Bristol, North Somerset and South Gloucestershire CCG Annual Report 2019/20

Contents

PERFORMANCE REPORT ...... 6 Performance Overview ...... 9 ACCOUNTABILITY REPORT ...... 81 Corporate Governance Report ...... 82 Members Report ...... 82 Statement of Accountable Officer’s Responsibilities ...... 87 Governance Statement ...... 89 Remuneration and Staff Report ...... 119 Remuneration Report ...... 119 Staff Report ...... 128 Parliamentary Accountability and Audit Report ...... 147 ANNUAL ACCOUNTS ...... 148

Clinical Chair and Chief Executive’s Introduction

The world looks very different today to how it did at the beginning of 2020. It’s fair to say that the coronavirus pandemic has presented an unparalleled challenge for us all.

Families and communities have lost loved ones before their time, and our daily lives have changed beyond recognition as we seek to reduce the spread of the virus. Community has never been more important than it is now, and we have seen thousands of volunteers step forward to support each other through mutual aid, direct help to local services and through voluntary sector routes.

We’re proud to serve the diverse communities of Bristol, North Somerset and South Gloucestershire and would like to take the opportunity to thank everyone in our area for the fortitude they have shown in this time. From using the right urgent care services for your needs, to following the government guidance and adapting to new digital GP appointments – you have shown us the meaning of community resilience.

Coronavirus is impacting on people’s health and wellbeing in a number of ways. Both nationally and locally, we are anticipating an increased demand for mental health support and bereavement services. Mental health needs to become everyone’s business now, with opportunities created for people to connect with the right support quickly and easily. In addition, we are committed to understanding the disproportionate impact coronavirus is having across our communities on an ongoing basis; both directly, and in terms of the wider impact on jobs, education and social interaction.

As we return to full provision of NHS services while continuing to manage the threat of coronavirus, we have many positives to build on from the last year. These include the establishment of primary care networks (PCNs) across BNSSG; groups of GP practices set up to work better together and focus on the needs of their local communities.

As part of this development, we have funded a number of new roles within GP practices, including social prescribing link workers. Social prescribing connects people with a wider range of support, including befriending services, exercise classes and social activity. We know that people experience better outcomes when they are listened to and their needs are considered holistically. As part of the local coronavirus response, social prescribing teams are linking those who are shielding with vital support such as food and medication deliveries, mental health advice and online wellbeing activities.

We have also established wider provider partnerships in each of our locality areas this year. These partnerships bring adult community services, mental health and social care together to

work seamlessly around the needs of individuals. Our plans for the next year will see further development of these integrated care partnerships, ensuring that people receive joined-up care, closer to home.

More than 3, 000 people took part in the Healthy Weston consultation, with 8 in 10 recognising the need for change. Several service developments related to the consultation are now in place, including a mental health recovery centre in the centre of Weston - currently operating as a helpline - and the introduction of a frailty service to better support the area’s older population with more proactive care.

The decision to proceed with the proposed clinical model for Weston helped to create the conditions for this year’s successful merger between University Hospitals Bristol and Weston Area Health Trust. The creation of the new University Hospitals of Bristol and Weston Trust (UHBW) will bring significant benefits for patients and staff.

Vita Health became the provider of our new Improving Access to Psychological Therapies (IAPT) service, offering a holistic model for people experiencing mild to moderate anxiety and depression across BNSSG, and following a comprehensive procurement process, Sirona care & health became the single provider of adult community services in our area. We are really excited about what this means for transformation of out-of-hospital care in the years ahead.

Our Integrated Urgent Care Service was successfully launched, linking 111 with out-of-hours GP services to provide a better experience for our population. The BNSSG Integrated Care Bureau is also up and running, supporting around 900 patients a month to get home from hospital sooner, and with the ongoing care they need in place.

While these developments give us a strong base from which to build as we face ‘the new normal’, the principles of how we work remain the same. We continue to strive to put people at the heart of what we do, and to take a value-based approach. That means ensuring that our resources are used in the best way to provide value for the individual, and value for the whole population of BNSSG – we are still determined to move from ‘what’s the matter with you’ to ‘what matters to you’.

We’re incredibly proud of health and care staff across BNSSG and their immense contribution to managing the outbreak and providing great care – whether in a hospital, care home, community or GP practice setting. Thank you to all of you. Seeing so many people collaborate across organisational boundaries and adapt to socially distanced ways of working - all while retaining the human touch that is so much a part of what we do – has been an inspiration.

As we move into the recovery phase, collaboration must remain core to the way we work - with staff, system partner organisations, stakeholders, and – most importantly – the public we serve. Only by working together and harnessing our shared expertise will we make the biggest difference.

Dr Jonathan Hayes, Clinical Chair

Julia Ross, Chief Executive

PERFORMANCE REPORT

This performance overview provides a short summary of our purpose, the key risks to our objectives in 2019/20 and how we performed during the year.

Chief Executive’s Statement

At the time of writing, the NHS is facing perhaps its greatest challenge since its creation in 1948. We are working together with our partners across Bristol, North Somerset and South Gloucestershire and across our Region, in response to the Covid-19 pandemic as it affects our population. Together with our partners, we are freeing up the maximum possible inpatient and critical care capacity across our system and commissioning additional services in the community to support people. We know that these services are vital to the care of patients who are hospitalised and require respiratory support as well as those being looked after at home. Whilst focusing on how we best create the capacity we need to meet the needs of our population, we are also working hard to ensure that our staff stay well and healthy. These are unprecedented challenges, and I would like to thank all the dedicate staff across our system who continue to support our patients, carers and members of the public.

We have made real strides to tackle the challenges facing our local health services during 2019/20. The increasing demand for care from a population that is growing older and living with more complex conditions means we have to think innovatively to ensure health care systems continue to be resilient and sustainable for the future. We have built on the progress made in our first year of existence, shaping better health across Bristol, North Somerset and South Gloucestershire. Our Operational Plan for the year set out our ambitions for managing demand for our urgent and emergency care services, creating a sustainable workforce, particularly in primary care, and moving our system closer to financial recovery.

We revisited our Primary Care Strategy, and taking on board the comments received from GPs, partner organisations and members of the public, refreshed our strategic priorities for primary care. We worked with our member practices to develop Primary Care Networks and lay the foundations for Integrated Care Partnerships, a central pillar of our plans for our Integrated Care System. Another pillar supporting our plans for an integrated system was the appointment of a single provider for community services. In July 2019 we announced that Sirona care & health would provide both adult and children’s community health services across Bristol, North Somerset and South Gloucestershire from 1st April 2020. Our plans create a network of integrated primary care and community services, which will ensure people receive

consistent high quality care wherever they live across our area and whenever they need it, as well as supporting urgent and emergency care services.

The successful completion of the Healthy Weston consultation and the decisions to make fundamental changes to the urgent and emergency services provided at Weston General Hospital further supports urgent and emergency care provision as it faces growing demands. The scale of involvement from our public consultation and wider stakeholder engagement has given us confidence in the new ways of working. Other elements of our transformation programme for urgent care have included the successful launch of our Integrated Urgent Care Service, which combines clinical assessment with the 111 telephone line, and the launch of the Integrated Care Bureau, which supports the inter-agency discharge of patients from hospital.

Mental health and wellbeing has been and continues to be one of our highest priorities. Working with people with lived experience, we have drafted an all age system wide mental health strategy focusing on promoting mental health and wellbeing and preventing ill health. We are grateful to the many people who engaged with us as we developed the strategy and look forward to taking it onto implementation in 2020/21. In response to people’s feedback the strategy focuses heavily on improving joint working to ensure that the focus of services is on the person and their needs, whilst creating sustainable solutions that continue to meet the expectations and needs of our citizens.

The Learning Disabilities Mortality Review (LeDeR) Programme is the first national programme of its kind aimed at making improvements to the lives of people with learning disabilities. We have worked to build a strong process in 2019/20, enhancing the requirements of national guidelines by introducing a Clinical Case Review Panel to strengthen the quality assurance and closure process of cases. We have also built a robust platform to share learning across all partners and continue improving our approach. We have engaged people with learning disabilities in a LeDeR Service User Forum to help us better understand what really matters to people with learning disabilities. Whilst we are not complacent about our approach, we have made significant improvements in 2019/20 and we will continue to review and improve services so that they better serve people with learning disabilities and their families.

Despite comprehensive actions to strengthen the sustainability of services, we were unable to achieve our financial control total set by NHS England for 2019/20. We agreed an overall deficit of £12 million for the year, however; increases in the number of complex continuing healthcare packages, changes to prescribing costs and a significant increase in the number of mental health out of area placements, resulted in an end of year deficit of £34 million.

Our plans for 2020/21 focus on working with our partners in the NHS and local authorities to build an Integrated Care System that will enable us to deliver the scale of system transformation needed to create a sustainable future for health and care services across Bristol, North Somerset and South Gloucestershire.

Julia Ross

Chief Executive

24th June 2020

Performance Overview

Our purpose and activities

Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group (CCG) is responsible for planning, buying and monitoring the majority of healthcare services for the one million people who live in our area.

We are a membership organisation, led by GPs from the 80 general practices in Bristol, North Somerset and South Gloucestershire. Our practices work across six localities and in 18 Primary Care Networks. Our Members use their knowledge of the local population’s health needs to guide the services we plan and purchase. Our local GPs provide the clinical leadership for all of our commissioning activities. We work with patients and partners to plan health services for Bristol, North Somerset and South Gloucestershire residents, based on the identified needs of our population. Our Governing Body ensures that we meet our responsibilities and its membership includes three lay members, local GPs, a secondary care doctor, an independent nurse member and executive members. The CCG employs 484 members of staff who work alongside our colleagues in primary and secondary care, and in community services, as part of the Healthier Together system to deliver our plans. The services we are responsible for include:

 Urgent and emergency care, such as NHS 111, A&E and ambulance services  Planned hospital care, such as operations and treatments  Community health services, such as community nursing and physiotherapy  Rehabilitation for those recovering from illness and operations  Maternity and new born services  Infertility services  Children and young people’s health services  Mental health services  Continuing healthcare for people with on-going health needs, such as nursing care  We are responsible for commissioning primary care services from local GP practices.

NHS England commissions other primary care services such as dentists, pharmacists and opticians. To ensure that we commission services that meet the needs of our communities we have worked with patients, service users, carers and members of the public to understand what matters to them. Our insights and engagement activities in 2019/20 included:

 Consulting with people in North Somerset about the future of services at Weston Hospital. We received over 2,000 responses from members of the public, which helped shape the proposals considered and approved by our Governing Body.  Supporting the development of the Primary Care Strategy through on-line surveys and meetings with patient groups and Healthwatch. We have used this feedback to develop a primary care strategy to provide primary care services that meet people’s needs.  Using focus groups, one to one activities and surveys to understand what people want from services aimed at supporting frail and elderly patients. These insights have helped us design services that are more responsive.  Working together with people with lived experience to develop an all age mental health strategy to drive real and sustained change.

We have created six localities across Bristol, North Somerset and South Gloucestershire. These localities allow our GPs, who understand their practice populations, to plan local services.

Our localities

Our population

Bristol, North Somerset and South Gloucestershire is a vibrant and dynamic area with a mix of urban and rural populations. Bristol is a largely urban area, whilst both North Somerset and South Gloucestershire are more rural. We have a diverse population with older populations in North Somerset and South Gloucestershire and a younger population living in Bristol. Our

population is growing, with increases in the numbers of people aged between 15 and 24 years old and people over the age of 60 years. The population predicted to increase most significantly over the next 25 years is those aged 85 and over. We have an ethnically diverse population, with Bristol having the greatest proportion of Black and Minority Ethnic (BME) people (16%) compared to South Gloucestershire (5%) and North Somerset (2.7%). Our younger people tend to have the greatest number belonging to a BME group. There are significant pockets of deprivation within our area, with around one in ten people living in a deprived location. Average life expectancy varies between those living in the most and least deprived areas by around six years, with some places seeing a 15-year difference.

If we describe our population as 100 people:

Our vision is to enable “healthy, fulfilled lives for everyone” across our area, with people both at the heart of what we do and working with us to shape services. We have worked together with our partners to improve physical and mental health, promote wellbeing and reduce inequalities in health outcomes for local people. The challenges facing our healthcare system include working towards financial recovery, meeting the workforce supply and the population demand

challenge, specifically, improving urgent care. Our response to these challenges were set out in our priorities in our 2019/20 operational plan. These priorities spanned:

 Working towards financial recovery  Creating stable and resilient primary care  Managing the challenges facing our urgent and emergency care system  Building strong localities to take forward our vision of integrated localities  Securing a single provider of community services across Bristol, North Somerset and South Gloucestershire  Improving cancer care, reducing waiting times, delivering early diagnosis for lung, colorectal and prostate cancers, and delivering the Living Well and Beyond cancer programme  Improving mental health services, and services for people with learning disabilities and autism  Improving our planned care services, including reducing waiting times for diagnostic services

We have focused on getting the best value for our population, ensuring that every NHS pound is spent in the most effective way possible. To help us take this forward we are using the principle of value-based healthcare so that our resources, financial and non-financial, are used equitably, openly and sustainably to achieve better outcomes and experiences for all of our population.

More information about our achievements and progress can be found in the Performance Analysis section of this report. A snapshot of our achievements in 2019/20 include:

In primary care we:

 Refreshed our Primary Care Strategy setting out our vision for resilient, high quality, accessible primary care services at the heart of our Integrated Care System.  Supported the recruitment of additional roles to our Primary Care Networks, strengthening our primary care workforce.  Provided programmes of support to individual GP practices, Primary Care Networks, and localities  Continued to improve access to primary care appointments  Tackled the differences in blood tests that people with long-term conditions have at their annual review at their GP practice. People have been having different tests and

there was not always a good reason for this. Now everyone can get the right tests at the right time.

Our localities established new ways of working including:

 Establishing in some localities multidisciplinary teams to support people with complex health and care needs and setting up GP based drug and alcohol clinics in other localities  Increased social prescribing. We know that these services provide important support to people, helping them take part in activities, often community-based, which prevent loneliness and ill health  Supporting the new Safe Haven Centre in Weston-super-Mare, providing support to people experiencing a mental health crisis

We completed our procurement process for community health services across Bristol, North Somerset and South Gloucestershire, realising our vision for consistent, proactive and joined up care, supporting people to stay well and independent for longer.

We reached a key milestone in the Healthy Weston Programme, completing a major public consultation on proposals for urgent and emergency care services in Weston-Super-Mare. Our consultation reached 3,000 people and the views shared with us helped shape the final proposals approved by our Governing Body in October 2019. The proposals, supported by local clinical leaders, set out new arrangements for adult and children’s urgent care services, and for patients needing critical care services.

Other developments in our urgent and emergency care services included:

 Launching our Integrated Urgent Care (IUC) Service, which brings together the 111 access line and clinical assessment. The service can now support people more by booking appointments for patients will minor illnesses with either local pharmacists or the Urgent Treatment Centre at South Bristol Community Hospital  Rolling out a new community-based model of care for older people with frailty. This will enable the most vulnerable members of our population to receive the care and support they need in the community.  Establishing our Integrated Care Bureau. This service supports the multi-agency discharge of patients from hospital to ensure people get home as soon as possible and with the right support.

Our cancer services saw improvements to diagnostics, although increased demand affected waiting times. Projects enabled an increase in screening uptake for certain cancers and uptake

by people with learning disabilities. As a system, we continued to support people to live well with and beyond cancer.

The development of an all-age mental health strategy with our Healthier Together partners has been a major achievement. The strategy has been co-designed with people with lived experience, their families and carers and sets out how we and our system partners will promote mental health and wellbeing, provide access and support through joined up services and create sustainable solutions. We are very pleased to have had extensive involvement of people with lived experience, enabling us to understand better their experience of current mental health services and to design for the future in a way that responds to their needs and expectations. The strategy is currently in final draft and we hope to achieve full sign off at the Healthier Together Partnership Board early in 2020/21.

Following a wide-ranging procurement exercise, we launched a new Improving Access to Psychological Therapies (IAPT) service in 2019. The initial focus of the new provider has been on clearing the backlog of people waiting for the service; once the waiting list is under control, the focus will shift to transformation and the delivery of new services to meet our population need.

With the transition of North Somerset Child and Adolescent Mental Health Services from Weston Hospital to our Children’s Community Partnership, we now have a single provider of these essential services across Bristol, North Somerset and South Gloucestershire. This will allow us to focus on developing consistent, high quality services across our area.

The waiting list for adult autism assessments is now compliant with the three-month standard, ensuring more timely and equitable access to care for those who need it. This is a significant achievement, the result of concentrated work to manage the rise in referrals seen in recent years.

We are committed to improving the way we care for people with learning disabilities and specifically to prevent premature death, which we know is a challenge in this population. We have substantially improved our processes to ensure we learn effectively from the Learning Disabilities Mortality Review (LeDeR), making sure that our review process are strong, involve all our partners, and result in real change.

We have seen a reduction in the number of Healthcare Acquired Infections, particularly Clostridium Difficile and MRSA. We have worked with partners to reduce pressure injuries, running a successful conference that brought together colleagues from both the NHS and

voluntary sector to share best practice. We are pleased to have reduced the number of serious pressure injuries experienced by our patients.

We improved eye care services, developed advice and guidance for our GPs across a number of clinical areas and introduced a new service for Deep Vein Thrombosis.

We have invested in digital technologies, together with our partners, to support the transformation of services across our healthcare system. From introducing online consultations in general practice, to piloting wearable technologies that monitor the health of people with long-term conditions, we are using digital solutions to provide better services for our residents.

Healthier Together – our local Sustainability and Transformation Partnership

Through Healthier Together, our Bristol, North Somerset and South Gloucestershire Sustainability and Transformation Partnership, we have committed, with our partners, to working together to improve health and care for our population. During 2019/20 we worked together to tackle our system’s financial sustainability, attract and retain a skilled and motivated workforce and improve the care of people with urgent health care needs. Alongside this, we worked on the arrangements needed to create an Integrated Care System for 2020. Our Integrated Care System will deliver our ambitions for our population through:

 Population health management; using data and insight to make proactive interventions, preventing ill health  Integrated care in localities; supporting people to live well in healthier communities  Networked hospital services; pooling resources and delivering consistent standards of care  Specialist centres of excellence; promoting cutting edge research and innovation

Based on these foundations, our collective response to the NHS Long Term Plan creates a vision and set of priorities for the next five years. Engaging with local people has been fundamental and we have used feedback from our Citizens’ Panel of 1,000 people, a public ‘call for evidence’ in the autumn of 2019 and a conference in October 2019 attended by 300 people to develop our plans. The views, opinions and discussions between local people, patients and Healthier Together partners at our conference were captured in a rich picture.

Joint ways of working will continue to embed as we develop our Integrated Care System. We have appointed Sirona care & health to provide community health services across Bristol, North Somerset and South Gloucestershire, and University Hospitals Bristol merged with Weston Area Health Trust to create University Hospitals Bristol and Weston Trust. We will continue to work together through our Partnership Board and programme structures, increasing the number of shared decisions and improving services for people in a coherent system that ensures consistent clinical standards and equitable access to all. To support this ‘system by default’ approach we are investing in our system leadership. We already have joint programmes looking at workforce development and together are investing in digital technology and our estates.

Key risks and issues to delivering our objectives

We identified and reported on the following key risks to the delivery of our objectives and Operational Plan during 2019/20. Further information can be found in our Governance Statement in this report. We identified and managed the following key risks to our objectives:

 Engagement across the system is insufficient to enable meaningful and truly shared purpose and joint ownership of system challenges and solution

 We do not achieve a sustainable health system, in part because we do not understand the outcomes that we get for the resources that we use and we do not sufficiently engage with the population and people who use services to define outcomes  If Primary Care Networks are not resilient they will be unable to deliver primary care plans that support system wide transformation  A lack of capacity and resilience in primary care will impact on the delivery of system wide transformation  If there is insufficient capacity and capability to develop and deliver integrated community localities, the system will not have the necessary building blocks in place for delivery of the system wide transformation required  Non-delivery of the same day urgent care model will lead to clinical risk and increasing cost to the system  Political and media discourse prevents wider public from hearing and understanding messages coming from the Healthy Weston consultation  Lack of capacity could impact on the effectiveness and credibility of the our quality function and the effectiveness of the CCG Quality Committee  The extent of change and improvement required our core mental health provider is not addressed, impacting on the care and services provided to the local population.  If we are unable to agree and deliver a financial plan for the system in 2019/20 the system may be subject to greater intervention and may lose control of decision making which may not be in the best interest of the population.

Other reported risks included:

 Increased waiting times across key services including A&E, 52 week waiting times, access to planned care and cancer waiting times, resulting in potential harm to patients  Patients were at risk of potential harm through contracting Healthcare Associated Infections  Preparing for the UK exit from Europe across the system  The risk to delivery of our CCG and systems plans resulting from the need to focus capacity to meet the demands placed the system by Covid-19

Adoption of the going concern basis

The CCG has an in year deficit of £34,053,000 against its Revenue Resource Limit and has therefore breached two of its key financial duties under the NHS Act 2006 and will be subject to a Section 30 referral to the Secretary of State by the external auditors.

The CCG as an accumulated deficit against its Revenue Resource Limit of £117,059,000 caused by the in year deficit and accumulated deficits of predecessor bodies. This accumulated deficit at the end of 2019/20 is made up of £83,006,000, which relates to previous years and an in-year deficit for 2019/20 of £34,053,000.

Despite these losses, the CCG has prepared accounts on a Going Concern basis.

Where a Clinical Commissioning Group ceases to exist, it considers whether or not its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of financial statements. If services will continue to be provided the financial statements are prepared on the going concern basis.

The Clinical Commissioning Group allocations for 2019/20 to 2023/24 were published in January 2019 and had final approval by the NHS England Board on 31 January 2019. The revenue allocations are backed by cash limits. Throughout this period, the CCG expects to maintain a positive cash flow and continue to meet the Better Payment Performance standard.

In 2019/20 the CCG had a £12 million deficit control total against revenue resource limit approved by NHS England; and an in year deficit against revenue resource limit of £34,053,000. NHS England have provided cash support to underwrite this position.

The CCG is in the process of agreeing a breakeven financial plan in principle with NHS England for 2020/21 set within the framework of the Five Year Long Term Plan. The Long Term Plan enables the CCG to achieve a recurrent deficit of less than 1% deficit by 2021/22 and 1% surplus in future years. The 2020/21 NHS England Operating Plan guidance describes an intention of writing off 50% of historic accumulated resource limit deficits, in this context. The CCG’s plan includes clearly identified investments and the savings target needed to deliver the proposed plan. The savings plan is supported by a structured and detailed programme developed from the control centres and supported by a Sustainability and Transformation Partnership Transformation programme. Performance management of savings includes regular review and reporting, risk assessment and mitigation and programme support from a dedicated programme management office.

In March 2020 there was a global pandemic caused by a novel coronavirus - Covid 19. The impact on healthcare delivery in direct response to this virus, changes in demand and capacity for other healthcare and the impact on wider society (through social distancing and the so- called 'lockdown') and economy has been dramatic. Two specifics items of relevance are firstly, the UK Government publically stating it will fund the NHS 'whatever it takes' to manage the pandemic; and secondly a significant overhaul of the financial architecture of the NHS, for example suspending the current financial performance management regime, moving all NHS providers onto a cost based 'block' payment regime, authorising pre-payments of one month’s operating costs to NHS providers, centralising the procurement of Independent Sector Capacity, providing new funding for Hospital Discharge Programme and NHS Nightingale 'surge' capacity. Taken together this package and Government statements effectively demonstrate how the CCG, as a statutory body in the NHS, will have its finances supported by the Government for the period of the pandemic and in the event of any future radical change to demand and funding for healthcare.

On this basis of the above the CCG considers it remains a going concern.

Summary of performance 2019/20

Overview of how CCG performance is measured

Our overall performance is assessed on an on-going basis within the wider system against NHS England’s NHS Oversight Framework. The outcome of this assessment will be published in 2020.

Activity and NHS constitutional standards

The following table shows Bristol, North Somerset and South Gloucestershire performance against NHS Constitutional Standards.

Key to symbols in table 1 below:

Better than last year but not achieving standard

Achieving standard

Worse than last year and not achieving standard

Indicator Standard 2018/19 2019/20 Change

Percentage of patients admitted, transferred or discharged 95.00% 84.28% 78.41% from A&E within 4 hours (BNSSG Acute Trusts)

Percentage of patients on an incomplete RTT Pathway waiting 92.00% 89.46% 82.28% less than 18 weeks

Number of patients on an incomplete RTT Pathway waiting 0 25 71 more than 52 weeks

Percentage of patients waiting six weeks or more for a 99.00% 96.73% 88.59% diagnostic test (15 key tests)

Maximum two-week wait for first appointment for patients 93.00% 90.86% 86.54% referred urgently for suspected cancer

Maximum two-week wait for first appointment for patients referred urgently with breast symptoms (where cancer was not 93.00% 76.19% 88.72% initially suspected)

Maximum 31 day wait from diagnosis to first definitive 96.00% 97.13% 95.36% treatment for all cancers

Maximum 31 day wait for subsequent treatment where that 94.00% 92.14% 87.59% treatment is surgery

Maximum 31 day wait for subsequent treatment where that 98.00% 98.60% 98.86% treatment is anticancer drug regimen

Maximum 31 day wait for subsequent treatment where that 94.00% 95.90% 95.35% treatment is radiotherapy

Maximum 62 day wait from urgent GP referral (two-month wait) 85.00% 82.85% 77.62% to first definitive treatment for cancer

Maximum 62 day wait from referral from an NHS screening 90.00% 87.35% 78.21% service to first definitive treatment for cancer

Total Number of CDIFF Cases 201 202 195

Total Number of MRSA Cases Reported 0 43 42

Eliminating Mixed Sex Accommodation 0 32 17

Meeting the standards set out the NHS Constitution is an important responsibility and the CCG is committed to working with our providers to ensure that the services they provide meet the standards required. Where performance has deteriorated we have worked with providers to put in place plans to improve services. In the following sections, we describe our performance in detail and the actions we are taking to improve the position.

Performance analysis

How we measure performance

Performance management is a key role that ensures services delivered to our population achieve the desired outcomes and provide good value for money. Performance is monitored and reported through:

 Finance: detailed financial plans are created to plan for patient care activity and outcomes, and to monitor the in-year performance of our providers

 Performance against NHS Constitutional Standards

 Performance in quality and outcomes: to ensure services are safe, patients have a positive experience of healthcare, and improvements in clinical outcomes are delivered

Financial performance & outlook

The CCG spent £1.445 billion on behalf of the patient population during 2019/20. Whilst the headline financial position was a deficit of £34 million (2.4% of in year allocation) the CCG made some good progress in stabilising its finances during the year. The CCG delivered £30 million of savings during the year, met the mental health investment standard, underspent again on Running Costs, broke even on delegated primary care allocation, and achieved a breakeven position on main acute care contracts for the first time in number of years. The CCG developed a £12 million joint financial recovery plan with system partners for the first time; and during the year has developed a five year financial plan that has support of all system partners, improves the CCG financial position every year and achieves a recurrent surplus of 1% by 2023/24.

Our expenditure by main programme area in 2019/20 is shown in Table 2.

Bristol, North Somerset and South Gloucestershire CCG Programme Expenditure 2019-20 £m Acute Services 734.903

Mental Health Services 142.143

Community Health Services 152.157

Continuing Care Services 84.255

Primary Care Services 170.804

Primary Care Co-Commissioning 126.170

Other Programme Services 14.766

Total Commissioned Services 1,425.198

Running Costs 20.637

TOTAL CCG NET EXPENDITURE 1,445.835

The newly merged CCG came into existence in 2018/19 with accumulated deficits against a Revenue Resource Limit of £85.0 million. In its first financial year the CCG delivered a breakeven financial position, with £10 million of Commissioner Sustainability Support and £5 million non recurrent savings planned.

Achieving ongoing financial recovery across the Bristol, North Somerset and South Gloucestershire health system was a key element of our system plans and the CCG objectives for 2019/20. The CCG had set an annual plan for 2019/20 with an in-year deficit of £12.0 million, after the Commissioner Sustainability Funding was withdrawn. NHS England agreed a Control Total deficit of £12 million, after a resubmission of the Annual Plan with an additional

system savings plan requirement of £12 million for which the majority of financial risk was held by the CCG.

Our 2019/20 Financial Plan had a savings requirement of £41.4 million, including the stretch system savings commitment and identified risks of £13.9 million, with £13.9 million potential mitigations. These mitigations included the full release of 0.5% of the CCG’s contingency reserve; this is the funding that we are required to set aside to guard against losses. The planned position was therefore challenging, without any contingency. The CCG ended the year £22 million adverse to this plan after a number of unforeseen cost pressures arose during the year, many of which the CCG had limited powers to controlling increases in:

 A 25% increase in Continuing Healthcare complex individual packages which the CCG has a statutory duty to provide

 Slippage on £6 million of £12 million Systems savings plans, added to the plan in May 2020. A number of the schemes, such as transformation of hospital outpatients, improve productivity of local hospitals to reduce reliance on Independent Sector additional capacity, and new models of care for frailty patients and same day emergency care form the bedrock of new Adult Community Services contract and the STP Long Term Plan and savings are beginning to be realised in the latter half of the year.

 £4 million of Prescribing price increases, £2 million due to a nationally negotiated change in Category M drug prices announced in July, and £2 million continued use of No Cheaper Stock Obtainable drugs due to international supply issues

 Overspend in Mental Health and Learning Difficulties out of area placements due primarily to a small number of patients with high care needs and national recruitment shortfall reducing staffing levels at the local service provider Avon & Wilshire Mental Health Partnership Trust

These cost pressures and the planned deficit will mean continued challenges to the position for 2020/21 and going forward. Before the Covid-19 outbreak an indicative budget with a planned deficit of £2.9 million; a £45 million savings requirement and £25 million identified new saving projects had been developed. This position was part of an overall Healthier Together System balanced budget. Future years’ financial performance will be increasingly linked to whole system planning and delivery.

NHS England’s planning guidance for 2020/21 requires NHS organisations to plan at a system level (i.e. across the NHS in Bristol, North Somerset and South Gloucestershire). Working in this way, and with our Healthier Together Partnership will enable us to deliver the scale of

change we believe is required to transform our challenged health and care system. The control totals set for the system require a significant improvement in the financial performance every part of the system and we are continuing to work through options to deliver this.

We are agreeing a financial plan with NHS England for 2020/21 and this will be the first year of the five year Long Term Plan agreed in February 2020. The detailed financial plan for 2020/21 will include clearly identified investments and the savings target needed to deliver the plan. The savings plan is supported by a structured and detailed programme of change, which is developed and managed by a number of CCG ‘control centres’ and the Healthier Together Programme. Performance management of savings includes regular review and reporting, risk assessment and mitigation, and programme support from a dedicated programme management office.

The Long Term Plan financial plan is based on 5-year allocations and linked to performance trajectories that return us to a 1% surplus by 2023/24, with a focus on transformation to reduce the rate of growth in acute care.

We are required to work within cash management targets and remain within our cash limit; this was achieved for 2019/20.

All CCGs are expected to meet the requirements of the ‘Better Payments Practice Code’ and aim to pay all relevant creditors within 30 days. We have paid all of our suppliers, both NHS organisations and non-NHS organisations within the 95% Better Payment Practice Code target.

The Covid-19 outbreak has caused a fundamental reset of the financial framework for the NHS. The full implications of this on the CCG financial position are too early to assess. The CCG is not planning for any change in five year allocations or Long Term Plan financial targets. In the short term NHS resources have been prioritised to ensure the NHS can cope with the initial surge in demand and additional funding has been provided from government to create more out of hospital capacity and fund increased operational costs such as the Nightingale Hospital, backfill of higher staff sickness levels, PPE and Testing. Some aspects of the Long Term Plan Transformation programme have been accelerated, whilst others will have been paused. The focus for the next phase is to capture and maintain the benefits of accelerated transformation; and undertaking a re-prioritisation process taking into account:

 the effects Covid-19 has on ongoing clinical service capacity,

 managing the impacts of unmet need during the first phase including pausing most elective care, and

 meeting new needs arising, such as impact of lockdown on mental health, and public concerns about risks of attending hospitals ad care homes.

Value based health and care

To help us work towards our ambition to get best value for our population and improve the health of people living in Bristol, North Somerset and South Gloucestershire we have started work to:

 Identify and measure the outcomes that are important for our population and valuable to individuals  Think about what we do that does and does not contribute to achieving those outcomes.  Use that information to make decisions about how and where we use all our resources.

During 2019/20, we have:

 Described in our long term plan what a value-based health and care approach to the changes that we need to make means for everyone  Started testing our approach by evaluating how the resources we use for musculoskeletal care could be used in a way that will achieve better outcomes; thinking about whether using more of the current resources on prevention or earlier physiotherapy and less on other musculoskeletal types of care would help  Worked with a wide range of people to base our work to improve stroke care and rehabilitation, and the care of ‘frail’ people, on the outcomes that matter to individuals.  Agreed with our partners that together we will buy the IT to enable us to track and monitor individual outcomes. People will be able to share that information with their healthcare professional before a consultation and review it afterwards to ensure those important outcomes are being achieved.  Addressed the unnecessary differences in the blood tests that people with a long-term condition have at their annual review in general practice. We found out that people living in our area were having different tests done when there was not always a good reason for that. We worked with GPs, practice nurses, and other specialists to agree the tests that people should have to support their care. This means that everyone can now get the ‘right’ tests and NHS resources are used most effectively.  Built a joined up record of people’s health and their use of services such as GPs and hospitals. We are using this new information to understand better our population and how people use services. This allows us to identify groups of people whose care we could improve. We call this approach Population Health Management. We can work

with those groups of people and the people who support them to design care and allocate resources to meet their needs in a better way.

All of this work and a range of other actions that we have included in the Healthier Together plans is crucial to helping us reduce the inequalities in health outcomes that we have in Bristol, North Somerset and South Gloucestershire.

Primary Care

General practice is a cornerstone of our healthcare system with 90% of people’s healthcare interactions taking place in GP practices. Creating stability and resilience was an important focus of our plans in 2019/20, which included:

 Primary Care Strategy  Workforce  Resilience and quality improvement improving access to primary care and  Primary care estates

We launched our refreshed Primary Care Strategy at an event in June 2019, attended by more than 150 stakeholders from health and care organisations including local authorities, voluntary sector organisations and patient and public representatives. Following this successful launch, we engaged with patients and staff through meetings, patient participation groups and online surveys. As part of this, we gathered insights from 525 people on the Healthier Together Citizens’ Panel helping us to understand what is most important to people when accessing healthcare services, and their perceptions about the use of digital technology to deliver healthcare services.

Using the feedback we developed a system wide strategy setting out our vision for primary care “delivering excellent, high quality, accessible care for patients in a sustainable, joined up way”. Our aim is to have resilient and thriving primary care at the heart of an Integrated Health and Social Care system by 2024. Our strategy focuses on Primary Care, Integrated Localities and Primary Care Networks. The feedback we received through our engagement helped us to identify what matters to our population and our Healthier Together system; we used this to prioritise our work:

 Models of care: Developing and promoting new models of care that support people to stay healthy and where possible get care close to home in the community.  Quality and resilience: Ensuring services are high quality for all by addressing differences in outcomes and health inequalities.

 Developing the workforce: Different healthcare professionals working together to provide the most appropriate care for patients, to help manage increasing demand alongside decreasing staff numbers.  Digital and estates: Supporting effective care by using technology and digital systems to improve access and efficient ways of working.

Our model for primary care involves networks of GP practices working together with community and mental health providers, social care and the voluntary sector to provide coordinated and joined up care within our six localities.

Within each locality, our practices have established Primary Care Networks (PCNs), so they can work together to improve services for people in their local areas. Localities and Primary Care Networks will focus on keeping people well and improving the overall health of their populations, supporting people to care for themselves, intervening early to prevent illness worsening, and working with patients to plan their care. Practices will work together, and with other services, to make better use of staff and resources both at Primary Care Networks and locality level as most appropriate to the service in hand.

Workforce is a challenge across the NHS and primary care is no exception. New roles have been introduced to support GPs with their workload and offer a wider range of care for people. We are helping Primary Care Networks with recruitment, which this year has focused on Social Prescribing Link Workers and Clinical Pharmacists. Over 28 whole time equivalent (WTE) roles have been recruited, with over nine WTE Clinical Pharmacists and 18 WTE Social Prescribing Link Workers joining our Primary Care Networks. An additional 13 WTE Clinical Pharmacists have transferred from the NHS England Clinical Pharmacist Scheme into local Primary Care Networks. We have worked with system partners to develop models for other posts to support GPs and benefit both Primary Care Networks and other organisations in our system. Our GP practices also use a web-based tool which gathers real time feedback from staff; this helps identify issues facing individuals and teams which can then be acted on.

The Primary Care Strategy describes our work to strengthen the primary care workforce. Our Training Hub programme includes a focus on GP retention, increasing the number placements and mentoring, and working with schools and colleges to increase numbers of school leavers entering health and social care professions. We have welcomed five international GP recruits to our practices, and we continue to work with NHS England to attract more GPs to the area.

We have continued to work closely with NHS England’s Sustainable Improvement Team to maximise the opportunities for our GP practices to release ‘Time for Care’. Forty-four practices have completed the Productive General Practice Quick Start Programme that aims to

implement practical improvements to release capacity. We also held a quality improvement workshop in partnership with the NHS England’s Sustainable Improvement Team, which was well attended and received by practices locally.

Following a successful pilot of a repeat prescribing hub, we are supporting the roll out of this model to all GP practices. Our pilot has shown how the hub reduces demands on GP workload, reduces the issuing of unnecessary prescription items, ensures good medicines optimisation and improves medicines quality and safety. Having a dedicated team experienced in managing prescribing issues enables practices to better action local and national programmes of work.

The Medicines Optimisation Prescribing Quality Scheme is available to all of our GP practices to improve the quality and safety of primary care prescribing. We have had excellent practice engagement with the scheme. Projects have focussed on antibiotic stewardship, (information about our performance against these standards is in the quality section of this report), medicines safety and roll out of PINCER, an IT-based intervention to reduce clinically important medication errors in primary care. We have also looked at medication reviews for groups of patients to reduce the amount of medicines prescribed, for example, a review of antipsychotic prescribing in people with learning difficulties or dementia, and those in care homes. Following a successful bid to NHS England’s Pharmacy Integration Fund, we commissioned a pilot project with a small team of care home pharmacists and pharmacy technicians. This team has been in place for a year and has delivered a significant number of medication reviews to improve quality and safety of prescribing, with a number of interventions potentially preventing hospital admissions. The team has also delivered a significant amount of support to care homes.

We have worked closely with the Avon Local Pharmacy Committee and NHS England to be one of four national pilot sites to implement GP referrals to the Community Pharmacy as part of the Community Pharmacist Consultation Service (CPCS) for minor illnesses. This aims to reduce GP workload by making better use of pharmacists’ skills in supporting patients to manage minor illnesses and to increase public awareness of self-care options. In addition, work is progressing to enable community pharmacists to treat some acute conditions that would normally require a prescription from a GP practice or hospital by enabling them to treat appropriate patients under a Patient Group Direction. Training is being rolled out and the service will go live in 2020.

We are working with:

 Primary Care Networks and Localities to develop their vision and priorities  GP practices both individually and as Primary Care Networks and localities to develop and implement bespoke programmes of support

We have commissioned a dedicated service to support practices to develop and embed active signposting, so people get to the right person first time to best meet their needs.

We have worked with GPs to improve patient access to appointments. We have worked with partners throughout 2019/20 to deliver, on average, an additional 45 minutes per 1,000 (weighted) population per week access to general practice. Our performance has ranged between 37 and 58 minutes per week throughout the year against a national minimum standard of 30 minutes per 1,000 population. We will continue to develop our programme in 2020/21, focusing on responding to local people’s needs and building integration. To understand how we can continue to improve access to primary care we are seeking feedback from our local communities through a Primary Care Access Review Survey.

We continue to work with our practices to develop digital approaches to support improved access to primary care. We have worked with a group of practices to pilot and evaluate online consultations. As part of our Covid-19 response, we are implementing on-line consultations systems across our GP practices. A significant amount of work has been done to provide the technology needed to support practices in these new ways of working, while maintaining patient safety and confidentiality.

There have been a number of GP practice mergers and closures in 2019/20, reducing the total number of practices from 84 in April 2019 to 80 in April 2020. To ensure that people are involved in deciding the future of primary care services we held public engagement activities in several different areas of our region, including Bishopston Medical Practice and Northville Practice.

We have published the Healthier Together Estates Strategy and secured additional Estate and Technology Transformation Fund capital funding; this has allowed us to work with practices to redevelop and extend a number of GP practices in our Localities. Other schemes, including the proposed new GP facility at Weston Parklands Village, are in the final stages of planning.

Our work with primary care and our plans for 2020/21 will help improve health outcomes for local people. We will support our practices, Primary Care Networks and Localities to develop tailored services for the local communities they serve, and to address health inequalities. Our ambitions over the next five years include:

 Develop a culture of continuous quality improvement and learning in primary care through a network of ‘quality champions’, improving the services we deliver  Reduce health inequalities by working with people to achieve their health goals, personalising care to each individual  Work with patients, using their experience of primary care, to design better care and access to services, as well as improving continuity of care, proactive planning and coordination of their care

As we now roll out the Primary Care Strategy, we intend to continue to engage and involve patients and the public in our work. We will create a patient reference group to support this work and other engagement activities.

Out of 80 GP practices, six have an overall rating of ‘requires improvement’ from their Care Quality Commission (CQC) inspections. We are working closely with these practices to improve their ratings, targeting specific areas to improve the resilience and quality of services. The results of the GP Friends and Family Test show that, across Bristol, North Somerset and South Gloucestershire 89.8% of respondents would recommend their GP practice compared to the national average of 90.2%. The percentage of patients who would not recommend their GP practice was 7.6%. This is 2.5% higher than the national average.

The response rate for the Bristol, North Somerset and South Gloucestershire 2019 GP Patient Survey was 36% (9,330 responses) which is higher than the national average (33%). 85% of respondents described their experience of their GP practice as good which was above the national average (83%) whilst 5% described their experience as poor, below the national average (6%). The survey asked about patients’ experience at their last general practice appointment:

 Giving you enough time – 87% respondents rated this as good or very good  Listening to you – 90% of respondents rated this as good or very good  Treating you with care and concern – 90% of respondents rated this as good or very good  Felt involved in decisions about care and treatment – 95% respondents rated this as good or very good  Had confidence and trust in the healthcare professional – 77% respondents rated this as good or very good  Felt their needs were met – 95% respondents rated this as good or very good

88% of respondents said the healthcare professional recognised and/or understood their mental health needs during their last general practice appointment (national average 86%).

Locality Development

Our localities are the building blocks of our Integrated Care System

We began the journey towards joining-up local services in autumn 2017 with the establishment of our Locality Transformation Scheme, which encouraged GP practices to work together in 6 localities. Through 2019/20, we have established wider provider partnerships in each locality to oversee the development of integrated local services. These partnerships include adult community services, mental health services and social care, and links are beginning to form with the acute sector. We are starting to see successful examples of locality working:

 Some localities have well established multidisciplinary teams working in each GP practice to bring together a range of practitioners to jointly support people with exceptionally complex needs  Others have set up new drug and alcohol clinics based in GP practices  Social prescribing services are working with GPs and others to support people in new ways, such as helping them to have the confidence to take part in activities to prevent loneliness and therefore ill health  In Weston, a new mental health crisis café has opened and specialists from the mental health trust are supporting GP practices so they can better treat people with less severe mental health problems in the community

 In Weston, practices have come together to form a super partnership, Pier Health Partnership and they are integrating services as well as addressing the resilience of some more challenged practices within the area  Delivered a deliberative workshop with 22 people from a range of life stages to explore peoples’ perceptions towards a more joined-up primary and community care system and personalised care

Our six localities are now planning how they will further join up services in the community to become a strong system of care at every level, enabling people to keep healthy, well and independent in the community. Digital technologies have an important role to underpin our locality plans, and Connecting Care, our technology programme supports:

 Better information sharing between local health and social care organisations  Joining up information to ensure care is better, safer and more joined-up  Ensuring that the people who are providing care have the information they need, when they need it

Our plans for 2020/21 set out how our localities will integrate support for mental and physical health and wellbeing, joining up public health, NHS and social care services as Integrated Care Partnerships. Localities will build strong partnerships between NHS and Social Care organisations, the voluntary sector and community organisations working will local people to deliver what matters to them.

Community Model of Care

Our vison for community health services is that they are seamlessly integrated with primary care, mental health, social care and other non-statutory community-based providers including the third sector, delivering personalised care and support through local Integrated Care Partnerships. These partnerships will increasingly grow to join with secondary care acute health services. Securing a single provider of high quality community health services has been fundamental to our plans in 2019/20, following the formal procurement of Adult Community Health services.

The initial phase of the procurement focused on engagement with service users and carers, local authorities, and providers including incumbent community service providers and the Third Sector. A range of workshops, meetings and an online survey were used to enable as wide engagement as possible. The feedback we received was used to develop the model of care and draft service specifications, ensuring that reducing health inequalities was built into future services.

The final phase of the procurement was completed in 2019/20. Bids were evaluated against a range of criteria by clinicians, subject specialists and patient representatives. In July 2019, we announced that from April 1st 2020 our single provider of community health services would be Sirona care & health. Since awarding the contract, we have worked closely with Sirona on mobilisation to ensure that the service is safe and ready to begin on 1 April 2020.

Following the procurement we have also delivered a single provider for children’s community health services across Bristol, North Somerset and South Gloucestershire, enabling consistent access to and standards of care for everyone. The contracts for these services have transferred to the Children’s Community Health Partnership (CCHP), along with community paediatrics and child & adolescent mental health services (CAMHS) formerly provided by Weston Area Health Trust.

A single provider of community services across our area will support the development of:  Integrated Network Teams who will lead multidisciplinary working in practices and Primary Care Networks. The focus will be on supporting people with complex needs.  Locality Hubs that deliver services such as same day emergency care based in the community, avoiding hospital admissions, and building proactive services that support older and frail people  Acute and reactive services that are available in the community seven days a week, 24 hours a day ensuring that wherever possible people have their needs met in the community. Where vulnerable people do end up in an acute bed these teams will ensure they are brought back to the community as soon as possible, with the support and follow up that gives them the best chance of recovery.

Healthy Weston

Work has been ongoing since 2017 to redesign services to deliver better health care in Weston-super-Mare, Worle and the surrounding areas. This work includes the services provided at Weston General Hospital. At every stage, there has been significant engagement with patients, carers, staff and local people. In February 2019, we launched a public consultation focusing on three changes to the hospital. We invited members of the public and our partner organisations to share their views through:

 10 public meetings and eight pop-up stands at local supermarkets, and shopping centres

 32 community meetings and, for local partners, staff meetings  The Healthier Together Citizen Panel  Face-to-face interviews with over 1,000 people and in-depth focus groups  Online and paper surveys  Individual feedback received by letters, emails and phone calls

We received over 2,300 responses, representing over 3,000 people. The consultation ended in June 2019 and after reviewing the feedback, we made a number of changes to our proposals, including:

 A&E and urgent care: enabling paramedics and other healthcare professionals to access direct overnight admission pathways to Weston General Hospital.  Critical care: transferring people between hospitals on clinical grounds rather than through a time-based decision.  Emergency surgery: patients needing Level 3 Critical Care to support their immediate post-operative recovery will remain in Weston General Hospital. A new model of care for ambulatory emergency surgery means that only people who require a procedure overnight or people needing more complex operations will be transferred to Bristol.

Our Governing Body considered and approved the following proposals for change in October 2019:

Proposals for Urgent and Emergency Care and A&E  To keep A&E at Weston General Hospital open 8am to 10pm, seven days per week, making the temporary overnight closure of the A&E permanent. The A&E would be staffed by a multi-disciplinary team of hospital and primary care clinicians working together. The overnight closure of A&E would be supported by 24/7 direct admissions to the hospital via referrals from GPs, paramedics and other healthcare professionals. Proposals for Critical Care  Provide up to Level 3 critical care for people who need single organ support at Weston General Hospital. This includes short stay post-operative recovery at Level 3 and longer- term intubation, where the lungs are the organ requiring support.

 Transfer people requiring critical care for two or more organs at Level 2 or 3 or people who would benefit from proximity to University Hospitals Bristol’s specialist clinical services via dedicated transfer team to University Hospitals Bristol.

 Establish a critical care service that is digitally linked to University Hospitals Bristol to provide oversight and monitoring from the larger unit of the people who remain at Weston General Hospital.

 Repatriate people following treatment in University Hospitals Bristol when care needs can be met at Weston General Hospital. Proposals for Emergency Surgery  Provide emergency surgery in the daytime only at Weston General Hospital. Theatres will close overnight from 8pm-8am.

 People requiring an emergency operation overnight (those who deteriorate on the ward or present to A&E in the evening) will be stabilised and transferred to Bristol for surgery.

 A small number of people who require more complex surgery will also be transferred to Bristol to receive support from specialists unavailable at Weston General Hospital.

 Ambulatory pathways for emergency surgery, including rapid access to daily clinics Monday to Friday and a dedicated afternoon emergency theatre session, will be established to improve the quality and responsiveness of the surgical service. Proposals for Acute Paediatrics (as part of wider supporting changes)  Specialist children’s staff will be available at Weston General Hospital seven days a week from 8am-10pm.

 This includes extending the hours of opening of the Seashore Centre from 8am to 10pm, Monday to Friday in Weston-super-Mare with paediatric expertise over the duration of its opening hours on Saturday and Sunday.

The changes agreed to emergency services in Weston-super-Mare are part of our plans to improve our urgent and emergency services across Bristol, North Somerset and South Gloucestershire. With our service providers we have started to implement the changes and will continue into 2020/21.

Urgent and Emergency Care

Managing the challenges facing our urgent and emergency care services is a priority for Bristol, North Somerset and South Gloucestershire. In 2019/20 we developed with Healthier Together partners a transformation programme for urgent and emergency care. This aims to provide a simplified system of value-based urgent and emergency healthcare that is easy to access, with the community as the default setting in future for urgent care provision, enabling the acute hospital sector to respond most effectively to genuine emergencies. Our plans build on the strategy agreed in 2018/19, and reflect the latest research and best practice for addressing the drivers of demand for urgent and emergency care.

The Integrated Urgent Care Service was successfully launched in 2019/20, and combines 111 with a clinical assessment service. Increasing numbers of patients are accessing the service

online as well as receiving advice over the telephone. Online contacts have more than doubled compared to the previous year, now averaging over 4,000 per month. The number of calls received via NHS 111 has similarly increased to 303,828, with 56% assessed by a clinician.

Patients with minor illnesses can now have an appointment directly booked by the service with a local pharmacist or at the Urgent Treatment Centre based in South Bristol Community Hospital. In 2020/21, direct booking will be extended to include appointments at GP practices and to other Urgent Treatment Centres as they are formally designated. The service is a key component of our transformation plans to reduce complexity and simplify access to urgent care services.

We have started the roll out of a major new community-based model of care for older people with frailty. This will continue throughout 2020/21, and enables more of our most vulnerable residents to receive the care that they need in the community. This is part of our plans to expand same day, community urgent care services, ensuring that only those who need acute care are referred to hospital.

North Bristol Trust has successfully introduced comprehensive clinical streaming at the front door of the A&E department. This is part of our plan to address the increasing numbers of people who attend A&E departments with healthcare need that could be helped in primary care or other services, reducing the pressure on hospital teams.

The Integrated Care Bureau launched this year to facilitate discharges from hospital. Over 900 patients a month have their discharge supported through the Integrated Care Bureau. In addition to freeing up hospital beds for those who most need them, getting people home earlier has been shown to improve patient outcomes, particularly for older people where a prolonged hospital stay can increase their long-term care needs and reduce their quality of life on discharge.

Overall, performance against the NHS Constitution target for waiting standards at A&E departments has dropped locally to 78.41% for 2019/20 but was significantly better than the national average of 76% for consultant-led A&E departments. Attendances at A&E departments increased by 2% in 2019/20 compared to the previous year, with 5856 more attendances, averaging 16 more per day. There has been a 1% increase in walk-in attendances in 2019/20 with over 209,319 attendances compared to 206,545 in 2018/19. Transforming services and improving waiting times at our A&E departments continues to be a high priority locally.

Total non-urgent (non-elective) admissions have also increased by 4.1% compared to the same period last year. Zero-length of stay non-elective admissions, where the patient does not need to stay overnight, increased by 8.2%, reflecting in part the expansion of hospital-based same day emergency care services that avoid the need for patients to be admitted overnight.

Cancer

Our aims in 2019/20 were to:

 Improve delivery of NHS Constitutional standards for cancer care  Implement national priorities, including earlier diagnosis, particularly lung, colorectal and prostate cancers  Continue to deliver the Living Well Beyond Cancer programme

We have seen increased demand for cancer services, particularly those for skin cancer and we have been unable to meet the 2-week waiting time standard for all of our patients. We are piloting schemes to improve waiting times and we continue to work with primary care and trusts to understand how we can ensure that patients who really need to access care for suspected skin cancer can be seen within the national standard of 2 weeks.

For 62 day cancer (referral to treatment), urology has continued to be the main area of challenge. A new, pioneering surgical robot is used at North Bristol Trust for prostate cancer surgery and this will have a positive impact, reducing waiting times. Robotic surgery is more accurate, less invasive and reduces length of stay in hospital. Men have much better long-term prospects for full recovery. Other initiatives have been introduced as part of our work to improve pathways for men with prostate cancer and will continue in the coming year.

We have not met the 31-day standard for our cancer patients. We have seen increased demand in urology, skin and some complex surgical pathways. The use of the surgical robot at North Bristol Trust and improved pathways for sentinel node biopsy at North Bristol Trust is being implemented to help increase capacity.

We have worked with our partners to ensure that surgery for cancer patients is cancelled only when there is no ‘safe bed’ for them. This will continue to be a focus to avoid surgery cancellations for cancer patients.

In 2019/20 we have

 Worked on how we can improve urgent access to diagnostics, along with reviewing the pathway for patients with vague symptoms to support earlier diagnosis

 Raised awareness in primary care of the needs of patients Living Well With and Beyond Cancer and the benefit of a comprehensive Cancer Care Review.

 Agreed the commissioning of Faecal Immunochemical Test (FIT) for patients at “low risk but not no risk” of colorectal cancer following the evaluation of an 18 month pilot

 Delivered the ‘Living Well With and Beyond Cancer’ programme across our area, understanding the needs of patients on cancer pathways, and developing care plans and health and wellbeing support in response. This programme will help us achieve our plans for appropriate personalised care packages for all patients diagnosed with cancer by April 2021

 Undertaken a bowel cancer-screening project to increase uptake in GP practices where uptake is below the national level.

 Started a pilot for Enhanced Supportive Care with palliative care consultants to improve quality of life.

 Started two pilot projects to evaluate and compare GP dermatoscopic images and clinical photography to ensure that appropriate people are referred in to the dermatology two week wait pathway. We have also rolled out teledermatology across Bristol, North Somerset and South Gloucestershire.

 Started a project in partnership with the CCG Learning Disabilities Team and Cancer Research UK to improve cancer screening uptake in people with learning disabilities

Our plans for 2020/21 include

 Delivery of the NHS Constitutional Standards for cancer treatment  Achievement of the new faster diagnosis standard to ensure that all patients who are referred for the investigation of suspected cancer find out, within 28 days, if they do or do not have a cancer diagnosis.  Provide equity of access to rapid diagnostics across Bristol, North Somerset and South Gloucestershire for patients who are suspected of having cancer including a pilot rapid a diagnostic pathway for patients with non-specific but serious symptoms  Increase diagnostics capacity to achieve earlier stage cancer diagnosis trajectory  Roll out of digital solutions to support personalised care (remote monitoring) earlier diagnosis (GP support tool)  Work with the CCG Learning disabilities team and Cancer Research UK to improve cancer screening uptake in people with learning disabilities

 With our partners, introducing digital technologies that support remote monitoring of people living with and beyond cancer so that they need to make fewer hospital visits.

Mental Health

In 2019/20, mental health was one of our highest priorities. The development of an all age mental health strategy with our Healthier Together partners to better respond to the needs of our population was core to these plans. Working closely with people with lived experience, we collaborated across our network to create a strategy that would set out what changes were needed over time to address existing issues, respond to feedback and ensure that we can implement national policy, making our services sustainable for the future. To ensure that our strategy has the right focus we have engaged with over 2,000 stakeholders. We have:

 Co-designed the strategy with people with lived experiences, their families and carers. We have commissioned experts with lived experience to help us write the strategy.  Set up a stakeholder engagement programme, including a social media campaign, deliberative citizens panels and focus groups  Analysed data and shared information about the problems we need to solve  Mapped and connected work that is already in progress, including work taken forward by our local authority partners  Researched best practice and innovation and built it into the strategy

The themes running through our strategy apply to all stages of life:

 Promoting mental health and wellbeing and preventing ill health  Easy access to advice and support  Integrating care by joint working across organisations and bringing the focus back to the person, their needs, and the needs of their families and carers  Creating sustainable solutions that best meet people’s expectations and demands

Working with people with lived experience made a considerable impact on the development of the North Somerset Safe Haven Centre. Feedback from people who have experienced mental health crisis suggested the centre should be based within the community and away from medical sites such as Weston General Hospital. Having listened to this feedback our new service has been established in Weston-super-Mare’s town centre. The crisis and recovery centre will be open seven days a week and will offer a welcoming, community-based alternative to A&E for people experiencing emotional distress. To ensure that people using the service have the right support we are using digital services that allow mental health workers to access important records.

Mental health crisis services, including ambulance, social work and police, save lives when people need services most, but there is more to do to improve responses and joint working to better support people at times of crisis. As part of the strategy development, a work programme has started to create a blueprint for how our services can work in the future to provide both better responses and experiences for those using crisis services, and improve services, which prevent crisis or support recovery.

We have worked with people with lived experience to understand the perceptions of mental health services across Bristol, North Somerset and South Gloucestershire. We received feedback from over 400 patients, carers and service users. This has helped review our contracts and consider proposals that we will take forward in 2020/21.

We closely monitor the performance of our services against national and local targets. Our performance against the dementia diagnosis rate for people aged 65 years was 68.8% for 2019/20. This was above the national standard of 66.7%. During the year, we supported our GP partners in making a dementia diagnosis without needing to refer to other services. This means that people are able to receive a diagnosis close to home. We will continue to build on this in 2020/21.

The national standard for access to Improving Access to Psychological Therapies is that 75% of people referred to these services should be seen within six weeks and 95% of people referred are seen within 18 weeks. We achieved the national standard for both standards with 79% of people referred to the services seen within six weeks and 99% of people referred seen within 18 weeks. The national standard for recovery is that 50% of people who have completed treatment should recover; our performance in 2019/20 fell below this standard to 41%. During 2019/20, we were pleased to announce that we had awarded a new 10-year contract to Vita Health Group, in partnership with Bluebell Care Trust and Windmill Hill City Farm, for the provision of Improving Access to Psychological Therapies across Bristol, North Somerset and South Gloucestershire. The service started in September 2019 and it was quickly identified that there was a significant waiting list. We are working with Vita Health Group to reduce this waiting list and continue to closely monitor the position.

During 2019/20, we reported a number of concerns about the quality of services provided by Avon and Wiltshire Mental Health Partnership NHS Trust and we have continued to monitor and review the Trust’s performance in these areas. We will continue to support the Trust in delivering its plans to improve services during 2020/21.

We have worked with the Avon & Wiltshire Partnership Trust and our local authority partners to reduce the number of delayed transfers of care. We have seen the number of delayed

transfers of care increase from 6.6% at the end of 2018/19 to 9.6% and we will continue to focus on this area during 2020/21. We have seen a challenging increase in the number of people requiring an inpatient bed who are placed out of area. There has been a significant amount of focus on this, and in year changes have included better discharge planning, understanding the number of beds required locally and a weekly call, to ensure that people are supported by all partners to be discharged quickly and safely when appropriate to do so. This will continue to be a focus next year, and we are committed to eliminating out of area placements by March 2021.

We continue to achieve the early intervention in psychosis target of more than 56% of people referred starting treatment within two weeks of referral. We fell short of our own local target of 81.8%, however, with performance at 77% at the end of 2019/20. Our performance against the 4-week waiting time from referral to assessment of 94.1% was under the national standard of 95%.

The CCG is measured against the requirement that treatment for psychosis can be accessed by patients in line with NICE recommendation that treatment is started within two weeks of referral. We have achieved the highest rating of Level 4 for our early intervention in psychosis services for South Gloucestershire, and we are working closely with Avon and Wiltshire Partnership Trust to deliver the same for Bristol and North Somerset.

In addition to developing the mental health strategy and commissioning the Safe Haven Centre in North Somerset, in 2019/20 we delivered:

 Additional funding to support the implementation of Skype to help perinatal women access support, and to meet the access target of 4.5% (we achieved 4.2%).  Seven GP practices in South Gloucestershire are leading a new multi-disciplinary team pilot to plan care for complex patients with mental health concerns who use both primary and secondary care services  A new Sexual Violence Therapies Service on behalf of NHS England, for those effected by sexual violence in the past 12 months  A better understanding of the ways to improve the crisis pathway. For example, we are currently looking at how we can better embed our street triage and focus the resource of our crisis team in a different way  The smooth transition of North Somerset Child and Adolescent Mental Health services from Weston Area Health Trust to our Children’s Community Health Partnership, creating a single service across Bristol, North Somerset and South Gloucestershire. Over time this will enable a significant improvement in services for the people of North

Somerset, bringing them up to the standard already enjoyed in Bristol and South Gloucestershire.  Roll out of our HOPE project, which supports middle aged men at risk of suicide  Review of all our contracts with both NHS providers and the voluntary sector across Bristol, North Somerset and South Gloucestershire, to understand where there are unwarranted variations in services available, what they are delivering for our population and work toward reducing fragmentation and a consistent offer. Work is underway to review existing adult service specifications and develop a new model of care in line with our Mental Health Strategy.

In 2020/21, our plans include:

 Supporting Avon and Wiltshire Partnership Trust to maintain safe, sustainable and resilient inpatient, community and specialist mental health services  Developing a new Individual Placement and Support Service (IPS)  Ensuring more young people in our Child and Adolescent Mental Health services are assessed and treated more quickly  Enabling more people to access our perinatal service  Supporting more people to access Improving Access to Psychological Therapies  Finalising our Mental Health Strategy  Developing a new model of care for adult mental health services to better meet the needs of our population.

To support the good mental health of our population and meet the Mental Health Investment Standard, we have committed to a number of investments in services in 2020/21 and beyond.

Learning Disabilities and Autism (Transforming Care)

The Transforming Care Programme has three aims:

 To improve the quality of care for people with a learning disability and/or autism  To improve the quality of life for people with a learning disability and/or autism  To enhance community capacity, thereby reducing inappropriate hospital admissions and length of stay

A sustained focus on admission prevention, clinical review and complex case management, and facilitating discharges has helped us reduce the number of CCG inpatient funded places to 11, and the number of places funded through NHS England’s specialised commissioning team to 19. The NHS England target for Bristol, North Somerset and South Gloucestershire was for a maximum of 30 inpatient placements and we have achieved this through strong multi agency

working across our system to get the right resources into place for very complex situations. The NHS long-term plan requires this number to be reduced further. Our local plans reflect this ambition to support safely very complex individuals in the community through the delivery of our wider Learning Disabilities and Autism programme.

Examples of work with our partners across Bristol, North Somerset and South Gloucestershire include:

 Increasing the uptake of flu immunisations by people with learning disabilities and autism  Ensuring our contracts include the ‘Learning Disability Improvement’ standard; as a result all of our NHS providers have completed assessments and development action plans to improve their services  Requiring our providers to use Hospital Passports to support people with learning disabilities and autism  Full participation in the STOMP project, ‘Stopping over medication of people with a learning disability, autism or both’ requires all GP practices across our area to review the records of all patients with a learning disability or autism who are prescribed an antipsychotic medication. The overall aim is to reduce the amount of antipsychotic medication individuals receive to the smallest dose required, and where clinically appropriate to stop unnecessary antipsychotic therapy. Results from across primary care will be collated and shared with stakeholders in 2020/21, providing an opportunity to share best practice across our area  Following the Adult Autism Assessment Waiting List initiative, our waiting lists for assessments are now compliant with the NICE standard of three months compared to 11 months in 2018/19. This follows intense efforts to manage the huge rise in referrals over recent years.  Increasing training in learning disabilities & autism, the Mental Capacity Act, consent, & Best Interest decision making for colleagues across the system  Reviewing our working arrangements to establish learning disabilities and autism network groups to support the coordination of plans and actions across health and social care

The NHS Long Term Plan includes a number of priorities to improve outcomes for people with a learning disability and/or autism. We will work collaboratively with our partners to enhance current provision and improve areas where we know there are gaps. As part of our ambitions, we will be working with our system partners to take a population and values based approach to

addressing the health inequalities experienced by people with a learning disability, autism or both. Our plans include:

 Supporting people to stay healthy and self-care  Enabling better access to mainstream services and optimise opportunities for independence  Reducing avoidable emergency hospital admissions, A&E attendances and admissions to long term care  Improving the patient experience of people with learning disabilities through a whole system pathway approach which will support people with learning disabilities and respond to their specific needs  Avoiding premature mortality rates  Preventing inappropriate admissions, reduce long time segregation, and stop over medication  Reducing lengths of stays for those in inpatient settings  Increasing training opportunities for staff providing mainstream services so they can support people with Learning Disabilities when they use these services  Expanding the learning disabilities nursing liaison service  Supporting the transition from children’s and young people’s services into adult services

The Quality section of this report describes our work focused on Learning Disabilities Mortality Reviews (LeDeR), a national programme aimed at improving the lives of people with Learning Disabilities. The outcomes of these reviews continue to help inform our plans to ensure both the quality of care and quality of life for people with learning disabilities and autism improves.

Frailty

We have found that 1% of users of urgent and emergency services use as much resource as the remaining 99% of the population. We know that these patients are often older, frail members of our community with complex needs. As our population ages and more people live with multiple long-term conditions this challenge will intensify. It is important that we act on this to design interventions and build our system to meet this challenge. To better understand what was needed we set out plans to:

 Map current services across our area  Review best practice  Engage with frail, older people, their families and carers to understand what mattered to them and their experiences of existing services

 Develop a frailty model of care

A range of sources of local and national evidence were gathered prior to engaging with local people to help support our understanding of the needs and aspirations of older, frail people. We undertook a desk-top review of evidence from national and local sources such as The Muslim Council of Britain, Age UK, NHS England, NHS Improving Quality, National Voices to local sources; Bristol Ageing Better, Healthy Weston Public Dialogue Report and South Gloucestershire Healthwatch. In addition, video resources were viewed as good sources of insight from Age UK and Bristol Ageing Better. These illustrated a range of insights about loneliness and isolation amongst older people, as well as perceptions of frailty, the language we use, what people want and say about frailty, and how older people with frailty can continue to contribute to the world we live in.

We engaged nearly 2,700 people using mixed quantitative and qualitative methods through surveys, focus groups and one to one activities. We met people in their own homes or communities, and in places where they socialise, to receive a wide range of views that reflect the diversity of the region. This included meeting with different faith groups and cultural community groups, with translator support as necessary. In addition, focused activities took place with those people with learning disabilities and with people with dementia.

Key themes and issues were collated from feedback received through the engagement activities undertaken as part of ‘Healthy Weston’, the Healthier Together Citizens’ Panel and outreach engagement activities with ‘harder to reach’ communities as identified through the Equalities Impact Assessment (EIA).

Participants in the engagement activities were asked ‘what matters to you?’ and in addition, were asked about the indicators that have been developed to measure the efficacy and outcomes of the Integrated Frailty Programme, which were found to be relevant and important to Bristol, North Somerset and South Gloucestershire populations. As a result a number of important additional outcomes were identified that matter to people, which had not previously been considered.

In addition, outcome measurement tools were tested particularly around loneliness and isolation, quality of life and fear of falling, to determine which questionnaires made sense to people from a practical point of view and which of the sets of questions reflected what people felt that were important to be asked.

Four key themes emerged:

 Support from healthcare professionals, and care and support in the home/community

 Keeping active and eating healthily  The importance of getting out and about, and transport  Overcoming language barriers and cultural differences

These key themes and other key learnings from the engagement process will form a critical part of developing both our models of care and the methods of evaluating the outcomes to ensure that we are continuing to develop and improve services for people across the region.

Planned Care

Our healthcare system continues to face significant challenges in some specialities with long waiting times. We have worked hard in 2019/20 to reduce the number of patients waiting 52 week for their treatment and we are making progress. Musculoskeletal services continue to be an area with long waiting times and we are working to resolve these with our partner organisations.

The number of patients waiting 6 weeks or more for a diagnostic test have increased and at the end of 2019/20, our performance was 96.73% against a target of 99% of patients having diagnostic tests within six weeks. Our Trusts have reported significant backlogs for endoscopy tests due to reduced capacity. Waiting times for CT (Computed Tomography) scans have also been longer as demand has grown. We are working to improve performance and reduce waiting times for all our diagnostic services using waiting list initiatives to ensure our patients have prompt access to the tests they need.

We continue to focus on improving the value of planned care activity to reduce risk, ensuring the best possible outcomes for patients and that people are seen at the best place for them. In 2019/20, we have, in line with our plans:

 Worked to improve eye care services, developing new pathways to better integrate community and hospital eye-care services, establishing clinical triage of all eye referrals to check compliance with our criteria based access policies to prevent inappropriate referrals to secondary care. The Bristol Eye Hospital, the Referral Service and the Local Optical Committee have written new eye care guidance to enable optometrists and GPs to manage more eye conditions in primary care. We have established an informed decision making pilot for cataract surgery, to find out if providing more information about cataract surgery and the alternatives at the start of the pathway reduces the number of people who choose not to have surgery after their first outpatient appointment

 Rolled out the clinical triage of referrals by the Referral Service across Bristol, North Somerset and South Gloucestershire  Introduced Advice and Guidance services for GPs in a number of clinical specialities  Continued to transform outpatient services with a new model for community urology services, piloting video consultation for patients at University Hospitals Bristol, increasing the number of patients whose consultations were conducted by phone, beginning focused work to redesign respiratory services – combining the expertise of primary, community and secondary care to reduce wait times for patients  Introduced new pathways for deep vein thrombosis (DVT) and faecal calprotectin testing (this helps detect possible inflammatory bowel disease), and a new policy for shoulder decompression (a treatment for shoulder pain). These new pathways provide care closer to people’s home and better value care for individuals and the health care system  With our partners, we are piloting the use of wearable digital technologies to help people living with long term conditions manage their health and wellbeing.

Our plans to improve planned care during 2020/21 include:

 Introducing an advice and guidance service for urgent eye problems to enable GPs and optometrists to manage these people in primary care without needing to attend A&E at the eye hospital. We will commission a new integrated eye care model, where optometrists work closely with hospital eye care services to manage people in the community  Providing support for people on the osteoarthritis hip and knee pathway to help them lose weight, exercise more and stop smoking by offering them a 12-week healthy lifestyle course run by Public Health. We are also rolling out ESCAPE-pain courses across Bristol, North Somerset and South Gloucestershire. These courses run in local leisure centres help people self-manage their osteoarthritis hip and knee conditions to reduce the need for surgery. We will also introduce shared decision making into musculoskeletal care pathways to improve patient experience, reduce unwarranted variation and improve access times for those people who want and need surgery  Developing and starting to implement a vision for networked acute trauma and orthopaedic services

Our plans for transforming outpatient services include:

 Video consultation, patient appointment booking and capturing outcomes

 New integrated diagnosis & treatment services in urology; these will be a blueprint for future models of care  Integrated locality management of respiratory conditions  Trial advice & guidance as the only referral route for neurology, linking consultants to GPs in localities to support two-way learning and education  Using digital approaches to reduce the number of unnecessary routine follow-ups so that patient initiated follow-ups become standard in at least one specialty. We will also look at a range of changes across all specialties to remove low value activity, for example routine follow-ups that could be done using technology

We will continue to improve:

 Access to key diagnostic services such as CT, MRI and endoscopy and develop a strategy for these services. Our value based healthcare approach will help us explore what ‘quick wins’ there are that will reduce low value diagnostic activity  Prevention and care along key cardiovascular disease pathways, creating better outcomes for patients and reducing future demand  Clinical peer review across our GP practices by rolling out Referral Service support

Medicines optimisation and primary care

Our Medicines Optimisation Team has worked closely with GP practices, acute trusts, local community providers, and community pharmacies to ensure clinically safe and cost-effective prescribing. Our Medicine Optimisation Programme links with NHS England’s Medicines Value Programme and the World Health Organisation’s Patient Safety Programme, alongside a number of local projects and initiatives to ensure safe, cost-effective prescribing linked to the NHS Long Term Plan priorities.

We are responsible for the prescribing budgets of our member GP practices and work closely with practices to support cost effective prescribing.

The Medicines Optimisation Team has been working closely with colleagues from across the system to lead the development of new pharmacy workforce opportunities, linking closely with the newly established Primary Care Networks to support their recruitment of pharmacists to enable network working.

This year has seen the development of a greater integrated approach to medicine optimisation across Bristol, North Somerset and South Gloucestershire, with a system wide programme of projects in place to improve quality and value. Through our joint working groups we:

 Manage the introduction of new drugs and shared care medicines across our area so that patients have access to safe, cost effective medicines that offer good outcomes.  Focus on medicines safety, ways to improve the safety and quality of medicines use, and support the delivery of the NHS Medicines Safety Improvement Programme. This will contribute to the World Health Organisation Challenge target to reduce severe avoidable medication-related harm globally by 50% over five years. We have specifically worked as a whole system focus on insulin safety and anticoagulation safety, which have been highlighted as two areas of high risk that significantly impact on patients and healthcare systems  Work on the implementation and assurance of NICE technology appraisals. A collaborative approach, consultant led, has been undertaken to develop system wide pathways in gastroenterology, ophthalmology, dermatology and rheumatology to ensure value and a consistent approach to treatment for all patients

Research and Evidence

Our research and evidence teams supports CCG colleagues and NHS staff across the wider health community. The team has strong relationships with external partners in local universities, public health, at the West of England Academic Health Science Network, Bristol Health Partners and the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC West).

The team works closely with colleagues to drive value through an evidence informed approach. A key role is to make it easier for commissioners to use the best available evidence to inform decisions in commissioning services, and subsequently to evaluate those services. Our work spans the boundary between the world of research and the world of health and care practice. Team members are ambassadors for research that, informed by NHS priorities, actively supports commissioners to use research results and other evidence in their work. Knowledge mobilisation between health and social care in practice and academia is a key driver for our work, and through this, we focus on both research informed practice and practice informed research.

We are working with Primary Care Networks to share emerging evidence from one of our hosted research projects to inform their implementation of the first contact physiotherapy model. This will form part of the GP contract from April.

We currently host 14 high quality research grants funded by the National Institute for Health Research (part of the Department of Health and Social Care). These are currently worth £17.7 million. Some of the areas covered by our hosted grants include:

 Treatment of osteoarthritis  Best emollients for eczema  GPs in Emergency Departments  Management of polypharmacy  First contact physiotherapy in primary care

Our success in terms of working with researchers and our grant hosting is recognised through the Research Capability Funding from the NIHR. This funding rewards high quality research and is used to drive forward new research ideas, new research infrastructure and research teams. In April 2019, we were awarded the highest Research Capability Funding award to any CCG in England, receiving £1,508,793.

Since April 2019, the Evaluation and Evidence Team has supported evaluations in areas as diverse as,

 the role of multi-disciplinary teams,  new models of urgent care and frailty, and  integrating child and adolescent mental health services.

In the same period, 44 evidence searches or reviews were undertaken on topics including end of life care, living well with and beyond cancer, and mental health crisis services.

We support Healthier Together by ensuring the principles of best use of research and evidence, and effective evaluation strategies, are part of everyday work. We have been involved in developing surveys to test value-based health and care training and supporting use of evidence in cancer referrals and diagnostics pathways, as well as supporting the evaluation aspects of the recent Sustain our System initiative.

Our Research and Evidence Team enjoys a high profile and reputation as an innovative and effective resource, both within our local area and nationally. The team supports our value based approach to health and care to understand our population health needs, and supports staff to ensure their decisions are evidence based, as well as helping identify outcome measures for new initiatives and supporting realistic evaluation plans. Research and evaluation

has an important role to play in delivering health and care services focused on high value activity and based on the specific needs of the population. Our work in the coming year will see us implement a new combined strategy across Research and Evidence and Clinical Effectiveness, supporting our vision through the development of evidence-based, pragmatic approaches to understanding our population and delivering value based health and care.

Improve quality

Quality is at the heart of everything we do as system leaders and commissioners. We have a duty to commission safe, high quality, and effective health services for the people of Bristol, North Somerset and South Gloucestershire, and a duty to support primary care services to continually improve under Sections 14R and 14S of the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012). Our Quality Committee ensures that there is comprehensive oversight and monitoring of the quality of our commissioned services.

Strong clinical leadership and engagement with partners is fundamental to improving quality and improving outcomes for patients. We work with the providers of our commissioned services to support continual improvement in the safety, experience and the effectiveness of care.

Our Quality Team works with colleagues across the CCG to lead Clinical Quality Review and Performance Meetings with each of our NHS providers. We consider performance and contractual information, identifying and responding to what this means for patients and staff. In 2020/21 we will publish a system quality strategy setting out our shared vision for quality, including our approach to system governance and accountability. This will reflect our collective commitment to place the quality and experience of care for our communities at the centre of all that we do and aspire to.

Patient Experience

Hearing the voice of local people and communities and engaging with them to co-design and co-create new services is at the core of our approach, and as we develop our system quality strategy, we will identify ways in which that voice is heard throughout our work. We will ensure that analysis and comparison of patient experience information enables us to identify themes and trends, to support ongoing improvement of the experience and quality of care.

Our Customer Services Team gathers feedback from patients through compliments and complaints, advice and liaison enquiries, MP enquiries, feedback from healthcare professionals, patient surveys and Healthwatch reports. We use social media, including Twitter and Facebook, and monitor responses posted on the NHS Choices and Care Opinions websites. Our Citizens Panel has an important role, providing feedback on their experiences of healthcare.

In 2019/20 we received 1,346 Patient Advice and Liaison Service (PALS) contacts, 296 formal complaints and 96 MP enquiries. In 2019/20 five complaints were reported to the Parliamentary and Health Service Ombudsman who declined to investigate two of these complaints. At the time of reporting decisions regarding three complaints were outstanding.

 We have used patient experience to improve how the CCG operates across the health system. We collate all feedback and analyse trends or themes and share these with the Quality Committee and Governing Body, to ensure that learnings are shared and patient experience is improved.  The Customer Services Team will provide training for CCG staff regarding patient feedback, how this is used and why it is important to the CCG as service commissioners.  Customer Services have implemented regular meetings with key service providers within the CCG, to discuss feedback from patients and to facilitate a swifter and smoother process for people contacting the Customer Services Team.  There have also been meetings with external providers, again to improve services and to facilitate a swifter and smoother process for patients. Learning and intelligence collected is used to inform and update policies and related documentation, with the aim of providing a fair and transparent service for patients.

Infection Prevention and Control

Healthcare associated infections

Tackling preventable healthcare-associated infections continues to be one of our key priorities. We continued to work in partnership with our service providers in 2019/20, hosting regular meetings of our Healthcare Associated Infection (HCAI) Working Group. Membership includes acute and community providers and Public Health England. Additionally, a Methicillin Resistant Staphylococcus Aureus (MRSA) Task and Finish Group was established, and an Escherichia coli (E-coli) Task and Finish Group was established in 2019/20.

Our local healthcare system continues to be challenged by the number of reported MRSA Blood Stream Infections cases. The number of MRSA cases assigned to us was 42 for 2019/20 compared to 44 in 2018/19. These are MRSA cases that are considered to be community acquired infections; they will have started 2 days before a hospital admission.

Table 3

BNSSG CCG BNSSG Assigned Assigned Indicator Threshold Cases Cases 2019/20 2018/19 Total Number of MRSA Cases Reported across 0 Bristol, North Somerset and South Gloucestershire 42 44

If an MRSA infection started two days after a patient’s admission to hospital this is considered a Hospital Acquired infection (post 48 hours). Our main hospital providers all recorded fewer MRSA cases in 2019/20 when compared to 2018/19

North Bristol Trust assigned cases decreased in 2019/20, from nine to four and University Hospitals Bristol saw a decrease from assigned cases from seven to six. Weston General Hospital had two assigned case compared to one in 2018/19.

MRSA cases in BNSSG Acutes 10

6 2017/18 2018/19 4 2019/20 2

0 NBT UHB WAHT

We continue to carry out post-infection reviews which all providers involved in a patients’ care, including GPs, contribute to. This has enabled us to identify and highlight learning and key risks.

We had a threshold of a maximum of 201 cases of clostridium difficile for 2019/20 and reported 195 cases. All community assigned clostridium difficile cases were reviewed with the patient’s GP using our community onset clostridium difficile reporting tool, which helps to identify learning than can be used to prevent future cases.

Table 4

BNSSG BNSSG Threshold Assigned Assigned Indicator 2019/20 Cases Cases 2018/19 2019/20

Total Number of clostridium difficile Cases 201 196 195

We review all cases of clostridium difficile attributed to our Trusts at regular meetings with Trust staff. These reviews consider any lapse in the quality of care provided and whether the case was avoidable. The majority of cases to date have been classed as unavoidable. If there has been a lapse in care, an action plan is put in place to prevent this happening again. We monitor these action plans with our partners and we are working to have a shared approach to action planning across all of our Trusts from April 2020.

Following the changes in apportionment guidance, a direct comparison from 2018/19 to 2019/20 is limited. NHS Improvement has provided a threshold for the number of cases assigned to each acute trust and each of our acute providers have remained within the thresholds set.

All C diff cases in BNSSG 25

15 2017/18 2018/19 10 2019/20 5

0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

We have used a clostridium difficile review tool with our acute providers to ensure we have consistent information about the key risks and the learning from each case. We have also looked at what care the patient received from community and primary care. This supports our continued focus on reducing the number of cases.

We continue to work towards achieving the escherichia coli (E. coli) NHS reduction targets. Our local ambition target for 2019/20 was 637. We achieved a 6% reduction, our final number of assigned cases was 662, compared to 708 for 2018/19.

During 2019/20, the total number of Trust apportioned cases was 134 and 528 were apportioned as community onset. University Hospitals Bristol reported 83 cases, compared to 85 in 2018/19, North Bristol Trust reported 60 cases compared to 57 in 2018/19, and Weston General Hospital reported 19 cases, compared to 23 cases reported in 2018/19.

E coli cases in BNSSG Acutes 100

60 2017/18 2018/19 40 2019/20 20

0 NBT UHB WAHT

National research shows that the most common sources of infection are urinary tract and catheter associated urinary tract infections, and most of these cases happen in community settings. We implemented the use of a catheter passport within Bristol, North Somerset and South Gloucestershire, and monitored its use. The passport allows vital information sharing, improving communication between hospitals, community services, GPs and practice nurses and patients. We require our providers to include information on bacterial infections, including E-coli, in their mandatory infection control training.

Where E-coli bacteraemia cases are above the ambition threshold, NHS Improvement encourages hospitals to undertake a retrospective audit of 30 cases. In 2019/20 we set up an E-coli task and finish group, which includes practice nurse leads, to review cases and develop and oversee an action plan related to commonly identified themes. Our providers completed a retrospective review of cases of E-coli infection to identify common themes. We will be continuing the implementation of the action plan in 2020/21.

Influenza (Flu)

Flu is a key factor in NHS winter pressures, impacting on those who become ill, the NHS services that provide direct care, and on the wider health and social care system that support people in at-risk groups. We worked with our partners to develop a flu plan for 2019/20, which aimed to reduce the impact of flu on our population through a series of complementary measures. Our plan included a vaccination programme for people in at risk groups, a workforce vaccination programme and a communications campaign to encourage the uptake of vaccinations. We have worked with GP practices to encourage patients to be vaccinated against flu. We achieved 75.8% uptake, exceeding the end of season ambition for 75% of people 65 years and over to have received the vaccination. For those people at risk between 6 months and 65 years old we reported 46.1% uptake against an ambition of 55%. Similarly for pregnant women in the not at risk group, uptake of 44.7% was reported compared to the ambition of 55%. A detailed review of the 2019/20 plan will be used to inform the flu plan for 2020/21.

Table 5

Flu Vaccination Uptake Rates Week 4 (ending 26.1.2020-season data due mid March)

At Risk – Pregnant & 65 and Over (6 mths - Under 65) NOT in At Risk Group

Endof season ambition National Uptake BNSSG Endof season ambition National Uptake BNSSG Endof season ambition National Uptake BNSSG 55% 43.1% 46.1% 75% 71.6% 75.8% 55% 41.39% 45.7%

The majority of our providers have exceeded the national flu vaccine CQUIN performance requirement of between 60-80% of frontline staff. Our providers achieved the following against their targets for flu vaccine uptake by front line staff

2018/19 2019/20 AVON AND WILTSHIRE MENTAL HEALTH PARTNERSHIP 54.3 54.8 0.5 BRISTOL COMMUNITY HEALTH 75.2 74.0 -1.2 NORTH BRISTOL 87.9 81.6 -6.3 NORTH SOMERSET COMMUNITY PARTNERSHIP 82.9 83.2 0.3 SIRONA CARE & HEALTH 58.1 58.8 0.7 SOMERSET PARTNERSHIP 46.7 51.3 4.6 SOUTH WESTERN AMBULANCE SERVICE 56.9 60.1 3.2 UNIVERSITY HOSPITALS BRISTOL 82.6 84.7 2.1 WESTON AREA HEALTH 80.4 84.0 3.6 Antimicrobial Stewardship

There are two main prescribing measures for antibiotic stewardship:

 The Antibiotics/STAR-PU (Specific Therapeutic group Age-sex Related Prescribing Unit) This measure shows the amount of antibacterial drugs that have been prescribed, in relation to what would be expected given the number and characteristics of patients registered at the practice, and  The percentage of all antibiotic prescriptions that are broad spectrum.

Out of our 80 GP practices, 69 are meeting the nationally set target of 0.985 antibiotics/STAR- PU and 71 are meeting the target for the percentage of all antibiotic prescriptions that are broad spectrum.

Pressure injuries

During 2019/20 we have increased reporting and reduced the number of more serious injuries (Grade 3 and 4). Our focus for 2020/ 21 is to maintain this and reduce Grade 2 pressure ulcers.

We have an active working group with clear objectives to ensure long-term improvements to pressure injury management. As part of our commitment to ensure consistent education for staff, in November last year we hosted a conference bringing together 120 healthcare workers on International Stop the Pressure Day. During the event experts from across the healthcare system shared best practice to drive up standards of care. In 2020/21 we will focus our plans on improving knowledge about pressure injury prevention for both staff and patients, including support for primary care staff and developing public information.

Patient dignity and privacy

We are committed to eliminating mixed sex accommodation within all of our local inpatient units unless there is a clinically justified reason. We have locally agreed exceptions to mixed sex accommodation breach reporting with the Trusts, for example in instances when patients need highly specialised care, such as patients who need to be in critical care units.

Instances of mixed sex accommodation are reported and each case is reviewed to determine whether it was justified. Action taken to avoid future breaches has been agreed and assurance visits undertaken where required. We impose financial sanctions on Trusts for unjustifiable mixed sex accommodation breaches. In 2019/20, there were 17 reported breaches, compared to 25 reported in 2018/19.

University Hospitals Bristol reported ten breaches this year compared to 25 in 2018/19, whilst both North Bristol Trust and Weston General Hospital report no breaches this year. The remaining breaches were identified as Bristol, North Somerset and South Gloucestershire patients in out of area locations.

Commissioning for quality and innovation (CQUIN)

CQUINs are offered on an annual basis to all providers of healthcare services commissioned under the NHS standard contract. CQUINs account for 1.25% of a provider’s total income, a change from 2.50% in previous years. CQUIN schemes are intended to support delivery of quality improvements and drive transformational change. The current CQUIN period was to implement national schemes and where possible to align these with existing work taking place in our Healthier Together programmes. The exception to this was the introduction of two local CQUINs for community providers regarding catheter care and pressure injuries.

Results of CQUIN delivery will be available following quarter 4 evidence submissions.

Patient safety – serious incidents and never events

The majority of patients receive safe high quality care, however, serious incidents do occur and it is essential these are reported and managed appropriately. Our role as commissioners is to gain assurance from service providers that serious incidents are properly identified, reported and investigated, to minimise the risk of a similar incident happening again. Serious incidents are subject to a thorough investigation to identify how and why the incident happened and a plan of action is developed to embed learning to prevent similar events occurring.

Our commissioned services reported a total of 327 serious incidents and never events (Feb 2020) compared to 400 serious incidents during 2018/19 and 419 reported serious incidents in 2017/18.

We hold a weekly Serious Incident Review Panel covering the whole of Bristol, North Somerset and South Gloucestershire. This Panel looks at the findings of all serious incident investigation reports to identify common themes and learning and the findings are shared with all of our service providers to drive improvements in patient safety across our area. The Serious Incident Review Panel looks at the action plans providers develop to prevent serious incidents happening again and monitors to ensure that they are implemented.

Never Events are serious incidents that are considered wholly preventable and are generally a result of human error. In 2019/20 11 Never Events were reported, the same number as reported in in 2018/19; 13 were reported in 2017/18. Two Never Event Summits were held this year for our providers to highlight themes and plan how learning will be used across the Bristol, North Somerset and South Gloucestershire footprint to prevent these Never Events from happening again.

Provider registration with the Care Quality Commission (CQC)

Out of 80 GP practices in Bristol, North Somerset and South Gloucestershire six have a ‘requires improvement’ overall rating. We support our service providers to develop and complete actions to ensure compliance with the requirements of the CQC. This work includes joint visits and assurance with NHS England, NHS Improvement, Health Education England and Healthwatch. The ratings across the individual CQC domains for our hospital service providers is below:

Table 6

Provider Overall Rating Safe Effective Caring Responsive Well-led

University Hospital Bristol Requires Outstanding Good Outstanding Good Outstanding improvement Report – 16TH August 2019

Weston Area Health NHS Trust Requires Requires Requires Requires Good Good improvement improvement improvement improvement Report – 17th December 2019

North Bristol NHS Trust (Southmead) Requires Good Good Good Outstanding Outstanding improvement Report – 25th September 2019

Avon and Wiltshire Mental Health Trust Requires Requires Requires Requires Good Good Improvement Improvement Improvement Improvement Report 21 December 2018

Bristol Community Health Good Good Good Good Good Good Report – 16 February 2017

North Somerset Community Partnership Requires Good Good Good Good Good Improvement Report – 31 March 2017

Sirona Care and Health Requires Good Good Outstanding Good Good Improvement Report – 28 March 2017

Safeguarding Adults

We continue to have strong systems in place to discharge our statutory duties for both adults and children safeguarding. Our safeguarding adults work includes quality assurance site visits to understand how our providers are meeting the requirements placed on them. In 2018/19, we were invited by a local Trust to complete a safeguarding adults site visit under the Care Act 2014 to review their care of older patients. In 2019/20 we returned to the Trust and noted significant improvements in relation to implementing the Mental Capacity Act and the deprivation of liberty safeguard legislation.

We continue to uphold the framework of safeguarding standards, working with acute and community providers to ensure training meets the required compliance. Our safeguarding team has worked with colleagues to ensure that staff within the CCG are trained, and we have a compliance rate of 85%.

We continue to work with partners, in a multi-agency approach, to ensure that health partners are effective in responding to both children and adults when they are at risk of harm. This work continues with input into statutory practice reviews, safeguarding adult’s reviews and domestic homicides, ensuring that learning is disseminated to both acute and community providers and to GPs through learning briefs. Male domestic violence has been an area of particular focus in 2019/20 and this continues into 2020/21.

Safeguarding Children

The key legislation for children and young people includes the Children Act (1989), the Children Act (2004) and the Children and Social Work Act 2017. Section 10 of the 2004 Act creates a statutory framework for local co-operation between local authorities, partner agencies and other bodies including the voluntary and community sector in order to improve the wellbeing of children in a local area. The CCG is represented by the Director of Nursing and Quality as a statutory partner at the recently reconfigured Adult and Children Partnership Boards and emerging sub groups as follows:

 Keeping Bristol Safe Partnership  South Gloucestershire Children’s Partnership  North Somerset Safeguarding Partnership  Safeguarding Adults Boards (SABs) across Bristol, North Somerset and South Gloucestershire

Our safeguarding activity in 2019/20 included:

 Multi-agency audit of North Bristol Trust referrals to Children’s Social Care  Audit of health input to child protection case conferences  South Gloucestershire Multi Agency Exploitation Audit  South Gloucestershire Multi Agency Quality Assurance Audit - Early Years Interventions  Quality of GP referrals  Joint Health and Social Care Audit with South West Ambulance Service NHS Trust and Care UK NHS 111 to identify areas for improvement of safeguarding practice.  Joint Audit of Agency Arrangements to Safeguard and Promote the Welfare of Children’, under Section 11 of the Children’s Act

We have engaged with and contributed to all the children’s safeguarding reviews, commissioned by the Partnerships, ensuring appropriate representation at review panels and submission of review reports and chronologies. We have implemented and monitored all health action plans, introducing changes and improvements as identified. Learning is shared across

the organisation via training events, safeguarding huddles, during supervision, and in patient stories.

Our work will continue in 2020/21 and will include working with partners to:

 Reduce knife crime  Identify and protect victims of Child Sexual Exploitation

Looked After Children

The CCG has a statutory responsibility to ensure that appropriate arrangements are in place to meet the physical and mental health needs of Looked After Children, working in partnership with the Corporate Parent and health providers. Looked after Children Health Services are provided through three providers, Sirona care and health for Bristol and South Gloucestershire, North Somerset Community Partnership and Weston Area Health Trust in North Somerset. This will move to a single community provider, Sirona care and health, in April 2020. Throughout 2019/20 we closely monitored the number of Initial Health Assessments and Review Health Assessments carried out by providers for our Looked after Children. Across the year the number of health assessments was below the level expected and we have worked closely with partners to improve performance. Improvements have included establishing clinics to carry Initial Health Assessments

Figures KPI Bristol South Gloucestershire North Somerset

X denotes data not available. Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Contracted reporting timelines are outside CCG reporting timelines.

Number of IHA’s required 43 56 34 29 28 15 29 20 11 30 30 17

Number of IHA’s carried out 85% 16.3% 42% 50% 37 28% 66.7% 41% 75% x 30% 40% 100% within 20 working days of % becoming looked after (7) (24) (17) (8) (10) (12) (15) (9) (12) (17) (11)

Number of IHA’s carried out 85% 32% 58.9% 61% 44. 64.3% 80% 65.5 90% x 33.3% 26.6% 100% within 25 days of referral 8% % (14) (33) (21) (18) (12) (18) (10) (8) (13) (19)

Number of RHA’s required 128 111 108 167 36 36 52 44 43 70 56 69

Number of RHA’s completed 85% 63% 83.8% 74% 58. 70% 78% 54% 52.3% 104% 85.7% 84% 91% on time. (80) (93) (80) 1% (25) (28) (28) (23) (45) (60) (47) (63) (97)

An external appreciative inquiry of the Looked after Children service was undertaken in January 2020. There are a number of recommendations for the CCG and for our provider organisations and we are developing a system wide plan to improve the health outcomes for this vulnerable group and ensure that we meet our statutory requirements.

Learning Disabilities Mortality Review (LeDeR)

The Learning Disabilities Mortality Review (LeDeR) Programme is the first national programme of its kind aimed at making improvements to the lives of people with learning disabilities. LeDeR is a non-statutory process set up to review deaths of all people with learning disabilities with a view to improve the standard and quality of care received.

Since February 2019 we have held monthly LeDeR Steering Group meetings. The Steering Group has representatives from all health providers plus the Local Authorities, adult social care providers, Care Quality Commission, GPs and NHSE regional LeDeR leads. The LeDeR Steering Group takes a strategic level oversight of the reviews, driving transformation to improve care with key roles to:

 Receive regular reports from the Local Area Contact about the Bristol, North Somerset and South Gloucestershire reviews

 Monitor action plans resulting from local reviews of deaths

 Take appropriate action as a result of information obtained from local reviews of deaths  Support the identification of and sharing of best practice in the review process and influence change.

To enhance the national LeDeR process our LeDeR team implemented a Clinical Case Review Panel to strengthen the quality assurance and closure process of cases. We also established additional support for the individuals who undertake the reviews, with the addition of a ‘buddy system’ for new reviewers, and a peer support group for all reviewers. We appointed a dedicated assistant to help source the relevant health and social care records for reviewers.

Involvement of people who have a learning disability in this process is essential to support learning, and in February 2020 we held our first LeDeR Service User Forum. The Service User Forum will ensure people have the opportunity to contribute to the LeDeR review process, feeding back their comments and ideas on findings of reviews to the LeDeR Steering Group to help us identify service improvements from the service users perspective.

During 2019, we received 56 notifications and completed and closed 32 cases during the calendar year, January to December 2019. Our data shows that people with a learning disability in our area live approximately eight years longer than the LeDeR national average.

From the completed reviews nine out of 10 people with a learning disability received satisfactory or good care.

Reviews identified the following areas for improvement in the care of people with learning disabilities:

 Communications between professionals,  Improving uptake of the annual health checks,  Early detection and access to screening programmes  Better management of illnesses, such as pneumonia and sepsis  Listening to people and their families and making reasonable adjustments

From our first annual review we have identified the following programme of work for 2020/21:

 Develop the LeDeR Steering Group work plan to support focused work on specific learning themes, capturing recommendations from reviewers into an action plan for providers  Ensure learning identified from reviews informs day-to-day practice in hospitals, community health and social care.  Continue to share learning into actions with the aim of ensuring all people with a learning disability have good or excellent care  Greater inclusion of people with learning disabilities in our work, including their attendance at the steering group workshop events.  Hosting learning events during 2020/21  Continue to work with system partners, including the West of England Academic Health Science Network Learning Disabilities Collaborative, to share learning and best practice

 Supporting GPs to undertake Annual Health Checks for people with learning disabilities and ensuring every individual has a Health Action Plan to identify the healthcare and support they need throughout the year.

SEND (Special Educational Needs and Disabilities) Children and Young Adults

The Children and Families Act (2014) aims to improve services for children, young people and families with special educational needs and disabilities, including those with complex health needs, in three main ways:

 Identifying children and young people (up to the age of 25) who have special educational needs and disabilities. This includes the timeliness of identification, and the

effective use of information from neonatal and new born screening and early health checks  Assessing and meeting their needs. This includes securing health input to Education Health and Care (EHC) Plans and information about health services through the Local Offer  Improving their adulthood outcomes

We are committed to improving the lives and outcomes for children and young people with special educational needs and disabilities and the legislative framework underpins our work and plans for this group of young people. We work with our local authority partners and jointly commission services for children and young people (up to age 25) with special educational needs and disabilities, and contribute to the Local Offer of services available. We have in place mechanisms to ensure practitioners and clinicians support the integrated Education Health and Care (ECH) needs assessment process, and agree Personal Budgets where they are provided for those with EHC plans. We co-produce services for children, young people and families with SEND, and enable them to participate in shared decision-making about their care.

Ofsted and the CQC have an inspection framework and each local area is expected to demonstrate a good understanding of how effective they are in meeting their duties, and the aspects of their responsibility requiring further development. Following the inspection, Ofsted and the CQC write a joint inspection outcome letter. This explains the main inspection findings, highlighting strengths but also making recommendations for improvement by identifying areas of significant weakness. The outcome letters are published on the Ofsted and CQC websites.

Each local area within Bristol, North Somerset and South Gloucestershire has received a SEND inspected by Ofsted and the CQC, and we have worked with our local authority partners to develop Written Statements of Action in response to the inspection findings. These Written Statements of Action detail the actions that we are taking as individual organisations, and jointly together, to improve those areas where there are weaknesses. These Written Statements of Actions can be found on our website.

Engaging people and communities

NHS commissioning organisations have a legal duty under the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012) to ‘make arrangements’ to involve the public in the commissioning of services for NHS patients (the ‘public involvement duty’). For CCGs, this duty is outlined in Section 14Z2 of the Act. As an organisation we are committed to going beyond our mandatory duties to engage with the people and communities we serve.

In order to support the CCG’s vision to deliver “healthy, fulfilled lives for everyone” in Bristol, North Somerset and South Gloucestershire, our engagement needs to shift the conversation with our population from “what’s the matter with you?” to “what matters to you?” To facilitate this change, our promise to our population is that during our engagement work we will always seek to:

 Listen with care to the needs, concerns and ideas of the people and communities we serve  Ensure that our involvement and engagement reflects the depth and breadth of our whole population  Take the insights gained from working with people and communities and use them to improve patient experiences  Continuously strive to design our services in partnership with the communities we serve

We have involved a wide range of people and organisations in the engagement work we do. This has allowed us to hear from a broad range of individuals across our diverse region.

Examples of our engagement activities can be found throughout this report and include:

 Consulting with people in North Somerset out the future of services at Weston Hospital. We received over 2,000 responses from members of the public, which helped shape the proposals considered and approved by our Governing Body.  Supporting the development of the Primary Care Strategy through on-line surveys and meetings with patient groups and Healthwatch. We have used this feedback to develop a primary care strategy to provide primary care services that meet people’s needs.

 Using focus groups, one to one activities and surveys to understand what people want from services aimed at supporting frail and elderly patients. These insights have helped us design services that are more responsive.  Working together with people with lived experience to develop an all age mental health strategy to drive real and sustained change. Insights from the Citizens’ Panel and other engagement activities in the past year have helped to provide information about health and wellbeing, self-care and prevention, including:

 The significant differences in self-reported happiness, health and control across our six localities  Peoples’ attitudes towards physical and emotional wellbeing and willingness to take more personal responsibility for their own health and wellbeing  Smoking, including rates and frequency of self-reported smoking and drivers and barriers to stopping smoking  Healthy eating, including information about the meals people cook and prepare and peoples’ confidence in cooking and preparing fresh, healthy meals  Self-reported adherence to prescribed medications and what may help to improve adherence

Over the past year, we have gathered insights from multiple surveys of the Citizens’ Panel, from approximately 800 people, to support the digital transformation of health and care services. These insights and other engagement activities in the past year have helped to provide information about:

 Peoples’ perceptions towards using digital technology to book appointments, communicate with health and care professionals, and receive information and test results following on from appointments  Peoples’ thoughts on the sharing of health and care records  Peoples’ experiences of booking appointments online

In addition to this work with the Citizens’ Panel we have worked with colleagues to evaluate people’s needs and the user experience when using online e-consultation platforms, which have been piloted in different parts of Bristol, North Somerset and South Gloucestershire.

In total, in 2019/20, we received 9,703 pieces of feedback as a result of our public involvement, engagement and participation activity.

Reducing health inequality

NHS commissioning organisations have a legal duty under the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012) to reduce inequalities. For CCGs, this duty is outlined in Section 14T of the Act. In 2019/20, we built on public health information, insights from our citizens, and population health management to develop a rich picture of our diverse communities across Bristol, North Somerset and South Gloucestershire. This detailed picture allows us to understand the health needs of local people and specifically the health needs of key groups in our communities that are often marginalised. As we develop as an Integrated Care System, we will continue to develop this detailed understanding.

We know that our communities are significantly diverse. Our most deprived communities are most affected by factors such as air pollution and smoking rates. Our deprived communities are characterised by lower self-rated levels of control over their lives and/or lower happiness.

1% of high users of urgent and emergency care have complex health and care needs and use services as much as the other 99% of the population. This focuses our attention to supporting people living in the most complex health and social circumstances and the wider determinants that most impact them.

Smoking remains the single most important behavioural risk factor and is a bigger problem among the most deprived and those with mental ill health. Each of our areas is described below as 100 people.

We have taken this information and used it to underpin our Healthier Together long-term plans, concentrating on reducing health inequalities across our system. Our ambition is to make a significant improvement in the health and wellbeing of our population by:

 Addressing the major health threats of cardiovascular/cerebrovascular, respiratory, mental health, musculoskeletal diseases and cancer.

 Addressing the gross inequalities in our system by deprivation and between groups, such as those with learning disabilities and serious mental health issues.

Below are examples of some of our activities to reduce health inequalities across Bristol, North Somerset and South Gloucestershire.

 We have focused on outcomes important to individuals and ensuring that the most vulnerable groups in our communities receive the urgent care they need through our frailty programme  We have worked with GPs to reduce the variation in long term condition review blood tests and put in place the tests that people need to support their care  Established social prescribing in our GP practices to support people access services  Built reducing health inequalities into the service specification for our new community services  We are opening the Safe Haven Centre in the centre of Weston-super-Mare to provide support for people experiencing a mental health crisis, ensuring it is accessible to people

For people with learning disabilities and autism we are:

 Improving the uptake of cancer screening and flu’ immunisations  Reducing the prescribing of antipsychotic medication  Increasing awareness of the needs of people with learning disabilities and autism across health settings

Our overall performance is assessed by NHS England through the NHS Oversight Framework. This has two indicators related to health inequalities.

 The Inequality in unplanned hospitalisation for chronic ambulatory care sensitive and urgent care sensitive conditions.  The proportion of people on GP’s severe mental illness register receiving physical health checks in primary care

Health conditions recorded under the first indicator, Inequality in unplanned hospitalisation for chronic ambulatory care sensitive and urgent care sensitive conditions, include:

 influenza and pneumonia  chronic obstructive pulmonary disease (COPD)  ear, nose and throat infections  convulsions and epilepsy

 diabetes complications  cellulitis  asthma

We have increased the same day urgent care capacity in primary care to ensure patients with chronic conditions have better community based pathways and out of hospital access to professional support. Currently, we are performing better than the England average measure for this indicator.

The standard for the proportion of people on GP severe mental illness register receiving physical health checks is 60%. Our performance in quarter 2 of 2019/20 (the most recent data available to us) was 21.3%, worse than the England average (30%). To improve performance we are bringing together Avon and Wiltshire Partnership Trust and GP practices to:

 Develop supporting shared care protocols between primary and secondary care  Develop and implement enhanced primary community/primary care service for the full annual physical health check as part of the integrated new care models programme  We have developed a simplified reporting tool to support GPs record important information

Reducing inequality

We are committed to advancing equality and reducing health inequalities for the diverse population we serve. Implementation of the Public Sector Equality Duty 2011 forms the foundation of our equality and diversity activities. This Duty stipulates we must have due regard to eliminate discrimination and any other conduct prohibited by the Act, advance equality and foster good relations between one group and another and between the public and the CCG.

We published our first Equality Annual Report since merging as a single organisation, in December 2019. The report charts progress against our equality objectives identified for the period from 2018-2021:

 To improve the use of equality analysis data in our commissioning cycle.  To build strong relationships with protected groups and communities to better understand their needs and improve our equality data.  To promote workforce equality and improve representation through effective employment practices.  To develop inclusive leadership throughout the CCG.

In 2018 we achieved a score of ‘Developing’ following the implementation of the Equality Delivery System2. This is a framework used by NHS organisations to understand their equality performance and main equality challenges, and to outline how they will make improvements. The framework compares a series of specified outcomes for people with protected characteristics against outcomes for all people. We demonstrated leadership commitment towards improving patient experience and outcome and to creating a more inclusive environment for our workforce. Perception around patient engagement was positive and we are taking steps to attract and develop a diverse workforce. You can read more about Equality Delivery System2 in 2018/19 in the our Equality Report https://bnssgccg.nhs.uk/library/bristol- equality-and-diversity-annual-report/)

Our programme for the 2019/20 year included establishing three diversity-related networks (affinity groups) – LGBT+, BAME and an Allies Network. The staff networks have delivered workshops, hosted distinguished external guest speakers and facilitated panel debates. The Proud Network (LGBT+) is an integral part of working towards Stonewall Accreditation. The Attracting & Developing a Diverse Workforce taskforce was set up to help to address under- representation in the workforce, to date they have developed a more values-based recruitment message, and are working with HR to remove barriers to recruitment. The Attracting & Developing a Diverse Workforce taskforce is also setting up a work experience programme, the CCG will have its first cohort of students in the summer of 2020. Improving representation at senior management level is also important and we will partner with Healthier Together to support delivery of the ‘NHS Changing Places’ Non-Executive Director developmental programme. Across the system, we sit on a number of boards including:

 Bristol Race Equality Strategic Leaders Group  Thrive Bristol  Responding to Hate Incident in North Somerset (RHINS) Partnership  North Somerset Council Equality Stakeholder Group  South Gloucestershire Race Equality Network (SGREN)  South Gloucestershire Ageing Better Group  Learning Disability Partnership Board

We have established a framework within our commissioning and policy-making programme to embed inclusion and equity throughout the commissioning cycle. The Joint Impact Assessment Panel was launched in November 2019, the Panel provides guidance, support and quality assurance across equality, quality and patient & public involvement. We continue to use national and local data including Joint Strategic Needs Assessments and Healthwatch data,

and we continue to develop the ground breaking Population Health Management Tool that will bring data together from different organisations, alongside patient/public involvement to help us to make the best decisions that are both values-based and value for money.

Our Governing Body continues to be accountable for ensuring our commitment to equality and diversity is implemented throughout the organisation, and all business is carried out in accordance with our values. Our Governing Body monitors the implementation of our equality and diversity work as part of the annual cycle of Governing Body reporting.

Our leadership team is committed to realising a step change in the equality programme of work that the organisation undertakes. This will include focussing on evidence-into-practice approaches, with CCG-led research, a greater level of partnership working between the CCG and stakeholders, and advances in the use of population health management tools. We will continue to develop innovative approaches to patient and public involvement that enable us to engage with and serve ‘seldom heard’ communities who typically have worse outcomes and reduced access to health and care services. As we progress towards embedding equality, diversity and inclusion throughout the commissioning cycle, we will see more take up of workforce equality training, a focus on developing cultural competence and intelligence, and an emphasis on increasing diverse representation within our workforce and increasing diversity in our engagement channels.

Working with Health and Wellbeing Boards and the Health and Wellbeing Strategies

The three Joint Strategic Needs Assessments set out the current and future health and care needs of our population and inform the three local authorities’ Health and Wellbeing Strategies. We and our local authority partners use the Joint Strategic Needs Assessments and the Health and Wellbeing Strategies to inform and guide how we plan and commission health, wellbeing and social care services across Bristol, North Somerset and South Gloucestershire. We have played an active role with our local Health and Wellbeing Boards for Bristol, North Somerset and South Gloucestershire. We are required to contribute to the delivery of our Joint health and wellbeing strategies under section 116B(1)(b) of the Local Government and Public Involvement in Health Act 2007

The Bristol Health and Wellbeing Board

The Bristol Health and Wellbeing Board set out its plan on a page and performance framework in July 2019 as a foundation for the development of the Health and Wellbeing Strategy, linking to the One City Plan and wider health and care integration plans within Healthier Together.

The gap between the most and least deprived areas in Bristol is 9.5 years for men and 7.4 years for women and the gap in healthy life expectancy ranges from 11 to 31 years for females and 10 to 24 years for males between the least and the most deprived areas. This gap describes the years lived in disability, discomfort or pain. It has an impact on employment, people’s ability to engage in daily life, and the need for health and social care interventions. The Health and Wellbeing Board has therefore agreed to frame the strategy around the opportunities to address the wider social and economic determinants of health, working alongside partners in the City as part of the One City Plan.

The plan on a page sets out the ambition that everyone in Bristol will have the opportunity to live a life in which:

 they are mentally and physically healthy,  mental health is as important as physical health,  health inequalities are reduced, and  children grow up free of adverse childhood experiences, having had the best start in life and support through their life.

The plan sets out six pillars for delivery including:

 Health and wellbeing ambitions set out as part of the One City Plan e.g. reduction in suicides; health in wider determinants such as housing  Delivering prevention, including targets around healthy weight and alcohol admissions  Delivering an integrated care system as part of the Healthier Together plan with a focus on localities and building healthier communities  Joint leadership on oversight health strategy and policy e.g. the implementation of Bristol Thrive as part of the mental health strategy and oversight and assurance to fulfil the Health and Wellbeing statutory role

The newly instituted performance report noted only two areas across a broad range of indicators where sufficient progress has not yet been made, namely reduction in alcohol

related admissions and Type 2 diabetes prevalence. Work is in place to develop and deliver both a healthy weight approach through the Alive and Thrive Programme and a drugs and alcohol strategy.

In pursuit of understanding and linking with other areas of work within the One City Plan, the Board has received reports and held seminars to discuss the impacts of the One City Climate plan and the Housing First Strategy, and discussed the city’s approach to air quality.

The North Somerset Health and Wellbeing Board

Following elections in May 2019, the new North Somerset Council administration decided to set up a new Health & Wellbeing Board (the functions of which had previously been combined with a community safety group). The new Committee, which has met three times to date, has a remit that includes:

 Development, sign-off and monitoring the implementation of the North Somerset Health & Wellbeing Strategy.  Overseeing and advising on the development of the Joint Strategic Needs Assessment (JSNA)  Overseeing development of effective co-production and public involvement and engagement in all areas of the Board's activity  Supporting the development of local joint commissioning arrangements  Strategic coordination of health and wellbeing matters with safeguarding functions, including consideration where appropriate of domestic homicide reviews, Child Death Overview Panel outcomes and serious case reviews  Monitoring and responding to the performance of local health and wellbeing services in the statutory, voluntary and commissioned sectors as well as consider the development and performance of services that impact on the wider determinants of health and wellbeing  Liaison with other Health & Wellbeing Boards across the region in order to share learning, coordinate activity and identify joint commissioning opportunities.

The Health & Wellbeing Board is drawing on the ‘place-based approaches to reducing health inequalities’, working in partnership with Public Health England (PHE), the Local Government Association and the Association of Directors of Public Health.

The Health & Wellbeing Board has reviewed and supported the Healthier Together long-term plan submission and is currently developing a social isolation & loneliness needs assessment and strategy, inputting into the Healthier Together mental health strategy, and developing a local pharmaceutical needs assessment.

The South Gloucestershire Health and Wellbeing Board

The South Gloucestershire Health and Well Being Board, in its joint Health and Wellbeing Strategy 2017/2021, has developed four areas for collective action:

 Improve educational attainment of children and young people, and promote their wellbeing and aspirations.  Promote and enable positive mental health and wellbeing for all  Promote and enable good nutrition, physical activity and a healthy weight for all  Maximise the potential of our built and natural environment to enable healthy lifestyles and prevent disease

In 2019/20 the Board agreed that each member organisation would support the implementation of the collective actions in the following ways:

 Champion a model for promoting and supporting workplace action to promote, protect and improve mental health and wellbeing by signing up to write a Time to Change Action Plan  Contribute data and information to the adult and children and young people mental health and wellbeing scorecards  Engage and contribute to the South Gloucestershire Early Help Review  Commit to the Special Education Needs (SEND) strategy

During 2019/20 the Board had a particular focus on mental health and gave its support for adopting the ‘Thrive’ approach in South Gloucestershire, which is a model that began in New York City and has more recently been brought to the West Midlands, London and Bristol. Thrive takes an area-wide population health and all systems approach to improve mental health and wellbeing.

The Board also received a report on children and young people’s mental health, drawing particular attention to mental health in schools and current gaps in provision. The report discussed the risk factors for poor mental health in children and young people, and the

opportunities to support young people with emerging mental health needs. Board members agreed to commit named senior officers to join discussions about how to address these.

Joint meeting of the Bristol, North Somerset and South Gloucestershire Health & Wellbeing Boards

A number of joint meetings of the Bristol, North Somerset and South Gloucestershire Health & Wellbeing Boards has led to the development of a number of priorities that informed Healthier Together’s Long Term plan response.

Sustainable Development

We have maintained our commitment to ensuring that the services we commission and the way we operate meet our responsibilities for sustainability and our impact on the planet.

Through our partnership working in Healthier Together we are fully engaged with other organisations to make changes to our buildings, services and the behaviours of our staff. In this year, we have formed our Environmental Sustainability Working Group. This Group supports the Healthier Together Sustainability work stream to meet obligations for a greener NHS. As part of Healthier Together we have developed a Climate Change Adaptation Plan, which sits alongside the Healthier Together Estates Strategy. We are partners to Bristol City Council’s declaration of an Ecological Emergency. We are committed to working with all of our local authority partners on their climate change activities.

Our endeavours span the organisation and our workforce benefits from a working environment that supports energy reduction and recycling. Colleagues are also able to benefit from schemes supporting a reduction in the impact of motorised travel, which includes the Cycle to Work Scheme. We have also ensured availability of other resources that promote the use of bicycles, including changing facilities and safe storage, which has been expanded in agreement with our landlord in South Plaza.

We have continued to invest in digital technology to increase efficiency, reduce the need for travel, and enhance resilience. Our workforce policies enable staff to maximise this investment and work flexibly thus reducing individual carbon footprints.

We have responded to the consultation on the proposal by Bristol City Council to reduce emissions in the city centre and will have to address the impact of this on partner NHS organisations in due course.

In 2020/21 we will maintain our commitment to:

 Environmental sustainability

 Being active in our the Healthier Together Partnership  Identifying opportunities for development that are created by collaboration and deliver maximum return to meet the goals stated in our Climate Change Adaptation Plan  Working with the landlord of South Plaza to ensure that planned developments meet our commitments to sustainability  Working with our estate partners NHS Property Services and Community Health Partnership to ensure that buildings are used efficiently

The main energy usage for the administrative offices is shown in Table 7. This is broken down in Table 8 to show the CCG’s estimated apportionments for South Plaza, Castlewood and Badminton Road, which are multiple occupied buildings shared with other organisations. We pay a service charge that includes all aspects of building services and use, including utilities, which are apportioned on the basis of the % of the space the CCG occupies in these buildings. We are therefore unable to provide the detailed breakdown of utility consumption costs as the landlord deems these commercially sensitive.

Table 7

Building Full Consumption (KWH/m2) Cost (£) Property Electricity Gas Water Electricity Gas Water GIA South Plaza 5,155 568,184 741,494 4,004 not not not available available available Castlewood 9,500 2,274,534 3,165,887 9,881 not not not available available available Badminton 10,510 1,128,996 653,007 5,221 not not not Road available available available

Table 8

Building CCG Consumption (KWH/m2) Cost (£) Occupancy Electricity Gas Water Electricity Gas Water GIA South Plaza 905 99,749 130,175 703 not not not available available available Castlewood 174 41,660 57,986 181 not not not available available available Badminton 131 14,112 8,163 65 not not not Road available available available

We expect our acute providers commissioned using the standard NHS contract to have sustainable development management plans in place and use the Good Corporate Citizenship Tool to measure their impact as an organisation on corporate social responsibility.

The carbon emissions data for 2019/20 for University Hospitals Bristol and North Bristol Trusts is not yet available to include in our sustainability report, but will be ready for review in their own annual reports for 2019/20. In the past year University Hospitals Bristol and North Bristol Trusts declared a climate emergency. The declaration gives a clear and positive commitment to tackling climate change and its effects on our pollution. The Trusts pledged to act on:

 Reducing single use plastics across the Trusts (eg wards, operating theatres and catering services)  Recycling and waste disposal  Greenhouse gas impact of anaesthetics  Energy for heating and lighting  Sustainable energy sources  Water use  Vehicle emissions from staff and patient travel and goods deliveries  Sustainable food services  Encourage staff, patients and local residents to live healthier, greener lives

Actions taken include:

 Reducing use of Desflurane, an anaesthetic gas which has a much greater environmental impact than alternatives  Reducing car journeys via lift-share, walking and cycle-to-work schemes for staff  Patients being discharged from the Trusts at risk of further illness from cold or damp homes will be referred for home energy efficiency measures such as central heating, draught-proofing and insulation  Improvements to lighting and heating to reduce carbon emissions at hospitals run by University Hospitals Bristol  Electric bikes are used by the Early Supported Discharged Team at South Bristol Community Hospital to visit stroke patients across the City and into North Somerset at home to provide therapy  A range of nature initiatives at Southmead Hospital including wildflower planting, bird boxes, ponds, and insect hotels and home-made lavender bags for patients  Sustainable food at Southmead Hospital including locally sourced, seasonal food for patients and staff, a weekly organic veg stall open to the public and staff allotments

ACCOUNTABILITY REPORT

Julia Ross

Chief Executive

24th June 2020

Corporate Governance Report

Members Report

Bristol, North Somerset and South Gloucestershire CCG is responsible for planning and commissioning health services for its local population. We were established by NHS England on 1st April 2018 and we operate in accordance with our Constitution. Our Governing Body is made up of local GPs, other clinicians, lay members, and executive directors. Our Chair is Dr Jonathan Hayes.

We are a clinically led membership organisation. Our member practices provide primary care services across Bristol, North Somerset and South Gloucestershire and are organised into six commissioning locality groups described in the Performance section of this report.

Our GP practices are listed by Locality below:

Locality Commissioning Group Practice Air Balloon Surgery Beechwood Medical Practice Broadmead Medical Centre Charlotte Keel Medical Practice Eastville Medical Practice Fireclay Health Inner City and East Bristol Fishponds Family Practice Commissioning Locality Group Compass Health (Homeless Health Service) Lawrence Hill Health Centre Maytrees Medical Practice Montpelier Health Centre The Old School Surgery The Wellspring Surgery Fallodon Way Medical Centre

The Family Practice Gloucester Road Medical Centre Greenway Community Practice Helios Medical Centre North and West Bristol Horfield Health Centre Commissioning Locality Group Monks Park Surgery Pembroke Road Surgery Pioneer Medical Group Sea Mills Surgery Shirehampton Group Practice

Southmead and Henbury Family Practice Students' Health Service Westbury on Trym Primary Care Centre Whiteladies Medical Group Armada Family Practice Bedminster Family Practice Birchwood Medical Practice Bridge View Medical Crest Family Practice Grange Road Surgery Bristol South Commissioning Locality Hartwood Healthcare Group Hillview Family Practice Lennard Surgery Merrywood Practice Nightingale Valley Practice Priory Surgery Stockwood Medical Centre Wells Road Surgery Almondsbury Surgery Bradley Stoke Surgery Cadbury Heath Health Centre Close Farm Surgery Concord Medical Centre Coniston Medical Practice Courtside Surgery South Gloucestershire Downend Health Group Commissioning Locality Group Emersons Green Medical Centre Severn View Family Practice Frome Valley Medical Centre Hanham Health Kennedy Way Surgery Kingswood Health Centre Leap Valley Surgery The Orchard Medical Centre Pilning Surgery St Mary Street Surgery Stoke Gifford Medical Practice Streamside Surgery Three Shires Medical Practice Wellington Road Family Practice West Walk Surgery Clevedon Medical Centre Harbourside Family Practice Woodspring Commissioning Locality Heywood Family Practice Group Mendip Vale Medical Group Tyntesfield Medical Group Portishead Medical Group The Cedars Sugery

Horizon Health (Locality Health Centre, and Clarence Park Practices) Graham Road Longton Grove Weston, Worle and Villages The Milton Surgery Commissioning Locality Group New Court Surgery Stafford Medical Group Tudor Lodge Winscombe and Banwell Practices

Our Governing Body is responsible for discharging the functions conferred on to it by legislation and through our Constitution. Our Governing Body met for the first time in April 2018; details of attendance throughout the year are provided in our Governance Statement. During 2018/19, and up to the signing of this annual report and accounts, our Governing Body members were:

Name Title Tenure in 2019/20 Jon Hayes Clinical Chair 2019/20 Kirsty Alexander GP Locality Representative 2019/20 Bristol North and West Janet Baptiste Interim Director Nursing and Jan 2019 Sep 2019 Grant Quality Peter Brindle Medical Director Clinical 2019/20 Effectiveness Colin Bradbury Area Director North Somerset 2019/20 John Cappock Lay Member Finance May 2019 to present Deborah El-Sayed Director of Transformation 2019/20 Jon Evans GP Locality Representative South 2019/20 Gloucestershire Felicity Fay GP Locality Representative South 2019/20 Gloucestershire Kevin Haggerty GP Locality Representative North 2019/20 Somerset Weston and Worle, Brian Hanratty GP Locality Representative 2019/20 Bristol South David Jarrett Area Director South 2019/20 Gloucestershire Martin Jones Medical Director Commissioning 2019/20 and Primary Care Nick Kennedy Independent Secondary Care 2019/20 Doctor Rachael Kenyon GP Locality Representative North 2019/20 Somerset Woodspring Lisa Manson Director of Commissioning 2019/20 Alison Moon Independent Registered Nurse 2019/20 Justine Rawlings Area Director Bristol 2019/20 Julia Ross Chief Executive 2019/20 John Rushforth Deputy Chair, Lay Member Audit 2019/20 and Governance

Rosi Shepherd Director Nursing and Quality Jan 2020 to present David Soodeen GP Locality Representative 2019/20 Bristol Inner City and East Sarah Talbot- Lay Member Patient and Public 2019/20 Williams Involvement Julie Thallon Interim Director Nursing and Sept 2019 – Dec 2019 Quality Sarah Truelove Chief Financial Officer 2019/20 [non-voting executive directors shaded]

Our Governing Body committees include:

 Audit, Governance and Risk  Remuneration  Primary Care Commissioning  Commissioning Executive  Strategic Finance  Quality  Patient and Public Involvement Forum

Details of the membership of our Governing Body committees and attendance, including the Audit, Governance and Risk Committee, are provided in the Governance Statement in this report. Further information about our Remuneration Committee can be found in the Remuneration Report in this report. Details of the declared interests of our Governing Body members and the members of Governing Body committees can be found at https://bnssgccg.nhs.uk/library/bnssg-ccg-register- interests/

Personal data related incidents

All Information Governance incidents are assessed in line with the NHS Digital “Guide to the Notification of Data Security and Protection Incidents”. We reported one incident to the Information Commissioner’s Office (ICO) during 2019/20. The incident involved potential inappropriate access to an email account. We completed an investigation and reported our findings to the ICO including our recommended remedial actions. The ICO has confirmed that there is no further action to take and that we are completing the right activities to address the root cause. Controls have been developed and implemented. The CCG’s Information Governance Group is routinely updated on any issues and remedial activities with learning cascaded to Information Asset Owners and materials published for staff.

Statement of Disclosure to Auditors

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

 so far as the member is aware, there is no relevant audit information of which the CCG’s auditor is unaware that would be relevant for the purposes of their audit report  the member has taken all the steps that they ought to have taken in order to make him or herself aware of any relevant audit information and to establish that the CCG’s auditor is aware of it.

Modern Slavery Act

Bristol, North Somerset and South Gloucestershire CCG fully supports the Government’s objectives to eradicate modern slavery and human trafficking but does not meet the requirements for producing an annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act 2015.

Statement of Accountable Officer’s Responsibilities

The National Health Service Act 2006 (as amended) states that each Clinical Commissioning Group shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed the Chief Executive to be the Accountable Officer of NHS Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group.

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

 The propriety and regularity of the public finances for which the Accountable Officer is answerable,  For keeping proper accounting records (which disclose with reasonable accuracy at any time the financial position of the Clinical Commissioning Group and enable them to ensure that the accounts comply with the requirements of the Accounts Direction),  For safeguarding the Clinical Commissioning Group’s assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities),  The relevant responsibilities of accounting officers under Managing Public Money,  Ensuring the CCG exercises its functions effectively, efficiently and economically (in accordance with Section 14Q of the National Health Service Act 2006 (as amended)) and with a view to securing continuous improvement in the quality of services (in accordance with Section 14R 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

87 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 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 disclosures set out below 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.

Disclosures:

 Our External Auditor has issued a section 30 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.

Governance Statement

Introduction and context

Bristol, North Somerset and South Gloucestershire CCG is a body corporate established by NHS England on 1 April 2018 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 2020, the clinical commissioning group is not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006.

Scope of responsibility

As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the clinical commissioning group’s policies, aims and objectives, whilst safeguarding the public funds and assets for which I am personally responsible, in accordance with the responsibilities assigned to me in Managing Public Money. I also acknowledge my responsibilities as set out under the National Health Service Act 2006 (as amended) and in my Clinical Commissioning Group Accountable Officer Appointment Letter.

I am responsible for ensuring that the clinical commissioning group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. I also have responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group as set out in this governance statement.

Governance arrangements and effectiveness

The main function of the Governing Body is to ensure that the group has made appropriate arrangements for ensuring that it exercises its functions effectively, efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it.

Our Constitution sets out the CCG’s roles and responsibilities for commissioning healthcare for patients within the Bristol, South Gloucestershire and North Somerset area. We describe in our Constitution our governing principles, and the rules and procedures we have in place to ensure probity and accountability in our day to day running; to ensure that decisions are taken in an open and transparent manner and that the interests of patients and the public remain central to our aims. Our Constitution is available on our website.

Bristol, North Somerset and South Gloucestershire CCG is a membership organisation. Our members include all providers of primary medical care services to the registered list of patients, under a General Medical Services (GMS), Personal Medical Services (PMS) or Alternative Provider Medical Service (APMS) contract. Our Constitution includes details of our membership and is available on our website https://bnssgccg.nhs.uk/library/bristol-north-somerset-and-south-gloucestershire-ccg- constitution/. We have six localities across our area:

 Inner City and East (ICE) Bristol

 North and West Bristol

 South Bristol

 Weston, Worle and Villages

 Woodspring

 South Gloucestershire

Each Locality has a Locality Commissioning Membership Forum where the GPs in each locality meet to discuss key commissioning matters, and a Locality Commissioning Leadership Group. Our member practices each send an appointed representative to relevant locality meetings. Our members are collectively responsible for agreeing the CCG’s Constitution and the governance arrangements it

90 describes, including the responsibilities of the Governing Body and its members’ terms of office.

We use our Internal Audit function to independently audit our governance arrangements and check that we are compliant with legal requirements and good practice.

The Governing Body

The main function of the Governing Body is to ensure that appropriate arrangements have been made for ensuring the CCG exercises its functions effectively, efficiently and economically, and that we comply with principles of good governance. Our Governing Body membership includes local GPs, three independent lay members, an independent secondary care doctor, an independent nurse and the CEO and CFO. All directors attend Governing Body meetings but do not have voting rights. A full list of members can be found on our website https://bnssgccg.nhs.uk/about- us/our-governing-body/ and the membership and attendance at meetings during 2019/20 is at table x. The Governing Body meets monthly in public, and papers and minutes of meetings are available on our website https://bnssgccg.nhs.uk/events/ . The Governing Body met 12 times during 2019/20 and was quorate for each meeting.

The Governing Body is responsible for:

 Approving any functions of the CCG that are specified in regulations

 Setting out of the vision and strategy of the CCG

 Signing off the annual commissioning plan which sets out how it proposes to discharge its financial duties.

 Monitoring performance against plan

 Receiving assurance against strategic risks

 Receiving assurances about the quality of commissioned services

 Ensuring engagement with members, the public and partners

 Determining the remuneration, fees and other allowances payable to employees or other persons providing services to the CCG and the allowance payable under any pension scheme it may establish

Governing Body Sub Committees

A number of committees of the Governing Body have been established and these are listed below with a summary of their purpose and functions. The Terms of Reference of these committees can be found at https://bnssgccg.nhs.uk/about- us/constitution-and-governance-handbook/ The Governing Body receives the minutes of the committees and these are available on our website at https://bnssgccg.nhs.uk/events/

Audit, Governance and Risk Committee

The Audit, Governance and Risk Committee is accountable to the Governing Body and provides an independent objective view of and assurance on our controls and governance arrangements. The Committee is responsible for the oversight of financial reporting and disclosure. The Audit, Governance and Risk Committee is chaired by a lay member who is a qualified accountant and with experience at Director of Finance level. Membership of the Committee and attendance at meetings are detailed in table 9.

The Audit, Governance and Risk Committee provides assurance to the Governing Body that an appropriate system of internal control is in place, so that:

 We conduct our business in accordance with the law and proper standards

 Public money is safeguarded and properly accounted for

 Financial statements are prepared in a timely fashion and give a true and fair view of the financial position for the period in question

 We secure economic, efficient and effective use of resources

 Adequate arrangements are in place and that reasonable steps are taken to prevent and detect fraud and other irregularities

During 2019/20 the Committee reviewed a number of internal audit reports and action plans; these are listed in the Head of Internal Audit Opinion section of this Governance Statement. In addition, the Committee has oversight of and receives regular reports on:

 Counter fraud

 The management of interests including gifts and hospitality

 The management of Freedom of Information requests

 Waivers of standing orders and standing financial instructions

Remuneration Committee

The Remuneration Committee is accountable to the Governing Body and makes recommendations about the remuneration fees and other allowances (including pension schemes) for employees and other individuals who provide services to the CCG. Our Remuneration Committee is chaired by the Governing Body Lay Member for Patient and Public Involvement. The full remuneration report can be found in the Annual Report. Membership of the Committee and attendance are detailed in table 9.

Primary Care Commissioning Committee

As a CCG with delegated authority for the commissioning of primary care we have established a committee that oversees the contracting of primary care services within the context of the CCG strategic plan. The Committee is chaired by the Independent Registered Nurse Member of the Governing Body. Membership and attendance at meetings are detailed in table 9. The Committee receives monthly reports on primary care contracts, quality and financial performance. Contract reports cover all core contracts and performance relating to improved access and enhanced services. Contractual changes, including requests for mergers, boundary applications and temporary closures are considered by the Committee. Reports on primary care quality include regular ‘deep dives’ in key aspects of quality. The Primary Care Commissioning Committee holds its meetings in public and the papers for these meetings are available on our website. Our Internal Auditors gave our Primary Care delegated commissioning arrangements an audit opinion of reasonable assurance.

Commissioning Executive

The Commissioning Executive is accountable to the Governing Body. The Committee’s remit includes development of the CCG’s commissioning strategy and operational plan, and the CCG’s procurement strategy. The Committee considers plans for the procurement of new services and disinvestment from existing services making, recommendations to the Governing Body where necessary. The Committee

93 considers commissioning policies and individual funding policies and procedures, making recommendations to the Governing Body where appropriate. The Committee reviews provider performance against contracts, agreeing actions to be taken and monitoring improvement. The Committee’s membership is primarily made up of CCG Clinical Leads and executive team. Attendance at meetings is detailed in table x. During 2019/20 the Committee received monthly reports on urgent care and the schemes established to support performance, Individual Funding Requests and the Corporate Risk Register and Governing Body Assurance Framework. The Committee received regular reports on patients waiting over 52 weeks, mental health and the review of Continuing Healthcare. The minutes of the Committee are available on our website (https://bnssgccg.nhs.uk/events/).

Quality Committee

The Quality Committee is chaired by the Independent Registered Nurse Governing Body Member and is accountable to the Governing Body. The Committee is responsible for ensuring that there is a cohesive and comprehensive structure in place for the oversight and monitoring of the quality of commissioned services, including patient safety, safeguarding children and young people and vulnerable adults and patient experience. This includes performance against NHS Constitution Standards. The Committee provides the Governing Body with assurance that CCG quality system and processes are robust, that commissioned services are being delivered in a high quality and safe manner, and that all relevant statutory and regulatory obligations are met. The Committee provides assurance that effective processes are in place for safeguarding children, young adults and vulnerable people. The Committee considers the CCG Improvement and Assessment Framework Clinical Indicators and assures plans to improve performance against clinical priority areas. The membership and attendance at meetings are detailed in table 9.

During 2019/20 the Committee received monthly reports from the Quality Surveillance Group, provider organisation risk registers, quality and performance, the Corporate Risk Register and the Governing Body Assurance Framework. Quarterly reports on Safeguarding for both Children and Adults, Looked After Children were received. Other quarterly reports included patient experience reports, primary care quality reports, Individual Funding Requests, Serious Incident reports, and

Healthcare Acquired Infections. Regular reports were received focusing on mental health service provider quality assurance, Healthcare Acquired Infections, South West Ambulance Service performance, the review of Continuing Healthcare, Serious Case reviews and Domestic Homicide Reviews, Learning Disability Mortality Review reports, SEND activities, care home quality, updates on Contract Performance Notices, workforce assurance reports, and reports on the Improvement and Assessment Framework. The minutes of the Committee are available on our website (https://bnssgccg.nhs.uk/events/).

Strategic Finance Committee

The Strategic Finance Committee is accountable to the Governing Body. The Committee considers all draft strategic and financial plans prior to their submission to the Governing Body for approval, including the financial plans associated with the CCG’s Operational Plan and savings plans. The Committee monitors the longer term financial strategic direction of the CCG, the delivery of savings plans and the CCG’s in year financial performance, identifies key issues and risks requiring discussion and decision by the Governing Body. The Committee has oversight of procurements. During 2019/20 the Committee received monthly reports on the financial position, the Financial Recovery Plan which included Control Centre deep dives, procurement plans and the Corporate Risk Register and Governing Body Assurance Framework. The membership and attendance at meetings are detailed in table 9. The minutes of the Committee are available on our website (https://bnssgccg.nhs.uk/events/).

Patient and Public Involvement Forum

The Patient and Public Involvement Forum is a committee of the Governing Body. Its role is to champion robust and meaningful patient and public involvement underpinned by principles of equality and inclusion. The Forum also maintains oversight and provides advice regarding the CCG’s statutory responsibilities for Patient and Public Involvement. The membership and attendance at meetings are detailed in table x. During 2019/20 the Forum received updates from the Locality Area Leads and engagement plans.

(table 9) Attendance at Governing Body Meetings and its number of meetings attended in 2019/20 Committees Name Title GB Audit Rem Com Quality SFC PCCC PPIF Exec Dr Jonathan Hayes Clinical Chair, 11/12 10/11 2/12 Chair of Commissioning Executive Dr Kirsty Alexander GP Locality Representative Bristol 11/12 10/10 North and West Janet Baptiste- Grant Interim Director Nursing and Quality 5/6 5/5 April 2019 - August 2019 Colin Bradbury Area Director North Somerset 11/12 7/11 9/10 3/4 Dr Peter Brindle Medical Director Clinical Effectiveness 9/9 9/11 9/12 John Cappock Lay Member, Chair of Strategic 8/11 3 /4 0/0 10/12 Finance Committee May 2019 – present Deborah El-Sayed Director of Transformation 10/12 5/11 1/4 Dr Jon Evans GP Locality Representative South 11/12 6/11 0/4 Gloucestershire Dr Felicity Fay GP Locality Representative South 11/12 Gloucestershire Dr Kevin Haggerty GP Locality Representative Weston 9/12 9/11 and Worle Dr Brian Hanratty GP Locality Representative Bristol 11/12 South David Jarrett Area Director South Gloucestershire 9/12 9/11 9/10 1/4 Dr Martin Jones Medical Director Commissioning and 11/12 9/11 5/12 10/11 Primary Care Dr Nick Kennedy Independent Secondary Care Doctor 11/12 4/4 1/1 9/12 Dr Rachael Kenyon GP Locality Representative 12/12 1/4 Woodspring Lisa Manson Director of Commissioning 12/12* 10/11* 9/12 11/11*

Alison Moon Independent Registered Nurse, Chair 11/12 1/1 11/12 11/11 of PCCC and Quality Committee Justine Rawlings Area Director Bristol 11/12 9/11 6/10 3/4 Julia Ross Chief Executive 12/12 7/11 9/12 10/11 John Rushforth Lay Member, Chair of Audit 10/12 4/4 1/1 10/12 9/11 Governance and Risk Committee Rosi Shepherd Director Nursing and Quality - 4/4 1/2 5/6 2/3* January 2020 - present David Soodeen GP Locality Representative Bristol 11/12 10/11 Inner City and East Sarah Talbot Williams Lay Member, Patient and Public 11/12 1/1 8/12 8/11 4/4 Involvement Chair of Remuneration Committee, Patient and Public Involvement Forum Julie Thallon Director Quality - October 2019 – 2/2 3/3* 1/1 2/2 January 2020 Sarah Truelove Chief Financial Officer 10/12 11/11 10/12 11/11* Alison Bolam Clinical Commissioning Area lead – 11/11 1/4 Bristol Jeremy Maynard Clinical Corporate Lead – Quality 5/9 4/9 April 2019-January 2020

Shabi Nabi Clinical Corporate Lead - Prescribing 8/11

Geeta Iyer Clinical Corporate Lead - Primary Care 11/11 Provider Development

Andrew Appleton Clinical Corporate Lead - Digital 8/11

David Peel Clinical Care Pathway Lead - Planned 6/11 Care

Lesley Ward Clinical Care Pathway Lead - 10/11 Unplanned Care

Michael Jenkins Clinical Care Pathway Lead - 6/11 Integrated Care

Alison Wint Clinical Care Pathway Lead - 8/11 Specialised Care

Sara Blackmore Director of Public Health, South 5/11* Gloucestershire Council

Mat Lenny Director of Public Health North 1/1 Somerset Christina Gray Director of Public Health Bristol 5/8 Andrew Burnett Interim Director Public Health North Somerset Or nominated deputy *

Annual Assessment of Committee Effectiveness

Our Governing Body committees carry out an annual assessment of effectiveness using a self-assessment checklist. Actions arising from the 2018-19 review included the addition of an item for all committee agendas looking at the effectiveness of the meeting. The Primary Care Commissioning Committee reviewed the frequency of meetings and established a seminar programme and committee work programme following its effectiveness review. Actions arising from the 2019-20 self-assessment will be included in the Committee work plans for 2020-21.

UK Corporate Governance Code

While the detailed provisions of the UK Corporate Governance Code are not mandatory for public sector bodies, compliance is considered to be good practice. We have reported on our corporate governance arrangements by drawing upon best practice available, including those aspects of the UK Corporate Governance Code we consider to be relevant to the CCG.

Discharge of Statutory Functions

In light of recommendations of the 2013 Harris Review, the CCG 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. The CCG is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions.

Responsibility for each duty and power has been clearly allocated to a lead officer. Officers have confirmed that their structures provide the necessary capability and capacity to undertake all of the CCG’s statutory duties, supported where appropriate by resources commissioned from South Central and West Commissioning Support Unit (SCWCSU).

Risk management arrangements and effectiveness

Our Risk Management Framework defines the structures for the management and ownership of risk. It encapsulates our attitude to risk and defines how risks are dealt

99 with and by whom. The Framework is updated annually and was last updated in July 2019 and approved by the Governing Body.

Integrated governance including financial governance is assured the Audit, Governance and Risk Committee and the Governing Body. The Governing Body receives the minutes of all of its committees, including the Audit, Governance and Risk Committee.

We have in place a Risk Appetite Statement, which was signed off by the Governing Body as part of the Risk Management Framework in July 2019.

“We recognise that decisions about our level of exposure to risk must be taken in context. We are committed, however, to a proactive approach and will take risks where we are persuaded that there is potential for benefit to patient outcomes/experience, service quality and/or value for money. We will not compromise patient safety; where we engage in risk strategies we will ensure they are actively monitored and managed. We will not hesitate to withdraw our exposure if benefits fail to materialise.”

“Our risk appetite takes into account our capacity for risk, that is, the amount of risk we are able to shoulder before we breach our statutory obligations and duties. Our capacity for risk is also delineated by the risks our stakeholders are willing to bear.”

“Our risk appetite statement is dynamic and its drafting is an iterative process that reflects the challenging environment facing the CCG and the wider NHS. We will review our risk appetite statement at least annually.”

The Governing Body Assurance Framework identifies where there are risks to our principal objectives, the controls in place to mitigate those risks, and the assurances available to the Governing Body that risks are being managed. The Governing Body Assurance Framework indicates where there are potential gaps in controls and assurances and provides a summary of the actions in place to resolve these gaps. Our Governing Body Assurance Framework is reviewed by Directors and is considered by the Governing Body committees as a standing item at their monthly meetings. The Audit, Governance and Risk Committee reviews the Governing Body Assurance Framework at its meetings. The Primary Care Commissioning Committee and the Governing Body review the Governing Body Assurance Framework quarterly.

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Risks are identified in a number of ways, including risk profiling through our programme management approach, incident reporting, complaints and litigation, data analysis, staff concerns/whistle blowing, and external and internal audit reports and other regulatory reporting mechanisms.

Risks are evaluated and assessed using a risk scoring matrix which is set out in our Risk Management Framework. Risk is reported through our Directorate and Corporate Risk Registers. Our Corporate Risk Register holds risks that have reached the CCG’s risk threshold of 15 and above. It is reviewed by Directors and is considered by the Governing Body committees as a standing item at their monthly meetings. The Audit, Governance and Risk Committee reviews the Corporate Risk Register at its meetings, the Primary Care Commissioning Committee, and the Governing Body review the Corporate Risk Register quarterly.

The assessment of risk is embedded within the reporting arrangements for the Governing Body and its committees as part of our standard template, which requires risks to be highlighted. Equality Impact Assessments are used to assist with the identification and mitigation of risks linked to inequalities. Equality Impact Assessments also form part of the standard template for papers to our Governing Body and committees.

There is a process in place for the reporting, investigation, management and learning from incidents. All serious incidents and risks are reported through incident reporting procedures, and the Risk Management Framework refers to our incident reporting procedures and Serious Reporting Policy. Incident reports and trends are used to identify risks, and this is detailed in the Risk Management Framework.

There is commitment to involving patients and members of the public at every stage of the commissioning cycle and this ensures ongoing opportunities for public stakeholders to highlight relevant risks and engage in discussions around how to mitigate them.

In support of the Risk Management Framework and Policy the CCG has adopted policies that describe our arrangements for managing conflicts of interest and gifts and hospitality, and our approach to tackling fraud and bribery. We have agreed detailed financial policies and have in place a Fraud and Bribery Policy.

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Capacity to Handle Risk

It is the policy of the CCG to identify, minimise, control and, where possible, eliminate risks that may have an adverse impact on patients, staff and the organisation. As Accountable Officer, I carry ultimate responsibility for all risks within the CCG.

Our Risk Management Framework describes our governance structures and the responsibilities for risk management within the organisation. The Risk Management Framework requires the identification, management and minimisation of events or activities which could result in unnecessary risks to patients, staff, visitors and members of the public. The CCG is committed to possessing the attributes associated with an active learning organisation where lessons learned are embedded into the organisation’s culture and practice. The Risk Management Framework is available on our website https://bnssgccg.nhs.uk/library/risk- management-framework/.

The responsibility for risk management sits with me and the Deputy Chief Executive and Chief Finance Officer who takes an active role in managing risk and provides challenge and oversight.

Risk is monitored through a structured reporting cycle. The Governing Body receives monthly reports on performance and quality, and finance. These reports provide timely, accurate data which supports our Governing Body in the assessment of risks to our compliance with statutory obligations. The Governing Body Assurance Framework and the Corporate Risk Register are reviewed by the Primary Care Commissioning Committee and the Governing Body quarterly. The Governing Body is supported in its monitoring of risk by the Audit Governance and Risk, Quality Committee, Strategic Finance Committee, and Commissioning Executive. Governing Body’s regular review and interrogation of these reports and other ad hoc reports enable it to have a robust and rigorous oversight of performance.

Staff are required to undertake training for the management of risk where relevant. In addition to core risk management training, training sessions are held and e-learning is available for key topics such as health and safety, manual handling, basic life support, infection control, fire safety, conflict resolution and information governance. Our employees must attend the courses or undertake e-learning on an annual, bi-

102 annual, or three-yearly basis, as appropriate to their role. Learning is taken from good practice, performance management, continuing professional development where relevant, audit and the application of evidence based practice.

Risk Assessment

Our risk assessment and management process, as described above, is set out in the diagram below

Establish Goals & Context

Identify Risks

Analyse Risks

Likelihood x impact

Review / Monitor

Evaluate the Risks

Stakeholder Consultation / Communication / Consultation Stakeholder Treat the Risks

Review

AS/NZS 4360:2004

Major risks to governance, risk management and internal control in 2019/20 that have affected the CCG and details of how these have been managed are detailed below and at page 103 ‘Control Issues’:

Mental health: we recognise the importance of commissioning resilient and effective mental health services for our population and set this as one of our principal objectives for 2019/20. We worked with commissioning partners to support our core mental health provider Avon and Wiltshire Partnership Trust. We established a new IAPT service for our population, to ensure a consistent service offer across Bristol, North Somerset and South Gloucestershire and worked with the new provider to reduce the backlog of referrals. Working with people with lived experience, carers

103 and partners we co-produced an all-age mental health strategy that will take our plans for mental health services forward.

Urgent and Emergency Care: We reported risks of potential patient harm arising from failure to recovery performance against A&E targets. We worked on plans across our system to improve performance and the progress made on the Healthy Weston programme, locality development and the model for community health services have set strong foundations for 2020/21.

Planned care risks related to the number of patients waiting for planned care reported in 2018/19 continued in 2019/20. We worked with individual providers to reduce the number of patients waiting over 52 weeks for planned treatment and looked at improving diagnostic services for patients.

Preparing for the UK exit from Europe across the system. Throughout 2019/20 risks relating the potential for a no-deal exit from Europe were reported alongside the mitigations focusing on the key work streams identified nationally.

Patients were at risk of potential harm through contracting Healthcare Associated Infections: a detailed analysis of all cases of Clostridium Difficile and MRSA is carried out with GPs involved in the review of all community assigned cases of C.fi. The CCG has established a HCAI Group with partner organisations and separate task and finish groups have been established to focus on key issues. There has been a reduction in the number of cases of Clostridium Difficile and MRSA; the number of E.coli cases reported has increased across all Trusts.

In March 2020 a new risk, that the focus on the NHS response to the Covid-19 pandemic would impact on the delivery of our plans for 2020/21 and beyond was reported. Arrangements were established for the management of the local system response to free up the maximum possible inpatient and critical care capacity, ensure CCG business critical functions remained operational and support staff to enable effective remote working, maximising their availability. An Incident Control Centre (Silver) was established with underpinning work streams focused on priority areas.

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Other sources of assurance

Internal Control Framework A system of internal control is the set of processes and procedures in place in the clinical commissioning group to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.

The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness.

Our system of internal control is described through our Standing Orders, Scheme of Preservation and Delegation and Detailed Financial Policies. These ensure compliance with our statutory requirements for the management of governance. Internal audit and the counter-fraud service provide an independent review of our internal controls.

The risk assessment component of our internal system of control is contained in our Risk Management Framework and Policy. The Governing Body Assurance Framework provides an overview of controls and assurance in place to achieve the CCG’s principal objectives.

Our Governing Body has a clear understanding of the key pressures facing the organisation. A key element of our control is providing assurance through regular reporting to the Governing Body, which includes a range of reports including but not limited to:

• Audit and assurance reports

• Minutes of committees of the Governing Body and other key groups

• Strategic planning

• Reports on patient safety and quality of clinical care

• Performance management

• Financial management

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Our procurement activities are carried out within the framework of control set out in legislation and regulation. The CCG has a range of policies relating to information governance, human resources, health and safety, equalities and diversities, and emergency preparedness and resilience, all of which contribute to the internal control framework.

As Accountable Officer I am responsible for reviewing the effectiveness of the system of control and for providing leadership and direction to staff. Other members of the executive team have lead responsibility for the specific systems of control as set out below:

Deputy Chief Executive/Chief Finance Officer:

 Governance framework and risk management framework,

 Financial controls and financial risk

 Management of information governance and related risks as the Senior Information Risk Officer (SIRO)

Director of Nursing and Quality:

 Quality of commissioned services

 Patient safety and safeguarding

 Customer experience and complaints

The Director of Commissioning:

 Arrangements for commissioning of services, including procurement

 Performance of commissioned services

The role of all of our Executive Directors is to ensure that appropriate arrangements and systems are in place so that risks are:

 identified and assessed

 eliminated or reduced to an acceptable level

 effectively managed

Executive Directors ensure that staff comply with our policies and procedures and statutory as well as regulatory requirements.

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Our Internal Auditors completed an Assurance Map for the CCG in December 2019. This map identifies the key sources of assurance that inform the Governing Body of the effectiveness of how key strategic risks are managed and mitigated and of the key controls and processes that are relied on to manage risks.

Annual audit of conflicts of interest management The revised statutory guidance on managing conflicts of interest for CCGs (published June 2016) requires CCGs to undertake an annual internal audit of conflicts of interest management. To support CCGs to undertake this task, NHS England has published a template audit framework.

I can confirm that the annual internal audit of Conflicts of Interest has been completed and the CCG received an assurance rating of ‘Substantial’. There were no areas where the CCG was found to be either partially compliant or non-compliant. The recommendations made were risk rated as low priority:

 The Corporate Services team will escalate out of date conflicts of interest training data to directorate leads, with the requirement for completion by 31 January 2020.

 When reporting training compliance, the Corporate Services team will provide adequate explanation or adjustment to account for staff on long-term sick, maternity leave etc.

 Where audits are completed, the Corporate Services team will check the form against company’s house (or other data sources available) to gain further assurance of the form’s accuracy.

 Each procurement programme will check its register against the CCG main Conflicts of Interest Register to reconcile declared interests.

Actions have been taken to address these recommendations.

Data Quality The information used by the Governing Body and its Committees enables the CCG to carry out its responsibilities and discharge its statutory functions. Information is strategic operational, financial, or relates to performance, quality and patient experience. The Governing Body and its Committees are engaged in a continuous cycle of improvement with regard to the quality of the information received. The

107 reports received have undergone regular review and improvement. The Governing Body has found the quality of data to be acceptable. No risks relating to the quality of data were highlighted in 2019/20.

Information Governance The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an information governance toolkit and the annual submission process provides assurances to the clinical commissioning group, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively. The Data Security and Protection Toolkit for 2019/20 was successfully completed with the status of ‘Standards Exceeded’. An independent assessment of the Data Security and Protection Toolkit for 2019/20 was undertaken on behalf of NHS Digital as part of a pilot. Four out of ten areas were found to have moderate assurance leading to an overall rating of moderate for the level of confidence. All areas will be reviewed for the 2020/21 toolkit submission.

We place high importance on ensuring there are robust information governance systems and processes in place to help protect patient and corporate information. We have established an Information Governance Management Framework and have developed information governance processes and procedures in line with the Information Governance Toolkit. We have ensured all staff undertake annual information governance training and have implemented a staff information governance handbook to ensure staff are aware of their information governance roles and responsibilities.

Information risk management is considered to be the responsibility of all staff. Our Chief Financial Officer is the Senior Information Risk Owner and is responsible for providing assurance to the Governing Body and to me regarding Information Governance. The Senior Information Risk Owner is familiar with, and takes ownership of, information risk management, acting as advocate for Information Risk Management on the Governing Body. The Medical Director of Commissioning and Primary Care is our Caldicott Guardian, actively supporting the CCG and enabling information to be shared where appropriate.

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There are processes in place for incident reporting and the investigation of serious incidents and this encompasses information governance. The NHS Digital checklist guidance for reporting, managing and investigating information governance serious incidents is used in the investigation of any information governance related incidents.

Business Critical Models I confirm that an appropriate framework and environment is in place to provide quality assurance of business critical models, in line with best practice recommendations of the 2013 MacPherson review into the quality assurance of analytical models.

Third party assurances The CCG purchases services from the South Central and West Commissioning Support Unit. These services include HR, procurement, IT, and information governance support. Independent assurances on these services are provided through service auditor reports. Day to day assurance of the above services is achieved through regular performance meetings attended by senior members of staff from both organisations. The Service Auditor Reports are shared with the CCG’s Chief Financial Officer and reviewed and reported through the Audit, Governance and Risk Committee via the Internal Auditors. The Internal Auditor reviewed:

 The Service Auditor Report from the internal auditors of NHS Shared Business Services who provide services to the CCG. No exceptions were noted and there was therefore no negative impact on the control environment.

 The Service Auditor Report from the internal auditors for the South Central and West Commissioning Support Unit covering financial and payroll services. Whilst a number of exceptions were identified as part of the review, there was nothing of sufficient significance to undermine the Head of Internal Audit overall opinion for the CCG.

 The Service Auditor Report from the internal auditors for NHS Digital in regards to GP Payments. Testing for one of the controls identified an exception but there was no significant impact for the CCG on its overall control environment.

 Tthe Service Auditor Report from the internal auditors for NHS Business Services Authority in regards to prescription payments. Exceptions were identified on

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testing for three of the controls although there was no significant impact for the CCG on its overall control environment.

Capita Business Services Limited provides Primary Care Support services for processing GP, Ophthalmic and Pharmacy payments and pensions administration. Assurance is provided within an Independent Service Auditor’s ISAE 3402 third party assurance report, which informs the CCG’s Annual Governance Statement. The 2019/20 report has been delayed due to the Covid-19 pandemic and will not be available until later in 2020/21. Therefore, we have restated the findings of the 2018/19 report.

The 2018/19 Independent Service Auditor’s report provided by KPMG, dated 30 April 2019, places certain caveats on the intended users and purpose of their report. KPMG’s overall opinion is qualified in certain respects. Two of the qualifications concern control objectives relating to payments to GP practices and access to data relating to GP pensions, two others relate to Ophthalmic services which are not relevant to the CCG. Except for these, the assurance report provides reasonable assurance in respect of the services provided by Capita.

Control Issues The Head of Internal Audit Opinion reports no significant controls issues. The following control issues and remedial actions were identified and reported in the 2019/20 Month 9 return to NHS England:

Issue: Quality and Performance – Mental Health

Mitigation: The CCG, alongside NHS England and Improvement and Bath, Swindon and Wiltshire CCGs, is working to support Avon and Wiltshire Partnership Trust regarding a number of strategic, operational, finance and quality risks. Monthly partnership, monitoring and assurance meetings are in place with the Trust.

Issue: A&E Performance is not delivered to NHS Constitution Standards

Mitigation: The CCG has in place comprehensive remedial action plans at a system and provider level and our strategic direction in developing integrated locality services supports reducing reliance on secondary care services.

Issue: RTT is not delivered to NHS Constitution Standards

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Mitigation: the CCG has required providers to produce remedial action plans to address the number of patients waiting over 52 weeks for planned treatment and has monitored their implementation. Work to meet the target will continue in 2020/21.

Issue: Ambulance services – call prioritisation

Mitigation: The CCG has worked with the CCG lead commissioner (Dorset CCG) for the service to support the Trust to increase validation and welfare calling/prioritisation, as well as the development of system wide escalation triggers.

Review of economy, efficiency & effectiveness of the use of resources We undertake a comprehensive range of contract monitoring, benchmarking and budget monitoring to ensure the robust management of our resources.

The Governing Body has overarching 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.

Detailed performance, quality and finance reports, which include the use of comparative analysis to assess performance, are presented at each Governing Body meeting. These reports provide an overview of progress against key indicators and financial objectives.

Our Audit, Governance and Risk Committee oversees internal and external audit, reviews financial and information systems and monitors the integrity of the financial statements. The Audit, Governance and Risk Committee receives regular reports from Internal and External Audit as well as Counter Fraud. External Audit, as part of its audit plan, reviews the CCG’s governance arrangements to identify whether it has in place appropriate arrangements for securing economy, efficiency and effectiveness in its use of resources. This is known as the Value for Money (VfM) conclusion. Part of the role of the Internal Audit service we commission involves reviewing, appraising and reporting on VFM within the organisation.

Our Standing Orders, Scheme of Reservation and Delegation and Detailed Financial Policies underpin the use of economic, efficient and effective resources. These are supplemented by budgetary controls and commissioning and other policies and

111 procedures. The Internal Audit Reports relating to savings plans and our main accounting process have provided assurance regarding these arrangements.

Regular contract management processes are established with main providers to link service quality, performance and financial management.

At the time of submission the publication of the CCG rating for the Quality of Leadership metric of the NHS England NHS Oversight Framework was delayed due to the covid-19 pandemic. The rating will be published by NHS England later in 2020.

Financial planning and in-year performance monitoring

We have clear and appropriate controls in place for the planning and monitoring of our financial activity including the development and monitoring of QIPP programmes through a robust Programme Management Approach.

A detailed budgeting process has been established to support delivery of the financial plan.

Regular financial monitoring and reporting arrangements exist and these are accompanied by actions to address emerging financial risks and development and delivery of recovery plans

There is robust challenge from the Strategic Finance Committee on the CCG’s financial performance, including contract monitoring and the delivery of QIPP savings, along with further review from the Governing Body.

Central management costs

Our central management costs are contained within our Running Cost Allowance. In 2019/20, this allowance contains £0.9m of one-off funding and expenditure. The Running Cost Allowance for 2019/20 was £21.7million and our expenditure for the year was £20.6m, an underspend of £1.1million. This has been achieved through economies arising from the merger of predecessor bodies, although pay costs did rise during the year as vacancies for filled. The CCG has planned for further savings in the future as the Running Cost Allowance will reduce to £18.3million in 2020/21.

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Delegation of functions

Where the CCG has chosen to commission business functions from other organisations, services are managed against a service level agreement and subject to regular performance review and independent audit where applicable. The CCG commissions the South Central and West Commissioning Support Unit to provide a number of services. Feedback is gained on business, use of resources and responses to risk through independent assurance, principally Service Auditor Reports. The CCG receives general ledger services from Shared Business Services Limited, and payroll services from North Bristol Trust.

Counter fraud arrangements An annual Counter Fraud Plan is overseen by the Audit, Governance and Risk Committee and focuses on fraud prevention and deterrence. We have a Fraud and Bribery Policy, which helps staff to understand in simple terms what fraud and bribery are and contains useful guides on how to identify fraud together with details on how to report and how cases will be dealt with. The policy also emphasises that it is the responsibility of all staff to work to prevent fraud and protect the assets of the NHS. The policy is supported by the Management of Conflicts of Interest and Gifts and Hospitality Policies, which set out the honest, transparent and accountable culture that the Clinical Commissioning Group expects. A Local Counter Fraud Specialist (LCFS) is contracted by the CCG to provide counter fraud training to all staff as part of the staff induction programme.

Our Chief Finance Officer is responsible for overseeing and providing strategic management and support for all anti-fraud, bribery and corruption work within the organisation. The Counter Fraud Specialist works in consultation with the Chief Finance Officer to identify and report cases of actual or suspected fraud and will ensure that learning identified from any subsequent investigation is implemented.

The Audit, Governance and Risk Committee receives an annual report against each of the Standards for Commissioners, and identified risks are addressed in an annual work plan that is overseen by the Committee.

Appropriate action is taken regarding any NHS Counter Fraud Authority quality assurance recommendations, in line with NHS Protect Standards.

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Head of Internal Audit Opinion

Following completion of the planned audit work for the financial year for the clinical commissioning group, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the clinical commissioning group’s system of risk management, governance and internal control. The Head of Internal Audit concluded that an overall Head of Internal Audit Opinion that

“the organisation has an adequate and effective framework for risk management, governance and internal control. However our work has identified further enhancements to the framework of risk management, governance and internal control to ensure that it remains adequate and effective”.

During the year, Internal Audit issued the following audit reports.

Area of Audit Level of Assurance Given

Conflicts of Interest Substantial Assurance

Corporate Policy Review Process Reasonable Assurance

Financial Controls and Reporting Substantial Assurance

Financial Recovery and QIPP - Compliance and Reasonable Assurance design

Financial Recovery and QIPP – effectiveness Partial Assurance

Learning Disability Mortality Review Programme Reasonable Assurance

Primary Care Delegated Commissioning Reasonable Assurance

Commissioning and Contract management Any Reasonable Assurance Qualified Providers performance

IT Disaster Recovery and Business Continuity Reasonable Assurance

The control issues identified in the Financial Recovery and QIPP audit report, ‘effectiveness’ review, and the actions and progress to date include (table 10):

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Control Issue leading Management Action progress to date to the conclusion The CCG is not The CCG has examined the The CCG commissioned currently on course to key adverse variances forecast an external review of achieve its prescribed for 2019/20 outturn position CHC processes in control total deficit of and understands the reasons January 2020. This £12m. and root causes behind these review has led to a CHC Contingency reserves variances. This information has Transformation are not available to been used to inform the programme for 2020/21 help bring the financial planning assumptions sponsored by the financial position back for 2020/21. In particular the Director of Nursing & into balance. CCG should take the learning Quality and identified above and incorporating a £6.5m from the independently savings programme for commissioned review of 2020/21. Budgets and Continuing Care to ensure any Savings Plans for lessons are built into the 2020/21 have been set financial budget drawn up for with regard to lessons 2020/21 and are therefore learned from 2019/20, achievable. the external review, national benchmarking and Strategic Change programme. They are stretching and assessed as high risk. The CCG did not Recognising the pressures Interim budgets were achieve full coverage placed on the CCG to agree a reviewed and developed of budget holder sign financial target / control total with budget holders and off of individual that is acceptable to the key savings budgets for 2019/20. Regulator, the CCG should programmes were ensure it has clearly set out the reviewed and developed risks and assumptions with Control Centre underpinning the financial plan leads. Both have been for 2020/21. Assumptions subject to Deep Dive at should take account of the run Strategic Finance rate in the final quarter of Committee in Jan, Feb 2019/20, as well as where the and March 2020. Final achievement of targets is budgets have not been reliant upon other health signed off due to the providers and partners within Covid pandemic and the the health economy. ‘pausing’ of NHS Operational Planning The CCG will consider a and Contracting for reasonable financial recovery 2020/21. expectation for 2020/21 based on the performance of this financial year’s savings delivery. This will help ensure a

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realistic and achievable savings figure can be factored into the 2020/21 Financial Plan. This is linked to Management Action 2 above The CCG Financial The CCG will ensure full See comment above. Recovery Plan and coverage of budget holders SFRP are not sign off for their respective currently on course to budgets. This will include achieve the savings signing a declaration that they required to understand and agree their achieve the CCG’s responsibility and prescribed control accountability for their total. delegated budgets. These responsibilities include identifying and managing key risks in relation to achieving financial balance. Review of the effectiveness of governance, risk management and internal control

My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, executive managers and clinical leads within the CCG who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me. My review is also informed by comments made by the external auditors in their annual audit letter and other reports.

Our assurance framework provides me with evidence that the effectiveness of controls that manage risks to the CCG achieving its principles objectives have been reviewed.

I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Governing Body, and Audit, Governance and Risk Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place:

• The Audit, Governance and Risk Committee agrees an annual plan for work to be undertaken by Internal Audit focusing on areas of particular concern or risk. Reports are made to the Committee on audit findings, with assurance and recommendations being given. Discussions are also held with the External Auditors regarding audit

116 plans, and regular reports are made to the Audit Committee on progress and findings.

• The Audit, Governance and Risk Committee reports to the Governing Body on the development, implementation and monitoring of integrated governance by providing assurance on the systems and processes by which the CCG leads, directs and controls its function in order to achieve organisational objectives, safety and quality of service.

• Internal Audit and Counter Fraud provide assurances through their reports on various aspects of internal control to the Audit, Governance and Risk Committee. These reports also provide assurances and support for the work undertaken by the external auditors.

• The Governing Body receives reports on significant risk identified through the risk register and Governing Body Assurance Framework reports

Conclusion With the exception of the control issues identified and reported in the 2019/20 Month 9 return to NHS England, and listed below, no significant control issues have been identified during the year.

 Quality and performance issues related to mental health services. The CCG is working with partners to support the Trust regarding a number of strategic, operational, finance and quality risks. Monthly partnership, monitoring and assurance meetings are in place with the Trust.

 Non-delivery of the A&E NHS Constitution Standard. The CCG has in place comprehensive remedial action plans at a system and provider level. The development of integrated locality services will support secondary care services.

 Non-delivery of the RTT NHS Constitution Standards. The CCG has required providers to produce remedial action plans to address the number of patients waiting over 52 weeks for planned treatment and has monitored their implementation. Work to meet the target will continue in 2020/21.

 Ambulance services – call prioritisation. The CCG has worked with the CCG lead commissioner (Dorset CCG) for the service to support the Trust to

117 increase validation and welfare calling/prioritisation, as well as the development of system wide escalation triggers.

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Remuneration and Staff Report

Remuneration Report

Remuneration Committee

Remuneration Committee and our policy on the remuneration of senior managers and Very Senior Managers

The Remuneration Committee makes recommendations to the Governing Body about the remuneration and allowances for senior managers and persons in senior positions within the CCG. Details of the members of the Committee are given in the Governance Statement in this report.

The policy on the remuneration of Very Senior Managers, including members of the Governing Body, has been set using NHS England guidance. We have applied national remuneration guidance for senior managers pay for 2019/20 and will continue to apply this guidance for the foreseeable future.

Remuneration of Very Senior Managers

Advance approval of the Chief Secretary to the Treasury (CST) is required for remuneration packages at £150,000 or above. Where we have Very Senior Manager roles that fall into this category we have to complete business cases for the posts, taking into consideration:

 Influence and impact of role  The specialist nature of the role including the skills and experience required  Labour market considerations  Relevant supporting benchmarking data  The package of the previous incumbent or any obvious comparators  Only when appropriate, biographical information

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Senior Manager Remuneration (including salary and pension entitlements)

This statement is audited by the external auditors and is covered by the audit opinion issued on the CCG's financial statements. (table 11)

2019-20 2018-19

Start Date End Date Salary Expense Performance Long term All Total Salary Expense Performance Long term All Total payments pay and performance Pension- payments pay and performance Pension- (taxable) bonuses pay and related (taxable) bonuses pay and related bonuses benefits bonuses benefits (Note 6)

(bands (Rounded (bands of (bands of (bands (bands of (bands (Rounded (bands of (bands of (bands (bands of to the £5,000) £5,000) of £5,000) of to the £5,000) £5,000) of of £5,000) nearest £2,500) £5,000) nearest £2,500) £5,000) £100) £100)

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

(Note 3) (Note (Note 9) 10) Julia 160- 225- 140- 140- Ross Chief Executive 01/04/2018 31/03/2020 0 0 0 385-390 0 0 0 0 165 227.5 145 145 (Note 9)

Jon 130- 210- Clinical Chair 01/04/2018 31/03/2020 80-85 0 0 0 20-22.5 100-105 80-85 Hayes 132.5 215 Deputy Chief Sarah 150- 150- 150- Executive/Chief 01/04/2018 31/03/2020 0 0 0 0 150-155 0 0 0 0 Truelove 155 155 155 Finance Officer

Lisa Director of 130- 130- 220- 01/04/2018 31/03/2020 0 0 0 0 125-130 0 0 0 90-92.5 Manson Commissioning 135 135 225

Janet Interim Director of Baptiste- Nursing and 07/01/2019 18/09/2019 60-65 0 0 0 0 60-65 35-40 0 0 0 0 35-40 Grant ( Quality Note 1)

Julie Interim Director of Thallon 16/10/2019 31/03/2020 55-60 0 0 0 0 55-60 0 0 0 0 0 0 Quality (Note 2)

Director of Rosalind Nursing and 01/01/2020 31/03/2020 20-25 0 0 0 30-32.5 55-60 0 0 0 0 0 0 Shepherd Quality

Deborah Director of 115- 115- 155- 01/04/2018 31/03/2020 0 0 0 22.5-25 140-145 0 0 0 37.5-40 El-Sayed Transformation 120 120 160

Justine Area Director - 105- 105- 100- 205- 01/04/2018 31/03/2020 0 0 0 22.5-25 130-135 0 0 0 Rawlings Bristol 110 110 102.5 210

Area Director - David 105- 105- 145- South 01/04/2018 31/03/2020 0 0 0 30-32.5 135-140 0 0 0 42.5-45 Jarrett 110 110 150 Gloucestershire Colin Area Director - 105- 105- 120- 01/04/2018 31/03/2020 0 0 0 22.5-25 130-135 0 0 0 12.5-15 Bradbury North Somerset 110 110 125

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Peter Medical Director - 115- 110- 145- Brindle Clinical 01/04/2018 31/03/2020 0 0 0 55-57.5 170-175 0 0 0 35-37.5 120 115 150 (Note 5) Effectiveness

Medical Director - Martin 115- Commissioning 01/04/2018 31/03/2020 85-90 0 0 0 27.5-30 110-115 90-95 0 0 0 22.5-25 Jones 120 and Primary Care

David GP Locality Soodeen 01/04/2018 31/03/2020 70-75 0 0 0 17.5-20 90-95 75-80 0 0 0 0 75-80 Representative (Note 6)

Kirsty GP Locality Alexander 01/04/2018 31/03/2020 55-60 0 0 0 60-62.5 115-120 55-60 0 0 0 0 0 Representative (Note 7)

Brian GP Locality Hanratty 01/04/2018 31/03/2020 45-50 0 0 0 10-12.5 55-60 35-40 0 0 0 5-7.5 45-50 Representative (Note 7)

Kevin GP Locality Haggerty 01/04/2018 31/03/2020 35-40 0 0 0 0 35-40 35-40 0 0 0 0 35-40 Representative (Note 8)

Rachael GP Locality Kenyon 01/04/2018 31/03/2020 35-40 0 0 0 2.5-5 40-45 35-40 0 0 0 22.5-25 60-65 Representative (Note 8)

Jon GP Locality 125- 160- Evans 01/04/2018 31/03/2020 35-40 0 0 0 7.5-10 40-45 35-40 0 0 0 Representative 127.5 165 (Note 8)

Felicity GP Locality 102.5- 120- 01/04/2018 31/03/2020 20-25 0 0 0 0 20-25 15-20 0 0 0 Fay Representative 105 125

Independent Lay Member - Chair John Audit, 01/04/2018 31/03/2020 20-25 600 0 0 0 25-30 25-30 0 0 0 0 25-30 Rushforth Governance and Risk

Independent Lay John Member - 13/05/2019 31/03/2020 15-20 0 0 0 0 15-20 0 0 0 0 0 0 Cappock Strategic Finance

Independent Lay Sarah Member - Patient Talbot- 01/04/2018 31/03/2020 25-30 300 0 0 0 25-30 25-30 0 0 0 0 25-30 and Public Williams Engagement

Independent Lay Alison Member - 01/04/2018 31/03/2020 25-30 400 0 0 0 25-30 25-30 0 0 0 0 25-30 Moon Registered Nurse

Independent Lay Nick Member - 01/04/2018 31/03/2020 25-30 600 0 0 0 25-30 25-30 0 0 0 0 25-30 Kennedy Secondary Care Doctor

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Dr Representative Christina local authority - 01/04/2019 31/03/2020 0 0 0 0 0 0 0 0 0 0 0 0 Gray Public Health (Note 4)

Notes: No senior manager waived his/her remuneration. No annual and long term performance related bonus payments were made to any senior managers in 2019/20 1 The Interim Director of Nursing and Quality was engaged via their company, Baptiste Grant Ltd. Since the engagement was for "office holder" position, the contract was assessed as within the scope of IR35 legislation and contract payments were processed via the CCG's payroll. VAT is charged on these payments. The salary figure given above does not include this VAT element.

2 The Interim Director of Quality was engaged via the company, Meraki Interim Solutions Ltd. Since the engagement was for "office holder" position, the contract was assessed as within the scope of IR35 legislation and contract payments were processed via the CCG's payroll. VAT was not charged on these payments.

3 The taxable expenses are payments for home to office travel. 4 This is non - remunerated post. 5 The salary in the table excludes the salary for his secondment role at NETSCC, University of Southampton from 1 April 2019 to 31 March 2020. The total salary for 2019/20 including the payment for the secondment would be within the band £130,000 to £135,000

6 In the salary figure. £12,320 relates to the Governing Body role and the remainder are for payments for Locality Leadership Group and clinical lead roles. The salary in the table excludes the salary for his secondment role at South West Clinical Networks which is hosted by NHS England. The total salary for 2019/20 including the payment of the secondment would be within band £95,000 to £100,000. 7 In the salary figure, £12,320 relates to the Governing Body role and the remainder are for Locality Leadership Group and clinical lead roles. 8 In the salary figure, £12,320 relates to the Governing Body role and the remainder are for the Locality Leadership Group role. 9 The individual received pay arrears totalling £16,275 from being under paid from 1 April 2018. This is not included in the salary figure in the table. 10 All Pensions Related Benefits The value of pension benefits accrued during the year is calculated as the real increase in pension multiplied by 20, less, the contributions made by the individual. The real increase excludes increases due to inflation or any increase or decrease due to a transfer of pension rights.

This value does not represent an amount that will be received by the individual. It is a calculation that is intended to convey to the reader of the accounts an estimation of the benefit that being a member of the pension scheme could provide. The pension benefit table provides further information on the pension benefits accruing to the individual. Factors determining the variation in the values recorded between individuals include but is not limited to :

A change in role with a resulting change in pay and impact on pension benefits A change in the pension scheme itself Changes in the contribution rates Changes in the wider remuneration package of an individual.

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Pension benefits as at 31 March 2020 Table 12 This statement is audited by the external auditors and is covered by the audit opinion issued on CCG's financial statements.

Real Increase in Real increase in Total accrued accrued Lump sum at pension Cash Equivalent Real increase in Cash Equivalent Employer's pension at pension lump pension at pension age related to accrued Transfer Value Cash Equivalent Transfer Value contribution to pension age sum at pension age at 31 March 2020 pension at 31 March at 1 April 2019 Transfer Value at March 31 partnership (bands of age (bands of (bands of £5,000) 2020 (bands of £5,000) 2020 pension £2,500) £2,500) Name Title £000 £000 £000 £000 £000 £000 £000 £000

Julia Ross Chief Executive 5-7.5 15-17.5 60-65 190-195 1196 131 1499 0

Jon Hayes Clinical Chair 0-2.5 0 10-15 20-25 151 11 178 0 Director of 0-2.5 0 45-50 95-100 747 0 780 0 Lisa Manson Commissioning Director of Nursing and 0-2.5 0-2.5 35-40 115-120 804 12 877 0 Rosalind Shepherd Quality Director of 0-2.5 0 30-35 65-70 541 18 589 0 Deborah El-Sayed Transformation Justine Rawlings Area Director - Bristol 0-2.5 0 25-30 55-60 474 21 520 0 Area Director - South 0-2.5 0-2.5 30-35 70-75 485 19 534 0 David Jarrett Gloucestershire Area Director - North 0-2.5 0 25-30 45-50 397 16 437 0 Colin Bradbury Somerset 2.5-5 2.5-5 40-45 90-95 694 60 790 0 Medical Director - Peter Brindle Clinical Effectiveness

Medical Director - 0-2.5 5-7.5 15-20 45-50 308 42 370 0 Martin Jones Commissioning and Primary Care 0-2.5 0 10-15 20-25 197 11 227 0 GP Locality David Soodeen Representative

GP Locality 2.5-5 7.5-10 35-40 110-115 814 0 819 0 Kirsty Alexander (note 4) Representative GP Locality 0-2.5 0-2.5 0-5 0-5 37 5 50 0 Brian Hanratty Representative GP Locality 0-2.5 0 10-15 25-30 172 3 184 0 Rachel Kenyon (note 3) Representative GP Locality 0-2.5 0 5-10 15-20 147 6 161 0 Jon Evans (note 3) Representative GP Locality 0-2.5 0 5-10 15-20 132 0 138 0 Felicity Fay Representative

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Pension benefits as at 31 March 2019 Table 13 This statement is audited by the external auditors and is covered by the audit opinion issued on CCG's financial statements

Real Increase in Real increase in Total accrued accrued Lump sum at pension Cash Equivalent Real increase in Cash Equivalent Employer's pension at pension lump pension at pension age related to accrued Transfer Value Cash Equivalent Transfer Value contribution to pension age sum at pension age at 31 March 2019 pension at 31 March at 1 April 2018 Transfer Value at March 31 partnership (bands of age (bands of (bands of £5,000) 2019 (bands of £5,000) 2019 pension £2,500) £2,500) Name Title £000 £000 £000 £000 £000 £000 £000 £000

Julia Ross Chief Executive 0 0 50-55 155-160 1102 71 1196 0

Jon Hayes Clinical Chair 5-7.5 12.5-15 5-10 20-25 32 107 151 0 Director of 5-7.5 7.5-10 40-45 100-105 584 143 747 0 Lisa Manson Commissioning Director of 2.5-5 0 30-35 65-70 452 72 541 0 Deborah El-Sayed Transformation 5-7.5 7.5-10 25-30 55-60 339 121 474 0 Justine Rawlings Area Director - Bristol

Area Director - South 2.5-5 0-2.5 30-35 65-70 388 83 485 0 David Jarrett Gloucestershire Area Director - North 0-2.5 0 20-25 45-50 336 46 397 0 Colin Bradbury Somerset Medical Director - 2.5-5 0-2.5 35-40 85-90 581 83 694 0 Peter Brindle Clinical Effectiveness Medical Director - 0-2.5 2.5-5 10-15 35-40 247 49 308 0 Martin Jones Commissioning and Primary Care GP Locality 0 0 10-15 20-25 186 0 196 0 David Soodeen Representative GP Locality 0 0 35-40 105-110 856 1 870 0 Kirsty Alexander (note 4) Representative GP Locality 0-2.5 0 0-5 0-5 27 5 37 0 Brian Hanratty Representative

GP Locality 0-2.5 0-2.5 10-15 25-30 149 36 191 0 Rachel Kenyon (note 3) Representative GP Locality 5-7.5 15-17.5 5-10 20-25 51 116 173 0 Jon Evans (note3) Representative GP Locality 2.5-5 12.5-15 5-10 15-20 36 91 132 0 Felicity Fay Representative

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Notes:

1. The CCG has no pension liabilities for Sarah Truelove, Deputy Chief Executive and Chief Finance Officer or Dr K Haggerty

Sarah Truelove and Dr K Haggerty are not in the NHS Pension Scheme.

2 Independent Lay Members do not receive pensionable pay. 3 The Cash Equivalent Transfer Value at 1st April 2019 (Table 12 ) for R Kenyon and J Evans do not agree to Cash Equivalent Transfer Value at 31st March 2019 (Table 13) due to the salary overpayments in 2018/19 identified in April 2019.

4 The Cash Equivalent Transfer Value at 1st April 2019 (Table 12) for K Alexander does not agree to Cash Equivalent Transfer Value at 31st March 2019 (Table 13) due to amendments to service record and survivor details.

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Cash Equivalent Transfer Values

A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s (or other allowable beneficiary's) pension payable from the scheme.

A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies.

The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost . CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries.

Real Increase in CETV

This reflects the increase in CETV that is funded by the employer. It does not include the increase in accrued pension due to inflation or contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement).

Pension and Lump sum data

The pension and lump sums figures above from NHS Pensions are derived from their systems without any adjustment for a potential future legal remedy required as result of the McCloud judgement ( a legal case concerning age discrimination over the manner in which UK public service pension schemes introduced a CARE benefit design in 2015 for all but the oldest members who retained a Final Salary design.) There is considerable uncertainty on how the affected benefits within the new NHS 2015 scheme would be adjusted in future once legal proceedings are completed

Indexation and CETV vales

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During the year, the Government announced that public sector pension schemes will be required to provide the same indexation in payment on part of a public service scheme pensions known as the Guaranteed Minimum Pension (GMP) as applied to the remainder of the pension i.e. the non GMP. Previously the GMP did not receive full indexation. This means that with effect from August 2019 the method used by NHS Pensions to calculate CETV values was updated. So the method in force at 31 March 2020 is different to the method used to calculate the value at 31 March 2019. The real increase in CETV will therefore be impacted (and will in effect include any increase in CETV due to the change in GMP methodology).

Compensation on early retirement of for loss of office

This statement is audited by the External Auditors and is covered by the Audit Opinion issued on the CCG’s Financial Statements. No payments for compensation on early retirement or for loss of office were received by any Senior Managers in 2019/20 (nil in 2018/19).

Payments to past members

This statement is audited by the External Auditors and is covered by the Audit Opinion issued on the CCG’s Financial Statements. No compensation was received by any Senior Manager in 2019/20 (nil in 2018/19).

Pay multiples

This statement is audited by the External Auditors and is covered by the Audit Opinion issued on the CCG’s Financial Statements.

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 highest -paid director/member is Julie Thallon, Interim Director of Quality.

The banded remuneration of the highest paid director/member in Bristol, North Somerset and South Gloucestershire CCG in the financial year 2019/20 was £175,000 to £180,000 (2018/19 £175,000-£180,000). This was 4.76 times (2018/19,

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4.84) the median remuneration of the workforce, which was £37,267 (2018/19, £36,644). In 2019/20, no employees received remuneration in excess of highest paid member of the Governing Body (one in 2018-19)

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. Remuneration range from £6,160 to £176,000 (2018/19 £6,160 - £193,600). 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 February 2020, the CHC team originally hosted by Bristol Community Health and North Somerset Community Partnership transferred to the CCG. 75 staff were transferred with salaries ranging from £17,652 to £52,306 and the median of £33,587.

Staff Report Number of Senior Managers, Staff Numbers and Costs

Staff Costs

This statement is audited by the External Auditors and is covered by the Audit Opinion issued on the CCG’s Financial Statements.

Table 14 Staff costs 2019/20

2019- Admin Programme Total 2020

Permanent Permanent Permanent Employees Other Total Employees Other Total Employees Other Total Employee Benefits £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Salaries and wages 10,560 563 11,123 4,020 609 4,629 14,580 1,172 15,752

Social security costs 1,245 1,245 397 397 1,642 - 1,642

Employer contributions to the NHS Pension Scheme 2,019 2,019 789 789 2,808 - 2,808

Apprenticeship Levy 66 66 - - - 66 - 66 Gross employee benefits expenditure 13,890 563 14,453 5,206 609 5,815 19,096 1,172 20,268

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This statement is audited by the External Auditors and is covered by the Audit Opinion issued on the CCG’s Financial Statements.

Table 15 Staff costs 2018/19

2018- Admin Programme Total 2019 Permanent Permanent Permanent Employee Benefits Employees Other Total Employees Other Total Employees Other Total

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Salaries and wages 9,764 1,118 10,882 3,583 481 4,064 13,347 1,599 14,946 Social security costs 1,086 1,086 366 - 366 1,452 - 1,452

Employer contributions to the NHS Pension Scheme 1,299 1,299 472 - 472 1,771 - 1,771 Apprenticeship Levy 53 53 53 53 Gross employee benefits expenditure 12,202 1,118 13,320 4,421 481 4,902 16,223 1,599 18,222

Staff Numbers 2019/20

This statement is audited by the external auditors and is covered by the audit opinion issued on CCG's financial statements.

There was an average of number 72 Senior Managers between 1 April 2019 and 31 March 2020.

Table 16

Senior Managers (WTE) Permanent Other Total Female Male Total Female Male Total Female Male Total Very Senior Manager 5 4 9 1 0 1 6 4 10 Band 9 2 0 2 2 2 4 4 2 6 Band 8D 3 4 7 0 0 0 3 4 7 Band 8C 19 9 28 0 0 0 19 9 28 Band 8B 13 8 21 0 0 0 13 8 21 Total 42 25 67 3 2 5 45 27 72

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Our average number by Staff, by Staff categories between 1 April 2019 to 31 March 2020. Table 17

Staff Category (WTE) Permanent Other Total Female Male Total Female Male Total Female Male Total Administrative and Clerical 155 64 219 2 6 8 157 70 227 Medical and Dental 5 5 10 1 0 1 6 5 11 Add Professional. Scientific and Technical 14 6 20 0 0 0 14 6 20 Nursing and Midwifery 16 4 20 0 0 0 16 4 20 Allied Health Professionals 0 0 0 0 0 0 0 0 0 Senior Managers 42 25 67 3 2 5 45 27 72 Total 232 104 336 6 8 14 238 112 350

Staff Composition 2019/20

There were 82 Senior Managers (headcount) between 1 April 2019 and 31 March 2020. Table 18

Senior Managers (headcount) Permanent Other Total Female Male Total Female Male Total Female Male Total Very Senior Manager 5 4 9 1 0 1 6 4 10 Band 9 2 0 2 3 3 6 5 3 8 Band 8D 3 4 7 1 0 1 4 4 8 Band 8C 21 10 31 1 0 1 22 10 32 Band 8B 16 8 24 0 0 0 16 8 24 Total 47 26 73 6 3 9 53 29 82

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Staff Numbers 2018/19

This statement is audited by the external auditors and is covered by the audit opinion issued on CCG's financial statements.

There was an average of number 68 Senior Managers between 1 April 2018 and 31 March 2019. Table 19

Senior Managers (WTE) Permanent Other Total Female Male Total Female Male Total Female Male Total Very Senior Manager 6 3 9 0 0 0 6 3 9 Band 9 2 2 4 1 1 2 3 3 6 Band 8D 4 2 6 0 1 1 4 3 7 Band 8C 19 9 28 0 1 1 19 10 29 Band 8B 10 6 16 0 1 1 10 7 17 Total 41 22 63 1 4 5 42 26 68

Our average number by Staff, by Staff categories between 1 April 2018 to 31 March 2019. Table 20

Staff Category (WTE) Permanent Other Total Female Male Total Female Male Total Female Male Total Administrative and Clerical 146 52 198 8 7 15 154 59 213 Medical and Dental 5 6 11 0 0 0 5 6 11 Add Professional. Scientific and Technical 15 4 19 0 0 0 15 4 19 Nursing and Midwifery 7 3 10 0 0 0 7 3 10 Allied Health Professionals 0 0 0 0 0 0 0 0 0 Senior Managers 41 22 63 1 4 5 42 26 68 Total 214 87 301 9 11 20 223 98 321

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Staff Composition 2018/19

There were 76 Senior Managers (headcount) between 1 April 2018 and 31 March 2019. Table 21

Senior Managers (headcount) Permanent Other Total Female Male Total Female Male Total Female Male Total Very Senior Manager 6 4 10 0 0 0 6 4 10 Band 9 2 2 4 1 3 4 3 5 8 Band 8D 4 2 6 0 0 0 4 2 6 Band 8C 22 9 31 0 1 1 22 10 32 Band 8B 13 6 19 0 1 1 13 7 20 Total 47 23 70 1 5 6 48 28 76

In February 2020, the CHC team originally hosted by Bristol Community Health and North Somerset Community Partnership transferred to the CCG. 75 staff were transferred with WTE of 65. In the year 2019/20 the WTE for the permanent staff has increased by 35 from 301 in 2018/19 to 336 in 2019/20. The impact of the transfer of CHC staff in February 2020 accounts for 11 of this increase.

Sickness absence data We have a detailed and robust Sickness Absence Policy. A range of services are available to support staff at work or returning to work. These services include access to Occupational Health and an Employee Assistance Programme, which includes access to counselling sessions. Human Resource support staff have worked with managers on best practice for managing sickness absence, how to identify and manage stress, how to support employees with disabilities in the workplace and how to increase wellbeing amongst staff.

We are required to report annual sickness absence data for the calendar year 2019.

The CCG had an average number of full time equivalent members of staff (FTE) of 332.6 over the period January 2019 to December 2019. The full time equivalent possible working days available was 84,143.

The table below has been provided by the Department of Health and Social Care using the Electronic Staff Record Data Warehouse.

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Table 22

Number of FTE staff FTE Average Sum of (average 1 January Sum of FTE sickness Annual FTE Days 2019 to 31 December Days Sick absence Sick Days Available 2019) % per FTE

NHS Bristol, North Somerset and South Gloucestershire CCG 332.6 2,993.6 84,143 3.55% 9

Staff policies and other employee matters We ensure fair and equitable treatment of all staff and applicants applying for any advertised posts. We are an accredited “Disability Confident” Employer, which ensures all declared disabled applicants are guaranteed an interview if they meet the essential requirements of the person specification of a role. The Recruitment and Selection Policy outlines the requirements for recruiting managers to make reasonable adjustments for disabled candidates where applicable, and this is reinforced through the line management training courses run for all staff with people management responsibilities.

All staff with a declared disability or who become disabled during their employment will have access to appropriate training courses, career development opportunities, and access to appropriate promotion opportunities. Reasonable adjustments are made to support these people with accessing and benefitting from these opportunities. All our policies that relate to the continued employment and training of disabled staff have been equality impact assessed to ensure they are not detrimental to any staff with protected characteristics, including disabled persons. These policies include (but are not restricted to) the Managing Sickness Absence Policy, Bullying and Harassment Policy, Disciplinary and Grievance Policy, Managing Performance (Capability Policy), Flexible Working Policy and Equality and Diversity in Employment Policy. All policies are developed in line with Agenda for Change Terms and Conditions where applicable. Further information about our work related to equality and diversity can be found in the Performance Analysis section of this report.

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We will continue to develop new staff policies and review existing policies. All of these will be subject to consultation with staff and Trade Union representatives through the Staff Partnership Forum. All policies will be developed to ensure we are able to recruit and retain a diverse workforce whilst ensuring equal treatment of staff and meeting the organisation’s duty of care around staff health and safety at work. All new policies will have an Equality Impact Assessment to ensure they are not detrimental to staff on the basis of any protected characteristics as defined in the Equality Act 2010. We have formed a working group focussed on attracting and developing diverse talent and will regularly monitor the diversity of the workforce. This group will also review recruitment practices and policies to ensure staff from the protected groups are attracted to work and stay at the organisation and are given the opportunities to develop their careers.

We actively engage with staff and Trade Unions on any employee relations matters which require wider consultation. The Staff Partnership Forum meets monthly with senior management and is chaired by the Deputy Chief Executive. The Staff Partnership Forum includes management representatives, staff representatives from each directorate, Human Resources representatives and Trade Union representatives from Unison, Unite, Royal College of Nursing and Managers In Partnership.

The Staff Partnership Forum has discussed staff policies including Health and Wellbeing, Flexible working, Hot-desking, Social media, Intranet, Learning and Development, Freedom to Speak Up, and the Appraisal Policy.

The Staff Partnership Forum has also discussed:

 Environmental Sustainability,  Embedding the Values,  Developing our Culture and Behaviours,  Exit interview themes and process,  Staff Survey Action Plan, The Workforce Report,  All Staff Events,  Staff Partnership Forum Review and TOR,  Vacancy Control Process,

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 Referral Service Consultation,  Area Directorate Senior Management Team Draft Consultation,  Renovations to the South Plaza Building, and  Staff Mental Health and Wellbeing.

We have in place policies to support staff when raising concerns, including our Freedom to Speak Up Policy, Fraud and Bribery Policy, and Bullying and Harassment Policy.

Freedom to Speak Up

Freedom to Speak Up was introduced by Sir Robert Francis following a 2015 review into NHS ‘whistleblowing’ processes. It incorporates whistleblowing but extends beyond that to develop cultures where concerns are identified and addressed at an early stage before people feel the need to ‘blow the whistle’.

Freedom to Speak Up is hugely important to us and we are committed to ensuring that a culture of speaking up is instilled throughout our organisation and that effective processes are in place to support staff. Our Freedom to Speak Up Policy provides a framework that supports a culture where staff feel comfortable to raise concerns. The policy gives guidance and advice to staff on raising a concern. Our Freedom to Speak Up network includes our Freedom to Speak Up Guardian, Sarah Talbot- Williams, a Governing Body Lay Member, and two champions, Sarah Truelove and David Jarrett, both Executive Directors.

No issues were raised by staff during 2019/20 and we want to ensure that our processes are not creating barriers that prevent staff from raising concerns. We believe that our Freedom to Speak Up network is important and we want to continue to raise the profile of our network, promoting it as a safe space for staff to raise concerns. We have started a conversation with our Staff Partnership Forum and staff are also encouraged to share their thoughts on how we can drive the right culture forward. These conversations will inform a review of our processes. We want to embed a more integrated Freedom to Speak Up Network as a core part of our cultural development. We want to look more widely to see how Freedom to Speak Up forms a strong culture within our Primary Care Networks, our membership and more broadly between all our partners in Healthier Together.

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Health and Safety

The CCG is committed to ensuring the health, safety and welfare of its employees and of other persons who may be affected by our activities. Our policy has been prepared to reflect our moral and legal obligations under the Health and Safety at Work etc. Act 1974. We commission University Hospitals Bristol to provide us with Health and Safety advice and guidance and act as our “competent person”.

We take steps to ensure that our statutory duties are met at all times including the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013’ (RIDDOR). The Governing Body provides leadership to ensure that exemplary health and safety practices are firmly embedded throughout the organisation to provide a secure and healthy environment in which to work, and has systems in place to identify and manage incidents and risks and eliminate or reduce any identified hazards. There have been no notifiable incidents during 2019/20.

Every employee is given the necessary information, instruction and training to be able to work safely, and undertaken appropriate training, which is refreshed on an annual basis.

Organisational Development

We have continued to build on our Organisational Development Plans, and have delivered several initiatives designed to develop a strong, resilient, and engaged workforce. In 2018/19 we invested strongly in the development of our senior leadership cadre to support them in delivering our vision. This has continued apace in 2019/20 and we have had a number of senior leaders attend The Peloton Programme, a Healthier Together Leadership Development initiative, which provides leaders across the system with enhanced capabilities to lead their organisations within a systems-oriented space.

In 2019 we implemented our new Appraisal Policy. The policy is aligned to the new Agenda for Change Pay Progression Framework which came into effect in April 2019. The policy aims to focus staff at all levels on developing their overall performance and understanding how they can make an effective contribution to the

136 achievement of the CCG’s strategic business plan. A critical output from that process is the creation of personal development plans, against which we employ and utilise our learning and development resources to drive and strengthen performance. In 2020 we will review the policy and examine how to improve both the process and the documentation we use to make it a more engaging and usable system.

To support employee development, hawse have established a Learning & Development Panel which includes members of the Executive Team. The panel considers staff requests for CCG funding to cover learning and development, including individual learning, apprenticeships, continuing professional development, and team or collective training. The panel ensures equality of access for all staff, and that we spend a limited budget to best effect. We have completed our work with our staff to create and share our Employee Values. We have adopted our Employee Values and reinforcement of these values is embodied in various aspects of our organisational day-to-day activities.

Corporate Induction happens every six weeks approximately, ensuring that new members of staff attend early in their employment. Induction covers our vision, aims, strategy, and objectives; facts and figures about the NHS; the way we conduct our business; our local system of care; and their part within it all. It focuses on welcoming new members of staff to the organisation, giving them a positive first impression of the CCG.

We continue to examine and review our recruitment activities, ensuring that they reflect our own values and are properly aligned to our intent to be seen as a fair and equitable employer. This places an emphasis on finding the right person for the role, recruiting diverse talent, and retaining such staff to develop further within the organisation. To this end, the CCG instigated an Attracting & Developing a Diverse Workforce Group in Jan 2019 with a single aim of promoting and supporting the CCG’s ambition to become a leader and best practice organisation in the field of equality, diversity and inclusion. The group has focused on a number of key recruitment issues. Including diverse representation on interview panels; values- based recruitment; and the design and implementation of a Work Experience Placement Programme to target BAME school students as potential future employees within the NHS and the CCG.

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The CCG is committed to supporting the health and wellbeing of its workforce and has over the last 12 months put much effort into providing a network of diverse individuals, groups, and services that together deliver a significant and well-rounded wellbeing support package for our staff. In 2019 we trained some 31 members of staff as Mental Health First Aiders, to help provide for the wellbeing and psychological safety of our staff, and to be a first point of contact service for any staff member who may be dealing with a mental health challenge. In October 2019, we signed up to become a Time to Change Employer, when Julia Ross and Dr Jon Hayes signed the Time to Change Employer Pledge at a Governing Body meeting. Having Time to Change Employer status means that we are committed to raising mental health awareness within the organisation, creating a work environment free of mental health stigma and supporting staff suffering from mental ill health.

We encourage the use of the Employee Assistance Programme which provides staff with access to a range of support measures including a 24/7 telephone helpline offering practical information, emotional support, and online counselling services. Staff also have access to an online health and wellbeing portal that provides extensive resources including personal wellbeing programmes, videos and webinars.

The CCG has had access to its Digital Apprenticeship Service Account since April 2019 and we now have four apprentices within the CCG with a further two awaiting an apprenticeship programme of choice. The Learning & Development Panel has recently considered how to invest the Apprenticeship Levy to best effect, we will devise a strategy in 2020 for the employment of new, and development of existing employees as apprentices.

We held two staff events in 2019/20, building on the events held in the previous year. The purpose of these events was again to brief all staff on how the CCG was developing and invest them in being a part of significant development and change programmes across the organisation. In 2020 we intend to hold a single event in late summer and to use newly created alternative communication channels to inform and involve staff in critical change issues and organisational development opportunities.

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Trade Union Facility Time Reporting Requirements The total number of employees who were relevant union officials during the period 1st April 2018 to 31st March 2019 is:

Number of employees who were Full time equivalent number relevant union officials during the relevant period 0 0

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Expenditure on consultancy The consultancy expenditure for the financial year 2019/2020 was £693k and this can be analysed as follows (table 24):

2019/20 2018/19 Consultancy Category £'000 £'000

Finance 11 8 Human Resources, Training and Education 0 10 Technical 118 24 Organisation and Change Management 224 15 Procurement 139 124 Property and Construction 15 37 Strategy 186 618 Total 693 836 The consultancy organisation spend relates to the professional development of the Governing body and directors. The spend under procurement is for the provision of technical support for adult community services procurement. The spend under strategy is for the provision of professional support for development of the frailty business case.

Off-payroll engagements NHS bodies are required to include disclosures in 2019/20 about their off-payroll engagements, and the details for the CCG are set out in the tables below.

Table 25: Off-payroll engagements longer than 6 months

For all off-payroll engagements as at 31 March 2020 for more than £245 per day and that last longer than six months:

Number

Number of existing engagements as of 31 March 2020 5

Of which, the number that have existed:

for less than one year at the time of reporting 2

for between one and two years at the time of reporting 3 for between 2 and 3 years at the time of reporting for between 3 and 4 years at the time of reporting for 4 or more years at the time of reporting

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Bristol, North Somerset and South Gloucestershire CCG confirms that all existing off-payroll engagements have been subject to an assessment for IR35 purposes using ‘ HMRC Check employment status for tax’ tool.

Table 26: New off-payroll engagements

For all new off-payroll engagement, or those that reached six months in duration, between 1 April 2019 and 31 March 2020, for more than £245 per day and that last for longer than six months:

Number Number of new engagements, or those that reached six months in 2 duration, between 1 April 2019 and 31 March 2020 Of which: Number assessed as caught by IR35 1 Number assessed as not caught by IR35 1

Number engaged directly (via PSC contracted to department) and are 1 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 following 0 the consistency review

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Table 27: Off-payroll engagements / senior official engagements

For any off-payroll engagements of Board members and / or senior officials with significant financial responsibility, between 1 April 2019 and 31 March 2020

Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during the 2 financial year (1) Total no. of individuals on payroll and off-payroll that have been deemed “board members, and/or, senior officials with significant 26 financial responsibility”, during the financial year. This figure should include both on payroll and off-payroll engagements. (2) Note

(1) Janet Bapiste-Grant was engaged via their company, Baptiste Grant Ltd. Since the engagement was for "office holder" position the contract was assessed as within the scope of IR35 legislation and the payments were processed via CCG's payroll

(2) Julie Thallon was engaged via their company, Meraki Interim Solutions Ltd. Since the engagement was for "office holder" position, the contract was assessed as within the scope of IR35 legislation and contract payments were processed via the CCG's payroll. These payments were not subject to VAT.

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Exit packages, including special (non-contractual) payments These statements are audited by the external auditors and is covered by the audit opinion issued on CCG's financial statements. Table 28: Exit Packages 2019/20 table There were no exit packages in 2019/20 but two payments for lieu in notice. Exit package cost Number of Cost of Number of Cost of other Total Total Number of Cost of band (including any compulsory compulsory other departures number cost of departures special special payment redundancies redundancies departures agreed of exit exit where payment element)) agreed packages packages special element payments included have been in exit made packages Whole Whole Whole Whole numbers numbers numbers numbers only £s only £s only £s only £s Less than £10,000 0 0 1 5,718 1 5,718 0 0 £10,000 - £25,000 0 0 0 0 0 0 0 0 £25,001 - £50,000 0 0 1 25,965 1 25,965 0 0 £50,001 - £100,000 0 0 0 0 0 0 0 0 £100,001 - £150,000 0 0 0 0 0 0 0 0 £150,001 - £200,000 0 0 0 0 0 0 0 0 >£200,000 0 0 0 0 0 0 0 0 Total 0 0 2 31,683 2 31,683 0 0 Agrees to A below Exit costs in this note are the full costs of departures agreed in the year. Where the Clinical Commissioning Group has agreed early retirements , the additional costs are met by the Clinical Commissioning Group and not by the Pension Scheme. Ill-health retirement costs are met by the NHS Pensions Scheme and are not include in the table. These tables report the number and value of exit packages agreed in the financial year. The expense associated with these departures may have been recognised in part or in full in a previous period.

143

Table 29: Analysis of Other Departures 2019/20

Agreements Total Value of agreements Number £000s Voluntary redundancies including early retirement contractual costs Mutually agreed resignations (MARS) contractual costs Early retirements in the efficiency of the service contractual costs Contractual payments in lieu 2 32 of notice* Exit payments following Employment Tribunals or court orders Non-contractual payments requiring HMT approval** TOTAL 2 32 (agrees to total)

As a single exit package can be made up of several components each of which will be counted separately in this Note, the total number above will not necessarily match the total numbers in table 28 and 29 which will be the number of individuals.

*any non-contractual payments in lieu of notice are disclosed under “non-contracted payments requiring HMT approval” below.

**includes any non-contractual severance payment made following judicial mediation, and X (list amounts) relating to non-contractual payments in lieu of notice.

144

Table 30: Exit Packages 2018/19

Exit package cost Number of Cost of Number of Cost of other Total Total Number of Cost of band (including any compulsory compulsory other departures number cost of departures special special payment redundancies redundancies departures agreed of exit exit where payment element)) agreed packages packages special element payments included have been in exit made packages

Whole Whole Whole Whole numbers numbers numbers numbers only £s only £s only £s only £s Less than £10,000 1 2,763 0 0 1 2,763 0 0 £10,000 - £25,000 0 0 0 0 0 0 0 0 £25,001 - £50,000 3 100,798 0 0 3 100,798 0 0 £50,001 - £100,000 1 73,333 0 0 1 73,333 0 0 £100,001 - £150,000 0 0 0 0 0 0 0 0 £150,001 - £200,000 0 0 0 0 0 0 0 0 >£200,000 0 0 0 0 0 0 0 0 Total 5 176,894 0 0 5 176,894 0 0 Agrees to A below

145

Table 31: Analysis of Other Departures 2018/19

Agreements Total Value of agreements Number £000s Voluntary redundancies 0 0 including early retirement contractual costs Mutually agreed resignations 0 0 (MARS) contractual costs Early retirements in the 0 0 efficiency of the service contractual costs Contractual payments in lieu 0 0 of notice* Exit payments following 0 0 Employment Tribunals or court orders Non-contractual payments 0 0 requiring HMT approval** TOTAL 0 0

146

Parliamentary Accountability and Audit Report

Bristol, North Somerset and South Gloucestershire CCG is not required to produce a Parliamentary Accountability and Audit Report. There were no gifts and remote contingent liabilities to note in the Financial Statements. Disclosures on losses and special payments, and fees and charges are included as notes in the Financial Statements of this report at pages 148 – 181. An audit certificate and report is also included in this Annual Report at page 182.

147

ANNUAL ACCOUNTS

Julia Ross

Chief Executive

24th June 2020

148

149 Data entered below will be used throughout the workbook:

Entity name: NHS Bristol, North Somerset and South Gloucestershire CCG This year 2019-20 Last year 2018-19 This year ended 31-March-2020 Last year ended 31-March-2019 This year commencing: 01-April-2019 Last year commencing: 01-April-2018

150 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

CONTENTS Page Number

The Primary Statements:

Statement of Comprehensive Net Expenditure for the year ended 31st March 2020 152 Statement of Financial Position as at 31st March 2020 153 Statement of Changes in Taxpayers' Equity for the year ended 31st March 2020 154 Statement of Cash Flows for the year ended 31st March 2020 155

Notes to the Accounts Note Accounting policies 1 156-161 Financial performance targets 2 162 Other operating revenue 3 163 Revenue 3 164 Employee benefits and staff numbers 4 165-167 Operating expenses 5 168 Better payment practice code 6 169 Operating leases 7 170 Property, plant and equipment 8 171 Intangible non-current assets 9 172 Trade and other receivables 10 173 Cash and cash equivalents 11 174 Trade and other payables 12 175 Provisions 13 176 Financial instruments 14 177-178 Operating segments 15 179 Related party transactions 16 180 Losses and special payments 17 181

151 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

Statement of Comprehensive Net Expenditure for the year ended 31 March 2020

2019-20 2018-19 Note £'000 £'000

Income from sale of goods and services 3 (6,602) (6,158) Other operating income 3 (82) (21) Total operating income (6,684) (6,179)

Staff costs 4 20,268 18,222 Purchase of goods and services 5 1,426,825 1,346,115 Depreciation and impairment charges 5 104 104 Provision expense 5 5 (47) Other Operating Expenditure 5 5,317 5,239 Total operating expenditure 1,452,519 1,369,633

Net Operating Expenditure 1,445,835 1,363,454

Finance income - - Finance expense - - Net expenditure for the year 1,445,835 1,363,454

Opening transfers by Absorption - 70,579 Total Net Expenditure for the Financial Year 1,445,835 1,434,033

Comprehensive Expenditure for the year ended 31 March 2020 1,445,835 1,434,033

The notes on pages 156 to 181 form part of this statement.

152 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

Statement of Financial Position as at 31 March 2020 2019-20 2018-19 Note £'000 £'000 Non-current assets: Property, plant and equipment 8 189 146 Intangible assets 9 - 31 Total non-current assets 189 177 Current assets: Trade and other receivables 10 17,735 14,328 Cash and cash equivalents 11 63 20 Total current assets 17,798 14,348

Total assets 17,987 14,525

Current liabilities Trade and other payables 12 (88,446) (97,177) Provisions 13 (58) (53) Total current liabilities (88,504) (97,230)

Non-Current Assets plus/less Net Current Assets/Liabilities (70,517) (82,705)

Financed by Taxpayers’ Equity General fund (70,517) (82,705) Total taxpayers' equity: (70,517) (82,705)

The notes on pages 156 to 181 form part of this statement

The financial statements on pages 152 to 181 were approved by the Audit, Governance and Risk Committee on 12th June 2020 with delegated authority from the Governing Body and signed on its behalf by:

Chief Executive Officer/Chief Accountable Officer

153 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

Statement of Changes In Taxpayers Equity for the year ended 31 March 2020 Total General fund reserves £'000 £'000 Changes in taxpayers’ equity for 2019-20

Balance at 01 April 2019 (82,705) (82,705)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2019-20 Net operating expenditure for the financial year (1,445,835) (1,445,835)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (1,445,835) (1,445,835) Net funding 1,458,023 1,458,023 Balance at 31 March 2020 (70,517) (70,517)

Total General fund reserves £'000 £'000 Changes in taxpayers’ equity for 2018-19

Balance at 01 April 2018 0 0 Opening transfers by absorption (70,579) (70,579) Adjusted NHS Clinical Commissioning Group balance at 01 April 2018 (70,579) (70,579)

Net operating costs for the financial year (1,363,454) (1,363,454)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (1,363,454) (1,363,454) Net funding 1,351,328 1,351,328 Balance at 31 March 2019 (82,705) (82,705)

The notes on pages 156 to 181 form part of this statement.

154 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

Statement of Cash Flows for the year ended 31 March 2020 2019-20 2018-19 Note £'000 £'000 Cash Flows from Operating Activities Net operating expenditure for the financial year (1,445,835) (1,363,454) Depreciation and amortisation 5 104 104 (Increase)/decrease in trade & other receivables 10 (3,407) (3,716) Increase/(decrease) in trade & other payables 12 (8,731) 15,814 Provisions utilised 13 0 (177) Increase/(decrease) in provisions 13 5 (47) Net Cash Inflow (Outflow) from Operating Activities (1,457,864) (1,351,476)

Cash Flows from Investing Activities (Payments) for property, plant and equipment 8 (116) 0 Net Cash Inflow (Outflow) from Investing Activities (116) 0

Net Cash Inflow (Outflow) before Financing (1,457,980) (1,351,476)

Cash Flows from Financing Activities Grant in Aid Funding Received 1,458,023 1,351,328 Net Cash Inflow (Outflow) from Financing Activities 1,458,023 1,351,328

Net Increase (Decrease) in Cash & Cash Equivalents 11 43 (148)

Cash & Cash Equivalents at the Beginning of the Financial Year 20 168 Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year 63 20

The notes on pages 156 to 181 form part of this statement.

155 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

Notes to the financial statements

1 Accounting Policies

NHS England has directed that the financial statements of clinical commissioning groups shall meet the accounting requirements of the Group Accounting Manual issued by the Department of Health and Social Care. Consequently, the following financial statements have been prepared in accordance with the Group Accounting Manual 2019-20 issued by the Department of Health and Social Care. The accounting policies contained in the Group Accounting Manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to clinical commissioning groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Group Accounting Manual permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the Clinical Commissioning Group for the purpose of giving a true and fair view has been selected. The particular policies adopted by the Clinical Commissioning Group are described below. They have been applied consistently in dealing with items considered material in relation to the accounts.

1.1 Going Concern

These accounts have been prepared on a going concern basis despite the issue of a report to the Secretary of State for Health and Social Care under Section 30 of the Local Audit and Accountability Act 2014.

Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents.

The Clinical Commissioning Group allocations for 2019/20 to 2023/24 were published in January 2019 and had final approval by the NHS England Board on 31 January 2019. The revenue allocations are backed by cash limits. Throughout this period, the Clinical Commissioning Group expects to maintain a positive cash flow and continue to meet the Better Payment Performance standard.

In 2019/20 the Clinical Commissioning Group had a £12,000k deficit control total against revenue resource limit approved by NHS England; and an in year deficit against revenue resource limit of £34,053k. NHS England have provided cash support to underwrite this position.

The Clinical Commissioning Group is in the process of agreeing a breakeven financial plan in principle with NHS England for 2020/21 set within the framework of the Five Year Long Term Plan. The Long Term Plan enables the Clinical Commissioning Group to achieve a recurrent deficit of less than 1% deficit by 2021/22 and 1% surplus in future years. The 2020/21 NHS England Operating Plan guidance describes an intention of writing off 50% of historic accumulated resource limit deficits, in this context.

The Clinical Commissioning Group’s plan includes clearly identified investments and the savings target needed to deliver the proposed plan. The savings plan is supported by a structured and detailed programme developed from the control centres and supported by a Sustainability and Transformation Partnership Transformation programme. Performance management of savings includes regular review and reporting, risk assessment and mitigation and programme support from a dedicated programme management office.

In March 2020 there was a global pandemic caused by a novel coronavirus - Covid 19. The impact on healthcare delivery in direct response to this virus, changes in demand and capacity for other healthcare and the impact on wider society (through social distancing and the so-called 'lockdown') and economy has been dramatic. Two specifics items of relevance are firstly, the UK Government publically stating it will fund the NHS 'whatever it takes' to manage the pandemic; and secondly a significant overhaul of the financial architecture of the NHS, for example suspending the current financial performance management regime, moving all NHS providers onto a cost based 'block' payment regime, authorising pre-payments of one months operating costs to NHS providers, centralising the procurement of Independent Sector Capacity, providing new funding for Hospital Discharge Programme and NHS Nightingale 'surge' capacity. Taken together this package and Government statements effectively demonstrate how the Clinical Commissioning Group, as a statutory body in the NHS, will have it's finances supported by the Government for the period of the pandemic and in the event of any future radical change to demand and funding for healthcare.

On this basis of the above the Clinical Commissioning Group considers it remains a going concern with no material uncertainties.

1.2 Accounting Convention

These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities.

1.3 Better Care Fund Aligned Budgets

The CCG and Bristol City Council, North Somerset Council and South Gloucestershire Council have agreed to treat the Better Care Fund as a non- pooled fund. The terms of this are set out in the section 75 agreement. Both parties have chosen to contract with individual providers without reference to each other using their own sources of funding alone and it is for this reason that neither party considers they are operating a pooled budget.

1.4 Critical Accounting Judgements & Key Sources of Estimation Uncertainty

In the application of the Clinical Commissioning Group’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods.

The CCG reviews the Section 75 agreements with Bristol City Council, North Somerset Council and South Gloucestershire Council to determine which party has control over the services being delivered, in accordance with IFRS 11 and the accounting policy at 1.3. As control of each of the elements of the Section 75 agreements resides with either the CCG or the relevant Council, the CCG considers that there is not a joint arrangement as defined in IFRS 11.

156 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

Notes to the financial statements

1.4.1 Critical Judgements in Applying Accounting Policies

The following are the critical judgements that management has made in the process of applying the Clinical Commissioning Group’s accounting policies that have the most significant effect on the amounts recognised in the financial statements:

The Clinical Commissioning Group has implemented the Better Care Fund Initiative via an aligned budget arrangements under Section 75 of the NHS Act 2006 with Bristol City Council, North Somerset Unitary Authority and South Gloucestershire Unitary Authority.

Management has reviewed the accounting transaction regarding the Better Care Fund and has made a judgement that the appropriate accounting arrangement is alignment (also see note 1.3 above).

1.4.2 Key Sources of Estimation Uncertainty

During March 2020 there was a global pandemic caused by novel coronviarus - Covid 19. As described in Note 1 this has radically changed demand for healthcare in the short term. The Clinical Commissioning Group has considered the impact of this on the estimates in the accounts and chosen to continue to estimate on an historic basis. This is due to the lack of precedent to establish more accurate estimates; and the estimates are temporary in nature and are expected to revert to long term trends in time; and therefore using historic basis still presents a true and fair view of the expenditure, assets and liabilities and financial performance of the Clinical Commissioning Group. There are no other sources of estimation uncertainty that have a significant risk of causing a material adjustment to the carrying amounts of assets and liabilities within the next financial year that require disclosure.

1.5 Operating Segments

Income and expenditure are analysed in the Operating Segments note and are reported in line with management information used within the Clinical Commissioning Group.

1.6 Revenue

Total net revenue expenditure for the year (before transfers) of £1,446m is funded by in-year revenue resource allocations from NHS England totalling £1,412m resulting in a deficit of £34m. The revenue resource allocation is accounted for by crediting the General Fund, but this funding is only drawn down from NHS England and accounted for, to meet payments as they fall due. The total funding credited to the General Fund during the year was equal to the revenue resource allocation (see Statement of Changes in Taxpayers Equity ).

In the application of IFRS 15 a number of practical expedients offered in the Standard have been employed. These are as follows; • As per paragraph 121 of the Standard the Clinical Commissioning Group will not disclose information regarding performance obligations part of a contract that has an original expected duration of one year or less, • The Clinical Commissioning Group is to similarly not disclose information where revenue is recognised in line with the practical expedient offered in paragraph B16 of the Standard where the right to consideration corresponds directly with value of the performance completed to date. • The FReM has mandated the exercise of the practical expedient offered in C7(a) of the Standard that requires the Clinical Commissioning Group to reflect the aggregate effect of all contracts modified before the date of initial application.

The Clinical Commissioning Group’s financial position is controlled by a limit on net expenditure rather than funding from DHSC. As such the Clinical Commissioning Group's income from other activities is very limited. The most significant element being R&D income. The Clinical Commissioning Group does not enter into long term revenue contracts (most income arises from recharging past performance) and so the assessment indicates that there is no impact on income recognition from adopting IFRS 15.

1.7 Employee Benefits

1.7.1 Short-term Employee Benefits

Salaries, wages and employment-related payments, including payments arising from the apprenticeship levy, are recognised in the period in which the service is received from employees, including bonuses earned but not yet taken.

The cost of leave earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period.

1.7.2 Retirement Benefit Costs

Past and present employees are covered by the provisions of the NHS Pensions Schemes. These schemes are unfunded, defined benefit schemes that cover NHS employers, General Practices and other bodies allowed under the direction of the Secretary of State in England and Wales. The schemes are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the schemes are accounted for as though they were defined contribution schemes: the cost to the Clinical Commissioning Group of participating in a scheme is taken as equal to the contributions payable to the scheme for the accounting period.

For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to expenditure at the time the Clinical Commissioning Group commits itself to the retirement, regardless of the method of payment.

The schemes are subject to a full actuarial valuation every four years and an accounting valuation every year.

1.8 Purchase of Goods and Services and Other Expenses

The purchase of goods and services and other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable.

157 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

Notes to the financial statements

1.90 Property, Plant & Equipment

1.9.1 Recognition

Property, plant and equipment is capitalised if: · It is held for use in delivering services or for administrative purposes; · It is probable that future economic benefits will flow to, or service potential will be supplied to the Clinical Commissioning Group; · It is expected to be used for more than one financial year; · The cost of the item can be measured reliably; and, · The item has a cost of at least £5,000; or, · Collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or, · Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost.

Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives.

1.9.2 Measurement

IT equipment and furniture and fittings that are held for operational use are valued at depreciated historic cost where these assets have short useful economic lives or low values or both, as this is not considered to be materially different from current value in existing use.

1.9.3 Subsequent Expenditure

Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised. Where subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing carrying value of the item replaced is written- out and charged to operating expenses.

1.10 Intangible Assets

1.10.1 Recognition

Intangible assets are non-monetary assets without physical substance, which are capable of sale separately from the rest of the Clinical Commissioning Group’s business or which arise from contractual or other legal rights. They are recognised only: · When it is probable that future economic benefits will flow to, or service potential be provided to, the Clinical Commissioning Group; · Where the cost of the asset can be measured reliably; and, · Where the cost is at least £5,000.

Software that is integral to the operating of hardware, for example an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software that is not integral to the operation of hardware, for example application software, is capitalised as an intangible asset. Expenditure on research is not capitalised but is recognised as an operating expense in the period in which it is incurred. Internally-generated assets are recognised if, and only if, all of the following have been demonstrated: · The technical feasibility of completing the intangible asset so that it will be available for use; · The intention to complete the intangible asset and use it; · The ability to sell or use the intangible asset; · How the intangible asset will generate probable future economic benefits or service potential; · The availability of adequate technical, financial and other resources to complete the intangible asset and sell or use it; and, · The ability to measure reliably the expenditure attributable to the intangible asset during its development.

1.10.2 Measurement

Intangible assets acquired separately are initially recognised at cost. The amount initially recognised for internally-generated intangible assets is the sum of the expenditure incurred from the date when the criteria above are initially met. Where no internally-generated intangible asset can be recognised, the expenditure is recognised in the period in which it is incurred.

Following initial recognition, intangible assets are carried at current value in existing use by reference to an active market, or, where no active market exists, at the lower of amortised replacement cost or the value in use where the asset is income generating . Internally-developed software is held at historic cost to reflect the opposing effects of increases in development costs and technological advances. Revaluations and impairments are treated in the same manner as for property, plant and equipment.

1.11 Depreciation, Amortisation & Impairments

Depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the Clinical Commissioning Group expects to obtain economic benefits or service potential from the asset. This is specific to the Clinical Commissioning Group and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over the shorter of the lease term and the estimated useful life.

At each reporting period end, the Clinical Commissioning Group checks whether there is any indication that any of its property, plant and equipment assets or intangible non-current assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount of the asset is estimated to determine whether there has been a loss and, if so, its amount. Intangible assets not yet available for use are tested for impairment annually.

158 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

Notes to the financial statements

A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Where an impairment loss subsequently reverses, the carrying amount of the asset is increased to the revised estimate of the recoverable amount but capped at the amount that would have been determined had there been no initial impairment loss. The reversal of the impairment loss is credited to expenditure to the extent of the decrease previously charged there and thereafter to the revaluation reserve.

1.12 Leases

Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases.

1.12.1 The Clinical Commissioning Group as Lessee

Property, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the clinical commissioning group’s surplus/deficit.

Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term.

Contingent rentals are recognised as an expense in the period in which they are incurred.

Where a lease is for land and buildings, the land and building components are separated and individually assessed as to whether they are operating or finance leases.

1.13 Cash & Cash Equivalents

Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value.

In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the Clinical Commissioning Group’s cash management.

1.14 Provisions

Provisions are recognised when the Clinical Commissioning Group has a present legal or constructive obligation as a result of a past event, it is probable that the Clinical Commissioning Group will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties. Where a provision is measured using the cash flows estimated to settle the obligation, its carrying amount is the present value of those cash flows using HM Treasury’s discount rate.

A provision for potential redundancy resulting from the merger of the three BNSSG CCGs was made in 2017-18. There is a remaining balance of £58k to cover one remaining potential redundancy.

1.15 Clinical Negligence Costs

NHS Resolution operates a risk pooling scheme under which the Clinical Commissioning Group pays an annual contribution to NHS Resolution, which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although NHS Resolution is administratively responsible for all clinical negligence cases, the legal liability remains with Clinical Commissioning Group.

1.16 Non-clinical Risk Pooling

The Clinical Commissioning Group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the Clinical Commissioning Group pays an annual contribution to the NHS Resolution and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due.

159 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

Notes to the financial statements

1.17 Continuing healthcare risk pooling

In 2014-15 a risk pool scheme was introduced by NHS England for continuing healthcare claims, for claim periods prior to 31 March 2013. Under the scheme, Clinical Commissioning Groups contributed annually to a national fund up to 2016-17, which has been used to settle these claims. There has been no further contribution from the Clinical Commissioning Group (see guidance note below from NHSE) as the national fund is deemed to be sufficient to cover any further outstanding claims.

Claims that have arisen since April 2013 with a retrospective element dating back to a maximum of 1.4.2013, have been assessed and, if appropriate, paid from the current year budget. Therefore, in each accounting period there may be some costs relating to previous years but the budget has funding for this (based on historical spend being built into the baseline) which obviates the need for a provision. It is also very difficult to estimate the level of retrospective liabilities as cases are not known until a claim is made and an estimate cannot be made with any certainty.

Guidance note: NHS England: Settlement of legacy PUPoC NHS Continuing Healthcare (NHS CHC) liabilities – Updated Process and Guidance on Completion of the Financial CHC Non-ISFE return for 17-18

‘As confirmed in the letter from Louise Hampson, Interim Director of Financial Control dated 29 December 2016, NHS England will continue to make reimbursements to CCGs from the centrally held reserve in relation to PUPoC CHC claims and no further contribution will be required from CCGs.’

1.18 Financial Assets

Financial assets are recognised when the Clinical Commissioning Group becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred.

Financial assets are classified into the following categories: · Financial assets at amortised cost; · Financial assets at fair value through other comprehensive income and ; · Financial assets at fair value through profit and loss.

The classification is determined by the cash flow and business model characteristics of the financial assets, as set out in IFRS 9, and is determined at the time of initial recognition.

1.18.1 Financial Assets at Amortised cost

Financial assets measured at amortised cost are those held within a business model whose objective is achieved by collecting contractual cash flows and where the cash flows are solely payments of principal and interest. This includes most trade receivables and other simple debt instruments. After initial recognition these financial assets are measured at amortised cost using the effective interest method less any impairment. The effective interest rate is the rate that exactly discounts estimated future cash receipts through the life of the financial asset to the gross carrying amount of the financial asset.

1.18.2 Financial assets at fair value through other comprehensive income

Financial assets held at fair value through other comprehensive income are those held within a business model whose objective is achieved by both collecting contractual cash flows and selling financial assets and where the cash flows are solely payments of principal and interest.

1.18.3 Financial assets at fair value through profit and loss

Financial assets measure at fair value through profit and loss are those that are not otherwise measured at amortised cost or fair value through other comprehensive income. This includes derivatives and financial assets acquired principally for the purpose of selling in the short term.

1.18.4 Impairment

For all financial assets measured at amortised cost or at fair value through other comprehensive income (except equity instruments designated at fair value through other comprehensive income), lease receivables and contract assets, the Clinical Commissioning Group recognises a loss allowance representing the expected credit losses on the financial asset.

The Clinical Commissioning Group adopts the simplified approach to impairment in accordance with IFRS 9, and measures the loss allowance for trade receivables, lease receivables and contract assets at an amount equal to lifetime expected credit losses. For other financial assets, the loss allowance is measured at an amount equal to lifetime expected credit losses if the credit risk on the financial instrument has increased significantly since initial recognition (stage 2) and otherwise at an amount equal to 12 month expected credit losses (stage 1).

HM Treasury has ruled that central government bodies may not recognise stage 1 or stage 2 impairments against other government departments, their executive agencies, the Bank of England, Exchequer Funds and Exchequer Funds assets where repayment is ensured by primary legislation. The Clinical Commissioning Group therefore does not recognise loss allowances for stage 1 or stage 2 impairments against these bodies. Additionally Department of Health and Social Care provides a guarantee of last resort against the debts of its arm's lengths bodies and NHS bodies and the Clinical Commissioning Group does not recognise allowances for stage 1 or stage 2 impairments against these bodies.

For financial assets that have become credit impaired since initial recognition (stage 3), expected credit losses at the reporting date are measured as the difference between the asset's gross carrying amount and the present value of the estimated future cash flows discounted at the financial asset's original effective interest rate. Any adjustment is recognised in profit or loss as an impairment gain or loss.

IFRS 9 financial instruments

The Clinical Commissioning Group does not have the powers to enter into complex financial instruments and so the main categories of financial instrument are in relation to debtors and creditors. In terms of invoices raised by the Clinical Commissioning Group there is a credit risk assessment undertaken at the point where the invoice is raised. The Clinical Commissioning Group’s main debt exposure is in respect of Local Authorities and, to a lesser extent, other NHS bodies. In line with the DHSC Accounting Manual, IFRS 9 has been adopted to exclude recognition of stage1 and stage2 impairments with core central government departments. In terms of other non WGA debts, which by their very nature are low in value, the risk is assessed as extremely low.

1.19 Financial Liabilities

Financial liabilities are recognised on the statement of financial position when the Clinical Commissioning Group becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are derecognised when the liability has been discharged, that is, the liability has been paid or has expired.

160 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

Notes to the financial statements

1.19.1 Financial Guarantee Contract Liabilities

Financial guarantee contract liabilities are subsequently measured at the higher of: · The premium received (or imputed) for entering into the guarantee less cumulative amortisation; and, · The amount of the obligation under the contract, as determined in accordance with IAS 37: Provisions, Contingent Liabilities and Contingent Assets.

1.19.2 Financial Liabilities at Fair Value Through Profit and Loss

Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial liabilities at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the Clinical Commissioning Group’s surplus/deficit. The net gain or loss incorporates any interest payable on the financial liability.

1.19.3 Other Financial Liabilities

After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method, except for loans from Department of Health and Social Care, which are carried at historic cost. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method.

1.20 Value Added Tax

Most of the activities of the Clinical Commissioning Group are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

1.21 Foreign Currencies

The Clinical Commissioning Group’s functional currency and presentational currency is pounds sterling and amounts are presented in thousands of pounds unless expressly stated otherwise. Transactions denominated in a foreign currency are translated into sterling at the exchange rate ruling on the dates of the transactions. At the end of the reporting period, monetary items denominated in foreign currencies are retranslated at the spot exchange rate on 31 March. Resulting exchange gains and losses for either of these are recognised in the Clinical Commissioning Group’s surplus/deficit in the period in which they arise.

1.22 Losses & Special Payment

Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled.

Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had the Clinical Commissioning Group not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure).

1.23 Accounting Standards That Have Been Issued But Have Not Yet Been Adopted

The Department of Health and Social Care GAM does not require the following IFRS Standards and Interpretations to be applied in 2019-20. These Standards are still subject to HM Treasury FReM adoption, with IFRS 16 being for implementation in 2021-22, and the government implementation date for IFRS 17 still subject to HM Treasury consideration. ● IFRS 16 Leases – The Standard is effective 1 April 2021 as adapted and interpreted by the FReM. ● IFRS 17 Insurance Contracts – Application required for accounting periods beginning on or after 1 January 2021, but not yet adopted by the FReM: early adoption is not therefore permitted.

It is estimated that the implementation of IFRS 16 Leases will not have a significant impact on the accounts. It is anticipated that the leases will be valued at £2m with matching liability obligations to the lessor.

Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the clinical commissioning group’s surplus/deficit. This accounting change will have minimal impact on the Clinical Commissioning Group's financial position.

161 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

2 Financial performance targets

The Clinical Commissioning Group have a number of financial duties under the NHS Act 2006 (as amended).

The Clinical Commissioning Group performance against those duties was as follows:

2019-20 2019-20 2019-20 2018-19 2018-19 2018-19 Target Performance Variance Target Performance Variance £000s £000s £000s £000s £000s £000s

Expenditure not to exceed income 1,418,582 1,452,635 (34,053) 1,369,633 1,369,633 - Capital resource use does not exceed the amount specified in Directions 116 116 - - - - Revenue resource use does not exceed the amount specified in Directions 1,411,782 1,445,835 (34,053) 1,363,454 1,363,454 - Capital resource use on specified matter(s) does not exceed the amount specified in Directions ------Revenue resource use on specified matter(s) does not exceed the amount specified in Directions ------Revenue administration resource use does not exceed the amount specified in Directions 21,665 20,637 1,028 22,344 18,887 3,457

It is allowable to use Running Costs allocations to support programme expenditure

The Clinical Commissioning Group set an annual plan with an in year deficit of £12.0m. The 2019-20 Financial Plan had a savings requirement of £41.4m and identified risks of £13.9m, as well as £13.9m potential mitigations, including full release of 0.5% contingency reserve.

The Clinical Commissioning Group outturn is a deficit of £34.053m and adverse to plan of £22.053m. The underlying recurrent deficit carried-forward into 2020-21 is estimated to be £37.066m. This includes re-instatement of 0.5% contingency reserve of £6.3m, and takes into account non-recurrent savings delivery in 2019/20 offset by non-recurrent exenditure reductions such as Category M drug costs and mental health out of area placements.

The Clinical Commissioning Group's saving programme, known as Quality, Innovation, Productivity and Prevention (QIPP), delivered savings of £30.7m (73%) against a target of £41.4m. The unidentified element of the QIPP target, £6.2m, included in the total of £41.4m, has been off-set by non-recurrent release of 0.5% contingency reserve. This gives an in-year shortfall of £4.4m. The table below provides the detail by Programme area.

The 2020-21 budget has been set with a deficit of £2.9m, as part of a four year plan to achieve an annual surplus of £20m by 2023-24. Outturn 2019-2020 Savings Plan & Achievement Target Achievement Variance Control Centre £'000 £'000 £'000 Planned, Ref Mgt, Cancer, Diagnostics 5,996 4,630 (1,365) Urgent and Community Care 6,458 2,580 (3,878) Mental Health 2,300 2,745 445 Primary Care 1,400 1,400 0 Medicines Optimisation 13,395 14,668 1,273 Complex Individual Care 2,584 1,674 (910) Other Enabling and Back Office 3,000 3,000 0 Identified Schemes 35,133 30,697 (4,436)

Unidentified (off-set by CCG Contingency Fund) 6,229 6,229 0

BNSSG total savings plan 41,362 36,926 (4,436)

2019-20 2018-19 £000s £000s

Programme Expenditure 1,431,800 1,350,746 Administration Expenditure 20,719 18,887 Total Expenditure 1,452,519 1,369,633

Programme Income (6,602) (6,088) Administration Income (82) (91) Total Income (6,684) (6,179)

Total Net Expenditure for the year 1,445,835 1,363,454

Revenue Resource Limit (RRL) 1,411,782 1,363,454

Surplus/(Deficit) (34,053) 0

Surplus/(Deficit) % of Revenue Resource Limit -2.41% 0.00%

162 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

3 Other Operating Revenue 2019-20 2018-19 Total Total £'000 £'000

Income from sale of goods and services (contracts) Non-patient care services to other bodies 6,438 6,020 Other Contract income 164 138 Total Income from sale of goods and services 6,602 6,158

Other operating income Charitable and other contributions to revenue expenditure: non-NHS 82 21 Total Other operating income 82 21

Total Operating Income 6,684 6,179

Revenue in this note does not include cash received from NHS England, which is drawn down directly into the bank account of the Clinical Commissioning Group and credited to the General Fund.

Revenue is totally from the supply of services. The Clinical Commissioning Group receives no money from sale of goods.

£ 5.2m (£5.1m 2018-2019 ) of this revenue figure relates to income from the Department of Health for Research and Development.

163 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

3.1 Disaggregation of Income - Income from sale of good and services (contracts)

Non-patient care Other Contract services to other income bodies £'000 £'000 Source of Revenue NHS 5,485 - Non NHS 953 164 Total 6,438 164

Non-patient care Other Contract services to other income bodies £'000 £'000 Timing of Revenue Point in time 6,438 164 Total 6,438 164

3.2 Transaction price to remaining contract performance obligations

Contract revenue expected to be recognised in the future periods related to contract performance obligations not Revenue expected Revenue expected Revenue expected 2019-20 Total from Other DHSC from Non-DHSC from NHSE Bodies Group Bodies Group Bodies £000s £000s £000s £000s Not later than 1 year - - - - Later than 1 year, not later than 5 years - - - - Later than 5 Years - - - - Total - - - -

164 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

4. Employee benefits and staff numbers

4.1.1 Employee benefits Total 2019-20

Permanent Employees Other Total £'000 £'000 £'000 Employee Benefits Salaries and wages 14,580 1,172 15,752 Social security costs 1,642 0 1,642 Employer Contributions to NHS Pension scheme 2,808 0 2,808 Apprenticeship Levy 66 0 66 Gross employee benefits expenditure 19,096 1,172 20,268

Total - Net admin employee benefits including capitalised costs 19,096 1,172 20,268

4.1.1 Employee benefits Total 2018-19

Permanent Employees Other Total £'000 £'000 £'000 Employee Benefits Salaries and wages 13,347 1,599 14,946 Social security costs 1,452 0 1,452 Employer Contributions to NHS Pension scheme 1,771 0 1,771 Apprenticeship Levy 53 0 53 Gross employee benefits expenditure 16,623 1,599 18,222

Total - Net admin employee benefits including capitalised costs 16,623 1,599 18,222

165 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

4.2 Average number of people employed 2019-20 2018-19 Permanently Permanently employed Other Total employed Other Total Number Number Number Number Number Number

Total 336.44 13.85 350.29 300.51 19.55 320.06

Of the above: Number of whole time equivalent people engaged on capital projects ------

4.3 Exit packages agreed in the financial year

2019-20 2019-20 2019-20 Compulsory redundancies Other agreed departures Total Number £ Number £ Number £ Less than £10,000 - - 1 5,718 1 5,718 £10,001 to £25,000 ------£25,001 to £50,000 - - 1 25,965 1 25,965 £50,001 to £100,000 ------£100,001 to £150,000 ------£150,001 to £200,000 ------Over £200,001 ------Total - - 2 31,683 2 31,683

2018-19 2018-19 2018-19 Compulsory redundancies Other agreed departures Total Number £ Number £ Number £ Less than £10,000 1 2,763 1 2,763 £10,001 to £25,000 - - - - £25,001 to £50,000 3 100,798 - - 3 100,798 £50,001 to £100,000 1 73,333 - - 1 73,333 £100,001 to £150,000 ------£150,001 to £200,000 ------Over £200,001 ------Total 5 176,894 - - 5 176,894

Analysis of Other Agreed Departures 2019-20 2018-19 Other agreed departures Other agreed departures Number £ Number £ Contractual payments in lieu of notice 2 31,683 - - Total 2 31,683 - -

These tables report the number and value of exit packages agreed in the financial year. The expense associated with these departures may have been recognised in part or in full in a previous period.

Redundancy and other departure costs have been paid in accordance with the provisions of the NHS terms and conditions of service (Agenda for Change).

Exit costs are accounted for in accordance with relevant accounting standards and at the latest in full in the year of departure.

166 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

4.5 Pension costs

Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions.

Both are unfunded defined benefit schemes that cover NHS employers, General Practices and other bodies allowed under the direction of the Secretary of State for Health and Social Care in England and Wales. They are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities.

Therefore, the each scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each scheme is taken as equal to the contributions payable to the scheme for the accounting period.

In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that "the period between formal valuations shall be four years, with approximate assessments in intervening years". An outline of these follows:

The employer contribution rate for NHS Pensions increased from 14.3% to 20.6% from 1st April 2019. For 2019/20, NHS CCGs continued to pay over contributions at the former rate with the additional amount being paid by NHS England on CCGs behalf. The full cost and related funding has been recognised in these accounts.

4.5.1 Accounting valuation

A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and is accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2020, is based on valuation data as 31 March 2019 updated to 31 March 2020 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme is contained in the report of the scheme actuary, which forms part of the annual NHS Pension Scheme Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office.

4.5.2 Full actuarial (funding) valuation into account recent demographic experience), and to recommend contribution rates payable by employees and employers.

The last actuarial valuation undertaken for the NHS Pension Scheme was completed as at 31 March 2016. The results of this valuation set the employer contribution rate payable from April 2019 to 20.6%, and the Scheme Regulations were amended accordingly.

The 2016 funding valuation was also expected to test the cost of the Scheme relative to the employer cost cap set following the 2012 valuation. Following a judgment from the Court of Appeal in December 2018 Government announced a pause to that part of the valuation process pending conclusion of the continuing legal process.

167 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

5. Operating expenses 2019-20 2018-19 Notes Total Total £'000 £'000

Purchase of goods and services Services from other CCGs and NHS England 6,778 7,306 Services from foundation trusts 314,180 297,346 Services from other NHS trusts 474,570 459,504 Services from Other WGA bodies 1,238 942 Purchase of healthcare from non-NHS bodies 337,718 307,471 Purchase of social care 4,055 3,733 Prescribing costs 129,951 122,713 Pharmaceutical services 0 4 GPMS/APMS and PCTMS 143,440 136,787 Supplies and services – clinical 5,155 4,260 Supplies and services – general 90 (80) Consultancy services 693 836 Establishment 2,602 1,847 Transport 105 57 Premises 4,091 2,349 Audit fees 78 102 1 & 2 Other non statutory audit expenditure · Other services - 57 Other professional fees 1,392 449 3 Legal fees 315 287 Education, training and conferences 374 145 Total Purchase of goods and services 1,426,825 1,346,115

Depreciation and impairment charges Depreciation 73 73 Amortisation 31 31 Total Depreciation and impairment charges 104 104

Provision expense Change in discount rate - - Provisions 5 (47) Total Provision expense 5 (47)

Other Operating Expenditure Chair and Non Executive Members 258 329 Research and development (excluding staff costs) 5,059 4,859 Expected credit loss on receivables - 3 Other expenditure 0 48 Total Other Operating Expenditure 5,317 5,239

Total operating expenditure 1,432,251 1,351,411

Notes 1. External audit liability is capped at £2m. 2. External audit fees net of VAT £65,000 (£85,000 2018-2019) 3. Internal Audit services are provided by an external provider RSM Risk Assurance Services LLP and fees for 2019-2020 totalled £62,400 net of VAT and these fees are included in the 'Other professional fees'.

168 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

6. Better Payment Practice Code

Measure of compliance 2019-20 2019-20 2018-19 2018-19 Number £'000 Number £'000 Non-NHS Payables Total Non-NHS Trade invoices paid in the Year 24,007 510,243 25,017 484,214 Total Non-NHS Trade Invoices paid within target 23,657 501,135 24,435 473,595 Percentage of Non-NHS Trade invoices paid within target 98.54% 98.21% 97.67% 97.81%

NHS Payables Total NHS Trade Invoices Paid in the Year 4,963 833,213 5,641 759,393 Total NHS Trade Invoices Paid within target 4,904 831,076 5,598 757,837 Percentage of NHS Trade Invoices paid within target 98.81% 99.74% 99.24% 99.80%

There were no payments made from claims under Late Payment of Commercial Debts (Interest ) Act 1998.

169 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

7. Operating Leases

7.1 As lessee

The Clinical Commissioning Group occupies and commissioning services in properties owned and managed by NHS Property Services Ltd and Community Health Partnerships Ltd. The costs incurred in relation to NHS Property Services Ltd and Community Health Partnerships are shown on Note 7.1 below.

Whilst our arrangements with Community Health Partnerships Ltd and NHS Property Services Ltd fall within the definition of operating leases, the rental charge for future years has not yet been agreed.

Consequently, this note includes only the known future lease payments from the other rental arrangements and does not include future minimum lease payments for these arrangements.

7.1.1 Payments recognised as an Expense 2019-20 2018-19 Land Buildings Other Total Land Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Payments recognised as an expense Minimum lease payments - 2,715 - 2,715 - 2,007 6 2,013 Contingent rents ------Sub-lease payments ------Total - 2,715 - 2,715 - 2,007 6 2,013

7.1.2 Future minimum lease payments 2019-20 2018-19 Land Buildings Other Total Land Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Payable: No later than one year ------Between one and five years ------After five years ------Total ------

170 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

8 Property, plant and equipment

Information Furniture & 2019-20 technology fittings Total £'000 £'000 £'000 Cost or valuation at 01 April 2019 605 100 705

Additions purchased 116 - 116 Cost/Valuation at 31 March 2020 721 100 821

Depreciation 01 April 2019 459 100 559

Charged during the year 73 - 73 Depreciation at 31 March 2020 532 100 632

Net Book Value at 31 March 2020 189 - 189

Purchased 189 - 189 Total at 31 March 2020 189 - 189

Asset financing:

Owned 189 - 189

Total at 31 March 2020 189 - 189

8.1 Cost or valuation of fully depreciated assets

The cost or valuation of fully depreciated assets still in use was as follows:

2019-20 2019-20 £'000 £'000 Information technology 365 365 Furniture & fittings 102 102 Total 467 467

8.2 Economic lives Minimum Life Maximum Life (years) (Years) Information technology 1 5 Furniture & fittings 1 5

171 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

9 Intangible non-current assets Computer Software: 2019-20 Purchased Total £'000 £'000 Cost or valuation at 01 April 2019 62 62

Cost / Valuation At 31 March 2020 62 62

Amortisation 01 April 2019 31 31

Charged during the year 31 31 Amortisation At 31 March 2020 62 62

Net Book Value at 31 March 2020 - -

9.1 Cost or valuation of fully amortised assets

The cost or valuation of fully depreciated assets still in use was as follows: 2019-20 2018-19 £'000 £'000 Computer software: purchased 62 - Total 62 -

9.2 Economic lives Minimum Life Maximum Life (years) (Years) Computer software: purchased 2 5

172 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

10.1 Trade and other receivables Current Current 2019-20 2018-19 £'000 £'000

NHS receivables: Revenue 7,229 3,397 NHS prepayments 4,742 4,542 NHS accrued income 142 1,042 Non-NHS and Other WGA receivables: Revenue 2,208 3,012 Non-NHS and Other WGA prepayments 2,823 428 Non-NHS and Other WGA accrued income 210 1,368 Expected credit loss allowance-receivables (3) (3) VAT 336 496 Other receivables and accruals 48 46 Total Trade & other receivables 17,735 14,328

Total current and non current 17,735 14,328

Included above: Prepaid pensions contributions - -

The great majority of trade is with NHS England. As NHS England is funded by Government no credit scoring is considered necessary.

£3,140,985 of the amount above has subsequently been recovered post the statement of financial position date.

10.2 Receivables past their due date but not impaired 2019-20 2019-20 2018-19 2018-19 DHSC Group Non DHSC DHSC Group Non DHSC Bodies Group Bodies Bodies Group Bodies £'000 £'000 £'000 £'000 By up to three months 494 27 79 178 By three to six months 15 - 107 2 By more than six months 581 - 134 - Total 1,090 27 320 180

Trade and other receivables - Non Total DHSC Group Bodies 10.3 Loss allowance on asset classes £'000 £'000 Balance at 01 April 2019 (3) (3) Total (3) (3)

The Clinical Commissioning Group did not hold any collateral against receivables outstanding at 31 March 2020.

173 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

11 Cash and cash equivalents

2019-20 2018-19 £'000 £'000 Balance at 01 April 2019 20 168 Net change in year 43 (148) Balance at 31 March 2020 63 20

Made up of: Cash with the Government Banking Service 62 19 Cash in hand 1 1 Cash and cash equivalents as in statement of financial position 63 20

Bank overdraft: Government Banking Service - - Bank overdraft: Commercial banks - - Total bank overdrafts - -

Balance at 31 March 2020 63 20

174 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

Current Current 12 Trade and other payables 2019-20 2018-19 £'000 £'000

NHS payables: Revenue 4,436 21,334 NHS accruals 6,066 3,534 Non-NHS and Other WGA payables: Revenue 5,474 16,669 Non-NHS and Other WGA accruals 70,080 53,572 Social security costs 259 232 Tax 216 200 Other payables and accruals 1,915 1,636 Total Trade & Other Payables 88,446 97,177

Total current and non-current 88,446 97,177

There are no liabilities included in the above for person/people due in future years under arrangements to buy out the liability for early retirement over 5 years.

Other payables include £1,728,016 outstanding pension contributions at 31 March 2020

175 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

13 Provisions Current Current 2019-20 2018-19 £'000 £'000 Redundancy 58 53 Total 58 53

Total current and non-current 58 53

Redundancy Total £'000 £'000

Balance at 01 April 2019 53 53

Arising during the year 5 5 Balance at 31 March 2020 58 58

Expected timing of cash flows: Within one year 58 58 Balance at 31 March 2020 58 58

Redundancy provision as a result of the merger of the three BNSSG CCGs. Value is the current estimate of potential redundant post but there is no agreement with the postholder as at the Statement of Financial Position date. The postholder is seconded within the Clinical Commissioning Group.

176 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

14 Financial instruments

14.1 Financial risk management

Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities. Disclosures of fair values are not required as per IFRS 7 as the SOFP carrying amount is a reasonable approximation of fair value and mainly relate to short term trade receivables and payables.

Because Clinical Commissioning Group is financed through parliamentary funding, it is not exposed to the degree of financial risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The Clinical Commissioning Group has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the Clinical Commissioning Group in undertaking its activities.

Treasury management operations are carried out by the finance department, within parameters defined formally within the Clinical Commissioning Group standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by the Clinical Commissioning Group and internal auditors.

14.1.1 Currency risk

The Clinical Commissioning Group is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The Clinical Commissioning Group has no overseas operations. The Clinical Commissioning Group and therefore has low exposure to currency rate fluctuations.

14.1.2 Interest rate risk

The Clinical Commissioning Group borrows from government for capital expenditure, subject to affordability as confirmed by NHS England. The borrowings are for 1 to 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The Clinical Commissioning Group therefore has low exposure to interest rate fluctuations.

14.1.3 Credit risk

Because the majority of the Clinical Commissioning Group and revenue comes parliamentary funding, Clinical Commissioning Group has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed in the trade and other receivables note.

14.1.4 Liquidity risk

The Clinical Commissioning Group is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. The Clinical Commissioning Group draws down cash to cover expenditure, as the need arises. The Clinical Commissioning Group is not, therefore, exposed to significant liquidity risks.

14.1.5 Financial Instruments

As the cash requirements of NHS England are met through the Estimate process, financial instruments play a more limited role in creating and managing risk than would apply to a non-public sector body. The majority of financial instruments relate to contracts to buy non-financial items in line with NHS England's expected purchase and usage requirements and NHS England is therefore exposed to little credit, liquidity or market risk.

177 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

14 Financial instruments cont'd

14.2 Financial assets

Financial Assets measured at amortised cost Total 2019-20 2019-20 £'000 £'000

Trade and other receivables with NHSE bodies 6,132 6,132 Trade and other receivables with other DHSC group bodies 1,523 1,523 Trade and other receivables with external bodies 2,182 2,182 Cash and cash equivalents 63 63 Total at 31 March 2020 9,900 9,900

14.3 Financial liabilities

Financial Liabilities measured at amortised cost Total 2019-20 2019-20 £'000 £'000

Trade and other payables with NHSE bodies 1,094 1,094 Trade and other payables with other DHSC group bodies 30,064 30,064 Trade and other payables with external bodies 56,812 56,812 Total at 31 March 2020 87,970 87,970

178 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

15 Operating segments

Gross Income Net expenditure Total assets Total liabilities Net assets expenditure £'000 £'000 £'000 £'000 £'000 £'000 Commissioning Healthcare 1,452,519 (6,684) 1,445,835 17,987 (88,504) (70,517) Total 1,452,519 (6,684) 1,445,835 17,987 (88,504) (70,517)

15.1 Reconciliation between Operating Segments and SoCNE

2019-20 £'000 Total net expenditure reported for operating segments 1,445,835 Total net expenditure per the Statement of Comprehensive Net Expenditure 1,445,835

15.2 Reconciliation between Operating Segments and SoFP

2019-20 £'000 Total assets reported for operating segments 17,987 Total assets per Statement of Financial Position 17,987

2019-20 £'000 Total liabilities reported for operating segments (88,504) Total liabilities per Statement of Financial Position (88,504)

179 NHS Bristol, North Somerset and South Gloucestershire CCG - Annual Accounts 2019-20

16 Related party transactions

Details of related party transactions with individuals are as follows:

2019-20 2018-19

Receipts Amounts Amounts Payments Receipts Amounts Amounts from owed to due from to from owed to due from Payments to Related Related Related Related Related Related Related Related Party Party Party Party Party Party Party Party £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Janet Baptiste-Grant (Interim Director of Nursing 72 0 0 0 35 0 0 0 & Quality) - Baptiste Grant Ltd Director /owner of Baptiste Grant Ltd Deborah El-Sayed (Director of Transformation) - 357 0 0 0 351 0 0 0 British Red Cross Trustee British Red Cross 1,237 0 37 0 1,576 0 0 0 Peter Brindle (Medical Director -Clinical Effectiveness), Rachel Kenyon (GP Locality Representative), Jon Evans (GP Locality Representative) - GP Care Peter Brindle and Rachel Kenyon are shareholders in GP Care, Jon Evans belongs to a GP Practice that is a shareholder in GP Care Alison Moon (Independent Lay Member - 1,941 0 0 0 1,721 0 6 0 Registered Nurse) - St Peter's Hospice Alison Moon is a Trustee of St Peters Hospice Julie Thallon (Interim Director of Quality) -Meraki 50 0 8 0 0 0 0 0 Interim Solutions Ltd owner/director of Meraki Interim Solutions Ltd

The Department of Health and Social Care is the parent department and is regarded as a related party. During the year the Clinical Commissioning Group has had a significant number of material transactions with entities for which the Department is regarded as the parent Department. For example: • NHS England; • NHS Foundation Trusts - significant parties University Hospitals NHS FT & South Western Ambulance FT; • NHS Trusts - significant parties Weston Area Health NHS Trust & North Bristol NHS Trust; • NHS Litigation Authority; and, • NHS Business Services Authority.

In addition, the Clinical Commissioning Group has had a number of material transactions with other government departments and other central and local government bodies. These transactions with Bristol City Council, North Somerset Council and South Gloucestershire Council have a total net spend of £79.6m in 2019/20 (£69.6m 2018/19). See table below for further deatils.

Expenditure with Local Authorities

South Bristol City North Somerset Total Gloucestershire Council Council Council £m £m £m £m Net expenditure 2019-20 79.6 31.3 31.3 17.0

Net expenditure 2018-19 69.6 27.9 25.0 16.7

Significant areas of expenditure Better Care Fund 2019-20 35.9 Better Care Fund 2018-19 33.5 Funded Nursing care 2019-20 18.7 Funded Nursing care 2018-19 18.0 Contining Health Care - Complex Clients 2019-20 13.8 Contining Health Care - Complex Clients 2018-19 9.0 N Somerset Adult Continuing Health Care 2019-20 11.2 N Somerset Adult Continuing Health Care 2018-19 9.1

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17 Losses and special payments

17.1 Losses

The total number of NHS clinical commissioning group losses and special payments cases, and their total value, was as follows:

Total Total Total Total Number Value of Number Value of of Cases Cases of Cases Cases 2019-20 2019-20 2018-19 2018-19 Number £'000 Number £'000 Cash losses 1 - 1 - Total 1 - 1 -

There was one cash loss totalling £187 for the write off a salary overpayment.

17.2 Special payments

Total Total Total Total Number Value of Number Value of of Cases Cases of Cases Cases 2019-20 2019-20 2018-19 2018-19 Number £'000 Number £'000

Ex Gratia Payments - - 1 2 Total - - 1 2

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Independent auditor's report to the members of the Governing Body of NHS Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group

Report on the Audit of the Financial Statements

Opinion We have audited the financial statements of NHS Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group (the ‘CCG’) for the year ended 31 March 2020, which comprise the Statement of Comprehensive Net Expenditure, the Statement of Financial Position, the Statement of Changes in Taxpayers Equity, the Statement of Cash Flows and notes to the financial statements, including a summary of significant accounting policies. The financial reporting framework that has been applied in their preparation is applicable law and International Financial Reporting Standards (IFRSs) as adopted by the European Union, and as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2019 to 2020. In our opinion, the financial statements:

 give a true and fair view of the financial position of the CCG as at 31 March 2020 and of its expenditure and income for the year then ended; and

 have been properly prepared in accordance with International Financial Reporting Standards (IFRSs) as adopted by the European Union, as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2019 to 2020; and

 have been prepared in accordance with the requirements of the Health and Social Care Act 2012.

Basis for opinion We conducted our audit in accordance with International Standards on Auditing (UK) (ISAs (UK)) and applicable law. Our responsibilities under those standards are further described in the ‘Auditor’s responsibilities for the audit of the financial statements’ section of our report. We are independent of the CCG in accordance with the ethical requirements that are relevant to our audit of the financial statements in the UK, including the FRC’s Ethical Standard, and we have fulfilled our other ethical responsibilities in accordance with these requirements. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion.

The impact of macro-economic uncertainties on our audit Our audit of the financial statements requires us to obtain an understanding of all relevant uncertainties, including those arising as a consequence of the effects of macro-economic uncertainties such as Covid- 19 and Brexit. All audits assess and challenge the reasonableness of estimates made by the Accountable Officer and Chief Executive and the related disclosures and the appropriateness of the going concern basis of preparation of the financial statements. All of these depend on assessments of the future economic environment and the CCG’s future operational arrangements. Covid-19 and Brexit are amongst the most significant economic events currently faced by the UK, and at the date of this report their effects are subject to unprecedented levels of uncertainty, with the full range of possible outcomes and their impacts unknown. We applied a standardised firm-wide approach in response to these uncertainties when assessing the CCG’s future operational arrangements. However, no audit should be expected to predict the unknowable factors or all possible future implications for an entity associated with these particular events.

Conclusions relating to going concern We have nothing to report in respect of the following matters in relation to which the ISAs (UK) require us to report to you where:

 the Accountable Officer and Chief Executive’s use of the going concern basis of accounting in the preparation of the financial statements is not appropriate; or

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 the Accountable Officer and Chief Executive has not disclosed in the financial statements any identified material uncertainties that may cast significant doubt about the CCG’s ability to continue to adopt the going concern basis of accounting for a period of at least twelve months from the date when the financial statements are authorised for issue. In our evaluation of the Accountable Officer and Chief Executive’s conclusions, and in accordance with the expectation set out within the Department of Health and Social Care Group Accounting Manual 2019 to 2020 that the CCG’s financial statements shall be prepared on a going concern basis, we considered the risks associated with the CCG’s operating activities, including effects arising from macro-economic uncertainties such as Covid-19 and Brexit. We analysed how those risks might affect the CCG’s financial resources or ability to continue operations over the period of at least twelve months from the date when the financial statements are authorised for issue. In accordance with the above, we have nothing to report in these respects. However, as we cannot predict all future events or conditions and as subsequent events may result in outcomes that are inconsistent with judgements that were reasonable at the time they were made, the absence of reference to a material uncertainty in this auditor's report is not a guarantee that the CCG will continue in operation.

Other information The Accountable Officer and Chief Executive is responsible for the other information. The other information comprises the information included in the Annual Report, other than the financial statements and our auditor’s report thereon. Our opinion on the financial statements does not cover the other information and, except to the extent otherwise explicitly stated in our report, we do not express any form of assurance conclusion thereon. In connection with our audit of the financial statements, our responsibility is to read the other information and, in doing so, consider whether the other information is materially inconsistent with the financial statements or our knowledge obtained in the audit or otherwise appears to be materially misstated. If we identify such material inconsistencies or apparent material misstatements, we are required to determine whether there is a material misstatement in the financial statements or a material misstatement of the other information. If, based on the work we have performed, we conclude that there is a material misstatement of the other information, we are required to report that fact. We have nothing to report in this regard.

Other information we are required to report on by exception under the Code of Audit Practice Under the Code of Audit Practice published by the National Audit Office in April 2015 on behalf of the Comptroller and Auditor General (the Code of Audit Practice) we are required to consider whether the Governance Statement does not comply with the guidance issued by the NHS Commissioning Board or is misleading or inconsistent with the information of which we are aware from our audit. We are not required to consider whether the Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls. We have nothing to report in this regard.

Opinion on other matters required by the Code of Audit Practice In our opinion:

 the parts of the Remuneration and Staff Report to be audited have been properly prepared in accordance with IFRSs as adopted by the European Union, as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2019 to 2020 and the requirements of the Health and Social Care Act 2012; and

 based on the work undertaken in the course of the audit of the financial statements and our knowledge of the CCG gained through our work in relation to the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources, the other information published together with the financial statements in the Annual Report for the financial year for which the financial statements are prepared is consistent with the financial statements.

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Qualified opinion on regularity required by the Code of Audit Practice

In our opinion, except for the effects of the matter described in the basis for qualified opinion on regularity section of our report, in all material respects the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions in the financial statements conform to the authorities which govern them. Basis for qualified opinion on regularity The CCG reported expenditure of £1,453 million against income of £1,419 million and a deficit of £34.1 million in its financial statements for the year ending 31 March 2020. The CCG thereby breached two of its duties under the National Health Service Act 2006, as amended by paragraphs 223H and 223I of Section 27 of the Health and Social Care Act 2012, to ensure that annual expenditure does not exceed income and revenue resource use does not exceed the amount specified by direction of the NHS Commissioning Board.

Matters on which we are required to report by exception Under the Code of Audit Practice, we are required to report to you if:

 we issue a report in the public interest under Section 24 of the Local Audit and Accountability Act 2014 in the course of, or at the conclusion of the audit; or

 we refer a matter to the Secretary of State under Section 30 of the Local Audit and Accountability Act 2014 because we have reason to believe that the CCG, or an officer of the CCG, is about to make, or has made, a decision which involves or would involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency; or

 we make a written recommendation to the CCG under Section 24 of the Local Audit and Accountability Act 2014 in the course of, or at the conclusion of the audit. We have nothing to report in respect of the above matters except on 23 April 2020 we referred a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014 in relation to NHS Bristol, North Somerset and South Gloucestershire CCG’s deficit budget and planned breach of its revenue resource limit for the year ending 31 March 2020.

Responsibilities of the Accountable Officer and Chief Executive and Those Charged with Governance for the financial statements As explained more fully in the Statement of Accountable Officer and Chief Executive's responsibilities set out on pages 87 to 88 the Accountable Officer and Chief Executive, is responsible for the preparation of the financial statements in the form and on the basis set out in the Accounts Directions, for being satisfied that they give a true and fair view, and for such internal control as the Accountable Officer and Chief Executive determines is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error. In preparing the financial statements, the Accountable Officer and Chief Executive is responsible for assessing the CCG’s ability to continue as a going concern, disclosing, as applicable, matters related to going concern and using the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity. The Accountable Officer and Chief Executive is responsible for ensuring the regularity of expenditure and income in the financial statements. The Audit, Governance and Risk Committee is Those Charged with Governance. Those Charged with Governance are responsible for overseeing the CCG’s financial reporting process.

Auditor’s responsibilities for the audit of the financial statements Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue an auditor’s report that includes our opinion. Reasonable assurance is a high level of assurance but is not a guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists.

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Misstatements can arise from fraud or error and are considered material if, individually or in the aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of these financial statements. A further description of our responsibilities for the audit of the financial statements is located on the Financial Reporting Council’s website at: www.frc.org.uk/auditorsresponsibilities. This description forms part of our auditor’s report. We are also responsible for giving an opinion on the regularity of expenditure and income in the financial statements in accordance with the Code of Audit Practice.

Report on other legal and regulatory requirements – Conclusion on the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources

Qualified conclusion

On the basis of our work, having regard to the guidance issued by the Comptroller & Auditor General in December 2019, except for the effects of the matter described in the basis for qualified conclusion section of our report, we are satisfied that, in all significant respects, NHS Bristol, North Somerset and South Gloucestershire CCG put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2020.

Basis for qualified conclusion

Our review of the CCG's arrangements for securing economy, efficiency and effectiveness in its use of resources identified the following matter:

The CCG agreed a financial plan with NHS England to deliver an in-year deficit of £12m. During the year, the CCG's financial position deteriorated, and it was unable to recover the position by the year- end, incurring a deficit of £34.1million. This was caused largely by overspends within continuing healthcare and slippage in savings plans. The CCG planned to make efficiency savings of £41.1 million during 2019/20, but only delivered £30.7 million (74%) of these in year.

This matter identifies weaknesses in the CCG's arrangements for setting a sustainable budget with sufficient capacity to absorb emerging cost pressures. This matter is evidence of weaknesses in proper arrangements for sustainable resource deployment in planning finances effectively to support the sustainable delivery of strategic priorities and maintain statutory functions.

Responsibilities of the Accountable Officer and Chief Executive As explained in the Governance Statement, the Accountable Officer and Chief Executive is responsible for putting in place proper arrangements for securing economy, efficiency and effectiveness in the use of the CCG's resources.

Auditor’s responsibilities for the review of the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources We are required under Section 21(1)(c) and Schedule 13 paragraph 10(a) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and to report where we have not been able to satisfy ourselves that it has done so. We are not required to consider, nor have we considered, whether all aspects of the CCG's arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively. We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criterion issued by the Comptroller and Auditor General in April 2020, as to whether in all significant respects, the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined this criterion as that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the CCG put in place

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proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2020, and to report by exception where we are not satisfied. We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to be satisfied that the CCG has put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources.

Report on other legal and regulatory requirements – Certificate We certify that we have completed the audit of the financial statements of NHS Bristol, North Somerset and South Gloucestershire CCG in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.

Use of our report This report is made solely to the members of the Governing Body of the CCG, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014. Our audit work has been undertaken so that we might state to the members of the Governing Body of the CCG those matters we are required to state to them in an auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the CCG and the members of the Governing Body of the CCG, as a body, for our audit work, for this report, or for the opinions we have formed.

Barrie Morris Barrie Morris, Key Audit Partner for and on behalf of Grant Thornton UK LLP, Local Auditor

Bristol 24 June 2020

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BRISTOL, NORTH SOMERSET & SOUTH GLOUCESTERSHIRE CCG

Annual internal audit report 2019/20

5 June 2020

This report is solely for the use of the persons to whom it is addressed. To the fullest extent permitted by law, RSM Risk Assurance Services LLP will accept no responsibility or liability in respect of this report to any other party.

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THE ANNUAL INTERNAL AUDIT OPINION This report provides an annual internal audit opinion, based upon and limited to the work performed, on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes. The opinion should contribute to the organisation's annual governance reporting. The opinion Scope and limitations of our work For the 12 months ended 31 March 2020, the head of internal audit opinion for The formation of our opinion is achieved through a risk-based plan of work, BNSSG CCG is as follows: agreed with management and approved by the audit and risk committee. Our opinion is subject to inherent limitations, as detailed below:

• internal audit has not reviewed all risks and assurances relating to the organisation; • the opinion is substantially derived from the conduct of risk-based plans generated from an organisation-led assurance framework. The assurance

framework is one component that the board takes into account in making its annual governance statement (AGS); • the opinion is based on the work undertaken, the scope of which was Please see appendix A for the full range of annual opinions available to us in agreed with management / lead individual; preparing this report and opinion. • where strong levels of control have been identified, there are still instances where these may not always be effective. This may be due to human It remains management’s responsibility to develop and error, incorrect management judgement, management override, controls maintain a sound system of risk management, internal being by-passed or a reduction in compliance; control and governance, and for the prevention and • due to the limited scope of our audits, there may be weaknesses in the detection of material errors, loss or fraud. The work of control system which we are not aware of, or which were not brought to internal audit should not be a substitute for management our attention; and responsibility around the design and effective operation of these systems. • Our internal audit work for 2019/20 was largely completed prior to the advent of the substantial operational disruptions caused by the Covid-19 pandemic. As such our audit work and annual opinion does not reflect the situation which has arisen in the final weeks of the year. We do, however, recognise that there has been a significant impact on both the operations of the organisation and its risk profile.

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FACTORS AND FINDINGS WHICH HAVE INFORMED OUR OPINION We have finalised eight assurance assignment reports for the year, of which five had a reasonable assurance opinion and two substantial assurance. We did raise two high risk action and therefore split the assurance opinion in the Financial Management and QIPP audit, whereby the effectiveness opinion was partial assurance, due to the position reported at the time of audit which showed that £6.7m of the planned £41.4m savings had not been identified, and the CCG was forecasting a £20.5m deficit, against its original planned deficit of £7m. We provided a reasonable assurance opinion over the design and application.

We agreed a further 11 medium risk actions with management to address other areas of weakness or risk exposure identified in the five reasonable assurance audits. Reasonable assurance and therefore positive conclusions were noted in the following areas:

Assignment Opinion issued

Corporate Policy Review Process Reasonable assurance

Delegated Commissioning Reasonable assurance

Financial Management and QIPP Reasonable assurance

Learning Disability Mortality Review Programme (LeDeR) Reasonable assurance

Any Qualified Provider (AQP) Commissioning and Contract Management Reasonable assurance

IT Disaster Recovery & Business Continuity Reasonable assurance

We did not undertake the planned risk management audit in 2019/20 as this was moved to an advisory workshop approach for governing body members, however, due to Covid-19 this was pushed back and was subsequently delivered on 2 June. A further risk management audit is scheduled in the first six months of 2020/21.

Topics judged relevant for consideration as part of the annual governance statement Based on the work we have undertaken to date on the CCG’s system on internal control, we do not consider that within these areas there are any issues that need to be flagged as significant control issues within the AGS, although the CCG may wish to consider the potential significance of the financial outturn, assigned a partial assurance opinion in relation to delivery of QIPPs, as set out above. The CCG may wish to consider whether any other issues have arisen, as well as recognise the challenging financial environment within which the CCG is operating, including the results of any external reviews, when determining whether anything should be highlighted within the AGS.

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THE BASIS OF OUR INTERNAL AUDIT OPINION As well as those headlines previously discussed, the following areas have helped to inform our opinion. A summary of internal audit work undertaken, and the resulting conclusions, is provided at appendix B.

We reviewed the Service Auditor Report from the internal auditors for the Acceptance of internal audit management actions South Central and West Commissioning Support Unit covering financial Management have agreed actions to address all of the findings reported and payroll services. Whilst a number of exceptions were identified as by the internal audit service during 2019/20. part of the review there was nothing of sufficient significance to undermine our overall opinion for the CCG.

Implementation of internal audit management We reviewed the Service Auditor Report from the internal auditors for NHS actions Digital in regard to GP Payments. Testing for one of the controls identified an exception but there was no significant impact for the CCG on its overall Where actions have been agreed by management, these are being control environment. monitored by Internal Audit through the action tracking process, with progress reported to each Audit, Governance and Risk Committee. We reviewed the Service Auditor Report from the internal auditors for NHS Business Services Authority in regard to prescription We did not perform a formal follow up audit in 2019/20 of all actions raised payments. Exceptions were identified on testing for three of the controls by the CCGs previous internal auditors, however, we have worked with although there was no significant impact for the CCG on its overall control CCG management to harmonise previous and legacy audit actions and environment. have added ongoing actions to our current action tracker, where these remain pertinent and are continuing to track progress of these actions. We have not yet received the Service Auditor Report in relation to Capita and therefore cannot place any reliance on the controls operated on behalf Working with other assurance providers of the CCG. Service Auditor reports Other assurance providers We reviewed the Service Auditor Report from the internal auditors of NHS We have liaised with the Local Counter Fraud Specialist and External Shared Business Services who, provide services to the CCG. No Audit as appropriate during the course of the year. exceptions were noted and there is therefore no negative impact on the control environment. We did not undertake a review of the Data Security Protection Toolkit for 2019/20 as alternative assurance was provided to the CCG by NHS Digital.

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OUR PERFORMANCE

Wider value adding delivery

Area of work How has this added value? Internal Audit agility To ensure internal audit continues to be focused and reflects changes in risk prioritisation we made a number of in-year changes to the internal audit plan. All changes were reported to and agreed by the Audit & Risk Committee and management.

Liaison with NHS England We liaised with NHS England to help confirm the CCG’s compliance with the NHS England IA Framework for Primary Care audits, based on work previously undertaken.

Data Analytics We used data analytics in our financial controls work to look at both supplier and pay data, not only to provide holistic assurance and identify significant outliers but to help improve the centralised controls. This also made the audit process more efficient and required less burden on the finance staff.

Health Matters As part of our client service commitment, during 2019/20 we have issued our NHS sector client briefings and provided our quarterly NHS publication ‘Health Matters’ which provides insights into topical issues within the sector.

Cyber publications We have shared various cyber security publications during the year, including the output from a detailed multi- sector survey to help understand industry awareness and strategies.

Off-payroll working (IR35) Our Tax team have prepared several documents on off-payroll working which we have circulated to the Finance team.

Trust in the Boardroom Our document was circulated which discusses how effective corporate governance is a passport to success and how it is the Governing Body’s responsibility to secure an ethical future for an organisation.

Healthcare benchmarking We have shared benchmarking information with the CCG including our annual report on the outcomes of Internal Audit opinions across our NHS client base. We have also shared outlines of those areas where our CCG clients have experienced fraud investigations to help highlight potential fraud risks. Audit Committee Involvement We contributed to the discussions at the Audit, Governance and Risk Committee on various items on the agenda to ensure that the Trust benefits from wider input, in order to strengthen its governance arrangements.

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Conflicts of interest RSM has not undertaken any work or activity during 2019/20 that would lead us to declare any conflict of interest.

Conformance with internal auditing standards RSM affirms that our internal audit services are designed to conform to the Public Sector Internal Audit Standards (PSIAS).

Under PSIAS, internal audit services are required to have an external quality assessment every five years. Our risk assurance service line commissioned an external independent review of our internal audit services in 2016 to provide assurance whether our approach meets the requirements of the International Professional Practices Framework (IPPF) published by the Global Institute of Internal Auditors (IIA) on which PSIAS is based.

The external review concluded that 'there is a robust approach to the annual and assignment planning processes and the documentation reviewed was thorough in both terms of reports provided to audit and risk committee and the supporting working papers.' RSM was found to have an excellent level of conformance with the IIA’s professional standards.

The risk assurance service line has in place a quality assurance and improvement programme to ensure continuous improvement of our internal audit services. Resulting from the programme, there are no areas which we believe warrant flagging to your attention as impacting on the quality of the service we provide to you.

Quality assurance and continual improvement To ensure that RSM remains compliant with the PSIAS framework we have a dedicated internal Quality Assurance Team who undertake a programme of reviews to ensure the quality of our audit assignments. This is applicable to all Heads of Internal Audit, where a sample of their clients will be reviewed. Any findings from these reviews are used to inform the training needs of our audit teams.

This is in addition to any feedback we receive from our post assignment surveys, client feedback, appraisal processes and training needs assessments.

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APPENDIX A: ANNUAL OPINIONS

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

Annual opinions Factors influencing our opinion The factors which are considered when influencing our opinion are: • inherent risk in the area being audited; • limitations in the individual audit assignments; • the adequacy and effectiveness of the risk management and / or governance control framework; • the impact of weakness identified; • the level of risk exposure; and • the response to management actions raised and timeliness of actions taken.

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APPENDIX B: SUMMARY OF 2019/20 INTERNAL AUDIT WORK

All of the assurance levels and outcomes provided above should be considered in the context of the scope, and the limitation of scope, set out in the individual assignment report.

Assignment Executive lead at time of review Assurance level Actions agreed L M H

Corporate Policy Review Process Chief Finance Officer Reasonable assurance 1 4 0 [⚫] Conflicts of Interest Chief Finance Officer Substantial assurance 3 0 0 [⚫] Delegated Commissioning Director of Commissioning Reasonable assurance 2 1 0 [⚫] Financial Management and QIPP Chief Finance Officer Reasonable assurance 0 1 2 (design and application) [⚫] Partial assurance (effectiveness) [⚫] Financial Controls and Reporting Chief Finance Officer Substantial assurance 2 0 0 [⚫]

Learning Disability Mortality Review Programme (LeDeR) Director of Quality Reasonable assurance [⚫] 3 1 0

Director of Commissioning Reasonable assurance Any Qualified Provider (AQP) Commissioning and Contract Management 1 2 0 [⚫]

IT Disaster Recovery & Business Continuity Chief Finance Officer Reasonable assurance [⚫] 4 2 0

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APPENDIX C: OPINION CLASSIFICATION

We use the following levels of opinion classification within our internal audit reports, reflecting the level of assurance the board can take:

Taking account of the issues identified, the board cannot take assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied or effective.

Urgent action is needed to strengthen the control framework to manage the identified risk(s).

Taking account of the issues identified, the board can take partial assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied or effective.

Action is needed to strengthen the control framework to manage the identified risk(s).

Taking account of the issues identified, the board can take reasonable assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective.

However, we have identified issues that need to be addressed in order to ensure that the control framework is effective in managing the identified

risk(s).

Taking account of the issues identified, the board can take substantial assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective.

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YOUR INTERNAL AUDIT TEAM

Nick Atkinson Vickie Gould

[email protected] [email protected]

07730 300307 07740 631140

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The matters raised in this report are only those which came to our attention during the course of our review and are not necessarily a comprehensive statement of all the weaknesses that exist or all improvements that might be made. Actions for improvements should be assessed by you for their full impact. This report, or our work, should not be taken as a substitute for management’s responsibilities for the application of sound commercial practices. We emphasise that the responsibility for a sound system of internal controls rests with management and our work should not be relied upon to identify all strengths and weaknesses that may exist. Neither should our work be relied upon to identify all circumstances of fraud and irregularity should there be any.

Our report is prepared solely for the confidential use of BNSSG CCG, and solely for the purposes set out herein. This report should not therefore be regarded as suitable to be used or relied on by any other party wishing to acquire any rights from RSM Risk Assurance Services LLP for any purpose or in any context. Any third party which obtains access to this report or a copy and chooses to rely on it (or any part of it) will do so at its own risk. To the fullest extent permitted by law, RSM Risk Assurance Services LLP will accept no responsibility or liability in respect of this report to any other party and shall not be liable for any loss, damage or expense of whatsoever nature which is caused by any person’s reliance on representations in this report.

This report is released to you on the basis that it shall not be copied, referred to or disclosed, in whole or in part (save as otherwise permitted by agreed written terms), without our prior written consent.

We have no responsibility to update this report for events and circumstances occurring after the date of this report.

RSM Risk Assurance Services LLP is a limited liability partnership registered in England and Wales no. OC389499 at 6th floor, 25 Farringdon Street, London EC4A 4AB.

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