annual report and accounts 2018/19 · to our new emerging community partnership approach....

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Annual Report and Accounts 2018/19

Annual report and accounts 2018/19 NHS Airedale, Wharfedale and Craven Clinical Commis sioning Group

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Annual report and accounts 2018/19

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To find out more about us:

Visit our website: www.airedalewharfedaleandcravenccg.nhs.uk Follow us on Twitter: @NHSBfdCraven Find our Facebook page: NHSBradfordCraven

Contact us: NHS Airedale, Wharfedale and Craven CCG Millennium Business Park Station Road, Steeton Keighley BD20 6RB Tel: 01274 237324

Within this annual report, many of the initiatives that you will read about will relate to the three Bradford district and Craven CC Gs. We work closely, and share a staff team, with Bradford City CCG and Brad ford Districts CCG and, where these are referenced within this document, we will refer to them as ‘he three Bradford district and Craven CCGs’.

If you would like this report in another format – for example – large print or as a summary version, please contact the communications team by email at [email protected] or by telephoning 01274 237546.



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Contents

Page

Foreword: Dr James Thomas, clinical chair 4

Chapter 1: Performance report 7

1 Performance overview 1.1 Our performance in 2018/19 a statement from the chief officer 7 1.2 About us 9 1.3 Our vision and principles 10 1.4 Our population 10 1.5 How we’re governed 10 1.6 Our main providers of service 11 1.7 The system in which we work 11 1.8 Sustainability and transformation: our plans and priorities 13 1.9 Key issues and risks 17 1.10 Our commitment to equality and diversity 21 1.11 Financial performance overview 21 1.12 Engaging people and communities 22 1.13 Highlights of the year 23

2 Performance analysis 2.1 Progress on priority areas 25 2.2 Sustainable development 34 2.3 Improve quality 40 2.4 Engaging people and communities 54 2.5 Reducing health inequalities 58 2.6 Health and wellbeing strategy 62 2.7 Financial performance 62

Chapter 2: Accountability report 67

1 Corporate governance report 1.1 Members’ report 67 1.2 Statement of accountable officer’s responsibilities 77 1.3 Governance statement 79

2 Remuneration and staff report 2.1 Remuneration report 120 2.2 Staff report 125

3 Parliamentary accountability and audit report

Chapter 3: Annual accounts

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Foreword – Dr James Thomas Welcome to the annual report for Airedale, Wharfedale and Craven Clinical Commissioning Group for 2018/19. Throughout 2018/19, the NHS has continued to face rising demand from a growing and older population and the most challenging financial climate in decades. Across Airedale, Wharfedale and Craven we also have a growing number of older people living in the area who increasingly have complex needs and long term conditions that need to be managed.

Over the last twelve months, we have been working even more closely with health and social care colleagues to develop the quality of our services and improve safety while also meeting the challenge of increased demand for health services. We play a key role in ensuring that services that are available to local people are safe and we gain assurance from our service providers in a number of ways which are detailed later in this report. Providing services that help people across the district live a healthier, happier and longer life is at the centre of our efforts. We are working to prevent unhealthy lifestyle choices that may affect their health in later life. At the same time, we are improving the way we support people with long term health conditions and help them manage their health needs better. This can only be achieved if we make sure we continue to listen to people who live across Airedale, Wharfedale and Craven and those who use our health services. Our successes are down to the hard work and efforts of our GPs, nurses and other staff as well as the work of our partners across the NHS, local authority and community sector. Tackling the wider determinants of health and reducing health inequalities is integral to our new emerging community partnership approach. Engagement in the community partnerships has gone from strength to strength with an equal partnership approach involving a range of stakeholders including local councillors. Informed by outcomes of asset based community development each community partnership has progressed priority areas: an inclusion project in Airedale (homeless; asylum seekers; refugees; street drinkers); mental health in schools (CYP) in Wharfedale; and loneliness and isolation in Craven. Antibiotic consumption in England is on the rise and increased antibiotic prescribing is fuelling increased resistance in bacteria. The CCG has been working hard to reduce its use of antibiotics in primary care. We have developed and updated local prescribing guidelines and regularly assist our local practices with audits of antibiotic use, to check that prescribing is in line with national and local recommendations. As a result the CCGs use of antibiotics is lower than the national average.



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Delivery of the four hour A&E standard is an ongoing issue across both acute providers as they struggle to manage increased demand and sicker patients in general. We are working with partners as part of the Bradford district and Craven urgent care and planned care programmes to manage demand and improve access to services and have seen recent improvements in performance. In partnership with social care we have multi-disciplinary teams in place to facilitate quick and effective discharges from hospital and minimise delayed transfers of care. As a result we continue to have one of the lowest rates of delayed transfers nationally and continue to minimise the use of hospital beds following emergency admission. Our frail elderly pathway (FEP) team are an award winning, specialist multidisciplinary team comprising of a number of professions working collaboratively in order to provide the best care possible for our patients. The FEP team support discharge planning for patients and help prevent unnecessary admissions and readmissions to hospital, as well as quick, safe and well considered discharges. Our new primary care extended access service is available to 100% of the CCG population and operates through two models, a large partnership (Modality) and an alliance of practices (WACA). Appointments are available Monday to Friday between 6:30pm and 8:00pm and morning appointments on weekends between 9:00am and 11:00am to see a doctor or an advanced nurse practitioner. We are committed to preventing the rise of diabetes in our communities and delaying its onset. Those diagnosed with type 2 diabetes are offered structured education, which we have adapted in 2018/19, to create several new options for patients. This has resulted in a marked increase in the numbers attending the courses on offer. We are also supporting patients to improve the management of blood pressure, glucose levels and cholesterol for people with diabetes to reduce the risk of patients developing complications. A diabetes steering group involving a range of stakeholders has been pivotal in leading work intended to reduce the incidence of diabetes and to improve diabetes care and outcomes for individuals We are part of wave 2 of the national diabetes prevention programme (NDPP) to identify those at risk of developing diabetes. Lifestyle advice over a number of weeks is offered to those identified by general practice as being at risk of developing diabetes and who have self-referred following information provided by their local GP. A number of practices are already implementing this and a further roll out is planned. We are also working together more on a regional level within the West Yorkshire and Harrogate Health and Care Partnership including work to further improve mental health services, maternity services, stroke care, urgent and emergency care as well as improving people’s general wellbeing.



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I would like to thank our CCG staff and board members, our clinical leads, clinical executives and the rest of our membership for their contributions to everything that we have achieved this year. I’d also similarly like to thank our system partners and providers, the councils, the voluntary sector, and the NHS, both in Airedale, Wharfedale and Craven and across the wider West Yorkshire and Harrogate system. The NHS is all about our people, both our staff and our public and it is only through working in partnership together that we are best able to make the improvements in the care and health outcomes that our staff aspire to and that our public deserve. Dr James Thomas Clinical chair NHS Airedale, Wharfedale and Craven CCG

NHS Airedale, Wharfedale and Craven CCG Annual report and accounts 2018/19

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Chapter 1: Performance report

1 Performance overview

The purpose of this section is to provide a short summary on NHS Airedale, Wharfedale and Craven Clinical Commissioning Group’s (CCG) activities in 2018/19. You will find details of our main priorities, performance against these and the principal risks that we face. Further information about the CCG can be found in later sections of the report (page 25 onwards). 1.1 Our performance in 2018/19: a statement from the accountable officer

This year we have seen a real step change in how we work together across the system of health, care and support. We have formalised our partnerships through our strategic partnering agreement and are putting our words into action through the way we do business as a system. We have seen huge progress in the development of the thirteen community partnerships across the district, the engagement of the voluntary and community sector as strategic partners in those arrangements and the collaboration of our two secondary care trusts in a formal alliance which should ensure the ongoing sustainability of acute, hospital based services for the district.

As we enter our seventh year as a CCG it becomes harder to identify – as belonging to one organisation – the achievements (as well as the areas for improvement). As three CCGs we now work as one in all significant strategic areas and during 2018/19 have continued to develop our single operating model. We have shared the experiences and learning from each other in areas such as health and care partnerships, expansion of the People’s Board and in our approach to QIPP (quality, innovation, productivity and prevention). We also increasingly work as one with our providers utilising our strategic commissioning capability through partnerships and the collaborative approaches we are taking to solving our system problems. Our partnerships across West Yorkshire and Harrogate are also developing and we are increasingly maximising the opportunities through the integrated care system (ICS) to achieve better outcomes for the people of Bradford district and Craven. One example of this is the work, as part of the ICS, to reduce variation in planned care by agreeing policies and pathways across the system to help reduce health inequalities.


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Our next step as CCGs is to consider whether to formalise our ‘working as one’ clinical commissioning model and create a single, new CCG for Bradford district and Craven. This should in turn lead to a broader discussion with our commissioning partners to make further progress on how we integrate our commissioning activity across the system; an area where there is still further work to do. The CCGs continue to be reviewed under the national improvement and assessment framework (IAF) and it was fantastic to start 2018/19 with an outstanding assessment for Airedale, Wharfedale and Craven (AWC). The financial position in the AWC system means that holding onto this level of attainment is particularly challenging in 2019. Bradford district and Craven system has struggled to meet the key national performance indicators for the NHS in areas such as improving access to psychological therapies (IAPT), cancer, referral to treatment times (RTT) and emergency care standard (ECS). However Airedale NHS Foundation Trust did achieve an average of over 90% in the ECS which was comparatively good with others regionally and nationally. 62 day cancer targets saw an improvement in the year as did two week waits for breast cancer. Overall the IAF rating for cancer in this CCG was good. IAPT waiting times and recovery rates are better than average. In areas such as extended primary medical care, dementia diagnosis, personal health budgets, health checks for people with learning disabilities and antibiotic prescribing, all three CCGs have performed well. Learning from the CQC system review for older people brought a focus on the quality of the care home sector and, together with Bradford Council and the sector themselves, we have prioritised improvement work in this area which has had immediate impact. Looking forward for Airedale, Wharfedale and Craven, 2019/20 is going to be a challenging year financially and maintaining service developments and improvements while reducing overall spend as a system will not be easy. As a CCG we have agreed a deficit plan this year and through our health and care partnership will develop a system recovery plan that enables the whole system to move back to financial balance. On a more optimistic note, the people we serve are living longer, happier and healthier lives and are at the heart of making the places they live better. AWC has a great track record of working with its communities to good effect and whatever we do we must maintain the focus on this work, utilising our collective resources to best effect. Continuing to develop the three community partnerships to deliver the strategy for the AWC partnership will be key. Helen Hirst Chief officer NHS Airedale, Wharfedale and Craven CCG


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1.2 About us NHS Airedale, Wharfedale and Craven Clinical Commissioning Group (CCG) is the NHS organisation responsible for planning and buying (commissioning) healthcare services for over 150,000 people registered with our 16 member practices, as well as for those unregistered patients living within, or visiting, our area. We are a clinically led organisation. GPs and other clinicians are at the forefront of how we operate, the decisions we make and the interaction we have with the public. We are responsible for commissioning most hospital and healthcare services in the local area and we are regulated by NHS England (NHSE). NHSE is responsible for commissioning primary care dental, optical and pharmaceutical services, as well as some specialised hospital services for people in Airedale, Wharfedale and Craven. The CCG has delegated authority from NHSE for commissioning GP services Through clinical commissioning, doctors have the power and freedom to make decisions about the care and services they commission for their local communities, within the context of the joint strategic needs assessment (JSNA), our own plans and priorities and the valuable feedback we receive from patients themselves. Although this list is not exhaustive, some of services we commission include: • urgent and emergency care including accident and emergency (A&E),

ambulance and out-of-hours services • community health services and equipment • planned and unplanned hospital care • therapy services • maternity services • rehabilitation services • healthcare services for children, people with mental health problems and

people with learning disabilities • continuing healthcare • palliative and end of life care • termination of pregnancy services • infertility services • wheelchair services • home oxygen services • treatment of infectious diseases. There are some treatments, available on the NHS, which we do not commission. These include cosmetic procedures, various fertility treatments, and treatments not approved by the National Institute for Health and Care Excellence (NICE). Patients who wish to have treatment that is not routinely funded can ask their GP to make an individual funding request (IFR) on their behalf.


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The CCG is part of the Bradford district and Craven health and care system and, collectively, we have a shared ambition of keeping people ‘Happy, healthy at home’.

Our ambition is to transform patients’ experiences of healthcare services; significantly improve their outcomes; and to use our member practices’ creativity, talent, expertise and ability to innovate local services to help people live longer, healthier lives. 1.3 Our vision and principles Our vision is to deliver proactive, coordinated, person-centred care with our health and care partners across our communities. Our principles are that: • no one should be in hospital unless their care cannot be delivered safely in the

community 24 hours-a-day, seven days-a-week • no one should be discharged to long-term care without the opportunity for a

period of enablement • our local population should have access to and delivery of coordinated care, 24

hours-a-day, seven days-a-week, which is needs driven and not about age, condition or location.

1.4 Our population We look after the health needs of more than 150,000 people, registered with family doctors in the Airedale, Wharfedale and Craven areas. Our areas cover two local authority boundaries, with approximately two thirds of the population living in the City of Bradford Metropolitan District Council area and the remainder in the North Yorkshire County Council area. 1.5 How we are governed The council of members (CoM) holds the governing body and clinical executive to account and is the voice of our member practices. It ensures effective engagement of all of our practices and represents their interests and statutory responsibilities as members of the CCG. Each practice is represented on the CoM by a GP and a practice manager and the council normally meets six times a year. Because we work closely with Bradford City and Bradford Districts CCGs – and therefore often have initiatives and issues in common – a number of our committees meet together on a regular basis, as committees in common. Our governing body meets bi-monthly in public as a committee in common with Bradford City and Bradford Districts CCGs. It provides oversight and assurance of the commissioning of health and care services for people in our area. Everyone is welcome to attend and observe governing body meetings; we publish the agenda and papers on our website in advance of the meetings.


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Our clinical executive meets twice monthly. Representatives of the clinical executive (the chair, another GP and our executive directors) also meet as part of the joint clinical committee , which discusses matters that we hold in common with Bradford City and Bradford Districts CCGs. The role of the clinical executive is to drive the commissioning process and lead the development and implementation of our vision and strategy. It reviews and influences service re-design to ensure pathways of care and commissioned services meet the needs of the local population. It engages practices, localities and the population in the work of the CCG. Following delegation of responsibilities for the commissioning of primary care from NHS England, which took effect from 1 April 2017, the primary care commissioning committee makes decisions on the review, planning and procurement of primary care services under delegated responsibility from NHS England. It meets every two months in public and we publish the agenda and papers on our website in advance of the meetings. Since June 2018 it has met as a committee in common with Bradford City and Bradford Districts CCGs. • Details of the membership of these committees are on our website or on page 79

onwards of this annual report. 1.6 Our main providers of services We buy (commission) services for patients predominantly from Airedale NHS Foundation Trust (ANHSFT), Bradford Teaching Hospitals NHS Foundation Trust (BTHFT), and Bradford District Care NHS Foundation Trust (BDCFT), which cares for people with community health, mental health and social care needs. Specialist services are provided by Leeds Teaching Hospitals NHS Trust. We also work with the City of Bradford Metropolitan District Council (Bradford Council), North Yorkshire County Council and Craven District Council to engage with local people to improve the health of the district. We work alongside the councils in their role as both commissioners, and providers of social care and public health. We buy services from a number of voluntary and community organisations. They provide locally focussed projects aimed at improving people’s health and wellbeing, for example, by promoting health awareness and healthy living messages. There are some services we jointly commission with other CCGs, for example: Yorkshire Ambulance Service, NHS 111 and the West Yorkshire GP out-of-hours service. We also buy a range of business expertise from eMBED to support us with our corporate functions. Altogether we have 61 contracts for services. A register of our contracts is available on our website. 1.7 The system in which we work Collaboration with the two Bradford CCGs: Although each CCG is a statutory organisation in its own right, we work closely with NHS Bradford City CCG and NHS Bradford Districts CCG including sharing some of the same functions and


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responsibilities. For example, we have a shared team of management and staff, committees that meet in common (such as the governing body) and shared committees – such as the joint quality committee (JQC) that monitors the quality of services we buy and patients’ experiences of them, and the joint clinical board that oversees our transformation programmes. On a day-to-day basis, we work together to secure the best possible, integrated and efficient services for people in the Bradford district and Craven. We also work with a number of other organisations and partnerships, including: Health and wellbeing boards (HWB): We actively participate in the two local health and wellbeing boards that cover our area: Bradford and Airedale Health and Wellbeing Board and North Yorkshire Health and Wellbeing Board. As a sub- committee of the council, the HWB brings together key people from the health and care system to work together to improve the health and wellbeing of the local population. The board has some specific responsibilities, such as approval and performance monitoring of the Better Care Fund. Integration and change board (ICB): The integration and change board (ICB) is a group of senior leaders from across health and social care. The board’s membership includes representatives from across the health and social care system, namely the hospital trusts, the BDCFT, the three CCGs, GP federations the voluntary and community sector, independent (care homes and domiciliary care) sector and the council. It is accountable to the Bradford and Airedale HWB, and has a number of system-wide boards reporting to it. These transformation programmes delivered in partnership and specific enabling programmes focusing on future areas which are common to all organisations and services. This includes: developing the right workforce; digital solutions; using our estates more effectively; and shared solutions to address the system-wide financial challenges. The principal role of the board is implementing the vision and direction for delivering the best outcomes for the population as set out in the district’s five-year strategy. By working together it ensures senior leadership share a common purpose across the health and social care system, set the vision and direction and enable the delivery of ‘Happy, healthy at home’ (see page 15). The North Yorkshire commissioners forum : This comprises of senior leaders across CCGs and North Yorkshire County Council. Accountable to the North Yorkshire HWB, the forum focusses on strengthening the integrated commissioning agenda to support the delivery of joint and local plans. As Craven is part of North Yorkshire, we work closely with both the county council and Craven District Council in developing local plans to integrate health and social care. Health and social care overview and scrutiny commit tees (HOSC): We report to two HOSCs (Bradford and North Yorkshire). These statutory committees act as a ‘critical friend’ by reviewing local health issues and considering our proposals to develop or change services. NHS England (NHSE): It commissions primary care optical, pharmaceutical and dental services and some specialised services. It is an independent organisation,


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working on behalf of the Department of Health. NHSE also handles patient complaints about GPs and GP practices. Since April 2017 we have delegated authority from NHSE for commissioning GP services. Services hosted by other CCGs: Our medicines management service is hosted by Harrogate and Rural District CCG and our serious incidents team is hosted by Greater Huddersfield CCG. On behalf of the CCGs in West Yorkshire and Harrogate, Bradford Districts CCG hosts the West Yorkshire research and development team. The team, which helps to transform research questions into research proposals, works closely with clinicians and partners from academia to increase evidence-based innovation and knowledge exchange within clinical care settings. eMBED Health Consortium: eMBED has provided us with a range of business expertise and support to enable us carry out our functions, for example, expertise in business intelligence and information technology. North of England Commissioning Support Unit (NECS): NECS supports us with the provision of data quality services. Bradford District Care NHS Foundation Trust (BDCFT) : The trust supports us with health and safety, learning and development and human resources management, along with providing healthcare services. Healthwatch: As an independent public watchdog, it works with people and organisations to make positive changes in health and social care services. Healthwatch Bradford and District provides services to people living in the Airedale or Wharfedale areas; and Healthwatch North Yorkshire to those living in the Craven area. GP practices: While continuing as independent businesses, a number of our practices are also collaborating with each other. For example, a super practice called the Modality Partnership, which includes seven local practices, and the Wharfedale and Craven Alliance (WACA) which is formed from eight independent GP practices. 1.8 Sustainability and transformation: our plans and pr iorities 1.8.1 West Yorkshire and Harrogate Health and Care Partne rship The West Yorkshire and Harrogate Health and Care Partnership (WY&H HCP) was formed in 2016 as one of 44 national sustainability and transformation partnerships (STPs) created to help drive a genuine and sustainable transformation in health and care. It brings together all health and care organisations in six places - Bradford district and Craven; Calderdale, Harrogate, Kirklees, Leeds and Wakefield - to meet the needs of people as close to home as possible. Our organisation is one of the partners which make up this unique partnership In February 2018, the partnership published ‘Our Next Steps to Better Health and Care for Everyone’. This document describes the progress made since the publication of the initial WY&H HCP plan in November 2016.


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In order to realise the ambitions of the partnership, we need to recruit, train, develop and retain our skilled and caring workforce so that health and social care services are fit for the future – for generations to come. The partnership’s workforce plan ‘A healthy place to live, a great place to work’ describes the challenges the partners face and the work being done together to address them. The NHS long term plan for the NHS gives formal backing to systems like West Yorkshire and Harrogate Health and Care Partnership. It gives a further boost to the priorities that the partnership has been working on locally and the help it needs to deliver reductions in health inequalities and unwarranted care variation (often referred to as the post code lottery). For example, the focus on mental health services, cancer, preventing ill-health, and primary care (GPs, district nurses and occupational therapists) will build on this approach and the progress the partnership has already made. The recognition of workforce challenges is welcome and the partnership is keen to understand how the full workforce plan will further support local efforts to secure a workforce for the future. This is perhaps our biggest single challenge. Alongside the NHS long-term plan the partnership will need additional resources and support for social care and for local government. Without these it cannot deliver its ambitions. WY&H HCP includes nine clinical commissioning groups (which buy and plan healthcare for local people), eight local councils, and services provided by a number of health and social care organisations, including hospitals, mental health care providers, the ambulance service, Healthwatch, and community organisations. These clinical commissioning groups make up the WY&H Joint Committee. They have a shared work plan and meet in public every other month. Our hospitals and mental health providers also work together on a shared work plan to further improve the care people receive. All partner organisations have now formally approved the partnership’s memorandum of understanding. A new partnership board will also bring NHS, councils and communities closer together. The first meeting in public will take place in June 2019. Partners also work together on priority programmes for the whole of West Yorkshire and Harrogate, including mental health, hospitals working together, maternity, urgent and emergency care; preventing ill-health and improving peoples’ wellbeing. They do this where it make sense to share learning, expertise and workforce skills. The partnership knows that more needs to be done to prevent ill-health. Peoples’ life chances are shaped in their early years of life so giving children and young people the best start in life is a priority. Similarly, with an ageing population, it’s also a priority to help frail and older people stay healthy and independent, tackle loneliness, and avoid hospital stays unless needed. It also knows that not only hospitals and doctors keep people well; a person’s life choices and where they live are also important. Housing and health go hand in hand.


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Working alongside communities is therefore essential and our work with community and carer organisations is extremely important if the partnership wants to build on the good work taking place across the area. The partnership has now developed its WY&H programmes of work into clear plans for delivery and begun to deliver in these important areas. Partners will be refreshing the plan in 2019. This will set out further our goals for the next five years. Our goals include: • better access to GP services during weekends and evenings; • reducing the number of people who take their own life; • a reduction in waiting times for autism assessment; • supporting people with learning disabilities better; • helping children and young people with mental health concerns; • tackling alcohol related harm; • reducing the number of people who smoke; and • identifying people at risk of diabetes, heart disease and stroke so we can keep

them healthy. A key part of our plans is re-thinking the way urgent and emergency care is provided to ensure more options are available away from hospital, ensuring our A&Es are supported by better primary and social care for both children and adults. The partnership is also working hard to return people home quickly and safely after a stay in hospital. This way of working needs a joined up approach that is better suited to people’s needs and provided by NHS services, councils and community organisations working together. Moving forward the partnership will build on our early success in attracting £32m of transformation funding and £38m of capital funding last year and the £230m additional funding as part of the £963m of capital funding, announced by Matt Hancock, Health and Social Care Secretary of State in December 2018 to boost health facilities across England. This additional funding will benefit three large acute and mental health care schemes including pathology and rehabilitation. This is particularly important to help reach our ambition for a more radical approach to empowering people to get the care and support they need as early and as locally as possible and to build up our community based services. This is just a snap shot of some of the work the partnership is doing – find out more at our website, read the difference our partnership is making or the joint committee of CCGs annual report or follow the partnership on Twitter. 1.8.2 Happy, healthy at home: a plan for the future of he alth and care in

Bradford district and Craven ‘Happy, healthy at home’ – a plan revised and published in November 2017 – is the next step in the development of joined up planning by the health and care system in Bradford district and Craven. The plan was informed by our greater understanding of what people want and need following the ‘Big conversation: our say counts’ engagement which took


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place in summer 2017 and aimed to hear the views of as many people as possible. It is owned by the health and wellbeing board and delivery is led by the integration and change board. The plan complements our joint health and wellbeing strategy and sets out the key actions needed to achieve three aims: • better outcomes, so that more people are living longer in better health; good

health enjoyed by everyone rather than being determined by where live. • better services that meet people’s needs; providing access to the highest

quality interventions, delivered by teams with the best expertise, at the times people want, through the routes they prefer.

• better use of resources: reducing waste, arranging services to avoid delay and duplication, and working together to keep people well.

By listening to people and working together we understand where we need to change, and many improvements have already begun.

1.8.3 Airedale, Wharfedale and Craven Health and Care Par tnership

Airedale, Wharfedale and Craven Health and Care Partnership (HCP) works as a system to improve health and care outcomes for local people. The partnership uses its joint resources in the most effective and efficient way possible, promoting prevention and achieving our vision of keeping people happy, healthy at home. The partnership – which is chaired by Brendan Brown, chief executive of Airedale NHS Foundation Trust – has full engagement of stakeholders, including NHS Trusts, local authority, voluntary and community sector, GP practices and the CCG. During the year, the HCP decided that it would begin to operate within new system partnership arrangements from 1 April 2019, and is continuing to evolve and develop. This will include further system work on governance, finance and performance, quality and safety and workforce. A communications and engagement plan is also being developed to support the partnership going forward. This integrated approach to health and care continues much closer working between the partner organisations, rather than traditional, top-down approaches based on mergers or the creation of a new organisation. While statutory responsibilities of the individual organisations will not change, system commissioning and budget conversations will be held through the new partnership arrangements – ensuring greater transparency on how local money is spent and mutual efficiencies will be achieved. It will also enable the partnership to work through financial plans as a system, looking at our resources as a whole instead of from an individual organisation perspective to inform decisions about how we make the best use of them for the good of our local population.


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Also within the partnership, primary and community-led models of care are being developed and tested, with self-care and prevention embedded within, and mental and physical health having equal importance. Re-design is taking place through our three communities, one system delivery. Within this model, each community has an optimum population to enable an asset-based approach involving statutory and non-statutory bodies, encouraging involvement and participation in design and delivery. Populations range from 67,277 people in Airedale, to 43,646 in Wharfedale (including Silsden) and 47,664 in Craven. Building on the general practice model of care, this approach allows for general practice delivery ‘at scale’ (that is, practices working together to achieve their aims) and greater integration of community level services. These are flexible enough to respond to local priorities and enable engagement of a range of community services and stakeholders – for example, volunteers, fire, police, housing and voluntary services. The design facilitates the establishment of an integrated neighbourhood/ community team and considers workforce and a person-centred approach for all levels of care – including community nursing, palliative care, GP services, therapy, social care, preventative and wellbeing services, as well as the involvement of wider service agencies. The communities are looking at service change opportunities where possible, to support current system challenges, whilst progressing the development of a more sustainable solution that meets the population’s needs over the longer term.

1.8.4 Operational plan

We are in the second year of our two-year operational plan for 2017/18 and 2018/19, which outlines the actions we will take to deliver both national and local priorities. Recognising the key relationship as a place, our operational plan covers the three CCGs in Bradford district and Craven, whilst also capturing our contribution towards the wider WY&H HCP aims. 1.9 Key risks and issues

1.9.1 Key issues from the risk register

The governing body assurance framework (GBAF)/strategic risk log is the key mechanism for identifying and monitoring the management of the key risks affecting the achievement of our strategic objectives. The GBAF, which is shared across the Bradford district and Craven CCGs, is reviewed and approved as a fair reflection of the CCG’s strategic risk position by the governing body twice per annum (September 2018 and March 2019). The full CCG GBAF can be found in the governing body papers on our website and is summarised below:


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Strategic objective Strategic risk

Sept

2017

March

2019

Move

m

ent

1. Closing the quality and care gap

Working collaboratively, we will develop and deliver targeted programmes to address the gaps in the quality and outcomes of our health and social care. We will reduce unwarranted variations in the quality and care provided for our patients and residents. We will improve outcomes and experience for our patients and residents.

1.1 There is a risk that unwarranted variations in quality and care cannot be effectively tackled due to shortfalls in workforce capacity, capability and skills resulting in failure to close the care and quality gap.

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1.2 There is a risk that our efforts may not have the impact we desire due to some determinants of quality and outcomes which lie outside of the control of health and social care resulting in a failure to close the care and quality gap.

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1.3 There is a risk that the care and support market in Bradford and Airedale will become increasingly unstable due to workforce, increasing complexity of the needs of people living in care homes and funding issues, leading to closure or de-registration of nursing home provision. This will result in a market that is unable to accept and care for patients, destabilising the wider health and care sector and impacting on the quality of care experienced by our patients.

N/A 16

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2. Closi ng the health and wellbeing gap

Working collaboratively, we will develop and deliver targeted programmes to address the gaps in the levels of health and wellbeing experienced by our population.

2.1 There is a risk that we fail to gain sufficient organisational traction towards integrated commissioning due to a range of factors including ‘programme creep’, staff attitude to change and weak leadership, resulting in failure to achieve the strategic objective.

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2.2 There is a risk of fractured relationships with partners due to growing financial pressures within the health and care system, particularly in areas such as continuing healthcare, out-of-hours, learning disability and substance misuse, resulting in negative impact on the commitment to integration.

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3. Closing the finance gap

Working collaboratively, we will maximise value for money in the use of healthcare services to ensure we can deliver financial sustainability and service transformation.

3.1 There is a risk that the medium-term financial plan does not deliver financial sustainability for the three CCGs due to under-delivery of QIPP plans resulting in financial targets not being achieved.

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3.2 There is a risk that the two accountable care systems are not financially sustainable due to the system financial gap not being closed resulting in action from the regulators.

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Strategic objective Strategic risk

Sept

2017

March

2019

Move

m

ent

4. Creating health and care partnerships

Working collaboratively, we will develop health and care partnerships in Airedale, Wharfedale and Craven to provide sustainable, effective, efficient and high quality health, care, and support services to the local populations.

4.1 There is a risk of provider organisations not committing to the development of a health and care partnership across AWC due to their perceived organisational risks resulting in failure to achieve an HCP by 2021.

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8

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5. Self -care and prevention Working collaboratively, we will improve the levels of self-care and ill-health prevention to enable and empower people to better help themselves, live well and maintain their independence and dignity for as long as possible.

5.1 There is a risk that we are unable to sufficiently change patient behaviour, sufficiently reshape GP behaviour and embed social prescribing, due to the normal factors associated with ‘change and resistance, resulting in failure to achieve the strategic objective.

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9

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1. Acute provider collaboration

Working collaboratively we will ensure that the acute collaboration programme being led by the local acute trusts and West Yorkshire mental health trusts improves the clinical and financial sustainability of acute physical and mental health services, complements the development of out of hospital services and underpins the delivery of key quality and performance objectives including constitutional standards.

6.1 There is a risk that the corporate cultures and behaviours within individual organisations continue to emphasise competition rather than collaboration as a means to deliver healthcare, resulting in risking the effectiveness of the collaboration programme.

6

3

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6.2 There is a risk that the changes to acute and mental health services required to achieve financial sustainability are not acceptable to key stakeholders, e.g. patients, the public or elected representatives, and cannot be implemented. This would result in the failure of the programme’s goals.

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6.3 There is a risk that the transformation required in primary and community services is compromised due to workforce capacity, capability and skills shortfalls and by out of date or unaffordable models of service which are preferred by some interest groups. This will result in clinical and financial instability.

9

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2. CCG development We will continue to review and develop our internal resources, structures and processes to ensure that we are able to achieve our strategic objectives and meet NHS constitutional standards.

7.1 There is a risk that staff struggle to adapt to new, externally facing, system-focus roles due to the need for role flexibility and the normal factors associated with change, resulting in failure to develop as an organisation.

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As reported to the governing body in March 2018: Progress is being made towards achieving the ‘enabling’ strategic objectives (SR 4, 5, 6 & 7), with scores reducing for the majority of related risks. Whilst we have yet to see a reduction in risk scores for the risks relating to our ‘core’ strategic objectives (SR 1, 2 & 3 – closing the quality and outcomes, health and wellbeing and finance gaps), it is felt that we are moving in the right direction. In the longer term, it is hoped that achievement of the ‘enabling’ objectives will assist with the achievement of the ‘core’ objectives. The GBAF is supported by the corporate risk register which records the operational risks faced by the organisations. Risk register reports, focussing on high level risks (those scoring 15 or more) are provided to each of the governing body public meetings and can be found in the governing body papers on our website. 1.9.2 Emergency preparedness, resilience and response (EP RR)

NHS England is responsible for the management of any health response to major emergencies and for leading incidents involving public health outbreaks. The Civil Contingencies Act (CCA) 2004 places duties on CCGs to make local arrangements to deal with emergencies, at the same time as maintaining services to patients and assisting other responders in preparing for emergencies. The NHS EPRR framework also places a number of key responsibilities on CCGs which include: • collaborating, co-ordinating and co-operating in planning for, and responding to

an incident or emergency; • ensuring contracts with provider organisations contain relevant EPRR elements

and are adhered to; • supporting NHS England in discharging its EPRR functions and duties locally • fulfilling our responsibilities as a category two responder under the Civil

Contingencies Act, including maintaining business continuity plans; and • co-operating and sharing information with category one and other category two

responders. Our 2018 self-assessment against NHS England’s core EPRR standards indicates we are ‘substantially’ compliant and our annual EPRR report provides further assurance to the governing body and NHS England. We have incident response plans in place, and are an active member of the West Yorkshire local health resilience partnership (LHRP), working with other organisations to develop and share plans in preparation for any health incidents. Together with our health and care partners, we have joint plans that describe how we will work together during periods, such as winter, when services are busy and under pressure. The CCGs have 24 hour, seven-day, on-call arrangements where providers can escalate issues if they cannot maintain delivery of core services. Directors and deputy directors from the Bradford district and Craven CCGs staff the rota. On-call staff train on a regular basis so that they have the skills and knowledge to respond to incidents, and representatives attend exercises of other organisations to


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act as players and observers. In the past year we have attended an exercise under the Control of Major Accident Hazards (COMAH) Regulations 2015 and an NHS England/Public Health England regional exercise to test the health response to major emergencies as part of a national exercise programme. We also held our annual local desktop exercise to test our winter plan. All these events test multi-agency response and recovery arrangements. We continue to review and make improvements to our business continuity plan, which has been updated to reflect our move to new premises at the end of 2018 and the potential impact of the UK’s exit from the European Union. Our business continuity plan was significantly tested in late 2018 when an IT failure resulted in prolonged issues in relation to access to IT systems for CCG staff and GP practices. Following the incident, a detailed independent review was conducted, and an action plan is in place and being implemented.

1.10 Our commitment to equality and diversity

We are committed to reducing health inequalities and to promoting equality and diversity. We see our work around equality and diversity as an integral part of our work to reduce health inequalities. Further information can be found on page 59.

1.11 Financial performance overview In 2018/19, revenue resources of £243.8m were available to the CCG. This included:

• £235m for the commissioning of healthcare services (programme allocation) • £3.4m for administration costs (running cost allocation) • £5.4m brought forward from last year.

The programme allocation included a national growth uplift of £4.3m (1.89%) on the 2017/18 resource baseline plus an additional £1.7m relating to the CCG’s share of the national £603m increase announced in the 2017 autumn budget statement. The overall increase on programme allocation was therefore £6m - equivalent to a growth uplift of 2.65%. This was used to fund local healthcare service demand pressures and national policy requirements.

The running cost allocation remained at the same value as last year, which again, given pay cost pressures, represented a real terms reduction.

Overall, the CCG continued to manage its resources effectively and met its statutory financial duties to keep revenue expenditure within available revenue resources, and to keep administration costs within the CCG’s running cost allocation. The cumulative surplus funds carried forward to 2019/20 remained at £5.4m.

For 2018/19, the CCG had a savings target of £6.7m set against a number of schemes targeting areas such as planned care, prescribing and new models of care. This was alongside schemes aiming to improve quality and deliver greater value for money.


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For the year, the CCG achieved savings of £4.1m with the greatest savings being on prescribing costs where the CCG has reduced spending by £1.4m and planned care activity where costs have been reduced by £0.7m. The CCG has continued to develop new schemes which are expected to deliver further cost savings in 2019/20.

1.12 Engaging people and communities

Our CCGs’ shared management arrangements include the engagement function, helping us make more effective use of our resources. All three CCGs have a strong commitment to involving local people and communities, and good engagement is central to achieving our strategic objectives. The engagement team works across the whole of Bradford district and Craven; we work with local stakeholders to ensure that our approach is adapted to suit each community, so that we’re hearing from people across our varied geography and from a range of backgrounds. As well as working together as commissioners, we are working collectively with other organisations to achieve a system-wide vision for people in Bradford district and Craven to be ‘Happy, healthy, at home’. This creates new opportunities to join up our communications and engagement, and develop a different relationship with local people and communities. For example, this year: • we worked jointly with the local authorities to understand the lives and needs of

unpaid carers across Bradford district and Craven; • in some of the developing community partnerships engagement events helped

identify the priorities and develop community capacity; and • our partnership with VCS organisations through Engaging People enables us to

build on existed trusted relationships and engage with ‘seldom heard’ communities.

Our approach to engaging people and communities is overseen by the CCGs’ Involve Group, which includes lay members of our governing body, senior management, and public representatives. The Involve group reports to every governing body meeting to provide assurance that we are meeting our statutory duties and involving the public in our decision making in a meaningful way. Further detail about engagement is presented in section 2.4. We also produce a separate Annual Statement on Patient and Community Engagement, which is published alongside this report. It includes detailed information about our approach and structures for engagement, governance and assurance, feedback and evaluation, and the impact that engagement has made.


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1.13 Highlights of 2018/19 Some of the many highlights of our year have included:

• Reducing health inequalities is key to our new emerging community partnership approach. Engagement in the community partnerships has gone from strength to strength and each community partnership has progressed in priority areas, for example, the Inclusion Project in Airedale (homeless; asylum seekers; refugees; street drinkers); mental health in schools (CYP) in Wharfedale; and loneliness and isolation in Craven.

• Reducing rates of antibiotic prescribing in primary care to below the national target. The CCG has been working hard to reduce its use of antibiotics in primary care. We have developed and updated local prescribing guidelines and regularly assist our local practices with audits of antibiotic use, to check that prescribing is in line with national and local recommendations. Achieving this will help towards reducing antibiotic resistance in the community

• Our frail elderly pathway (FEP) team is an award winning, specialist team comprising of a number of professions working collaboratively in order to provide the best care possible for our patients. The FEP team enables and supports discharge planning for patients and aims to prevent unnecessary admissions and re-admissions to hospital, as well as quick, safe and well considered discharges from the acute admissions unit and the emergency department.

• Providing exercise and home based strength and balance programmes to prevent falls and working alongside urgent care practitioners, employed by the Yorkshire Ambulance Service (YAS) to assist with treatment at home / care home, reducing the need to take people who have fallen to hospital. Emergency admissions following injuries from falls for people aged 65 years or older has reduced and is now amongst the lowest rate in England.

• Reducing delayed transfers of care to an average of just over five and a half days which is much lower than the national average delays of 11 days As a health and care system, we are continuing use a multi-agency approach to ensure no-one remains in hospital longer than they need to.

• Extending access to primary care services in the evenings and at the weekend to all registered patients in Airedale, Wharfedale and Craven, since October 2018. Appointments are available 6.30-8pm Monday to Friday, and 9-11am-at weekends and provide extended access to a doctor or advanced nurse practitioner.

• Our diabetes prevention programme supports people who are at high risk of developing type 2 diabetes. It works to provides lifestyle advice, support and education in order to reduce their risk. We have created several new education options for patients and are now seeing a marked increase in the numbers attending one of the many courses on offer – by June 2018, our rate had increased to one in five patients. We are part of wave 2 of the national diabetes prevention programme (NDPP) to identify those at risk of developing diabetes.


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• Training 552 GP reception staff and administrators to be care navigators in GP practices across Bradford district and Craven. The project launched in early December 2018 and GP practices are now offering a range of services when a patient calls or comes into the practice to book a GP appointment. These services include sexual health, drugs and alcohol, community connectors, community pharmacy, midwives and low level mental health services.

• Commissioning a new self-care champion role into each of the thirteen community partnerships to work with all GP practices, patient groups, providers and voluntary and community sector organisations to support and promote self-care and prevention activities and events at a local level.

• Expanding the reach of the social prescribing service into all GP practices across Bradford and the thirteen community partnerships, offering additional support for people from central and eastern European communities and also delivering a service based in the Accident & Emergency department.

Further information about these highlights, and other achievements, can be found in the performance analysis section of this report (below).


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2 Performance analysis

2.1 Progress on our priority areas over the last year

CCGs are statutory organisations responsible to their governing body for the delivery of their statutory and constitutional duties, and improvements in the health outcomes of their population. Our constitutional duties include delivery of a range of national access targets for both hospital and mental health services. Performance for 2018/19 is shown in table 1 below: Target Q1 Q2 Q3 Q4 18 week referral to treatment waits

92% 88.5% 88.7% 90.1% 90.9%

Diagnostics <1% 6.5% 1.9% 1.9% 2.8% A&E four hours * 95% 92.9% 90.6% 91.2% 88.1% Cancer two week wait 93% 75.8% 71.3% 78.9% 94.1% Cancer two week wait (breast) 93% 91.7% 96.1% 93.1% 89.7% Cancer 31 day (first treatment) 96% 99.3% 97.8% 97.3% 96.1% Cancer 31 day (subsequent treatment surgery)

94% 96.4% 100.0% 96.8% 92.2%

Cancer 31 day - (anti-cancer drugs)

98% 100.0% 100.0% 100.0% 100.0%

Cancer 31 day - (radiotherapy) 94% 100.0% 100.0% 100.0% 100.0% Cancer 62 day 85% 78.7% 81.1% 86.1% 83.4% Cancer 62 day (NHS screening) 90% 85.7% 95.2% 86.2% 87.5% Cancer 62 day (consultant referral upgrade)

N/A 68.8% 64.3% 85.7% 80.0%

IAPT access**

4.2% for 17-18 rising to

4.75% by the end of 18-19

3.7% 3.6% 4.3% 3.9%

IAPT six week waits** 75% 96.7% 94.8% 98.7% 98.2%

IAPT 18 week waits** 95% 98.4% 98.3% 100.0% 100.0%

IAPT recovery** 50% 50.0% 49.1% 54.3% 55.8% Early intervention in psychosis - % seen within two weeks

53% 53.3% 40.0% 58.3% 80.0%

Care programme approach (CPA): follow up within seven days of discharge

95% 100.0% 96.6% 100.0% 100.0%

Table 1: NHS Constitutional Targets * A&E performance is for main Provider Trust (Airedale Hospital Foundation Trust) **Performance to February 2019 NHS England has a statutory duty to make an annual assessment of CCG performance. It meets this duty through its CCG improvement and assessment framework (IAF), which contains 58 indicators grouped within four domains: better health; better care; sustainability; and leadership, and an assessment against six national clinical priorities.


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NHS England uses the IAF to provide oversight and holds quarterly and annual review meetings with the CCG. The CCG’s overall rating for 2017/18 was outstanding, and our quality of leadership rating places us in the top 30 CCGs in England. Our national clinical priority ratings are shown in table 2.

Rating 2016/17 Rating 2017/18 Cancer Outstanding Good Dementia Good Outstanding Diabetes Requires improvement Requires improvement Learning Disability Requires improvement Requires improvement Maternity Requires improvement Good Mental health Requires improvement Good

Table 2: Ratings for the six national clinical priorities At the time of writing this annual report, the 2018/19 year-end assessment for the performance of the CCG was not available. From July 2019 the rating can be found on MyNHS at www.nhs.uk/service-search/Performance/Search. At present, the CCG is currently performing above the England average in a number of areas. However, there is always room for improvement, and the CCG uses these metrics to identify areas for further work.

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Tackling the wider determinants of health and reducing health inequalities is integral to our new emerging community partnership approach. Engagement in the community partnerships has gone from strength to strength with an equal partnership approach involving a range of stakeholders including local councillors. Informed by outcomes of asset based community development each community partnership has progressed priority areas:

• inclusion project in Airedale (homeless; asylum seekers; refugees; street drinkers);

• mental health in schools (CYP) in Wharfedale; and • loneliness and isolation in Craven.

Childhood obesity levels are below the England average. However, with three in every 10 children aged 10/11 years of age being overweight or obese this remains an area of concern. Interventions, delivered by the City of Bradford Metropolitan District Council (BMDC) public health team, include:

• early years interventions; • direct work with children and with schools; and • neighbourhood initiatives.

Antibiotic consumption in England is on the rise and increased antibiotic prescribing is fuelling increased resistance in bacteria. We have been working hard to reduce the use of antibiotics in primary care. We have developed and updated local prescribing guidelines and regularly assist our local practices with audits of antibiotic use, to check that prescribing is in line with national and local recommendations. As a result the CCGs use of antibiotics is lower than the national average.

A personal health budget (PHB) is an amount of money given to someone to help them design a package of care from clinicians and others. This means they have more control over the nature of the support provided, instead of simply getting care set out by the NHS.

We are a national development site for PHBs and introduced budgets for people subject to section 117 of the Mental Health Act (Aftercare). Since then, we have held two local workshops with BMDC and Bradford District Care NHS Foundation Trust (BDCFT) and have plans to further develop PHBs with the voluntary and community sector (VCS). From 1 April 2019 PHBs for people at home will be the default and we have trained all our staff in preparation.

2.1.1 Better Health

Childhood obesity

Three out of 10 children aged ten or eleven years of age are overweight or obese. This result is better than the average across England.

��

Health inequalities

The frequency of people being admitted to hospital for long- term conditions, from our poorest communities, is higher than other areas in England.

��

�� Better �� Similar �� Worse compared to England

Appropriate Antibiotic prescribing

AWC has reduced the rate of antibiotic prescribing in primary care to below the national target. Achieving this will help towards reducing antibiotic resistance in the community.

��

Personal Health Budgets

The uptake of personal health budgets is still low at 23 per 100,000 population, although this is a similar result to the average across England.

��

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The NHS Constitution sets out that patients should wait no longer than 18 weeks from GP referral to treatment (RTT), patients should be seen within four hours at A&E and a range of cancer access standards should be adhered to. Airedale NHS Foundation Trust (ANHSFT) continues to deliver the majority of these standards, although CCG performance has at times fallen below national expectations as a result of service pressures at other local providers.

Delivery of the four hour A&E standard is an ongoing issue across both acute providers as they struggle to manage increased demand and sicker patients in general. We are working with partners as part of the Bradford district and Craven urgent care and planned care programmes to manage demand and improve access to services and have seen recent improvements in performance. However, there is currently a national clinically-led review of access standards that aims to check whether these standards remain relevant in today’s NHS.

Bradford was selected by the Care Quality Commission (CQC) to undergo a local system review, which focused on people over the age of 65 as they move through the health and care system. The CQC was positive about the care and services provided in Bradford. We aim to support our local providers and have established an approach called 'Better Together‘, to provide enhanced support for any care home providers where CQC concerns have been identified. The result is that over the past three years we have seen a reduction of inadequate rated care home providers, from 14.9 % to 2% and in the last year an increase of good and outstanding rated homes from 49% to 70%. We have also developed a quality assurance process aimed at improving both the quality of services and CQC ratings of GP practices and progress against CQC action plans to improve the ratings at ANHSFT and BDCFT (both rated ‘requires improvement’) continue through our joint quality committee.

In partnership with social care we have multi-disciplinary teams in place to facilitate quick and effective discharges from hospital and minimise delayed transfers of care . As a result we continue to have one of the lowest rates of delayed transfers nationally and continue to minimise the use of hospital beds following emergency admission.

Our frail elderly pathway (FEP) team is an award winning, specialist team comprising of a number of professions working collaboratively in order to provide the best care possible for our patients. The FEP team enables and supports discharge planning for patients and aims to prevent unnecessary admissions and re-admissions to hospital, as well as quick, safe and well considered discharges from the acute admissions unit and the emergency department.

Our new primary care extended access service is available to 100% of the CCG population and operates through two models, a large partnership (Modality) and an alliance of practices (WACA). Appointments are available Monday to Friday between 6:30pm and 8:00pm and morning appointments on weekends between 9:00am and 11:00am to see a doctor or an advanced nurse practitioner.

2.1.2 Better Care

Care quality ratings

Ratings for primary care are good. However, ratings for hospitals and community services and for care homes and residential homes are in need of improvement.

��

NHS Constitution standards

Waiting times for cancer treatment, for hospital outpatient appointments or accident and emergency have not been met consistently, although results are similar to across England.

��


Delayed transfers of care

People were delayed on average by 5 ½ days which is much lower than the national average of eleven days.

��

Extended access in primary care

From October 2018, extended access in the evenings and at the weekend has been available to all registered patients

��

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This section of the IAF assessment looks at how the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends, and is therefore predominantly covered elsewhere within this report. The CCG has a highly effective system and processes in place for monitoring in-year financial performance , analysing and acting on a range of information about quality, performance and finance and has an excellent track record in identifying early warnings of failing services, and in identifying areas for improvement in otherwise successful, high quality services. However, as a CCG we do have challenges to achieve the level of productivity savings required to remain in balance each year.

Adopting full use of the NHS electronic referral service (e-RS) is a key element in the move to a paperless NHS. The benefits of using e-RS are immediate for patients being referred through the service and for Trusts. Patients have more choice and control over their healthcare, the quality of referral information is improved and Trusts benefit through reducing ‘did not attend’ (DNA) rates and improving administrative efficiencies. The national ambition is for all referrals to be made using the e-RS service from 1 October 2018 and we have seen significant improvement since ANHSFT, as an early adopter, went live from 1 March 2018.

We rank amongst the top 20 CCGs in England for quality of leadership , demonstrating that we have excellent leadership capability and capacity, robust systems of quality improvement and assurance, as well as strong financial leadership and are driving transformation with our new community partnership approach. The CQC remarked on the breadth and strength of partnership arrangements and relationships here in Bradford district, observing that system leaders across health and social care were compassionate, caring and clear that the needs of the person sit at the heart of our plan ‘Happy, healthy at home’ . In the past year we have taken a more system-wide approach to leadership and, by local agreement, appointed Brendan Brown to become chief executive of ANHSFT but also leader of the AWC Health and Care Partnership.

We have made some changes to the way we engage. We have introduced the People’s Board, which represents patients and communities providing a range of views from as many of the diverse communities that make up AWC to help shape plans and influence thinking and provide challenge and support. We have made significant improvements to the way we communicate through our website. In addition, we now publish our patient and community engagement annual statement at the same time as our annual report is published.

Amber

2.1.3 Sustainability

Financial performance

We want to make every pound go further and have developed plans to improve quality whilst saving money. However, at this time we are not fully delivering planned savings.

Amber Uptake of new e -referrals service

Currently seven out of 10 referrals are made electronically via the e-referrals services. It is expected that all GP referrals are ‘paperless’ from 1 October 2018.

��


2.1.4 Leadership

Quality of Leadership

In 2017/18 the quality of our leadership was assessed as amongst the best in England, an improvement on last year’s Green rating

Green Star

Patient and Community engagement

Governance, practice and equality and health inequalities were rated as Good. However, how we communicate this engagement could be further improved


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We are part of the West Yorkshire Cancer Alliance and actively involved in leading changes to cancer services provision. The overall objective of the alliance is to join up working across West Yorkshire to implement the national cancer strategy and the cancer taskforce recommendations.

Diagnosis at an early stage greatly improves cancer survival and our rate of diagnosis of cancer at an early stage is improving, with around half of people receiving their diagnosis at that stage. We want to continue to increase the proportion of people diagnosed in stage 1 or 2 of the cancer in support of the national ambition which rising to three-quarters by 2028.

We continue to work closely with public health and NHS England to support national educational and promotional campaigns including smoking cessation, as well as cancer screening services such as breast, bowel and cervical cancer. Through continuing to educate people and promote services, we will improve the uptake locally of these programmes.

Encouraging timely diagnosis leads to better planned treatment, and the CCG is performing amongst the top CCGs in England for estimated dementia diagnosis rate. We estimate that 6,000 people aged 65 or over and more than 100 people aged under 65 are living with dementia in Bradford district and Craven, and these numbers are expected to increase. The Bradford and Airedale dementia strategy, 2015-2020 aims to improve life for people living with dementia, their families and carers.

We aim to ensure that dementia patients receive quality care and support and the CCG is performing well for providing dementia care planning and post-diagnostic support. We are promoting dementia friendly communities which support neighbourhoods to include people with dementia in everyday life and have worked with BDCFT to improve the experience of leaving hospital for people with advanced dementia. We recognise the importance of making sure a good care plan is in place as part of the support package patients living with dementia receive after a diagnosis and will continue to make sure these plans are of the highest quality.

Dementia diagnosis

Almost 3 out of 4 people estimated to have dementia in our population have been found, this result is amongst the best in England

��

2.1.6 Dementia

Care planning

4 out of every 5 people with a diagnosis have care planning and post-diagnostic support in place. This is amongst the best in England

��


Cancer survival at one year

Almost 3 out of every 4 people with cancer survive beyond the first year. This result is higher than seen across England

��

Cancer diagnosis at an early stage

Diagnosing cancer at an early stage is important. However, only ½ of all cancer cases are diagnosed early, a similar rate as across England.

��

2.1.5 Cancer


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People with type 2 diabetes are offered structured education . However, we recognise that not enough people attend and have created several new education options for patients and are now seeing a marked increase in numbers. By June 2018, our attendance rate had increased to one in five patients and we are expecting to see further increases. We are supporting patients to improve the NICE recommended treatment targets including the management of blood pressure, glucose levels and cholesterol for people with diabetes to reduce the risk of patients developing complications. A diabetes steering group involving a range of stakeholders has been pivotal in leading work intended to reduce the incidence of, and improve care for, diabetes and outcomes for individuals.

We are part of wave 2 of the national diabetes prevention programme (NDPP) to identify those at risk of developing diabetes. Lifestyle advice over a number of weeks is offered to those identified by primary care as being at risk of developing diabetes and who have self–referred following information provided by their local GP. A number of practices are already implementing this and a further roll out is planned.

Across Bradford district and Craven, we are working to improve outcomes for people living with learning disabilities so that they live longer and better lives. Our transforming lives programme is implementing a system-wide change to enable more people to live in the community, with the right support, and closer to home, and reduce the need for specialist inpatient care . We are developing a programme to help support people with learning disabilities move into new housing developments by ensuring they meet their individual needs as part of a bespoke tenancy. We are also part of the West Yorkshire and Harrogate Health and Care Partnership initiative to develop specialist assessment and treatment beds for people with learning disabilities and autism.

We are working to ensure everyone with a learning disability is offered an annual physical health check (AHC) so that they get the health advice they need, as well as a health action plan to help them remember what actions they need to take. AHCs are an important tool to help improve health and reduce premature death in people with a learning disability and we have plans to increase uptake to at least 25% by the end of 2019/20.

2.1.7 Diabetes

3 recommended Treatment levels

Good control of blood pressure, cholesterol and HbA1c (sugar) is important. However, only seven out of 20 people with diabetes have good control of all three. We need to make improvements.

��

Structured education

Attendance for people with a new diagnosis of diabetes is low across England and locally we are about the same with just 6% attending.

��

�� Better �� Similar �� Worse compared to England 2.1.8 Learning Disabilities

Reduce specialist inpatient care

Across Bradford district and Craven the rate of specialist inpatients is 41 per 1 million population. We need to reduce this further.

��

Health checks

Only nine out of every 20 people aged 14 or over, with a learning disability receive their annual health check, this result needs to improve further.

��


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We welcomed the publication of Better Births in 2016 which set the vision for future maternity services and we have engaged with the West Yorkshire and Harrogate local maternity system programme to implement the recommendations, whilst applying local learning from the Better Start Bradford research project and becoming an early adopter for perinatal mental health services.

Smoking at the time of delivery has increased and continues to impact on infant mortality rates. In the last year we have worked with the Women’s Health Network and Better Start Bradford to understand why women from some of our communities don’t use smoking cessation services, and to put what we have learned into practice.

We commission a full range of maternity choices for local women and are focusing on how these are offered to them so that they feel they have been offered the full range of services available to them.

There is strong evidence that tackling mental ill-health early improves lives and around one in every six adults in England suffers from common mental health problems such as depression or anxiety disorder.

Access to mental health service (psychological therapies (IAPT) and early intervention psychosis (EIP)) continues to improve with almost all patients able to access IAPT services within six weeks of referral and around 50% able to access EIP within two weeks. Our early intervention team provides a range of services including psychological therapies, medical and social interventions designed to meet peoples’ needs and help them to get their lives back on track.

Outcomes also remain good with IAPT recovery rates above the national target.

Our vision is to deliver care for people who need mental health support as close to home as possible as this leads to better outcomes for people in the long term. This commitment means we have taken a full system approach to reducing out-of-area placements and we have had very few inappropriate out of area placements this year.

Smoking in pregnancy

Above one in 10 women are still smoking at the time of delivering their baby. This result is similar to the England rate, but needs to reduce.

��

2.1.9 Maternity

Choice in maternity service

Experience of choice offered across the pathway (antenatal, intrapartum and postnatal) in 2017 was reported as performing well with a score of 61.4

��


Early intervention psychosis

Access to intervention for psychosis just above the 50% standard, with 1 out of every 2 people being seen within 2 weeks for a NICE recommended care package

��

Out-of-area placements

Reducing out of area placements for people with mental health problems is a key priority – currently we have zero bed days placed out of area

2.1.10 Mental Health

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2.1.11 Self-care and prevention The self-care and prevention programme works to support people who live in Bradford district and Craven to understand what self-care means and have the skills, confidence and tools to manage and take control of their own health and wellbeing. Self-care is a term used to include all the actions taken by people to recognise, treat and manage their own health and wellbeing. A person may do this independently or in partnership with health and care services. We also want to promote self-care and prevention with our staff who work in health and care organisations locally and we want to help them to better understand what self-care is and have the skills, resilience, confidence and tools to support people to self-care. Work is underway to develop a new ‘Living Well’ programme to incorporate the learning and success of the self-care and prevention programme and the Healthy Bradford work. The Living Well programme aims to deliver a system-wide response to improving health and wellbeing through making it easier for everyone, everywhere to live a healthy and active lifestyle every day. Living Well will also include a public facing campaign to motivate people and promote positive wellbeing. Highlights for 2018/19 include: • Workforce training: One of the key targets from the Bradford and Craven

Health and Care Plan is to deliver or facilitate self-care training to 10% of the health and care workforce over five years. This year we have identified 9,800 staff to target across health and social care and had a target of 980 staff to train (10%), however we have actually trained 2,100 staff exceeding the target. Our training is delivered at the three levels:

o Level 1 - Basic awareness and e-learning - an introduction to self-care o Level 2 - Making every contact count – creating opportunities to

encourage healthier lifestyle choices o Level 3 - Conversations for change - in-depth behaviour change training

utilising motivational interviewing techniques

• Children and young people: We commissioned health visitors to deliver a new ‘DIY Health’ parenting course in children’s centres. They ran six courses and 53 parents or carers attended. All of the attendees reported an increase in confidence to manage poorly children and people also said that they were less likely to use the GP or Accident and Emergency as the first point of contact for minor ailments. We are also working with an organisation called RIPEN to run a ‘Mindfulness in schools’ project where 14 teachers have been training to deliver sessions to children in primary schools.

• Community connectors: HALE and partners have expanded the reach of the social prescribing service into all GP practices across Bradford and the thirteen community partnerships. They have tailored some additional support for people from central and eastern European communities and are also delivering a service based in the Accident and Emergency department. Within the first six


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months of 2018, the connectors have seen 486 service users and data has shown that there has been significant improvement in wellbeing, self-care and satisfaction levels for people using the service.

• Care navigation: We have trained 552 GP reception staff and administrators to

be care navigators in GP practices across Bradford district and Craven. The project launched in early December 2018 and GP practices are now offering a range of services externally to the practice when a patient calls or comes into the practice to book a GP appointment. These services include sexual health, drugs and alcohol, community connectors, community pharmacy, midwives and low level mental health services. We will be reviewing the impact and success of the project over the next few months and asking patient groups and communities to tell us about their experience of the service to shape our future plans.

• Self-care champions: We have commissioned a new self-care champion role into each of the thirteen community partnerships to work with all GP practices, patient groups, providers and voluntary and community sector organisations to support and promote self-care and prevention activities and events at a local level.

• Asset based community development: We have provided small funding

grants through the Voluntary and Community Sector Alliance to stimulate investment into grassroots community activities which will support the health and wellbeing needs of local people. The first round of funding supported over a 100 small community groups.

During self-care week (November 2018) the self-care and prevention programme ran the ‘Make one change challenge’ to complement the national theme of ‘Choose self-care for life’. The aim was to encourage people across Bradford district and Craven to make small changes which could have a big impact on their health and wellbeing both mentally and physically and help them to feel better about themselves. People were encouraged to use a Living Well weekly planner to record their progress Over 70 organisations took part from health, council and local charity teams and they provided health and wellbeing information in over 40 locations across the patch. These included shopping centres and markets, schools and colleges, faith based buildings, hospitals, pharmacies, GP practices, mother and toddler groups and workplaces. Community nurses offered health MOTs and gave advice, encouraging people to have their flu jab, where to get it and how to get ready for the winter months to come. 2.2 Sustainable development The CCG is committed to ensuring we continually develop our sustainable working practices within our organisation, through our commissioning and with our member practices and staff, as sustainable development has good health and wellbeing at its heart.


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Many local people in Bradford district and Craven will live longer and expect their lives to be healthier and happier than those of their predecessors. But there needs to be a step change if we are to make inroads into the health inequalities experienced by them and to address the future health needs of our population. The system-wide vision described in the Bradford district and Craven plan for the future of health and care ‘Happy, healthy at home’ reflects this: to create a sustainable health and care economy that supports people to be healthy, well and independent. The plan is being driven by the health and wellbeing board and we are working ever more closely with our partners, through health and care partnerships, to transform the health and care landscape, join up services around our patients, realise efficiencies and drive forward the self-care and prevention agendas. We are committed to reducing waste and have continued with our campaign – It’s your NHS, don’t waste it! – aimed at working together to ensure we can meet increasing demand with local services to meet local needs. In the last year the focus has continued looking at how to be more innovative and more productive while helping people use NHS resources better, ensuring services remain of the highest quality. This report provides an update of our progress in 2018/19 and sets out our focus for 2019/20. 2.2.1 Governance Fiona Jeffrey, (associate director of corporate affairs), is the CCG’s sustainability lead, working with colleagues across the organisation to ensure sustainability is built into its day to day operations. Through our annual reporting we outline the progress made in sustainable development across the CCG and set out our priorities for the forthcoming year. Integration and partnership working: We are working towards a model of integrated health and care to ensure people are happy, healthy at home Key elements of these arrangements are: • Partnership forums including:

o West Yorkshire and Harrogate Health and Care Partnership o Health and Wellbeing Board o Executive Commissioning Board o Integration and Change Board o Airedale, Wharfedale and Craven Health and Care Partnership o Three communities o Joint clinical committee across the three Bradford district and Craven CCGs


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o Provider alliance o Mental health partnership board o VCS alliance o Integrated workforce programme board o Bradford digital 2020 board

We have continued to embed our shared management structure across the three CCGs in Bradford district and Craven and there has been further development of appropriate governance arrangements. Strategic partnering agreement (SPA): Partners (commissioners and providers) across the district have worked together to develop a SPA, to provide an operating framework that governs integrated multi-party solutions for health and social care. It provides a framework to formalise how we work together. Resilience: Part of being a sustainable organisation is around ensuring we are resilient in the event of an incident. Page 20 provides details on our work on emergency planning, resilience and response. Climate change adaptation planning: As a member of Bradford and Airedale health and wellbeing board, we continue to be signed up to the Bradford low emission strategy. 2.2.2 Commissioning We have recently been involved in the development of a combined quality and equality impact assessment process which will be used across West Yorkshire and Harrogate Health and Social Partnership. Through adopting this consistent ‘do once and share’ approach to assessing the quality and equality impacts of proposed changes resulting from its commissioning decisions and recommendations, the partnership will avoid the duplication of work across different partnership organisations. The process aims to ensure that services are high quality and meet the needs of all patients and service users, especially those from groups of people who experience disadvantage and/or discrimination. • Winter planning: We have had a robust and coordinated approach to winter

planning underpinned by a comprehensive system-wide communications plan which focussed on self-care and right care, flu and cold weather advice and a “know your normal” campaign to support people with long term respiratory conditions.

• Self-care and prevention • Care navigation: including communications and engagement /community

development approach • Mental wellbeing partnership event • Carers’ procurement including in-built engagement with service users and

carers • New model of integrated diabetes care – collaboration with providers • GP@ssist – systematic use of technology and pathways to reduce variation


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Engagement with local people: engaging with local people is fundamental in the commissioning of services in order to ensure that services are needs led and fit for now and the future. Key elements of this over the last year have included:

• The People’s Board has developed to cover the whole Bradford district and

Craven area, and has recruited further members to represent this. • Engagement with young people: Successful bid to host a partnership project re

youth participation and the NHSE Takeover Challenge (CCGs are hosting an intern)

• Grass roots patient experience development • Engagement around our three communities • Engaging people: building capacity in communities • Talk cancer programme • Review of the engagement and involvement sections of the website in order to

make it easier for local people to work in partnership

Planning and strategy:

• It’s your NHS, don’t waste it: part of the organisation’s approach to the national quality, innovation, productivity and prevention programme

• Ongoing development and delivery of QIPP • Delivery of sustainability objectives and planning for the forthcoming year

Process:

• Provider environmental performance: There is a requirement in the standard

contract with all providers to “demonstrate (its) progress on climate change adaptation, mitigation and sustainable development, including performance against carbon reduction management plans, and must provide a summary of that progress in its annual report.”

• System commissioning, demand and efficiency: See section 1.8.3 • Pharmaceuticals waste: See section 2.3.5 • Social value: Our focus has been on developing a strategic partnering

agreement that will provide the basis for all future service developments and the potential procurements. Social Value factors heavily within the SPA and is a significant aspect of the vision.

2.2.3 Corporate Resource use and associated CO2 impact (energy, waste, water):

• Our utilities – we are a tenant occupying part of one floor in an industrial unit in

Steeton. The office uses electric storage heaters, hot water and electricity. We have motion-sensitive lights in the office communal areas so the lights are only used when needed and our staff ensure other lights are switched off at the end of each day.

• We have trialled an e-bike scheme over the last year.


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• We have implemented and further embedded ModernGov technology, using tablets to significantly reduce the need for printing CCG meeting papers. ModernGov is now used at the majority of CCG formal meetings and we have significantly reduced the numbers of paper copy packs produced.

• We have continued to use multi-functional printing and have supported staff to use minimum paper solutions where possible. Our printers are set to double-sided, grey scale by default, further reducing paper and ink use and are completely switched off each night.

• We continually strive to reduce our impact on the environment, for example paper and plastic use and efficiency around electrical appliances (for example, recycled printing paper and reduction in the use of disposable drinking cups)

Staff travel: Our offices are near to a bus route and the Steeton and Silsden train station so staff and visitors can easily travel by public transport, including a direct link between the two CCG sites. We encourage car sharing where appropriate which is reflected in mileage rates for staff – there is an additional payment for car sharing and mileage rates for cyclists.

Member practice sustainability: • Primary care improvement – see section 2.3.2 • Primary care engagement at monthly engagement forum and quarterly local

commissioning forum • Supported development of primary care at scale • Mobilised community partnerships with GP leadership roles embedded • Implemented GP extended access • Implementing primary medical care commissioning strategy • IT – working with practices further to an IT outage to identify best practice and

increase resilience • Weekly member practice bulletins

Organisation and workforce development: • Provision of health and wellbeing employee assistance programme • Partners in the Airedale, Wharfedale, Craven and Bradford integrated

workforce programme board: an overarching and enabling programme which aims to work collaboratively to identify and work towards developing a system-wide integrated workforce that is fit for the future

• Staff engagement mechanisms: Continuation of weekly face to face SMT weekly briefings which are recorded so all staff can access; weekly staff bulletin

• Volunteering and charitable opportunities including ongoing participation in Takeover Day

• Support for internship and work experience • The appointment of several commissioning support officers into developmental

posts using innovative recruitment


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• Comprehensive programme of learning and development, keep in touch and wellbeing opportunities (including coaching and mindfulness) underpinned by an interactive web based calendar of activities

• Comprehensive programme of organisational development • Participation in the system-wide engaging leaders programme as well as

Leadership Academy, Nye Bevan and similar programmes • Stretch opportunities for staff to take on fixed term developmental roles • Coaching and mentoring including cross system mentoring with the VCS • Disability confident employer

Social sustainability: Our staff continue to lead the approach to investing in our communities by fund raising for local and national charities including Shelter Box, the Salvation Army, Scotties Little Soldiers, Children in Need and Red Nose Day. 2.2.4 2019/2010 priorities

Governance: • Further development of our system collaborative arrangements through health

and care partnerships and communities. • SPA: further development and empowerment of and delegation to the SPA Commissioning: • Long term plan • Further developing our engagement approach with young people : rolling out

partnership youth project and hosting a system-wide youth engagement event • Engagement around the AWC health and care partnership and the three

communities including the role of the People’s Board and Engaging People • Embedding People’s Board across the district • Embedding the use of the combine equality and quality impact assessment • Further development of Grass Roots to inform commissioning decisions • Self-care and prevention • Care navigation • Personalised commissioning

Corporate: • Long term plan and five year framework for GP contract reform • Realise integration through community partnerships • GP international recruitment

Our results for staff engagement in the 2018/19 NHS staff survey have increased from 7.2 to 7.5 and are higher than the national CCG average.


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• Mobilise online consultations • Review staff communications mechanisms to ensure they are up to date and fit

for purpose • Re-introduction of monthly staff briefings • Organisational approach to employers for carers • Continual refreshment of learning and development offer for staff to ensure

skills and experience are fit for the future • Staff engagement and action around staff survey and WRES data • Continuation of staff driven programme of community support • Continue to promote sustainable travel and working arrangements

2.3 Improve quality We are dedicated to delivering and developing high quality, safe and innovative healthcare services that meet the needs of local people. We put patients at the heart of everything we do. To deliver the NHS constitution standards we ensure all quality measures are based on the best available evidence and monitor them accordingly. We work with our providers to ensure that quality requirements are achieved and co-ordinate rapid intervention when quality and safety is compromised, where appropriate. Our providers must meet a number of essential quality and safety standards set out by the Care Quality Commission (CQC). As service commissioners, our contracts include other quality requirements for providers that are above the essential CQC requirements. We are a member of the West Yorkshire quality surveillance group (QSG). This group enables commissioners and regulators to discuss and share system-wide quality concerns and agree improvements. By encouraging partnership working it supports a culture of open and honest co-operation.

As part of our governance structure, the joint quality committee (JQC) provides assurance to the governing body that the services we commission are safe, effective and deliver good outcomes to our population, and makes recommendations in relation to matters within its remit. This includes testing and challenging a wide range of evidence to ensure quality, safety and effectiveness of services, regularly reviewing our CCG clinical risk management processes and advising our clinical boards/clinical executive group in the formulation of the overall clinical commissioning strategy. It includes the scrutiny of quality innovation productivity and prevention (QIPP) plans to ensure quality is not compromised by financial imperatives.

The governing body receives the following reports:

• A bi-monthly report of assurance and quality matters in the securing of high quality, effective care services for our patient population across our respective providers. This includes our patient’s experiences of care, through grass roots reporting.


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• A bi-monthly quality report – following the implementation of shared management arrangements introduced April 2017, the quality committees from each of the three CCGs merged to form a single JQC from July 2017. This has enabled us to share quality issues across the CCGs’ boundaries and has facilitated greater system-wide focus on quality of services. The JQC has a principle of openness and transparency and provides robust challenges to provision of care.

• In addition to regular reports to the JQC, the committee also received reports and/or presentations of ‘deep dive’ focus areas, including cancer.

• Improvement and assessment framework updates are provided to the JQC and governing body including each CCG’s scorecard.

• The minutes of the monthly JQC are provided to the GB. • Outcomes of quality deep dives – for example, cancer services and

maternity services are also sighted at JQC and through to the governing body.

• Quality walk rounds in care homes continue across the footprint including joint assessment visits with North Yorkshire County Council and City of Bradford Metropolitan District Council.

• Highlight reports are provided to Airedale Accountable Care where quality concerns are identified.

Under the direction of JQC, we continue to take a methodical approach to understanding, monitoring, analysing and acting on a range of quality data and information, using curiosity as an underpinning principle. We triangulate and assess a range of quality metrics and associated information for exceptions, along with local intelligence and workforce data to elicit a quality picture/position of services.

As part of our mainstream contractual process each main provider has a quality and performance group (QPG) supported by operational sub groups (patient safety and quality sub Group – PSQSG) which report through to the provider contract management board (CMB). The PSQSG provides an opportunity for us to delve deeper with the provider on quality areas within scope and enables us to identify areas that may require further understanding or interrogation. Over the last year this has enabled identification of several quality areas which required a further ‘deep dive’ and subsequent presentation and discussion at the JQC such as provider response to serious incidents. Following JQC discussion, this has often resulted in further challenge or action for providers to ensure delivery of high quality, effective services of positive patient experience. Demonstrating a floor to board approach, information from operational deep dives is fed into the CCG clinical executive group (CEG), JQC and governing body. In addition, we review contractual reporting requirements in response to intelligence and this helps to influence and inform design and progress of our strategic programme areas.

• We review all serious incident (SI) investigations and do thematic reviews

where clusters of incidents are identified. Data on all incidents is reviewed quarterly.


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• Healthcare associated infections (HCAIs) remain a high priority. As part of the CCG integrated assessment framework (IAF) indications, we have identified clinical board sepsis leads for each CCG and commenced discussions to lead sepsis identification, education and management within general practice. Joint partnership working continues across healthcare organisations, to understand the root cause of infection, prevention and control actions and share learning.

• We review mortality data mortality via existing governance processes and monitor the engagement of families and the quality of investigations. Working with the system, we have agreed to utilise and embed learning from the LeDeR programme to guide changes in health and social care. National Learning Disability Mortality Reviews (LeDER) seek to improve the quality of health and social care delivery for people with learning disabilities through a retrospective review of their deaths.

Nationally, the NHS standard contract provides us with a mechanism for setting a consistent approach to quality requirements. Quality accounts are a vehicle for shared understanding of quality improvement priorities with our providers, and include mandatory reporting on a core set of quality indicators. Importantly, providers are encouraged to celebrate excellence.

As part of our delegated responsibility to commission GP primary care services, we have a duty to improve the quality of such services. Ultimately, this is discharged through the JQC which oversees the roll out of the Primary Care Quality Assurance Framework.

We are continually reviewing available information and data to ensure effective and efficient service delivery and also that the best possible outcomes for people are provided. We use the monitoring of outcomes data to inform and review our priorities, areas of emphasis, and work plans through regular reporting to clinical board, governing body and JQC. We use nationally published data and regularly benchmark with similar CCGs to so that we can identify where we can learn from others to improve our outcomes. In 2019/20, we will continue to develop a culture of quality improvement in terms of health outcomes. We will use and analyse both qualitative and quantitative data to understand the overall picture to identify lapses in quality and consider potential solutions.

We have developed a wealth of mechanisms and processes based on the above standards, indicators and domains to facilitate and drive the quality agenda.

2.3.1 Safety

Incidents and serious incidents – Responding appropriately when things go wrong in healthcare is a key way we can continually improve the safety of services delivered. We strive to reduce the occurrence of avoidable harm and have robust assurance mechanisms in place. We monitor patient safety with all our providers and ensure that all serious incidents (including never events) are


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reported and robustly investigated. Appropriate action plans are developed as a result of incidents and learning is shared and, most importantly, put in into practice. This process has enabled key quality themes to be highlighted and picked up by provider service development/operational groups to intervene and learn from.

We have established systems and processes to receive prompt information on incidents, investigation and monitoring of outcomes. We have established systems that support the prompt reporting of incidents, along with robust processes to help investigate incidents and monitor any outcomes. All staff must report incidents and near misses proactively using the single incident reporting system. We meet regularly with our main acute providers to discuss details and ensure any necessary actions are implemented to maximise learning, improve patient safety and reduce avoidable harm.

Infection prevention – Health care associated infections (HCAIs) remain a high priority for us and in partnership with our system providers we have agreed a system-wide improvement plan to reduce gram-negative bloodstream infections (GNBSI) by 50% by 2021. Currently we are working hard to achieve this ambition. Joint partnership working continues across healthcare organisations, which includes training and audits in care homes, reviewing and learning from post- infection reviews to achieve our ambition in reducing infections.

NHS safety thermometer is a tool for measuring patient safety, developed by the NHS Information Centre (NHS IC). It is a 'temperature check' to measure and understand levels of harm in healthcare organisations. Importantly, it provides staff with a simple and quick way to measure the proportion of patients who are 'harm free'.

The tool focuses on measuring four different basic types of harm: pressure ulcers, falls, venous thromboembolism and urinary tract infections in patients with catheters.

National Learning Disability Mortality Review (LeDe r) Programme – People with learning disabilities are four times more likely to die of preventable causes compared with the general population (Disability Rights Commission, 2006). The programme is the first national review set up to get to the bottom of why people with learning disabilities typically die much younger, and to inform a strategy to reduce this inequality. It seeks to improve the quality of health and social care services for people with learning disabilities through a retrospective review of their deaths. The CCG has led the introduction locally with our system providers, the case reviews of learning disability deaths, notified through the LeDER system. In partnership with our providers, this is enabling system learning from the case reviews, which will support health and social care staff and others, to identify, and take action on, the avoidable contributory factors leading to premature deaths. In addition, to support this Bradford district and Craven CCGs have been instrumental in introducing the THiNK LD initiative across our partners. This encourages staff to


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consider access, flexibility and equality when commissioning, planning or caring for people with a learning disability. The initiative has been extremely successful in raising awareness across our providers and system partners and we have enabled the initiative to reach out across the Yorkshire and Humber region.

2.3.2 Care Quality Commission inspections

Providing high quality care for all is a fundamental principle for health and social care services. The Care Quality Commission (CQC) rates the quality of care by asking five key questions: Is it safe? Is it effective? Is it caring? Is it responsive? Is it well- led?

In hospitals these key questions are asked for each core service provided. They are intended to provide a rounded assessment of quality. Using the lowest level of ratings provides the broadest possible assessment of progress. Over time, this CQC indicator will enable people to look at improvements in the quality of care. We meet quarterly with the CQC to share information and work collaboratively to gain assurance around the quality of services we commission. Airedale NHS Foundation Trust Inspection: 13 November 2018- 31 December 2018 Report publication: 14 March 2019 Overall rating: requires improvement NHSI and CQC Combined rating: Good The trust’s urgent and emergency services, medical care, surgical services, critical care and diagnostic imaging received an unannounced inspection in late 2018. Urgent and emergency care, and surgery, were rated as ‘requires improvement’ and medicine, critical care and diagnostic imaging as ‘good’.

Although the 2019 inspection outcome remains ‘requires improvement’ it is important to note that the trust has made significant improvements from the 2017 inspection with an overall rating of good for the combined aggregation of quality, well led and use of resources assessments. The domains of effective, caring and responsive remain rated as ‘good’ with safe and well-led rated as ‘requires improvement’. The CQC found examples of outstanding practice in the emergency department, medical services, surgical services and critical care. The trust breached four legal requirements which related to: staffing, good governance, safe/care and treatment, and premises and equipment. The trust had 13 ‘must do’ actions which decreased from the previous report. The number of ‘should do’ actions decreased to 17, progress will continue to be monitored.


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Bradford District Care NHS Foundation Trust

Inspection: November 2017 and several other unannounced visits Report publication: 9 February 2018 Overall rating: requires improvement

Within the overall rating (above), the safe, effective and well-led domains were rated as ‘requires improvement’ whilst the caring and responsive domains remained rated as ‘good’.

The CQC inspected nine core services. The report gave an ‘outstanding’ rating for caring in its community health services for adults, and ‘responsive’ for its community based end of life care. The following mental health services were rated as ‘requires improvement’: acute wards for adults of working age and psychiatric intensive care units; long stay or rehabilitation mental health wards for working age adults; wards for older people with mental health problems; wards for people with a learning disability or autism; community based mental health services for adults of working age and mental health crisis services and health based places of safety.

The trust breached seven legal requirements which related to: staffing, good governance, safeguarding service users from abuse and improper treatment, safe/care and treatment, dignity and respect, person-centred care and fit and proper persons (directors). The trust had 11 ‘must do’ actions and two ‘should do’ actions from CQC. Bradford Teaching Hospitals NHS Foundation Trust (BTHFT) Inspection: January 2018 Report publication: 15 June 2018 Overall rating: Requires Improvement

Within the overall rating (above), the safe, effective, responsive and well-led domains were rated as ‘requires improvement’ whilst the caring domain was rated as ‘good’. The trust’s urgent and emergency services, medical care, maternity and surgical services received an in 2018. Urgent and emergency care and surgery were rated as ‘good’, and the medical and maternity services were rated as ‘requires improvement’. The trust breached three legal requirements which related to: staffing, good governance and safe/care and treatment. The trust had eight ‘must do’ actions and 41 ‘should do’ actions from CQC.


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Primary medical services

All 16 GP practices within Airedale, Wharfedale and Craven CCG have been rated by the CQC. Fifteen were rated as ‘good’ with one being rated as ‘outstanding’ by the CQC. We recognise that practices are the lynchpin of care and work closely with them to support them in delivering quality care. We support practices to improve their services through the using of ‘soft’ and ‘hard’ intelligence data. Through the locality commissioning forum with member practices, we have developed an incident reporting system so that learning can be shared across all practices.

Quality assurance of general practice continues to be addressed through a primary care contract assurance group (CAG). Areas of concern from the CAG around the services that are commissioned are reported to the joint quality committee and to YOR Local Medical Committee. Themes and trends for quality improvement are also reported to the JQC. Work is ongoing across the three Bradford district and Craven CCGs to standardise data sets for primary care information in regard to both quality improvement and contract assurance purposes.

Local clinical commissioning forum sessions organised by the CCGs are also being used to drive forward quality in primary care. Bradford local system review Inspection: 12-16 February 2018 Report publication: 25 May 2018 Overall rating: awaited

This review sought to understand how people move through the health and social care system with a focus on the interfaces between services. Overall the system review was very positive. The report demonstrated there was a clear shared and agreed purpose, vision and strategy which were articulated throughout all levels of the system. Staff are committed to the vision, whether working in adult social care, primary and secondary care sectors or in the voluntary sector.

2.3.1 Patient experience

Complaints and principles for remedy It is a priority for the CCG to have local people at the heart of our work, to hear what they think, to use this information as we make decisions about services, and to tell people how we have used their views. Sometimes things go wrong, and when they do we make sure that concerns and complaints are investigated to help us learn lessons and improve services.


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Between 1 April 2018 and 31 March 2019 we received six formal complaints from patients, or on their behalf, in relation to the CCG. Three involved continuing healthcare (CHC) funding, two related to commissioning, one about mental health and the other about complex care services. The remaining complaint was about the availability of flash glucose monitors for people with type 1 diabetes. Forty-nine people also contacted us raising concerns and enquiries in relation to the CCG, 33% (16 cases) of these were about personalised commissioning which included CHC funding decisions, assessments and our processes. Eleven (22.4%) involved commissioning and the changes in care pathways, the majority of which (six cases) related to the provision of spinal injections. Eight (16%) cases involved IFR (individual funding request) referrals and/or funding decisions. In addition 20.5% (10) referred to prescribing, for example the availability of flash glucose monitoring devices (7) and gluten-free products (2). Our chief officer received 28 enquiries from our local MPs which raised 32 issues and concerns on behalf of their constituents about NHS services. Fourteen cases (44%) related to commissioning and/or funding issues, five (38%) of which were about the availability of flash glucose monitoring devices. Five (16%) involved personalised commissioning – care packages (3) and care home charges (2); and 22% (8) related to the provision of services by our hospitals (7) and a GP practice (1) concerning an individual’s care and treatment. In addition, 56 complaints and concerns were raised with the CCG about our commissioned services, of which 61% (34) involved secondary care services, for example those provided in our hospitals and other providers of NHS services, and 23% (13) related to services provided by our GP practices. Other cases involved care homes (2) concerning the care provided for CHC funded patients. There were a further 34 contacts made by patients registered with unnamed GP practices, the majority of them 44% (14) being about our hospitals and other NHS providers, 18% (6) were in relation to CCG commissioning and 9% (3) involved services provided by our GP practices. In all these cases, advice was given or the complaint or concern was passed on to the appropriate organisation for investigation and a response. The main issues within complaints and concerns raised about our commissioned services were about aspects of care and treatment, communication, access and waiting times. The CCG was notified of three complaints where our patients approached the Parliamentary and Health Service Ombudsman (PHSO) as they remained dissatisfied with the outcome of their complaints locally. Two cases involved the outcome of CHC retrospective reviews; the other was a complaint about access to BANDS (Bradford and Airedale Neurodevelopment Service). None of these cases were investigated formally by the PHSO. The CCG has fully adopted the Principles for Remedy in which the Parliamentary and Health Service Ombudsman (PHSO) has set out six principles for remedy which include getting it right, being customer focussed, being open and


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accountable, acting fairly and proportionately, putting things right and seeking continuous improvement. A full explanation of the principles can be found at www.ombudsman.org.uk and are referred to within our policy for the management of compliments, comments, concerns and complaints. 2.3.2 Effectiveness NICE guidance – Systems have been developed to distribute NICE guidance updates on a monthly basis to primary care, nursing and residential homes to ensure services are delivered within the national guidance. We also monitor secondary care compliance with NICE technology appraisals and guidance via the providers’ quarterly reports. Care homes - Over the past few years we have established a 'Better Together,' ethos across organisations through enhanced support for providers of concern, creating networks and clinical forums to look at the issues facing the sector, share best practices and improve the way we do things together. As a result of this approach, we have been integral in reducing the number of inadequate providers across the three CCGs from 14.9 % to 1.75% in three years. In addition the number of good and outstanding homes has increased from 49% in January 2018 to 69.5% today. In addition, 3.5% of our providers have been rated as outstanding overall with an additional 8.7% of homes rated as outstanding in the CQC caring domain.

The current position notes that that CQC has inspected 106 out of 114 care homes across the Bradford district and Craven CCGs. Currently two homes are inadequate, 28 require improvement, 72 were rated as good and four providers are outstanding. Comparison against the national picture demonstrates that there is still some work to be done locally to improve care home quality. However it should be noted that the quality gap is narrowing and substantial progress has been made over the last 12 months. All 12 care homes in Craven (which are not included in the above) are rated as good. Working in partnership (with local authority, health colleagues and care home providers) to improve safe effective high quality care, we have completed a number of joint quality visits to homes with the relevant local authority (LA) to gain assurance that safe, high quality, effective services are provided. This has helped to further develop relationships with private providers and ensure partnership working with social care. Although still a very challenging sector, care home quality improvement continues to be a focus and a priority area identified within the CCG and working in collaboration with the LA.

This has enabled further focus to improve the quality of provision in our care home sector through the provision of different initiatives. These include provider access to clinical and leadership training, including the innovative Brightening Minds workshops, based on the CQC key lines of enquiry which supported care home leaders in feeling prepared, confident, and in control of their inspection process.


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We have developed and embedded effective contract reporting requirements for providers that support people with continuing healthcare needs. This includes care home CQUINs which link to organisation priorities to improve outcomes and reduce harm (such as hospital admission avoidance, sepsis, advanced care planning, etc). Despite the transient nature of the sector, we have improved compliance of mandatory reporting requirements from 64% in 2016 to 98% in 2018.

This year we have led and enabled a ‘whole system adoption’ of the innovative red bag hospital transfer pathway which was introduced across 115 care homes, two hospital trusts and the ambulance service in Bradford district and Craven. It has facilitated not only closer integrated working across our health and social care system but has also resulted in reduced lengths of stay and improved peoples experience of care through a joined up approach. Currently we are working with the Improvement Academy to reduce avoidable harm, enhance clinical outcomes and improve the experience of people in care homes through the implementation of ‘softer signs’ to recognise and respond to deterioration. Although in its infancy of implementation it is anticipated this will bring positive benefits to both residents and staff by creating a safety culture in care homes.

Across Bradford district and Craven CCGs we are mindful that the long term future sustainability of health and wellbeing is reliant on effective and closer working with our partners in the independent care home sector. As per the recommendations of the CQC system review (2018), and building on the good relationships that already exist, we have worked with the independent care sector to invite participation in local partnership, governance and programme delivery arrangements. The Bradford Care Association now represents the sector at ICB, health and care partnership boards, provider alliances and out of hospital programme board. We have also established a MDT care home service improvement board, which has enabled market engagement, information sharing and joint working to continuously improve. Primary care - We recognise that GP practices are the lynchpin of the healthcare system and work closely with them to support the delivery of high quality care. We support practices to improve their services through the using of ‘soft’ and ‘hard’ intelligence data. We will continue to support practices throughout the formation of primary care networks.

Secondary care – Across all providers there are challenges in recruiting and retaining a skilled workforce. Whilst we collate and monitor specific information for each provider, further work is ongoing to add national targets/ expectation for this area. Castleberg Hospital in Giggleswick (where care was provided by ANHSFT), was temporarily closed in April 2017 due to health and safety concerns. An increased level of service was offered in the community to allow time for us to consider the future of the hospital and associated services. Following a period of engagement and consultation with local people and other stakeholders, our governing body decided to repair and re-open the building, and


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it is anticipated that Castleberg Hospital will reopen later in 2019. We have been exploring opportunities with a group of stakeholders, including members of the public, to make best use of the facilities available at the hospital once it re-opens.

2.3.3 Medicines optimisation The quality, safety and value from the use of prescribed medication continue to be enhanced for our population. New initiatives have been introduced to build upon the successful effort and support over recent years by our colleagues in primary and secondary care, as well as the positive engagement of our public to make best use of NHS resources. Further planning is in progress for implementation during 2019/20 and beyond, using a number of different channels to plan, resource and deliver further improvements to the value from medication. Each year continues to offer opportunities to further improve the cost effectiveness of prescribing. Timely and thorough delivery of change has meant that the potential benefits from appropriate changes to prescribing are realised early on, in a manner that retains or improves the quality of care. Primary care prescribing data (available to November 2018) demonstrates a reduction in the CCG’s weighted prescribing costs by 5.4% compared to the national reduction of 1.7%. There is considerable commitment to improving cost efficiency across the country, therefore the CCG greatly appreciates how this additional improvement represents a narrowing of the gap the CCG is above national to just 2.2% for year to date. As a result of detailed planning, the CCG set itself a high target for prescribing cost efficiencies for 2018/19. By early February it was well advanced in its delivery and expected to achieve its medicines and prescribing efficiency plan. An external factor may affect the CCG’s final overall position against its prescribing budget, with slippage expected in final months due to the increased list prices for some commonly used drugs in response to shortages in the supply chain. Yet overall, the CCG and its partners have been very successful in achieving and delivering its plans in prescribing and medicines. Key areas of focus during 2018/19 have included: • Reducing medicines waste by improving the ordering system for repeat

medication and assisting individuals to avoid unnecessary over-ordering. Effective campaigning will continue but there is already demonstrable evidence of the success of this work.

• Further encouragement to local clinicians to review and reduce their prescribing of those medicines identified nationally as ‘items that should not be routinely prescribed in primary care’. Data demonstrates ongoing reductions in usage including in those topics where the CCG was already well below national average.

• Our local programme to encourage self-care has been supplemented by a national programme of the same purpose; encouraging patients, carers and clinicians not to prescribe ‘over the counter medication’ that can be purchased at low cost or that have limited clinical benefit. Recent data analysis demonstrates reduced spend and fewer items being prescribing.


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• Medication review, in particular the residents of local care homes, discussing with individual patients any medicines they may no longer take or need and those that may cause them harm now or in the near future. This activity has produced clear evidence of savings in prescribing costs but the resultant benefits of reduced risks (quantified as reductions in hospital admissions) and improved quality of life for patients is very rewarding for all. This is supplemented by the ongoing advice and guidance in the social care setting to support the safe and effective use of medicines.

• Antimicrobial prescribing, aiming to minimise and avoid their unnecessary use and assist appropriate drug selection when truly required. Results continue to demonstrate controlled use, remaining well below national rates on all antibiotics and seeing ongoing reductions in the use of trimethoprim on patients over 70 years of age.

The local health economy is also benefiting from closer working relationships between the CCG and its local hospital providers. System adjustments have made it more practical for patients to access medication that would previously have required the patient to visit the hospital. Improved liaison also means NHS spend on some traditionally high cost hospital costs has been reduced by the early and appropriate conversion of patients to low cost alternatives (biosimilars). Joint consideration and effort to maintain and develop the local drugs formulary continues to benefit patients and clinicians and has resulted in clarity (and greater consistency) in commissioning positions. The CCG’s medicines management team continues to work closely with local partners as well as neighbouring organisations. This encourages new ideas and initiatives to be considered, debated and enhanced, resulting in a more assured but singular medicines and prescribing programme across five CCGs. While the mode of delivery can vary between CCGs to ensure best fit, there is overall benefit in efficiency and consistency of outcomes. This approach is also applied to other resources such as prescribing advisory software, monitoring tools and reporting documents. Our health system has also benefited from the increasing number of practice based pharmacists, be they funded from NHS resources or internal investment from a growing number of GP practices. They have added to the resource for delivering of the CCG’s programme and crucially expanded the skills available with the practices’ teams, allowing medicines experts to support patients and their colleagues. It is expected that this will grow further during 2019/20. 2.3.4 Safeguarding All health organisations have a vital role to play in safeguarding and promoting the welfare of children and adults and the CCG safeguarding team provides leadership, support and expert advice to both the CCG wider health economy. In close collaboration with our CCG colleagues, health providers and other multiagency partners, the CCG safeguarding team works to support the development of effective safeguarding arrangements across Bradford district and Craven.


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The team includes; designated safeguarding professionals and named safeguarding GPs for both children and adults, a domestic abuse manager (health) and specialist practitioners who provide health expertise into the children’s multi-agency safeguarding team (MASH) and Child Sexual Exploitation teams, alongside colleagues from the police, children’s social care and education. The CCG is actively represented by the safeguarding team on a wide range of strategic partnerships including the safeguarding adults and children’s boards, domestic and sexual violence board and the community safety partnership. This ensures that the CCG is fully engaged in local safeguarding work, including emerging areas of concern such as trafficking, modern-day slavery, radicalisation, scams and frauds and female genital mutilation. Representation on the through care strategy group ensures a focus on children and young people who are looked after. The CCG safeguarding team regularly contributes to statutory safeguarding reviews for children and adults, as well as domestic and mental health homicide reviews. This involves: senior representation on overview panels, production of individual management reports on behalf of GP practices and ensuring that learning from reviews are disseminated and used to inform safeguarding practice. An important part of the safeguarding teams role is also to support the CCG in its service development and commissioning work, as well as to provide assurance that the CCG and its healthcare providers are meeting their statutory duties and wider safeguarding obligations. The team compiled a comprehensive annual report detailing the external assurance given to safeguarding boards, internal governance arrangements, and an overview of the wide range of safeguarding work undertaken by the CCG. This was complemented by a new safeguarding strategy, setting out key areas of work for CCG safeguarding team until 2020. The team also presented a report summarising the levels of assurance in relation to the safeguarding performance of local health providers. These reports help to ensure that the organisation, including governing body members, remains up-to-date with specific areas of work and sighted on the range of safeguarding issues across the district. 2.3.5 Freedom of information During 2018/19, 219 freedom of information (FOI) requests were made to Airedale, Wharfedale and Craven CCG, a decrease of 11 on 2017/18 (234). Information was requested from members of the public, private companies, professional organisations and charities, the media, MPs and academic researchers. 34%of all requests were received from individuals, 27% from businesses, with media requests at 14%.


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The five most popular request categories have been in relation to commissioning, contracts/SLAs, continuing healthcare, mental health and medicines management. FOI gives individuals or organisations the right to request information held by public authorities. We aim to make as much information available as possible on our website through our publication scheme however, when the information is not available on the website, it can be requested in writing and will be provided unless an exemption applies. 2.3.6 Health and safety BDCFT became our provider of health and safety competency advice from 1 March 2016. The agreed work plan included the provision of the following outputs and there were regular meetings during the year to review delivery: • risk assessments: first aid, security, premises and fire • review and development of relevant policies • monitoring and (where appropriate) investigation of reportable incidents • health and safety and fire training • circulation of relevant health and safety information via the staff bulletin Reports were presented to audit and governance committee meetings giving an overview of the operational health and safety activity during each quarter and to provide assurance that any health and safety risks have been identified and are being managed. Reports included any Health and Safety Executive national priorities/new guidance issued during this timeframe. The committee noted the following assessments (which identified a low level of risk) and action plans arising at our Millennium Business Park office: • security review • health and safety site assessment • fire safety assessment The standard for mandatory training attendance is 90% of staff, our figures for staff mandatory and health and safety training as at March 2018 are detailed below: • fire safety (yearly – alternating between on-line and classroom training) – 75% • health and safety (three yearly – on-line) – 89% • moving and handling (three yearly – on-line) – 89% There were a total of 12 health and safety incidents or near misses reported across the Bradford district and Craven CCGs during 2018/19:

Violence and aggression against staff 0 Staff member taken ill at work 2 Staff accident 4 Equipment 3 Other health, safety and security 3 12


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Actions taken as a result of these incidents include: replacement of extension leads and repairs to the server room air conditioning in our Millennium Business Park office and development of s suspect packages procedure. There were no RIDDOR incidents reportable to the Health and Safety Executive.

2.4 Engaging people and communities

We are committed to using the experiences of, and insight from, local people to shape the services we commission in Airedale, Wharfedale and Craven. To ensure that we are listening, engaging and involving patients in the planning and design of our local NHS, we have a structure and governance in place to ensure we have the right mechanisms for engaging and involving people and to channel this through the organisation. The CCGs take our statutory duties*1 to involve the public in our decision-making and governance seriously, and we aim to ensure our engagement with the public creates opportunities for real influence and involvement. In addition to carrying out specific engagement or consultation projects, we discharge our duty through a range of ongoing activities throughout the year:

• Grass roots is where the CCG brings together feedback from people who use services, so we can see the bigger picture of what’s working well and where things need to improve. When people share their stories on Care Opinion or NHS Choices, talk to our patient support team, or feedback via social media, this insight gets pulled together to look for trends and patterns. Grass Roots reports and information are routinely used to inform the planning, buying and monitoring of health services.

• Healthwatch are the independent watchdog for health and care – we work

closely with both Healthwatch Bradford and District and Healthwatch North Yorkshire. What people tell Healthwatch is included in our Grass Roots system, ensuring that we hear from a wide range of groups and individuals. Healthwatch are invited to represent people’s views in our decision-making through attendance at meetings such as the Joint Quality Committee. We also work with Healthwatch on specific engagement projects.

• Patient groups (or PPGs) in each of our GP practices give patients a voice on

developments in primary care and engage with local patients in lots of different ways, from self-care events to walking groups. The CCG bring practice volunteers together through events, training and networks to help share ideas and support involvement.

• The People’s Board are a diverse group of people from across Bradford who

come together to influence the CCGs’ plans and help us shape the future of

1 Under the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012), CCGs have

duties to involve the public in commissioning, (under section 14Z2).


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health services. They bring different perspectives into the organisation, and challenge us to think differently when planning health care.

These different methods work together, putting the views and experiences of local people at the heart of what we do. When there are significant changes planned to the services we commission, the CCGs’ will carry out formal consultation processes in line with statutory guidance. As well our own ways for people to get involved, we take an asset based approach – working with the groups and organisations that are already well connected in the community. This includes our Engaging People grant, delivered by a partnership of local voluntary sector organisations, and supporting a number of forums such as the Women’s Health Network and the VCS Health and Wellbeing Hub. Information about all the different ways to get involved is available on our websites, and this year we have worked to improve the way we report back to people about the difference engagement makes. This included working with our People’s Board, local Healthwatch and the Involve Group to refresh our websites and create new content. We also produce a separate Annual Statement on Patient and Community Engagement, which is published alongside this report, and which gives greater detail about individual engagement projects and their outcomes. Highlights from 2018/19 include: • Carers’ engagement • Care Navigation • Domestic violence • Women’s Health Network • Talk Cancer • Community Partnerships 2.4.1 Carers Throughout June and July 2018, we worked with the local authority to hear the views and experiences of local carers across Bradford district and Craven. Around 450 carers took part, telling us about what matters most to them, what challenges they face and what helps them keep going. This insight is being used to develop the support service for carers across our district. For example, we found out that carers from BAME backgrounds and working carers found accessing support more challenging, so the service specification for carers’ support will now include elements to address these needs. The People’s Board were also involved throughout, helping us develop our approach to engaging carers. They offered advice about effective approaches and challenged commissioners to make connections with different communities to help us reach ‘hidden carers’. Two members of the People’s Board, who are both carers themselves, were involved in the evaluation of bids for the Carer’s Support Service contract.


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The insight from our engagement with carers will also be used to develop a refreshed strategy for supporting unpaid carers across Bradford district and Craven. 2.4.2 Care navigation Our approach to care navigation has been influenced by feedback from the grass roots system, and engaging with local people has been central to rolling out care navigation in practices. People said it was particularly important that patients understood the change and why it might help them; they said we needed to make sure this information reached people with different communication needs and from different backgrounds. We developed a communications toolkit for practices to help make sure that patients across Bradford district and Craven were getting good information about care navigation which was sent to practices before care navigation launched in December 2018. This included information in a range of accessible formats. We also encouraged practices to work with their patient participation groups and practice volunteers. Engaging People teams took information about care navigation out to the community, to make sure that people from different backgrounds understood what was happening and how it would help them. They gave out information leaflets and talked to people at lots of different locations, such as mosques and other places of worship, community centres, knit and natter groups, and schools. The feedback gathered from patients and carers was presented to practice staff in workshops set up to continually improve the way Care Navigation works for patients. 2.4.3 Domestic violence Across June and July 2018, Engaging People partners worked with the CCGs to gather views and experiences which could help inform the development of services for domestic violence and sexual violence. Commissioners came to the Women’s Health Network to discuss these questions and hear directly from people about the issues they see in their communities and the types of approach that are needed. The report from the engagement work highlights commonly-occurring themes and key issues for commissioners to take into account when developing services. It has been used to help design the way this support is offered across Bradford district and Craven, ahead of a joint procurement process which will be led by the council in 2019. 2.4.4 Women’s Health Network The Women's Health Network identifies and addresses health issues and inequalities affecting women and their families living in Bradford district and Craven, and is supported by the Engaging People grant from the CCGs. In the past year the Women’s Health Network has thrived, developing an action plan and setting its own


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direction based on the issues that matter most to members, as well as the issues that the CCGs want to address. For example, members identified that women can often experience challenges due to a lack of information about menopause. As a result, the Women’s Health Network is piloting menopause cafe's across Bradford to provide a safe space for conversations about menopause. They aim to increase the awareness of the impact of the menopause on those experiencing it, their friends, colleagues and families. 2.4.5 Talk Cancer In Bradford City CCG area we ran a programme of Talk Cancer workshops to engage community workers, volunteers and frontline healthcare staff to come together, learn and share ideas about how to improve cancer outcomes for our population. The workshops develop the skills, information and confidence to talk about cancer; helping people reduce their risks, take part in screening programmes, and spot signs earlier. Twenty four workshops have taken place in community settings, with over 200 people taking part. As part of our commitment to accessible information, we worked with Bradford Talking Media to deliver a BSL interpreted session for the deaf community – the first time that Cancer Research UK has done this. We are working with Cancer Research UK to fully evaluate the impact of this engagement work, and our Annual Statement on Patient and Community Engagement features a case study of how Talk Cancer has made a difference. 2.4.6 Community Partnerships As community partnerships develop across Bradford district and Craven, it’s vital that local people and the voluntary and community sector (VCS) are represented. The CCGs are encouraging and supporting each community partnership to develop their own plans for engaging and involving people, in the way that best works for their population. We’re also supporting Community Action Bradford and District to further develop their database of community organisations, groups and activities to enable a better understanding of the assets that exist in each area, and help people connect. In the 10 Bradford community partnership areas, VCS anchor organisations have been identified to connect communities with this new way of working. Small grants funding has been invested to support and activate grassroots community activities and ideas which will improve the health and wellbeing of local people. In Airedale, Wharfedale and Craven the Community Partnerships have embraced an asset based community development approach, and held successful ‘open space’ events to understand what local people care about and what action the community wants to take forward to improve wellbeing. Further detail about all our engagement activity, is reported separately in our Annual Statement of Patient and Community Engagement which is published alongside this report.


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2.5 Reducing health inequalities

2.5.1 Health inequalities

Health inequalities” are the differences in the health of different parts of the population. For example, people in more deprived areas have a shorter life expectancy than those who live in less deprived areas. We also know that unhealthy behaviours such as smoking, physical inactivity, poor diet, alcohol and stress increase the risk of long-term illness and poor health. Inequalities also exist between groups according to other factors, such as gender, ethnic background, certain sorts of disability and sexual orientation.

Tackling health inequalities is a long-term process, but with the strength of partnership working we can shape joint plans for the coming years around the need to promote self-care and prevention work to help people improve their health and wellbeing. The joint strategic needs assessments are developed with partners in the public, private and voluntary sector organisations and we are party to two of these in Bradford district and Craven. They identify the health and wellbeing needs of the local population and aim to support the development of services to reduce inequalities. In addition, the new Bradford and Airedale Joint Health and Wellbeing Strategy – Connecting people and place for better health and wellbeing – describes our commitment to reducing health inequalities in Bradford district. This is further supplemented by the Healthy Bradford Plan (our prevention strategy), the Children, Young People and Families Plan 201-2020 and the Bradford district and Craven Mental Wellbeing Strategy 2016-2021.

Our focus from these plans has been on the main causes of preventable deaths including:

• cardiovascular diseases • respiratory diseases • cancer

Our work to address these issues is documented earlier in this report.

2.5.2 Equality and diversity

Equality and diversity We are committed to reducing health inequalities and to promoting equality and diversity. We see our equality and diversity work as an integral part of our work to reduce health inequalities. The Equality Act 2010: The Act has two broad aspects, the first of which prohibits discrimination, harassment and victimisation against people with one or more protected characteristics. The protected characteristics are age, disability, gender reassignment, marriage and civil partnership (only with regards to eliminating


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discrimination), pregnancy and maternity, race, religion or belief, sex and sexual orientation In addition, the public sector equality duty (PSED) places an obligation on public bodies such as the CCG to be proactive in improving equality for people with one or more protected characteristics. It aims to help public authorities avoid discriminatory practices and integrate equality into core business. Equality objectives The Act requires public bodies to publish at least one, specific and measurable equality objective, at least every four years that they believe will support them to achieve the aims of the general duty. In line with the Equality Act 2010 and following extensive engagement with CCG staff and with the local community and voluntary sector in 2018 we agreed the following equality objectives:

• tackle loneliness and isolation and promote self-care and emotional and

social connections amongst protected groups • work with the voluntary and community sector to ensure ongoing involvement

and engagement with protected groups and enable the participation of vulnerable seldom heard groups in shaping our services

• increase awareness of stigma and mental health issues and to improve access and experience of mental health services for young people, including access to self-care

• promote inclusive leadership and staff development progression

In March 2019 we reviewed our progress in meeting these objectives and the update report is available on our website. We use Equality Impact Assessments (EIAs), to measure the impact of our decisions on equalities and to ensure that we carefully consider how they may affect the local population, particularly in relation to people with protected characteristics. The assessments also help to identify actions we can take to reduce or remove any negative impacts. We use EIAs as a tool to analyse and consider a range of information, including engagement, to inform our decision making both as an employer and commissioner. This year we have been involved in the development of a combined quality and equality impact assessment process which will be used across West Yorkshire and Harrogate Health and Social Partnership. Through adopting this consistent ‘Do Once and Share’ approach to assessing the quality and equality impacts of proposed changes resulting from its commissioning decisions and recommendations, the partnership will avoid the duplication of work across different partnership organisations. The process aims to ensure that services are high quality and meet the needs of all patients and service users, especially those from groups of people who experience disadvantage and/or discrimination.


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Our commitment to local people Tackling inequalities is one of our key priorities: we are committed to making sure that equality and diversity is a priority when planning and commissioning local healthcare. We work closely with local communities to understand their needs and how best to commission the most appropriate services to meet those needs. We have been using the national Equality Delivery System 2 (EDS2). EDS2 is a performance framework that helps NHS organisations to improve the services they commission or provide for their local communities, consider health inequalities in their locality and provide better working environments, free of discrimination, for those who work in the NHS. NHS organisations are required to assess and grade their equality progress using the NHS EDS2. The involvement of key stakeholders, representing the interests of our diverse communities, is an essential element of this. You can find out more about EDS2 on the NHS England website. Nationally the EDS framework is being reviewed and EDS3 is due to be piloted during 2019 and then rolled out across the NHS in 2020. Working in partnership with Bradford City and Bradford Districts CCGs, with our NHS provider trusts: Bradford District Care NHS Foundation Trust (BDCFT), Bradford Teaching Hospitals NHS Foundation Trust (BTHFT) and Airedale NHS Foundation Trust (ANHST), and with representatives from the local community and voluntary sector we have begun to develop a joint strategy to make sure we are use EDS in the most effective way possible. Once agreed this strategy will be published on our website. Each year, the CCG must publish information describing the key inequalities experienced by people with protected characteristic(s) and demonstrating the impact of its policies and practices on people with protected characteristics. This year we have reviewed our equality and diversity web page, in order for this to be compliant as our Public Sector Equality Duty (PSED) report. More detailed information on our equality objectives, EDS2 and WRES and previous PSED reports can be found on our website. We have also been supporting our practices to implement the Accessible Information Standard (AIS), which requires health and social care organisations to identify record and share information to meet the needs of patients who have a disability, impairment or sensory loss. CCGs are expected to give consideration to the duty and ensure their providers are meeting this standard and we are monitoring the progress of our providers through the contract monitoring process. Our commitment to our staff To ensure that our staff members do not experience discrimination, harassment and victimisation we have a range of policies to support staff including flexible working, bullying and harassment, employing disabled people, home working and retirement. All relevant policies have had an equality impact assessment.


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The implementation of these policies, along with occupational health support, helps ensures the retention of staff. They also ensure access for all of our employees, including disabled staff members to training, career development and promotion opportunities. We recognise that in order to remove the barriers experienced by disabled people, we need to make reasonable adjustments for our disabled employees. We do this on an individual basis and involve occupational health services as appropriate. We continue to be accredited to the Disability Confident Employer scheme. Further information can be found here: https://disabilityconfident.campaign.gov.uk/. This year we have continued to deliver our face to face mandatory equality and diversity training to staff including senior managers. In response to feedback from CCG staff the training has been redeveloped and now focuses on how to effectively intervene to challenge any stereotyped views or myths expressed about people with protected characteristics. In April 2015, the NHS Workforce Race Equality Standard (WRES) became a mandatory requirement which requires NHS organisations to demonstrate progress against nine indicators. The CCGs’ WRES report is available on the website along with its action plan. This year we have developed a joint action plan with Bradford City CCG and Bradford Districts CCG. A summary of what our WRES data tells us along with actions we are implementing and planning in response is also available in our equality objectives progress report. The NHS Workforce Disability Equality Standard (WDES) has just been introduced. It is not mandatory for CCGs to submit WDES returns but in line with good practice, we looked last year at whether our staff survey results showed any disability inequalities. In some areas our disabled staff did report poorer experience than their non-disabled colleagues. Details along with what we plan to do in response are available in our equality objectives progress report. Supporting and monitoring NHS provider organisation s As a commissioner of health care, we have a duty to ensure that all of our local healthcare service providers are meeting their statutory duties under the Equality Act 2010 Public Sector Equality Duty. We do this in two ways. Firstly the Equality and Diversity leads from the CCGs and our three main NHS provider trusts: Bradford District Care NHS Foundation Trust (BDCFT), Bradford Teaching Hospitals NHS Foundation Trust (BTHFT) and Airedale NHS Foundation Trust (ANHST) meet regularly to share good practice and develop joint strategy and implementation projects. We work together to make best use of the Equality Delivery System for example and share learning about interventions that work in reducing inequalities. In addition to this, the provider trusts submit to the CCGs six monthly update reports on progress in meeting their equality objectives (this includes progress with national initiatives like WRES and the Accessible Information Standard) and the CCG provides detailed feedback.


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Our independent sector providers submit annual update reports and receive written feedback along with bespoke support as necessary.

2.6 Health and wellbeing strategy

Bradford district: Our joint health and wellbeing strategy is the product of genuine collaboration between all partners including the CCGs, whose staff were involved in the development and drafting as well as in the sign off at the Board. Our Health and Wellbeing Strategy focuses on the improvement of the long term health outcomes for people, and the CCGs have demonstrated their intent to focus on prevention and early intervention through their commissioning and their place shaping roles

North Yorkshire: The North Yorkshire joint health and wellbeing strategy was published in 2015 to cover the period 2015-2020. As preparations are made to review the strategy, for example, through an annual refresh of the joint strategic needs assessment, we will actively contribute and support engagement with the people of Craven in the development of the strategy.

2.7 Financial performance

In 2018/19, revenue resources of £243.8m were available to our CCG, made up of £212.2m for the commissioning of healthcare services (programme allocation), £22.8m for the commissioning of primary care medical services, £3.4m for administration costs (administration resource allocation) and £5.4m brought forward from last year. This represents an increase of £10.6m over last year with the most significant changes in our resources being due to:

• an increase of £0.2m (1.00% - national growth uplift) for the commissioning

of primary care medical services; • an increase of £4.1m (1.99% - national growth uplift) for the commissioning

of healthcare ; • an additional increase of £1.7m (share of national funding following

2017 Autumn Budget statement); • an increase of £3.1m in the surplus brought forward from 2017/18; and • a non-recurrent increase of £0.4m for GP Forward View Improved

Access, £0.2m for achievement of 2017/18 Quality Premium, £0.1m support for prescribing cost pressures and other national policy requirements.

The CCG’s running cost allocation remained at £3.4m, the same level as 2017/18, which represented a real terms decrease in light of pay and non-pay cost inflation.

Expenditure budgets of £238.4m were set to match in-year revenue resources (total resources of £243.8m less resources brought forward from 2016/17 of £5.4m) with actual expenditure for the year reflecting:

• healthcare service demand pressures on acute hospital services;


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• increased demand for continuing healthcare (nursing home placements and home care);

• additional investment in mental health services across including the expansion of the GP wellbeing service, funding to reduce waiting times for assessment and diagnosis of autism and ADHD and significant growth in other services for children and young people;

• primary medical care services reflecting the first year of delegation and additional investment as part of the GP Five Year Forward View programme;

• primary care prescribing costs where savings achieved through the implementation of the savings target schemes were offset by price concession cost pressures.

Overall, we managed our expenditure within budget and reported a break-even position as planned.

Therefore the total cumulative surplus for the CCG remains at £5.4m and this will be carried forward to 2019/20 for drawdown in future years.


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Our actual expenditure in 2018/19 across the main budget areas is shown below:

Total CCG net expenditure – 2018/19 (£238.4m)

Figure 1: total CCG net expenditure 2018/19


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Acute healthcare expenditure of £122.9m in 2018/19 was incurred as follows:

Figure 2: acute healthcare expenditure 2018/19

Overall performance against our statutory financial targets was:

Target

Actual Target

Achieved

Keep Revenue Expenditure within the Revenue Resource Limit (excluding prior year surplus) of £238.4m

Revenue Expenditure of £238.4m

Yes

Keep Administration Spend within the Administration Resource Limit of £3.4m

Administration Spend of £3.0m

Yes

Table 3: overall performance against statutory fina ncial targets

Note: the CCG did not have a capital resource limit or any capital expenditure in 2018/19.


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2.3.1 Quality, innovation, productivity and prevention (Q IPP)

In relation to its cost savings target, the CCG achieved £4.1m of savings against a plan of £6.7m with the majority of savings being achieved against prescribing and planned care budgets. Building on the good performance this year, work has continued to develop a robust plan for 2019/20 which will include the continuation of some schemes from 2018/19 and new schemes that will have an impact in the new financial year.

Looking ahead, we now have resource allocations that reflect the five year funding settlement for the NHS. Whilst this does include additional growth funding, the cost of healthcare demand pressures, changes in national tariffs and the implementation of national policy requirements is expected to be greater than the total increase in CCG funding. Therefore, the financial outlook for our local health system remains challenging and will require further cost savings to be made over the medium term. Also, in line with national requirements we will be aiming to reduce our administration costs by 20% in real terms by 2020/21.

To ensure financial sustainability in the longer term, we have continued to work with local health organisations and the local authority in developing our health and care plan for the Bradford district and Craven. As part of this, our local health and social care system is implementing plans to deliver efficiencies through a combination of local and West Yorkshire wide initiatives designed to improve the use of our resources and introduce new care models.

2.3.2 Annual accounts – 2018/19

Our accounts have been prepared in accordance with the directions issued by the NHS Commissioning Board to show a true and fair view of the financial affairs of the CCG. These accounts comply with the requirements of the Department of Health’s Group Accounting Manual for 2018/19.

The full accounts for the CCG are shown on page 134 onwards.

2.3.3 External audit

KPMG LLP acts as our external auditor and the following services have been provided during the year:

• Statutory audit services - total fees of £43,200.

No other services were provided.


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Chapter 2: Accountability report

1 Corporate governance report

1.1 Members’ report

1.1.1 Member profiles

Helen Hirst, accountable officer Helen became the accountable officer for the three CCGs in the Bradford district and Craven – Airedale, Wharfedale and Craven, Bradford City and Bradford Districts – in October 2016 having previously been in the same role for Bradford City and Districts CCGs since their establishment in 2013. In the last few years she has also undertaken interim roles with NHS England (Director of CCG Development) and with the Vale of York CCG (accountable officer). Helen has worked in Bradford since 1992 and was the deputy chief executive of the former Bradford and Airedale Teaching Primary Care Trust (PCT). In 2010 Helen took a two-year secondment with the Department of Health as programme director for primary care commissioning as part of the NHS Commissioning Board establishment team. Outside work, Helen spends her time with her family, she’s married with a 13 year old daughter and 30 year old step-daughter who has just made her a proud ‘granny’.


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Dr James Thomas, clinical chair James is originally from London where he carried out his medical training and initially worked. He moved to Yorkshire in 1995 and trained as a GP in the Airedale area. In 2002, James joined the Fisher Medical Centre in Skipton as GP partner. He has a keen clinical interest in sport and exercise medicine and he was involved in the Olympics in 2012. He is also passionate about education in local primary care services and teaches medical students, young doctors and GPs. He was the school lead for GP trainers for Health Education England in Yorkshire and Humber. He was previously a GP executive at Airedale, Wharfedale and Craven CCG leading on children’s services and the new models of care programme. James is now the clinical chair at the CCG and clinical lead for standardisation of clinical policies across West Yorkshire and Harrogate Health and Care Partnership. He is married to Kate who is also a GP and he likes to spend his free time with his family. He enjoys watching American football and rugby; and plays baseball when he is able.

Julie Lawreniuk, chief finance officer/deputy chief officer – governing body and clinical board Julie is a qualified accountant who has worked in the NHS since 1991. During this time, she has worked in a number of senior finance roles across West Yorkshire including, more recently, joint chief finance officer for Calderdale and Greater Huddersfield CCGs and executive director of finance and efficiency for NHS Calderdale. Julie is married and lives in Bradford. She has two grown up daughters and is a passionate supporter of Bradford City football club.


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Dr Bruce Woodhouse, chair of the council of members (until Jan 2019) – governing body Bruce qualified from Nottingham University in 1989 before moving to Airedale to complete his general practice training at Airedale General Hospital. Since 1994, he has been GP principal at Dyneley House in Skipton. For 13 years, he has worked as a GP trainer and is currently involved in medical student training. His areas of clinical interest include diabetes and orthopaedics. Away from work, Bruce is a keen cyclist and plays cricket for the Skipton Church Institute Cricket Club. Note: Dr Caroline Rayment was appointed as chair from February 2019 and elected not to take up a role on the governing body (see page 84)

Dr Peter Brunskill, FRCOG, secondary care consultant Peter is an obstetrician and gynaecologist who held a consultant post at Airedale General Hospital, from 1991 to 2009. During that time, he developed a number of new and innovative clinical services and led the gynaecological cancer team. From 1992 to 1996, he was Chair of the District Audit Committee and the Theatre Management Group, from 2005 to 2008. He played an active role in the development of maternity IT services and the gynaecology out-patient facilities. Since leaving Airedale Hospital, Peter has continued to live in the area and works as a medicolegal expert witness in the UK and Ireland. He is an active medical teacher both for the UK Advanced Life Support Group and for the Liverpool School of Tropical Medicine in Africa. His main passions outside work are golf and the success of Burnley Football Club.


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Angie Clegg, registered nurse Angie qualified as a nurse at St James’ Hospital in Leeds in 1984. Since then she has worked as a nurse, clinical leader, consultant nurse, lecturer, senior manager and director in Leeds, Bradford and Airedale. She has been awarded a BSc in health studies from Leeds Metropolitan University and an MSc in leadership and advanced practice from her studies at Bradford University. As a nurse leader, Angie’s research, publications and area of expertise includes innovations in intermediate care, out of hospital care, advanced practice, clinical leadership and quality.

Pam Essler, lay member (patient and public involvement) and deputy chair Pam has a long standing involvement with the NHS - as a lay person at a local, regional and national level. She was chair of Airedale Primary Care Trust (PCT) before Bradford and Airedale Teaching Primary Care Trust was formed, where she was deputy chair. As independent chair of the Standards Committee of Bradford Council she was involved in the development of the ethical governance framework and oversaw the associated complaints process. She is also chair of Bradford and Airedale Citizens Advice. For the three CCGs in Bradford and Airedale, Pam is chair of the Individual Funding Request Committee. She is also trustee of a number of local charities. She has four grandchildren, who she spends lots of time with and jokingly refers to looking after them as her new exercise regime.


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Neil Fell, lay member (governance) Neil has worked in numerous NHS roles over many years. After a short period in industry he began his NHS career in Rotherham in 1974. Between 1974 and 1986, he held a number of accounting positions with Rotherham and Sheffield health authorities. In 1986, he joined Bradford Area Health Authority as chief internal auditor and held a number of management roles before he was appointed as director of finance in 1993. He was an executive director at Bradford Health Authority and at the Airedale Primary Care Trust (PCT), until 2007. Since then he has undertaken a variety of finance related roles as a consultant, finance director and financial trustee. Married with a grown-up family, he is a fellow of the Association of Chartered Certified Accountants. When not working he enjoys hill walking, fishing and watching most sports – particularly football. .

Bryan Millar, lay member (finance) – governing body Bryan retired as chief executive of Bradford Teaching Hospitals NHS Foundation Trust (BTHFT) in August 2014, having worked in the NHS since 1977 in a variety of roles within Yorkshire and the North East of England. After occupying a number of posts at district and regional health authorities, he joined Northgate and Prudhoe NHS Trust becoming their director of finance and performance management in 1993. He became director of finance at Bradford Community Health NHS Trust in 1999 before moving to Bradford South and West Primary Care Trust (PCT) where he was director of finance and deputy chief executive. Bryan joined BTHFT in October 2005. He is a fellow of the Association of Chartered Certified Accountants.


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In addition to his former role as chief executive of BTHFT, Bryan was also a board member of Health Education England, Yorkshire and the Humber (and chair of its finance, governance and risk committee), chair of the local comprehensive research network partnership group, and director of Medipex (an intellectual property company and NHS innovation hub).

Sue Pitkethly, director of accountable care Airedale/executive director (until 19 December 2018) Sue has worked in the health service for 42 years. After qualifying as a registered nurse and intensive care specialist, Sue had a number of clinical roles before she embarked on a clinical leadership role at the Zurich University Hospital. She returned to England to clinically lead the successful development of a new independent hospital. Moving back to the NHS as Director of Nursing at a major teaching hospital, Sue then made a significant career change to become Director of Planning and Performance. She led improvements that resulted in the hospital become a high performing organisation and managed its successful application to become a foundation trust. Again seeking a challenge, Sue switched her career from 'provider' to ‘commissioner’; she led the Airedale and Wharfedale Practice Based Commissioning Alliance which involved quality improvement, delegated budgets and contracts. She was the ‘think tank’ behind and pioneered the national award winning Airedale Collaborative Care Team, before embarking on the development of our CCG, to full authorisation, across two local authority boundaries. Sue is married with two daughters and her hobbies include cooking, cycling and horse riding; and she particularly enjoys three-day eventing with her daughter.


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Nancy O’Neill, executive director (from 20 December 2018) Nancy qualified as a registered general nurse in 1984 before going on to work as a practice nurse providing health promotion and long-term conditions services. With the development of primary care groups in 1998, Nancy was appointed to the role of nurse representative on the board of Bradford City Primary Care Group. During this time she completed a degree in community health and developed an interest in implementing clinical governance in practice. After completing a masters in quality assurance in health and social care, Nancy held a number of director posts in NHS commissioning organisations with responsibility for service development and ensuring effective systems for managing clinical and organisational risk and governance. Nancy also has significant experience in operational management, having spent a number of years in the post of chief operating officer for an arm’s length NHS provider organisation with around 2,000 staff and over 50 different services. More recently, Nancy has been working across health and social care organisations to develop and implement an effective strategy for promoting collaboration through the development of effective relationships. Outside work, Nancy’s main passions are her four grandchildren, travelling and watching rugby league.


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Michelle Turner, director of quality and nursing

Michelle is a registered nurse; she trained as a district nurse and health visitor and holds degrees from King's College, London and City University, London. She entered health service management in West London in 2002 after a long period of frontline practice as a health visitor in White City. She has been acting director of primary care for two primary care trusts (PCTs), and was deputy director for transformation and integration for NHS Bradford and Airedale. She was seconded to Calderdale and Huddersfield NHS Foundation Trust in 2010 to lead the development of the trust's end of life strategy. Michelle is passionate about the NHS and its services to patients.

Dr Colin Renwick, elected GP (until March 2019) – governing body Colin is a retired GP who has spent over 25 years working in Airedale, Wharfedale and Craven, having completed his training at Airedale Hospital. Born and brought up in Surrey, he moved to Yorkshire to the Leeds Medical School in 1981 and he has been a GP in Settle since 1992. He was a member of the practice based commissioning alliance in Craven for four years and became Chair after the first year, working in partnership with the North Yorkshire Primary Care Trust (PCT) as they managed the financial challenges they faced. He was vice chair of the working group set up to develop our CCG. Currently, he is leading the urgent care programme and is a member of the Bradford and Airedale A&E delivery board and the North Yorkshire health and wellbeing board. He also currently leads on children’s and maternity and medicines management. His wife Jackie is also a GP at the Settle practice and they have four children. In Colin’s spare time, he enjoys cooking and walking in the Yorkshire Dales with the family’s Labrador dog.


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• IG Medical (Ilkley Moor and Grassington) • Ilkley and Wharfedale Medical Practice • Kilmeny Group Medical Practice* • Ling House Medical Centre • North Street Surgery • Oakworth Medical Practice* • Silsden and Steeton Medical Practice • Townhead Surgery

Sarah Muckle, public health representative (non-voting advisor) – governing body Sarah is Bradford’s director of public health. She worked previously in Bradford as deputy director of public health and in Kirklees as a public health consultant in both the primary care trust (PCT) and local authority. Some of her key achievements include developing a community based chronic pain service which achieved national recognition and informed a national chronic pain strategy and Royal College of General Practitioners (RCGP) commissioning guidance, development of an online self-care tool that was nominated for a national award, and development of a nationally recognised self-care programme. Sarah started her public health career 12 years ago in the Scottish Borders working in a role focused on applying public health knowledge and skills in primary care and community services to embed principles around improving health, protecting health and reducing health inequalities.

1.1.2 Member practices

*These practices are part of the Modality Partnership You can find out more about our member practices on our website.

1.1.3 Composition of governing body The composition of the governing body can be found on page 83 onwards of this annual report.

• Addingham Medical Centre • Cross Hills Group Practice* • Dyneley House Surgery • Farfield Group Practice* • Fisher Medical Centre* • Grange Park Surgery • Haworth Medical Practice* • Holycroft Surgery*


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1.1.4 Committee(s), including audit committee

The composition of the committees of the CCG and committees of the governing body can be found on page 86 onwards of this annual report. 1.1.5 Register of interests Our registers of interests can be found on our website. 1.1.6 Personal data related incidents During 2018/19 we reported one incident via the Data Protection and Information Toolkit to NHS Digital and the Information Commissioner’s Office. This incident was reported by NHS Bradford Districts CCG on behalf of the three Bradford district and Craven CCGs and all member practices and related to the availability of personal data used for healthcare purposes following an IT network outage. There was no loss of or unauthorised access to personal data as a result of this incident. It later transpired that this was not an incident that the ICO deemed reportable, however, we felt doing so was in line with the spirit of NHS data security and protection incident reporting guidance. The case was closed by the ICO with no further action required. Further details about this incident can be found at section 1.3.11 (information governance) of the annual governance statement on page 109. A further 11 data related incidents or near misses were reported during the year across the Bradford district and Craven CCGs; none of these were classed as ‘serious’. All incidents reported within the CCG are reviewed by the audit and governance committee. 1.1.6 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 the audit report;

• the member has taken all the steps that they ought to have taken in order to make him or herself aware of any relevant audit information and to establish that the CCG’s audit committee is aware of it.

1.1.7 Modern Slavery Act We fully support the government’s objectives to eradicate modern slavery and human trafficking but do not meet the requirements for producing an annual slavery and human trafficking statement as set out in the Modern Slavery Act.


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1.2 Statement of accountable officer’s responsibilities

The National Health Service Act 2006 (as amended) 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 Helen Hirst to be the Accountable Officer of Bradford City CCG.

The responsibilities of an Accountable Officer are set out under the National Health Service Act 2006 (as amended), Managing Public Money and in the Clinical Commissioning Group Accountable Officer Appointment Letter. They include responsibilities for: • The propriety and regularity of the public finances for which the Accountable

Officer is answerable, • Keeping proper accounting records (which disclose with reasonable accuracy

at any time the financial position of the Clinical Commissioning Group and enable them to ensure that the accounts comply with the requirements of the Accounts Direction,

• For safeguarding the Clinical Commissioning Group’s assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities),

• The relevant responsibilities of accounting officers under Managing Public Money,

• Ensuring the CCG exercises its functions effectively, efficiently and economically (in accordance with Section 14Q of the National Health Service Act 2006 (as amended)) and with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the National Health Service Act 2006 (as amended))

• Ensuring that the CCG complies with its financial duties under Sections 223H to 223J of the National Health Service Act 2006 (as amended).

Under the National Health Service Act 2006 (as amended), NHS England has directed each Clinical Commissioning Group to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Clinical Commissioning Group and of its income and expenditure, Statement of Financial Position and cash flows for the financial year.

In preparing the accounts, the Accountable Officer is required to comply with the requirements of the Government Financial Reporting Manual 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 Government


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Financial Reporting Manual have been followed, and disclose and explain any material departures in the accounts; and

• Prepare the accounts on a going concern basis; and • Confirm that the Annual Report and Accounts as a whole is fair, balanced and

understandable and take personal responsibility for the Annual Report and Accounts and the judgements required for determining that it is fair, balanced and understandable.

To the best of my knowledge and belief, and subject to the disclosure set out below, (e.g. directions issued, s30 letter issued by external auditors), I have properly discharged the responsibilities set out under the National Health Service Act 2006 (as amended), Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter. I also confirm that: • as far as I am aware, there is no relevant audit information of which the CCG’s

auditors are unaware, and that as Accountable Officer, I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the CCG’s auditors are aware of that information.

Helen Hirst Accountable officer NHS Airedale, Wharfedale and Craven CCG

28 May 2019


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1.3 Governance statement 1.3.1 Introduction and context NHS Airedale, Wharfedale and Craven CCG is a body corporate established by NHS England on 1 April 2013 under the National Health Service Act 2006 (as amended). The clinical commissioning group’s statutory functions are set out under the National Health Service Act 2006 (as amended). The CCG’s general function is arranging the provision of services for persons for the purposes of the health service in England. The CCG is, in particular, required to arrange for the provision of certain health services to such extent as it considers necessary to meet the reasonable requirements of its local population. As at 1 April 2018, the clinical commissioning group is not subject to any directions from NHS England as issued under Section 14Z21 of the National Health Service Act 2006. 1.3.2 Scope of responsibility As accountable officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the clinical commissioning group’s policies, aims and objectives, whilst safeguarding the public funds and assets for which I am personally responsible, in accordance with the responsibilities assigned to me in Managing Public Money. 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. 1.3.3 Governance arrangements and effectiveness The main function of the governing body is to ensure that the group has made appropriate arrangements for ensuring that it exercises its functions effectively, efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it. The following sections set out how this main function is achieved. 1.3.4 Constitution and governance structure Our governance framework is clearly set out in the constitution, which is based on the model constitution developed by the NHS Commissioning Board. Our original constitution was approved by the NHS Commissioning Board in January 2013 as part of the CCG establishment process. As we have developed our structures further and in response to legislative changes, amendments have been necessary to the constitution and these have been approved by member practices and NHS England.


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Our constitution sets out a commitment that we will promote good governance and proper stewardship of public resources in pursuing our goals and in meeting our statutory duties. Good corporate governance arrangements are critical to achieving our objectives and are reflected in the duties of the committees and sub-committees; and in the roles of CCG officers. The key elements of the constitution relating to the CCG’s governance and internal control arrangements are: • Section 5: functions and general duties • Section 6: decision making: the governing structure • Section 7: roles and responsibilities • Section 8: standards of business conduct and managing conflicts of interest • Appendix C: standing orders • Appendix D: scheme of reservation and delegation (supplemented by the

financial scheme of delegation) • Appendix F: prime financial policies

The scheme of reservation and delegation sets out those decisions that are: • reserved to the membership as a whole; • delegated to the CCG’s committees and sub-committees, the governing body, its

committees and sub-committees, individual members and employees In March 2019 CCG members approved a revised version of the constitution which was updated in line with the new CCG model constitution issued during the year and will be submitted to NHS England in due course. Terms of reference for committees of the CCG and committees of the governing body are available on our website and our governance structure, from 1 July 2017, when collaborative governance arrangements were established with NHS Bradford City CCG and NHS Bradford Districts CCG, is shown below:


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Figure 3: CCG governance structure during 2018/19

1.3.5 Membership body and governing body

Council of members Role: The council of members plays a crucial role in ensuring engagement of all members in the development and operation of our CCG, including a key role in holding the clinical executive and governing body to account. The council of members is accountable to the member practices. Key responsibilities: The council of members • agrees the overall vision, values and strategic direction of the group. • reviews the effectiveness of the governing body and holds it to account for the

delivery of its functions. • approves the selection and appointment process for governing body and (where

applicable) clinical executive members and arrangements for succession planning.

• recommends the appointment of the accountable officer to NHS England. • works effectively with all GPs and primary care clinical and practice staff to

contribute to the practice’s views into commissioning decisions • considers and approves applications to NHS England in respect to changes to

the constitution, the CCG’s standing orders, scheme of reservation and delegation and prime financial policies.

• maintains a positive and responsive relationship with NHS England and member practices.


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• sets a culture of continuously improving the services for patients, carers, communities and member practices.

Membership and attendance: The council of members has representation from a clinician and the practice manager from each of the CCG’s member practices; the clinical representative cannot be an elected GP member of the clinical executive. On behalf of the membership, the chair is elected by the member practice representatives of the council of members. Dr Bruce Woodhouse was chair of the council of members from CCG establishment until 31 January 2019, with Dr Caroline Rayment appointed as chair from 1 February 2019. Until January 2018, each practice had a single vote (per contract) at the council of members. Following approval by the council, the voting mechanism was changed and is now based on practice list size as at 1 April each year. Whilst it is generally expected that decision-making at the council of members (or any CCG forum) is by consensus, a voting mechanism is in place in case this cannot be achieved. All council of members decisions during 2018-19 were taken by consensus. The council of members has met six times during 2018/19, as well as the 2017/18 CCG annual general meeting held jointly with the governing body and clinical executive in September 2018. Attendance by practice is shown below:

Figure 4: 2018/19 attendance at council of members


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Council of members highlights 2018/19

The council of members: • received the 2017/8 annual report and

accounts at a joint meeting in public with the governing body and clinical executive.

• approved terms of reference for ‘committees of the CCG’ (clinical executive and all of the joint committees) and the CCG’s revised constitution.

• reviewed the council’s effectiveness. • appointed Dr Caroline Rayment as the new

council chair from 1st February 2019. • approved contract extensions for two GP

clinical executive member and to hold one GP position vacant to 31 March 2020.

• discussed proposals to merge the three Bradford district and Craven CCGs from April 2020 (for decision in June 2019)

• receiving briefings and providing comment and challenge on: - development of the AWC health and care

partnership, including underpinning community partnerships, and the Bradford district and Craven system

- Castleberg Hospital, Settle - 2019/20 financial plans and medium term

sustainability - procedures of limited clinical

effectiveness - stroke services - delivery of the mental health strategy - statin project - orthotics and wheelchairs referral criteria

Standing agenda Items • Declaration of interests • Minutes of previous meetings • Action log • Updates on the work of the

clinical executive • Updates on the work of the

joint committee of West Yorkshire and Harrogate CCGs

• Updates on the QIPP programme and the CCG financial position

• Members’ questions and answers

• Updates on national and local CCG developments

Conclusion: The Council of members has fulfilled its role and responsibilities.

Governing body The governing body meets in public six times per annum. Since July 2017, the meetings have been held as ‘committees in common’ with the governing bodies of Bradford City CCG and Bradford Districts CCG. In addition to meetings in public, the governing body and the clinical executive have joint strategy and development sessions up to six times per annum. During 2018-19, all but one of these sessions was held jointly with the Bradford CCGs.

100%

Membership:

Practice

Representatives


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Role: The governing body is responsible for ensuring that appropriate arrangements are in place to exercise its functions effectively, efficiently and economically; and in accordance with our principles of good governance. Key responsibilities: The governing body has responsibility for • ensuring that the CCG has appropriate arrangements in place to exercise its

functions effectively, efficiently and economically and in accordance with the CCG’s principles of good governance (its main function).

• determining the remuneration, fees and other allowances payable to employees or other persons providing services to the CCG and the allowances payable under any pension scheme it may establish under paragraph 11(4) of Schedule 1A of the 2006 Act, inserted by Schedule 2 of the 2012 Act.

• approving any functions of the CCG that are specified in regulations. • monitoring performance in line with our reporting mechanisms. • providing assurance to the CCG that its committees are undertaking their

functions in accordance with the constitution. • approving the financial plan. Membership and attendance: Dr James Thomas Pam Essler Neil Fell Bryan Millar Angie Clegg Peter Brunskill Dr Bruce Woodhouse Dr Colin Renwick Helen Hirst Julie Lawreniuk Michelle Turner Sue Pitkethly

Clinical chair and elected GP Lay member, patient and public involvement (deputy CCG chair) Lay member, governance Lay member, finance Registered nurse Secondary care consultant Chair of the council of members (until 31.01.19) Elected GP (deputy clinical chair) Chief officer Chief finance officer and deputy chief officer Director of quality and nursing CCG executive director (until 19.12.18)

Nancy O’Neill CCG executive director (from 20.12.18) In addition to the members above, Sarah Muckle attends governing body meetings in a non-voting, advisory capacity as a representative of public health. Historically the chair of the council of members was also a non-statutory member of the CCG governing body. In November 2018, the council of members determined that this should be an optional role on the governing body going forwards; the chair of the council of members may be a governing body member but this is not a requirement of the role. Following the resignation of Dr Bruce Woodhouse, his successor as chair of the council of members, Dr Caroline Rayment, elected not to take up a role on the governing body.


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Figure 5: 2018/19 attendance at governing body

Governing body highlights 2018/19 The governing body: • approved the 2018/19 financial and

operational plan. • approved the decision to provide

inpatient care in the community and keep Castleberg Hospital open.

• approved the 2018/19 version of the memorandum of understanding governing working arrangements with the Bradford CCGs.

• endorsed the West Yorkshire and Harrogate Health and Care Partnership memorandum of understanding.

• approved the Strategic Partnering Agreement of the Bradford and AWC Health and Care Partnerships.

• considered the following strategic themes: - evaluation of the people’s board, - community engagement in

tackling winter pressures, - dementia in commissioning

engagement. • approved contract awards for: CCG

and GP IT and IG services and CCG office move building works.

• approved pay awards for staff and

Standing agenda items: • Declaration of interests • Minutes of previous meetings • Action log • Chair and chief officer’s report (including

updates on the clinical executive, joint clinical committee and West Yorkshire and Harrogate CCGs joint committee)

• Performance reports - quality - finance - contracting

• Strategic partnerships report • Updates on the development of the AWC

health and care partnership and underpinning community partnerships

• High level risk report

42%

36%

18%

Membership at

March 2019

Lay & Professional Executive GP


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contractors outside of agenda for change, in line with recommendations from the Remuneration Committee.

• received the investigation reports (IT and clinical quality) arising from the October 2018 network availability incident.

• reviewed and approved the governing body assurance framework as a fair reflection of the CCG’s strategic risk position.

• approved revisions to terms of reference for the audit and governance committee, the PCCC and the remuneration committee.

• reviewed its effectiveness and that of the Bradford district and Craven CCGs collaborative governance structure.

• Minutes of JQC, JFPC, PCCC, audit and governance and remuneration committees

• INVOLVE engagement tracker Annual reports received: • Audit and governance committee • External audit letter • Safeguarding • Emergency preparedness, resilience and

response • Human resources

Conclusion: The governing body has fulfilled its role and responsibilities.

1.3.6 Committees of the CCG and committees of the g overning body Clinical executive The clinical executive is a committee of the CCG and as such is accountable to member practices via the council of members. Assurance on the work of the clinical executive is provided to the governing body via the clinical chair’s report. Role: The clinical executive is responsible for leading the development of the CCG’s vision and strategy, developing and approving commissioning plans and overseeing the commissioning process. Membership and attendance: Dr James Thomas Dr Colin Renwick Dr Brendan Kennedy Dr Jake Jeffrey Dr Graeme Summers Helen Hirst Julie Lawreniuk Michelle Turner Sue Pitkethly Nancy O’Neill

Elected GP and clinical chair Elected GP Elected GP Elected GP Elected GP Chief officer Chief finance officer Director of quality and nursing CCG executive director (to 19.12.18) CCG executive director (from 20.12.18)


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In addition to the members above, Dr Andrew O’Shaughnessy (or colleague) attends clinical executive meetings in a non-voting, advisory capacity as a representative of public health.

The clinical executive met on 21 occasions during 2018/19 and attendance is recorded below:

Figure 6: 2018/19 attendance at clinical executive

Note: Helen Hirst and Julie Lawreniuk shared attendance at clinical executive during the year but both attended where possible.

Clinical executive highlights 2018/19

The clinical executive: • received updates on and input to the

development of the AWC Health & Care Partnership and its Strategic Partnering Agreement

• agreed that there should be a reduction in the number of beds at Curregate nursing home.

• were in agreement for the AWC Area Prescribing Committee to join the South West Yorkshire Area Prescribing Committee.

• received a presentation on the Self-Care and Prevention review 2017-18.

• received regular updates regarding progress towards re-opening Castleberg Hospital.

Standing or regular agenda items

56%

44%

Membership

GP Executive


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• considered an options appraisal for the prescribing incentive scheme.

• considered the implications of the new GP contract and the development of Primary Care Networks.

• agreed to the referral process for Orthotics and Wheelchairs as part of QIPP.

• received updates on dermatology transformation.

• supported the diabetes model. • received a report on the re-procurement of

North Yorkshire specialist adult drug and alcohol service.

• were updated on the Mental Health Strategy Delivery

• approved the change to the terms of reference of the Peoples Board to cover AWC CCG and to recruit members from the AWC area

• received a presentation on the Public Health 0-19 Children’s Service Update and Family Hub Prevention and Early Help (PEH) approach

• agreed the Procedures of Limited Clinical Value policy

• agreed the Wellness Service as a 12 month proof of concept

• received a presentation on the statin initiation scheme

• agreed the changes to its Terms of Reference which were subsequently approved by the Council of Members

• declarations of interest • minutes of the previous

meeting and action log • updates on performance,

finance and QIPP • updates from partnership

groups • area prescribing committee

minutes • risk register (bi-monthly)

Conclusion: The clinical executive has fulfilled its role and responsibilities.

Joint clinical committee (JCC) Role: The purpose of the JCC is to operate as a joint committee of the three Bradford district and Craven CCGs with delegated decision making for the discharge of specific commissioning functions as set out in its terms of reference and annual work plan. In addition, the JCC acts as a key forum for communications and information sharing between the Clinical Boards/Executive of the three Bradford district and Craven CCGs


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Key responsibilities: the JCC

• review and approves commissioning statements and policies. • reviews and makes recommendations to each CCG’s governing body on the

Bradford district and Craven CCGs’ memorandum of understanding that governs collaborative working arrangements.

• informs CCG input to the joint committee of the West Yorkshire and Harrogate CCGs.

• has delegated decision-making for system-wide strategic commissioning areas as set out in the JCC work plan - for 2018/19 these have been:

o acute provider collaboration o mental health and learning disabilities o urgent and emergency care o children and young people o cancer o planned care o medicines optimisation

• has established the Joint Individual Funding Request Panel (JIRFP) as a sub-committee of JCC and receives reporting from the panel on its work

Membership and attendance: Dr Akram Khan Dr James Thomas Dr Andy Withers Dr Shane Beggan Dr Sohail Abbas Dr Carsten Grimm Dr Louise Clarke Helen Hirst Julie Lawreniuk Michelle Turner Sue Pitkethly Nancy O’Neill Liz Allen Ali Jan Haider Fiona Jeffrey

Clinical chair – BC (chair) Clinical chair – AWC Clinical chair – BD Associate GP – AWC (from June 18) Elected GP - BC Elected GP – BD (to May 18 – maternity cover) Elected GP – BD (from June 18 – return from maternity) Chief officer Chief finance officer Director of quality and nursing Executive director - AWC (to 19.12.18) Executive director - AWC (to 20.12.18) Executive director – BC Executive director – BD Associate director of corporate affairs

Key: BC – Bradford City CCG BD – Bradford Districts CCG AWC – Airedale, Wharfedale and Craven CCG


90

Figure 7: 2018/19 attendance at JCC

Joint clinical committee highlights 2018/19

• Reviewed the memorandum of understanding between the three Bradford district and Craven CCGs and the governing body assurance framework / strategic risk log and recommended these for approval by the governing body.

• Received updates on and input to the following work-streams:

bariatrics service stroke services mental health services BTHFT CQC inspection over the counter medicines and low value medicines consultations urgent and emergency care services Health checks for patients with serious mental illness children, young people and maternity fertility treatment commissioning policy medicines optimisation IT incident investigation quality review of MIND IT services re-procurement BDMC proposed budgetary cuts QIPP

• Approved, supported or recommended: funding for dedicated dietetics service for cancer patients proposals for integrated urgent care direction of travel for dermatology services increased funding for school nursing special needs service the CCG’s pharmaceutical rebates policy

Standing agenda items • Declarations of interest • Minutes of the last meeting and

action log • Updates on the work of the joint

committee of the West Yorkshire and Harrogate CCGs.

• Updates on the work of the acute provider collaboration

50%50%

Membership

GP Executive


91

personalised care demonstrator sites proposals for the minor eye condition service

• Reviewed the effectiveness of JCC, its terms of reference and its work plan.

• Approved the terms of reference of the joint individual funding request panel (sub-committee of JCC) and received an update on its work.

Conclusion: The joint clinical committee has fulfilled its role and responsibilities.

Joint quality committee (JQC) Role: The role of the JQC is to review and provide assurance to the governing bodies of Airedale, Wharfedale and Craven CCG, Bradford Districts CCG and Bradford City CCG on the degree to which services commissioned by the CCGs are safe, effective and deliver the best outcomes for local populations. The scope of the JQC is all services commissioned by the CCGs, including those delegated by NHS England (GP services), for children, young people and adults including those services that are jointly commissioned with the local authority and those services commissioned from the voluntary and community sectors. For a full list of JQC’s detailed responsibilities, please see the terms of reference document on our website. Membership and attendance: Pam Essler Max McLean David Richardson Angie Clegg Peter Brunskill John Young Dr Graeme Summers / Dr Jake Jeffreys Dr Andy Withers Michelle Turner Fiona Jeffrey Healthwatch

Lay member for patient and public involvement – AWC (chair) Lay member for patient and public involvement – BC (chair) Lay member for patient and public involvement - BD Registered nurse – AWC, BC, BD Secondary care consultant - AWC Secondary care consultant – BC & BD Executive GP – AWC Executive GP – BD Director of quality and nursing Associate director of corporate affairs Lay representative from Healthwatch

JQC held 12 meetings during 2018/19 and attendance is detailed on the next page.


92

Figure 8: 2018/19 attendance at JQC

Joint quality committee highlights 2018/19

In addition to standing and regular items, other agenda items are identified through exception reporting, persistent quality concerns or discussions emerging from local, regional or national initiatives or issues. During 2018/19 have included deep dive discussions and reports on: • Cancer • Personalised Commissioning • IT Clinical Audit Review • Yorkshire Clinic’s Governance

Arrangements • BTHFT Maternity • Stroke Services • Received assurance on actions being

taken following the October 2018 network availability incident and on clinical issues arising.

• Reviewed the committee’s effectiveness, its work plan and agreed revisions to its terms of reference.

Standing/regular agenda items • Declaration of interests • Minutes of previous meetings

and action log • Quality report supported by the

Grassroots and performance reports

• Serious concerns/incidents report

• JQC risk register report (every second meeting)

• Annual reports: CCG and provider safeguarding adults and children reports, care home report

64%

18%

18%

Membership

Lay & Professional GP Executive


93

Conclusion: The JQC is achieving and delivering its role, responsibilities and functions.

Joint finance and performance committee (JFPC) Role: The role of the joint finance and performance committee is to advise and support the governing body through performance oversight of key financial and performance indicators/targets, including QIPP, as specified in the CCGs’ strategic and operational plans. For a full list of JFPC’s detailed responsibilities, please see the terms of reference document on our website. Membership and attendance: Neil Fell Bryan Millar Julie Lawreniuk Sue Pitkethly Liz Allen Dr Colin Renwick Dr Dave Tatham Dr Aamer Khan

Lay member for governance – AWC (chair) Lay member for finance – AWC, BC, BD Chief finance officer – AWC, BC, BD Director: AWC health and care partnership Director: Bradford health and care partnership Elected GP – AWC Elected GP – BD Elected GP – BC

The joint finance and performance committee met 12 times during 2018/19 and attendance has been as follows:

Figure 9: 2018/19 attendance at JFPC


94

Joint finance and performance committee highlights 2018/19

At each meeting during the year, JFPC has robustly monitored the finance and performance of each of the Bradford district and Craven CCGs. In particular, JFPC has reviewed the differing challenges with QIPP and financial pressures faced by each of the CCGs and received assurance on how these were managed In doing so, the CCGs have: • met constitutional targets • met financial targets In addition, JFPC have: • reviewed the committee’s

effectiveness and agreed revisions to its terms of reference (for approval by council of members)

• received assurance on actions being taken following the October 2018 network availability incident and the independent IT investigation report


action log • Performance report • Contracting report • QIPP report • Finance report • Issues to highlight to Clinical Board /

Executive and Governing Bodies • JFPC risk register (every second

meeting)

Conclusion: JFPC has fulfilled its role and responsibilities.

Joint committee of the West Yorkshire and Harrogate CCGs

Role: The joint committee is part of the WY&H Health and Care Partnership, with delegated authority to take commissioning decisions at West Yorkshire and Harrogate level on specific programmes including: cancer, elective care/standardisation of commissioning policies, mental health, stroke and urgent care. The committee aims to ensure that its decisions include public and patient engagement, clinical input and have authority from the CCGs. The committee has a work plan, memorandum of understanding and terms of reference, which were agreed by the members of each CCG. The Committee’s work plan reflects the partnership priorities for which the CCGs believe collective decision making is essential. Although it can only make decisions on the programmes of work that have been delegated to it, the committee also makes recommendations to the CCGs on other matters where it feels that a WY&H-wide approach would be beneficial.

28%

44%

28%

Membership

Lay Executive GP


95

Meetings, attendance and highlights: The joint committee meets formally in public every second month, with development and strategy sessions in intervening months. Each CCG is represented at the committee by the clinical chair and accountable officer (with one vote between them). For further details, including meeting highlights and attendance during 2018/19, please see the committee’s annual report which is available on its website: https://www.wyhpartnership.co.uk/meetings/west-yorkshire-harrogate-joint-committee-ccgs Primary care commissioning committee (PCCC) The PCCC meets in public six times per annum. Since May 2018 these meetings have been held as ‘committees in common’ with the PCCCs of Bradford City CCG and Bradford Districts CCG. Role: NHS England has delegated to the CCG authority to exercise the primary care commissioning functions set out in Schedule 2 in accordance with section 13Z of the NHS Act. The committee has been established in accordance with the above statutory provisions to enable the members to make collective decisions on the review, planning and procurement of primary care services in the Airedale, Wharfedale and Craven CCG area under delegated authority from NHS England. Key responsibilities: The committee carries out the following functions relating to the commissioning of primary medical services under section 83 of the NHS Act including: • GMS, PMS and APMS contracts (including the design of PMS and APMS

contracts, monitoring of contracts, taking contractual action such as issuing branch/remedial notices, and removing a contract);

• newly designed enhanced services (“local enhanced services” and “directed enhanced services”);

• design of local incentive schemes as an alternative to the quality outcomes framework (QOF);

• decision making on whether to establish new GP practices in an area; • approving practice mergers; • making decisions on ‘discretionary’ payments (eg returner/retainer schemes). • Planning primary medical care services - including needs assessment; reviewing

primary medical care services; • co-ordinating a common approach to the commissioning of primary care services

generally; • managing the budget for commissioning of primary medical care. Membership and attendance: As required by the delegation agreement with NHS England and CCG guidance on conflicts of interest management: • the PCCC has a lay and executive majority (the two GPs on the PCCC have a

non-voting role); and • the chair of the PCCC does not also act at the chair of the CCG’s audit committee.


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Neil Fell Pam Essler Angie Clegg Peter Brunskill Helen Hirst Julie Lawreniuk Michelle Turner Sue Pitkethly Lynne Scrutton Dr James Thomas Dr Colin Renwick

Lay member for governance (chair) Lay member for patient and public involvement Registered nurse Secondary care consultant Chief officer Chief finance officer Director of quality and nursing Director AWC Health and Care Partnership (to 19.12.18) Deputy Director AWC Health and Care Partnership (from 20.12.18) Clinical chair – non-voting Elected GP – non-voting

In addition to the members above, the following groups have standing invitations to attend PCCC meetings: NHS England, Bradford Healthwatch, North Yorkshire Healthwatch, Public Health (CBMDC), Public Health (NYCC), Local Medical Committee.

The PCCC has met six times during 2018/19 and attendance is detailed below:

Figure 10: 2018/19 attendance at PCCC

Primary care commissioning committee highlights 201 8/19

Highlights of the PCCC’s work have included: • reviewing the committee’s

effectiveness and agreeing revisions to its terms of reference (for approval by Governing Body).

• receiving updates on 18/19 contract changes, the internal audit framework for delegated commissioning and on the 5 Year GP contract.

46%

35%

18%

Membership

Lay & Professional Executive

GP (non-voting)


97

• approved the Standard Access Scheme and received assurance on the delivery of the scheme.

• approved the Special Allocations Scheme and received assurance on the delivery of the scheme.

• approved the Temporary List Reassignment Policy.

• received assurance on anti-microbial prescribing.

• approved the contract extension for North Street Surgery, Keighley.


matters arising • Contract assurance and performance

report • Questions from the public on agenda

items

Conclusion: The PCCC has fulfilled its role and responsibilities.

Audit and governance committee The audit and governance committees meets ‘committees in common’ with the audit and governance committees of NHS Bradford City CCG and NHS Bradford District CCG. Role: To review and provide assurance to the governing body on the adequate and effective operation of the CCG’s overall internal control system, with particular responsibilities related to financial reporting and management. Responsibilities: • Monitors the integrity of the financial statements and any formal announcements

relating to the CCG’s financial performance • Ensures that there is an effective internal audit functions that meets mandatory NHS

Internal Audit Standards and provides appropriate independent assurance to the Committee, Accountable Office and CCG

• Reviews the arrangements for integrated governance and risk management activities within the CCG

• Critically reviews the CCG’s financial reporting and internal control principles • Ensures there is an appropriate relationship with both internal and external auditors • Reviews the work and findings of the external auditors and consider the implications

and management’s responses to their work • Ensures adequate arrangements are in place for countering fraud, bribery and

corruption • Maintains an overview of the adequacy and effectiveness of Information

Governance (IG) activities and provides assurance to the governing body that risks associated with IG are being managed

• Maintains an overview of the adequacy and effectiveness of Health and Safety (H&S) activities and provides assurance to the governing body that risks associated with H&S are being managed

• Reviews the findings of other significant assurance functions, both internal and external and consider the implications for the governance of the CCG


98

Membership and attendance:

Bryan Millar Lay member for finance (chair) Neil Fell Lay member for governance Angie Clegg Registered nurse

The audit and governance committee has met five times during 2018/19; 2 meetings in May 2018 relating to the review and approval of the 2017/18 accounts and annual report, and three standard committee meetings. Attendance at these meetings is detailed below:

Figure 11: 2018/19 attendance at A&G

Audit and governance committee highlights 2018/19 • approved the 2017/18 annual report and

accounts. • received the 2017/18 head of internal audit

opinion and external audit’s ISA 260 summary of audit findings report.

• approved the 2018/19 internal audit and counter fraud annual plans.

• approved the 2018/19 external audit plan. • monitored the work of internal and external

audit and CCG implementation of recommendations arising.

• reviewed the performance of internal and external audit.

• reviewed and approved a number of information governance and health and safety policies.

• reviewed the CCG’s standing orders, standing financial instructions and scheme of delegation.

• received the findings of a gap analysis of the CCG’s security management arrangements.

• received updates on actions being taken following the October 2018 network

Standing agenda items • Declaration of interests • Minutes of previous meetings

and action log • Internal audit and counter fraud

Progress reports • External audit progress reports

and technical updates • Corporate risk and assurance

report (includes risk register / GBAF / conflicts of interest management / compliance with SOs and SFIs, CCG incidents, mandatory training compliance, etc)

100%

Membership

Lay & Professional


99

availability incident. • reviewed the committees own

effectiveness and its terms of reference.

• Information governance report • Health and safety report • A&G committee work

programme

Conclusion: The audit and governance committee has fulfilled its role and responsibilities.

Remuneration committee Role: The committee makes recommendations to the governing body on pay, remuneration and conditions of service for employees of the CCG who are outside of the national Agenda for Change pay system (such as very senior managers) and people who provide services to the CCG (such as clinical leaders). In addition, the committee receives assurance on the objective setting and performance review processes for elected GPs and senior management. Membership and attendance:

Pam Essler Neil Fell Bryan Millar Angela Clegg

Lay member for patient and public involvement (chair) Lay member for governance Lay member for finance Registered nurse

The committee is supported by independent advice from our HR providers, Bradford District Care NHS Foundation Trust. There have been three meetings of the remuneration committee during 2018/19; two of these meetings were held as ‘committees in common’ with the remuneration committees of the two Bradford CCGs. Attendance details are shown below:

Figure 12: 2018/19 attendance at Remuneration Commi ttee


100

Remuneration committee highlights 2018/19

• Received assurance on the 2017/18

performance review process for the chief officer, chief financial officer, director of nursing and quality, CCG executive director, ICB programme director and the clinical executive, including the clinical chair – and details of their 2018/19 objectives.

• Considered and made recommendations on pay and contractual arrangements for clinical speciality leads.

• Considered and made recommendations to the governing body on a pay award for those outside of agenda for change.

• Reviewed the committee’s effectiveness and agreed revisions to its terms of reference (for approval by the governing body).

Standing items • Declaration of interests • Minutes of previous meeting

and action log

Conclusion: The remuneration committee has fulfilled its role and responsibilities

1.3.7 UK corporate governance code Whilst the UK corporate governance code is not mandatory for NHS bodies, compliance, where applicable, is considered to be good practice. This governance statement is intended to demonstrate our compliance with the applicable principles set out in the code. For the financial year ended 31 March 2019, and up to the date of signing this statement, we have had regard to the provisions set out in the code and complied with the spirit of the code, insofar as they are applicable to the public sector and the responsibilities of clinical commissioning groups as established under the Health and Social Care Act 2012. As a revised version of the code was issued during the year, a more detailed review has been undertake against the code which will be reported to the audit and governance committee at its July 2019 meeting; the review found the CCG complies with the spirit of the code with a few areas where arrangements could be strengthened further. 1.3.8 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

100%

Membership

Lay & Professional


101

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 senior lead. Teams have confirmed that their structures provide the necessary capability and capacity to undertake all of the clinical commissioning group’s statutory duties. 1.3.9 Risk management arrangements and effectivenes s We have had a comprehensive integrated risk management framework (IRMF) in place since establishment. The IRMF was reviewed and updated to apply across the three Bradford district and Craven CCGs from July 2017. It describes our approach to managing risk, our risk appetite, our risk management objectives and the processes in place to ensure these objectives are achieved. Our risk management objectives are to: • effectively identify, report and manage risk • ensure clear accountability for the management and reporting of risk • effectively capture and learn from mistakes to reduce future risks • ensure and evidence statutory and regulatory compliance • effectively manage partnership and project risks. We monitor and report on risk in two key ways:

• The governing body assurance framework (GBAF) / strategic risk log focuses on strategic/long-term risks to the delivery of our strategic objectives. This is a shared GBAF across the three Bradford district and Craven CCGs and is reviewed and updated twice a year.

• The corporate risk register focuses on more operational risks that may rise and fall within relatively short time periods. The corporate risk register is reviewed and updated six times a year and is shared across the Bradford district and Craven CCGs. Whilst a number of risks are shared across the three CCGs, there are a number of CCG specific risks; our on-line risk register system allows risk to be monitored and reported at both individual CCG level and collectively.

Risk appetite Our aim is to minimise the risk of harm wherever possible to service users, the public, staff, members and other stakeholders. However, we also recognise the need to take considered risks in some areas (for example, transformation/re-design of services) and that an overly risk averse approach can be a threat to the achievement of some strategic objectives. All risks on our risk register and assurance framework specify the target risk score (ie, the level at which the risk can be tolerated). The acceptability of the target risk score is subject to review by senior management and the relevant committee as part of the normal review and reporting process for the risk register and assurance framework.


102

Other controls to manage risk Our key control mechanisms of the corporate risk register, GBAF and reporting and learning systems, are complemented by a range of other control mechanisms designed to deliver assurance on the prevention of risk and management of current risks. These include: • an approved standards of business conduct and conflicts of interest policy, which

has been reinforced by training for governing body and senior management team members and senior staff involved with service development and contracting.

• approval of an anti-fraud, bribery and corruption policy, which has been reinforced by mandatory training for both employees and governing body members.

• a business continuity plan which sets out our contingency plans to maintain an effective service in the event of a critical incident.

• undertaking regular health and safety, fire and premises risk assessments. • commissioning support in equality and diversity expertise to ensure that we are

compliant with the Equality Act 2010 Public Sector Equality Duty. All our staff have participated in equality and diversity training appropriate to their role. This equips them to identify our policies, governing body papers and improvement programmes that will need a detailed equality impact assessment to identify and mitigate any potential adverse impact on any group of local people with an Equality Act protected characteristic. An equality and diversity specialist employed by the eMBED Health Consortium provides expert support with these assessments.

Involving public stakeholders in managing risks which impact on them We engage with patients and carers to improve current services and inform the development of new or reviewed services. During 2018/19 specific engagement and consultation was undertaken, see page 54. In addition, we produce a monthly Grass Roots report of patient views/feedback which is reported to the joint quality committee. This insight helps us to identify any gaps or potential risks to current or future service delivery. Capacity to handle risk Effectiveness of governance structures All committees of the CCG and committees of the governing body have documented terms of reference, approved by the body to whom they are accountable, which are reviewed annually, or more regularly if required. Work programmes are maintained and regularly reviewed for all key groups and committees. The effectiveness of the governing body and its committees is reviewed regularly. Committee reviews were undertaken during the first quarter of the year, with findings considered by each committee and reported to the audit and governance committee. A small number of changes to agendas / work programmes and terms of reference have arisen as a result of these reviews.


103

The effectiveness of the governing body and of overall collaborative governance arrangements, both retrospectively and in terms of fitness for future purpose, was considered at a joint development session with the Bradford CCGs in December 2018 and included input from the CCG’s external advisors (KPMG, Audit Yorkshire, Hill Dickinson). The review found that the envisaged benefits of the structure had been achieved and the meeting chair summarised the session as follows: Trusting and respectful discussion that evidences how we’ve moved on in the two years since we first met as a group. Lots of good has come out of the collaboration, with keenness to continue and some appetite for taking it further. Some challenges, particularly the issue of connectivity with members. Some amendments were made to the structure of governing body agendas following the session to alleviate time pressures. During 2018/19 internal audit have reviewed our risk management and board assurance framework; an opinion of significant assurance has been provided. A small number of recommendations were raised and actions have been agreed in response to these. Responsibilities of the senior management team and committees Our principal risks to achieving our strategic objectives are set out in the governing body’s assurance framework. Each of the principle risks has an identified senior management team lead. Twice per annum the risk lead is responsible for reviewing the risk, assessing the key controls for mitigating the risk and sources of assurance, identifying positive assurance and any gaps in control or assurance, as well as taking forward specific actions within the timescales outlined. The roles and responsibilities of staff as owners of risks on the corporate risk register and senior management team as reviewers are clearly set out in the IRMF. This ensures that there is clarity about the levels of accountability for the management and monitoring of risks. The senior management team is expected to ensure that there are robust control measures in place to manage identified risks and that the appropriate assurances are generated. Reporting lines and accountabilities between the governing body, committees and the senior management team The reporting lines and accountabilities are set out in the Integrated Risk Management Framework and reflected in committee terms of reference. As stated earlier, the senior management team undertakes a formal review of all risks at the beginning of each reporting cycle and identifies any new risks or changes to risk score as they arise. Following review by the senior management team, the risk register is submitted to the appropriate committee (JQC or JFPC) for review. Each committee has clear responsibility for the monitoring of existing risks and identification of further risks as set out in its terms of reference. The CCG risk register is then reported in full to the clinical executive. High level risks (those scoring 15 or more on a matrix with a maximum score of 25) are reported to the governing body, as well as details of new and closed risks.


104

The audit and governance committee provides assurance on the effectiveness of the risk management system to the governing body. It is supported in this by annual review of the system by internal audit. Timely and accurate information to assess risks to compliance with the clinical commissioning group’s licence The assessment of risks is a continuous process informed by:

• staff or the senior management team identifying new risks or changes to risk profile

• financial, contracting and performance reports, which are submitted on a monthly basis to the joint finance and performance committee

• quality reports submitted monthly to the joint quality committee • discussions taking place at partnership meetings, committees, clinical executive

and governing body Degree and rigour of oversight of our performance by the governing body At each of its meetings, the governing body provides challenge and scrutiny of a suite of reports which focus on the delivery of the key performance targets, quality, safety, financial and contractual requirements: • Clinical chair’s report (including updates on the work of the clinical executive, joint

clinical committee and the joint committee of West Yorkshire and Harrogate CCGs)

• Chief officer’s reports • Finance, performance and contracting reports • Quality reports • Strategic partnership reports • AWC health and care partnership reports • Engagement tracker • Minutes from the joint finance and performance committee, the joint quality

committee, the primary care commissioning committee, the audit and governance committee and the remuneration committee

The reports provide a RAG (red, amber, and green) rating for all our main performance targets and, where adequate performance is not being achieved, the governing body is provided with an overview of remedial action. This oversight, which has been supported by the detailed work of the committees, has placed us in a strong position to deliver our performance and financial targets this year and ensure mitigating actions, that are regularly monitored, have been developed for areas of underperformance. Staff training to manage risk as appropriate to their authority and duties All staff are required to do mandatory training on data security awareness, fire safety, health and safety, manual handling, fraud awareness, safeguarding (including adults,


105

children and the ‘Prevent’ anti-radicalisation initiative) and equality, diversity and human rights. Staff receive other mandatory training appropriate to their roles (e.g. infection prevention for clinical staff, conflicts of interest for ‘decision taking staff’) and further training as agreed with line managers and detailed in personal development plans. Learning from incidents, near misses and from good practice is shared via our normal communication channels (team meetings, staff briefings, etc.) and via reporting to committees. A comprehensive suite of policies and procedures is available for staff and the maintenance of our policy framework is reviewed by the audit and governance committee. Detailed guidance is available for users of the on-line risk register system and to support the maintenance of the GBAF. Support on any aspect of our risk management framework is available to staff via the governance team or external advisors as required (IG, data protection officer, health and safety, counter fraud, internal audit, etc.). Risk assessment Risk assessments in relation to governance, risk management and internal control are carried out through a number of mechanisms including: • Through internal governance arrangements taking account of: risk assessment

guidance in the IRMF, self-assessment activity, review of our constitution, new national guidance or regulations and external inquiries.

• Through the annual internal audit plan by Audit Yorkshire. The plan is developed from a risk assessment of all areas of our activities and work undertaken in line with the plan is reported to the audit and governance committee.

• Through external audit throughout the year by KPMG, which includes attendance at the audit and governance committee and focused pieces of external audit work as set out in the auditors annual work plan, culminating in the risk review undertaken prior to annual reporting and accounts.

Detailed guidance on risk assessment is provided in our integrated risk management framework. Major risks to governance, risk management and inte rnal control We have identified twelve key risks to the achievement of strategic objectives. These are detailed in the governing body assurance framework, along with the controls in place to manage these risks, the mechanisms by which we receive assurance on the management of these risks and planned actions to address any gaps in control and / or assurance. The governing body assurance framework is reviewed, updated and submitted to the governing body for approval every six months. The GBAF can be viewed on our website. Of these twelve strategic risks, only one is considered to relate directly to governance, risk management or internal control; details of this risk are provided below. The CCG’s other strategic risks are related to partnership working, provider delivery and wider system level (local health economy) issues and developments.


106

Risk Key actions to mitigate risk Means to assess outcome

Staff struggle to adapt to new, externally facing system-focus roles due to the need for role flexibility and the normal factors associated with change, resulting in failure to develop as an organisation.

• Standard staff support mechanisms; regular one-to-one meetings with line managers, personal development plans, etc.

• Staff briefing and communication channels, including weekly staff update immediately after the senior management team meeting

• Organisational development programme

• Staff survey feedback • Sickness and turnover

rates • Delivery of CCG

objectives and statutory duties

• CCG 360o survey

Table 4: strategic risks related directly to govern ance, risk management or internal control The governing body assurance framework is supported by the corporate risk register which details the CCG’s operational risks and their management. As at the end of March 2019 there were a total of 29 open risks on the corporate risk register, with 10 of these risks classed as ‘major’ (i.e. scoring 15 or more). Of these 10 ‘major’ risks, two risks are considered to relate to governance, risk management or internal control (other major risks relate to provider delivery and health economy wide issues). Neither of these risks were newly identified in-year

Risk summary Key actions to mitigate risk Means to assess outcome

The CCG’s' abilities to plan for and respond to any potential adverse impact on services or strategic priorities due to unforeseen financial cuts by BMDC, particularly within public health, adult social care and children’s services.

• Executive commissioning board (ECB) established between the CCG and BDMC

• Strategic financial planning is a standing item at ECB meetings

• ECB issues log in place • CCG input to BMDC

consultations

• Monitoring via senior management team, clinical boards/executive and joint finance and performance committee

• Achievement of CCG financial plans

There is a risk to the delivery of CCGs and GP practices business and patient services due to the lack of a second back- up server (IT infrastructure).

• Funding secured for second server

• Project plan in place • Business continuity plans

reviewed and strengthened

• Fortnightly highlight reports to SMT on project progress

Table 5: open risks classed as “major” that directl y to governance, risk management or internal control


107

Whilst not assessed as a ‘major’ risk at the end of the year (that is, scoring 15 or more in the corporate risk register), during 2018/19 there were significant internal control risks related to the CCG financial position and to QIPP identification and delivery. Both risks were successfully managed in-year and closed in the last risk cycle of the financial year (new risks relating to 2019/20 will be raised in the first risk cycle of the next financial year). 1.3.9 Other sources of assurance Internal control The system of internal control is the set of processes and procedures in place in the clinical commissioning group to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness. The effective working of the system of internal control is achieved through the: • operation of the governing body, clinical executive and committees in accordance

with clear terms of reference and delegated responsibilities as described in the scheme of delegation and reservation;

• annual review of governing body and committee effectiveness; • the management of key risks to the achievement of our strategic objectives as

identified in the governing body’s assurance framework; • the management of operational risks as identified in the corporate risk register; • establishment, maintenance and review of operational policies across all areas of

business, including reviews on the application of those policies; • application of appropriate financial accounting and financial management

procedures as described in the standing financial instructions; • regular reporting of performance on our duties and responsibilities to the

governing body and clinical executive; • review of the effectiveness of the system of internal control carried out by the

internal and external audit functions; and • quarterly CCG assurance submission to NHS England. Annual audit of conflicts of interest management The revised statutory guidance on managing conflicts of interest for CCGs (published June 2017) 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. This audit has been undertaken for the three Bradford and Craven CCGs by Audit Yorkshire, our internal auditors, and their conclusion is detailed on the next page.


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Significant Assurance

The review has confirmed that the Clinical Commissioning Groups (CCG) can demonstrate that there are, in the main, effective arrangements in place to manage potential conflicts of interest during the performance of CCG business. The arrangements are substantially in line with the revised NHS England (NHSE) statutory guidance on managing conflicts of interest for CCGs as issued in June 2017. A review of the recommendations from the previous conflicts of interest audit (report 2017/12) confirmed that management have taken action to address the findings of this audit, with the majority of recommendations being implemented in full. The audit confirmed that the CCG has the required arrangements in place to comply with the Management of Conflicts of Interest Improvement and Assessment Framework 2018/19. At the time fieldwork was undertaken the relevant CCG policies were being updated; it was expected that the updated versions will be formally approved and issued in May 2019. In testing the application of controls some areas were identified where compliance could be strengthened. Some of these were minor points relating to maintenance of policies and registers on the CCG’s websites. The key areas for attention however related to:

• the adequacy of recording the management of conflicts of interest in meetings and maintaining an adequate audit trail where procurement decisions have been taken; we identified some historic issues relating to the quality of evidence supporting the Register of Procurement Decisions but note that a revised process for the maintenance of this register is now in place.

• putting in place a control check to provide, on an annual basis,

assurance that Registers of Interest are complete, with quarterly reporting on the level of up to date entries.

1.3.10 Data quality Under the current arrangements around the handling of confidential data we are not permitted to handle, process or view any patient identifiable data which includes NHS number, postcode or date of birth. As a result, the processing of this provider supplied confidential data is undertaken by the Yorkshire DSCRO (Data Services for Commissioners regional office). At present this team is hosted by NECS (North of England CSU) and all staff have the required legal status under NHS Digital terms and conditions. The Business Intelligence service is provided by eMBED Health Consortium. Business intelligence staff undertake regular key analyses to support the CCGs in monitoring key performance targets as well as providing reports to assist with the CCG’s contracting and commissioning functions. In addition, the business Intelligence


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team regularly monitor the flow of information from providers to ensure they are meeting their contractual obligations. The business intelligence team is also responsible for monitoring the quality of the data being submitted and this is discussed with the main providers at regular contract meetings. Where issues around data quality or non-receipt of datasets are unresolved at this level, this is escalated to the joint finance and performance committee and included on the corporate risk register, where appropriate. All information provided to the CCG undergoes rigorous data quality checking processes to ensure the highest quality of data is provided to the governing body and council of members. Both are reviewing their effectiveness during 2018/19 and no issues were raised with regards to the quality of data reported. 1.3.11 Information governance The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular person identifiable information. The framework is supported by an the data security and protection 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. Specialist information governance support is provided to the CCG by eMBED Health Consortium and our data protection officer is Susan Hall, IG Specialist at Audit Yorkshire. In 2018/19, we achieved compliance with all mandatory standards in the NHS data security and protection toolkit. During the year, our internal auditors reviewed our i toolkit submission and our implementation of General Data Protection Regulations (GDPR) requirements and an opinion of significant assurance was provided for both audits. 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 policy framework and have developed information governance processes and procedures in line with the DSP toolkit and the requirements of GDPR. We ensure 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. Staff are regularly reminded of the need to ensure that person identifiable information is secure at times. Risks relating to data security are mitigated by ensuring all laptops are encrypted and that unencrypted devices (USB sticks, etc.) are unable to operate on personal computers. During 2018/19 alerts and guidance relating to cyber-security risks were circulated to staff several times. Our chief finance officer is the nominated senior information risk owner (SIRO) with responsibility for information governance. Our director of nursing and quality is the nominated Caldicott Guardian with responsibility for the confidentiality of patient data. Regular reports on information governance matters and progress against our


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information governance work-plan are reported to the audit and governance committee. There are processes in place for incident reporting and investigation of incidents. During our network availability incident in autumn 2018, we reported a serious incident to the ICO and NHS digital via the NHS data security and protection toolkit on the grounds of data availability (a single incident was reported by NHS Bradford District CCG on behalf of the three Bradford district and Craven CCGs and all GP practices). As Network information system regulations 2018 do not apply to CCGs or GP practices, it transpired that we were not required to report this particular incident, however, we felt doing so was in line with the spirit of NHS data security and protection incident reporting guidance. The case was closed by the ICO with no further action required. An independent investigation was undertaken into this incident and its management and has been reported to the governing body; implementation of the action plans arising from the investigation are being monitored by JFPC and JQC. 1.3.12 Business critical models In the Macpherson report Review of Quality Assurance of Government Analytical Models, published in March 2013, it was recommended that the governance statement should include confirmation that an appropriate quality assurance framework is in place and is used for all business critical models. Business critical models were deemed to be analytical models that informed government policy. We can confirm that in 2018/19 the CCG has not developed any analytical models which have informed government policy. Our IG framework ensures that business critical systems are identified and managed effectively. As part of this framework information asset owners have been identified that cover the range of business systems used by the CCG. The responsibility of information asset owners includes the maintenance of an information asset register and data flow map relevant to their organisational remit, the maintenance of service continuity plans for business critical systems and the continuity of key skills to operate such systems. 1.3.13 Third party assurances For functions that are carried out on behalf of the CCG by third parties, we receive assurance from the organisation or their auditors that appropriate systems and internal control are in operation. We receive services from the following organisations and details of assurances received for 2018/19 are provided below: • NHS Shared Business Services (provision of financial and accounting services

and primary care payments services) – service auditors report: reasonable assurance.

• NHS Business Services Authority (prescription pricing services) – service auditors report: reasonable assurance

• Capita Business Services (payments to GP contractors) – service auditors report: unqualified opinion other than for pension leavers update


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• eMBED Health Consortium (provision of IT, business intelligence, information governance, freedom of information, procurement and equality and diversity services) – assurance provided via contract management arrangements.

• North East Commissioning Service (provision of data services for commissioners) – no assurance received to date.

• Bradford District Care NHS Foundation Trust (provision of payroll services, human resources, learning and development and health and safety services) – assurance on payroll services provided to consortium members, including the CCG; assurance on other services provided via contract management arrangements.

1.3.14 Control Issues During October 2018 the CCG and CCG member practices were affected by a serious IT network availability incident. The incident originally arose due to failure of the air-conditioning in the CCG server room and was then exacerbated by issues experienced during an already planned migration of data to a new server. This resulted in disruption to the delivery of CCG business, GP services and some community services (e.g. ability to review full clinical records; need to revert to manual prescriptions and referrals, loss of time and efficiency, etc.). However, there were no cancellation of appointments, no loss or inappropriate access to data, GP practices continued to have access to core clinical records ‘in contingency mode’ and no evidence of any clinical harm arising has been identified. Actions taken included: • GP practices immediately made aware of the issues and mitigating actions. • Local NHS Trusts and the Independent Sector, NHS England, CQC, Healthwatch

and the Local Medical Committee were made aware and kept updated. • ‘Gold Command’ response established for the duration of the incident – daily, senior

level meetings to review the incident. • Hotline set up for GP practices to report issues and clinical risks for the duration of

the incident. • Daily communications with all GP practices established. • Manual process implemented for 2 week cancer referrals and referrals to the rapid

access chest pain clinic. • Individual patients using primary care (data subjects) informed of the issues arising

from the incident and its possible impact, e.g., speed of referrals. GP practices provided with a daily quality and safety update to support conversations with patients.

• £1K goodwill payment offered to all practices to assist with increased costs as a result of the incident.

• Full review of CCG and GP practice business continuity arrangements. • Full independent investigation undertaken including root cause analyses, recovery

planning and implementation phases and lessons learnt, with reporting to the governing body; implementation of the action plan arising is being monitored by JFPC and JQC.


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Since the time of this incident, NHS England have agreed funding for a second, back-up server which is due to be in operation in April 2019 (the lack of a back-up server being a known risk recorded on the CCG risk register and for which business cases had previously been submitted to NHS England). The senior management team have received fortnightly highlight reports on progress towards the installation and operation of this back-up server. In addition to the IT network incident, the CCG also reported on CQC overall ‘inadequate’ ratings for one of its member practices as part of the Month 9 interim governance statement. Since this time, a further two member practices has received this rating from the CQC. Further details about this can be found in section 2.3.2 of the performance report. 1.3.15 Review of economy, efficiency and effectiven ess of the use of resources The governing body reviews and approves the budget for the financial year to ensure that the use of CCG resources reflect its commissioning priorities and are applied to the delivery of key performance targets, including efficiency targets and financial balance. The governing body receives a comprehensive finance, performance and contracting report from the chief finance officer at each of its meetings. The joint finance and performance committee advises and supports the governing body in providing assurance on the delivery of key targets. The clinical executive scrutinises and tracks the delivery of key financial and service priorities, outcomes and targets, as well as leading the development and monitoring of remedial action where performance is below plan. Our audit and governance committee takes the lead role, on behalf of the accountable officer and governing body, in maintaining and reviewing the effectiveness of the system of internal control, including financial control. The audit and governance committee advises and assures the governing body upon the adequacy and effective operation of the organisations’ overall internal control system focussing upon the framework of risks, controls and assurances that underpin the delivery of the organisations objectives and to review the disclosure statements that flow from those assurance processes. We have agreed a robust and ambitious approach to the QIPP challenges faced by the NHS to maximise value for money across all services. The governing body receives regular updates on the QIPP programme through the finance and contracting reports. Reporting and discussions on QIPP are a standing item at meetings of the clinical executive and council of members, whilst detailed scrutiny of performance against the QIPP plan is undertaken by the joint finance and performance committee. We are forecasting that we will achieve 61.6% of planned QIPP savings for 2018/19. Our external auditors, KPMG LLP, have undertaken a range of work against their 2018/19 plan. Our internal auditors, Audit Yorkshire, have completed the programme of a risk-based plan of work, agreed with management and approved by the audit committee, which was designed to provide a reasonable level of assurance, for


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2018/19. We have agreed action plans with auditors to improve our control environment. All audits undertaken during 2018/19 received ‘significant assurance’ with the exception of personal health budgets and mental health act section 117 which received ‘limited assurance’. The CCG’s rating for the ‘quality of leadership’ indicator in the CCG improvement and assessment framework as at Quarter 3 2018/19 is ‘Green Star’ (full year ratings to be available from July 2019. This indicator covers the governance arrangements in place related to ensuring value for money in the use of resources. 1.3.16 Delegation of functions The council of members has oversight of the functions delegated to the governing body, clinical executive and committees via reporting to its meetings and on its review and receipt of the CCG annual report. The governing body has oversight of the functions delegated to committees through it overview of CCG performance and specifically via: • receipt and review of performance reports (finance and contracting,

performance and quality) • receipt and review of the clinical chair’s report (which provides updates on

clinical executive, JCC and the joint committee of the West Yorkshire and Harrogate CCGs)

• receipt and review of committee minutes (JFPC, JQC, PCCC, A&G and remuneration committee) and the INVOLVE engagement tracker

Where functions are carried out on behalf of the CCG by third parties, there are regular meetings to review performance against contracts and work programmes. In addition we receive an annual assurance statement from the auditors of these third parties that appropriate systems and internal control are in operation. These organisations are specified in the third party assurance section of this report (page 110). 1.3.17 Counter fraud arrangements We have access to a local counter fraud specialist (LCFS) to meet the requirements set out in the standard commissioning contract. Their work is risk-based and in-line with the Government’s National Fraud Strategy and Chartered Institute of Public Finance and Accountancy (CIPFA) Managing the Risk of Fraud document, which are considered as best practice when countering fraud. An anti-fraud, bribery and corruption policy is in place and the chief finance officer is the executive lead for this area. An anti-fraud, bribery and corruption plan - based on NHS Protect’s standards for Commissioners - is developed by the LCFS annually and is approved by the audit and governance committee. The plan includes a significant proactive element. The committee receives reporting against this plan at each of its meetings.


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During the year, the LCFS has provided alerts to our CCG on frauds relating to bank mandates, personal health budgets, cancellation of training courses and phishing emails; these alerts are sent to the chief financial officer and then disseminated as appropriate to staff and/or CCG members. The LCFS also provided a number of face-to-face training sessions for staff and governing body members and published an anti-crime newsletter which was widely circulated. We participate in the annual national fraud initiative. 1.3.18 Head of internal audit opinion on the effect iveness of the system of internal control at NHS Airedale, Wharfedale and Cr aven Clinical Commissioning Group for the year ended 31 March 201 9 Roles and responsibilities On behalf of the Clinical Commissioning Group the Governing Body is collectively accountable for maintaining a sound system of internal control and is responsible for putting in place arrangements for gaining assurance about the effectiveness of that overall system. The Governance Statement is an annual statement by the Accountable Officer, on behalf of the Clinical Commissioning Group and the Governing Body, setting out:

• how the individual responsibilities of the Accountable Officer are discharged with regard to maintaining a sound system of internal control that supports the achievement of policies, aims and objectives;

• the purpose of the system of internal control as evidenced by a description of the risk management and review processes, including the Assurance Framework process;

• the conduct and results of the review of the effectiveness of the system of internal control including any disclosures of significant control failures together with assurances that actions are or will be taken where appropriate to address issues arising. The organisation’s Assurance Framework should bring together all of the evidence required to support the Governance Statement requirements. In accordance with the 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 (i.e. the organisation’s system of internal control). This is achieved through a risk-based plan of work, agreed with management and approved by the Audit Committee, which should provide a reasonable level of assurance, subject to the inherent limitations described below. The opinion does not imply that Internal Audit has reviewed all risks and assurances relating to the organisation. As such, it is one component that the Clinical Commissioning Group and Governing Body take into account in making its Governance Statement.


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The Head of Internal Audit Opinion The purpose of my annual Head of Internal Audit Opinion is to contribute to the assurances available to the Accountable Officer, the Commissioning Clinical Group and Governing Body which underpins the assessment of the effectiveness of the organisation’s system of internal control. This opinion will in turn assist the organisation in the completion of its Governance Statement. My opinion is set out as follows:

1. Overall opinion; 2. Basis for the opinion; 3. Commentary.

My overall opinion is that o Significant assurance can be given that there is a generally sound system

of internal control, designed to meet the organisat ion’s objectives, and that controls are generally being applied consistently. However, some weaknesses in the design and/or inconsistent applic ation of controls, put the achievement of particular objectives at risk.

The basis for forming my opinion is as follows:

1. An assessment of the design and operation of the underpinning Assurance Framework and supporting processes; and

2. An assessment of the range of individual opinions arising from risk-based audit assignments, contained within the internal audit risk-based plan, that have been reported throughout the year. This assessment has taken account of the relative materiality of these areas and management’s progress in respect of addressing control weaknesses.

The commentary below provides the context for my opinion and together with the opinion should be read in its entirety. The design and operation of the Assurance Framework and associated processes. Since 2017/2018 Airedale, Wharfedale and Craven Clinical Commissioning Group (AWCCCG) has been operating through a joint management and governance structure with its two neighbouring CCGs, Bradford City and Bradford Districts Clinical Commissioning Groups. In light of the collaborative governance structure a new Integrated Risk Management Framework was agreed in June 2017. Following approval of the new integrated framework significant work has been undertaken to revise and standardise the risk management arrangements across the three CCGs. The revised approach recognises that the three CCGs remain separate statutorily accountable bodies. A corporate risk register is maintained that can report at all levels, including Governing Body, individual CCG and committee level. The risk register is reviewed at least six times a year with a timetable being in place to govern


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the review and reporting cycle. The Governing Body is well sighted on risk. Strategic risks are reported via the Assurance Framework twice a year and high level risks are reported to the Governing Body every cycle. To support the Governing Body in obtaining assurance the Joint Finance and Performance and Joint Quality Committees have been nominated to maintain oversight of specific risk areas. An audit of the framework has been completed in 2018/2019 and this has confirmed that the arrangements are embedded and operating in practice. A Significant Assurance opinion was awarded. The range of individual opinions arising from risk-based audit assignments, contained within risk-based plans that have been reported throughout the year. The 2018/19 Internal Audit Plan was approved by the Audit and Governance Committee on 12 February 2018. The work of Internal Audit focuses on the design and embedding of core processes to underpin the delivery of the CCG’s strategic objectives. This is informed by the Governing Body Assurance Framework and engagement with the Executive Team. As such the audit plan was structured around the following key responsibilities of the CCG: • Governance and Accountability • Quality and Safety • Performance (including Commissioning and Contracting) • Partnership Working • Financial Governance • Information Governance Following the completion of an audit, an audit report is issued and an assurance level awarded. The following assurance levels are used:

Opinion Level Opinion Definition

HIGH (STRONG)

High assurance can be given that there is a strong system of internal control which is designed and operating effectively to ensure that the system’s objectives are met.

SIGNIFICANT (GOOD)

Significant assurance can be given that there is a good system of internal control which is designed and operating effectively to ensure that the system’s objectives are met and that this is operating in the majority of core areas.

LIMITED (IMPROVEMENT REQUIRED)

Limited assurance can be given as whilst some elements of the system of internal control are operating, improvements are required in the system’s design and/or operation in core areas to effectively meet the system's objectives.


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Opinion Level Opinion Definition

LOW (WEAK)

Low assurance can be given as there is a weak system of internal control and significant improvement is required in its design and/or operation to effectively meet the system's objectives.

An action plan is agreed with management for each audit report. In order to ensure progress is being made in the implementation of agreed actions a tracker is issued monthly to the management team and an update on progress provided to each Audit and Governance Committee. Internal Audit also supports the organisation when undergoing process design/redesign through the completion of advisory audit work. These audits are designed to provide advice as opposed to an assurance level. One piece of advisory work has been undertaken in 2018/2019. The outcome of the assurance audit reports from the 2018/2019 audit plan are summarised below. The audit in italics is a draft report. Audit Area Assurance Level Primary Medical Care Commissioning and Contracting

Significant

Learning Disabilities Framework Significant Mental Health Act Section 117 Limited Emergency Planning Significant Mental Health Wellbeing Strategy Significant Contract Management Significant QIPP Significant GDPR Implementation Significant Risk Management and Board Assurance Framework Significant Key Financial Controls Significant Personal Health Budgets Limited Conflicts of Interest Significant Data Security Protection Toolkit Significant

Two Limited Assurance Opinion audit reports have been issued in 2018/19 where gaps in the control environment were identified. With reference to the Mental Health Section 117 audit report this audit was conducted jointly with the local authority and covered the whole system. A detailed joint action plan between the CCG and the Local Authority has been put in place to address the recommendations made. Several risks were identified and remained outstanding as at 31 March 2019 as work to address them is ongoing with the majority of actions being due for implementation by 31 October 2019. The key risks related to funding care services in another district, patients receiving insufficient or excessive care as a result of care plans not making clear the Section 117 after care needs, risk of disputes and inefficiencies due to the joint policy agreement being out


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of date and care being provided not being regularly reassessed in a timely manner. The second Limited Assurance Opinion audit report related to Personal Health Budgets (PHB). The key risks identified related to local procedures not reflecting the latest national guidance, overdue annual assessments, surplus funds on PHB accounts and the accuracy and currency of PHB records. A number of the agreed actions have been completed with the remaining actions due by 30 June 2019. Management is addressing the recommendations made to address the strengthening of controls where reported. Helen Kemp-Taylor Head of Internal Audit and Managing Director Audit Yorkshire 13 May 2019


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1.3.19 Review of the effectiveness of governance, r isk management and internal control My review of the effectiveness of the system of internal control is informed by assurance from 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 internal and external auditor reviews and assurance reviews by NHS England. 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 of the effectiveness of the system of internal control by the governing body and the audit and governance committee and plans to address weaknesses and ensure continuous improvement of the system are in place. Under the CCG improvement and assessment framework our quality of leadership is currently rated GREEN STAR indicating that our CCG is performing well in regards to its leadership capability and capacity, our approach quality improvement, strong governance and decision making and progress towards introducing new models of care and transforming services fit for the future. For 2017/18 the CCG’s overall rating was OUTSTANDING. Ratings and the level of achievement against the framework scorecard are published on my NHS which is a microsite of the NHS choices website. Conclusion It is my conclusion, based on the information submitted and my belief about the effectiveness of the systems and processes within the CCG that no significant control issues have been experienced during the year other than, as reported in the Month 9 interim governance statement, the IT network availability incident experienced in October 2018. Further details about this incident and the mitigating actions taken are set out at section 1.3.14 of this governance statement. The control issues related to this incident have been now been remedied with the exception of the installation of a second back-up server which is scheduled for completion in April 2019. Helen Hirst Accountable officer NHS Airedale, Wharfedale and Craven CCG 28 May 2019


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2 Remuneration and staff report

2.1 Remuneration report

This report provides details of the policy regarding the remuneration of senior managers employed by the clinical commissioning group (CCG), how this policy has been implemented and the amounts awarded in 2018/19. Comparative information for 2017/18 is also shown.

For the purposes of this report senior managers are defined as members of the clinical commissioning group's governing body and director level members of the clinical commissioning group's clinical board.

2.1.1 Remuneration committee

Details of the remuneration committee, including its role, responsibilities and membership, can be found on page 99 of this report.

2.1.2 Policy on the remuneration of senior managers

Senior manager remuneration levels are set by the remuneration committee on the following basis:

Accountable officer/chief finance officer/lay members

Remuneration guidance for CCGs as issued by NHS England

Other CCG directors Very Senior Managers pay framework.

Clinical officers Annual equivalent salary based on GP remuneration levels

Annual pay uplifts are made in line with Secretary of State determinations for basic pay uplifts and the application of local performance review processes for any other changes in remuneration. As part of our assurance process, personal objectives are set for clinical commissioning group directors and performance against these objectives is reviewed formally by the accountable officer each year. The remuneration committee assesses the performance of the accountable officer, chief finance officer and staff on Very Senior Manager contracts and makes appropriate recommendations to the governing body regarding any proposed changes in remuneration, taking into account relevant guidance, benchmarking information and local circumstances


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2.1.3 Senior managers contract terms

The CCG’s senior managers are employed on the following contract terms:

Post Status Duration Notice period Accountable officer Officer Not fixed 6 months Chief finance officer Officer Not fixed 6 months Director Officer Not fixed 3 months Clinical chair Office holder Fixed (3 years) 3 months Clinical /lay members Office holder Fixed (up to 3 years) 3 months Table 6 employment contract terms for senior manage rs

There are no special payments due on termination of a contract. In the event of early contract termination, a senior manager would receive any applicable statutory entitlement to a redundancy payment and any entitlements due under the NHS pension scheme if they are a member of this.

Service contract details for each senior manager who served during the year were:

Name Contract Start

date Contract end date (where applicable)

Notice period

Helen Hirst 1 October 2016 N/A 6 months Dr James Thomas 2 September 2014 31 March 2020 3 months Julie Lawreniuk 1 September 2016 N/A 6 months Dr Bruce Woodhouse

1 April 2013 31 January 2019 3 months

Peter Brunskill 1 April 2013 31 March 2020 3 months Angie Clegg 1 January 2017 31 March 2020 3 months Pam Essler 1 April 2013 31 March 2020 3 months Neil Fell 2 January 2014 31 March 2020 3 months Bryan Millar 1 June 2017 30 November 2021 3 months Sue Pitkethly 1 April 2013 19 December 2018 3 months Nancy O’Neill 20 December 2018 N/A 3 months Michelle Turner 1 April 2017 N/A 3 months Dr Colin Renwick 1 April 2013 31 March 2019 3 months Dr Brendan Kennedy

1 April 2013 31 March 2020 3 months

Dr Graeme Summers

1 April 2013 31 March 2020 3 months

Dr Jake Jeffrey 3 April 2017 31 March 2020 3 months Table 7 service contract details for senior manager s


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2.1.4 Senior manager remuneration (including salary and p ension entitlements)

Table 8 (subject to audit): provides details of the remuneration paid to each senior manager employed by the clinical commissioning group in 2018/19, together with comparative information for 2017/18. Where the post is a shared appointment with another clinical commissioning group, only the appropriate share of the remuneration is shown in the table. Total remuneration for shared posts is shown in a note to the table.

Table 9 (subject to audit): provides details of the accrued benefits under the NHS pension scheme for each senior manager employed by the clinical commissioning group in 2018/19, together with comparative information for 2017/18, where the clinical commissioning group paid superannuation contributions into the NHS pension scheme.

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NHS Airedale, Wharfedale and Craven CCG


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NHS Airedale, Wharfedale and Craven CCG


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2.1.5 Pension benefits as at 31 March 2019 See table 8 on page 123

2.1.6 Cash equivalent transfer values

See table 9 on page 124 Real increase in CETVs

See table 9 on page 124 2.1.7 Compensation on early retirement or loss of office

There were no payments made in 2018/19, or in 2017/18, relating to compensation on early retirement or for loss of office.

2.1.8 Payments to past members

There were no payments made to past senior managers in 2018/19, or in 2017/18.

2.1.9 Fair pay disclosure (subject to audit)

Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director/member in their organisation and the median remuneration of the organisation’s workforce. The mid-point of the banded remuneration of the highest paid member of the governing body in the clinical commissioning group in financial year 2018/19 was £137,500 (2017/18: £137,500). This was 3.75 times the median remuneration of the workforce, which was £36,644 (2017/18: 3.86 times the median remuneration which was £35,577).

In 2018/19, no employees received remuneration in excess of the highest paid member of the governing body.

Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind, but not severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions. In 2018/19 remuneration ranged from £6,561 to £139,964 (2017/18: £4,848 to £137,219). 2.2 Staff Report

Under the shared management arrangements all shared staff are employed by Airedale, Wharfedale and Craven, Bradford City and Bradford Districts clinical commissioning groups. The information included in the table below reflects only the clinical commissioning group’s share of total staff numbers and costs for 2018/19.

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2.2.1 Number of senior managers

For the purpose of these figures senior managers by band are any employees band 8a and above, including board/director, medical and dental staff. The number of senior managers at 31 March 2019 was as follows:

Band Permanently

Employed

Other

Band 8a 25 1

Band 8b 27 1

Band 8c 2 1

Band 8d 12 0

Band 9 1 0

Board/Director 5 1

Medical Staff 4 0

Total 76 4

Table 10: number of senior managers at 31 March 201 9

2.2.2 Staff numbers and costs (subject to audit)

The information included in table 11 overleaf reflects only the clinical commissioning group’s share of total staff numbers and costs for 2018/19 and 2017/18.

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2.2.3 Staff composition At 31 March 2019, the total number of staff employed by Bradford and AWC CCGs was 212 of whom 165 were female and 47 are male, and 132 worked full time and 80 worked part time. These figures exclude non-exec directors/lay governing body members and staff on external secondment.

Table 12: numbers of staff by band and Table13: num ber of staff by band and gender working hours

Band Full

Time Part Time Band Male Female

Band 1 Band 1 Band 2 1 0 Band 2 0 1 Band 3 8 5 Band 3 1 12 Band 4 10 8 Band 4 6 12 Band 5 14 13 Band 5 8 19 Band 6 24 17 Band 6 6 35 Band 7 25 7 Band 7 6 26 Band 8a 13 13 Band 8a 5 21 Band 8b 19 9 Band 8b 10 18 Band 8c 1 2 Band 8c 0 3 Band 8d 11 1 Band 8d 2 10 Band 9 1 0 Band 9 1 0 Board/Director 5 1 Board/Director 2 4 Medical Staff 0 4 Medical Staff 0 4 Total 132 80

Total 47 165


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Figure 13: number of staff by band and employee cat egory

Figure 14: number of staff by band and gender (new)

2.2.4 Sickness absence data

The average for sickness absence for the twelve month period January 2018 to December 2018 was 8.8% (against a target of 2.5%, set by NHS England for non-patient facing organisations). The total number of FTE days lost due to sickness absence during this period was 2,798.73 days (an average of 233.23 days per month). This information relates to the total number of staff employed by Bradford district and Craven CCGs and is provided centrally by the NHS England Central Team.

0

5

10

15

20

25

30

Staff by band and employee category

Full Time Part Time

0

5

10

15

20

25

30

35

40

Staff by Band and Gender

Male Female


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Sickness absence is managed under the CCG policy for absence management that requires both employees and managers to actively report and discuss periods of sickness absence, including return to work interviews and attending formal absence management meetings once the CCG triggers for absence have been invoked. Employee healthcare (occupational health) support ensures that employees are supported in a timely and appropriate manner and that staff have access to interventions needed.

2.2.5 Staff policies

The CCG HR policies and procedures are important functional elements to ensuring that staff do not experience discrimination, harassment and victimisation: • acceptable standards of behaviour policy and procedure (this includes dignity at

work, victimisation and harassment issues) • equal opportunities and diversity employment policy • flexible working policy • recruitment and selection policy • maternity, adoption and parental leave (including shared parental leave) policy • whistleblowing and raising concerns policy • retirement policy • education, training and development policy • study leave policy • employment break policy • grievance policy • alcohol, drugs and substance misuse policy • secondment, acting up policy • managing sickness absence policy • annual and special leave policy • pay progression policy • organisational change policy • working time regulation policy • managing concerns with performance policy • Disciplinary policy All policies were reviewed and amended in April 2018 in line with GDPR regulations and in line with any employment legislation updates. The implementation of these policies along with occupational health support ensures the continuation of employment and provision of appropriate training to any employee, who becomes disabled and ensures access for all CCG employees, including disabled staff members to training, career development and promotion opportunities. 2.2.6 Trade union facility time NHS Airedale, Wharfedale and Craven, Bradford City and Districts CCGs do not


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have any TU stewards for recognised unions at the organisation. Individuals can join and be a member of a recognised union. The policy on trade union and recognition and facilities and time off for trade union representatives is in place to support. Within the context of this agreement and the exclusion of others, the CCGs currently recognise the following trades unions / societies:

• UNISON • Managers in Partnership • UNITE - AMICUS • Royal College of Nursing • British Medical Association • GMB

An employee who chooses not to join will not be the subject of any discrimination by the CCGs or a trade union.

2.2.8 Expenditure on consultancy The clinical commissioning group spent £10,000 on external consultancy in 2018/19 (compared to £15,863 in 2017/18).

2.2.9 Off-payroll engagements

The clinical commissioning group has engaged a number of individuals that are paid through their own companies and as such, are responsible for their own tax and national insurance arrangements. The number of these engagements and how long they have been in place is:

(a) Off-payroll engagements as at 31 March 2019, for mo re than £245 per

day that lasts longer than six months:

Number of existing engagements as of 31 March 2019

Number

0

Of which, the number that have existed:

for less than one year at the time of reporting

for between one and two years at the time of reporting

for between 2 and 3 years at the time of reporting

for between 3 and 4 years at the time of reporting

for 4 or more years at the time of reporting Table 14: off-payroll engagements as at 31 March 20 19, for more than £245 per day that lasts longer than six months

All existing off-payroll engagements have at some point been subject to a risk based assessment.


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(b) New off-payroll engagements between 1 April 2018 an d 31 March 2019, for more than £245 per day and that last longer than si x months:

Number

Number of new engagements, or those that reached six months in duration, between 1 April 2018 and 31 March 2019

0

Of which:

Number assessed as IR35 being applicable

Number assessed as IR35 being not applicable

Number engaged directly (via PSC contracted to department) and are on the departmental payroll

0

Number of engagements reassessed for consistency / assurance purposes during the year 0

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

0

Table 15: New off-payroll engagements between 1 Apr il 2018 and 31 March 2019, for more than £245 per day and that last longer than six months (c) Off-payroll engagements of board members and/or sen ior officials with

significant financial responsibility, between 1 Apr il 2018 and 31 March 2019

Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during the financial year.

0

Total number of individuals on payroll and off-payroll that have been deemed “board members, and/or, senior officials with significant financial responsibility”, during the financial year. This figure should include both on payroll and off-payroll engagements.

16

Table 16: Off-payroll engagements of board members and/or senior officials with significant financial responsibility, between 1 April 2018 and 31 March 2019

Helen Hirst Accountable officer NHS Airedale, Wharfedale and Craven CCG 28 May 2019


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3 Parliamentary accountability and audit report

NHS Airedale, Wharfedale and Craven CCG is not required to produce a Parliamentary accountability and audit report. Disclosures on contingent liabilities, losses and special payments, gifts and fees and charges are included as notes in the financial statements of this report at page 144. An audit certificate and report is also included in this annual report at page 114.

Helen Hirst Accountable officer NHS Airedale, Wharfedale and Craven CCG 28 May 2019


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CHAPTER 3: ANNUAL ACCOUNTS

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annual report and accounts 2018/19 · to our new emerging community partnership approach....

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