NHS Halton Clinical Commissioning Group Annual Report 2018/2019

NHS Halton Clinical Commissioning Group

Annual Report

2018/2019

CONTENT

PERFORMANCE REPORT 3 Performance overview 4 Performance analysis 22

ACCOUNTABILITY REPORT 74 Corporate Governance Report 74 Members Report 75 Statement of Accountable Officer’s Responsibilities 82 Governance Statement 84 Remuneration and Staff Report 130 Remuneration Report 130 Staff Report 138 Parliamentary Accountability and Audit Report 147

EXTERNAL AUDITORS OPINION 148

ANNUAL ACCOUNTS 153

PERFORMANCE REPORT

Andrew Davies Accountable Officer

28th May 2019

Performance overview

The purpose of this overview is to give readers information about who we are, what we do, our achievements this financial year and how well we’ve performed as well as our key risks and how we manage them:

Welcome to our Annual Report for the year 2018/2019.

The purpose of this Annual Report is to share with stakeholders how the organisation has discharged its functions in the financial year 2018/2019.

The report includes several key statements supporting the financial year-end reporting and the annual accounting requirements for the whole of the NHS and is subject to audit review.

Our financial accounts, which form part of this submission, have been prepared in accordance with the going concern principle as part of International Financial Reporting Standards. The Governance Statement included in this report sets out how we identify, manage and control risks such as assuring business continuity.

The past year has been incredibly busy, with several changes and challenges in addition to some significant things that we should be proud of and celebrate which we do so throughout this report.

This year has also been one of change. We have formalised our working with NHS Warrington Clinical Commissioning Group by creating a joint Management Team across both organisations. Following undertaking the role of Interim Clinical Chief Officer, Dr Andrew Davies was made substantive Clinical Chief Officer across both NHS Halton CCG and NHS Warrington Clinical Commissioning Group in March 2019.

In June 2018, Dr David Lyon, temporarily stepped away from the position of Chair due to a personal issue, which impacted on his ability to carry out the duties of Chair. We would like to formally record our thanks to Mr David Merrill, Vice Chair who took on the interim role of Chair in June 2018, taking responsibility for discharging the duties of Chair in the absence of Dr David Lyon. During the interim period Mrs Ingrid Fife, Vice Chair of the Audit Committee took over responsibility from Mr David Merrill as the Chair of the Audit Committee.

Following the resignation of Dr Lyon in March 2019, we are now working with the CCG membership to appoint a new substantive Chair.

During 2018/19, it was identified that work needed to be undertaken with regards to improving and strengthening internal governance considering several issues and challenges with regards to governance structures and members. In order to progress this, work the CCG has engaged the services of an associate from Mersey Internal Audit Agency (MIAA) to take forward a programme of work including a full review of all committee terms of reference, membership and attendance of members. Where there is national guidance in place for specific committees, all terms of reference are being cross referenced to ensure they fully reflect what is required. This work will continue through 2019/20 to ensure robust governance arrangements are in place.

Whilst this has been a challenging year, it has also been a year which has seen a number of key achievements which are highlighted in this report, including NHS Halton CCG being chosen by NHS England as one of only 14 CCGs nationally to run a new Targeted Lung Health Check programme. Another success to celebrate is Well Halton, which won the Partnerships in Innovation Award for the second year running at the North West Coast Research and Innovation Awards 2019. We lead Well Halton and we have adopted an approach of wide and inclusive partnership across multiple sectors. Our range of partners includes Widnes Vikings Rugby Team, The Science and Technology Facilities Council, Runcorn Shopping Centre, Runcorn Veterans Association and many others.

A new Primary Care Dermatology Lesion Service was commissioned and has seen real benefits and improved outcomes for local people. The service, which was co-designed and launched by local GPs, in partnership with us is based in both Widnes and Runcorn and has created 120 additional appointments for routine queries every month. The service has resulted in a significant reduction in waiting times from around 16 – 18 weeks to just three weeks or less and only 3% of patients seen are then referred to secondary care. Patient experience has been radically improved with 100% patients telling us they would use service again and 100% of patients would recommend the service.

Another major highlight of the year was the celebrations for the NHS’ 70th birthday in July.

This signification milestone gave us a chance to reflect on our achievements of the health service nationally and locally.

We are sure you’ll agree that despite its many challenges, we are very lucky to have a health service that 70 years on provides help to all, regardless of wealth or status.

Finally, enjoy reading the review of the year and a date for your diary – our Annual General Meeting on 5th September 2019.

Dr Andrew Davies David Merrill Clinical Chief Officer Chair

Our performance against the NHS England Constitution The NHS Constitution establishes the principles and values of the NHS in England. It sets out rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieve, together with responsibilities, which the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively. Within Section 3a of the NHS Constitution there are certain rights and pledges regarding access to services and respect/confidentially.

The actual performance against each individual indicator can be seen in the dashboard, which can be accessed here. In summary of the total 24 rights and pledges included within the NHS Constitution:

• Both of the two NHS Constitution Rights were not achieved

• 12 of the NHS Constitution Pledges were achieved • 8 of the NHS Constitution Pledges were not achieved

• One of the cancer waiting times indicators does not have a specific target and the cancelled operations data reflects the number treated within 28 days not the number offered treatment within 28 day (which is the NHS Constitutional requirement). These are therefore not rated

Our joint Management Team structure

Our objectives Objective one: To commission services which continually improve the health and wellbeing of Halton residents

Objective Two: Continually improve the quality of the services we commission ensuring compliance with NHS constitutional requirements

Objective Three: To deliver our statutory duties in respect of commissioning, quality, equality, safeguarding, engagement, consultation, and finance including QIPP

Objective Four: To create a high performing organisation that seeks to create excellence in its skill base enabling the building of effective partnerships with our staff and key stakeholders.

Our commissioning priorities 2018/2019 Our Commissioning Plan details our priorities, aligned to the requirements of the Five Year Forward View, and local challenges and opportunities. Building upon firm foundations of Primary Care and Community provision, the delivery of the five Change Programmes will bring about the positive impact needed in terms of use of elective, non-elective and specialised services:

Fulfilling our duties…real engagement We continue to fulfil our statutory duties and strive to make real differences in the way that the people of Halton access health and social care working, collaboratively with partners and providers.

During 2018/2019, we have strengthened our engagement capabilities with increased focus on ensuring that our patients are at the heart of our decision making. We held eight public Health Forums throughout the year which attracted members of the public, provider organisations and other professionals and our Annual General Meeting was delivered in September 2018 at the Halton Stadium. We led the consultation events relating to the closure of the Hale Village Branch Surgery and, in December 2018, we launched the public engagement into the future development of the Urgent Treatment Centres. We have worked collaboratively with partners to develop our priorities for 2019/2020.

More information can be found under the engaging people and communities’ section on page 59.

Improving Primary Care During 2018/2019, we have continued to work with our fourteen GP practices, two GP Federations and two emerging Primary Care Networks in order to support the continuous improvement of Primary Care Services.

The work undertaken supports our:

• Statutory duty to improve the quality of services provided by local GP practices • Responsibilities contained with the delegation agreement, which allow us to commission General Practice services locally and; • Transformation agenda, as detailed within the national GP Five Year Forward View, which aims to improve the sustainability and resilience of general practice

Specific developments to note include:

Improving Patient Access Evening and weekend GP services continue to be available with a GP, Advanced Nurse Practitioner or Health Care Assistant. The service is available from 6.30pm to 9.00pm on weekday evenings and 9.00am to 3.30pm at the weekend. The service offers routine appointments that are booked via the patient’s own practice during the week. At the weekend, patients can phone the service for an appointment. Over 2018, the use of these appointments by patients has increased from 62% utilisation in April 2018 to 80% in December 2018.

A comprehensive review of current practice telephone hardware and processes was undertaken

9 with the introduction of call recording software across nine practices. Following this review, we have invested in new hardware to support practices to better deal with increasing telephony demands during peak periods.

Eight practices also offer on-line consultations. Via the practice website patients respond to a series of questions relating to their condition. A GP at the practice reviews the patients email and replies within 48 hours with advice and treatment options. It is hoped that all practices will soon offer online consultations.

During 2018, Care Navigation was introduced into all Halton practices. Whilst reception staff have historically signposted patients to the most appropriate service, the introduction of a standardised approach across all practices ensures consistency for our patients. Reception staff, who have received extensive training in Care Navigation, can direct a patient to the person who would be most suitable to help them, which may not always be the GP. The aim is to reduce the amount of time it takes for patients to access the right help for their condition and to support patients to make informed decisions by providing more information about local health and wellbeing services. It is hoped that this service will help to reduce the overall waiting times for patients to see their GP or Nurse.

Improving how services work together Following the alignment of practices to specific Care Homes, there has been an increase in the number of patients who reside in a Care Home and choose to register with the aligned GP practice. Practices continue to offer regular ward rounds, proactive care to patients and are developing how they work with the Care Homes to provide medical care when required.

During 2018, two Primary Care Networks were established - one in Runcorn (which includes the six Runcorn practices) and one in Widnes (which includes the eight Widnes practices.) The role of Primary Care Networks is to support the resilience and sustainability of General Practice and to integrate General Practice with the wider health and social care workforce. This aims to deliver holistic, proactive care tailored to the needs of the population. Both the Runcorn and Widnes Primary Care Networks have been successful in accessing funding from NHS England to deliver key areas of work which focus on improving care to patients.

Improving General Medical Services Nine Halton GP practices successfully completed the Productive General Practice (PGP) programme last year. PGP is a hands on, practical support package for practices, delivered in practice by a team of experts. The main aim is to help staff to improve their work processes, increasing efficiency and releasing time to devote to improving patient care, experience and staff 10 wellbeing. Practices also increased their quality improvement skills. It is planned to build on this successful programme during 2019/2020.

Quality, contracting and transformation visits continue to be held with all GP practices in Halton. To support this programme, a dashboard has been developed that provides practices with a view of the care delivered across several key indicators, allowing comparisons between practices and the identification of areas of good practice or where improvement is required. It is anticipated that this will help reduce variation in care.

Improving the use of information and technology Practices have reviewed their correspondence management processes and received upgraded software to facilitate more effective management and clinical coding of incoming documentation. This increases the availability of documentation which improves the quality of care for patients. The use of IT systems to support an integrated health record have also been developed. For example, clinicians across General Practice and Community Services, who have a legitimate relationship with a patient, can record and view a patient’s care in the same clinical record. This reduces the need for patients to repeat their concerns to several health practitioners and allows more timely, informed and accurate decisions to support patient care.

NHS patient Wi-Fi is now available across all of Halton’s Primary Care locations. This allows patients to access health information, via the internet, within practice locations on their mobile devices. This development is not only positive for the short term but opens future possibilities of clinically prescribed applications, telehealth and assistive technologies which can support patients to manage their conditions and access health advice when required.

Managing performance We continue to operate a robust regime of performance monitoring and management that includes committees for Performance and Finance, Quality and Primary Care Commissioning.

We have a well-established Programme Management Office which supports and co-ordinates commissioning intentions from inception through planning, implementation and review, ensuring that there is appropriate clinical, financial and performance oversight throughout.

There are also regular provider, NHS England and Halton Borough Council review and assurance meetings. This combination is the Assurance Framework we adopted with regards to performance management.

2018/2019, as in 2017/2018, has been financially and operationally challenging. The CCG’s NHS Improvement and Assessment Framework rating for 2017/2018 was ‘requires improvement’. We await the updated outcome in July.

However, against this background, we are proud to say that we have continued to successfully deliver against many of our objectives.

Whilst a great deal of focus and effort has been placed on delivering national and local targets, as has been seen nationally, the urgent care system in Halton has continued to be under significant pressure.

We play a key role in the Mid Mersey A&E Delivery Board and continue to work collaboratively with our main providers and partners to support the effective delivery of urgent and emergency care.

Looking to 2019/2020, we will continue to work with our providers and partners to achieve long term clinical and financial stability for the Halton health economy. A key focus for the next 12 months will be the development of a closer working relationship with NHS Warrington Clinical Commissioning Group, the implementation of the transition year priorities in the NHS England long term plan and the delivery of the local Halton priorities centred around frailty and falls, ambulatory care sensitive conditions, workforce and estates development and public health improvement.

Delivering on our Strategic Commissioning Plans With the backing of an incredibly dedicated support team and a strong clinical leadership, we continue to successfully deliver against our strategic commissioning plans. For 2018/2019, plans were built around five key change programmes, all of which were supported by our vision and values, with the focus on developing an out of hospital care model. Our plans for 2018/2019 can be viewed by clicking here.

Delivering Quality, Improvement, Productivity and Prevention Supported by our member practices, we developed our Quality, Improvement, Productivity and Prevention (QIPP) programme that totalled £5.64 million in 2018/2019.

Financial Performance Clinical Commissioning Groups have a statutory duty to spend within their allocated budget, referred to as delivering operational financial balance. As at 31st March 2019, we achieved financial balance along with the other required financial duties and has applied its resources effectively.

The reported financial position at 31st March 2019 is a break-even position in year consistent with the agreed NHS England control total for 2018/2019. The cumulative brought forward deficit position is maintained at £11.2m.

Statutory duties We are committed to fulfilling our statutory duties. Within this annual report there is a particular focus on demonstrating how we meet the following duties: a) Duty to improve the quality of services (Section 14R of Health and Social Care Act 2012 (HSCA) b) Duty to reduce inequalities (Section 14T of HSCA 2012) c) Public involvement and consultation by clinical commissioning groups (Section 14Z2 of HSCA) d) Contribution to the delivery of the Joint Health and Wellbeing Strategy e) Duty to be prepared for dealing with relevant emergencies (Sections 46 and 47 of HSCA) f) Sustainable development

We are confident that we meet our statutory duties in respect of the above, and this report provides details of the governance structures, strategies and plans, partnership and joint working arrangements, engagement and participation mechanisms, roles and responsibilities, service delivery and other initiatives, monitoring, reporting and accountability in place.

Working with partners – contributing to joint strategies We continue to be an active member of the Halton Health and Wellbeing Board, the Executive Partnership Board, the Halton Health Policy and Performance Board and various other forums and sub-groups to take forward the One Halton Health and Wellbeing Strategy.

In addition, we have, and continue to, play a lead and active part in the One Halton place-based transformation programme. Our Chief Commissioner is the programme director and is a member of the Health and Wellbeing Board alongside our senior officers and senior officers at the Local Authority, provider organisations, the Federations (Primary Care Networks) and third sector representatives. During 2018/19, we continue to make a significant contribution to the Health and

Care Partnership for Cheshire and Merseyside, with our Clinical Chief Officer taking the lead for the Urgent and Emergency Care programme. In addition, other Senior members of the Integrated Management team taking an active role in other key workstreams such as the Prevention Board, Palliative Care Board, CVD and the Communications and Engagement group.

Whilst there have been various small governance reviews on elements of the Board’s activities, particularly considering a 2018/2019 CQC action plan, it was felt there was a need for a facilitated 13

development day as in the past two years the health and social care landscape has changed considerably.

It was therefore agreed that the Health and Wellbeing Board (HWBB) would take some time out to review their evolving role, refresh terms of reference and membership and look at a performance dashboard.

On the 16th January 2019 a development session was held, facilitated by the Advancing Quality Alliance.

The development session focussed on:

• Describing factors in the current context that have an impact on what the HWBB is trying to do • Assessed how its performing and identified areas for improvement • Agreed priority areas of change that will improve performance • Agreed specific changes that members of the HWBB will make and; • Identified actions needed to take to implement them

The session was delivered in the context of the HWBB’s priorities for 2017 to 2022 as previously agreed in the One Halton Health and Wellbeing Strategy:

• Children and Young People: Improved levels of early child development • Generally, Well: Increased levels of physical activity and healthy eating and reduction in harm from alcohol • Long-term Conditions: Reduction in levels of heart disease and stroke • Mental Health: Improved prevention, early detection and treatment • Cancer: Reduced level of premature death; • Older People: Improved quality of life

In addition, the Health and Wellbeing Board have been instrumental in the One Halton Population Health Framework. This Framework was developed in conjunction with us, the Cheshire and Merseyside Health and Care Partnership Prevention Board, Public Health England, Halton Borough Council, NHS providers, the voluntary sector and third sector to seek support in the delivery of the prevention challenge.

Traditionally, efficiencies have been delivered through improved delivery of care but meeting the current goals of saving lives, reducing morbidity, improving quality, being more cost effective and reducing inequalities requires a new solution and a focus on stemming demand through delaying or preventing the onset of need.

This Population Health Framework sets out evidence-based guidelines partners can use to create a transformational and sustainable shift in the health and wellbeing of the Cheshire and Merseyside population.

This approach promotes the integration of health, mental health and social care services, the development of multidisciplinary and multisector teams working together to improve population health. This includes individual care management, the mobilisation of community assets, committing to integrated care models and making every contact count across sectors, as well as population level interventions such as access to employment and workplace health and education.

In support of this approach the Prevention Framework provides practical guidelines and the opportunity to self-assess and review against them for each place-based care system working on population health with:

• Local system leaders • Local communities • General Practices or Primary Care Hubs • Local tertiary and acute providers

The Executive Partnership Board The Executive Partnership Board (EPB) is responsible for the development and implementation of the Joint Working Agreement and the integrated Joint Health and Social Care Commissioning across the NHS and Local Authority in Halton:

• The role of the EPB is to determine the strategic direction and policy for the provision of services to those with identified care and support needs to improve quality, productivity and prevention • Promote inter-agency cooperation, via appropriate joint working agreements/ arrangements, to encourage and help develop effective working relationships between different services and agencies, based on mutual understanding and trust • Review all budgets, including the Better Care Fund, associated with the running of the Services supporting those with identified care and support needs, ensuring financial probity • Drive forward the continued implementation of achieving a whole system coordinated approach, including the strategic aims outlined in Halton’s Better Care Plan by overseeing the associated work of Partner organisations, monitoring performance, reviewing and evaluating services and taking assertive action where performance is not satisfactory

Halton Health Policy and Performance Board We adhere to the rights and pledges to patient involvement protected in the NHS Constitution and we are also guided by the additional duties that CCGs have a mandate to deliver, these being:

• To involve people in the commissioning arrangements relating to the planning, provision and delivery of NHS services (14Z2 of the Health and Social Care Act 2012)

• The legal duty to consult Local Authority Overview and Scrutiny Committees on substantial developments or variations in the provision of services

Our Chief Clinical Officer and the Chief Commissioner attends each Halton Health Policy and Performance Board to present key updates and developments.

Equality, diversity and human rights obligations Promoting equality is at the heart of our core values, ensuring that we commission services fairly and that no community or group is not involved and engaged in the changes that will be made to health services to meet the challenges the NHS faces, as outlined in the Five Year Forward View.

We will continue to work internally, and in partnership with our providers, community and voluntary sector and other key organisations to ensure that we advance equality of opportunity and meet the exacting requirements of the Equality Act 2010.

We facilitate an Engagement and Involvement Group and this group has representation from the community to discuss a range of our initiatives. This group strengthens our model for engagement, involvement and consultation, and provides a more robust scrutiny of our work and management of risks.

Due regard to the Equality Act 2010 We are required to pay due regard to the Public Sector Equality Duty (PSED) as defined by the Equality Act 2010. Failure to comply has legal, financial and reputational risks.

The key functions that enable us to make commissioning decisions, and monitor the performance of their providers, must demonstrate (in an auditable manner) that the needs of protected groups have been considered in:

• Commissioning processes • Consultation and engagement • Procurement functions • Contract specifications • Quality contract and performance schedules • Governance systems

The Equality Act requires us to meet our Public Sector Equality Duty across a range of protected characteristics, including age, gender, race, sexual orientation, religion/belief, marital/civil partnership status and pregnancy/maternity status.

“Due regard” is a legal requirement and means that the decision makers of the CCG has to give advanced consideration (consider the equality implications of a proposal before a decision has been made) to issues of ‘equality and discrimination’ before making any commissioning decision or policy that may affect or impact on people who share protected characteristics. It is vitally important to consider equality implications as an integral part of the work and activities that the CCG does, particularly during these difficult and challenging times.

We continue to carry out Equality Analysis reports – commonly known as Equality Impact Assessments (EIAs). These reports test the proposal and say whether it meets PSED and ultimately complies with the Equality Act 2010. Failure to carry out EIAs would be grounds for Judicial Review and may widen health inequalities.

We are becoming stronger at developing and delivering Equality Analysis reports and linking them to the current change programmes however there is still progress to be made. All staff are aware of the support mechanisms in place to help them and the organisation to develop and deliver timely and accurate reports.

Equality Delivery Systems 2 We adopted the Equality Delivery System (EDS2) toolkit as its performance toolkit to support the NHS England Assurance process on equality and diversity. Our performance and grades have progressed incrementally over the last six years to ‘achieving’ status across twelve outcome areas and ‘developing’ status across all other outcomes. Caution should always apply to performance managing equality performance as health inequalities across the north of England are poor and PSED is an anticipatory duty and always applies to us as and when we make commissioning decisions that impact on patients.

We have led on implementing EDS 2 across Merseyside. All Merseyside Clinical Commissioning Groups and all the main NHS providers who operate within the sub region have worked collaboratively to implement the toolkit in an innovative and integrated way across the area. Over the last 17 months all partners have worked closely with a range of stakeholders who represent the interests of people who share protected characteristics at a national, regional and local level to ensure that Merseyside identifies ‘barriers’ that impact on access and unequal outcomes and is able to address and mitigate these collectively across the area via the development of revised and integrated equality objectives

Equality objectives As a direct result of the EDS2 collaborative outlined above, we have significantly revised their equality objectives plan 2019 to 2023. This was approved by the quality committee and the Governing Body.

Our equality objectives are to:

• Make fair and transparent commissioning decisions. • Improve access and outcomes for patients and communities who experience disadvantage. • Improve the equality performance of our providers through robust monitoring and collaboration. • Empower and engage our workforce.

Key progress and highlights against our Equality Objectives over the past year include:

• Continuing to monitor Equality and Diversity compliance across all key NHS providers through the quality contract schedule. • The duty to carry out Reasonable Adjustments (Equality Act 2010) to support better access and outcomes for disabled people and frail elderly is often misunderstood and is also being addressed via contract monitoring and collaborative work between providers of secondary and community services and primary care. A task and finish group across the collaborative is developing a Merseyside wide action plan for implementation • The development of local Translation and Interpretation Quality Standards to remove variation and poor outcomes for people whose first language is not English or people who communicate via British Sign Language etc. These standards will be incorporated into NHS secondary and community care provider contracts during 2019. The standards are currently being consulted on by key community stakeholders and other key parties including NHS England • An equality information and communication strategy has been drafted to specifically support Halton GPs to implement Translation and Interpretation best practice standards, Accessible Information Standards and Reasonable Adjustments. The strategy has been welcomed and agreed in Primary Care Committee and welcomed in the Practice Managers forum • Merseyside CCGs are working closely with NHS providers on improving transparency and decision- making during the unprecedented financial and demographic challenges faced by the NHS. There has never been more pressure on the system to change and adapt and it’s important that ‘due regard’ is given to the Public Sector Equality Duty (PSED) and the duty to reduce health inequalities is met • The development of a Transgender pathway via the Cheshire Merseyside Gender Identify Collaborative (CMAGIC). CMAGIC is a multifaceted collaboration between clinicians and patients involved in the support and care of Transgender individuals within the Cheshire and Mersey area, established by NHS South Sefton CCG and NHS Southport and Formby CCG. The pathway is currently being considered as a national pilot by NHS England and a bid to extend the pathway across the Cheshire & Merseyside Health and Care Partnership is supported by Chief Executive Officers 18

from all Merseyside CCGs and from Mersey Care NHS Foundation Trust and Wirral University Teaching Hospital NHS Foundation Trust. The bid is due to be considered by the Cheshire and Merseyside Health and Care Partnership in the summer of 2019 • A deaf access engagement event organised by NHS Liverpool CCG’s engagement team highlighted a range of issues and poor outcomes for people not being able to move smoothly from one service to another across physical health and mental health services. NHS Halton CCG has adopted a Merseyside wide strategic plan to improve access to health services for D/deaf people across Merseyside and all CCGs and providers are reporting progress regularly • The link between the lack of cultural sensitivity/understanding diversity and the impact this has on patient safety and experience has been explored over the year and a range of work streams have been developed to improve outcomes • Our Equality and Inclusion specialist continues to work closely with Black Asian and Minority Ethnic (BAME) communities via the Merseyside wide meeting to ensure the service is supporting access and outcomes for the BAME population

Provider performance We work closely with our providers to improve equality performance on access and outcomes for protected groups through robust contract monitoring, via the quality contract schedule.

Key areas of focus include:

• Information standards, including reasonable adjustments are implemented and meet the needs of our disabled community • Decision making across trusts pays ‘due regard’ to our Public Sector Equality Duty prior to decisions being made • Ensuring specific duties are met

Our staff We have duties to meet under the Equality Act 2010 in relation to workforce and organisational development. We take positive steps to ensure that our policies deal with equality implications around recruitment and selection, pay and benefits, flexible working hours, training and development, policies around managing employees and protecting employees from harassment, victimisation and discrimination. It is mandatory for all our staff to complete equality training and, in addition, we have a workforce equality plan, which has contributed to us paying due regard to our Workforce Race Equality Standard. We implemented a Transgender Employment Policy, which aims to ensure that the provision for transgender people is responsive to individual need, is prejudice free and challenges any discrimination individuals may experience.

As a direct result of our WRES and EDS 2 work, our commissioner and provider collaborative are working with staff from our BAME backgrounds on developing a number of positive action programmes, including extending existing staff support networks in Merseyside for CCG and NHS Providers across the borough.

Legal requirements The Equality Act 2010 (applies to all organisations within the UK) makes it unlawful to discriminate, harass or victimise people because of a reason related to their protected characteristic. Public Sector Equality Duty 2011 (PSED section 149 of the Equality Act 2010 (applies to Public Bodies and bodies delivering public services).

Organisations in the exercise of their functions must have due regard to the duty to:

• Eliminate unlawful discrimination, harassment, victimisation and other prohibited conduct • Advance equality of opportunity between people who share a protected characteristic and those who do not • Foster good relations between people who share a protected characteristic and those that do not

The Human Rights Act 1998 (applies to all organisations within the UK)

The Health and Social Care Act (2012) 14T duties as to reducing inequalities Each Clinical Commissioning Group, must in the exercise of its functions, have due regard to the need to: a) Reduce inequalities between patients with respect to their ability to access health services and; b) Reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services

The Health and Social Care Act (2012) 1422 Public involvement and consultation The Clinical Commissioning Group must make arrangements to secure that individuals to whom the services are being or may be provided are involved (whether by being consulted or provided with information or in other ways): a) in the planning of the commissioning arrangements by the group b) in the development and consideration of proposals by the group for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them c) In decisions of the group affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact.

NHS mandated requirements The Equality Delivery System (EDS 2) (applies to commissioners and providers). Requirements are in four key areas: Better Health Outcomes, Improved patient access and Experience, A representative and Supported Workforce and Inclusive Leadership.

The Workforce Race Equality Standard (WRES) (applies to commissioners and providers) Requirements to collect and publish workforce and workforce training data.

The Workforce Disability Equality Standard (WDES 2018 onwards) (applies to commissioners and providers) Requirements to collect and publish workforce and workforce training data.

The Accessible Information standard (AIS) {applies to commissioners and providers) Requirements to collect information about accessible information needs and produce information in accessible formats.

The NHS Standard Contract 2018/2019 and Service Conditions 2018/2019

• Section SC12 Communicating with and Involving Service Users, Public and Staff (provider compliance with the AIS) • Section SC13 Equity of Access Equality and Non- Discrimination (Provider compliance with EDS, WRES & WOES) • Section SC14 Pastoral, Spiritual and Cultural Care (provider compliance with religious, pastoral and cultural needs of service users)

Places a requirement on commissioners to evaluate the ability of providers to be compliant with all the above duties at Invitation to Tender (ITT) stage and a duty to evaluate compliance throughout the life of the contract and Places a duty on the provider to be compliant and produce annual monitoring reports.

Key issues and risks Our high rated risk this year is as follows:

• As a result of the number of serious incidents reported involving spinal surgery in the service, long waiting times within the service, non - compliance with NICE guidance for spinal injections resulted in voluntary suspension of complex spinal surgery and the receipt of a notification to suspend all surgery on the grounds of patient safety.

Additional information about our risks, together with the mitigating actions we are taking to address these can be found from page 89.

Performance analysis Performance and discharge of duties The Five Year Forward View, NHS Operational Planning and Contracting Guidance, and the Cheshire and Merseyside Healthcare Partnership (formally STPs) are all driven by the pursuit of the “triple aim”: (i) improving the health and wellbeing of the whole population; (ii) better quality for all patients, through care redesign; and (iii) better value for taxpayers in a financially sustainable system.

NHS England’s CCG Improvement and Assessment Framework (IAF) was introduced in 2016/2017 and aligns key objectives and priorities, informing the way NHS England manages its relationships with CCGs.

The framework is intended as a focal point for joint work, support and dialogue between NHS England, CCGs and Cheshire and Merseyside Healthcare Partnership. Data is available at least quarterly for nearly all the indicators, which enables everyone to see, in-year, what is working well and what is off-track. NHS England’s national and regional teams are working together to ensure that the breadth of the framework is discussed with all CCGs during the year, through a rolling programme of local conversations, drawing on expertise and insight from the national programme teams.

Our latest IAF position is available here.

The Assurance Framework assesses each CCG into one of four categories dependent on the results of the metrics within the framework; the four categories are ‘outstanding’, ‘good’, ’requires improvement’ and ‘inadequate’

In 2018, we received a ‘requires improvement’ assessment based on 2017/2018 results. We await the new outcome in July 2019.

The Framework covers indicators located in four domains and six clinical priority areas:

• Better health: This looks at how we are contributing towards improving the health and wellbeing of our population and bending the demand curve • Better care: This principally focuses on care redesign, performance of constitutional standards and outcomes, including important clinical areas • Sustainability: This section looks at how we are remaining in financial balance and is securing good value for patients and the public from the money we spend

• Leadership: This domain assesses the quality of our leadership, the quality of our plans, how we work with partners and the governance arrangements that we have in place to ensure we act with probity, for example in managing conflicts of interest

Clinical Priority Area assessment

Area IAF assessment

Learning Disability Requires improvement

Diabetes Requires improvement

Mental Health Good

Dementia Good

Cancer Requires improvement

Maternity Requires improvement

Moving forward, to address our IAF assessments our PPGplus and Halton’s Peoples Health Forum will be working with us to discuss, and where required action, the requires improvement rating for diabetes and cancer. For more information about how we work with our patients to improve our work, please see page 60.

We regularly report and publish performance against indicators included in the IAF and use this information to contribute to the development to the priority’s areas for 2019/2020.

As required by NHS England, we use the NHS Standard Contract for all contracts for healthcare services. We performance monitor all our providers of NHS Funded Healthcare in line with the terms and conditions of the NHS Standard Contract and apply all financial adjustments in relation to breaches of the contract. Each provider is subject to regular reviews through regular dialogue including, but not limited to, more formal Contract Review meetings and Clinical Quality Focus groups.

Our Performance and Contracting Team compiles formal reports based on intelligence received from formal contract monitoring and from national evidence sources. These reports are then presented to and discussed at the Performance and Finance Committee, the Quality Committee and the Governing Body, detailing:

• A performance summary: This is a monthly summary of our key performance indicators 23

• A summary demonstrating whether patients are getting good quality care • Details of whether patients’ rights under the NHS Constitution are being met • A summary indicating whether health outcomes are improving for the Halton population • Whether we are performing within its financial allocation • Performance indicators from the local quality schedules within our contracts with providers

Performance summary of our main providers 2018/2019

Warrington and Halton Hospitals NHS Foundation Trust – Acute provider Achievements against • Aggregate 18 weeks referral to treatment*(see note below) Standards • Quarterly cancer waiting times (Excluding 14-day Breast Symptomatic) Q1 and Q2 • 52-week referral to treatment

Non-achievements against • Six week waits for diagnostic Tests (April – July) Achieved standards from August onwards. • Health care acquired infections o 1 MRSA hospital acquired breach in December 2018 (Note: This was not a Halton patient) • Mixed sex accommodation - NHS Standard Contract Conditions/Sanctions applied o 91 breaches reported April – January 2019 • Accident and Emergency Performance at constitutional level – NHS Standard Contract Conditions/Sanctions applied o Monthly non-achievement of 95% threshold. Range of performance in year 73.1% - 89.4% April – December 2018F • Ambulance handovers – NHS Standard Contract Conditions/Sanctions applied o Approximately 1,450 breaches of the >30 minutes handover threshold April – December 2018 o Approximately 553 breaches of the >60 minutes handover threshold April – December 2018 • Quarterly cancer waiting times – 14-day Breast Symptomic Q1

Service Suspension • Spinal surgery service

o Service suspended September 2017. Patients transferred to alternative providers Suspension remains in place as at March 2019.

Performance notices • Accident and Emergency performance (Remains open in 2015/2016 2018/19 as action plan requirements not met)

Next steps for 2019/2020 • Continued development and implementation of workplans through the Collaborative Sustainability Meeting which was established in 2018/2019 to extend a collaborative approach for the local healthcare system. *It should be noted that whilst Warrington and Halton Hospitals NHS Foundation Trust are achieving the 18-week Referral to Treatment target as a Trust, there are a small number of breaches which have affected Halton patients, as such the standard for Halton patients attending Warrington and Halton Hospitals NHS Foundation Trust falls just below the national standard. (91.8% against a target of 92%)

St Helens & Knowsley Hospitals NHS Trust – Acute provider YTD position as at November 2018 Achievements against Standards • Cancer 31-day wait from diagnosis to treatment (98% v target of 96%) • Cancer 62-day wait from referral to treatment (88.9% v target of 85%) • 52-Week treatment breaches – none. • More than a 6-week wait for a diagnostic test (0.2% v target of 1%) • C-difficile infections (plan 29, actual 20)

Non-achievements against • Cancer 2-week wait from referral to first standards consultation (90.8% v target 93%) • MRSA infections (plan 0, actual 1) • A&E 4-hour waiting time (75.7%)

Performance notes • The introduction of a new patient recording system by the trust has led to a significant delay in Referral to Treatment data being made available to all CCG’s. This was only made available from December 2018 • Following an increase in the number of short stay emergency admissions the Mid Mersey CCG’s commissioned an audit to identify the causes, the

results of this audit may require changes to be made in the Trusts reporting of this activity

Performance notices • No formal performance notices were issued during 2018/20

Next steps for 2019/2020 • We introduced a local lesion service which will reduce the number of dermatology referrals to the

trust (Dermatology cases made up 50% of cancer 2-week wait breaches) this will free up capacity in the trust to see patients sooner

• The Mid Mersey CCG’s and the Trust will work towards an agreement on the delivery of short stay admissions based on the finding of the MIAA audit

• We will work together with the Trust to develop a collective plan for activity provision at the Trust

North West Boroughs Healthcare NHS Foundation Trust – Mental health provider (as at November 2018)

Achievements against standards • IAPT access standards (4.8% v target 4.8% • IAPT 6 week waiting time standards (97% v target 83.3%) • IAPT 18-week waiting time standard (100% v target 95%) Psychosis treatment waiting times (85.6% v target 76.9%) Non-achievements against standards • IAPT recovery rate (48.6% v target 50%)

Performance notices 2018/2019 • No formal performance notices were issued during 2018/2019

North West Ambulance Service (NWAS) NHS Trust Ambulance response During 2017, NHS England announced new ambulance service standards programme as part of the Ambulance Response Programme (ARP) which went live implementation with the new standards in the North West in August 2017.

A targeted training programme for NWAS dispatchers, clinicians and managers in emergency operation centres ensured staff were prepared to effectively implement the Programme.

The new standards are designed to change the rules so that ambulance service targets are met by doing the right thing for the patient.

Under previous targets, life-threatening and emergency calls should have been responded to in eight minutes, which often more than one vehicle was sent to have the best chance of meeting the eight-minute target. By changing this target to focus on sending the right response, more vehicles and staff are free to get to emergencies.

Ambulance service demand has increased by about 6% year on year. The new system enables ambulance services to be much more stable and able to deal with unexpected events and peaks in demand. ARP will make sure the best, most appropriate response is provided to patients, first time.

The aim of the ARP Programme is to improve patient care and survival. ARP is the result of the largest study of an ambulance system ever completed, anywhere in the world. More than 14 million ambulance calls were monitored as part of a trial, with no patient safety concerns.

NWAS covers a large, geographically diverse area and issues affecting performance are often geography specific. The narrative below refers to the NWAS performance in the Cheshire, Merseyside and Halton regions:

• Looking at the year to date position in Halton the average response time for the most urgent calls is eight minutes 41 seconds against

a standard of seven minutes. This has improved over the course of 2018/2019 and further improvements are planned. The average response time in Halton is almost one minute slower than the Cheshire and Mersey average. However, this average is heavily influenced by the large activity volume in Liverpool which has generally a much better response time performance due to its built- up geography. Although the average response time has been missed, the C1 90th percentile to the year is being achieved (90% of ambulances arrive within 15 minutes for the most urgent calls)

• The C2 mean is showing as 25 minutes against a standard of 18 and although missing the standard is the second best performing in Cheshire and Merseyside (after Liverpool)

• The C3 90th Percentile is being missed significantly in Cheshire and Mersey, by almost an hour although the C4 (least urgent) 90th percentile at 3hours 17 minutes is almost at the target of three hours. In Halton, this standard is being achieved with 90% of ambulances arriving at a category 4 call in two hours 59 minutes or less

• The data shows variance across the patch for C1 calls and there have been significant performance gains on C2. There have been marginal changes to the C3 mean, likewise the 90th percentile has not really changed on the previous year. On the A&E figures, there have been 6.5% fewer ambulance conveyances, 4313 less compared December 2017 to 2018

• The data suggests that performance is 6.5 minutes better at an NWAS level compared to December 17 and there have been significantly fewer handover delays. In terms of ARP, there has been really strong performance comparing December 2017 to December 2018

NWAS are continually striving to improve performance and meet the ARP standards. During the next financial year, NWAS will continue to make

29 further changes in control processes and incremental roster changes possible real performance gain.

A summary of the most recent available data for the month of December 2018 and year to date:

Category 1 Category 2 Cat 3 Cat 4

Mean 90th Mean 90th 90th 90th Centile Centile Centile Centile

Target 7 mins 15 mins 18 mins 40 mins 2 hours 3 hours

Dec 18 09:03 16:05 24:52 48:12 02:34:08 02:56:15

18/19 08:41 14:55 24:54 50:25 02:32:55 02:59:36 YTD

Sustainable Development

Sustainable development is 'development that meets the needs of the present, without compromising the ability of future generations to meet their own needs'. It is about balancing the environmental, social and economic decisions so that no one area outweighs another.

In the past, economic factors have often taken precedence in decision making - leading to the situations faced today such as global warming (where the environment has not been considered highly enough in the decision making process), or poverty and inequality (where social factors have not been considered highly enough in the decision making process).

Although today this still occurs, there is learning on a national, and even global, scale that this imbalance is what is causing many of the problems we see today. Readdressing the balance will build a future for today and for tomorrow.

Sustainable development in the context of health and care

For health and care the precedent is even higher. Quite simply, social and environmental factors impact on a person's health and wellbeing. Figure 3 illustrates just how intrinsically sustainable improvement areas can affect the health and wellbeing of a local area.

By limiting negative impacts, or promoting positive ones, the need for the treatment of health conditions and care needs can be reduced. In turn, this can release pressure on the health service as a whole - leading to a more sustainable healthcare system. This approach is set out clearly in the National Sustainability Strategy for Health and Care which defines the requirements on the health and care system to incorporate sustainable development into its ethos. It describes a sustainable health and care system being achieved by 'delivering high quality care and improved public health without exhausting natural resources or causing severe ecological damage'.

The vision of sustainable health and care:

'A sustainable health and care system works within the available environmental and social resources protecting and improving health now and for future generations. This means working to reduce carbon emissions, minimising waste & pollution, making the best use of scarce resources, building resilience to a changing climate and nurturing community strengths and assets. 'The One Halton approach itself is conducive to sustainable development. While there are requirements that we must adhere to and meet as an

individual organisation; by fully embedding sustainable development into the One Halton way much more can be achieved.

While the One Halton Sustainable Management Plan is a three-year plan, the actions set out within the action plans are expected to be delivered in the financial year 2018/2019. The plan, as an organic document will be reviewed by us on an annual basis to identify and develop the best course of action for the coming year.

In the organisation, we can demonstrate our commitment to sustainability through:

• Our headquarters in partnership with landlords, Halton Borough Council. has daily recycling of paper, cans, ink cartridges and plastics

• Promoting the use of telephone/video conferencing to reduce carbon emissions from driving

• Encouraging car sharing when attending off-site meetings

• Promoting printing on both sides, in black and white, where paper copies are required

• Using tablet computers for all staff, reducing the need for hard copies

• Storing scanned documents electronically (where legally appropriate)

We continue to develop plans to assess risks, enhance our performance and reduce our impact, including against carbon reduction and climate change adaptation objectives. This involves establishing mechanisms to embed social and environmental sustainability across policy development, business planning and commissioning.

As we look toward 2019/2020 and shared office accommodation with NHS Warrington Clinical Commissioning Group, our priority is the development of a more formal Sustainability Development Plan.

Improve quality We place quality at the core of the way we commission and monitor services. We do this by making our expectations clear and measurable and then monitoring these standards closely. The Quality Team have five key elements that drive its work:

• Patient safety • Patient experience • Clinical effectiveness • Responsiveness • Being well-led

• Organisations from which we commission care must meet essential standards of quality and safety, as defined by the (CQC)

Provider Trust CQC Inspection Inspection Rating

St Helens and Knowsley March 2019 Outstanding Hospitals Trust

Warrington and Halton November 2017 Requires Improvement Hospitals NHS Foundation (re-inspected March 2019 Trust awaiting results)

North West Boroughs October 2018 Good Partnership NHS Foundation Trust

Bridgewater Community December 2018 Requires improvement Healthcare Foundation Trust

In many cases, we set quality standards for our providers that are above these essential requirements and use Commissioning Quality and Innovation (CQUIN) targets to improve standards of care. We work closely with our acute, mental health, community and Primary Care services throughout the year to ensure that they meet these standards, providing challenge and requesting assurance where the care provided is not as expected.

Quality is firmly placed at the heart of all we do, taking our duties as detailed in section 14R of the Health and Social Care Act 2012 extremely seriously. We are pleased to confirm that there have been no serious lapses in the discharge of this duty during 2018/2019.

Key achievements in 2018/2019

• Implementation of Enhanced Health in Care Home Initiatives • Achieved ‘Substantial Assurance’ from Merseyside Internal Audit for Safeguarding Children and Looked After Children arrangements • Met all Quality Premium key performance indicators for Continuing Healthcare and Funded Nursing Care through service improvement programmes • Medicines Management improved quality, innovation, performance and productivity through medicines safety initiatives • Increased number of pharmacists with non-medical prescribing training • Established a collaborative commissioning forum across 12 organisations to improve quality and safety in community services • Deputy Chief Nurse selected for the NHS Leadership Academy Directors of Nursing Talent Management Programme • Worked in partnership with Local Authority to improve quality and outcomes in nursing and residential homes

Supporting quality improvement in Primary Medical Care Whilst it is recognised that most healthcare professional and providers of Primary Medical Care operate to a very high standard, it is essential that commissioners have robust monitoring arrangements in place.

The annual GP practice self-declaration (eDec) collection, alongside a rolling programme of deep dive reviews support these monitoring arrangements. The arrangements should create a balance of support, oversight and intervention where necessary. Furthermore, it should create a culture of openness and transparency and a vehicle to promote peer to peer improvement.

Whilst practices as providers are accountable for the quality of services and are required to have their own quality monitoring processes in place, NHS England and us as commissioners, have a shared responsibility for quality assurance. Through the Duty of Candour and the contractual relationship with commissioners, practices are required to provide information and assurance to commissioners and engage in system wide approaches to improving quality.

All 14 GP practices in Halton received a quality, contracting and transformation visit. The outcome of the practice visits was reported into the Primary Care Commissioning Committee. This will continue annually.

Improving the patient experience We use information from patient experience, patient safety and safeguarding information, complaints, staff surveys, the CQC, local Healthwatch site visits, GP alerts and national data, as well as key quality and performance information to develop a programme of targeted clinical visits where assurance is sought from patients using the service.

Healthwatch are a key partner in listening to the views and experience of Halton residents and they ensure this information is heard at the Engagement and Involvement Group, the Quality Committee, the Governing Body and the Cheshire and Merseyside Quality Surveillance Group of which they are members. We also use local Healthwatch data to inform us of issues and help us target areas for improvement.

The Engagement and Involvement Group reports to the Quality Committee and has the responsibility of reviewing and scrutinising consultation, engagement and involvement work programmes across our organisation. They act as a critical friend to the work providing practical advice and support where required.

A patient story is heard at every Governing Body meeting to ensure the patient voice is central to everything we do. This also enables Governing Body members to make recommendations for change as a result and to celebrate good experience stories.

We also conduct assurance visits within primary and secondary settings including contracted services with non-NHS providers. Joint visits also take place in partnership with the Local Authority conducting assurance visits to care homes as required.

Improving quality under section 14R of the Health & Social Care Act 2012 We have a robust and thorough governance process underpinned by the requirements of the NHS Standard Contract to ensure that all services that it commissions and all of those providers that it commissions from, not only meet but where possible exceed minimum quality requirements.

Working practices such as regular quality meetings with providers, review of statutory information and liaison with Public Health colleagues is a business as usual process. Evidence

of this functioning is detailed within the performance element of this report where the outcome of non-delivery (of service provision and/or quality standards) includes performance notices and suspension notices. You can find this information on page 25.

We have a governance process with reporting to both our Quality Committee and Governing Body to ensure that services are provided meeting the required standards which then continue to be monitored by us through local and national reporting.

Reduction of inequalities under section 14T of the Health & Social Care Act 2012 It has been another challenging year for the NHS both nationally and locally.

There continues to be significant pressure on our health and social care system and a challenging financial position. However, we continue to work to reduce health inequalities and ensuring NHS services are fit for the long term. The Better Health area of the Improvement and Assessment Framework sets targets to demonstrate we are improving the health and wellbeing of our population and address health inequalities, where appropriate with our partners.

We have embedded reducing health inequalities in all aspects of our commissioning processes and have made the requirement to consider the impact on health inequalities much clearer in our business cases. The Quality Impact Assessment and Equality Impact Assessment processes are now firmly embedded in commissioning cycles and governance methods.

Through the One Halton model, we are working with our partners to radically change the way we do things so that by 2022 fewer people will be suffering from poor health. The One Halton Health and Wellbeing Strategy is our borough-based plan to improve the health and wellbeing local people, their families and communities. For more detailed information about One Halton, the One Halton Health and Wellbeing Strategy and the work we are doing across our area with our partners to reduce health inequalities, please click here.

The One Halton Population Health Framework developed in conjunction with Cheshire and Merseyside Health & Care Partnership Prevention Board, Public Health England (PHE), Halton Borough Council, NHS Halton CCG, NHS providers, the voluntary sector and third sector seeks to support the delivery of the prevention challenge.

Traditionally efficiencies have been delivered through improved delivery of care but meeting the current goals of saving lives, reducing morbidity, improving quality, being more cost effective and reducing inequalities requires a new solution and a focus on stemming demand through delaying or preventing the onset of need.

This Population Health Framework sets out evidence based guidelines partners can use to create a transformational and sustainable shift in the health and wellbeing of the Cheshire and Merseyside population.

This approach promotes the integration of health, mental health and social care services, the development of multidisciplinary and multisector teams working together to improve population health. This includes individual care management, the mobilisation of community assets, committing to integrated care models, and making every contact count across sectors, as well as population level interventions like access to employment and workplace health and education.

• Local system leaders. • Local communities. • General Practices or Primary Care Hubs. • Local tertiary and acute providers.

Learning from deaths and mortality reviews As a result of the publication of Mazzar’s “Report into deaths at Southern Cross Healthcare” (December 2015), the CQC report into “Learning, Candour and Accountability” (December 2016) and the National Guidance on Learning from Deaths, (National Quality Board 2017) there has been an increased requirement on providers to be explicit in the way in which they investigate deaths within their organisation particularly about the death of patients with a learning disability. Investigations into deaths are required to involve, family/carers or others who were close to the person who has died.

Learning from Maternal Deaths There is a system in place at all maternity service providers where maternal deaths are mandatorily reported into the Mother and Baby Reducing Risk through Audits and Confidential Enquiries (MBRRACE). The system already exist for oversight and assurance of healthcare provision.

Learning Disabilities Mortality Review Programme We seek assurance that providers have followed processes for the review of deaths relating to those people who have a learning disability (including other service providers, primary care and linking with safeguarding systems where appropriate) as well as ensuring the whole health economy learns as a result of any findings from deaths subject to review. This is ongoing work.

Incidents, complaints and serious incidents The Quality and Governance Teams monitor our partner organisations in reporting, investigating and learning from incidents and serious incidents which occur within a provider of NHS healthcare. A serious incident review group panel is tasked with reviewing submitted reports and action plans from our providers to gain assurance that a robust investigation has been completed, reasons for the incident occurring identified and recommendations have been actioned to prevent something similar from happening again. We work with our partners to ensure learning and actions from all investigations are embedded in practice.

We have recruited two new members of staff to help strengthen the management of the serious incident process internally, and with providers, in line with the NHS England 2015

Serious Incident Framework. We have undertaken a review during 2018/2019 of our system and process to ensure that we have a robust and cohesive approach to the management of incidents. As part of the review the Quality Team is currently working with neighbouring CCGs to seek out best practice and align processes, including reporting requirement to committees.

We have responsibility for reviewing the following provider’s serious incidents: Bridgewater Community Healthcare Foundation Trust British Pregnancy Advisory Service Halton Haven Hospice

However, as the Lead Commissioner we have responsibility for reviewing and actioning all investigations for Halton patients who are involved in serious incidents with other providers. Where this happens, these investigations would be led by the lead commissioning CCG.

We have purchased a new incident reporting system, Datix, during 2018. A key priority for 2019/2020 is to implement the use of Datix in Primary Care. This will include training for Primary Care on conducting significant event audits to ensure learning from incidents is capture appropriately.

Healthcare Acquired Infection We have a responsibility to ensure that systems and processes are in place to support the management, prevention and control of Health Care Associated Infections. We consistently meet our access targets for both diagnostic tests and treatment targets.

We continue to work in partnership with all providers we commission services from to ensure that the management of infection control is undertaken, and that provider Trusts have made progress in improving the systems and processes of reporting and investigating the number of healthcare-acquired infections.

NHS Halton Warrington & ST Helens Bridgewater North West CCG Halton & Knowsley Community Boroughs Hospitals Hospitals Healthcare NHSFT NHSFT Trust NHSFT

T A T A T A T A T A

C.Diff 35 26 26 22 40 16 No 0 No 0 target target

MRSA 0 1 0 1 0 0 0 0 0 0

Source: January 2019 (T=target, A= Actual)

There has been a reduction in the number of MRSA cases (which is an improvement) and each case has been reviewed to explore any learning that can be shared to support clinicians in daily practice.

The Clostridium Difficle (CDiff) cases continue to be monitored and investigated and we are an active member of the CDiff appeals review panel that reviews CDiff cases from across the health economy to identify themes and trends. This data helps inform learning where there has been evidence of no lapses in care. We have a clear plan of review for the investigation of E. coli with clinicians exploring all cases of infection for any opportunities for learning.

We are eager to ensure that organisations recognise and acknowledge their responsibilities to ensure that high standards of infection control are achieved.

This is achieved through the provision of training, information sharing and advice with infection prevention and control teams across the Halton area sharing best practice. As a result, infection rates are closely monitored, and outbreaks are responded to quickly, improving the patient experience. 40

Antimicrobial resistance In the UK, 80% of antibiotic prescribing occurs in Primary Care. Antimicrobial resistance is the ability of microbes to resist the effects of drugs. That is, the germs are not killed, and their growth is not stopped. Infections with resistant organisms are difficult to treat, requiring costly and sometimes toxic alternatives.

The inappropriate use of antibiotics is related to bacterial resistance. Primary Care prescribers can tackle resistance, keep antibiotics effective and prevent healthcare acquired infections by: • Only prescribing antibiotics when necessary • Following antimicrobial prescribing guidelines • Prescribing antibiotics only in response to a symptomatic or microbiologically proven diagnosis and not patient expectation • Advising patients on the risks of inappropriate antibiotic use • Avoiding use of high-risk antibiotics where possible (especially in elderly high-risk patients)

We have continued to work with Primary Care prescribers and other providers regarding effective Antimicrobial Stewardship and appropriate prescribing of antimicrobials. This has been in several ways during 2018/2019: • Inclusion of antimicrobial prescribing within the 2018/2019 GP Prescribing Quality Initiative. All practices are required to incorporate the following into their practice specific action plan • A reduction in the Trimethoprim: Nitrofurantoin prescribing ratio (our target is 10% reduction)

• A reduction in the number of Trimethoprim items prescribed to patients aged 70 years or greater (our target is a 10% reduction) • A reduction in overall antibacterial items per specific therapeutic group age-sex related prescribing units (STAR-PU) (our target is to reduce to the national mean or lower)

• Re-establishing the local Antimicrobial Group that provides high level advice and decision making with regards to the overall approach to optimising antimicrobial use and specific strategies to improve prescribing • Inclusion of antimicrobial prescribing in provider quality schedules • Introduction of the 'To Dip or Not to Dip' project within Halton care homes. This aims to improve management of urinary tract infections for care home patients by focussing on the symptoms and the patient rather than dipstick results in isolation • Update of the local antimicrobial prescribing guidelines

We have also established a group to support the national ambition to reduce healthcare associated gram-negative blood stream infections (healthcare associated GNBSls) by 50% by March 2021. The group's membership is from across the Halton health economy and concentrates on several areas including: • Understanding urinary tract infection coded data for admissions into hospital and what the data is telling us • Review of Primary/Secondary Care pathways for urinary tract infections (UTI) and catheter infections • Map available services and understand the capacity of those services

Care homes We recognise the importance of working with Care Homes in Halton to ensure quality care for our patients. We work closely with the Local Authority on improving the quality of care in Care Homes. Over the past year, successes have included:

• Millbrow, a purpose built two storey care home situated in Widnes, registered to provide both nursing and personal care for up to 44 people was inspected by the CQC during August/September 2017 and was rated as inadequate in all areas. Initially, it was proposed that the home would need to be closed. However, recognising the need for this provision for older people in the borough of Halton the Local Authority agreed to take ownership of the home in December 2017. Within four months of the rating, the CQC have recognised the vast improvement made to the home and the care. This was demonstrated by some previous 42

residents who had left the home due to inadequate care, returning. The learning from this work has resulted in the home being a model home, which we hope can become a 'Centre of Excellence' and 'Teaching Care Home'. It also provides evidence for robust financing models whilst ensuring we are providing safer staffing • The development of a Clinical Quality Framework is also underway and is a key milestone for implementation in 2019/2020 • Use of the Enhanced Health in Care Homes Framework, which is based on a suite of evidenced based interventions designed to be delivered within and around a care home in a coordinated manner. This is in order to support and make a difference to the lives of residents • We have introduced the React to Red pressure ulcer prevention initiative, the Red Bag scheme which supports the transfer of patient documentation on admission to hospital and supports early discharges from hospital using patient real time information and the Medicines Optimisation initiative which ensures residents medication is reviewed regularly, safely and reduces waste • We are currently working with all Nursing Homes to provide them with a secure nhs.net email address to support the future paper switch off in the NHS and ensure General Data Protection Regulation (GDPR) compliance. This should be completed by April 2020 • We have also reviewed the way GP's provide Primary Care to Care Homes: With the aligning of practices to care homes, residents, their families and clinicians are reporting a very positive experience

Safeguarding The organisation's principle philosophy, for children and adult safeguarding, is: "safeguarding is everybody's business". All staff members have a responsibility to raise and act upon any concerns. We have clear lines of accountability and responsibility for safeguarding: • Chief Accountable Officer: Dr A Davies • Executive Chief Nurse for safeguarding children and adults: Michelle Creed • Deputy Chief Nurse: Denise Roberts • Designated Nurse for Safeguarding Children and Children in Care: Hayley McCulloch • Designated Nurse for Safeguarding Adults – Sam Atkinson 43 • Designated Doctor for Safeguarding Children: Service commissioned from

Alder Hey Children’s NHS Foundation Trust • Designated Doctor for Children in Care: Service is being commissioned from Alder Hey Children’s NHS Foundation Trust

The statutory functions for children and adults require us to be a statutory member of both the Local Children and Local Adult Safeguarding Boards. This is fulfilled by representation from the Chief Nurse, Deputy Chief Nurse and Designated Nurses for both Children and Adults. The Designated Nurses also sit on the sub-groups to the board across the partnership.

The Safeguarding Health Sub-Group formally reports to our Quality Committee, Governing Body and the Local Children and Adult Safeguarding Boards. The Health Subgroup has representation from all provider organisation safeguarding Named Nurses, Designated Professionals and has strategic leadership from the Deputy Chief Nurse. The Health subgroup have an agreed action plan and monitors compliance of agreed safeguarding standards through a performance framework and audit programme. During 2018/2019, our safeguarding policy was revised.

The Designated Nurses have provided additional capacity to support GP practices in understanding and meeting their safeguarding duties, revising GP standards and offering support to any practice that was not fully compliant. The Governing Body had a Safeguarding Development Session facilitated by Designated Nurses, both Children and Adult Safeguarding Board Managers and the Chief Nurse.

The reporting of safeguarding issues is explicit within the Governance Framework and embedded into the quality reports to Quality Committee and the Governing Body. This provides assurance to committees and Governing Body to support the continual improvement of quality and learning of lessons from incidents and individual experiences.

We work to the principles set out in NHS England’s Accountability and Assurance Framework that sets out the responsibilities of each of the key organisations for safeguarding. This Framework was developed in partnership with colleagues from the Department of Health (DH), the Department for Education (DfE) and the wider NHS and Social Care system. 44

The Designated Nurses for children and adults ensure safeguarding issues are expressly included in all the organisation’s contractual arrangements, policies and procedures. The Designated Nurses have reviewed and refreshed the Safeguarding Commissioning Standard Audit and Key Performance Indicators used with commissioned services which provide safeguarding assurance and have developed a small contracts framework for implementation in 2019/2020.

Safeguarding training is mandatory within the organisation’s induction programme for all new employees. All members of staff are required to complete annual refresher training to support them in having the requisite skills, knowledge and competence to undertake their specific roles in accordance with best safeguarding practice. We are committed to delivering a safeguarding children and adults training programme, linked to training needs analysis, to continually develop Primary Care and to strengthen the delivery of the safeguarding obligations for all GP practices.

Safeguarding Children We provide assurance to the Quality Committee, the Governing Body, NHS England and the Local Safeguarding Children Board to evidence we are fulfilling our statutory obligations in relation to safeguarding children.

This has been demonstrated through the Children Act Section 11 Audits and Internal Audit reporting that provides evidence of safeguarding from all levels of the organisation and across all business/commissioning functions. This provides a view to agencies outside the health sector that the organisation has robust safeguarding procedures in place.

We continue to build upon good practice, further strengthening safeguarding in every area of clinical practice, commissioned services and assurance delivery.

Our Safeguarding Children Policy is in place and regularly reviewed and updated taking into consideration the responses to recommendations from serious case reviews, serious incidents/audits and any changes in national or local guidance. 45

We work in partnership with the Local Safeguarding Children Board in respect of policy development along with the Pan Cheshire Policy and Procedures Group.

All providers are contractually required to have systems in place that identify vulnerable children and flag issues that increase risks to vulnerable individuals, children and families. They are also required to report safeguarding issues, conduct and participate in enquiries/investigations to reduce the risk of reoccurrence, including participating in and cooperating with any multi-agency enquiries.

Following concerns raised by the Government about the effectiveness of Local Safeguarding Children Boards to safeguard children (as well as their procedural arrangements including their child death overview arrangements and their serious case reviews), Alan Wood was commissioned to conduct a review in 2016. Subsequently, significant changes to ensure collective accountability around safeguarding and promoting the wellbeing of children and young people were created by the new Children and Social work Act 2017.

The Wood review (2016) of the role and functions of Local Safeguarding Children Boards found widespread agreement that the current system of local multi-agency child safeguarding arrangements needed to change. He proposed a new model that would ensure collective accountability across local authorities, the police and health. He also recommended a new system of local and national reviews, to replace serious case reviews; and new arrangements for child death reviews. The review’s key recommendations are now included in the Children and Social Work Act 2017 and reflected in the revised Working Together (2018) Guidance.

The revised guidance creates the following key changes and approaches: Three core safeguarding partners – the Chief Executive of the Local Authority, the Chief Officer of Police for an area that falls with the local authority area and the CCG’s Chief Officer for an area that falls with the local authority area - have the statutory duty to make arrangements to safeguard and promote the welfare of all children in that area.

The safeguarding partners have been working together with equal and joint responsibility for developing the new safeguarding arrangements in consultation with partners. We continue to strive to support a consistent partnership approach to multi-agency working. 46

For children, this includes monitoring progress ensuring that relevant professionals work together effectively to promote safeguarding the health and wellbeing of vulnerable children and families.

Key priority for 2019/2020 Implementation of new Safeguarding Partnership arrangements

Safeguarding adults We employ a Designated Nurse for Safeguarding Adults whose role encompasses the wider safeguarding assurances across commissioned services including the Mental Capacity Act/Deprivation of Liberty Safeguards, domestic abuse, modern slavery, PREVENT (anti radicalisation), hate crime and areas that cross over between the community safety partnership boards and the Adult Safeguarding Board.

The Safeguarding Team provides assurance to our Quality Committee, Governing Body, NHS England and the Local Safeguarding Adults Board in fulfilling our statutory obligations in relation to safeguarding adults.

We undertake our statutory safeguarding responsibilities regarding safeguarding adults at risk by ensuring that all our members of staff are trained to the required level according to their role and responsibility.

Prevention is a key focus in ensuring adults at risk receive high quality care, are well informed of their choices and can make risk-based decisions.

The statutory functions for adults under the Care Act 2014 require us to be a statutory member of the Safeguarding Adults Board. This is fulfilled by representation from the Chief Nurse and Designated Safeguarding Nurse for Adults.

Our Safeguarding Adults and Mental Capacity Act policy is in place, embedded in the organisation and is regularly reviewed to update, taking into consideration the responses to legislation or any changes in national or local guidance.

We work in partnership with Halton Safeguarding Adults Board in respect of the multi-agency policy and procedures, 47

leadership of the safeguarding adult agenda across health and active partnership working.

All provider organisations are required to report safeguarding issues internally to us and externally to the Local Authority. They also are required to conduct and participate in inquiries and investigations to reduce the risk of reoccurrence, including participating in and cooperating with any multi-agency queries and learning events.

Primary Care and safeguarding All GP practices have a named safeguarding lead to enable safeguarding principles and procedures are embedded into front‐line practice. A GP Safeguarding Leads Forum operates quarterly to provide local and national updates, a targeted training session and opportunity for case discussion.

During 2018/2019, the Quality Team have worked with the Primary Care Team in developing a schedule of quality visits to practices to support the implementation of the GP Five Year Forward View. An area of development highlighted is to support practices in the management of incidents and risk using the Datix system, with the team being able to identify themes and trends to support quality monitoring of providers.

The Practice Nurse Forum has been a key partnership in improving, immunisations, flu vaccinations, infection control and developing the Practice Nurse workforce during 2018/2019. This also includes exploring the workforce issues including agreement of job descriptions, training and mentorship.

The Primary Care Commissioning Committee, of which the Chief Nurse is a member, has oversight of these reports and can identify areas that require further analysis and can commission pieces of work to support.

In addition, we have adopted the Quality Concerns, Quality Risk Profile methodology guidance from NHS England to enable us to spot 'early warning signs' of quality concerns and work with providers to develop action plans to improve.

NHS Continuing Healthcare and NHS-funded Nursing Care (Revised 2018)

Key changes The implementation of the revised Framework sets out the principles and processes for NHS Continuing Healthcare (CHC) and NHS-funded Nursing Care. This guidance replaces the previous version of the National Framework, published in November 2012, and followed an extensive period of external engagement with stakeholders, across the NHS, Local Authorities and patient representative groups.

The CHC Team function within a complex care service across health and social care and provide an integrated approach to the end to end process for the delivery of NHS Continuing Healthcare and Funded Nursing care.

NHS Continuing Healthcare Quality Improvements. During 2018/2019, our CHC Team have delivered a Quality Improvement Programme to improve performance and compliance with the National Framework for NHS Continuing Healthcare and Funded Nursing care.

NHS England requires assurance that we are delivering NHS Continuing Healthcare in a legally compliant, fair, efficient and cost-effective manner.

Assurance is on two levels: Quarterly benchmarking returns to NHS England and the use of the Continuing healthcare Assurance Tool. Achievement of Quality Indicators in relation to undertaking at least 80% of Continuing Healthcare assessments within 28 days and that no more than 15% of NHS Continuing Healthcare assessments take place in an acute setting.

The CHC Team have achieved compliance with both targets, this demonstrates effective partnership working across health and social care services, improving people’s experience and preventing duplication.

A monitoring dashboard is being developed for implementation in 2018/2019 to monitor performance on a quarterly basis for NHS Continuing Healthcare and Funded Nursing Care activity.

During 2018/2019, the CHC Team have maintain improved performance and achieved targets as set by NHS England. This demonstrates that local people are assessed for CHC eligibility within the agreed timeframe from point of Checklist referral through the Completion of the National Framework Decision Support Tool (DST).

Quality Premium targets

Continuing Healthcare Quality premium average 2018/19.

Quality Premium Target Average achieved

% of new CHC applications determined within 28 Above days (Adults) 80% 89%

% of CHC assessments taking place outside of acute Less than 15% hospital setting (Adults) 1%

NHS Continuing Healthcare Eligibility decisions Our key areas for improvements are linked to targets set by NHS England to deliver an end to end service for Continuing Healthcare. This will ensure people receive timely assessments that are of high quality and improve their experience of the NHS Continuing Healthcare process.

National Benchmarking: During 2018/2019, we were an outlier in relation to CHC eligibility decisions. This has significantly improved during 2018/2019 and we are now in line with regional North West regional average (as detailed below) but remain an outlier nationally.

Eligibility for CHC Individuals eligible for NHS CHC (Standard NHS CHC and Fast Track) at quarter end per 50,000 GP population size:

Key achievements in 2018/2019: • High level, standard Continuing Healthcare pathway is in place to streamline processes • Improved Screening: An individual must receive a positive CHC checklist to enter the standard CHC eligibility process; training delivered across the wider multi- disciplinary team to improve referrals process • A process for 28-day compliance has been implemented: A multi-disciplinary team approach in place to determine if individuals are eligible for Standard CHC (through use of the national Decision Support Tool assessment) • Individuals not eligible for CHC may be deemed eligible for Funded Nursing Care within a Care Home setting; increase in Funded Nursing care placement • Robust case management and review of Continuing NHS health care and Funded nursing care review in place and up to date • CCGs verification with daily sign off and quality assurance process in place to support 28-day compliance • We work jointly with Halton Borough council to procure and broker services by identifying a suitable local provider (Domiciliary Care or a Nursing Home) • A joint approach to completing all reviews is being developed which will reduce duplication and strengthen joint working relationships • Integrated working with Community nursing services to ensure people receiving End of life care are reviewed three months or earlier if change in need identified • Personal Health Budget (PHB) to be delivered as default position by 2019. New joint PHB role recruited to NHS Warrington Clinical Commissioning Group to Lead on PHB individualised commissioning

Continuing healthcare Strategic Improvement programme (SIP) The NHS England CHC Strategic Improvement Programme provides opportunities for CCGs to optimise the end to end process and embed consistency to enhance patient experience, outcomes and efficiency.

NHS England identified us as a case example of shared learning and best practice in response to the Strategic Improvement Quality Improvement programme 2018/2019. Our Chief Nurse and Complex Care Clinical lead, in conjunction with NHS England, presented high level case study within the ‘Future NHS Collaborative Platform’. This was an opportunity for us to demonstrate improvements made and share best practice on a regional basis.

Joint End of Life Project with NHS England National End of Life Team and CHC SIP 2018/2019 Fast Tracks are agreed when a person has a rapidly deteriorating health condition which is entering a terminal phase. The person may need NHS Continuing Healthcare funding to enable their needs to be urgently met (e.g. to enable them to go home to die or to provide appropriate end of life support to be put in place either in their own home or in a care setting). It would be unusual for a Fast Track case to continue beyond 12 weeks without a comprehensive assessment with the End of Life service.

We have been identified as a CCG where end of life services are commissioned elegantly and expertly; NHS CHC Fast Track funding is not accessed as often in Halton and therefore we have a low fast track spend.

NHS England wish to understand if urban and rural location influences expenditure on fast track funding and the variation in expenditure rates between CCG’s.

We have therefore agreed to provide NHSE with case study evidence in order that NHSE may identify critical success factors proving or disproving that excellent commissioning end of life services results in better outcomes and experience for patients and their families with a lower need for CHC fast track funding.

A project team including CHC, Commissioners and Halton Borough Council have agreed to take this forward 2018/2019. Early work stream included developing a case study and being an

active part of the Strategic Improvement Programme for End of Life service.

Aligned working across NHS Halton Clinical Commissioning Group and NHS Warrington Clinical Commissioning Group (CCG) The Standard operating procedure has been reviewed and updated with NHS Warrington CCG to align CHC procedures and improve good practice to be approved at Quality Committee for both organisations. In addition, both areas are aligning roles across both teams.

Personalisation and choice We have invested in a new post to lead on Personal Health Budgets and the broader individualised care agenda to to enable a changed, more effective relationship between the NHS and the people it serves and offer a better experience of health and care. This post is shared across two CCG’s in order to maximise opportunities for sharing best practice and ensure best use of resources.

During 2018/2019, 196 people received their care via a Personal Health Budget including those at end of life, children and young people in receipt of Continuing Care and adults receiving NHS Continuing Healthcare and joint care arrangement with Halton Borough Council.

NHS Continuing care for Children and Young people We work with stakeholders including providers, the Local Authority and Education to implement NHS Continuing Care for Children and Young People in accordance with the National Framework for Children and Young People’s Continuing Care.

We have a dedicated Children’s Complex Care Nurse for ‘Children and Young People’s Continuing Care’ and Continuing Care packages are delivered through a Personal Health Budget.

Personal Health Budgets for a range of children and young people have been implemented in partnership with Local Authority and Education partners, enhancing the experience of care.

Individual Commissioning for Mental Health and Learning Disability We have a dedicated Specialist Mental Health Nurse who has oversight of individual commissioning for people whose care we commission, either fully or as a joint package with the Local Authority. Significant progress has been achieved developing

integrated discharge pathways and commissioning care plans to support individuals discharge from hospital.

The use of out of area placements has reduced via a multi-agency approach to the delivery of Section 117 aftercare inclusive of health, social care, housing and Third Sector providers.

During 2018/2019, work has been undertaken to establish a Section 117 policy review work stream with Halton Borough Council and North West Borough Healthcare NHS Foundation Trust mental health services.

Key priorities for 2019/2020 • To continue to achieve quality indicators relating to NHS Continuing Healthcare • To build upon sharing of best practice in NHS Continuing Healthcare and individual commissioning through working with a neighbouring CCG’s Continuing Healthcare Team • To implement CHC training programmes across the wider multi-disciplinary teams, promoting personalisation and improved health outcome • To ensure the CCG delivers an end to end CHC service promoting evidence- based practice and CHC case management • To review of End of Life services as part of the National SIP programme • To extend personal health budgets beyond NHS Continuing Healthcare to other groups with a ‘right to have’ • To ensure best practice on the commissioning of home care for people in receipt of NHS Continuing Healthcare • To continue to support the Enhanced Care Home model within Halton supported by initiatives through NHS England Leadership training programme • To maintain a multi-agency approach to complex care case management to meet the needs of the individuals to improve health and social care outcomes • To support the development of a Quality Assurance Framework with Halton Borough Council Quality Monitoring team to support self- assessment and Clinical audit to maintain quality standards in line with CQC requirements and National Institute for Health and Care Excellence Guidance

Medicines Management Key achievements in 2018/2019 • Delivery of the Medicines Management Quality, Innovation, Productivity and Prevention plan covering safety, quality and cost-effectiveness work programmes • Development and delivery of Halton specific Medicines Management Training for local care homes and commissioning of a competency training resource for Care Home Managers • Joint medicines improvement plans are now in place with both our local acute Trusts • Continued work with the Local Pharmaceutical Committee to build relationships with Community Pharmacies and to ensure a collaborative approach to medicines optimisation localy • Development of the clinical resource within the Medicines Management Team to include Non-Medical prescribers - Recruitment of additional care homes Medicines Management Technician support via the national Medicines Optimisation in Care Homes programme • Development of a template review form to support high dose opioids quality initiative work; Supports comprehensive reviews and includes prompts for care planning and non-pharmacological options • Practice Medicines Co-ordinators: agreement for full roll out in practices and implementation in 2019/2020

Medicines Optimisation within Halton We are part of the Pan Mersey Area Prescribing Committee (APC) to develop formulary, guidance and recommendations for use of medicines across the Pan Mersey health economy. There are four subgroups that focus on the following: • New Medicines • Formulary and Guidelines • Shared Care

Safety Alongside our stakeholders, our Medicines Management Team (MMT) provides pharmacist input into all these groups in order to support the workplan in the most efficient and effective way.

Our Medicines Management Working Group has continued to ensure we have robust clinical (GP, Nurse and Pharmacist) consideration of all APC proposals and recommendations so they are fit for local needs and reflect local clinician views. Our MMT has continued to work directly with local prescribers to ensure safe, cost-effective use of medicines for our population.

Liaison with local acute Trusts and providers to address interface issues has helped support adherence to formulary and safer use of more complex medication that requires specialist input prior to prescribing.

With the development of two local Primary Care networks in Widnes and Runcorn, our MMT has been supporting the work programmes around diabetes and hypertension. MMT pharmacists have also been exploring how they can support test bed projects around Chronic Obstructive Pulmonary Disease and Care Homes.

During 2018/2019, we became part of the joint medicines’ optimisation working group between St Helens & Knowsley Teaching Hospitals NHS Trust, NHS St Helens CCG and NHS Knowsley CCG. We have also worked with Warrington and Halton Hospitals NHS Foundation Trust and NHS Warrington CCG to develop a similar approach between those stakeholders. This has proved to be a positive piece of work, especially the development of joint plans that reflect the priority areas across both Secondary and Primary Care

Addressing safety – Valproate In April 2018, a national alert was published regarding the use of valproate in women and girls of childbearing potential. The MMT has worked closely with all local GP practices to support them to implement this alert and any subsequent updates and to ensure our GP practices are compliant with the national guidance. This work included: • GP practice support for specialist referral process plus sample letter • GP practice support for informing patients of the referral process plus sample letter • Prescriber support regarding any practice queries, particularly highlighting any interface issues regarding specialist review process with relevant trust representatives • Communications to practice Prescribing Leads regarding any updates following the initial valproate alert

• Communications to local community pharmacies and practice pharmacists regarding any pharmacy specific correspondence • MMT re-audit is planned for late March 2019 in order to provide further assurance to NHS England regarding our and GP practice compliance with the Pregnancy Prevention Programme

Supporting Clinical Development for Local Prescribers The MMT held two prescriber education events in March and September 2018. These events formed part of a regular education programme run by us and have proved to be very popular with prescribers, both medical and non-medical. Following feedback, we incorporated sessions suitable for Practice Nurses as well as GPs and for selected topics we have extended the invitation to wider community teams to promote joint learning and shared experiences. Sessions were delivered by local Specialist Clinicians and our Clinical Pharmacists:

Topics covered were: • Chronic pain management and psychology of pain • Contraception update • Frailty – polypharmacy and deprescribing • Diabetes update • Heart failure • Paediatric asthma • Vitamin D guidelines

Addressing variation – Prescribing for chronic pain We are an outlier with regards to prescribing for chronic pain. This is with regards to high dose opioids, gabapentinoids and other medications commonly used for pain such as lidocaine plasters.

Prescribing varies significantly between our practices but due to the risks associated with prescribing of opioids we asked all GP practices, during 2018/2019, to review any patients being prescribed over 120mg morphine equivalent.

This was done as part of the annual prescribing quality initiative for GP practices and has raised the profile of the risks in this area with both patients and clinicians. supported more

regular conversations with patients about the risks and the need for future management plans. This will be evaluated in full in June/July 2019 and a report will be submitted to our Quality Committee.

Non-medical prescribing developments During 2018/2019, we worked with Midlands and Lancashire Commissioning Support Unit to put in place a more effective system to support governance around non-medical prescribing within Halton.

As a direct result of this work, we have also been able to commission an education programme targeted specifically at these staff which will cover key therapeutic areas as well as covering updates around law, ethics and accountability.

This programme started in February 2019 and will run until the end of the year and is a joint approach with NHS Warrington, West Cheshire and Wirral CCGs to support non-medical prescribers working within these areas.

Key priorities for 2019/2020: • Implement the Practice Medicines Co-ordinators project across GP practices in Halton • Implement the Self Care strategy to support a reduction in prescribing for minor illnesses by GP practices • Continue to focus on reducing the prescribing of high dose opioids and lidocaine plasters • Use of our pharmacists in a more clinical role for targeted medication reviews around frailty and falls • New model of working for Medicines Management Care Home staff to ensure we are working in a collaborative way to support care home staff more effectively • Continue to target high priority prescribing areas where we are an outlier nationally and regionally

Engaging people and communities

“We have continued, through 2018/2019 to work with our partners to ensure the voice of

people are heard in the health care services used by people who live in Halton.

This has included ongoing support for the Patient Participation Groups (PPGs) with the

positive support of the chair Dianne McCormick. The PPG’s have increased their scrutiny of medicines management process over the last year, and importantly influenced the delivery and agreed to provide information on the roll out of the Care Navigation services introduced in GP practices in 2018.

In addition, we have worked closely with other partners such as Healthwatch to ensure issues and concerns raised by people who use the services are heard e.g. community paediatric services review was informed by a Healthwatch report gathering the views of a wide range of parents and the young people they care for.

These meetings and reports along with Halton Peoples’ Health Forum and other community meetings have been invaluable for me, and other people involved in our work, to

understand and ensure the issues and concerns of people living in Halton are included in the developments taking place. More recently this has included going out through the

above networks and to local community meetings to discuss the proposed changes to the Urgent Treatment Centres. This work was also supported by an online survey if people couldn’t attend these meetings.

We have committed to working with partners to review and revise the way in which we ensure that the different concerns and needs of people who live in Halton can be heard and ensure this links with partners such as the council. A workshop will take place in 2019 to support us in identifying next steps in strengthening our engagement processes. This will

take account of the commitment in the NHS Long Term Plan to ensure that patients and people who use health services can create genuine partnerships with health care services in their area. This will be used to support and further develop engagement through 2019.”

Ruth Austen-Vincent, Lay member of the Governing Body (Patient and Public Involvement Lead)

Through meaningful engagement, we are committed to putting our patients at the heart of every decision we make to ensure we commission the best possible health services for the people of Halton.

To support our engagement and communication work, we have a dedicated Communications and Engagement Team that consists of a Chief of Public Affairs and Engagement, an Engagement Manager and a Senior Communications Officer.

We have continued to build upon our strategic work and, thanks to an evaluation of our Communications and Engagement Strategy, we have considered feedback from local people to help us review our engaging, listening and responding mechanisms, enabling us to continue to embed the patient voice throughout our work.

During the year, we have once again worked with our Peoples’ Health Forum and Patient Participation Group Network to listen to their feedback and use this intelligence to inform change.

Click here to read about the changes we’ve made based on our patient’s voices.

Continuing the success of closer engagement with our stakeholders Our vision is to involve everybody in improving the health and wellbeing of the people of Halton. This is supported by a culture of openness and transparency that is supported by a network of engagement activities which involve stakeholders, patients and the public in a variety of ways.

Engagement and consultation is our opportunity to listen, understand and respond to people’s need, perception and expectations. It has significant benefits to help us learn more about people’s experience, relationships and improve health outcomes and services. We have many ways that we keep our close links with patients, the public, the voluntary sector and providers.

GP practice Patient Participation Groups (PPGs) GP practice Patient Participation Group are a way we engage with patients and residents at a practice level. This model of engagement provides us with regular feedback through individual PPGs to clearly understand local issues. Each PPG varies in size, how it functions and what activity it undertakes.

There are quarterly PPG Plus meetings chaired by the chairperson of Appleton PPG and planned by PPG members. It invites each PPG to send representatives to share best practice and networking opportunities. Past topics have included the introduction of Care Navigation in GP practices ensuring that patients are aware of this new service and how it will not impact on them requesting to see a GP.

Halton Peoples’ Health Forum Halton Peoples’ Health Forum is another regular free public event where wider collective view are shared and solutions explored. It offers presentations from health professionals and our key representatives, followed by question and answer sessions. Those attending can get involved in shaping the future of health services and pathways, for example Care Navigation, development of Urgent Treatment Centres, Mental Health, Sexual Health, Self-Care, GP Federations and Cardiac Rehabilitation.

The Halton Peoples’ Health Forum Steering Group is formed of volunteers from Halton as well as members of our staff. The group meets prior to the Health Forums to discuss topics should be covered at future Health Forums.

Halton Community Radio 92.3 FM On the last Thursday of the month, we produce a two-hour show on Halton Community Radio 92.3 FM providing a platform for local people to listen to important health messages, health professional’s advice for patients. Each show features guests from partner agencies, providers and third sector and enables members of the public to phone in and ask questions. Over the last year, we heard from the Deafness Resource Centre with an interpreter, the Red Cross, a mindfulness coach, information about Health Checks, Self-Care, Halton Carers Centre and updates from Well Halton.

Consultations As with all NHS bodies we have a legal duty to involve and consult the public about the running of local health services. Patients are listened to and actions taken to meet their concerns. All consultations need to adhere to the 'Gunning Principles' to ensure the process is fair,

enough time and information is given on the proposals and feedback to/from the consultation is taken into consideration

Upton Rocks Practice - Hale Village Branch Surgery Upton Rocks GP practice notified us that due to operational and financial reasons, the branch surgery at Hale village was no longer viable. Appointments offered at the Hale Village branch site have historically been underutilised and the building was not fully compliant with the required Disability Building Regulations (Disability Discrimination Act). The Halton Strategic Plan 2015/2020 identified that Hale Village branch site is classified as a “condition C” estate meaning that, “the property is operational but major repairs or replacement will be needed soon, for building and engineering elements.”

A formal consultation was undertaken in partnership with the GP practice to seek the views of the practice’s patients and the wider community.

Following pre-consultation in 2017 with the GP practices and their PPGs, the formal consultation took place over six weeks from 25th June 2018 to 6th August 2018. The methods of engagement and communications were varied. Whilst the focus of the activity was the 313 patients who could potentially be impacted, the activity also focused on Third Sector organisations who represented groups and communities that were identified in the equality impact assessment (EIA).

Frequently asked questions were developed to ensure patients and the public had enough information to understand the proposals, these were added to throughout the consultation. A survey was also developed to obtain people’s views, this was available both online and in hard copies. A letter was sent to all 313 patients registered with Upton Rocks that live in Hale Village. The letter outlined the proposals being consulted on, how to access the online survey, where to access further information and how to get involved.

Two drop-in events were arranged to capture the views of the community and to support them to complete the survey. These were promoted via:

• The frequency asked questions • Letter sent to patients • Press releases • Circulation of information to our and partners • Social media channels • Website hub page • Healthwatch Halton • Halton Community Radio • Halton’s third sector organisations • Posters • A public event to promote the consultation was also attended, Disability Awareness Day at Walton Hall Gardens, which was attended by Halton residents

From the EIA, those groups and organisations who represent and work with those patients who could be impacted by the proposals were sent the frequently asked questions and the survey and were asked if they would like further information presented to them.

The Engagement Manager also visited high footfall areas in the Hale Village area to promote the consultation, including shops, a pharmacy, the village hall, the youth centre, nursery and primary school.

The communications promoting the consultation were far reaching and varied. The summary documents were electronically sent and displayed at various venues across Halton, these included at Runcorn Town Hall, Healthwatch Halton, partners and providers websites, provider members, GP practices, school newsletters for parents and teachers, community centres and community newsletters, third sector newsletter and e-news, children’s centres, residents’ groups, pharmacies and care homes.

Information was also sent to key stakeholders including MPs and councillors and discussed at the Health Policy and Performance Board. Social media was used throughout the consultation and the consultation was advertised in the media, specifically the Runcorn and Widnes Weekly News and the Runcorn and Widnes World.

For the full consultation report and outcomes please click here

The Beeches Medical Centre – relocation We were informed by the Beeches Medical Centre of their intention to relocate to a new site. The decision to relocate was based on issues regarding capacity and maintenance of the current site and the opportunity to move to a state-of-the-art facility.

A formal consultation programme was launched on 2nd July 2018. During the consultation period information came to light which needed further consideration. On 5th September 2018, the consultation was ended to provide the commissioners and the practice to consider the information and any additional options.

Urgent Treatment Centres The National Urgent and Emergency Care Review led by Professor Sir Bruce Keogh and Professor Keith Willet commenced in 2013 and called for emergency and urgent care services to be more responsive and personalised for patients and deliver even better clinical outcomes. The national review set out five key elements to be taken forward to ensure success. The review undertook patient and public consultation and engagement. Where patients and public informed the national review, it was found that there is a confusing mix of Walk-In Centres, Minor Injuries Units and Urgent Care Centres.

To end this confusion and to support the national future model of urgent care, a nationally set of core standards for Urgent Treatment Centres has been established to ensure as much commonality as possible. By December 2019, the full range of out of hospital urgent care services (i.e. Walk in Centres, Minor Injuries Units and Urgent Care Centres) will be rebranded to Urgent Treatment Centres which will follow the new national standards.

Locally, we undertook a period of pre-engagement and consultation on the model for Urgent Treatment Centres (UCC).

We undertook a seven-week pre-consultation from Wednesday 24th October 2018 to 12th December 2018. The aims of the pre-consultation were to ensure the local population were aware of the new model of urgent care, to ensure the local population were able to be involved in the development of the localised model, to give an opportunity for the public to share their initial views of the proposals to reduce the opening hours to feed into the formal consultation process and to provide sufficient evidence and information for us to ensure the new model will meet the needs of the population. Healthwatch Halton’s previous engagement and gathering of patient experiences when accessing the UCCs was invaluable at this stage.

For the full pre-consultation report please click here.

Following this, a formal consultation to seek views and experiences on the proposal to reduce and standardised the opening hours of the new Urgent Treatment Centre was undertaken from Monday 7th January 2019 – Sunday 3rd March 2019. The timings and co-ordination of the procurement process ensured the outcomes of the consultations could be conscientiously considered.

The consultation took place over eight weeks. The methods of engagement and communications for the consultation were varied as was the target audience. The activity also focused in on Warrington’s patients and stakeholders as the UCCs are heavily utilised by Warrington patients.

A summary booklet explaining the need and vision for the new model of care and the options to reduce the opening hours was produced with a survey to obtain people’s views. A range of meetings and events were attended. These meetings were with various groups including Youth Carer Forums, Stroke Association, Halton People’s Health Forum (both Widnes and Runcorn), Warrington Health Forum, individual Patient Participation Groups, Cancer Support Groups, Fibromyalgia Group.

Our staff spent time at public venues to capture views and experiences. Time was spent at Widnes Market and Runcorn Shopping City. Commissioners spent time at the UCCs at the proposed time of reducing the hours (7am – 8am and 9pm – 10pm) to understand any potential impact for patients who use the services at these times.

The communications were far reaching and varied. The summary documents were electronically sent and displayed at various venues across Halton, these included at both UCC sites, Runcorn Town Hall, Healthwatch Halton, partners and providers websites, information sent to provider members, GP Practices, community centres, community newsletters, third sector newsletter and e-news, children’s centres, pharmacies, and care homes, NHS Warrington Clinical Commissioning Group’s public newsletter.

Stakeholder briefings were sent to both Halton and Warrington MPs, Councillors, Health and Wellbeing Boards, provider organisations and overview and scrutiny committees.

Social media was used throughout the consultation and it was advertised in the media, specifically the Runcorn World.

For the full report and outcomes of the consultation please click here

Pre-consultation: Eastern Cancer Sector Hub We have been working with neighbouring CCGs, local people and professionals to transform cancer care in Halton, Knowsley, St Helens and Warrington. We have great specialist cancer care across Cheshire and Merseyside. Our local specialist centre, the Clatterbridge Cancer Centre, ranks as one of the best in the country. This means that currently local people in the Halton, Knowsley, St Helens and Warrington areas can access these specialist services.

We have looked at the future of these services and are working with clinical experts to make sure they remain the best possible. To enable this to happen a proposal to develop local cancer hubs was developed. A Case for Change document set out what needed to change in the future to make sure local people still benefit from these high-quality cancer care services.

From September 2018, there was focused engagement activity as pre-consultation engagement to feed into the consultation planned for Autumn 2019. The pre-consultation engagement included three stakeholder panels for key stakeholders, which included patients and carer representatives, Third Sector organisations and healthcare staff across the four areas. The panels were to help shape and develop the draft proposal of the new hub. Alongside the panel sessions were one to one interview with staff, 66

focus groups and attendance at Third Sector organisations, specifically focusing on those most relevant to cancer care.

Following the pre-consultation stage of engagement, a full report was produced, and a fourth stakeholder panel was facilitated to thank those involved, inform them of the main findings and help to shape and design the formal consultation.

The full consultation is now being planned for 2019/2020 via the Communications and Engagement Subgroup which covers the four CCGs and Healthwatch organisations.

General Data Protection Regulation (GDPR) – public engagement We updated our GDPR requirements and have created a process for the public to receive communications from us, which they can choose to opt out of at any time.

Criteria Based Clinical Treatments From June 2017, together with Knowsley, Liverpool, Southport and Formby, South Sefton, St Helens and Warrington NHS Clinical Commissioning Groups, we have been reviewing over 100 treatment policies to ensure that the latest medical guidance and techniques are being used, so that the best treatment is being provided to each patient, that NHS resources were being used in the best possible way for all patients and to provide equal access to healthcare and treatments, where possible, across the Mid Mersey area.

For 2018/2019 phase three of this review focused on seven policies: Cough Assist Devices Secondary Care Administered Joint Injections Surgery for Prostatism/Lower Urinary Tract System Botulinum Toxin A&B Continuous Glucose Monitoring systems for continuous monitoring in Type 1 Diabetes Mellitus and Insulin pump Transanal Irrigation

Equality Impact Assessments have been undertaken on each of the policies reviewed which set out the approach for the engagement plans, providing a clear understanding

of the change to each policy and what would be proportionate and fit for purpose engagement, considering the level of change.

For Halton, there will be an extensive period of engagement which started on 12th February 2019 and runs until July 2019. The following tools were implemented to ensure that as many people as possible can have their say on the impact of any changes brought about by this review of policies:

Online survey (and available offline in paper format), targeting specific cohorts of people through social media and support groups/charities

Website hub pages with accompanying frequently asked questions

A plain English document was provided which summarised the policy and provided the rationale for the proposed change to allow participants to make an informed decision

Local media support

To read the full review of the engagement, please click here.

Work has also started on planning the pre-consultation engagement on the assisted conception policy – a review of the existing policy has been undertaken and the engagement work is being planned for 2019.

Clinical engagement As we are a membership organisation it is vital that we engage with our clinicians – not only our Clinical Leads but all our Primary Care staff, including Practice Nurses and Practice Managers. A weekly clinical bulletin is produced that is sent to Primary Care staff. This provides up-to-date information on guidelines, clinical procedures and referral pathways, as well as third sector support available in Halton. To strengthen this

relationship, we hold Commissioning PLT sessions, with the aim of discussing, interacting and engaging with GPs, Practice Nurses and Practice Managers on CCG commissioning plans and priorities.

We are responsible for the GPs and Practice Nurses bi-monthly Protected Learning Time (PLT) sessions. These sessions are used to update our GPs on topics such as clinical procedures and new National Institute for Health and Care Excellence (NICE) guidelines. Our Clinical Leads are involved in the sessions to ensure that they are localised and as worthwhile as possible for the GPs. Feedback from these sessions has been extremely positive.

We hold quarterly Practice Managers Meetings to be able to share relevant information and to discuss any issues. These meetings are attended by the Primary Care Service Development Managers to ensure relationships between us and Primary Care is further strengthened. Topics have included winter campaigns involvement, adult safeguarding updates, information on Third Sector organisations that can support patients and Public Health NHS Health Checks.

Stakeholders Using stakeholder mapping, we chart and focus activity to key cohorts of the community, public and Third Sector stakeholders to give us insight and understanding of their needs, the best ways to communicate and engage with them, and to identify any gaps.

Events: Key meetings attended • Disability Awareness Day: Joint stand with NHS Warrington Clinical Commissioning Group. The focus was information on adult safeguarding and raising awareness of PPGs • Youth Parliament • Third Sector Engagement • Loneliness task and finish group • Dementia carers group • Better tomorrow, BME launch

Care Navigation Care Navigation is one of the top 10 high impact actions in the GP Five Year Forward View. Care Navigation encourages patients to self-refer to local community services where they do not need to see a GP first. This takes place when a patient contacts the GP practice to arrange an appointment where trained Care Navigators have been given the information to advise and direct patients to an alternative service, providing their needs fit within the agreed exclusion and inclusion criteria for each participating service.

From a communications perspective standardised artwork for both digital and print were created. Meetings were organised with patient representatives and PPG members to help design the artwork and what the key messages should be in the terms of patient choice.

PPG plus raised some important issues in relation to patient choice and the Care Navigation service. Posters were altered and communications developed to address this feedback. In addition, the Primary Care lead agreed to include PPGplus in the review of the service six to nine months from the introduction.

As part of the Care Navigation workshops, communications were discussed in terms of how to communicate with the public and what materials were available, this was engagement with GP practice staff. A film for Halton explaining Care Navigation was produced and a communications toolkit for GP practices. It was advertised on social media and with the Widnes Vikings and created icons for the service criteria.

Other communication campaigns • Pharmacy Public Waste Campaign - marketed via social media posts and videos. Rugby match day programme, posters, leaflets and information for our website • Child and adolescent mental health services - Changed its service name to HeadzUp Halton • Self-Care – Production of digital assets to support self-care messaging • Promotion of Extended Access and GP Extra • Let’s do it Together winter campaign • Flu jabs

• NHS 70 - several events to mark this including a work plan for schools • Respiratory services survey

• Worked jointly with Halton Borough Council to produce a brand for Halton Safeguarding Adults Board

Social media We recognise that social media is an ever-expanding channel to reach people living in our town and beyond. With the benefit of minimal costs and the prospect to reach tens of thousands of social media users, we believe that engaging via social media is a priority. It allows us to respond to questions or queries quickly and provide relevant and up to date information.

We have used social media to alert and inform users, as well as encouraging engagement and participation. Social media allows us to almost instantly post updates on services or allows us to reach a wider audience when we undertake engagement to form public opinion such as consultations.

Throughout 2018/2019, our social media accounts have continued to grow. Our Twitter account has a following of over 6400 and our Facebook page has over 215 followers.

Reducing health inequality Health inequalities are the preventable, unfair and unjust differences in health status between groups, populations or individuals that arise from the unequal distribution of social, environmental and economic conditions within societies, which determine the risk of people getting ill, their ability to prevent sickness, or opportunities to act and access treatment when ill health occurs.

It has been another challenging year for the NHS both nationally and locally.

The Better Health area of the Improvement and Assessment Framework sets targets to demonstrate that that we are improving the health and wellbeing of our population and address health inequalities, where appropriate with our partners.

We have embedded reducing health inequalities in all aspects of its commissioning processes and has made the requirement to consider the impact on health inequalities much clearer in our business cases. The Quality Impact Assessment and Equality Impact Assessment processes are now firmly embedded in commissioning cycle and governance.

The local Public Health Priorities for 2019 /2020 and how we will work together to tackle them are as follows:

Health and wellbeing strategy We continue to be an active member of the Health and Wellbeing Board, One Halton Programme Board and the Halton Health Policy Board (OSC), and various other

forums and sub-groups, to take forward Halton’s Health and Wellbeing Strategy.

Health and Wellbeing Board is now in its eighth year of operation as the main strategic body with oversight for promoting health and wellbeing in Warrington.

The main responsibilities of the Board are the delivery of a local Joint Strategic Needs Assessment, Joint Health and Wellbeing Strategy and promoting integrated health and social care.

More information regarding the Health and Wellbeing Strategy can be found here.

In addition, we have, and continue to play a lead and active part in One Halton – Halton’s place-based transformation programme. Our Chief Commissioner is a member of the One Halton Board alongside senior officers of the Local Authority, our provider organisations, lead GPs and third sector representatives.

During 2018/2019, we have continued to make a significant contribution to the Health and Care Partnership for Cheshire and Merseyside, with our Clinical Chief Officer taking the lead for the Urgent and Emergency Care programme, in addition to other staff taking an active role in other key workstreams

Counter Fraud Arrangements We are committed to the fight against fraud affecting the NHS and wider health service and work with the relevant bodies to protect vital resources intended for patient care. For more information, about our Counter Fraud Arrangements, please see page 110.

ACCOUNTABILITY REPORT

Dr. Andrew Davies

Accountable Officer

22nd May 2019

Corporate Governance Report Members Report

Our 14 practices work within two GP Federations and across four hubs.

We have a culture of strong engagement with our member practices. Forums such as Protected Learning Time sessions provide practices with an opportunity to come together, focusing on specific topic areas.

In addition, the weekly GP bulletin provides a mechanism by which important information and updates are shared with all member practices. Our Governing Body are also responsible for preparing an Annual Governance Statement which sets out how they discharged their responsibilities. This statement is provided and can be found on page 84.

Member profiles Our 14 practices, split across Runcorn and Widnes work together in federations to provide care for local people. Moving into next year, we will continue to support our practices to develop Primary Care Networks in line with the GP Contract Review, as part of the NHS Long Term Plan.

Primary Care Networks build on the core of current Primary Care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care. Clinicians describe this as a change from reactively providing appointments to proactively car for the people and communities they serve.

Member practices Our member practices are: Runcorn practices Brookvale Practice

Hallwood Health Centre (co location of Brookvale and Weaver Vale practices)

Castlefield Health Centre

Tower House Practice

Murdishaw Health Centre

Grove House Practice (hosts Heath Road Medical Centre as a branch practice)

Widnes practices

Upton Rocks Surgery

Peelhouse Medical Plaza

Oaks Place Surgery

Newtown Healthcare Centre

Hough Green Health Park

Beeches Medical Centre

Bevan Group Practice (hosts Westbank Medical Centre as a branch practice)

Appleton Village Surgery

Composition of Governing Body The members of our Governing Body and the Committees on which they serve are outlined below. Unless stated, this covers the period 1st April 2018 to 31st March 2019:

Voting Members

Ruth Austen-Vincent - Lay Member

David Cooper - Chief Finance Officer

Ingrid Fife - Lay Member

Dr Claire Forde - General Practitioner Governing Body Member

Dr Julie Langton - Secondary Care Doctor

David Merrill - Lay Member and Deputy Chair of the Governing Body

Dr Gary O’Hare - General Practitioner Governing Body Member

Eileen O'Meara - Director of Public Health

Michelle Creed - Chief Nurse

Shahzad Tahir - Lay Member

Leigh Thompson - Chief Commissioner

Dr Andy Davies - Clinical Chief Officer

Dr David Wilson - Federation Representative

Dr Latha Meda - Federation Representative

Dr David Lyon - CCG Chair (up to 14th March 2019)

Diane Henshaw – Practice Manger representative (up to 30th June 2018)

Non voting members

Ann McIntyre - Operational Director, Education, Inclusion and Provision

Sue Wallace-Bonner - Director Adult Social Services

Kath Parker - Chair Halton Healthwatch

Dr David Lyon Chair: Serves on Clinical Advisory Group, Performance and Finance Committee; and Primary Care Commissioning Committee. (Dr David Lyon resigned from his position during 2018/2019 on 14th March 2019)

Dr Andrew Davies Interim Clinical Chief Officer (substantive as at March 2019)

Michelle Creed, Chief Nurse Serves on Clinical Advisory Group; Quality Committee (Vice Chair); Primary Care Commissioning Committee and Remuneration Committee

David Cooper, Chief Finance Officer Serves on Audit Committee, Performance and Finance Committee and Primary Care Commissioning Committee

Leigh Thompson, Director of Commissioning Serves on Performance and Finance Committee and Primary Care Commissioning Committee.

David Merrill, Lay Member (see note below) Serves on Audit Committee (Chair until June 2018); Performance and Finance Committee and Primary Care Commissioning Committee

Eileen O'Meara, Director of Public Health, Halton Borough Council Serves on Primary Care Commissioning Committee

Dr Julie Langton, Secondary Care Doctor Serves on Quality Committee; Primary Care Commissioning Committee and Clinical Advisory Group, Remuneration Committee (with effective from March 2019)

Dr Gary O'Hare, GP representative Serves on Clinical Advisory Group

Dr Claire Forde, GP representative Serves on Quality Committee and Clinical Advisory Group (Chair)

Ingrid Fife, Lay Member Serves on Audit Committee (Vice Chair – please see note below), Remuneration Committee (Chair) and Primary Care Commissioning Committee (Chair)

Ruth Austen-Vincent, Lay Member Serves on Audit Committee and Quality Committee (Chair)

Shahzad Tahir, Lay Member Serves on Audit Committee, Remuneration Committee and Performance and Finance Committee (Chair)

Dr David Wilson, GP Federation Representative Serves on Clinical Advisory Group

Dr Latha Meda, GP Federation Representative Serves on Clinical Advisory Group

Note: The Audit Committee Chair David Merrill has been acting into the Chair Position since June 2018, during this period, the Vice Chair of Audit Committee has chaired the Committee. This was reviewed and follow governance advice from the Internal Auditors.

Our Governing Body has a programme of Governing Body development sessions which happen bi-monthly and focus on areas of strategic development, training and pertinent local and national issues.

During 2018/2019, we continued to embed our person-centred approach to our consultation and engagement activity with the support of

our four Governing Body Lay Members.

Our decision to create extra capacity through the appointment of four Lay Members rather than the mandated two, has enabled greater public involvement in our work. This has been further enhanced with the support of our third sector partners. You can find out more about how we have engaged with local people on page 59.

Forums and events are held on a quarterly basis and the agenda is set through a collaborative approach. This Forum links to the Clinical Advisory Group and receives advice from the Committee in determining priorities for debate that are aligned to our commissioning plans. All staff from GP practices are encouraged to attend and the format provides a mix of educational sessions and space our business to be challenged and plans updated. Each practice has Clinical Lead representation on the Clinical Advisory.

Items from the Forum that may require further work can be escalated to this Committee for further deliberation and action. The Committee is chaired by one of the Governing Body GP representatives and this ensures Clinical Leadership and engagement in the delivery of Clinical Commissioning in Halton.

Personal data related incidents Our arrangements for Information Governance are described in the Governance Statement on page 84. There were no confidentiality breaches during the year 2018/2019.

Statement of Disclosure to Auditors We, the Directors of NHS Halton Clinical Commissioning Group confirm:

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

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

Modern Slavery Act Although we do not meet the requirements for producing an annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act 2015, we fully support the government’s objectives to eradicate modern slavery and human trafficking and our lead officers for safeguarding take responsibility for working with our partners in relation to this area. .

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 Dr Andrew Davies to be the Accountable Officer of NHS Halton CCG.

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

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

I also confirm that:

• As the 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 NHS Halton CCG’s auditors are aware of that information • So far as I am aware, there is no relevant audit information of which the auditors are unaware.

Governance Statement

Introduction and context NHS Halton Clinical Commissioning Group is a body corporate established by NHS England on 1 April 2013 under the National Health Service Act 2006 (as amended).

The clinical commissioning group’s statutory functions are set out under the National Health Service Act 2006 (as amended). The CCG’s general function is arranging the provision of services for persons for the purposes of the health service in England. The CCG is, in particular, required to arrange for the provision of certain health services to such extent as it considers necessary to meet the reasonable requirements of its local population.

As at 1 April 2018, the Clinical Commissioning Group is not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006.

For more information about us, please visit our website.

Scope of responsibility

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

I am responsible for ensuring that the clinical commissioning group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. I also have responsibility for reviewing

the effectiveness of the system of internal control within the clinical commissioning group as set out in this governance statement.

Governance arrangements and effectiveness

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

In accordance with section 14L(2)(b) of the 2006 Act, the group will at all times observe ‘such generally accepted principles of good governance’ in the way it conducts its business.

These include: a) The highest standards of propriety involving impartiality, integrity and objectivity in relation to the stewardship of public funds, the management of the organisation and the conduct of the business; b) The Good Governance Standard for Public Services; c) The standards of behaviour published by the Committee on Standards in Public Life (1995) known as the ‘Nolan Principles’; d) The seven key principles of the NHS Constitution; and e) The Equality Act 2010.”

Independent Committee Members are governed by the NHS Code of Accountability and Executive Directors by the Code of Conduct for NHS Managers. As part of the NHS Code of Accountability, all Governing Body members declare any relevant interests on a public register of Declarations of Interest.

The Clinical Commissioning Group upholds the Seven Principles of Conduct in Public Life known as the Nolan Principles1and consequently all Governing Body members are duty bound to abide by them.

We have commenced a programme of work utilising an associate from Mersey Internal Audit Agency (MIAA). The programme of work includes a full review of all committee terms of reference, membership and attendance of members. Where there is national guidance in place for specific committees, all terms of reference are being cross referenced to ensure they fully reflect what is required. This work will continue through 2019/2020 to ensure robust governance arrangements are in place.

Composition of Governing Body The members of our Governing Body and the Committees on which they serve are outlined below. Unless stated, this covers the period 1st April 2018 to 31st March 2019:

Voting Members

Ruth Austen-Vincent - Lay Member

David Cooper - Chief Finance Officer

Ingrid Fife - Lay Member

Dr Claire Forde - General Practitioner Governing Body Member

Dr Julie Langton - Secondary Care Doctor

David Merrill - Lay Member and Deputy Chair of the Governing Body

Dr Gary O’Hare - General Practitioner Governing Body Member

Eileen O'Meara - Director of Public Health

1 Selflessness, Integrity, Objectivity, Accountability, Openness, Honesty and Leadership 86

Michelle Creed - Chief Nurse

Shahzad Tahir - Lay Member

Leigh Thompson - Chief Commissioner

Dr Andy Davies - Clinical Chief Officer

Dr David Wilson - Federation Representative

Dr Latha Meda - Federation Representative

Dr David Lyon - CCG Chair (up to 14th March 2019)

Diane Henshaw – Practice Manger representative (up to 30th June 2018)

Non- Voting Members

Ann McIntyre - Operational Director, Education, Inclusion and Provision

Sue Wallace-Bonner - Director Adult Social Services

Kath Parker - Chair Halton Healthwatch

Dr Andrew Davies Interim Clinical Chief Officer (substantive as at March 2019)

Michelle Creed, Chief Nurse Serves on Clinical Advisory Group; Quality Committee (Vice Chair); Primary Care Commissioning Committee and Remuneration Committee

87 David Cooper, Chief Finance Officer

Serves on Audit Committee, Performance and Finance Committee and Primary Care Commissioning Committee

Leigh Thompson, Director of Commissioning Serves on Performance and Finance Committee and Primary Care Commissioning Committee.

David Merrill, Lay Member (see note below) Serves on Audit Committee (Chair); Performance and Finance Committee and Primary Care Commissioning Committee

Eileen O'Meara, Director of Public Health, Halton Borough Council Serves on Primary Care Commissioning Committee

Dr Julie Langton, Secondary Care Doctor Serves on Quality Committee; Primary Care Commissioning Committee and Clinical Advisory Group, Remuneration Committee (with effective from March 2019)

Dr Gary O'Hare, GP representative Serves on Clinical Advisory Group

Dr Claire Forde, GP representative Serves on Quality Committee and Clinical Advisory Group (Chair)

Ingrid Fife, Lay Member Serves on Audit Committee (Vice Chair – please see note below), Remuneration Committee (Chair) and Primary Care Commissioning Committee (Chair)

Ruth Austen-Vincent, Lay Member Serves on Audit Committee and Quality Committee (Chair)

Shahzad Tahir, Lay Member Serves on Audit Committee, Remuneration Committee and Performance and Finance Committee (Chair) 88

Dr David Wilson, GP Federation Representative Serves on Clinical Advisory Group

Dr Latha Meda, GP Federation Representative Serves on Clinical Advisory Group

Note: The Audit Committee Chair David Merrill has been acting into the Chair Position since June 2018. This was reviewed and advice sought from the Internal Auditors as to whether this would be an acceptable arrangement in the short term.

Committees of the Governing Body The Committees have been mapped against our statutory functions and duties and enable clear escalation, accountability and assurance for our Governing Body. Both the Performance and Finance Committee and the Quality Committee are key governance committees that provide significant oversight to our Governing Body on critical aspects of CCG business. A summary of all Committees, including

attendance and highlights of their work in 2018/2019 is outlined below:

Name Position Governing Body Audit Committee Performance and Finance Committee PrimaryCare Commissionin g Committee Quality Committee Remuneration Committee Clinical Advisory Group Date of Committees

Governing Body Members

Ruth Austin- Lay Member 6/6 3/4 10/11 Vincent

David Cooper Chief Finance 6/6 4/4 10/11 3/6 Officer

Ingrid Fife Lay Member 5/6 4/4 6/6 3/3

Name Position Governing Body Audit Committee Performance and Finance Committee PrimaryCare Commissionin g Committee Quality Committee Remuneration Committee Clinical Advisory Group Dr Claire Forde General 3/6 3/11 3/10 Practitioner & Clinical Lead

Diane Hanshaw Practice 1/1 0/3 Manager

Dr Julie Langton Secondary 3/6 3/6 7/11 Care Doctor

Dr David Lyon General 1/6 2/11 0/11 2/10 Practitioner and Governing Body Chair

David Merrill Lay Member 6/6 4/4 9/11 6/6 and Governing Body Vice- Chair

Eileen O’Meara Director of 2/6 Public Health

Michelle Creed Chief Nurse 6/6 8/11 3/3 5/10

Shahzad Tahir Lay Member 5/6 3/4 11/11 3/3

Leigh Thompson Chief 6/6 10/11 5/6 7/10 Commissioner

Dr Andrew Clinical Chief 6/6 Davies Officer

Kath Parker Healthwatch 4/4 Representative

Dr Latha Meda Federation 6/6 10/10 Representation

Dr Gary O’Hare General 5/6 6/10 Practitioner

Other Members

Ifeoma Onyia Public Health 0/11 9/10 Representative

David Wilson Health Watch 10/11 Representative

Brookvale Practice 8/10 Practice Clinical Lead

Castlefields Practice 8/10 Health Centre Clinical Lead

Grove House Practice 5/10 Practice Clinical Lead

Murdishaw Practice 8/10 Health Centre Clinical Lead

Tower House Practice 0/10 Practice Clinical Lead

Weaver Vale Practice 4/10 Practice Clinical Lead

Appleton Village Practice 0/10 Surgery Clinical Lead

Bevan Group Practice 0/10 Practice Clinical Lead 91 Hough Green Practice 0/10 Health Park Clinical Lead

Newtown Practice 0/10 Health Centre Clinical Lead

Oaks Place Practice 10/10 Surgery Clinical Lead

Peelhouse Practice 3/10 Medical Plaza Clinical Lead

Upton Rocks Practice 0/10 Primary Care Clinical Lead

Dr Rhian Cancer Clinical 10/10 Thomas Lead

Dr Chris Respiratory 0/10 Woodforde Clinical Lead

Dr David Wilson Informatics 5/10 Clinical Lead

Lisa Birtles- Learning 2/10 Smith Disabilities Clinical Lead

Dr Claire Forde Medicine 3/10 Management Clinical Lead

Name Position Governing Body Audit Committee Performance and Finance Committee PrimaryCare Commissionin g Committee Quality Committee Remuneration Committee Clinical Advisory Group Dr Smitha Diabetes 9/10 Joseph Clinical Lead & Primary Care Clinical Lead

Denise Roberts Children’s 925/10 Clinical Lead

Dr Vivien CVD Clinical 4/10 Williams Lead

Lisa Horne MSK Clinical 5/10 Lead

Dr Averil End of Life 3/10 Fountain Clinical Lead

Dr Salil Veedu Dermatology 2/10 Clinical Lead

The Executive Partnership Board is a Committee in Common across health and social care. This Committee focuses on delivery of the Better Care Fund plan and delivery of integrated commissioning of complex adult health and social care work programmes funded through the pooled budget.

We are developing an on-going programme of self-assessment effectiveness reviews in respect of the Governing Body and Committees, the result of which informs a refresh of Committee terms of reference and work plans. This demonstrates how the we recognise the important role that its Committees undertake as part of our overall governance framework and the importance of on•

going development enabling each Committee to identify potential areas for development. The Audit Committee supports our Governing Body by critically reviewing and reporting on the relevance and robustness of the governance structures and assurance processes on which our Governing Body places reliance. This requires the Audit Committee to understand and scrutinise the organisation’s overarching framework of governance, risk and control. This includes risk management and performance management systems underpinned by the Assurance Framework. In effect, the Audit Committee is the ‘lens’ through which the Governing Body examines the assurances it requires to discharge its duties.

The roles of the individuals forming the Audit Committee throughout the year and up to the signing of the Annual Report and Accounts are as listed below:

Ingrid Fife, Lay Member (Vice Chair)

Ruth Austen-Vincent, Lay Member

Shahzad Tahir, Lay Member

The following officers are in attendance to support the Committee:

Dr Andrew Davies Interim Clinical Chief Officer (CCG)*

David Cooper, Chief Finance Officer (CCG)

Suzanne Barker, Chief of Corporate Services (CCG)

Rebecca Knight, Head of Assurance and Risk (CCG)

Internal Auditors - Mersey Internal Audit Agency (MIAA)**

External Auditors - Grant Thornton

* The Chief Officer and Chair are only expected to attend one Audit Committee meeting per year. **MIAA Internal Audit attend on a regular basis however, the Counter Fraud representative is to attend a minimum of two meetings a year.

This year the MIAA governance reviews94 provided varying assurance. You can read MIAA’s report on page 111.

The Audit Committee received follow up of audits which were assessed in the audit plan for 2018/2019.

A tracker system is now in place to monitor improvements and programme of recommendations. All recommendations arising from internal audits are now added to the risk register and monitored via the risk management process. The Committee receives annually the Director of Internal Audit opinion and Annual Report. The Audit Committee obtains external audit advice and opinions ensuring appropriate review and implementation of national guidance and reviews in detail the process for financial management. The Audit Committee also receives the Board Assurance Framework (BAF) and Corporate Risk Register (CRR) for review and further challenge. The Audit Committee has not undertaken a self-assessment of effectiveness in year 2018/2019 but this is planned to take place in the new financial year 2019/20. This will be supported by Mersey Internal Audit Agency (MIAA).

The NHS Audit Committee Handbook includes two self-assessment checklists designed to help in assessing the effectiveness of the Audit Committee. Once the self-assessment has taken place, this will help to support any further developments necessary to improve the work of the Audit Committee

The Committees of our Governing Body We have five internal Committees reporting to our Governing Body and one Committee in Common that is co-ordinated through Halton Borough Council. A Joint Committee with Health Care Partners was also established in 2017. Each Committee is established in accordance with our Constitution and the remit, responsibilities, and

reporting arrangements shall have effect as if incorporated into the Constitution and Standing Orders.

Membership and Terms of Reference for each Committee are reviewed on a rolling programme and the current versions are available here.

Every Committee agrees an annual Work Plan that is informed by its responsibilities, as defined in the Terms of Reference, and is required to provide the Governing Body with a key issue report from each meeting for information and assurance.

An overview of the responsibilities of each Committee is described below:

Audit Committee Chair, David Merrill, Lay Member and Governing Body Vice Chair The duties of this Committee are driven by priorities identified by us and the associated risks. In summary, it is responsible for reviewing the establishment and maintenance of integrated governance, risk management and internal control; ensuring effective internal and external audit; reviewing findings of other significant assurance functions; policies for ensuring compliance with regulatory, legal and code of conduct requirements; counter fraud; whistle-blowing and the integrity of financial reporting.

This Committee met four times this year.

Performance and Finance Committee Chair, Shahzad Tahir, Lay member This Committee advises our Governing Body on all financial matters and provides assurance in relation to the discharge of statutory duties in line with the Standing Financial Instructions. The Committee also ensures that the performance of commissioned services is monitored. In summary, the committee is delegated by our Governing Body to approve and monitor the annual financial plan, ensure we deliver

financial balance, meets statutory financial targets, monitors QIPP, contract expenditure and financial performance indicators and approves variation to planned investments.

This committee met 11 times during the year.

Primary Care Commissioning Committee Chair, Ingrid Fife, Lay Member Primary Care Commissioning Committee is accountable to our Governing Body and responsible for ensuring adequate Primary Care our area. It does this by designing, monitoring and awarding/removing contracts to providers of Primary Care. The Committee also decides on investment in new practices, enhanced services, training, education and infrastructure. The Governing Body has approved and keeps under review the terms of reference for the Primary Care Commissioning Committee, includes information on its membership.

This committee met six times during the year.

Quality Committee Chair, Ruth Austen-Vincent, Lay Member This Committee reports our Governing Body on the development, improvement and monitoring of all areas of quality. This includes clinical effectiveness, patient safety and patient experience. The Committee provides assurance on the systems and processes by which we lead, direct and control our functions in relation to quality of care in order to achieve organisational objectives.

This Committee met 11 times during the year.

Remuneration Committee Chair, Ingrid Fife, Lay Member Members - Shahzad Tahir, Lay Member, Julie Langton, Secondary Care Doctor (with effect March 2019), Michelle Creed, Diane Henshaw – Practice Manger representative (up to 30th June 2018)

The Committee’s role is to oversee and agree the remuneration and Terms of Service of the Clinical Chief Officer, our Management Team of the Governing Body, together with any staff whose terms of service are not covered by the national agreements. It provides advice to our Governing Body on a range of employment issues for all staff (for example pensions and termination of employment).

This committee met three times during the year.

Clinical Advisory Group Chair, Dr Claire Forde, GP representative and Governing Body Member Although the Clinical Advisory Group is not a Committee it has an advisory function and operates as a subgroup of the Performance and Finance committee.

Note: Dr Ifeoma Onyia, Public Health Consultation undertook the role of Chair of the Clinical Advisory Group from July 2018

The purpose of the group is to provide an inclusive forum to engage and involve all clinicians in the development of clinical proposals. The Clinical Advisory Group, in conjunction with the Commissioning Oversight Group is a key enabler for ensuring that all clinical programmes of work are properly established with clinical inputs at the commencement of any programmes. The Group determines whether there is a sound clinical basis, supported by relevant clinical evidence for programmes of work to progress through the commissioning process.

The Clinical Advisory Group is advisory in capacity and any request for financial support following a positive clinical view from the Group will be subject to a fully worked up proposal, supported by the Commissioning Oversight Group, being submitted to the Performance and Finance Committee. The same procedure applies in the event that there is any proposal for service cessation, closure or disinvestment.

All proposals that signal a service change are subject to a quality impact assessment and/or an equality impact assessment that will be submitted to the Quality Committee for approval.

This Committee met 10 times during the year.

Urgent Issues Committee Chair, Dr Andrew Davies, Interim Clinical Chief Officer The Urgent Issues Committee is established in accordance our Constitution. These Terms of Reference set out the membership, remit responsibilities and reporting arrangements of the Committee and shall have effect as incorporated into the Constitution and Standing Orders.

This committee did not meet during the 2018/2019 year.

UK Corporate Governance Code NHS Bodies are 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.

Discharge of Statutory Functions In light of recommendations of the 1983 Harris Review, the Clinical Commissioning Group has reviewed all of the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. As a result, I can confirm that the Clinical Commissioning Group is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions.

Responsibility for each duty and power has been clearly allocated to a lead Director. Directorates have confirmed that their structures provide the necessary capability and capacity to undertake all of the Clinical Commissioning Group’s statutory duties.

Risk management arrangements and effectiveness An internal audit was undertaken, by Mersey Internal Audit Agency on our risk management arrangements. The Audit assigned limited assurance to the risk management arrangements in place. The audit found that overall there was a need to strengthen the risk management arrangements. An action plan was put in place and all actions required to mitigate the risk have now been completed.

The Risk Management Policy was due to be reviewed and therefore a completely refreshed Risk Management Policy, Procedure and Toolkit has been developed to address some of the recommendations outlined within the report. The Policy was ratified by our Governing Body in March 2019. The Policy includes roles and responsibilities for all staff within the CCG.

An action which has been identified going forward in 2019/20 is the need for the CCG to develop its risk appetite. A section has been included in the updated Risk Management Policy, which is to be populated once the Governing Body has met to agree its risk appetite. It is expected that this will be complete in Quarter 2 in 2019/20.

Risk reports are presented on a monthly basis to the Integrated Management Team where any issues or concerns about mitigation of risks are discussed. Risk reports are also presented to the relevant Committee to provide oversight to the Committee on all risks identified, which are associated with the terms of reference of the Committee. This provides assurance to each Committee that risks are being managed appropriately and in the event of the Committee requiring further information, lead owners are asked to provide update reports to the Committee with further detail on the issue.

Another development to the risk report is the introduction of a dashboard, which tracks all risks from month to month to show the risk score and any increase or decrease in this. This helps to identify the length of time a risk is open as well as monitoring any change in risk score and the reasons for the change.

Within the new Risk Management Policy, Procedure and Toolkit, key performance indicators (KPIs) have been identified which will support the monitoring of compliance with the Policy. Regular reports will be provided on compliance with KPIs to the Integrated Management Team, relevant Committee with regular summaries being presented on all identified risks to the Audit Committee.

The updated Policy also includes the frequency of reporting of strategic and operational risks to committees and the Governing Body.

Within the updated Policy, the risk matrix now includes scoring for opportunities as well as threats, which has been used successfully to support the identification of opportunities for the previous financial recovery plan. The new risk table is shown below for identification of impact:

Threat Risk Matrix Opportunity Consequence 1 2 3 4 5 5 4 3 2 Very 1 Likelihood Insignificant Minor Moderate Major Catastrophic Exceptional substantial Substantial Minor Not substantial 5 Almost 5 10 15 20 25 certain 25 20 15 10 5 4 Likely 4 8 12 16 20 20 16 12 8 4 3 3 6 9 12 15 Possible 15 12 9 6 3 2 Unlikely 2 4 6 8 10 10 8 6 4 2 1 Rare 1 2 3 4 5 5 4 3 2 1

All risks on the risk register were reviewed as part of the review of the arrangements to ensure that they were described and scored appropriately.

The CCG involves public stakeholders in the identification, management and monitoring of risk, where applicable. The CCG works proactivity with Halton Healthwatch and other organisations through the CCGs engagement channels to seek insight into local services. During 2018/19, the CCG, along with Healthwatch Halton undertook work to obtain insight from parents and carers of young people accessing children’s services in relation to the Woodview Child Development Centre. This insight was fed back via the CCG Engagement and Involvement Group, which reports to the CCG Quality Committee and was utilised by commissions in line with provider quality contract discussions.

In addition, the CCG has an accredited Anti-Fraud Specialist who is contracted in from Mersey Internal Audit Agency. The CCG agree a fraud, bribery and corruption risk-based plan of anti-fraud activity at the beginning of each financial year and the Anti-Fraud Specialist completes a range of work to meet the NHS Counter Fraud Authority Standards for Commissioners. The work, including any fraud investigations, is regularly monitored by the CCG’s Audit Committee via progress

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reports and at year end via the Annual Anti-Fraud Report. The CCG is undertaking a review of any fraud related risks for addition to the risk register.

Capacity to Handle Risk The updated Risk Management Policy includes a section on roles and responsibilities. The Policy also identifies that committees have a role for overseeing risk reports and to receive assurance that risks have been mitigated appropriately. The Audit Committee is responsible for understanding and scrutinising the CCG overarching framework for governance, risk and control. This includes risk management and performance management systems underpinned by the assurance framework.

The Audit Committee supports the Governing Body by:

• Obtaining assurances about controls and whether they are working as they should; • Seeking assurances about the underlying data, to ensure it is reliable, robust and accurate; • Putting challenge in the system if assurances are poor or unreliable or when controls are not working

The Audit Committee receives regular updates from lead owners for all strategic risks, whereby the above can be applied, if appropriate and necessary.

The Institute of Risk Management was procured to facilitate a “Fundamentals of Risk Management” two-day course in November 2018. A lead was identified for each team to attend, to ensure that the learning was disseminated across the organisation. These champions will also be expected to support staff within their team to identify and manage risk, where necessary.

Internal training sessions have also been delivered to staff throughout the year to raise awareness of risk management and the process to follow. These sessions will continue to be delivered as part of an ongoing programme.

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Risk management e-learning has now been approved as a mandatory training session for all staff and there will be a requirement for all staff to complete this training every two years with effect from April 2019.

As part of the launch of the new Policy, a training programme will also be delivered to support the implementation of the Policy. This will be implemented with effect from April 2019 onwards.

Risk Assessment The Risk Management Policy outlines the various sources to support the identification of risk. These include, but are not limited to:

• Strategic objectives • Business continuity disruptions • Projects • Internal audit • Complaints • Mandatory and statutory targets • Health and Social Care Act Regulations • Consultation with patients, service users and staff

A range of risks have been identified throughout the year, with actions put in place to mitigate the risk. The table below shows the number of risks identified and the associated risk score and actions taken to mitigate the risk.

Number of risks by risk score

High (15-25) Medium (6-12) Low (1-5)

1 27 1

High rated risk

Risk description Actions to mitigate risk

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As a result of the number of serious • Await outcome of Royal College incidents reported involving spinal surgery in of Surgeons review the service, long waiting times within the • Report any further breaches of service, non - compliance with NICE NHS Constitution guidance for spinal injections, resulted in • Monitoring of media activity • Redesign of service following voluntary suspension of complex spinal options appraisal surgery and the receipt of a notification to • Monitoring of waiting lists and suspend all surgery on the grounds of transfer lists patient safety

An area of development for risk management in the year 2018/19 was to ensure robust action plans were in place to mitigate all risks. This work was started in year and has now been completed; robust action plans are now in place to mitigate all risks.

As part of the review of risk management and assurance provided, it was agreed that any recommendations arising from internal audits, conducted by Mersey Internal Audit Agency (MIAA) are converted into risks and placed on the Corporate Risk Register. This allows full oversight and monitoring of the completion of recommendations through to closure.

An exercise was undertaken in year to identify any outstanding recommendations from internal audits. These have been converted into risks and will be monitored via the risk register process going forward.

Other sources of assurance Internal Control Framework A system of internal control is the set of processes and procedures in place 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.

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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.

We have a set of processes and procedures in place to ensure we deliver our policies, aims and objectives and this is audited internally. The governance structure and sub committees comprise of a mix of senior managers, clinical professionals, independent lay members and internal audit representation to provide an effective balance and to ensure that decision making is effectively triangulated.

Internal audit provides us with an unbiased identification of actions required to reduce risk and follow best practice guidance. Below is a summary of reports receiving this year and the assurance/requirements provided:

Review Title Assurance Level Risk Management Arrangements Limited Third Party Financial Services Review Substantial Financial Systems, Reporting and Integrity Substantial Data Protection and Security Toolkit Substantial Safeguarding Children Substantial Primary Care Co-Commissioning Review Substantial

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Annual audit of conflicts of interest management The revised statutory guidance on managing conflicts of interest for CCGs (published July 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.

We undertook an annual audit review 2018/2019. The following compliance levels were reported:

Scope Area Compliance Level Governance Arrangements Partially Compliant Declarations of Interests and Gifts and Hospitality Partially Compliant Register of interests, gifts and hospitality, Partially Compliant sponsorship and procurement decisions Decision making processes and contract monitoring Partially Compliant Identifying and managing breaches / noncompliance Fully Compliant

An action plan has been developed to address the areas of partial compliance. Some of the key actions which are being addressed include:

• Documentation to reflect the implementation of the MES System • Implementation of process to highlight to staff the need to complete mandatory training and monitoring of this by the Management Team • Register of Interest to be continually updated on our website • Update of the Gifts and Hospitality Register is required • Minutes for all meetings should include reference to any conflicts of interest that are declared and how they are managed

Data Quality

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Data Quality assurance is provided by Data Services for Commissioners Regional Offices (DSCRO), Arden and Greater East Midlands Commissioning Support Unit, for our secondary care data reports and St Helen’s and Knowsley Health Informatics System for our primary care data reports. DSCRO undertake a validation and reconciliation process of all SUS and SLAM data against a set of control algorithms and in line with NHS Digital and the NHS standards contract requirements. The CCG receives alerts and monthly reports demonstrating any related data quality issues.

Any significant unresolved issues identified relating to the quality of data is risk assessed and discussed at Governing Body if relevant.

Information Governance 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 we 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 information governance handbook to ensure staff are aware of their information governance roles and responsibilities.

There are processes in place for incident reporting and investigation of serious incidents. We are developing information risk assessment and management procedures and a programme will be established to fully embed an information risk culture throughout the organisation against identified risks.

Business Critical Models We have produced and maintain an organisational Information Asset Register which identifies business critical assets for each service within the organisation, including the shared finance service and hosted services. Information Asset Owners and Information Asset Administrators have been assigned and all information assets are under review to ensure they are recorded correctly. The SIRO is responsible for 106

identifying and managing the information risks and the Caldicott Guardian oversees risk relating to patient data. We are supported through a contract arrangement with Midlands & Lancashire Commissioning Support Unit.

Data Flow mapping has been completed which enables an understanding of the flows of information related to all information assets with the Information Asset Register. Information Asset Owners are responsible for providing updates and highlighting any risks to the SIRO. We receive our IT services from St Helens & Knowsley Health Informatics Service. There is a joint Service Level Agreement between the parties who have agreed to share their health informatics service with the intention of pooling their collective resources and expertise in order to ensure that they have the capacity, capability and flexibility required for 21st century health informatics service. The partner organisations are committed to ensuring that their shared informatics service provides value for money for their respective organisations.

We are represented on the Partnership Board that is responsible for the oversight of the service and has both clinical and managerial representation on the sub-group of the Board.

Third party assurances We receive a level of commissioning support through the local Commissioning Support Unit and a neighbouring CCG. The services provided are delivered in line with a clear service specification and performance is monitored and managed through a lead manager and local managerial links. Regular performance reviews and communication meetings enables us to ensure the effectiveness of the provision. There are no identified issues currently.

Control issues Absence of the CCG Chair since June 2018, as reported previously to NHS England. The CCG appointed the Chair of the Audit Committee as an interim chair and, to manage governance issues with the joint role, appointed the Vice Chair of the Audit Committee as the interim Chair of that Committee.

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NHS Halton CCG does not consider the above issue to be a significant control issue. Advice was sought from Mersey Internal Audit Agency (MIAA) regarding the acceptability of this interim arrangement. The previous CCG Chair resigned in March 2019 and the interim Chair is still undertaking this role. NHS Halton CCG is now working with the CCG membership to appoint a new substantive Chair.

The other declaration made was identified as :

Bridgewater Community Healthcare Foundation Trust (BCHFT) on enhanced quality surveillance. Supported by NHS England via the Collaborative Commissioning Forum (CCF). This Forum has been established to guide the Quality Surveillance Group (QSG) in supporting the achievement of quality improvement requirements. The CCG’s Chief Nurse is coordinating the approach.

NHS Halton CCG does not consider the above issue to be a significant control issue. Following the development of the CCF and a robust performance monitoring107 process, the Trust has been removed from enhanced surveillance onto routine monitoring.

Review of economy, efficiency & effectiveness of the use of resources We have in place a robust decision-making framework that enables thorough review and scrutiny of the way our resource allocation is utilised. All investment proposals are initially submitted to the Clinical Advisory Group (CAG), a multi-disciplinary forum that assesses the clinical case for change, the evidence base, the link to our strategic objectives as well a critical clinical analysis of what is being proposed.

If recommended by the CAG, our Commissioning Oversight Group (COG) develops the full business case ensuring input from all other relevant commissioning support functions (e.g. BI, finance, procurement, contracting, quality and legal). The full business case is then submitted to the Performance and Finance Committee (P&F) for approval.

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Within the amounts delegated by our Governing Body, the P&F committee is responsible for prioritising our investments based on affordability and the likely return on investment to ensure we can secure the greatest benefit from the limited resources available. Business cases requiring funding in excess of the committee’s financial limits are reserved for the Governing Body. All business cases are subject to equality and quality impact assessments.

The Performance and Finance committee provides assurances to the Governing Body that the arrangements in place are robust and ensure that we are managing our resources in an effective manner.

We participate in monthly provider contract meetings to ensure that providers are delivering as per the services specified in the contract and activity is in-line with agreed finance and activity planning schedules. In the event of unplanned overperformance, activity management plans are requested in line with contract requirements and are routinely reported to the Performance and Finance Committee and Governing Body.

We have successfully implemented a challenging Quality, Innovation, Productivity and Prevention (QIPP) programme that compromises schemes aimed at reducing spend, whilst improving quality, within planned care, unplanned care, prescribing. Other ad- hoc schemes aimed at reducing operational spend to an optimum level have been implemented in-year. Delivery of these programmes is underpinned by a robust Programme Management Office (PMO) that has been strengthened during 2018/1209.

The Governing Body has clear oversight of performance through bi-monthly corporate performance reports that track our progress against NHS Constitutional Standards, the Improvement and Assessment Framework indicators, the quality of leadership assessment and other organisational priorities. This is also supported by detailed finance reports to each Governing Body meeting, along with key issues reports from each of the Governing Body’s sub committees.

Composition of our Governing Body and sub committees can be found on page 86.

Delegation of functions

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We use service organisations to carry out certain business functions on its behalf, for example, financial accounting and payroll. Assurance over the internal controls and procedures operated by these services is provided through a Service Auditor Report (prepared in accordance with International Standards on Assurance Engagements).

We have an accredited Anti-Fraud Specialist who is contracted in from the Mersey Internal Audit Agency. We agree a plan of anti-fraud activity at the beginning of each financial year and the Anti-fraud Specialist completes the work to meet the NHS Counter Fraud Authority (formally NHS Protect) Standards for Commissioners. The work is regularly monitored by our Audit Committee via progress reports and at year end via the Annual Anti-fraud Report.

Counter fraud arrangements We have anti-fraud arrangements in place in line with the NHS Counter Fraud Authority Standards for Commissioners: Fraud, Bribery and Corruption.

The key features of our arrangements are:

• An Accredited Anti-Fraud Specialist is contracted from Mersey Internal Audit Agency to undertake anti-fraud work that is proportionate to identified risks contained within the Annual Plan for the financial year.

• Our Audit Committee receives a report against each of the Standards for110 Commissioners annually. There is executive support from the Governing Body via the Chief Financial Officer for a proportionate proactive work plan to address identified risks that demonstrates corporate responsible for tackling fraud, bribery and corruption.

• During this and previous financial years, we have not been chosen for any NHS Counter Fraud Authority Quality Assurance Inspections therefore have no recommendations to implement or follow up

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Head of Internal Audit Opinion

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

Substantial assurance can be given that there is a good system of internal control designed to meet the organisation’s objectives and that controls are generally being applied consistently.

Internal Audit Annual Report & Head of Internal Audit Opinion 2018/19

NHS Halton Clinical Commissioning Group

1. Introduction The purpose of this Head of Internal Audit Opinion is to contribute to the assurances available to the Accountable Officer and the Governing Body which underpin the Governing Body’s own assessment of the effectiveness of the organisation’s system of internal control. This Opinion will assist the Governing Body in the completion of its Annual Governance Statement (AGS), along with considerations of organisational performance, regulatory compliance, the wider operating environment and health and social care transformation. This opinion is provided in the context that the CCG like other organisations across the NHS is facing a number of challenging issues and wider organisational factors.

2. Executive Summary This annual report provides the 2018/19 Head of Internal Audit Opinion for NHS Halton CCG, together with the planned internal audit coverage and output during 2018/19 and MIAA Quality of Service Indicators.

Key Area Summary

Head of Internal The overall opinion for the period 1st April 2018 to 31st March 2019 Audit Opinion provides Substantial Assurance, that that there is a good system of internal control designed to meet the organisation’s objectives, and that controls are generally being applied consistently.

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Key Area Summary Planned Audit The 2018/19 Internal Audit Plan has been delivered in accordance Coverage and with the schedule agreed with the Audit Committee at the start of Outputs the financial year, including approved plan variations. This position has been reported within the progress reports across the financial year, with the final report concluding completion of the Internal Audit Plan. Review coverage has been across governance and leadership, financial performance and financial sustainability, quality, and information and technology. We have raised 28 recommendations as part of the reviews undertaken during 2018/19. All recommendations raised by MIAA have been accepted by management. MIAA has continued to undertake follow up reviews during the course of year. MIAA operate systems to ISO Quality Standards. The External MIAA Quality of Quality Assessment, undertaken by CIPFA, provides assurance of Service Indicators MIAA’s compliance with the Public Sector Internal Audit Standards.

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3. Head of Internal Audit Opinion 3.1 Roles and responsibilities The whole Governing Body is collectively accountable for maintaining a sound system of internal control and is responsible for putting in place arrangements for gaining assurance about the effectiveness of that overall system. The Annual Governance Statement (AGS) is an annual statement by the Accountable Officer, on behalf of the Governing Body, setting out: • how the individual responsibilities of the Accountable Officer are discharged with regard to maintaining a sound system of internal control that supports the achievements of policies, aims and objectives; • the purpose of the system of internal control as evidenced by a description of the risk management and review processes, including the Assurance Framework process; and • the conduct and results of the review of the effectiveness of the system of internal control, including any disclosures of significant control failures together with assurances that actions are or will be taken where appropriate to address issues arising. The organisation’s Assurance Framework should bring together all of the evidence required to support the AGS requirements. In accordance with Public Sector Internal Audit Standards, the Head of Internal Audit (HoIA) is required to provide an annual opinion, based upon and limited to the work performed, on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes (i.e. the organisation’s system of internal control). This is achieved through a risk-based plan of work, agreed with management and approved by the Audit Committee, which can provide assurance, subject to the inherent limitations described below. The outcomes and delivery of the internal audit plan are provided in Section 4. The opinion does not imply that Internal Audit has reviewed all risks and assurances relating to the organisation. The opinion is substantially derived from the conduct of risk-based plans generated from a robust and organisation-led Assurance Framework. As such, it is one component that the Governing Body considers in making its AGS.

3.2 Opinion Our opinion is set out as follows:

• Basis for the opinion • Overall opinion • Commentary

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3.2.1 Basis The basis for forming our opinion is as follows:

Basis for the Opinion

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

2. An assessment of the range of individual assurances arising from our risk-based internal audit assignments that have been reported throughout the period. This assessment has taken account of the relative materiality of systems reviewed and management’s progress in respect of addressing control weaknesses identified.

3. An assessment of the organisation’s response to Internal Audit recommendations, and the extent to which they have been implemented.

3.2.2 Overall Opinion Our overall opinion for the period 1st April 2018 to 31st March 2019 is:

High Assurance, can be given that there is a strong system of internal control which has been effectively designed to meet the organisation’s objectives, and that controls are consistently applied in all areas reviewed.

Substantial Assurance can be given that that there is a good system of internal  control designed to meet the organisation’s objectives, and that controls are generally being applied consistently.

Moderate Assurance, can be given that there is an adequate system of internal control, however, in some areas weaknesses in design and/or inconsistent application of controls puts the achievement of some of the organisation’s objectives at risk.

Limited Assurance, can be given that there is a compromised system of internal control as weaknesses in the design and/or inconsistent application of controls impacts on the overall system of internal control and puts the achievement of the organisation’s objectives at risk.

No Assurance, can be given that there is an inadequate system of internal control as weaknesses in control, and/or consistent non-compliance with controls could/has resulted in failure to achieve the organisation’s objectives.

3.3.3 Commentary The commentary below provides the context for our opinion and together with the opinion should be read in its entirety. 115 Our opinion covers the period 1st April 2018 to 31st March 2019 inclusive and is underpinned by the work conducted through the risk based internal audit plan.

Assurance Framework

The organisation’s Assurance Framework is structured to meet the NHS requirements, could be more visibly used by the Governing Body and clearly reflects the risks discussed by the Governing Body.

Conflicts of Interest As required by NHS England’s Managing Conflicts of Interest: Revised Statutory Guidance for CCGs (June 2017), an audit of conflicts of interest was completed following the prescribed framework issued by NHS England. The following compliance levels were assigned to each scope area:

Scope Area Compliance Level RAG rating

1. Governance Arrangements Partially Compliant ⚫

2. Declarations of interests and gifts Partially Compliant ⚫ and hospitality 3. Register of interests, gifts and Partially Compliant ⚫ hospitality and procurement decisions 4. Decision making processes and Partially Compliant ⚫ contract monitoring 5. Reporting concerns and identifying Fully Compliant ⚫ and managing breaches / noncompliance

Primary Medical Care Commissioning and Contracting Arrangements The Primary Medical Care Commissioning and Contracting Internal Audit Framework for Delegated CCGs was issued in August 2018. NHSE require an Internal audit of delegated CCGs primary medical care commissioning arrangements. The purpose of this is to provide information to CCG’s that they are discharging NHSE’s statutory primary medical care functions effectively, and in turn to provide aggregate assurance to NHSE and facilitate NHSE’s engagement with CCGs to support improvement.

The 2018/19 Primary Medical Care Commissioning and Contracting review focused upon Governance and provided Substantial (assurance rating provided as per the NHSE guidance).

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Risk Based Reviews We issued

No high assurance opinions: Finance Shared Service Review Five substantial assurance opinions: Financial Systems Review Safeguarding Children – Process Review Primary Medical Care Commissioning and Contracting Arrangements Data Protection and Security Toolkit N/a No moderate assurance opinions: Risk Management Review One limited assurance opinion:

N/a No no assurance opinions:

We raised no critical and 1 high risk recommendations in respect of the above assignments. The high-risk recommendation was in relation to the Risk Management review.

Follow Up During the course of the year we have undertaken follow up reviews and can conclude that the organisation has made good progress with regards to the implementation of recommendations. We will continue to track and follow up outstanding actions.

Wider organisation context This opinion is provided in the context that the Governing Body like other organisations across the NHS is facing a number of challenging issues and wider organisational factors.

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Financial Sustainability Annual Assessment • The CCGs financial plan has been rated • The CCG has been rated as requires as Amber by NHS England. improvement by NHS England in its • The CCG has a challenging QIPP. The annual assessment of performance CCG is anticipating that this will not be against key performance indicators. fully achieved.

NHS Halton CCG

Leadership Provider Performance • The CCG has continued to regularly • Senior management within the CCG has report providers’ performance against a been subject to some change during range of targets. The CCG’s primary 2018/19 with a new Interim Clinical Chief provider has consistently met the targets Officer being appointed and the new joint for RTT and diagnostic waiting times but working arrangements for the Senior has struggled to maintain required Management Team. performance levels for A&E waiting times. •

The CCG is part of the Cheshire & Mersey Health and Care Partnership, working in partnership to deliver transformation across the health system. An Integrated Care Partnership has been established, One Halton. This is inclusive of all local NHS organisations, Local authority and third sector. One Halton involves joining up all the services that deliver care and wellbeing to the people of Halton to ensure they have the right support, at the right time, in the right way to provide the best possible outcomes. In providing this opinion I can confirm continued compliance with the definition of internal audit (as set out in your Internal Audit Charter), code of ethics and professional standards. I also confirm organisational independence of the audit activity and that this has been free from interference in respect of scoping, delivery and reporting. Tim Crowley Head of Internal Audit, MIAA March 2019

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4. Internal Audit Coverage and Outputs The Internal Audit Plan has been delivered in accordance with the schedule agreed with the Audit Committee at the start of the financial year. This position has been reported within the progress reports across the financial year, with the final report concluding completion of the Internal Audit Plan. Of the reviews completed in the year, assurance ratings were given in 6 cases. Assurance rating were not applicable 2 reviews, due to the nature of this work. The audit assignment element of the Opinion is limited to the scope and objectives of each of the individual reviews. Detailed information on the limitations (including scope and coverage) to the reviews has been provided within the individual audit reports and through the Audit Committee Progress Reports throughout the year. A summary of the reviews performed in the year is provided below:

Recommendations Raised Assurance Review Opinion Uncla Critical High Medium Low Total ssified

1 Assurance Framework N/A N/A N/A N/A N/A N/A 2 Risk Management Limited 1 2 2 5 3 Finance Shared Service Substantial 2 2 Review 4 Financial Systems Substantial 2 2 Review 5 Safeguarding Children – Substantial 4 2 6 Process Review 6 Primary Medical Care Substantial 2 2 4 Commissioning and Contracting Arrangements 7 Data Security and Substantial Protection Toolkit 8 Conflict of Interest N/a 9 9 Review TOTAL 1 12 6 9 28

All recommendations raised were accepted by management. We will continue to follow up progress against all recommendations as part of the 2019/20 Internal Audit Plan.

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ADVISORY SUPPORT AND GUIDANCE: Areas where MIAA have supported the organisation in strengthening arrangements in respect of governance, risk management and internal control. Support in relation to conflict of interest. Specifically looking to establish whether conflicts have been identified and managed in accordance with the CCG Conflict of Interest Policy where members of the Governing Body also have an affiliation with a local Federation.

CONTRIBUTION TO GOVERNANCE, RISK MANAGEMENT AND INTERNAL CONTROL ENHANCEMENTS: Additional areas where MIAA have provided added value contributions. Detailed insight into the overall Governance and Assurance processes gained from liaison throughout the year with the Senior Management Team, regular review of Governing Body papers and discussion to support the ongoing development of the Assurance Framework. Ongoing discussion with lead Officers and Managers throughout the year. Specific audit review of third-party assurances to the CCG (e.g. Western Cheshire Shared Financial Service). Effective utilisation of internal audit including in year communication, and changes to the audit plan in respect of the Primary Care Co Commissioning review.

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Contribution through MIAA Insights

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5. Areas for consideration – your Annual Governance Statement The Head of Internal Audit Opinion is one source of assurance that the organisation has in providing its AGS other third-party assurances should also be considered. In addition, the organisation should take account of other independent assurances that are considered relevant. We have identified a number of other strategic challenges that should be considered by the Governing Body when drafting the AGS. Whilst the scope of the Internal Audit Plan would have considered elements of these, it is important that the Governing Body reflects more widely on how these should be factored into the AGS. Areas for consideration include: • Wider partnership working and engagement as part of the Cheshire and Mersey Health and Care Partnership (Region) and ICS (Place) level, including the development of One Halton as part of an integrated commissioning approach with the local authority. • Continued establishment and delivery of cross-organisation arrangements for the Better Care Fund and other pooled budget developments. • Organisation performance, including challenges in achieving financial duties, ongoing financial viability, delivery of QIPP, service pressures and key relationships with and performance of Providers. Alongside this the CCG needs to consider the implications of the NHS long term plan, including the new financial framework. • Outcomes form external governance reviews, and assessment and feedback from the NHS England Improvement and Assessment Framework processes in year. • Ongoing development of the Governing Body and its Membership throughout the year. • Any implications relating to in year changes to the Executive and new joint working arrangements with the Senior Management Team. • Relationship and management of 3rd party providers upon which the Clinical Commissioning Group places reliance, and the provision of assurances from these (including Commissioning Support Unit, SBS and McKesson). • Communication and engagement with the membership, key stakeholders and other partners. • Information governance arrangements, risks and any associated incidents relating to Patient Identifiable Data. • Workforce capacity, engagement and development. • Cyber security, information governance risks and any associated reportable incidents to the Information Commissioner.

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6. MIAA quality service indicators MIAA’s strategy has quality at the heart of everything we do and our overall approach to quality assurance includes ISO9001:2015 accreditation, compliance with Public Sector Internal Audit Standards, the quality of our people and outcome measures.

6.1 Externally accredited quality systems Since 1992 we have held ISO9001:2015 quality certification for our audit process. This includes, but is not limited to, the scoping, conduct and review of audit assignments and is independently assessed every year. The MIAA Audit (Quality) Manual defines the operational procedures and processes within which all our work is delivered. Audit work is supervised, reviewed and signed off at each stage prior to review by the Audit Manager for overall quality assurance and reporting. As part of the quality control process “coaching notes” are raised electronically on the audit assignment working paper file to ensure the assignment is delivered to the highest standard. In addition, Audit Committee Reports are subject to Quality Assurance at Director Level. The latest confirmation of our ongoing ISO9001:2015 accreditation was received in 2018.

6.2 Compliance with Internal Audit Standards MIAA comply fully with professional best practice, internal audit standards and legal requirements. We assess our compliance with the Public Sector Internal Audit Standards (PSIAS) each year.

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Internal Audit MIAA Compliance Standards 1000 - Purpose, Authority & Responsibility

MIAA undertakes audit work to evaluate and improve the effectiveness of risk management, control and governance processes. An annual Director of Audit Opinion is provided to support the Annual Governance Statement.

1100 - Independence & Objectivity

MIAA is managed independently from, and with no executive responsibilities for, the audited body. MIAA have direct access to the

Audit Committee Chair and are represented at meetings. All MIAA staff complete an annual declaration of interest, including actions taken to mitigate these.

1200 - Proficiency & Due Professional Care Professional care is monitored and achieved through compliance with MIAA’s quality and review systems. The Director of Audit is a CCAB Qualified accountant and MIAA’s staff are either fully or part qualified (including CCAB, IIA, CISA, QICA, and LCFS).

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Internal Audit MIAA Compliance Standards 1300 - Quality Assurance & MIAA have accreditations for systems, processes and training. We Improvement are ISO9001:2015 quality assessed, Investors in People, Finance Skills Development (Level 2) and training accreditations with CCABs. All reports follow a strict quality assessment process.

MIAA have a defined approach for risk assessment, planning, 2000 - Managing the performance and reporting. Three-year risk-based audit plans are Internal Audit developed for our client organisations, with regular progress reported Activity to the Audit Committee. MIAA’s internal audit activity evaluates and contributes to the improvement of governance, risk management and internal control. 2100 - Nature of There is regular liaison with the Local Counter Fraud Specialist, Work External Auditor and other review bodies to facilitate effective coordination of work. MIAA’s work is structured to comply with Department of Health and Social Care and NHS Improvement requirements and the role as 2200 - Engagement defined in the Audit Committee Handbook. We establish risk-based Planning audit plans in conjunction with the organisation and with the approval of the Audit Committee. Terms of Reference are established and agreed for each review, including objectives, scope, timing and resource allocations. MIAA 2300 - Performing staff identify, analyse, evaluate and document sufficient information the Engagement to achieve the assignment objectives. All assignments are properly supervised. MIAA communicate the results of each assignment. Working with the 2400 - organisation, the Director of Internal Audit ensures that Communicating communications are accurate, objective, clear, concise, constructive, Results complete and timely. MIAA establish follow up processes to monitor and ensure that management actions have been effectively implemented or that 2500 - Monitoring senior management has accepted the risk. This is operated alongside Progress the organisations own management follow up and provides independent assurance to the Audit Committee. 2600 – MIAA recognise the professional role of Internal Audit to challenge Communicating the the level of risk accepted by management, support resolution and Existence of Risks ensure transparency in reporting to Audit Committee.

Independent confirmation of our compliance with professional standards is required every 5 years and is provided through our External Quality Assessment.

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“From the evidence reviewed as part of the External Quality Assessment, no areas of noncompliance with the standards have been identified that would affect the overall scope or operation of the internal audit activity, nor any significant areas of partial non-compliance.

On this basis it is our opinion that Mersey Internal Audit Agency conforms to the requirements of the Public Sector Internal Audit Standards.”

MIAA EQA, CIPFA, 2016

6.3 Quality of our staff The majority of MIAA’s staff are qualified or progressing towards qualification, with either CCAB bodies (e.g. CIPFA, ACCA, ICAEW) or the IIA or relevant specialist qualification. The high quality of the staff that deliver your Internal Audit service ensures that we have a clear focus on providing the quality of work that is required to add value to you. All of our senior team that work at the CCG are CCAB/CIIA qualified and we ensure at least 65% of the work is delivered by qualified staff. Since 1994 we have been an Investor in People. We are accredited to Finance Skills Development (FSD) Level 2 and have successfully gained training and CPD accreditations with all CCAB bodies. We were short-listed for the Public Finance Innovation Award 2017 in the category for “Finance Training & Development Initiatives” and in 2018 won the HFMA “Governance Award” in partnership with the Northern Care Alliance.

6.4 Service delivery and outcome measures It is important that client organisations ensure an effective Internal Audit Service, and whilst input and process measures offer some assurance, the focus should be on outcomes and impact from the service. The figure below confirms the measures that we believe demonstrate an effective service to you.

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(i) (ii) MIAA regularly report on input and process KPIs as part of our Audit Committee Progress reports, and the impact and effectiveness measures can be assessed through the HOIA Opinion.

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

Review Assurance opinion Assurance Framework The organisation’s Assurance Framework is structured to meet the NHS requirements, could be more visibly used by the Governing Body and clearly reflect the risks discussed by the Governing Body. Risk Management Limited Finance Shared Services Substantial Financial Systems Review Substantial Safeguarding Children - Process Substantial Review

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Primary Care Commissioning and Substantial Contracting Arrangements Date Security and Protection Toolkit Substantial Conflicts of Interest Review Governance Arrangements - Partially compliant Declarations of interest and gifts and hospitality - Partially compliant Register of interests, gifts and hospitality and procurement decisions - Partially compliant Decision making processes and contract monitoring - Partially compliant Reporting concerns and identifying and managing breaches/noncompliance - Fully compliant

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Review of the effectiveness of governance, risk management and internal control

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

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

We have continued to strengthen our process for managing risk by ensuring that all risks are highlighted in a report to the relevant committee, each time the committee meets. This is to ensure that the committee has full oversight of all risks relating to the committee and be assured of the progress of actions to mitigate the risks.

The risk register is also presented each month for discussion at Management Team meetings. This includes an overview of risks which have been identified through committee meetings, but which have not yet been placed on the risk register and also provides an opportunity to review those risks where there have been slippages in timescales to achieve specific actions. This process has become fully embedded as the year has progressed.

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

In conclusion, there are no significant internal control issues have been identified.

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Remuneration and Staff Report (subject to audit)

Remuneration Report Remuneration Committee Our Remuneration Committee has recommended to their Governing Body the remuneration and terms of service for the Clinical Chief Officer, Chair, Chief Finance Officer and members of our Management Team to ensure they are fairly rewarded for their individual contribution to the organisation.

These recommendations are in accordance within the requirements of the nationally developed framework for Very Senior Managers. Advice to our Governing Body on such remuneration includes all aspects of salary, provisions for other benefits including pensions as well as arrangements for termination of employment and other contractual terms.

Additionally, the Remuneration Committee:

• Make recommendations to the Governing Body on the remuneration, allowances and terms of service of other officer members to ensure they are fairly rewarded for their individual contribution to the organisation

• Monitor and evaluate the performance of individual and other members of the senior management team and;

• Advise on, and oversee, appropriate contractual arrangements for such staff including the proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate

Composition and Membership of the Remuneration Committee The membership comprises of two Lay Members, the Governing body Registered Nurse and a Governing Body practice manager representative

The committee is established in accordance with NHS Halton Clinical Commissioning Group’s (the CCG) Constitution, Standing Orders and Scheme of Delegation.

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The terms of reference set out the membership, remit, responsibilities and reporting arrangements of the Committee.

Further details relating to the attendance and frequency at meetings can be found from page 89 of this report.

Independent Human Resources advice and guidance is provided by the Head of Human Resources through the service level agreement in place with the Midlands and Lancashire Commissioning Support Unit and, if required, ad hoc external subject matter expert consultancy. This ad-hoc advice relates to legislative employee matters and benchmarking of NHS salaries not included in the service level agreement.

Most of our support staff are employed on Agenda for Change terms and conditions. For other appointments such as Clinical Chief Officer, Chair, Chief Finance Officer, Lead Nurse and GP Governing Body Members, remuneration is based on HAY Group guidance.

Where members of staff are not on Agenda for Change, local agreements are in place, for example GP leads; agreement with respect to salary is based on independent HR advice as cited above in relation to terms and conditions.

The Committee’s role is to oversee and agree the remuneration and Terms of Service of the Clinical Chief Officer, our Management Team of the Governing Body, together with any staff whose terms of service are not covered by the national agreements. It provides advice to the Governing Body on a range of employment issues for all staff (for example pensions and termination of employment).

The committee is established in accordance with our Constitution and scheme of delegation.

Policy on the remuneration of senior managers The remuneration awarded to our senior managers is not subject to the achievement of defined performance conditions.

Remuneration of Very Senior Managers have been set by our Remuneration Committee in accordance with the requirements

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of the DH Pay Framework for Very Senior Managers (2013) and Hay Group recommendations. The remuneration for these roles, pro rata, exceeds £142,500.

The remuneration awarded to our senior managers is not subject to the achievement of defined performance conditions.

Senior manager remuneration (including salary and pension entitlements)

8500

**Note: Taxable expenses and benefits in kind are expressed to the nearest £100

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Comparative Governing Body Remuneration detail for the 2017/2018 financial year is below:

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Pension benefits as at 31 March 2019 All employees have access to and are entitled to join the NHS Pension Scheme that provides pensions on a final salary basis. There are no employees who have stakeholder pensions in place of being a member of the NHS pension scheme.

Pension benefits for Senior Employees in 2018/2019 are detailed in the table below:

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Pension Costs Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. Both are unfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State for Health in England and Wales. They are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, each scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each scheme is taken as equal to the contributions payable to that scheme for the accounting period.

In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of these follows: a) 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.

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b) 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 latest actuarial valuation undertaken for the NHS Pension Scheme was completed as at 31 March 2016. The results of this valuation set the employer contribution rate payable from April 2019. 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.

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 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 membership of the pension scheme. This may be for more than just their service in a senior capacity to which disclosure applies (in which case this fact will be noted at the foot of the table). The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme.

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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 effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, 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.

Compensation on early retirement or loss of office There has been no compensation on early retirement or loss of office in year.

Payments to past members There have been no payments to past members in year.

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 our Governing Body during the financial year 2018/2019 was £102,500 to £105,000 (2017/18 £165,000 to £170,000). This was 2.55 times (2017/18 4.71 times) the median remuneration of the workforce, which was £40,123 (2017/18 £35,577). This was due to the full value of the WTE used in 2017/18

In 2018/2019, no employees received remuneration in excess of the highest-paid member of the Governing Body.

Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind, but not severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions.

The year-on-year variance in multiples is due to the median calculation, the point at which the median falls, being a higher value than in the previous year.

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Staff Report Our people are our most valuable assets and our staff remain at the centre of what we do.

As a whole team, we meet weekly to receive management updates and provide a means to share updates on work programmes, new reports and guidelines.

A weekly staff e-bulletin is produced to keep everyone informed. Monthly development sessions are held to deliver training and involve staff in our work, vision and values.

We offer flexible/agile working and all staff have been provided with IT equipment to enable them to work from virtually anywhere to support work life balance.

Occupational Health services are key in supporting staff when needed and all staff has access to a full range of occupational health support packages.

What our people say…

I have worked for here since September 2017 and since day one, I have always found my colleagues to be very helpful and supportive. As an organisation, we’ve faced some challenging times (I am sure there will be more to come) but I am confident we can achieve what is required to meet the needs and demands of the population of Halton.

Michelle Cassidy Executive Assistant

I really do have the best job at Halton CCG; I love working with colleagues and most of all the people in the local community to co-design optimal services that truly delivers person centered care. I find my role so rewarding and no two days are the same, every day is different, challenging and exciting. The culture and ethos of the CCG is one that allows employees to grow, and actively encourages innovative ways of working. Despite the future direction of travel and challenges and opportunities this presents, there is a sense that we are working collaboratively with all health and

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social care partners towards an achievable vision for place-based care and I proudly see us making it a reality.

Nicky Ambrose-Miney Senior Commissioning Manager Urgent Care I feel that I am honoured and empowered by working for the CCG. The genesis of this feeling is, I can dispel the dogmatic views about different socio-economic groups especially disabled people. Owen Ashworth Administrative assistant for Communications and Engagement

Number of senior managers For the details of the number of senior managers, please see the staff composition section.

Staff numbers and costs We directly employ 89 people ranging from senior managers to our support staff. We have 1.25 WTE employees who have declared they have a disability.

We pride ourselves on looking our people and we have a range of staff support policies, including flexible working and carers leave. In addition, our approach to agile/flexible working supports our staff to achieve work life balance.

For this information, please see note four of the Annual Accounts. The Annual Accounts can be found from page 152.

Staff composition As at 31st March 2019, our gender analysis is as follows:

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Headcount be gender Staff Grouping Female Male Unknown* Totals Governing Body 4 6 1 11 Other Senior Management (Band 8C+) 11 6 0 17 All Other Employees 61 7 0 68 Grand Total 76 19 1 96 % by Gender Female Male Unknown* 36.4% 54.5% 9.1% 64.7% 35.3% 0.0% 89.7% 10.3% 0.0% 79.17% 19.79% 1.04% *Unknown Gender pertains to Governing Body Members without an entry in the CCG Electronic Staff Record (ESR) system

For staff costs and associated expenses please see Financial Statements notes 4.5 – ‘Employees Benefits and Staff Numbers.’

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We take a supportive approach to managing sickness absence and all staff have access to Occupational Heath support. The Managing Attendance Policy provides a supportive structure for managing periods of sickness absence and supporting staff back to work.

At the end of the March 2019, the rolling sickness absence level was 4.70% (3.88% in 2017/2018). The total number of Whole Time Equivalent day’s absence in the 12- month period was 1,276 days (930.15 days in 2017/2018), equating to a total annual estimated cost of £194.092. There was no Whole Time Equivalent figure detailed 2017/2018.

Further detail in relation to our staffing is included in the Financial Statements for 2018/2019, within note 5 Employee Benefits and Staff numbers.

Sickness absence data At the end of the March 2019, the rolling sickness absence level was 4.70% (3.88% in 2017/2018). The total number of Whole Time Equivalent day’s absence in the 12- month period was 1,242 days (930.15 days in 2017/2018), equating to a total annual estimated cost of £194,092.

No Whole Time Equivalent day’s figure was detailed in the report covering 2017/2018.

Policies applied during the year All operational policies were applied during the year, these include:

• Annual leave • Managing absence • Maternity leave

No formal action in line with HR policies was applied during the year.

Other employee matters We are wholly supportive of partnership working and as such is an active participant in the Staff Partnership Forum facilitated by NHS Midlands and Lancashire Commissioning Support Unit (CSU). We utilise this forum as a vehicle and

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mechanism to support proactive staff engagement, consultation and, where appropriate, negotiation. We do not employ anyone who undertakes relevant union official duties as outlined in the Trade Union (TU) (Facility Time Publication Requirements) Regulations 2017 and therefore no time is released from this employer in relation to official duties. We liaise and works with CSU TU representatives and area/regional representatives from those recognised unions whose time will be recorded with their employing authority.

Expenditure on consultancy The Expenditure on Consultancy was £3k in respect of Maternity Vanguard Consultation.

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Off-payroll engagements

Table 1: For all off-payroll engagements as of 31 March 2019, for more than £245 per day and that last for longer than six months Main Agencies ALBs department No. of existing engagements as of 31 March 2019 0 0 0 Of which... No. that have existed for less than one year at time of reporting. 0 0 0 No. that have existed for between one and two years at time of reporting. 0 0 0 No. that have existed for between two and three years at time of reporting. 0 0 0 No. that have existed for between three and four years at time of reporting. 0 0 0 No. that have existed for four or more years at time of reporting. 0 0 0

Table 2: For all new off-payroll engagements, or those that reached six months in duration, between 1 April 2018 and 31 March 2019, for more than £245 per day and that last for longer than six months Main Agencies ALBs department No. of new engagements, or those that reached six months in duration, between 1 April 2018 and 31 March 0 0 0 2019 Of which... No. assessed as caught by IR35 0 0 0 No. assessed as not caught by IR35 0 0 0 No. engaged directly (via PSC contracted to department) and are on the departmental payroll 0 0 0 No. of engagements reassessed for consistency / assurance purposes during the year. 0 0 0 No. of engagements that saw a change to IR35 status following the consistency review. 0 0 0

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Table 3: For any off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1 April 2018 and 31 March 2019

Main Agencies ALBs department No. of off-payroll engagements of board members, and/or, senior officials with significant financial 2 X X responsibility, during the financial year. (1)

Total no. of individuals on payroll and off-payroll that have been deemed “board members, and/or, senior 15 X X officials with significant financial responsibility”, during the financial year. (2)

Exit packages, including special (non-contractual) payments Table 1: Exit Packages There was one exit package in year:

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Exit Number of Cost of Number of Cost of Total Total Number of Cost of special package compulsory compulsory other other number of cost of departures payment element cost band redundancies redundancies departures departures exit exit where included in exit (inc. any agreed agreed packages packages special packages special payments payment have been element made WHOLE WHOLE WHOLE WHOLE NUMBERS NUMBERS NUMBERS NUMBERS ONLY £s ONLY £s ONLY £s ONLY £s Less than 1 6,560 0 0 0 0 0 0 £10,000 £10,000 - 0 0 0 0 0 0 0 0 £25,000 £25,001 - 0 0 0 0 0 0 0 0 £50,000 £50,001 - 0 0 0 0 0 0 0 0 £100,000 £100,001 - 0 0 0 0 0 0 0 0 £150,000 £150,001 – 0 0 0 0 0 0 0 0 £200,000 >£200,000 0 0 0 0 0 0 0 0 TOTALS 0 0 0 0 0 0 0

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Table 2: Analysis of Other Departures

There were no other departures in year:

Agreements Total Value of agreements

Number £000s

Voluntary redundancies including 0 0 early retirement contractual costs

Mutually agreed resignations 0 0 (MARS) contractual costs

Early retirements in the efficiency 0 0 of the service contractual costs

Contractual payments in lieu of 0 0 notice*

Exit payments following 0 0 Employment Tribunals or court orders

Non-contractual payments 0 0 requiring HMT approval**

TOTAL 0 0

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Parliamentary Accountability and Audit Report

NHS Halton Clinical Commissioning Group is not required to produce a Parliamentary Accountability and Audit Report but has opted to include disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges in this Accountability Report on page 74.

An audit certificate and report is also included in this Annual Report on page 148.

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EXTERNAL AUDIT OPINION

148

149

150

151

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ANNUAL ACCOUNTS

NHS Halton CCG 2018/2019

Andrew Davies

Clinical Accountable Officer

22nd May 2019

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The notes on pages 157 to 195 form part of this statement

The financial statements on pages 153 to 195 were approved by the Audit Committee on 22ns May 2019 and signed on its behalf

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NHS Halton CCG - Annual Accounts 2018-19

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 of NHS Halton CCG have been prepared in accordance with the Group Accounting Manual 2018-19 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 The CCG's financial accounts have been prepared under a direction issued by the NHS Commissioning Board under the National Health Service Act 2006 (as amended) The CCG's financial recovery plan approved by NHS England for 2018-19 has been achieved and this will be further enhanced for 2019-20 For non-trading entities in the public sector, the anticipated continuation of the provision of a service in the future, as evidenced by inclusion of financial provision for that service in published documents is normally sufficient of going concern. Therefore based on the above the accounts have been prepared on a going concern basis on the basis that Healthcare services will continue to be provided for the residents of Halton The CCG' s Financial recovery plan has been approved by NHS England The CCG has been given indicative budgets until 2021 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 Transfers as part of reorganisation fall to be accounted for by use of absorption accounting in line with the Government Financial Reporting Manual, issued by HM Treasury. The Government Financial Reporting Manual does not require retrospective adoption, so prior year transactions (which have been accounted for under merger accounting] have not been restated. 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 Subsidiaries

Entities over which the Clinical Commissioning Group has the power to exercise control are classified as subsidiaries and are consolidated. The Clinical Commissioning Group has control when it has the ability to affect the variable returns from the other entity through its power to direct relevant activities. The income, expenses, assets, liabilities, equity and reserves of the subsidiary are consolidated in full into the appropriate financial statement lines. The capital and reserves attributable to non-controlling interests are included as a separate item in the Statement of Financial Position. Appropriate adjustments are made on consolidation where the subsidiary’s accounting policies are not aligned with the Clinical Commissioning Group or where the subsidiary’s accounting date is not coterminous.

Subsidiaries that are classified as ‘held for sale’ are measured at the lower of their carrying amount or ‘fair value less costs to sell’.

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1.5 Associates

Material entities over which the Clinical Commissioning Group has the power to exercise significant influence so as to obtain economic or other benefits are classified as associates and are recognised in the Clinical Commissioning Group’s accounts using the equity method. The investment is recognised initially at cost and is adjusted subsequently to reflect the Clinical Commissioning Group’s share of the entity’s profit/loss and other gains/losses. It is also reduced when any distribution is received by the Clinical Commissioning Group from the entity.

Associates that are classified as ‘held for sale’ are measured at the lower of their carrying amount or ‘fair value less costs to sell’.

1.6 Joint arrangements Arrangements over which the clinical commissioning group has joint control with one or more other entities are classified as joint arrangements. Joint control is the contractually agreed sharing of control of an arrangement. A joint arrangement is either a joint operation or a joint venture. A joint operation exists where the parties that have joint control have rights to the assets and obligations for the liabilities relating to the arrangement. Where the Clinical Commissioning Group is a joint operator it recognises its share of, assets, liabilities, income and expenses in its own accounts. A joint venture is a joint arrangement whereby the parties that have joint control of the arrangement have rights to the net assets of the arrangement. Joint ventures are recognised as an investment and accounted for using the equity method.

1.7 Pooled Budgets The clinical commissioning group has entered into a pooled budget arrangement with Halton Borough Council[in accordance with section 75 of the NHS Act 2006]. Under the arrangement, funds are pooled for Continuing Health Care and Note 35 to the accounts provides details of the income and expenditure, assets and Liabilities. The pool is hosted by Halton Council. The clinical commissioning group accounts for its share of the assets, liabilities, income and expenditure arising from the activities of the pooled budget, identified in accordance with the pooled budget agreement 1.9 Revenue The transition to IFRS 15 has been completed in accordance with paragraph C3 (b) of the Standard, applying the Standard retrospectively recognising the cumulative effects at the date of initial application. In the adoption 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. 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. Significant terms include the CCG has signed up to the Better Practice payment code

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.

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1.10 Employee Benefits 1.10.1 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. 1.10.2 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. 1.11 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. 1.12 Grants Payable Where grant funding is not intended to be directly related to activity undertaken by a grant recipient in a specific period, the clinical commissioning group recognises the expenditure in the period in which the grant is paid. All other grants are accounted for on an accruals basis. 1.13 Property, Plant & Equipment 1.13.1 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.

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1.13.2 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. 1.13.3 Subsequent Expenditure Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised. Where subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing carrying value of the item replaced is written-out and charged to operating expenses.

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1.14 Intangible Assets 1.14.1 Recognition Intangible assets are non-monetary assets without physical substance, which are capable of sale separately from the rest of the clinical commissioning group’s business or which arise from contractual or other legal rights. They are recognised only: · When it is probable that future economic benefits will flow to, or service potential be provided to, the clinical commissioning group; · Where the cost of the asset can be measured reliably; and, · Where the cost is at least £5,000. Software that is integral to the operating of hardware, for example an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software that is not integral to the operation of hardware, for example application software, is capitalised as an intangible asset. Expenditure on research is not capitalised but is recognised as an operating expense in the period in which it is incurred. Internally-generated assets are recognised if, and only if, all of the following have been demonstrated: · The technical feasibility of completing the intangible asset so that it will be available for use; · The intention to complete the intangible asset and use it; · The ability to sell or use the intangible asset; · How the intangible asset will generate probable future economic benefits or service potential; · The availability of adequate technical, financial and other resources to complete the intangible asset and sell or use it; and, · The ability to measure reliably the expenditure attributable to the intangible asset during its development. 1.14.2 Measurement

Intangible assets acquired separately are initially recognised at cost. The amount initially recognised for internally-generated intangible assets is the sum of the expenditure incurred from the date when the criteria above are initially met. Where no internally-generated intangible asset can be recognised, the expenditure is recognised in the period in which it is incurred. Following initial recognition, intangible assets are carried at current value in existing use by reference to an active market, or, where no active market exists, at the lower of amortised replacement cost or the value in use where the asset is income generating . Internally-developed software is held at historic cost to reflect the opposing effects of increases in development costs and technological advances. Revaluations and impairments are treated in the same manner as for property, plant and equipment. 1.14.3 Depreciation, Amortisation & Impairments Freehold land, properties under construction, and assets held for sale are not depreciated. Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the clinical commissioning group expects to obtain economic benefits or service potential from the asset. This is specific to the clinical commissioning group and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over their estimated useful lives. At each reporting period end, the clinical commissioning group checks whether there is any indication that any of its property, plant and equipment assets or intangible non-current assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount of the asset is estimated to determine whether there has been a loss and, if so, its amount. Intangible assets not yet available for use are tested for impairment annually. A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Where an impairment loss subsequently reverses, the carrying amount of the asset is increased to the revised estimate of the recoverable amount but capped at the amount that would have been determined had there been no initial impairment loss. The reversal of the impairment loss is credited to expenditure to the extent of the decrease previously charged there and thereafter to 162 the revaluation reserve.

1.15 Donated Assets The CCG had no donated assets as at 31 March 2019 (2018; nil) 1.16 Government grant funded assets Government grant funded assets are capitalised at current value in existing use, if they will be held for their service potential, or otherwise at fair value on receipt, with a matching credit to income. Deferred income is recognised only where conditions attached to the grant preclude immediate recognition of the gain. 1.17 Non-current Assets Held For Sale The CCG had no non current assets held for sale as at 31 March 2019 (2018 ; nil) 1.18 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. 1.18.1 The CCG 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.

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1.18.2 The CCG as Lessor Amounts due from lessees under finance leases are recorded as receivables at the amount of the clinical commissioning group’s net investment in the leases. Finance lease income is allocated to accounting periods so as to reflect a constant periodic rate of return on the clinical commissioning group’s net investment outstanding in respect of the leases. Rental income from operating leases is recognised on a straight-line basis over the term of the lease. Initial direct costs incurred in negotiating and arranging an operating lease are added to the carrying amount of the leased asset and recognised on a straight-line basis over the lease term. 1.19 Private Finance Initiative Transactions The CCG is not party to any Private Finance Initiative (PFI) schemes as at 31 March 2019 (2018; nil) 1.20 Inventories The CCG did not hold any inventories as at 31 March 2019 ( 31 March 2018 ; nil) 1.21 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. 1.22 Provisions Provisions are recognised when the clinical commissioning group has a present legal or constructive obligation as a result of a past event, it is probable that the clinical commissioning group will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties. Where a provision is measured using the cash flows estimated to settle the obligation, its carrying amount is the present value of those cash flows using HM Treasury’s discount rate as follows: Early retirement provisions are discounted using HM Treasury’s pension discount rate of positive 0.29% (2017-18: positive 0.10%) in real terms. All general provisions are subject to four separate discount rates according to the expected timing of cash flows from the Statement of Financial Position date: • A nominal short-term rate of 0.76% (2017-18: negative 2.42% in real terms) for inflation adjusted expected cash flows up to and including 5 years from Statement of Financial Position date. • A nominal medium-term rate of 1.14% (2017-18: negative 1.85% in real terms) for inflation adjusted expected cash flows over 5 years up to and including 10 years from the Statement of Financial Position date. • A nominal long-term rate of 1.99% (2017-18: negative 1.56% in real terms) for inflation adjusted expected cash flows over 10 years and up to and including 40 years from the Statement of Financial Position date. • A nominal very long-term rate of 1.99% (2017-18: negative 1.56% in real terms) for inflation adjusted expected cash flows exceeding 40 years from the Statement of Financial Position date. All 2018-19 percentages are expressed in nominal terms with 2017-18 being the last financial year that HM Treasury provided real general provision discount rates.

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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. A restructuring provision is recognised when the clinical commissioning group has developed a detailed formal plan for the restructuring and has raised a valid expectation in those affected that it will carry out the restructuring by starting to implement the plan or announcing its main features to those affected by it. The measurement of a restructuring provision includes only the direct expenditures arising from the restructuring, which are those amounts that are both necessarily entailed by the restructuring and not associated with on-going activities of the entity. 1.23 Clinical Negligence Costs NHS Resolution operates a risk pooling scheme under which the clinical commissioning group pays an annual contribution to NHS Resolution, which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although NHS Resolution is administratively responsible for all clinical negligence cases, the legal liability remains with clinical commissioning group. 1.24 Non-clinical Risk Pooling The clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to the NHS Resolution and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due. 1.25 Carbon Reduction Commitment Scheme The Carbon Reduction Commitment scheme is a mandatory cap and trade scheme for non-transport CO2 emissions. The clinical commissioning group is registered with the CRC scheme, and is therefore required to surrender to the Government an allowance for every tonne of CO2 it emits during the financial year. A liability and related expense is recognised in respect of this obligation as CO2 emissions are made. The carrying amount of the liability at the financial year end will therefore reflect the CO2 emissions that have been made during that financial year, less the allowances (if any) surrendered voluntarily during the financial year in respect of that financial year. The liability will be measured at the amount expected to be incurred in settling the obligation. This will be the cost of the number of allowances required to settle the obligation. Allowances acquired under the scheme are recognised as intangible assets. The CCG considers this to immaterial therefore no provisions was recognised as at 31 March 2019 ( 31 March 2018; nil) 1.26 Contingent liabilities and contingent assets A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group, or a present obligation that is not recognised because it is not probable that a payment will be required to settle the obligation or the amount of the obligation cannot be measured sufficiently reliably. A contingent liability is disclosed unless the possibility of a payment is remote. A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the clinical commissioning group. A contingent asset is disclosed where an inflow of economic benefits is probable. Where the time value of money is material, contingent liabilities and contingent assets are disclosed at their present value. The CCG had no contingent assets or liabilities as at 31 March 2019 ( 31 March 2018 ; nil)

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1.27 Financial Assets

Financial assets are recognised when the CCG 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. 1.27.1 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. 1.27.2 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. 1.27.3 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. 1.27.4 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 DHSC 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.

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1.28 Financial Liabilities Financial liabilities are recognised on the statement of financial position when the clinical commissioning group becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are derecognised when the liability has been discharged, that is, the liability has been paid or has expired. 1.28.1 Financial Guarantee Contract Liabilities Financial guarantee contract liabilities are subsequently measured at the higher of: · The premium received (or imputed) for entering into the guarantee less cumulative amortisation; and, · The amount of the obligation under the contract, as determined in accordance with IAS 37: Provisions, Contingent Liabilities and Contingent Assets. 1.28.2 Financial Liabilities at Fair Value Through Profit and Loss Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial liabilities at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the CCG group’s surplus/deficit. The net gain or loss incorporates any interest payable on the financial liability.

1.28.3 Other Financial Liabilities

After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method, except for loans from Department of Health and Social Care, which are carried at historic cost. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method.

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1.29 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. 1.30 Foreign Currencies

The CCG’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. 1.31 Third Party Assets Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the clinical commissioning group has no beneficial interest in them. 1.32 Losses & Special Payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had the clinical commissioning group not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure). 1.33 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. 1.33.1 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. 1.33.2 Sources of estimation uncertainty The following are the key estimations that management has made in the process of applying the clinical commissioning group's accounting policies that have the most significant effect on the amounts recognised in the financial statements.

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Payables estimates Primary Care Practice prescribing information is received by the CCG approximately 6 weeks following the end of each reporting period. Management have estimated the year-end prescribing expenditure based on the forecast provided by the Prescription Pricing Division of the NHS Business Services Authority. This forecast is based on 11 Months actual prescribing data, and the forecast outturn within Month 11 reporting date from the NHSBA for 2018/19 is £23,307, therefore £3.608 has been included for the March 2019 period (2017/18 £3.9 million March 2018 period). Analysis of previous years' data would suggest that there is no reason for this forecast to be materially different to actual year-end prescribing results PPA forecast GP Prescribing outturn in 2017/18 at month 10 (period used for estimate ) was £24,067, with actual expenditure reported at £23,447 ( 0.006m movement, less than 1% of accrual value included 2017/18) 1.34 Gifts Gifts are items that are voluntarily donated, with no preconditions and without the expectation of any return. Gifts include all transactions economically equivalent to free and unremunerated transfers, such as the loan of an asset for its expected useful life, and the sale or lease of assets at below market value. 1.35 Accounting Standards That Have Been Issued But Have Not Yet Been Adopted The DHSC GAM does not require the following IFRS Standards and Interpretations to be applied in 2018-19. 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 – Application required for accounting periods beginning on or after 1 January 2019, but not yet adopted by the Frem: early adoption is not therefore permitted. ● IFRS 17 Insurance Contracts – Application required for accounting periods beginning on or after 1 January 2021, but not yet adopted by the FReM: early adoption is not therefore permitted. ● IFRIC 23 Uncertainty over Income Tax Treatments – Application required for accounting periods beginning on or after 1 January 2019.

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NHS Halton CCG - Annual Accounts 2018-19

2 Other Operating Revenue 2018-19 2017-18 Total Total £'000 £'000 Income from sale of goods and services (contracts) Education, training and research - - Non-patient care services to other bodies 561 423 Patient transport services - - Prescription fees and charges - - Dental fees and charges - - Income generation - - Other Contract income 215 - Recoveries in respect of employee benefits - 98 Total Income from sale of goods and services 776 521

Other operating income Rental revenue from finance leases - - Rental revenue from operating leases - - Charitable and other contributions to revenue expenditure: NHS - - Charitable and other contributions to revenue expenditure: non-NHS - 7 Receipt of donations (capital/cash) - - Receipt of Government grants for capital acquisitions - - Continuing Health Care risk pool contributions - - Non cash apprenticeship training grants revenue - - Other non contract revenue - 1,085 Total Other operating income - 1,092

Total Operating Income 776 1,613

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NHS Halton CCG - Annual Accounts 2018-19

3.1 Disaggregation of Income - Income from sale of good and services (contracts)

Non-patient care Recoveries in Education, training Patient transport Prescription fees Dental fees and Other Contract services to other Income generation respect of employee and research services and charges charges income bodies benefits £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Source of Revenue NHS - 472 - - - - 18 - Non NHS - 89 - - - - 197 - Total - 561 - - - - 215 -

Non-patient care Recoveries in Education, training Patient transport Prescription fees Dental fees and Other Contract services to other Income generation respect of employee and research services and charges charges income bodies benefits £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Timing of Revenue Point in time - 561 - - - - 215 - Over time ------Total - 561 - - - - 215 -

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3.2 Transaction price to remaining contract performance obligations

Contract revenue expected to be recognised in the future periods related to contract performance obligations not yet Revenue expected Revenue expected Revenue expected 2018-19 Total from Other DHSC from Non-DHSC from NHSE Bodies Group Bodies Group Bodies £000s £000s £000s £000s Not later than 1 year - - - - Later than 1 year, not later than 5 years - - - - Later than 5 Years - - - - Total - - - -

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173

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NHS Halton CCG - Annual Accounts 2018-19

4.2 Average number of people employed 2018-19 2017-18 Permanently Permanently employed Other Total employed Other Total Number Number Number Number Number Number

Total 54 8 62 53 11 64

Of the above: Number of whole time equivalent people engaged on capital projects ------

4.3 Notes in respect of Staff sickness and Ill Health Retirements are shown within the Annual Report

4.4 Exit packages agreed in the financial year

2018-19 2018-19 2018-19 Compulsory redundancies Other agreed departures Total Number £ Number £ Number £ Less than £10,000 1 6,560 - - 1 6,560 £10,001 to £25,000 ------£25,001 to £50,000 ------£50,001 to £100,000 ------£100,001 to £150,000 ------£150,001 to £200,000 ------Over £200,001 ------Total 1 6,560 - - 1 6,560

2017-18 2017-18 2017-18 Compulsory redundancies Other agreed departures Total Number £ Number £ Number £ Less than £10,000 1 6,000 - - 1 6,000 £10,001 to £25,000 ------£25,001 to £50,000 1 29,000 - - 1 29,000 £50,001 to £100,000 ------£100,001 to £150,000 ------£150,001 to £200,000 ------Over £200,001 ------Total 2 35,000 - - 2 35,000

There are no departures where special payments have been made in 2018-19 ( 2017-18; nil)

There were no other Agreed Departures in 2018-19 ( (2017-18 nil :)

Exit costs are accounted for in accordance with relevant accounting standards and at the latest in full at the year of departure The Departure shown above in the less than £10k is shown as total payments

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NHS Halton CCG - Annual Accounts 2018-19

4..5 Employee benefits and staff numbers 2018-19 4.5.1 Employee benefits Admin Programme Total Permanent Permanent Permanent Employees Other Total Employees Other Total Employees Other Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Employee Benefits Salaries and wages 1,062 28 1,090 1,586 356 1,942 2,648 384 3,032 Social security costs 126 - 126 172 - 172 299 - 299 Employer contributions to the NHS Pension Scheme 138 - 138 211 - 211 348 - 348 Other pension costs ------Apprenticeship Levy ------Termination benefits - - - 6 - 6 6 - 6 Gross employee benefits expenditure 1,326 28 1,354 1,975 356 2,331 3,301 384 3,685

Less recoveries in respect of employee benefits (note 4.1.2) (0) - (0) - - - (0) - (0) Total - Net admin employee benefits including capitalised costs 1,326 28 1,354 1,975 356 2,331 3,301 384 3,685

Less: Employee costs capitalised ------Net employee benefits excluding capitalised costs 1,326 28 1,354 1,975 356 2,331 3,301 384 3,685 -

2017-18 4.5.2 Employee benefits Admin Programme Total

Permanent Permanent Permanent Employees Other Total Employees Other Total Employees Other Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Employee Benefits Salaries and wages 903 75 978 1,966 175 2,141 2,869 250 3,119 Social security costs 103 - 103 196 - 196 299 - 299 Employer contributions to the NHS Pension Scheme 108 - 108 241 - 241 349 - 349 Other pension costs ------Apprenticeship Levy - - - - Termination benefits - - - 11 - 11 11 - 11 Gross employee benefits expenditure 1,114 75 1,189 2,413 175 2,588 3,528 250 3,778

Less recoveries in respect of employee benefits (note 4.1.2) (98) 0 (98) - - - (98) 0 (98) Total - Net admin employee benefits including capitalised costs 1,016 75 1,091 2,413 175 2,588 3,430 250 3,680

Less: Employee costs capitalised ------Net employee benefits excluding capitalised costs 1,016 75 1,091 2,413 175 2,588 3,430 250 3,680

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4.6 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 atwww.nhsbsa.nhs.uk/pensions. Both are unfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State for Health in England and Wales. They are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, each scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each scheme is taken as equal to the contributions payable to that scheme for the accounting period.

4.6.1 Pension costs (Accounting Valuation) A Valuation of scheme liability is carried out annually by the scheme actuary (currently the Governments 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 for providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2019 is based on data as at 31 March 2018, updated to 31 March 2019 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme in contained in the report of the scheme actuary, which forms part of the annual NHS Pensions 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.

4.6.2 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.

For 2018-19, employers’ contributions of £348,634 were payable to the NHS Pensions Scheme (2017-18: £348,417) were payable to the NHS Pension Scheme at the rate of 14.38% of pensionable pay. The scheme’s actuary reviews employer contributions, usually every four years and now based on HMT Valuation Directions, following a full scheme valuation. The latest review used data from 31 March 2012 and was published on the Government website on 9 June 2012. These costs are included in the NHS pension line of note 4.1.1

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NHS Halton CCG - Annual Accounts 2018-19

5. Operating expenses 2018-19 2017-18 Total Total £'000 £'000 Purchase of goods and services Services from other CCGs and NHS England 1,520 1,521 Services from foundation trusts 92,240 92,437 Services from other NHS trusts 55,116 53,326 Provider Sustainability Fund (Sustainability Transformation Fund 1718) - - Services from Other WGA bodies 9 0 Purchase of healthcare from non-NHS bodies 17,680 20,226 Purchase of social care 13,167 12,697 General Dental services and personal dental services - - Prescribing costs 24,001 24,792 Pharmaceutical services - - General Ophthalmic services - - GPMS/APMS and PCTMS 18,242 17,733 Supplies and services – clinical - - Supplies and services – general 115 147 Consultancy services 3 - Establishment 313 254 Transport 15 6 Premises 526 305 Audit fees 46 46 Other non statutory audit expenditure · Internal audit services · Other services 10 - Other professional fees 164 458 Legal fees 5 27 Education, training and conferences 91 78 Funding to group bodies - - CHC Risk Pool contributions - - - - Total Purchase of goods and services 223,263 224,053 Depreciation and impairment charges Depreciation 138 138 Amortisation 27 - Impairments and reversals of property, plant and equipment - - Impairments and reversals of intangible assets - - Impairments and reversals of financial assets - - · Assets carried at amortised cost · Assets carried at cost - - · Available for sale financial assets - - Impairments and reversals of non-current assets held for sale - - Impairments and reversals of investment properties - - - - Total Depreciation and impairment charges 165 138 Provision expense Change in discount rate Provisions 203 - - Total Provision expense 203 - Other Operating Expenditure Chair and Non Executive Members 97 103 Grants to Other bodies 1,725 1,450 Clinical negligence - - Research and development (excluding staff costs) - - Expected credit loss on receivables - - Expected credit loss on other financial assets (stage 1 and 2 only) - - Inventories written down - - Inventories consumed - - Non cash apprenticeship training grants - - Other expenditure 46 66

Total Other Operating Expenditure 1,868 1,619 Total operating expenditure 225,499 225,810

Internal Audit and Counter Fraud services are provided by Royal Liverpool and Broadgreen University Hospitals NHS Trust. The costs incurred in the Financial year 2018-19 £45,760 ( 2017-18 £45,760). The CCG;s contract with its External Auditors does contain a limit of liability clause with the absolute limit of liability of both parties being capped at 2 million 2018-19, (2017-18 2 million). This is in line with the standard consultancy one approach and external auditors standard terms and conditions. The Audit Fees shown are gross of VAT 178

NHS Halton CCG - Annual Accounts 2018-19

6.1 Better Payment Practice Code

Measure of compliance 2018-19 2018-19 2017-18 2017-18 Number £'000 Number £'000 Non-NHS Payables Total Non-NHS Trade invoices paid in the Year 3,688 54,520 3,733 53,381 Total Non-NHS Trade Invoices paid within target 3,555 51,241 3,645 52,754 Percentage of Non-NHS Trade invoices paid within target 96.39% 93.99% 97.64% 98.83%

NHS Payables Total NHS Trade Invoices Paid in the Year 2,214 154,463 1,981 146,838 Total NHS Trade Invoices Paid within target 2,169 154,166 1,964 146,717 Percentage of NHS Trade Invoices paid within target 97.97% 99.81% 99.14% 99.92%

6.2 The Late Payment of Commercial Debts (Interest) Act 1998 The CCG did not make any payments under the provision of the Late Payment of Commercial Debts ( Interest) Act 1998 in the financial year 2018-19 (2017-18;nil)

7 Income Generation Activities The CCG had no Income Generating Activities in the Financial Year 2018-19 (2017-18; nil)

8. Investment Revenue The CCG had no investment revenue in the Financial year 2018-10 (2017-18; nil)

9. Other Gains and Losses The CCG had no other Gains or losses in the Financial year 2018-10 (2017-18; nil)

10.1 Finance Costs The CCG had no Finance Costs in the Financial year 2018-10 (2017-18; nil)

10.2 Finance Income The CCG had no Finance Costs in the Financial year 2018-10 (2017-18; nil)

11. Net gain/(loss) on transfer by absorption The CCG had no net gains and losses on transfer by absorption in the financial year 2018-19 (2017-18; nil)

17 9

NHS Halton CCG - Annual Accounts 2018-19

12. Operating Leases

12.1 As lessee The Majority of the Buildings balance is in relation to payments made to NHS Property Services Ltd (NHSPS) and Community Health Partnerships ltd (CHP). The other category in tables 12.1.1. and 12.1.2 relates to lease cars

12.1.1 Payments recognised as an Expense 2018-19 2017-18 Land Buildings Other Total Land Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Payments recognised as an expense Minimum lease payments - 510 17 527 - 299 22 321 Contingent rents ------Sub-lease payments ------Total - 510 17 527 - 299 22 321

Whilst our arrangements with Community Health Partnership's Limited and NHS Property Services Limited fall within the definition of operating leases, rental charge for future years has not yet been agreed . Consequently this note does not include future minimum lease payments for the arrangements only

12.1.2 Future minimum lease payments 2018-19 2017-18 Land Buildings Other Total Land Buildings Other Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Payable: No later than one year - - 17 17 - - 13 13 Between one and five years ------After five years ------Total - - 17 17 - - 13 13

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NHS Halton CCG - Annual Accounts 2018-19

13 Property, plant and equipment

Assets under Buildings construction excluding and payments Plant & Transport Information Furniture & 2018-19 Land dwellings Dwellings on account machinery equipment technology fittings Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Cost or valuation at 01 April 2018 - - - - 31 - 783 - 814 Addition of assets under construction and payments on account - - Additions purchased ------143 - 143 Additions donated ------Additions government granted ------Additions leased ------Reclassifications ------Reclassified as held for sale and reversals ------Disposals other than by sale ------Upward revaluation gains ------Impairments charged ------Reversal of impairments ------Transfer (to)/from other public sector body ------Cumulative depreciation adjustment following revaluation ------Cost/Valuation at 31 March 2019 - - - - 31 - 925 - 956

Depreciation 01 April 2018 - - - - 20 - 246 - 266

Reclassifications ------Reclassified as held for sale and reversals ------Disposals other than by sale ------Upward revaluation gains ------Impairments charged ------Reversal of impairments ------Charged during the year - - - - 4 - 134 - 138 Transfer (to)/from other public sector body ------Cumulative depreciation adjustment following revaluation ------Depreciation at 31 March 2019 - - - - 24 - 380 - 404

Net Book Value at 31 March 2019 - - - - 7 - 545 - 552

Purchased - - - - 7 - 545 - 552 Donated ------Government Granted ------Total at 31 March 2019 - - - - 7 - 545 - 552

Asset financing:

Owned - - - - 7 - 545 - 552 Held on finance lease ------On-SOFP Lift contracts ------PFI residual: interests ------

Total at 31 March 2019 - - - - 7 - 545 - 552

Revaluation Reserve Balance for Property, Plant & Equipment Assets under construction & payments on Plant & Transport Information Furniture & Land Buildings Dwellings account machinery equipment technology fittings Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Balance at 01 April 2018 ------Revaluation gains ------Impairments ------Release to general fund ------Other movements ------181 Balance at 31 March 2019 ------1

13 Property, plant and equipment cont'd

13.1 Additions to assets under construction The CCG had no additions to assets under construction in the financial year 2018-19 ( 2017-18; nil)

13.2 Donated assets The CCG had not donated assets as at 31 March 2019 (31 March 2018; nil)

13.3 Government granted assets The CCG had no Government granted assets as at 31 March 2019 (31 March 2018; nil)

13.4 Property revaluation The CCG had no property revaluations in the Financial year to 31 March 2019 ( 31 March 2018; nil)

13.5 Compensation from third parties There have been no compensation received from third parties for assets impaired, lost or given up in the Financial year 31 March 2019 (31 March 2018; nil)

13.6 Write downs to recoverable amount There have been no assets written down to recoverable amounts and no reversals of previous write downs in the Financial year 31 March 2019 ( 31 March 2018; nil)

13.7 Temporarily idle assets The CCG had no temporary idle assets in the Financial year to 31 March 2019 ( 31 March 2018; nil)

13.8 Cost or valuation of fully depreciated assets The CCG had no fully depreciated assets still in use as at 31 March 2019 ( 31 March 2018; nil)

13.9 Economic lives Minimum Life Maximum (years) Life (Years) Buildings excluding dwellings 0 0 Dwellings 0 0 Plant & machinery 2 4 Transport equipment 0 0 Information technology 1 5 Furniture & fittings 0 0

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NHS Halton CCG - Annual Accounts 2018-19

14 Intangible non-current assets Computer Development Computer Software: Expenditure Software: Internally Licences & (internally 2018-19 Purchased Generated Trademarks Patents generated) Total £'000 £'000 £'000 £'000 £'000 £'000 Cost or valuation at 01 April 2018 153 - - - - 153

Additions purchased ------Additions internally generated ------Additions donated ------Additions government granted ------Additions leased ------Reclassifications ------Reclassified as held for sale and reversals ------Disposals other than by sale ------Upward revaluation gains ------Impairments charged ------Reversal of impairments ------Transfer (to)/from other public sector body ------Cumulative amortisation adjustment following revaluation ------Cost / Valuation At 31 March 2019 153 - - - - 153

Amortisation 01 April 2018 ------

Reclassifications ------Reclassified as held for sale and reversals ------Disposals other than by sale ------Upward revaluation gains ------Impairments charged ------Reversal of impairments ------Charged during the year 27 - - - - 27 Transfer (to) from other public sector body ------Cumulative amortisation adjustment following revaluation ------Amortisation At 31 March 2019 27 - - - - 27

Net Book Value at 31 March 2019 126 - - - - 126

Purchased 126 - - - - 126 Donated ------Government Granted ------Total at 31 March 2019 126 - - - - 126

Revaluation Reserve Balance for intangible assets Computer Development Computer Software: Expenditure Software: Internally Licences & (internally Purchased Generated Trademarks Patents generated) Total £'000 £'000 £'000 £'000 £'000 £'000 Balance at 01 April 2018 ------Revaluation gains ------Impairments ------Release to general fund ------Other movements ------Balance at 31 March 2019 ------

183

NHS Halton CCG - Annual Accounts 2018-19

14.1 Donated assets The CCG had no donated intangible assets as at 31 March 2019 ( 31 March 2018; nil)

14.2 Government granted assets The CCG had no donated government granted intangible assets as at 31 March 2019 ( 31 March 2018; nil)

14.3 Revaluation There have been no revaluation of intangible non current assets in the financial year 2018-19 ( 2018019 ; nil)

14.4 Compensation from third parties There have been no compensation received from third parties for intangible assets impaired , lost or given up in the financial year 2018-19 ( 2018019 ; nil)

14.5 Write downs to recoverable amount There have been no intangible assets written down to recoverable amounts and no reversals of previous write downs in the financial year 2018-19 ( 2018019 ; nil)

14.6 Non-capitalised assets There have been no non capitalised intangible assets in the financial year 2018-19 ( 2018019 ; nil)

14.7 Temporarily idle assets The CCG had no temporary idle intangible assets as at 31 March 2019 ( 31 March 2018; nil)

14.8 Cost or valuation of fully amortised assets The CCG had no fully amortised intangible assets as at 31 March 2019 ( 31 March 2018; nil)

14.9 Economic lives Minimum Life Maximum Life (years) (Years) Computer software: purchased 1 5 Computer software: internally generated 0 0 Licences & trademarks 0 0 Patents 0 0 Development expenditure (internally generated) 0 0

15 Investment property The CCG had no investment property as at 31 March 2019 ( 31 March 2018; nil)

16 Inventories The CCG had no inventories as at 31 March 2019 ( 31 March 2018; nil)

184

185

186

NHS Halton CCG - Annual Accounts 2018-19

18 Other financial assets

The CCG had no other financial assets as at 31 March 2019 ( 31 March 2018; nil)

18.2 Non-current

The CCG had no non current assets as at 31 March 2019 ( 31 March 2018; nil)

18.3 Expected Credit Losses on Financial Assets After reviewing the outstanding debt it was deemed unnecessary to provide for an expected credit lost

18.4 Non-Current: capital analysis The CCG had no non current capital assets as at 31 March 2019 ( 31 March 2018; nil) 19 Other current assets The CCG had no other current assets as at 31 March 2019 ( 31 March 2018; nil)

187

NHS Halton CCG - Annual Accounts 2018-19

20 Cash and cash equivalents

2018-19 2017-18 £'000 £'000 Balance at 01 April 2018 11 58 Net change in year (6) (47) Balance at 31 March 2019 5 10

Made up of: Cash with the Government Banking Service 5 10 Cash with Commercial banks - - Cash in hand 0 (0) Current investments - - Cash and cash equivalents as in statement of financial position 5 10

Bank overdraft: Government Banking Service - - Bank overdraft: Commercial banks - - Total bank overdrafts - -

Balance at 31 March 2019 5 10

The CCG doesn’t hold patients money - -

21 Non-current assets held for sale The CCG had no non-current assets held for sale as at 31 March 2019 ( 31 March 2018; nil)

22 Analysis of impairments and reversals

The CCG had no impairments or reversals of impairments recognised in the financial year 2018-2019 ( 31 March 2018; nil)

188

NHS Halton CCG - Annual Accounts 2018-19

Current Non-current Current Non-current 23 Trade and other payables 2018-19 2018-19 2017-18 2017-18 £'000 £'000 £'000 £'000

Interest payable - - - - NHS payables: Revenue 3,681 - 2,663 - NHS payables: Capital - - - - NHS accruals 420 - 489 - NHS deferred income - - - - NHS Contract Liabilities - - - - Non-NHS and Other WGA payables: Revenue 3,947 - 1,629 - Non-NHS and Other WGA payables: Capital - - - - Non-NHS and Other WGA accruals 1,352 - 2,248 - Non-NHS and Other WGA deferred income - - - - Non-NHS Contract Liabilities - - - - Social security costs 47 - 41 - VAT - - - - Tax 43 - 34 - Payments received on account - - - - Other payables and accruals 5,860 - 7,087 - Total Trade & Other Payables 15,350 - 14,191 -

Total current and non-current 15,350 14,191

Other payables include £53k outstanding pension contributions in respect of Staff at 31 March 2019 (31st March 2018 49k) and GP Pensions (164k 31st March 2019 (31st March 2018 130k)

23.1 Impact of Application of IFRS 9 on financial liabilities at 1 April 2018 Trade and Trade and other Trade and Other Other Total other payables payables - other other payables borrowings financial - NHSE bodies DHSC group bodies - external (including liabilities finance lease obligations) £000s £000s £000s £000s £000s £000s Classification under IAS 39 as at 31st March 2018 Financial Assets held at FVTPL ------Financial Assets held at Amortised cost 3,152 - 10,965 - - 14,117 Total at 31st March 2018 3,152 - 10,965 - - 14,117

Classification under IFRS 9 as at 1st April 2018 Financial Liabilities designated to FVTPL ------Financial Liabilities mandated to FVTPL ------Financial Liabilities measured at amortised cost 3,152 - 10,965 - - 14,117 Financial Assets measured at FVOCI ------Total at 1st April 2018 3,152 - 10,965 - - 14,117

Changes due to change in measurement attribute ------Other changes ------Change in carrying amount ------

189

24 Other financial liabilities

The CCG had no other financial liabilities as at 31 March 2019 (31 March 2018; nil)

25 Other liabilities

The CCG had no other liabilities as at 31 March 2019 (31 March 2018; nil)

26 Borrowings The CCG had no borrowing in 2018-19 (2017-18; nil)

27 Private finance initiative, LIFT and other service concession arrangements The CCG had no Private Finance initiatives LIFT or other service concession arrangements as at 31 March 2019 (31 March 2018 nil)

28 Finance lease obligations The CCG had no Finance Lease obligations as at 31 March 2019 (31 March 2018; nil)

29 Finance lease receivables

The CCG had no Finance Lease receivables as at 31 March 2019 (31 March 2018; nil)

190

NHS Halton CCG - Annual Accounts 2018-19

30 Provisions Current Non-current Current Non-current 2018-19 2018-19 2017-18 2017-18 £'000 £'000 £'000 £'000 Pensions relating to former directors - - - - Pensions relating to other staff - - - - Restructuring - - - - Redundancy - - - - Agenda for change - - - - Equal pay - - - - Legal claims - - - - Continuing care - - - - Other 203 - - - Total 203 - - -

Total current and non-current 203 -

Pensions Relating to Pensions Former Relating to Agenda for Continuing Directors Other Staff Restructuring Redundancy Change Equal Pay Legal Claims Care Other Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Balance at 01 April 2018 ------

Arising during the year ------203 203 Utilised during the year ------Reversed unused ------Unwinding of discount ------Change in discount rate ------Transfer (to) from other public sector body ------Transfer (to) from other public sector body under absorption ------Balance at 31 March 2019 ------203 203

Expected timing of cash flows: Within one year ------203 203 Between one and five years ------After five years ------Balance at 31 March 2019 ------203 203

The Provision included relates to charges against the CCG for the prior year reporting period

191

NHS Halton CCG - Annual Accounts 2018-19

31 Contingencies

The CCG had no contingencies as at 31 March 2019 ( 31 March 2018; nil)

32 Commitments

The CCG had no capital or other financial commitments as at 31 March 2019 ( 31 March 2018; nil)

33 Financial instruments

33.1 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.

Because NHS clinical commissioning group is financed through parliamentary funding, it is not exposed to the degree of financial risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The clinical commissioning group has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the clinical commissioning group in undertaking its activities.

Treasury management operations are carried out by the finance department, within parameters defined formally within the NHS clinical commissioning group standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by the NHS clinical commissioning group and internal auditors.

33.1.1 Currency risk

The NHS clinical commissioning group is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The NHS clinical commissioning group has no overseas operations. The NHS clinical commissioning group and therefore has low exposure to currency rate fluctuations.

33.1.2 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.

33.1.3 Credit risk

Because the majority of the NHS clinical commissioning group and revenue comes parliamentary funding, NHS clinical commissioning group has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed in the trade and other receivables note.

33.1.4 Liquidity risk

NHS clinical commissioning group is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. The NHS clinical commissioning group draws down cash to cover expenditure, as the need arises. The NHS clinical commissioning group is not, therefore, exposed to significant liquidity risks.

33.1.5 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.

192

NHS Halton CCG - Annual Accounts 2018-19

33 Financial instruments cont'd

33.2 Financial assets

Financial Assets Equity Instruments measured at designated at amortised cost FVOCI Total 2018-19 2018-19 2018-19 £'000 £'000 £'000

Equity investment in group bodies - - Equity investment in external bodies - - Loans receivable with group bodies - - Loans receivable with external bodies - - Trade and other receivables with NHSE bodies 597 597 Trade and other receivables with other DHSC group bodies 2,446 2,446 Trade and other receivables with external bodies 954 954 Other financial assets 1,183 1,183 Cash and cash equivalents 5 5 Total at 31 March 2019 5,185 - 5,185

33.3 Financial liabilities

Financial Liabilities measured at amortised cost Other Total 2018-19 2018-19 2018-19 £'000 £'000 £'000

Loans with group bodies - - Loans with external bodies - - Trade and other payables with NHSE bodies 480 480 Trade and other payables with other DHSC group bodies 4,383 4,383 Trade and other payables with external bodies 4,536 4,536 Other financial liabilities 5,860 5,860 Private Finance Initiative and finance lease obligations - - Total at 31 March 2019 15,260 - 15,260

34 Operating segments

193 The CCG considers that is only has one operating segment commissioning of healthcare services

NHS Halton CCG - Annual Accounts 2018-19

35 Joint arrangements - interests in joint operations

CCGs disclosure in relation to joint arrangements in line with the requirements in IFRS 12 - Disclosure of interests in other entities.

35.1 Interests in joint operations Amounts recognised in Entities books ONLY Amounts recognised in Entities books ONLY 2018-19 2017-18

Parties to the Description of Name of arrangement Assets Liabilities Income Expenditure Assets Liabilities Income Expenditure arrangement principal activities

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 POOLED BUDGET ARRANGEMENTS FOR THE NHS Halton CCG/ PROVISION OF Integrated pool for Adult HALTON CARE PACKAGES 1,365 1,365 14,355 14,355 1,600 0 13,141 13,224 Continuing Healthcare BOROUGH FOR ADULTS WHO COUNCIL QUALIFY FOR CHC/FNC, ARE S117 OR JOINT FUNDED POOLED BUDGET ARRANGEMENT NHS Halton CCG/ FOR THE HALTON Better Care Fund PROVISION OF 0 0 9,844 9,844 0 0 9,714 9,714 BOROUGH INTEGRATED COUNCIL SPEND ON HEALTH AND SOCIAL CARE

The CCG entered into a Pooled Budget arrangement with Halton Borough Council on the 1st April 2013. The pool is hosted by Halton Borough Council, for the majority of Continuing Health Care (CHC ) and share financial risk on the pooled budget fund with the CCG contributing £14.1 million of the Total spend of £38 million The Better Care Fund was added to this Pooled Budget arrangement on the 1st April 2015, the budget between the Council and CCG totalled £10.5 million with the CCG contributing £9.4 million of this. Under the arrangements funds are pooled under Section 75 of the NHS Act 2006 for Complex Care.

36 NHS Lift investments The CCG had no LIFT investments as at 31 March 2019 ( 31 March 2018; nil)

194

195

NHS Halton CCG - Annual Accounts 2018-19

38 Events after the end of the reporting period

There are no events after the reporting period that require disclosure

39 Third party assets The CCG has no third party assets as at 31 March 2019 ( 31 March 2018; nil)

40 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:

2018-19 2018-19 2017-18 2017-18 Target Performance Target Performance Expenditure not to exceed income 229,327 229,327 221,657 229,741 Capital resource use does not exceed the amount specified in Directions 143 143 153 153 Revenue resource use does not exceed the amount specified in Directions 228,408 228,408 219,891 227,975 Capital resource use on specified matter(s) does not exceed the amount specified in Directions - - - - Revenue resource use on specified matter(s) does not exceed the amount specified in Directions - - - - Revenue administration resource use does not exceed the amount specified in Directions 2,737 2,730 2,734 2,734

41 Analysis of charitable reserves The CCG had no charitable reserves in the financial year 2018-19 ( 2017-18; nil)

42 Effect of application of IFRS 15 on current year closing balances

The application of IFRS 15 has had nil effect on the current year closing balance of NHS Halton Clinical Commissioning Group.

196