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Annual Report and Accounts 2018/19
Annual report and accounts 2018/19 NHS Bradford City Clinical Commissioning Group 2
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.
To find out more about us:
Visit our website: www.bradfordcityccg.nhs.uk Follow us on Twitter: @NHSBfdCraven Find our Facebook page: NHSBradfordCraven
Contact us: NHS Bradford City CCG Scorex House 1 Bolton Road Bradford BD1 4AS Tel: 01274 237290
Within this annual report, many of the initiatives that you will read about will relate to the three Bradford district and Craven CCGs. We work closely, and share a staff team, with NHS Bradford Districts CCG and NHS Airedale, Wharfedale and Craven CCG and, where these are referenced within this document, we will refer to them as ‘the three Bradford district and Craven CCGs’. Where reference is made to the ‘two Bradford CCGs’ this refers to NHS Bradford City and NHS Bradford Districts CCGs.
NHS Bradford City CCG Annual Report and Accounts 2018/19 3
Contents Page
Foreword: Dr Akram Khan, clinical chair 4
Chapter 1: Performance report 6
1 Performance overview 1.1 Our performance in 2018/19: a statement from the chief officer 6 1.2 About us 8 1.3 Our vision and principles 9 1.4 Our population 9 1.5 How we’re governed 9 1.6 Our main providers of service 10 1.7 The system in which we work 10 1.8 Sustainability and transformation: our plans and priorities 12 1.9 Key issues and risks 16 1.10 Our commitment to equality and diversity 21 1.11 Financial performance overview 21 1.12 Engaging people and communities 21 1.13 Highlights of the year 22
2 Performance analysis 2.1 Progress on priority areas 24 2.2 Sustainable development 34 2.3 Improve quality 40 2.4 Engaging people and communities 53 2.5 Reducing health inequalities 57 2.6 Health and wellbeing strategy 61 2.7 Financial performance 61
Chapter 2: Accountability report 66
1 Corporate governance report 1.1 Members’ report 66 1.2 Statement of accountable officer’s responsibilities 76 1.3 Governance statement 78
2 Remuneration and staff report 2.1 Remuneration report 11 8 2.2 Staff report 123
3 Parliamentary accountability and audit report 131
Chapter 3: Annual accounts 132
NHS Bradford City CCG Annual Report and Accounts 2018/19 4
Foreword – Dr Akram Khan
Welcome to the annual report for Bradford City 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.
While the city of Bradford has one of the youngest populations in Europe, 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 city 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 Bradford 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 with community partnerships has gone from strength to strength with an equal partnership approach involving a range of stakeholders including local councilors. Examples include ‘Living Well’ events supporting people in the community to live well and maintain their independence through signposting and promoting self-care and prevention; and proactive multi-disciplinary community support for people with frailty to ensure their needs are understood so future support packages can be tailored to meet this.
Our Bradford Breathing Better programme, which looks to correctly diagnose those with chronic obstructive pulmonary disease (COPD) and help put a stop to preventable asthma deaths, has raised awareness of earlier diagnosis, improved clinical management and supported self-management of respiratory disease. We are ensuring individual patients are on the correct therapy and understand what their medication is and how it works. By doing this we aim to provide people who have a respiratory condition, with the tools and techniques to feel comfortable about managing their condition. NHS Bradford City CCG Annual Report and Accounts 2018/19 5
We aim to support our providers locally and have developed a quality assurance process aimed at improving both the quality of services and CQC ratings of GP practices. We have also established an approach called 'Better Together‘, to provide enhanced support for any care home providers where concerns have been identified. Over the past three years we have seen a reduction of inadequate care home providers from 14.9 % to 2% and over the last year an increase of good and outstanding homes from 49% to 70%.
We continue to maintain a focus on reducing delayed transfers of care to ensure no-one remains in hospital longer than they need to. Our GP extended access service is available to 100% of the Bradford population and operates from three hubs. Appointments are available 6.30-9.30pm Monday to Friday, and 10am-1pm Saturday and Sunday. This provides extended access to primary care services including GPs, physiotherapists, nurses, children and young people’s mental health.
We are committed to preventing the rise of diabetes in our communities and delaying its onset. Our diabetes prevention programme works to identify those who are at high risk of developing type 2 diabetes and provides lifestyle advice, support and education in order to reduce their risk and has seen close to 3,000 people referred.
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.
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.
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 council, the voluntary sector, and the NHS, both in Bradford City 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 Akram Khan Clinical chair NHS Bradford City CCG
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Chapter 1: Performance report 1 Performance overview
The purpose of this section is to provide a short summary on NHS Bradford City 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 24 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 (SPA) 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.
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
NHS Bradford City CCG Annual Report and Accounts 2018/19 7 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 Bradford City. The IAF, while including a number of clinical domains, concentrates on areas such as leadership and financial health. Our IAF performance on clinical areas remains as inadequate or requiring improvement in all areas except dementia and learning disabilities. These health inequalities have been recognised in the national funding formula for CCGs and as a consequence Bradford City received an additional allocation. Making inroads into health inequalities in a short space of time is challenging. We are developing plans that look at short term clinical interventions, medium term lifestyle actions as well as longer term, wider determinants of health issues.
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 the emergency care standard (ECS). However RTT has shown improvements of late as has IAPT recovery and cancer waiting times. IAPT waiting times continue to be 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 Care Quality Commission (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 Bradford City CCG, we have a great opportunity to utilise the additional resources we have received to target the inequalities in health experienced by people living in our inner city area. This will be accounted for through the three central community partnerships in the Bradford health and care partnership.
Although Bradford City is in good financial health, there is still a requirement to ensure the resources are spent appropriately and therefore Bradford City will be subject to the efficiency challenge being addressed as a whole system. The impact in Bradford City would be to create further resources to tackle the extreme health inequalities.
Helen Hirst Chief officer NHS Bradford City CCG
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1.2 About us
NHS Bradford City Clinical Commissioning Group (CCG) is the NHS organisation responsible for planning and buying (commissioning) healthcare services for over 118,000 people registered with our 25 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 the people registered with GP practices in our area. 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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Our ambition is to transform our patients’ experiences of health services; significantly improve their outcomes; and to use our member practices’ creativity, talent and ability to innovate local services to help people live longer, healthier lives.
1.3 Our vision and principles
Our vision is reducing health inequalities .
Our values are to drive innovation and clinical excellence; to put the interests of patients and the community at the heart of everything we do; and to act with honesty and integrity.
Being a clinically-led organisation gives us a fantastic opportunity to focus on delivering improved health outcomes, quality, innovation and public engagement.
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’
1.4 Our population
We are responsible for buying and contracting healthcare services for people registered with family doctors in the Bradford City area. Within the area we look after the health needs of over 118,000 people who live in some of the most deprived wards in the country .
1.5 How we are governed
The council of members (CoM) holds the governing body and clinical board 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. Members of the CoM are clinicians (usually a GP) and meet no fewer than four times a year.
Because we work closely with Airedale, Wharfedale and Craven 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 Districts and Airedale, Wharfedale and Craven 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.
Our clinical board meets twice monthly as a committee in common with Bradford Districts CCG (the joint clinical board ) and also meets separately to discuss
NHS Bradford City CCG Annual Report and Accounts 2018/19 10 issues relating only to Bradford City CCG. Representatives of the clinical board (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 Districts and Airedale, Wharfedale and Craven CCGs.
The aim of the clinical board system 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.
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; 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 Districts and Airedale, Wharfedale and Craven CCGs.
• Details of the membership of these and other CCG committees are on our website or on page 80 onwards of this annual report.
1.6 Our main providers of services
We buy (commission) services for patients from Bradford Teaching Hospitals NHS Foundation Trust (BTHFT), which runs Bradford Royal Infirmary (BRI) and St Luke’s Hospital; and Bradford District Care NHS Foundation Trust (BDCFT), which cares for people with community health, mental health and social care needs.
We also work with the City of Bradford Metropolitan District Council to engage with local people to improve health in the district. We work alongside the council in their role of providers of social care and public health for the local population.
We buy services from a number of voluntary and community sector organisations. They provide locally-focused projects aimed at improving people’s health and wellbeing, for example, by promoting awareness, prevention and healthy living.
There are some areas where we work with CCGs across Yorkshire and Humber to commission services – for example: commissioning the Yorkshire Ambulance Service; NHS 111; and the West Yorkshire GP out-of-hours service.
Altogether the CCG has about 65 contracts for services. A register of contracts is available on our website.
1.7 The system in which we work
Collaboration with local CCGs: Although each CCG is a statutory organisation in its own right, we work closely with Airedale, Wharfedale and Craven CCG and Bradford Districts CCG including sharing some of the same functions and responsibilities. For example, we have a shared team of management and staff,
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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 also 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 board (HWB): We are an active member of the Bradford District Health and Wellbeing Board which is constituted as a committee of City of Bradford Metropolitan District Council (Bradford Council). It brings together key perspectives from across the health and care sector alongside other agencies that act on the wider determinants of health and wellbeing. The board is chaired by the leader of the council and the deputy chair is our clinical chair, Dr Akram Khan. The clinical chairs of Bradford Districts CCG and Airedale Wharfedale and Craven CCG are also members of the board, as is the chief officer of the three local CCGs.
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, BDCFT, the three CCGs, GP federations, the voluntary and community sector, independent (care home 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 are 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 ICB is implementing the vision and direction to deliver the best outcomes for local people 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 14).
Health and social care overview and scrutiny committee: This statutory committee acts as a ‘critical friend’ by reviewing local health issues and considering NHS 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, 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 serious incidents team is hosted by Greater Huddersfield CCG.
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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 support s 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.
Healthwatch Bradford and District: An independent public watchdog, Healthwatch works with people and organisations to make positive change happen in health and social care services in the district.
Bradford Care Alliance: GPs across Bradford are members of this community interest company, which pools their expertise to deliver new models of care that will improve the health and wellbeing of the community. Working with the National Association of Primary Care, BCA introduced ‘primary care home ’ community teams (subsequently named ‘Community Partnerships’) to work collaboratively with health and social care providers. BCA also provides extended access services in Bradford, working from three hubs across the two Bradford CCGs, to provide primary care services to patients during the evenings and weekends.
GP federations: there are a number of GP federations across Bradford with whom we work. These include City Health Limited, Trust Primary Care and a super practice called Affinity Care.
1.8 Sustainability and transformation: our plans and priorities
1.8.1 West Yorkshire and Harrogate Health and Care Partnership
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 plan in November 2016.
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In order to realise the ambitions of the partnership, it needs 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 and with an ageing population, helping frail and older people stay healthy and independent, tackling loneliness, avoiding hospital stays unless needed and giving children and young people the best start in life is a priority. 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 includes better access to GP services 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 rethinking 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 www.wyhpartnership.co.uk , read the difference our partnership is making or the joint committee of CCGs annual report or follow the partnership on twitter @wyhpartnership .
1.8.2 Happy, healthy at home: a plan for the future of health 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
NHS Bradford City CCG Annual Report and Accounts 2018/19 15 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 the three aims below.
• 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 Bradford Health and Care Partnership
The Bradford Health and Care Partnership board – a forum of health and care commissioners and providers – oversees the work of the transformational and enabling programmes through which we aim to develop new models of care for our population.
Bradford City and Bradford Districts CCGs signed a legally binding alliance agreement in April 2017 with members of the Bradford Provider Alliance, parties to which include the Bradford Care Alliance (a single community interest company covering all GP practices across Bradford), BDCFT, BTHFT, Bradford VCS Alliance Ltd and the adult and community services provision arm of Bradford Council. This agreement articulates the commitment of each party towards the achievement of a health and care partnership, looking to provide an overarching arrangement which governs integrated multi-party solutions for health, care and support across the geographical area covered by the two Bradford CCGs.
Across the Bradford health and social care system it has been agreed that the first steps in developing our new model of care is through the development of ten community partnerships (CP) and three localities. There is a leadership team for each CP that includes representation from GP practices, community nursing services, secondary care, community pharmacy, voluntary and community sectors (VCS) and local authority.
Each of these community partnerships reviews their population profile data and undertakes a range of activities to understand better the health, care and support needs of their population. The teams consider areas of duplication, gaps, blocks, and opportunities across current service delivery models. This supports the identification of service improvement initiatives.
Due to scale considerations, not all service delivery will be taken at a community partnership (CP) level. Some services will be delivered at locality level. There are
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three localities within Bradford: North locality (comprising of three CPs and with an approximate population of 130,000), Central locality (three CPs; 160,000 population) and South locality (four CPs; 180,000 population). Services delivered at this level will be the more specialised services; for example specialised nursing and reablement services.
The system recognises the importance of the community partnerships as they will be the foundations on which health and social care partnerships will be built in future. A key focus is developing a sustainable model for the use of both health and social care community beds, enabling appropriate care to take place in the community and closer to home.
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 our local footprint, 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:
March Move 2019 ment 2017 Strategic Sept Strategic Risk Objective
1. Closing the 1.1 There is a risk that unwarranted variations in quality and quality and care cannot be effectively tackled due care gap to shortfalls in workforce capacity, capability and 16 16 ÎÏ skills resulting in failure to close the care and Working quality gap. collaboratively, we will develop and deliver targeted 1.2 There is a risk that our efforts may not have programmes to the impact we desire due to some determinants of address the gaps quality and outcomes which lie outside of the 16 16 ÎÏ in the quality and control of health and social care resulting in a outcomes of our failure to close the care and quality gap. health and social
NHS Bradford City CCG Annual Report and Accounts 2018/19 17 March Move 2019 ment 2017 Strategic Sept Strategic Risk Objective care. We will 1.3 There is a risk that the care and support reduce market in Bradford and Airedale will become unwarranted increasingly unstable due to workforce, increasing N/A 16 ÎÏ variations in the complexity of the needs of people living in care quality and care homes and funding issues, leading to closure or provided for our de-registration of nursing home provision. This will patients and result in a market that is unable to accept and care residents. We will for patients, destabilising the wider health and improve outcomes care sector and impacting on the quality of care and experience experienced by our patients. for our patients and residents.
2. Closing the 2.1 There is a risk that we fail to gain sufficient health and organisational traction towards integrated wellbeing commissioning, due to a range of factors, 12 12 ÎÏ gap. including ‘programme creep’, staff attitude to change and weak leadership, resulting in failure to Working achieve the strategic objective. collaboratively, we will develop and 2.2 There is a risk of fractured relationships with deliver targeted partners due to growing financial pressures within programmes to the health and care system, particularly in areas 9 9 ÎÏ address the gaps such as CHC, OOH, LD and substance misuse, in the levels of resulting in negative impact on the commitment to health and integration. wellbeing experienced by our population.
3. Closing the 3.1 There is a risk that the medium term financial finance gap plan does not deliver financial sustainability for the 3 CCGs due to under delivery of QIPP plans 16 16 ÎÏ Working resulting in financial targets not being achieved. collaboratively, we will maximise 3.2 There is a risk that the two Accountable Care value for money in Systems are not financially sustainable due to the the use of system financial gap not being closed resulting in 16 16 ÎÏ healthcare action from the regulators. services to ensure we can deliver financial sustainability and service transformation.
NHS Bradford City CCG Annual Report and Accounts 2018/19 18 March Move 2019 ment 2017 Strategic Sept Strategic Risk Objective
4. Creating 4.1 There is a risk of provider organisations not health and committing to the development of a Health & Care care Partnership across Bradford due to their perceived 12 9 Ó partnerships organisational risks resulting in failure to achieve an HCP by 2021. Working collaboratively, we will develop a Health and Care Partnership to provide sustainable, effective, efficient and high quality health, care, and support services to the local populations.
5 Self-care and 5.1 There is a risk that we are unable to prevention sufficiently change patient behaviour, sufficiently reshape GP behaviour and embed social 16 9 Ó Working prescribing, due to the normal factors associated collaboratively, we with ‘change and resistance, resulting in failure to will improve the achieve the strategic objective. 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.
6. Acute 6.1 There is a risk that the corporate cultures and provider behaviours within individual organisations collaboration continue to emphasise competition rather than 6 3 Ó collaboration as a means to deliver healthcare, Working resulting in risking the effectiveness of the collaboratively we collaboration programme. will ensure that the acute 6.2 There is a risk that the changes to acute and collaboration mental health services required to achieve programme being financial sustainability are not acceptable to key 12 12 ÎÏ led by the local stakeholders, e.g. patients, the public or elected acute trusts and representatives, and cannot be implemented. West Yorkshire This would result in the failure of the programme’s mental health goals. trusts improves
NHS Bradford City CCG Annual Report and Accounts 2018/19 19 March Move 2019 ment 2017 Strategic Sept Strategic Risk Objective the clinical and 6.3 There is a risk that the transformation required financial in primary and community services is sustainability of compromised due to workforce capacity, 9 9 ÎÏ acute physical capability and skills shortfalls and by out of date or and mental health unaffordable models of service which are services, preferred by some interest groups. This will result complements the in clinical and financial instability. development of out of hospital services and underpins the delivery of key quality and performance objectives including constitutional standards.
7. CCG 7.1 There is a risk that staff struggle to adapt to development new, externally facing system-focus roles due to the need for role flexibility and the normal factors 12 8 Ó We will continue associated with change, resulting in failure to to review and develop as an organisation. develop our internal resources, structures and processes to ensure that we are able to achieve our strategic objectives and meet NHS constitutional standards.
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
NHS England is responsible for the management of any health response to major emergencies and for leading incidents involving public health outbreaks. The Civil
NHS Bradford City CCG Annual Report and Accounts 2018/19 20
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 emergency preparedness, resilience and response (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 24/7 on-call arrangements where providers can escalate issues if they cannot maintain delivery of core services. This on call-rota is staffed by members of the senior management team from the Bradford district and Craven CCGs. On-call staff undertake training on a regular basis to ensure they have the skills and knowledge to respond to incidents, and representatives attend exercises of other organisations to 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 for health organisations to test the health response to major emergencies as part of a national exercise programme.
We also held our annual local desk top 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 UKs exit from the EU. Our business continuity plan was significantly tested in late 2018 when 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.
NHS Bradford City CCG Annual Report and Accounts 2018/19 21
1.10 Our commitment to equality and diversity
We are committed to reducing health inequalities and 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 57.
1.11 Financial performance overview
In 2018/19, revenue resources of £174.8m were available to the CCG, comprising £168.1m for the commissioning of healthcare services (programme allocation), £2.5m for administration costs (running cost allocation) and £4.2m brought forward from last year. The programme allocation included a national growth uplift of £3.8m (2.52%) on the 2017/18 resource baseline plus an additional £1.3m 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 £5.1m equivalent to a growth uplift of 3.36% which 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 CCG achieved a breakeven position in line with its plan for the year and maintained its cumulative surplus funds of £4.2m to be carried forward to 2019/20.
For 2018/19, the CCG had a savings target of £1.7m, set against a number of schemes targeting areas such as planned care, prescribing and urgent care. This was alongside schemes that aimed to improve quality and deliver greater value money in the use of CCG resources.
For the year, the CCG achieved savings of £1.7m for the year with the greatest savings being on prescribing costs where the CCG has reduced spending by £0.3m and planned care where costs have been reduced by £0.4m.
During the year the CCG has continued to develop new schemes that 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 CCGs’ engagement team work across the whole of Bradford district and Craven; we work with local stakeholders to ensure that our approach is adapted to suit each
NHS Bradford City CCG Annual Report and Accounts 2018/19 22
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 existing 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 report 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.
1.13 Highlights of 2018/19
Some of the many highlights of our year have included:
• 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 three 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 Bradford, since October 2018. Operating from three hubs, appointments are available 6.30-9.30pm Monday to Friday, and 10am-1pm Saturday and Sunday and provide
NHS Bradford City CCG Annual Report and Accounts 2018/19 23
extended access to GPs, physiotherapists, nurses, children and young people’s mental health. • Referring close to 3,000 people, who are at high risk of developing type 2 diabetes, to our diabetes prevention programme. 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 • Ensuring that everyone with a learning disability is offered an annual health check (AHC). Almost two out of every three people aged 14 or over, with a learning disability receives their AHC across Bradford City CCG, which is among the highest across England. However, we are working to provide everyone with a learning disability an AHC to ensure they get the health advice they need, as well as a health action plan to help them remember what actions they need to take. • Supporting BDCFT, through its MyWellbeing College service, to implement a range of steps to address the challenges around waiting times for access to psychological therapies, including the development of self-referral access, a range of guided self-help books and the launch of a new telehealth service, which provides guided self-help resources, at The Cellar Trust. Access will be further enhanced during 2019 with the introduction of video conferencing options, digitised work books and work books translated into Urdu and Punjabi. • Engaging with community partnerships around ‘Living Well’ events supporting people in the community to live well and maintain their independence through signposting and promoting self-care and prevention. • 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 (see next section).
NHS Bradford City CCG Annual Report and Accounts 2018/19 24
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 both 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 92% 75.5% 76.3% 81.5% 84.8% waits Diagnostics <1% 0.3% 0.8% 8.7% 5.7% A&E 4 hours * 95% 85.1% 83.5% 78.0% 73.7% Cancer 2 Week Wait 93% 71.0% 74.9% 80.3% 94.0% Cancer 2 Week Wait (Breast) 93% 66.7% 66.7% 75.0% 80.0% Cancer 31 day (First 96% 87.8% 88.2% 94.4% 92.7% Treatment) Cancer 31 day (Subsequent 94% 93.8% 83.3% 100.0% 100.0% Treatment Surgery) Cancer 31 day - (anti-cancer 98% 100.0% 100.0% 100.0% 100.0% drugs) Cancer 31 day - (radiotherapy) 94% 100.0% 100.0% 100.0% 100.0% Cancer 62 day 85% 69.0% 83.3% 62.5% 70.0% Cancer 62 day (NHS 90% NA NA NA 100.0% Screening) Cancer 62 day (Consultant N/A 100.0% 66.7% 100.0% 100.0% referral upgrade) 4.2% for 17- 18 rising to IAPT Access** 3.7% 3.5% 3.5% 3.8% 4.75% by the end of 18-19 IAPT 6 week waits** 75% 97.1% 97.4% 100.0% 96.2% IAPT 18 week waits** 95% 100.0% 100.0% 100.0% 100.0% IAPT Recovery** 50% 40.0% 48.7% 41.7% 45.7% Early Intervention in Psychosis 53% 61.3% 46.2% 53.9% 69.6% - % seen within 2 weeks Care Programme Approach (CPA): Follow up within 7 days 50% 96.0% 94.4% 90.7% 100.0% of discharge
Table 1: NHS Constitutional Targets * A&E performance is for main Provider Trust (Bradford Teaching Hospital Foundation Trust) **Performance to February 2019
NHS Bradford City CCG Annual Report and Accounts 2018/19 25
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.
The nature of the CCG IAF is for NHS England to provide oversight and our CCG holds quarterly and annual review meetings.
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 Requires improvement Requires improvement Dementia Outstanding Good Diabetes Inadequate Inadequate Learning Disability Requires Improvement Good Maternity Requires improvement Requires improvement Mental health Requires improvement Requires improvement 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.
NHS Bradford City CCG Annual Report and Accounts 2018/19 26
ŸŸŸ Better ŸŸŸ Similar ŸŸŸ Worse compared to England Tackling the wider determinants of health and reducing health 2.1.1 Better 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. Recurrent investment Childhood obesity Health inequalities community partnership plans include: • ‘Living Well’ events supporting people in the community to live well ŸŸŸ ŸŸŸ and maintain their independence through signposting and promoting self-care and prevention; and Two out of five children aged ten The frequency of people being • Proactive multi-disciplinary community support for people with or eleven years old are admitted to hospital for long-term frailty to ensure their needs are understood so future support overweight or obese, this result is conditions, from our poorest packages can be tailored to meet this. communities is three times higher higher than the England average, Reducing inequalities in City (RIC) aims to support people to have a than the England average. which is three out of 10. better start, with living well, secondary prevention, complex care needs and end of life care. Personal Health Falls injuries Our Bradford Breathing Better programme has raised awareness of Budgets earlier diagnosis, improved clinical management and supported self- ŸŸŸ ŸŸŸ management of respiratory disease. We are ensuring individual patients are on the correct therapy and understand what their During October to December 2018 At 17 per 100,000 the rate of medication is and how it works. By doing this we aim to provide people there were 1,461 per 100,000 personal health budgets is who have a respiratory condition, with the tools and techniques to feel population emergency admissions below the England average about managing their condition. following injuries from falls for and needs to improve. people aged 65 years or older. Our key work streams include improvement management (including This result has reduced over time self-care) for people with chronic obstructive pulmonary disease and is amongst the lowest rate in (COPD) and people with asthma. The following simple strategies aim England. to help people look after their own health and give people the necessary resources to do so resulting in a reduction in people going to hospital as an emergency: The current programme on childhood obesity , is delivered by • Focus on helping people who smoke to quit and will be linking with Bradford Council public health team and includes: early years colleagues across West Yorkshire to share best practice; interventions, direct work with children and with schools and • Recently commissioned MyCOPD which is an online resource for neighbourhood initiatives. A Children’s Healthy Lifestyle Group has people who would benefit from pulmonary rehabilitation but are developed the Healthy Bradford Plan which aims to address childhood unable to attend a class; obesity as part of a broader approach.
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• Working with colleagues in public health, to support GP practices to encourage staff have their flu vaccination and also to ensure vaccination for people with long term conditions; and • There are many resources from the British Lung Foundation and Asthma UK which inform patients about the care that they should receive. We aim to provide one of these short plans to help them to understand what care to expect from their healthcare professionals. Our local falls team provide services including exercise programmes and home-based strength and balance programmes. Also, we have urgent care practitioners employed by the Yorkshire Ambulance Service (YAS) to liaise with care homes to assist with treatment at the scene reducing the need to take people who have fallen to hospital. We are a national development site for Personal Health Budgets (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 Bradford Council and Bradford District Care NHS Foundation Trust (BDCFT) and have plans to further develop 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.
28 ŸŸŸ Better ŸŸŸ Similar ŸŸŸ Worse compared to England improvements in performance. However, there is currently a national 2.1.2 Better Care 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 NHS Constitution Care quality ratings undergo a local system review, which focused on people over the age Standards of 65 as they move through the health and care system, and the CQC ŸŸŸ ŸŸŸ were positive about the care and services provided in Bradford. We Ratings for primary care aim to support our providers locally and have developed a quality Waiting times for cancer services are similar to England. assurance process aimed at improving both the quality of services and treatment, for hospital outpatient However for hospitals and CQC ratings of GP practices. We have also established an approach appointments or Accident and community services and for care called 'Better Together‘, to provide enhanced support for any care Emergency have not been met homes and residential homes home providers where concerns have been identified. Over the past this quarter, although results ratings show there is a need for three years we have seen a reduction of inadequate care home were similar to across England improvement in our area providers from 14.9 % to 2% and over the last year an increase of good and outstanding homes from 49% to 70%. Airedale NHS Delayed Extended Access Foundation Trust (ANHSFT) and BDCFT were both rated as requires Transfers of Care in Primary Care improvement and we continue to monitor their progress through our ŸŸŸ ŸŸŸ joint quality committee. We continue to maintain a focus on reducing delayed transfers of People were delayed on average From October 2018 extended care to ensure no-one remains in hospital longer than they need to. As just over 3½ days which is much access in the evenings and at a health and care system, we are continuing to adopt the high impact lower than the national average the weekend has been available change model and strengthening the multi-agency integrated delay of eleven days to all register patients discharge team (MAIDT). This includes seven day acute medical unit The NHS Constitution sets out a number of standards in relation to ward rounds to facilitate weekend discharged to our integrated access to hospital and mental health services, which over the last 12 community teams (collaborative care teams) and trusted assessment, months our main providers have, at times, struggled to deliver. There which means nurses on wards can restart a domiciliary care package have been particular challenges at Bradford Teaching Hospital within 30 days as long as needs have not changed whilst the Foundation Trust (BTHFT) in delivering the 18 week referral to individual has been an inpatient. treatment and cancer standards as a result of increased demand and capacity issues, and delivery of the 4 hour emergency care (A&E) Our GP extended access service is available to 100% of the Bradford standard is an ongoing issue across both acute providers as they population and operates from three hubs. Appointments are available struggle to manage increased demand and sicker patients in general. 6.30-9.30pm Monday to Friday, and 10am-1pm Saturday and Sunday. This provides extended access to primary care services including GPs, We are working with partners as part of the Bradford district and physios, nurses, children and young people’s mental health. Craven Urgent Care and Planned Care programmes to manage demand and improve access to services and have seen recent
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ŸŸŸ Better ŸŸŸ Similar ŸŸŸ Worse compared to England ŸŸŸ Better ŸŸŸ Similar ŸŸŸ Worse compared to England
2.1.3 Sustainability 2.1.4 Leadership
Financial Uptake of new e - Green performance referrals system Quality of Green Effectiveness of Star relationships ŸŸŸ Leadership We want to make every pound ŸŸŸ Currently under 17 out of every Working relationships, as go further and have developed In 2017/18 the quality of our 20 referrals are made assessed by our annual 360 plans to improve quality whilst leadership was again electronically via the e-referrals degree stakeholder survey, saving money services. This needs to be the assessed as amongst the top CCGs in England were amongst the highest way all patients are referred across England, ranked 15 out from October 2018 of 195 CCGs
The CCG has a highly effective systems and processes in place for monitoring in-year financial performance , analysing and acting on a We rank amongst the top 20 CCGs in England for Quality of range of information about quality, performance and finance and has Leadership which demonstrates that we have excellent leadership an excellent track record in identifying early warnings of failing capability and capacity, robust systems of quality improvement and services, and in identifying areas for improvement in otherwise assurance as well as strong financial leadership and are driving successful, high quality services. transformation with our new community partnership approach. The uptake of the e-referral service supports patient’s choice with the The CQC remarked on the breadth and strength of partnership national ambition for all referrals to be made using the e-referrals arrangements and relationships here in the Bradford district, service from 1 October 2018. To support uptake, payments for observing that system leaders across health and social care were services in hospitals now rely on all patients being offered choice via compassionate and caring. The CQC reported that leaders are clear the new e-referral service. BTHFT were an early adopter site and that the needs of the person sit at the heart of our plan Happy, Healthy moved to ‘paperless’ in June 2018. As a result we are seeing a steady at Home and that there are robust arrangement for the transformation increase in the percentage of referrals made via the e-referral system. of services in line with our plan.
30 ŸŸŸ Better ŸŸŸ Similar ŸŸŸ Worse compared to England ŸŸŸ Better ŸŸŸ Similar ŸŸŸ Worse compared to England
2.1.5 Bradford Improving Cancer Survival (BICS) 2.1.6 Dementia
Dementia Care diagnosis planning Cancer Cancer survival diagnosis at at one year ŸŸŸ ŸŸŸ an early stage 17 out of 20 people 3 out of 4 people with a ŸŸŸ ŸŸŸ estimated to have dementia diagnosis have care in our population have been planning and post- Diagnosing cancer at an 7 out of every 10 people identified. This result is diagnostic support in place, early stage is important with cancer survive amongst the best in this places us in Band 3, and over half of all cancer beyond the first year. This England indicating we need to cases are diagnosed result is much lower than improve early, which is higher than seen across England and across England we need to improve 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 We are part of the West Yorkshire Cancer Alliance and actively and Craven and these numbers are expected to increase. We involved in leading changes to cancer services provision. The overall recognise the importance of making sure a good care plan is in place objective of the alliance is for joined up working across West Yorkshire as part of the support package patients living with dementia receive to implement the national Cancer Strategy and the Cancer Taskforce after a diagnosis and will continue to make sure those with dementia recommendations. have a care plan of the highest quality.
We continue to work closely with public health and NHS England to The Bradford and Airedale dementia strategy, 2015-2020 aims to both support national educational and promotional campaigns. This improve life for people living with dementia, their families and carers. includes smoking cessation, as well as to increase uptake of screening By 2020 we aim to have: services specifically including breast, bowel and cervical cancer • Shorter waiting times (6 weeks or less) between visiting a memory screening programmes. Through continuing to educate people and clinic and receiving a diagnosis; promote services, we aim to improve uptake of these programmes. • A named care coordinator for everyone living with dementia; • Individual care plans which everyone providing care for the person Diagnosis at an early stage greatly improves cancer survival and can see; our rate of diagnosis of cancer at an early stage is improving, with • A voice for people living with dementia and their carers; and around half of people receiving their diagnosis early. We want to • We would like people living with dementia and their carers to have continue to increase the proportion of people diagnosed in stage 1 or 2 a voice in improving care. of the cancer in support of the national ambition, which is rising to three-quarters by 2028. We are promoting Dementia Friendly communities and have worked with BDCFT to improve the experience of leaving hospital for people with advanced dementia.
31 ŸŸŸ Better ŸŸŸ Similar ŸŸŸ Worse compared to England ŸŸŸ Better ŸŸŸ Similar ŸŸŸ Worse compared to England 2.1.7 Bradford Beating Diabetes (BBD) 2.1.8 Learning Disability
Structured 3 recommended Reduce specialis t Health checks education Treatment levels inpatient care ŸŸŸ ŸŸŸ ŸŸŸ ŸŸŸ
Attendance for people Good control of BP, For all three CCGs across Almost 2 out of every 3 with a new diagnosis of cholesterol and HbA1c Bradford district and people aged 14 or over, with diabetes is low across (sugar) is important. Craven the rate of specialist a learning disability, receive England at just 8.54%. However, only 7 out of inpatients is 41 per 1 million their annual health check. Our local result is even 20 people with diabetes population. We need to This result is amongst the lower with just 1 out of have good control of all reduce this further highest across England every 100 attending three. We need to make Across Bradford district and Craven, we are working to improve improvements outcomes for people living with learning disabilities so that they live We are committed to preventing the rise of diabetes in our longer and better lives. Our transforming lives programme is communities and delaying its onset. Our diabetes prevention implementing a system-wide change to enable more people to live in programme has seen close to 3,000 people referred. This programme the community, with the right support, and closer to home. This is works to identify those who are at high risk of developing type 2 being done by looking at implementing best practice, improving access diabetes and provides lifestyle advice, support and education in order to training for health and social care workers and by improving services to reduce their risk. for people with more challenging behavior. Those diagnosed with type 2 diabetes are offer structured education The number of people with learning disabilities who are receiving but we recognise that not enough people attend. As a result, we have annual health checks (AHCs) across Bradford City CCG is amongst created several new education options for patients and are now seeing the best in the country. However, we are working to ensure everyone a marked increase in the numbers attending one of the many courses with a learning disability is offered an AHC to ensure they get the on offer (by June 2018, our rate had increased to one in five patients health advice they need, as well as a health action plan to help them and we are expecting to see further increases). remember what actions they need to take. To help people live closer to home and reduce the need for specialist We are supporting patients to improve the NICE recommended inpatient care , we are developing a programme to help support treatment targets including the management of blood pressure, people with learning disabilities move into new housing developments glucose levels and cholesterol for people with diabetes to reduce the by ensuring they meet their individual needs as part of a bespoke risk of patients developing complications. tenancy. We are also part of the West Yorkshire Health and Care Partnership initiative to develop specialist assessment and treatment beds for people with learning disabilities and autism.
32 ŸŸŸ Better ŸŸŸ Similar ŸŸŸ Worse compared to England ŸŸŸ Better ŸŸŸ Similar ŸŸŸ Worse compared to England
2.1.9 Maternity 2.1.10 Mental Health Early Intervention Out of area Smoking in Neonatal mortality Psychosis placements pregnancy and stillbirths ŸŸŸ ŸŸŸ ŸŸŸ ŸŸŸ Access to intervention for Reducing out of area More than 1 in 10 women The rate of neonatal psychosis is above the 50% placements for people with still report as smokers at mortality and stillbirths is 8.4 standard, with almost 3 out of mental health problems is the time of delivering their per 1,000 births and there is every 5 people being seen a key priority – currently baby. This result is similar a national ambition to reduce within two weeks for a NICE we have zero bed days to the England rate, this by half recommended care package placed out of area however it needs to reduce Our Early Intervention Psychosis service is for people aged 14-65 We welcomed the publication of Better Births in 2016 which set the years of age who may be experiencing issues with their mental health. vision for future maternity services and we have engaged with the We aim to ensure that people receive specialist care within two weeks West Yorkshire and Harrogate Local Maternity System programm e to of a referral, with the team providing a range of services including implement Better Births . Locally, we are learning from the Better Start psychological therapies and medical and social interventions designed Bradford research project and becoming an earlier adopter for to meet people’s needs and help them to get their lives back on track. perinatal mental health services. Our vision is to deliver care for people who need mental health support Smoking at the time of delivery has increased further to 13.7%. The as close to home as possible, as this leads to better outcomes for results for our population overall reflect the effects of smoking during people in the long term. This commitment means we have taken a full pregnancy, particularly on the numbers of stillbirths and deaths in the system approach to reducing out of area placements and we have first year of life. In the last year we have worked with the Women’s had no inappropriate out of area placements this year. Health Network and Better Start Bradford to understand why women from some of our communities don’t use smoking cessation services, Waiting times for access to psychological therapies continue to be and to put what we have learned into practice. By supporting women to within national requirements. However ensuring enough people access stop smoking and implementing the saving babies lives’ care bundle services and have positive recovery rates continues to be a challenge. we want to see a 50% reduction in the rate of neonatal mortality and BDCFT, through its MyWellbeing College service, continues to stillbirths by 2025. implement a range of steps to address these challenges including: • Development of self-referral access, a range of guided self-help books and wider choice of support services; and
• The launch of a new telehealth service, which provides guided self- help resources, at The Cellar Trust. Access will be further enhanced in early 2019 with the introduction of video conferencing options, digitised work books and work books translated into Urdu and Punjabi
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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 which will 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 & 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 & Emergency department. Within
NHS Bradford City CCG Annual Report and Accounts 2018/19 34
the first six 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 surgeries, 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.
NHS Bradford City CCG Annual Report and Accounts 2018/19 35
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 Bradford Health and Wellbeing Board o Executive Commissioning Board o Bradford Integration and Change Board o Bradford Health and Care Partnership Board o Three Bradford localities o Ten community partnerships o Joint clinical committee across the three Bradford district and Craven CCGs NHS Bradford City CCG Annual Report and Accounts 2018/19 36
o Bradford 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 19 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 • Bradford Beating Diabetes • Bradford Healthy Hearts • Bradford Breathing Better
NHS Bradford City CCG Annual Report and Accounts 2018/19 37
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 ten 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 (SPA) 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):
• Sustainable considerations in move to new building – close to transport networks and partner locations, encouraging use of public transport and walking, recycling of office waste etc • Our utilities – we are located on three floors of a modern city centre office block which is managed by NHS Property Services (NHSPS). As a tenant and not an owner of the property, we have limited opportunity to make a significant reduction in the use of our utilities and require NHSPS to look at any improvements. NHS Bradford City CCG Annual Report and Accounts 2018/19 38
• We have trialled an e-bike scheme over the last year. • 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. In moving into our new office space, we have reduced the number of printers, introduced the use of recycled paper options, and the 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 (eg recycled printing paper and reduction in the use of disposable drinking cups)
Staff travel: We are situated in the city centre with immediate access to local bus services and two railway stations each serving different commuter routes, including a direct link between the two CCG sites. We operate a cycle to work scheme and also provide showers to support cycling or walking to work. 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 • Local estates prioritisation scheme • Implementation of our Primary Medical Care Commissioning Strategy – Supporting delivery of primary care at scale • Further development of The Local Quality Assurance Process • Robust systems for governing delegated commissioning primary medical care (Contracts assurance group and primary care commissioning committee) • Secure resilience funding for practices rated inadequate • Support for Bradford Care Alliance • Extended access • IT – working with practices further to an IT outage to identify best practice and increase resilience • Weekly member practice bulletins • Practices taking part in the Pride in Practice initiative which aims to make services more lesbian, gay, bisexual and trans friendly
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 NHS Bradford City CCG Annual Report and Accounts 2018/19 39
• 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 • 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
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.
Social sustainability: Our staff continue to lead the approach to investing in our communities by fund raising for local and national charities including Down Syndrome Training and Support Service, the local MS Society, Shelter, Bradford Food Bank and Epilepsy Action. We have also supported a local social enterprise which provides services for people who are homeless or in unstable accommodation and those who have come to Bradford as refugees or to seek asylum.
2.2.4 2019/2010 priorities
Governance:
• Further development of our system collaborative arrangements through health and care partnerships and communities. • Strategic Partnering Agreement (SPA): coming into effect on 1 April 2019 (and replacing Bradford’s Alliance Agreement) the Bradford district and Craven SPA set out how partners will share decision making across the health and care system
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 Bradford health and care partnership and the ten communities including the role of the People’s Board and Engaging People • Embedding People’s Board across the district • Embedding the use of the combined equality and quality impact assessment • Further development of Grass Roots to inform commissioning decisions • Self-care and prevention NHS Bradford City CCG Annual Report and Accounts 2018/19 40
• Care navigation • Personalised commissioning
Corporate:
• Primary care at scale • Long term plan and five year framework for GP contract reform • Continue to strengthen our local quality assurance process – giving practices the tools to succeed. • Local estates prioritisation scheme • 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 and the ‘must dos’ 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 adhered to and coordinate 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 . This group enables commissioners and regulators to discuss and share system wide quality concerns. 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, making 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. NHS Bradford City CCG Annual Report and Accounts 2018/19 41
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. • A bi-monthly quality report – following the implementation of shared management arrangements in 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 GB 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 (PSQSG) which report through to the 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. 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 clinical executive group, JQC and governing body. We review contractual reporting requirements in response to intelligence and this helps to influence and inform design and progress of our strategic programme areas.
NHS Bradford City CCG Annual Report and Accounts 2018/19 42
• We review all serious incident (SI) investigations and do thematic reviews where clusters of incidents are identified. Data on all incidents is reviewed quarterly. • 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) seeks 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
NHS Bradford City CCG Annual Report and Accounts 2018/19 43 assurance mechanisms in place. We monitor patient safety with all our providers and ensure that all serious incidents (including never events) are 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. Joint partnership working continues across healthcare organisations which includes training and audits in care homes, reviewing and learning from post- infection reviews.
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 (LeDer) Programme – People with learning disabilities are four times as 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 case reviews will support health and social care staff and others, to identify, and take action on, the avoidable contributory factors leading to premature deaths.
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?
NHS Bradford City CCG Annual Report and Accounts 2018/19 44
In hospitals these questions are asked for each core service provided. These key questions 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
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.
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 NHS Bradford City CCG Annual Report and Accounts 2018/19 45 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.
Primary Medical Services
All 25 GP practices within Bradford City CCG have been rated by the CQC, 22 of which were rated as ‘good’, one as ‘outstanding’ and two as ‘inadequate’.
We want primary medical care providers to consistently provide high quality, safe care to the whole of our population. There have been huge improvements in quality over the last 10 years and this needs to continue. This will include ensuring continuity of care, especially in relation to working with other providers; patients who are transitioning between services and end of life care, and ensuring patients' wishes are actioned whenever possible
The CCGs will work with the CQC to ensure that our primary medical care service providers meet their contractual and regulatory requirements. The CCG is a delegated commissioner of primary medical services and as such we have a local quality assurance framework this describes our approach to ensuring that our practices deliver high quality and sustainable primary medical care. Our framework requires us to interrogate available data, information and patient feedback to enable the CCG to have a view of practice performance. A primary care dashboard has been developed locally to support this process.
NHS Bradford City CCG Annual Report and Accounts 2018/19 46
When concerns are raised – either through our local process or through the CQC inspection regime – we work collaboratively with the CQC, NHSE and YOR Local Medical Committee to develop practice-based improvement plans to address any failings and use contractual levers to support this. Our practices receive enhanced surveillance visits throughout this time.
Oversight of delivery of our delegated commissioning responsibilities is undertaken by the Primary Care Commissioning Committee.
Bradford local system review Inspection: 12-16 February 2018 Report publication: 25 May 2018 Overall rating: awaited
The 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 reviews 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 were committed to the vision, whether working in adult social care, primary and secondary care sectors or in the voluntary sector.
2.3.3 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 people think and 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.
Between 1 April 2018 and 31 March 2019 we received two formal complaints from patients or on their behalf, in relation to the CCG, one involved an individual care packaged funded by continuing healthcare (CHC) and the other involved a review of a service specification for services provided within secondary care.
Nineteen people also contacted us raising concerns and enquiries about the CCG, 53% (10) of these related to the personalised commissioning department (PCD), in connection with CHC funding decisions, assessments, care packages, personal health budgets and processes. The other cases were about various issues, such as the availability of flash glucose monitors for type 1 diabetic patients, gluten free products and the change of the commissioning pathway for spinal injections.
Our chief officer received 13 letters from our local MPs and councillors raising issues and concerns on behalf of their constituents, who were registered with our practices, including two about our mental health commissioning and two in relation to our PCD, one concerning a care package and the other a CHC assessment. The other correspondence included enquiries about cervical screening and other provider organisational issues.
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In addition, 74 enquiries, complaints and concerns were raised with the CCG by our patients about our commissioned services, 42% (31 cases) related to those services provided by our GP practices and 40.5% (30) concerned the changes of GP practice at Hillside Bridge Health Centre. Ten (13.5%) were about secondary care services, 2.7% (2) concerned care homes in connection with the care provided for CHC funded patients. The remaining case involved the local authority.
There were a further 34 contacts made from patients where their GP practice was not given, the majority of calls 44% (14) being about our hospitals and other NHS providers, 18% (6) were in relation to the CCG’s commissioning and 9% (3) involved GP primary care services. In all these cases, advice was given or the complaint or concern was passed on to the appropriate organisation for investigation and a response.
We also received, 31 contacts from patients following receipt of the patient letter advising of the changes in the provision of GP services at Hillside Bridge.
The main issues within complaints and concerns raised about our commissioned services were about aspects of care and treatment, communication, access and waiting times.
There were no complaints reported to the CCG, from the Parliamentary and Health Service Ombudsman, where patients can complain if they remained dissatisfied with the outcome of their complaint locally.
However, 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 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.
2.3.4 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 the CCG has 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, the CCG has been integral in reducing the number of inadequate providers across the 3 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. 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. NHS Bradford City CCG Annual Report and Accounts 2018/19 48
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 4 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.
Craven care homes are not included in the above but have 12 homes and 100% 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, which includes provider access to both 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.
The CCG has developed and embedded effective contract reporting requirements and 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 (i.e. hospital admission avoidance, sepsis, advanced care planning etc.) Despite the transient nature of the sector, the CCG has 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 NHS Bradford City CCG Annual Report and Accounts 2018/19 49 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.
2.3.5 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:
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• 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. • 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 optimisation 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.
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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.
2.3.6 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 the Bradford district and Craven.
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 contribute 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 complied 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. NHS Bradford City CCG Annual Report and Accounts 2018/19 52
2.3.7 Freedom of Information requests
During 2018/19:
• 216 freedom of information (FOI) requests were made to NHS Bradford City CCG, an increase of 2 on 2017/18 (214). • 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, 26% from businesses with media requests at 14%. • The five most popular request categories have been: commissioning, mental health, contracts/SLAs, continuing healthcare 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.
2.3.8 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 reported 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 Scorex House premises:
• 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%
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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 & security 3 12
Actions taken as a result of these incidents include: replacement of extension leads and development of a 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.
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). NHS Bradford City CCG Annual Report and Accounts 2018/19 54
• 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 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, the CCGs 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 carer’s support will now include elements to address these needs.
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The People’s Board was 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.
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. NHS Bradford City CCG Annual Report and Accounts 2018/19 56
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 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.
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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.
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 2017-2020 and the Bradford district and Craven Mental Wellbeing Strategy 2016-2021 .
The major health issues for our area are:
• Chronic disease (long-term health conditions): we have higher levels of obesity, diabetes and mental ill-health than our neighbouring CCGs, but a lower rate of depression. We think that our patients are less likely to report having, or be diagnosed with, depression • Premature death: some of our patients are dying prematurely, aged less than 75 years, mainly from heart and respiratory diseases • Respiratory disease: our patients suffer with chronic obstructive pulmonary disease (COPD) and asthma in particular. Respiratory diseases are one of the causes of our high rates of urgent hospital admissions • Infant mortality: this issue affects the whole of the Bradford district and is a priority for all of our local strategic partners. Three wards – Little Horton, City and Bradford Moor – have higher infant mortality rates and are within NHS Bradford City CCG Annual Report and Accounts 2018/19 58
our area For both Pakistani and white populations, reducing the number of babies born with extreme and very low birth weight and reducing deprivation would help to reduce the number of infant deaths, so early access to high quality ante-natal care is essential • Mental health: our main mental health focus areas are dementia and ‘talking therapies’ such as counselling, psychotherapy and cognitive behavioural therapy (CBT) • Cancer: this is a leading cause of premature death and the second most significant cause of all deaths in our area.
You can read about how we have been addressing these issues within the performance analysis section of this annual 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 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:
• Improve uptake of cancer screening for protected groups and reduce the variation of uptake rates between practices. • Reduce health inequalities by improving access to health services and increased support for self-care for protected groups. • Tackle loneliness and isolation, by supporting emotional and social connections amongst protected groups • To promote inclusive leadership and staff development progression
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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.
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 Districts and Airedale, Wharfedale and Craven 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.
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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.
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 Districts CCG and Airedale, Wharfedale and Craven 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 NHS Bradford City CCG Annual Report and Accounts 2018/19 61 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 Organisations
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.
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
2.7 Financial performance
In 2018/19, revenue resources of £174.8m were available to our CCG, made up of £148.0m for the commissioning of healthcare services (programme allocation), £20.1m for the commissioning of primary care medical services, £2.5m for administration costs (administration resource allocation) and £4.2m brought forward from last year. This represents an increase of £13.9m over last year with the most significant changes in our resources being due to:
• increase of £0.3m (1.93% - national growth uplift) for the commissioning of primary care medical services, plus £0.2m for the full year impact of Practice list transfers from Bradford Districts CCG; • increase of £3.5m (2.60% - national growth uplift), plus £6.9m for the full year impact of Practice list transfers from Bradford Districts CCG; • an additional increase of £1.3m (share of national funding following 2017 Autumn Budget statement); NHS Bradford City CCG Annual Report and Accounts 2018/19 62
• increase of £0.9m in the surplus brought forward from 2017/18; • finalisation of HRG4+ national tariff impact of £0.1m; and • non-recurrent increase of £0.4m for GP Forward View Improved Access scheme and other national policy requirements.
Expenditure budgets of £170.6m were set to match in-year revenue resources (total resources of £174.8m less resources brought forward from 2016/17 of £4.2m) with actual expenditure for the year reflecting: • healthcare service demand pressures on acute hospital services; • increased demand for continuing healthcare (nursing home placements and home care); • additional investment in mental health services 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 national contract uplift 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; and • increased costs in all areas reflecting the full year impact of practice list transfers from Bradford Districts CCG.
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 £4.2m 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 (£170.6m)
Other Non Recurrent Services, Running Costs, Programme, £5.2m, 3% £0.2m, 0% £2.3m, 1%
Primary Medical Care, £22.8m, 13% Acute Prescribing, Healthcare, £18.5m, 11% £75.9m, 45%
Mental Health, £16.1m, 9%
Continuing Healthcare (incl. Community Ambulance FNC & PHB), Out of Services, Services, £9.3m, 5% Hours, £13.2m, 8% £2.6m, 2% £4.5m, 3%
Figure 1: total CCG net expenditure 2018/19
NHS Bradford City CCG Annual Report and Accounts 2018/19 64
Acute healthcare expenditure of £75.9m in 2018/19 was incurred as follows:
Figure 2: acute healthcare expenditure in 2018/19
Overall performance against our statutory financial targets was:
Target Target Actual Achieved
Keep Revenue Expenditure within the Revenue Resource Limit Revenue Expenditure of Yes (excluding prior year surplus) of £170.6m £170.6m
Keep Administration Spend within Administration Spend of Yes the Administration Resource Limit £2.3m of £2.5m
Table 3: overall performance against statutory financial targets
Note: the CCG did not have a capital resource limit or any capital expenditure in 2018/19.
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2.2.1 Quality, innovation, productivity and prevention (QIPP)
In relation to its cost savings target, the CCG achieved £1.7m of savings against a plan of £1.7m where the majority of savings were achieved within prescribing and planned care. The CCG over-performed against the prescribing savings plan by £0.4m which offset shortfalls in other areas of the plan following delays in starting the schemes. 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. For 2019/20, the CCG has received an uplift of 15.25% which reflects the high level of deprivation and unmet health need in the local population. This means that we will be able to invest additional resources to help reduce health inequalities and improve mortality rates over time. In subsequent years, whilst the funding settlement 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.
2.2.2 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 group manual for accounts 2018/19.
The full accounts for the CCG are shown on page 132 onwards.
2.2.3 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.
.
NHS Bradford City CCG Annual Report and Accounts 2018/19 66
Chapter 2: Accountability report
1 Corporate governance report
1.1 Members’ report
1.1.1 Member profiles
Dr Sohail Abbas, clinical board
Sohail completed his undergraduate medical training in Pakistan and moved to the UK in 2002. He worked in various clinical specialities and completed his general practice training in 2007. Along with his interest in elderly medicine and diabetes, he has always been keen to participate in service development and improving patient care. He worked as a clinical director of adult community services in Salford before joining Kensington Partnership, Bradford, as a GP partner in 2012. As a clinical board member he is leading on the out-of- hospital care programme.
Liz Allen, CCG executive director – governing body and clinical board
Proud to be born and bred in Bradford, Liz is a registered nurse, who has spent a large part of her working life on the frontline of delivering healthcare as a practice nurse. In that time she gained a community nursing degree and then went on to work for Bradford Health Authority as a practice nurse advisor and primary care facilitator.
Having completed a master’s degree in management and leadership, Liz then moved into the world of primary care trusts (PCTs), first managing teams of community staff and then taking lead roles in nursing, professional and practice development, learning and development and quality.
Formerly the director of strategy for Bradford City CCG, from April 2017 she has taken the lead commissioner role with the two Bradford CCGs for the achievement of a health and care partnership across Bradford.
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Dr Junaid Azam, clinical board
Junaid was born and bred in Bradford and graduated from the University of Leeds Medical School in 2011. Since qualifying, he has worked in various specialties across Bradford and Dewsbury, including emergency medicine, psychiatry, paediatrics, care of the elderly and obstetrics and gynaecology. He completed his GP training in Bradford in 2016 and is currently a GP partner at Park Grange Medical Centre. Junaid is the CCG’s GP lead for prescribing and long-term conditions, including diabetes and Bradford’s Healthy Hearts . He also has an interest in IT solutions and contributes to the ASSIST GP development group.
Ruby Bhatti OBE, lay member (governance) – governing body
Ruby is a solicitor with over 20 years’ experience in the legal field. As a lay member, she brings over 20 years’ experience in governance as a non-executive director, presently with Incommunities Housing Association, Action For Business Ltd, Arise Yorkshire Ltd (social enterprises), Bradford Diocesan Academies Trust, Rainbow Academy and Dixon Multi Academies Charitable Trust Ltd. Ruby sits as an independent member of the mental health panel which enables patients to have their cases considered independently. She chairs numerous schools in Bradford and is the chair of the primary care commissioning committee and remuneration committee for Bradford City CCG. She is a national leader for governance in education (NLG) and a fellow of the Royal Society of Arts (FRSA). Ruby was recently awarded an OBE in the New Year Honours List 2019, for services in housing and young people. She was appointed as deputy chair of the CCGs governing body from 14 May 2019, replacing Max Mclean.
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Angie Clegg (f) registered nurse – governing body
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.
Dr Anne Connolly, clinical board
After a two year posting to a mission hospital in rural Zimbabwe, Anne returned to general practice in Bradford in 1990 where she helped develop a leading edge teaching practice. She has recently joined Bevan Healthcare in Bradford city centre, providing healthcare for those who find this most difficult to access; including asylum seekers, refugees, homeless and sex workers. Over the years, Anne has developed enhanced skills in gynaecology and contraception and has worked as clinical specialty lead commissioning services for maternity, women’s and sexual health for Bradford and Airedale since 2006.
Anne is chair of the primary care women’s health forum and is clinical champion for women’s health for the Royal College of
GPs (RCGP). Her board role for Bradford City CCG includes leading on the transformation of maternity and children and young people’s healthcare.
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Helen Hirst (f), accountable officer - governing body and clinical board
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’
Dr Waheed Hussain (m) - clinical board (until 31 May 2019)
Waheed has been GP lead for diabetes and medicinal management at his practice and is lead for quality outcomes framework (QOF) and key prescribing performance indicator (KPPI) and interventions with district nurses and palliative care, along with management responsibilities.
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Dr Aamer Khan (m) - clinical board
Born and educated in Bradford, Aamer has worked as a general practitioner in the heart of Bradford for 18 years. He qualified from Leeds University School of Medicine and then worked in a variety of specialties in training roles in West Yorkshire, including surgery and psychiatry, prior to his GP training.
He is currently the managing partner of four practices in Bradford and Leeds. Aamer is the CCG’s GP lead for urgent care and planned care.
Dr Akram Khan (m), clinical chair - governing body and clinical board
Akram trained in Sheffield and took on house jobs in Worksop and Halifax followed by a stint in casualty in Barnsley. He spent 18 months in a general medicine hospital career before he decided to go into primary care, joining the Bradford GP training scheme. He spent six months as a locum and then settled into his current practice, Avicenna Medical Practice, which has since consolidated from three sites to one inner city site.
He was secretary of the small practices’ association – made up of 47 practices – and was then elected to Bradford City Teaching PCT where he was health improvement and inequalities lead and also focused on clinical staff training and research governance.
He is active in the voluntary sector, with a focus on education, community development, and race equality. He also has interests in international health development, especially in Pakistan and Saudi Arabia.
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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.
Dr Max Mclean, lay member (patient and public involvement) – governing body (until 30 April 2019)
Max retired from a 30-year West Yorkshire policing career in 2010 where he had spent his last 12 years as the force’s senior detective. As head of CID and head of the homicide team he oversaw all major criminal investigations in the county and led on partnership working with a variety of local and national agencies tackling crime in some of the country’s most deprived communities. He has led nationally for the police service on tackling domestic abuse and made significant national and international improvements in responses to domestic violence and child protection.
Since retirement, Max has been awarded a PhD from the University of Huddersfield after studying ways in which coroners carry out their duties. He teaches a masters course in criminology, and is a lay advisor to the patient safety research centre at Bradford Teaching Hospitals NHS Foundation Trust. As a lay member, Max brings an independent perspective to the governing body as vice chair and in particular, champions the involvement of patients in influencing how we commission services. Max is vice chair of the CCG’s governing body
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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. 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).
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.
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Michelle Turner, director of quality and nursing – governing body and clinical board
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.
Toni Williams, public health consultant – clinical board
Toni Williams is a consultant in public health in Bradford. After graduating from the University of Edinburgh she worked for a number of years in health protection, before moving to London where she worked for Westminster Primary Care Trust (PCT) and Westminster City Council, providing public health support for the joint commissioning of services for vulnerable adults, tackling issues around mental health, homelessness, drugs and alcohol, and suicide prevention.
In 2010 Toni moved to Yorkshire to begin her higher specialty training in public health. Over the four years of training she worked in a number of settings, with a range of partners including NHS Bradford and Airedale, the Health Protection Agency, University of Sheffield, West Yorkshire Police, and Wakefield Council. In 2014 Toni joined the public health team at Bradford Council and provides public health support and advice to the CCG.
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Professor John Young (m), secondary care consultant – governing body
John Young trained at the Middlesex Hospital, London and was appointed as a consultant geriatrician in Bradford in 1986 where he developed numerous new services including an elderly care assessment unit; a stroke unit; and an orthogeriatric unit. In 2005 he was appointed as head of the academic unit of elderly care and rehabilitation, University of Leeds (based in the Bradford Institute for Health Research), now one of the largest research units of its kind in the UK. John was seconded to the Department of Health (2001-2007) to assist with the national service framework for older people, and then to NHS England (2013-2016) as national clinical director for the frail elderly and
integration.
1.1.2 Member practices
• Avicenna Medical Practice • Moor Park Medical Practice • Barkerend Health Centre • The Primrose Surgery • Bevan Healthcare CIC • The City Medical Practice, • Bilton Medical Centre Whetley Hill Medical Centre • Bradford Student Health Service • The Family Practice, Whetley Hill • Clarenden Medical Centre Medical Centre • Dr I M Raja and Partner • The Lister Surgery • Farrow Medical Centre • Thornbury Medical Practice • Frizinghall Medical Centre • Park Grange Medical Centre • Grange Medical Centre • Parkside Medical Centre • Kensington Partnership • Peel Park @ Hillside Bridge: • Kensington Street Health Centre • Peel Park Surgery, Undercliffe • Little Horton Lane Medical • Picton Medical Centre Practice • Valley View Surgery
25 practices
1.1.3 Composition of governing body
The composition of the governing body can be found on page 82 onwards of this annual report. 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 pages 85 onwards of this annual report.
NHS Bradford City CCG Annual Report and Accounts 2018/19 75
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 107. 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 Financial Reporting Manual have been followed, and disclose and explain
NHS Bradford City CCG Annual Report and Accounts 2018/19 77
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 Bradford City CCG
28 May 2019
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1.3 Governance statement
1.3.1 Introduction and context
NHS Bradford City 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 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 Airedale, Wharfedale and Craven 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 board 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 board 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 from each of the CCG’s member practices; this representative cannot be an elected GP member of the clinical board . On behalf of the membership, the chair is elected by the member practice representatives of the council of members. Dr Jahangir Akhtar is chair of the council of members.
The council of members has met five times during 2018/19, including the 2017/18 CCG annual general meeting held jointly in public with the governing body and clinical board 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
2018/19 Council of Members Highlights Membership: • receiving the 2017/18 Accounts and Annual Practice Report at a joint meeting in public with the Representatives governing body and clinical board. • approving the CCG’s revised constitution and terms of reference for ‘committees of the CCG’. • review and approval of the council’s own
terms of reference. 100% • updates on the CCG’s financial and QIPP position and the CCG’s improvement and assessment framework ratings. • discussed proposals to merge the three Standing agenda Items Bradford district and Craven CCGs from • April 2020 (for decision in June 2019) declaration of interests • • Receiving briefings and providing comment minutes of previous meetings and challenge on: • action log - low value and over the counter medicines • clinical board member updates - diabetes and question time– this is a - maternity, children and young people significant agenda item at all services meetings - procedures of limited clinical • updates on national and local effectiveness CCG developments - implications of revisions to NHS planning • updates on the work of the guidance joint committee of West - development of the Bradford health and Yorkshire & Harrogate CCGs care partnership - development of the West Yorkshire & Harrogate health and care partnership
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, these meetings have been held as ‘committees in common’ with the governing bodies of NHS Airedale, Wharfedale and Craven CCG and NHS Bradford Districts CCG. In addition to meetings in public, the governing body and the clinical board 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 NHS Airedale, Wharfedale and Craven CCG and NHS Bradford Districts CCG.
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.
NHS Bradford City CCG Annual Report and Accounts 2018/19 83
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 Akram Khan Clinical chair and elected GP Max McLean Lay member, patient and public involvement (deputy CCG chair) Ruby Bhatti Lay member, governance Bryan Millar Lay member, finance Angie Clegg Registered nurse John Young Secondary care consultant Dr Sohail Abbas Elected GP (deputy clinical chair) Helen Hirst Chief officer Julie Lawreniuk Chief finance officer and deputy chief officer Michelle Turner Director of quality and nursing Liz Allen CCG executive director
In addition to the members above, Sarah Muckle attends governing body meetings in a non-voting, advisory capacity as a representative of public health .
Figure 5: 2018/19 attendance at governing body
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Governing body highlights 2018/19
The governing body: Membership • approved the 2018/19 financial and operational plan. 18% • approved the 2018/19 version of the memorandum of understanding governing working arrangements with the 46% Airedale, Wharfedale and Craven and Bradford Districts CCGs. • endorsed the West Yorkshire and 36% Harrogate Health and Care Partnership memorandum of understanding • approved the Strategic Partnering Lay Executive GP Agreement of the Bradford and AWC Health and Care Partnerships. • considered the following strategic Standing agenda items: themes: - evaluation of the people’s board, • Declaration of interests - community engagement in tackling • Minutes of previous meetings winter pressures, • Action log - dementia in commissioning • Chair and chief officer’s report (including engagement. updates on the clinical board, joint • approved contract awards for: CCG and clinical committee and West Yorkshire & GP IT and IG services and CCG office Harrogate CCGs joint committee) move building works. • Performance reports • approved pay awards for staff and • quality contractors outside of agenda for • finance change, in line with recommendations • contracting from the Remuneration Committee. • Strategic partnerships report • received the investigation reports (IT and • Updates on the development of the clinical quality) arising from the October Bradford health and care partnership 2018 network availability incident. • High level risk report • reviewed and approved the governing • Minutes of JQC, JFPC, PCCC, audit and body assurance framework as a fair governance and remuneration reflection of the CCG’s strategic risk position. committees • • approved revisions to terms of reference INVOLVE engagement tracker for the audit and governance committee, the PCCC and the remuneration Annual reports received: committee. • reviewed its effectiveness and that of the • Audit and governance committee Bradford district and Craven CCGs • External audit letter collaborative governance structure. • Safeguarding • Emergency preparedness, resilience and response • Human resources
Conclusion: The governing body has fulfilled its role and responsibilities.
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1.3.6 Committees of the CCG and committees of the governing body
Clinical board
The clinical board 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 board is provided to the governing body via the clinical chair’s report.
Role: The clinical board 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 Akram Khan Elected GP and clinical chair Dr Sohail Abbas Elected GP and deputy clinical chair Dr Waheed Hussain (until 31 May 2019) Elected GP Dr Aamer Khan Elected GP Dr Anne Connolly Elected GP Dr Junaid Azam Elected GP Helen Hirst Chief officer Julie Lawreniuk Chief finance officer Michelle Turner Director of quality and nursing Liz Allen CCG executive director
In addition to the members above, Dr Tony Williams (or colleague) attends clinical board meetings in a non-voting capacity as a representative of public health .
The clinical board met on 25 occasions during 2018/19. Eighteen of these meetings were held as ‘committees-in-common’ with the clinical board of NHS Bradford Districts CCG; the remaining seven meetings were specific to NHS Bradford City CCG. Attendance is recorded below:
Figure 6: 2018/19 attendance at clinical board Note: Helen Hirst and Julie Lawreniuk shared attendance at clinical board during the year but both attended where possible. NHS Bradford City CCG Annual Report and Accounts 2018/19 86
Clinical board highlights 2018/19
The clinical board: Membership
• received updates and provided comment and
challenge on: 40% - 0-19 services re-procurement by public health
and the prevention and early help agenda 60% - development of a new model for community beds - clinical quality and patient safety issues GP Executive following at IT network incident
- out of hospital programme Standing or regular agenda - QIPP engagement scheme items - diabetes new models of care
- primary care commissioning strategy • declarations of interest evidence based approach to prevention and - • minutes of the previous meeting health inequalities and action log - NHS long term plan • updates from finance, contracting, - GP online consultations QIPP and performance - Bradford Improving Cancer Survival (BICS) • JFPC and JQC key risks and - interim outcomes associated with projects issues utilising the non-recurrent resource • updates from partnership groups - financial allocation for the next 5 years and • programmes update how to effectively target the resource in order • risk register (bi-monthly) to reduce health inequalities, increase access to services and improve outcomes • supported the following initiatives - the development of Strategic Partnering Agreement of the Bradford district and Craven Health and Care Partnership - the development of community partnerships - an option for the future commissioning of telemedicine in care homes - the CCG’s position on gluten free prescribing - software supporting the management of frailty - the roll out of the QIPP Plus initiative - the development of the Bradford Breathing Better Programme - delivery of the cardiometabolic pathway in Bradford - Refugee and Asylum Seekers Healthcare Professionals (REACHE) programme working closely with Bradford University - Rollout of the Bradford Healthy Hearts programme • reviewed its effectiveness, terms of reference (for approval by council of members) and work plan.
Conclusion: The clinical board has fulfilled its role and responsibilities.
NHS Bradford City CCG Annual Report and Accounts 2018/19 87
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
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: - acute provider collaboration - mental health and learning disabilities - urgent and emergency care - children and young people - cancer - planned care - 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 Clinical chair – BC (chair) Dr James Thomas Clinical chair – AWC Dr Andy Withers Clinical chair – BD Dr Shane Beggan Associate GP – AWC (from June 18) Dr Sohail Abbas Elected GP - BC Dr Carsten Grimm Elected GP – BD (to May 18 – maternity cover) Dr Louise Clarke Elected GP – BD (from June 18 – return from maternity) Helen Hirst Chief officer Julie Lawreniuk Chief finance officer Michelle Turner Director of quality and nursing Sue Pitkethly Executive director - AWC (to 19.12.18) Nancy O’Neill Executive director - AWC (to 20.12.18) Liz Allen Executive director – BC Ali Jan Haider Executive director – BD Fiona Jeffrey Associate director of corporate affairs
Key: BC – Bradford City CCG BD – Bradford Districts CCG AWC – Airedale, Wharfedale and Craven CCG
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Figure 7: 2018/19 attendance at JCC
Joint clinical committee highlights 2018/19
Membership • 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. 50% 50% • Received updates on and input to the following work-streams: bariatrics service stroke services GP Executive
mental health services BTHFT CQC inspection Standing agenda items over the counter medicines and low value • Declarations of interest medicines consultations • Minutes of the last meeting and urgent and emergency care services action log Health checks for patients with serious mental • illness Updates on the work of the joint children, young people and maternity committee of the West fertility treatment commissioning policy Yorkshire and Harrogate medicines optimisation CCGs. • IT incident investigation Updates on the work of the quality review of MIND acute provider collaboration 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 NHS Bradford City CCG Annual Report and Accounts 2018/19 89
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 City CCG and Bradford Districts 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 Lay member for patient and public involvement – AWC (chair) Max McLean Lay member for patient and public involvement – BC (chair) David Richardson Lay member for patient and public involvement - BD Angie Clegg Registered nurse – AWC, BC, BD Peter Brunskill Secondary care consultant - AWC John Young Secondary care consultant – BC, BD Dr Graeme Summers / Dr Jake Jeffrey Executive GP – AWC Dr Andy Withers Executive GP – BD Michelle Turner Director of quality and nursing Fiona Jeffrey Associate director of corporate affairs Healthwatch Lay representative from Healthwatch
JQC held 12 meetings during 2018/19 and attendance is detailed on the next page.
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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 Membership discussions emerging from local, regional or 18% national initiatives or issues. During 2018/19 have included deep dive discussions and reports on:
• Cancer 18% • Personalised Commissioning 64% • IT Clinical Audit Review • Yorkshire Clinic’s Governance Arrangements
• BTHFT Maternity Lay & Professional GP Executive • Stroke Services • Received assurance on actions being taken Standing/regular agenda items following the October 2018 network • Declaration of interests availability incident and on clinical issues • Minutes of previous meetings and arising. action log • Reviewed the committee’s effectiveness, its • Quality report supported by the work plan and agreed revisions to its terms of Grassroots and performance reports reference. • Serious concerns/incidents report • JQC risk register report (every second meeting) • Annual reports: CCG and provider safeguarding adults and children reports, care home report
Conclusion: The JQC is achieving and delivering its role, responsibilities and functions.
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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 Lay member for governance – AWC (chair) Bryan Millar Lay member for finance – AWC, BC, BD Julie Lawreniuk Chief finance officer – AWC, BC, BD Sue Pitkethly Director: AWC health and care partnership Liz Allen Director: Bradford health and care partnership Dr Colin Renwick Elected GP – AWC Dr Dave Tatham Elected GP – BD Dr Aamer Khan 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
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Joint finance and performance committee highlights 2018/19
At each meeting during the year, JFPC Membership has robustly monitored the finance and performance of each of the Bradford 28% 28% district and Craven CCGs.
In particular, JFPC has reviewed the differing challenges with QIPP and financial pressures faced by each of the 44% CCGs and received assurance on how Lay Executive GP these were managed
In doing so, the CCGs have: Standing agenda items • • met constitutional targets Declarations of interest • • met financial targets Minutes of the last meeting and action log • In addition, JFPC have: Performance report • • reviewed the committee’s Contracting report effectiveness and agreed revisions to • QIPP report its terms of reference (for approval by • Finance report council of members) • Issues to highlight to Clinical Board / • received assurance on actions being Executive and Governing Bodies taken following the October 2018 • JFPC risk register (every second network availability incident and the meeting) independent IT investigation report
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 & 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.
Meetings, attendance and highlights: The joint committee meets formally in public every second month, with development and strategy sessions in intervening months. NHS Bradford City CCG Annual Report and Accounts 2018/19 93
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 Airedale, Wharfedale and Craven 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 Bradford City 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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Ruby Bhatt Lay member for governance (chair) Max McLean Lay member for patient and public involvement Angie Clegg Registered nurse John Young Secondary care consultant Helen Hirst Chief officer Julie Lawreniuk Chief finance officer Michelle Turner Director of quality and nursing Liz Allen CCG executive director Dr Akram Khan Clinical chair – non-voting Dr Sohail Abbas Elected GP – non-voting
In addition to the members above, the following groups have standing invitations to attend PCCC meetings: NHS England, Bradford Healthwatch, Public Health (CBMDC), 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 2018/19
Highlights of the PCCC’s work have included: Membership
18% • reviewing the committee’s effectiveness and agreeing revisions to its terms of reference (for approval 46% by Governing Body). • receiving updates on 18/19 contract 35% changes, the internal audit framework for delegated commissioning and on Lay & Professional Executive the 5 Year GP contract. GP (non-voting) • approved the Standard Access Scheme and received assurance on Standing agenda items the delivery of the scheme. • Declarations of interest • approved the Special Allocations • Minutes of the last meeting and NHS Bradford City CCG Annual Report and Accounts 2018/19 95
Scheme and received assurance on matters arising the delivery of the scheme. • Contract assurance and performance • approved the Temporary List report Reassignment Policy. • Questions from the public on agenda • received assurance on anti-microbial items prescribing. • updates on CQC ratings for Hillside Bridge, Avincenna Medical Centre & Farrow Medical Centre. • approved the contract transfer for Hillside Bridge to Dr Akbar. • approved the merger of Kensington Partnership and Woodroyd at Kensignton contracts
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 Airedale, Wharfedale and Craven CCG and NHS Bradford Districts 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
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• Reviews the findings of other significant assurance functions, both internal and external and consider the implications for the governance of the CCG
Membership and attendance
Bryan Millar Lay member for finance (chair) Ruby Bhatti Lay member for governance Angie Clegg Registered nurse Max McLean Lay member for patient and public involvement (alternate member if required for quorum purposes)
The audit and governance committee has met five times during 2018/19; two 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 Membership 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. 100% • approved the 2018/19 external audit plan. Lay & Professional • monitored the work of internal and external audit and CCG implementation of Standing agenda items recommendations arising. • Declaration of interests • reviewed the performance of internal and • Minutes of previous meetings external audit. and action log • reviewed and approved a number of • Internal audit and counter fraud NHS Bradford City CCG Annual Report and Accounts 2018/19 97
information governance and health and Progress reports safety policies. • External audit progress reports • reviewed the CCG’s standing orders, and technical updates standing financial instructions and scheme • Corporate risk and assurance of delegation. report (includes risk register / • received the findings of a gap analysis of GBAF / conflicts of interest the CCG’s security management management / compliance with arrangements. SOs and SFIs, CCG incidents, • received updates on actions being taken mandatory training compliance, following the October 2018 network etc) availability incident. • Information governance report • reviewed the committees own • Health and safety report effectiveness and its terms of reference. • 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:
Ruby Bhatti Lay member for governance (chair) Max McLean Lay member for patient and public involvement Bryan Millar Lay member for finance Angela Clegg Registered nurse
The committee is supported by independent advice from our HR providers, Bradford District Care NHS Foundation Trust.
There have been two meetings of the remuneration committee during 2018/19; these were held as ‘committees in common’ with the remuneration committees of the Airedale, Wharfedale and Craven and Bradford Districts CCGs with part of one meeting relating to Bradford City CCG only, where assurance on the performance review process for clinical board members was considered. Attendance details are shown on the next page.
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Figure 12: 2018/19 attendance at Remuneration Committee
Remuneration committee highlights 2018/19
• Received assurance on the 2017/18 Membership performance review process for the chief officer, chief financial officer, director of nursing and quality, CCG executive director, ICB programme director and the clinical board, including the clinical chair – and details of their 2018/19 objectives. • Considered and made recommendations on 100% Lay & Professional pay and contractual arrangements for clinical speciality leads. • Considered and made recommendations to Standing items the governing body on a pay award for those • Declaration of interests outside of agenda for change. • Minutes of previous meeting • Reviewed the committee’s effectiveness and and action log agreed revisions to its terms of reference (for approval by the governing body).
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.
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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 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 effectiveness
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.
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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 (i.e. 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.
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. 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.
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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.
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 Airedale, Wharfedale and Craven and Bradford Districts 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.
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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.
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 board 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 board, 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 • Bradford health and care partnership reports • Engagement tracker
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• 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, 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.
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• 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 internal 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.
Risk Key actions to mitigate risk Means to assess outcome Staff struggle to • Standard staff support • Staff survey feedback adapt to new, mechanisms; regular one-to- • Sickness and turnover externally facing one meetings with line rates system-focus roles managers, personal • Delivery of CCG due to the need for development plans, etc. objectives and role flexibility and • Staff briefing and statutory duties the normal factors communication channels, • CCG 360 o survey associated with including weekly staff update change, resulting in immediately after the senior failure to develop as management team meeting an organisation. • Organisational development programme
Table 4: strategic risks related directly to governance, 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 33 open risks on the corporate risk register, with 11 of these risks classed as ‘major’ (i.e. scoring 15 or more). Of these 11 ‘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
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Risk summary Key actions to mitigate risk Means to assess outcome The CCG’s' abilities to • Executive commissioning • Monitoring via plan for and respond to board (ECB) established senior management any potential adverse between the CCG and team, clinical impact on services or BDMC boards/executive strategic priorities due to • Strategic financial planning and joint finance unforeseen financial cuts is a standing item at ECB and performance by BMDC, particularly meetings committee within public health, adult • ECB issues log in place • Achievement of social care and children’s • CCG input to BMDC CCG financial plans services. consultations There is a risk to the • Funding secured for • Fortnightly highlight delivery of CCGs and GP second server reports to SMT on practices business and • Project plan in place project progress patient services due to • Business continuity plans the lack of a second reviewed and strengthened back- up server (IT infrastructure). Table 5: open risks classed as “major” that directly to governance, risk management or internal control
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 board 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;
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• 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 district and Craven CCGs by Audit Yorkshire, our internal auditors, and their conclusion is detailed below:
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 Significant expected that the updated versions will be formally approved and issued Assurance 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.
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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 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.
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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 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 Districts 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 this 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.
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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 • 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.
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• 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.
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 of the performance report.
1.3.15 Review of economy, efficiency and effectiveness 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 board 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.
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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 98.8% 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 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 action 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 board 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 109).
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 NHS Bradford City CCG Annual Report and Accounts 2018/19 112
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.
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 effectiveness of the system of internal control at NHS Bradford City Clinical Commissioning Group for the year ended 31 March 2019
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
NHS Bradford City CCG Annual Report and Accounts 2018/19 113 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.
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
• Significant assurance can be given that there is a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls are generally being applied consistently. However, some weaknesses in the design and/or inconsistent application 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.
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Since 2017/2018, Bradford City Clinical Commissioning Group (BCCCG) has been operating through a joint management and governance structure with its two neighbouring CCGs, Airedale, Wharfedale and Craven and Bradford Districts Clinical Commissioning Groups. To reflect this collaborative arrangement an 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 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 assurance can be given that there is a strong system of internal HIGH control which is designed and operating effectively to ensure that the (STRONG) system’s objectives are met.
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Opinion Level Opinion Definition
Significant assurance can be given that there is a good system of SIGNIFICANT internal control which is designed and operating effectively to ensure (GOOD) that the system’s objectives are met and that this is operating in the majority of core areas.
Limited assurance can be given as whilst some elements of the LIMITED system of internal control are operating, improvements are required in (IMPROVEMENT the system’s design and/or operation in core areas to effectively meet REQUIRED) the system's objectives.
Low assurance can be given as there is a weak system of internal LOW control and significant improvement is required in its design and/or (WEAK) 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.
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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 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.
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, risk 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 • CQC overall ratings of ‘inadequate’ for three of our member practices
Further details about the IT 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.
Further details relating to the performance of primary care services is set out at section 2.1 of the performance report.
Helen Hirst Accountable officer NHS Bradford City CCG 28 May 2019 NHS Bradford City CCG Annual Report and Accounts 2018/19 118
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, 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, are on page 97 onwards of this report.
2.1.2 Policy on the remuneration of senior managers
The remuneration committee sets senior manager remuneration levels on the following basis:
Accountable officer/chief finance Remuneration guidance for CCGs as issued officer/lay members by NHS England
Other CCG directors NHS Terms and Conditions of Service 2018 (Agenda for Change) and the 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. For Directors on the Agenda for Change pay scale, progression along and retention of pay step points is dependent on satisfactory performance against a director's personal objectives. 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
Senior managers are employed on the following contract terms:
Post Status Duration Notice period Accountable Officer Not fixed 6 months officer Chief finance Officer Not fixed 6 months Officer Director Officer Not fixed 3 months Clinical chair Office holder Fixed (three years) 3 months Clinical/lay Office holder Fixed (up to three years) 3 months members Table 6: senior managers’ contract terms
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 Notice (where applicable) period Helen Hirst 1 April 2013 N/A 6 months Dr Akram Khan 1 April 2013 31 July 2019 3 months Julie Lawreniuk 1 May 2016 N/A 6 months Max Mclean 1 April 2013 31 March 2019 3 months Angie Clegg 1 April 2017 31 March 2020 3 months Bryan Millar 3 November 2014 30 November 2019 3 months John Young 1 April 20198 31 March 2021 3 months Ruby Bhatti 16 January 2015 31 March 2021 3 months Elizabeth Allen 1 April 2013 N/A 3 months Michelle Turner 1 April 2013 N/A 3 months Dr Waheed Hussain 1 April 2013 31 May 2019 3 months Dr Aamer Khan 1 April 2013 31 March 2020 3 months Dr Anne Connolly 1 August 2016 31 July 2019 3 months Dr Sohail Abbas 19 January 2015 31 March 2020 3 months Dr Junaid Azam 1 April 2018 31 March 2021 3 months Table 7: service contract details for senior managers
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2.1.4 Senior manager remuneration (including salary and pension 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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2.1.1 Pension benefits as at 31 March 2019
See table 8 on page 121
2.1.2 Cash equivalent transfer values
See table 9 on page 122
Real increase in CETVs
See table 9 on page 122
2.1.3 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.
2.1.4 Payments to past members
There were no payments made to past senior managers in 2018/19, or in 2017/18.
2.1.5 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 £132,500 (2017/18: £137,500). This was 3.62 times the median remuneration of the workforce, which was £6.644 (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 £2,477 to £134, 015 (2017/18: £2,144 to £137,188).
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.
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The information included in the table below reflects only the clinical commissioning group’s share of total staff numbers and costs for 2018/19.
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 Other Employed 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 2019
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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NHS Bradford City CCG Annual Report and Accounts 2018/19 126
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.
Full Part Band Time 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 Table 12: numbers of staff by band and Table13: number of staff by band and gender working hours
NHS Bradford City CCG Annual Report and Accounts 2018/19 127
Staff by Band & Employee Category 30 25 20 15 10 5 0
Full Time Part Time
Figure 13: number of staff by band and employee category
Staff by Band and Gender 40 35 30 25 20 15 10 5 0
Male Female
Figure 14: number of staff by band and gender
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.
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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.
2.2.4 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 NHS Bradford City CCG Annual Report and Accounts 2018/19 129
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.
2.2.7 Expenditure on consultancy
The clinical commissioning group spent £10,000 on external consultancy in 2018/19 (compared to £15,863 in 2017/18).
2.2.8 Off-payroll engagements
We have 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. This includes payments to GP practices for the services of GPs as clinical specialty leads for the clinical commissioning group.
(a) Off-payroll engagements as at 31 March 2019, for more than £245 per day that lasts longer than six months: Number
Number of existing engagements as of 31 March 2019 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 2019, 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. NHS Bradford City CCG Annual Report and Accounts 2018/19 130
(b) New off-payroll engagements between 1 April 2018 and 31 March 2019, for more than £245 per day and that last longer than six months:
Number
Number of new engagements, or those that reached six months in 0 duration, between 1 April 2018 and 31 March 2019 Of which: Number assessed as IR35 being applicable Number assessed as IR35 being not applicable
Number engaged directly (via PSC contracted to department) and 0 are on the departmental payroll Number of engagements reassessed for consistency / assurance 0 purposes during the year Number of engagements that saw a change to IR35 status 0 following the consistency review Table 15: New off-payroll engagements between 1 April 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 senior officials with significant financial responsibility, between 1 April 2018 and 31 March 2019
Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during the 0 financial year. Total number of individuals on payroll and off-payroll that have been deemed “board members, and/or, senior officials with 15 significant financial responsibility”, during the financial year. This figure should include both on payroll and off-payroll engagements. 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 Bradford City CCG
28 May 2019
NHS Bradford City CCG Annual Report and Accounts 2018/19 131
3 Parliamentary accountability and audit report
Bradford City 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 142. An audit certificate and report is also included in this annual report at page 112.
Helen Hirst Accountable officer NHS Bradford City CCG
28 May 2019
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CHAPTER 3: ANNUAL ACCOUNTS
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NHS Bradford City CCG Annual Report and Accounts 2018/19