Richmond Clinical Commissioning Group Annual Report and Financial Accounts 2018/19 Contents PERFORMANCE REPORT
Welcome from Accountable Officer and Chair Page 3 Performance overview Page 4 Corporate objectives Page 4 The Richmond story Page 6 Summary of achievements during 2018/19 Page 8 Performance analysis Monitoring the quality of health services Page 29 Patient advice and liaison services and complaints Page 30 Freedom of Information (FOI) Page 31 Performance summary Page 31 Sustainability report Page 37 Patient and public engagement (PPE) Page 40
Equality report Page 47 Reducing health inequalities Page 47 Health and wellbeing strategy Page 53
ACCOUNTABILITY REPORT Corporate governance report Members’ report Page 58 Statement of Accountable Officer’s responsibilities Page 75 Governance statement Page 77 Risk management arrangements and effectiveness Page 79 Head of internal audit opinion Page 87 Remuneration and staff report Remuneration report Page 91 Staff report Page 98 Parliamentary accountability and audit report Page 107
Annual Accounts Annex 1 External Audit Opinion Annex 2
2 | Page Welcome from Accountable Officer and Chair Welcome to NHS Richmond Clinical Commissioning Group’s Annual Report for the financial year 2018/19.
We have been working as part of the South West London Alliance with our partners Kingston, Sutton, Merton and Wandsworth CCGs for two years now, sharing expertise and making more efficient use of resources.
Richmond and Kingston CCGs have also been working together during this time as a local delivery unit within the Alliance headed by Tonia Michaelides as Managing Director. Merton and Wandsworth CCGs have also been operating in this way.
In July 2018, the NHS turned 70 and we celebrated the occasion with a range of activities with our partners across the borough. On the day itself a group of our staff attended a service in Westminster Abbey in celebration of the NHS’s 70th birthday.
Following publication of the NHS Long Term Plan in January 2019, our governing bodies in south west London are now discussing a potential merger of all six south west London CCGs which would be implemented by April 2020. This would bring a number of benefits, such as reducing duplication, pooling resources and, cutting management costs by 20% – money that will be redirected to patient care. We are now working with our staff and all of our partners on how we can make this happen.
We are also working with our GP membership to support the development of primary care networks, which aim to spread best practice more easily, reduce bureaucracy, help alleviate workload pressures and allow GPs to concentrate on the most complex patients.
In 2018/2019, we are already seeing the benefits of working together in south west London. One example of this is south west London‘s Health and Care Partnership commitment to champion children and young peoples’ mental health and well-being. This year has seen exciting developments in a new programme bringing together school leadership teams with health and social care professionals to deliver training
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and support for children and young people, their families and teachers. You can read more about it in this report.
Health and care organisations across south west London have formed local partnerships to develop local health and care plans. To help shape our plans, we hosted a partnership engagement event in Twickenham which brought together health and care staff, local people and representatives from different community organisations to talk about what’s important for health and care in Richmond.
The local partnership has identified priority areas for improvement and it is clear that health and care organisations must be more joined up, particularly in areas where no single organisation can make progress alone, like improving mental health, combating childhood obesity, and encouraging active, resilient and inclusive communities that support older people to live at home independently.
It was fantastic to hear from local people who are clearly very passionate about improving health and care in Richmond and who brought a range of fresh ideas. We are also pleased that we have been shortlisted for a Health Service Journal Value Award for these local partnership events. The nomination shines a light on the importance of engaging residents and frontline staff when bringing together health and care services.
Finally, we would like to say a huge thank you to our GP members, staff, health providers, our partners and stakeholders for all your support over the year. I am grateful for your hard work and dedication which helps us to provide the best possible healthcare we can for the people of Richmond. We are looking forward to working with you all further in the year ahead.
Sarah Blow, Accountable Officer
South West London Alliance (Kingston, Richmond, Merton, Wandsworth and Sutton CCGs)
Date:
Dr Graham Lewis, Chair of Richmond CCG
Date:
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Performance overview
This section of the annual report gives an overview of the CCG’s corporate objectives, the health profile of its communities and a review of its activities during 2018/19.
Richmond CCG (the CCG) has a vision to deliver the best possible health and wellbeing outcomes for the local community, within the resources available. It does this through using a combined leadership of local GPs, a nurse and secondary care clinician, independent lay people, public health, local authority and NHS commissioning staff.
Richmond CCG works with patients, partners and member practices to commission safe, effective health services that continuously improve health outcomes, patient experience and reduce health inequalities. We strive to deliver cost effective, sustainable and integrated health services.
The CCG works in partnership with colleagues within the South West London Alliance (Kingston, Richmond, Merton, Wandsworth and Sutton CCGs), from NHS England, NHS trusts and other providers, CCGs, Richmond Health & Wellbeing Board, local authorities and the voluntary sector.
Corporate objectives Working together Kingston and Richmond CCG has developed a shared set of corporate objectives for 2018 to 2020 which has guided our work and influenced our commissioning decisions. They are as follows: 1. Enable local people, patients, carers and stakeholders to have greater influence on the services we commission and keep the patient voice at the centre of what we do. 2. Improve the quality, safety and effectiveness of healthcare services and ensure that national performance targets are met and that people experience high quality care. 3. Work in partnership with local health and care providers, commissioners and the voluntary sector to improve and transform services that achieve better health outcomes, are accessible and reduce inequalities.
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4. Ensure the continued development of the CCG as a clinically-led and well governed organisation with strong leadership, and effective membership and staff engagement. 5. Achieve a financially sustainable health economy balancing the need for effective use of resources and better value for money with the need for innovation.
Statutory duties
Deliver our statutory and organisational duties and ensure the CCG is a highly effective membership organisation.
The Richmond story
See Richmond’s Strategic Needs Assessment for more information about local health and social care needs https://www.richmond.gov.uk/jsna
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Summary of achievements during 2018/19
Children and young people’s mental health Across south west London we are working to do more to ensure that children and young people get the mental health and emotional wellbeing support they need. Our partnership approach brings together school leadership teams with health and social care professionals to deliver training and support for children and young people, their families and teachers.
“A lot of teachers are really lacking the confidence when it comes to addressing or talking about mental health issues in children and young people. Improving their awareness and confidence (as well as their own wellbeing) is key.” – teacher feedback
Support workers will be put in place in schools to offer both one-to-one support and group-work sessions for pupils and parents. The sessions they will deliver will give children and young people practical skills for managing a range of feelings and offer parents an opportunity to practise the conversations that encourage better mental health and wellbeing. Where needed, they will also signpost or refer to specialist child and adolescent mental health services.
This new way of working will initially be piloted in around 15% of schools in south west London. We will be seeking to gather evidence to demonstrate that this new way of working makes a difference. Our ambition is to ensure that all schools across south west London will be included in the future.
Neuro-developmental assessments for children and young people in Richmond
During 2018/19 we piloted a new local specialist assessment clinic for children and young people aged 6-18 years with suspected autism (without complex co-morbid problems, such as additional physical and / or mental health problems.) The service delivered by Richmond Council’s Achieving for Children team proved to be successful in delivering 73 local assessments with an average wait time of 2–4 weeks. This pilot service will now be commissioned on a longer term in Richmond and introduced in Kingston from April 2019.
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Access target for treatment for children and young people with mental health conditions NHS England has set a national target that by 2021/2 at least 70,000 additional children and young people each year will received evidence based treatment for mental health conditions. This target means that at least 35% of children and young people with a diagnosable mental health condition will receive treatment from an NHS funded community mental health service. This target will be delivered over five years with year on year percentage increases. In Richmond we are well on the way to achieving the 32% target for 2018/19.
“We are desperate for help and have no idea where to go” – parent view
This means that an additional 493 children and young people in Richmond will have been able to access treatment for mental health conditions.
New perinatal mental health service
South West London Health and Care Partnership secured £1.6 million to ensure that more women in south west London have access to specialist mental health teams.
These teams offer psychiatric and psychological assessments and care for women with complex or severe mental health problems during the perinatal period.
Between September 2018 and March 2019, the service saw over 60 perinatal women. These are women that might have ended up in A&E or community mental health services, both of which do not adequately meet the needs of women experiencing perinatal mental ill health.
Opening of the Teddington Urgent Treatment Centre
On 2 July 2018, the Teddington Urgent Treatment Centre opened, combining the Teddington Walk-In Centre with the GP out of hours service, based in Teddington Memorial Hospital.
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The CCG worked with Hounslow and Richmond Community Health Trust to run an extensive communications campaign (including social media and newspaper advertising, a targeted poster campaign and stakeholder briefings) to inform the public about the changes.
The main difference for patients using the former walk-in centre is that bookable appointments are now available in addition to walk-in appointments and the opening hours have changed. The service is now open until 8pm, rather than the previous time of 10pm, bringing it in line with other urgent treatment centres. Patients are advised to call NHS 111 after 8pm.
This change has happened because the NHS is working to standardise urgent care services. Feedback from the public suggests the range of services currently on offer is confusing, from minor injury units, to urgent care centres, urgent treatment centres and walk-in centres – all doing a similar thing. This is about bringing a local service into line with the rest of the NHS and securing the future of services at Teddington Memorial Hospital.
Transforming outpatient services at Kingston Hospital NHS partners in Kingston and Richmond have launched a programme of work to transform outpatient services so patients and GPs can access the support of specialist clinicians in the most efficient and effective way. The work is being led by clinicians with input from patients and other local stakeholders.
We need to do this to improve the services we provide, but we also know that we cannot continue to meet the growing demand for outpatient services if we carry on working the way we do now. If we do nothing by 2028 we predict an extra 35,000 first outpatient appointments each year will be needed, so we need to adapt and innovate to ensure we continue to provide good quality care.
What the transformation looks like is currently being determined. Some of the ideas being discussed include giving patients greater control over access to specialist advice and checks following major surgery, and developing a stronger network between GPs and hospital consultants so they can support patients as a more effective team and continually learn from each other.
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Ideas are based on best practice from other parts of the country. We will start by testing and trialling changes on a small scale, continually evaluating our progress throughout the process.
North west London outpatient transformation
Hospitals in north west London, which includes West Middlesex (which provides care and treatment for many Richmond patients) have implemented new guidelines for referral to hospital appointments in the areas of cardiology, dermatology, gynaecology, gastroenterology and musculoskeletal.
The new guidelines launched earlier this year seek to standardise referrals ensuring patients have all the right tests and results they need before seeing a hospital specialist. This change aims to improve the efficiency of outpatient appointments for patients and clinicians.
Referrals for these specialities are triaged by a hospital specialist. This means that for patients who do not need to see a specialist, they will not have to wait for a hospital appointment. Instead advice about the next steps of their care will be provided to their GP, again saving patients time.
Primary care
In 2018/2019, south west London received £8 million to help continue to transform primary care services.
All CCGs across south west London now offer access to primary care services from 8am to 8pm, seven days a week, as set out in the General Practice Forward View.
The funding has also been used to enable NHS 111 to book appointments directly into the services, for patients who would be better served by primary care, and has therefore helped to alleviate demand on other services within the local health and care system.
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“The event was a great opportunity for me to talk to a wide range of people and shopkeepers and give them our leaflet about GP appointments, which are available 8am to 8pm, seven days a week, and seeing a pharmacist first for illnesses. Some families were unaware they needed to get the flu vaccine for their youngest children and appreciated the advice.” – NHS winter champion, speaking about attending the Teddington Lights Up event in November
We have also invested in new ways to support our workforce as we know that to be able to deliver high quality care, we need a high quality workforce. We are now part of the international GP recruitment programme, and have secured GP retention funding to encourage and support GPs to remain in practice.
Our focus for 2019/2020 will be to continue looking at how technology can transform ways of working; retaining our workforce; and supporting general practices to work collaboratively in larger groups, called primary care networks (PCNs).
PCNs will consist of a grouping of GP practices within a geographical area, typically covering a population of 30-50,000 patients. By July 2019, it is expected that all areas within England will be covered by a PCN. Over the coming years PCNs will be supported in developing an expanded primary care team, with member practices also working alongside other organisations such as community trusts and the voluntary sector, to help alleviate workload pressures on practices and allow GPs to concentrate on the most complex patients. PCNs will also be able to spread best practice more easily, reduce bureaucracy, offer more personalised and preventative care, tackle workforce issues and manage a range of administrative functions more efficiently.
Locality infrastructure This year, working with local practices, Hounslow and Richmond Community Healthcare NHS Trust and the Richmond GP Alliance have developed the locality infrastructure to deliver primary care at scale and multi-disciplinary team working to manage complex care. This puts us in a strong position to implement the PCNs. A key focus for the CCG has been working with providers to ensure that care for patients who are frail and/or have complex needs is tailored to individual needs and that no-one is disadvantaged.
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This has included establishing teams made up of health and care professionals from primary, community, hospitals, mental health and voluntary sector organisations. Working together the team will plan and manage care to support people with complex needs in managing their conditions, avoid crisis and reduced unplanned admissions in their local area. These areas cover a population of 50,000, aligned to emerging primary care networks.
The teams will support early discharge from hospital and end of life care for those requiring care in hospital. This is about organisations working together to support individuals to manage their conditions, avoid crisis and reduce unplanned care needs using risk stratification.
Connecting your Care
Health and social care providers are working to improve the way they connect care for patients across south west London.
For people registered with a GP in Richmond, Connecting your Care will be joining up GP and hospital records across the four south west London acute hospitals. This will enable GPs, along with doctors and nurses, to immediately see important information about their patients through a secure system, to help them make more informed decisions about patient care.
The four hospitals that are linked into the system are:
• Kingston Hospital NHS Foundation Trust • Croydon Health Services NHS Trust • St George’s University Hospitals NHS Foundation Trust • Epsom & St Helier University Hospitals NHS Trust
Chelsea & Westminster Hospital NHS Foundation Trust, as part of the north west London health and care partnership of CCGs is not currently included in the Connecting your Care system, which means that for Richmond patients attending West Middlesex Hospital this join up will happen at a later date.
In the future, we will also be working with other health and social care providers to share a more detailed care record for patients across south west London. This will 13 | Page
include the treatment they receive from community NHS services, mental health services and some social care services.
Materials to support the launch in March 2018 were made available in GP practices, in the hospitals and this was supported with a programme of media and social media activity. Patients can opt out of Connecting your Care by visiting www.swlondon.nhs.uk/connectingyourcare and downloading the opt-out form, copies of which are available in GP practices and the PALS teams within the participating hospitals.
Doctorlink Doctorlink is an online clinical triage tool which we launched at the end of September 2018 to help patients get the advice or treatment they need in a convenient way, streamlining access to GP appointments. The tool means that patients will be able to get clinically approved medical information around the clock, and advice on how to best manage symptoms.
This new system will also allow patients who require an appointment to book directly with their practice, within a timeframe suitable to their clinical need. If appropriate, patients can also be directed to their local pharmacy, reducing unnecessary GP practice appointments by getting patients to the right place for their clinical need.
The system can be accessed online through practice websites or through the Doctorlink website. We are also launching a mobile app to make it easier for patients to access the service. Doctorlink is being introduced gradually to all GP practices in south west London. At the end of March 2019, Doctorlink was being used in three Richmond GP practices and this number is set to rise as it is offered to more practices, with a plan to offer it to all practices by July 2019.
End of life care During the year we worked with Kingston CCG and other local health and care partners including the voluntary sector, patients and carers to develop an end of life care strategy. Everyone deserves to be confident that the health and care system will
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give them and their families the support they need when they are coming to the end of their life.
“I’m the End of Life Care champion for my team and I’m passionate about it. I love working with patients and families, and it’s a real honour to be welcomed into their homes. My aim is to make their transition as comfortable as possible towards the end of their lives.” – community nurse
Since launching the strategy we have seen a six fold increase in the use of advance care planning, as recorded on our online system ‘Coordinate my Care’ and this is supporting more people dying in their place of choice and not in hospital.
We have worked collaboratively with partners to ensure that training on advance care planning is available to colleagues in GP practices, community and hospital staff and ensuring more care plans are recorded and shared on our online system, ‘Coordinate my Care’. This system allows healthcare professionals to record patients’ wishes and ensure that their personalised urgent care plan is available 24/7 to all those who care for them. This includes the NHS 111 service, the GP out of hours and the ambulance service.
Over the next three years the strategy aims to support the CCG to commission adult and children’s end of life and palliative care services and support community development that draws on current best evidence. It will also consider the support needs of those affected by the impact of death in different circumstances such as suicide, sudden death, maternal death or loss of a child.
We will work with specialist paediatric teams, social care and other relevant agencies to ensure that the end of life care needs of neonates, children and young people are met through a comprehensive model of palliative care for children and young people. Training will be provided for staff supporting patients with dementia who are at the end of life.
Training will be available for staff covering the diversity of beliefs for various groups and to ensure that these are at the forefront of providing end of life care. We will endeavour to ensure that patient information will be produced which is accessible to all patient groups in line with the NHS accessible information standards. 15 | Page
Mental health We are committed to providing the best possible mental health support to people who live in south west London, and have set out four key aspirations:
• To ensure that no person takes their own life • No-one has to attend A&E for a mental health crisis • Everyone with a long-term condition receives support for their mental health • People with serious mental illness have the same life expectancy as the general population
We will be undertaking a transformation programme, jointly with South West London & St George’s Mental Health NHS Trust, to review community and crisis support services to ensure they are able to deliver quality care for patients when and where they need it, avoiding the use of A&E wherever possible.
“Because of my unique expert by experience knowledge, I’ve been able to use my skills to help other mental health patients but also service users generally in south west London. I strongly believe the key to better services is patient involvement. I try and encourage hope and a voice to all especially the more vulnerable people.” – patient view
We will also be focusing efforts on suicide prevention, jointly with our local authority public health colleagues, both in our at-risk groups and for those bereaved by suicide. Finally, we will be working towards implementation of new NICE guidance for dementia care across all areas.
Richmond Wellbeing Service
Richmond Wellbeing Service is a high-performing IAPT service (Improving Access to Psychological Therapies) which has this year exceeded all access and recovery targets for IAPT.
The Five Year Forward View for mental health outlines targets for the expansion of IAPT services as well as maintenance of core standards to 2020/21.
In 2018/19, IAPT services targets were: 16 | Page
• IAPT expansion
o Increased access to psychological therapies for at least 19% of people with common mental health conditions.
o Progress with development of an integrated IAPT service for people with long term conditions, as well as co-location of therapists in primary care • Maintenance of core standards
o 50% IAPT recovery rate o 75% of people accessing treatment within six weeks IAPT waiting time o 95% of people accessing treatment within 18 weeks IAPT waiting time
Richmond Wellbeing Service exceeded all targets which included delivering a 55.7% recovery rate over the first 10 months of the year, against a national target of 50%.
Since being selected as an early implementer site for an IAPT service for people with long term conditions, the Richmond Wellbeing Service has been at the forefront of developing targeted psychological wellbeing interventions. This cohort of service users typically has a more complex profile of clinical need than the general population, requiring a more resource intensive approach to treatment.
As well as high access rates into the service, this is benefiting patients by contributing to an overall improvement in the care of conditions such as diabetes, chronic obstructive pulmonary disease (COPD) and medically unexplained symptoms (MUS). The Richmond Wellbeing Service has been sharing their learning with other IAPT services in south west London.
Annual physical health checks for people with serious mental illness
By the end of 2018/19, there was a requirement that at least 60% of people on serious mental illness registers within GP practices should receive an annual NICE compliant physical health check. The indications are that Richmond CCG will exceed this target for 2018/19.
In Richmond, a locally commissioned service with GP practices was seen as the best way to ensure that annual physical health checks are carried out and every practice in the borough has signed up to the service. In promoting it, we met with service users
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through Richmond MIND to share information around the need for physical health monitoring and to encourage service users to book their health check. Our diabetic specialist nurse is working with MIND staff to provide health promotion and prevention sessions for people with diabetes and those at risk of developing the condition due to their weight and treatment. We continue to provide training for staff in GP practices to support the development of this service.
The Richmond mental health alliance clinical interface group
Last year, the Richmond mental health alliance clinical interface group began holding weekly virtual meetings attended by senior clinicians from all areas within the mental health provider network to discuss the care of people with complex mental health needs, especially where the service user has experienced difficulties in their journey through the care pathway.
Over the last year the group has taken collective responsibility and ownership of these difficulties, resulting in resolution of individual cases, improvements in care pathways and identification of service gaps.
The group has developed a common assessment framework to use across services to avoid service users having to repeat their story. The group also review reports into deaths of Richmond residents under the care of mental health services to consider the recommendation for changes and improvements within local service provision.
This group has been proactive and productive in trying to influence change and reinforce good practice.
Learning disability and autism spectrum disorder
Richmond CCG continues to work with partners to ensure reduced hospital admissions for people with learning disabilities and autistic spectrum diagnoses. We have been working with Your Healthcare and Richmond Council to facilitate reviews in the community for patients at risk of admission into hospital settings to establish if patients are ready for discharge, or if they are receiving the appropriate care and treatment in a least restrictive environment.
Reducing health inequalities for patients with learning disabilities 18 | Page
Working with Mencap and NHS England, we have produced a short film for GPs and their teams looking at how they can help to improve the quality of care experienced by people with a learning disability and positively contribute to reducing health inequalities. According to figures from the Learning Disabilities Mortality Review Programme (LeDeR) it is known that people with a learning disability have a significantly lower life expectancy than people in the general population. For men, life expectancy can be reduced by 22 years, and for women by 29 years. For people experiencing profound or multiple learning disabilities, the mean age of death is 41 years.
The film seeks to encourage GPs to engage with the Learning Disabilities Mortality Review Programme (LeDeR), which reviews the deaths of all people with a learning disability aged 4 years or over. This and other preventative actions such as ensuring people attend for an annual flu jab, participate in cancer screening programmes, and attend for an annual health check, can also make a difference. The film is on YouTube: https://www.youtube.com/watch?v=ZLn4qEM5X4c
Maternity Our vision is to ensure that women and families are at the centre of the maternity care provided in south west London.
In 2018/2019, we successfully launched the booklet My Maternity Journey in South West London across four trusts which included Kingston Hospital. The booklet is a collection of local maternity services to help empower women to make informed decisions about the care they receive. We are currently developing an easy-read version of the booklet and producing an animated film which will be available soon.
With the aim to standardise the delivery of maternity services across south west London, we developed professionals involved in the delivery of maternity services to become Choice Champions to help ensure that women and families are informed on the choices available to them throughout the maternity care pathway. We secured funding to recruit a specialist midwife to work with Choice Champions and trusts, implemented a training programme for midwifery staff, and held a training seminar for GPs.
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Through our Continuity of Carer work stream, we ensured that 20% of women booking in south west London receive care from a known midwife throughout their pregnancy, during and after birth.
We are delighted to be one of the seven Maternity Choice and Personalisation Pioneers across the country commissioned by NHS England, and examples of our work on good practice and local development have been shared at the regional London Maternity Transformation Board, at pioneer showcase events, and in webinars hosted by NHS England.
Looking ahead, we will work towards the national target of 35% of women receiving care from a known midwife throughout their pregnancy, during and after birth. This work will also focus on ensuring that women from black and minority ethnic communities, and women from deprived communities receive these models of care as they have poorer outcomes.
Diabetes During 2018/19 the South West London Health and Care Partnership, working with the Health Innovation Network and the London Diabetes Clinical Network, has implemented a number of diabetes projects following successful bids for NHS England transformation funding:
• The Diabetes Book and Learn service (https://diabetesbooking.co.uk/) launched in October 2018. It provides people with access to any diabetes education course irrespective of where they live, including online, weekend and evening options. All Richmond GP practices have signed up to this service meaning that it is available to everyone who is registered with a GP in the borough.
• Pathfinder podiatrists in all four acute trusts in south west London including Kingston Hospital are now aiding discharge, rapid referrals and admission, as well as supporting clinicians in primary care with training. An initial audit has shown fewer amputations in people with diabetes compared to previous years during 2018/19.
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• Increasing the provision of diabetes hospital inpatient specialist nursing teams: Additional nurses are now in post at all four south west London hospitals working to improve management of people with diabetes while they are in hospital; reducing errors and incidents of harm and associated length of stay, which is significantly higher for people living with diabetes.
We have already trained over 20 GP practices in a new approach to joint care and support planning for patients with diabetes, to give patients a greater say in the management of their condition.
Later this year, we will be focusing on the You & Type 2 programme which is designed to make it easier for people living with Type 2 Diabetes to get the most from the health and social care systems, by combining innovative digital technologies and other support to provide each person with their own easily accessible personal plan of care, education and support.
We will also be launching new technology including personalised video messaging, a one-to-one digital diabetes support programme and a smartphone app to allow patients to access their care plans, alongside other resources that can help them, including educational materials, mental health support and local exercise groups.
Cancer
We have worked with national and local partners to diagnose cancer earlier, build on existing high quality services and support our residents living with and beyond cancer.
As a result of our participation in the RM Partners Cancer Alliance Bowel Cancer Screening Communication Services Programme, we have seen an additional 300 kits in Richmond. We are also participating in London text reminders for cervical cancer screening to support uptake of the cervical cancer screening programme where we know that early detection improves outcomes and increase survival rates.
Across south west London we have been developing enhanced support for prostate cancer patients in primary care including annual holistic reviews and prostate-specific
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antigen (PSA) monitoring. This service will enable more men to receive the care they need closer to home.
Musculoskeletal Musculoskeletal (MSK) conditions affect the joints, bones and muscles, and also include rarer autoimmune diseases and back pain. MSK is also a generic term for services such as physiotherapy, rheumatology, trauma and orthopaedics – which are one of the top specialties with the highest spend across all CCGs in south west London. We have been working with Kingston CCG to redesign and improve how local people access MSK services to ensure consistency with other CCGs in south west London.
In response to local need, this year we expanded our single point of triage for patients with MSK conditions, which is helping to ensure that patients are directed to the correct practitioner for their condition, more quickly. We also made changes during the year to streamline pain management referrals by incorporating them into the single point of access, and it is anticipated that the scheme will deliver benefits this year.
GP referrals sent to the single point of triage are clinically assessed to ensure patients with a musculoskeletal need are given the right treatment at the right time. This year an additional 2,500 Richmond referrals were managed through the single point of access, which shows that more of our GPs are using the service.
We are also piloting first contact practitioner services in primary care. In these services, patients contacting their surgery with MSK symptoms are offered the choice of a consultation with an extended scope physiotherapist instead of the GP. The pilots are being run across the country and we are working with national partners to evaluate the effectiveness of the service as a new model of care, to help take some pressure off GPs.
Effective commissioning
In 2018/19 with other CCGs in south west London we refreshed the Effective Commissioning Initiative that covers 55 treatments and procedures against which the
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CCGs have considered evidence of clinical effectiveness, the clinical cost and the cost effectiveness of the treatments .
We need to make sure that NHS funded treatments are evidenced-based, clinically effective and safe and that access to treatments across south west London is equitable for patients with similar clinical need, which reduces variation in care.
Through implementation of this policy we have been able to deliver an additional 187 procedures in Richmond delivering savings of £432,000, meaning that we have directed the resources to where the most clinical benefit can be achieved.
The ECI policy makes provisions for clinicians to apply on behalf of their patient to a south west London wide funding panel for individual funding where they consider that the patient need is exceptional or has a rare condition.
Prescribing changes to over the counter medicines We want to help people lead longer, healthier lives and support them to take better care of their health, and in particular for minor health conditions such as coughs, colds, and mild dry skin.
By patients managing minor health needs through self-care, and seeking support from pharmacists this will help to ease pressure on the NHS, saving an estimated £136 million a year nationally.
Therefore, in March 2018, in line with NHS England’s guidance, Richmond together with all CCGs in south west London, decided to stop prescriptions for medicines for a number of minor health conditions that can be bought ‘over the counter’, and often at a lower cost than that which would be incurred by the NHS or at a cost less than the prescription charge.
We published our position statement in August 2018, and provided materials to support the implementation of the new guidance to all prescribers within south west London, including GPs, extended hours, urgent care, A&E departments as well as pharmacies.
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These prescribing changes have saved approximately £778,000 annually (exceeding the 2018/19 annual target of £618,000) across south west London, positioning community pharmacists as the healthcare professional for minor health conditions. This has also allowed GPs to focus more of their time on patients with more complex needs such as cancer, diabetes and mental health problems.
Workforce – Jobs that Care Following on from a pilot launched in Autumn 2018, the South West London Health and Care Partnership has launched an innovative new careers programme for secondary school students.
Developed in collaboration with Health Education England, Jobs that Care is a multi- faceted education programme aimed at year 8 students which encourages active participation through: • An engaging and thought-provoking play, scripted specifically with students in mind, to introduce them to different health and social care roles • A bespoke game which reinforces all of the learnings from the play and encourages students to develop their general knowledge of the health and social care sectors and learn about particular roles in more detail • A supplementary app and website, which brings the students’ new found knowledge from the play and game to fruition in a form they’re most familiar with.
We’re now rolling out the programme to all south west London health and social care providers to use as part of their own school programmes.
The South West London Health and Care Partnership is also working with Our Healthier South East London to develop an improved approach to apprenticeships. This is in collaboration with Health Education England and health and social care organisations across south London.
The partnership is supporting health and social care organisations across south London to meet their 2.3% government apprenticeship targets and utilise levy funding
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before the end of May 2019, by recruiting new apprentices into the healthcare sector, and using apprenticeship programmes to upskill their existing workforce.
Supporting health and care providers over winter This winter health and care partners across south west London came together to agree joint health priorities to keep people well, while reducing demand on GP practices and on A&E departments.
Using insight from local people, and with the support of the Kingston and Richmond accident and emergency delivery boards, we worked across health and care to run targeted communication and engagement campaigns in the borough, phased to sit alongside NHS England and Public Health England national campaigns to maximise impact.
In the first phase, parents of two and three year olds and staff working in care homes in south west London were identified as key audiences for the flu vaccination. In order to increase uptake among these audiences, we implemented an integrated communications campaign, using digital advertising, localised promotional materials and social media activity to share our messages.
A key part of the campaign involved training CCG staff to become winter champions, sharing seasonal health advice with voluntary groups who support people who are more at risk of a winter illness. A number of our staff signed up to volunteer, including Vicky Fraser, Designated Nurse for Children Looked After. She ran an information session for a group of young people, who are part of the Children in Care Council, to talk to them about staying well over the winter months.
Winter champion, Vicky Fraser said: “The Children in Care Council is a fantastic initiative, which is led by a group of young people who represent the looked after population in Richmond. They were really interested to hear about what they can do to look after themselves, such as keeping a well-stocked medicine cabinet and visiting a pharmacist for minor illnesses instead of waiting for a GP appointment.
“It is important we empower young people to look after themselves, directing them towards pharmacists, who have a wealth of experience, and NHS 111 instead of 25 | Page
visiting A&E for non-life threatening ailments. Also, we explained that small lifestyle changes such as walking instead of getting the bus, can make a huge difference to someone’s health.”
As we moved further in to the winter period, we also promoted extended access GP appointments and pharmacy first messages, based on research highlighting pressure points in both primary and secondary care settings. This work continues, focusing on hyper-local pilots to encourage patients with minor health concerns to visit their local pharmacy before considering other NHS services.
Funding healthcare in Richmond
This information serves as a summary of the CCG’s annual accounts including the controls assurance and auditor’s statements. Our performance against the key financial performance indicators is summarised below.
Income and expenditure target
In 2017/18 the CCG ended the year with a deficit of £4.5m. For the 2018/19 financial year the CCG was set a surplus target of £0.3m by NHS England, with the underlying deficit the CCG carried forward this meant the CCG required net savings of £16.1m in year.
During the financial year it was acknowledged that it would not be able to achieve the planned surplus and so following discussions with NHS England the CCG revised its expected outturn to a £3.9m deficit. The CCG closed the year with a deficit of £3.9m.
Expenditure by type
The CCG was allocated a total of £272.51m to spend in 2018/19 and incurred £276.36m giving a deficit of £3.9m. Nearly half of this expenditure was acute services (£137.4m). The other significant areas of expenditure were mental health services £28.85m, community health services £22.32m, continuing care placements £23.46m and primary care prescribing costs £20.25m. The CCG spent £4.04m on the organisation’s running costs.
An analysis of the CCG’s net expenditure in 2018/19 is set out below.
Commissioning areas Expenditure £m 18/19 Total acute commissioning 137.40 Mental health 28.85 Continuing care 23.46 Community 22.32 Prescribing 20.25 Primary care 32.01 26 | Page
Other (including social care) 8.03 Running costs 4.04 TOTAL 276.36
Richmond CCG Expenditure in 2018/19 Total Acute 3% 2% Commissioning 11% Mental Health
8% 49% Continuing Care 8% Community
9% Prescribing 10% Primary Care
Other (including social care) Running Costs
Developments in 2018/19
The CCG has continued to invest in key areas to improve services and the long-term health of the population.
Better payment practice code
The NHS executive requires that all trusts pay their creditors in accordance with the Confederation of British Industries (CBI) prompts payment code and government accounting rules; that is to pay their creditors within 30 days of receipt of invoice. The CCG’s performance against this target is provided within this report and action is being taken to improve performance in this area. We were not subject to any actions or interest charges from suppliers during the year due to late payments.
Value for money
The CCG’s financial strategy is concerned with using our resources wisely, promoting value for money and having measures in place to promote economy, efficiency and effectiveness in using resources for the exercise of its functions. During the year, the CCG has focused on developing robust financial information and financial controls to 27 | Page ensure that best use is made of available resources. This has facilitated delivery of financial targets. Additionally, the CCG’s commissioning decisions are becoming increasingly informed by ‘value for money’ or ‘best value’ considerations using ‘health outcomes’ and ‘programme budgeting’ comparisons.
Going concern
These accounts have been prepared on the going concern basis. Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents.
Whilst the CCG is in financial recovery, the following is clear evidence that it is appropriate for Richmond CCG to prepare its annual accounts on a going concern basis: - Richmond CCG was established on 1st April 2013 as a separate statutory body. - Richmond CCG has agreed, and is operating to, it constitution to govern its activities. - Richmond CCG has been allocated funds for the 5 years from 2019/20 to 2023/24. - The CCG is planning for a surplus of £0.1m in 2019/20. - Detailed financial plans for 2019/20 have been submitted to the Governing Body and NHS England.
Where a clinical commissioning group ceases to exist, it considers whether its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of Financial Statements. If services will continue to be provided the financial statements are prepared on a going concern basis.
It should be noted that a report to the Secretary of State for Health under Section 30 of the Local Audit and Accountability Act 2014 has been issued for the breach of financial duties, i.e. failure to contain expenditure within the Revenue Resource Limit.
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Performance analysis
Improve quality Monitoring the quality of health services – and making improvements
Richmond CCG expects good quality health services for its residents. The CCG monitors the quality of services by provider organisations by undertaking clinical quality reviews to measure performance against the quality standards we have set.
Quality groups review achievement, by the provider, against set quality standards. The CCG primarily looks at outcomes for patients, which means how the patient feels about the outcome of treatments and how the result of the treatment has improved their quality of life. The CCG also asks about the experience patients and their families have of services, which is about how the provider has interacted with the patient, their family and friends. The measuring of quality standards includes the training and support staff receive so they are able to provide the best care.
The CCG and the community provider, Hounslow and Richmond Community Healthcare have a serious incident review process that supports early review of the root cause analysis and development of the actions plans. The clinical quality manager works with the provider to ensure that actions are targeted at improving quality and safety.
There was recognition that there was a need to develop the continuing healthcare team from quality and performance metric monitoring, concerns raised, quality reviews of providers and feedback from patients and families. This has resulted in further development of the continuing healthcare team within which there is now a team of nurse assessors, social workers and support staff who have developed systems and processes in line with the framework, to ensure the appropriate quality care is given to the residents of Richmond. The provision is monitored within the CCG’s Quality, Safety and Performance Committee.
Along with the CCG’s monitoring, our providers, including general practices, are inspected by the Care Quality Commission (CQC). If the CQC highlights areas that need development or improvement the CCG supports the provider and monitors the action plans within CCG quality review groups to address any concerns which are raised. The CQC’s judgement of quality of care is based on a combination of what 29 | Page
inspectors find during inspections and information provided by the provider, patients, the public and other organisations. Providers, again including general practices, are inspected by the Care Quality Commission (CQC) under five main domains – caring, effective, responsive, safe and well-led.
Patient advice and liaison service (PALS) and complaints
During 2018/19 our complaints team and patient advice and liaison service handled 503 patient concerns, there were also further contacts requiring redirection and/or information. There were 10 formal complaints raised by patients and/or their families.
Concerns received by Richmond Clinical Commissioning Group related to the services we commission locally; currently primary care complaints are handled by NHS England.
Richmond CCG continues to use the six principles of remedy to address concerns and complaints. (Parliamentary and Health Service Ombudsman report October 2007)
• Getting it right
• Being customer focused
• Being open and accountable
• Acting fairly and proportionately
• Putting things right
• Seeking continuous improvement
Members of the PALS team always listen carefully to the concerns being raised and provide advice or make recommendations, where possible, as to the best way forward for the patient or member of the public. It is not always possible to resolve a concern to the caller’s satisfaction; however, the PALS team can give information about support services and voluntary organisations that may be able to help.
Richmond CCG believes that a successful PALS service reduces the number of issues that go on to become formal complaints, however they recognise that complaints help
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to raise concerns that the CCG may not have been aware of and support continuous improvement.
Freedom of Information Richmond CCG is committed to being open and transparent. The Freedom of Information Act (FOI) 2000 gives members of the public a right to request access to all types of recorded information held by public authorities. You can read more about this on our website: http://www.richmondccg.nhs.uk/contact/freedom-of-information
The key performance measures for the CCG are the constitutional standards, which include treatment within 18 weeks from referral, being seen for a diagnostic test within 6 weeks, the proportion of people attending an A&E department being admitted, discharged or transferred within four hours, waiting no more than 62 days for cancer treatment after being urgently referred by a GP, having improved and timely access to psychological therapies and ensuring that there are no breaches of the mixed sex accommodation standard.
The CCG meets with local providers regularly to understand the issues related to performance. The CCG scrutinises and tests action plans as needed, ensuring that the CCG understands the risks and uncertainty in continued achievement of the standards, as well as the timeline and trajectory for recovery. Performance against standards and other performance metrics are checked and reported within the governance framework of the CCG, are reported to the CCG board, and are included within the CCG risk register where there is a risk to non-compliance.
NHS England annual assessment of Richmond CCG
NHS England monitors performance of CCGs against the following constitutional standards:
1. Dementia diagnosis rate 2. Referral to treatment (18 weeks) and diagnostics 3. Access to cancer services 4. Mixed sex accommodation breaches 5. Mental health/ Improving Access to Psychological Therapies (IAPT) 6. Health outcome frameworks (MRSA and C Difficile breaches)
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7. Urgent care (A&E and ambulance response times) 8. Cancelled operations 9. Health visitor numbers 10. Winterbourne View
A full scorecard, showing all the standards and CCG outcomes framework measures is available upon request to [email protected]
The full scorecard includes the following: • CCG outcomes framework (includes diabetic structured education, the friends and family test and healthcare acquired infections) • Local contract measures (includes South West London and St George’s and Your Healthcare) • Financial measures (includes QIPP, and financial spend against plan) • Organisational indicators (includes freedom of information requests, and sickness absence rate)
The table below shows the summary position against these areas for the last 5 financial years:
Indicator 2014/15 2015/16 2016/17 2017/18 2018/19
CCG Outcomes Indicators 1. Preventing people from dying prematurely G A G G G 2. Enhancing quality of life for people with long-term conditions G G A G G 3. Helping people to recover from episodes of ill health or following injury A G A G G 4. Ensuring that people have a positive experience of care R G A A G 5. Treating and caring for people in a safe environment and protecting them from avoidable harm A G A A A
CCG National Measures Acute Care A A A A A Mental Health/ Non-Acute Care A G G G G Supporting Activity Metrics G A R G A Everyone Counts - Local Priorities G G G G G
CCG Local Measures South West London and St Georges MHT G A A G G Hounslow and Richmond Community Health NHS Trust A G G G G
CCG Internal Measures Organisational Indicators G G G G G
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As at 31 March, 2019 Richmond CCG was showing an overall position of achieving 114 (83.2%) of the indicators in the areas listed above.
Financial measures are included within the finance report. Measures relating to the CCG outcomes framework and other local standards and contractual measures are included within the integrated quality governance report.
Whilst the CCG achieved 114 of the 137 metrics that make up the Richmond CCG performance scorecard, there were 8 indicators which were not achieved (red). These are: • A&E waiting time >4 hours (Kingston Hospital) * • Cancer 1st treatment 62 days: screening referral * • Incidence of healthcare associated infection: MRSA * • Number of 52-week referral to treatment pathways * • NHS 111: calls answered within 60 seconds * • Mixed sex accommodation (MSA) breaches (zero tolerance) * 33 | Page
• Proportion of patients referred to first outpatient services via e-referral service • Bed days lost to delayed transfers of care (average daily health delays) * Constitutional standards
Richmond CCG performance – performance analysis • Accident & emergency performance at Kingston Hospital – whilst the 95% target was not achieved in 2018 /19, Kingston Hospital achieved 89.25% against the national standard, and met the sustainability and transformation fund expectation • All cancer waiting time targets have been met except for the 62-day screening target, which has been missed for 5 months. The numbers of patients within this cohort is very small, and work is being continued to smooth screening pathways in St George’s and The Royal Marsden • Referral to treatment – the national 18 weeks waiting time target was met, but there were a number of patients waiting over 52 weeks at Imperial College. • Dementia diagnosis rate target of 66.7% has been met • While Richmond CCG narrowly missed the delayed transfers of care trajectory, the number of bed days lost to health delays has reduced significantly • Improving Access to Phycological Therapies (IAPT): the access, recovery and waiting times targets were achieved in 2018/19, including increasing the access to 4.75% of the expected cohort in quarter 4 2018/19 • The monthly Friends and Family Test surveys show excellent outcomes reported for inpatients, outpatients, community care, A&E and maternity services • Antimicrobial resistance: broad spectrum prescribing - reduction in the number of co-amoxiclav, cephalosporins and quinolones as a percentage of the total number of selected antibiotics prescribed in primary care. This reduction is now in line with the 2018/19 quality premium expectation
Key areas for improvement for Richmond CCG are: • There has been a great deal of work within Kingston Hospital and around the whole health and social care system to increase the proportion of people treated within the 4 hour standard. The Kingston, Richmond and Surrey Downs A&E
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Delivery Board has refreshed its programme of work under the heading of the eight pillars for improvement in urgent and emergency care. • While the number of delays has reduced for Richmond CCG patients in 2018/19, there is work continuing to discharge patients earlier with support. • Supporting the IAPT service to meet the 22% access rate for 2019/20 (5.5% in quarter 4 2019/20) and to maintain the recovery rate throughout 2018/19. To increase the proportions of people with long term health conditions, older people and people from black and minority ethnic communities accessing local IAPT services in line with best practice.
In addition to national and local targets, Richmond CCG’s performance is underpinned by outcome indicators as reported centrally by NHS Digital, which are used to benchmark performance and to aid the CCG in discharging its duties. The 2018/19 CCG Improvement and Assessment Dashboard for Richmond CCG is below, showing the areas where Richmond CCG is in the best, worst and interquartile ranges benchmarked with all CCGs in England.
Provision of High Quality Care NHS Continuing Healthcare Personalisation and choice Urgent & Emergency care Anti-microbial resistance Learning disability Health Inequalities Mental Health Child obesity Elective access Diabetes 7 day services Carers Primary Care Falls Maternity Dementia Cancer RichmondDelivering the Five Year Forward View CCG
Progress against WRES Staff engagement index Quality of CCG leadership Right Care Probity and corporate governance Financial sustainability Working relationship effectiveness Paper-free at the point of care Public and patient participation compliance
Report Date: November 2018
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CCG Improvement and Assessment Framework - leadership rating
The CCG Improvement and Assessment Framework (IAF) aligns key objectives and priorities for NHS organisations in delivering the Five Year Forward View. As part of the CCG IAF, quality of leadership ratings are reviewed on a quarterly basis.
Following the latest review, the leadership rating for Richmond CCG has moved from green to amber. The change in rating is due to concerns that NHS England (London) has around the need for significant improvements in the governing body’s leadership to drive the necessary transformation across primary care and community services. Also, the CCG has a challenged financial position in part linked to the limited impact of recent investment in primary care, as well as poor delivery on our transformational QIPP programme.
In light of our financial position, we have focused over the last few months on developing our transformation programme in Richmond. We have worked in partnership with our health and care partners in the borough to develop shared priorities to ensure that we are working together on our key transformation priorities. This is because all of the evidence from national programmes shows that working together can have a real impact on improving patient care and outcomes for local people.
Going forward, we will build on this work to develop strong alliances with partners to accelerate progress on service transformation to improve quality of care, outcomes and our financial position. It is essential that we work together, with other healthcare providers, to give our transformational programmes of work the energy and focus they need to deliver improved patient care and lasting financial change.
Performance on social matters, respect for human rights, anti-corruption and anti-bribery matters. Information about the CCG’s performance on social matters and human rights can be found in our public sector equality duty report, which is discussed later in this report.
Counter fraud arrangements are in place in the CCG to ensure compliance with standards set by the NHS Counter Fraud Authority. An accredited counter fraud specialist is contracted to undertake counter fraud work proportionate to identified
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risks. The CCG’s audit committee receives progress reports throughout the year and an annual report against each of the standards for commissioners.
There is executive support and direction for a proportionate proactive work plan to address identified risks. Regular fraud related communications are shared with CCG staff and training is available for all staff.
The local counter fraud specialist meets with the finance director and internal audit to agree tasks to be undertaken and produce the workplan. The local counter fraud specialist also has regular liaison with the finance director to discuss any concerns that come to light throughout the year.
A member of the executive team (the finance director) is proactively and demonstrably responsible for tackling fraud, bribery and corruption.
There have been no assessments from the NHS Counter Fraud Authority but should one occur an action plan would be taken forward following any recommendation made.
Sustainability
What is meant by sustainability? Sustainability in this context is about the smart and efficient use of natural resources, to reduce both immediate and long term social, environmental and economic risks. The cost of all natural resources is rising and there are increasing health and wellbeing impacts from the social, economic and environmental costs of natural resource extraction and use. The most widely accepted definition for sustainable development comes from the 1992 Rio Earth summit, which defines it as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs.”
Summary of performance Richmond CCG is committed to reducing its impact on the environment and moving towards a more environmentally friendly way of working. Leadership for sustainability within the CCG sits with the Director of Corporate Affairs and Governance.
While the CCG does not have a sustainable development management plan (SDMP) at present, we demonstrate commitment to reducing the impact the work we do has on
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the environment. For example, staff are encouraged to work from home to reduce the impact of travel, and use public transport for work related travel where possible. You can read more about the work we do to promote sustainability at work in Richmond CCG within the staff report.
As a part of the NHS, public health and social care system, it is our duty to contribute towards the level of ambition set in 2014 of reducing the carbon footprint of the NHS, public health and social care system by 34% (from a 1990 baseline) equivalent to a 28% reduction from a 2013 baseline by 2020.
Modelled carbon footprint Most of the environmental and social impacts are through the services we commission. Area Is sustainability considered? Commissioning (environmental) Yes Commissioning (social impact) Yes Suppliers’ impact Yes Business cases Yes Travel Yes
Other actions to encourage environmental sustainability: Since 23 March 2018 we have been co-located with Kingston CCG, in Thames House which is run by Hounslow and Richmond Community Healthcare (HRCH) NHS Trust. Our direct environmental impact arises mainly from our use of office accommodation, which sits under HRCH’s sustainability and environmental policy which is available on their website. The policy aims to ensure that energy consumption and waste products produced are minimised as much as practically possible through: • Staff awareness and good housekeeping • Energy efficiency and usage • Financial investment in innovation and technology • Effective energy procurement
Some of the actions taken under the HRCH policy are summarised below:
• We have a zero waste-to-landfill policy • We hold monthly waste management training sessions to ensure colleagues follow correct protocols
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• All domestic waste is burned to generate energy, enabling zero landfill; this energy is distributed to the National Grid • Public transport usage and agile working is encouraged • Continuous auditing and the introduction of ISO9001 processes, ensuring legal compliance and capturing any missed carbon and/or financial saving opportunities • Up-to-date reporting identifies trends in utility consumption and waste production and enables the estates team to take action to resolve issues
Utilities Electricity is hourly metered, so we can see daily peaks and troughs, enabling closer usage management. We have efficient gas boilers and anticipate that we will realise the benefits in the first quarter of 2019, with no increase in gas consumption.
Water consumption has been tightly controlled, reducing stored water on site, and a more reliable water system of reducing leaks and water waste.
Waste We recycle just over 61% of non-clinical waste, which is almost double the UK national average of 35%.
Richmond CCG has also supported Richmond Council’s programme of work this year to improve air quality by reducing vehicle related emissions.
Procurement for social value and sustainability Social value is the recognition that social outcomes such as stronger communities, improved health and improved environments have a value to society. Commissioning of services and the procurement of products are very powerful levers to influence the delivery of sustainable services. Commissioners can develop and use criteria to stimulate more ambitious and innovative approaches to delivering care that costs less, creates less environmental harm and reduces inequalities. Equally, the significant procurement budget for goods and products used by the health and social care system provides multiple opportunities to maximise social, economic and environmental value. The CCG uses the Department of Health Standard NHS Contracts which have a requirement for all providers apart from small ones to demonstrate their progress on climate change adaptation, mitigation and sustainable development, including
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performance against carbon reduction management plans; they are also required to provide a summary of that progress in their annual report.
Commissioners recognise that to expand, raise the quality of and increase the capability of community health and social care, ensuring its future sustainability, the landscape of providers may change. Commissioners in south west London are particularly interested in exploring outcomes-based commissioning and integrated service specifications, creating new opportunities for providers, including partnerships between health and social care providers. They aim to explore the collective impact of commissioning services differently and providing opportunities for providers to work together which will help to reduce organisational barriers.
The south west London CCG leaders recognise that the transformation of primary care in the local health economy is pivotal to achieving sustainability and improved clinical, public health and social care outcomes for the people of south west London.
Partnerships As a commissioning organisation, we will need effective contract mechanisms to deliver our ambitions for sustainable healthcare. The NHS policy framework sets the scene for commissioners and providers to operate in a sustainable manner. For us as a CCG, evidence of this commitment will need to be provided in part through contracting mechanisms. Providers must demonstrate progress on climate change adaptation, mitigation and sustainable development, including performance against carbon reduction management plans and must provide a summary of that progress in their annual report.
More information on these measures is available here: www.sduhealth.org.uk/policy- strategy/reporting/organisational-summaries.aspx
Patient and public engagement
The CCG has discharged its duties under section 14Z2 Health Act 2012 (public involvement and consultation by clinical commissioning groups). We are committed to ensuring that the views and experiences of local people are at the heart of our plans, 40 | Page
driving forward the changes needed to improve local services that reflect the needs of the people who use them.
In 2017/18 the CCG was rated as good for patient and public engagement against NHS England’s new patient and public engagement indicator. We have continued to make further improvements in this area of our work and await our rating for 2018/19.
Our approach to engagement
An integrated approach to engagement and communications for the South West London Health and Care Partnership ensures consistency across the six boroughs of our Partnership and in our locally delivered engagement. A small central team provides support for us in the CCGs, facilitating knowledge sharing and collaboration, and coordinating activity that is best carried out at scale across the six boroughs in south west London.
We have created professional communities through borough-level communications and engagement steering groups that bring together leads from local authorities, NHS trusts, CCGs, the voluntary sector and Healthwatch to work on local joint projects, share knowledge, map stakeholders and coordinate plans for involving local people. Our borough group has met approximately every six weeks during 2018/19.
“Our partnerships with the CCG and with the SWL Health and Care Partnership have helped to enhance engagement and involvement; for example, through helping to build high quality involvement in local health and care plan development.” – local voluntary sector organisation
Local people and their representatives are involved in all areas of our work and that of the South West London Health and Care Partnership, from assessment of local need and development of strategy, in close collaboration with our partners, to monitoring of contracts with providers.
Locally we have several established channels to ensure regular engagement with our communities either directly with patients or via local voluntary and community sector organisations. These include working with our GP practice patient participation groups (PPGs) via our PPG network, specific interest groups via our community involvement group and holding CCG governing body and primary care commissioning committee meetings in public. 41 | Page
Our community involvement group acts as an engagement and equalities reference group for the CCG. The group is a valuable source of insight and input from key voluntary sector and community organisations on local patient and public engagement in commissioning. Membership is drawn from local organisations representing key local voluntary and community sector organisations, Richmond Council, Richmond Council for Voluntary Service (CVS) and Healthwatch Richmond. The PPG network is a forum for PPG representatives to come together and share information and ideas about their PPGs. It is also one of the ways the CCG ensures that the patient voice is shaping the CCG’s primary care programme. The network is represented on the primary care commissioning committee.
Richmond CVS coordinates several forums with local voluntary and community organisations and people with lived experience of services which the CCG takes part in to maintain ongoing engagement with local communities and patient groups. These include RCVS’ health and wellbeing network for local VCS; Richmond users and carers group and the health and social care co-production group.
For south west London programmes of work our engagement is overseen and constructively challenged by our SW London Patient and Public Engagement Steering Group (PPESG), an advisory sub-group to the South West London Health and Care Partnership Programme Board. The PPESG membership includes representatives from Healthwatch, south west London’s voluntary and community sector organisations, as well as CCG lay members from across the six boroughs.
Strategy - engaging local people in developing our health and care plan
Following our STP refresh in 2017, informed by feedback and engagement with local people and stakeholders, our strategic approach has shifted to working in local partnerships at borough level to integrate health and care, and encouraging partnerships to develop local health and care plans at borough level to set joint priorities for local action. In November 2018, we held an event which brought together around 150 people including local people stakeholders including local councillors, community organisations and Healthwatch, alongside senior managers and front-line staff to discuss the key challenges for health and care in the borough and to generate priority actions for joint action across our Partnership to enable people to start well, live well and age well. Careful sampling and recruitment of local people to reflect the
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borough’s demographic brought new faces and fresh insights, as well as a pool of people who have registered an interest in working with us to improve health and wellbeing in the coming months and years. Following publication of our local health and care plan engagement will move to more focused co-design work with target populations.
Decision-making - our direct engagement programme
Patient and public voice representatives, or PPVs, sit on several local and south west London clinical work streams including mental health, planned care, cancer, end of life care and urgent care. Together with Healthwatch, PPVs bring insight and challenge to support more effective planning and decision-making. PPVs have an induction and ongoing support to enable them to fulfil their role. PPVs involved in south west London work streams are also members of a new readers’ panel we established in 2018 to help us test materials prior to publication.
Service and pathway design – our targeted engagement programme
Focused engagement influences and shapes strategy and service development in each of our work streams. Activities include focus groups, interviews and online channels such as surveys and readers’ panels. Depending on the project, this will either take place locally or at a south west London level on behalf of the local CCGs. Examples include:
Children and young people In the summer of 2018, we engaged children and young people and parents and carers, as well as teachers and schools, to examine root causes of self-harm and poor emotional wellbeing, as well as to test several potential solutions. We reached children and young people primarily through voluntary sector organisations and schools in each of the south west London boroughs. We ran 8 meetings, spoke to 42 young people, and had over 1200 responses to our online survey.
In response to what we heard we:
. Narrowed down our long-list of possible interventions to a shorter list that children, young people, parents, carers and teachers told us would work for them.
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. Developed a diverse model of support that is based outside of a medical environment – in schools – and that includes one-to-one and group sessions for children and young people, online self-help and counselling, an online directory of services and education/training programmes for parents and teachers . Secured funding to deliver some innovative ways to deliver emotional wellbeing initiatives through schools, using newly trained mental health support workers who will be based in schools.
“Groups are really great and help you feel more accepted so you are less likely to take out frustrations about loneliness on yourself.” - young person view
“Focus on friendships within those activities.” – child view
The involvement of children and young people will be critical as we put our plans into practice, and we have developed a framework for involvement to ensure that at every opportunity we act to ensure that the voice of children, young people, parents and carers is built in to our work – in needs assessment, in service design, in service delivery, in monitoring the quality of the services we provide and in our assurance processes.
For example:
. We are involving young people in designing and procuring new services we introduce as part of this programme; for example, in February 2019, the Wandsworth Youth Council and a school student council took part in deliberations to inform the selection of the provider of a new online counselling service for young people across south west London.
Diabetes
At the end of March 2018, we invited stakeholders from across the local healthcare system to come together to discuss how to improve care for people with diabetes in primary care. Sixty- nine people attended including people with diabetes, practice nurses, community nurses, GPs, commissioners, and public health consultants.
Key areas highlighted at the event have been taken forward during 2018-19 including:
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• Care planning – we used insights from the event to design a wider survey to ask people with diabetes what they would like their diabetes care to look like in the future. Feedback from the survey helped to secure £565,000 to introduce and test a patient-centred approach to care planning in GP practices under the NHS England test bed programme; this is initially being tested in about 20 GP practices across south west London and if this shows good results we will look to spread to further practices
• Working together - we are developing a funding proposal for the next wave of the Treatment and Care funding programme that was announced in the NHS Long Term Plan that will include funding to introduce more multi-disciplinary team working and virtual clinics.
• Using the whole team - we have promoted the use of e-learning resources via primary care teams and visits to locality meetings. We are also putting on training sessions for healthcare assistants in foot care for people with diabetes, to support both our test bed project and our diabetes foot care project.
NHS111 We wanted to hear from people who live within south west London who had used the NHS 111 telephone service about what was working well and what could be improved. At the end of December 2018 until January 2019 we ran a survey promoted via our local networks, including patient representatives, Healthwatch and the community and voluntary sector. We also promoted the survey across south west London via Twitter and Facebook. We received almost 200 responses. Findings from the survey have been shared with the south west London Integrated Urgent Care Board and the south west London Integrated Urgent Care Patient Representative group, and will inform service development in the coming year.
Macmillan primary care nursing project – cancer care reviews Listening to patients and ensuring their experience and views help to shape the project’s outputs has been key to the south west London Macmillan Primary Care Nursing project from the beginning. Whilst it is well documented that patients experience a high level of unmet need following the end of their main hospital treatment and that there is a gap in the supportive care and cancer expertise available
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in primary care, the project team identified that to their knowledge no attempt had been made to find out from patients what their experience of a cancer care review was like. As our patient partner put it: ‘how do we know that patients find them helpful?’. Attempting to answer this question formed the basis for a focus group with cancer patients in December 2018. Insights from these discussions are informing the education and influencing strategy for the project over the next year.
Reaching diverse communities – our community outreach programme
We regularly visit community groups and organisations to listen to people about their experiences of local services and give them the opportunity to shape future services. Through our outreach we can have meaningful conversations with local communities who do not always feel their voice is heard or face specific barriers to being involved in our work.
Our local outreach programme has been enhanced by the south west London grassroots programme run in collaboration with Healthwatch. By funding and attending a series of fun, community-based events and activities we have had the opportunity to hear about people’s experiences and understanding of local services.
“I was already a volunteer at my local gurdwara, Sri Guru Singh Sabha Gurdwara in Hounslow, and wanted to offer winter health messages at the weekly wellbeing stall that is held there every Sunday. The stall provides information on various health conditions and is run by a team of volunteers.
“I wanted to make sure that members of my community knew what to do to stay well this winter, including having the flu vaccination. I have done a few shifts with the team already and will continue to provide winter health advice over the next couple of months.” – NHS winter champion
The programme expanded our reach into communities and enhanced our understanding of the needs of specific populations where health is just one of several challenges associated with daily living. We used insights from these sessions to set the scene and present a picture of health at our large-scale local health and care plan
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event in November 2018. You can read more about our local health and care plan event here
Equalities
Our annual public sector equality duty (PSED) report brings together information and evidence which demonstrates how the CCG is meeting its statutory duties under the Equality Act 2010. During 2019/20 Kingston and Richmond CCGs will build on our joint approach for equalities e.g. shared equality objectives and equality analysis process. We will explore joint working where it adds value across the wider Kingston and Richmond local health and care partnership - working with our key NHS, council and voluntary sector partners. Areas of focus for the coming year include:
• Review effectiveness of our shared process for equality analysis across both CCGs • Identify opportunities to run the equality delivery audit (EDS2) across both CCGS and where appropriate with our providers • Explore sharing staff training and development opportunities with NHS partners, including those in primary care. • Review our community outreach programme to ensure the focus is on communities who face specific barriers to being involved in our work and whose specific needs must be considered. • Implement Workforce Disability Equality Standard
Our latest PSED report was published in January 2019 and is available on our website.
Reducing health inequalities
Our role as a CCG is to reduce inequalities between patients in accessing the services we commission. A key area of focus is to support parity of esteem for mental health both in improving mental health outcomes and promoting the physical health of those with mental health needs.
To reduce health inequality and improve outcomes for all we work with colleagues in the public health team at Richmond Council, as they provide us with a source of 47 | Page
expertise in using health related data sets to inform commissioning, reduce inappropriate variation in the local area, identify vulnerable populations and marginalised groups, and support commissioning to meet their needs. Our work to reduce health inequalities is also reviewed by the local Health and Wellbeing Board.
Key areas of health inequality in the borough are:
• Life expectancy at birth was about 3.5 years lower for women and 7.9 years lower for men in 2015-2017 in the most deprived areas of Richmond, compared to the least deprived areas. (source: PHOF). • Thirteen out of 115 small areas in Richmond, with around 21,000 (11%) residents in total, had levels of deprivation above the England average in 2015. In 2016, 8.8% of children in Richmond were living in low income families (source: HMRC). • Adults in routine and manual occupations (aged 18-24) are twice as likely to be smokers, with 18.9% being smokers compared to 9.8% of the general population (source: Local tobacco profile). • Although the number of ‘children in need’ has reduced against the previous year with 844 in 2017 compared to 895 in 2016 and remains lower than London and England averages, the number of children on a child protection plan remains the same with 117 in 2016 compared to 115 in 2015. (source: Children and young people needs assessment, 2017). • Between 2014/15 and 2016/17 there was a 7% increase in the number of rough sleepers in the borough, however between 2015/16 and 2016/17 the figure decreased from 133 to 128. Given the comprehensive outreach work that exists in the London Borough of Richmond there is a high degree of confidence in these figures compared to other boroughs reporting lower levels of rough sleeping where there is minimal or no outreach provision (source: JSNA). • There is a 66.5% gap in the employment rate for those in contact with secondary mental health services in Richmond and the overall employment rate. There is also an 8.5% gap in the employment rate between those with a long- term health condition and the overall employment rate (source: PHOF). • Adults with serious mental illness in Richmond are almost twice as likely to die prematurely than the general population.
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• People with disabilities are more likely to suffer a range of barriers and are at higher risk of other health problems. 21,447 (12%) people report that they have some form of disability or health problem that affects their day-to-day activities. This ranges from 2.3% (862) of children (0-15 year olds), to 79% (2,774) of people aged 85 and over. Between October 2017 and September 2018, 3,800 (14.5%) of unemployed people aged 16-64 in Richmond were inactive due to long-term sickness or disability, compared to 17.1% in London and 22.4% in Great Britain (source: ONS, APS
Richmond Council’s data website DataRich hosts Health Needs Assessments for the nine protected characteristics of the Equality Act which provide further details of inequalities in health across the borough. DataRich also has dedicated Deprivation and Equalities pages where you can easily find information. The previous joint strategic needs assessment includes further details on the nine protected characteristics of the Equality Act which provides more information about health inequalities across the borough.
“What I most enjoy is that working closely with GPs, we strive to reduce the health inequalities that exist in our locality. As a pharmacy, we provide a wide-range of healthcare services, including: seasonal vaccinations, NHS health checks, chlamydia screening and treatment, and smoking cessation.” – community pharmacist
To help us respond to health inequalities in the population, equality impact needs assessments are carried out for all services we commission. We also review the uptake of services to ensure they are accessible to all and link in with public health colleagues for advice on steps to take when health inequalities are identified.
Healthy London Partnership
Richmond CCG, along with all of London’s 32 CCGs, Greater London Authority, London Councils, Public Health England and NHS England (London) contributed funding towards Healthy London Partnership (HLP) in 2018/19. The aim was to bring together the NHS and partners in London to work towards the common goals set out
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in Better Health for London, NHS Five Year Forward View and the devolution agreement.
HLP works as a partnership across London’s health and care system and beyond to achieve these goals. This includes NHS organisations in London, including NHS Richmond CCG, NHS England, NHS Improvement, hospital trusts and providers, as well as working across health and care with the Greater London Authority (GLA), the Mayor of London, Public Health England and London Councils. Additionally, HLP hosts the London Health and Care Strategic Partnership Board which provides oversight and leadership for devolution plans, working closely with the London Health Board secretariat. HLP is supporting the development of the refreshed shared vision for health and care to ensure all partners are clear about their role in making London the world’s healthiest city.
2018/19 has been another busy year for Healthy London Partnership. Through successful partnership working across health and care in London, HLP has helped to deliver on a range of programmes, outputs and achievements spanning primary and community care, secondary care and mental health, as well as those focussed on integration of health and care and place based care. All this work is part of the partnership’s collective aim to make London the world’s healthiest city.
HLP director, Shaun Danielli, outlines how by working together we are improving Londoners’ health and wellbeing, so everyone can live healthier lives:
“Healthy London Partnership has continued to support the transformation of health and care for Londoners in 2018. There has been significant progress in areas such as mental health, greater use of technology and increased access to family doctors.
“None of this would be possible without key agencies, organisations and people working together. Partnership working is the only way in which we will tackle London’s most complex health and care challenges and ensure that we meet our shared aim of making London the healthiest global city.
“As we look ahead, the NHS Long Term Plan and a five year funding settlement gives us a huge opportunity to transform the way we support the health and care of Londoners. Everyone involved with HLP looks forward to shaping and implementing improvements for London.”
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During 2018, there was a collaborative focus on social prescribing, which is a way of linking patients in primary care with sources of support within the community for non- medical needs. The HLP proactive care team has worked closely with partners to develop a draft ‘Social Prescribing Vision for London’. The draft vision was developed by the GLA, NHS England, HLP and the London Social Prescribing Network, in collaboration with partners across the NHS, local authority and voluntary, community and social enterprise (VCSE) sector to support the scale and spread of social prescribing across London.
Other engagement highlights in 2018/19 include a number of significant projects undertaken by Thrive LDN, the citywide movement launched by Mayor Sadiq Khan to improve the mental health and wellbeing of all Londoners. This included helping young Londoners to organise a festival of cultural activity as part of Thrive LDN’s wider Are we OK London? campaign, which this year had a potential reach of over 23 million people. This year’s campaign engaged with a more diverse audience, grew Thrive LDN’s followers and subscribers and increased discussion and action around how inequality and discrimination can affect Londoners’ mental health and wellbeing.
More recently, Thrive LDN published Londoners Said… – a report summarising the findings of the 17 community conversations run in partnership with the Mental Health Foundation (MHF) in half of London’s boroughs. Each community conversation produced a comprehensive write-up to underpin a plan for local action. The report includes 10 recommendations from Londoners on how to ensure people have the right support to stay mentally healthy.
Following on from the Great Weight Debate, which engaged Londoners on how best to tackle childhood obesity, HLP has worked with fast food shops, businesses and charities and young people in three London boroughs (Southwark, Lambeth and Haringey) to pilot their ideas for making high streets healthier for children and young people through the Healthy High Streets Challenge. The Challenge provided invaluable insights into how to make healthier choices easier on London’s high streets. The findings informed obesity strategies across all London boroughs and the Mayor’s policy to restrict the advertising of food and drink that is high in fat, sugar and salt across Transport for London’s advertising estate from February 2019.
Further focus on children and young people was demonstrated through London’s annual #AskAboutAsthma campaign. Led by HLP in conjunction with NHS England
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London region, the campaign coincided with the start of the new school year when hospital admission rates for asthma are at their highest. The campaign reached over 5.9 million people online in 2018. Additionally, HLP has developed the London asthma standards for children and young people, bringing ambitions for how asthma care should be delivered across the city with national and local standards, along with a new online toolkit for staff which to date has been accessed just under 19,000 times.
2018 saw a further increase in patients across London accessing online GP appointment booking, ordering of repeat prescriptions and access to coded information in records. HLP has been working with London’s CCGs and NHS England London region to support GP practices to offer and promote online services to patients.
Elsewhere on digital developments in 2018, London saw the full rollout of an NHS e- Referral Service (e-RS) across 23 providers one month earlier than the national target date. This was achieved through proactive and successful partnership working between London’s health and care organisations and now means that all GP practices in the capital can manage a patient’s first referral from primary care to hospital through a paperless process.
The London Mental Health Dashboard makes a wide range of London’s mental health data publicly accessible in one place. Urgent suspected cancer referral activity data is also now presented in a useful interactive dashboard developed by HLP.
There has also been a strong focus on mental health transformation across London during 2018/19. London’s crisis care system has been working to improve the quality and consistency of care for people in mental health crisis. Through HLP, London’s A&E departments and police forces have worked together to develop a handover process for voluntary mental health patients in emergency departments, which has resulted in 83% fewer people going missing from A&E during a mental health crisis compared to the previous year. The handover process was awarded the Best Patient Safety Initiative in A&E at the 2018 HSJ Awards.
This year saw the NHS in London invest an extra £6 million into specialist mental health services to support women during pregnancy and in the first year after giving birth. From March 2019, services for perinatal mental health problems will be available across all of London. The extra resource has resulted in 79 new whole time equivalent
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clinicians for London during 2018/19 and this important specialist care is now offered to nearly 5,300 women a year.
HLP also launched a Mental Health in Schools Toolkit in 2018 which provides a range of information for schools, governors and commissioners on mental health and emotional wellbeing in schools. The suite of resources includes links to relevant guidance, practical tools and resources, and examples from across London of new initiatives and approaches in schools or across local authorities.
By October 2018, Good Thinking – London’s unique digital mental wellbeing service – had supported over 100,000 Londoners to actively tackle anxiety, sleeplessness, stress and depression. Since its launch at the end of 2017, Good Thinking has offered personalised new ways to improve mental wellbeing for Londoners.
Elsewhere through partnership working in 2018, a whole system estates planning function has been established through the London Estates Board. In spring 2019, the first London Health and Care Estates Strategy was developed which will support a coordinated approach to using capital and the release of surplus to requirement NHS estate, meaning much needed money is reinvested back into London’s health and care system.
Finally, the clinically-led London Choosing Wisely programme concluded its work in 2018 to develop eight pan London commissioning policies. Managed by HLP, the programme established clinical expert working groups to inform the harmonisation of clinical commissioning policies for a limited number of specific treatments. The policies were presented to CCG governing bodies in December 2018 for further engagement as required, prior to any implementation. Once implemented, the policies will reduce variation of care for patients across London.
This is only a snap shot of all HLP’s work to make London the healthiest global city. You can explore HLP’s various programmes via its website or search the HLP resources section for publications or case studies.
Health and wellbeing strategy The Health and Social Care Act gives health and wellbeing boards statutory duties to encourage integrated working and to exercise the functions of a local authority and its partner clinical commissioning groups. In addition, the Act permits a local authority to
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arrange for a health and wellbeing board to exercise any functions that are exercisable by the authority. The Richmond Health and Wellbeing Board works collectively to ensure that people in the borough experience services of the highest quality and that promote their good health and wellbeing. The aims of the Health and Wellbeing Board are to:
• lead the development of the local authority’s role in integrating the commissioning of health, social care and other services
• lead the development of local partnerships for health and social care which share a common view about local need, priorities and service development
• ensure the engagement and involvement of local people in the development of the health and social care system locally
• work with regional and pan London bodies to ensure that the health and social care needs of local people are understood and taken account of in the commissioning of services at regional and pan London level
The ‘core’ membership of the Board is laid down in government regulations and consists of representatives of the Clinical Commissioning Group (CCG), who commission local health services and the Council, who commission a range of local services including social care, housing, environmental and cultural services, which support wellbeing. Local Healthwatch is the consumer champion for health and social care for residents and is also represented on the Board. A representative of NHS England, the body responsible for commissioning health services at a sub-regional and regional level, will also be a member of the Board. A list of the membership of Richmond Health and Wellbeing board is published on Richmond Council’s website.
The responsibilities of the board are to:
• Produce a Joint Strategic Needs Assessment (JSNA) which will identify the priorities that will inform the commissioning decisions of the Council and the Clinical Commissioning Group (CCG).
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• Develop and agree a joint Health and Wellbeing Strategy, which the Council, CCG and the NHS England must have regard to when carrying out their functions, including the commissioning decisions they make. • To encourage and promote integrated working between health and social care commissioners and other local services, including housing and voluntary sector services. • To communicate and consult with stakeholders and the wider community on the work of the Health and Wellbeing Board and its priorities.
Below is a summary of the contribution of the CCG to the delivery of the joint Health and Wellbeing Strategy for Richmond, provided by Councillor Piers Allen, chair of the Health and Wellbeing Board.
Our current Joint Health and Wellbeing Strategy (2016-2021) was developed with significant contribution from Richmond CCG and other statutory partners. It is based on the theme “Prevention and joined-up services throughout people’s lives, to enable all residents to start well, live well and age well.” This strategy marked an important shift in thinking towards redirecting resources towards community-based initiatives and working with residents to improve and promote health throughout the life course.
Working together with partners, Richmond CCG has contributed towards delivery of the strategy through various commissioning strategies and action plans. Here, I outline notable contributions, but this is merely a snapshot and is by no means exhaustive. I will also outline areas that require development and conclude with a list of potential opportunities for increased collaboration.
Start Well • Child and Adolescent Mental Health Service: The CCG leads on the CAMHS Transformation Plan which includes key objectives such as prevention and early intervention and care for the most vulnerable. Specific programmes include; supporting parents and carers to develop resilient children through early years; Whole School Approaches to improving the emotional health and well-being of pupils through the PATHS programme; developing a simple
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single point of access for early help and new pathways for neurodevelopmental conditions.
Live Well • Social prescribing: primary care in Richmond have developed a model for social prescribing which links to the locality model and part of the primary care networks and is aimed at meeting the needs of the most vulnerable residents whilst offering a solution at the scale required. The CCG is working in collaboration with adult social care to inform an aligned service specification for the community information and navigation service. • Healthy Workplace Charter: The CCG is committed to the healthy workplace charter. With the support of public health, they have submitted an application to sign up to the scheme as a combined Kingston and Richmond CCGs.
Age Well • Outcomes based commissioning (mental health). The CCG has led the development of a multi-agency clinical interface meeting to improve the coordination and integration of community mental health support. • Richmond CCG lead a cancer strategy group that aims to maintain links to preventative and lifestyle services, including for example smoking cessation, NHS Health Checks, substance misuse and health screening. Some work is underway to establish a public health approach to cancer for 19/20. • Richmond CCG commissions dementia specialist nurses provided by Hounslow and Richmond Community Healthcare Trust (HRCH). Their key performance indicators for the service have been refreshed recently in line with the development of integrated locality teams in Richmond.
Areas for development • Progressive discussions are taking place across the partnership in preparation for extending the social prescribing model for Richmond. Following the announcement of NHS funding for social prescribing, we wish to see a longer-term resource commitment from the CCG in addition to committed voluntary sector funding from adult social care.
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“When you feel lonely it makes you feel down – you don’t have any energy. I try and get out every day to stop me feeling this way and give me something to do.” – attendee at Richmond Full of Life fair
Opportunities for collaboration • The NHS Long Term plan provides a clear direction on the role of the NHS in Prevention. The Health and Wellbeing Board is keen for the CCG to take a stronger role to embed healthy lifestyles in clinical pathways and to do more to improve workplace health and address air quality. This work is completely aligned with our cross-Council and CCG Prevention Framework, supported by Public Health.
In addition, the CCG is at the forefront of efforts to develop a Local Health and Care Plan and with the full support of the Health and Wellbeing Board. The draft priorities in the plan closely mirror those identified through our Joint Health and Wellbeing Strategy.
Looking further into the future, and the prospect of our working with the CCG towards an integrated care system across SW London, we would welcome guidance on how NHS London would view the most effective operational and governance arrangements with our Health and Wellbeing Board.
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ACCOUNTABILITY REPORT Corporate governance report Members’ report Richmond CCG is a clinically led member organisation. This means that GPs make decisions about local health services by using their local knowledge to improve services and focus resources where there is greatest need. The CCG is made up of 28 GP practices and is responsible for a budget of around £263 million. Together the GP practices have a registered population of 217,413 patients (April 2018). The membership is represented by a governing body of local GPs, a nurse representative, a secondary care doctor and lay members, supported by a management team. Richmond CCG’s work is overseen by an elected governing body which is chaired by Dr Graham Lewis, a GP at Hampton Medical Centre. Sarah Blow is the Accountable Officer for south west London CCGs, including Richmond. All governing body members have specific areas of responsibility and sit on committees of the governing body. The members exercise their constitutional rights in respect of the CCG through a membership group. Each member practice has a representative on the membership group.
Member practices by locality Our member practices work across two localities – Richmond & Barnes and Teddington, Twickenham & Hampton as set out below.
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Our governing body Richmond CCG’s governing body was established following independent elections for the GP governing body members and an open recruitment process for the secondary care doctor and lay member roles. There are also representatives from Richmond Council and Healthwatch.
Richmond CCG’s governing body members lead on specific areas to ensure their knowledge and skills are effectively utilised to provide the best quality, safe care.
Our governing body meets in public every other month, and we encourage our community to join us to find out about the work we’re doing. Details of public governing body meetings, and meeting papers are published on the Richmond CCG website (www.richmondccg.nhs.uk)
Governing body: voting members Dr Graham Lewis, GP Chair Graham is a partner at the Hampton Medical Centre. Graham was brought up and educated in the West Country and is of maritime heritage. He undertook his medical training in Leeds and trained as a GP in Croydon. He has worked as a GP in Richmond since 1983 and is the longest serving GP at his practice in Hampton. Graham helped form a Richmond based out of hours organisation (TedDoc) and chaired Harmoni for 3 years following their merger. He was a clinical lead with the National Primary Care Development Team. Graham has a continued desire to be involved in improving local health services. His focus is to encourage local GP practice involvement in the CCG and to develop GPs as the leaders for primary care. Graham has been Richmond CCG’s Chair for five years. In 2006, Graham was awarded an MBE for services to the NHS.
Sarah Blow, accountable officer Sarah was appointed accountable officer for the South West London Alliance of CCGs, taking full accountability for Kingston, Merton, Richmond and Wandsworth Clinical Commissioning Groups in April 2017 and Sutton Clinical Commissioning Group in April 2018. Sarah is also the senior responsible officer for the South West London Health and Care Partnership. All health and care organisations across South West London continue to work closely together through the South West London STP programme, known as the South West London Health and Care Partnership, and are supported by Sarah as the lead.
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Prior to her role in south west London, Sarah led Bexley CCG, as chief officer, through authorisation and significant financial challenge to be a successful organisation with a strong collaborative approach. Sarah has held numerous senior management roles in the NHS; leading programmes across South East London STP and London, transformation and redesign in East Sussex and working widely across systems to improve services and deliver sustainability including joint posts with East Sussex County Council. Sarah has previously worked in operational roles and strategic roles within providers and the Department of Health.
Sarah is very familiar with south west London and has been a resident in south west London all her life, and has worked at Sutton and Merton PCT in the past. Sarah holds an MBA, PG Dip in healthcare systems management and a BA (Hons) in history and humanities.
Tonia Michaelides, Managing Director (Tonia is Managing Director for both Kingston and Richmond CCGs.)
Tonia has over 27 years of NHS management experience including in strategic leadership roles in both provider and commissioning organisations, including chief officer at Kingston CCG.
As managing director of Kingston and Richmond CCGs she is responsible for the delivery of the CCGs’ quality, finance and performance targets as well as working with leaders across the two boroughs to transform health and care services.
Tonia also leads on delivering transformation on a wider footprint as south west London senior responsible officer (SRO) for mental health. Tonia also operates at a London level, co-sponsoring the development of the London mental health dashboard and the implementation of the s136 pathway. Tonia’s interest and passion is the transformation of services and the integration of health and care to achieve the best possible outcomes for people.
James Murray, Chief Finance Officer James has been working within the NHS for over 25 years across a number of different NHS organisations at a senior level in provider and commissioning organisations and the civil service at a regional level.
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He has held interim director roles at both NHS trust and commissioning organisations and worked on several major projects including system wide financial and services review, Foundation Trust development and acquisition and a wide variety of NHS business cases.
On 1st April 2018, James was successful in moving from Interim CFO for SWL Alliance CCGs to the substantive position of CFO for SWL Alliance CCGs.
Dr Kate Moore, Vice Clinical Chair Kate is a GP partner at Hampton Wick Surgery. Kate qualified from St George’s Hospital in 1992. She trained locally as a GP at West Middlesex Hospital and joined her current practice as a GP trainee in 1997. Kate’s focus is to commission high quality, excellent care for the population of Richmond. She would like to reduce inefficiencies by utilising technology to support and develop strategies to deliver out of hospital care and care closer to home.
Kate is also the governing body’s lead for primary care and is focussed on developing relationships at all levels across the borough.
Kate enjoys all aspects of general practice but her special interests include child health and immunisations, mental health problems and women’s health. She is married with 3 children and lives locally.
Dr Anne Dornhorst, Secondary Care Doctor Anne is a consultant physician and honorary senior lecturer in endocrinology and diabetes at Imperial College Hospital with an interest in all aspects of adult diabetes. She is the senior diabetes expert for Charing Cross and Hammersmith Hospitals. Anne received her doctorate of medicine from Oxford University and her clinical training from John Hopkins University in Maryland, USA and at St Mary's Hospital, London. She has published extensively in the field of diabetes in pregnancy and has been a member of the national guideline committees on the management of diabetes in pregnancy.
Dr Nicola Bignell, GP Member Nicola is a GP partner at Thameside Medical Practice and the lead GP for planned care. She studied at Cambridge University and then the Royal London Hospital and has worked as a GP in Richmond ever since. Her main areas of interest are around referral management, outpatient transformation and pathway and service development. 61 | Page
Dr Branko Momic, GP Member Branko is a GP partner at the Acorn Group Practice in Twickenham. He studied at the University of Zagreb and completed his training at West Middlesex University Hospital. Branko is the CCG’s lead for urgent care and clinical governance lead for NHS 111. Branko is also a member of the Kingston A&E delivery board.
Dr Stavroula Lees-Karipoglou, GP member Stavroula is a Richmond borough GP and the CCG’s clinical lead for mental health. Stavroula studied in Berlin and began her career as a doctor in the UK in 1998. She has an MSc in Healthcare Commissioning at the HSMC of the University of Birmingham. Previously she was a hospital doctor specialising in surgery.
Stavroula has been Richmond CCG’s mental health lead since 2013 and has a particular interest in dementia. Her aim is to raise awareness of mental health issues and improve services for patients and carers and the public.
Dr Zehra Rashid, GP Member (to 19 June 2018) Zehra is a GP at the Broad Lane surgery in Hampton, having completed her training in the local area. She studied and trained at Imperial College London and has a specialist interest in medical education, cancer and palliative medicine. In 2017, she completed a two-year diploma in this field at Cardiff University. She aims to ensure that patients in Richmond have continued access to the highest quality cancer care and to raise the profile of end of life care in the community.
Dr Sylwia Ferguson, GP Member (from 1 September 2018) Sylwia is a GP at Cross Deep Surgery. She graduated from Gdansk Medical University in Poland in 1997 and from St George’s University in London in 1999. Sylwia joined her current practice in January 2014 having worked at other local GP practices. She has broad medical interests which include caring for the ageing population, mental health and family planning.
Sylwia is also involved in training of medical students from St George’s University. Sylwia is Richmond CCG’s lead for prescribing, quality and safety.
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Dr Alireza Salehzadeh, GP Member Alireza is a GP partner at Glebe Road Surgery in Barnes. He qualified as a GP in August 2014 from the Kingston and Roehampton GP training programme. Before that he studied medicine at the University of Liverpool and studied for an intercalated bachelor’s degree in anatomy and human sciences at King’s College London.
Alireza has an interest in minor surgery and primary care IT. His aim is to make IT more user friendly and to increase the use of IT in primary care to improve efficiency and establish seamless communication between primary and secondary care. He also hopes to champion the transition of more services from secondary care to the community, making them more cost effective and more convenient for patients.
Alireza is the clinical lead for cardiology and respiratory care.
Paul Gallagher, Lay Member for audit (from 1 April 2018) Paul is a chartered accountant, and a lay member on the governing body and chair of the CCG’s audit committee.
Following a career that began in local government, he has since worked in the private sector where he has held a number of senior leadership roles supplying IT, professional and support services to both private and public sector organisations. Paul currently works in management consulting and advises companies on finance transformation, strategy and operations. Paul is also a lay member on the governing body of Kingston CCG and chair of Kingston CCG’s audit committee.
Bob Armitage, Vice Chair and Lay Member for finance, remuneration, primary care and governance Bob worked for 18 years in the pharmaceutical industry in senior management positions ranging from country managing director to finance director. He retired from full-time employment but remains active in a variety of roles. His priorities for Richmond CCG are to ensure the achievement of appropriate quality standards, maintaining robust governance processes and financial strength.
Susan Smith, Lay Member for patient and public involvement 63 | Page
Susan has had extensive experience working in the voluntary and statutory sectors. Until recently Susan was the chief executive at Richmond Citizens Advice Bureau, a post she held for seven years. Prior to this, Susan worked as regional director for Save the Children UK. She is committed to ensuring that local health services are inclusive and service users from all groups of society, including excluded groups who often do not have a voice, are encouraged to participate in the commissioning and planning cycle.
Fergus Keegan, Director of Quality (covering chief nurse role up to 1 October 2018) Fergus is director of quality for both Kingston and Richmond CCGs and is the governing body nurse for Richmond CCG.
Fergus has been a nurse since 1988 and worked in a variety of acute hospitals around the UK – with a specialist interest in A&E. After ten years in senior operational management roles, Fergus was a deputy director of nursing, most recently in Kingston Hospital, before coming to work at Kingston and then joining Richmond CCG in April 2017.
Kathryn Yates, Nurse Member (from 2 October 2018)
Kathryn is a registered nurse, health visitor and nurse teacher and has worked across London in a variety of positions within health, education and social care.
Kathryn moved from Wales to London to train as a nurse, qualifying as a registered nurse in 1991. Her first post was at Kingston Hospital specialising in gynaecology and urology, followed by seven years working in the intensive care team at Atkinson Morley’s Hospital. Kathryn then studied psychology and trained as a counsellor before becoming a health visitor and then designated nurse for looked after children and young people in Southwark.
Kathryn later became a senior lecturer in public health, community and primary care, with specialist interests which include clinical supervision, public health, domestic abuse and pre- post-natal depression. Kathryn is a clinical supervisor, trainer and consultant and was a lead for practice learning at Kingston and St George’s University of London before taking up the Royal College of Nursing UK lead for primary, community and integrated care.
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Kathryn is currently the director for primary care nursing, workforce transformation and innovation at Londonwide Local Medical Committees. Kathryn is an honorary lecturer at Kingston and St George’s, and a Royal Society of Medicine, general practice with primary healthcare section council member.
Governing body: non-voting members
Houda Al-Sharifi Director of Public Health for the London Boroughs of Richmond Upon Thames and Wandsworth Houda serves the boroughs of Richmond and Wandsworth and has extensive board level experience having served as a director of public health for Richmond and Twickenham Primary Care Trust and Wandsworth Primary Care Trust. She has led public health for five years and has the additional responsibility for community safety, environmental health and regulatory services across both boroughs.
John Thompson Chair, Healthwatch Richmond John Thompson sadly died after a short illness in March 2019. John was a valued member of Richmond CCG’s governing body.
John, a former civil servant and a resident of East Sheen for over 30 years, was also Chair of the Board of Trustees of the Richmond Carers Centre and a Non-Executive Director on NHS boards in South West London (including Richmond Primary Care Trust and Croydon University Hospital) for 8 years. He was chair of the lay advisory panel, a lay trustee and a council member of the College of Optometrists, and a trustee of VISION 2020 and the Thomas Pocklington Trust.
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The governing body normally meets in public six times per year. Membership and attendance is shown in the table below:
Governing body No. of meetings attended
Dr Graham Lewis GP (CCG chair) 6
Sarah Blow Accountable Officer 5
Managing Director Kingston & Richmond Tonia Michaelides 6 CCGs
Paul Gallagher Lay Member for audit 4
Vice Chair and Lay Member for finance, Bob Armitage 5 remuneration and governance
Lay Member for patient and public Susan Smith 6 engagement
James Murray Chief Finance Officer 6
Dr Kate Moore Vice Clinical Chair 6
Dr Branko Momic GP Member 5
Dr Nicola Bignell GP Member 3
Dr Stavroula Lees GP Member 6
Dr Zehra Rashid (to 1 GP Member 19 June 2018) (up to June 2018)
Dr Sylwia Ferguson 3 (from 1 September GP Member (since September 2018) 2018)
Dr Alireza GP Member 6 Salehzadeh
Fergus Keegan (to Director of Quality (covering chief nurse 3 1 October 2018) role) (up to October 2018)
Kathryn Yates (from 2 Nurse Member 2 October 2018) (since October 2018) Dr Anne Dornhorst Secondary Care Doctor 4
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The governing body meeting agenda, papers and minutes are available on the CCG’s website (www.richmondccg.nhs.uk)
The governing body also receives a report from the audit committee chair as appropriate. Recommendations from the remuneration committee and its minutes are taken to the governing body at its part two private meetings.
Committees of the governing body
The governing body has established several committees of the governing body and these are described below. The extent of authority to act of these committees depends on the powers delegated to them by the CCG, as set out in its scheme of reservation and delegation (appendix D of the CCG’s constitution), and in their terms of reference.
The CCG’s scheme of reservation and delegation sets out:
• Decisions that are reserved to the membership as a whole • Decisions delegated to the governing body and its committees • Decisions delegated to individual members and employees
The CCG remains accountable for all of its functions including those that it has delegated.
In discharging their delegated responsibilities, the governing body and its committees are required to:
• Comply with the principles of good governance • Operate in accordance with the CCG’s scheme of reservation and delegation • Comply with the CCG’s standing orders • Comply with the CCG’s arrangements for discharging its statutory duties • Where appropriate, ensure that members have had the opportunity to contribute to the CCG’s decision-making process through the membership group
When discharging their delegated functions, the governing body and committees operate in accordance with their approved terms of reference.
Primary Care Commissioning Committee (meeting in public)
The Primary Care Commissioning Committee enables its members to make collective decisions on the review, planning and procurement of primary care services in Richmond under delegated authority from NHS England. The committee acts as a sub-committee of the Governing Body.
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The functions of the committee are undertaken in the context of a desire to promote increased co- commissioning to maximise quality, efficiency, productivity and value for money and to remove administrative barriers. The role of the committee shall be to carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act.
Membership of the Primary Care Commissioning Committee includes representation from:
• NHS Richmond CCG
• NHS England
• London Borough of Richmond
• Surrey and Sussex Local Medical Committee
• The public (patient participation group network representative)
• Healthwatch Richmond
The Primary Care Commissioning Committee met 6 times in 2018-19.
Primary Care Commissioning Committee
(Voting members)
Vice Chair and Lay Member for finance, Bob Armitage remuneration, primary care and governance
Susan Smith Lay Member for patient and public involvement
Paul Gallagher Lay Member for audit
Tonia Michaelides Managing Director
Yarlini Roberts (to 20 January 2019) Director of Finance
Neil Ferrelly (from 21 January 2019) Director of Finance
Fergus Keegan (to 1 October 2018) Director of Quality
Kathryn Yates (from 2 October 2018) Nurse Member
Dr Anne Dornhorst Secondary Care Doctor
Dr Pete Smith or Dr Gareth Hull Independent GP
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Audit Committee The Audit Committee is responsible for reviewing the establishment and maintenance of an effective system of governance, risk management and internal control, across the whole of the CCG’s activities that support the achievement of its objectives.
The audit committee met four times during 2018-19. Membership is shown below:
Audit Committee
Paul Gallagher Lay Member for audit (chair)
Lay Member for finance, remuneration, primary care Bob Armitage and governance Dr Alireza Salehzadeh GP
Sarah Blow Accountable Officer
James Murray Chief Finance Officer
In addition, there are a number of regular attendees including auditors and other CCG officers.
The committee has reviewed the adequacy and effectiveness of:
• All risk and control related disclosure statements (in particular the annual governance statement) together with any appropriate independent assurances, prior to endorsement by the CCG • The underlying assurance processes that indicate the degree of achievement of CCG objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements • The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and related reporting and self-certification • The policies and procedures for all work related to fraud and corruption as set out in Secretary of State Directions and as required by the NHS Counter Fraud Authority
In carrying out this work the audit committee primarily utilises the work of internal audit, external audit and other assurance functions, but is not limited to these sources. It also seeks reports and assurances from the accountable officer, executive management team and managers as 69 | Page
appropriate focusing on the over-arching systems of governance, risk management and internal control, together with indicators of their effectiveness.
Quality, Safety and Performance Committee The committee is responsible for overseeing, understanding, reviewing and ensuring action is taken for all issues in relation to the quality of services commissioned by the CCG. The committee is responsible for ensuring the appropriate governance systems and processes are in place to commission, monitor and ensure the delivery of high quality and safe patient care in commissioned services, primary care and the nursing home sector in line with the CCG’s vision.
The committee provides oversight and scrutiny of arrangements for supporting NHS England in relation to securing continuous improvement in the quality for primary medical services. The committee approves arrangements for handling CCG patient advice and liaison service contacts (PALS) and complaints, information governance including arrangements for handling Freedom of Information (FoI) requests and provides oversight and scrutiny on arrangements for business continuity and emergency planning.
The Quality, Safety and Performance Committee held eleven meetings during 2018-19. Membership is shown below:
Quality, Safety and Performance Committee Dr Sylwia Ferguson (from 1 GP and chair September 2018) Dr Zehra Rashid (to 19 June GP 2018)
Fergus Keegan Director of Quality
Ruth Harkness Clinical Quality Manager
Emma Richmond Chief Pharmacist
Bob Armitage Lay Member for audit, remuneration and governance
Dr Graham Lewis GP (CCG chair)
Susan Smith Lay Member for patient and public engagement
Dr Branko Momic GP
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Dr Anne Dornhorst Secondary Care Doctor
Tonia Michaelides Managing Director
Sue Lear Deputy Director of Commissioning
John Anderson Healthwatch Member
Finance Committee The Finance Committee is responsible for providing assurance on key financial indicators, ensuring that the organisation is meeting its financial duties. Part way through 2017/18 we reviewed the Finance and Performance Committee and re-ordered the agenda for this committee to provide the best opportunity to focus on key finance issues. As a result, we made arrangements for the Quality and Safety Committee to oversee the performance of services.
The finance committee held eleven meetings during 2018-19. Membership is shown below:
Finance committee
Lay Member for finance, remuneration, primary care and Bob Armitage governance (chair)
Paul Gallagher Lay Member for audit
Yarlini Roberts (to 21 January 2019) Director of Finance
Neil Ferrelly (from 21 January 2019) Interim Director of Finance
James Murray Chief Finance Officer
Sue Lear Deputy Director of Commissioning
Dr Graham Lewis GP (CCG Chair)
Dr Kate Moore GP (CCG Vice Clinical Chair)
Dr Branko Momic GP member
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Executive Management Team The Executive Management team supports the governing body and the managing director in discharging their functions. It assists the governing body in its duties to promote a comprehensive health service, reduce inequalities and promote innovation. The remit of the executive management team is to acquire, manage and develop the resources, infrastructure, systems and business processes required to enable the discharge of the CCG’s functions and the delivery of the CCG’s strategy.
During 2018-19 there were eight meetings held. Membership is shown below:
Executive Management Team
Tonia Michaelides Managing Director
Dr Naz Jivani GP (Kingston CCG Chair)
Dr Graham Lewis GP (Richmond CCG Chair)
Dr Phil Moore GP (Kingston CCG Deputy Clinical Chair)
Dr Kate Moore GP (Richmond CCG Deputy Clinical Chair)
Julia Travers Director of Commissioning
Director of Corporate Affairs and Vicki Harvey-Piper Governance
Fergus Keegan Director of Quality
Kathryn MacDermott Director of Primary Care and Planning
Yarlini Roberts (to 21 January 2019) Director of Finance
Neil Ferrelly (from 21 January 2019) Interim Director of Finance
Clinical Executive Team The Clinical Executive Team fulfils the clinical leadership function of the CCG, supporting the governing body and the accountable officer in discharging their functions. It assists the governing body in its duties to promote a comprehensive health service, reduce inequalities and promote innovation. The remit includes the development and implementation of plans for commissioning services and in the championing of transformational change, the development of pathways of care for local clinical delivery, and ensuring that the group’s vision and strategy are translated into
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annual priorities including the provision of a plan for local out of hospital services which improves clinical outcomes, service quality and coherence for Richmond residents.
The Clinical Executive Team met seven times, and membership of the committee is shown below.
Clinical Executive Team Dr Kate Moore Vice Clinical Chair (chair) Dr Graham Lewis GP CCG Chair Dr Branko Momic GP member Dr Nicola Bignell GP member Dr Stavroula Lees-Karipoglou GP member
Dr Zehra Rashid (to 19 June 2018) GP member Dr Sylwia Ferguson (from 1 September 2018) GP member GP (Richmond and Barnes clinical network Dr Patrick Gibson lead) GP (Teddington, Twickenham and Hampton Dr Heather Byrne clinical network lead from November 2017) Dr Alireza Salehzadeh GP member (from June 2017) Yarlini Roberts (to 21 January 2019) Director of Finance Neil Ferrelly (from 21 January 2019) Interim Director of Finance Julia Travers Director of Commissioning Fergus Keegan Director of Quality Houda Al-Sharifi Director of Public Health, Richmond Council Emma Richmond Chief Pharmacist
The South West London ‘Committees in Common’ The South West London Clinical Commissioning Groups have agreed the establishment of Committees in Common (CiC) for the purpose of strategic decision making, with particular reference to the South West London Five Year Forward Plan or any successor strategy as agreed by the CCGs.
The role of a CiC is to take decisions on behalf of the CCGs as set out in the Establishment Agreement. Decisions will be taken by the representatives of each CCG on behalf of their individual CCG and will be taken only after consideration of the issues by the CCG governing body
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and the engagement of CCG membership. The meeting convenor (a pre-agreed SWL CCG Lay Member) chairs the meetings on a quarterly basis
Management of conflicts of interest The CCG operates a robust policy for the management of conflicts of interest for CCG members, governing body members, office holders, employees and contractors working on behalf of Richmond CCG. It applies to all the CCG’s business but is particularly relevant considering the CCG’s decision to take on a role in the co-commissioning of primary care with NHS England and in preparation for full delegated commissioning from April 2016.
Register of interests
A summary of the governing body’s register of interest 2018/19 is available to view on our website. This includes details of company directorships and other significant interests held by members of the governing body.
Personal data related incidents There have been no serious internal incidents or information governance issues relating to data security breaches that have been reported to the Information Commissioner.
Statement of disclosures to auditors
Everyone who is a member of the CCG at the time the Members’ Report is approved confirms:
• so far as the member is aware, there is no relevant audit information of which the CCG’s auditor is unaware that would be relevant for the purposes of their audit report • the member has taken all the steps that they ought to have taken in order to make themselves aware of any relevant audit information and to establish that the CCG’s auditor is aware of it.
Modern Slavery Act Richmond CCG fully supports the Government’s objectives to eradicate modern slavery and human trafficking but does not meet the requirements for producing an annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act 2015.
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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). The accountable officer for CCGs in south west London including Richmond is Sarah Blow.
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:
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• 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;
To the best of my knowledge and belief, and subject to the disclosures set out below, I have properly discharged the responsibilities set out under the National Health Service Act 2006 (as amended), Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter.
• The CCG was unable to limit its use of financial resources in 2018/19 to the amount specified by NHS England for revenue expenditure as set out in the Financial Review section of this report. This failure to meet its ‘break-even’ duty has been formally communicated to the Secretary of State for Health via a letter from the external auditors, as required by Section 30 of the Local Audit and Accountability Act 2014.
I also confirm that:
• as far as I am aware, there is no relevant audit information of which the CCG’s auditors are unaware, and that as accountable officer, I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the CCG’s auditors are aware of that information.
• the annual report and accounts as a whole is fair, balanced and understandable and that I take personal responsibility for the annual report and accounts and the judgments required for determining that it is fair, balanced and understandable.
Sarah Blow
Accountable Officer
South West London Alliance (Kingston, Richmond, Merton, Wandsworth and Sutton CCGs)
Date:
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Governance statement
Introduction and context Richmond CCG is a body corporate established by NHS England on 1 April 2013 under the National Health Service Act 2006 (as amended).
The clinical commissioning group’s statutory functions are set out under the National Health Service Act 2006 (as amended). The CCG’s general function is arranging the provision of services for persons for the purposes of the health service in England. The CCG is 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 2019, the clinical commissioning group is not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006.
Scope of responsibility
As accountable officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the clinical commissioning group’s policies, aims and objectives, whilst safeguarding the public funds and assets for which I am personally responsible, in accordance with the responsibilities assigned to me in Managing Public Money. I also acknowledge my responsibilities as set out under the National Health Service Act 2006 (as amended) and in my clinical commissioning group accountable officer appointment letter.
I am responsible for ensuring that the clinical commissioning group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. I also have responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group as set out in this governance statement.
Governance arrangements and effectiveness The main function of the governing body is to ensure that the group has made appropriate arrangements for ensuring that it exercises its functions effectively, efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it.
Richmond CCG’s constitution sets out how it shall fulfil its statutory duties and the primary governance rules for the CCG. It complies with the Act and relevant guidance issued by NHS England. The CCG is a clinically led membership organisation and is accountable for exercising the statutory functions of the CCG. It grants authority to act on its behalf to its: • Membership group 77 | Page
• Governing body • Employees, and; • Committees of the governing body, namely an audit committee, a finance committee, a remuneration committee, a quality, safety and performance committee, a clinical executive team and an executive management team. A summary of the role of each committee can be found in our constitution.
The members exercise their constitutional rights in respect of the CCG through the membership group which met three times in 2018-19. Each member practice has a representative on the membership group.
Two clinical networks enable the membership to drive clinical commissioning at a locality and practice level. The clinical networks met four times in 2018-19. The networks report into the clinical executive team (CET). The CET has a formal reporting line to the governing body and takes commissioning recommendations to the governing body for approval. The CET also produces a quarterly report for the membership group, summarising the work of the clinical networks.
The CCG’s governing body has most statutory and business functions delegated to it including the powers and authority to lead the CCG and set its strategic direction.
The governing body comprises: • Seven GPs (one of whom is the CCG chair and one the vice clinical chair) • One registered nurse • One secondary care specialist doctor • Three lay members: - Finance, remuneration and governance (the lay member for finance, remuneration and governance is the vice chair) - Patient and public engagement - Audit and conflicts of interest guardian • The accountable officer • The chief finance officer • The director of adult social services (Richmond Council)
Discharge of statutory functions During establishment, the arrangements put in place by the CCG and explained within the corporate governance framework were developed with extensive expert external legal input, to 78 | Page
ensure compliance with the all relevant legislation. That legal advice also informed the matters reserved for membership group and governing body decision and the scheme of delegation. In light of recommendations of the 2013 Harris review, the CCG has reviewed all the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. Thus, I can confirm that the CCG is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions.
Responsibility for each duty and power has been clearly allocated to members of the executive team who ensure the necessary capability and capacity to undertake all of the CCG’s statutory duties.
Risk management arrangements and effectiveness
Board assurance and risk management framework The Board Assurance Framework (BAF) provides assurance to the governing body on the delivery of its corporate objectives.
The corporate objectives are achieved through the delivery of a number of priority programmes which are identified and risk assessed in the BAF document.
The BAF has been designed to provide assurance on the delivery and impact of the priority programmes as well as the risks threatening delivery and therefore impact on corporate objectives being achieved. It sets out mitigating actions for the risks and timescales in respect of these actions being completed.
Various priority areas are managed under the CCG’s five strategic objectives:
1. Enable local people, patients, carers and stakeholders to have greater influence on the services we commission and keep the patient voice at the centre of what we do
2. Improve the quality, safety and effectiveness of healthcare services and ensure that national performance targets are met and that people experience high quality care
3. Work in partnership with local health and care providers, commissioners and the voluntary sector to improve and transform services that achieve better health outcomes, are accessible and reduce inequalities
4. Ensure the continued development of the CCG as a clinically-led and well governed organisation with strong leadership, and effective membership & staff engagement
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5. Achieve a financially sustainable health economy balancing the need for effective use of resources and better value for money with the need for innovation
Capacity to handle risk
The responsibilities of Directors and committees are set out in the CCG Constitution and the accompanying Scheme of Delegation, as well as the governance reporting lines. Timely and accurate information to assess risk and ensure compliance with the CCGs statutory obligations, is submitted in line with the CCGs annual plan of committee work. The Governing Body has rigorous oversight of the performance of the CCG, via formal Governing Body meetings, seminars and through assurances received from committees and audits.
Risk assessment in relation to governance, risk management and internal control
• The executive management team (EMT) is the designated committee responsible for oversight of the risk management process and at its monthly meetings reviews the full Board Assurance Framework (BAF) and has oversight of all residual risks (after mitigation). It evaluates the status of risks, identifies new risks and monitors effectiveness of the CCG’s board assurance and risk management control systems. Individual members of the executive management team lead on each of the priority areas and are ultimately accountable for their delivery. • The clinical executive team focuses on high or extreme risk priority areas with a clinical focus, and the primary care commissioning committee those relating to primary care. • The audit committee provides scrutiny and independent assurance to the governing body on the effectiveness of the CCG’s board assurance and risk management processes • The governing body reviews the content of the BAF twice a year as a means of assessing the current level and receives summary BAF reports in the intervening months. • All other sub committees of the governing body review those risks specific to their corporate objective area and are made aware of significant changes to the risk register at each meeting
Operational management of the BAF is provided by the CCG’s corporate affairs and governance team. Regular meetings are held with manager leads to review progress and performance of each of the priority areas and associated risks.
The BAF summary reflects the risk status of the CCG’s strategic risks. It identifies the target score, the current score and any movement from the previous month. The detail sitting within the overall
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BAF describes the individual programme, its outcome measures, risks to delivery, controls in place, how the governing body is assured and actions to address gaps in control or assurance including timelines for completion.
The areas of high risk for Richmond CCG are as follows:
- Failure to deliver financial recovery plan implementation to achieve operating plan target
A monitoring regime is in place to support achievement of this.
- Failure to deliver year on year QIPP targets
Plans are in development, some in collaboration with Kingston CCG, to look at additional areas of opportunity and extend existing schemes.
- Failure to fully identify the required QIPP saving for 2018/19
The CCG has an established programme management office (PMO) which provides support and quality assurance for Richmond CCG’s priority commissioning programmes, including QIPP and the Better Care Fund.
As part of the embedded portfolio, programme and project management process both equality and quality impact assessments are carried out to provide an overview of the potential impact of any service changes on diverse groups in Richmond.
The CCG views risk management as key to the successful delivery of its business and remains committed to ensuring staff are equipped to assess, manage, escalate and report risks. The Board Assurance Framework (BAF) and Corporate Risk Register are currently managed using 4Risk software. This ensures a comprehensive overview of all the risks affecting the organisation and facilitates decision making about those risks that need immediate treatment and those that the organisation can tolerate for a specified amount of time.
Considering incidents and risks in this way enables such events to be graded into one of four categories: low, medium, high, and very high. Grading in this way allows:
• The appropriate level of investigation and causal analysis to be carried out
• Identification of the level at which the risk will be managed, the assigning of priorities for remedial action and determination of whether the risk will be accepted
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Incident reporting
We also encourage people to report incidents and to discuss learning from these with their line manager and within teams. Staff are encouraged to approach any manager or HR within the organisation with any concerns, in the knowledge that and all incidents and concerns are taken seriously. Feedback is always given to staff following any incident reported.
Other sources of assurance
Internal Control Framework A system of internal control is the set of processes and procedures in place in the clinical commissioning group to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.
The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness.
Annual audit of conflicts of interest management The revised statutory guidance on managing conflicts of interest for CCGs (published June 2016 and further updated in June 2017) requires CCGs to undertake an annual internal audit of conflicts of interest management. To support CCGs to undertake this task, NHS England has published a template audit framework.
An internal audit review was carried out in December 2018 on the conflicts of interest processes set in place within the CCG. The outcome of the review noted that the CCG can take reasonable assurance that the controls upon which the organisation relies to manage the identified risk(s) are suitably designed, consistently applied and operating effectively.
Data quality The CCG has a business intelligence and performance function which monitors how local providers are performing against key performance indicators. This information is reported to the governing body on a regular basis.
Information governance The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by the Data Security and
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Protection toolkit and the annual submission process provides assurances to the clinical commissioning group, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively.
The Data Security and Protection Toolkit (DSP) came into force for the 2018-19 financial year and replaces the Information Governance toolkit. The DSP toolkit is now the recognised standard for cyber and data security within the NHS. The toolkit requires the CCG to demonstrate compliance with ten data security standards along with demonstrable compliance with the General Data Protection Regulations (GDPR).
We have been working with our information governance expert service, NEL, in respect to submission of the DSP toolkit. The National Data Guardian (NDG) standards have been calculated for Richmond CCG based on the responses provided in the organisation’s profile and for each of the data guardian standards, Richmond CCG gained 100% compliance with all 70 mandatory requirements and met 54 out of 59 of the non-mandatory requirements. The CCG places high importance on ensuring there are robust information governance systems and processes in place to protect patient and corporate information. We have an information governance management framework, including information governance processes and procedures in line with the Data Security and Protection toolkit. We have ensured all staff undertake annual information governance training. There are processes in place for incident reporting and investigation of serious incidents. We continue to develop information risk assessment and management procedures and a programme is in place to fully embed an information risk culture throughout the organisations against identified risks.
How we look after information securely The senior information risk owner (SIRO) for Richmond CCG is the Director of Corporate Affairs and Governance; she is a member of the senior executive team and attends governing body meetings.
Business critical models The CCG confirms that no business critical models have been identified that would require information about quality assurance processes for those models to be provided to the Analytical Oversight Committee, chaired by the Chief Analyst in the Department of Health.
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Third party assurances During the year, the CCG has received a number of assurance reports relating to audits performed on other organisations that provide services to the CCG. Key reports received include the following:
KPMG ISAE 3402 Type II report – Primary Care Support England
This audit provided assurance over the service provider (Capita Business Services Ltd) control systems in place for Primary Care Support England services for processing GP, Ophthalmic and Pharmacy payments and the administration of the pension scheme on behalf of NHS England. The report provided a qualified opinion for 3 of the 16 control objective which although not considered acceptable does represent an improvement from the 7 qualifications the previous year. Further steps have been laid down in the report to address the control gaps.
Deloitte Report on Internal Controls – NHS England NEL Commissioning Support Unit
This report provides annual assurance over the following business process areas provided by NEL CSU:
• Payroll • Financial ledger • Accounts payable • Accounts receivable • Financial reporting • Treasury and cash management
During the period 1 October 2018 to 31 March 2019, all controls relevant to the SAR process operated effectively, with the exception of 2 controls, both of which did not impact on the CCG.
Control Issues No significant control issues have been identified at the CCG during 2018/19.
Review of economy, efficiency & effectiveness of the use of resources The governing body through its meetings retains primary oversight of the appropriateness of arrangements in pace within the organisation to exercise its functions in an effective, economic and efficient manner. It is my role as Accountable Officer to retain overall executive responsibility for the use of our resources.
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The organisation has a number of key processes and internal mechanisms that provide assurance that we are operating within our statutory authority:
• Within our constitution there are clearly defined standards for conducting business, standing orders, scheme of reservation and delegation along with prime financial policies that ensure the effective management and protection of assets and public funds • Key policies are in operation in respect of contract management and procurement that ensure effective operational and financial performance whilst ensuring we operate within regulatory frameworks and reduce the likelihood and impact of risk • There is a clearly defined process for the consideration of business cases and saving opportunities to ensure transparency and value for money is upheld. The Financial Delivery Group evaluate the robustness of proposed business cases before these are then considered by the Finance Committee • The finance committee and the quality, safety and performance committee is accountable for overseeing a robust, organisation-wide system of quality, performance and financial management. • The finance committee ensures that the finances of the CCG are scrutinised to ensure budgets are managed in an appropriate and timely manner. It will ensure that the governing body is fully aware of any financial risks which may materialise throughout the year. It works alongside the audit committee to ensure financial probity in the organisation.
These committees have, on behalf of the governing body, an overview of all aspects of finances (including capital spend and cash management).
Counter fraud arrangements Counter fraud arrangements are in place in the CCG to ensure compliance with standards set by the NHS Protect Standards for Commissioners: Fraud, Bribery and Corruption.
• An accredited counter fraud specialist is contracted to undertake counter fraud work proportionate to identified risks. • The CCG’s audit committee receives progress reports throughout the year and an annual report against each of the standards for commissioners. • There is executive support and direction for a proportionate proactive work plan to address identified risks. 85 | Page
• Regular fraud related communications are shared with CCG staff and training is available for all staff. • The local counter fraud specialist meets with the local director of finance and internal audit to agree tasks to be undertaken and produce the workplan. • The local counter fraud specialist also has regular liaison with the local director of finance to discuss any concerns that come to light throughout the year. • A member of the executive team (the local director of finance) is proactively and demonstrably responsible for tackling fraud, bribery and corruption.
There have been no assessments from the NHS Counter Fraud Authority but should one occur an action plan would be taken forward following any recommendation made.
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HEAD OF INTERNAL AUDIT OPINION
In accordance with Public Sector Internal Audit Standards, the head of internal audit is required to provide an annual opinion, based upon and limited to the work performed, on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes. The opinion should contribute to the organisation's annual governance statement.
1.1 Head of internal audit opinion
For the 12 months ended 31 March 2019, the head of internal audit opinion for Richmond Clinical Commissioning Group is as follows:
Head of internal audit opinion 2018/19
1.2 Scope and limitations of our work The formation of our opinion is achieved through a risk-based plan of work, agreed with management and approved by the audit committee, our opinion is subject to inherent limitations, as detailed below:
• 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, the assurance framework is one component that the Governing Body takes into account in making its annual governance statement (AGS);
• the opinion is based on the findings and conclusions from the work undertaken, the scope of which has been agreed with management / lead individual;
• the opinion is based on the testing we have undertaken, which was limited to the area being audited, as detailed in the agreed audit scope;
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• where strong levels of control have been identified, there are still instances where these may not always be effective. This may be due to human error, incorrect management judgement, management override, controls being by-passed or a reduction in compliance;
• due to the limited scope of our audits, there may be weaknesses in the control system which we are not aware of, or which were not brought to our attention; and • it remains management’s responsibility to develop and maintain a sound system of risk management, internal control and governance, and for the prevention and detection of material errors, loss or fraud. The work of internal audit should not be seen as a substitute for management responsibility around the design and effective operation of these systems.
1.3 Factors and findings which have informed our opinion
Based on the work undertaken to date in 2018/19 there is a generally effective system of internal control, designed to meet the CCG’s objectives, and controls are generally being applied consistently. We have provided substantial or reasonable levels of assurance in the majority of areas reviewed.
However, we issued two reports, on QIPP and Financial Management where we only provided Partial Assurance that the controls to manage risks were suitably designed and consistently applied, and that action was needed to enhance the control framework to manage the identified risks. Further detail is provided below
• QIPP – The review highlighted five key areas where timely management attention was necessary. These included an absence of timelines for closing the CCG’s £6.9m savings gaps through identification of alternative schemes and new opportunities, absence of KPIs for both Kingston & Richmond Outpatients Re-Design to allow the CCG to know how well the Outpatients Re-Design programme/scheme is performing, absence of an up to date terms of reference for both the Kingston and Richmond CCGs Programme Delivery Group (PDG) and the Joint Delivery Group and Clinical Financial Recovery Group and absence of monthly QIPP/CIP programme meetings between Kingston and Richmond CCGs and service providers.
• Financial Management - we identified the need to develop and document actions with budget holders around negative budget variances. We also raised an action regarding the
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scrutiny of the budgets that are approved by the Governing Body, and the need to discuss the control totals further with NHSE if the Governing Body is not confident that the budget can be achieved. This linked specifically to the large amount of unidentified QIPP in the agreed plan, which remained unidentified in September 2018, and followed on from 2017/18 where the QIPP programme under-delivered by £3.875m. Finally, we raised an action around KPI reporting to the Governing Body, as the month 4 finance report noted QIPP delivery as green, even though the CCG was forecasting a 42.5% negative variance in delivery
The following internal audit reports issued received Substantial or Reasonable assurance opinions and have not identified any significant control issues Medicines Management (SWL wide) – Substantial Assurance
• Medicines Management (SWL wide) – Substantial Assurance • Governance (SWL wide) – Reasonable Assurance • Contract Commissioning (SWL wide) – Reasonable Assurance • Conflict of Interest (LDU Wide) – Reasonable Assurance • Risk Management (LDU Wide)- Reasonable Assurance • Primary Care Commissioning (SWL wide) - Substantial Assurance • SWL STP Governance (SWL Wide) – – Reasonable Assurance
Additionally, we have issued one advisory report, in relation to NHS Data Security and Protection Toolkit 2018-19, and whilst no significant issues were identified, we noted at the time of completing the fieldwork, some further review work was required to compile the evidence in the toolkit to confirm compliance with requirements. Separately, we also conducted an Assurance Mapping exercise to assist the CCG in determining its various sources of assurance over its controls in operation to mitigate its principal risks.
1.4 Topics judged relevant for consideration as part of the annual governance statement Based on the work we have undertaken on the CCG’s system on internal control, we do not consider that within these areas there are any issues that need to be flagged as significant control issues within the Annual Governance Statement (AGS). However, the CCG may wish to consider the findings from the partial assurance reports referenced above to consider whether any of these issues should be referenced. The CCG may also wish to consider whether any other issues have
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arisen, including the results of any external reviews which it might want to consider for inclusion in the Annual Governance Statement.
Review of the effectiveness of governance, risk management and internal control
My review of the effectiveness of the system of internal control for this year has been 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 also 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 principle objectives have been reviewed.
I have been advised on the implications of the result of this review by:
• The governing body • The Quality, Safety & Performance committee • The audit committee • The Executive Management Team • Internal audit
Conclusion
Internal Audit has not identified any significant issues that need to be flagged as significant control issues within the Annual Governance Statement
Sarah Blow
Accountable Officer South West London Alliance (Kingston, Richmond, Merton, Wandsworth and Sutton CCGs) Date:
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Remuneration and Staff Report
Remuneration report Under the Government Financial Reporting Manual NHS bodies are required to prepare a remuneration report that is published as part of their annual report and financial accounts. This report must contain information about the remuneration of (pay received by) senior managers.
Senior managers are defined as people in senior positions having authority or responsibility for directing or controlling the major activities of the clinical commissioning group. This means those who influence the decisions of the CCG as a whole rather than the decisions of individual directorates or departments.
To ensure remuneration is in line with national guidance, current good practice and ensures value for public money, the CCG has set up a remuneration committee.
The committee, which is accountable to the governing body, makes recommendations on the remuneration, fees and other allowances for employees and for people who provide services to the CCG. This includes advising on salaries for the CCG’s most senior staff (known as very senior managers). It would also make recommendations on allowances under any pension scheme that the CCG may establish as an alternative to the NHS pension scheme.
Remuneration committee report (not subject to audit)
The local Remuneration Committee did not meet during 2018/19. Instead the business of this meeting was discussed at a south west London level, as described below.
SWL Remuneration Committees in Common
In respect of Alliance wide roles, the Remuneration Committee meets as a committee in common to agree a unanimous basis for decision making. This committee provides advice and recommends decisions to each Governing Body in determining remuneration, fees and allowances payable to employees and other persons providing services as well as determining allowances payable under pension schemes established by the CCG.
Remuneration policy (not subject to audit) Remuneration for governing body members, including the accountable officer and chief finance officer, is determined on the basis of reports to the remuneration committee, taking into account 91 | Page
national guidance on pay rates, any independent evaluation of the post and national and market rates.
All other managers are covered by terms and conditions set out in the national NHS Agenda for Change arrangements. Individual staff performance is assessed as part of the staff appraisal process, which includes objective setting and annual reviews with line managers. In line with national guidance and the Agenda for Change programme, staff progress through an incremental pay scale if their performance during the year has been in line with agreed targets and objectives.
Senior managers’ performance related pay The CCG does not have a policy of performance related pay for senior managers.
Senior managers’ service contracts (not subject to audit) The CCG’s policy concerning permanent senior managers’ contracts is that they have no end date, with a notice period of 6 months.
Payments to past senior managers (not subject to audit) The CCG has not made any payments to past senior managers.
Senior manager remuneration (subject to audit) The table below discloses salaries and allowances paid by the CCG to Directors of significant influence in 2018/19.
Name and title Salary Taxable Annual Long-term All pension TOTAL and/or benefits performance performance related fees related related benefits (rounded bonuses bonuses to the (bands of (bands nearest (bands of (bands of £2,500) (bands of of £100) £5,000) £5,000) £5,000) £5,000) £000 £ £000 £000 £000 £000 Graham Lewis, CCG Chair 55-60 0 0 0 0 55-60
Kate Moore, Vice Chair 55-60 0 0 0 0 55-60
Sarah Blow, Accountable Officer 25-30 0 0 0 5-7.5 30-35 (1)
James Murray, Chief Finance 25-30 0 0 0 0 25-30 Officer (2)
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Jonathan Bates, Director of 20-25 0 0 0 2.5-5 25-30 Commissioning Operations, SWL Alliance (3)
Charlotte Gawne, Director of 20-25 0 0 0 5-7.5 30-35 Communications, SWL Alliance (4)
Tonia Michaelides, Managing 55-60 0 0 0 10-12.5 70-75 Director (5)
Fergus Keegan, Registered 45-50 0 0 0 0 45-50 Nurse (to 1st October 2018) (6)
Kathryn Yates, Registered Nurse 0-5 0 0 0 -2.5-0 0-5 (from 2nd October 2018)
Nicola Bignell, GP Member 40-45 0 0 0 0 40-45
Alireza Salehzadeh, GP Member 25-30 0 0 0 0 25-30
Anne Dornhurst, Secondary 10-15 0 0 0 0 10-15 Care Doctor
Stavroula Lees-Karipoglou, GP 40-45 0 0 0 0 40-45 Member
Branko Momic, GP Member 25-30 0 0 0 0 25-30
Zehra Rashid, GP Member (to 5-10 0 0 0 0 5-10 19th June 2018)
Sylwia Ferguson, GP Member 20-25 0 0 0 0 20-25 (from 1st September 2018)
Bob Armitage, Lay Member 10-15 0 0 0 0 10-15 (finance, remuneration, primary care & governance)
Susan Smith, Lay Member 5-10 0 0 0 0 5-10 (Patient & Public Involvement)
Paul Gallagher, Lay Member 0 0 0 0 0 0 (Audit and Conflicts of Interest Guardian) (7)
Notes
1: Sarah Blow is the Accountable Officer for South West London Alliance, and is on Wandsworth CCG’s payroll; her total salary is in the range £140k-£145k. Richmond CCG is responsible for 20% of her costs. 93 | Page
2: James Murray is Chief Financial Officer for South West London Alliance and is on Wandsworth CCG’s payroll; his total salary is in the range £140-£145k. Richmond CCG is responsible for 20% of his costs. The CCG does not make any employer’s pension contribution in respect of James Murray.
3: Jonathan Bates is Director of Commissioning Operations for South West London Alliance and is on Wandsworth CCG’s payroll; his total cost is in the range £115-£120k. Richmond CCG is responsible for 20% of his costs.
4: Charlotte Gawne is Director of Communications for South West London Alliance and is on Wandsworth CCG’s payroll; her total cost is in the range £115-£120k. Richmond CCG is responsible for 20% of her costs.
5. Tonia Michaelides is Managing Director for Kingston & Richmond CCGs and is on Kingston CCG’s payroll; her total cost is in the range £115-£120k. Richmond CCG is responsible for 50% of her costs.
6. Fergus Keegan was Registered Nurse until 1st October 2018 and is on Kingston CCG’s payroll; his total cost is in the range £95-£100k. Richmond CCG is responsible for 50% of his costs. The costs shown are the Richmond CCG contribution for the whole of 2018/19.
7. Paul Gallagher is the Lay Member for Audit and Conflicts of Interest Guardian. He fulfils the same role in Kingston CCG and is remunerated by them.
The table below gives the equivalent information for 2017/18.
Name and title Salary Taxable Annual Long-term All TOTAL and/or benefits performance performance pension fees related related related (rounded bonuses bonuses benefits to the (bands of (bands of nearest (bands of (bands of (bands of £5,000) £5,000) £100) £5,000) £5,000) £2,500)
£000 £ £000 £000 £000 £000 Graham Lewis, CCG Chair 55-60 0 0 0 0 55-60
Kate Moore, Vice Chair 55-60 0 0 0 0 55-60
Sarah Blow, Accountable 25-30 0 0 0 27.5-30 55-60 Officer (1)
James Murray, CFO (2) 65-70 0 0 0 0 65-70
Tonia Michaelides, Managing 55-60 0 0 0 32.5-35 90-95 Director (5)
Fergus Keegan, Registered 45-50 0 0 0 17.5-20 65-70 Nurse (6)
Nicola Bignell, GP Member 40-45 0 0 0 0 40-45
Alireza Salehzadeh, GP 20-25 0 0 0 0 20-25 Member (from June 2017)
Anne Dornhurst, Secondary 10-15 0 0 0 0 10-15 Care Doctor
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Stavroula Lees-Karipoglou, 40-45 0 0 0 0 40-45 GP Member
Branko Momic, GP Member 25-30 0 0 0 0 25-30
Zehra Rashid, GP Member 20-25 0 0 0 0 20-25 (from June 2017)
Bob Armitage, Lay Member 10-15 0 0 0 0 10-15 (finance, remuneration, primary care & governance)
Susan Smith, Lay Member 5-10 0 0 0 0 5-10 (Patient & Public Involvement)
Charles Humphry, Lay 10-15 0 0 0 0 10-15 Member (audit and Conflicts of Interest Guardian) to January 18
Notes
The table above shows the remuneration reported in the 2017/18 annual report. A change has been made in 2018/19 to the basis of reporting, to align the annual reports of all South West London CCG’s. In 2017/18 the full pension benefits were included for directors working across multiple CCG’s. In 2018/19, the relevant share of pension benefits has been shown.
Pensions entitlement table (This section is subject to audit).
Where the CCG contributed to pension schemes for senior managers, the benefits are shown in the table below:
Name and title Real Real Total Lump sum Cash Cash Real Emplo increas increase in accrued at age 60 equivalent equivalent increase in yer’s e in pension pension at related to transfer transfer cash contrib pensio lump sum pension accrued value at value at equivalent ution n at at aged 60 age at 31 pension at 31 March 31 March transfer to age 60 March 31 March 2019 2018 value stakeh 2019 2018 olders pensio (bands of n (bands of (bands of £5,000) (bands £2,500) £5,000) of £2,500) £000 £000 £000 £000 £000 £000
£000 £000 Sarah Blow, Accountable 0-2.5 -2.5-0 35-40 85-90 731 609 104 20 Officer (1)
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James Murray, n/a n/a n/a n/a n/a n/a n/a n/a CFO (2) Jonathan Bates, Director of Commissioning 0-2.5 -2.5-0 35-40 90-95 678 557 105 16 Operations, SWL Alliance (3) Charlotte Gawne, Director of 2.5-5 0-2.5 30-35 70-75 554 441 99 16 Communication s, SWL Alliance (4) Tonia Michaelides, 0-2.5 -2.5-0 30-35 75-80 615 508 92 17 Managing Director (5) Fergus Keegan, Registered Nurse (to 1st 2.5-5 0-2.5 25-30 65-70 533 426 94 0 October 2018) (6) Kathryn Yates, Registered -2.5-0 -2.5-0 5-10 15-20 165 140 20 0 Nurse (from 2nd October 2018)
Notes
1: Sarah Blow is the Accountable Officer for South West London Alliance on Wandsworth CCG’s payroll. Richmond CCG is responsible for 20% of her costs, but we are showing the full costs.
2: James Murray is Chief Financial Officer for South West London Alliance on Wandsworth CCG’s payroll. Wandsworth CCG does not make any employer’s pensions contribution in respect of James Murray.
3: Jonathan Bates is Director of Commissioning Operations for South West London Alliance on Wandsworth CCG’s payroll. Richmond CCG is responsible for 20% of his costs, but we are showing the full costs.
4. Charlotte Gawne is Director of Director of Communications for South West London Alliance on Wandsworth CCG’s payroll. Richmond CCG is responsible for 20% of his costs, but we are showing the full costs.
5: Tonia Michaelides is on Kingston CCG’s payroll: Richmond CCG is responsible for 50% of her costs. We are showing her full pension costs.
6: Fergus Keegan is on Kingston CCG’s payroll: Richmond CCG is responsible for 50% of his costs. We are showing his full pension costs.
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Cash equivalent transfer values A cash equivalent transfer value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s (or other allowable beneficiary’s) pension payable from the scheme.
A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies.
The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries.
Real increase in CETV This reflects the increase in CETV that is funded by the employer. It does not include the increase in accrued pension due to inflation or contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement).
Compensation on early retirement or for loss of office
This is not applicable for Richmond CCG during 2018/19.
Payments to past members
This is not applicable for Richmond CCG during 2018/19.
Pay multiples (This section is subject to audit).
Reporting bodies are required to disclose the relationship between the remuneration of the highest- paid director/Member in their organisation and the median remuneration of the organisation’s workforce.
The banded remuneration of the highest paid governing body member in the financial year 2018/19 was £165k-£170k per annum. This was 2.9 times the median remuneration of the
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workforce, which was £59k. The workforce only includes permanent staff and excludes off payroll engagements.
The banded remuneration of the highest paid governing body member in the financial year 2017/18 was £165k-£170k per annum. This was 3.2 times the median remuneration of the workforce, which was £53k. The workforce only includes permanent staff and excludes off payroll engagements.
The reason for the decrease in the ratio from 2017/18 to 2018/19 is that the pay of the main body of staff has increased in line with NHS Agenda for Change pay settlement, whereas governing body members’ pay has increased at a lower rate or remained static, thus reducing the gap between the higher and lower paid members of staff.
In 2018/19, one employee received remuneration in excess of the highest-paid director/Member (2017/18 was one). Remuneration ranged from £18k to £168k (In 2017/18 remuneration ranged from £10k to £167k). 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.
Staff Report Keeping our staff informed and engaged
During the year, we have built on the progress we made last year to further develop staff communication and organisational development activities. This is important so that CCG staff understand the shared work objectives across south west London, and are engaged in them, as well as their local CCG priorities. The staff engagement group with representation from all CCGs in south west London continues to meet on a six-weekly basis to steer organisational development and internal communications activities to ensure that staff engagement remains an area of focus.
We held a second staff conference for all CCG staff in south west London in May 2018, and are planning another one for 2019. We have aligned our monthly staff briefings – ‘Team Talk’ – to ensure there is consistency in our approach to staff communications. Each monthly briefing contains key messages from the senior management team and are localised with updates on initiatives from the local delivery unit’s managing director. Feedback from staff from these briefings is collated and shared with the management team. In addition, we hold a quarterly live broadcast with the accountable officer who provides an overview of national and local developments. During the broadcast, there is an opportunity for staff to ask the accountable officer questions directly. 98 | Page
At a more local level, we have moved offices and are now co-located with Kingston CCG in Teddington. Staff from both CCGs in conjunction with the CCGs’ Ways of Working group were involved in the design and layout of the offices to maximise the space available and to create a conducive working environment. As a consequence of the move, we have introduced a smart working policy which enables staff to work more flexibly depending on the job or task they are undertaking. For example, with the investment in new IT equipment and a move to a cloud-based solution, staff are now more easily able to work in locations such as their homes or other NHS offices. This has enabled greater flexibility with a view to staff being more productive. With staff undertaking less travel by car to our offices we are positively impacting the environment. Initiatives such as ‘Cyclescheme’ which enable staff to spread the cost of buying a bike have been promoted. In addition, since moving to Teddington, we have encouraged staff to reduce their use of plastic water bottles by providing sustainably produced and reusable glass water bottles.
We have continued our focus on healthy workplace initiatives throughout the year including signing up for the ‘Global Walking Challenge’ for the third year in a row. The challenge encourages staff to work together in teams and to count their steps each day over a one-hundred-day period. League tables within the organisation and globally provide for some friendly rivalry but the premise is for people to think more about both their physical and mental health, hydration and sleep.
The CCG has also signed up to the Time to Change employer pledge, to demonstrate our commitment to changing attitudes and behaviours about mental health in the workplace and to make sure our staff know they will be supported in their mental health. We also run weekly mindfulness sessions at lunchtimes and held a mental health awareness session for staff to help with their own mental health and to help colleagues if they appear to be struggling.
Since co-locating, we have developed a joint intranet for both CCGs’ staff using the new technology and software available to us. The site has enabled us to reduce the number of emails sent to staff and have news items, briefings, information, policies and guidance available in one, easy to navigate place.
Ways of Working group members have discussed the results of the NHS annual staff surveys for both CCGs and the mid-year staff satisfaction survey which is undertaken as a ‘temperature check’ for the organisation. The group has agreed an action plan to address the concerns that staff have raised.
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As part of our commitment to make south west London a great place to work and having listened to staff feedback from the staff conference, we launched the South West London Alliance Awards for Making a Difference (The SAMs), a new annual reward and recognition programme for staff. Reward and recognition is a key element of staff engagement. Awards can help to support the recognition of the good work that staff undertake, the contribution they make as well as making them feel more valued. There are six award categories ranging from quality improvement, leadership and unsung hero. A judging panel consisting of the accountable officer, a CCG chair and a lay member make the final decision.
Staff policies and other information
We have statutory and mandatory training requirements and reporting procedures in place. This training is provided both on line via e-learning and in house.
We have an annual appraisal system to support staff and set personal development plans. Training is available to staff to support personal development and career progression.
Employee consultation is covered by an agreed CCG-wide organisational change policy.
Staff who have a disability are protected under the terms of the Equality Act 2010. The sickness absence policy states: ‘If an employee is disabled or becomes disabled, the CCG is legally required under the Equality Act 2010 to make reasonable adjustments to enable the employee to continue working – for example, providing an ergonomic chair or a power-assisted piece of equipment. The CCG must ensure the individual is not disadvantaged because of their disability. If their absence is related to disability, records should be kept separate from other sickness absence’.
Candidates who apply to the CCG and who declare they have a disability are given full and fair consideration for employment and are not discriminated against on the ground of their disability at any stage of the recruitment process. For example, candidates are asked if any adjustments are needed in order for them to attend interview and / or undertake assessments, and any reasonable adjustments to enable a disabled person to take up a role would also be given consideration.
The CCG has an organisational development plan which includes plans for the development of all staff in the organisation.
The majority of roles in the CCG are paid in accordance with the national Agenda for Change payscales.
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Number in March 2019 Very senior manager 0 Band 9 1 Band 8D 2 Total 3
These figures include only staff employed directly through Richmond CCG’s payroll.
Staff numbers and costs (subject to audit) Permanently Other staff Total employed staff Category Cost, Average Cost, Average Cost, Average £000 WTE £000 WTE £000 WTE A: Ambulance staff 0 0.0 0 0.0 0 0.0 G: Administration and 2,680 43.4 466 5.1 3,146 48.5 estates staff H: Healthcare Assistants 0 0.0 0 0.0 0 0.0 and other support staff M: Medical and Dental 30 0.5 1 0.0 31 0.5 staff N: Nursing, Midwifery 143 2.3 84 2.4 227 4.7 and health visiting staff P: Nursing, midwifery and health visiting 0 0.0 0 0.0 0 0.0 learners S: Scientific, therapeutic 432 7.0 95 0.7 527 7.7 and technical staff U: Healthcare science 0 0.0 0 0.0 0 0.0 Total 3,284 53.2 647 8.2 3,931 61.4
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Staff composition Female Male Total Directors 0 0 0 Senior managers 2 1 3 Employees 46 14 60 Total 48 15 63
These figures exclude directors and staff on the payrolls of other CCGs who are part-recharged to Richmond CCG.
Staff composition
Equalities for staff
An equalities breakdown of staff by six categories in line with guidance is available and key areas are presented regularly to the CCG in the form of workforce reports. Tables do not include governing body members and clinical leads. Monitoring will continue to identify any priority areas to address.
As at 31 March 2019 The following tables are a profile of the CCG relating to the main protected characteristics. Tables do not include governing body members/clinical leads.
Disability
Disabled Headcount Percentage FTE No 40 83.33% 37.99 Not Declared 7 14.58% 6.19 Yes 1 2.08% 1.00 Grand Total 48 100.00% 45.17
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Ethnic origin
Ethnic origin Headcount Percentage FTE A White - British 22 45.83% 20.37 B White - Irish 1 2.08% 1.00 C White - Any other white background 4 8.33% 3.60 D Mixed - White & black Caribbean 1 2.08% 0.91 G Mixed - Any other mixed background 2 4.17% 2.00 H Asian or Asian British - Indian 4 8.33% 4.00 J Asian or Asian British - Pakistani 1 2.08% 1.00 L Asian or Asian British - any other Asian background 1 2.08% 1.00 M Black or black British - Caribbean 4 8.33% 4.00 N Black or black British - African 1 2.08% 1.00 S Any other ethnic group 2 4.17% 2.00 Z Not Stated 5 10.42% 4.29 Grand total 48 100.00% 45.17
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Sexual orientation
Sexual orientation Headcount Percentage FTE Heterosexual or straight 36 75% 34.60
Not stated (person asked but declined to provide a response) 12 25% 10.57 Grand Total 48 100% 45.17
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Religious Belief
Religious Belief Headcount Percentage FTE Atheism 5 10.42% 4.69 Christianity 21 43.75% 19.69 Hinduism 2 4.17% 2.00 I do not wish to disclose my religion/belief 14 29.17% 12.79 Islam 1 2.08% 1.00 Other 3 6.25% 3.00 Sikhism 2 4.17% 2.00 Grand Total 48 100.00% 45.17
Age Range
Headcoun Age Group t Percentage FTE 20-24 1 2.08% 0.80 25-29 5 10.42% 5.00 30-34 2 4.17% 2.00 35-39 4 8.33% 3.80 40-44 9 18.75% 7.99 45-49 10 20.83% 9.40 50-54 9 18.75% 8.39 55-59 5 10.42% 5.00 60-64 3 6.25% 2.80 Grand Total 48 100.00% 45.17
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Age Range
25.00%
20.00%
15.00%
10.00%
5.00%
0.00% 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64
Employee Category Headcount FTE Full Time 37 37 Part Time 26 11.00 Grand Total 63 48.00
Gender
23.81%
Female Male
76.19%
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Sickness absence data
The CCG sickness absence percentage rate is presented regularly to the CCG in the form of workforce reports. Individual sickness absence cases are managed by the line manager with advice and support from HR.
An occupational health (OH) service is available to provide professional medical advice to the CCG. Staff can access OH for a self-referral.
The CCG also has access to an employee assistance programme which offers confidential access to emotional and practical support, including legal and financial advice.
Number of days lost 566.7 Total staff years 49.7 Average working days lost 11.4
Consultancy
The reported expenditure on consultancy was -£6k in 2018/19. The negative balance is caused by an unused accrual. (£1k in 2017/18).
Off-payroll engagements (not subject to audit) Table 1: Off-payroll engagements longer than 6 months
For all off-payroll engagements as of 31 March 2019, for more than £245 per day and that lasted longer than six months were as follows:
Number Number of existing arrangements as of 31 March 2019. 5
Of which, the number that have existed: for less than one year at the time of reporting 1 for between one and two years at the time of reporting 2 for between 2 and 3 years at the time of reporting 1 for between 3 and 4 years at the time of reporting 0 for between 4 or more years at the time of reporting 1
The CCG confirms that all existing off-payroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax and, where necessary, that assurance has been sought.
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Table 2: New off-payroll engagements
Where the reformed public sector rules apply, entities must complete 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 6 months:
Number
Number of new engagements or those that reached six months in 3 duration between 1 April 2018 and 31 March 2019.
Of which… Number assessed as caught by IR35 0 Number assessed as not caught by IR35 3
Number engaged directly (via PSC contracted to the entity) and are on 0 the departmental payroll Number of engagements reassessed for consistency / assurance 0 purposes during the year Number of engagements that saw a change to IR35 status following the 0 consistency review.
Table 3: Off-payroll engagements / senior official engagements
For any off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1 April 2018 and 31 March 2019
Number Number of off-payroll engagements of board members, and/or senior 0 officers with significant financial responsibility, during the financial year
Number of individuals that have been deemed governing body 18 members, and/or senior officers with significant financial responsibility during the financial year. This figure includes both off-payroll and on- payroll engagements.
Exit packages, including special (non-contractual) payments (subject to audit) During 2018-19 there were no exit packages at Richmond CCG.
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Sarah Blow Accountable Officer
Date:
Parliamentary Accountability and Audit Report
Richmond CCG is not required to produce a Parliamentary Accountability and Audit Report. Disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges are included as notes in the Financial Statements of this report at. An audit certificate and report is also included in this Annual Report.
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Annex 1: Annual Accounts
Entity name: NHS RICHMOND CCG
This year 2018-19
This year ended 31-March-2019
This year commencing: 01-April-2018 Richmond CCG - Annual Accounts 2018-19
CONTENTS Page Number
The Primary Statements:
Statement of Comprehensive Net Expenditure for the year ended 31st March 2019 3 Statement of Financial Position as at 31st March 2019 4 Statement of Changes in Taxpayers' Equity for the year ended 31st March 2019 5 Statement of Cash Flows for the year ended 31st March 2019 6
Notes to the Accounts Accounting policies 7-11 Other operating revenue 12 Employee benefits and staff numbers 13-15 Operating expenses 16 Better payment practice code 17 Operating leases 18 Property, plant and equipment 19 Trade and other receivables 20 Cash and cash equivalents 21 Trade and other payables 22 Provisions 23 Financial instruments 24 Operating segments 25 Related party transactions 26 Events after the end of the reporting period 27 Financial performance targets 27
2 Richmond CCG - Annual Accounts 2018-19
Statement of Comprehensive Net Expenditure for the year ended 31 March 2019
2018-19 2017-18 Note £'000 £'000
Other operating income 2 (2,688) (3,667) Total operating income (2,688) (3,667)
Staff costs 3 3,931 4,491 Purchase of goods and services 4 272,714 265,752 Depreciation and impairment charges 4 79 - Provision expense 4 849 (46) Other Operating Expenditure 4 1,478 658 Total operating expenditure 279,051 270,855
Total Net Expenditure for the Financial Year 276,363 267,188
Comprehensive Expenditure for the year 276,363 267,188
3 Richmond CCG - Annual Accounts 2018-19
Statement of Financial Position as at 31 March 2019 2018-19 2017-18
Note £'000 £'000 Non-current assets: Property, plant and equipment 7 157 236 Total non-current assets 157 236 Current assets: Trade and other receivables 8 2,849 5,704 Cash and cash equivalents 9 174 264 Total current assets 3,023 5,968
Total assets 3,180 6,204
Current liabilities Trade and other payables 10 (31,483) (33,550) Provisions 11 (849) (183) Total current liabilities (32,332) (33,733)
Non-Current Assets plus/less Net Current Assets/Liabilities (29,152) (27,529)
Assets less Liabilities (29,152) (27,529)
Financed by Taxpayers’ Equity General fund (29,152) (27,529) Total taxpayers' equity: (29,152) (27,529)
The notes on pages 7 to 27 form part of this statement
The financial statements on pages 3 to 6 were approved by the Audit Commitee on 23rd May and signed on its behalf by:
Sarah Blow Chief Accountable Officer
4 Richmond CCG - Annual Accounts 2018-19
Statement of Changes In Taxpayers Equity for the year ended 31 March 2019 Total General fund reserves £'000 £'000 Changes in taxpayers’ equity for 2018-19
Balance at 01 April 2018 (27,529) (27,529) Impact of applying IFRS 9 to Opening Balances (4) (4) Adjusted NHS Clinical Commissioning Group balance at 31 March 2018 (27,533) (27,533)
Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2018-19 Net operating expenditure for the financial year (276,363) (276,363)
Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (276,363) (276,363) Net funding 274,744 274,744 Balance at 31 March 2019 (29,152) (29,152)
Total General fund reserves £'000 £'000 Changes in taxpayers’ equity for 2017-18
Balance at 01 April 2017 (21,979) (21,979) Transfer of assets and liabilities from closed NHS bodies as a result of the 1 April 2013 transition 0 0 Adjusted NHS Clinical Commissioning Group balance at 31 March 2018 (21,979) (21,979)
Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year (267,186) (267,186) Net funding 261,636 261,636 Balance at 31 March 2018 (27,529) (27,529)
The notes on pages 7 to 27 form part of this statement
5 Richmond CCG - Annual Accounts 2018-19
Statement of Cash Flows for the year ended 31 March 2019 2018-19 2017-18 Note £'000 £'000 Cash Flows from Operating Activities Net operating expenditure for the financial year (276,363) (267,186) Depreciation and amortisation 4 79 0 Non-cash movements arising on application of new accounting standards (3) 0 (Increase)/decrease in trade & other receivables 8 2,856 1,077 Increase/(decrease) in trade & other payables 10 (2,067) 4,947 Provisions utilised 11 (183) (122) Increase/(decrease) in provisions 11 849 (46) Net Cash Inflow (Outflow) from Operating Activities (274,832) (261,330)
Cash Flows from Investing Activities (Payments) for property, plant and equipment 0 (236) Net Cash Inflow (Outflow) from Investing Activities 0 (236)
Net Cash Inflow (Outflow) before Financing (274,832) (261,566)
Cash Flows from Financing Activities Grant in Aid Funding Received 274,743 261,638 Net Cash Inflow (Outflow) from Financing Activities 274,743 261,638
Net Increase (Decrease) in Cash & Cash Equivalents 9 (89) 72
Cash & Cash Equivalents at the Beginning of the Financial Year 264 192
Cash & Cash Equivalents (including bank overdrafts) at the End of the Financial Year 175 264
The notes on pages 7 to 27 form part of this statement
6 Richmond 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 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 These accounts have been prepared on a going concern basis (despite the issue of a report to the Secretary of State for Health under Section 30 of the Local Audit and Accountability Act 2014 for the breach of financial duties). Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents. Whilst the CCG is in financial recovery, the following is clear evidence that it is appropriate for Richmond CCH to prepare its annual accounts on a going concern basis: - Richmond CCG was established on 1st April 2013 as a separate statutory body. - Richmond CCG has agreed, and is operating to, it constitution to govern its activities. - Richmond CCG has been allocated funds for the 5 years from 2019/20 to 2023/24. - The CCG is planning for a surplus of £0.1m in 2019/20. - Detailed financial plans for 2019/20 have been submitted to the Governing Body and NHS England. Where a clinical commissioning group ceases to exist, it considers whether its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of Financial Statements. If services will continue to be provided the financial statements are prepared on a going concern basis. It should be noted that a report to the Secretary of State for Health under Section 30 of the Local Audit and Accountability Act 2014 has been issued for the breach of financial duties, i.e. failure to contain expenditure within the Revenue Resource Limit.
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 Pooled Budgets The clinical commissioning group has entered into a pooled budget arrangement with London Borough of Richmond in accordance with section 75 of the NHS Act 2006. Under the arrangement, funds are pooled for commissioning out of hospital services and a note to the accounts provides details of the income and expenditure. 1.4 Operating Segments Income and expenditure are analysed in the Operating Segments note and are reported in line with management information used within the clinical commissioning group. 1.5 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. 1.6 Employee Benefits 1.6.1 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.
1.6.2 Retirement Benefit Costs Past and present employees are covered by the provisions of the NHS Pensions Schemes. These schemes are unfunded, defined benefit schemes that cover NHS employers, General Practices and other bodies allowed under the direction of the Secretary of State in England and Wales. The schemes are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the schemes are accounted for as though they were defined contribution schemes: the cost to the clinical commissioning group of participating in a scheme is taken as equal to the contributions payable to the scheme for the accounting period. For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to expenditure at the time the clinical commissioning group commits itself to the retirement, regardless of the method of payment. The schemes are subject to a full actuarial valuation every four years and an accounting valuation every year. 1.7 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. 1.8 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.
7 Richmond CCG - Annual Accounts 2018-19
Notes to the financial statements
1.9 Property, Plant & Equipment 1.9.1 Recognition Property, plant and equipment is capitalised if: · It is held for use in delivering services or for administrative purposes; · It is probable that future economic benefits will flow to, or service potential will be supplied to the clinical commissioning group; · It is expected to be used for more than one financial year; · The cost of the item can be measured reliably; and, · The item has a cost of at least £5,000; or, · Collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or, · Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives. 1.9.2 Measurement All property, plant and equipment is measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. Assets that are held for their service potential and are in use are measured subsequently at their current value in existing use. Assets that were most recently held for their service potential but are surplus are measured at fair value where there are no restrictions preventing access to the market at the reporting date Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Current values in existing use are determined as follows: · Land and non-specialised buildings – market value for existing use; and, · Specialised buildings – depreciated replacement cost. Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are re-valued and depreciation commences when they are brought into use. IT equipment, transport equipment, furniture and fittings, and plant and machinery that are held for operational use are valued at depreciated historic cost where these assets have short useful economic lives or low values or both, as this is not considered to be materially different from current value in existing use. An increase arising on revaluation is taken to the revaluation reserve except when it reverses an impairment for the same asset previously recognised in expenditure, in which case it is credited to expenditure to the extent of the decrease previously charged there. A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Gains and losses recognised in the revaluation reserve are reported as other comprehensive income in the Statement of Comprehensive Net Expenditure. 1.9.3 Subsequent Expenditure Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised. Where subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing carrying value of the item replaced is written- out and charged to operating expenses. 1.10 Leases Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases. 1.10.1 The Clinical Commissioning Group as Lessee Property, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the clinical commissioning group’s surplus/deficit. Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term. Contingent rentals are recognised as an expense in the period in which they are incurred. Where a lease is for land and buildings, the land and building components are separated and individually assessed as to whether they are operating or finance leases. 1.11 Cash & Cash Equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value. In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the clinical commissioning group’s cash management.
8 Richmond CCG - Annual Accounts 2018-19
Notes to the financial statements
1.12 Provisions Provisions are recognised when the clinical commissioning group has a present legal or constructive obligation as a result of a past event, it is probable that the clinical commissioning group will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties. 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 cashflows 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.
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. 1.13 Clinical Negligence Costs NHS Resolution operates a risk pooling scheme under which the clinical commissioning group pays an annual contribution to NHS Resolution, which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although NHS Resolution is administratively responsible for all clinical negligence cases, the legal liability remains with clinical commissioning group. 1.14 Non-clinical Risk Pooling The clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to 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. 1.15 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. 1.16 Financial Assets Financial assets are recognised when the clinical commissioning group becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred. Financial assets are classified into the following categories: · Financial assets at amortised cost; · Financial assets at fair value through other comprehensive income and ; · Financial assets at fair value through profit and loss. The classification is determined by the cash flow and business model characteristics of the financial assets, as set out in IFRS 9, and is determined at the time of initial recognition. 1.16.1 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. 1.16.2 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. 1.16.3 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.
9 Richmond CCG - Annual Accounts 2018-19
Notes to the financial statements
1.16.4 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. 1.17 Financial Liabilities Financial liabilities are recognised on the statement of financial position when the clinical commissioning group becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are de- recognised when the liability has been discharged, that is, the liability has been paid or has expired. 1.17.1 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. 1.17.2 Financial Liabilities at Fair Value Through Profit and Loss
Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial liabilities at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the clinical commissioning group’s surplus/deficit. The net gain or loss incorporates any interest payable on the financial liability. 1.17.3 Other Financial Liabilities After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method, except for loans from Department of Health and Social Care, which are carried at historic cost. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method. 1.18 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. 1.19 Foreign Currencies The clinical commissioning group’s functional currency and presentational currency is pounds sterling and amounts are presented in thousands of pounds unless expressly stated otherwise. Transactions denominated in a foreign currency are translated into sterling at the exchange rate ruling on the dates of the transactions. At the end of the reporting period, monetary items denominated in foreign currencies are retranslated at the spot exchange rate on 31 March. Resulting exchange gains and losses for either of these are recognised in the clinical commissioning group’s surplus/deficit in the period in which they arise. 1.20 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. 1.21 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).
10 Richmond CCG - Annual Accounts 2018-19
Notes to the financial statements
1.22 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. 1.22.1 Critical accounting judgements in applying accounting policies Apart from those involving estimations (see below), there are no critical judgements that management has made in the process of applying the clinical commissioning group’s accounting policies that have a significant effect on the amounts recognised in the financial statements. 1.22.2 Sources of estimation uncertainty The following are assumptions about the future and other major sources of estimation uncertainty that have a significant risk of resulting in a material adjustment to the carrying amounts of assets and liabilities within the next financial year: · Estimates of the final two months prescribing expenditure have been conservatively based on historical expenditure patterns · Estimates of continuing care expenditure in the final three months have been based on invoices received during the financial year. 1.23 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.
1.24 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 2019-20, 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.
11 Richmond CCG - Annual Accounts 2018-19
2. Other Operating Revenue 2018-19 2017-18 Total Total £'000 £'000
Other operating income Charitable and other contributions to revenue expenditure: non-NHS 6 20 Other non contract revenue 2,682 3,647 Total Other operating income 2,688 3,667
Total Operating Income 2,688 3,667
12 Richmond CCG - Annual Accounts 2018-19
3. Employee benefits and staff numbers
3.1.1 Employee benefits Total 2018-19
Permanent Employees Other Total £'000 £'000 £'000 Employee Benefits Salaries and wages 2,692 647 3,339 Social security costs 269 0 269 Employer Contributions to NHS Pension scheme 323 0 323 Gross employee benefits expenditure 3,284 647 3,931
Less recoveries in respect of employee benefits (note 3.1.2) - - - Total - Net admin employee benefits including capitalised costs 3,284 647 3,931
Less: Employee costs capitalised - - - Net employee benefits excluding capitalised costs 3,284 647 3,931
3.1.1 Employee benefits Total 2017-18
Permanent Employees Other Total £'000 £'000 £'000 Employee Benefits Salaries and wages 2,852 1,027 3,879 Social security costs 275 0 275 Employer Contributions to NHS Pension scheme 337 0 337 Gross employee benefits expenditure 3,464 1,027 4,491
Less recoveries in respect of employee benefits (note 3.1.2) (2) 0 (2) Total - Net admin employee benefits including capitalised costs 3,462 1,027 4,489
Less: Employee costs capitalised - - - Net employee benefits excluding capitalised costs 3,462 1,027 4,489
3.1.2 Recoveries in respect of employee benefits 2018-19 2017-18 Permanent Employees Other Total Total £'000 £'000 £'000 £'000 Employee Benefits - Revenue Salaries and wages - - - (2) Total recoveries in respect of employee benefits - - - (2)
13 Richmond CCG - Annual Accounts 2018-19
3.2 Average number of people employed 2018-19 2017-18 Permanently Permanently employed Other Total employed Other Total Number Number Number Number Number Number
Total 53 8 61 50 10 60
3.3 Exit packages agreed in the financial year There have been no compulsory redundancies or other agreed departures" in 2018-19. (2017-18, Nil)
14 Richmond CCG - Annual Accounts 2018-19
3.4 Pension costs
Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions.
These schemes are unfunded, defined benefit schemes that cover NHS employers, General Practices and other bodies allowed under the direction of the Secretary of State in England and Wales. The schemes are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities.
Therefore, the schemes are accounted for as though they were defined contribution schemes: the cost to the clinical commissioning group of participating in a scheme is taken as equal to the contributions payable to the scheme for the accounting period.
The schemes are subject to a full actuarial valuation every four years and an accounting valuation every year.
3.4.1 Accounting valuation
A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and is accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2018, is based on valuation data as 31 March 2017, updated to 31 March 2018 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.
3.4.2 Full actuarial (funding) valuation
The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account recent demographic experience), and to recommend contribution rates payable by employees and employers.
The 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.
For 2018-19, employers’ contributions of £322,895 were payable to the NHS Pensions Scheme (2017-18: £325,920) 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.
15 Richmond CCG - Annual Accounts 2018-19
4. Operating expenses 2018-19 2017-18 Total Total £'000 £'000
Purchase of goods and services Services from other CCGs and NHS England 4,264 3,892 Services from foundation trusts 118,750 113,083 Services from other NHS trusts 61,617 58,324 Services from Other WGA bodies 45 - Purchase of healthcare from non-NHS bodies 36,724 37,550 Prescribing costs 19,850 21,369 GPMS/APMS and PCTMS 29,723 28,800 Supplies and services – clinical 385 304 Supplies and services – general 70 506 Consultancy services (6) 1 Establishment 809 1,205 Transport 137 130 Premises 219 277 Audit fees 39 39 Other professional fees 32 71 Legal fees 28 178 Education, training and conferences 28 24 Total Purchase of goods and services 272,714 265,753
Depreciation and impairment charges Depreciation 79 - Total Depreciation and impairment charges 79 -
Provision expense Provisions 849 (46) Total Provision expense 849 (46)
Other Operating Expenditure Chair and Non Executive Members 367 378 Expected credit loss on receivables 1,111 280 Total Other Operating Expenditure 1,478 658
Total operating expenditure 275,120 266,365
4.1 Limitation on auditor's liability In accordance with the terms of engagement with the clinical commissioning group's external auditors, Grant Thornton UK LLP, its members, partners and staff (whether contract, negligence or otherwise) in respect of services provided in connection with or arising out of the audit shall in no circumstances exceed £2million in the aggregate in respect of all such services.
16 Richmond CCG - Annual Accounts 2018-19
5.1 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 9,895 69,761 8,927 61,909 Total Non-NHS Trade Invoices paid within target 9,744 68,668 8,696 60,834 Percentage of Non-NHS Trade invoices paid within target 98.47% 98.43% 97.41% 98.26%
NHS Payables Total NHS Trade Invoices Paid in the Year 3,140 186,911 3,295 179,871 Total NHS Trade Invoices Paid within target 3,025 186,443 3,101 177,508 Percentage of NHS Trade Invoices paid within target 96.34% 99.75% 94.11% 98.69%
5.2 The Late Payment of Commercial Debts (Interest) Act 1998 2018-19 2017-18 £'000 £'000
Amounts included in finance costs from claims made under this legislation - - Compensation paid to cover debt recovery costs under this legislation - - Total - -
17 Richmond CCG - Annual Accounts 2018-19
6. Operating Leases
6.1 As lessee
The CCG occupies space at Thames House for use as its headquarters. Currently, there is no signed lease with Hounslow and Richmond Community Healthcare trust for the use of Thames House. Richmond CCG have a right to occupy arrangement with the trust, the cost for 2018/19 is included in note 6.1.1, however we have not included any future minium lease payments. 6.1.1 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 - 150 - 150 - 176 - 176 Contingent rents ------Sub-lease payments ------Total - 150 - 150 - 176 - 176
18 Richmond CCG - Annual Accounts 2018-19
7 Property, plant and equipment
Information 2018-19 technology Total £'000 £'000 Cost or valuation at 01 April 2018 236 236
Cost/Valuation at 31 March 2019 236 236
Depreciation 01 April 2018 - -
Charged during the year 79 79 Depreciation at 31 March 2019 79 79
Net Book Value at 31 March 2019 157 157
Purchased 157 157 Total at 31 March 2019 157 157
Asset financing:
Owned 157 157
Total at 31 March 2019 157 157
7.1 Economic lives Minimum Life Maximum Life (years) (Years) Buildings excluding dwellings 0 0 Dwellings 0 0 Plant & machinery 0 0 Transport equipment 0 0 Information technology 1 3 Furniture & fittings 0 0
19 Richmond CCG - Annual Accounts 2018-19
8.1 Trade and other receivables Current Non-current Current Non-current 2018-19 2018-19 2017-18 2017-18 £'000 £'000 £'000 £'000
NHS receivables: Revenue 3,486 - 3,961 - NHS prepayments 773 - 818 - NHS accrued income - - 1,566 - Non-NHS and Other WGA receivables: Revenue 972 - 232 - Non-NHS and Other WGA prepayments - - 161 - Non-NHS and Other WGA accrued income 32 - 270 - Non-NHS and Other WGA Contract Receivable not yet invoiced/non-invoice 6 - - - Expected credit loss allowance-receivables (2,431) - (1,316) - VAT 9 - - - Other receivables and accruals 2 - 13 - Total Trade & other receivables 2,849 - 5,705 -
Total current and non current 2,849 5,705
Included above: Prepaid pensions contributions - -
8.2 Receivables past their due date but not impaired 2018-19 2018-19 2017-18 2017-18 DHSC Group Non DHSC DHSC Group Non DHSC Bodies Group Bodies Bodies Group Bodies £'000 £'000 £'000 £'000 By up to three months 658 - 1,256 68 By three to six months - - 232 77 By more than six months 2,563 - 1,993 (79) Total 3,221 - 3,481 66
8.3 Impact of Application of IFRS 9 on financial assets at 1 April 2018 Trade and other Trade and other Trade and other Other financial Total receivables - receivables - receivables - assets NHSE bodies other DHSC external group bodies £000s £000s £000s £000s £000s Classification under IAS 39 as at 31st March 2018 Financial Assets held at Amortised cost 263 5,528 - 515 6,306 Total at 31st March 2018 263 5,528 - 515 6,306
Classification under IFRS 9 as at 1st April 2018 Financial Assets measured at amortised cost 263 5,528 - 515 6,306 Total at 1st April 2018 263 5,528 - 515 6,306
8.4 Movement in loss allowances due to application of IFRS 9 Trade and other Trade and other Trade and other Other financial Total receivables - receivables - receivables - assets NHSE bodies other DHSC external group bodies £000s £000s £000s £000s £000s
Impairment and provisions allowances under IAS 39 as at 31st March 2018 Financial Assets held at Amortised cost (ie the 1718 Closing Provision) - - (1,316) - (1,316) Total at 31st March 2018 - - (1,316) - (1,316)
Loss allowance under IFRS 9 as at 1st April 2018 Financial Assets measured at amortised cost - - (1,320) - (1,320) Total at 1st April 2018 - - (1,320) - (1,320)
Change in loss allowance arising from application of IFRS 9 - - (4) - (4)
IFRS 9 replaced IAS39 which set out how to recognise losses relating to financial assets. For CCGs it mainly impacted trade receivables. Under IAS 39 they were only impaired when there was objective evidence of a loss. Under IAS 39, an entity only considered those impairments that arose as a result of incurred loss events. The effects of possible future loss events could not be considered, even when they were expected.
IFRS 9 introduced a new expected credit loss (‘ECL’) model which broadens the information that an entity is required to consider when determining its expectations of impairment. Under this new model, expectations of future events must be taken into account and this results in the earlier recognition of accounts receivable impairments. In practice this means applying a risk factor to all outstanding unimpaired debt and calculating a potential loss. The movement in year is reflected though Income and Expenditure and a provision is carried on the Statement of Financial Position.
20 Richmond CCG - Annual Accounts 2018-19
9 Cash and cash equivalents
2018-19 2017-18 £'000 £'000 Balance at 01 April 2018 263 192 Net change in year (89) 72 Balance at 31 March 2019 174 264
Made up of: Cash with the Government Banking Service 174 264 Cash and cash equivalents as in statement of financial position 174 264
Total bank overdrafts - -
Balance at 31 March 2019 174 264
21 Richmond CCG - Annual Accounts 2018-19
Current Non-current Current Non-current 10 Trade and other payables 2018-19 2018-19 2017-18 2017-18 £'000 £'000 £'000 £'000
NHS payables: Revenue 6,611 - 8,349 - NHS accruals 2,293 - 1,201 - Non-NHS and Other WGA payables: Revenue 8,552 - 2,978 - Non-NHS and Other WGA accruals 11,516 - 20,379 - Social security costs 43 - 45 - Tax 41 - 32 - Other payables and accruals 2,427 - 566 - Total Trade & Other Payables 31,483 - 33,550 -
Total current and non-current 31,483 33,550
Other payables include £47,472 outstanding pension contributions at 31 March 2019
10.1 Impact of Application of IFRS 9 on financial liabilities at 1 April 2018 Trade and Trade and Trade and Other other other other borrowings payables - payables - payables - (including NHSE bodies other DHSC external finance lease group bodies obligations) £000s £000s £000s £000s Classification under IAS 39 as at 31st March 2018 Financial Assets held at Amortised cost 9,550 - 23,923 - Total at 31st March 2018 9,550 - 23,923 -
Classification under IFRS 9 as at 1st April 2018 Financial Liabilities measured at amortised cost 9,550 - 23,923 - Total at 1st April 2018 9,550 - 23,923 -
22 Richmond CCG - Annual Accounts 2018-19
11 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 849 - 183 - Other - - - - Total 849 - 183 -
Total current and non-current 849 183
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 ------183 - 183
Arising during the year ------849 - 849 Utilised during the year ------(183) - (183) 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 ------849 - 849
Expected timing of cash flows: Within one year ------849 - 849 Between one and five years ------After five years ------Balance at 31 March 2019 ------849 - 849
The Continuing Care Provision relates to retrospective cases where the eligibty to CHC is still to be determined.
23 Richmond CCG - Annual Accounts 2018-19
12 Financial instruments
12.1 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.
12.1.1 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.
12.1.2 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.
12.1.3 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.
12.1.4 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.
24 Richmond CCG - Annual Accounts 2018-19
12 Financial instruments cont'd
12.2 Financial assets
Financial Assets measured at amortised cost Total 2018-19 2018-19 £'000 £'000
Trade and other receivables with NHSE bodies 3,483 3,483 Trade and other receivables with other DHSC group bodies 907 907 Trade and other receivables with external bodies 106 106 Other financial assets 2 2 Cash and cash equivalents 174 174 Total at 31 March 2019 4,672 4,672
12.3 Financial liabilities
Financial Liabilities measured at amortised cost Total 2018-19 2018-19 £'000 £'000
Trade and other payables with NHSE bodies 1,522 1,522 Trade and other payables with other DHSC group bodies 10,963 10,963 Trade and other payables with external bodies 16,487 16,487 Other financial liabilities 2,427 2,427 Total at 31 March 2019 31,399 31,399
13 Operating segments Richmond CCG reports as one operating segment.
25 Richmond CCG - Annual Accounts 2018-19
14 Related party transactions
Details of related party transactions with individuals are as follows: 2018-19 2017-18 Receipts Amounts Amounts Receipts Amounts from owed to due from Payments to from Amounts due from Payments to Related Related Related Related Related owed to Related Table 1. Governing Body Related Party Transactions Related Party Party Party Party Party Party Related Party Party £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000
Glebe Road Surgery (Y01206) 1,186 0 102 0 1,086 0 59 0 Thameside Medical Practice (H84059) 594 0 137 0 375 0 232 0 The Acorn Group Practice (H84007) 1,225 0 47 0 1,138 0 56 0 The Hampton Medical Centre (H84040) 1,542 0 102 0 1,380 0 60 0 Hampton Wick Surgery (H84032) 1,291 0 66 0 1,217 0 70 0 Kingston Hospital NHS Foundation Trust 51,187 0 243 0 48,769 0 1,385 (91) Chelsea and Westminster Hospital NHS Foundation Trust 38,257 0 836 0 35,649 0 613 20 Barts Health NHS Trust* 336 0 87 0 0 0 0 0 Your Healthcare CIC* 1,740 0 24 0 0 0 0 0 Richmond General Practice Alliance 1,211 0 160 0 992 0 138 0
Table 2. Material Related Party Transactions St George's Healthcare NHS Trust 15,209 0 (1,443) 0 12,555 0 (68) 0 Epsom & St Helier NHS Trust 2,768 0 (281) 0 2,677 0 (311) 0 South West London & St George's Mental Health NHS Trust 15,657 0 528 0 14,803 0 359 0 London Ambulance NHS Trust 6,346 0 (214) 0 5,824 0 118 0 Richmond upon Thames Borough Council 10,178 (85) 2,290 0 16,210 (2,344) 6 (2,375) NHS England 3 (166) 24 0 0 (490) 31 375 Imperial College HC Foundation Trust 10,518 0 454 0 10,391 0 (377) (25) Houslow and Richmond Community Healthcare NHS Trust 22,246 (124) 387 0 21,373 0 (67) 626 East London NHS Foundation Trust 3,060 0 1 0 3,471 0 (4) 0
*There is no 2017/18 comparative figure for Barts Health NHS Trust & Your Healthcare CIC as this was not considered a related party transaction in 2017/18
The Department of Health is regarded as a related party. During the year the clinical commissioning group has had a significant number of material transactions with entities for which the Department is regarded as the parent department. For example: • NHS England; • NHS Foundation Trusts; • NHS Trusts; • NHS Litigation Authority; and, • NHS Business Services Authority.
In addition, the clinical commissioning group has had a number of material transactions with other government departments and other central and local government bodies. Most of these transactions have been with the Richmond upon Thames Borough Council
Table 1 - Disclosure is made when a Governing Body member has an interest in an organisation that has material transactions with the clinical commissioning group. This disclosure applies to all GP governing body members. The materiality level set for Table 1 is £50k
Table 2 - Disclosure is made for the six NHS organisations with which the clinical commissioning group spends most of its resources. Houslow and Richmond Community Healthcare is disclosed as the clinical commissioning group provides approximately 33% of Houslow and Richmond Community Healthcare income. Richmond upon Thames Borough Council has also been included as the clinical commissioning group has material balances with the borough. The materiality level set for Table 2 is £2.6m
26 Richmond CCG - Annual Accounts 2018-19
15 Events after the end of the reporting period
There are no events after the end of the reporting period.
16 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 Duty 2017-18 2017-18 Duty Target Performance Achieved? Target Performance Achieved? Expenditure not to exceed income 275,194 279,051 No 266,408 270,855 No Capital resource use does not exceed the amount specified in Directions - - Yes 236 236 Yes Revenue resource use does not exceed the amount specified in Directions 272,506 276,363 No 262,739 267,186 No Capital resource use on specified matter(s) does not exceed the amount specified in Directions - - Yes - - Yes Revenue resource use on specified matter(s) does not exceed the amount specified in Directions - - Yes - - Yes Revenue administration resource use does not exceed the amount specified in Directions 4,373 4,041 Yes 4,314 4,226 Yes
27 Independent auditor's report to the members of the Governing Body of NHS Richmond Clinical Commissioning Group
Report on the Audit of the Financial Statements
Opinion We have audited the financial statements of NHS Richmond Clinical Commissioning Group (the ‘CCG’) for the year ended 31 March 2019, which comprise the Statement of Comprehensive Net Expenditure, the Statement of Financial Position, the Statement of Changes in Taxpayers Equity, the Statement of Cash Flows and notes to the financial statements, including a summary of significant accounting policies. The financial reporting framework that has been applied in their preparation is applicable law and International Financial Reporting Standards (IFRSs) as adopted by the European Union, and as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2018- 19.
In our opinion, the financial statements:
give a true and fair view of the financial position of the CCG as at 31 March 2019 and of its expenditure and income for the year then ended; and
have been properly prepared in accordance with International Financial Reporting Standards (IFRSs) as adopted by the European Union, as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2018-19; and
have been prepared in accordance with the requirements of the Health and Social Care Act 2012.
Basis for opinion We conducted our audit in accordance with International Standards on Auditing (UK) (ISAs (UK)) and applicable law. Our responsibilities under those standards are further described in the ‘Auditor’s responsibilities for the audit of the financial statements’ section of our report. We are independent of the CCG in accordance with the ethical requirements that are relevant to our audit of the financial statements in the UK, including the FRC’s Ethical Standard, and we have fulfilled our other ethical responsibilities in accordance with these requirements. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion.
Conclusions relating to going concern We have nothing to report in respect of the following matters in relation to which the ISAs (UK) require us to report to you where:
the Accountable Officer’s use of the going concern basis of accounting in the preparation of the financial statements is not appropriate; or
the Accountable Officer has not disclosed in the financial statements any identified material uncertainties that may cast significant doubt about the CCG’s ability to continue to adopt the going concern basis of accounting for a period of at least twelve months from the date when the financial statements are authorised for issue.
Other information The Accountable Officer is responsible for the other information. The other information comprises the information included in the Annual Report and Accounts, other than the financial statements and our auditor’s report thereon. Our opinion on the financial statements does not cover the other information and, except to the extent otherwise explicitly stated in our report, we do not express any form of assurance conclusion thereon. In connection with our audit of the financial statements, our responsibility is to read the other information and, in doing so, consider whether the other information is materially inconsistent with the financial statements or our knowledge obtained in the audit or otherwise appears to be materially misstated. If we identify such material inconsistencies or apparent material misstatements, we are required to determine whether there is a material misstatement in the financial statements or a material misstatement of the
Grant Thornton UK LLP. 1 other information. If, based on the work we have performed, we conclude that there is a material misstatement of the other information, we are required to report that fact. We have nothing to report in this regard.
Other information we are required to report on by exception under the Code of Audit Practice Under the Code of Audit Practice published by the National Audit Office on behalf of the Comptroller and Auditor General (the Code of Audit Practice) we are required to consider whether the Governance Statement does not comply with the guidance issued by the NHS Commissioning Board or is misleading or inconsistent with the information of which we are aware from our audit. We are not required to consider whether the Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls. We have nothing to report in this regard.
Opinion on other matters required by the Code of Audit Practice In our opinion:
the parts of the Remuneration and staff report to be audited have been properly prepared in accordance with IFRSs as adopted by the European Union, as interpreted and adapted by the Department of Health and Social Care Group Accounting Manual 2018-19 and the requirements of the Health and Social Care Act 2012; and
based on the work undertaken in the course of the audit of the financial statements and our knowledge of the CCG gained through our work in relation to the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources, the other information published together with the financial statements in the Annual Report for the financial year for which the financial statements are prepared is consistent with the financial statements.
Qualified opinion on regularity required by the Code of Audit Practice
In our opinion, except for the effects of the matters described in the Basis for qualified opinion on regularity section of our report, in all material respects the expenditure and income recorded in the financial statements have been applied to the purposes intended by Parliament and the financial transactions in the financial statements conform to the authorities which govern them. Basis for qualified opinion on regularity The CCG reported a deficit of £3.9 million in its financial statements for the year ending 31 March 2019, thereby breaching its duty under the National Health Service Act 2006, as amended by paragraph 223I of Section 27 of the Health and Social Care Act 2012, to ensure that its revenue resource use in a financial year does not exceed the amount specified by direction of the NHS Commissioning Board. This deficit also resulted in a breach of the CCG’s duty under the National Health Service Act 2006, as amended by paragraph 223H of Section 27 of the Health and Social Care Act 2012, to ensure that its expenditure in a financial year does not exceed its income.
Matters on which we are required to report by exception Under the Code of Audit Practice, we are required to report to you if:
we issue a report in the public interest under Section 24 of the Local Audit and Accountability Act 2014 in the course of, or at the conclusion of the audit; or
we refer a matter to the Secretary of State under Section 30 of the Local Audit and Accountability Act 2014 because we have reason to believe that the CCG, or an officer of the CCG, is about to make, or has made, a decision which involves or would involve the body incurring unlawful expenditure, or is about to take, or has begun to take a course of action which, if followed to its conclusion, would be unlawful and likely to cause a loss or deficiency; or
we make a written recommendation to the CCG under Section 24 of the Local Audit and Accountability Act 2014 in the course of, or at the conclusion of the audit.
Grant Thornton UK LLP. 2 We have nothing to report in respect of the above matters except on 28 May 2019, we referred a matter to the Secretary of State under section 30b of the Local Audit and Accountability Act 2014 in relation to NHS Richmond CCG’s breach of its revenue resource limit and its break-even duty for the year ending 31 March 2019.
Responsibilities of the Accountable Officer and Those Charged with Governance for the financial statements As explained more fully in the Statement of Accountable Officer's responsibilities, the Accountable Officer, is responsible for the preparation of the financial statements in the form and on the basis set out in the Accounts Directions, for being satisfied that they give a true and fair view, and for such internal control as the Accountable Officer determines is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error. In preparing the financial statements, the Accountable Officer is responsible for assessing the CCG’s ability to continue as a going concern, disclosing, as applicable, matters related to going concern and using the going concern basis of accounting unless they have been informed by the relevant national body of the intention to dissolve the CCG without the transfer of its services to another public sector entity. The Accountable Officer is responsible for ensuring the regularity of expenditure and income in the financial statements. The Audit Committee is Those Charged with Governance. Those charged with governance are responsible for overseeing the CCG’s financial reporting process.
Auditor’s responsibilities for the audit of the financial statements Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue an auditor’s report that includes our opinion. Reasonable assurance is a high level of assurance, but is not a guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in the aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of these financial statements. A further description of our responsibilities for the audit of the financial statements is located on the Financial Reporting Council’s website at: www.frc.org.uk/auditorsresponsibilities. This description forms part of our auditor’s report. We are also responsible for giving an opinion on the regularity of expenditure and income in the financial statements in accordance with the Code of Audit Practice.
Report on other legal and regulatory requirements – Conclusion on the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources
Qualified conclusion On the basis of our work, having regard to the guidance issued by the Comptroller and Auditor General in November 2017, except for the effects of the matter described in the basis for qualified conclusion section of our report, we are satisfied that in all significant respects NHS Richmond CCG put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2019.
Basis for qualified conclusion Our review of the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources identified the following matters:
The CCG reported a deficit of £3.9 million in its financial statements for the year ending 31 March 2019, which was a £4.2 million overspend against the financial target set for it by NHS England.
The deterioration in the CCG’s financial position was due to:
Grant Thornton UK LLP. 3 - the CCG only delivering £12.4 million of efficiency savings compared to the £16.1 million efficiency savings target set for it by NHS England - £6.9 million of required efficiency savings remaining unidentified at year end - growth in patient care activity resulting in higher expenditure on healthcare services than was originally budgeted for.
These matters identify weaknesses in the CCG’s arrangements for developing and delivering savings plans and setting a sustainable budget with sufficient capacity to absorb emerging cost pressures. They are evidence of weaknesses in proper arrangements for sustainable resource deployment in planning finances effectively to support the sustainable delivery of strategic priorities and maintain statutory functions.
Responsibilities of the Accountable Officer As explained in the Governance Statement, the Accountable Officer is responsible for putting in place proper arrangements for securing economy, efficiency and effectiveness in the use of the CCG's resources.
Auditor’s responsibilities for the review of the CCG’s arrangements for securing economy, efficiency and effectiveness in its use of resources We are required under Section 21(1)(c) and Schedule 13 paragraph 10(a) of the Local Audit and Accountability Act 2014 to be satisfied that the CCG has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and to report where we have not been able to satisfy ourselves that it has done so. We are not required to consider, nor have we considered, whether all aspects of the CCG's arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively. We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criterion issued by the Comptroller and Auditor General in November 2017, as to whether in all significant respects, the CCG had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The Comptroller and Auditor General determined this criterion as that necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the CCG put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2019, and to report by exception where we are not satisfied. We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to be satisfied that the CCG has put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources.
Report on other legal and regulatory requirements – Certificate We certify that we have completed the audit of the financial statements of NHS Richmond Clinical Commissioning Group in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice.
Use of our report This report is made solely to the members of the Governing Body of the CCG, as a body, in accordance with Part 5 of the Local Audit and Accountability Act 2014. Our audit work has been undertaken so that we might state to the members of the Governing Body of the CCG those matters we are required to state to them in an auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the CCG and the members of the Governing Body of the CCG, as a body, for our audit work, for this report, or for the opinions we have formed. Sarah L Ironmonger Sarah Ironmonger, Key Audit Partner for and on behalf of Grant Thornton UK LLP, Local Auditor Crawley 28 May 2019
Grant Thornton UK LLP. 4