view of the CCG’s financial systems, compliance with laws and compliance with best practice in its arrangements for corporate governance. The committee has reflected on its work and had agreed that it goes about its work in organised, accountable and informed way. In 2017/18:

• Its work programme followed a plan agreed at the start of the year. • It makes it clear to CCG management and staff what is required from them in the

preparation and running of meetings. • It reports to the Governing Body via provision of minutes of the meetings once confirmed.

During the year, the work of the Audit Committee included:

• Approved the 2016/17 Annual Report and Annual Accounts on behalf of the Governing

Body. • Received the Head of Internal Audit Opinion for 2016/17. • Approved the Internal Audit Plan for 2017/18 and commented on reports of the reviews. • Reviewed Service Auditor Reports. • Approved the counter fraud work plan for 2017/18 and commented on progress. • Scrutinised and advised on the format and content of the Board Assurance Framework,

including detailed discussions in to specific areas. • Reviewed the local security management workplan for 2017/18 and commented on

progress. There were four meetings of the Audit Committee during the year. The committee was supported by the CCG management team, with appropriate attendance as required. The Chief Finance Officer attended all meetings.

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UK Corporate Governance Code We are not required to comply with the UK Corporate Governance Code. However, we have reported on our corporate governance arrangements by drawing upon best practice available, including those aspects of the UK Corporate Governance Code we consider to be relevant to the CCG.

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 risk management framework sets out the overarching approach to the management of risk in the organisation. The Governing Body is aware of all significant risks and has sufficient information to enable it to make decisions on the implementation of appropriate controls and the allocation of appropriate resources.

The risk management framework outlines definitions, accountabilities and responsibilities of all staff, the risk management process and its governance, including managing risk across organisational boundaries and training.

All directors and managers are required to identify risks specific to their own activities and circumstances. Risks may be identified from a number of sources, both internal and external. No valid risk will be excluded from the register due to its identification source. Staff are encouraged to be risk aware. The Director of Quality and Integrated Governance maintains a strategic overview of risk.

Zero tolerance risks are clearly identified on the CCG’s risk register and in all reporting. The Governing Board assurance framework provides the Governing Body with a clear understanding of the principal risks which may affect the achievement of performance objectives for the financial year and therefore informs the annual statement of internal control declaration. The Governing Body assurance framework is formally reviewed at every meeting of the Governing Body and Greenwich Executive Group (monthly basis).

Control measures are in place to ensure that obligations under equality, diversity and human rights legislation are complied.

The CCG’s integrated risk management framework sets out the overarching approach to the management of risk in the CCG. The CCG adopted the risk management framework in July 2013. The framework was updated and changes approved by the CCG Governing Body in November 2016. The strategy outlines the CCG’s approach to risk and the manner in which

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the CCG seeks to prevent, eliminate and control risks and the successful management of the risks that impact most upon the CCG’s objectives.

Risk management is embedded within all activities of the CCG. The CCG is able to ensure accountability of risk at all levels of the organisation.

The purpose of this framework is to define and document the CCG’s approach to risk and risk management and to:

• Enable the Governing Body to have an overview of the risks it faces, taking into

account all aspects of its business. • Provide assurance to the Governing Body that action is being taken to mitigate risk to

acceptable levels. • Assure the public, patients, practices, partner organisations and staff that the CCG is

managing its risks effectively. • Enable the strategic deployment of resources to meet risk, beyond allocations made if

necessary, including financial funding, human resources, capacity and knowledge. • Enable constant and consistent improvement of healthcare provision and patient

experience. Below is the risk appetite statement which was agreed by the Governing Body and is included in the CCG’s risk management framework: NHS Greenwich CCG is working toward a ‘mature’ risk appetite. The CCG has no appetite for financial risk and zero tolerance for fraud and regulatory breaches (e.g. safeguarding breaches, poor professional conduct of its staff and information governance [data protection] breaches).

Greenwich CCG may take considered risks, where the long-term benefits outweigh any short- term losses. The CCG supports well managed risk taking and will ensure that the skills, ability and knowledge are there to support innovation and maximise service improvement. The Governing Body commits to review its risk appetite statement on an annual basis.

Zero tolerance risks are clearly identified on the CCG’s risk register and in all reporting. All risks are recorded on the Risk Register and clearly identify the responsible director and clinical lead with the levels of risk including actions which should be taken to mitigate the risks. These are reviewed monthly and discussed at appropriate committees. The CCG also identifies and manages risks via internal and external methods such as complaints, claims, serious incidents, audits, patient satisfaction surveys, risk assessments, staff surveys, whistle blowing, new legislation, and review from partnership working.

The CCG is responsible for overseeing the commissioning of healthcare and other services from a wide variety of providers. One of the key purposes of the CCG’s risk management process is to ensure that services are commissioned from providers who themselves operate high standards of risk management processes.

By ensuring that all staff are aware of their responsibilities in regard to both governance and health and safety, a substantial amount of progress has been made towards ensuring the ownership of risk by staff and the wider membership of each of the sub-committees.

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The CCG places a 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 that all staff undertake annual information governance training. There are processes in place for incident reporting and investigation of serious incidents.

Public involvement in managing risk We use a variety of patient experience data to understand how different services are performing. Whilst these are individually addressed, a thematic analysis is undertaken regularly. The results are presented to the Greenwich Executive Group and the Quality Committee and used to inform our commissioning intentions. There are a number of methods used to ensure our public stakeholders are involved in managing any risks that impact on them:

• Quality alerts raised by GPs and other healthcare professionals on behalf of their

patients. Alongside our ‘quality alert’ system, there are many other routes through which the public can make us aware of any concerns. They can raise issues through their GP practice’s Patient Participation Group.

• Lay members sit on the Governing Body and a number of committees. Through their attendance they are involved in the review of the risk register and challenge/input into the way in which the organisation mitigates those risks.

• The risk register detailing all identified risks and plans for how they will be addressed is published on our public website.

• Prior to Governing Body meetings held in public there is a question and answer session where any issues can be raised. All questions are answered at the time, where possible, and then taken away to be answered more fully, where necessary. The feedback is then published on our public website and fed back in person at the next Governing Board meeting.

• A Patient Reference Group, that includes representation from Healthwatch and METRO GAVS has been established to seek assurance and monitor engagement, and to review progress on our patient and public engagement strategy. This group also provides guidance to our commissioners to ensure involvement is embedded into every stage of the commissioning cycle, including identifying risks and their mitigation.

• Public stakeholders inform service redesign and the issues and concerns they raise are picked up during this process.

• We have built relationships with our local MPs who can raise constituents’ issues for us to address and we have a system in place to respond appropriately.

• We attend the Royal Borough of Greenwich Healthier Communities and Adult Social Care Scrutiny Panel. This gives elected Council members and the public the opportunity to question and challenge the CCG. The committee has reviewed our QIPP plan for the year, the performance of the whole system emergency care pathway, the implementation of a new musculoskeletal service in April 2017 and the outcome of our consultation on extensions to the current treatment access policy.

Deterrents to risk arising: counter fraud During 2017/18 the CCG commissioned TIAA, a local counter fraud specialist, to deliver a counter fraud service. The TIAA follows the guidance and standards, set by NHS

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Protect. The local counter fraud specialist TIAA provides the CCG with assurance through regular meetings with the Chief Finance Officer to review the counter fraud plan and discuss cases. The local counter fraud specialist also presented regular reports to the CCG Audit Committee and also provides training regarding counter fraud, bribery and corruption to all CCG Staff. Counter fraud policies and services are provided by internal audit. Regular updates and alerts are communicated to all staff.

The following arrangements are in place:

• Proactive and reactive measures are taken by the counter fraud services to deter

and identify fraud as well as to encourage staff to report fraud. • The CCG’s standing orders, standing financial instructions and the scheme of

reservation and delegation. • Conflicts of interests (CoI) are declared at all Governing Body and Committee

meetings and subcommittee meetings. The CCG is compliant with CoI guidance and the Governing Body and Senior Management Team participate in development sessions on CoI.

• Management notifies the local counter fraud service and/or Chief Finance Officer of any concerns of fraud. At the conclusion of an investigation, the local counter fraud service forwards recommendations to the Chief Finance Officer, which are also reported to the Audit Committee. internal audit and the local counter fraud service hold liaison meetings during the year in order to discuss high risk areas.

• Where management identifies any risk of fraud they are able to introduce appropriate controls to counter the risk.

Risks relating to fraud and bribery will be added to the risk register when they occur and then reviewed by the Governing Body as appropriate.

Capacity to handle risk The capacity to handle risk is clearly described within the risk management framework. Leadership is given to the risk management process through the roles and responsibilities set out within the strategy from the Accountable Officer, directors, senior managers, lead managers with specific remits for risk, patient safety and compliance through to all staff.

Staff are trained or equipped to manage risk in a way appropriate to their authority and duties. The Datix system is established and utilised across the organisation in risk management. The Greenwich CCG risk management framework is available on the CCG intranet under the section of policies. All staff are encouraged to access this and familiarise themselves with the strategy whilst developing an understanding of what is expected of them in line with risk management within the CCG.

To enable the integrated risk management framework to be fully implemented, training sessions and workshops are delivered to managers, staff and clinical professionals. The sessions include:

• Introductory and refresher training for risk management and governance as appropriate

to the roles and responsibilities of staff within Greenwich CCG and the Governing Body.

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• The provision of appropriate resources to ensure the ongoing development of risk management capacity and capability within the Governing Body.

Greenwich CCG staff have embedded learning events with providers to ensure shared learning and good practice with regard to serious incidents. The CCG culture is such that it encourages openness and transparency throughout the system about matters of concern. This is in line with the recommendations from the Francis Report (Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry 2013).

Where risk is created by deliberate failure to adhere to policy or acting outside professional codes of conduct, action may be taken against individuals under the disciplinary committee. Greenwich CCG fosters a risk aware culture shared by all in the services in putting patients first.

To support the culture of listening, learning and responding within the organisation, the CCG will:

• Be open and fair. • Approach all incidents, complaints and issues fairly and equally. • Ensure transparency in the review of incidents and complaints and other issues and

transfer the learning both internally and externally. • Ensure all staff are aware of this strategy and processes and all other associated

policies that complement robust risk management and internal control within the CCG.

• Support and advise staff with matters relating to risk management. • Provide relevant training and information resources. • Acknowledge reports received and provide feedback on actions and decisions to

demonstrate that the CCG has listened. • Ensure there is a framework through which staff can raise concerns, malpractice

and impropriety in a supportive manner. • Respond to gaps in policy and processes to improve outcomes, experience and the

overall management of risk. Risk assessment Our risk management framework sets out our risk assessment process and is based on the national patient safety advice (NPSA) guidance and aligned to the adopted internationally recognised AS/NZS 4360:1999 guideline which provides a model for identifying, assessing and controlling risks. Further information on how the CCG manages the principles of risk management, can be found under the risk management framework section above. Risks in relation to governance, risk management and internal control were identified and have been incorporated into the Governing Body board assurance framework (BAF) and the CCG’s risk register for scrutiny.

The BAF broadly provides assurance of the controls in place that mitigate the risks that may prevent Greenwich CCG meeting its annual strategic objectives. Throughout 2017/18 the Governing Body has received detailed reports of the controls in place, assurances given and further actions being taken to manage or mitigate those risks that have a residual score of 12

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or above (score of likelihood x impact). These reports are contained within the papers for our Governing Body meetings which are published on our website.

During 2017/18, four risks were assessed at the end of the year to have a ‘very high’ rating in March 2018. These were:

• Breaching of 62 day referral to treatment cancer target may create delays in

accessibility and impact on treatment. • Breaching of the 18 week referral to treatment (RTT) standard which may impact on

patients’ diagnoses and treatment. • Potential loss of organisational memory due to the transition process of senior

manager roles in the organisation. • Acute contracts may over perform in 2017/8, which may impact on the CCG’s ability to

deliver its core functions. In response to this risk rating the Governing Body received detailed action plans for how the CCG would work in conjunction with partners or internally to reduce these. . Risk assessment matrix used within the CCG

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.

NHS Greenwich CCG’s system of internal control is intended to manage risks and not to eliminate risks. To this effect, we have different committees who are responsible for

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overseeing the process of risk management within the CCG. Overall responsibility for risk management rests with the Governing Body.

Our system of internal control has been maintained through the monitoring and delivery of its Governing Board assurance framework (GBAF) by the Governing Body. Led by the Director of Quality and Integrated Governance, the GBAF provides a structure and process that enables the CCG to focus on those risks that might compromise achieving its most important (principal) annual objectives. It maps out both the key controls that should be in place to manage those objectives and confirms that the Governing Body has gained sufficient assurance about the effectiveness of those controls.

The effectiveness of the system of internal control is informed by the work of internal auditors, external auditors, Governing Body, committees, directors and clinical leads within the CCG who have responsibility for the development and maintenance of the internal control framework. The Governing Body assurance framework provides the evidence that the effectiveness of controls that manage the risks of the CCG achieving its strategic corporate objectives have been reviewed. The framework has been actively managed and reviewed regularly by the Executive Team, Governing Body and Audit Committee.

The risk management framework sets out the overarching approach to the management of risk in the organisation. The Governing Body is aware of all significant risks and has sufficient information to enable it to make decisions on the implementation of appropriate controls and the allocation of appropriate resources.

The CCG’s aims and objectives are aligned to the Governing Body assurance framework, which is presented at each meeting of the Governing Body in public. Organisational objectives are embedded in the annual objectives of CCG staff at all levels within the organisation and success in achievement of them is measured through the staff appraisal process. All CCG policies follow a standard operating procedure and adhere to the CCG’s policy on policies. The policy on policies outlines the appropriate governance route for approval of policies.

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 carried out their annual internal audit of conflicts of interest in 2017/18 and was assessed as having “substantial” assurance. The extract from the auditor report sets out their recommendations and the actions the CCG will be taking to address them.

To make staff across CCGs more aware of their duty to make true declarations, NHS England has developed online training that was launched in January 2018 and is mandatory for all decision-makers in the CCG to complete by the end of May 2018.

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Data quality In line with the “need to know” principles set out in the Caldicott 2 Information Governance Review Report, the CCG ensures that information presented to the Governing Body and other governance fora does not identify individuals and is fully anonymised.

Senior management diligently reviews information to be set out in governance and decision- making prior to consideration and presentation to the relevant governance fora.

The quality of information that the Governing Body and other governance fora receive to consider and direct decision making is also assured through service level specification arrangements with the North East London Commissioning Support Unit and the use of contractual arrangements with commissioned providers.

Information governance

The NHS information governance framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS information governance framework is supported by an information governance (IG) 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 CCG demonstrated a high level of compliance by completion of the IG Toolkit which was published in March 2018 with a score of 89%.

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.

The Director of Quality and Integrated Governance is the executive lead on the Governing Body for information governance and also the senior information risk owner (SIRO). The Caldicott Guardian is a GP and Governing Body member. The Information Governance Steering Group meets bi-monthly.

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

NHS England recognises the importance of quality assurance across the full range of its analytical work. In partnership with analysts in the Department of Health we have developed an approach that is fully consistent with the recommendations in Sir Nicholas Macpherson's review of quality assurance of government models. The framework includes a programme of mandatory workshops for NHS England analysts, which highlights the importance of quality assurance across the full range of analytical work.

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The Macpherson Report on the review of quality assurance (QA) of Government Analytical Models set out the components of best practice in QA making eight key recommendations. We recognise the importance of this and have been working with partners to ensure appropriate quality assurance processes are in place across its analytical work.

For 2017/18 Greenwich CCG has continued to work with other CCGs and NHS providers in South East London, through the Sustainability and Transformation Partnership (STP), to develop the business and financial modelling for the five year strategic plan. The modelling is led through South East London project management office (PMO) and reports back to the South East London finance leads group. The group includes directors of finance and chief financial officers from all organisations within the STP. The group is chaired by the Chief Financial Officer of Southwark CCG, who acts as the senior responsible officer (SRO) for the development of the model. The output of the financial modelling is reviewed by a varied number of stakeholders from different disciplines, both internal and external, and underpins the modelling of the impact of service changes over the next five years.

Locally Greenwich CCG has developed a number of business and financial models which underpin areas such as local financial planning, QIPP delivery and service transformation. The identified senior responsible officer is the Chief Financial Officer, who ensures that there are effective processes underpinning the modelling, including appropriate guidance, documentation and training, as well as sharing best practice. This includes ensuring that appropriate assurance processes are in place to govern the robustness of any modelling.

Control issues No significant control issues have been identified.

Review of economy, efficiency and effectiveness of the use of resources In year monitoring of performance against our plans, in terms of quality, finance and other performance standards (e.g. NHS constitutional standards) has been carried out by our Quality Committee and Finance, Performance and QIPP Committee. This includes assuring that projects and programmes are delivering economic, effective and high quality services. Under the CCG improvement and assessment framework indicators leadership ratings are reviewed on a quarterly basis, the latest available results (to the end of December 2017) show that the CCG is rated red for the Quality of Leadership. The CCG is optimistic that this rating will improve in early 2018. Year end results for the Improvement and Assessment Framework are published by NHS England.

Counter fraud arrangements We contract an accredited counter fraud specialist to provide the full range of anti-crime work that is proportionate to the risks identified and fully compliant with the NHS Standards for Commissioners. The annual work-plan is developed from risks identified through the counter fraud risk assessment and discussions with key staff within the CCG. The annual work-plan is agreed with the Chief Financial Officer and ratified by the Audit Committee. Progress is regularly reported to the Chief Financial Officer and the Audit Committee. The Audit Committee reviews the results of the CCG annual self-assessment against the NHS counter fraud standards for commissioners. The Audit Committee monitors progress on remedial actions against areas of non-compliance or following an NHS Protect Quality Inspection.

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The accredited counter fraud specialists also delivered training to staff, which complies with the CCG mandatory training requirements.

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Final Head of Internal Audit Opinion 2017/2018 The head of internal audit opinion In accordance with Public Sector Internal Audit Standards, the head of internal audit is required to provide an annual opinion, based upon and limited to the work performed, on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes. The opinion should contribute to the organisation's annual governance statement.

1.1 The opinion For the 12 months ended 31 March 2018, the head of internal audit opinion for Greenwich Clinical Commissioning Group is as follows:

The enhancements relate to our findings from the reviews of Better Care Fund, Continuing Healthcare, Financial Planning and QIPP Delivery, and Cyber Security.

Please see appendix A for the full range of annual opinions available to us in preparing this report and opinion.

1.2 Scope and limitations of our work

The formation of our opinion is achieved through a risk-based plan of work, agreed with management and approved by the audit committee, our opinion is subject to inherent limitations, as detailed below:

the opinion does not imply that internal audit has reviewed all risks and assurances relating to the organisation;

the opinion is substantially derived from the conduct of risk-based plans generated from a robust and organisation-led assurance framework. As such, the assurance framework is one component that the board takes into account in making its annual governance statement (AGS);

the opinion is based on the findings and conclusions from the work undertaken, the scope of which has been agreed with management / lead individual;

the opinion is based on the testing we have undertaken, which was limited to the area being audited, as detailed in the agreed audit scope;

where strong levels of control have been identified, there are still instances where these may not always be effective. This may be due to human error, incorrect management judgement, management override, controls being by-passed or a reduction in compliance;

due to the limited scope of our audits, there may be weaknesses in the control system which we are not aware of, or which were not brought to attention; and

Head of internal audit opinion 2017/18

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• it remains management’s responsibility to develop and maintain a sound system of risk management, internal control and governance, and for the prevention and detection of material errors, loss or fraud. The work of internal audit should not been seen as a substitute for management responsibility around the design and effective operation of these systems.

1.3 Factors and findings which have informed our opinion We have issued reasonable or substantial assurance opinions in relation to the following reviews:

Primary Care Delegated Commissioning (reasonable assurance) Risk Management Board Assurance Framework (reasonable assurance) Conflicts of Interest (substantial assurance)

However, we issued partial assurance opinions in relation to the following reviews:

Better Care Fund: Our review found there was an absence of a Better Care Fund Plan (BCF) for 2017/18, and there were instances where it was not clear how the schemes met BCF requirements. Specifications for schemes were not always in place, were sometimes out of date, and/or specifications did not have specific information included i.e. exit arrangements, safeguarding policies. Furthermore, there was a lack of transparency over the financial and non-financial arrangements, for example, invoicing was based on expenditure rather than actual, lack of financial reporting via the Joint Commissioning Executive committee, underperformance on BCF KPIs, and a lack of a value for money exercise on schemes.

There were a total of five actions (two high, two medium and one low) raised during the review, of which three actions had been implemented (two medium and one low), and two actions were in the process of being implemented (two high).

Continuing care

Testing identified that in instances there was no evidence of any three-month review, and one example where a patient had also not had their twelve-month review. There was also a lack of provider contracts for providers, no formal performance monitoring of providers and an absence of verification check procedures and of conflict of interest declarations when selecting providers. In addition, there were no formal periodic review of data quality of Caretrack system.

There were a total of eight actions (one high, five medium and two low) raised during the review, of which five actions (one high, two medium and two low) were implemented. There are three medium action open and overdue.

Financial planning and QIPP delivery controls (effectiveness)

We raised a partial assurance rating in relation to the overall effectiveness, this was in relation to the £5.3m risk delivery gap within the QIPP programme at the time of the review, a significant proportion of risk-assessed savings identified being back-ended and were forecast to deliver later in the year.

There were a total of two actions (one high and one medium) raised during the review, of which both had been implemented.

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Joint working across South London - cyber assurance An advisory audit of Cyber Security was undertaken as part of the 2017/18 approved internal audit periodic plans for Lambeth, Southwark, Lewisham, Greenwich, Croydon, Merton, Richmond, Sutton and Wandsworth CCGs.

Based upon the evidence available at the time of our fieldwork, we are able to agree that 21 of the 34 requirements for the five cyber essentials control themes had evidence to support the CSU self-assessment that controls are established. Of the remaining 13 requirements there were four where the CSU is categorised as ‘Self-assessed as implemented but not tested’, one where we ‘Agree not fully implemented’, seven where ‘Evidence does not fully support the self-assessment score’, and one ‘Not applicable’. All 13 were across the following theme areas: boundary firewalls and internet gateways, secure configuration, user access controls and patch management.

The validated self-assessment scores generate an overall status of “Working Towards Implementation for the CSU’s implementation of cyber essentials” for this domain.

Follow up

During 2017/18, there were a total of 62 actions (eight high, 39 medium and 15 low) open, which included actions outstanding from previous years’ Internal Audit work (30 actions – four high, 17 medium and nine low), as well as actions raised during 2017/18 (32 actions – four high, 22 medium and six low). Of these 62 actions, five actions (three medium and two low), were not yet due for implementation at the time of drafting this opinion. A total of 38 actions (six high, 21 medium and 11 low) had been implemented. There are 19 actions (two high, 15 medium and two low) open and overdue.

1.4 Further issues relevant to this opinion We have reviewed the Service Auditor Report for National Shared Business Services, who provide financial transactional support to the CCG, via its contract with NHS England. No notable exceptions were reported.

The Service Auditor Report for NHS Digital did not raise any exceptions. NHS Digital (the trading name of the “Health and Social Care Information Centre”) provides IT services as part of the end to end service alongside other organisations to support processing of NHS payments and deductions to providers of general practice (“GP”) services in England. The service auditor report was for the year ending 31 March.

We reviewed the Service Auditor Reports for Capita, who process payments to providers of general practice via a contract with NHS England, from whom the CCG has delegated primary care commissioning responsibilities. Whilst there has been some improvement in the number of control exceptions, there remained seven out of sixteen key controls assessed as suitably designed but not appropriately complied with over the period October 2017 to March 2018. Management action plans are in place to remedy the issues identified.

We have reviewed the Service Auditor Report for NEL Commissioning Support Unit, who provide some financial and payroll services to the CCG. We reviewed reports covering the eleven months to 28 February 2018 and the accompanying bridging letter to take the period

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covered up to 31 March 2018. Whilst we noted a number of exceptions were identified, we do not consider amongst these there are any which represent a significant risk to the CCG’s control environment.

1.5 Topics judged relevant for consideration as part of the annual governance statement Based on the work we have undertaken on the CCG’s system on internal control, we do not consider that within these areas there are any issues that need to be flagged as significant control issues within the Annual Governance Statement (AGS). However, we would expect the CCG to consider in the formulation of the AGS the internal control weaknesses identified within our partial assurance opinions summarised above, along with the actions being taken to address the issues identified.

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Appendix A: Annual opinions The following shows the full range of opinions available to us within our internal audit methodology to provide you with context regarding your internal audit opinion.

The factors which are considered when influencing our opinion are:

inherent risk in the area being audited;

Limitations in the

individual audit assignments

The adequacy and

effectiveness of the risk management and / or governance control framework

The impact of

weakness identified

The level of risk exposure

The response to

management actions raised and timeliness of actions taken

RSM Risk Assurance Services LLP

May 2018

Annual opinions Factors influencing our opinion

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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 this review by the Governing Body, the Audit Committee, the Quality Committee, Internal Audit and a plan to address weaknesses and ensure continuous improvement of the system is in place.

The Governing Body and Audit Committee have provided regular feedback on the completeness and effectiveness of our systems of internal control via comments and feedback on the completeness of the Board Assurance Framework. Control and assurance gaps were sometimes identified, resulting in existing controls and assurances being further reviewed and strengthened. The Audit Committee also carried out reviews in to the risks associated with the CCG priorities.

The report into the Board Assurance Framework (BAF) process from our Internal Auditors stated that there is reasonable assurance that the controls in place to manage the risks are suitably designed and consistently applied. Issues were identified that need to be addressed in order to ensure that the control framework is effective in managing the identified risks. The risk management arrangements at Greenwich CCG were reviewed and an overall assessment of reasonable assurance was provided.

Conclusion In conclusion I can confirm that no significant internal control issues have been identified.

Andrew Bland Accountable Officer Date: 25 May 2018

Remuneration and staff report Remuneration Committee The Remuneration Committee comprises of four members and has met on occasion during the past year.

A full list of the NHS Greenwich CCG members and their roles is below.

Name Role

Jim Wintour Lay Member / Vice Chair (Audit and COI) until 11 June 2017

Maggie Bucknell Governing Body Registered Nurse

Greg Ussher Lay member (PPI) Dr Iyngarun Vanniasegarum Secondary Care Doctor

Amana Humayun Lay Member/ Vice Chair (Audit and COI) from 12 June 2017

In addition to the members listed above, the following CCG employees provided the committee with advice which was material to the committee’s deliberations.

Name Role Service

Joanne Murfitt Chief Officer Advice Yvonne Leese Director of Quality and Integrated

Governance Advice

The North East London Commissioning Support Unit (CSU) provides HR advice and support to the CCG in accordance with an agreed Service Level Agreement. This includes advice and support to the Remuneration Committee including agreeing agendas with the Chair of the Committee and preparing and presenting papers at Committee meetings. The advice given to the Remuneration Committee is based on national guidance and benchmarking information. The HR Business Partner is appointed by the CSU.

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Remuneration policy The committee’s deliberations are carried out within the context of national pay and remuneration guidelines, local comparability and taking account of independent advice regarding pay structures. Business expenses are reimbursed in accordance with the CCG policy based on national guidelines. There are no benefits in kind. This policy remains the same for 2018/19.

Senior managers’ performance related pay The CCG does not have a policy of performance related pay for senior managers.

Senior managers’ service contracts Senior managers’ contracts are permanent with a notice period of six months. There have been no termination payments in year or any awards to current or former members of the Governing Body, although the CCG made a settlement agreement with one person.

Senior managers’ salaries and allowances 2017/18 (audited) All members of the Governing Body are deemed to be individuals with significant financial responsibility during the financial year and are therefore regarded as ‘senior managers’. No other CCG senior managers have significant financial responsibility.

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Name

Title

Salary & Fees

Taxable Benefits

Annual

Performance Related Bonuses

Long-term

Performance Related Bonuses

All Pension Related Benefits

Total

bands of

£5,000

Disclosed in £ to the

nearest £100

bands of

£5,000

bands of

£5,000

bands of

£2,500

bands of

£5,000

£000 £000 £000 £000 £000 £000 Joanne Murfitt

Chief Officer from 1 November 2016 to 10 September 2017

50-55

0

0

0

0

50-55

Annabel Burn Chief Officer until 31 October 2016 Not Applicable

David Maloney Chief Financial Officer from 20 February 2017 120-125 0 0 0 37.5 - 40 120-125

Neil Kennett-Brown Managing Director from 25 September 2017 65-70 0 0 0 0 65-70

Ian Fisher

Interim Chief Financial Officer From 1st October 2015 to 3 February 2017

Not Applicable

Liz James

Interim Director of Commissioning Until 30 September 2017

70-75

0

0

0

377.5-380

70-75

Vanessa Fowler

Director of Commissioning from 1st October to 15th December 2017

20-25

0

0

0

0

20-25

Regina Shakespeare

Interim Turnaround director and Acting Director of Commissioning - From 3 February 2016 to 31 October 2016

Not Applicable Simon Hall

Deputy Chief Officer and Director of Strategy and Performance Until 3 May 2016

Not Applicable

Yvonne Leese Director of Quality and Integrated Governance 100-105 0 0 0 90 - 92.5 100-105

Virginia Morley Director of Commissioning from 27 November 2017 20-25 0 0 0 0 20-25

Diane Jones

Director of Integrated Governance from 24 August 2015 to 28 February 2017

Not Applicable

Dr Ellen Wright

Chair and GP Member of the NHS Greewich CCG Governing Body

55-60

0

0

0

0

55-60

Dr Hany Wahba GP Member of the NHS Greewich CCG Governing Body 40-45 0 0 0 0 40-45

Dr Nayan Patel

GP Member of the NHS Greewich CCG Governing Body

40-45

0

0

0

0

40-45

Dr Sylvia Nyame

GP Member of the NHS Greewich CCG Governing Body - From 1 August 2015

40-45

0

0

0

0

40-45

Dr Ranil Perera

GP Member of the NHS Greewich CCG Governing Body - From 1 May 2014

40-45

0

0

0

280 - 282.5

40-45

Dr Krishna Subbarayan

GP Member of the NHS Greewich CCG Governing Body - From 1 July 2014

40-45

0

0

0

75-77.5

40-45

Dr Sabah Salman

GP Member of the NHS Greewich CCG Governing Body from 1 August 2015

30-35

0

0

0

0

30-35

Dr Iyngaran Vanniasgarum

Secondary Care doctor on the NHS Greewich CCG Governing Body from 08 January 2014

15-20

0

0

0

0

15-20

Maggie Buckell

Registered Nurse on the NHS Greewich CCG Governing Body from 08 January 2015

10-15

0

0

0

0

10-15

Dr Greg Ussher

Lay Member on the NHS Greewich CCG Governing Body from 01 April 2013

10-15

0

0

0

0

10-15

Mr Jim Wintour

Lay Member on the NHS Greewich CCG Governing Body from 01 April 2013 until 11 June 2017

0-5

0

0

0

0

0-5

Mr Richard Rice

Lay Member on the NHS Greewich CCG Governing Body from 20 March 2017

10-15

0

0

0

0

10-15

Dr Jaisun Vivekanandaraja

GP Member of the NHS Greewich CCG Governing Body from 17 January 2018

5-10

0

0

0

0

5-10

Amana Humayun

Vice Chair and Lay Member for Audit and Remuneration and Conflicts of Interest Guardian from 12 June 2017

0

0

0

0

0

0

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Mr Andrew Bland held the position of Accountable Officer for Greenwich CCG from 11/09/2017. During that time he also held Accountable Officer roles at Southwark CCG and Bexley CCG. His salary was paid in full by Southwark CCG.

No Governing Body member, or any other manager, received any performance related pay or bonus, or taxable benefit.

Pension Benefits 2017-18

Name

Real Increase in

pension at age 60 (bands of

£2,500)

Real Increase in

pension lump sum at age 60 (bands of

£2,500)

Total accrued pension at age 60 at 31

March 2018 (bands of £5,000)

Lump Sum at age 60 related to accrued

pension at 31 March 2018 (bands of £5,000)

Cash equivalent

Transfer Value at 31 March

2018

Cash equivalent

Transfer Value at 31 March 2017

Real Increase in Cash

(Proportion of time in Post)

Equivalent

Transfer Value

Employer contribution to

stakeholder pension

£000 £000 £000 £000 £000 £000 £000 £000

David Maloney Chief Financial Officer

2.5 - 5

0 - 2.5

35 - 40

95 -100

669

591

71

Nil

Liz James

Director of Commissioning

15 - 17.5

22.5 - 25

15 - 20

45 - 50

354

0.00

177

Nil

Yvonne Leese Director of Quality and Integrated Goverance

2.5 - 5

12.5 - 15

35 - 40

105 - 110

786

645

138

Nil

Joanne Murfitt Chief Officer

0

0

20 - 25

65 - 70

498

1,090

-270

Nil

Ranil Perera Member of Governing Body

10 - 12.5

35 - 37.5

10 - 15

35 - 40

166

0

166

Nil

Krishna Subbarayan Member of Governing Body

2.5 - 5

7.5 - 10

0 - 5

5 - 10

46

0

46

Nil

The pension benefit figure is based on the HMRC method for calculating the increase in the annual pension entitlement for deferred benefit schemes. It is not the same as the cost to the CCG of its contribution in respect of the individual concerned (the employer’s contribution).

NHS organisations are required to disclose the pension benefits for those persons disclosed as senior managers of the organisation, where the clinical commissioning group has made a direct contribution to a pension scheme.

Pay multiples (audited) 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.

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The banded remuneration of the highest paid member of the Governing Body in NHS Greenwich CCG in financial year 2017/18 was £127,500 (in 2016/17 it was £285,000, including VAT and agency premium). This is 2.65 times higher than the median remuneration of the workforce, which was £48,106 (2016/17 was 6.95 and £47,171.)

The change in ratio relates to a period of turnaround in the previous year, in which it was necessary to use a turnaround director who incurred higher costs than the chief officer role.

In 2017/18 no employees received remuneration in excess of the highest-paid member of the Governing Body. Remuneration ranged from £17,613 to £126,176 (annualised estimated earnings of highest paid director).

In calculating the relationship between the highest paid person in the organisation and the median remuneration, the CCG has to remove VAT and an estimate of agency premiums from the payments for all contractors and treat all appointments and employments as if they were full-time and for twelve months.

Total remuneration includes salary and pensionable benefits. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions.

Off-payroll engagements Off-payroll engagements existing at 31 March 2018 for more than £245 per day and have lasted longer than six months are as follows:

The number that have existed: For less than one year at 31/3/18 1 For between one and two years 0 For between two and three years 0 For between three and four years 0 For four years or more 0 Total number of existing engagements at 31/3/17 4

All existing off-payroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax and, where necessary, that assurance has been sought.

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For all off-payroll engagements in 2017/18 for more than £245 per day and more than six months:

Number Total number of new engagements, or those that reached six months in duration, between 1 April 2017 and 31 March 2018

3

Of which Number assessed as caught by IR35 0 Number assessed as NOT caught by IR35 3

Number engaged directly (via PSC contract to department) and are on departmental payment

0

Number of engagements reassessed for consistency/ assurance purposes during the year

0

Number of engagements that saw a change to IR35 following the consistency review

0

Off-payroll engagement of Governing Body members and senior officials with “significant financial responsibility” between 1 April 2017 and 31 March 2018

Number of off-payroll engagements of Governing Body members, and senior officials with “significant financial responsibility” during the financial year

1

Number of individuals who have been deemed Governing Body members, and senior officials with “significant financial responsibility”, during the financial year (payroll and off-payroll)

6

The off-payroll engagement relates to a one month period whilst the individual was brought on to the CCG’s payroll where they remained until their employment ceased.

I hereby sign off the Remuneration Report element of the NHS Greenwich CCG Annual Report 2017/18.

Andrew Bland Accountable Officer 25 May 2018

Exit packages, including special (non-contractual) payments Table 1: Exit packages

Exit package

cost band (inc. any special

payment element

Number of compulsory

redundancies

Cost of compulsory

redundancies

Number of other

departures agreed

Cost of other departures

agreed

Total number of

exit packages

Total cost of exit packages

Number of departures

where special payments have been

made

Cost of special payment element

included in exit packages

WHOLE NUMBERS

ONLY

£s

WHOLE NUMBERS

ONLY

£s

WHOLE NUMBERS

ONLY

£s

WHOLE NUMBERS

ONLY

£s Less than £10,000

£10,000 - £25,000

£25,001 - £50,000

£50,001 - £100,000

1 67,974

£100,001 - £150,000

£150,001 – £200,000

>£200,000 TOTALS 1 67,974 These tables report the number and value of exit packages agreed in the financial year. In 2017/18 the CCG made a settlement agreement with a member of CCG staff. This was approved by the Remuneration Committee and is accounted for in accordance with relevant accounting standards.

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Table 2: Analysis of other departures Agreements Total value of

agreements Number £000s

Voluntary redundancies including early retirement contractual costs

Mutually agreed resignations (MARS) contractual costs

1 67,974

Early retirements in the efficiency of the service contractual costs

Contractual payments in lieu of notice

Exit payments following Employment Tribunals or court orders

Non-contractual payments requiring HMT approval

TOTAL 1 67,974

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Our staff Communicating and engaging There are a number of ways in which we communicate and engage with staff and member practices including:

• Weekly staff briefs which are shared on the intranet and where staff are

encouraged to pose questions, celebrate success and share ideas. • Intranet. • Newly introduced monthly lunch and learn sessions offering a chance to

network and share knowledge across the organisation. • Staff away days and events. • Team and directorate meetings. • Regular 1:1s. • Annual staff survey with collective all-staff action planning. • Annual awards which were relaunched for 2017/18 to include staff and

member practices and built around our organisational values. Training and development We offer a comprehensive training package online via e-learning with some opportunities for face to face training. All staff are required to complete their statutory and mandatory training, and compliance is monitored through the workforce system. Staff have regular 1:1s and appraisals and are offered training and support through personal development plans. Objective-setting takes place in quarter 1 of the year and is linked to the corporate objectives to ensure that each member of staff understands the role they and their team plays in achieving the CCG’s objectives.

Employee consultation Organisational change is managed in accordance with the principles and procedures contained within the CCG's organisational change policy. The CCG also informally communicates and consults with employees via regular staff briefings.

Policy on disabled employees Disabled employees are protected under the protected characteristics of the Equality Act 2010, one of which is disability. The CCG ensures that requirements and reasonable adjustments necessary for employees with disabilities are managed during their employment and that people with disabilities are not discriminated against on the ground of their disability at any stage of the recruitment process or in their employment with the CCG.

The CCG's sickness absence policy confirms that where an employee becomes disabled as a result of sickness, the CCG will make any necessary reasonable adjustments, as required, and in accordance with the Equality Act to enable the employee to return to work. The types of adjustments may include adjustments to work base, working hours, redeploying the employee to another suitable position and providing any necessary equipment to assist the employee to perform their role.

Equalities for staff The CCG promotes a working environment in which all parties and procedures relating to recruitment, selection, training, promotion and employment are free from

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unfair discrimination, ensuring that no employee or prospective employee is discriminated against, whether directly or indirectly on the grounds of age; disability; gender reassignment; pregnancy and maternity; race including ethnic or national origins, colour or nationality; religion or belief; sex (gender); sexual orientation; marriage and civil partnership; trade union membership; responsibility for dependents or any other condition or requirement which cannot be shown to be justifiable.

Trade union facility time As a CCG with a full time equivalent employee number of more than 49 people, we are obliged to report on paid time off for union representatives to carry out trade union activities. In 2017/18, one member of staff was a relevant union official, with 0.1 whole time equivalent (WTE) of their paid time allocated for union activities. This accounts for 0.061% of the CCG total pay bill.

Staff composition In 2017/18 our headcount was 86, and full time equivalent was 63.43.

This table shows staff numbers, with a gender breakdown for Governing Body, Senior Management Team and all staff for 2017/18. Female Male Grand Total Director/VSM 3 3 6 Employee 44 20 64 Governing Body 7 9 16 Grand Total 54 32 86

This table shows staff breakdown by gender and NHS band for 2017/18. Female Male Band 3 1 Band 4 6 1 Band 5 5 1 Band 6 2 1 Band 7 10 5 Band 8A 7 2 Band 8B 6 3 Band 8C 5 3 Band 8D 3 1 Band 9 3 1 Other - Local Salary 7 13 Grand Total 54 32

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The following tables are a profile of CCG staff relating to the main protected characteristics as at 31 March 2018. Tables do not include Governing Body members and clinical leads.

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99

100

Sickness absence data 2017/18 Total days lost 655.80 Total staff years 65.29 Average working days lost 10.04 Cumulative % absence rate (FTE) 2.74% Number of sickness episodes 80 Number of persons retiring on ill health grounds 0

Parliamentary Accountability and Audit Report NHS Greenwich CCG is not required to produce a Parliamentary Accountability and Audit Report. Disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges are included as notes in the financial statements of this report at section 3 Annual Accounts. An audit certificate and report is also included in this Annual Report at page 81

102

INDEPENDENT AUDITOR’S REPORT TO THE MEMBERS OF THE GOVERNING BODY OF NHS GREENWICH CLINICAL COMMISSIONING GROUP REPORT ON THE AUDIT OF THE FINANCIAL STATEMENTS

opinion We have audited the financial statements of NHS Greenwich Clinical Commissioning Group (“the CCG”) for the year ended 31 March 2018 which comprise the Statement of Comprehensive Net Expenditure, Statement of Financial Position, Statement of Changes in Taxpayers Equity and Statement of Cash Flows, and the related notes, including the accounting policies in note 1.

In our opinion the financial statements:

• give a true and fair view of the state of the CCG’s affairs as at 31 March 2018 and of its income and expenditure for the year then ended; and

• have been properly prepared in accordance with the accounting policies directed by the NHS Commissioning Board with the consent of the Secretary of State as being relevant to CCGs in England and included in the Department of Health Group Accounting Manual 2017/18.

Basis for opinion

We conducted our audit in accordance with International Standards on Auditing (UK) (“ISAs (UK)”) and applicable law. Our responsibilities are described below. We have fulfilled our ethical responsibilities under, and are independent of the CCG in accordance with, UK ethical requirements including the FRC Ethical Standard. We believe that the audit evidence we have obtained is a sufficient and appropriate basis for our opinion.

Going concern

We are required to report to you if we have concluded that the use of the going concern basis of accounting is inappropriate or there is an undisclosed material uncertainty that may cast significant doubt over the use of that basis for a period of at least twelve months from the date of approval of the financial statements. We have nothing to report in these respects.

Other information in the Annual Report

The Accountable Officer is responsible for the other information presented in the Annual Report together with the financial statements. Our opinion on the financial statements does not cover the other information and, accordingly, we do not express an audit opinion or, except as explicitly stated below, any form of assurance conclusion thereon.

Our responsibility is to read the other information and, in doing so, consider whether, based on our financial statements audit work, the information therein is materially misstated or inconsistent with the financial statements or our audit knowledge. Based solely on that work we have not identified material misstatements in the other information. In our opinion the other information included in the Annual Report for the financial year is consistent with the financial statements.

Annual Governance Statement

We are required to report to you if the Annual Governance Statement does not comply with guidance issued by the NHS Commissioning Board. We have nothing to report in this respect.

Remuneration and Staff Report

In our opinion the parts of the Remuneration and Staff Report subject to audit have been properly prepared in accordance with the Department of Health Group Accounting Manual 2017/18.

Accountable Officer’s responsibilities

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As explained more fully in the statement set out on page 63, the Accountable Officer is responsible for: the preparation of financial statements that give a true and fair view; such internal control as they determine is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error; assessing the CCGs ability to continue as a going concern, disclosing, as applicable, matters related to going concern; and using the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity.

Auditor’s responsibilities

Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue our opinion in an auditor’s report. Reasonable assurance is a high level of assurance, but does not guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of the financial statements.

A fuller description of our responsibilities is provided on the FRC’s website at www.frc.org.uk/auditorsresponsibilities

REPORT ON OTHER LEGAL AND REGULATORY MATTERS

Opinion on regularity

We are required to report on the following matters under Section 25(1) of the Local Audit and Accountability Act 2014.

In our opinion, in all material respects, the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them.

Report on the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources

Under the Code of Audit Practice we are required to report to you if the CCG has not made proper arrangements for securing economy, efficiency and effectiveness in its use of resources.

Qualified conclusion

Except for the matters outlined in the basis for qualified conclusion paragraph below we are satisfied that in all significant respects NHS Greenwich CCG put in place proper arrangements for securing economy, efficiency and effectiveness in the use of resources for the year ended 31 March 2018.

Basis for qualified conclusion

In considering the Clinical Commissioning Group’s arrangements for informed decision making, we identified that the Clinical Commissioning Group was placed under legal directions from NHS England from 1 September 2017. The legal directions require the Clinical Commissioning Group to cease to exercise its acute commissioning functions including the contract with Lewisham and Greenwich NHS Trust. During the period of legal directions, acute commissioning functions are to be exercised by NHS Southwark Clinical Commissioning Group on behalf of NHS Greenwich Clinical Commissioning Group.

The legal directions also require the production and implementation of a Recovery Plan in respect of the contract between Lewisham and Greenwich NHS Trust and the Clinical Commissioning Group, specifically addressing urgent and emergency care services and ensuring that such services meet all applicable national standards.

Respective responsibilities in respect of our review of arrangements for securing economy, efficiency and effectiveness in the use of resources

104

As explained more fully in the statement set out on page 63, the Accountable Officer is responsible for ensuring that the CCG exercises its functions effectively, efficiently and economically. We are required under section 21(1)(c) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources.

We are not required to consider, nor have we considered, whether all aspects of the CCGs arrangements for securing economy, efficiency and effectiveness in the use of resources are operating effectively.

We have undertaken our review in accordance with the Code of Audit Practice, having regard to the specified criterion issued by the Comptroller and Auditor General (C&AG) in November 2017, as to whether the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. We planned our work in accordance with the Code of Audit Practice and related guidance. Based on our risk assessment, we undertook such work as we considered necessary.

Statutory reporting matters

We are required by Schedule 2 to the Code of Audit Practice issued by the Comptroller and Auditor General (‘the Code of Audit Practice’) to report to you if:

• we refer a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014 because we have reason to believe that the CCG, or an officer of the CCG, is about to make, or has made, a decision which involves or would involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency; or

• we issue a report in the public interest under section 24 of the Local Audit and Accountability Act 2014; or

• we make a written recommendation to the CCG under section 24 of the Local Audit and Accountability Act 2014.

We have nothing to report in these respects.

THE PURPOSE OF OUR AUDIT WORK AND TO WHOM WE OWE OUR RESPONSIBILITIES

This report is made solely to the Members of the Governing Body of NHS Greenwich CCG, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014. Our audit work has been undertaken so that we might state to the Members of the Governing Body of the CCG, as a body, those matters we are required to state to them in an auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Members of the Governing Body, as a body, for our audit work, for this report or for the opinions we have formed.

CERTIFICATE OF COMPLETION OF THE AUDIT

We certify that we have completed the audit of the accounts of NHS Greenwich CCG in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.

Richard Hewes for and on behalf of KPMG LLP, Statutory Auditor Chartered Accountants 15 Canada Square London, E14 5GL 25 May 2018

NHS GREENWICH CCG - Annual Accounts 2017-18

Statement of Comprehensive Net Expenditure for the year ended

31 March 2018

2017-18 2016-17

Note £'000 £'000

Income from sale of goods and services 2 (7,055) (7,955)

Other operating income 2 (233) (2,454)

Total operating income (7,288) (10,409)

Staff costs 4 5,040 6,792

Purchase of goods and services 5 416,939 379,535

Depreciation and impairment charges 5 361 122

Other Operating Expenditure 5 534 579

Total operating expenditure 422,874 387,027

Net Operating Expenditure 415,586 376,618

Finance income

Finance expense 0 0

Net expenditure for the year 415,586 376,618

Net Gain/(Loss) on Transfer by Absorption 0 0

Total Net Expenditure for the year 415,586 376,618

Other Comprehensive Expenditure 0 0

Comprehensive Expenditure for the year ended 31 March 2018 415,586 376,618

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Statement of Financial Position as at

31 March 2018

2017-18 2016-17

Note £'000 £'000

Non-current assets:

Property, plant and equipment 12 1,262 1,601

Total non-current assets 1,262 1,601

Current assets:

Trade and other receivables 15 15,118 11,497

Cash and cash equivalents 16 141 287

Total current assets 15,259 11,784

Non-current assets held for sale 0 0

Total current assets 16,521 11,785

Total assets 16,521 13,386

Current liabilities

Trade and other payables 17 (45,421) (47,039)

Total current liabilities (45,421) (47,039)

Non-Current Assets plus/less Net Current Assets/Liabilities (28,900) (33,654)

Total non-current liabilities 0 0

Assets less Liabilities (28,900) (33,654)

Financed by Taxpayers’ Equity

General fund (28,900) (33,654)

Total taxpayers' equity: (28,900) (33,654)

The notes on pages 109 to 129 form part of this statement

Andrew Bland

Chief Accountable Officer

The financial statements on pages 105 to 108 have been approved by the Audit Committee on behalf of the Governing Body

on 21st May 2018 and signed on its behalf by:

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NHS GREENWICH CCG - Annual Accounts 2017-18

Statement of Changes In Taxpayers Equity for the year ended

31 March 2018

General fund

Revaluation

reserve

Other

reserves

Total

reserves

£'000 £'000 £'000 £'000

Changes in taxpayers’ equity for 2017-18

Balance at 01 April 2017 (33,654) 0 0 (33,654)

Transfer between reserves in respect of assets transferred from closed NHS

bodies 0 0 0 0

Adjusted NHS Clinical Commissioning Group balance at 31 March 2018 (33,654) 0 0 (33,654)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2017-18

Net operating expenditure for the financial year (415,586) 0 0 (415,586)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (449,240) 0 0 (449,240)

Net funding 420,340 0 0 420,340

Balance at 31 March 2018 (28,900) 0 0 (28,900)

General fund

Revaluation

reserve

Other

reserves

Total

reserves

£'000 £'000 £'000 £'000

Changes in taxpayers’ equity for 2016-17

Balance at 01 April 2016 (23,337) 0 0 (23,337)

Transfer of assets and liabilities from closed NHS bodies as a result of the 1

April 2013 transition 0 0 0 0

Adjusted NHS Clinical Commissioning Group balance at 31 March 2017 (23,337) 0 0 (23,337)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2016-17

Net operating costs for the financial year (376,618) 0 0 (376,618)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (399,955) 0 0 (399,955)

Net funding 366,301 0 0 366,301

Balance at 31 March 2017 (33,654) 0 0 (33,654)

The notes on pages 109 to 129 form part of this statement

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Statement of Cash Flows for the year ended

31 March 2018

2017-18 2016-17

Note £'000 £'000

Cash Flows from Operating Activities

Net operating expenditure for the financial year (415,586) (376,618)

Depreciation and amortisation 5 361 122

(Increase)/decrease in trade & other receivables 15 (3,621) (5,443)

Increase/(decrease) in trade & other payables 17, 20 (1,640) 15,809

Net Cash Inflow (Outflow) from Operating Activities (420,486) (366,130)

Cash Flows from Investing Activities

Interest received 0 0

(Payments) for property, plant and equipment 0 (3)

Net Cash Inflow (Outflow) from Investing Activities 0 (3)

Net Cash Inflow (Outflow) before Financing (420,486) (366,133)

Cash Flows from Financing Activities

Grant in Aid Funding Received 420,340 366,301

Net Cash Inflow (Outflow) from Financing Activities 420,340 366,301

Net Increase (Decrease) in Cash & Cash Equivalents 16 (146) 168

Cash & Cash Equivalents at the Beginning of the Financial Year 287 119

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 141 287

The notes on pages 109 to 129 form part of this statement

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NHS GREENWICH CCG - Annual Accounts 2017-18

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 and Social Care. Consequently, the following financial statements have been prepared in

accordance with the Group Accounting Manual 2017-18 issued by the Department of Health and Social Care. 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.

During the year the Governing Body and its sub-committees has considered and approved a number of documents that assume that services will

be provided on an on-going basis:

- South East London Sustainability and Transformation Plan (STP) updates

- Operational plan

- Commissioning Intentions

- Better Care Fund Plan approved by the Health and Well-Being Board

- Acceptance of full delegation from NHS England for the co-commissioning of primary care services. NHS Greenwich CCG has assumed full

responsibility for contractual GP performance management, budget management and the design and implementation of local incentive schemes

from 1st April 2018

- New governance arrangements for CCG and co-commissioning scrutiny and decision making

- Changes to the CCG's Constitution

- Approval of shared executive management and leadership arrangements across 5 CCGs and the SEL STP

- The CCG has agreed main service contracts for 2018/19 and has a cash plan for 2018/19 based on the CCG's notified Maximum Cash

Drawdown

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 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.

1.4 Critical Accounting Judgements & Key Sources of Estimation Uncertainty

In the application of the clinical commissioning group’s accounting policies, management is required to make judgements, estimates and

assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated

assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those

estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the

period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision

affects both current and future periods.

1.4.1 Critical Judgements in Applying Accounting Policies

The following are the critical judgements, apart from those involving estimations (see below) that management has made in the process of

applying the clinical commissioning group’s accounting policies that have the most significant effect on the amounts recognised in the financial

statements:

· The Governing Body does not consider the activities of the NHS Greenwich Charitable Funds to be material to NHS Greenwich CCG. The

charitable funds represent approximately 0.9% (2017 – 1.0%) of the revenue resource outturn position of NHS Greenwich CCG. Accordingly, the

Governing Body has decided not to consolidate the NHS Greenwich Charitable Funds accounts with that of the CCG.

- Greenwich CCG has estimated the value of its acute position where no year end agreement has been reached based on provider activity at

Month 11 extrapolated to Month 12. For the two of the CCG's three main acute providers a year end agreement has been reached to secure

financial stability for both parties.

1.4.2 Key Sources of Estimation Uncertainty

The following are the key estimations that management has made in the process of applying the clinical commissioning group’s accounting

policies that have the most significant effect on the amounts recognised in the financial statements:

·  Management has determined that the value of the Property asset at Eltham Community Hospital, brought into use during the financial year

2015-16, is best estimated at the value of the costs incurred during 2014-15, depreciated on a straight-line basis over the life of the asset, being

25 years. Management has used information from Prescribing Pricing Authority (PPA) and Acute SLAM reports as key sources of estimated

outturn expectation for Primary care and acute costs to reduce any uncertainty.

1.5 Revenue

Revenue in respect of services provided is recognised when, and to the extent that, performance occurs, and is measured at the fair value of the

consideration receivable.

Where income is received for a specific activity that is to be delivered in the following year, that income is deferred.

1.6 Employee Benefits

1.6.1 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.

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Notes to the financial statements

1.6.2 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.

1.7 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.

1.8 Property, Plant & Equipment

1.8.1 Recognition

Property, plant and equipment is capitalised if:

·                It is held for use in delivering services or for administrative purposes;

·                It is probable that future economic benefits will flow to, or service potential will be supplied to the clinical commissioning group;

·                It is expected to be used for more than one financial year;

·                The cost of the item can be measured reliably; and,

·                The item has a cost of at least £5,000; or,

·                Collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are

functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under

single managerial control; or,

·                Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective

cost.

Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated

as separate assets and depreciated over their own useful economic lives.

1.8.2 Valuation

All property, plant and equipment are measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset

and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. All assets are

measured subsequently at valuation.

Land and buildings used for the clinical commissioning group’s services or for administrative purposes are stated in the statement of financial

position at their re-valued amounts, being the fair value at the date of revaluation less any impairment.

Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be

determined at the end of the reporting period. Fair values are determined as follows:

·                Land and non-specialised buildings – market value for existing use; and,

·                Specialised buildings – depreciated replacement cost.

HM Treasury has adopted a standard approach to depreciated replacement cost valuations based on modern equivalent assets and, where it

would meet the location requirements of the service being provided, an alternative site can be valued.

Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes

professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value.

Assets are re-valued and depreciation commences when they are brought into use.

Fixtures and equipment are carried at depreciated historic cost as this is not considered to be materially different from current value in existing

use.

An increase arising on revaluation is taken to the revaluation reserve except when it reverses an impairment for the same asset previously

recognised in expenditure, in which case it is credited to expenditure to the extent of the decrease previously charged there. A revaluation

decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation

reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear

consumption of economic benefit are taken to expenditure. Gains and losses recognised in the revaluation reserve are reported as other

comprehensive income in the Statement of Comprehensive Net Expenditure.

1.8.3 Subsequent Expenditure

Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised. Where

subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing carrying value of the item

replaced is written-out and charged to operating expenses.

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Notes to the financial statements

1.9 Intangible Assets

1.9.1 Recognition

Intangible assets are non-monetary assets without physical substance, which are capable of sale separately from the rest of the clinical

commissioning group’s business or which arise from contractual or other legal rights. They are recognised only:

·                When it is probable that future economic benefits will flow to, or service potential be provided to, the clinical commissioning group;

·                Where the cost of the asset can be measured reliably; and,

·                Where the cost is at least £5,000.

Intangible assets acquired separately are initially recognised at fair value. Software that is integral to the operating of hardware, for example an

operating system, is capitalised as part of the relevant item of property, plant and equipment. Software that is not integral to the operation of

hardware, for example application software, is capitalised as an intangible asset. Expenditure on research is not capitalised but is recognised as

an operating expense in the period in which it is incurred. Internally-generated assets are recognised if, and only if, all of the following have been

demonstrated:

·                The technical feasibility of completing the intangible asset so that it will be available for use;

·                The intention to complete the intangible asset and use it;

·                The ability to sell or use the intangible asset;

·                How the intangible asset will generate probable future economic benefits or service potential;

·                The availability of adequate technical, financial and other resources to complete the intangible asset and sell or use it; and,

·                The ability to measure reliably the expenditure attributable to the intangible asset during its development.

1.9.2 Measurement

The amount initially recognised for internally-generated intangible assets is the sum of the expenditure incurred from the date when the criteria

above are initially met. Where no internally-generated intangible asset can be recognised, the expenditure is recognised in the period in which it

is incurred.

Following initial recognition, intangible assets are carried at current value in existing use by reference to an active market, or, where no active

market exists, at the lower of depreciated replacement cost or the value in use where the asset is income generating . Internally-developed

software is held at historic cost to reflect the opposing effects of increases in development costs and technological advances.1.10' Depreciation, Amortisation & Impairments

Freehold land, properties under construction, and assets held for sale are not depreciated.

Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-

current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or

service potential of the assets. The estimated useful life of an asset is the period over which the clinical commissioning group expects to obtain

economic benefits or service potential from the asset. This is specific to the clinical commissioning group and may be shorter than the physical

life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a

prospective basis. Assets held under finance leases are depreciated over their estimated useful lives.

At each reporting period end, the clinical commissioning group checks whether there is any indication that any of its tangible or intangible non-

current assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount of the asset is estimated to

determine whether there has been a loss and, if so, its amount. Intangible assets not yet available for use are tested for impairment annually.

A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the

revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise

from a clear consumption of economic benefit are taken to expenditure. Where an impairment loss subsequently reverses, the carrying amount

of the asset is increased to the revised estimate of the recoverable amount but capped at the amount that would have been determined had there

been no initial impairment loss. The reversal of the impairment loss is credited to expenditure to the extent of the decrease previously charged

there and thereafter to the revaluation reserve.

1.11 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.

1.11.1 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.

1.11.2 Inventories

Inventories are valued at the lower of cost and net realisable value.

1.12 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.

1.13 Clinical Negligence Costs

The NHS Resolution operates a risk pooling scheme under which the clinical commissioning group pays an annual contribution to the NHS

Resolution which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although the NHS Resolution is

administratively responsible for all clinical negligence cases the legal liability remains with the clinical commissioning group.

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Notes to the financial statements

1.14 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 Resolution 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.

1.15 Continuing healthcare risk pooling

In 2014-15 a risk pool scheme was introduced by NHS England for continuing healthcare claims, for claim periods prior to 31 March 2013.

1.16 Contingencies

A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or non-

occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group, or a present obligation that is

not recognised because it is not probable that a payment will be required to settle the obligation or the amount of the obligation cannot be

measured sufficiently reliably. A contingent liability is disclosed unless the possibility of a payment is remote.

A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or non-occurrence

of one or more uncertain future events not wholly within the control of the clinical commissioning group. A contingent asset is disclosed where an

inflow of economic benefits is probable.

Where the time value of money is material, contingencies are disclosed at their present value.

1.17 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.

1.17.1 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.

The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition.

1.17.2 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.

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.

1.18.1 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.

1.18.2 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.

1.18.3 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 and Social Care, 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.

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Notes to the financial statements

1.19 Value Added Tax

Most of the activities of the clinical commissioning group are outside the scope of VAT and, in general, output tax does not apply and input tax on

purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of

fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.1.20' 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).

1.21 Subsidiaries

Material entities over which the clinical commissioning group has the power to exercise control so as to obtain economic or other benefits are

classified as subsidiaries and are consolidated. Their income and expenses; gains and losses; assets, liabilities and reserves; and cash flows are

consolidated in full into the appropriate financial statement lines. Appropriate adjustments are made on consolidation where the subsidiary’s

accounting policies are not aligned with the clinical commissioning group or where the subsidiary’s accounting date is not co-terminus.

Subsidiaries that are classified as ‘held for sale’ are measured at the lower of their carrying amount or ‘fair value less costs to sell’.

For 2017-18, NHS Greenwich CCG will not consolidate the results of NHS Greenwich Charitable Funds over which it considers it has the power

to exercise control in accordance with IAS27 requirements, as the Governing Body does not consider the NHS Greenwich Charitable Funds to be

material to NHS Greenwich CCG.

1.22 Joint Operations

Joint operations are activities undertaken by the clinical commissioning group in conjunction with one or more other parties but which are not

performed through a separate entity. The clinical commissioning group records its share of the income and expenditure; gains and losses; assets

and liabilities; and cash flows.

1.23 Research & Development

Research and development expenditure is charged in the year in which it is incurred, except insofar as development expenditure relates to a

clearly defined project and the benefits of it can reasonably be regarded as assured. Expenditure so deferred is limited to the value of future

benefits expected and is amortised through the Statement of Comprehensive Net Expenditure on a systematic basis over the period expected to

benefit from the project. It should be re-valued on the basis of current cost. The amortisation is calculated on the same basis as depreciation.

1.24 Accounting Standards That Have Been Issued But Have Not Yet Been Adopted

The DHSC Group accounting manual does not require the following Standards and Interpretations to be applied in 2017-18. These standards

are still subject to FREM adoption and early adoption is not therefore permitted.

·                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)

·                IFRS 17: Insurance Contracts (application from 1 January 2021)

·             IFRIC 22: Foreign Currency Transactions and Advance Consideration (application from 1 January 2018)

·             IFRIC 23: Uncertainty over Income Tax Treatments (application from 1 January 2019)

The application of the Standards as revised would not have a material impact on the accounts for 2017-18, were they applied in that year.

113

NHS GREENWICH CCG - Annual Accounts 2017-18

2 Other Operating Revenue

2017-18 2017-18 2017-18 2016-17

Total Admin Programme Total

£'000 £'000 £'000 £'000

Prescription fees and charges 0 0 0 553

Education, training and research 0 0 0 108

Charitable and other contributions to revenue expenditure: non-NHS 19 0 19 23

Non-patient care services to other bodies 7,055 96 6,959 7,847

Other revenue 214 1 213 1,878

Total other operating revenue 7,288 97 7,191 10,409

3 Revenue

2017-18 2017-18 2017-18 2016-17

Total Admin Programme Total

£'000 £'000 £'000 £'000

From rendering of services 7,288 96 7,192 10,409

Total 7,288 96 7,192 10,409

114

NHS GREENWICH CCG - Annual Accounts 2017-18

4. Employee benefits and staff numbers

4.1.1 Employee benefits 2017-18

Total

Permanent

Employees Other

£'000 £'000 £'000

Employee Benefits

Salaries and wages 4,287 3,255 1,032

Social security costs 354 354 0

Employer Contributions to NHS Pension scheme 396 396 0

Other pension costs 0 0 0

Apprenticeship Levy 3 3 0

Other post-employment benefits 0 0 0

Other employment benefits 0 0 0

Termination benefits 0 0 0

Gross employee benefits expenditure 5,040 4,008 1,032

Less recoveries in respect of employee benefits (note 4.1.2) 0 0 0

Total - Net admin employee benefits including capitalised costs 5,040 4,008 1,032

Less: Employee costs capitalised 0 0 0

Net employee benefits excluding capitalised costs 5,040 4,008 1,032

4.1.1 Employee benefits 2016-17

Total

Permanent

Employees Other

£'000 £'000 £'000

Employee Benefits

Salaries and wages 6,056 3,313 2,743

Social security costs 351 351 0

Employer Contributions to NHS Pension scheme 385 385 0

Other pension costs 0 0 0

Apprenticeship Levy 0 0 0

Other post-employment benefits 0 0 0

Other employment benefits 0 0 0

Termination benefits 0 0 0

Gross employee benefits expenditure 6,792 4,049 2,743

Less recoveries in respect of employee benefits (note 4.1.2) 0 0 0

Total - Net admin employee benefits including capitalised costs 6,792 4,049 2,743

Less: Employee costs capitalised 0 0 0

Net employee benefits excluding capitalised costs 6,792 4,049 2,743

Total

Total

115

NHS GREENWICH CCG - Annual Accounts 2017-18

4.2 Average number of people employed

2016-17

Total

Permanently

employed Other Total

Number Number Number Number

Total 74 63 11 64

Of the above:Number of whole time equivalent people

engaged on capital projects 0 0 0 0

4.4 Exit packages agreed in the financial year

2017-18 2017-18 2017-18

Number £ Number £ Number £

Less than £10,000 0 0 0 0 0 0

£10,001 to £25,000 0 0 0 0 0 0

£25,001 to £50,000 0 0 0 0 0 0

£50,001 to £100,000 0 0 1 67,974 1 67,974

£100,001 to £150,000 0 0 0 0 0 0

£150,001 to £200,000 0 0 0 0 0 0

Over £200,001 0 0 0 0 0 0Total 0 0 1 67,974 1 67,974

Number £ Number £ Number £

Less than £10,000 1 7,878 0 0 1 7,878

£10,001 to £25,000 2 42,253 0 0 2 42,253

£25,001 to £50,000 3 103,092 0 0 3 103,092

£50,001 to £100,000 0 0 0 0 0 0

£100,001 to £150,000 1 100,675 0 0 1 100,675

£150,001 to £200,000 0 0 0 0 0 0

Over £200,001 0 0 0 0 0 0

Total 7 253,898 0 0 7 253,898

Number £ Number £

Less than £10,000 0 0 0 0

£10,001 to £25,000 0 0 0 0

£25,001 to £50,000 0 0 0 0

£50,001 to £100,000 0 0 0 0

£100,001 to £150,000 0 0 0 0

£150,001 to £200,000 0 0 0 0

Over £200,001 0 0 0 0

Total 0 0 0 0

Analysis of Other Agreed Departures

Number £ Number £

Voluntary redundancies including early retirement contractual costs 0 0 0 0

Mutually agreed resignations (MARS) contractual costs 1 67,974 0 0

Early retirements in the efficiency of the service contractual costs 0 0 0 0

Contractual payments in lieu of notice 0 0 0 0

Exit payments following Employment Tribunals or court orders 0 0 0 0

Non-contractual payments requiring HMT approval 0 0 0 0

Total 1 67,974 0 0

The Remuneration Report includes the disclosure of exit payments payable to individuals named in that Report.

2017-18

Other agreed departures

These tables report the number and value of exit packages agreed in the financial year.

Compulsory redundancies Other agreed departures Total

Departures where special

payments have been made

2016-17 2016-17

Departures where special

payments have been made

2017-18

In 2017/18 the CCG made a settlement agreement with a member of CCG staff. This was approved by the Renumeration Committee and is accounted for in

accordance with relevant accounting standards.

2016-17

Compulsory redundancies Other agreed departures

2016-17

Other agreed departures

Total

2017-18 2016-17

116

NHS GREENWICH CCG - Annual Accounts 2017-18

4.5 Pension costs

Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of

the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions.

Both are unfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed under the direction of the

Secretary of State in England and Wales. They are 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, each scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each

scheme is taken as equal to the contributions payable to that scheme for the accounting period.

In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be

determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be

four years, with approximate assessments in intervening years”. An outline of these follows:

4.5.1 Accounting valuation

A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the

end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated

membership and financial data for the current reporting period, and is accepted as providing suitably robust figures for financial reporting

purposes. The valuation of the scheme liability as at 31 March 2018, is based on valuation data as 31 March 2017, updated to 31 March

2018 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19,

relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme is contained in the report of the scheme actuary, which forms part of the annual NHS

Pension Scheme Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be

obtained from The Stationery Office.

4.5.2 Full actuarial (funding) valuation

The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account recent

demographic experience), and to recommend contribution rates payable by employees and employers.

The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2012. The

Scheme Regulations allow for the level of contribution rates to be changed by the Secretary of State for Health, with the consent of HM

Treasury, and consideration of the advice of the Scheme Actuary and employee and employer representatives as deemed appropriate.

The next actuarial valuation is to be carried out as at 31 March 2016 and is currently being prepared. The direction assumptions are

published by HM Treasury which are used to complete the valuation calculations, from which the final valuation report can be signed off by

the scheme actuary. This will set the employer contribution rate payable from April 2019 and will consider the cost of the Scheme relative

to the employer cost cap. There are provisions in the Public Service Pension Act 2013 to adjust member benefits or contribution rates if

the cost of the Scheme changes by more than 2% of pay. Subject to this ‘employer cost cap’ assessment, any required revisions to

member benefits or contribution rates will be determined by the Secretary of State for Health after consultation with the relevant

stakeholders.

For 2017-18, employers’ contributions of £428,835 were payable to the NHS Pensions Scheme (2016-17: £385,300) were payable to the

NHS Pension Scheme at the rate of 14.3% of pensionable pay. The scheme’s actuary reviews employer contributions, usually every four

years and now based on HMT Valuation Directions, following a full scheme valuation. The latest review used data from 31 March 2012

and was published on the Government website on 9 June 2012. These costs are included in the NHS pension line of note 4.1.1. 

117

NHS GREENWICH CCG - Annual Accounts 2017-18

5. Operating expenses

2017-18 2017-18 2017-18 2016-17

Total Admin Programme Total

£'000 £'000 £'000 £'000

Gross employee benefits

Employee benefits excluding governing body members 4,466 2,535 1,931 6,092

Executive governing body members 574 574 0 699

Total gross employee benefits 5,040 3,109 1,931 6,792

Other costs

Services from other CCGs and NHS England 2,623 1,636 987 3,740

Services from foundation trusts 121,536 0 121,536 128,241

Services from other NHS trusts 150,376 0 150,376 151,215

Services from other WGA bodies 0 0 0 143

Purchase of healthcare from non-NHS bodies 68,607 0 68,607 53,469

Chair and Non Executive Members 385 385 0 477

Supplies and services – clinical 1,253 0 1,253 1,285

Supplies and services – general 807 10 797 4,782

Consultancy services 957 271 686 1,675

Establishment 1,043 385 658 684

Transport 3 3 0 7

Premises 709 247 462 1,041

Depreciation 361 0 361 122

Audit fees 52 52 0 71

Other non statutory audit expenditure

·          Internal audit services 28 28 0 44

Prescribing costs 31,623 0 31,623 31,934

GPMS/APMS and PCTMS 36,941 0 36,941 0

Other professional fees excl. audit 311 0 311 381

Legal fees 70 62 8 0

Education and training 0 0 0 171

CHC Risk Pool contributions 0 0 0 652

Other expenditure 149 0 149 102

Total other costs 417,834 3,079 414,755 380,236

Total operating expenses 422,874 6,188 416,685 387,027

In 2017/18, Greenwich CCG adopted payment responsibility for Primary Care as part of the Delegated Commissioning Arrangements, this is reflected in the movement in

GPMS/ APMS and PCTMS.

Audit fees relates to statutory audit services, excluding VAT this is £43k, the amount shown £52k is inclusive of VAT (2016-17: £71k). There were no non-audit fees paid to the

external auditors in 2017-18 (2016-17: Nil). The CCG's contract with its auditor provides for a limitation of £2m of the auditor's liability.

118

NHS GREENWICH CCG - Annual Accounts 2017-18

6.1 Better Payment Practice Code

Measure of compliance 2017-18 2017-18 2016-17 2016-17

Number £'000 Number £'000

Non-NHS Payables

Total Non-NHS Trade invoices paid in the Year 8,413 120,971 6,603 56,849

Total Non-NHS Trade Invoices paid within target 8,312 119,749 6,524 56,346 Percentage of Non-NHS Trade invoices paid within target 98.80% 98.99% 6,524 56,346

NHS Payables

Total NHS Trade Invoices Paid in the Year 3,515 305,989 3,273 280,528

Total NHS Trade Invoices Paid within target 3,444 305,285 3,219 279,790 Percentage of NHS Trade Invoices paid within target 97.98% 99.77% 98.35% 99.74%

6.2 The Late Payment of Commercial Debts (Interest) Act 1998 2017-18 2016-17

£'000 £'000

Amounts included in finance costs from claims made under this legislation 0 0

Compensation paid to cover debt recovery costs under this legislation 0 0Total 0 0

7 Income Generation Activities

There were no income generation activities whose full cost exceeded £1m, or was otherwise material.

8. Investment revenue

There was no investment revenue received by NHS Greenwich CCG in the year.

9. Other gains and losses

There was no other gains and losses recognised by NHS Greenwich CCG in the year.

10. Finance costs

There was no finance costs incurred by NHS Greenwich CCG in the year.

11. Operating Leases

11.1 As lessee

NHS Greenwich CCG paid £160k as rent for the Woolwich Centre for a 10 year lease which expires in 2025.

NHS Greenwich paid £15k for Photocopier rental for leases that expire in 2023.

11.1.1 Payments recognised as an Expense 2017-18 2016-17

Land Buildings Other Total Land Buildings Other Total

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Payments recognised as an expense

Minimum lease payments 0 160 15 175 0 31 18 49

Contingent rents 0 0 0 0 0 0 0 0

Sub-lease payments 0 0 0 0 0 0 0 0

Total 0 160 15 175 0 31 18 49

11.1.2 Future minimum lease payments 2017-18 2016-17

Land Buildings Other Total Land Buildings Other Total

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Payable:

No later than one year 0 134 15 149 0 133 3 136

Between one and five years 0 535 60 595 0 532 6 538

After five years 0 345 0 345 0 266 - 266

Total 0 1,014 75 1,089 0 931 9 940

119

NHS GREENWICH CCG - Annual Accounts 2017-18

12 Property, plant and equipment

2017-18 Land

Buildings

excluding

dwellings Dwellings

Assets under

construction

and payments

on account

Plant &

machinery

Transport

equipment

Information

technology

Furniture &

fittings Total

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Cost or valuation at 01 April 2017 0 1,008 0 0 13 0 488 591 2,100

Addition of assets under construction and payments on account 0 0

Additions purchased 0 0 0 0 0 0 21 0 21

Cost/Valuation at 31 March 2018 0 1,008 0 0 13 0 509 591 2,121

Depreciation 01 April 2017 0 71 0 0 11 0 179 237 498

Charged during the year 0 40 0 0 2 0 148 170 361

Depreciation at 31 March 2018 0 111 0 0 13 0 328 407 859

Net Book Value at 31 March 2018 0 897 0 0 0 0 181 184 1,262

Purchased 0 897 0 0 0 0 181 184 1,262

Total at 31 March 2018 0 897 0 0 0 0 181 184 1,262

Asset financing:

Owned 0 897 0 0 0 0 181 184 1,262

Total at 31 March 2018 0 897 0 0 0 0 181 184 1,262

Revaluation Reserve Balance for Property, Plant & Equipment

Land Buildings Dwellings

Assets under

construction &

payments on

account

Plant &

machinery

Transport

equipment

Information

technology

Furniture &

fittings Total

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Balance at 01 April 2017 0 0 0 0 0 0 0 0 0

Revaluation gains 0 0 0 0 0 0 0 0 0

Impairments 0 0 0 0 0 0 0 0 0

Release to general fund 0 0 0 0 0 0 0 0 0

Other movements 0 0 0 0 0 0 0 0 0Balance at 31 March 2018 0 0 0 0 0 0 0 0 0

120

NHS GREENWICH CCG - Annual Accounts 2017-18

12 Property, plant and equipment cont'd

12.1 Additions to assets under construction

There were no additions to assets under construction in the year.

12.2 Compensation from third parties

12.3 Write downs to recoverable amount

12.4 Cost or valuation of fully depreciated assets

The cost or valuation of fully depreciated assets still in use was as follows:

2017-18 2016-17

£'000 £'000

Information technology 77 77

Total 77 77

12.5 Economic lives

Buildings excluding dwellings 25 25

Dwellings 0 0

Plant & machinery 3 3

Transport equipment 0 0

Information technology 0 5

Furniture & fittings 3 3

13 Intangible non-current assets

The CCG holds no intangible non-current assets.

There was no compensation from third parties in respect of assets imparied, lost or given up in the year.

There were no write-downs to recoverable amounts in the year.

Minimum

Life (years)

Maximum

Life (Years)

121

NHS GREENWICH CCG - Annual Accounts 2017-18

14 Investment property

The CCG has no investment property.

15 Trade and other receivables Current Non-current Current Non-current

2017-18 2017-18 2016-17 2016-17

£'000 £'000 £'000 £'000

NHS receivables: Revenue 2,670 0 3,261 0

NHS prepayments 3,301 0 2,003 0

NHS accrued income 2,901 0 1,912 0

Non-NHS and Other WGA receivables: Revenue 2,224 0 4,052 0

Non-NHS and Other WGA prepayments 3,786 0 0 0

Non-NHS and Other WGA accrued income 234 0 236 0

VAT 2 0 33 0

Total Trade & other receivables 15,118 0 11,497 0

Total current and non current 15,118 11,497

Included above:

Prepaid pensions contributions 0 0

15.1 Receivables past their due date but not impaired 2017-18 2017-18 2016-17

£'000 £'000 £'000

DH Group

Bodies

Non DH

Group

Bodies

All receivables

prior years

By up to three months 1,333 109 1,333

By three to six months 426 27 207

By more than six months 314 2,072 856 Total 2,073 2,208 2,396

£ 68,624 of the amount above has subsequently been recovered post the statement of financial position date.

122

NHS GREENWICH CCG - Annual Accounts 2017-18

16 Cash and cash equivalents

2017-18 2016-17

£'000 £'000

Balance at 01 April 2017 286 119

Net change in year (145) 168

Balance at 31 March 2018 141 287

Made up of:

Cash with the Government Banking Service 141 287

Cash and cash equivalents as in statement of financial position 141 287

Bank overdraft: Government Banking Service 0 0

Total bank overdrafts 0 0

Balance at 31 March 2018 141 287

Patients’ money held by the clinical commissioning group, not included above 0 0

123

NHS GREENWICH CCG - Annual Accounts 2017-18

Current Non-current Current Non-current

2017-18 2017-18 2016-17 2016-17

£'000 £'000 £'000 £'000

NHS payables: revenue 6,824 0 7,515 0

NHS accruals 4,906 0 10,237 0

NHS deferred income 124 0 0 0

Non-NHS and Other WGA payables: Revenue 10,619 0 10,183 0

Non-NHS and Other WGA payables: Capital 21 0 0 0

Non-NHS and Other WGA accruals 14,307 0 16,807 0

Non-NHS and Other WGA deferred income 1,982 0 0 0

Social security costs 60 0 47 0

VAT 0 0 0 0

Tax 59 0 45 0

Other payables and accruals 6,519 0 2,205 0

Total Trade & Other Payables 45,421 0 47,039 0

Total current and non-current 45,421 47,039

18 Provisions

The CCG has no provisions.

19 Contingencies

The CCG has no contingent liabilities.

124

17 Trade and other payables

NHS GREENWICH CCG - Annual Accounts 2017-18

20 Commitments

20.1 Capital commitments

2017-18 2016-17

£'000 £'000

Property, plant and equipment 21 0

Intangible assets 0 0

Total 21 0

20.2 Other financial commitments

2017-18 2016-17

£'000 £'000

In not more than one year 0 0

In more than one year but not more than five years 0 0

In more than five years 0 0

Total 0 0

21 Financial instruments

21.1 Financial risk management

21.1.1 Currency risk

21.1.2 Interest rate risk

21.1.3 Credit risk

21.1.3 Liquidity risk

The NHS clinical commissioning group has entered into non-cancellable contracts (which are not leases, private finance initiative contracts

or other service concession arrangements) which expire as follows:

The clinical commissioning group borrows from government for capital expenditure, subject to affordability as confirmed by NHS England.

The borrowings are for 1 to 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate,

fixed for the life of the loan. The clinical commissioning group therefore has low exposure to interest rate fluctuations.

Because the majority of the NHS clinical commissioning group and revenue comes parliamentary funding, NHS clinical commissioning group

has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed

in the trade and other receivables note.

125

Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or

changing the risks a body faces in undertaking its activities.

Because NHS clinical commissioning group is financed through parliamentary funding, it is not exposed to the degree of financial risk faced

by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed

companies, to which the financial reporting standards mainly apply. The clinical commissioning group has limited powers to borrow or invest

surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks

facing the clinical commissioning group in undertaking its activities.

Treasury management operations are carried out by the finance department, within parameters defined formally within the NHS clinical

commissioning group standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by the

NHS clinical commissioning group and internal auditors.

The NHS clinical commissioning group is principally a domestic organisation with the great majority of transactions, assets and liabilities

being in the UK and sterling based. The NHS clinical commissioning group has no overseas operations. The NHS clinical commissioning

group and therefore has low exposure to currency rate fluctuations.

NHS clinical commissioning group is required to operate within revenue and capital resource limits, which are financed from resources voted

annually by Parliament. The NHS clinical commissioning group draws down cash to cover expenditure, as the need arises. The NHS clinical

commissioning group is not, therefore, exposed to significant liquidity risks.

NHS GREENWICH CCG - Annual Accounts 2017-18

21 Financial instruments cont'd

21.2 Financial assets

At ‘fair value

through profit and

loss’

Loans and

Receivables

Available for

Sale Total

2017-18 2017-18 2017-18 2017-18

£'000 £'000 £'000 £'000

Embedded derivatives 0 0 0 0

Receivables:

·          NHS 0 5,570 0 5,570

·          Non-NHS 0 2,459 0 2,459

Cash at bank and in hand 0 141 0 141

Other financial assets 0 0 0 0

Total at 31 March 2018 0 8,171 0 8,171

At ‘fair value

through profit and

loss’

Loans and

Receivables

Available for

Sale Total

2016-17 2016-17 2016-17 2016-17

£'000 £'000 £'000 £'000

Embedded derivatives 0 0 0 0

Receivables:

·          NHS 0 5,173 0 5,173

·          Non-NHS 0 4,288 0 4,288

Cash at bank and in hand 0 286 0 286

Other financial assets 0 0 0 0

Total at 31 March 2018 0 9,747 0 9,747

21.3 Financial liabilities

At ‘fair value

through profit and

loss’ Other Total

2017-18 2017-18 2017-18

£'000 £'000 £'000

Embedded derivatives 0 0 0

Payables:

·          NHS 0 11,730 11,730

·          Non-NHS 0 31,465 31,465

Total at 31 March 2018 0 43,195 43,195

At ‘fair value

through profit and

loss’ Other Total

2016-17 2016-17 2016-17

£'000 £'000 £'000

Embedded derivatives 0 0 0

Payables:

·          NHS 0 13,098 13,098

·          Non-NHS 0 16,027 16,027

Total at 31 March 2018 0 29,125 29,124

22 Operating segments

The Clinical Commissioning Group considers that it has one segment, Commissioning of Healthcare Services.

126

NHS GREENWICH CCG - Annual Accounts 2017-18

23 Pooled budgets

2017-18 2016-17

£'000 £'000

Income 18,741 18,411

Expenditure 16,446 16,153

The tabulation below identifies the budget and expenditure by both parties for 2017/18.

2017-18 2016-17

Budget £'000 £'000

Royal Borough of Greenwich 10,932 12,430

Greenwich CCG 7,809 5,981

Total Budget 18,741 18,411

Expenditure

Royal Borough of Greenwich 10,932 11,953

Greenwich CCG 5,514 4,200

Total Expenditure 16,446 16,153

Budget Less Expenditure 2,295 2,258

Debtors

Greenwich CCG 5,466 4,858

5,466 4,858

Creditors

Royal Borough of Greenwich 5,466 4,858

5,466 4,858

24 NHS Lift investments

The CCG has no NHS Lift Investments.

127

The NHS clinical commissioning group shares of the income and expenditure handled by the pooled budget in the financial

year were:

Under Section 75 of the NHS Act 2006 (as amended), the Secretary of State can make provision for local authorities and

National Health Service (NHS) bodies to enter into partnership arrangements in relation to certain functions, where these

arrangements are likely to lead to an improvement in the way in which those functions are exercised.

These arrangements are known as pooled budgets where the CCG funds Local Authority expenditure. Hence, the CCG

records the total funding and expenditure by both parties in its accounts. This note reflects the CCG funded element of the

Better Care Fund, and excludes the iBCF and Disabilities Facilities Grant which are reported and accounted for by the Royal

Borough of Greenwich.

NHS GREENWICH CCG - Annual Accounts 2017-18

25 Related party transactions

Payments to

Related Party

Receipts from

Related Party

Amounts owed to

Related Party

Amounts due from

Related Party

£'000 £'000 £'000 £'000

Vanburgh Group Practice PMS - Dr Ellen Wright & Dr Jasiun Vivekanadaraja 1,789 0 211 0

Conway PMS - Dr Ranil Perera 483 0 29 0

Blackheath Standard Surgery PMS - Dr Nayan Patel 874 0 6 0

Sherard Road Medical Centre - Dr Krishna Subbarayan 1,523 0 16 0

Burnley Street PMS - Dr Sylvia Nyame 1,598 0 19 0

Gallions Reach Health Centre - Dr Sabah Salman 1,823 0 0 (1)

River View Limited Liability Partnership (LLP) - Dr Hany Wahba 13 (9) 0 0

St. Marks Health Centre - Dr Hany Wahba 1,205 0 0 0

Greenwich Action for Voluntary Services - Greg Usher 20 0 0 0

The GPs individually named as above are clinical commissioners on the Governing Body.

The payments above are not made to the individuals themselves but to their General Practice for clinical services commissioned by the CCG. These payments to the GP Practices exclude funding for prescribing.

Payments to

Related Party

Receipts from

Related Party

Amounts owed to

Related Party

Amounts due from

Related Party

£'000 £'000 £'000 £'000

London LMC - Dr Tuan Tran (LMC Greenwich) 195 0 0 0

Valentine Health Centre - Dr Tuan Tran 3,016 0 0 0

Eltham Park Surgery - Dr John Livingstone 663 0 0 0

The GPs individually named as above served as a clinical representative on one of the CCG's committees during 2017-18

The payments above are not made to the individuals themselves but to their General Practice for clinical services commissioned by the CCG. These payments to the GP Practices exclude funding for prescribing.

The Department of Health is regarded as a related party. During the year the clinical commissioning group has had a significant number of material transactions with entities for which the Department is regarded as the parent Department. For example

• NHS England;

• NHS Foundation Trusts;

• NHS Litigation Authority; and,

• NHS Business Services Authority.

The NHS organisations listed below are those where transactions over the year 2016-17 and/or 2017-18 have exceeded £500k:

Barts Health NHS Trust NHS North East London Commissioning Support Unit

Chelsea and Westminster Hospital NHS Foundation Trust NHS Southwark CCG

Dartford and Gravesham NHS Trust Oxleas NHS Foundation Trust

Guys St Thmas NHS Foundation Trust South London And Maudsley NHS Foundation Trust

Kings College Hospital NHS Foundation Trust University College London NHS Foundation Trust

Lewisham And Greenwich NHS Trust NHS Bexley CCG

Lewisham Hospital NHS Trust NHS Bromley CCG

London Ambulance NHS Trust NHS Lewisham CCG

Moorfields Eye Hospital NHS Foundation Trust NHS Property Services

In addition, the clinical commissioning group has had a number of material transactions with other government departments and other central and local government bodies. Transactions with other Government Departments over the year 2017/18 which have exceeded £500k:

Royal Borough of Greenwich

128

Details of related party transactions with individuals are as follows:

A financial Risk-Share agreement is in place across the six CCGs in south east London. It was agreed through the governance of each CCG that the Risk-Share agreement be enacted in 2017/18. The final revenue resource limit values included in the 2017/18 annual

accounts of each CCG reflect the outcome of the Risk-Share agreement.

NHS GREENWICH CCG - Annual Accounts 2017-18

26 Events after the end of the reporting period

27 Third party assets

The CCG has no third party assets.

28 Financial performance targets

NHS Clinical Commissioning Group have a number of financial duties under the NHS Act 2006 (as amended).

NHS Clinical Commissioning Group performance against those duties was as follows:

2017-18 2017-18 2016-17 2016-17

Target Performance Target Performance

£'000s £'000s £000's £000's

Expenditure not to exceed income 423,608 422,895 386,457 387,027

Capital resource use does not exceed the amount specified in Directions 0 0 0 0Revenue resource use does not exceed the amount specified in Directions 416,299 415,586 376,048 376,618

Capital resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 0

Revenue resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 0

Revenue administration resource use does not exceed the amount specified in Directions 6,093 6,092 6,067 6,033

Greenwich CCG was underspent against its Revenue resource limit by £713k in 2017/18.

29 Impact of IFRS

The DHSC Group accounting manual does not require the following Standards and Interpretations to be applied in 2017-

18. These standards are still subject to FREM adoption and early adoption is not therefore permitted.

·                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)

·                IFRS 17: Insurance Contracts (application from 1 January 2021)

·             IFRIC 22: Foreign Currency Transactions and Advance Consideration (application from 1 January 2018)

·             IFRIC 23: Uncertainty over Income Tax Treatments (application from 1 January 2019)

The application of the Standards as revised would not have a material impact on the accounts for 2017-18, were they

applied in that year.

30 Analysis of charitable reserves

129

NHS Greenwich CCG is the Corporate Trustee to NHS Greenwich Charitable Funds. The Governing Body does not consider the activities of the NHS Greenwich Charitable

Funds to be material to NHS Greenwich CCG. The charitable funds represent approximately 0.9% (2017 – 1.0%) of the revenue resource outturn position of NHS Greenwich

CCG. Accordingly, the Governing Body has decided not to consolidate the NHS Greenwich Charitable Funds accounts with that of the CCG.

As a result of amended calculation methodology from NHS England, the 2017/18 in year revenue allocation has been calculated on the basis of the total allocation, adjusted for the historic outturn

of the CCG. In 2016/17 the figure was recorded as just the total in year allocation notified to the CCG.

With effect from 1st April 2018, the management structure across the south east London CCGs has moved to there being one Accountable Officer and one Chief Financial Officer across Bexley, Bromley,

Greenwich, Lewisham and Southwark CCGs. There is a Director of Finance managing Lewisham and Greenwich CCGs and one Director of Finance managing Bexley, Bromley and Southwark CCGs. There is

also a Strategic Finance Director who is responsible for reporting at an STP level for both commissioners and providers. A separate Accountable Officer is responsible for Lambeth and Croydon CCGs (as is

currently the case) and Lambeth CCG have a separate Chief Financial Officer. There has been a phased transition to this structure and there is not expected to be any impact from these changes for the

organisations in question