NHS Mid Essex CCG Annual Report and Accounts 2019/20
We want everyone in mid Essex to livewell NHS Mid Essex CCG Annual Report and Accounts 2019/20 Contents Contents...... 2 Chair’s foreword ...... 3 1. Performance Report ...... 4 Accountable Officer’s introduction ...... 4 1.1 Performance Overview ...... 5 1.1.1 What Mid Essex CCG does ...... 5 1.1.2 Key issues and challenge ...... 12 1.1.3 Performance Summary ...... 17 1.1.4 Financial Overview ...... 21 1.2 Performance Analysis ...... 26 1.2.1 Improve quality ...... 26 1.2.2 Health and wellbeing strategy ...... 33 1.2.3 Engaging people and communities...... 34 1.2.4 Reducing health inequality ...... 41 1.2.5 Detailed review of the CCG’s development and performance ...... 43 1.2.6 Sustainable development ...... 51 2. Accountability Report...... 53 2.1 Corporate Governance Report...... 54 2.1.1 Members Report – member practices ...... 54 2.1.2 Composition of Governing Body ...... 55 2.1.3 Personal-data-related incidents ...... 60 2.1.4 Statement as to disclosure to auditors ...... 60 2.1.5 Donations to political parties and charitable organisations ...... 60 2.1.6 Modern Slavery Act ...... 61 2.1.7 Statement of Accountable Officer’s Responsibilities...... 61 2.2 Governance Statement ...... 63 2.2.1 Scope of responsibility ...... 63 2.2.2 Governance arrangements and effectiveness ...... 64 2.2.3 Risk management arrangements and effectiveness ...... 71 2.2.4 Other sources of assurance ...... 73 2.2.5 Control Issues...... 78 2.2.6 Review of economy, efficiency and effectiveness of the use of resources ...... 79 2.2.7 Review of the effectiveness of governance, risk management and internal control ...... 83 2.3 Remuneration and Staff Report ...... 84 2.3.1 Remuneration Committee Report ...... 84 2.3.2 CCG staff ...... 93 2.3.3 Expenditure on consultancy ...... 100 2.3.4 Off-payroll engagements ...... 100 2.3.5 Pension liabilities ...... 101 2.4 Parliamentary Accountability and Audit Report ...... 102 3. Independent Auditor’s Report to the Members of the Governing Body ...... 103 4. Annual Accounts ...... 106 Appendix A: Glossary of non-financial terms ...... 107 Appendix B: Glossary of financial terms ...... 109
2 NHS Mid Essex CCG Annual Report and Accounts 2019/20 Chair’s foreword
It is something of a cliché to say, “It has been a busy year,” in an annual report but 2019/20 has proven to be uniquely challenging to say the least. The principal reason for this of course is the pandemic of novel coronavirus known as COVID-19.
This global threat to our health has seen an unprecedented response from the NHS and partner organisations. NHS Mid Essex Clinical Commissioning Group (CCG) and our neighbouring CCGs in the south of the county were a key part of organising the local response to the virus to limit its spread and treat the people who fell ill as a result of the virus.
It will probably be some time before we have a full understanding of the effect COVID-19 has had on our health and care system and our society, but I can already say with a great deal of confidence that Mid Essex CCG’s member GP practices and staff have all made an enormous effort to help our residents to livewell through the pandemic.
Many of the nurses who work in the CCG’s Quality team, whose work you can read about later in this report, returned to front-line care. Pharmacists from our Medicine Optimisation team joined them, and some of our non-clinical staff were also redeployed across mid and south Essex, even into other parts of the NHS, so we could act in as unified and coordinated fashion as possible.
Local GPs had to change completely the way they worked to protect their staff and patients, in an almost impossibly short time-frame. And our acute hospitals and community NHS providers totally shifted focus of their work to coronavirus response. Swift action was needed to save lives and I am hugely proud of my fellow NHS and social care colleagues, and other key workers who have helped us stay on our feet, for their vital efforts during what many have found a frightening time.
Months before the COVID-19 outbreak, Mid Essex CCG was already managing another, more localised, outbreak of invasive Group A streptococcus or iGAS. We led the incident management of this outbreak and worked in partnership with our community healthcare provider, regional bodies and other partners. The incident management team had planned to publish an independent serious incident investigation report on the iGAS outbreak in the Spring of 2020. The purpose of this independent investigation was to draw together the findings and learnings from those affected or involved in managing the incident, so steps may be taken to reduce the risk of reoccurrence.
NHS resources, like many other public services, are now focused on responding to the COVID-19 pandemic. In April 2020, we informed families affected by the iGAS outbreak and other stakeholders that we would release the report once the NHS has started to recover from the impact of COVID-19. However, we will not let the delay stop us making improvements that can be actioned now. Our thoughts remain with all those who lost their lives to both iGAS and COVID-19.
Dr Anna Davey Chair, NHS Mid Essex CCG
16 June 2020
3 NHS Mid Essex CCG Annual Report and Accounts 2019/20 1. Performance Report
Accountable Officer’s introduction
I contribute to this Annual Report within 40 days of starting as interim Accountable Officer, or AO, for the 5 Mid and South Essex CCGs. When asked to step into the role of Joint AO (and Lead Executive for the Health and Care Partnership of which the CCGs are part) I expected much of my time to be focused on strengthening the commissioning and other functions across our geography.
So, I was very appreciative of the outgoing Accountable Officers’ in-depth handovers and pleased to see how much progress local GP practices had made in forming Primary Care Networks. Such changes lay the foundations for delivery of the NHS Long Term Plan that you can read more about in section 1.1.1 below.
Then COVID-19 overtook all of us – and almost everything. Rather than attending meetings with partners and residents about our plans, the pandemic required all of us in the NHS to develop new ways of working very quickly, as Dr Davey mentions in her foreword.
CCG staff achieved this quickly and relatively smoothly, establishing a single COVID-19 Incident Management Team for mid and south Essex with dedicated workstreams to support the pandemic response across the full range of activities for which our organisation carries prime responsibility. Without these arrangements it would have been impossible to coordinate what we are doing to combat COVID-19 and save lives.
The new teams have developed ‘on the fly’ but are ensuring that everyone is kept informed about their activities, ensuring good governance as well as effective communication.
Eventually the pandemic will pass and we will be able to re-set our system. When that happens, I would expect recruitment for the permanent Joint Accountable Officer for the 5 CCGs to progress swiftly. In the meantime I will continue to work with the senior management team to support staff and make sure our organisation can do what is expected of it. The application for Mid Essex CCG to merge with the 4 CCGs in south Essex that we had intended to submit to NHS England and Improvement in September 2020 will have to wait a while. You can read more about the merger plans in section 1.1.2.
We will of course keep all our stakeholders updated and we are grateful for the continuing support we are receiving from partners and our communities. I hope the achievements outlined in this report will demonstrate that, even in changing times, there will always be a place for organisations like ours that add value in healthcare. Stay safe.
Anthony McKeever Joint Accountable Officer, Mid and South Essex CCGs Executive Lead, Mid and South Essex Health and Care Partnership
16 June 2020
4 NHS Mid Essex CCG Annual Report and Accounts 2019/20 1.1 Performance Overview
This section explains what the CCG does and provides a snapshot of the CCG’s core work in 2019/20. The overview also shows our performance against key NHS targets, the way we work with our many partner organisations and how our funding is used.
1.1.1 What Mid Essex CCG does
NHS Mid Essex CCG is a clinically-led organisation responsible, since April 2013, for the planning, buying and monitoring – a process called commissioning – of most NHS care in Braintree District, Chelmsford City and Maldon District. These three “localities” cover an area of about 520 square miles and are collectively Mid Essex boundary District/city boundary known as mid Essex, as shown on the map to the left.
We were set up by the Health and Social Care Act 2012, which made major changes to the way the NHS works, locally and nationally. One of the most significant changes the Act brought to the NHS was putting GPs at the heart of planning care for their communities. As of 31 March 2020, the CCG is made up of 40 general practices in mid Essex. They are listed in full in section 2.1.1 of this report.
Our member practices elect GPs to represent local views on our governing body, the Board. Our Chair, Clinical Vice Chair and some of the other Board members are experienced mid Essex GPs.
There is more information about CCGs on the NHS Clinical Commissioners website, but we can set out our main goal in one sentence:
We want everyone in mid Essex to livewell.
This means making sure that you, your family and loved ones have high-quality health services that support you to stay well throughout your life within the resources we have available. To do that, we buy your NHS hospital care, medicines and prescribing, mental health services, urgent
5 NHS Mid Essex CCG Annual Report and Accounts 2019/20 care, community care and ambulance services. And as noted at the beginning of this report, we also undertake emergency planning and response to incidents such as outbreaks of disease.
NHS Mid Essex CCG – facts and figures Population (registered with a GP) Total Mid Essex GP-registered population is 397,162 at 1 January 2020 Number of member GP practices 40 (with about 250 GPs between them) at 31 March 2020 CCG Headquarters Wren House, Hedgerows Business Park, Colchester Road, Chelmsford, Essex, CM2 5PF Number of CCG employees 162.27 Whole Time Equivalents permanently employed on 31 March 2020 Expenditure for 2019/20 Healthcare expenditure of £501.7m (including £6.8m spent on behalf of Mid and South Essex Health and Care Partnership); plus running costs of £7.7m; for a total spend of £509.4m Providers of commissioning Arden and Greater East Midlands (GEM) Commissioning support services Support Unit. Local Essex CCGs lead on delivering a number of support services across the Essex footprint such as information governance.
The CCG’s responsibilities under the NHS Long Term Plan Our plans for local healthcare reflect our legal obligation and commitment as an organisation to follow the NHS Constitution, alongside emerging needs in our own communities and national NHS priorities set out in the 10-year NHS Long Term Plan. This document, published on 7 January 2019, has shaped much of the CCG’s planning and activity prior to the onset of the COVID-19 pandemic in the UK.
The goals of the Long Term Plan are:
• Moving the NHS to a new service model in which patients get more options, better support, and properly joined-up care at the right time in the best care setting • Taking new action to strengthen the contribution of the NHS to preventing illness and addressing health inequalities • Setting the priorities for care quality and better outcomes for patients over the next 10 years, with particular focus on adults’ and children’s mental health services, cancer, cardiovascular disease, clinical research, diabetes, learning disabilities, maternity and neonatal services, respiratory disease, stroke care and shorter waits for planned care • Tackling workforce pressures and making sure current NHS staff are supported • Upgrading NHS technology and ensuring digital access to services is widespread so patients and carers can better manage health conditions and get care backed by good data • Making sure the NHS is sustainable financially.
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The CCG has already taken a number of specific actions around each of the Long Term Plan’s major goals. To implement new service models, linking different health and care organisations more closely, we have taken initial steps to develop what is known as an Integrated Care System, or ICS, in mid and south Essex to focus on the health of all 1.2m people who live within that area.
Mid Essex CCG had already begun preparatory work by outlining proposals for a merger with its four south Essex neighbours until the COVID-19 pandemic meant the process had to pause. At the time of publication a date has not been established for resumption of the process but the situation remains under review.
The Long Term Plan discusses “place-based” planning for NHS services within each ICS. Major services like acute hospitals and emergency ambulances are best bought for this sort of population size because only one or at most a handful of providers will be needed to deliver such services. Having a single contract for them rather than a host of different agreements with smaller CCGs is more efficient.
But these 1.2m population areas also need smaller elements so the most appropriate mix of local knowledge and planning at scale can be used to tackle health inequalities and provide better care – the “place-based” work that the Long Term Plan enshrines. The next step down in size is the “locality”, and in mid and south Essex four are developing, based on geographical and administrative factors. These are Basildon and Brentwood, mid Essex, south east Essex and Thurrock. Mid Essex is the largest of the four, encompassing about 400,000 residents.
Inside each of these localities are “neighbourhoods” of about 30,000 to 50,000 people where more local planning may be needed to reflect local needs and issues. The Long Term Plan anticipates clusters of GP practices called Primary Care Networks, or PCNs, taking on more planning for neighbourhoods over the next few years and over the summer of 2019, Mid Essex CCG supported our 40 member practices to form 9 PCNs.
The PCNs in which each practice sits are listed in section 2.1.1 and each has a designated Clinical Director, one of the GPs from a local practice, to drive their development. Our Chair and key senior staff at the CCG meet the Clinical Directors at least once a month to seek their input in our plans, and during the COVID-19 pandemic they have continued to meet using teleconferencing.
Once the pandemic has passed, the PCNs and the CCG will continue to build on an approach to local health and care initiated by Braintree District Council called livewell. Now adopted by most local authorities and CCGs in mid and south Essex, livewell means identifying and offering appropriate support to people who are still early in their journey through health and care. Such an approach can give patients better health outcomes at lower cost, which in turn makes health and social care in mid Essex more sustainable in the years to come.
Reducing health inequality and meeting more people’s needs through early intervention, before health problems become too serious, are both part of this process, as is strengthening links with non-NHS community and voluntary groups and resources. The act of signposting people to such resources is known as “social prescribing” and there are two such schemes now operating in our area, called “Live Well, Link Well” and “Connect Well”.
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Organisations we work with Even before the Long Term Plan was published, Mid Essex CCG leaders recognised that health and care planning and delivery is most successful when it is collaborative. Working with other organisations that have an interest in local health and care really does benefit our residents.
Our most immediate working relationships are with:
• the 4 south Essex CCGs covering Basildon and Brentwood, Castle Point and Rochford, Southend, and Thurrock • the 3 “top-tier local authorities” responsible for local social care (Essex County Council, Southend Borough Council and Thurrock Council) • the second-tier local authorities within mid and south Essex, including the 3 in mid Essex • the local acute hospital trust • the 3 major NHS community and mental health service providers commissioned locally
Together, these organisations cover the area of 1.2m people mentioned above and comprise the Mid and South Essex Health and Care Partnership. This evolved from the Sustainability and Transformation Partnership mentioned in last year’s Annual Report and you can find out more about the change in section 1.1.2.
We also work closely with other organisations that have similar goals. For example, alongside CCGs the Health and Social Care 2012 also created NHS England and NHS Improvement, two national organisations that work as one to allocate resources and support across the NHS and check performance of local health services. The CCG shares responsibility with NHS England for buying GP services through a process called “co-commissioning” while NHS England leads on buying other sorts of “primary care” – optician, dental and community pharmacy services, along with a variety of specialist services (including certain types of heart, kidney, cancer and genetic services).
The 2012 Act also moved responsibility for Public Health from the NHS to local authorities. Essex County Council’s Director of Public Health works with us to reduce health inequalities – in other words making sure everyone has access to the healthcare they need and experiences the same outcomes. This joint working will develop further and include Thurrock Council’s and Southend-on- Sea Borough Council’s Directors of Public Health too as we move towards integrated working.
Our three “top-tier” local authorities’ Public Health teams provide health intelligence, advice and support to mid and south Essex CCGs through dedicated Consultants in Public Health under a local agreement. These consultants attend CCG Board meetings, and the Director of Public Health supports a Joint Health and Wellbeing Strategy for Essex under the guidance of the Essex Health and Wellbeing Board (see section 1.2.2).
In mid Essex the health and social care system is made up of NHS Mid Essex CCG, Essex County Council, Chelmsford City Council, Maldon District Council and Braintree District Council plus key providers Mid and South Essex University Hospital NHS Trust, Essex Partnership University NHS Foundation Trust, Provide Community Interest Company, East of England Ambulance Service NHS Trust and a range of smaller providers working together.
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We also regularly work with national and local charities, community organisations and voluntary groups on a variety of projects that bring health benefits to local people.
The CCG is in regular contact with Healthwatch Essex, an independent organisation that represents local people’s views about health and care to help improve services.
Where we buy healthcare: Commissioned services summary for 2019/20 Type of healthcare Where we buy it from on your behalf Community services: Provide Community Interest Company (CIC) This includes district nursing, speech and language therapy, podiatry, community Service agreements with 30+ other providers hospitals, community stroke and including voluntary sector and smaller rehabilitation services organisations
Hospital services: Mid and South Essex University Hospital NHS This includes outpatient clinics, planned Trust – mainly from Broomfield Hospital with inpatient treatment and emergency care some services also offered at other locations including Braintree Community, Basildon and Southend Hospitals
East Suffolk & North Essex NHS Foundation Trust
Ramsay Healthcare Springfield Hospital
The Princess Alexandra Hospital NHS Trust (Harlow)
Hospitals outside Essex such as Addenbrooke’s Hospital in Cambridge and a number of London trusts – referrals to such hospitals are made for some specialist services such as complex emergency trauma cases or due to patient choice Mental health services: Improving Access to Psychological Therapies This includes psychological therapies, (IAPT) and online mental health support community mental health teams and (SilverCloud) provided by Hertfordshire learning disability services Partnership University NHS Foundation Trust (HPFT)
Secondary Care Mental Health services including dementia care provided by Essex Partnership University NHS Foundation Trust (EPUT)
Emotional Wellbeing and Mental Health Service for children and young people provided by North East London NHS Foundation Trust (NELFT)
“Locally enhanced” GP services We hold contracts with GP practices for provision of add-on services for some areas of mid Essex
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Extended Access to GP Services Elizabeth Courtauld Medical Ltd Emergency transport service East of England Ambulance Service NHS Trust Non-emergency transport service TASL (Thames Ambulance Service Ltd) Integrated Urgent Care (including NHS 111 Integrated Care 24 and out-of-ours GP services), commissioned on our behalf by the Acute Commissioning Team – Mid and South Essex CCGs One CCG may lead the buying of shared services on behalf of several local CCGs:
Emotional Wellbeing and Mental Health West Essex CCG leads on behalf of the seven Service for children and young people (see Essex CCGs and three Essex Tier 1 local above) authorities (Southend-on-Sea Borough, Essex County and Thurrock Councils)
Adult Mental Health Services (see above) Thurrock CCG leads on behalf of the five mid and south Essex CCGs
Services for people with learning disabilities Essex County Council takes the lead on buying (LD) LD services for the local area
Emergency Health Services and Transport All CCGs across the east of England region buy (see above) as a consortium, which is led by NHS Ipswich and East Suffolk CCG
Children’s continuing care for Essex Mid Essex CCG is the “host commissioner” for this service, which means buying it on behalf of the entire Essex area
What we have achieved together We pride ourselves on the innovation, high quality and good value we bring to local NHS care. Working with our partners, providers and patient representatives, the CCG has taken the livewell agenda forward in a number of important ways during 2019/20. Several of these achievements have received national recognition.
• We established 9 Primary Care Networks despite geographical and administrative challenges by working with our member practices to identify common elements of their “neighbourhoods”, in one case building a network in only 3 days following a change in national guidance. • We led the response to an outbreak of invasive Group A Streptococcus (iGAS) in community settings around mid and west Essex that required months of intensive incident management. • Working across the 5 mid and south Essex CCGs, our acute commissioning team successfully introduced the “FIT test” (or “faecal immunochemical test”) which aids early diagnosis of bowel cancer. FIT testing was delivered in mid and south Essex thanks to
10 NHS Mid Essex CCG Annual Report and Accounts 2019/20
close collaboration between the CCGs, Cancer Research UK, the local hospital trust and Macmillan Cancer Support. Its use is expected to improve outcomes for many patients. • A rigorous academic evaluation by Anglia Ruskin University’s Positive Ageing Research Institute that we arranged for an intergenerational project in Maldon concluded it was of clear benefit to both the Year 6 schoolchildren and care home residents involved. The CCG had supported the project since its inception and helped to secure funding for it to continue. • We set up a new infant cow’s milk allergy service for parents in mid Essex with easy access to dieticians’ advice and simple online tools that allowed mothers whose newborns suffer from this allergy a simple one-stop solution when breastfeeding is not possible for them. We received two awards including the top prize at the 2019 PresQIPP Awards for this initiative. • We developed a brand new weekly GP newsletter for GPs, nurses and managers in our member practices, giving a concise, easily searchable update on important changes in the local health and care system and opportunities for practice staff to improve their skills. • We ran a successful pilot of a new treatment framework for people suffering with chronic obstructive pulmonary disease (COPD). It allowed those with the condition to access better care more quickly and supported GPs to make the right decisions first time. • With our 4 neighbouring CCGs in mid Essex, we made a successful bid to be the flagship Rapid Diagnostic Centre site for the East of England Cancer Alliance South footprint – an area covering nearly 4m people • We launched our Instagram channel to make better use of imagery on social media and connect with a younger audience than the groups who typically engage with the CCG. • We were named Active Workplace of the Year for the second year in a row at the Active Essex Awards 2019. This time we won the award for our “Time to Shine” 6 month staff challenge, which you can find out more about in section 2.3.2. Previously, in 2018, we won the award for promoting activities and encouraging staff to make pledges around the Five Steps to Mental Wellbeing.
Advice for parents is available online thanks to CCG innovation
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1.1.2 Key issues and challenge
The two principal challenges to Mid Essex CCG in the 2019/20 financial year have been outbreaks of infectious diseases, first a localised invasive Group A Streptococcus incident as noted above, and then, more severely, the COVID-19 pandemic.
Winter is often the most challenging time for the NHS, as hospitals can struggle to cope with constant pressure from very high patient numbers. While the very mild 2019/20 winter meant there was less pressure than usual for the time of year, the mid Essex health and care system had to draw upon all its resilience as the COVID-19 response required a radical reprioritisation and reorganisation of services. The pandemic response also put some estates projects on hold, for example the new health hub in Maldon and primary care facilities in Southminster.
Pressures on our plans and finances prior to the pandemic included the continuing growth in population of our area, and the proportion of that population who are frail elderly and chronically ill rising faster than the national average. Cuts in local government spending over recent years have contributed to the system-wide challenges.
At the start of the financial year, NHS England again required Mid Essex CCG to find significant savings for 2019/20 to repay some of our historical deficit that had resulted from the CCG receiving less funding than national calculations say we should have. Additional cost pressures arose during the year for the reasons outlined in section 1.1.4.
Recruiting suitably skilled and experienced clinical staff is also difficult for local health and care organisations. NHS and social care providers in mid Essex have many vacancies going unfilled.
All these issues place particular pressure on the NHS national clinical priorities: diabetes care, mental health services, support for people with learning disabilities, cancer and maternity care, respiratory and cardiovascular conditions and health services for people living with dementia. Our response to the NHS Long Term Plan as part of the Mid and South Essex Health and Care Partnership and our ongoing innovation in the way we plan and buy services are helping us to address these issues.
Changing the way we work is particularly important in light of the expected growth of the mid Essex population from just over 397,000 at the start of 2020 to 419,000 by 2034 (figure from Office of National Statistics based on 2016 population data).
Commissioning in mid and south Essex During 2017, the five CCGs in mid and south Essex formed a Joint Committee to enable commissioners to act collectively in the planning, commissioning and monitoring of services to meet the needs of the whole population of the area they cover between them. To enable the Joint Committee to discharge its functions, and following a staff consultation process, relevant staff across the five CCGs have now formed combined teams such as the Acute Commissioning Team.
The Joint Committee comprises the Chairs and Accountable Officers of the five CCGs (prior to the appointment of the Interim Joint Accountable Officer for Mid and South Essex), with the Chief Nurse, Chief Finance Officer, Medical Director and Director of Commissioning for the Joint Commissioning Team in attendance. The committee is chaired by one of the CCG Chairs on a 6- monthly rotation.
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The functions of the Joint Committee include:
• Decisions on STP-wide service configurations • Leadership of public consultation activities on significant service change • Agreement of STP-wide service restriction policies • Agreement of STP-wide outcomes, frameworks and pathways • Agreement of the STP local health and care strategy.
The Joint Committee has delegated responsibility for a range of functions including patient safety and quality, commissioning and contracting and performance management for the following services:
• All acute hospitals (NHS and independent sector) • Integrated Urgent Care services, including NHS111 • Ambulance services • Patient transport services • Learning disability decision-making (with the existing pan-Essex arrangements) • Acute mental health services • Community dermatology services for South East Essex.
Importantly, the formation of the Joint Committee and Acute Commissioning Team enables individual CCGs to focus on developing and enhancing primary, community and local mental health services and to work closely with member practices and local authorities to build strong localities delivering a broader range of services outside hospital.
The Joint Committee’s work may in the future be subsumed into the merger of all 5 mid and south Essex CCGs and in the meantime it facilitates the work of the Mid and South Essex Health and Care Partnership, outlined in the next section.
The Mid and South Essex Health and Care Partnership The Mid and South Essex Health and Care Partnership, formerly known as the Sustainability and Transformation Partnership, is a collaboration between local organisations: acute hospitals, community and mental health providers, clinical commissioning groups, our three top-tier local authorities and our three Healthwatch organisations (Essex, Thurrock and Southend), along with Community and Voluntary Sector organisations, and clinical and service user representatives.
The Partnership is independently chaired by Professor Mike Thorne CBE. Over the past year the Partnership has been working to define its 5 Year Strategy and Delivery Plan, in response to the NHS Long Term Plan and the commitments that all partners have given to working together to improve the health and wellbeing of our 1.2m population.
Our 5 Year Strategy has been developed to reflect that we need to work together to address not only issues of access and quality of clinical services, but also the wider determinants of health – including healthy lifestyles and behaviours, socio-economic factors and elements of the built
13 NHS Mid Essex CCG Annual Report and Accounts 2019/20 environment – as collectively these issues have a large impact on people’s lives. The diagram below shows the relative impact on an individual’s life of each of these aspects.
Mid and South Essex Health and Care Partnership has this vision: “A health and care partnership working for a better quality of life in a thriving mid and south Essex, with every resident making informed choices in a strengthened health and care system.” In practice, this means:
A Healthy Start – helping every child to have the best start in life
• Supporting parents and carers, early years settings and schools, tackling inequality and raising educational attainment.
Healthy Minds – reducing mental health stigma and suicide
• Supporting people to feel comfortable talking about mental health, reducing stigma and encouraging communities to work together to reduce suicide
Healthy Places – creating environments that support healthy lives
• Creating healthy workplaces and a healthy environment, tackling worklessness, income inequality and poverty, improving housing availability, quality and affordability, and addressing homelessness and rough sleeping
Healthy Communities – which spring from participation
• Making sure everyone can participate in community life, empowering people to improve their own and their communities’ health and wellbeing, and tackling loneliness and social isolation
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Healthy Living – supporting better lifestyle choices to improve wellbeing and independent lives
• Helping everyone to be physically active, making sure they have access to healthy food and reducing the use of tobacco, illicit drugs, alcohol and gambling
Healthy Care – joining up our services to deliver the right care, when you need it, closer to home
• From advice and support to keep well, through to life saving treatment, we will provide access to the right care in the best place whether at home, in your community, GP practice, online or in our hospitals.
The Partnership has 4 key ambitions around the central aim of reducing health inequalities:
• Creating Opportunities – for our communities to thrive we need good education, opportunities for employment, decent housing and a vibrant local economy. Our Partnership represents some of the largest employers and purchasers of goods and services locally, so we have an important role to play. By working together, we can harness these opportunities for the benefit of local residents. • Supporting Health and Wellbeing – by working in different ways and in closer partnership with our communities we can do more to prevent the things that cause poor health and mental illness. Up to 40 per cent of ill health can be avoided so by getting a grip on issues sooner we can stop them becoming bigger problems in the future. • Bringing Care Closer to Home – joining up our different health, care and voluntary sector services means we can bring services closer to people’s home – whether that is through support on-line, or by bringing health and care services into the community, such as some hospital outpatient appointments, tests like x-rays and blood tests and support for people living with long term conditions like diabetes or breathing problems. • Improving and Transforming Our Services – we want to make sure our residents have the highest chances of recovery from their illness or condition and get the best treatment we can offer. Demand for services is changing as people grow older and live with more long-term conditions and there is much more we can do with technology, medical advances and new ways of working to treat people at an earlier stage and avoid more serious illness.
You can find more details of all these ambitions at www.msehealthandcarepartnership.co.uk.
Alongside agreement of our 5-year Strategy, in the past year the Partnership has also:
• Further implemented our primary care strategy, including agreement to form 28 Primary Care Networks, each with a Clinical Director in place to bring together physical and mental health, local authority and community and voluntary sector organisations • Further established our four defined “places”: Basildon and Brentwood, mid Essex, south east Essex and Thurrock, all of which have plans to better support residents through partnership working • Established an Ageing Well programme to support improvements in the way we support our older residents
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• Driven a number of enabling work programmes to support delivery of the strategy, including a comprehensive estates strategy and agreeing a joint health and care workforce strategy • Agreed a system-wide population health strategy to support use of the vast amount of information we collect to better understand the needs of our communities and to develop services and support offers that are evidence-based • Implemented the first phase of the hospital reconfiguration plans that were approved by commissioners in 2018 • Worked to embed a system-wide approach to innovation.
Over the next year we will:
• Continue to support our Places and Primary Care Networks to flourish, supporting local residents to live healthy, fulfilling lives • Implement phase 2 of the acute hospital services improvements to deliver better care to our residents • Submit an application to be designated an Integrated Care System, as envisioned by the NHS Long Term Plan • Update our digital strategy and start implementation of an Integrated Shared Care Record • Launch our citizens’ panel, called Virtual Views, a demographically representative group of 1,500 residents with whose help we can obtain views and insight on planned developments in health and care services.
Changing landscape of commissioning in mid and south Essex In September 2019 at their public Governing Body meetings each of the 5 CCGs in mid and south Essex agreed to progress towards making an application to merge in September 2020 which if successful will enable a merger to take place in April 2021. This will enable the creation of a single strategic commissioning function and significantly streamline decision-making for commissioning decisions that affect all of our health and care system, for example services commissioned from the newly merged Mid and South Essex Hospitals Group.
The CCGs agreed in the first instance to appoint a single Joint Accountable Officer (JAO) and for this role to incorporate the Executive Lead for the wider Health and Care Partnership. There is a process of recruiting to this new role now, having been unable to appoint substantively in January 2020. The new Joint Accountable Officer will need to appoint an executive team, ensure place- based teams are fully supported and consider the resource required to support ICS development.
The JAO will work closely with CCG member practices and Governing Bodies to support the application for merger which will allow (if agreed) a single governing body over all CCGs. In the interim, the CCGs are already considering how governance will work in 2020/21 and are looking at whether the current Joint Committee arrangements can be expanded to enable more decisions to be made once and not five times.
Part of the set-up for a single CCG will be much greater emphasis on our “places”. The CCGs have identified 4 of these across the Mid and South Essex Health and Care Partnership, namely Basildon and Brentwood, mid Essex, south east Essex and Thurrock.
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These local partnerships are building strong, locally focused plans to collaborate and support their local communities. Each ‘place’ sets out its vision within the Health and Care Partnership’s 5-year plan available online at www.msehealthandcarepartnership.co.uk.
1.1.3 Performance Summary
The CCG has plans in place to contribute to delivery of the nine national NHS “must dos” as set out in Delivering the Forward View: NHS Planning Guidance 2016/17 – 2020/21. The nine national “must dos” are to:
• Develop a high quality and agreed STP with progress towards the “triple aim” of improved health and wellbeing, transformed quality of care delivery and sustainable finances • Return the healthcare system to overall financial balance • Develop and implement a local plan for general practice sustainability and quality • Meet access standards for accident and emergency (A&E) and ambulance waits • Ensure 92% of patients wait no more than 18 weeks from the time of referral to treatment • Deliver cancer standards targets • Meet mental health access standards and the dementia diagnosis target • Transform care for people with learning disabilities • Have an affordable plan to make improvements in quality.
In addition, NHS England regularly checks all CCGs across the country against a number of key clinical indicators to ensure national consistency for key commissioning objectives and priorities. From 2016 to 2019 the indicators used to measure how well CCGs were performing were set out in the CCG Improvement and Assessment Framework (IAF), with Mid Essex CCG improving from a rating of “Requires improvement in 2017/18 to “Good” for 2018/19. A detailed breakdown of the assessment was available on the now discontinued MyNHS section of the nhs.uk website.
From 2019/20, the IAF has been replaced by the new NHS Oversight Framework which brings both commissioning and provider organisations within the NHS into a single reporting structure. The change also reflects the closer links between NHS England and NHS Improvement.
There are 65 different measures within the framework, the majority of which apply to CCGs. Mid Essex CCG’s performance against these is set out in the table below, continued over the page.
NHS Oversight Framework Outturns and Benchmarking at January 2020*
17 NHS Mid Essex CCG Annual Report and Accounts 2019/20
18 NHS Mid Essex CCG Annual Report and Accounts 2019/20
* Performance at 22 January 2020 is listed under the “Value” column and is highlighted in red to indicate a failing standard (where there are constitutional standards with a national target). There is a time lag in securing data for some indicators, so the relevant reporting period is noted in the “Period” column. In the “DoT” column the arrows show the direction of travel since the previous reporting period – these are red if opposite to the desired direction and green if the direction of travel is desired. The symbol “=” is used to demonstrate if there is no movement and “x” if the direction is unable to be calculated. The “England” column shows the CCG’s rank for that indicator compared with others across England. The outturn in this column is red if it is in the lowest quartile, amber for the interquartile range and green for the top quartile. Amber does not necessarily indicate there is a problem.
The CCG considers three of its most important acute care performance targets to be the 18-week care pathway, four-hour target for A&E wait times and 2-week, 31-day and 62-day cancer pathways, all of which remain challenged in the mid Essex health and care system. The pressures on urgent care discussed in previous years’ annual reports continued into 2019/20 even before the onset of the COVID-19 pandemic.
The following sections outline actions that we are taking to address this along with the ongoing challenge of meeting the cancer 62-day pathway and 18-week referral to treatment (RTT) national standards. Information on how we are managing other areas where our performance is in the lowest 25% among all CCGs (as shown in the rightmost column and explained beneath the table) can be found in section 1.2.5.
18 weeks pathway Patients have a legal right to start non-emergency NHS consultant-led treatment within 18 weeks of referral, unless they choose to wait longer or it is necessary for better health outcomes.
19 NHS Mid Essex CCG Annual Report and Accounts 2019/20
Reporting challenges (see section 2.2.5) meant there were no 2018/19 figures for comparison at Mid Essex Hospital Services NHS Trust (MEHT), but this year’s figures remain below target and updated recovery plans were being implemented across treatment pathways to remedy this until the COVID-19 pandemic disrupted elective and non-urgent care nationwide.
Accident and Emergency – 4-hour wait times NHS services generally have been under pressure during much of 2019/20, particularly A&E, with local attendances rising year-on-year as they have for the past 4 years. Such pressure resulted in MEHT not meeting the national standard of 95% of patients at A&E being seen and treated within four hours, as was also the case in 2018/19.
Pressure on the Broomfield Hospital A&E department continued during 2019/20
With operations cancelled as a result of beds being needed for emergency admissions, there was a consequent effect on the 18-week referral-to-treatment target as noted above. The CCG’s Resilience team has been working with the trust and partner organisations to support reductions in the number of people going to or being admitted to hospital and swifter discharge when clinically appropriate for those who do require an inpatient stay.
To support the acute trust in this work, the CCG leads an A&E Delivery Board comprising some of the organisations listed in section 1.1.1. Specifically, Board members are representatives from:
• Mid Essex Hospital Services NHS Trust (part of Mid and South Essex NHS Foundation Trust as of 1 April 2020) • NHS England and NHS Improvement • East of England Ambulance Service NHS Trust • Essex Partnership University NHS Foundation Trust • Essex County Council • Provide Community Interest Company • Farleigh Hospice • Voluntary organisations such as the Red Cross • IC24 • NHS Mid Essex CCG
20 NHS Mid Essex CCG Annual Report and Accounts 2019/20
Between them, with contributions from other partners as required, members of the A&E Delivery Board continue to implement the local immediate care strategy. One element of this is the “GP in ED” scheme, which continued to operate in Broomfield Hospital following its relaunch in March 2019 and sees patients with minor ailments triaged to a primary care clinician working within the emergency department.
Cancer standards – 31-day and 62-day standards These are the principal measures of good cancer care performance in the NHS. The first is a target of no more than 31 days between clinical staff making a decision to treat any patient for cancer and the patient receiving their first treatment. The second is a target of no more than 62 days between a GP’s “2 week wait” referral for urgent cancer care and the first definitive treatment for that patient.
Prior to its merger with neighbouring trusts, the former Mid Essex Hospital Services NHS Trust had continued to perform below expected standards but had been making changes agreed with NHS England and NHS Improvement designed to improve its position and patient care.
The Mid and South Essex CCGs’ Acute Commissioning Team also worked with the trust and other partners during 2019/20 to introduce a number of innovations in cancer care across our joint footprint. These included:
• Introducing the FIT Test (see section 1.1.1) to improve early diagnosis rates for bowel cancer • Securing agreement to establish the first regional Rapid Diagnostic Centre for cancer (see section 1.1.1) in our area • Updating referral processes to ensure more patients were seen within the 31 and 62 day constitutional standards • Building closer ties with partner organisations such as Cancer Research UK and Macmillan Cancer support to facilitate better cancer care
1.1.4 Financial Overview
Our full statutory financial accounts are included in part four. This section provides a summary of our current financial position. Our Head of Internal Audit offers an opinion on Financial Systems Key Controls and other matters which can be found in section 2.2.6. Our overall financial management arrangements were subject to review by our external auditors, KPMG, as part of their annual review of our accounts – see section 3 for their comments.
CCG funding Mid Essex CCG receives funding according to a national formula designed to calculate healthcare needs based on the makeup of the local patient population. Mid Essex’s population is considered to have a relatively low need for healthcare expenditure under the formula so our assessed need to spend (or “target”) per head of population is the lowest in Essex.
21 NHS Mid Essex CCG Annual Report and Accounts 2019/20
We received £488.4m baseline funding for healthcare in 2019/20 which was marginally above target funding by 0.1% (£0.5m). In addition to that baseline funding, we received a number of extra one-off allocations (£15.2m) for spending on specific areas of care including:
• transformation funding on behalf of the Mid and South Essex Health and Care Partnership (formerly the STP – see section 1.1.2) including cancer and maternity services, primary care and project and planning costs on behalf of the wider system (£5.2m) • allocations for CCG specific primary care projects and transformation (£3.8m) • winter pressures funding on behalf of the Mid and South Essex STP (£1.6m) • £1.4m reimbursement of Covid-19 related costs incurred by the CCG, our community provider and Essex County Council’s pan-Essex response to the hospital discharge pathway in March 2020
In 2019/20 those allocations brought our total healthcare funding to £503.7m. Funding for running the CCG in 2019/20 (called “running cost expenditure” and representing the maximum allowed spending on operations) was £22.24 per mid Essex resident, or £8.7m. This included a £0.4m one-off allocation to fund the 6.3% increase in employer pension contributions. Overall funding for 2019/20 was £512.4m of which we were permitted to spend £509.4m, as the clinical commissioning group was mandated to deliver a £3m surplus to reduce the cumulative deficit (see section 2.2.6).
We have a number of financial duties at the CCG:
• to contain revenue expenditure within allocated financial resources and any specified Directions • to contain capital expenditure within allocated financial resources and any specified Directions • to keep running cost expenditure to a maximum of the running cost allocation, which is £22.24 per head.
NHS planning guidance requires CCGs to meet the ‘Mental Health Investment Standard’ (MHIS). This requires CCGs to demonstrate that expenditure on mental health services has grown year on year. In 2019/20 the CCG has achieved the MHIS by increasing expenditure by 6.2%.
As of 1 April 2019 the CCG had a remaining accumulated deficit from previous years of £7.8m. As stated above, NHS England required us to underspend against funding in order to generate a surplus towards paying off this deficit. We were originally required to set a £4m in-year surplus budget but during the course of 2019/20 we were permitted to reduce the target to £3m, which was delivered. In 2019/20 we therefore repaid £3m of the accumulated deficit and carried forward into 2020/21 a remaining deficit of £4.8m. The £3m surplus was generated by non-recurrent opportunities and the CCG closed the year with a £500k underlying deficit.
All healthcare providers are expected to deliver a continuous programme of cost improvements and the CCG has also continued to deliver on its own internal cost improvement plan. The main areas of focus for 2019/20 related to managing expenditure on Continuing Health Care (CHC) and prescribing costs – where we have made further reductions in the prescribing of low clinical value medication and over the counter medicines.
22 NHS Mid Essex CCG Annual Report and Accounts 2019/20
How your money was spent In 2019/20 we spent £501.7m on healthcare services including £6.8m on behalf of the Mid and South Essex Sustainability and Transformation Partnership – see section 1.1.2 – and a further £7.7m on running costs, totalling £509.4m. We have met HM Treasury’s guidelines on cost allocation. The following chart shows the major areas of expenditure for healthcare in mid Essex (including our running costs).
23 NHS Mid Essex CCG Annual Report and Accounts 2019/20
Core GP-led services (primary care) are jointly commissioned by the CCG and NHS England but not accounted for in the CCG’s accounts. However, the CCG has invested a significant sum in our member practices this year. We spent £6.9m on our Primary Care Foundations programme, support to the newly formed Primary Care Networks and extended access to primary care during 2019/20. This will support primary care transformation and continue with delivery of the national seven-day access targets.
Other payments to Primary Care Networks including for Additional Roles Reimbursement and Clinical Directors were made by NHS England.
For more details of the Better Care Fund – Protection of Social Care segment, see section 1.2.2. Our full Annual Accounts are published in section 4.
Capital spending We did not require a CCG capital allocation for 2019/20, but the Mid and South Essex Health and Care Partnership footprint was awarded Estates and Technology Transformation Funding (ETTF) towards primary care estates projects and GP IT. ETTF expenditure is accounted for by NHS England.
Since 31 March 2013, clinical premises previously owned or leased by Mid Essex Primary Care Trust have belonged to NHS Property Services or other local NHS providers, but getting the best use from these resources and keeping buildings fit for purpose are still important roles for the CCG.
Paying our suppliers and providers National rules mean we must aim to pay all valid invoices by the due date or within 30 days of receiving them, whichever is later. The NHS aims to pay at least 95% of invoices within 30 days of receipt, or within agreed contract terms. In 2019/20 we met all four targets (based on invoice numbers and value of expenditure) for NHS and non-NHS invoices – see Note 6 of the Financial Statements for details.
We are also an approved signatory of the Prompt Payment Code. The government designed this initiative with the Chartered Institute of Credit Management to tackle the crucial issue of late payment and to help small businesses. Suppliers can have confidence that any organisation signed up to the code will pay them within clearly defined terms and that proper processes are in place to deal with any disputed payments. Approved signatories have committed to:
• Paying suppliers on time • Giving clear guidance to suppliers and resolving disputes as quickly as possible • Encouraging suppliers and customers to sign up to the code.
The national measures for payment performance do not include any delays in payment during the time that an invoice is on hold.
24 NHS Mid Essex CCG Annual Report and Accounts 2019/20
2020/21 financial plans and looking to the future As we developed our 2020/21 plans, we expected the financial environment to continue to be extremely challenging for the CCG.
We have made good progress working across the System Transformation Partnership (STP) to prioritise programmes of work towards achieving a financially sustainable health and social care system. We also began working with our local System partners to consider the merger of the 5 CCGs and to develop an application to become an Integrated Care System.
The CCG has been permitted to set an in-year break-even budget for 2020/21 but is also expected to work with system partners to ensure that in aggregate, the local NHS system partners deliver their planned financial targets.
During the last few weeks of 2019/20, all NHS organisations and system partners were required to begin to respond to the COVID-19 pandemic. The financial impact upon the CCG in 2019/20 was relatively limited and the CCG has received funding to cover the additional costs.
The impact on the CCG’s expenditure and financial arrangements will be significant in 2020/21. Some payments towards the local pandemic response will be made at a national level rather than through the usual local CCG arrangements. The impact upon local funding and expenditure plans will therefore need to be calculated and reflected.
Service investments to deliver the CCG’s medium-term operational plan and cost improvement plans will now be delayed and the CCG has had to invest in a number of services as part of the Mid and South Essex Health and Mid and South Essex NHS Care Partnership’s system-wide response to COVID-19. Foundation Trust staff, both
clinical and non-clinical, have The CCG expects to receive additional funding to cover been a key part of the mid reasonable additional costs incurred from this. Essex health and care Nevertheless, 2020/21 will be extremely challenging as we system’s response to work with partners across mid and south Essex to ensure COVID-19 (image courtesy of an appropriate and value-for-money response to the the Trust) pandemic and the ongoing delivery of local healthcare services.
Although the CCG had a cumulative deficit of £4.8m as of 31 March 2020, for accounting and risk management purposes the CCG is assumed to be a “Going Concern” as it has made significant repayments against the original deficit. NHS England has agreed that no further repayment is required in 2020/21.
25 NHS Mid Essex CCG Annual Report and Accounts 2019/20
1.2 Performance Analysis
1.2.1 Improve quality
The CCG has a legal duty under section 14R of the National Health Service Act 2006 to improve the quality of services. Some of that work, around acute services commissioned by the CCG Joint Committee, is now delegated to the Mid and South Essex CCGs’ Patient Safety and Quality team. Both they and Mid Essex CCG’s own Nursing and Quality team remain committed to monitoring performance against the NHS Constitution and core national measures (see sections 1.1.3 and 1.2.5).
We assess the quality of the care we plan and buy in three ways: effectiveness, patient experience and patient safety. To deliver high-quality care, CCGs work to the NHS Outcomes Framework, ensuring improvements in the areas of:
• Preventing people from dying prematurely • Enhancing quality of life for people with long-term conditions • Helping people to recover from episodes of ill health or following injury • Offering people a positive experience of care • Giving care in a safe environment, protecting patients from avoidable harm.
We are committed to working with all organisations that provide mid Essex health services to make sure patients receive the best possible care, have a positive experience of healthcare and are treated safely and with compassion. Our Quality and Governance Committee is at the centre of this work, as it is responsible for giving our governing body, the Board, assurance that appropriate and effective governance mechanisms are in place for all aspects of quality.
The committee also supports the Board to fulfil its statutory functions around quality, which are:
• Securing continuous improvement in the quality of services for patients and in outcomes, with particular regard to clinical effectiveness, safety and patient experience • Assisting and supporting NHS England in securing continuous improvement in quality.
All main contracts that we issue to healthcare providers contain clear quality requirements, measures and incentives where relevant to ensure that services meet the expectations of both mid Essex patients and the CCG. This process allows us to meet local and national quality standards and to remain focused on getting the best outcomes for the people who live in the area we serve.
Our Nursing and Quality team seeks assurance of quality from a number of sources, including provider reports, feedback from patients using services we commission and our own assurance visits to providers. Quality assurance processes cover acute care, community care, nursing homes, mental health and learning disabilities.
The CCG’s Nursing and Quality team is responsible for:
• Ensuring we meet statutory and mandatory patient quality and safety requirements • Making sure quality is incorporated into the commissioning and procurement processes
26 NHS Mid Essex CCG Annual Report and Accounts 2019/20
• Monitoring performance in quality, safety and patient experience for commissioned services’ contracts through formal Clinical Quality Review meetings, patient experience feedback and both announced and unannounced site visits, more details of which are given later in this section. Performance monitoring includes triangulation of available intelligence.
Our quality monitoring processes are based around principles and recommendations for best practice following a number of high-profile national reviews and reports such as Francis, Berwick, Keogh, Hart and Cavendish, as well as Safer Staffing guidance.
We also have governance arrangements to provide assurance on and support decisions relating to contracts and providers. These arrangements involve working with statutory organisations, partners, patients, carers and providers to give us access to a range of intelligence that can support decisions affected by the quality of services we buy.
National indicators (targets) in the NHS Outcomes Framework cover Clinical Effectiveness, Patient Experience and Patient Safety. These indicators allow us to seek assurance of the quality of services being delivered by our providers and, when necessary, to challenge and intervene.
The Care Quality Commission’s regulations for providers include a requirement to be open and transparent about care and treatment with people receiving the services and with those properly acting on their behalf. The requirements also include specific rules on what providers must do when care and treatment go wrong. In those cases, we check that providers are exercising their duty of candour and being open with patients and their representatives.
The Quality and Governance Committee receives a ‘dashboard’ at each of its quarterly meetings that details key performance measures for all providers. Quality Assurance ‘deep dives’ – a thorough review of a service that focus on all aspects of quality, patient experience and safety for both NHS and independent providers – take place across commissioned services.
To assure the quality of the services it commissions, the CCG uses a variety of tools, one of which is to visit providers, observe practice and to speak with patients where appropriate, to understand their experience of services provided. These announced visits are undertaken on a quarterly basis and cover an overarching topic. During 2019/20 the following visits took place within Provide and the topics covered were:
• Quarter 1: Children’s and cardiac services • Quarter 2: End of Life services • Quarter 3: Home First service • Quarter 4: Endoscopy and minor surgery.
Clinical effectiveness We follow national guidance including the NHS Outcomes Framework and draw on clinical advice from national bodies alongside local priorities to make sure that providers deliver services that follow the latest best-practice guidance and protocols. Examples of this relate to accessing psychological therapies and improving quality of life for people with dementia.
Checking that provider policies consider National Institute for Health and Care Excellence (NICE) guidance through Quality Review meetings is another key element of CCG monitoring. We also
27 NHS Mid Essex CCG Annual Report and Accounts 2019/20 review data to measure local providers’ performance. Regional and national comparisons can be drawn against this data to understand where and why we see differences in performance, such as in caesarean section rates and dementia diagnosis in primary care.
Commissioning acute services – monitoring quality and patient safety One of the responsibilities for the Mid and South Essex CCGs’ Patient Safety and Quality Team is assuring patient safety and quality at the Mid and South Essex Hospital Group. The Mid and South Essex Hospital Group consists of three trusts: Mid Essex Hospital Services NHS Trust (MEHT), Southend University Hospital NHS Foundation Trust (SUHFT) and Basildon and Thurrock University NHS Trust (BTUH).
All mid-Essex-commissioned providers are required to report Serious Incidents (SIs) and Never events. SIs are defined as any incident that has a direct or indirect impact on patient safety, or affects the organisation’s ability to deliver on-going healthcare. Never events are defined as “serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers”.
Integrated Sis / NEs Reported Independent Providers MEHT BTUH SUHFT EEAST Urgent Care 1 April 2019 – Ramsay 31 March 2020 Spire IC24 Springfield Serious Incident (SI) 120 111 58 9 4 7 6 Never Event (NE) 1 1 5 0 2 0 0
The highest reported category of SI is “Treatment Delay” with 78 SIs being reported between April 2019 and February 2020 across the provider organisations. This is followed by Slips/Trips/Falls with 39 SIs reported leading to patient harm; 29 pressure ulcers were reported.
The CCG Patient Safety and Quality Team assumes responsibility for the overall management of SIs and Never events. Serious incident and never event root cause analysis reports are subject to peer review by the CCG acute commissioning patient safety and quality team and the wider nursing team. They are also discussed on a weekly basis at the SINE (Serious Incident Never Event) panel where they are subject to further scrutiny and challenge.
Action plans for Never events and those SIs that are deemed to require additional assurance are retained on an action plan tracker and monitored by Mid and South Essex CCGs’ Quality teams until there is sufficient evidence that actions have been completed and implemented. Follow-up of these actions is also monitored via quality assurance visits with providers on a quarterly basis.
Emergency ambulance service During 2019/20 contract quality oversight for the local emergency ambulance service provided by the East of England Ambulance Services Trust (EEAST) has continued to be led by the Suffolk CCGs with the Mid and South Essex Acute Commissioning team leading for the locality.
EEAST has an integrated improvement plan in place to address ongoing issues highlighted by recent CQC inspection reports. This plan also includes actions to address concerns raised internally through a variety of sources. Additional monitoring is provided through deep dives, for
28 NHS Mid Essex CCG Annual Report and Accounts 2019/20 example a review of 18 delayed attendance incidents that confirmed no harm had been caused while recognising poor patient experience.
Infection Prevention and Control Infection Prevention and Control (IPC) continues to be a function supported by the Acute Commissioning Team of all the Mid and South Essex CCGs.
Meticillin – also known as methicillin – Resistant Staphylococcus Aureus blood steam infection (MRSABSI) There continues to be a zero-tolerance approach to MRSABSI, but following revised guidance in 2018/19 Mid Essex CCG and Mid Essex Hospitals Trust were no longer required to undertake a formal post-infection review for cases of MRSABSI. The decision was made across both community and acute care providers together with the five CCGs that the formal review would continue to take place for all cases of MRSABSI. At the time of reporting there have been 13 cases assigned to the CCG.
Clostridioides difficile Infection (CDI – formerly known as Clostridium difficile or C.diff) For 2019/20 the case assignment and definition of CDI changed significantly. The previous community and acute definition reduced from pre-72 hours and post-72 hours to pre and post 48 hours in line with other significant gram negative bacterial infections. Case definitions were also added to ensure patient safety was maximised and lessons learnt were gained.
The definitions are:
• Hospital onset healthcare associated (HOHA): cases that are detected in the hospital two or more days after admission • Community onset healthcare associated (COHA): cases that occur in the community (or within two days of admission) when the patient has been an inpatient in the trust reporting the case in the previous four weeks • Community onset indeterminate association (COIA): cases that occur in the community (or within two days of admission) when the patient has been an inpatient in the trust reporting the case in the previous 12 weeks but not the most recent four weeks • Community onset community associated (COCA): cases that occur in the community (or within two days of admission) when the patient has not been an inpatient in the trust reporting the case in the previous 12 weeks.
There were 125 cases assigned to the CCG against a ceiling of 136. In line with the definitions above these cases were assigned as follows:
• HOHA: 37 (28 cases within MEHT and 9 from out of area trusts) • COHA: 27 (22 cases with MEHT and 5 from out of area trusts) • COIA: 16 • COCA: 45
29 NHS Mid Essex CCG Annual Report and Accounts 2019/20
Root cause analysis (RCA) is undertaken for all cases of CDI. Common themes for all CDI cases remain unchanged from previous years. There is ongoing work with the East of England Public Health epidemiology service to undertake a review of CDI.
Escherichia coli (E.coli) bacteraemia In 2016, the Department of Health and Social Care set an ambition for England to halve the number of healthcare-associated gram negative bloodstream infections (GNBSIs) by March 2021. Within the UK five year plan for antimicrobial resistance for 2019-2024, the global concern for human health has been recognised. In light of this, working together is essential to ensure antibiotics remain effective and use is restricted to clinical need.
The ambition for a 50% reduction has not been achieved due to the complex nature of the organisms and appropriate control measures to manage subsequent GNBSIs. Recognising this is a complex challenge with more than 50% of infections occurring in people outside of hospital settings, the date for achievement of this goal has been revised to March 2024 with a 25% reduction by March 2021.
There have been 267 cases reported at the time of this report against a reduction target of 177.
A system-wide antimicrobial stewardship and healthcare associated infection group has been established, led by the acute commissioning team and chaired by the nominated Senior Responsible Officer.
Integrated Urgent Care This service includes the local provision of NHS111 and Out of Hours Primary Care as an integrated function. In mid and south Essex this service is provided by Integrated Care 24. The service is monitored by commissioners through monthly contract and quality oversight meetings including senior clinical leadership from the Acute Commissioning Team. The East of England Ambulance Service NHS Trust often attends these meetings too.
Checks carried out include monthly reviews of a sample of calls to identify any common themes that might arise from them for system partners to discuss. EEAST representatives often attend these meetings.
Maternity The national aspiration for maternity care is to reduce stillbirths, neonatal and maternal deaths and perinatal brain injuries by 50% by 2025. There are 10 local work streams to deliver this expectation.
In partnership with our system, maternity units operated by MEHT, SUHFT and BTUH, health visitors and mental health providers, as well as public health providers, service users and service user representatives’ organisations such as Maternity Voices Partnership and Healthwatch have been involved in these work streams.
Together, these partners have worked over the past year to produce co-designed, evidence-based services in line with the national programme of transformation for maternity services.
30 NHS Mid Essex CCG Annual Report and Accounts 2019/20
During 2019/20, a robust and evidenced-based Continuity of Carer (CofC) training package gave local midwives extra skills that helped them to standardise their approach in delivering maternity care. This system-wide service will provide a sustainable model of CofC teams for 2020/21 on all three local maternity sites. The change is complemented by a new suite of equipment that will enable midwives to continue this new approach regardless of where the woman receives care.
Three “Better Births” specialist midwives have been appointed and are now based at each of the three sites within our system. Their role is central to ensure a consistent service for women within the maternity units. They promote care that is personalised to women’s needs and delivered by a named midwife.
The Maternity Voices Partnership (MVP) joined Healthwatch Essex and patient partners to discuss service developments through listening exercises that consider the experiences of women using local maternity services. The partnership helped to design the “Maternity App”, which provides advice and information about healthy pregnancies. It also has the facility to hold live “web chats” personalised to the woman’s need.
The MVP undertakes visits as part of a national scheme called 15 Steps to Maternity. This ensures that feedback goes to each maternity unit on how patients perceive them, their environments and the way staff conduct their work and interact with women under their care.
The Mid and South Essex CCGs team has developed a personalised care plan for women with the support of MVP, Healthwatch Essex and other partners. This care plan is personal to the woman and is updated at each point of contact.
A “choice booklet” is in development to offer women the choice of delivering their babies at any site within the mid and south Essex system. Women are currently able to access the website that offers choice of location for their birth (which includes hospital, home births and midwifery-led units). This choice booklet will be available to women at the point of referral, allowing them to share their choice at point of booking with their midwife.
Nationally the NHS is working towards providing neonatal care within each postnatal ward. This should keep mothers and babies together wherever possible, enhancing bonding and improving outcomes. Each site within the system has undertaken work to ensure this expectation is met.
Each local maternity unit has taken part in a “Maternity and Neonatal Health Safety Collaborative”. This means that at each site, work is ongoing to improve safety and quality of care, with a focus at Southend Hospital on avoiding sepsis and at Basildon and Broomfield Hospitals on reducing smoking in pregnancy and reducing the likelihood of post-partum haemorrhage.
Work has begun to review and provide a consistent and revised perinatal mental health pathway, eliminating variation across the system. This will improve the delivery of, and access to, mental health care and support to women and their partners.
A national review of neonatal critical care was published in December 2019 and the Quality team expects recommendations from the review to be implemented in the coming year. Mid and South Essex Health and Care partners will continue work in 2020/21 to embed changes in practice and deliver more improvements to safety, personalisation and choice for women using maternity services.
31 NHS Mid Essex CCG Annual Report and Accounts 2019/20
Non-acute physical care In 2019/20 a total of 22 serious incidents (SIs) were reported for non-acute care (which Mid Essex CCG continues to plan and buy for our 400,000 residents). Of these, 8 SIs were reported by Provide CIC; 13 from Commissioning (7 of which occurred in nursing homes); and 1 occurred within Farleigh Hospice. Of the 22 reported the main themes were falls (5); development of category 3 or above pressure ulcers as a result of breach in policy (5); and treatment delay (3).
Of the 22 Serious Incidents reported, 3 were later de-escalated as they were found not to meet SI criteria. No non-acute Never Events were reported to the CCG during 2019/20.
Ophthalmology Significant challenges remain in delivering ophthalmology services across mid and south Essex. Delays for both new patients and follow-ups remain due to inadequate capacity within hospitals’ eye services. The risk to patients is being monitored and a robust and comprehensive review process that is already in place for patients in high risk categories across south Essex is being introduced within the mid Essex service.
There have been no new Serious Incidents (see above) relating to patient harm caused by delayed appointments since May 2019, but the Patient Safety and Quality Team for Mid and South Essex CCGs continues to monitor this and remains involved with this workstream.
Community pathways have and continue to be rolled out in the case of post-operative cataract checks and children’s vision screening. Other pathways such as community glaucoma monitoring under shared care, again in place in south Essex for some time, are also being introduced in mid Essex. An interim community service for minor eye conditions has been commissioned while the substantive service is developed and implemented.
Pressure ulcers The NHS Improvement report “Pressure Ulcers: revised definition and measurement” contained recommendations for NHS trusts in England to support a consistent approach to defining, measuring and reporting pressure ulcers. To support these recommendations, each of the trusts across the Mid and South Essex Hospital Group have implemented “Harm Free Care” panels to review all hospital acquired pressure ulcers.
The root-cause analysis of pressure ulcers allows for lapses in care and any associated learning to be identified. A number of targeted interventions are then implemented to reduce the risk for future patients.
Quality Assurance Visits The Patient Safety and Quality team have coordinated a programme of quality assurance visits with acute providers serving the mid and south Essex area on behalf of the five CCGs. In most cases, these have been the first time that quality assurance visits have been undertaken by the Mid and South Essex CCGs team. The programme for 2019/20 has seen four visits to each of the three trusts of the Mid and South Essex Hospital Group looking at Maternity (Quarter 1), Paediatrics (Quarter 2), Support with CQC preparation (Quarter 3) with a particular focus on End of Life care in Basildon Hospital and Emergency Department/Ward Back to Basics revisits at Southend Hospital. The Broomfield Hospital visit (Quarter 4) was postponed due to the 5 CCGs’
32 NHS Mid Essex CCG Annual Report and Accounts 2019/20 shift in focus towards the COVID-19 response. There have also been visits to private and patient transport providers.
The theme of each visit is determined in advance based on feedback received from serious incidents, complaints and other intelligence gathered in the months prior to the visit. Areas to be reviewed are not revealed to the organisations prior to the visits, findings from which have been generally positive during 2019/20 with examples of notable practice fed back following each visit.
Areas for improvement have also been highlighted and the Patient Safety and Quality team are monitoring any action plans developed by each organisation. The team is now finalising the programme for 2020/21 and is working on a Standard Operating Procedure to be adopted for all quality assurance visits in the future.
Safer staffing Part of the Mid and South Essex CCGs’ role is to monitor provider staffing levels on a monthly basis. This is discussed at the Clinical Quality Review Group (CQRG) meetings with providers. Local acute trusts share workforce data as part of the Integrated Performance Report (IPR), including ongoing recruitment and retention work. Collaborative work across the system to address staffing issues has included agreement of a retention and recruitment action plan.
Safer staffing reports are now standardised and a joint one is presented to the governing body that oversees the acute hospitals in mid and south Essex.
Venous thromboembolism Venous thromboembolism (VTE, sometimes known as deep vein thrombosis) is a condition in which a blood clot forms most often in the deep veins of the leg, groin or arm. VTE risk assessment compliance is a national performance indicator requirement, with 95% of adult inpatients expected to receive it.
Locally, the Acute Commissioning Team monitors the compliance of the 3 trusts and this is then reported through the Mid and South Essex CCGs Patient Safety and Quality Committee. The threshold for compliance is 95% and this has been consistently met by both BTUH and SUHFT over the last year. MEHT continues to underperform in this respect, but work led by their Medical Director has resulted in a steady increase, with the Trust averaging about 90% compliance over quarters 2 and 3 (improving from 83% in quarter 1).
1.2.2 Health and wellbeing strategy
A key outcome of the Health and Social Care Act 2012 was to establish a statutory Health and Wellbeing Board in every local authority area. These Boards offer system-wide leadership to improve both health and care services. In particular, they have a duty to promote integrated working and drive improvements in health and wellbeing.
In particular, Health and Wellbeing Boards are responsible for:
• Leading on the production and regular updates of the Joint Strategic Needs Assessment (JSNA) which reviews local health and wellbeing needs across healthcare, social care and public health
33 NHS Mid Essex CCG Annual Report and Accounts 2019/20
• Producing and annually reviewing a Joint Health and Wellbeing Strategy, which section 116B(1)(b) of the Local Government and Public Involvement in Health Act 2007 mandates the local NHS to consider in commissioning strategies. The Joint Health and Wellbeing Strategy is formulated in response to the JSNA and provides a strategic framework for such local commissioning.
The Essex Health and Wellbeing Board brings together locally elected councillors and key commissioners, including representatives of CCGs, Directors of Public Health, Children’s Services and Adult Social Services and a representative of Healthwatch Essex, which provides an independent voice on healthcare for people in our county.
The Health and Wellbeing Board’s Chair is Essex County Council Cabinet Member for Health, Councillor John Spence, and there are 23 voting members including clinical representation from CCGs and a member from the NHS England Area Team. The CCG’s Chair, Dr Anna Davey, became a voting member of the Health and Wellbeing Board in September 2018.
There are two non-voting members: the Police, Fire and Crime Commissioner for Essex and the independent chair of the Essex Safeguarding Boards. Together, all the Health and Wellbeing Board members oversee implementation of the new strategy agreed by members in consultation with the county’s CCGs, including mid Essex, during 2019/20.
Each year, the CCG’s annual report is made available to Health and Wellbeing Board members so they have the opportunity to offer feedback before the report is finalised. For 2019/20, due to its own focus on the COVID-19 pandemic the Health and Wellbeing Board offered no comment on this report.
People living in mid Essex and elsewhere can attend Essex Health and Wellbeing meetings. Minutes of previous meetings are also available from the Essex County Council website. You can email [email protected] to request further details of meetings.
1.2.3 Engaging people and communities
Patients – at the heart of everything we do Mid Essex CCG received more than £500m from the Government in 2019/20 to buy NHS services and help the people of Braintree District, Chelmsford City and Maldon District to livewell. We have a duty to involve our residents in how we allocate this funding and plan health and care services. So, we need the help of our partners and the people of mid Essex when making these plans.
Public involvement is important to us because we have a duty to involve our residents in their care. We also believe that the people who receive the NHS care we fund know best how it works for them and whether it meets their needs. Patients using a health service can sometimes spot ways to improve it that would bring better outcomes for others, but that the NHS has missed.
The CCG cannot act on ideas if we do not know about them – and it is our responsibility to help people share them with us.
Demand for many NHS services is rising each year. So another important part of the CCG’s role is working with local partners and our residents to find ways we can support communities to livewell,
34 NHS Mid Essex CCG Annual Report and Accounts 2019/20 stay well and avoid the need for inpatient hospital care even if they have existing long-term health conditions.
Duty to involve Section 14Z2 of the NHS Act 2006 (as amended in the Health and Social Care Act 2012) requires that the CCG must make arrangements to involve the public in the commissioning of health services for patients. It asks CCGs to involve the public in the planning of services and the development of proposals for changes to services.
The NHS Constitution, established in 2012, places this commitment at the heart of the health service. It makes a guarantee to everyone that they have, “the right to be involved, directly or through representatives, in the planning of healthcare services commissioned by NHS bodies, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services”.
Governance and assurance – engagement overview During 2019/20, the CCG has continued to implement its commitment to widening public involvement in discussions and decisions on health in a number of ways. We helped the 3 GP practices in the town of South Woodham Ferrers to explain to their patients the reasons for and benefits of their planned move into a single clinical building. We arranged two public drop-in events with senior CCG leadership present to answer questions. More than 200 people in the town had lively conversations with us across the two events.
The CCG placed our 3 locality resident panels at the heart of our wider engagement strategy, inviting representatives from more varied demographic groups than before. There are two main reasons for holding separate meetings with residents in Braintree District, Chelmsford City and Maldon District – to make sure discussions are more relevant to everyone who attends and to reflect the move within the NHS towards more locality-based service planning.
The invitation list for each of the 3 more localised groups includes:
• Chairs of the locality’s GP practice patient groups • Chairs of local hospitals’ friends groups and patient council • Each locality’s umbrella organisation for voluntary groups and charities • Representatives from local physical and learning disability groups • Faith and minority ethnic groups • Healthwatch Essex, the county’s independent health and care watchdog • Youth Council members • Resident and housing associations with an interest in healthcare • Local authority partners • Representatives from Mid and South Essex Health and Care Partnership.
Attendees at these locality meetings are asked to give feedback on CCG proposals for future healthcare development, but as well as engaging with a broad range of residents, we also try to identify particular groups of people who will be particularly affected by our decisions so we can have direct discussions with them. The most recent example of this was a series of engagement events we arranged with local learning disability support groups.
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The CCG wanted to co-design a set of printed materials that would encourage more adults with learning disabilities to take up their free annual health checks, so we took some initial designs to a number of meetings arranged for us by the support groups – City of Chelmsford Mencap, Sport for Confidence and InterAct – so that we could seek the opinions of people in the groups we wanted to reach. You can find out more about this initiative in section 1.2.5.
Overall, the CCG aims to map the diversity of our local population using intelligence and data from the local Joint Strategic Needs Assessment, Primary Care Network profiles provided by Essex County Council and user feedback from providers and other available data. Using this information helps the CCG to target audiences to involve when planning services or proposing change.
Governance and assurance – engagement at Board meetings The CCG’s Governing Body (the Board – see section 2.1.2 for further details) includes a Lay Board Member – Patient and Public Engagement (PPE), whose role is to hold us to account in meeting our commitment to the NHS Constitution principles around involving patients in planning local health and care. The Lay Member attends a number of meetings including the CCG’s Equality and Diversity Committee and many of our place-based resident panels (see above).
The CCG generally holds a Board meeting in public once a quarter (though these are currently suspended due to the social distancing necessitated by the COVID-19 pandemic). Each of these meetings is promoted on our website and social media channels to enable as many mid Essex residents as possible to attend. The agenda includes public questions as a standing item, offering residents an opportunity to ask questions of the Board, with a commitment from the CCG to respond in writing if the question cannot be answered at the time.
Report papers for each meeting are published on our website a week in advance so the public can see how CCG Board members review the quality, performance and service developments of the health and care provision bought by the CCG. Included in the public papers is a regular communications and engagement update, outlining how the CCG has engaged with local communities in the past 3 months, what this has achieved, and what plans there are for the coming quarter.
The Lay Member – PPE and other members of the Board actively scrutinise the stakeholder engagement and public involvement. To support this, the CCG’s Communications and Engagement team designed a new “dashboard” called Insight that offers Board members an “at-a- glance” summary of recent engagement activity.
Over the past 3 years, the CCG has also actively asked for patients’ lived experience to be shared at Board – hearing how patients have engaged with services, what works and how we can improve. Our Patient Stories (see below) are available to view on the CCG’s YouTube channel.
The CCG Board also receives quarterly reports on patient experience including data from the family and friends test, patient complaints and requests for information about local NHS services.
Governance and assurance – decision-making The CCG and the Mid and South Essex CCGs teams working on behalf of the Joint Committee always seek a patient representative to be involved with the procurement of new services. So far
36 NHS Mid Essex CCG Annual Report and Accounts 2019/20 this year, local patient volunteers have been invited to take part in the scoping of a specialist neuro-rehabilitation centre at Basildon Hospital, considering non-emergency patient transport service providers and helping to draft the specification for an online consultation tool to be rolled out to mid and south Essex GP practices. During 2019, patient representatives also regularly attended the CCG-led Operational Group responsible for planning and delivering a new health hub in the Maldon area.
Until its replacement by a system wide Livewell Partnership Board involving organisations across the mid Essex health and care system, the CCG held a monthly “Livewell Committee” meeting to which patient representatives were invited. The intention was to allow patient voice to be heard by commissioners and clinicians before recommendations are finalised for the CCG’s Board, making patient involvement more meaningful.
As CCG plans and strategies were presented to the Livewell Committee before going to Board, our patient representatives were able to share views on these at a stage where they could be amended, prior to Board approval and implementation.
Some community representatives have noted that the Livewell Partnership Board has no lay membership, something the CCG is working with the rest of the Mid and South Essex Health and Care Partnership to address in part through the “Citizens’ Panel” outlined below. The CCG will also keep our engagement activities under review to ensure we are meeting our duty to involve.
Governance and performance – independent assessment In previous years NHS England commissioned polling company Ipsos MORI to seek feedback from health and care partners and patients about how CCGs involve them in our work. This independent “360° Stakeholder Survey” is conducted across a range of stakeholders, including GP practices, patient representatives and local authorities. In 2019, 62% of the mid Essex people invited to take part completed the survey, 2% above the national average.
As the questions in the survey have remained largely the same each year, the CCG can track what our partners think about our engagement with them.
Once the 2019 survey results were published, our communications and engagement team produced a report setting out how we planned to improve our stakeholder engagement in the coming year. There were both positive and negative results, which you can read about in the full report for 2019 on our website, but some pleasing outcomes included:
• 86% of respondents rating the effectiveness of their working relationship with the CCG as “fairly good” or “very good” • 80% of respondents agreeing that the CCG works collaboratively with other system partners on the vision to improve the future health of the population.
While NHS England and Improvement have now discontinued the 360° Stakeholder Survey, the CCG nevertheless took action to address issues raised by the 2019 results. This included a refreshed Communications and Engagement Strategy setting out how we should engage with more seldom-heard and minority groups, and producing a “Quality Update” for stakeholders to raise awareness of improvements the CCG is overseeing in local NHS services.
37 NHS Mid Essex CCG Annual Report and Accounts 2019/20
Showing our residents how we involve them Acknowledging the cessation of the 360° Stakeholder Survey and the value it had given us, the CCG decided to undertake a smaller scale survey of patient representatives and other stakeholders itself in early 2019. While the sample size was small and self-selecting, the results of this survey were a useful indication of where we can improve our engagement work.
Most significantly, a majority of respondents told us they neither felt like they had a voice in local NHS planning decisions nor knew how to use it even if they did. Continuing to broaden access to our engagement groups, conducting more outreach work – going to people where they are rather than expecting them to come to us – and sharing more information about how we are already involving the population should all help to change this perception.
The CCG has made a commitment to all the residents of mid Essex that we will share the outcomes of feedback we have received, so community representatives and our own Lay Member – Patient and Public Engagement can hold us to account for acting on the input we receive. The CCG publishes requests and comments from our residents and the actions we have taken as a result of that feedback. You can find this information on the You Said, We Did page of our website. Examples from 2019/20 include:
• You said – More Extended Access appointments are needed during the week and fewer on Sundays, with some people being put off booking appointments by the distance they needed to travel to a hub (August 2019)
We did – The CCG worked with the NHS teams delivering the appointments to move some provision from the weekend to week nights and made them available in more parts of mid Essex. • You said – South Woodham Ferrers residents and patient representatives wanted more information about the plans for and construction of the new medical centre being built in the town (January to July 2019).
We did – The CCG arranged a series of engagement events between January and July 2019 and supported the town’s three GP practices moving into the new building to produce newsletters and Frequently Asked Questions to inform their patients. • You said – GP practices in mid Essex asked if we could help them to deal with the volume of emails they received each day so they could use their time more effectively (November 2019). • We did – The CCG now emails a weekly newsletter to GPs and staff in their surgeries, summarising news and information from the NHS they need to be aware of. Initial feedback has been very positive. • You said – Our patient representatives in Braintree District, Chelmsford City and Maldon District all asked for briefings on how healthcare provision is affected by new housing developments and how the NHS is involved (July to September 2019).
We did – The Director of Estates for the Mid and South Essex CCGs went to each locality to discuss legal requirements on housing developers around community services and NHS involvement.
To share the full breadth of the engagement we undertake with our communities and assuage some of the concerns raised in our recent engagement survey, we have for the first time produced
38 NHS Mid Essex CCG Annual Report and Accounts 2019/20 a dedicated engagement report called “Listening to our communities – and acting on what you tell us”, which you can download from our website. Details of other engagement we have undertaken is also available from the “How we engage” web page and our broader “Get involved” page.
How we seek to involve diverse, potentially excluded and disadvantaged groups We have taken active steps during 2019/20 to focus on engaging with seldom-heard groups through targeted campaigns to ensure they can have a say in any changes to services, get involved in our work including designing pathways, new diagnosis tools and discussing how they could access services and support more easily. This has included patients affected by physical mobility issues and people with learning disabilities. Both groups helped to design materials around services they use to ensure they are as accessible as possible.
We have also continued to develop our locality-based resident panels within Braintree, Chelmsford and Maldon, with outreach to groups representing seldom-heard communities leading to new attendees.
We have introduced ways to request translations on the back of all our printed reports and magazines, including this one, offering people who need a different language, Easy Read or Braille a way to access this information more easily. Work with Healthwatch Essex, our patient groups and partners is continuing in 2020/21 as we look at further ways of improving involvement in and access to local NHS services.
How we work with partner organisations Members of the CCG Executive team attend a wide variety of partnership meetings including the Livewell Partnership Board mentioned above, the Chelmsford One Board, health and care meetings at Braintree and Maldon District Councils and Healthwatch Essex events. These meetings offer an opportunity to widen our engagement on health service plans and ensure we act on wider feedback. The CCG also reports regularly to the Health Overview and Scrutiny Committee of Essex County Council, where elected representatives can scrutinise our work.
As well as these meetings, the informal relationships with our key stakeholders are strong and there is much collaboration on campaigns, awareness events and information days to ensure local people can access and are informed about health and wellbeing services. The CCG has established a communications and marketing steering group to which colleagues from across the mid Essex health and care system are invited, so we can coordinate our campaigns with partner organisations, engage with a broader spread of our communities and avoid repetition of effort.
Patient stories Our Board members are committed to putting patient voice at the heart of our planning decisions. One of the ways we support this is showing a film at our Board meetings about the journey of a mid Essex patient through one of the services we have bought for our residents. Each patient story helps to offer some insight into how these services could be improved or streamlined.
Stories presented to Board during 2019/20 include:
• a positive experience of our local Discharge to Assess service, Home First
39 NHS Mid Essex CCG Annual Report and Accounts 2019/20
• mixed experiences of Continuing Health Care in mid Essex (improved by the intervention of the CCG’s in-house team) • mixed experiences of care in local care home for a person living with dementia.
Community awards and Annual General Meeting We include a community awards ceremony, the Marvels of Mid Awards, in each of our Annual General Meetings to thank members of our community who help others to livewell. Previous years’ award ceremonies have garnered considerable engagement, with more than 100 people attending, and also received coverage in the local press.
We promote the awards – and the good work of the healthcare professionals and patient volunteers who receive them – through our digital channels and in our newsletter (see below) to encourage nominations and show how we form links with our communities. Our website includes details of the awards and previous winners.
Engage newsletter Our patient and public newsletter, called Engage, used to be distributed electronically every two months. Following patient feedback that a hard copy would be more widely read – and better for people with certain disabilities – we now produce a quarterly printed edition, completely redesigned to make it more accessible. Electronic copies are also available on our website and we seek input from patients and stakeholders on articles they might like to see in future editions.
Increasing our reach and use of digital media In 2019/20 our social media presence continues to grow and the paid advertising to target specific audiences we have been undertaking yielded measurable improvements in referrals to underutilised services. We have also started producing more content for Instagram and YouTube, which have a different, often younger, demographic in their users than the audiences for our more established Twitter, Facebook and LinkedIn channels.
Downloads for the Mid Essex Child Health app for young parents and carers continued to rise on both Apple and Android devices during 2019/20 and at 31 March 2020 it had been downloaded more than 3,000 times, a 200% increase on comparable figures of 1,000 downloads the previous year. As a result, more of our residents are now empowered to seek the most appropriate care for their children.
Because we appreciate that digital marketing alone is not a sufficient means of involving and engaging with our residents, we aim to make it part of broader communications plans wherever possible. In the case of the app, we accompanied its launch with a series of face-to-face workshops at local schools hosted by mid Essex clinicians.
Supporting wider consultation across mid and south Essex The CCG supported the Mid and South Essex Health and Care Partnership communications director in developing a Citizens’ Panel of 1,000 residents representative of the area’s wider population, who can be engaged with efficiently on commissioning decisions. Prior to being
40 NHS Mid Essex CCG Annual Report and Accounts 2019/20 paused during the local COVID-19 response, the CCG also delivered the engagement in our three localities around the proposed merger of the 5 mid and south Essex CCGs.
Learning, best practice and future plans The CCG always seeks to evaluate its campaigns and learn from them, with debrief meetings held as a matter of course after major initiatives and events such as our developing locality resident panels. This learning then forms part of future strategies and plans.
We also continue to listen to our community representatives about ways we can support their engagement with us and the wider health and care system. For example, some of our volunteer Community Champions have told us that they would like more support in meeting Primary Care Network Clinical Directors. We aim to meet that request once the COVID-19 response allows.
The CCG is keen to share best practice, seeking national awareness of our innovations through award entries, some of which are noted above, and attending regional and national NHS events to discuss what we have done. We also offer guidance on our successful activities with partners inside Mid and South Essex Health and Care Partnership.
From creating proactive and targeted social media and marketing campaigns to having a presence at both large-scale and localised community events, a virtual network of residents informed by regular e-newsletters to individuals sharing their lived experience at public Board meetings, patient and public involvement is at the heart of everything we do.
1.2.4 Reducing health inequality
Working towards an NHS that is personal, fair and diverse We are committed to working within the framework of the Equality Act 2010, which replaced previous anti-discrimination laws and aims to protect people from unfavourable treatment. Nine different characteristics are protected under the Act, some of which apply to everyone and some only to specific groups of people. The nine characteristics are:
Age Pregnancy and maternity Disability Religion or belief Gender reassignment Sexuality Marriage and civil partnership Sexual orientation Race (including nationality and ethnicity)
The public sector general Equality Duty applies to all public authorities including CCGs who must, as they carry out their work, take appropriate actions to:
• Eliminate unlawful discrimination, harassment and victimisation, and other conduct prohibited under the Act • Advance equality of opportunity between people who share a relevant protected characteristic and people who do not • Foster good relations between people who share a relevant protected characteristic and people who do not.
41 NHS Mid Essex CCG Annual Report and Accounts 2019/20
The CCG regularly reviews its local Equality and Diversity objectives and monitors its achievement against both these and the NHS Equality and Delivery System (EDS2) goals, which are:
• Goal 1 – better health outcomes • Goal 2 – improved patient access and experience • Goal 3 – a representative and supported workforce • Goal 4 – inclusive leadership.
The CCG has self-assessed its performance against these goals as follows:
Goal No. of ‘outcomes’ Final rating* 1. Better Health Outcomes 5 Developing – 0 Achieving – 5 2. Improved patient access and experience) 4 Developing – 0 Achieving – 4 3. A representative and supported 6 Developing – 0 workforce Achieving – 6 4. Inclusive Leadership 3 Developing – 1 Achieving – 2
* The definitions for “Developing” and “Achieving” vary from category to category, but descriptions for these and other EDS2 ratings are available on the NHS England website.
Our overall score of 1 x Developing and 17 x Achieving remains the same as our 2018/19 position with no outcome areas classed as “undeveloped” against any of the four goals. The CCG will continue to seek to improve its EDS2 ratings during 2020/2021.
The CCG’s local Equality and Diversity objectives are:
• Objective 1 – ensuring there is local engagement from vulnerable and ethnic groups in assessing health needs, service redesign and measuring the impact of commissioned services • Objective 2 – gathering the intelligence to enable the CCG to understand the experience of protected groups when accessing and using NHS Services • Objective 3 – improving overall staff health & wellbeing within the CCG by implementing a variety of approaches including the provision of workplace health activities and social events planned in partnership with the CCG’s Work Well Committee. • Objective 4 – ensuring the CCG has a representative workforce who suffers no inequity in remuneration and is empowered to promote equality at work, and to provide assurance to the Board and seek their support on action being taken by the CCG to achieve this • Objective 5 – embedding equality and diversity at Board level and at every level within the CCG.
Progress against these objectives was monitored during the year by the Equality and Diversity Sub- Committee and a number of key actions were completed during 2019/20. The CCG’s Annual
42 NHS Mid Essex CCG Annual Report and Accounts 2019/20
Equality and Diversity report will be presented to the Board later this year, including a copy of the CCG’s latest EDS2 assessment.
Duty to reduce inequality The CCG has a duty under Section 149 of the Health and Social Care Act 2012 to reduce inequalities. There have been no serious lapses in the CCG’s fulfilment of that duty, as demonstrated by our EDS2 outcomes for 2019/20 outlined above.
When commissioning, the CCG uses the NHS Standard Contract, which sets out to avoid discrimination through its terms and conditions. There are provisions to protect equality under Service Condition 13 (“Equity of Access, Equality and Non-Discrimination”), the full text of which is available on the NHS England website. The CCG requires contracted healthcare providers to demonstrate compliance with all relevant provisions as part of the contract monitoring process.
In its dealings with both patients and staff, the CCG also follows relevant human rights legislation.
1.2.5 Detailed review of the CCG’s development and performance
Adult mental health – dementia The CCG’s dementia care had the greatest need for improvement in 2018/19, with an estimated diagnosis rate of just 59.7%. In response, the CCG drafted and implemented a comprehensive action plan including reviews of GP registers and the dementia care pathway. The detailed investigation into dementia services run by the CCG during 2019/20 revealed that the low diagnosis rate was due to the time lag between diagnosis and disclosure meetings and thus to the national dataset. The CCG has been meeting the national target for diagnosis as of April 2019 and at January 2020 the figure was at 71%.
The data time lag meant the CCG’s dementia care planning and post-diagnostic support was performing at 74% at March 2019. To maintain this figure the CCG worked with the provider, Essex Partnership University NHS Foundation Trust (EPUT) to introduce measures including a training package to upskill the primary care workforce, updating the referral process and documentation, offering Dementia Friends training in primary care and the launch of a Dementia Clinic pilot project.
The CCG also developed a community dementia model with EPUT to bring additional staff to dementia care. This saw the relaunch in January 2020 of the Dementia Intensive Support Service (DISS) that was originally commissioned in 2017. It now offers people living with dementia and their carers a one-stop shop for physical and mental health needs, accessible by both clinicians and through self-referral. The enhanced community element to more closely match the crisis support commissioned by the four south Essex CCGs.
Adult mental health services – Improving Access to Psychological Therapies (IAPT) When people access mid Essex IAPT treatment they have very good outcomes in general and our recovery rates often exceed 50%, with most patients experiencing reliable improvement. But the CCG’s IAPT access target is currently not meeting NHS England prevalence rates – in other words, the proportion of the population in need of the service who are using it.
43 NHS Mid Essex CCG Annual Report and Accounts 2019/20
At January 2020, the CCG was below trajectory for take-up of its IAPT digital pathway, due in part to difficulties in building usage among the long-term condition (LTC) cohort of patients. To address this, the CCG took a number of steps, including a successful marketing campaign for our online mental wellbeing solution, SilverCloud, in October 2019. This led to increased access the following month and the national Every Mind Matters campaign is now supporting the CCG’s messaging.
We arranged a local “IAPT Digital Workshop” with and for partners on 17 December 2019 and we continue to develop the integrated service model we have agreed with our two mental wellbeing providers, Hertfordshire Partnership University NHS Foundation Trust and Mid and North Essex Mind. The CCG continues to monitor progress of Mind’s agreed action to promote SilverCloud.
Adult mental health services – general The coordinating commissioner for the Essex Partnership University NHS Foundation Trust (EPUT) contract to deliver Mental Health services on behalf of the Mid and South Essex Health and Care Partnership is NHS Thurrock Clinical Commissioning Group. EPUT provides a range of Mental Health inpatient and community services to: • Thurrock Clinical Commissioning Group • South East Essex Clinical Commissioning Groups • Basildon and Brentwood Clinical Commissioning Group • Mid Essex Clinical Commissioning Group All commissioned providers are required to report serious incidents (SIs) and Never Events as detailed in section 1.2.1. EPUT Mid and South Essex Mental Health Services reported 54 SIs during 2019/20, with no incidents deemed Never Events. The highest reported incident categories were “unexpected/potentially avoidable death”, “unexpected/potentially avoidable injury causing serious harm” and pressure-ulcer-related SIs.
Thurrock Clinical Commissioning Group Nursing and Quality team assumes responsibility for the commissioning assurance process and review of SIs and Never Events including the review of all root cause analysis reports.
Action plans are also monitored by Thurrock Clinical Commissioning Group Quality and Patient Safety team until there is sufficient evidence that actions have been completed and implemented. Follow-up of these actions is also monitored via quality assurance visits with the provider during the contractual year.
There are three noteworthy independent investigations relevant to 2019/20 for EPUT Mid and South Essex Mental Health Services.
• Level 3 Independent Investigation (Inpatient Death): commissioned by Thurrock Clinical Commissioning Group as coordinating commissioner following an inpatient death within Essex Partnership University Trust. The Independent Level 3 Report has been reviewed and shared with the Coroner and the family. The learning from this investigation will be used to shape the new personality disorder pathway. • Level 3 Independent Investigation (Legacy Case): a legacy case from 2016 was transferred to the coordinating commissioner in October 2019 and NHSE have commissioned a Level 3 Independent Investigation. The Investigation Team have been appointed and the Independent Investigation has commenced.
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• Further NHS England and Improvement Commissioned Review (Inpatient Death): The Parliamentary and Health Service Ombudsman (see section 1.2.1) published a report highlighting care and service delivery issues from a 2012 legacy case. Following the report’s publication, NHS England and Improvement commissioned an Independent Review, while a separate Health and Safety Executive investigation is nearing completion.
Essex Partnership University Trust are an early adopter for the national Patient Safety Incident Response Framework (PSIRF, 2020). The PSIRF has been developed as a result of the 2018 engagement programme and building on evidence gathered and best practice. The PSIRF includes a list of incident types that must be investigated and offers a risk-based approach to patient safety incident response, prioritising help for the people affected and sustainably reducing future risk.
EPUT will develop a readiness assessment document setting out the criteria that have to be met by early adopter organisations, which commissioners will agree before approving implementation.
There is also a comprehensive Urgent and Emergency Care Project underway with an implementation plan that is reported via the governance framework to the Service Development Oversight Group (SDOG) and Mental Health Partnership Board.
The Nursing and Quality team completed a schedule of 15 planned contractual Quality Visits during 2019/20. Each visit’s theme is determined by commissioners in advance based on feedback received from SIs, complaints, CQC outcomes and other intelligence. Areas to be reviewed are not revealed to the organisations prior to the visits.
Each visit’s findings have been generally positive during 2019/20. Examples of notable practice were fed back to EPUT after each visit and areas for improvement highlighted with action plans monitored. These visits will continue in 2020/21.
Anti-microbial resistance – appropriate primary care prescribing of antibiotics At January 2020, 26 of the CCG’s member practices were below 10% broad spectrum antibiotic prescribing, compared to 23 practices in the previous quarter. Co-amoxiclav prescribing was almost twice as high as other broad spectrum antimicrobials.
The CCG’s Medicine Optimisation team arranged antibiotic audits and shared the learning and recommendations from them with primary care colleagues. The CCG also distributed an antibiotic patient education to practices for display on screens in GP surgery waiting areas.
The total number of broad spectrum antibiotics prescribed in the 6 months to January 2020 was about 2,000 items fewer than the previous period.
Better Care Fund The Better Care Fund – Protection of Social Care expenditure shown on the chart in section 1.1.4 reflects money passed from the NHS to pay for adult social care, which the NHS recognises as playing an important part in reducing demand on healthcare services.
45 NHS Mid Essex CCG Annual Report and Accounts 2019/20
In 2019/20 we and Essex County Council had a Mid Essex Better Care Fund totalling £24.3m, of which £9.1m related to protection of social care. The remaining £15.2m related to health services which are included in the relevant healthcare expenditure categories in the same chart.
In 2019/20 Essex County Council received further Improved Better Care Fund money of which £0.4m was provided to the CCG to contribute to the costs of continuing improvements in dementia and end of life services. As the grant was reduced from 2018/19 the remainder of the funding for these schemes was provided from CCG allocations.
In March 2020 NHS England announced additional funding for local authorities as part of the nationally mandated Hospital Discharge Programme which is providing a key element of the local response to patient flows during the COVID-19 crisis. Additional expenditure by Essex County Council relating to its entire geographic footprint is accounted for in the Mid Essex Better Care Fund and for 2019/20 totalled £683,000.
Carers with a long-term health condition Not enough carers with a long-term conditions felt supported by the local NHS in managing their condition compared to national benchmarks. The CCG acknowledged in public Board papers that the work the CCG has been doing on supporting carers did not have a focus on those with long- term conditions.
To remedy this, the CCG worked with Essex County Council to deliver the priorities identified in the Essex Carer Strategy and began developing plans for delivery of “Carer Friendly GP Surgeries” across mid Essex. Additional support for carers of people living with dementia was also commissioned from the Alzheimer’s Society.
Diabetes care In mid Essex 35.2% of diabetes patients have achieved all the NICE-recommended treatment targets, a figure in the bottom quartile for England CCGs. To improve care further, the CCG has implemented a comprehensive diabetes action plan which has a number of elements:
• Offering all mid Essex GP practices training for healthcare assistants (HCAs) so they can manage the diabetes care process, with an incentive for practices to allocate HCA time for diabetes project work and running diabetes clinics • Providing clinical pharmacist resources to the bottom 10 performing practices for NICE- recommended treatment targets, so they can so offer 1,000 priority diabetes patients first and follow-up medication reviews • Running pilot projects with our diabetes providers enabling closer working between practices and specialist teams. This includes giving practices access to a telephone helpline during business hours for diabetes specialist nurse advice and guidance. Practices will also get access to diabetes education events and monthly diabetes specialist nurse visits to discuss complex cases. • Providing accurate, up-to-date data to each GP practice about their diabetes population, including information on essential health checks, how well standards are being met and attainment of treatment targets
46 NHS Mid Essex CCG Annual Report and Accounts 2019/20
• Supporting rapid identification of patients at most risk so their cases can be reviewed and enhanced support put in place, including development and monitoring of individualised management plans to better control their condition • Creating a dynamic centralised database to improve integrated care, remote reviews and efficient use of the extended healthcare team • Ensuring patients understand what health checks and other support are available to them annually under NICE recommended care processes and how to access these • Continuing provision of 275 extra structured education places for people with diabetes so more patients have access to information about diabetes, giving them the knowledge and tools to better self-manage their condition whether newly diagnosed or having lived with the condition for some time • Running a trial of 100 places on a 4-week myDiabetes digital structured education pathway that offers patients increased choice for attending a structured education course.
Additionally, in 2019/20 the CCG has continued to see 100% of mid Essex GP practices take part in the National Diabetes Audit.
Effectiveness of working relationships in the local system In the 2019 CCG 360 Stakeholder Survey, conducted by Ipsos MORI on NHS England’s behalf, 86% of Mid Essex CCG stakeholders rated the effectiveness of their working relationship with us as very good or fairly good. This figure has increased by 10% since 2018, though it is still 2% behind the national average of 88%.
There was a larger disparity in our stakeholders’ rating of the CCG as an either very or fairly effective local system leader, with 69% of survey respondents doing so. The national average was 74% and only 10% of our stakeholders rated the CCG as very effective compared to 22% nationally. The smaller numbers of stakeholders rating us as very good or very effective compared to our other local CCGs had an impact on our overall score.
To address these perceptions among our stakeholders, the CCG has implemented a refreshed communications and engagement strategy focused on how we involve patients and partners at a locality level and engage with them at an early stage in our commissioning decisions and work. While this indicator is no longer included in NHS Oversight Framework reporting, the CCG remains committed to delivering the new strategy.
Leadership at the CCG as reviewed by national assessment frameworks The CCG’s overall rating in the now-discontinued Improvement and Assessment Framework (or IAF – see section 1.1.3) has risen to “Good” for 2018/19 from its earlier “Requires Improvement”, reflecting a number of changes we have made to our commissioning and quality monitoring.
Similarly, in the “Well-led” category of the IAF the CCG’s assessment changed from “Requires Improvement” to “Good” in 2018/19. In part, this change is due to the effective way the CCG has been bringing down its historic budgetary deficit. See section 1.1.4 for more details.
47 NHS Mid Essex CCG Annual Report and Accounts 2019/20
Learning disabilities Mid Essex CCG worked with all our member GP practices during 2019/20 to maintain a live register of patients with a learning disability (LD). Nearly all practices – 38 of 40 – are signed up to provide the Learning Disabilities Directed Enhanced Service (DES).
Regular health checks for adults with LD are a key target for the CCG and essential to the wellbeing of this group of people. NHS England and Improvement monitor the proportion of annual health checks carried out by practices in each CCG area against the total number people on their LD registers to ensure as many people in this vulnerable group as possible have support to livewell.
By the end of December 2019 practices had completed 575 checks, 41% of the total number of people on the local LD register (1,575). The sharp increase from Quarter 1 (April-June 2019) to Quarter 2 (July-September 2019) was due to training and support provided to the practices in December 2018 and February 2019 to carry out these checks.
Qtr 1 Qtr 2 Qtr 3 Total to Q3 Total number of health 104 237 204 545 checks carried out Percentage of patients 7.23% 17.38% 16.74% 41.35% on practice LD registers
Monitoring disparities between practices in their volume of LD health checks allowed the CCG to contact those with lower figures to offer support. In addition to this, we secure validation against social care registers for 20 of our practices’ LD registers. Key issues for patients have been highlighted with social care.
The CCG received assurances from practices that these health checks would be carried out, although some external factors such as patients not wishing to take part or not attending appointments continue to affect take-up.
To improve take-up, reassure people with LD who are worried about having a health check and offer them a better experience when they attend one, the CCG organised a series of engagement events with people who have LD. We asked for their input to help us develop a resource pack we plan to share with all mid Essex practices once the COVID-19 pandemic has passed. The pack is intended to support all practices in engaging with their LD patients and more details of the engagements can be found in section 1.2.3.
Patient correspondence and Parliamentary and Health Service Ombudsman cases There were 162 cases logged as complaints and/or MP enquiries during 2019/20. One case involving the CCG went to the Ombudsman but the case is not yet completed so there is no result or learning as this report is written. The CCG aims to respond to all patient correspondence within 25 days, although this target was not fully met in 2019/20.
Planning for emergencies CCGs have a duty under the Civil Contingencies Act to be prepared for incidents and emergencies. CCGs are classed as a “category two” responder and are seen as a “co-operating
48 NHS Mid Essex CCG Annual Report and Accounts 2019/20 body”. This means that they are less likely to be at the heart of planning but will be involved in any incident that affects the health sector. The CCG’s role is one of co-operation, coordination and sharing information.
The seven Essex CCGs have an Emergency Preparedness, Resilience and Response (EPRR) and Business Continuity Strategy. This ensures that the Essex CCGs respond according to the Civil Contingencies Act 2004, Health and Social Care Act 2012 and NHS England national policy and guidance, including the NHS England EPRR Framework 2015 and NHS England EPRR core standards.
The Essex CCGs have an Incident Response and Incident Coordination Centre Plan which outlines the process for establishing an Incident Coordination Centre and an Incident Response Team within the local CCG. These were activated during 2019/20 when the CCG led the response to the invasive Group A Streptococcus outbreak in mid and west Essex and then again in the final quarter of the year to coordinate the local response to the COVID-19 pandemic.
Business Continuity Management (BCM) is a statutory requirement for all Essex CCGs. Suitable plans aligned to the international Business Continuity Standard ISO22301 have been developed to enable the Essex CCGs to respond to an internal incident or disruption. This process is supported by the CCG’s Business Continuity Management System, Policy and Business Continuity Plan.
In early March 2020, Mid Essex CCG undertook a test of its business continuity plans by closing its main office for 1 day and encouraging home working wherever possible. This proved largely successful and was invaluable in identifying potential problems ahead of the Government’s tightening of COVID-19 social distancing guidance later in the month. This meant that the CCG was prepared for the longer-term office closure that the guidance suggested.
The Mid and South Essex CCGs EPRR team have also been closely involved in the preparations for exiting the European Union by the leaving date of 31 January 2020.
The EPRR team enjoys strong partnership working with NHS England and Improvement’s East of England regional team and with local providers, ensuring the five CCGs in mid and south Essex are key partners in the Local Health Resilience Partnership and the Essex Resilience Forum.
Primary care services – ensuring high quality provision At January 2020, 3 mid Essex GP practices had CQC ratings of “requires improvement”, 1 fewer than the previous quarter. However, the suspension of routine CQC assessments during the COVID-19 pandemic has meant it is not possible to demonstrate whether further progress has been made.
Prior to this suspension, 1 mid Essex practice was rated “Outstanding” by the CQC during 2019/20 having been “Good” previously and another had its previous rating of “Requires Improvement” raised to “Good”.
The CCG now has 4 Outstanding surgeries practices in its footprint and is making progress with challenged practices due to regular monitoring of agreed action plans that address CQC concerns and contractual matters. The CCG also undertakes regular monthly meetings internally to assess risk in primary care quality and uses both data and “soft intelligence” to assess the likelihood of practices becoming vulnerable, so pre-emptive support can be offered.
49 NHS Mid Essex CCG Annual Report and Accounts 2019/20
Primary care services – patient experience GP Patient Survey data released during 2019/20 demonstrated low patient satisfaction in relation to their ability to contact practices and get access to appointments. There has been a slight improvement in the overall mid Essex position in 2019 compared with 2018 and the difference between local and national averages has narrowed slightly. The survey is undertaken annually and so performance will not change until the new survey results are published in the summer.
In the meantime, the CCG is looking to further improve local patient experience of GP-led services by continuing work with our extended access provider and local practices to review and further develop service provision and improve utilisation, especially with a significant drop in take-up during the COVID-19 pandemic.
The CCG has also confirmed its follow-up “Foundations 2 offer” to practices, building on the original Primary Care Foundations scheme using CCG funding to improve member practice resilience and workforce diversification.
The CCG is also meeting practices that have the lowest overall levels of patient satisfaction to ensure that appropriate actions have been taken in advance of the 2020 national survey, unless it is postponed or cancelled due to the pandemic.
QIPP and the Health and Social Care Act (2012) QIPP (Quality, Innovation, Productivity and Prevention) is the umbrella term used to describe the approach the NHS is taking locally, regionally and nationally to reform and redesign services in the light of financial challenge. The Health and Social Care Act 2012 outlined the Government’s commitment to ensuring that QIPP supports the NHS in making efficiency savings that can be reinvested to continue improving the quality of NHS care.
The focus for transformational change in 2019/20 has been to continue to support the sustainability of GP Practices and to provide services for patients outside of the acute setting where appropriate. That includes continuing our Home First service which supports patients to recover in their own homes where possible, frequently giving them a shorter recovery time and freeing up acute hospital beds for patients who really need them.
During this year an enhanced end of life scheme was set up with hospice-led care for patients choosing to spend their final weeks or days in their own home. We also delivered substantial cost improvements, particularly in the areas of prescribing and Continuing Health Care.
We have continued to build awareness of inappropriate A&E attendance through patient engagement with the aim of reducing occurrences so hospital staff can better prioritise patients who require emergency treatment. During 2020/21 we will continue to work closely with Essex County Council and other System partners to identify new ways services can link together and improve the efficiency and effectiveness of patient flows into and out of hospital.
Requests under Freedom of Information rules The Freedom of Information (FoI) Act 2000 gives a general right of access to recorded information held by public authorities, subject to certain conditions and exemptions. The CCG received 246 FoI requests during 2019/20. The CCG responded to 98.8% of these within the statutory timescale
50 NHS Mid Essex CCG Annual Report and Accounts 2019/20 of 20 working days. We certify that we have complied with HM Treasury’s guidance on setting charges for information.
Workforce measures in the NHS Oversight Framework The mid Essex health economy is in the bottom quartile nationally for progress against the Workforce Race Equality Standard and Staff Engagement Index at January 2020, but these are both provider performance indicators and so not within the direct remit of the CCG.
We have requested staff survey and associated action plans from the former Mid Essex Hospitals NHS Trust (now part of Mid and South Essex NHS Foundation Trust) and Essex Partnership University NHS Foundation Trust via the Chief Nurse to review their action plans.
More details of our own staff diversity and engagement can be found in section 2.3.2.
1.2.6 Sustainable development
Environmental sustainability is recognised nationally as an essential part of delivering high-quality healthcare efficiently, so it needs to be part of our everyday work and the work of partner organisations and the wider NHS.
Sustainability is not just about the CCG using its limited financial resources carefully. It is also about ensuring we make the most of existing social and community resources (such as community buildings and local groups) and minimising the impact on the local environment by considering sustainability during commissioning and procurement processes.
The CCG has responsibilities as a commissioner and as a corporate body so we work closely with staff and GP member practices to use resources wisely, minimise waste from day-to-day work and improve the sustainability of services. In 2019/20 we have:
• committed to largely paperless operation by the end of 2020, with investigation underway into processes that will support this • developed STP-wide business continuity preparedness both internally and with health and social care partners to keep services sustainable and resilient in the event of adverse weather conditions, power failure, possible challenges from EU exit or other major business interruptions • made further progress in changing working practices to reduce fuel consumption and continued to promote sustainable travel • investigated opportunities with GP practices to reduce patient travel through the use of information technology • promoted the use of video and teleconferencing to reduce staff travel
Data on resource consumption for our headquarters building, Wren House, is based on use, size (measured in “net internal area”, or NIA) and expected performance. Electricity data is based on estimates for this building type as the actual data is not available from the suppliers. Gas data is based on billing and estimated for a full year from a partial year of data available (six months). Water data is based on averages for the past few years.
51 NHS Mid Essex CCG Annual Report and Accounts 2019/20
NHS Property Services have not provided 2019/20 figures due to the COVID-19 pandemic, but with Wren House not occupied by Mid Essex CCG for the final 10 days of 2019/20 in line with Government social distancing guidance, and with many CCG staff already working from home prior to 21 March 2020, our resource consumption is expected to be well below the 2018/19 figures. These are provided below along with the 2017/18 figures, which show a significant decline in both gas and water use (though electricity use did increase).
Wren House – full property Year Full Consumption Cost Property Electricity Gas Water Electricity Gas Water NIA 2018/19 1,316 181,762.11 132,020.00 683.00 £50,787.80 £4,950.98 £3,805.23 2017/18 1,316 123,940.88 280,202.72 1,065.96 £15,864.43 £6,724.87 £3,006.33
Wren House – CCG Area Year Tenant Consumption Cost Occupancy Electricity Gas Water Electricity Gas Water NIA 2018/19 878 121,297.20 88,102.56 455.53 £33,892.75 £3,303.99 £2,539.39 2017/18 878 84,976.73 192,113.46 730.85 £10,877.02 £4,610.72 £2,061.21
The CCG has a commitment to promoting sustainability in the healthcare developments planned for primary care and health hub premises. This is reflected through our adherence to Building Research Establishment Environmental Assessment Method (BREEAM) design and build quality standards for development proposals.
Sustainability is also a standard part of our procurement processes to ensure that all providers we contract with are environmentally responsible. The CCG is committed to working with all our partners to commission sustainable healthcare and help make sure that the people of mid Essex receive high-quality services both now and into the future.
In the year ahead our focus will be to:
• Continue to work with partner organisations in the Mid and South Essex Health and Care Partnership to ensure services are planned sustainably • Ensure that our emergency planning arrangements (see section 1.2.5) continue to develop greater resilience to the increased risk of climate-related impacts such as flooding • Further reduce our carbon footprint by continually reviewing the way we work and the opportunities afforded by implementing new technology.
This concludes the 2019/20 Mid Essex CCG Performance Report.
Anthony McKeever Joint Accountable Officer, Mid and South Essex CCGs
16 June 2020
52 NHS Mid Essex CCG Annual Report and Accounts 2019/20 2. Accountability Report
Forming the second part of Mid Essex Clinical Commissioning Group’s Annual Report and Accounts 2019/20, the Accountability Report, has several elements.
• The Corporate Governance Report (section 2.1 below) explains how the CCG is managed and run (its governance structure) and how that helps meet CCG objectives. • The Statement of Accountable Officer’s Responsibilities (section 2.1.8) sets out who is answerable for the CCG’s finances and functions, with outlines of their duties. • The Governance Statement (section 2.2) explains how the CCG’s internal controls work. • The Remuneration and Staff Report (section 2.3) sets out the CCG’s policy for paying directors and senior managers, and explains the payments made under that policy during 2019/20. CCG Board members’ details, staffing numbers, policies relating to staff and equality and diversity are also included in this element of the Accountability Report.
KPMG are the CCG’s external auditors. The total planned fee for the 2019/20 audit was £41k plus VAT.
Anthony McKeever Joint Accountable Officer, Mid and South Essex CCGs
16 June 2020
53 NHS Mid Essex CCG Annual Report and Accounts 2019/20
2.1 Corporate Governance Report
2.1.1 Members Report – member practices
CCGs are clinically-led membership organisations made up of general practices. As of 31 March 2019, the following 40 NHS practices are members of Mid Essex CCG.
Practice Area served Primary Care Network Baddow Village Surgery Great Baddow Chelmsford City Health Beacon Health Group Chelmsford and Danbury Phoenix Beauchamp House Surgery Chelmsford Chelmsford City Health Blackwater Medical Centre Maldon Witham and Maldon Blandford Medical Centre Braintree Braintree Blyth’s Meadow Surgery Braintree Braintree Brickfields Surgery South Woodham Ferrers Dengie and SWF Burnham Surgery Burnham-on-Crouch Dengie and SWF Chelmer Medical Partnership* Western Chelmsford Chelmsford West Chelmer Village Surgery Chelmsford Chelmer Church Lane Surgery Braintree Braintree Coggeshall Surgery Coggeshall Colne Valley Collingwood Road Surgery Witham Witham and Maldon Dengie Medical Partnership Tillingham, the Maylands Dengie and SWF Dickens Place Surgery Chelmsford Chelmsford West Douglas Grove Surgery Witham Aegros Elizabeth Courtauld Surgery Halstead Colne Valley Fern House Surgery Witham Witham and Maldon Freshford Practice Finchingfield Colne Valley Greenwood Surgery South Woodham Ferrers Dengie and SWF Hedingham Medical Centre** Castle Hedingham, Sible Colne Valley Hedingham, Yeldham Kelvedon and Feering Health Centre*** Kelvedon Colne Valley Kingsway Surgery South Woodham Ferrers Dengie and SWF Little Waltham and Great Notley Little Waltham Aegros Surgeries Longfield Medical Centre Maldon Phoenix Mount Chambers Surgery Braintree Braintree North Chelmsford Healthcare Centre Chelmsford Chelmer Pump House Surgery Earls Colne Colne Valley Rivermead Gate Medical Centre Chelmsford Chelmer Sidney House & The Laurels Surgeries Hatfield Peverel, Boreham Aegros Silver End Surgery Witham Braintree Stock Surgery Stock Chelmsford City Health Sutherland Lodge Surgery Chelmsford Chelmer Tollesbury Surgery Tollesbury Phoenix Trinity Medical Practice The Maylands Dengie and SWF Whitley House Surgery Chelmsford Chelmsford City Health William Fisher Medical Centre Southminster Dengie and SWF Witham Health Centre Witham Witham and Maldon Writtle Surgery Writtle Chelmsford West Wyncroft Surgery Bicknacre, East Dengie and SWF Hanningfield
54 NHS Mid Essex CCG Annual Report and Accounts 2019/20
* Chelmer Medical Partnership was formed from a merger of neighbouring practices Humber Road Surgery, Melbourne House Surgery and Tennyson House Surgery during 2019/20.
** Hedingham Medical Centre was formed from a merger of the Castle Surgery and Hilton House Surgery during 2019/20.
*** Kelvedon and Feering Health Centre includes Brimpton House Surgery, also in Kelvedon, which was a separate practice until its incorporation into the group during 2019/20.
2.1.2 Composition of Governing Body
The CCG’s Board is the accountable body for the performance of the CCG. It has 4 GP members elected by their fellow GPs to lead the organisation alongside the Executive membership. One of these elected GPs chairs the Board.
The Board also has 3 lay members. Their roles include ensuring views and suggestions from patients and the public are properly considered by the CCG, providing independent judgment and sound commercial knowledge, and helping to ensure the CCG is well run and uses public funds properly. The CCG’s constitution makes provision for secondary care representation on the Board.
As of 31 March 2020, the Board consisted of 13 members. Of these, 7 are female and 6 are male.
Membership of the Board, together with information on which of the main CCG committees each Board member attends, is set out below and in the Governance Statement in section 2.2.2.
Board meetings are held on a quarterly basis and Board papers are published on the CCG website in advance of each meeting. At all formal meetings of the Board and its Committees, members must declare if they have an interest in any agenda items under discussion.
The CCG maintains a register of interests declared by Board members, a copy of which is provided at all Board meetings. The full register of Board members’ interests is available on the CCG’s website.
The following people have been CCG Board Members during 2019/20.
Viv Barnes Director of Governance and Performance
Viv joined the CCG in August 2014 as Director of Corporate Services, following a secondment from NHS England where she was Assistant Director of Clinical Strategy for the Essex Area Team.
She has a background in Corporate Governance and has worked at Board level within a number of Primary Care Trusts in south Essex and a London health authority. Viv began her career in the NHS supporting the development of primary care in Southend. Viv was appointed Director of Governance and Performance on 15 January 2018 and is a non-voting member of the Board.
55 NHS Mid Essex CCG Annual Report and Accounts 2019/20
Dr Daniel Dalton Secondary Care Doctor until November 2019
Dr Daniel Dalton graduated in medicine from St Bartholomew’s and the Royal London School of Medicine and Dentistry in 1999. He then undertook core postgraduate training in psychiatry in east London before moving to higher training in forensic psychiatry on the Eastern Region Training Scheme, achieving a Certificate of Completion of Specialist Training (CCST) in forensic psychiatry in 2009.
Dr Dalton is currently a consultant psychiatrist for Norfolk and Suffolk NHS Foundation Trust, following a previous role as Clinical Director for Learning Disability and Forensic Strategic Business at Hertfordshire Partnership University NHS Foundation Trust. He joined Mid Essex CCG’s Board as Secondary Care Consultant in March 2018.
Dr Anna Davey Elected GP and Chair
Dr Anna Davey qualified from the Guy’s and St. Thomas’ Medical School in 1999, going on to train at The Ipswich Hospital NHS Trust and Colchester Hospital University NHS Trust in junior doctor posts.
Anna worked as a GP in Halstead for 12 years before moving to Coggeshall Surgery in 2017. She became a clinical lead for out-of- hospital care at Mid Essex CCG in 2016 and became Chair in October 2018. Her clinical interests are women’s health, dermatology and the complex care of frail elderly patients.
Dee Davey Chief Finance Officer
Dee is responsible for financial systems, strategy and reporting. Dee worked in Local Government for 20 years before joining the NHS. Since October 2018 Dee has also been the Interim Chief Finance Officer for Basildon and Brentwood CCG.
Dan Doherty Director of Clinical Transformation
Dan was previously Director of Clinical Commissioning and from 15 January 2018 was appointed Director of Clinical Transformation and Deputy Accountable Officer. In March 2016 Dan was seconded to the Mid and South Essex Success Regime (Locality Health and Care) for 18 months, working on system transformation with a particular focus on innovation in health and care.
56 NHS Mid Essex CCG Annual Report and Accounts 2019/20
Dan is a practising physiotherapist who previously worked at St Peter's Hospital in Maldon.
John Gilham Lay Board Member (Governance) and Deputy Chair
John Gilham was appointed as Lay Member for Governance in July 2018. He was formerly chief executive of two NHS hospital trusts in Essex covering a period of almost nine years.
John has over 30 years’ management experience across a range of functions in the NHS. He has most recently served as a public sector non-executive director with the NHS, including undertaking the role as Chair of the Risk and Quality Committee at East & North Hertfordshire NHS Trust.
John also has experience of working with the private sector over the last six years as a management consultant, focusing on how their services can best be matched to the needs of the NHS and to give patients an improved service experience.
Rachel Hearn Director of Nursing and Quality
Rachel is a Registered Nurse and Director of Nursing and Quality at the CCG. Rachel has over 18 years’ clinical experience as a nurse within the NHS. Having worked predominantly in emergency and general medicine, Rachel has led work streams on the changing face of emergency care.
Alan Hubbard Lay Board Member (Commercial)
Alan Hubbard is a former Senior Executive with the Lloyds Banking Group. He has over 30 years’ management experience across a range of functions in the UK and abroad. Alan has served for over 11 years as a public sector non-executive director with the local NHS in various roles, including Vice-Chair.
He was previously Chair of the Essex Probation Trust and has worked as a part-time consultant supporting Essex businesses. He is an Independent Member of the Joint Audit Committee for the Essex Police, Fire and Crime Commissioner, Chief Constable and Essex County Fire and Rescue Authority.
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Dr Julie McGeachy Elected GP and Clinical Vice Chair
Dr Julie McGeachy qualified from Nottingham University medical school in 1987 and trained as a GP in Derby. She has been a GP at the Tillingham Medical Centre for more than 20 years.
Julie also spent 5 years experiencing primary care in different settlings – New Zealand and the South Pacific – and has an interest in change and innovation in a challenging NHS environment.
Julie completed the Future Clinical Commissioning Leadership course run by the NHS Leadership Academy in 2018. Her clinical interests are dermatology, care of the elderly and mental health.
Anthony (Mac) McKeever Interim Joint Accountable Officer, Mid and South Essex CCGs since 2 March 2020; also Executive Lead, Mid and South Essex Health and Care Partnership from the same date
Anthony, known to all as Mac, has more than 40 years’ experience in the NHS and other healthcare organisations, most recently before joining the Mid and South Essex CCGs team as Director General for Health and Community Services for the States of Jersey.
Mac has specialised in helping Boards deliver reform and required results in healthcare. A strategic thinker combining business skills and public service values, he establishes productive working relationships with medical, non-executive and other colleagues.
Originally a “fast stream” Civil Servant, Mac joined the NHS in 1987, operating for 25 years as a CEO, helping to turn around performance at several hospitals and commissioning organisations. Having established his own business, he served on the Future Forum in 2010, and returned to work in the NHS in 2015.
Caroline Rassell Accountable Officer until 1 March 2020; also SRO – Mid and South Essex STP (Locality Health and Care) and Lead Accountable Officer for STP CCG Joint Committee to the same date
Caroline joined the CCG as Interim Accountable Officer in January 2014, on secondment from NHS Property Services Ltd, where she was the Director of Finance. Caroline was appointed as Accountable Officer on a permanent basis on 1 November 2014.
58 NHS Mid Essex CCG Annual Report and Accounts 2019/20
From 2009 Caroline was Deputy Chief Executive at Community Health Partnerships (CHP), an arm’s length Company of the Department of Health. Prior to this, Caroline worked in a number of Primary Care Trusts in Essex as a Director of Finance and Director of Commissioning. Before joining the NHS, she worked for 15 years in local government.
Caroline was seconded to the Mid and South Essex Success Regime on 25 March 2016 as Senior Responsible Officer for Locality Health and Care. In September 2017 she was appointed Lead Accountable Officer for the Mid and South Essex STP CCG Joint Committee.
Dr Fatai Salau Elected GP
Dr Fatai Salau qualified from the College of Medicine, University of Lagos, Nigeria in 1992 and has been a GP at the Douglas Grove Surgery in Witham since 2006.
Fatai is a member of the Royal College of Physicians and has been involved with developing changes to primary care in the Witham area. His clinical interests are acute medicine and gastroenterology.
Dr Elizabeth Towers Elected GP
Dr Liz Towers has been a GP at Whitley House Surgery for more than 30 years, having spent three years as a junior doctor in the Chelmsford area. Her interests lie particularly in cancer and end of life care and she became a Macmillan GP in 2010.
James Wilson Chief Strategy and Transformation Officer
James began his career on the Surrey County Council fast-track graduate scheme. James has since worked across local government predominantly within social care and education.
In 2013 James moved into the NHS, focusing on health contracting and commissioning. James was appointed to the role of Acting Director of Acute Commissioning from 2 September 2016 and in January 2018 was appointed as Chief Strategy and Transformation Officer.
Nathalie Wright Lay Board Member (Patient and Public Engagement)
59 NHS Mid Essex CCG Annual Report and Accounts 2019/20
Nathalie joined the CCG’s Board as the Lay Member – Patient and Public Engagement in April 2018. Much of her earlier career was spent as a manager in the financial services industry but more recently she gained experience of the NHS when she took a new direction through work with mid Essex cancer services.
After qualifying as a counsellor, Nathalie has also offered support for local people through voluntary work with family charities and membership of her GP surgery’s patient participation group.
Committees A full list of the committees supporting the Board, including the Audit Committee, and membership of those committees is provided within the Governance Statement at section 2.2.2.
Declaration Each director has confirmed that he or she knows of no information which would be relevant to the auditors for the purposes of their audit report, and of which the auditors are not aware; and has taken all the steps that he or she ought to have taken to make himself/herself aware of any such information and to establish that the auditors are aware of it.
2.1.3 Personal-data-related incidents
There were no serious incidents requiring investigation and involving personal data reported to the Information Commissioner’s Office in 2019/20.
2.1.4 Statement as to 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.
2.1.5 Donations to political parties and charitable organisations
The CCG does not make donations to political parties.
The CCG has made payments to a number of charitable organisations. The majority of these payments are in relation to Service Level Agreements (particularly to local hospices) or as a result of successful grant applications.
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2.1.6 Modern Slavery Act
The Modern Slavery Act 2015 has introduced changes in UK law focused on increasing transparency in supply chains to ensure our supply chains are free from modern slavery – that is, slavery, servitude, forced and compulsory labour and human trafficking.
As both a local leader in commissioning health and care services for the population of mid Essex and as an employer, the CCG provides the following statement in respect of its commitment to, and efforts in, preventing slavery and human trafficking practices in the supply chain and employment practices.
NHS Mid Essex Clinical Commissioning Group fully supports the Government’s objectives to eradicate modern slavery and human trafficking. Our Slavery and Human Trafficking Statement for the financial year ending 31 March 2020 will be published on our website at midessexccg.nhs.uk/about-us/our-key-documents/2504-modern-slavery-and-human-trafficking- statement/file by 14 June 2020.
Dr Anna Davey Chair
16 June 2020
2.1.7 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 Anthony McKeever to be the Accountable Officer of NHS Mid Essex 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
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with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the National Health Service Act 2006 (as amended)) • Ensuring that the CCG complies with its financial duties under Sections 223H to 223J of the National Health Service Act 2006 (as amended).
Under the National Health Service Act 2006 (as amended), NHS England has directed each Clinical Commissioning Group to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Clinical Commissioning Group and of its income and expenditure, Statement of Financial Position and cash flows for the financial year.
In preparing the accounts, the Accountable Officer is required to comply with the requirements of the Government Financial Reporting Manual and in particular to:
• Observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; • Make judgements and estimates on a reasonable basis; • State whether applicable accounting standards as set out in the Government Financial Reporting Manual have been followed, and disclose and explain 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 I have properly discharged the responsibilities set out under the National Health Service Act 2006 (as amended), Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter.
I also confirm that:
• as far as I am aware, there is no relevant audit information of which the CCG’s auditors are unaware, and that as Accountable Officer, I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the CCG’s auditors are aware of that information.
Anthony McKeever Joint Accountable Officer, Mid and South Essex CCGs
16 June 2020
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2.2 Governance Statement
Mid Essex CCG (“the CCG”) is a body corporate established by NHS England on 1 April 2013 under the National Health Service Act 2006 (as amended).
The CCG’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 31 March 2020, the clinical commissioning group was not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006.
The clinical commissioning group is part of the Mid and South Essex Health and Care Partnership (HCP) formerly known as the Sustainability and Transformation Partnership) covering the geographic areas of mid Essex, Basildon and Brentwood, Castle Point and Rochford, Southend, and Thurrock CCGs. The HCP has been created to bring local health and care leaders together to plan for the long-term needs of local communities.
In July 2017 the five mid and south Essex CCGs formally established a CCG Joint Committee (JC) to act collectively in the planning, securing and monitoring of services to meet the needs of their 1.2 million population, as well as representing the STP footprint for services commissioned over a larger area.
Specifically, the JC commissions and manages the contracts for acute hospital services (NHS and independent sector), NHS 111 and Out of Hours services, ambulance services, Patient Transport services and acute Mental Health services. The Joint Committee also plays a role in decision- making about Learning Disability services within the existing pan-Essex arrangements.
All other decisions about healthcare continue to be taken locally by the relevant CCG.
The five CCGs have implemented a revised staffing structure to support the JC in delivering its delegated commissioning functions.
2.2.1 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.
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2.2.2 Governance arrangements and effectiveness
The main function of the governing body (the Board) 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.
CCGs are clinically-led membership organisations made up of general practices. The members of the Mid Essex CCG have determined the governing arrangements for the CCG as set out in its constitution, which is based on the Model Constitution Framework for CCGs and was originally approved on 28 March 2013. The CCG did not make any amendments to its constitution during 2019/20.
There are 40 member practices within Mid Essex CCG, serving a registered population of 397,162 patients as of 1 January 2020. The practices were formed into nine Primary Care Networks (PCNs) across mid Essex from 1 July 2019. Details of the nine PCNs are shown in the table below:
Registered Patient Primary Care Network Number of practices Population as at 1 January 2020 Braintree 5 56,547 Colne Valley 6 53,878 Aegros 3 36,534 Witham and Maldon 4 37,821 Phoenix 3 43,687 Dengie and South Woodham Ferrers 8 46,964 Chelmer 4 37,856 Chelmsford West 3 41,714 Chelmsford City 4 42,161
Each of the PCNs is led by Clinical Directors who have standing membership of the CCG’s Clinical Cabinet and are accountable to their constituent practices under the Terms of Reference. The CCG Clinical Cabinet is responsible for engagement with member practices and other stakeholders in respect of primary care matters.
The Clinical Cabinet provides a forum through which member practices as representatives of primary care can share their views, concerns, ideas and be involved in the service planning, provision and decision-making processes of the CCG.
Practices work together within their PCNs to collaborate on the effective provision of primary care in their local areas and to engage in the commissioning of services on behalf of their populations.
In some PCNs these working together arrangements are facilitated through the sharing of workforce, sharing back office functions, and collaborative working in certain chosen clinical areas. Practices are gradually working towards developing standardised policies, processes and agreed governance structures.
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Governing Body (the Board) The CCG’s constitution sets out the governance arrangements, roles and responsibilities of the Board and its membership. The CCG’s constitution also has a set of Standing Orders, Standing Financial Instructions and a Scheme of Reservation and Delegation. During 2019/20 the Board met in public on three occasions. The meeting due to take place on 26 March 2020 was cancelled as a result of the national requirements in relation to Covid-19. However, appropriate arrangements were implemented to ensure that any key decisions were taken forward. All of the publicly held meetings were quorate (there are step-down / co-opting arrangements in place to maintain a clinical majority or in cases of conflict of interest where voting members of the Board recuse themselves from a relevant vote).
As at 31 March 2020, the Board membership comprised of the following voting members: The Chair (a GP member), Accountable Officer, Chief Finance Officer, three other GP members, three Lay Members, Director of Nursing and Quality (Registered Nurse), Director of Clinical Transformation and the Chief Strategy and Transformation Officer. The Director of Governance and Performance is also a non-voting Board member.
The CCG’s secondary care Board member resigned from his position from 1 November 2019. This position remains vacant.
The Accountable Officer, Caroline Rassell, continued her role as Lead Accountable Officer for the JC and Senior Responsible Officer for the Mid and South Essex HCP (Locality Health and Care). This role includes leading the Acute Commissioning Team which has operational responsibility for those functions delegated to the JC. Caroline’s employment as Accountable Officer ended on 1 March 2020 as a result of the appointment of Anthony McKeever as Interim Joint Accountable Officer for the Mid and South Essex CCGs.
Board representation also includes a Public Health Consultant from Essex County Council (ECC). An elected ECC councillor is also entitled to attend Board meetings as an observer with speaking rights.
The Board undertakes an annual review of its effectiveness and has determined that it fulfils its role effectively either all or most of the time and that there is good engagement of members. Appraisals of Board members are undertaken to evaluate individuals’ contributions and performance and regular group development sessions are held to assist members to address emerging issues and priorities. Board Development sessions also facilitate the provision of a range of training for members e.g. cyber-security, information governance, safeguarding and equality and diversity training.
To support the Board in carrying out its duties effectively, committees reporting to the Board are formally established. The current committee structure was approved at the Board meeting held on 29 March 2018 and took effect from 1 April 2018.
In January 2019 the Board agreed to split the Quality, Finance and Performance Committee into two separate committees, namely the Quality and Governance Committee and Finance and Performance Committee and this committee structure remained in place until September 2019, when the Live Well Committee was dis-established. The Live Well Committee has been replaced by the Mid Essex Live Well Partnership Board which includes representation from the CCG, local authorities, Healthwatch Essex, the voluntary sector, Anglian Ruskin University and the CCG’s main providers. The remit and terms of reference of committees were reviewed during the year.
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Each committee submits a summary of discussions and decisions to every Board meeting and reports any key issues. The main committees providing assurance to the Board are as follows.
Audit Committee This Committee provides the CCG Board with an independent and objective view of the CCG’s financial systems, financial information and compliance with laws, regulations and directions governing the CCG insofar as they relate to finance, good corporate governance, information governance, cyber-security, emergency planning, response and resilience (EPRR), business continuity management (BCM) and the CCG’s responsibility to act effectively, efficiently and economically. The Audit Committee is chaired by the Lay Member (Governance) and Deputy Chair of the CCG, John Gilham.
As at 31 March 2020, the Committee’s other members comprised Alan Hubbard, the Lay Member (Commercial), and an elected GP Board member, Dr Elizabeth Towers. During 2019/20 the Committee met on five occasions and attendance has been quorate in line with its Terms of Reference (minimum of two core members) on all occasions.
During 2019/20 the Audit Committee continued to focus upon ensuring the development of the systems, policies, procedures and processes fundamental to the governance of the organisation. This included a review of the CCG’s suite of emergency planning and business continuity management policies and procedures and the Cyber Security Protocol.
The Committee has received assurance from internal audit of key systems and processes and, in addition to routine reporting, has received updates on counter-fraud initiatives and investigations and implementation of audit recommendations. The Committee reviewed the CCG’s draft accounts and approved the final accounts and management response to the auditor on behalf of the Board and received regular reports on the CCG’s Assurance Framework, risk registers and risk profile.
The Committee also received the minutes of the Board’s other main committees; the minutes of the Joint Primary Care Commissioning Committee (operating in partnership between the CCG and NHS England/NHS Improvement as noted below to reflect the joint commissioning of primary care in mid Essex); and the minutes of meetings of the Mid and South Essex CCGs Risk and Assurance Sub-Committees in Common, which reviews the establishment and maintenance of an effective system of governance, risk management and internal control across the activities of the JC.
In line with NHS England guidance on the management of Conflicts of Interest, the Chair of the Audit Committee acts as the CCG’s Conflicts of Interest Guardian. The Committee approved revised Conflicts of Interest, Gifts and Hospitality and Standards of Business Conduct Policies following their annual review in September 2019.
The Audit Committee Chair received assurance from the Director of Governance and Head of Corporate Governance that the guidance was being implemented prior to signing the quarterly and annual conflicts of interest self-certificates submitted to NHS England.
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Remuneration Committee The Remuneration and Terms of Service Committee is a committee of the CCG Board with delegated responsibility for making recommendations to the Board on all aspects of remuneration and terms of service of employees, including the Accountable Officer, Directors and Lay Members.
In addition, the Committee is responsible for making decisions concerning the remuneration and terms of service for Elected GP members and other people who provide services to the CCG (all of whom are not employees of the CCG), taking in to account any national or local guidance as appropriate, so as to ensure that individuals are fairly rewarded for their contribution to the CCG. The Remuneration Committee also provides scrutiny of the Chair’s assessment of the performance of the Accountable Officer, Lay Members and Elected GP Members.
In making such recommendations and decisions the Committee ensures that any relevant national guidance or other guidance is taken into account as appropriate. The Remuneration Committee is chaired by the Lay Member (Governance)/Deputy Chair of the CCG and, as at 31 March 2020, its other membership comprised the Chair of the CCG, the Lay Member (Commercial) and the Accountable Officer. The regular adviser to the Committee is the Head of Human Resources and Workforce Development.
The Committee met on three occasions during 2019/20 and was quorate on all occasions.
Quality and Governance Committee This Committee provides assurance regarding the safety and quality of services directly commissioned by the CCG, i.e. rehabilitation services, community health services, services for children and younger persons, community mental health and learning disability services. The Committee also scrutinises and receives assurance regarding the CCG’s governance arrangements including risk management, information governance, equality and diversity, health and safety, and CCG workforce management
The Committee was chaired by the Lay Member for Patient and Public Engagement and its core decision making membership comprised a GP Representative (Vice Chair), Director of Nursing and Quality. Director of Governance & Performance. Deputy Director of Nursing and Quality, Chief Pharmacist and Head of Corporate Governance. The committee is also attended by other managers with specific responsibility for areas within the remit of the committee.
During 2019/20 the Committee particularly focused upon the management of the activity of the CCG’s main community service providers and the maintenance of performance and quality indicators. The Committee met quarterly with a total of four meetings during the year. Attendance was quorate in line with the Committee’s Terms of Reference on all occasions.
Finance and Performance Committee This Committee scrutinises and provides the CCG Board with assurance on the delivery of the CCG’s remit in respect of the CCG’s overall financial position (including running costs) and for service performance for commissioned services not delegated to the Joint Committee (JC). The Committee also maintains local oversight of information management and technology, estates developments and the Savings Programme Board’s scrutiny and challenge role to ensure the delivery of the CCG’s programme of financial savings. The Committee acts as a point of approval for major changes to existing projects and plans, where these are based on considerations related
67 NHS Mid Essex CCG Annual Report and Accounts 2019/20 to the achievement of financial or other benefits. The Committee also assesses whether there is continued business justification for existing projects and programmes where the financial or other benefits have changed.
The Committee was chaired by the Lay Member (Commercial) and its membership comprised a GP Representative (Vice Chair), Deputy Accountable Officer, Chief Transformation and Strategy Officer, Chief Finance Officer, Director of Governance and Performance, Director of Nursing and Quality (or a senior nurse from the Nursing & Quality Directorate) and Deputy Chief Finance Officer.
During 2019/20 the Committee particularly focused upon financial control to ensure that the CCG remained on track to deliver the planned outturn position and the maintenance of performance indicators. The Committee met bi-monthly with a total of six meetings during the year. Attendance was quorate in line with the Committee’s Terms of Reference on all occasions.
Live Well Committee This committee provided the main forum for assurance of the delivery of the CCG’s livewell strategy, championing the livewell vision within the mid Essex health and social care system and overseeing and assuring the CCG’s contribution to the implementation of all aspects of the livewell health and wellbeing programmes. The Committee ensured that all clinical, strategic and operational activity commissioned by the CCG supports and aligns with the livewell strategy.
The Committee was chaired by the Chair of the CCG, who is an elected GP Board member and its other membership comprised the two Clinical Chairs for Primary Care, Clinical Chair for Out-of- Hospital, Clinical Chair for Mental Health, Accountable Officer, Director of Clinical Transformation (Deputy Chair), Director of Nursing and Quality, Director of Governance and Performance, Chief Pharmacist, Consultant in Public Health (Essex County Council), Deputy Chief Finance Officer and Chief Transformation and Strategy Officer.
During 2019/20 the Committee focused on health and wellbeing initiatives, the Primary Care and Mental Health Foundation programmes and a wide variety of other developments to transform care and deliver sustainable efficiencies. The Committee also received regular updates from the Primary Care, Out of Hospital, and Mental Health Transformation sub-committees.
The committee met monthly until September 2019 making a total of three meetings held during the year. Attendance was quorate in line with the committee’s Terms of Reference on all occasions.
The Live Well Committee was dis-established in September 2019 and has been replaced by the Mid Essex Live Well Partnership.
Mid Essex Live Well Partnership
The aim of the Mid Essex Live Well Partnership (MELWP) is to bring key partners together to provide the localism needed within the Mid & South Essex system to create opportunities for people to live well in mid Essex. This includes determination of vision and strategy and agreement of outcomes, measures and priorities. The MELWP will also work to understand and determine the future governance requirements needed for mid Essex once the wider Mid & South Essex HCP has transitioned to a fully operational Integrated Care System.
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Its membership comprises Director level representation from the CCG, PCN Clinical Director or CCG Chair, representation from Essex County Council and Braintree, Chelmsford and Maldon District Councils, Provide Community Interest Company, Essex Partnership University NHSFT, the Mid and South Essex Group of Hospitals, Farleigh Hospice, Anglia Ruskin University, Chelmsford and Maldon CVS, Community 360, Virgin Healthcare, Healthwatch Essex and North East London NHSFT.
The MELWP has met on four occasions since it was established and was quorate on all occasions.
Joint Primary Care Commissioning Committee The Committee is attended by both the CCG and NHS England/NHS Improvement as the CCG currently commissions primary care in mid Essex jointly with these national bodies. The committee is chaired by the Lay Member for Patient and Public Engagement. Meetings in public were held on a bi-monthly basis, with a total of six public meetings held during 2019/20. The Committee also meets in private each month if there are confidential matters requiring an urgent decision. Attendance was quorate in line with the Committee’s Terms of Reference on all occasions.
During 2019/20 the Committee focused on Primary Care finance, quality, IT, premises and Primary Care Network developments, and local operational issues requiring a decision, e.g. applications for practice mergers, reductions in practice opening hours and branch closures.
Better Care Fund (including Improved Better Care Fund) Governance A Better Care Fund (BCF) Partnership Board meets to fulfil the governance requirements with Essex County Council.
In line with the terms of the Section 75 Better Care Fund Agreement, decision-making relating to the BCF is delegated to two nominated representatives of the CCG and two representatives of Essex County Council. Utilisation of the BCF funds was agreed in the Section 75 Agreement and in-year reporting focused upon expenditure on the approved services and monitoring against agreed performance targets.
Mid and South Essex STP CCG Joint Commissioning Committee As outlined in the introduction, the five mid and south Essex CCGs formally established a CCG Joint Committee (JC) to act collectively in the planning, securing and monitoring of services to meet the needs of their 1.2million population. The JC was established as a committee of each CCG, not of the CCG’s governing bodies, and therefore sits alongside the CCG governing bodies, rather than being accountable to them. The JC meets in public every two months. Private meetings are also held on a monthly basis.
At a publicly held meeting on 6 July 2018, the JC considered the 19 recommendations within the acute hospital reconfiguration decision making business case, all of which were approved. Subsequent to this, referrals were made by the Thurrock and Southend Oversight and Scrutiny Committees to the Secretary of State for Health and Social Care regarding the JC’s decision. In July 2019 the Secretary of State ruled that the changes to hospital services proposed could go ahead.
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During 2019/20, the JC focused on further developing its risk register which is also reviewed by the JC’s Finance and Performance and Patient and Safety Sub-Committees. The JC Risk and Assurance Sub-committee, attended by the five CCG Audit Chairs, and the Boards of the five mid and south Essex CCGs also receive a copy of the JC risk register to provide assurance that services within the remit of the JC are being risk-managed effectively.
The JC reviewed Evidence Based Commissioning Policies in response to NHS England guidance and received regular reports on the transformation of mental health services and contracts for patient transport services. Committee members also held in-depth discussions regarding action being taken to improve performance against constitutional standards, including referral to treatment and cancer services.
The JC received performance reports in relation to the quality, safety and performance of services within its remit at each bi-monthly publicly held meeting. The JC also received regular updates on the outcome of the OFSTED Special Educational Needs and Disability (SEND) inspections carried out across the mid and south Essex STP, together with details of action that will be taken by the relevant organisations to address recommendations made. Senior nursing representatives from the Mid and South Essex University Hospitals Group attended the committee to provide a presentation on the hospitals’ Quality Account review for 2018/19 and quality improvement plan for 2019/20.
As of 31 March 2020, the JC was chaired by Dr Sunil Gupta, Chair of Castle Point and Rochford CCG and membership consisted of the Chair from each of the five mid and south Essex CCGs, the Joint Accountable Officer of the five CCGs (see section 2.1.2) and a Lay representative for patient and public participation. The committee is also attended by the Medical Director, Director of Nursing, Director of Commissioning and Chief Finance Officer for the Acute Commissioning Team. The Director of Governance and Performance for Mid Essex CCG performs the role of committee secretary.
The committee met in public a total of five times during the year. Attendance was quorate in line with the committee’s Terms of Reference on all occasions.
UK Corporate Governance Code The CCG is not required to comply with the UK Code of Corporate Governance. However, we have reported on our Corporate Governance arrangements by drawing upon best practice available, including those aspects of the UK Corporate Governance Code we consider to be relevant to the CCG and best practice.
As part of its annual review of effectiveness, the CCG Board undertook an assessment which encompassed the relevant principles of the UK Corporate Governance Code.
The Board concluded from this assessment that it was generally following best practice in relation to providing effective leadership, having an appropriate balance of skills, experience, independence and knowledge to enable Board members to discharge their duties and responsibilities effectively, presenting a balanced and understandable assessment of the CCG’s position in its financial and other reporting and ensuring that remuneration is set appropriately.
Areas for improvement identified from the review of effectiveness will be incorporated in the Board’s ongoing development programme.
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Discharge of Statutory Functions In light of recommendations of the 2013 Harris Review, the clinical commissioning group has reviewed all of the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. As a result, I can confirm that the clinical commissioning group is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions.
Responsibility for each duty and power has been clearly allocated to a lead Director. Directorates have confirmed that their structures provide the necessary capability and capacity to undertake all of the CCG’s statutory duties.
2.2.3 Risk management arrangements and effectiveness
The CCG is committed to ensuring that risk management forms an integral part of its philosophy, practices and business plans, rather than viewed or practised as a separate programme, and that responsibility for implementation is accepted at all levels of the CCG.
The Risk Management Policy, which encompasses both clinical and non-clinical risks, was last updated in January 2020. The Policy is based on the Australia/New Zealand risk management model and sets out the risk management system, supporting processes and reporting arrangements which aim to protect patients, the public, staff and the CCG’s assets and reputation. The policy includes a requirement to undertake a review of any risk which has not had its risk rating decreased for three consecutive quarters.
The Board collectively reviewed and agreed its Risk Appetite levels for risks falling within the categories of safety and security, quality, regulatory compliance/national policy, reputation, innovation, finance/value for money and partnerships in January 2020. This assists managers to identify when risk levels are tolerable or where further action is required to reduce risk ratings to an acceptable level. The Board reviews the strategic risk register at each Board meeting and will be carrying out a comprehensive review of its risk register in 2020/21.
Throughout 2019/20 the CCG has had the following arrangements in place.
• Clear ownership of risks, with responsible Directors and lead officers identified, with escalation arrangements in place to the Board • Strategic and Operational risk registers on which the latest updates from lead officers were recorded and reported to directorate meetings, the Quality & Governance Committee, Audit Committee and Board • Accurate reflection of strategic risks to the organisation through the Board Assurance Framework • Recording and investigation processes for incidents, including identification of learning • Triangulation of learning from incidents, complaints and claims (should they arise) as a standing item on the agenda of the Quality and Governance Committee • Monitoring of completion of Equality and Health Inequality Impact Assessments by the Equality and Diversity Sub-Committee. • Regular review of anti-fraud and bribery arrangements by the Audit Committee.
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The CCG’s Whistleblowing Policy, supported by the appointment of a Freedom To Speak Up Guardian, also supports risk management by providing a framework for employees to raise concerns, in line with the Public Interest Disclosure Act 1998, without the perception of being disloyal to colleagues, managers or the organisation. The Whistleblowing Policy was last updated in March 2020.
The CCG is committed to identifying the underlying or root causes of incidents, claims and complaints, and the principal objective is to identify ‘system failures’, rather than focusing on individual failures.
Stakeholders, including staff, patients and the public have been involved in the risk management process, for example by ensuring that relevant staff were identified to input into any risk assessments in their function or area of work; that CCG staff and contractors were made aware of agreed risk reporting procedures; that contracts clearly stated the responsibilities of contracted personnel with regard to risk identification, reduction, mitigation and reporting; that feedback on risk issues was encouraged via the CCG’s complaints and enquiries services and through its public engagement and consultation mechanisms, e.g. patient stories at Board meetings, engagement with the public and other stakeholders on future plans for services.
Risk management awareness training is provided to CCG staff at directorate meetings and specific training sessions. Board members received refresher risk management awareness training at their May 2019 development session.
The effectiveness of these risk management arrangements are summarised under the ‘Review of the Effectiveness of Governance, Risk Management and Internal Control’ section, which includes the monitoring, review and management of the Assurance Framework by the Audit Committee, and Board.
The annual audit of risk and governance was finalised by the CCG’s Internal Auditor in January 2020 and identified ‘substantial’ assurance.
Prevention of Risk The application of this framework enables the prevention of risk through:
• Commitment to identifying the underlying or root causes of incidents, complaints and claims (should they arise) • Promoting an open, just and non-punitive culture • Driving an ongoing information and education programme which empowers and supports staff in the risk management process generally and in relation to specific areas of risk • Updating and maintaining the knowledge of Board members, including regular training at Board development sessions on specific areas of risk • All staff being familiar with the Anti-fraud and Anti-bribery policies’ terms through promotion and training, and the issuing of fraud alerts, with the help of counter-fraud services • All staff being familiar with the terms of the Conflicts of Interest, Gifts and Hospitality and Standards of Conduct Policies.
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• Registers of Interests being produced for Board and Committee meetings and those sub committees with decision-making powers, or capacity to influence decisions made by the CCG, so that the relevant Chair can ensure that potential conflicts are managed appropriately.
2.2.4 Other sources of assurance
Internal Control Framework A system of internal control is the set of processes and procedures in place in the CCG to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.
The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness.
The system of control in place is set out within the Board, Committee and Risk Management sections of this statement.
Financial arrangements The CCG’s key financial systems are operated by third party providers. The CCG Finance team oversee the operation of internal financial control arrangements and the dissemination of good financial management and professional standards. The CCG’s financial arrangements are assessed annually by external parties as part of the internal and external audit functions.
The Finance and Performance Committee exercises the Board’s functions in respect of the oversight of financial control and the Savings Programme Board provides detailed scrutiny and impetus to the delivery of the Quality, Innovation, Productivity and Prevention (QIPP) programme (see section 1.2.5 of the Annual Report).
Risk Assessment Risks included on the CCG’s risk registers are identified via a number of routes, including horizon scanning by Board/senior managers, by committees/sub-committees/working groups, financial analysis, impact assessments and specific risk assessments.
The CCG classifies risks as either Strategic or Operational with red rated risks being automatically escalated to Strategic level.
Strategic Risks
New Strategic Risks during 2019/20 were as follows:
• Risks associated with containment/control of Invasive Group A Streptococcus within the community. • Risks associated with a lack of domiciliary care providers on the CCG's provider framework.
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• Risks associated with insufficient capacity to undertake assessment of eligibility for children's continuing care. • Risks associated with the potential merger of the five Mid and South Essex CCGs. • Risk of loss of primary care services due to COVID-19.
The profile of the strategic risks at the end of March 2020 was:
Extreme High Moderate Low Total (Red) (Amber) (Yellow) (Green) 2 14 5 1 22
This represents an increase in the number of strategic risks, but a decrease in the number of these rated as ‘extreme’ compared to the position as at March 2019. Progress on the controls and mitigating actions being implemented to address the identified risks to achieving the CCG’s strategic objectives was reported through the Assurance Framework to the Audit Committee, the Quality and Governance Committee and the Board.
Despite the robust efforts made to manage or reduce the risks, the following red risks remained at the end of the year with a resulting impact on the overall achievement of the CCG’s strategic objectives:
Risk of lack of domiciliary care providers on the CCG's provider framework. Risk of insufficient capacity to undertake assessment of eligibility for children's continuing care. The CCG has also been liaising with the other mid and south Essex CCGs to develop a comprehensive register of risks identified as a result of the Covid-19 pandemic.
Operational Risks
The table below sets out the number of operational risks as at the end of March 2020:
Extreme High Moderate Low Total (Red) (Amber) (Yellow) (Green) 0 12 12 1 25
This represents a slight increase of one in the number of operational risks, but a reduction in the number of risks rated as ‘high’ compared to the position at March 2019.
Risks that remain open will be carried forward to the 2020/21 risk registers and will continue to be monitored by the appropriate committees and responsible lead directors and managers. The Audit Committee and Quality and Governance Committee will provide scrutiny and challenge to the management of these risks and provide an assurance opinion to the Board. The Board will ensure that any additional measures are fully explored in order to manage or reduce the identified risks.
Joint Committee (JC) Risks
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The JC risk register was initially compiled by reviewing risks on the five mid and south Essex CCGs’ risk registers to agree those to be included on the JC register. During 2019/20 the JC continued to develop the register to include further high level risks within its remit.
The JC Finance and Performance Sub-committee and the JC Patient Safety and Quality Sub-committee review those risks within their area of responsibility on a bi-monthly basis and recommend closure of risks where appropriate.
The full risk register is then submitted to each publicly held meeting of the JC for members to review and formally agree closure of relevant risks. The JC Risk and Assurance Sub-committee also receives a copy of the JC risk register for assurance purposes.
A copy of the JC risk register is also provided to each of the five mid and south Essex CCGs for inclusion within their Board meeting papers, to provide assurance regarding the management of risks within the remit of the JC.
The table below shows the number of risks on the JC risk register as at the end of March 2020.
Extreme High Moderate Low Total (Red) (Amber) (Yellow) (Green) 5 15 3 1 24
This represents an increase in the number of risks (as a result of the register having been further developed during 2019/20) and a decrease of one in those risks rated ‘extreme’ when compared with March 2019.
Despite the robust efforts made to manage or reduce the risks, the following red risks remained on the JC risk register at the end of the year.
• Risk of non-delivery of NHS Constitutional Standards for Cancer. • Risk of non-delivery of NHS Constitutional standards for Referral to Treatment. • Risk of Local Maternity System (LMS) failing to ensure delivery of full completion of the Saving Babies Lives Care Bundle (SBLCB) version 2. • Risk that the LMS fails to increase the number of women receiving Continuity of Carer to 35% by 2020. • Risk of not meeting Infection Prevention & Control targets.
Financial Risks
The CCG was required to deliver a £3m surplus in 2019/20. There were a number of significant cost pressures during the year although slippage on some planned investments and a number of underspends in other areas enabled the CCG to deliver the required £3m surplus.
75 NHS Mid Essex CCG Annual Report and Accounts 2019/20
Exit from the European Union NHS England led the response to EU Exit planning and the CCG contributed as required to the national response. As further NHS England guidance is published regarding the UK’s future relationship with the EU, the CCG will respond appropriately.
Annual Audit of Conflicts of Interest Management The revised statutory guidance on managing conflicts of interest for CCGs (published June 2017) requires CCGs to undertake an annual internal audit of conflicts of interest management. To support CCGs to undertake this task, NHS England has published a template audit framework. The annual internal audit of conflicts of interest 2019/20, which was undertaken as part of the wider audit of the CCG’s risk management and governance arrangements, identified ‘substantial’ assurance.
Data quality The CCG Board can have confidence that the CCG reports data after establishing that the data is precise, inclusive, and meets particular criteria. The CCG’s data validation procedures are designed to improve the quality of data by finding inconsistencies in the data.
The CCG commenced their contractual relationship with Arden and GEM Commissioning Support Unit in 2018/19. This contract provides the CCG with our Business Intelligence function including continually looking for ways of improving data monitoring. The CCG continues to scrutinise and challenge data and seek daily and weekly ‘raw’ data to learn its parameters of accuracy before validation so it can be used to provide an early indication of any issues.
For contracts and billing the CCG undertakes numerous validation checks which are built into our data processing methodology to ensure providers are billing correctly. This includes monitoring and challenging contracted performance through the data validation process.
All contracts have an expectation to have a data improvement plan, with agreed actions and timelines to improve data quality and completeness as required. Commissioners continued through 2019/20 to work with Mid Essex Hospital Trust to ensure that the data validation required since they introduced their new Patient Tracking System in 2017 is on track to meet the completion date agreed with their Regulators.
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 a Data Security and Protection Toolkit and the annual submission process provides assurances to the CCG, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively.
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 Data Security and Protection Toolkit. We have ensured all staff undertake annual information governance training and have implemented a staff
76 NHS Mid Essex CCG Annual Report and Accounts 2019/20 information governance handbook to ensure members of staff are aware of their information governance roles and responsibilities and how to access information or assistance.
There are processes in place for incident reporting and investigation of serious incidents. No serious incidents requiring investigation involving personal data were reported to the Information Commissioner in 2019/20.
The CCG has nominated information asset owners who have completed the new data flow mapping and information asset registers to ensure compliance with the General Data Protection Regulations. This was done with support from the IG Team to ensure consistency of approach.
In 2019/20 the CCG met all mandatory assertions in relation to the requirements of the Data Security and Protection Toolkit. The CCG’s Senior Information Risk Owner (SIRO) attended GCHQ Cyber Security training in November 2019.
Business-critical models The CCG supports the principles of the Macpherson Report and is committed to embedding best practice in relation to quality assuring our prioritised business critical models and other functions.
The Essex CCGs each have a Business Continuity Plan supported by an overarching Essex-wide Business Continuity Policy, both of which have been approved by CCG Boards. Although the documents are updated on a constant basis, a comprehensive annual review takes place each year.
A memorandum of understanding has been signed by the Essex CCGs which sets out the intentions of the CCGs to provide mutual aid and assistance to each other during a business continuity incident which cannot be managed internally within each CCG’s own business continuity arrangements and which involves one or more of the following: critical loss of key staff, temporary loss of premises or loss of a significant amount of IT hardware.
In March 2020, the CCG reviewed, tested and updated its internal business continuity arrangements as a result of the Covid-19 pandemic and continues to up-date these in line with operational and Government requirements.
Third-party assurances The CCG relies on a number of third party providers which are listed below, together with information on how assurance is received from each provider, the effectiveness of these arrangements and whether any improvements are planned in the future.
• Human Resources transactional, recruitment and workforce services and occupational health advice are provided by Anglian Community Enterprise (ACE). This arrangement has been in place since October 2014, and the relationship between the two organisations continues to grow positively. Both the CCG and Anglian Community Enterprise (ACE) have received good internal and external audit reviews of their HR/recruitment functions. The CCG receives regular KPI data regarding the performance of the ACE service and monthly client/provider meetings are held. • Payroll and pension services are provided to MECCG by Whittington Health NHS Trust. This arrangement came into force on 1 March 2018, with support provided to the CCG from
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the Whittington health Head office in north London. The CCG continues in a positive relationship with Whittington Health.
The Employment Services Lead (ACE) leads the monthly client ‘conference call’ with Whittington, involving the HR Manager and Head of HR at the CCG where necessary, and face to face meetings with Whittington occur at the CCG’s headquarters on a quarterly basis. In addition the Employment Services Lead (ACE) will liaise with the Whittington team on behalf of the CCG to address payroll and Electronic Staff Record issues as and when they arise. The annual audit of payroll identified ‘substantial’ assurance. • The CCG retains the services of a procurement expert company (Attain) to ensure probity during procurement processes. During 2019/20 the Finance & Performance Committee received procurement reports at each meeting. A Register of procurement decisions, which is published on the CCG’s public-facing website, is reviewed at each meeting of the Audit Committee to ensure rigour is being applied. • As from 1 July 2018, Arden and GEM CSU became the CCG’s provider for Information Technology (IT) services as well as its Business Intelligence service. Regular IT update meetings are held to discuss performance and any ongoing concerns. At these meetings, assurances have been received regarding the robustness of back-up procedures. Similar assurances have also been sought and received by the CCG’s Head of Emergency Planning in relation to business continuity management arrangements.
2.2.5 Control Issues
Within our 2018/19 Governance Statement, the CCG highlighted that Mid Essex Hospitals Services NHS Trust (MEHT) implemented a new Patient Administration System (Lorenzo) in May 2017. The implementation of this new system impacted on MEHT’s ability to produce accurate and timely data and also impacted on their ability to meet both local (CCG) and national reporting requirements. MEHT were given permission to pause some elements of national reporting to give them the opportunity to resolve data recording issues.
This arrangement is still in place and continues to adversely affect the CCG’s ability to effectively plan for activity and achieve NHS constitutional standards. The Lorenzo system continues to be highlighted on the STP Joint Committee’s risk register.
Following an outbreak of invasive Group A Streptococcus in early 2019, the CCG commissioned an independent serious incident investigation into the outbreak, in line with the NHS Serious Incident Framework. The purpose of this independent investigation was to draw together the findings and learnings from those affected or involved in managing the incident, in order that steps may be taken to reduce the risk of reoccurrence.
The independent investigation has now been completed and the initial draft report covering the findings has been prepared, although its publication will be delayed until the NHS has started to recover from the impact of the Covid-19 pandemic. Families affected by the iGAS outbreak and other stakeholders were informed of the delay to the publication of the report in April 2020.
The NHS declared Coronavirus as a ‘level 4 incident’ (the highest category of emergency) on 30 January 2020. Organising the local response to limit the spread of the virus and treat its effects therefore became a key focus for the CCG and partner organisations during Quarter 4 and a system-wide incident management structure was set up to coordinate this work. In accordance
78 NHS Mid Essex CCG Annual Report and Accounts 2019/20 with the CCG’s Business Continuity Plan, a number of its functions have either been paused or scaled down in order to enable resources to be directed to the management of this outbreak.
However, the CCG has also implemented good practice guidance issued by organisations such as the Internal Audit Network and the Healthcare Financial Management Association to ensure that it continues to comply with its statutory duties and that its governance arrangements remain effective.
As detailed within the Head of Internal Audit Opinion section below, the CCG received one Internal Audit report during 2019/20 which identified ‘Requires Improvement’. The CCG will monitor implementation of the recommendations arising from this report through its internal process and provide progress updates to the Audit Committee.
2.2.6 Review of economy, efficiency and effectiveness of the use of resources
The CCG was pleased to be able to repay £3.0m of its accumulated deficit in 2019/20. This was the revised target agreed by NHS England and represents a very significant achievement. Although the CCG has repaid over £20m of the accumulated deficit in the last four financial years regrettably there remains a carried forward deficit of £4.8m.
The CCG compares favourably with peer CCGs in benchmarking exercises of service utilisation and health outcomes and in 2019/20 these outcomes have been delivered in the context of per capita funding £76 below the Essex CCG average and lower than all other Essex CCGs. The CCG must continue to look for significant cost reduction opportunities in order to contain expenditure within allocated resources.
Savings made in 2019/20 include substantial savings made in GP Prescribing and continuing health care. The continuation of our Home First model has ensured that patients are assessed for future care provision in the most appropriate setting and this year we have launched our enhanced End of Life scheme giving hospice-led care to patients choosing to spend their final weeks or days at home. The CCG continued to work with other local health and social care organisations to further develop a co-ordinated and consistent approach across the STP footprint.
The Finance and Performance Committee, Savings Programme Board and CCG Board have each received regular financial reporting and had the opportunity for detailed review of the CCG’s position.
The Finance and Performance Committee has continued to monitor the CCG’s procurement planning arrangements in order to ensure value for money from commissioned services. The CCG has been using benchmarking data across service areas to help inform the QIPP planning process.
The Finance and Performance Committee and the Joint Committee’s Finance and Performance Sub-Committee received detailed reporting on financial and service performance with a focus on key priority areas.
The CCG’s 2019/20 running (management) costs were more than 12% below permitted expenditure.
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The CCG was Amber rated for its leadership in 2019/20, based on data released in Quarter 2. The year-end assessment rating will be reported in future Board papers.
The Internal Auditor has reviewed the CCG’s financial systems and processes, including the arrangements for financial reporting and confirmed that the CCG has reasonable arrangements in place. The external auditor’s comments on our arrangements for securing economy, efficiency and effectiveness in use of resources in 2019/20 are included in their report immediately preceding the Annual Accounts (see section 3).
Delegation of functions Acute services are commissioned on behalf of Mid Essex CCG by the Mid and South Essex JC Acute Commissioning Team, which is hosted by Mid Essex CCG.
Acute mental health services are commissioned on behalf of Mid Essex CCG by a central mental health commissioning team hosted for the Mid and South Essex STP by Thurrock CCG. The individual placements team which commissions placements for individuals with Section 117 after- care rights, as well as specialist placements for children and for adults requiring tertiary care, is hosted by North East Essex CCG, which provides this function on a pan-Essex basis.
Tier 2 (Social Care) and Tier 3 Community Secondary Mental Health Services for Children, previously known as Children and Adolescent Mental Health Services (CAMHS), were replaced from November 2015 by the Emotional Wellbeing and Mental Health Service (EWMHS). Which was commissioned on a pan-Essex basis. West Essex CCG is the co-ordinating commissioner for this service. Children’s in-patient services continue to be commissioned by NHS England.
Learning Disability (LD) services are commissioned by Essex County Council, with Castle Point and Rochford and Southend CCGs leading on this for health for the Mid and South Essex STP.
Better Care Fund resources have been managed through partnership arrangements. In common with other CCGs, the Mid Essex CCG Director of Nursing is a member of the Quality Surveillance Group which allows quality intelligence to be shared across Essex with other commissioners and with the CQC.
No adverse information has been received from third party assurance reports relating to West Essex’s host commissioner role for EWMHS or North East Essex CCG’s host commissioner role for section 117 services.
Counter fraud arrangements An accredited Local Counter Fraud Specialist (LCFS), who is an employee of the CCG’s internal auditors, is contracted to undertake counter fraud work proportionate to identified risks. The CCG Audit Committee receives an update from the LCFS regarding any counter-fraud initiatives or investigations at each meeting and a report against each of the NHS Counter Fraud Authority Standards for Commissioners: Fraud, Bribery and Corruption, at least annually.
There is executive support and direction from the Chief Finance Officer and Director of Governance and Performance for a proportionate proactive work plan to address identified risks. The Chief Finance Officer is the identified member of the executive team named within the Anti-
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Fraud, Bribery and Corruption Policy who is proactively and demonstrably responsible for tackling fraud, bribery and corruption.
The CCG is committed to robustly investigating all reports of fraud, bribery and corruption and will seek to recover lost NHS funds where proportionate and necessary.
At the end of each financial year, the CCG submits a self-assessment to the NHSCFA against the NHS Counter Fraud Authority (CFA) against the NHSCFA Standards for Commissioners. The Chief Finance Officer and Chair of the Audit Committee sign this assessment.
There were no NHSCFA quality assurance recommendations received by the CCG during 2019/20.
Head of Internal Audit Opinion Following completion of the planned audit work for the financial year for the CCG, 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 final Head of Internal Audit Opinion concluded that reasonable assurance can be given that there is a generally sound system of internal control, designed to meet the CCG’s objectives, and that controls are generally being applied consistently. However, some weakness in design and/or inconsistent application of controls put the achievement of particular objectives at risk.
The Head of Internal Audit’s opinion also concluded that he can provide substantial assurance that the Assurance Framework and associated processes are sufficient to meet the requirements of the 2019/20 Governance Statement and contribute to an effective system of internal control designed to manage the significant risks identified by the CCG.
During the 2019/20 year Internal Audit issued the following audit reports:
Area of audit Level of assurance given Financial Systems Key Controls Substantial Governance, Assurance Framework, Risk Substantial Management and Conflicts of Interest Organisational Development Substantial Payroll Substantial Information Governance Reasonable Prescribing Performance Management Reasonable Quality of Domiciliary Care Reasonable Serious Incident Reporting Oversight Reasonable Cyber Security Requires Improvement
A further planned audit of NHS Constitutional Standards was suspended due to COVID-19.
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The number and priority rating of recommendations made within the one audit report that identified ‘Requires Improvement’ were as follows:
Cyber Security
Internal Audit raised a total of 6 priority 1 recommendations, 15 priority 2 recommendations and 6 priority 3 recommendations.
The CCG’s Internal Auditors identified a number of recommendations on our cyber security
The priority 1 recommendations were:
• The CCGs should seek to strengthen user awareness relating to phishing. • Recovery Point Objectives should be produced and formally recorded for all relevant information assets. • The draft Cyber Security Plans should be reviewed, finalised and circulated in a timely manner. • The CCGs should gain formal assurances from GPs that they have appropriate business continuity plans in place to assist during IT related incidents. • Log retention schedules should be reviewed and modified so that operating and central application activity logs are retained for appropriate periods of time. • The CCGs should ensure Windows Advanced Threat Protection is deployed to all end user devices in a timely manner.
An action plan has been established to respond to the recommendations. The Audit Committee will receive regular reports on progress with implementation.
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2.2.7 Review of the effectiveness of governance, risk management and internal control
My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, executive managers and clinical leads within the clinical commissioning group and the Acute Commissioning Team who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me. My review is also informed by comments made by the external auditors in their annual audit letter and other reports.
Our assurance framework provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving its principal objectives have been reviewed.
I have been advised on the implications of the result of this review by:
• The Board • The Audit Committee • Remuneration Committee • Quality and Governance Committee and Finance and Governance Committee • The Mid and South Essex CCGs Acute Commissioning Team and Joint Committee • Internal audit • A review of the draft Governance Statement by Caroline Rassell, former Accountable Officer of Mid Essex CCG • Other explicit review/assurance mechanisms.
Conclusion I concur with the Head of Internal Audit Opinion that during the 2019/20 financial year there has been a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls have been generally applied consistently.
Action plans to implement any outstanding recommendations from audits, including those arising from the Cyber Security audit which received an audit opinion of ‘Requires Improvement’, are in place and will continue to be monitored during the 2020/21 financial year.
I confirm that there are no risks which may affect the CCG’s Licence or serious lapses in control.
Anthony McKeever Joint Accountable Officer, Mid and South Essex CCGs
16 June 2020
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2.3 Remuneration and Staff Report
2.3.1 Remuneration Committee Report
For 2019/20 the membership of the Remuneration Committee was as follows:
• John Gilham – Committee Chair, Lay Member (Governance), Deputy Chair (Lay Member) of the CCG Board and Audit Committee Chair • Dr Anna Davey – Elected GP and Chair of the CCG • Alan Hubbard – Lay Member (Commercial) • Caroline Rassell – Accountable Officer until 1 March 2020
(The Accountable Officer withdrew at any time their own remuneration and performance were discussed.)
The Committee met on 3 occasions in 2019/20. The Committee Chair was present at these meetings and the meeting was quorate in line with the Committee’s Terms of Reference. HR and Remuneration advice was provided to the Committee by Julie Burton, Head of HR and Workforce Development. The Committee relied upon national and local guidance and documentation relating to subjects brought to the Remuneration Committee.
Policy on remuneration of senior managers All the CCG’s Executive Directors are subject to Agenda for Change terms and conditions. The Lay Members and the elected GP members of the CCG Governing Body are remunerated under a locally agreed pay framework and the Accountable Officer is remunerated in accordance with the NHS Very Senior Managers (VSM) pay framework. The salaries of all Governing Body members are determined by the Remuneration Committee, with national and local guidance (provided by the Chief Finance Officer and Head of Human Resources) being considered in all decisions.
Remuneration of Very Senior Managers The CCG does not employ any Very Senior Managers (VSMs) on a salary exceeding £150,000. The CCG does however pay a share of the Interim Joint Accountable Officer, who is employed by Basildon and Brentwood CCG on a salary in excess of £150,000, since 2 March 2020. The CCG also has four clinicians whose payment level for their Board role, when represented as a full-time notional salary, exceeds the given threshold of £150,000. They are all engaged as Office Holders (Elected GP members) – a statutory position for the CCG.
The rate payable for the CCG’s Elected GPs is set at £306.03 per session (following a 1% increase agreed by the Remuneration Committee from 1 April 2019) and is for work undertaken by Office Holders who are not entitled to ‘employed’ benefits – in other words, no contractual/NHS sickness or maternity pay or holiday over and above the statutory minimum.
Market forces coupled with a desire to attract already stretched GPs to consider working with the CCG with the aim of making services better for the population for mid Essex are a significant factor in setting the sessional rate. It is considered that the sessional rate (£306.03 per session /
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£159,573 per annum Whole Time Equivalent) shows parity with those across the Essex region. None of the elected GPs works more than an average of four sessions per week for the CCG.
Senior managers’ performance-related pay The performance of all staff (including the Accountable Officer, Directors and senior managers) is monitored and assessed through the use of a robust appraisal system. A formal appraisal review is undertaken at least annually (see section 2.3.2).
Agenda for Change contracts do not contain provision for performance-related remuneration beyond the element introduced in 2018 for bands 8c, 8d and 9. Specifically, in the year after an employee has reached the top of any of those bands, subject to performance the employee will retain their basic salary, or their salary will be reduced by 5 per cent or 10 per cent. The employee will be able to restore their salary at the end of the following year by achieving agreed levels of performance.
The 2018 NHS contract refresh updated Agenda for Change pay banding across the NHS, including CCG staff
Under the VSM pay framework, there is the potential for performance-related pay under the terms and conditions of the contract. No proportion of remuneration for any staff member has been subject to performance conditions at the CCG during 2019/20.
Policy on the duration of contracts, notice periods and termination payments The duration of contracts is determined by the duration of the roles and responsibilities to be undertaken. The contracts of the Accountable Officer, Directors and other CCG staff are permanent unless applicable to a time-limited project or funding, in which case contracts will be offered on a fixed term.
The notice period applying to the Accountable Officer is six months. For Directors and other Senior Managers it is three months. Any termination payments would be in accordance with relevant contractual, legislative and HMRC requirements.
Salary and pension entitlements The following tables set out information in relation to salaries, benefits in kind and pension entitlements of the decision makers of the organisation. There are no elements of remuneration outside the standard terms and conditions of the contracts of employment of senior managers.
Tables and narrative from this point until the end of the “Staff numbers” subsection of section 2.3.2 are subject to independent audit by KPMG.
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Salaries and allowances Note Date served 2019/20 2018/19 Name and Title Salary Expense Other All Total Salary Expense Other All Pension Total (bands of Payments Remun- Pension (bands of (bands of Payments Remun- Related (bands of £5,000) (taxable) eration Related £5,000) £5,000) (taxable) eration Benefits £5,000) Commenced Ceased (total to (bands Benefits (total to (bands of (bands of nearest of (bands of nearest £5,000) £2,500) £100) £5,000) £2,500) £100)
£000 £ £000 £000 £000 £000 £ £000 £000 £000
Caroline Rassell 1,2 & 01-Nov-14 01-Mar-20 65-70 1,300 0 35-40 100-105 70-75 1,200 0 80-82.5 150-155 Accountable Officer, 3 CCG 0.5wte
Anthony McKeever, 1b 02-Mar-20 5-10 0 0 0 5-10 0 0 0 0 0 Interim Joint Accountable Officer
Viv Barnes 01-Aug-14 95-100 0 0 52.5-55 150-155 90-95 0 0 17.5-20 110-115 Director of Governance and Performance
Dee Davey 4 01-Apr-13 16-Sep-18 45-50 0 0 50-52.5 95-100 Chief Finance Officer
Chief Finance Officer 17-Sep-18 70-75 2,000 0 57.5-60 130-135 35-40 1,100 0 57.5-60 95-100 Mid Essex CCG 0.6wte
Dan Doherty 01-Apr-13 105-110 1,000 0 25-27.5 130-135 100-105 1,600 0 40-42.5 145-150 Director of Clinical Transformation and Deputy Accountable Officer
Rachel Hearn 25-Mar-16 31-Oct-18 50-55 700 0 17.5-20 65-70 Interim Director of Nursing 1 & 5 Interim Director of 01-Nov-18 12-Feb-19 Nursing, CCG 0.5wte , 50-55 400 0 60-62.5 110-115 20-25 100 0 12.5-15 35-40 Director of Nursing, 13-Feb-19 CCG 0.5wte
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James Wilson 02-Sep-16 100-105 600 0 25-27.5 130-135 95-100 900 0 25-27.5 120-125 Chief Transformation and Strategy Officer
Elizabeth Towers 6 01-Apr-15 55-60 0 0 0 55-60 10-15 0 35-40 0 50-55 Elected GP - Governing Body Member
Anna Davey 01-Apr-18 Elected GP – Governing Body 60-65 300 0 0 60-65 55-60 100 5-10 0 65-70 Member and
CCG Chair (Clinical) 01-Oct-18
Julie McGeachy 7 01-Apr-18 10-15 0 0 0 10-15 10-15 0 0 0 10-15 Elected GP – Governing Body Member
Fatai Salau 7 01-Apr-18 10-15 0 0 0 10-15 10-15 0 0 0 10-15 Elected GP – Governing Body Member
Alan Hubbard 01-Apr-13 31-Mar-20 5-10 200 0 0 5-10 5-10 100 0 0 5-10 Lay Member, Commercial
John Gilham 01-Jul-18 15-20 0 0 0 15-20 10-15 0 0 0 10-15 Lay Member, Governance and Audit Chair
Nathalie Wright 01-Apr-18 5-10 0 0 0 5-10 5-10 0 0 0 5-10 Lay Member, Patient & Public Participation
Daniel Dalton 8 01-Mar-18 31-Oct-19 0 0 0 0 0 0-5 0 0 0 0-5 Secondary Care Consultant from
* Whole time equivalent
Performance pay and bonuses and Long Term performance pay and bonuses are not paid by the CCG.
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Notes • Note 1: Joint Committee Executives. Remuneration paid to the executives shown in the tables below is funded by the five CCGs. These amounts are in addition to the amounts reported by CCGs in respect of their roles specific to individual CCGs.
The following were on the CCG payroll but were working for the Mid and South Essex Acute Commissioning Team:
Commenced Ceased Name Title (if during (if during Comments year) year) Joint 100% of costs for the period employed, shared by 5 CCGs. Total remuneration paid Mike Bewick Committee 05-Jul-19 was in the band £20k-£25k and our share of the costs were in the remuneration band Chair £5k-£10k. Caroline Accountable 50% of costs for the year, shared by 5 CCGs. Total remuneration paid was in the band Rassell Officer £70k-£75k and our share of the costs were in the remuneration band £20k-£25k. Chief 100% of costs for the year, shared by 5 CCGs. Total remuneration paid was in the Andy Ray Finance band £145k-£150k and our share of the costs were in the remuneration band £45k- Officer £50k. 50% of costs for the year, shared by 5 CCGs. Total remuneration paid was in the band Rachel Hearn Chief Nurse £50k-£55k and our share of the costs were in the remuneration band £15k-£20k. Donald Medical 100% of costs for the year, shared by 5 CCGs. Total remuneration paid was in the McGeachy Director band £90k-£95k and our share of the costs were in the remuneration band £25k-£30k.
The CCG received a share of the following costs via a recharge in respect of their roles as Acute Commissioning Team executives: Commenced Ceased Name Title Comments (if during year) (if during year) Karen Wesson (employed 100% of costs for the year, shared by 5 CCGs. Our share of Director of by NHS Basildon and the costs were in the remuneration band £35k-£40k. Commissioning Brentwood CCG) Anthony McKeever Interim Joint 80% of costs for the period employed, shared by 5 CCGs. (employed by NHS Basildon Accountable 02-Mar-20 Our share of costs (including associated agency fees) was in and Brentwood CCG) Officer remuneration band £5k-£10k. Costs were paid via invoice. * The share of the cost of Mid and South Essex Joint Committee executives is based on size of participating CCG.
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• Note 1a: The total remuneration for Andy Ray is in the range £145k-£150k and includes All Pension Related Benefits which are in the range £7.5k-£10k. The pension benefit figures for other staff, who are also CCG directors, are shown in full in that CCG's remuneration report. • Note 1b: Anthony McKeever was appointed with effect from 2 March, on a fixed term contract, to the post of Interim Joint Accountable Officer across the mid and south Essex CCGs. Anthony is on the payroll of Basildon and Brentwood CCG, and our share of his costs are shown in the Joint Committee table above. • Note 2: The Salary and Allowances table above shows the salary and expense payments made to Caroline Rassell for the Accountable Officer role of the CCG and total pension benefits for this role and her JCT role. The total remuneration (including of Pension benefits and Expense payments) for Caroline Rassell across both Mid Essex CCG and Mid and South Essex Joint Committee roles was in the band £180-£185k. With effect from 2 March 2020, Caroline Rassell was no longer the Accountable Officer for Mid Essex CCG, but was still employed by the CCG, undertaking project work and ensuring a smooth transition to the new Interim Accountable Officer, Anthony McKeever. • Note 3: Caroline Rassell received an exit package in April 2020, as a result of the termination of her employment as Accountable Officer. The detail of this package is included under the Payments for Loss of Office sub-section below. • Note 4: There is currently a staff-sharing arrangement for Dee Davey in the roles of Interim Chief Finance Officer for Basildon and Brentwood CCG for 2 days a week (0.4 WTE), and her substantive post as Chief Finance Officer for Mid Essex CCG (continuing on a reduced 3 days a week, 0.6 WTE). The Mid Essex CCG share of Dee Davey’s remuneration is shown in the table above, along with the pension benefits for both roles. The total remuneration band (inclusive of Pension benefits and Expense payments) for Dee Davey was £175k-£180k • Note 5: The Salary and Allowances table above shows the salary and expense payments made to Rachel Hearn for the Director of Nursing role of the CCG and total pension benefits for this role and her Joint Committee role. The total remuneration (including of Pension benefits and Expense payments) for Rachel Hearn across both Mid Essex CCG and Mid and South Essex CCG Joint Committee roles was in the band £160k-£165k • Note 6: The Salary Band for Elizabeth Towers includes work undertaken for the CCG under separate contracts. These are: CCG Clinical Lead, Macmillan GP Facilitator and as Clinical Lead – Rapid Diagnostic Centre initiative. The Macmillan GP Facilitator role is largely funded by Macmillan Cancer Support, with the Clinical Lead – Rapid Diagnostic Centre being funded by NHS England. • Note 7: Julie McGeachy and Fatai Salau, GP Elected members of the Governing Body, are employed as ‘Off Payroll Workers’ but processed through the CCG’s payroll to ensure the statutory HMRC deductions are made. The salary disclosure includes employer pension contributions (where applicable). They are not reported in section 2.3.4, Off Payroll Engagements. • Note 8: Daniel Dalton employed by Norfolk and Suffolk NHS Foundation Trust, was a member of the CCG’s Governing Body to 31 October 2019. No remuneration was paid to his employer in 2019-20.
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Mid Essex CCG Annual Report and Accounts 2019/20
Pension benefits
Name and Title Real Total Lump sum Real increase accrued at pension Real increase in Cash Employer’s pension age increase in in pension Cash Equivalent contribution at related to Cash pension lump sum Equivalent Transfer to pension accrued Equivalent at at Transfer Value at 31 stakeholder age at 31 pension at Transfer pension pension Value at 1 March 2020 pension March 31 March Value age age April 2019 2020 2020 (bands of (bands of (bands of (bands of £2,500) £2,500) £5,000) £5,000)
£000 £000 £000 £000 £000 £000 £000 £000
Caroline Rassell Accountable Officer CCG (0.5wte) and 2.5-5 0 25-30 40-45 444 24 503 0 Lead Accountable Officer Joint Committee (0.5wte) (Note 1)
Viv Barnes Director of Performance 2.5-5 2.5-5 40-45 90-95 706 55 791 0 and Governance
Dee Davey Chief Finance Officer Mid Essex CCG (0.6wte) and 2.5-5 10-12.5 55-60 175-180 1317 0 0 0 Interim Chief Finance Officer Basildon and Brentwood CCG (0.4wte) (Note 2 & 3)
Dan Doherty Director of Clinical Transformation and 0-2.5 0 25-30 50-55 353 15 391 0 Deputy Accountable Officer
Rachel Hearn Director of Nursing CCG 0.5wte and 2.5-5 2.5-5 25-30 50-55 338 41 401 0
Chief Nurse Joint Committee 0.5wte
James Wilson Chief Transformation 0-2.5 0 10-15 0 83 7 105 0 and Strategy Officer
Notes • Note 1: The Pension Benefits show the amount accrued due to membership of the pension scheme, and no adjustment has been made to reflect secondments to the Joint Committee. • Note 2: The Pension Benefits show the amount accrued due to membership of the pension scheme, and no adjustment has been made to reflect secondments out of the CCG. • Note 3: No CETV will be shown for pensioners or senior managers over NPA age 60 in the 1995 Section, age 65 in the 2008 Section or SPA or age 65, whichever is the later, in the 2015 Scheme.
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Lay Members do not receive pensionable remuneration so there are no disclosures in respect of Lay Members.
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 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) and uses common market valuation factors for the start and end of the period.
Discount rate calculations On 16 March 2016, the Chancellor of the Exchequer announced a change in the Superannuation Contributions Adjusted for Past Experience (SCAPE) discount rate from 3.0% to 2.8%. This rate affects the calculation of CETV figures in this report.
Fair Pay Disclosure (Pay Multiples) Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation’s workforce.
The banded remuneration of the highest paid member of the Governing Body in the CCG in the financial year 2019/20 was £155k-£160k (2018/19, £155k-£160k) excluding employer on-costs. This was 4.25 times (2018/19, 4.31 times) the median remuneration of the workforce, which was £37,570 (2018/19, £36,644). All staff remuneration was within the range of £9,648 to £157,993
In 2019/20, 0 (2018/19: 0) employees received remuneration in excess of the highest-paid member of the Governing Body. Remuneration ranged between £5k-£160k (2018/19 £5k-£160k).
Total remuneration includes salary, non-consolidated performance-related pay and benefits-in- kind. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions.
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Payments for Loss of Office There has been 1 payment for Loss of Office in 2019/20.
Name and Title Redundancy Pay in Pay in Total £s Lieu of Lieu of £s Notice £s Annual Leave £s Caroline Rassell, 133,333 56,416 10,386 200,135 Accountable Officer, CCG and Lead Accountable Officer, Joint Committee
Payments made for loss of office were contractual payments.
The redundancy payment has arisen due to the appointment of the Interim Joint Accountable Officer for the 5 clinical commissioning groups. Each CCG has accounted for a share of the redundancy in line with its running cost allocation. Similarly, Mid Essex CCG has funded a share of the resultant redundancies of the other Accountable Officers across the five CCGs.
The payment was agreed in 2019/20 when Caroline Rassell ceased being the Accountable Officer for Mid Essex CCG, but was not paid until after the termination date of 10 April 2020.
Payments to Past Senior Managers There have been 0 payments to Past Senior Managers in 2019/20.
Exit packages There were 6 exit packages in 2019/20. These are disclosed in the Annual Accounts Note 4.4.
Cost of Number of Exit special departures package payment Number of Cost of where special cost band Total Total element Number of Cost of other other number of payments (including cost of included compulsory compulsory departures departures exit exit have been in exit any special redundancies redundancies agreed agreed packages packages made packages payment element) Whole Whole Whole numbers numbers Whole numbers only £s only £s only £s numbers only £s Less than 3 21,260 3 21,260 £10,000 £10,000 - 2 28,749 2 28,749 £25,000 £25,001 -
£50,000 £50,001 - 1 66,802 1 66,802 £100,000 £100,001 - 1 133,333 1 133,333 £150,000 £150,001 -
£200,000 >£200,000 Totals 1 133,333 6 116,811 7 250,144
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Notes • Note 1: Redundancy and other departure costs have been paid in accordance with the provisions of the NHS Pension Scheme. The Exit costs in this note are the full costs of departures agreed in the year. However, it has been agreed that the restructuring costs across Mid and South Essex will be shared between all CCGs. As such, the share for Mid Essex CCG amounts to £243k.
This disclosure reports the number and value of exit packages agreed in the year. The expense associated with these departures may have been recognised in part or in full in a previous period.
Table 2: Analysis of Other Departures Total value of Agreements Type of other departures agreements – number £ Voluntary redundancies including early retirement contractual costs Mutually agreed resignations (MARS) contractual costs 5 50,009 Early retirements in the efficiency of the service contractual costs Contractual payments in lieu of notice* 2 66,802 Exit payments following Employment Tribunals or court orders Non-contractual payments requiring HMT approval** Total 7 116,811 * Any non-contractual payments in lieu of notice are disclosed under “non-contractual payments requiring HMT approval” below
** Includes any non-contractual severance payment made following judicial mediation, and 0 relating to non- contractual payments in lieu of notice
As a single exit package can be made up of several components, each of which will be counted separately in this table, the total number above will not necessarily match the total numbers in Table 1 which will be the number of individuals.
There were 0 non-contractual payments (£0,000) made to individuals where the payment value was more than 12 months of their annual salary.
The Remuneration Report includes disclosure of exit payments payable to individuals named in that Report.
2.3.2 CCG staff
Number of senior managers There were 16 senior managers employed by the CCG as of 31 March 2020, with a 15.61 Whole Time Equivalent (WTE). These include 3 Lay Board Members, and 1 senior manager who works across the Mid and South Essex CCGs’ teams rather than working solely on behalf of Mid Essex CCG. The table below shows further details.
Staff numbers and costs Mid Essex CCG hosts the Acute Commissioning Team (ACT) and holds a majority of those contracts of employment although the 5 Mid & South Essex CCGs share the ACT costs. As a result Mid Essex CCG accounts only for its share of the ACT costs. The number of staff and 93
Mid Essex CCG Annual Report and Accounts 2019/20 related costs disclosed in Notes 4.1 and 4.2 of the Annual Accounts reflect this share of those staff. The total number of staff employed by Mid Essex CCG as at 31 March 2020 was 162.27 WTE which includes 153.12 permanent staff and 9.15 fixed term and Office Holders. In addition the CCG engaged 10.25 agency and interim staff. The WTE figure for permanent staff as at 31 March 2020, including the CCG’s share of the ACT staff, was 121.23. The salaries and wages of these staff was £5,505k.
Information of our staffing numbers according to occupation code as recorded on the Electronic Staff Record (ESR) can be found below, as of 31 March 2020:
Occupation Female Male Total Job Role Total WTE Code Headcount WTE Headcount WTE Headcount General Medical 921 1 0.4 1 0.75 2 1.15 Practitioner Senior Manager - G0A 15 14.61 3 3 18 17.61 Central Functions Senior Manager - G0B 1 1 0 0 1 1 Estates Manager - Central G1A 12 10.81 7 7 19 17.81 Functions G1B Manager - Estates 1 1 0 0 1 1 Clerical and admin G2A 78 70 13 12.8 91 82.8 - Central Functions Nurse Manager - N0A 5 4.8 0 0 5 4.8 General Nurse Manager - N0H 1 1 0 0 1 1 Community Children's Nurse - N1H 6 4.95 0 0 6 4.95 Community Other 1st level - N6A 1 0.85 2 2 3 2.85 General Other 1st level - N6H 24 18.92 0 0 24 18.92 Community Manager - S0E 1 0.4 1 1 2 1.4 Physiotherapy Manager - S0P 3 2.65 1 0.8 4 3.45 Pharmacy Scientist - S2P 3 2.53 0 0 3 2.53 Pharmacy Technician - S4P 1 1 0 0 1 1 Pharmacy Z2E General payments 1 0 2 0 3 0 Totals 154 134.92 30 27.35 184 162.27
It should be noted that the staffing figures above: • Include 3 Lay Members (who are Office Holders and remunerated via the payroll) • Exclude 4 x Elected GP members (who are Office Holders but engaged via Contract for Services and are therefore not recorded on ESR as ‘staff’) • Include Donald McGeachy who is employed by MECCG but seconded to the Joint Commissioning Team • Include other staff employed in STP facing roles, and as part of the Acute / Joint Commissioning Team (plus wider services which support the Mid and South Essex CCGs, e.g. Contract Finance) as opposed to purely MECCG. • Exclude Dr Dan Dalton – Secondary Care Consultant (who is not directly employed by MECCG) and who ceased to be part of the CCG Board in November 2019 • Exclude Essex County Council Public Health representative
This concludes the independently audited elements of the Accountability Report, with the exception of the Parliamentary Accountability and Audit Report at section 2.4. 94
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Staff composition At 31 March 2020, the breakdown of CCG (Governing body and rest of CCG) gender ratios was: Female Female Male Male Total Total (Total (WTE) (Total (WTE) Staff WTE Staff) Staff) Governing Body 5 4 5 3.6 10 7.6 All Other Staff 149 130.92 25 23.75 174 154.67 Grand Total 154 134.92 30 27.35 184 162.27
It should be noted that the staffing figures above: • Include 3 Lay Members (who are Office Holders and remunerated via the payroll) • Exclude 4 x Elected GP members (who are Office Holders but engaged via Contract for Services and are therefore not recorded on ESR as ‘staff’) • Include Donald McGeachy who is employed by MECCG but seconded to the Joint Commissioning Team • Include other staff employed in STP facing roles, and as part of the Acute / Joint Commissioning Team (plus wider services which support the Mid and South Essex CCGs, e.g. Contract Finance) as opposed to purely MECCG. • Excludes Dr Dan Dalton – Secondary Care Consultant (who is not directly employed by MECCG) and who ceased to be part of the CCG Board in November 2019 • Excludes Essex County Council Public Health representative
Sickness absence data Sickness absence levels for the CCG during 2019/20 are again well below the NHS 2019 average rate of 4.36%%. They are also below the national CCG average for 2019 which stands at 2.99%% (figures from NHS Digital)*.
Average sickness days Date range % Absence rate lost per employee**
1 April 2019 – 31 March 2020 6.16 2.64%*
Source: Mid Essex CCG Electronic Staff Record
*Based on an average FTE of 162.27 and average headcount of 181.33 ** Figure calculated based on 261 working days during 2019/20
Absence is supportively managed within the CCG and we have an Absence Management Policy (which was updated during 2019/20) that addresses both short-term and long-term issues. Staff are supported through any absences, with return-to-work meetings held following periods of absence and referrals made to Occupational Health for support in achieving regular, sustained attendance at work.
Persistent short-term absence is addressed through formal procedures. Where staff members have been significantly unwell or developed a disability during the course of their employment, measures are taken to facilitate reasonable adjustments as recommended by Occupational Health.
We also actively encourage the use of Stress Risk Assessments to address any related issues – often in advance of any Occupational Health referral. This forms part of our preventative approach and we have supported a number of staff to remain at work (as appropriate) through stressful times via this approach. The CCG’s Stress Risk Assessment process was updated in 2019/20 to 95
Mid Essex CCG Annual Report and Accounts 2019/20 include a more comprehensive risk assessment form, and detailed line manager training was rolled out to ensure that managers are competent to manage the process (with support from the HR team for particularly complex situations).
During 2019/20 the CCG also put in place an ‘Employee Assistant Programme’ (EAP) aimed to give fast access to confidential support, advice and counselling for employees and their families on a wide range of personal, work and financial issues.
The CCG’s absence rates overall have remained consistently ‘low’ compared to national NHS comparator figures and national CCG average figures for sickness absence.
Staff redeployment and secondment during 2019/20 There were 8 secondments in and out of the CCG workforce during 2018/19.
Start Date End Date Duration WTE Days Title Secondment Employer In/Out 01/04/2019 31/03/2020 365 0.2 73 Sessional Clinical In Beauchamp Surgery Chair - Primary Care 01/04/2019 31/03/2020 365 1 365 Commissioning Officer In Basildon & Brentwood CCG 01/04/2019 31/03/2020 365 1 365 Neuro Navigator In Basildon and Thurrock University Hospitals Foundation Trust 01/04/2019 31/03/2020 365 0.4 146 CFO Out Basildon & Brentwood CCG 01/04/2019 31/03/2020 365 1 365 CFO - JCT In Barking, Havering and Redbridge University Hospital Trust 01/04/2019 31/03/2020 365 0.2 73 Special Clinical In Thurrock CCG Pharmacist 01/04/2019 31/03/2020 365 0.2 73 Sessional Clinical In PROVIDE Chair - Out of Hospital 06/01/2020 31/03/2020 85 1 85 Contract Finance In Arden & GEM CSU Manager
Staff and CCG values Our staff are committed to ensuring that the population of mid Essex (which includes a majority of our staff) livewell.
Staff once again embraced our livewell values throughout 2019/20 and have participated in a number of initiatives to personally livewell and to support others to do so.
At the start of the 2019/20 financial year we launched our third staff challenge called Time to Shine, which encouraged staff to embrace activities supporting physical health, mental wellbeing and “giving back” to the communities that we represent. Examples of activities undertaken by our staff include:
• 26 staff walked 26.2 miles in the ‘Shine Night Walk’ for Cancer Research UK, raising over £11,000 for charity • 12 staff gave their time to take part in a day-long churchyard clearance, improving a community asset for one of the CCG’s outlying areas • Staff supported a number of events for residents of local care homes – volunteering to take them on a walk to the park, a tea party and even a beer festival at care homes around mid Essex • Co-ordinated donations to the local food bank
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• Staff ran several events for their colleagues on a weekly basis, including mindfulness sessions, a “knit and natter” crafts club, an after-work run and lunchtime walk.
Staff recorded their personal activities and challenges on “Loyalty to Livewell” cards that earned them bronze, silver and gold certificates depending on the number of activities they had logged. This years’ challenge spanned a 6-month period, allowing the approach to be embedded across the CCG and enabling staff to genuinely feel the benefit of ‘living the values’ of our organisation.
Staff participation in activities and the challenge as a whole was inspiring enough to see the CCG named Active Workplace of the Year for the second year running at the 2019 Active Essex Sports Awards.
During 2019/20 we have again seen more staff train to be Mental Health First Aiders (MHFAs), empowering them to provide support to colleagues and signpost to appropriate services where required.
Equal opportunities The organisation is committed to equal opportunities for all staff. As of 31 March 2020, 6.52% of all staff employed by the CCG (12 staff in total) had declared (as part of workforce disclosures) that they have a disability.
All recruitment and selection processes (including both external and internal recruitment and promotion) follow NHS Employers “good practice guidance” and meet NHS employment checks standards. Where job applicants declare a disability, we ensure that appropriate arrangements are made throughout the interview and selection process.
The CCG is also a ‘Mindful Employer’, which means that the CCG demonstrates a commitment to supporting people with mental health illnesses both during the recruitment process and during the course of their employment with the CCG. Our ‘Time to Change’ employer pledge remains in place which reinforces our positive approach to Mental Health.
During 2019/20 the CCG became a ‘Disability Confident’ employer and has made a commitment to the disability agenda through this process.
The CCG continues to access dedicated (in-house) Human Resources professionals and high quality Occupational Health advice to support any employees who fall within the scope of the Equality Act 2010. Each employee is different and so this support is tailored to individual circumstances.
Training and development opportunities are open to and accessible by all, including those with long-standing or newly acquired disabilities.
We have an Equality and Diversity (E&D) working group that addresses all issues relating to E&D within the CCG and is responsible for implementing the NHS Equality Delivery System (EDS2 – see section 1.2.4) and giving due regard to the NHS Workforce Race Equality Standards.
Employee engagement The CCG continues to involve staff in CCG activities through its staff social and engagement group – known as the Work Well Engagement Group.
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The CCG again undertook a bespoke in-house Staff Survey in 2019/20 to make a firm attempt to get to the heart of matters that are most important to our staff. The survey was positively received and the main findings show that there is an overwhelming feeling among the workforce that the CCG is a good employer, with 87% of respondents confirming this. 82.5% of respondents feel supported by mental health, Work Well and anti-bullying and harassment and initiatives (an increase of 17.5% from the 2018 Staff Survey results).
Once again, our staff overwhelmingly feel that our CCG is a friendly and inclusive place to work and this year we are pleased to report the positive impact of the introduction of an Agile Working Policy, which has been endorsed by nearly 80% of our staff who report that the CCG supports agile working. Other major highlights include:
• General agreement that the CCG takes positive action on health and wellbeing and is committed to improving the health and wellbeing of staff • 88% of respondents are clear about their work responsibilities • 86.25% of respondents state that their work aligns with the CCG’s core business goals • 88% of respondent participate in activities inside or outside of work which embrace the CCG’s livewell values
In July 2019, one of our partner organisations helped to arrange a volunteering day for CCG staff, supporting them on the 5 steps to mental wellbeing (image courtesy of Community360)
• Staff feel very high levels of personal and professional support from their line managers and colleagues • Appraisals are constructive and meaningful and staff have clear SMART objectives set • Staff feel trusted to do their job • Wellbeing initiatives such as free flu jabs for staff are positively received (87% of respondents).
The CCG continues to promote staff engagement in a number of other ways too, including regular briefing sessions, an internal newsletter called Digest, email updates and staff events. A new 98
Mid Essex CCG Annual Report and Accounts 2019/20 intranet platform was launched in 2019/20 which has been very well received – making access to information and general communication with staff fast and easy.
Organisational development The CCG offers a wide range of development opportunities to staff, including the opportunity for formal development in a relevant subject area (leading to professional qualifications such as CIMA), in addition to a number of ‘skills’ sessions.
The in-house HR team has also run sessions on:
• Bullying and Harassment • Appraisals – both ‘soft skills’ and ‘system skills’ • Managing Absence • IR35 / Off payroll workers • Contact Officers (for advice on bullying and harassment) • ESR navigation • Recruitment • Pay Progression • ‘The Manager as Coach’
We have sourced a number of ‘expert’ sessions from external providers on ’resilience for change’, recruitment and interview preparation, Mental Health First Aid, Unconscious Bias and information governance. In addition, we have continued in the ILM level 3 programme which commenced in 2018/19 to develop the management skills of a number of our staff – which also uses our Apprenticeship Levy contribution.
This programme offers a detailed understanding of a broad range of leadership and management topics and enables first-line managers to hone their skills and embed their understanding. We have been fortunate to hear first-hand from participants of the positive impact that the development has had on them, both personally and professionally.
We are in the processes of reviewing options for the use of our Apprenticeship Levy funding for the year ahead.
Health and safety The CCG’s health and safety policy sets out our responsibilities and those of employees under the Health and Safety Work Act 1974. Health and safety, fire safety and manual handling are included in the mandatory training programme for all CCG staff.
Risk assessment and inspections identify health and safety issues to enable appropriate action to be taken to reduce risks to staff and other users of CCG premises.
Trade Union Facility Time There was no Trade Union Facility Time in 2019-20.
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2.3.3 Expenditure on consultancy
The CCG paid the following for consultancy in 2019/20 (with the previous two years’ totals included for comparison).
Year Administrative Programme
2019/20 £150k £78k
2018/19 £83k £347k
2017/18 £249k £603k
2.3.4 Off-payroll engagements
For all off-payroll engagements as of 31 March 2020, for more than £245 per day and that last longer than six months:
Numbers of existing engagements as of 31 March 2020 16
Of which, the number that have existed:
• For less than one year at the time of reporting 0
• For between one and two years at the time of reporting 5
• For between two and three years at the time of reporting 0
• For between three and four years at the time of reporting 0
11 • For four or more years at the time of reporting
The clinical commissioning group’s Central Referral Service engages 14 GPs and other clinicians to remotely triage GP referrals.
Contracts have been assessed using the government’s off payroll test as falling outside of IR35 (a UK anti-avoidance tax rule) and therefore the clinical triagers are not required to be paid through the payroll. The number of clinical triagers engaged is usually approximately 14 and they account for the majority of off payroll engagements disclosed above.
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New off-payroll engagements For all new off-payroll engagements, 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 longer than six months.
Number of new engagements, or those that reached six months in 2 duration, between 1 April 2019 and 31 March 2020
Of which…
No. assessed as caught by IR35 0
No. assessed as not caught by IR35 2
• No. engaged directly (via PSC contracted to department) and are on the 0 departmental payroll
• No. of engagements reassessed for consistency/assurance purposes during the year 0
• No. of engagements that saw a change to IR35 status following the consistency 0 review
For contractors assessed as caught by IR35, invoices are submitted and paid through payroll, where tax and NI payments are deducted at source.
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 Governing Body members and/or senior officials with significant financial responsibility during the financial year 0
Total number of individuals on payroll and off-payroll deemed to be “board members and/or senior officials with significant financial responsibility” during the financial 15 year.
2.3.5 Pension liabilities
The CCG’s annual accounts detail the accounting policy adopted regarding the NHS pension scheme liabilities. This can be found in Note 4.5 of the Financial Statements in section 4. 101
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2.4 Parliamentary Accountability and Audit Report
NHS Mid Essex Clinical Commissioning Group is not required to produce a Parliamentary Accountability and Audit Report. Disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges are included in the Notes to the Financial Statements. An audit certificate and report are also included in this Annual Report, from the next page.
This concludes the 2019/20 Mid Essex CCG Accountability Report.
Anthony McKeever Joint Accountable Officer, Mid and South Essex CCGs
16 June 2020
102 INDEPENDENT AUDITOR’S REPORT TO THE MEMBERS OF THE GOVERNING BODY OF NHS MID ESSEX CLINICAL COMMISSIONING GROUP REPORT ON THE AUDIT OF THE FINANCIAL STATEMENTS Opinion We have audited the financial statements of NHS Mid Essex Clinical Commissioning Group (“the CCG”) for the year ended 31 March 2020 which comprise the Statement of Comprehensive Net Expenditure, Statement of Financial Position, Statement of Changes in Taxpayers Equity and Statement of Cash Flows, and the related notes, including the accounting policies in note 1. In our opinion the financial statements:
• give a true and fair view of the state of the CCG’s affairs as at 31 March 2020 and of its income and expenditure for the year then ended; and
• have been properly prepared in accordance with the accounting policies directed by the NHS Commissioning Board with the consent of the Secretary of State as being relevant to CCGs in England and included in the Department of Health and Social Care Group Accounting Manual 2019/20. Basis for opinion We conducted our audit in accordance with International Standards on Auditing (UK) (“ISAs (UK)”) and applicable law. Our responsibilities are described below. We have fulfilled our ethical responsibilities under, and are independent of the CCG in accordance with, UK ethical requirements including the FRC Ethical Standard. We believe that the audit evidence we have obtained is a sufficient and appropriate basis for our opinion. Going concern The Accountable Officer has prepared the financial statements on the going concern basis as they have not 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. They have also concluded that there are no material uncertainties that could have cast significant doubt over its ability to continue as a going concern for at least a year from the date of approval of the financial statements (“the going concern period”).
We are required to report to you if we have concluded that the use of the going concern basis of accounting is inappropriate or there is an undisclosed material uncertainty that may cast significant doubt over the use of that basis for a period of at least a year from the date of approval of the financial statements. In our evaluation of the Accountable Officer’s conclusions we considered the inherent risks to the CCG’s operations and analysed how these risks might affect the CCG’s financial resources, or ability to continue its operations over the going concern period. 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 in the Annual Report The Accountable Officer is responsible for the other information presented in the Annual Report together with the financial statements. Our opinion on the financial statements does not cover the other information and, accordingly, we do not express an audit opinion or, except as explicitly stated below, any form of assurance conclusion thereon. Our responsibility is to read the other information and, in doing so, consider whether, based on our financial statements audit work, the information therein is materially misstated or inconsistent with the financial statements or our audit knowledge. Based solely on that work we have not identified material misstatements in the other information. In our opinion the other information included in the Annual Report for the financial year is consistent with the financial statements. Annual Governance Statement We are required to report to you if the Annual Governance Statement does not comply with guidance issued by the NHS Commissioning Board. We have nothing to report in this respect.
Remuneration and Staff Report In our opinion the parts of the Remuneration and Staff Report subject to audit have been properly prepared in accordance with the Department of Health and Social Care Group Accounting Manual 2019/20. Accountable Officer’s responsibilities As explained more fully in the statement set out on page 61, the Accountable Officer is responsible for the preparation of financial statements that give a true and fair view. They are also responsible for such internal control as they determine is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error; assessing the CCGs ability to continue as a going concern, disclosing, as applicable, matters related to going concern; and using the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity. Auditor’s responsibilities Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue our opinion in an auditor’s report. Reasonable assurance is a high level of assurance, but does not guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of the financial statements. A fuller description of our responsibilities is provided on the FRC’s website at www.frc.org.uk/auditorsresponsibilities REPORT ON OTHER LEGAL AND REGULATORY MATTERS Opinion on regularity We are required to report on the following matters under Section 25(1) of the Local Audit and Accountability Act 2014. In our opinion, in all material respects, the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions conform to the authorities which govern them. Report on the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources Under the Code of Audit Practice we are required to report to you if the CCG has not made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. We have nothing to report in this respect.
Respective responsibilities in respect of our review of arrangements for securing economy, efficiency and effectiveness in the use of resources As explained more fully in the statement set out on page 61, the Accountable Officer is responsible for ensuring that the CCG exercises its functions effectively, efficiently and economically. We are required under section 21(1)(c) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. We are not required to consider, nor have we considered, whether all aspects of the CCGs arrangements for securing economy, efficiency and effectiveness in the use of resources are operating effectively. We have undertaken our review in accordance with the Code of Audit Practice, having regard to the specified criterion issued by the Comptroller and Auditor General (C&AG) in December 2019 and updated in April 2020 as to whether the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. We planned our work in accordance with the Code of Audit Practice and related guidance. Based on our risk assessment, we undertook such work as we considered necessary. Statutory reporting matters We are required by Schedule 2 to the Code of Audit Practice issued by the Comptroller and Auditor General (‘the Code of Audit Practice’) to report to you if:
• we refer a matter to the Secretary of State under section 30 of the Local Audit and Accountability Act 2014 because we have reason to believe that the CCG, or an officer of the CCG, is about to make, or has made, a decision which involves or would involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency; or
• we issue a report in the public interest under section 24 of the Local Audit and Accountability Act 2014; or
• we make a written recommendation to the CCG under section 24 of the Local Audit and Accountability Act 2014. We have nothing to report in these respects. THE PURPOSE OF OUR AUDIT WORK AND TO WHOM WE OWE OUR RESPONSIBILITIES This report is made solely to the Members of the Governing Body of NHS Mid Essex CCG, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014. Our audit work has been undertaken so that we might state to the Members of the Governing Body of the CCG, as a body, those matters we are required to state to them in an auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Members of the Governing Body, as a body, for our audit work, for this report or for the opinions we have formed. CERTIFICATE OF COMPLETION OF THE AUDIT We certify that we have completed the audit of the accounts of NHS Mid Essex CCG for the year ended 31 March 2020 in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.
Stephanie Beavis for and on behalf of KPMG LLP Chartered Accountants Botanic House 100 Hills Road Cambridge CB2 1AR
25 June 2020 Mid Essex CCG Annual Report and Accounts 2019/20
4. Annual Accounts
NHS Mid Essex Clinical Commissioning Group Annual Accounts 2019/20
106
NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
CONTENTS Page Number
The Primary Statements:
Statement of Comprehensive Net Expenditure for the year ended 31st March 2020 1 Statement of Financial Position as at 31st March 2020 2 Statement of Changes in Taxpayers' Equity for the year ended 31st March 2020 3 Statement of Cash Flows for the year ended 31st March 2020 4
Notes to the Accounts Accounting policies 5 Other operating revenue 9 Revenue 10 Employee benefits and staff numbers 11 Operating expenses 14 Better payment practice code 15 Operating leases 16 Property, plant and equipment 17 Trade and other receivables 19 Other financial assets 20 Other current assets 20 Cash and cash equivalents 21 Trade and other payables 22 Provisions 23 Commitments 24 Financial instruments 24 Operating segments 25 Joint Arrangements 25 Related party transactions 26 Events after the end of the reporting period 27 Financial performance targets 27 Losses and special payments 27
Please note that occasionally £1k differences occur between the primary statements and the notes to the accounts and within individual lines which is unavoidable due to rounding discrepancies. NHS Mid Essex Clinical Commissioning Group - 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 2 (1,359) (2,990) Other operating income 2 - (11) Total operating income (1,359) (3,001)
Staff costs 4 8,228 7,358 Purchase of goods and services 5 502,213 470,669 Depreciation and impairment charges 5 2 15 Provision expense 5 13 (71) Other Operating Expenditure 5 316 381 Total operating expenditure 510,772 478,352
Net Operating Expenditure 509,413 475,351
Net expenditure for the year 509,413 475,351
Comprehensive Expenditure for the year 509,413 475,351
The notes on pages 5 to 27 form part of this statement
1 NHS Mid Essex Clinical Commissioning Group - 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 - 2 Total non-current assets - 2 Current assets: Trade and other receivables 9 5,215 7,772 Cash and cash equivalents 12 0 0 Total current assets 5,215 7,772
Total assets 5,215 7,774
Current liabilities Trade and other payables 13 (36,907) (40,267) Borrowings 12 (650) (721) Provisions 14 (560) (949) Total current liabilities (38,117) (41,937)
Non-Current Assets less Net Current Liabilities (32,902) (34,163)
Non-current liabilities Provisions 14 (729) (729) Total non-current liabilities (729) (729)
Assets less Liabilities (33,631) (34,892)
Financed by Taxpayers’ Equity General fund (33,631) (34,892)
Total taxpayers' equity: (33,631) (34,892)
The notes on pages 5 to 27 form part of this statement
The financial statements on pages 1 to 27 were approved by the Governing Body on 16 June 2020 and signed on its behalf by:
Anthony McKeever Interim Accountable Officer 16 June 2020
2 31 March 2020 Total General fund reserves £'000 £'000 Changes in taxpayers’ equity for 2019-20
Balance at 01 April 2019 (34,891) (34,891)
Adjusted NHS Clinical Commissioning Group balance at 31 March 2019 (34,891) (34,891)
Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2019-20 Net operating expenditure for the financial year (509,413) (509,413) Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (509,413) (509,413)
Net funding 510,673 510,673
Balance at 31 March 2020 (33,631) (33,631)
Total General fund reserves £'000 £'000 Changes in taxpayers’ equity for 2018-19
Balance at 01 April 2018 (28,222) (28,222)
Adjusted NHS Clinical Commissioning Group balance at 31 March 2019 (28,222) (28,222)
Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2018-19 Net operating costs for the financial year (475,351) (475,351)
Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (475,351) (475,351)
Net funding 468,682 468,682
Balance at 31 March 2019 (34,891) (34,891)
The notes on pages 5 to 27 form part of this statement
3 NHS Mid Essex Clinical Commissioning Group - 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 (509,413) (475,350) Depreciation and amortisation 5 2 15 (Increase)/decrease in trade & other receivables 9 2,557 (3,338) Increase/(decrease) in trade & other payables 13 (3,359) 10,860 Provisions utilised 14 (402) (778) Increase/(decrease) in provisions 14 13 (71) Net Cash Inflow (Outflow) from Operating Activities (510,602) (468,662)
Cash Flows from Investing Activities
Net Cash Inflow (Outflow) before Financing (510,602) (468,662)
Cash Flows from Financing Activities Grant in Aid Funding Received 510,673 468,682
Net Cash Inflow (Outflow) from Financing Activities 510,673 468,682
Net Increase (Decrease) in Cash & Cash Equivalents 12 71 20
Cash & Cash Equivalents at the Beginning of the Financial Year (721) (740)
Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year (650) (721)
The notes on pages 5 to 27 form part of this statement
4 NHS Mid Essex Clinical Commissioning Group - 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. The clinical commissioning group delivered a £3m surplus in 2019-20. 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. 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 Movement of Assets within the Department of Health and Social Care Group As Public Sector Bodies are deemed to operate under common control, business reconfigurations within the Department of Health and Social Care Group are outside the scope of IFRS 3 BusinessCombinations. Where functions transfer between two public sector bodies, the Department of Health and Social Care GAM requires the application of absorption accounting. Absorption accounting requires that entities account for their transactions in the period in which they took place, with no restatement of performance required when functions transfer within the public sector. Where assets and liabilities transfer, the gain or loss resulting is recognised in the Statement of Comprehensive Net Expenditure, and is disclosed separately from operating costs. Other transfers of assets and liabilities within the Department of Health and Social Care Group are accounted for in line with IAS 20 and similarly give rise to income and expenditure entries. 1.4 Pooled Budgets
The clinical commissioning group has not been part of any pooled budget arrangements in 2019-20. Mid Essex clinical commissioning group and Essex County Council have continued to operate a Better Care Fund during 2019-20 under a Section 75 agreement. The arrangements under which the Better Care Fund has operated in 2019-20 do not constitute a pooled budget as the risks of each scheme have remained with the respective commissioners. Each scheme within the Better Care Fund has been reviewed and accounted for on an appropriate basis (see Note 18). The clinical commissioning group (along with 6 other Essex CCGs and 3 Local Authorities) is a party to a Section 75 agreement in providing for the costs of discharged long-term in-patients with learning disabilities as identified by the Transforming Care programme. Essex County Council and the clinical commissioning groups have agreed that Joint Control does not exist within this arrangement as both health and community packages continue to be commissioned by the respective partners. 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 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 main source of funding for the Clinical Commissioning Group is from NHS England. This is drawn down and credited to the general fund. Funding is recognised in the period in which it is received. Revenue in respect of services provided is recognised when (or as) performance obligations are satisfied by transferring promised services to the customer, and is measured at the amount of the transaction price allocated to that performance obligation. Where income is received for a specific performance obligation that is to be satisfied in the following year, that income is deferred. Payment terms are standard reflecting cross government principles.
The value of the benefit received when the clinical commissioning group accesses funds from the Government’s apprenticeship service are recognised as income in accordance with IAS 20, Accounting for Government Grants. Where these funds are paid directly to an accredited training provider, non-cash income and a corresponding non-cash training expense are recognised, both equal to the cost of the training funded. 1.70 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.
5 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
Notes to the financial statements
1.8 Other Expenses Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable. 1.9 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 All property, plant and equipment is measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. Assets that are held for their service potential and are in use are measured subsequently at their current value in existing use. Assets that were most recently held for their service potential but are surplus are measured at fair value where there are no restrictions preventing access to the market at the reporting date. Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Current values in existing use are determined as follows: · Land and non-specialised buildings – market value for existing use; and, · Specialised buildings – depreciated replacement cost.
Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are re-valued and depreciation commences when they are brought into use. IT equipment, transport equipment, furniture and fittings, and plant and machinery 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. An increase arising on revaluation is taken to the revaluation reserve except when it reverses an impairment for the same asset previously recognised in expenditure, in which case it is credited to expenditure to the extent of the decrease previously charged there. A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Gains and losses recognised in the revaluation reserve are reported as other comprehensive income in the Statement of Comprehensive Net Expenditure. 1.9.3 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 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. 1.10.1 The Clinical Commissioning Group as Lessee Property, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the clinical commissioning group’s surplus/deficit. Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term. Contingent rentals are recognised as an expense in the period in which they are incurred. Where a lease is for land and buildings, the land and building components are separated and individually assessed as to whether they are operating or finance leases. 1.11 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. 1.12 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.
When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised as an asset if it is virtually certain that reimbursements will be received and the amount of the receivable can be measured reliably. 1.13 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.
6 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
Notes to the financial statements
1.14 Non-clinical Risk Pooling The clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to NHS Resolution and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due. 1.15 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. 1.15.1 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. 1.15.2 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. 1.15.3 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. 1.15.4 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 the 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. 1.16 Financial Liabilities Financial liabilities are recognised on the statement of financial position when the clinical commissioning group becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are de- recognised when the liability has been discharged, that is, the liability has been paid or has expired. 1.16.1 Other Financial Liabilities After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method, except for loans from the 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. 1.17 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. 1.18 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. 1.19 Losses & Special Payments
Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled.
Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had the clinical commissioning group not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure). The clinical commissioning group's losses and special payments are disclosed in Note 22.
7 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
Notes to the financial statements
1.20 Critical accounting judgements and key sources of estimation uncertainty In the application of the clinical commissioning group's accounting policies, management is required to make various judgements, estimates and assumptions. These are regularly reviewed. 1.20.1 Critical accounting judgements in applying accounting policies
The following are the judgements, apart from those involving estimations, that management has made in the process of applying the clinical commissioning group's accounting policies and that have the most significant effect on the amounts recognised in the financial statements. Mid Essex clinical commissioning group and Essex County Council have continued to operate a Better Care Fund during 2019-20 under a section 75 agreement. The arrangements under which the Better Care Fund has operated during 2019-20 do not constitute a pooled budget as the risks of each scheme have remained with the respective commissioner. See Note 18 for further information. The clinical commissioning group is part of a section 75 agreement with the members of the Essex Transforming Care Partnership. The arrangement is not considered to be one of Joint Control as both health and community packages continue to be commissioned by the respective partners. See Note 18 for further information. 1.20.2 Sources of estimation uncertainty The following are assumptions about the future and other major sources of estimation uncertainty that have a significant risk of resulting in a material adjustment to the carrying amounts of assets and liabilities within the next financial year.
Where possible the value of year end transactions has been agreed with NHS counter parties on an estimated basis. Where information is not available, the clinical commissioning group has made estimates of the value of liabilities in respect of activity in the final weeks of the year. Asset life assumptions are based on standard assumptions for each category of non-current asset. The clinical commissioning group carries a number of provisions which are reflected in Note 14. A number of high value accruals have been made which include a prescribing accrual - the amount of £9.7m reflects the amount needed to bring the ledger position to the latest forecast from the NHS Business Services Authority plus a further accrual of £0.5m which is an estimate of the impact of the Covid-19 pandemic on prescribing activity in the final two weeks of March 2020.
1.21 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 2020-21, 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 2023, but not yet adopted by the FReM: early adoption is not therefore permitted. ● IFRIC 23 Uncertainty over Income Tax Treatments – Application required for accounting periods beginning on or after 1 January 2019.
The CCG does not anticipate any significant impact from Standards that have not yet been adopted.
8 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
2 Other Operating Revenue 2019-20 2019-20 2019-20 2018-19 Admin Programme Total Total £'000 £'000 £'000 £'000
Income from sale of goods and services (contracts) Education, Training & Research 10 - 10 173 Non-patient care services to other bodies 50 1,241 1,291 2,529 Other Contract income 30 29 58 288 Total Income from sale of goods and services 89 1,270 1,359 2,990
Other Operating Income Non cash apprenticeship training grants revenue - - - 11
Total Operating Income 89 1,270 1,359 3,001
Admin Revenue is revenue received that is not directly attributable to the provision of healthcare or healthcare services.
Allocation funding received from NHS England is not included in this note as it is drawn down directly into the bank account of the clinical commissioning group and credited to the General Fund.
The clinical commissioning group received £0.4m Improved Better Care Fund income and £0.3m winter funding from Essex County Council. This income together with £0.3m from NHS England for primary care Additional Roles Reimbursement is disclosed as non-patient services to other bodies in the table above. In 2018-19 the Improved Better Care Fund income from Essex County Council was much higher at £1.6m.
Income disclosed as education, training & research in 2018-19 included £145k received from NHS England to support the implementation of the Extended Access service.
9 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
3.1 Disaggregation of Income - Income from sale of good and services (contracts)
Education, Non-patient care 2019-20 Other Contract training and services to other Total income research bodies £'000 £'000 £'000 £'000 Source of Revenue NHS 371 - 371 - Non NHS 988 10 920 58 Total 1,359 10 1,291 58
Education, Non-patient care 2019-20 Other Contract training and services to other Total income research bodies £'000 £'000 £'000 Timing of Revenue £'000 Point in time - - - - Over time 1,359 10 1,291 58 Total 1,359 10 1,291 58
3.2 Transaction price to remaining contract performance obligations
There is no contract revenue expected to be recognised in future periods related to contract performance obligations not yet completed at the reporting date.
All the clinical commissioning group's revenue is generated from the supply of services and there is no revenue from the sale of goods.
10 NHS Mid Essex Clinical Commissioning Group - 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 5,505 765 6,270 Social security costs 605 6 611 Employer Contributions to NHS Pension scheme 1,073 0 1,073 Other pension costs 6 0 6 Apprenticeship Levy 24 0 24 Termination benefits 243 0 243 Gross employee benefits expenditure 7,456 771 8,228
Total - Net admin employee benefits including capitalised costs 7,456 771 8,228
Net employee benefits excluding capitalised costs 7,456 771 8,228
4.1.1 Employee benefits Total 2018-19
Permanent Employees Other Total £'000 £'000 £'000 Employee Benefits Salaries and wages 5,198 947 6,145 Social security costs 552 0 552 Employer Contributions to NHS Pension scheme 632 0 632 Other pension costs 3 0 3 Apprenticeship Levy 18 0 18 Termination benefits 8 0 8 Gross employee benefits expenditure 6,411 947 7,358
Total - Net admin employee benefits including capitalised costs 6,411 947 7,358
Net employee benefits excluding capitalised costs 6,411 947 7,358
In 2019-20 no employee benefits were recovered from third parties not capitalised (2018-19 - £Nil).
The clinical commissioning group hosts staff employed by the Acute Commissioning Team which supports the Joint Committee on behalf of the 5 CCGs in the Mid and South Essex system. An adjustment has been made to reflect the Mid Essex share of these costs only.
The increase in employer's contributions to NHS pension scheme is due to the rate increase from 14.38% to 20.6% with effect from 1 April 2019 which was paid by NHS England on behalf of all clinical commissioning groups. The full cost and related funding has been recognised in these accounts (see Note 4.5).
11 NHS Mid Essex Clinical Commissioning Group - 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 124 9 133 119 10 129
Staff numbers disclosed in the above note are lower than those disclosed in the Annual Report as the above figures show only the proportion of the shared Acute Commissioning Team that Mid Essex CCG funds. The Annual Report discloses the number of staff who are employed by Mid Essex CCG.
4.3 Ill health retirements There were no early retirements on health grounds in 2019-20 or 2018-19.
4.4 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 - - 3 21,260 3 21,260 £10,001 to £25,000 - - 2 28,749 2 28,749 £50,001 to £100,000 - - 1 66,802 1 66,802 £100,001 to £150,000 1 133,333 - - 1 133,333 Total 1 133,333 6 116,811 7 250,144
2018-19 2018-19 2018-19 Compulsory redundancies Other agreed departures Total Number £ Number £ Number £ Less than £10,000 3 7,998 - - 3 7,998 Total 3 7,998 - - 3 7,998
Analysis of Other Agreed Departures 2019-20 2018-19 Other agreed departures Other agreed departures Number £ Number £ Mutually agreed resignations (MARS) contractual costs 5 50,009 - - Contractual payments in lieu of notice 2 66,802 - - Total 7 116,811 - -
* As a single exit package can be made up of several components each of which will be counted separately in this table, the total number will not necessarily match the total number in the table above, which will be the number of individuals. The figures reported in the tables in Note 4.4 are the number and value of exit packages agreed for staff employed by the clinical commissioning group in the financial year. The expenditure recorded in table 4.1 (£243k) is the clinical commissioning group's share of all exit packages agreed across the 5 Mid & South Essex CCGs in 2019-20. Each CCG has accounted for a share of the total costs in line with its running cost allocation (apart from a small number of mutually agreed resignations for Mid Essex clinical commissioning group staff where costs have not been shared). Most of the costs, although only one package, disclosed in table 4.4 have arisen following the appointment of the Interim Joint Accountable Officer for the 5 clinical commissioning groups. 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 Agenda for Change. Other exit costs have been agreed under a local Mutually Agreed Resignation Scheme which mirrored the national Mutually Agreed Resignation Scheme and was endorsed by NHS England.
Exit costs are accounted for in accordance with relevant accounting standards and at the latest in full in the year of departure.
Where entities has agreed early retirements, the additional costs are met by NHS Entities and not by the NHS Pension Scheme, and are included in the tables. Ill-health retirement costs are met by the NHS Pension Scheme and are not included in the tables.
No non-contractual payments were made to individuals where the payment value was more than 12 months’ of their annual salary.
The Remuneration Report includes the disclosure of exit payments payable to individuals named in that Report.
12 NHS Mid Essex Clinical Commissioning Group - 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.
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.
The schemes are subject to a full actuarial valuation every four years and an accounting valuation every year.
The employer contribution rate for NHS Pensions increased from 14.38% 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 2019, is based on valuation data as 31 March 2018 updated to 31 March 2019 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.
The latest assessment of the liabilities of the scheme is contained in the report of the scheme actuary, which forms part of the annual NHS Pension Scheme Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office.
4.5.2 Full actuarial (funding) valuation
The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account recent demographic experience), and to recommend contribution rates payable by employees and employers.
The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2016. The results of this valuation set the employer contribution rate payable from April 2019. The Department of Health and Social Care have recently laid Scheme Regulations confirming that the employer contribution rate will increase to 20.6% of pensionable pay from this date.
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.
13 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
5. Operating expenses 2019-20 2018-19 Total Total £'000 £'000
Purchase of goods and services Services from other CCGs and NHS England 1,685 1,659 Services from foundation trusts 82,310 75,707 Services from other NHS trusts 218,408 205,725 Services from Other WGA bodies 1 1 Purchase of healthcare from non-NHS bodies 132,675 121,919 Prescribing costs 54,994 54,541 General Ophthalmic services 6 3 GPMS/APMS and PCTMS 5,017 3,732 Supplies and services – general 693 1,047 Consultancy services 228 430 Establishment 1,742 1,480 Transport 3,333 2,896 Premises 661 1,045 Audit fees 48 48 Other non statutory audit expenditure · Other services - 20 Other professional fees 347 323 Legal fees 4 27 Education, training and conferences 61 64 Total Purchase of goods and services 502,213 470,669
Depreciation and impairment charges Depreciation 2 8 Amortisation - 7 Total Depreciation and impairment charges 2 15
Provision expense Provisions 13 (71) Total Provision expense 13 (71)
Other Operating Expenditure Chair and Non Executive Members 114 173 Grants to other bodies 152 155 Expected credit loss on receivables (19) 32 Non cash apprenticeship training grants - 11 Other expenditure 69 8 Total Other Operating Expenditure 316 381
Total operating expenditure 502,544 470,993
The clinical commissioning group's external auditors are KPMG. The external audit contract limits KPMG's liability for losses in connection with this engagement to a maximum aggregate of £1m. Any claim must be brought within 4 years. The fee for auditing the 2019-20 accounts was £41,075 plus VAT of £8,215.
As well as general increases in acute commissioning activity and costs there has been a significant value (£6.8m) of system transformation and winter funding that has been received by the clinical commissioning group on behalf of the system. Most of this was passed to the 3 system acute providers which has impacted on the spend with Foundation and NHS Trusts disclosed in Note 5 above. £2.4m of unspent transformation and winter funding is shown in purchase of healthcare from non-NHS bodies in Note 5 until the provider can be confirmed in 2020-21.
The remainder of the increase in spend on purchase of healthcare from non-NHS bodies is largely due to the increase in continuing healthcare costs (£2.2m), reimbursement of Covid-19 pandemic costs for March 2020 (£1.4m - mostly Essex County Council on behalf of the Essex CCGs and Community providers) and changed arrangements for Equipment provision (£1.5m).
The increase in spend in Primary Care is due to continuing investment in the Primary Care Foundations programme and the ongoing investment in the national Extended Access programme. In addition a number of national GP Forward View allocations are included in the clinical commissioning group's accounts on behalf of the system's clinical commissioning groups.
There was one provision arising in 2019-20 for maternity leave (£13k) and no provisions were reversed unutilised.
15 NHS Mid Essex Clinical Commissioning Group - 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 14,966 165,550 14,951 143,048 Total Non-NHS Trade Invoices paid within target 14,596 160,813 14,499 137,977 Percentage of Non-NHS Trade invoices paid within target 97.53% 97.14% 96.98% 96.46%
NHS Payables Total NHS Trade Invoices Paid in the Year 3,164 325,271 3,192 315,539 Total NHS Trade Invoices Paid within target 3,094 323,068 3,115 313,786 Percentage of NHS Trade Invoices paid within target 97.79% 99.32% 97.59% 99.44%
15 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
7. Operating Leases
7.1 As lessee 7.1.1 Payments recognised as an Expense 2019-20 2018-19 Buildings Other Total Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000 Payments recognised as an expense Minimum lease payments 508 1 509 1,088 2 1,090 Total 508 1 509 1,088 2 1,090
Whilst our arrangements with NHS Property Services Limited fall within the definition of operating leases, rental charges for future years have not yet been agreed. Consequently this note does not include future minimum lease payments for the arrangements only. Other lease is a franking machine.
7.1.2 Future minimum lease payments 2019-20 2018-19 Buildings Other Total Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000 Payable: No later than one year - 1 1 - 3 3 Between one and five years - 3 3 - 2 2 After five years ------Total - 4 4 - 4 4
The clinical commissioning group did not receive any revenue as lessor.
16 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
8 Property, plant and equipment 2018-19 Furniture & Furniture & 2019-20 fittings Total fittings £'000 £'000 £'000 Cost or valuation at 01 April 2019 78 78 78
Cost/Valuation at 31 March 2020 78 78 78
Depreciation 01 April 2019 76 76 68
Charged during the year 2 2 8 Depreciation at 31 March 2020 78 78 76
Net Book Value at 31 March 2020 - - 2
Purchased (0) (0) 2 Total at 31 March 2020 (0) (0) 2
Asset financing:
Owned (0) (0) 2
Total at 31 March 2020 (0) (0) 2
The clinical commissioning group does not hold any revaluation reserve balances for property, plant and equipment.
17 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
8 Property, plant and equipment cont'd
8.1 Compensation from third parties
There is no compensation from third parties to report
8.2 Write downs to recoverable amount
No assets were written down to recoverable amount.
8.3 Economic lives Minimum Maximum Life Life (years) (Years) Furniture & fittings 1 1
18 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
9.1 Trade and other receivables Current Non-current Current Non-current 2019-20 2019-20 2018-19 2018-19 £'000 £'000 £'000 £'000
NHS receivables: Revenue 2,819 - 3,433 - NHS prepayments 1,199 - 1,199 - NHS accrued income 519 - 1,329 - Non-NHS and Other WGA receivables: Revenue 262 - 1,360 - Non-NHS and Other WGA prepayments 357 - 285 - Non-NHS and Other WGA accrued income 35 - 188 - Expected credit loss allowance-receivables - - (32) - VAT 24 - 10 - Total Trade & other receivables 5,215 - 7,772 -
Total current and non current 5,215 7,772
There are no prepaid pensions contributions included in the above figures.
9.2 Receivables past their due date but not impaired 2019-20 2019-20 2018-19 2018-19 DHSC Group Non DHSC Group DHSC Group Non DHSC Group Bodies Bodies Bodies Bodies £'000 £'000 £'000 £'000 By up to three months 1,583 279 63 109 By three to six months 30 1 1 28 By more than six months 2 (30) 2 106 Total 1,615 250 66 243
Receivables past their due date but not impaired include £1m which was due from NHS North East Essex CCG for equipment recharges at 31 March and has subsequently been paid in full. Other amounts still outstanding include £0.5m due from NHS England for flu and specialist drug recharges.
The clinical commissioning group did not hold any collateral against receivables outstanding at 31 March 2020.
19 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
10. Other financial assets
The clinical commissioning group had no other financial assets as at 31 March 2020.
11. Other current assets
The clinical commissioning group had no other current assets as at 31 March 2020.
20 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
12. Cash and cash equivalents
2019-20 2018-19 £'000 £'000 Balance at 01 April 2019 (721) (740) Net change in year 71 19 Balance at 31 March 2020 (650) (720)
Bank overdraft: Government Banking Service (650) (721) Total bank overdrafts (650) (721)
Balance at 31 March 2020 (650) (721)
No patients’ money held by the clinical commissioning group.
The clinical commissioning group's cash position is reported in the financial statements as an overdraft at 31 March 2020 due to outstanding payments clearing after the year end. As at 31 March 2020, the clinical commissioning group had a net positive cash balance deposited in its Government Banking Service bank account of £130k.
21 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
Current Non-current Current Non-current 13. Trade and other payables 2019-20 2019-20 2018-19 2018-19 £'000 £'000 £'000 £'000
NHS payables: Revenue 4,097 - 6,719 - NHS accruals 5,380 - 4,654 - Non-NHS and Other WGA payables: Revenue 1,458 - 7,372 - Non-NHS and Other WGA accruals 24,966 - 21,036 - Social security costs 122 - 115 - Tax 102 - 110 - Other payables and accruals 782 - 261 - Total Trade & Other Payables 36,907 - 40,267 -
Total current and non-current 36,907 40,267
Other payables include £135k outstanding pension contributions at 31 March 2020.
22 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
14. Provisions Current Non-current Current Non-current 2019-20 2019-20 2018-19 2018-19 £'000 £'000 £'000 £'000
Continuing care 449 729 533 729 Other 110 - 416 - Total 560 729 949 729
Total current and non-current 1,288 1,677
Continuing Care Other Total £'000 £'000 £'000
Balance at 01 April 2019 1,262 416 1,677 Arising during the year - 13 13 Utilised during the year (84) (319) (402) Balance at 31 March 2020 1,178 110 1,288
Expected timing of cash flows: Within one year 449 110 560 Between one and five years 729 - 729 Balance at 31 March 2020 1,178 110 1,288
Provisions held by NHS England Under the Accounts Directions issued by NHS England on 12 February 2014, NHS England is responsible for accounting for liabilities relating to NHS continuing healthcare claims related to periods of care before establishment of the clinical commissioning group. However, the legal liability remains with the clinical commissioning group. The total value of the legacy continuing healthcare provisions accounted for by NHS England on behalf of this clinical commissioning group at 31 March 2020 is £772k an increase on 2018-19 (£481k).
There are two remaining cases originally found eligible or partially eligible awaiting financial settlement and the costs will be met by the NHS England risk pool arrangement. In addition at 31 March 2020 there were 37 appeals in progress with the NHS England Independent Panel and 4 with the Ombudsman. Financial settlement of any cases that are successful at appeal will also be made from the NHS England risk pool arrangement.
Provisions held by the clinical commissioning group The main provisions held by the clinical commissioning group as at 31 March 2020 are:
An estimate of the costs of settling the outstanding continuing healthcare retrospective claims received since 31 March 2013 and which are outside of the NHS England risk pool arrangement and the liability of the clinical commissioning group (£1.2m).
23 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
15. Commitments
There are no capital commitments to report. The clinical commissioning group has not entered into any non-cancellable contracts (which are not leases, private finance initiative contracts or other service concession arrangements).
16. Financial instruments
16.1 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.
As the 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.
16.1.1 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.
16.1.2 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.
16.1.3 Credit risk
Because the majority of the clinical commissioning group and revenue comes parliamentary funding, the 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.
16.1.4 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.
16.1.5 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.
24 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
16. Financial instruments cont'd
16.2 Financial assets
Financial Assets measured at amortised cost Total 2019-20 2019-20 £'000 £'000
Trade and other receivables with NHSE bodies 2,871 2,871 Trade and other receivables with other DHSC group bodies 505 505 Trade and other receivables with external bodies 259 259 Cash and cash equivalents 0 0 Total at 31 March 2020 3,635 3,635
16.3 Financial liabilities Financial Liabilities measured at amortised cost Total 2019-20 2019-20 £'000 £'000
Trade and other payables with NHSE bodies 487 487 Trade and other payables with other DHSC group bodies 18,843 18,843 Trade and other payables with external bodies 17,353 17,353 Other financial liabilities 650 650 Total at 31 March 2020 37,333 37,333
17. Operating segments
The clinical commissioning group has only one segment, commissioning of healthcare services (2018-19 one segment).
18. Joint Arrangements
The clinical commissioning group was not party to any joint operations during 2019-20.
Better Care Fund The clinical commissioning group has operated a Better Care Fund of £24.3m during 2019-20 (2018-19 - £23.2m) together with Essex County Council under a section 75 agreement. This arrangement has been reviewed and both parties have agreed that it does not constitute a pooled fund. This conclusion has been reached as both parties have retained the financial risks associated with each of the schemes as existed before the fund was set up.
The arrangements for each scheme within the Better Care Fund have been reviewed to determine the appropriate accounting treatment by the clinical commissioning group and agreed with Essex County Council.
Control of the commissioning arrangements has been key to determining the nature of each scheme within the fund. Where Essex County Council has been identified as Lead Commissioner or Principal, the accounting treatment has been for the transaction with Essex County Council to be recorded in the clinical commissioning group ledger - £10.0m (2018-19 - £9.5m). Where the clinical commissioning group has control over the commissioning of the service the transactions with the individual provider(s) are recorded in the ledger - £14.3m (2018-19 - £13.7m).
In addition to the £24.3m accounted for as above, Essex County Council has received disabilities factilities grants which have been passed to housing authorities in accordance with allocations determined by the Ministry of Housing, Communities and Local Government. The amount of disabilities facilities grants aligned to the clinical commissioning group's localities was £2.4m (2018-19 £2.3m). This scheme is technically within the Better Care Fund but as the clinical commissioning group has no control or input into how this is spent it is not recorded within the clinical commissioning group's accounts.
Transforming Care Partnership The clinical commissioning group has also been a party to a Transforming Care Partnership section 75 agreement with Essex County Council. This agreement determines the arrangements for funds released from discharged long-stay in-patients with learning disabilities as identified by the national Transforming Care programme. The costs of health packages for this cohort of patients have been accounted for by the clinical commissioning group on a net accounting basis as the clinical commissioning group is acting as Principal. Where funding is released to Essex County Council to fund community packages for patients who have been discharged this would have been accounted for by the clinical commissioning group on a gross accounting basis as the local authority is acting as principal. The arrangement is not considered to be one of Joint Control as both health and community packages continue to be commissioned by the respective partners, the local authorities take the risk of releasable funding being insufficient for community packages and the role of the health partners on the Transforming Care Partnership is one of oversight and to check that the fund manager is spending the funds on the agreed purposes.
25 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
19. Related party transactions The clinical commissioning group is a body corporate established by order of the Secretary of Health & Social Care.
Members of the decision making forums (and all members of staff) are required to complete a formal declaration of interest statement annually and registers of interests are provided for all attendees at Committee meetings with a request from the Chair to declare any changes each time the meeting is held. Declarations relate to themselves, interests of close family members and associates. This disclosure enables the clinical commissioning group to ensure that the accounts disclose transactions with related parties declared in those annual statements.
The Department of Health and Social Care and NHS England are regarded as related parties. During 2019-20 the clinical commissioning group has had a significant number of material transactions with the Department of Health and Social Care and NHS England and with other entities for which these organisations are regarded as he parent organisation. These entities are:
Mid and South Essex University Hospital Group (previously Mid Essex Hospital Services NHS Trust, Basildon & Thurrock University Hospital NHS Foundation Trust and Southend University Hospital NHS Foundation Trust) East Suffolk and North Essex NHS Foundation Trust Princess Alexandra Hospital NHS Trust Cambridge University Hospital NHS Foundation Trust Specialist acute London hospitals Essex Partnership University NHS Foundation Trust Hertfordshire Partnership University NHS Foundation Trust North East London NHS Foundation Trust East of England Ambulance Services Trust North East Essex CCG West Essex CCG Basildon & Brentwood CCG Castlepoint & Rochford CCG Southend CCG Thurrock CCG NHS Business Services Authority Arden & Greater East Midlands Commissioning Support Unit
In addition, the clinical commissioning group has had a significant number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with Essex County Council, Braintree District Council, Chelmsford City Council and Maldon District Council.
During the year and in addition to the transactions reported in the remuneration report in the Annual Report, the following GP and other clinical leads had significant transactions with the clinical commissioning group in respect of their practice and private accounts. These transactions were in accordance with the usual arrangements with practices for the provision of services.
Payments to Receipts from Amounts owed to Amounts due from 2019-20 related party related party related party related party £000 £000 £000 £000
Beacon Health Group - Dr Caroline Dollery - Salaried GP 314 0 16 0 Beauchamp Surgery - Dr Ikechukwu Adiukwu - GP Partner 231 0 20 0 Coggeshall Surgery - Dr Anna Davey - GP Partner 78 0 18 0 Dengie Medical Partnership - Dr Julie McGeachy - GP Partner 72 0 8 0 Douglas Grove Surgery - Dr Fatai Salau - GP Partner 91 0 4 0 Whitley House Surgery - Dr Elizabeth Towers & Dr Hollie McNaughton-Garrett - GP Partners 173 0 20 0 959 0 86 0
Payments to Receipts from Amounts owed to Amounts due from 2018-19 related party related party related party related party £000 £000 £000 £000
Beacon Health Group - Dr Caroline Dollery - Salaried GP 203 0 57 0 Beauchamp Surgery - Dr Ikechukwu Adiukwu - GP Partner 93 0 29 0 Coggeshall Surgery - Dr Anna Davey - GP Partner 52 0 0 0 Dengie Medical Partnership - Dr Julie McGeachy - GP Partner 40 0 8 0 Douglas Grove Surgery - Dr Fatai Salau - GP Partner 49 0 3 0 Whitley House Surgery - Dr Elizabeth Towers & Dr Hollie McNaughton-Garrett - GP Partners 133 0 56 0 570 0 153 0
The clinical commissioning group also had transactions with the following organisations with whom decision makers of the clinical commissioning group have declared an interest:
Payments to Receipts from Amounts owed to Amounts due from 2019-20 related party related party related party related party £000 £000 £000 £000
Barking, Havering & Redbridge Hospitals NHS Trust - John Gilham - family friend is Chair and close family member is employee 1236 0 45 0 Basildon & Brentwood CCG - Dee Davey - Interim Chief Finance Officer, Anthony McKeever - Interim Joint Accountable Officer 115 0 0 48 Care UK Ltd - Caroline Rassell - spouse is employee 205 0 1 0 Castlepoint & Rochford CCG - Anthony McKeever - Interim Joint Accountable Officer 0 0 77 14 East of England Ambulance Service NHS Trust - Karl Edwards - Deputy Director of Service Delivery 16,668 0 60 0 Essex Partnership University NHS Foundation Trust - John Gilham - close family member is employee 28,862 0 1,564 0 Farleigh Hospice - Dr Donald McGeachy - Trustee 2,678 0 35 0 IC24 - Dr Ikechukwu Adiukwu - OOH GP 4,943 0 0 0 Norfolk & Suffolk NHS Foundation Trust - Daniel Dalton - Consultant Psychiatrist 20 0 4 0 North East London NHS Foundation Trust - John Gilham - family friend is Chair; Daniel Doherty - spouse is an employee 3033 0 50 0 Provide Community Interest Company - Daniel Doherty - Honorary clinical contract 35,505 (137) 264 0 Southend CCG - Anthony McKeever - Interim Joint Accountable Officer 117 0 73 13 Thurrock CCG - Anthony McKeever - Interim Joint Accountable Officer 117 0 0 15 93,499 (137) 2,173 90
Payments to Receipts from Amounts owed to Amounts due from 2018-19 related party related party related party related party £000 £000 £000 £000
Barking, Havering & Redbridge Hospitals NHS Trust - John Gilham - family friend is Chair 1,237 0 33 (137) Basildon & Brentwood CCG - Dee Davey - Interim Chief Finance Officer 77 (10) 0 (262) Care UK Ltd - Caroline Rassell - spouse is employee 435 0 71 0 East of England Ambulance Service NHS Trust - Karl Edwards - Deputy Director of Service Delivery 15,042 0 220 0 Essex Partnership University NHS Foundation Trust - John Gilham - close family member is employee 26,465 (496) 1,106 (496) Farleigh Hospice - Dr Donald McGeachy - Trustee 2,259 0 8 0 Hertfordshire Partnership University NHS Foundation Trust - Daniel Dalton - Clinical Director LD & Forensic Services (until Sept 2018) 5,087 0 223 0 IC24 - Dr Ikechukwu Adiukwu - OOH GP 346 0 2 (61) Norfolk & Suffolk NHS Foundation Trust - Daniel Dalton - Consultant Psychiatrist (from Sept 18) 16 0 0 (1) North East London NHS Foundation Trust - John Gilham - family friend is Chair; Daniel Doherty - spouse is an employee 2,805 0 74 0 Provide Community Interest Company - Daniel Doherty - Honorary clinical contract 34,574 0 3,015 0 88,343 (506) 4,752 (957)
26 NHS Mid Essex Clinical Commissioning Group - Annual Accounts 2019-20
20. Events after the end of the reporting period
During the last few weeks of 2019-20, all NHS organisations and system partners were required to begin to respond to the COVID-19 pandemic. The financial impact on the clinical commissioning group in 2019-20 was relatively limited and the clinical commissioning group has received funding to cover the additional costs. The impact on the clinical commissioning group's expenditure and financial arrangements will be significant in 2020-21, for example some payments to key service providers will be made at a national level rather than through the usual clinical commissioning group arrangements. The impact on local funding and expenditure plans will therefore need to be calculated and reflected. The clinical commissioning group is also incurring some unplanned expenditure in a number of service areas as part of the Mid and South Essex Health and Care Partnership's system-wide response to COVID-19. The clinical commissioning group expects to receive additional funding to cover additional expenditure.
21. Financial performance targets
NHS Clinical Commissioning Group have a number of financial duties under the NHS Act 2006 (as amended). NHS Clinical Commissioning Group performance against those duties was as follows:
2019-20 2019-20 2018-19 2018-19 Target Performance Target Performance
Expenditure not to exceed income 513,772 510,772 484,351 478,351
Revenue resource use does not exceed the amount specified in Directions 512,413 509,413 481,350 475,350
Revenue administration resource use does not exceed the amount specified in Directions 8,752 7,685 8,428 7,743
The difference between the target and performance for 2019-20 is the £3m surplus that was generated and reduced the carried forward cumulative deficit to £4,785k.
22. Losses and special payments
There were 3 losses and special payments in 2019-20 which were bad debts relating to continuing healthcare payments totalling £23k. These payments were provided for in 2018/19 as expected credit losses. There were no losses and special payments in 2018-19.
27 Mid Essex CCG Annual Report and Accounts 2019/20
Appendix A: Glossary of non-financial terms
Term Definition Care pathway The route that a patient will take from their first point of contact with an NHS or Social Services member of staff (usually their GP), through referral, to the completion of their treatment. Clinical Commissioning Formally established on 1 April 2013, Clinical Commissioning Group (CCG) Groups (CCGs) are statutory bodies responsible for commissioning most healthcare – planning, buying and monitoring services to meet the needs of their local communities. Civil Contingencies Act 2004 Provides a single framework for UK civil protection against any challenges to society – it focuses on local arrangements and emergency powers. Commissioning The process of planning, purchasing, monitoring and reviewing health and social services Community services Health or social care and services provided outside of hospital. They can be provided in a variety of settings including clinics and in people's homes. Community services include a wide range of services such as district nursing, health visiting services and specialist nursing services. Commissioning Support Units Commissioning Support Units provide capacity to clinical (CSU) commissioners as an extension of their local team to ensure that commissioning decisions are informed and processes structured. Enhanced services Enhanced services are: • essential or additional services delivered to a higher specified standard, for example, extended minor surgery • services not provided through essential or additional services They are services provided by GPs, over and above the core (essential and additional) services to their patients. Equality Delivery System The EDS2 has been designed nationally as an optional tool (EDS2) launched in 2011 to support NHS commissioners and providers to deliver better outcomes for patients and communities and better working environments for staff, which are personal, fair and diverse. The EDS2 is all about making positive differences to healthy living and working lives. 107
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Term Definition Equality Impact Assessment An equality impact assessment involves assessing the likely or (EIA) actual effects of policies or services on people in respect of disability, gender and racial equality. It helps us to make sure the needs of people are taken into account when we develop and implement a new policy or service or when we make a change to a current policy or service. NHS111 NHS 111 makes it easier for people to access local NHS healthcare services. People can call 111 when they need medical help fast but it is not a 999 emergency. NHS 111 is available 24 hours a day, 365 days a year. Calls are free from landlines and mobile phones. NHS Long Term Plan A document published by NHS England in January 2019 that sets the future direction of the NHS and the way services within it will work more closely with each other and partner organisations. Net internal area (NIA) The usable area within a building measured to the face of the internal finish of perimeter or party walls ignoring skirting boards, but excluding spaces such as toilets, lobbies, boiler rooms and tank rooms, stair wells, lift wells and columns. Palliative Care The total care of patients whose disease is incurable. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Place The NHS Long Term Plan sets out requirements to commission services across populations numbering up to about 450,000 – the “place” – in a way that addresses not just immediate health and care needs but underlying causes of health inequality too. Primary Care Network (PCN) A collaboration of GP practices in a distinct geographical area with a total patient population of between approximately 30,000 and 50,000, led by a nominated Clinical Director. PCNs are responsible under the NHS Long Term Plan for developing neighbourhood health and care services in the future. Primary Care Trust (PCT) Primary Care Trusts were abolished on 31 March 2013. Prior to that they were responsible for the planning and securing of health services and improving the health of the local population. Whole Time Equivalent The WTE is a workforce term. The WTE for each person is (WTE) based on their hours worked as a proportion of the contracted hours normally worked by a full-time employee in the post.
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Appendix B: Glossary of financial terms
Term Definition Administrative/admin costs Funding spent on the CCG’s operational costs.
Current Assets Assets held for less than one year that can be converted to cash such as stocks of consumables, monies held in the CCG’s bank account and the amount of money that is owed to the CCG by individuals or organisation. Capital Expenditure Items of expenditure that have a useful life of more than one year and are individually valued at £5k or more e.g. large pieces of equipment. It is possible to capitalise smaller items but they have to be over £250 in value and be interdependent. Capital expenditure purchases non-current assets (fixed assets) or adds to the value of an existing fixed asset. Capital Resource Limit The total amount of capital expenditure (see above for definition) that the CCG can incur in the financial year. The CCG has a duty to not spend above its allocated Capital Resource Limit. Cash Limit The Government sets the amount of cash which the CCG may spend during a given financial year – the Cash Limit (CL). The CCG must ensure that the net amount of cash flowing out of the CCG over the financial accounting period is not more than the CL. Depreciation The annual charge in relation to the utilisation/wearing out of non-current assets. The charge for the non-current assets is spread over the useful life. Financial Instrument A contract that gives rise to a financial asset of one entity and a financial liability of another entity e.g. cash and a contractual right to receive cash. Finance Lease An arrangement that transfers substantially all the risk and rewards related to ownership of an asset to the CCG although title may not have transferred.
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Term Definition General Fund The General Fund is similar to a Profit and Loss reserve, the operating cost of the CCG is charged here as well as an opposite entry for the Net Parliamentary Funding (amount of cash drawn down from the Department of Health). Intangible Assets An invisible or ‘soft’ asset that has been purchased using capital expenditure and has a real current market value and contributes to the (future) operation of the CCG e.g. IT software. IFRS – International Financial The principles-based standards, interpretations and Reporting Standards framework which govern the production of the CCG’s accounts. Impairment A decrease in the values of non-current assets compared to those values recorded on the Statement of Financial Position. A CCG is required to undertake routinely revaluation reviews of its fixed assets or undertake an impairment review when there is a decline in an asset’s value. The impairment (loss) is treated in the same way as depreciation, as a cost in the Statement of Comprehensive Net Expenditure (SCNE), if the change in the value of the asset is permanent. Losses and Special Payments Payments that Parliament would not have foreseen healthcare funds being spent on, for example fraudulent payments, personal injury payments or payments for legal compensation. Miscellaneous Income Income that the CCG receives over and above its revenue resource limit, e.g. room rental and training income. Net Cash Outflow from Operating This is the amount of cash actually paid out less Activities miscellaneous income actually received. It differs from the Net Operating Cost which includes non-cash items such as depreciation and movements in Debtors and Creditors. Net Parliamentary Funding This is the amount of cash drawn down by the CCG from the Department of Health for payments relating to commissioning services and running the CCG. Non-Current Assets Tangible assets that have been purchased using Capital Expenditure (see definition above). (Previously known as Fixed Assets). The CCG does not hold the leases for or own any buildings – all building assets are owned or leased by NHS Property Services. Programme costs Funding spent on healthcare commissioned by the CCG. Whole of Government Accounts A consolidated set of financial statements for the UK public (WGA) sector.
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We hope you have found this report of Our contact details are below. interest. If you have any comments or 01245 398750 questions about it, please get in touch. [email protected] midessexccg.nhs.uk/contact-us @midessexccg /CCGMidEssex NHS Mid Essex Clinical Commissioning Group Wren House Hedgerows Business Park Chelmsford Essex CM2 5PF
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